Median Comprehensive Complication Index Research Articles

Preliminary Results from the International Registry on Liver Venous Deprivation (EuroLVD)

Abstract Background Liver venous deprivation (LVD) is a recently developed method to reach maximal liver hypertrophy before major hepatectomy. LVD combines simultaneous portal and ipsilateral hepatic vein embolization. An international registry was created in 2021. Aims This study aimed to describe the outcomes after LVD of patients included in the registry. Methods Since its creation, 7 international expert HPB centers participated to the registry. Preoperative characteristics, data on liver regeneration after LVD, and postoperative results after hepatectomy were collected. Future liver remnant (FLR) and standardized FLR ratios were defined as FLR/total functional liver volume and FLR/total estimated liver volume. Results A total of 191 patients were included (71 women). Median age was 63 (IQR 53-69) and body-mass index 24.8 kg/m2 (IQR 22.3-28.7). Fifty-three patients were ASA III/IV. Main surgical indication was colorectal metastases (n=116). Median FLR and standardized FLR ratios before LVD were 33% (IQR 26-47) and 32% (IQR 23-39). Median time for the LVD procedure was 122 minutes (IQR 99-164). In one patient right hepatic vein embolization failed. Complications after LVD occurred in 14 patients (7%), including 7 hemorrhages/hematomas. After LVD, median FLR and standardized FLR ratios significantly increased to 46% (IQR 39-59, p<0.001) and 44% (IQR 35-50, p<0.001), corresponding to a median kinetic growth rate of 3.2%/week (IQR 1.6-5.3). Hepatectomy was performed in 142 patients (69 extended hepatectomies), while 49 dropped out (7 for insufficient hypertrophy (4%), 27 for tumor progression (14%), and 15 for other reasons (8%)). Seventy-one patients had postoperative complications (50%), and only 2 developed postoperative liver failure (1%). Median Comprehensive Complication Index was 20.9 (IQR 0-30.8) and 10 patients were reoperated (7%). Conclusion The preliminary data of this international registry showed that LVD had a high technical success rate (190/191) with few post-procedural complications and significant kinetic growth. Major hepatectomy after LVD appeared to be safe.

Cumulative morbidity of ureteroscopy for upper tract urothelial carcinoma

ObjectiveTo assess complications after ureteroscopy (URS) for upper tract urothelial carcinoma (UTUC) management and to assess its postoperative cumulative morbidity burden using the Comprehensive Complication Index (CCI). Materials and methodsSingle center retrospective study including patients submitted to URS for UTUC suspicion. URSs were both diagnostic and operative. Postoperative complications were recorded according to the EAU Guidelines and graded according to Clavien-Dindo Classification (CDC). The cumulative postoperative morbidity burden developed by patients experiencing multiple events was assessed using the CCI. Multivariable logistic regression (MLR) analyses identified factors independently associated with the development of any grade and major postoperative complications. ResultsOverall, 360 patients with UTUC suspicion were included with a total of 575 URSs performed. The cumulative number of all postoperative complications recorded was 111. In 86 (15%) procedures, patients experienced at least one postoperative complication, while 25 (4.3%) experienced more than one complication. Of these, 16 (14%) were severe (CDC ≥ IIIa). The most frequent type of complications were urinary (34%), bleeding (30%) and infectious (30%). The higher the CDC grade, the higher the median CCI, with a statistically significant increase in median CCI from CDC II to major complications. Patients who experienced intraoperative complications were at higher risk of developing any grade and major postoperative complications at MLR. ConclusionsComplications after ureteroscopy for UTUC are relatively uncommon events. Patients who experience intraoperative complications are at higher risk of developing postoperative complications. The comprehensive complication index appeared more representative of the cumulative postoperative morbidity rather than the Clavien-Dindo classification.

Outcome and survival were similar with laparoscopic and open pancreatectomy in 102 solid pseudopapillary neoplasms.

Solid pseudopapillary neoplasms of the pancreas (SPNP) are rare tumors predominantly in young women. We report the largest single-center cohort study comparing resection of SPNP by laparoscopic approach (LA) and the open approach (OA). Between 2001 and 2021, 102 patients (84% women, median age: 30) underwent pancreatectomy for SPNP and were retrospectively studied. Demographic, perioperative, pathological, early and the long-term results were evaluated between patients operated by LA and those by OA. Population included 40 LA and 62 OA. There were no significant differences in demographics data between the groups. A preoperative biopsy by endoscopic ultrasound was performed in 45 patients (44%) with no difference between the groups. Pancreatoduodenectomy (PD) was less frequently performed by LA (25 vs 53%, p = 0.004) and distal pancreatectomy (DP) was more frequently performed by LA (40 vs 16%, p = 0.003). In the subgroup analysis by surgical procedure, LA-PD was associated with one mortality, less median blood loss (180 vs 200ml, p = 0.034) and fewer harvested lymph nodes (11 vs 15, p = 0.02). LA-DP was associated with smaller median tumor size on imaging (40 vs 80mm, p = 0.048), shorter surgery (135 vs 190 min, p = 0.028), and fewer complications according to the median comprehensive complication index score (0 vs 8.7, p = 0.048). LA-Central pancreatectomy was associated with shorter surgery (160 vs 240, p = 0.037), less median blood loss (60 vs 200, p = 0.043), and less harvested lymph nodes (5 vs 2, p = 0.025). After a median follow-up of 60months, two recurrences (2%) were observed and were unrelated to the approach. The LA for SPNP appears to be safe, should be applied cautiously in case of PD for large lesion, and was not associated with recurrence.

Perioperative Changes in Serum Transaminase Levels: Impact on Postoperative Morbidity Following Liver Resection of Hepatocellular Carcinoma.

To define how dynamic changes in pre- versus post-operative serum aspartate aminotransferase (AST) and alanine aminotransaminase (ALT) levels may impact postoperative morbidity after curative-intent resection of hepatocellular carcinoma (HCC). Hepatic ischemia/reperfusion can occur at the time of liver resection and may be associated with adverse outcomes following liver resection. Patients who underwent curative resection for HCC between 2010-2020 were identified from an international multi-institutional database. Changes in AST and ALT (CAA) on postoperative day (POD) 3 versus preoperative values () were calculated using the formula: based on a fusion index via Euclidean norm, which was examined relative to the comprehensive complication index (CCI). The impact of CAA on CCI was assessed by the restricted cubic spline regression and Random Forest analyses. A total of 759 patients were included in the analytic cohort. Median CAA was 1.7 (range, 0.9 to 3.25); 431 (56.8%) patients had a CAA<2, 215 (28.3%) patients with CAA 2-5, and 113 (14.9%) patients had CAA ≥5. The incidence of post-operative complications was 65.0% (n=493) with a median CCI of 20.9 (IQR, 20.9-33.5). Spline regression analysis demonstrated a non-linear incremental association between CAA and CCI. The optimal cutoff value of CAA=5 was identified by the recursive partitioning technique. After adjusting for other competing risk factors, CAA≥5 remained strongly associated with risk of post-operative complications (Ref. CAA<5, OR 1.63, 95%CI 1.05-2.55, P=0.03). In fact, the use of CAA to predict post-operative complications was very good in both the derivative (AUC 0.88) and external (ACU 0.86) cohorts (n=1137). CAA was an independent predictor of CCI after liver resection for HCC. Use of routine labs such as AST and ALT can help identify patients at highest risk of post-operative complications following HCC resection.

A O06 Impact of complications on survival and postoperative recovery using Comprehensive Complication Index versus Clavien-Dindo grading after laparoscopic and open D2-gastrectomy in the multicenter randomized LOGICA-trial

Abstract Background Complications can be classified using the most-severe Clavien-Dindo-Classification (CDC) per patient or the total complication burden per patient expressed in the Comprehensive Complication Index (CCI). This study determined the additional value of CCI to CDC in examining the impact of complications after gastric cancer surgery. Methods The CCI and CDC were determined in the multicenter randomized LOGICA-trial comparing laparoscopic versus open D2-gastrectomy for cancer (cT1-4aN0-3M0). Differences in median CCI between laparoscopic and open gastrectomy were compared for overall postoperative complications, and infectious, gastrointestinal, pulmonary, and cardiovascular complications. CCI and CDC were correlated to hospitalization, ICU-stay and reoperations using Spearman’s rho-test, and compared with standard Fisher’s z-transformation. Results Between 2015-2018, 211 patients underwent laparoscopic (n=106) or open (n=105) D2-gastrectomy, and 157 (74%) received neoadjuvant chemotherapy. Median CCI was comparable between laparoscopic versus open gastrectomy regarding overall complications (CCI 0 [IQR 0-23.5] versus 0 [IQR 0-22.6]; p=0.755) and subgroups of complications (p&amp;gt;0.05). Both CCI and CDC showed moderate positive correlations for hospitalization (rs=0.646 versus rs=0.628; p=0.001, clinically irrelevant), and reoperations (rs=0.590 versus rs=0.599; p=0.070), and weak correlations for ICU-stay (rs=0.446 versus rs=0.440; p=0.189). Conclusions The CCI is a composite scoring system based on the CDC, and reflects a subjective interpretation of complication burden from the perspectives of both physicians and patients, after abdominal surgery other than gastrectomy. Implementation of CCI had no clinically relevant benefit and produced additional workload compared to CDC for assessing complication burden. Therefore, the use of CCI alongside the CDC after gastric cancer surgery is not recommended.

The Comprehensive Complication Index versus Clavien-Dindo grading after laparoscopic and open D2-gastrectomy in the multicenter randomized LOGICA-trial

BackgroundComplications can be classified using the most-severe Clavien-Dindo-Classification (CDC) per patient or the total complication burden per patient expressed in the Comprehensive Complication Index (CCI). This study determined the additional value of CCI to CDC in examining the impact of complications after gastric cancer surgery. MethodsThe CCI and CDC were determined in the multicenter randomized LOGICA-trial comparing laparoscopic versus open D2-gastrectomy for cancer (cT1-4aN0-3M0). Differences in median CCI between laparoscopic and open gastrectomy were compared for overall postoperative complications and cardiovascular, gastrointestinal, infectious, pulmonary, and other complications. CCI and CDC were correlated to hospitalization, ICU-stay and reoperations using Spearman's rho-test and compared with standard Fisher's z-transformation. ResultsBetween 2015 and 2018, 211 patients underwent laparoscopic (n = 106) or open (n = 105) D2-gastrectomy, and 157 (74%) received neoadjuvant chemotherapy. Median CCI was comparable between laparoscopic versus open gastrectomy regarding overall complications (CCI 0 [IQR 0–23.5] versus 0 [IQR 0–22.6]; p = 0.755) and subgroups of complications (p > 0.05). Both CCI and CDC showed moderate positive correlations for hospitalization (rs = 0.646 versus rs = 0.628; p = 0.001, difference clinically irrelevant), and reoperations (rs = 0.590 versus rs = 0.599; p = 0.070), and weak correlations for ICU-stay (rs = 0.446 versus rs = 0.440; p = 0.189). ConclusionsThe CCI is a composite scoring system based on the CDC and reflects a subjective interpretation of complication burden from the perspectives of both physicians and patients, following abdominal surgery other than gastrectomy. Implementing CCI showed no clinically relevant benefit and caused additional workload compared to CDC for assessing complication burden. Therefore, using the CCI alongside the CDC after gastric cancer surgery is not recommended.

Routine End-ischemic Hypothermic Oxygenated Machine Perfusion in Liver Transplantation from Donors After Brain Death: A Randomized Controlled Trial.

To assess whether end-ischemic hypothermic oxygenated machine perfusion (HOPE) is superior to static cold storage (SCS) in preserving livers procured from donors after brain death (DBD). There is increasing evidence of the benefits of HOPE in liver transplantation, but predominantly in the setting of high-risk donors. In this randomized clinical trial, livers procured from DBDs were randomly assigned to either end-ischemic dual HOPE for at least 2h or SCS ( 1:3 allocation ratio). The Model for Early Allograft Function (MEAF) was the primary outcome measure. The secondary outcome measure was 90-day morbidity. (ClinicalTrials. gov, NCT04812054). Of the 104 liver transplantations included in the study, 26 were assigned to HOPE and 78 to SCS. Mean MEAF was 4.94 and 5.49 in the HOPE and SCS group (P=0.24), respectively, with the corresponding rates of MEAF >8 of 3.8% (1/26) and 15.4% (12/78; P=0.18). Median comprehensive complication index was 20.9 after transplantations with HOPE and 21.8 after transplantations with SCS (P=0.19). Transaminases activity, bilirubin concentration, and international normalized ratio were similar in both the groups. In the case of donor risk index >1.70, HOPE was associated with significantly lower mean MEAF (4.92 vs. 6.31; P=0.037) and lower median comprehensive complication index (4.35 vs. 22.6; P=0.050). No significant differences between HOPE and SCS were observed for lower donor risk index values. Routine use of HOPE in DBD liver transplantations does not seem justified as the clinical benefits are limited to high-risk donors.

Surgical Apgar Score can accurately predict the severity of post-operative complications following emergency laparotomy

BackgroundThe Surgical Apgar Score (SAS) describes a feasible and objective tool for predicting surgical outcomes. However, the accuracy of the score and its correlation with the complication severity has not been well established in many grounds of low resource settings.ObjectiveTo determine the accuracy of Surgical Apgar Score in predicting the severity of post-operative complications among patients undergoing emergency laparotomy at Muhimbili National Hospital.MethodsA prospective cohort study was conducted for a period of 12 months; patients were followed for 30 days, the risk of complication was classified using the Surgical Apgar Score (SAS), severity of complication was estimated using the Clavien Dindo Classification (CDC) grading scheme and Comprehensive Complication Index (CCI). Spearman correlation and simple linear regression statistic models were applied to establish the relationship between Surgical Apgar Score (SAS) and Comprehensive Complication Index (CCI). The Accuracy of SAS was evaluated by determining its discriminatory capacity on Receiver Operating Characteristics (ROC) curve, data normality was tested by Shapiro–Wilk statistic 0.929 (p < 0.001).Analysis was done using International Business Machine Statistical Product and Service Solution (IBM SPSS) version 27.ResultsOut of the 111 patients who underwent emergency laparotomy, 71 (64%) were Male and the median age (IQR) was 49 (36, 59).The mean SAS was 4.86 (± 1.29) and the median CCI (IQR) was 36.20 (26.2, 42.40). Patients in the high-risk SAS group (0–4) were more likely to experience severe and life-threatening complications, with a mean CCI of 53.3 (95% CI: 47.2–63.4), compared to the low-risk SAS group (7–10) with a mean CCI of 21.0 (95% CI: 5.3–36.2). A negative correlation was observed between SAS and CCI, with a Spearman r of -0.575 (p < 0.001) and a regression coefficient b of -11.5 (p < 0.001). The SAS demonstrated good accuracy in predicting post-operative complications, with an area under the curve of 0.712 (95% CI: 0.523–0.902, p < 0.001) on the ROC.ConclusionThis study has demonstrated that SAS can accurately predict the occurrence of complications following emergency laparotomy at Muhimbili National Hospital.

Clavien-Dindo, comprehensive complication index and classification of intraoperative adverse events: a uniform and holistic approach in adverse event registration for (deep) endometriosis surgery.

What is the additional value of the comprehensive complication index (CCI) and ClassIntra system (classification for intraoperative adverse events (ioAEs)) in adverse event (AE) reporting in (deep) endometriosis (DE) surgery compared to only using the Clavien-Dindo (CD) system? The CCI and ClassIntra are useful additional tools alongside the CD system for a complete and uniform overview of the total AE burden in patients with extensive surgery (such as DE), and with this uniform data registration, it is possible to provide greater insight into the quality of care. Uniform comparison of AEs reported in the literature is hampered by scattered registration. In endometriosis surgery, the usage of the CD complication system and the CCI is internationally recommended; however, the CCI is not routinely adapted in endometriosis care and research. Furthermore, a recommendation for ioAEs registration in endometriosis surgery is lacking, although this is vital information in surgical quality assessments. A prospective mono-center study was conducted with 870 surgical DE cases from a non-university DE expertise center between February 2019 and December 2021. Endometriosis cases were collected with the EQUSUM system, a publicly available web-based application for registration of surgical procedures for endometriosis. Postoperative adverse events (poAEs) were classified with the CD complication system and CCI. Differences in reporting and classifying AEs between the CCI and the CD were assessed. ioAEs were assessed with the ClassIntra. The primary outcome measure was to assess the additional value toward the CD classification with the introduction of the CCI and ClassIntra. In addition, we report a benchmark for the CCI in DE surgery. A total of 870 DE procedures were registered, of which 145 procedures with one or more poAEs, resulting in a poAE rate of 16.7% (145/870), of which in 36 cases (4.1%), the poAE was classified as severe (≥Grade 3b). The median CCI (interquartile range) of patients with poAEs was 20.9 (20.9-31.7) and 33.7 (33.7-39.7) in the group of patients with severe poAEs. In 20 patients (13.8%), the CCI was higher than the CD because of multiple poAEs. There were 11 ioAEs reported (11/870, 1.3%) in all procedures, mostly minor and directly repaired serosa injuries. This study was conducted at a single center; thus, trends in AE rates and type of AEs could differ from other centers. Furthermore, no conclusion could be drawn on ioAEs in relation to the postoperative course because the power of this database is not robust enough for that purpose. From our data, we would advise to use the Clavien-Dindo classification system together with the CCI and ClassIntra for a complete overview of AE registration. The CCI appeared to provide a more complete overview of the total burden of poAEs compared to only reporting the most severe poAEs (as with CD). If the use of the CD, CCI, and ClassIntra is widely adapted, uniform data comparison will be possible at (inter)national level, providing better insight into the quality of care. Our data could be used as a first benchmark for other DE centers to optimize information provision in the shared decision-making process. No funding was received for this study. The authors have no conflicts of interest to declare. N/A.

Comprehensive Complication Index to Monitor Morbidity and Mortality After Liver Transplantation in Primary Sclerosing Cholangitis.

The objective of this study was to investigate the short-term and long-term morbidity after liver transplantation (LTx) in patients with primary sclerosing cholangitis (PSC). PSC is a common indication for LTx in Scandinavia. Recently, research has focused on long-term survival and morbidity. The Comprehensive Complication Index (CCI) precisely describes postsurgical complications, by considering both number and severity. Two patient groups were compared: those with classical PSC symptoms (n=148) and those with increased risk of cholangiocarcinoma (n=51, premalignant group). Two CCI scores were calculated, at 1-year post-LTx and a cumulative overall score at the latest follow-up. In addition, we investigated factors potentially related to high CCI. The 1-year median CCI were 29.6 and 26.2 in the classical and premalignant groups, respectively ( P =0.308). The median overall CCI were 43.2 and 46.8 ( P =0.765), respectively. Patient survival was significantly lower in patients with 1-year CCI>42. The most common complications associated with low survival were cholangitis, infections, and hypertension. One-year and overall CCI were similar between sexes and different types of biliary anastomosis. Patients with pre-LTx Model for End-stage Liver Disease scores >20 had higher 1-year and overall CCI (36.2 and 52.6, respectively) than those with lower Model for End-stage Liver Disease scores. Both low (<22) and high (>25kg/m 2 ) body mass indices were associated with high overall 1-year and overall CCI (50.9 and 41.8, respectively), but median body mass indices were associated with significantly lower 1-year and overall CCI (38.4, P =0.023). The previously determined 1-year CCI cutoff of 42 could significantly predict survival post-LTx. Mortality and morbidity were not significantly different between the PSC groups analyzed.

Prognostic value of preoperative CT scan derived body composition measures in resected pancreatic cancer

BackgroundIt remains unclear whether preoperative body composition may affect the prognosis of pancreatic cancer patients undergoing surgery. The aim of the present study was to assess the extent to which preoperative body composition impacts on postoperative complication severity and survival in patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC). MethodsA retrospective cohort study was performed on consecutive patients who underwent pancreatoduodenectomy with preoperative CT scan imaging available. Body composition parameters including total abdominal muscle area (TAMA), visceral fat area (VFA), subcutaneous fat area and liver steatosis (LS) were assessed. Sarcopenic obesity was defined as a high VFA/TAMA ratio. Postoperative complication burden was evaluated with the comprehensive complication index (CCI). ResultsOverall, 371 patients were included in the study. At 90 days after surgery, 80 patients (22%) experienced severe complications. The median CCI was 20.9 (IQR 0–30). At multivariate linear regression analysis, preoperative biliary drainage, ASA score ≥3, fistula risk score and sarcopenic obesity (37% increase; 95%CI 0.06–0.74; p = 0.046) were associated to an increase in CCI. Patient characteristics associated to sarcopenic obesity were older age, male gender and preoperative LS. At a median follow-up of 25 months (IQR 18–49), median disease-free survival (DFS) was 19 months (IQR 15–22). At cox-regression analysis, only pathological features were associated with DFS, while LS and other body composition measures did not show any prognostic role. ConclusionThe combination of sarcopenia and visceral obesity was significantly associated with increased complication severity after pancreatoduodenectomy for cancer. Patients’ body composition did not affect disease free survival after pancreatic cancer surgery.

Assessment of the Predictive Value of Preoperative Serum Albumin and Postoperative Albumin Drop (ΔAlb) for Complications after Pancreas Surgery: A Single-Center Cross-Sectional Study.

Serum albumin has been shown to be predictive of complications after various gastrointestinal operations. The present study aimed to assess whether preoperative serum albumin and serum albumin drop on postoperative day 1 are associated with postoperative complications after pancreatic surgery. A single-center cross-sectional study was performed. All patients who underwent pancreatectomy between January 2010 and June 2019 and had preoperative serum albumin value and serum albumin value on postoperative day 1 were included. ΔAlb was defined as the difference between preoperative serum albumin and serum albumin on postoperative day 1. Binary logistic regressions were performed to determine independent predictors of postoperative complications. A total of 185 patients were included. Pancreatoduodenectomies were performed in 133 cases, left pancreatectomies in 36, and other pancreas operations in 16. The preoperative serum albumin value was found to be an independent predictor of complications (OR 0.9, 95%CI 0.9-1.0, p = 0.041), whereas ΔAlb was not significantly associated with postoperative complications (OR 1.0, 95%CI 0.9-1.1, p = 0.787). The threshold of 44.5 g/L for preoperative albumin level was found to have the highest combined sensitivity and specificity based on the maximum Youden index. Patients with preoperative albumin < 44.5 g/L had a higher incidence of postoperative complications and higher median comprehensive complication index than patients with preoperative albumin ≥ 44.5 g/L. This study highlighted that preoperative serum albumin is an independent predictor of postoperative complications after pancreas surgery.

Prevalence of reported penicillin allergy and associations with perioperative complications, length of stay, and cost in patients undergoing elective cancer surgery.

Up to 10% of patients report penicillin allergy (PA), although only 1% are truly affected by Ig-E-mediated allergies. PA has been associated with worse postoperative outcomes, but studies on the impact of reported PA in cancer patients are lacking, and especially in these multimorbid patients, a non-complicated course is of utmost importance. Retrospective analysis of patients undergoing elective oncological surgery at a tertiary reference center. Data on surgical site infections (SSI), postoperative complications (measured by Clavien-Dindo classification and Comprehensive Complication Index (CCI)), hospitalization duration, and treatment costs were collected. Between 09/2019 and 03/2020, 152 patients were identified. 16/152 patients (11%) reported PA, while 136/152 (89%) did not. There were no differences in age, BMI, Charlson Comorbidity Index, and smoking status between groups (p > 0.4). Perioperative beta-lactam antibiotics were used in 122 (89.7%) and 15 (93.8%) patients without and with reported PA, respectively. SSI and mean numbers of infections occurred non-significantly more often in patients with PA (p = 0.2 and p = 0.47). The median CCI was significantly higher in PA group (26 vs. 51; p = 0.035). The median hospitalization duration and treatment costs were similar between non-PA and PA groups (4 vs 3 days, p = 0.8; 16'818 vs 17'444 CHF, p = 0.4). In patients undergoing cancer surgery, reported PA is common. Failure to question the unproven PA may impair perioperative outcomes. For this reason, patient and provider education on which reactions constitute a true allergy would also assist in allergy de-labeling. In addition, skin testing and oral antibiotic challenges can be performed to identify the safe antibiotics and to de-label appropriate patients.

Clinical Validation of the Comprehensive Complication Index in a Pancreaticoduodenectomy Cohort

Introduction: Although the Clavien-Dindo classification (CDC) is the most widely utilized method for quantifying surgical complications, it fails to properly capture all events. To address this, the comprehensive complication index (CCI) was introduced. The purpose of this study was to compare the CCI and CDC as predictors of postoperative length of stay (PLOS) and total hospitalization costs in patients undergoing pancreaticoduodenectomy (PD). Methods: Data were collected from February 2018 to February 2021. Complications were graded on the CDC scale and the CCI was calculated for each patient. The correlations between CDC and CCI with PLOS and hospitalization costs were compared. Linear analyses were performed to identify factors associated with PLOS and costs. Results: 291 patients were enrolled with an average age of 61.2 years. 286 of them developed postoperative complications at CDC grade 1 (17.8%), 2 (59.9%), 3a (13.4%), 3b (4.5%), 4 (2.1%), and 5 (0.6%). Median CCI of the study cohort was 30.8. Spearman’s correlation analysis showed the CDC and CCI were significantly correlated with PLOS and hospitalization costs, but the CCI showed a stronger correlation with PLOS (+0.552 day of stay for each additional CCI point; CCI: ρ = 0.663 vs. CDC: ρ = 0.581; p = 0.036). There were no significant differences in the correlations between total hospitalization costs and the CDC or CCI (CCI: ρ = 0.566 vs. CDC: ρ = 0.565; p = 0.78). Conclusion: CCI is an accurate tool for quantifying morbidities after PD and shows a stronger correlation with PLOS compared with the CDC.

Predictive Value of Body Composition Parameters for Postoperative Complications in Patients Who Received Pancreaticoduodenectomy

Introduction: Sarcopenia and visceral obesity have been identified as risk factors for postoperative complications following hepatobiliary and colon surgery. However, the correlation between body composition parameters and morbidity following pancreatectomy remains unclear. This study aimed to assess the predictive value of body composition parameters measured from preoperative CT images for postoperative complications following pancreaticoduodenectomy (PD). Methods: A retrospective study of patients who underwent PD between January 2018 and January 2021 was performed. Areas of subcutaneous adipose tissue, visceral adipose tissue, total abdominal muscle area, and mean muscle radio-attenuation were measured from preoperative CT images. Postoperative complications were categorized according to the Clavien-Dindo classification, and comprehensive complication index (CCI) scores were calculated. Logistic regression analysis was performed to identify factors associated with clinically relevant postoperative pancreatic fistula (CR-POPF) and high CCI score (≥26.2). Results: From the data collected on 129 study patients, sarcopenia, visceral obesity, and myosteatosis were detected in 47 (36.4%), 38 (29.4%), and 50 (38.7%) patients, respectively. CR-POPF developed in 51 (39.5%) patients, the overall median CCI score was 30.8 (22.6–36.2), and high CCI scores were identified in 70 (54.3%) patients. Multivariate analysis indicated sarcopenia and visceral obesity were independent risk variables for CR-POPF. Preoperative sarcopenia, visceral obesity, age, preoperative biliary drainage, and a positive culture of postoperative drainage were predictors of high CCI scores. Conclusion: Sarcopenia and visceral obesity were significant predictors of CR-POPF and high CCI score. Preoperative body composition assessment by CT images may help identify high-risk patients who undergo PD.

Does the mesh type influence the outcomes and costs of robotic inguinal hernia repair?

The aim of this study was to compare the clinical outcomes and hospital costs associated with two different meshes in robotic transabdominal preperitoneal inguinal hernia repair (IHR). Patients who underwent IHR were assigned to either the polyester self-gripping (PSG) or the polypropylene (PP) group depending on the mesh used. A propensity score matching analysis was performed to obtain balanced populations. Postoperative variables included complications such as surgical site events and recurrences. Hospital costs included all possible expenses generated by the surgery during the hospitalization period. From a database of IHR performed between February 2012 and July 2022, 131 PSG patients were matched to 131 PP repairs. Median operative time was shorter in the PSG group [55 (40-78) vs. 80 (60-116) minutes, p < 0.001]. No intraoperative complications were recorded. Patients who received the PSG mesh experience reduced immediate postoperative pain compared to the PP group. Average follow-up time was 35.2months in the PSG group vs. 12.5months in the PP group (p < 0.001). Median Comprehensive Complication Index was comparable in both groups (p = 0.489), with no surgical site infections logged. No cases of chronic pain were noted. Only two recurrences were recorded in the cohort, both of them in the PSG repairs. Hospital costs were USD $232 higher in the PP group but did not statistically differ (p = 0.523). There were no differences between the polyester self-gripping and the polypropylene mesh in terms of postoperative complications, clinical outcomes and hospital costs. Surgeons may opt for either meshes depending on their preferences and familiarity with each of the products.

The Impact of Postoperative Complications on Survival after Simultaneous Resection of Colorectal Cancer and Liver Metastases.

Background: The aim of this study was to investigate the impact of postoperative complications on the long-term outcomes of patients who had undergone simultaneous resection (SR) of colorectal cancer and synchronous liver metastases (SCLMs). Methods: We conducted a single-institution survival cohort study in patients with SR, collecting clinical, pathological, and postoperative complication data. The impact of these variables on overall survival (OS) and disease-free survival (DFS) was compared by log rank test. Multivariate Cox regression analysis identified independent prognostic factors. Results: Out of 243 patients, 122 (50.2%) developed postoperative complications: 54 (22.2%) major complications (Clavien–Dindo grade III–V), 86 (35.3%) septic complications, 59 (24.2%) hepatic complications. Median comprehensive complication index (CCI) was 8.70. Twelve (4.9%) patients died postoperatively. The 3- and 5-year OS and DFS rates were 60.7%, 39.5% and 28%, 21.5%, respectively. Neither overall postoperative complications nor major and septic complications or CCI had a significant impact on OS or DFS. Multivariate analysis identified the N2 stage as an independent prognostic of poor OS, while N2 stage and four or more SCLMs were independent predictors for poor DFS. Conclusion: N2 stage and four or more SCLMs impacted OS and/or DFS, while CCI, presence, type, or grade of postoperative complications had no significant impact on long-term outcomes.

SP6.2.3 Boerhaave's Syndrome vs Iatrogenic Oesophageal Perforation - A Comparison Between Aetiology

Abstract Aim Oesophageal perforation is a rare surgical condition with high mortality. Boerhaave's syndrome (BS) may be associated with worse outcomes due to the degree of mediastinal contamination when compared to ‘clean’ iatrogenic perforations. This study aims to assess the differences in treatment and outcome between these two groups. Methods Data was collected from a tertiary centre from 2009–2021 (n=73, 42 BS, 31 Iatrogenic). Data was collected retrospectively using the electronic patient record. Complications were quantified using the comprehensive complication index (CCI). Univariate analysis was used to determine statistical significance. Results BS had a higher 30-day mortality compared to iatrogenic perforations (21.4% vs 3.2% p=0.025), however this was no longer significant at 90 days and 1 year (21.4% vs 16.1% p=0.57, 21.4% vs 19.4% p=0.83). Iatrogenic perforations were more likely to be managed non-operatively (73.8% vs 25.8% p&amp;lt;0.001). All of the iatrogenic deaths that occurred between 30 days-1 year had been managed non-operatively. Median length of intensive care stay was higher in BS (15 days vs 6 days p=0.047), with no significant difference in median overall length of stay (48 days BS vs 38 days iatrogenic p=0.88). Median CCI was greater in BS (53.9 vs 29.6 p=0.002). Conclusion Whilst CCI and 30-day mortality was higher in Boerhaave's there was no difference in 90-day and 1 year mortality suggesting that long-term survival is not dictated by aetiology of the perforation. Most of the iatrogenic perforation were managed non-operatively which raises the question whether iatrogenic perforation should be managed more aggressively.

Conduits in Vascular Pancreatic Surgery: Analysis of Clinical Outcomes, Operative Techniques, and Graft Performance.

We analyze successes and failures of pushing the boundaries in vascular pancreatic surgery to establish safety of conduit reconstructions. Improved systemic control from chemotherapy in pancreatic cancer is increasing the demand for surgical solutions of extensive local vessel involvement, but conduit-specific data are scarce. We identified 63 implanted conduits (41% autologous vessels, 37% allografts, 18% PTFE) in 56 pancreatic resections of highly selected cancer patients between October 2013 and July 2020 from our prospectively maintained database. Assessed parameters were survival, perioperative complications, operative techniques (anatomic and extra-anatomic routes), and conduit patency. For vascular reconstruction, 25 arterial and 38 venous conduits were utilized during 39 pancreatoduodenectomies, 14 distal pancreatectomies, and 3 total pancreatectomies. The median postoperative survival was 2 years. A Clavien-Dindo grade ≥IIIa complication was apparent in 50% of the patients with a median Comprehensive Complication Index of 29.6. The 90-day mortality in this highly selected cohort was 9%. Causes of mortality were conduit related in 3 patients, late postpancreatectomy hemorrhage in 1 patient, and early liver metastasis in 1 patient. Image-based patency rates of conduits were 66% and 45% at postoperative days 30 and 90, respectively. Our perioperative mortality of vascular pancreatic surgery with conduits in the arterial or venous system is 9%. Reconstructions are technically feasible with different anatomic and extra-anatomic strategies, while identifying predictors of early conduit occlusion remains challenging. Optimizing reconstructed arterial and venous hemodynamics in the context of pancreatic malignancy will enable long-term survival in more patients responsive to chemotherapies.

Noninferiority multicenter prospective randomized controlled study of rectal cancer T2–T3s (superficial) N0, M0 (T2T3sN0M0) undergoing neoadjuvant treatment and local excision (TEM) versus total mesorectal excision (TME): Preoperative, surgical, and pathological outcomes—The TAUTEM-study.

3501 Background: The standard surgical treatment of rectal adenocarcinoma above T1 is total mesorectal excision (TME), but it is associated with high morbidity and quality of life disorders. Transanal endoscopic microsurgery (TEM) achieves minimal postoperative morbidity rates. The treatment of T2, T3 superficial, N0, M0 rectal cancers is TME due to local excision achieving high recurrence rates. Initial reports of preoperative chemoradiotherapy (CRT) in association with TEM shows reduction in local recurrence. The TAU-TEM study aims to demonstrate the non-inferiority of the oncological outcomes and the improvement in morbidity and quality of life achieved with CRT-TEM compared with TME. Methods: Prospective, multicenter, randomized controlled non-inferiority trial including patients with rectal adenocarcinoma less than 10 cm from the anal verge and up to 4 cm in size, staged as T2T3sN0M0. Patients were randomized to: CRT-TEM (Arm A) or TME (Arm B). Postoperative morbidity and mortality were recorded and patients in both arms completed quality of life questionnaires when starting treatment and 6 months after surgery. Patients attended follow-up controls for local and systemic relapse. Trial registration: ClinicalTrials.gov Identifier: NCT01308190. Results: From July/2010 to October/2021, 173 patients from 17 Spanish hospitals were included (Arm A: 86, Arm B: 87). Ten were excluded after randomization (Arm A: 4, [3 re-staged &gt; T2T3sN0M0, 1 refused follow-up study]; Arm B: 6 [4 refused the arm, 2 re-staged &gt; T2T3sN0M0]). Therefore, the patients with modified intention to treat analysis were: TME, 81 and CRT-TEM, 82. There was no mortality after CRT. In this group, 2 patients abandoned neoadjuvant therapy; thus 80/82 (97.6%) completed CRT. The CRT-morbidity was low (25/82, 30%) and of low grade (95% G1-2). In the CRT-TEM group, MRI showed disease progression in 3 patients who were treated with TME. Finally, 77 patients underwent TEM surgery. One patient died in each arm (1.2%). Postoperative morbidity was 41/81 (50.6%) (Arm B) and 17/82 (20.7%) (Arm A) (p &lt; 0.001, 95 CI% 43.9 to 15.9). Median Comprehensive Complication Index was 8.7 (IQR 20.9) Arm B and 0 (IQR 0) Arm A (p &lt; 0.001). Median hospital stay was 7 days (IQR 7) Arm B and 2 days (IQR 2) Arm A (p &lt; 0.001). Complete response in Arm A was 45.3% (34/75 patients) with 5.3% ypT3 (4/75 patients) and in Arm B: pT1 (12.3%; 10/81patients), deep-pT3 (4.95; 4/81patients), pN1 (21%; 17/81). Conclusions: CRT-TEM treatment obtains high pathological complete response rates (45.3%), with a high CRT compliance rate (97.6%) and low morbidity. Postoperative complications and hospitalization are significantly lower in the CRT-TEM group. We await the results of the follow-up. Clinical trial information: NCT01308190.