Median Length Of Postoperative Hospital Research Articles

Open versus endoscopic great saphenous vein harvest for lower extremity revascularization of critical limb ischemia

This study determined wound complication rates, intervention rates, failure mechanisms, patency, limb salvage, and overall survival after lower extremity revascularization using open vein harvest (OVH) vs endoscopic vein harvest (EVH) for critical limb ischemia. A single-institution review was conducted of consecutive patients who underwent infrainguinal bypass with a single-segment reversed great saphenous vein between 2005 and 2012. A total of 251 patients with critical limb ischemia underwent revascularization, comprising 153 with OVH and 98 with EVH. The OVH group had a lower mean body mass index (26.7 vs 29.9 kg/m(2); P = .001). There were no other differences in demographics, comorbidities, medications, smoking, or in the proximal or distal anastomotic site. Median operative times were 249 minutes (OVH) vs 316 minutes (EVH; P < .001). Median postoperative hospital length of stay was 7 days (OVH) vs 5 days (EVH; P < .001). Median follow-up was 295 days (OVH) vs 313 days (EVH; P = .416). During follow-up, 21 OVH grafts (14%) and 27 EVH grafts (28%) underwent an intervention (P = .048). There were a similar number of surgical interventions: 50% (OVH) vs 61% (EVH; P = .449). Failed grafts had a mean of 1.2 stenoses per graft, regardless of harvest method. Median stenosis length was 2.1 cm (OVH) vs 2.5 cm (EVH; P = .402). At 1 and 3 years, the primary patency was 71% and 52% (OVH) vs 58% and 41% (EVH; P = .010), and secondary patency was 88% and 71% (OVH) vs 88% and 64% (EVH; P = .266). A secondary patency Cox proportional hazard model showed EVH had a hazard ratio of 2.93 (95% confidence interval, 1.03-8.33; P = .044). Overall and harvest-related wound complications were 44% and 29% (OVH) vs 37% and 12% (EVH; P = .226 and P = .002). At 5 years, amputation-free survival was 48% (OVH) vs 54% (EVH; P = .305), and limb salvage was 89% (OVH) and 91% (EVH; P = .615). OVH and EVH have similar failure mechanisms, limb salvage, amputation-free survival, and overall survival. EVH is associated with impaired patency, increased need for intervention, longer operative times, shorter hospital stays, and decreased vein harvest site wound complications. OVH of the great saphenous vein may provide optimal patency but was not necessarily associated with better patient-centered outcomes. Similar limb salvage rates and amputation-free survival may justify the use of EVH, despite inferior patency, to capture shorter hospital stays and decreased wound complications.

Incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery

Minimally invasive valve surgery has been associated with increased cerebrovascular complications. Our objective was to evaluate the incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery. We retrospectively reviewed all the minimally invasive valve surgery performed at our institution from January 2009 to June 2012. The operative times, lengths of stay, postoperative complications, and mortality were analyzed. A total of 1501 consecutive patients were identified. The mean age was 73 ± 13 years, and 808 patients (54%) were male. Of the 1501 patients, 206 (13.7%) had a history of a cerebrovascular accident, and 225 (15%) had undergone previous heart surgery. The procedures performed were 617 isolated aortic valve replacements (41.1%), 658 isolated mitral valve operations (43.8%), 6 tricuspid valve repairs (0.4%), 216 double valve surgery (14.4%), and 4 triple valve surgery (0.3%). Femoral cannulation was used in 1359 patients (90.5%) and central cannulation in 142 (9.5%). In 1392 patients (92.7%), the aorta was clamped, and in 109 (7.3%), the surgery was performed with the heart fibrillating. The median aortic crossclamp and cardiopulmonary bypass times were 86 minutes (interquartile range [IQR], 70-107) minutes and 116 minutes (IQR, 96-143), respectively. The median intensive care unit length of stay was 47 hours (IQR, 29-74), and the median postoperative hospital length of stay was 7 days (IQR, 5-10). A total of 23 cerebrovascular accidents (1.53%) and 38 deaths (2.53%) had occurred at 30 days postoperatively. Minimally invasive valve surgery was associated with an acceptable stroke rate, regardless of the cannulation technique.

Isolated complete caudate lobectomy for hepatic tumor of the anterior transhepatic approach: surgical approaches and perioperative outcomes

BackgroundHow to resect the caudate lobe safely is a major challenge to current liver surgery which requires further study.MethodsNine cases (6 hepatic cell carcinoma, 2 cavernous hemangioma and 1 intrahepatic cholangiocacinoma) were performed using the anterior transhepatic approach in the isolated complete caudate lobe resection. During the operation, we used the following techniques: the intraoperative routine use of Peng’s multifunction operative dissector (PMOD), inflow and outflow of hepatic blood control, low central venous pressure and selective use of liver hanging maneuver.ResultsThere were no perioperative deaths observed after the operation. The median operating time was 230 ± 43.6 minutes, the median intraoperative blood loss was 606.6 ± 266.3 ml and the median length of postoperative hospital stay was 12.6 ± 2.9 days. The incidence of complications was 22.22% (2/9).ConclusionPMOD and “curettage and aspiration” technique can be of great help of in the dissection of vessels and parenchyma, clearly making caudate lobe resection safer, easier and faster.

Laparoscopic Surgery for Inflammatory Bowel Disease—The Experience in China

ABSTRACTBackground: The incidence of inflammatory bowel disease (IBD) has risen rapidly in China over the last 15 years. Increasing numbers of people with IBD require surgery during their lifetime, but few reports of IBD in Eastern populations have been described to date. The aim of this study was to assess the short-term effects of the laparoscopic surgery for IBD in Chinese patients. Materials and methods: From February 2010 to March 2012, 35 patients with IBD underwent laparoscopic operations and the clinical data obtained for these patients were reviewed. Results: Patients with Crohn's disease (CD) (N = 21) and ulcerative colitis (UC) (N = 14) underwent laparoscopic surgery. In the CD group, the mean age was 37.4 years. Two patients (9.5%) required conversion to an open procedure. The median length of postoperative hospitalization was 9 (7–40) days. Overall morbidity was 26.3% and no patients required re-operation. In the UC group, the mean age was 55.2 years. The conversion rate was 14.3% (2/14). The median time to regular diet was 4 (3–10) days and the median length of postoperative hospitalization was 8 (7–25) days. Four patients developed postoperative complications and one patient developed ileostomy retraction requiring urgent operative intervention to rebuild the stoma. Conclusions: Laparoscopic surgery in patients with IBD can be accomplished safely and with reasonable operative times, conversion rates and morbidity rates. The main advantages of the laparoscopic approach are rapid recovery, improved cosmesis, less postoperative pain, and patient satisfaction.

Minimally invasive liver surgery for metastases from colorectal cancer: oncologic outcome and prognostic factors

Few reports exist on long-term survival after minimally invasive liver surgery (MILS) for colorectal liver metastases (CRLM). No data are available assessing prognostic factors in the era of current modern treatment strategies.Between October 2002 and December 2008, 274 consecutive patients were analyzed on an intention-to-treat basis. Open liver surgery (OLS) was performed in 193 patients for a total of 437 metastases, and MILS was performed in 81 patients for 176 metastases. Systemic chemotherapy was administered preoperatively in 173 and postoperatively in 174 patients. The impact of 23 potential prognostic factors on disease-free (DFS) and overall survival (OS) was evaluated using univariable and multivariable Cox regression models.Postoperative complications were observed in 54 patients after OLS and in 11 after MILS (p = 0.016). The median postoperative length of hospital stay was 9 days after OLS and 5 days after MILS (p < 0.0001). For the entire patient population, the 5 year DFS and OS rates were 29.9 and 59.5%, respectively. No differences in survival between patients treated with MILS and OLS were observed (p = 0.63). In univariable analyses, the number of liver metastases and the overall Fong's clinical risk score (CRS) were the only two variables that predicted DFS (p ≤ 0.0035) and OS (p ≤ 0.0005). In multivariable analyses, the total CRS was the only independent predictor of both DFS (p = 0.0002) and OS (p = 0.002).The long-term oncologic outcome of surgically treated patients with CRLM is determined by the Fong's CRS. Although MILS does not influence long-term survival, it has a beneficial impact on the immediate postoperative clinical outcome.

Transanal endoscopic microsurgery approach for rectal stump resection as an alternative to transperitoneal stump resection

Transperitoneal rectal stump resection is a complicated procedure with risk of inadvertent bowel, vascular and nerve injury. This study analysed the feasibility and safety of the use of transanal endoscopic microsurgery (TEM) to excise rectal stumps that would otherwise require a combined transabdominal and perineal approach. Rectal stump resection was performed by a transanal approach using TEM. Stumps were removed by complete rectal wall resection and intersphincteric resection of the anus, leaving the mesorectum in place. The study included nine patients with a rectal stump ranging in length from 8 to 20 cm after previous surgery for inflammatory bowel disease (6), Lynch syndrome (1), collagenous colitis (1) or anastomotic leakage (1). The median duration of operation was 161 (range 107-239) min. The median postoperative length of hospital stay was 5 (range 2-71) days. One patient required an additional small-incision laparotomy to remove a stump extending up to the promontory and another developed a postoperative abscess. There were no perioperative complications. TEM appeared to be a useful and safe approach for close rectal dissection and removal of a rectal stump while avoiding an abdominal approach for pelvic dissection.

Implementation of an enhanced recovery programme following pancreaticoduodenectomy

ObjectivesThe aim of this prospective study was to investigate the implementation of an enhanced recovery after surgery (ERAS) programme following pancreaticoduodenectomy (PD). MethodsPatients undergoing PD were managed according to an ERAS protocol. Outcome measures included postoperative mortality, morbidity, hospitalization and 30-day readmission rate. Key protocol targets were: nasogastric tube (NGT) removal [postoperative day (PoD) 1]; resumption of oral fluids (PoD 1); urinary catheter removal (PoD 3); high-dependency unit (HDU) discharge (PoD 3); tolerating diet (PoD 4); drain removal (PoD 5), and hospital discharge (PoD 6). ResultsData were collected for 50 patients (24 male; median age 67 years). Rates of mortality, morbidity and readmission were 4%, 46% and 4%, respectively. The median length of postoperative hospitalization was 10 days. The proportions of patients achieving key targets were: 78% for NGT removal; 82% for resumption of oral fluids; 48% for urinary catheter removal; 82% for HDU discharge; 86% for tolerating diet; 84% for meeting mobility targets, and 72% for drain removal. One patient was discharged by PoD 6, eight patients by PoD 7, 15 patients by PoD 8 and 26 patients (52%) by PoD 10. Discharge was delayed in 16 patients for social or transport-related reasons. ConclusionsThe ERAS protocol was implemented safely. Achieving certain targets was challenging. Non-medical causes remain a significant factor in delayed discharge following PD.

Short-term outcomes of laparoscopic intersphincteric resection from a phase II trial to evaluate laparoscopic surgery for stage 0/I rectal cancer: Japan Society of Laparoscopic Colorectal Surgery Lap RC

Laparoscopic intersphincteric resection (Lap ISR) is not yet an established technique and its safety and feasibility are unclear. Our aim was to clarify the safety and feasibility of Lap ISR for clinical stage 0/I rectal cancer (Lap RC) in a prospective multicenter study of laparoscopic surgery in Japan. To examine the technical and oncological feasibility of laparoscopic surgery for rectal cancer, we conducted a confirmatory phase II trial to evaluate laparoscopic surgery for preoperative clinical stage 0/I rectal cancer. Eligibility criteria included histologically proven carcinoma, size ≤ 8 cm, age 20-75 years, no bowel obstruction, and no prior chemotherapy or radiotherapy. Between February 2008 and September 2010, 495 patients with rectal cancer underwent laparoscopic surgery at 43 institutions. Patients' background characteristics and operative and postoperative outcomes were recorded prospectively. Seventy-seven patients (15.6 %) underwent Lap ISR. A diverting stoma was created in 69 patients (89.6 %). Conversion to open surgery occurred in 4 patients (5.2 %): 2 patients were converted because of uncontrollable bleeding, and the other 2 patients because of the need for pelvic side wall lymphadenectomy. There was no mortality. Median operative time was 345 min (range = 198-565), median amount of blood loss was 100 ml (range = 0-1760), and three patients (3.9 %) were transfused intraoperatively. The median number of dissected lymph nodes was 14 (range = 3-33), and all (proximal, distal, and vertical) pathological cut margins were negative. Postoperative complications of grade 2 or more were detected in 17 patients (22.1 %), including anastomotic leakage in 5 (6.4 %), bowel obstruction in 5 (6.5 %), and surgical site infection in 2 (2.6 %). Abdominal drainage and diverting stoma were necessary in two patients (2.6 %) due to anastomotic leakage. Median length of postoperative hospital stay was 13 days (range = 7-167). Lap ISR was feasible and safe for clinical stage 0/I rectal cancer with favorable short-term outcome.

Open Versus Laparoscopic Resection of Primary Tumor for Incurable Stage IV Colorectal Cancer

To investigate the hypothesis that laparoscopic primary tumor resection is safe and effective when compared with the open approach for colorectal cancer patients with incurable metastases. There are only a few reports with small numbers of patients on laparoscopic tumor resection for stage IV colorectal cancer. Data from consecutive patients who underwent palliative primary tumor resection for stage IV colorectal cancer between January 2006 and December 2007 were collected retrospectively from 41 institutions. Short- and long-term outcomes were compared between patients who underwent laparoscopic or open resection. A total of 904 patients (laparoscopic group: 226, open group: 678) with a median age of 64 years (range: 22-95) were included in the analysis. Conversion was required in 28 patients (12.4%) and the most common reasons for conversion (23/28: 82%) were bulky or invasive tumors. There was no 30-day postoperative mortality in either group. The complication rate (NCI-CTCAE grade 2-4) after laparoscopic surgery (17%) was significantly lower than that after open surgery (24%) (P = 0.02), and the difference was greater (4% vs 12%; P < 0.001) when we limited the analysis to severe (≥grade 3) complications. The median length of postoperative hospital stay in the laparoscopic group was significantly shorter than that in the open group (14 vs 17 days; P = 0.002). In univariate analysis, overall survival for the laparoscopic group was significantly better than that for open surgery (median survival time: 25.9 vs 22.3 months, P = 0.04), although no difference was apparent in multivariate analysis. Compared with open surgery, laparoscopic primary tumor resection has advantages in the short term and no disadvantages in the long term. It is a reasonable treatment option for certain stage IV colorectal cancer patients with incurable disease.

CLINICAL OUTCOME OF INTERSPHINCTERIC RESECTION FOR ULTRA-LOW RECTAL CANCER

BACKGROUND: Laparoscopic surgery has been reported to be one of the approaches for total mesorectal excision (TME) in rectal cancer surgery. Intersphincteric resection (ISR) has been reported as a promising method for sphincter-preserving operation in selected patients with very low rectal cancer. METHODS: We try to underline the important surgical issues surrounding the management of patients with low rectal cancer indicated to laparoscopic intersphincteric resection (ISR). From January 2007 till now, 35 patients with very low rectal cancer underwent laparoscopic TME with ISR. We report and analyze the results from them RESULTS: Conversion to open surgery was necessary in one (3%) patient. The median operation time was 293 min and median estimated blood loss was 40 ml. The pelvic plexus was completely preserved in 32 patients. There was no mortality. Postoperative complications occurred in three (9%) patients. The median length of postoperative hospital stay was 11 days. Macroscopic complete mesorectal excision was achieved in all cases. Complete resection (R0) was achieved in 21 (91%) patients. CONCLUSIONS: Laparoscopic TME with ISR is technically feasible and a safe alternative to laparotomy with favorable short-term postoperative outcomes. The literature research made by us found that the laparoscopic approach can be underwent in most patients with low rectal cancer in which laparoscopic ISR represents a feasible alternative to conventional open surgery.

Total Endovascular Repair of Thoracoabdominal Aortic Aneurysms

Endovascular graft designs incorporating sidebranches, fenestrations and scallops offer a minimally-invasive alternative to open surgery and hybrid approaches for thoracoabdominal aortic aneurysms (TAAA). Our unit has offered total endovascular TAAA repair to selected higher-risk patients since 2008. We report the largest UK series to date of total endovascular TAAA repair. Retrospective analysis of a prospectively-maintained operative database. 31 patients (21 male, 10 female) median age 71 years (range 58-84), with TAAA (12 Crawford type I, 13 type III, 6 type IV), median diameter 6.4 (4.3 (mycotic)- 9.9) underwent endovascular TAAA repair (total 48 sidebranches, 26 fenestrations, 13 scallops) between July 2008 and January 2011. Median operating time 225 min (65–540 min), X-ray screening time 58 min (4–212 min), contrast dose 175 ml (70–500 ml), blood loss 325 ml (100–400 ml). Median post-operative length of hospital stay 6 days (2–22 days). Three patients (3/31, 9.7%) died within 30 days of operation: multisystem organ failure (1) acute renal failure and paraplegia (1) and paraplegia (1). There were no other cases of in-hospital organ failure, paraplegia or major complications. The median change in pre-discharge from pre-operative renal function was 3.4% deterioration in eGFR (range: 32.7% deterioration to 73.0% improvement) One patient presented with late-onset paraparesis, a second developed acute renal failure 8 months after repair. One early high-pressure endoleak (type 3) required correction. Three patients had died by median follow-up 12 months (1–36), 2 from heart disease and one from haemopericardium secondary to acute dissection of the ascending aorta (the dissection did not involve, nor extend close to, the endovascular graft). Total endovascular repair of TAAA offers patients a minimally-invasive alternative to open surgery with early results at least comparable to those seen with open or hybrid surgical approaches.

Risk Factors for Surgical Site Infections After Elective Gastrectomy

ObjectiveThe aim of this study was to identify the risk factors for surgical site infections (SSIs) after elective gastrectomy. MethodsThis study reviewed the medical records of 842 patients who underwent elective gastrectomy. Multivariate analyses were performed to determine the risk factors for SSIs. ResultsSuperficial incisional, deep incisional, and organ/space SSIs were detected in 50 (5.9%) patients, 2 (0.2%) patients, and 90 (10.7%) patients, respectively. A multivariate analysis demonstrated that female gender (p = 0.0332) and allogenic blood transfusion (p = 0.0266) were independent predictors for superficial incisional SSIs, while a male gender (p = 0.0355), corticosteroid therapy (p = 0.037), total gastrectomy (p < 0.0001), and a duration of operation ≥300 min (p = 0.0062) were independent predictors for organ/space SSIs. The median length of postoperative hospital stay was significantly longer in patients with organ/space SSIs in comparison to those without SSIs (p < 0.0001) and with superficial incisional SSIs (p < 0.0001). The patients with organ/space SSIs had a significantly higher re-operation rate in comparison to those without SSIs (p < 0.0001). ConclusionsThe risk factors both for incisional SSIs and for organ/space SSIs are strongly associated with surgical results. Meticulous surgical techniques are therefore required to prevent SSIs.

Minimally invasive liver surgery for metastases from colorectal cancer: oncologic outcome and prognostic factors

Few reports exist on long-term survival after minimally invasive liver surgery (MILS) for colorectal liver metastases (CRLM). No data are available assessing prognostic factors in the era of current modern treatment strategies. Between October 2002 and December 2008, 274 consecutive patients were analyzed on an intention-to-treat basis. Open liver surgery (OLS) was performed in 193 patients for a total of 437 metastases, and MILS was performed in 81 patients for 176 metastases. Systemic chemotherapy was administered preoperatively in 173 and postoperatively in 174 patients. The impact of 23 potential prognostic factors on disease-free (DFS) and overall survival (OS) was evaluated using univariable and multivariable Cox regression models. Postoperative complications were observed in 54 patients after OLS and in 11 after MILS (p = 0.016). The median postoperative length of hospital stay was 9 days after OLS and 5 days after MILS (p < 0.0001). For the entire patient population, the 5 year DFS and OS rates were 29.9 and 59.5%, respectively. No differences in survival between patients treated with MILS and OLS were observed (p = 0.63). In univariable analyses, the number of liver metastases and the overall Fong's clinical risk score (CRS) were the only two variables that predicted DFS (p ≤ 0.0035) and OS (p ≤ 0.0005). In multivariable analyses, the total CRS was the only independent predictor of both DFS (p = 0.0002) and OS (p = 0.002). The long-term oncologic outcome of surgically treated patients with CRLM is determined by the Fong's CRS. Although MILS does not influence long-term survival, it has a beneficial impact on the immediate postoperative clinical outcome.

Total Endovascular Repair of Thoracoabdominal Aortic Aneurysms

BackgroundEndovascular graft designs incorporating sidebranches, fenestrations and scallops offer a minimally-invasive alternative to open surgery and hybrid approaches for thoracoabdominal aortic aneurysms (TAAA). Our unit has offered total endovascular TAAA repair to selected higher-risk patients since 2008. We report the largest UK series to date of total endovascular TAAA repair. MethodsRetrospective analysis of a prospectively-maintained operative database. Results31 patients (21 male, 10 female) median age 71 years (range 58–84), with TAAA (12 Crawford type I, 13 type III, 6 type IV), median diameter 6.4 (4.3 (mycotic)- 9.9) underwent endovascular TAAA repair (total 48 sidebranches, 26 fenestrations, 13 scallops) between July 2008 and January 2011. Median operating time 225 min (65–540 min), X-ray screening time 58 min (4–212 min), contrast dose 175 ml (70–500 ml), blood loss 325 ml (100–400 ml). Median post-operative length of hospital stay 6 days (2–22 days). Three patients (3/31, 9.7%) died within 30 days of operation: multisystem organ failure (1) acute renal failure and paraplegia (1) and paraplegia (1). There were no other cases of in-hospital organ failure, paraplegia or major complications. The median change in pre-discharge from pre-operative renal function was 3.4% deterioration in eGFR (range: 32.7% deterioration to 73.0% improvement) One patient presented with late-onset paraparesis, a second developed acute renal failure 8 months after repair. One early high-pressure endoleak (type 3) required correction. Three patients had died by median follow-up 12 months (1–36), 2 from heart disease and one from haemopericardium secondary to acute dissection of the ascending aorta (the dissection did not involve, nor extend close to, the endovascular graft). ConclusionsTotal endovascular repair of TAAA offers patients a minimally-invasive alternative to open surgery with early results at least comparable to those seen with open or hybrid surgical approaches.

Scarless Single-Incision Laparoscopic Loop Ileostomy: A Novel Technique

Laparoscopic surgery has become a favorable alternative to conventional open surgery for the creation of intestinal stomas, and it offers many benefits including reduced postoperative pain, ileus, and hospital stay. Single-incision laparoscopic surgery has been described for many abdominal operations. It may offer better cosmetic outcomes and reduce incisional pain, adhesions, and recovery time. In this study, we aimed to describe a novel technique of scarless single-incision laparoscopic loop ileostomy for fecal diversion and to report our experience with 8 patients who underwent this procedure within a 1-year period. This study was designed as a retrospective case series. This investigation was conducted at a single-institution, tertiary referral center. Eight consecutive patients undergoing scarless single-incision laparoscopic loop ileostomy between August 2009 and August 2010 were included. Scarless single-incision laparoscopic loop ileostomies were performed. Among the outcomes measured were operation time, intraoperative blood loss, recovery of intestinal function, length of hospital stay, and surgical complications. Seven patients underwent surgery for active Crohn's disease refractory to medical therapy. One patient underwent surgery for radiation-induced rectovesical fistula. Median surgery time was 76 minutes, and median intraoperative blood loss was 10 mL. Median length of postoperative hospitalization was 7 days. Of the 8 patients included in our series, 2 patients (25%) required reoperation for stoma ischemia because of vascular congestion that we attribute to a tight fascial opening or extensive bowel manipulation. Other surgical complications included nonoperative readmission for ileus and partial small-bowel obstruction (n = 2), anal dilation to evacuate an obstructed distal colon (n = 1), and peristomal cellulitis (n = 1). This study was limited by its small sample size and its retrospective nature. Scarless single-incision laparoscopic loop ileostomy is a feasible alternative to standard laparoscopy for fecal diversion. Surgeons attempting this technique should do so with caution, given the high stoma ischemia rate in our small case series.

Incidence and treatment of local stenosis or occlusion at the vascular access site leading to limb ischemia and new‐onset intermittent claudication after percutaneous interventions: Implications of Vascular Closure Devices

Vascular access site complications (ASCs) are an ongoing hazard of percutaneous interventions (PI). We analyzed incidence, indication, and results of operative repair of access site complications leading to acute limb ischemia (ALI) or new-onset severe claudication (CI) in our institution during an 8-year period. Retrospective analysis: demographic parameters, details of coronary or vascular intervention, use of a vascular closure device (VCD), clinical presentation, diagnosis and therapy. perioperative outcome (death, limb loss, and need for re-operation/intervention) and length of hospital stay. For comparison of annual operation rates, patients were grouped by the years 2001 to 2004 (no use of VCD) and 2005 to 2008 (selective use of a VCD; in all cases: Angio-Seal), and Chi-Square-test was applied. Fifty-one patients (19 female; median age: 64.5 years) underwent repair of arterial ASCs causing ALI (n = 32) or new-onset severe CI (n = 19) after 58,453 catheter interventions (overall rate: 0.087%; ALI: 0.055%; CI: 0.032%). Corresponding with more widespread VCD use, the annual number of ALI and new onset CI increased significantly (P < 0.001). PERIOPERATIVE OUTCOME: 30 day mortality was 4%. No limb loss occurred. Re-operations were indicated in 10 patients (20%) for: hematoma (n = 5), local infection (n = 3), revision of fasciotomy (n = 1), and repeated thrombectomy (n = 1). Median length of postoperative hospital stay: 7 days (range: 1-28). ALI and new-onset severe CI due to access site complications after PI are rare, however, they are potentially threatening life and limb. The use of VCDs results in an overall increase of ischemic complications.

Outcomes in Patients 65 Years or Older Treated with Trimodality Therapy for Esophageal Carcinoma

Purpose/Objective(s): There is little published information on the results of neoadjuvant chemoradiotherapy (CRT) followed by surgery in older patients due to the presumed increased risk for morbidity and mortality. We report our single institutional experience of trimodality therapy in patients with esophageal carcinoma 65 years of age or older. Materials/Methods: Patients treated with preoperative CRT followed by esophagectomy from 2002-2010 were identified for this IRB approved retrospective study. Patient and treatment characteristics, tolerance, response, and survival were analyzed in patients ≥ 65 years of age versus patients 65 years of age (26.1%), 19 patients were >70 years. Median follow up was 27.5 months (range 5.093.8), and 93.3% of patients were treated to a median dose of 50.4 Gy with concurrent non-cisplatin/5-fluorouracil based concurrent chemotherapy. Between groups, there were no differences in gender, performance status, diabetes, cardiac history, pulmonary disease, smoking status, histology, radiation dose, days to completion of CRT, or days from completion of CRT to surgery. Overall peri-operative mortality was low, with no 30 day mortality and 3.5% 60 day mortality; both mortalities occurred in patients >70 years. The median length of post-operative hospital stay for patients >65 years was 15.5 days versus 11.0 days for patients 65 years compared to patients 65 years of age, median survival was 35.2 months and 3 and 5 year overall survival rates were 45.9% and 37.1% respectively. Conclusions: These data suggest that older patients can be appropriately selected for neoadjuvant chemoradiotherapy followed by surgery when a comprehensive multidisciplinary approach is utilized. Age alone should not preclude consideration for trimodality therapy in patients with esophageal carcinoma.

102 OPCAB is not associated with better postoperative renal function compared to CABG

The perioperative renal effects of off-pump coronary artery bypass grafting (OPCAB) versus on-pump coronary artery bypass grafting (CABG) are not well understood. Studies have shown conflicting results and no large case-matched or randomized comparison has yet been made available in the literature. This study was conducted to compare OPCAB versus CABG in regards to changes in postoperative creatinine and postoperative creatinine clearance, when compared to preoperative values. We also examined the need for de novo postoperative dialysis. Between 2002 and 2010, 5,589 consecutive patients at a single center underwent OPCAB or CABG. All preoperative, intraoperative, and postoperative data were prospectively collected. Patients were matched by using a nearest neighbor matching estimation method for average treatment effects, with bias correction (Stata 10.1, College Station, TX). The matching characteristics were: age, gender, body mass index, hypertension, diabetes, peripheral vascular disease, cerebrovascular disease, left ventricular grade, preoperative serum creatinine, operative priority, and Cardiac Anesthesia Risk Evaluation score. The mean patient age was 64.9 ± 10.0 years, and there were 4,387 (78.5%) males. Mean preoperative creatinine clearance was 82.0 ± 32.6 mL/min. Perioperative mortality was 1.45% with OPCAB and 1.73% with CABG (P = 0.6). The mean change in creatinine clearance, from preoperative to the lowest postoperative value, was −6.3 ± 14.1 mL/min with OPCAB, versus −5.0 ± 15.5 mL/min with CABG (P = 0.06). In patients with a preoperative creatinine clearance between 30-60 mL/min, the weighted effect of OPCAB on postoperative creatinine change was an additional −1.8 ± 0.9, when compared to CABG (P = 0.04). After matching, OPCAB patients had a greater creatinine rise and greater loss of creatinine clearance postoperatively, compared with CABG patients (both P < 0.05). Requirements for de novo postoperative dialysis were equivalent at 2.6% in OPCAB versus 2.1% in CABG patients (P = 0.4). Median postoperative hospital length of stay was 8 days in both groups (P = 0.8). OPCAB is not associated with better postoperative preservation of creatinine and creatinine clearance when compared to CABG. In fact, patients with moderate renal dysfunction may be more susceptible to a fall in creatinine clearance after OPCAB compared to CABG. These changes in renal indices do not appear, however, to influence clinical outcomes.

Reoperative Completion Pancreatectomy for Suspected Malignant Disease of the Pancreas

Completion pancreatectomy (CP) is a reoperative procedure to excise remnant pancreatic tissue after a prior pancreatic resection. In this study, we document our institution's experience with CP for recurrent malignant disease of the pancreas, describing indications for surgery, procedures performed, and patient outcomes. We performed a retrospective review of 861 patients from the pancreatic surgery database in the Department of Surgery of Thomas Jefferson University from October 2005 to December 2010 to identify all cases of CP performed for suspected malignant disease. Eleven patients underwent reoperative CP at our institution from 2005 to 2010. The median time interval between the initial operation and CP was 32 mo. A combination of clinical symptoms, elevated tumor markers, and imaging studies were used for diagnosis of recurrent disease. Pancreatic ductal adenocarcinoma was the most common pathology, found in six patients. The postoperative complication rate was 18% and the median postoperative hospital length of stay was 6 d. There were no 30-d readmissions and no perioperative deaths. The 1-y survival rate following CP was 71% with an overall median survival of 17.5 mo. CP is a safe and effective option for a highly selected group of patients with suspected recurrent malignant disease of the remnant pancreas. Morbidity and mortality rates are within acceptable limits and similar to initial pancreatic resection. Eligibility depends heavily upon the absence of distant metastatic disease, technical factors for resection, and patient performance status.

Surgical and pathological outcomes after right hemicolectomy: case‐matched study comparing robotic and open surgery

To compare the surgical and pathological outcomes of patients with right-sided colon cancers operated on by means of open and robotic surgery with extracorporeal anastomosis. Thirty-three consecutive patients who underwent robotic right hemicolectomy due to right-sided colon cancer were retrospectively well matched with 102 patients operated on by the open approach. Data were included in a prospectively maintained database. Mean operative time was longer in the robotic group (P < 0.001), 191.7 min (134-250) versus 136.2 (45-240) min in the open group. Estimated intraoperative blood loss was less in the robotic group, which presented a mean of 6.1 ml versus 94.8 ml in the open group (P < 0.001). Despite the similar length of the surgical specimen and number of lymph nodes retrieved between both groups, 15 or more lymph nodes were found in the specimen in 90 out of 102 patients (88.2%) operated on by the open technique versus 33 out of 33 patients (100%) who underwent robotic hemicolectomy (P = 0.038). The median length of postoperative hospital stay was shorter in the robotic group, 5 versus 8 days (P < 0.001). No other statistically significant difference was observed in terms of pathological and postoperative results. Robotic right hemicolectomy is an oncologically safe and effective procedure. The number of lymph nodes retrieved in the robotic group compared with the open group of our series was more homogeneous, and none of the patients operated on with this technique had a suboptimal lymphadenectomy. Further clinical trials are needed to confirm current evidence and determine whether this can influence the prognosis.