Large-volume Tertiary Center Research Articles

Robotic colorectal procedures: does operative start time impact short-term outcome?

Previous publications revealed more complications in afternoon versus morning surgeries. With much attention given to robotic surgery outcomes, we sought to evaluate whether morning versus afternoon start time matters. In a retrospective review of a prospective database, 210 robotic colorectal surgeries were grouped into 97 morning versus 113 afternoon cases. Preoperative risk factors, intraoperative events, and 30-day postoperative outcomes were compared. An independent samples t-test, Fisher's exact test, and linear regression were used for categorical and continuous variables. Morning patients were significantly younger than afternoon patients (59.5 vs. 65.5, p = 0.004), but there were no significant differences in gender, mean BMI, Charlson Comorbidity Index score, total operative time, console time, estimated blood loss, indications for surgery, and resection type. Morning patients had a significantly shorter mean length of stay (6.0 vs. 8.0days, p = 0.021), but no significant differences in overall postoperative complications (0.30 vs. 0.30, p = 0.715), wound infection (5.2% vs. 7.1%, p = 0.564), anastomotic leak (0% vs. 2.7%, p = 0.251), ileus/small bowel obstruction (29.9% vs. 22.1%, p = 0.199), and 30-day readmission (8.2% vs. 7.1%, p = 1.000). When analyzing time of day as a continuous variable, we found no significant associations with intra- or postoperative complications. We found no correlation between surgery start time and intra- or postoperative outcomes. This can be partly attributed to these cases being non-emergent and performed primarily by two experienced surgeons with highly trained operating room robotic staff in a large volume tertiary center. This, along with decreased fatigue attributed to superior ergonomics of robotic surgery, may have mitigated previously reported differences between morning and afternoon procedures.

Racial Comparison of Patients Undergoing Minimally Invasive Partial Nephrectomy for Renal Masses at a Large Volume Tertiary Center.

Introduction and Objective: African American (AA) race has been identified to have a higher incidence of chronic kidney disease (CKD) and worse renal cancer survival compared with Caucasian Americans (CA), irrespective of tumor size, pathologic type, and surgical procedure. We aimed to compare the outcomes between CA and AA patients undergoing minimally invasive partial nephrectomy (PN) at our high-volume center. Materials and Methods: We queried our PN data repository from 2007 to 2017. We identified 981 cases of PN (robotic n = 943 and laparoscopic n = 38), of which there were 852 CA and 129 AA patients. We compared age, sex, body mass index (BMI), operative time, estimated blood loss (EBL), nephrometry score, tumor size, pre- and postoperative estimated glomerular filtration rate (eGFR), length of stay, Charlson Comorbidity Index (CCI), tumor characteristics, and 30-day complication rate. We then estimated the overall survival and disease-specific survival. Results: Age, BMI, operative time, EBL, nephrometry score, tumor size, CCI, length of stay, and sex were not statistically different. The mean preoperative eGFR was higher in the AA cohort (91.4 mL/min/1.73 m2 vs 86.1 mL/min/1.73 m2, p = 0.007); however, at 1 year, there was no mean difference (76.8 mL/min/1.73 m2 vs 74.5 mL/min/1.73 m2, p = 0.428). There was a higher percentage of Fuhrman Grade 3/4 in the AA cohort (33.3% vs 22.5%, p = 0.044). The AA cohort had a 2.66 × higher incidence of papillary renal cell carcinoma (RCC) (34.9% vs 13.1%, p < 0.001) and unclassified RCC (3.9% vs 0.4%, p = 0.001). There was no difference in tumor stage (p = 0.260) or incidence of benign histology (15.3% vs 11.6%, p = 0.278). There were no differences in 30-day complications (p = 0.330). The median follow-up was 43.2 months. By using Kaplan-Meier curves, there was no observed difference in overall survival (p = 0.752) or disease-free survival (p = 0.403). Conclusions: Our cohort of AA and CA patients with intermediate follow-up showed no worse outcomes for CKD or survival when undergoing laparoscopic or robotic PN. For low-stage renal cancer, there was no difference in overall survival and disease-free survival at a median follow-up of 43.2 months among AA patients, despite having higher grade tumors and a higher percentage of unclassified RCC. Our cohort of AA patients did have a higher incidence of papillary RCC. The equivalent overall survival and disease-free survival could be due to the earlier discovery of lower stage renal masses incidentally identified on imaging studies performed equally for other reasons in both AA and CA patients.

Excimer Laser Coronary Angioplasty: Clinical Applications and Procedural Outcome, in a Large-Volume Tertiary Centre

Excimer-laser coronary angioplasty can be used to modify undilatable and uncrossable lesions in native arteries and in-stent restenosis which are increasingly encountered with the ageing population undergoing coronary intervention. We present our laser experience over a 10-year period in a large cardiac tertiary centre. Method: Retrospective analysis of prospectively collected data on all procedures where laser was used from August 2008 to December 2019. Clinical presentation, demographics, and procedural details were all recorded. Successful procedures were defined as <30% stenosis at the end. Periprocedural and in-hospital complications were recorded and verified. Results are presented as numbers and percentages. Results: A total of 331 patients were identified with 473 lesions treated with laser and an overall total of 637 lesions. Of the 473 lesions treated, 46 (9.9%) were in-stent restenosis, 146 (30.9%) were chronic total occlusions, and the rest were uncrossable or undilatable lesions. The vast majority of procedures (97.0%) were performed with the 0.9-mm laser catheter. The overall success rate was 81.6% (58–87%) from low- to high-volume user. Complications included dissection 3 (0.6%), no-reflow 3 (0.6%), coronary perforation 13 (2.7%), and tamponade in 1 (0.2%). Only 3 (0.6%) of the perforations were seen after the laser catheter passage, the rest were seen later following balloon preparation or stent insertion. Conclusion: Laser is a valuable tool for treating complex and resistant coronary lesions. Its efficacy and safety are well established and when applied appropriately, it helps to achieve optimal outcomes for our patients.

Sentinel Node Biopsy in Ductal Carcinoma in Situ: Is it Justifiable?

Background: For invasive breast cancer, sentinel node biopsy (SNB) is an acceptable alternative to axillary node clearance (ANC), although in the recent era, its role is under review. In ductal carcinoma in situ (DCIS), the benefit of SNB is even less well defined. Despite this, guidelines still recommend that it is performed in selected cases of DCIS. The aim of our study was to evaluate the diagnostic value of performing SNB in DCIS.Methods: Patients with a diagnosis of DCIS who underwent axillary staging with SNB between 2008-2019 in our large volume tertiary centre were identified and included in the study.Results: Out of the 48 patients who were identified, four patients had a positive SNB (8%). Two of those patients were found to have micro metastatic disease. None of the patients with a positive SNB had local or systemic recurrence (median follow up: 40 months). One non-breast cancer-related mortality was reported. Two patients were identified who had recurrent disease, one with an invasive recurrence in the breast, and the other with systemic recurrence in the form of bone disease. Both of these patients had a negative SNB.Conclusion: Our results confirm that performing axillary staging with SNB in DCIS is not justifiable, as it does not affect patient outcomes. This supports the emerging evidence that being more surgically conservative may decrease morbidity without affecting patient survival.

201 Cardiac Device Related Complications Over 3 Years in a Large Volume Tertiary Centre

Recent, controversial evidence suggests the complication rate in Australia and New Zealand for ICD/ Pacemaker procedures is ∼8.2%. It has been suggested that this figure is skewed by high complication rates in low volume centres. To investigate this, we analysed device related complications over 3 years in a large volume tertiary centre. A total of 1137 devices were implanted over 3 years with 815 new devices (72%), 288 generator changes (25%) and 34 device upgrades (3%). 204 (25%) of the new devices were implantable defibrillators. During the 3 year period, 83 (7.2%) of patients encountered a complication. 25 patients developed a pocket hematoma. Hematoma rates were 5% in patients anticoagulated and 1.25% without anticoagulation. 1 patient developed an infection requiring device extraction. 20 patients required lead revisions for lead dislodgement. 9 patients developed a pneumothorax requiring drainage. 1 patient required pericardiocentesis for RV perforation. There were an additional 10 pneumothoraces and 2 pericardial effusions which were not clinically significant. 15 patients developed other minor complications such as antibiotics allergies. There were no deaths. Even in a high volume centre, device implantation related complications occur at a rate of around 7%. This confirms previous work and should be used to ensure appropriate informed consent is gained from patients.

Determinants of Significant Out-Of-Hospital Bleeding in Patients Undergoing Percutaneous Coronary Intervention.

Although several variables have been identified as bleeding determinants (BDs), their occurrence and predictive value in patients undergoing percutaneous coronary intervention (PCI) in the real world remain unclear. We aimed to characterize the rate of BDs in patients undergoing PCI with stent implantation in a large volume tertiary centre. We included patients undergoing coronary stenting at our institution from January 2012 to December 2016, and defined post-discharge bleeding (PDB) as bleeding requiring hospitalization or transfusion. Several BDs, identified by the PARIS bleeding and PRECISE-DAPT scores and inclusion criteria of the LEADERS FREE trial, were analysed. In a population of 10,406 subjects who underwent PCI, 2,938 patients (28.2%) had 1, 2,367 (22.8%) had 2 and 2,913 (28.0%) had ≥3 pre-specified BD. Compared with patients without PDB, subjects who experienced PDB were older (70.43 ± 11.94 vs. 65.90 ± 11.54 years, p < 0.0001) with a higher prevalence of common cardiovascular risk factors. One-year PDB occurred in 177 patients (2.4%), and consistently increased according to the number of BDs involved (1.12, 2.11 and 4.35%, respectively; p < 0.0001). Analogously, 1-year rates of post-discharge myocardial infarction or stent thrombosis increased according to the number of BDs (2.44, 3.38 and 4.87%, respectively; p < 0.0001). Only 7 BDs remained independently associated with PDB at 1 year, with anaemia, oral anticoagulant at discharge and malignancy representing the strongest predictors of such risk. Many risk factors predispose to PDB; they were often clustered together and conferred additive PDB risk at 1-year of follow-up.

Abstract TP392: Evaluation of the CHADS 2 , CHA 2 DS 2 -VASc, and R 2 CHADS 2 Risk Assessment Scores in Continuous Flow LVADs

Background: The development of stroke while on continuous flow left ventricular assist device (CF-LVAD) remains a source of significant morbidity and mortality. The ability to risk stratify these patients can improve postoperative management. Objective: To describe the overall experience of cerebrovascular accidents in CF-LVAD patients at a large volume tertiary center and compare the utility of CHADS 2 , CHA 2 DS 2 -VASc, and R 2 CHADS 2 scores. Methods: A retrospective analysis of 522 patients (524 CF-LVADs: HeartMate-II=402; Heartware=122), between 2003 and 2016, was conducted. Post-operative heparin for 2-3 days, warfarin (goal INR 2-3), and 80-325mg aspirin were administered daily. Cerebrovascular vascular accident (CVA) was defined as any focal or global deficit with positive imaging. The CHADS 2 , R 2 CHADS 2 and CHA 2 DS 2 -VASc scores were calculated. Baseline characteristics and risk assessment scores were compared between patients with ischemic CVA (ICVA) and no CVA (nCVA). Kaplan-Meier analysis was conducted. Results: Mean age was 54.7±13.6 years, 21.8% were female and 44.8% had ischemic cardiomyopathy. Eighty patients (15.3%) had 98 events of ICVA. Median duration between implant and ICVA was 127 [range 1-2226] days. Hemorrhagic conversion occurred in 9 (9.2%) patients. The CHADS 2 (ICVA=2.4±1.0, nCVA=2.3±1.1, p-value=0.53), CHA 2 DS 2 -VASc (ICVA=3.2±1.3, nCVA=2.9±1.3, p-value=0.08) and R 2 CHADS 2 (ICVA=3.5±1.5, nCVA=3.2±1.6, p-value=0.22) were all higher for ICVA cohort. Patients with multiple ICVAs had a mean CHADS 2 score of 2.5±0.74, CHA 2 DS 2 -VASc score of 3.5±1.1, and R 2 CHADS 2 score of 4±1.2. Freedom from stroke was significantly lower in the CHA 2 DS 2 -VASc ≥3 compared to the CHA 2 DS 2 -VASc &lt;3 [Figure: Kaplan-Meier log-rank p-value=0.009]. Conclusion: CHA 2 DS 2 -VASc of ≥3 was associated with ICVA in this cohort of CF-LVAD patients. Specifically tailored risk-scores are needed to better predict those at risk for neurological events in CF-LVADs

Dedicated Multidisciplinary Ventilator Bundle Team and Compliance with Sedation Vacation

How compliance with a ventilator bundle is monitored varies from institution to institution. Some institutions rely on the primary intensive care unit team to review the bundle during their rounds; others rely on a separate team of health care personnel that may include representatives from disciplines such as nursing, respiratory therapy, and pharmacy. To compare rates of compliance with ventilator bundle components between a dedicated ventilator bundle rounding team and the primary intensive care unit rounding team in a 68-bed medical intensive care unit. A query of the medical intensive care unit's database was used to retrospectively determine rates of compliance with specific ventilator bundle components at a tertiary care hospital in an urban community for 1 year. Compared with the intensive care unit rounding team, the ventilator bundle rounding team had better compliance with sedation vacation (61.7% vs 54.0%, P < .001). Rates of compliance with spontaneous breathing trials and prophylaxis of peptic ulcer disease were similar in both study groups. A dedicated ventilator bundle rounding team improves compliance with sedation vacation, but not with spontaneous breathing trials and prophylaxis of peptic ulcer disease. In a large-volume tertiary center, a dedicated ventilator bundle rounding team may be more effective than the primary rounding team in achieving compliance with some bundle components.