Intra-abdominal Surgery Research Articles

A221 EFFECT OF PROXIMITY TO A SPECIALTY TERTIARY CENTRE ON OUTCOMES IN INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED RETROSPECTIVE COHORT STUDY

Abstract Background The etiology of inflammatory bowel disease (IBD) is unknown; however, developed nations such as Canada ranking amongst the highest worldwide. With many diseases patients in urban and rural areas have different access to care and resources. Purpose To describe the differences in outpatient healthcare utilization, use of biologic agents and complication of IBD based on proximity to a tertiary health care centre. Method A retrospective cohort study was conducted comparing IBD patients seen in IBD clinics at affiliated with Western University in London, Canada between August 2019 – December 2019. IBD patients were compared on their use of outpatient healthcare utilization, biologic agents and IBD complications based on their proximity to a tertiary care centre (>100 km and <100 km). Patients residing >100 km from a tertiary centre were termed “rural” while <100 km from a tertiary centre were termed “urban.” Retrospective chart review occurred over a six-month period between January to June 2021. Result(s) A total of 481 were reviewed. Of those, 97 (UC, n=29; CD, n=68) and 95 (UC, n=30; CD, n=65) met inclusion for the urban and rural groups respectively. Patient demographics were similar between the two groups except IBD disease location with pancolitis seen more commonly in urban patients compared to ileocolonic in rural patients (urban, n=39; rural, n=34). IBD patients in both groups had similar number of appointments (urban, n=20.1 ± 13.8; rural, n=17.5 ± 12.1) and endoscopic procedures (urban, n= 4.9 ± 3.1; rural, n= 4.7 ± 3.2) with their gastroenterologists. More urban patients were managed with no therapy for their IBD (urban, n=16; rural, n=5). A higher rate of rural patients were managed with biologics (urban, n=56; rural, n=66) and combination therapy (urban, n=16; rural, n=27). The most common related IBD-related complications were IBD flares (urban, n=55; rural, n=60), intestinal strictures (urban, n=25; rural, n=34), intestinal obstructions (urban, n=10; rural, n=23) and rectal/genitourinary fistulas (urban, n=6; rural, n=21). Similar numbers of intra-abdominal surgery were seen between both groups with partial bowel resection (urban, n=13; rural, n=12) and right hemicolectomy (urban, n=10; rural, n=18) as the predominant surgery in urban and rural patients, respectively. Conclusion(s) This study demonstrated outpatient healthcare utilization when attending specialty gastroenterology appointments and outpatient endoscopies were numerically similar in rural and urban patients. IBD patient residing further from a tertiary care centre were numerically more likely to be managed with biologics and combination therapy. However the dataset is small and generalizations cannot be made. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Gossypiboma: A Cause of Iatrogenic Fecal Enterocutaneous Fistula

The word ‘gossypiboma’ or ‘textiloma’ is used to describe a retained surgical sponge in the body after an operation. If it is left in the abdomen, it may cause serious morbidity and mortality of the patient as well as medico legal problems. It varies between 1 out of 1000-1500 intra-abdominal operations and 1 out of 300-1000 of all operations1. Herein, we report one case, the first presenting about 2 months after caesarean section with fever with chills and rigor and pain at the operative area. Imaging detected presence of foreign body in the abdomen. Then she went for exploration of the wound and a mop was removed. After that she came to us with pain and feculent discharge from the wound site.
 AKMMC J 2021; 12(1) : 58-61

Trends and In-Hospital Mortality for Perioperative Myocardial Infarction After the Introduction of a Diagnostic Code for Type 2 Myocardial Infarction in the United States Between 2016 and 2018.

The frequency of perioperative myocardial infarction has been declining; however, previous studies have only described type 1 myocardial infarctions. Here, we evaluate the overall frequency of myocardial infarction with the addition of an International Classification of Diseases 10th revision (ICD-10-CM) code for type 2 myocardial infarction and the independent association with in-hospital mortality. A longitudinal cohort study spanning the introduction of the ICD-10-CM diagnostic code for type 2 myocardial infarction using the National Inpatient Sample (NIS) from 2016 to 2018. Hospital discharges that included a primary surgical procedure code for intrathoracic, intraabdominal, or suprainguinal vascular surgery were included. Type 1 and type 2 myocardial infarctions were identified using ICD-10-CM codes. We used segmented logistic regression to estimate change in frequency of myocardial infarctions and multivariable logistic regression to determine the association with in-hospital mortality. A total of 360,264 unweighted discharges were included, representing 1,801,239 weighted discharges, with median age 59 and 56% female. The overall incidence of myocardial infarction was 0.76% (13,605/1,801,239). Before the introduction of type 2 myocardial infarction code, there was a small baseline decrease in the monthly frequency of perioperative myocardial infarctions (odds ratio [OR], 0.992; 95% confidence interval [CI], 0.984-1.000; P = .042), but no change in the trend after the introduction of the diagnostic code (OR, 0.998; 95% CI, 0.991-1.005; P = .50). In 2018, where there was an entire year where type 2 myocardial infarction was officially a diagnosis, the distribution of myocardial infarction type 1 was 8.8% (405/4580) ST elevation myocardial infarction (STEMI), 45.6% (2090/4580) non-ST elevation myocardial infarction (NSTEMI), and 45.5% (2085/4580) type 2 myocardial infarction. STEMI and NSTEMI were associated with increased in-hospital mortality (OR, 8.96; 95% CI, 6.20-12.96; P < .001 and OR, 1.59; 95% CI, 1.34-1.89; P < .001). A diagnosis of type 2 myocardial infarction was not associated with increased odds of in-hospital mortality (OR, 1.11; 95% CI, 0.81-1.53; P = .50) when accounting for surgical procedure, medical comorbidities, patient demographics, and hospital characteristics. The frequency of perioperative myocardial infarctions did not increase after the introduction of a new diagnostic code for type 2 myocardial infarctions. A diagnosis of type 2 myocardial infarction was not associated with increased in-patient mortality; however, few patients received invasive management that may have confirmed the diagnosis. Further research is needed to identify what type of intervention, if any, may improve outcomes in this patient population.

Neurodevelopmental effects of prenatal exposure to anaesthesia for maternal surgery: a systematic review and classification of the reported effect sizes.

Neurodevelopmental effects of prenatal exposure to anaesthesia for maternal surgery: a systematic review and classification of the reported effect sizes.

A Rare Hernia Mimicking Implant in a Patient with Rectal Adenocarcinoma: Internal Herniation.

Internal herniation may be seen more frequently in patients with intra-abdominal surgery and malignancy history. We presented a 58-year-old male patient diagnosed with rectal adenocarcinoma seven years ago with a history of surgery and pelvic radiotherapy. When the abdominal computed tomography (CT) image was taken during routine oncology follow-up, a lesion mimicking a serosal implant on the anterior abdominal wall was detected. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT imaging was performed the suspicion of recurrence. It was concluded that the lesion, which was evaluated as an implant in abdominal CT with 18F-FDG PET/CT imaging, was a spontaneously reducing internal herniation. 18F-FDG PET/CT imaging in cancer patients is crucial in illuminating the suspicion of recurrent lesions in these patients and sheds light on the course of the patients in oncology practice.

Uterine Prolapse as a Rare Cause of Intestinal Obstruction: A Case Report and Literature Review

Background: The etiology of pelvic organ prolapse is multifactorial. Age and parity are especially the two most important risk factors for this condition. Small bowel obstruction is one of the most common clinical presentations to the emergency department that can result in significant morbidity and mortality. Case presentation: A 79-year-old woman with a previous history of uterine prolapse and no previous history of intraabdominal surgery or malignancies presented with nausea and vomiting, abdominal pain, and constipation from 2 days ago. Upright and supine x-rays showed dilated small bowel loops and confirmed bowel obstruction. Due to primary obstruction, the patient was a candidate for surgery. During the surgery, we observed that 100 cm of the terminal ileum and the uterus protruded in the vaginal canal and the ileal loops were strangulated. We decided to perform a right hemicolectomy surgery. Conclusion: In patients with uterine prolapse, we suggest a careful examination and consideration of the entrapment of small bowel loops in the prolapse site as a rare cause of small bowel obstruction.

P240 Low surgery rates first year after diagnosis in Crohn’s disease; results from a large population-based inception cohort - the IBSEN III study

Abstract Background Surgery rates in Crohn’s disease (CD) have declined during recent years, in parallel with the introduction and increased use of biological treatment. The aim of this study was to describe the use of first-line biologic therapy and to estimate the intra-abdominal surgery rate during the first year after the CD diagnosis. Methods The Inflammatory Bowel Disease in South-Eastern Norway III (IBSEN III) study is a population-based inception cohort with a prospective follow-up of newly diagnosed inflammatory bowel disease patients from the South-Eastern Health Region of Norway included in the period 2017 to 2019. Five hundred and seven patients ≥18 years were diagnosed with CD and those attending the one-year follow-up visit were included in this study. Clinical data, including Montreal classification, were registered at time of diagnosis. At the one-year follow-up, use of biologic therapy and need for CD-related intra-abdominal surgery since diagnosis were registered. Kaplan-Meier plots estimated the cumulative incidence of first-line biologic therapy and intra-abdominal surgery. Results A total of 431/507 (85%) CD patients attended the one-year follow-up and were included, 54.8% female, median age 37 years (range 18-80). At diagnosis 218 (50.6%) presented with ileal disease location, 76 (17.6%) colonic and 137 (31.8%) ileocolonic disease location, while 11 (2.6%) also had upper gastrointestinal involvement. The majority, 351 (81.4%), had a non-stricturing non-penetrating disease behavior, 70 (16.2%) a stricturing and 10 (2.3%) a penetrating disease behavior, while 17 (3.9%) also had perianal disease. Within one year of follow-up, 165 (38.7%) received at least one biologic therapy (60.6% infliximab, 35.8% adalimumab and 3.6% vedolizumab). Seven patients (1.6%) underwent perianal surgery and 21 (4.9%) had intra-abdominal surgery within the first year. Three of these were diagnosed during their primary surgery. Time from diagnosis to start of first-line biologic therapy and first intra-abdominal surgery is shown in Figure 1 and Figure 2, respectively. Figure 1: Kaplan-Meier plot showing cumulative incidence of first-line biologic therapy. Figure 2: Kaplan-Meier plot showing cumulative incidence of Crohn's related intra-abdominal surgery. Conclusion In the IBSEN III cohort, the rate of intra-abdominal surgery during the first year of disease was low (4.9%) compared to a previous population-based study from the same geographic area during the pre-biologic era, the IBSEN study, where the surgery rate was reported as 15.9 %.1 We hypothesize that a large preponderance of patients presenting with milder phenotypes at diagnosis combined with high use of biologicals contribute to the low surgery rates.

P204 Preoperative optimization of patients with inflammatory bowel disease: a multicentre study of EIGA Group

Abstract Background A significant percentage of patients with inflammatory bowel disease (IBD) will require surgical treatment at some point in their disease. Preoperative optimization (PO) intends to ensure that the patient arrives in optimal condition to surgery and to minimize the risk of complications. The aim of this study was to assess whether optimization criteria were met in patients with IBD undergoing elective surgery and to describe the percentage of post-surgical complications based on exposure to any of these risk factors. Methods IBD patients undergoing intra-abdominal surgery between 1st January 2013 and 30st September of 2021 were retrospectively selected. Data collection included clinical characteristic of IBD, nutritional biochemical parameters and surgical aspects. In addition, risk factors associated with a worse prognosis were collected. Among them, anemia, risk of malnutrition (using the Malnutrition Universal Screening Tool, MUST), smoking, presence of intra-abdominal sepsis and treatment received for IBD in the 30 days prior to surgery, especially the use of corticosteroids. Postsurgical complications were defined as those occurring within 30 days after surgery. Results A total of 212 surgeries performed in 5 centres from northwest of Spain were included: 87% in Crohn’s disease, 11% in ulcerative colitis and 2% in unclassified-IBD patients. Patients' clinical and demographic characteristics are summarized in Table 1. Postoperative complications were reported in 20.1% (n=62) of the patients, including suture dehiscence, infection, obstruction, bleeding and thrombosis. The most frequent complication was surgical site infection (10.8% of all the cases). Up to 35.6% of the patients were at risk of malnutrition at the time of surgery (MUST&amp;gt;=1), only half of these patients received some type of nutritional therapy. 20% of patients received at least 20 mg daily of prednisone or equivalent four weeks prior to surgery. Risk factors of post-surgical complications are presented in Table 2. Corticosteroid therapy (&amp;gt; 20 mg daily prednisone or equivalent) (OR 3.52 [95% CI: 1.05–12.6] (p=0.042) and the absence of nutritional support (OR 2.34 [95% CI:1.17-4.65] (p=0.016) were associated with postoperative complications. Multivariate and univariate analysis for postoperative complications are shown in Table 3 and Table 4. Conclusion The absence of a PO model increases the risk of postoperative complications. Inadequate preoperative nutritional care and corticosteroid therapy are risk factors for complications in our study. Protocols of PO in IBD patients are recommended.

Outcomes of Complex Abdominal Wall Reconstruction After Oncologic Resection: 14-Year Experience at an NCI-Designated Cancer Center.

Outcomes studies for abdominal wall reconstruction (AWR) in the setting of previous oncologic extirpation are lacking. We sought to evaluate long-term outcomes of AWR using acellular dermal matrix (ADM) after extirpative resection, compare them to primary herniorrhaphy, and report the rates and predictors of postoperative complications. We conducted a retrospective cohort study of patients who underwent AWR after oncologic resection from March 2005 to June 2019 at a tertiary cancer center. The primary outcome was hernia recurrence (HR). Secondary outcomes included surgical site occurrences (SSOs), surgical site infection (SSIs), length of hospital stay (LOS), reoperation, and 30-day readmission. Of 720 consecutive patients who underwent AWR during the study period, 194 (26.9%) underwent AWR following resection of abdominal wall tumors. In adjusted analyses, patients who had AWR after extirpative resection were more likely to have longer LOS (β, 2.57; 95%CI, 1.27 to 3.86, p < 0.001) than those with primary herniorrhaphy, but the risk of HR, SSO, SSI, 30-day readmission, and reoperation did not differ significantly. In the extirpative cohort, obesity (Hazard ratio, 6.48; p = 0.003), and bridged repair (Hazard ratio, 3.50; p = 0.004) were predictors of HR. Radiotherapy (OR, 2.23; p = 0.017) and diabetes mellites (OR, 3.70; p = 0.005) were predictors of SSOs. Defect width (OR, 2.30; p < 0.001) and mesh length (OR, 3.32; p = 0.046) were predictors of SSIs. Concomitant intra-abdominal surgery for active disease was not associated with worse outcomes. AWR with ADM following extirpative resection demonstrated outcomes comparable with primary herniorrhaphy. Preoperative risk assessment and optimization are imperative for improving outcomes.

Steep ramp test protocol for preoperative risk assessment and short-term high-intensity interval training to evaluate, improve, and monitor cardiorespiratory fitness in surgical oncology.

Steep ramp test protocol for preoperative risk assessment and short-term high-intensity interval training to evaluate, improve, and monitor cardiorespiratory fitness in surgical oncology.

Postoperative Handheld Gastric Point-of-Care Ultrasound and Delayed Bowel Function.

Delayed bowel function (DBF) following intra-abdominal surgery is a common problem that contributes to postoperative complications and prolonged length of stay. Use of a handheld gastric point-of-care ultrasound (GPOCUS) can identify a full vs empty stomach in the postoperative period. We hypothesized that the findings of a full stomach identified on a postoperative day 1 (POD1) GPOCUS exam would predict an increased risk of delayed bowel function. A blinded, prospective cohort study was performed. Postoperative colorectal surgery patients were identified as having either a full or empty stomach based on previously published definitions. GPOCUS examinations were performed on POD1 using a handheld ultrasound device, and the clinicians were blinded to the results. Demographic and perioperative data were collected. The primary outcome variable was gastrointestinal-3 (GI-3) recovery, defined as time to tolerance of diet and either flatus or bowel movement. Fifty-six patients agreed to participate in the study; fifty were eligible and included. Eighteen patients' stomachs were identified as full on POD1 GPOCUS examination, and thirty-two were identified as empty. No significant demographic or perioperative differences existed between groups. Patients with full stomachs had significantly delayed GI-3 recovery (4 vs 1 days, p < 0.0001) and longer length of stay (5 vs 3 days, p < 0.0001). Full-stomach patients also had significantly more emesis and nasogastric tube (NGT) placement (both p < 0.05). GPOCUS performed on POD1 can predict DBF, length of stay, likelihood of emesis, and NGT placement. Use of handheld devices for GPOCUS showed promise for the identification of patients at high risk for DBF and could provide an opportunity for pre-emptive intervention.

Efficacy of intra-abdominal cytoreductive surgery in advanced endometrial cancer with distant metastasis.

The efficacy of intra-abdominal cytoreductive surgery in patients with endometrial cancer and distant metastasis is equivocal. We investigated the effectiveness of such surgical treatment and whether it should be performed before or after chemotherapy (CT). This study included patients with an International Federation of Gynecology and Obstetrics stage IVB endometrial cancer who received initial treatment at our hospital between January 2006 and December 2017. We retrospectively reviewed 67 patients with stage IVB endometrial cancer with distant metastases and classified them into preceding surgery (PS, n=23), chemotherapy followed by a surgery (CS, n=27), and CT (n=17) groups. We examined the achievement of resection with [R (1)] or without [R (0)] intra-abdominal macroscopic residue and survival. The median survival time for R (0) was 44 (95% confidence interval [CI]=9-not available [NA]) months in the PS group and 27 (95% CI=11-NA) months in the CS group. The median survival time for R (1) was 9 (95% CI=0-24) months in the PS group and 12 (95% CI=7-19) months in the CS group. The similar prognosis in both groups was worse with R (1) than with R (0). The survival curve for R (1) in the resection groups was similar to that of the CT group. Achieving resection without intra-abdominal macroscopic residue for endometrial cancer with distant metastases, whether before or after CT, could extend patients' survival.

The Frail Elderly Patient and the Need for a Video Store on Regional Anaesthesia Blocks

The Frail Elderly Patient and the Need for a Video Store on Regional Anaesthesia Blocks

Recent advances in the treatment of biofilms induced surgical site infections.

Recent advances in the treatment of biofilms induced surgical site infections.

Variable Anatomical Presentation of Testicular Veins: A Cross-sectional Study

Introduction: The anatomy of gonadal veins is of growing importance, with an increased number of laparoscopic and open intra-abdominal surgical procedures. Gonadal veins display great variability concerning their course, number, and termination site. Aim: To explore the possible anatomical variations in the course and termination pattern of testicular veins. Materials and Methods: A cross-sectional study was conducted on 35 human male cadavers in Gandhi Medical College, Secunderabad, Telangana, India and All India Institute of Medical Sciences (AIIMS), Bibinagar, Telangana, India, from 2019-2021. The course numbers and drainage pattern of testicular veins were analysed for any anatomical variations. Results: Two out of the 35 (5.71%) cases had shown multiple testicular veins. One case showed quadruple testicular veins with two oblique communicating veins on the right side and double left testicular veins on the left side. In another case, double right testicular veins with a single vein on the left side. However, no significant variations of arteries were noted in any of these cases. Conclusion: Detailed knowledge of variable presentations of testicular veins is necessary for vascular surgeons, urologists, nephrologists, and radiologists in safeguarding these veins intraoperatively and also, reducing any postoperative vascular complications.

Exploring heterogeneity in hospital length of stay post emergency abdominal surgery in Ireland: A quantile regression approach

Background Emergency Abdominal Surgery (EAS) refers to a range of complex intra-abdominal surgical procedures associated with high mortality risk and long length of hospital stay (LOS). LOS is often used as a proxy measure for hospital resource utilisation in hospital capacity management and planning. Our objective was to explore the heterogeneity in LOS among EAS patients admitted at publicly funded hospitals in Ireland. Methods We analysed national hospital inpatient data (2014 – 2022) for adults discharged following EAS. We used Quantile Regression (QR) methods to explore the heterogeneous effects along the LOS distribution between 10 th - 90 th percentiles. We compared QR with Ordinary Least Squares (OLS) estimates, and identified from which point in the LOS distribution heterogeneous effects were different from OLS estimates. Results From the National Healthcare Quality Reporting System (NHQRS) records for 15,408 EAS adult inpatient episodes were obtained for analysis. We observed significant (p &lt; 0.001) heterogeneous effects across most quantiles of the LOS distribution. LOS was longer for patients with Charlson comorbidity indices of 4 or higher, American Society of Anaesthesiologists physical status scores of 2 and higher, admissions to critical care units, hospital readmissions within 30-days, discharges to nursing home and other hospital, and for patients treated in Model 4 hospitals. LOS was shorter for patients with a cancer diagnosis and patients who died during admission. Across these factors, statistically significant heterogeneous effects above OLS estimates were observed at the 70 th to the 90 th quantile. Conclusions The QR methods identified the presence of significant heterogeneity across the entire LOS distribution. Relative to OLS mean estimates, QR is a better method for identifying heterogeneous effects by exploring the entire LOS distribution. Our results highlight the importance of using appropriate methods for estimating skewed outcomes. This is important to provide valid and relevant empirical analysis to inform policy.

Optimal Timing of Perioperative Chemical Thromboprophylaxis in Elective Major Abdominal Surgery: A Systematic Review and Meta-analysis.

To investigate the effect of the timing of chemoprophylaxis on venous thromboembolisms (VTEs) and bleeding rates in patients undergoing major abdominal surgery. Postoperative bleeding and VTE incur significant morbidity, mortality, and health care costs. Chemoprophylaxis is used routinely to prevent VTEs but increases bleeding risk. The perioperative timing of chemoprophylaxis initiation may influence both VTE and bleeding risks. The optimal window for commencing chemoprophylaxis in the perioperative period is unclear. MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were searched using PRISMA guidelines. Randomized trials and cohort studies published between January 1, 2000 to May 10, 2022, which reported on chemoprophylaxis timing as well as the incidence of VTE and bleeding after elective abdominal surgery were meta-analyzed. From 6175 studies, 14 (24,922 patients) were meta-analyzed. Bariatric (4 studies), antireflux (1 study), hepato-pancreatic-biliary (5 studies), colorectal (1 study), ventral hernia (1 study), and major intra-abdominal surgeries (2 studies) were included. Chemoprophylaxis was initiated before skin closure in 10,403 patients, and postoperatively in 14,519 patients. Both symptomatic [risk ratios (RR), 0.81; 95% CI, 0.45-1.43; P =0.460] and overall (RR, 0.74; 95% CI, 0.45-1.24; P =0.250) VTE rates were comparable between study groups. Compared with postoperative chemoprophylaxis, early usage increased the risk of all bleeding (RR, 1.56; 95% CI, 1.13-2.15; P =0.007), major bleeding (RR, 1.63; 95% CI, 1.16-2.28; P =0.005), blood transfusion (RR, 1.48; 95% CI, 1.24-1.76; P <0.001), and reintervention (RR, 1.94; 95% CI, 1.19-3.18; P =0.008). Our findings advocate for initiating chemoprophylaxis postoperatively in elective abdominal surgery to minimize bleeding risk without compromising VTE protection.

Robotic assited perineal prostatectomy (RAPP) as a new era for anesthesiology: It's effects on hemodynamic parameters and respiratory mechanics.

Robotic-assisted perineal prostatactomy(RAPP) is a new alternative surgical technique, in prostate cancer patients especially with a history of intra-abdominal surgery. The aim of this study is to examine the effects of the challenging patient position and CO2 insufflation in perineal space during RAPP on both hemodynamic parameters and respiratory mechanics. Hemodynamic and respiratory parameters of 30 patients who underwent RAPP and 31 patients who underwent Robotic-assisted laparoscopic prostatectomy (RALP) for prostate cancer between 2017 and 2019 were retrospectively evaluated. Comparison between RAPP and RALP patients showed that anesthesia, surgery and insufflation times were shorter in RAPP patients (p < 0.05). Blood pCO2 level was higher, and the pH decrease was more prominent in the RAPP patients 30 and 60min after perineal CO2 insufflation (p < 0.05). The mean arterial pressures, driving pressure, Ppeak and Pplato values were statistically higher in the RALP patients and 60min after insufflation while static and dynamic lung compliance values were found to be lower. Our results showed that blood pCO2 level may severely increaseafter perineal CO2 insufflation. The fact that respiratory mechanics are less affected despite the difficult patient position for lungs in RAPP patients, the presence of higher CO2 level supports that the perineal CO2 insufflation plays a more important role in increased CO2 level. Considering these changes, especially the sudden increase in the risk of CO2 level, close follow-up and timely intervention by anesthesiology can ensure all changes remain in a clinically safe range.

Psoas muscle mass index as a predictor of long-term mortality and severity of complications after major intra-abdominal colorectal surgery – A retrospective analysis

Study objectiveDetermine if psoas muscle area measured in routine preoperative computed tomography scans (CT) can be used to identify patients at increased risk of adverse postoperative outcomes after major elective abdominal surgery. DesignRetrospective analysis of data from a single-centre cohort study conducted in York Hospital between the 1st August of 2015 and the 31st of august of 2020. SettingPreoperative clinic. Patients639 patients who attended the preoperative assessment clinic prior to major elective colorectal surgery and had an abdominal CT scan done up to 120 days before surgery. InterventionsNone. MeasurementsPsoas muscle area at the L3 level was measured in preoperative CT scans and normalised to patient height (psoas muscle index). The lowest sex-stratified tertile of psoas muscle index (PMI) was classed as sarcopenic.The primary outcome was 2-year mortality. Secondary outcomes included postoperative complications assessed using Clavien-Dindo graded major and minor complications, comprehensive complication index (CCI), and length of stay. Main resultsMultivariable regression analysis showed that sarcopenia was associated with 2-year mortality (aOR 1.79, 95% CI 1.03–3.10; p = 0.037) and survival at 2-years was significantly reduced in sarcopenic patients (log-rank test, p = 0.012). Sarcopenia was the only statistically significant predictor of major complications in multivariable logistic regression analysis (aOR 1.69, 95% CI 1.04–2.74, p = 0.034) and associated with an estimated increase of 16.6% in the comprehensive complication index (CCI) score of patients that had complications in multivariable linear regression analysis. Sarcopenia was not associated with length of stay. ConclusionsSarcopenia defined by psoas muscle mass is an independent predictor of 2-year mortality, major complications and severity of complications after major colorectal surgery and may be used for preoperative risk assessment.

Volume-outcome relationship in intra-abdominal robotic-assisted surgery: a systematic review.

As robotic-assisted surgery (RAS) expands to smaller centres, platforms are shared between specialities. Healthcare providers must consider case volume and mix required to maintain quality and cost-effectiveness. This can be informed, in-part, by the volume-outcome relationship. We perform a systematic review to describe the volume-outcome relationship in intra-abdominal robotic-assisted surgery to report on suggested minimum volumes standards. A literature search of Medline, NICE Evidence Search, Health Technology Assessment Database and Cochrane Library using the terms: "robot*", "surgery", "volume" and "outcome" was performed. The included procedures were gynecological: hysterectomy, urological: partial and radical nephrectomy, cystectomy, prostatectomy, and general surgical: colectomy, esophagectomy. Hospital and surgeon volume measures and all reported outcomes were analysed. 41 studies, including 983,149 procedures, met the inclusion criteria. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale and the retrieved data was synthesised in a narrative review.Significant volume-outcome relationships were described in relation to key outcome measures, including operative time, complications, positive margins, lymph node yield and cost. Annual surgeon and hospital volume thresholds were described. We concluded thatin centres with an annual volume of fewer than 10 cases of a given procedure, having multiple surgeons performing these procedures led to worse outcomes and, therefore, opportunities should be sought to perform other complimentary robotic procedures or undertake joint cases.