Medium-volume Center Research Articles

Severe morbidity after pancreatectomy is accurately predicted by preoperative pancreatic resection score (PREPARE): A prospective validation analysis from a medium-volume center

BackgroundMajor morbidity in pancreatic surgery remains high. Different scores for predicting complications have been described. Preoperative pancreatic resection (PREPARE) score is based on objective preoperative variables and offers good predictive accuracy for Clavien ≥ III complications. This study aimed to validate this score and analyze other preoperative variables in a prospective study performed in a medium-volume center. MethodsA total of 50 pancreatic resections were included. Preoperative variables were registered and PREPARE was calculated. The main outcome was severe morbidity (Clavien ≥ III) up to 30 days after discharge. The secondary outcomes were length of stay (LOS) and readmission. Statistical validation was performed to compare severe morbidity rate among the scores categories. Association with other preoperative variables (not included in PREPARE) was also tested. ResultsOf the 50 pancreatic resections, the severe morbidity was 34.0%, with median LOS of 11 days. Readmission rate was 25.5%. Severe morbidity rates according to PREPARE categories were 18.5% in low-risk group, 41.7% in intermediate-risk group, and 63.6% in high-risk group, respectively (P = 0.023). The accuracy was 72% (Hosmer–Lemeshow, P = 0.86). ROC curve was obtained both for PREPARE score expressed as incremental values and categorized as the three risk groups, showing an area under curve (AUC) of 0.736 (95% CI: 0.586–0.887; P = 0.007) and 0.712 (95% CI: 0.555–0.869; P = 0.015), respectively. PREPARE was significant in multivariate analysis. Median LOS was statistically higher as PREPARE category increases (9, 11 and 15 days in low-, intermediate- and high-risk groups, respectively; P = 0.009). Readmission was not associated with any variables. ConclusionsPREPARE behaves as an independent risk factor for severe morbidity after pancreatic surgery. Score validation shows good accuracy prediction. Increasing PREPARE category is also associated with longer LOS.

Benchmark values for transthoracic esophagectomy are not set as the defined "best possible"-a validation study.

Recently, benchmark values for low-comorbidity patients at high-volume centers were set to define "best achievable results" for transthoracic minimally invasive esophagectomy (MIE). We aimed to validate suggested benchmark values by comparing them to outcomes at a medium-volume center in Finland. All MIEs (n=82) performed at Central Finland Central Hospital between September 2012 and November 2017 including 75 totally MIE and 7 hybrid procedures. The aim of the study was to compare the results to previously suggested benchmark parameters for postoperative morbidity measured with the Clavien-Dindo classification and comprehensive complication index. Target benchmark parameters were ≤55.7% for any complications, ≤30.8% for major complications (Clavien-Dindo ≥3a), ≤40.8% for 30-day and ≤42.8% for 90-day comprehensive complication index, ≤20% for anastomosis leak, ≤31.6% for pulmonary complications, ≤1.0% for 30-day mortality and ≤4.6% for 90-day mortality. Compared with benchmark patients, our patients were older (median 68 vs. 58 years), with more comorbidities. All parameters measuring complications showed better results in our study than benchmark values. Median intensive care unit stay of 1 (IQR, 1-1) and hospital stay of 9 (IQR, 9-12) days were also shorter. At least 1 complication developed in 45.1%, and 6.1% faced major morbidity. Median (IQR) comprehensive complication index for both 30 and 90 days was 0 (IQR, 0-20.9 days). Anastomosis leak and pulmonary complications were observed in 3.7% and 22.0%, respectively. The 30- and 90-day mortality was 1.2% (1/82). Benchmark values assessing postoperative morbidity after MIE do not represent the defined "best achievable" results after completed learning curves.

Quality of care in oncology: quality indicators in testicular cancer: a hospital-based approach

Introduction: The Belgian Health Care Knowledge Centre (KCE) conducted a literature search leading to twelve quality indicators for testicular cancer. Data obtained from three nationwide databases, showed only five fully measurable quality indicators, one was partially measurable, and two could be determined using a proxy indicator. The four remaining indicators could not be assessed. In this study, we aimed to investigate if these quality indicators were registered and measurable in a medium-volume center.Methods: In our medium-volume cancer center new testicular cancer diagnoses were registered since 2003. 48 patients were diagnosed with testicular cancer between 2004 and 2014. Through medical file review we measured and evaluated the predefined set of indicators. The results were pooled in a database and compared to the KCE report (KCE Reports 149A. D2010/10.273/96).Results: All 12 indicators could be measured in the entire patient cohort of 48 patients. Mean age was 34.9 years (range 16–85). In comparison with the KCE report, we documented higher rates of tumor marker assessment (98% vs. 73%), staging imaging (100% vs. 95%), multidisciplinary board discussion (100% vs. 58%), orchidectomy (98% vs. 84%), follow-up imaging (100% vs. 54%), and active surveillance (77% vs. 21%). In contrast, we found a lower rate of radiotherapy (6% vs. 20.3%) and chemotherapy (41.6% vs. 53%). Two patients were lost to follow-up, the remaining 46 patients are still alive. Four patients relapsed, all were seminomas.Conclusion: Implementation of quality indicators for testicular cancer is feasible for a medium-volume peripheral cancer center.

A comparative study of laparoscopic and robotic assisted radical prostatectomy performed by a single surgeon

ObjectiveTo present the transition from laparoscopic radical prostatectomy (LRP) to robotic-assisted laparoscopic radical prostatectomy (RALP) over 10 years in a medium volume center by a single surgeon. Materials and methodsWe retrospectively reviewed 140 prostate cancer patients who underwent LRP (100 patients) or RALP (40 patients) between May 2005 and May 2015. Preoperative parameters included age, body mass index, and serum prostate specific antigen. Operative course parameters included operative time, estimated blood loss, intraoperative blood transfusion, conversion to open surgery, hospitalization days, duration of Foley catheterization, and complications. Pathological stage, surgical margin status, biochemical recurrence (BCR) rate, and continence rate at 12 months after surgery were reviewed and compared between the LRP and RALP groups. ResultThe operative outcomes revealed significantly less blood loss (143 mL vs. 306 mL, p<0.001), shorter hospital stay (6.9 days vs. 8.7 days, p=0.006), and shorter duration of Foley catheterization (9.3 days vs. 11.3 days, p<0.001) in patients who underwent RALP. Major perioperative complications occurred in four LRP patients (4%), and none were observed in RALP patients. LRP and RALP had similar positive surgical margin rates (p=0.285) and BCR rates (p=0.88). RALP resulted in better continence recovery than LRP (55% vs. 82.5%, p=0.003). ConclusionPatients who underwent RALP had better perioperative and functional outcomes. Oncologic outcomes were similar compared to patients who underwent LRP.

Towards a cardiac allocation score: a retrospective calculation for 73 patients from a German transplant center

BackgroundDue to a growing discrepancy between the transplant waiting list and decreasing numbers of available donor hearts, cardiac transplantation rates in Germany have been declining in the past years. Currently, patients on the waiting list are prioritized by medical urgency and waiting time and therefore a majority of all cardiac transplants is performed in very ill patients. Recently, a different allocation algorithm was proposed that included predicted post-transplant survival as a parameter for organ allocation. So far, little data exists on how such a “Cardiac Allocation Score” (CAS) relates to our current transplant patient population and on how such a change in organ allocation could change clinical practice.MethodsWe calculated a theoretical retrospective Cardiac Allocation Score for 73 patients recruited and transplanted at our medium-volume center in Germany based on a hypothetical scoring algorithm recently published by Eurotransplant.ResultsOverall, 37 patients (50.7%) were transplanted on high urgency status (HU), 27 (37%) were being supported by a VAD at time of transplant. 57 (78.1%) were male. We found a relatively normal distribution of the hypothetical CAS with a median of 32.91 and a mean of 31.95 +/−10.02. Overall, CAS-Scores were lower than previously described for a Eurotransplant patient cohort of high urgency patients, but there was a significant overlap in score values between patients on HU and T status. CAS-values of VAD-supported patients were lower than in patients without mechanical support. The IMPACT-score as part of the CAS was used for prediction of post-transplant survival and seems suitable to predict outcome in our patient population.ConclusionIn a retrospective analysis, the recently proposed Cardiac Allocation Score seems to show a normal distribution of priority values in our patient cohort. The IMPACT-score predicted outcome after transplantation and could serve as part of the CAS-algorithm to predict post-transplant survival in this single center real-world scenario. Implementation of the CAS could significantly change organ allocation practice, including a potential prioritization of current T-status patients over HU-status patients.

P132 Cooperation to improve quality of IPAA surgery in IBD: south Netherlands experience

Background: Total proctocolectomy and ileal pouch-anal anastomosis (IPAA) for IBD is low volume surgery. In The Netherlands from 2009 quality and volume indicators have been defined for low volume oncologic procedures and since 2015 also for IPAA surgery following the ECCO guidelines. The two South Netherlands IBD centers (The Zuyderland Hospital [ZH], Maastricht University Medical Center [MUMC]) started to collaborate to meet the volume norm on IPAA surgery and deliver optimal quality. The present study describes the outcome of surgery in this cooperation and aims at defining further priorities in surgical care. Methods: Data were collected from the prospective South Limburg IBD cohort which includes all newly diagnosed IBD patients of the two centers since 1991. All non-surgical data and the core surgical data are included in this database. More specific surgical information was collected retrospectively. Results: Fifty-four patients were included that received an IPAA between January 2010 and December 2015. In 2015 the volume norm of >10 was reached, contrary to the 3 preceding years. Mean age was 39.6 (17–82) and mean disease duration 7.5 yrs (1–22.5). 35 patients (62%) previously underwent a subtotal colectomy, 13 in an open procedure, 22 laparoscopically. 41 (76%) of IPAA's were performed laparoscopically, 93% were stapled and in 44% a temporary ileostoma was performed. Three ileostomies were given due to postop complications. Postop diagnosis was UC in 52 patients, IBD-U in 1 and CD in 1. Major early complications were small bowel obstruction (n=14), partial anastomotic dehiscence (n=7), pouch bleeding (n=2), distal anastomotic stricture occurred in 9 patients. Pouch failure occurred in 5 patients resulting in 4 permanent ileostomies, two of which due to chronic pouchitis. Conversion from laparoscopic to open procedure was positively associated with anastomotic dehiscence. Stool frequency at follow-up was median 7.6/24hrs; 41% of patients used no antidiarrheal medication. Full continence was achieved in 77%. No data on sexual function could be retrieved. From 2015, one team (EB and LS) operated all patients. Incidence of leakage seemed lower after cooperation, although conclusions require a larger cohort. Conclusions: The cooperation resulted in increase from a low- to a medium volume center. Several focus points have been defined based on the results observed: progressive cooperation and optimal multidisciplinary approach to optimize timing of surgery and outcome; continue implementation of novel techniques; prospective registration of all surgical parameters including quality of life and sexuality; evolve as a regional referral and expert center and increase patient numbers.

External Validation of a Gastric Cancer Nomogram Derived from a Large-volume Center Using Dataset from a Medium-volume Center.

PurposeRecently, a nomogram predicting overall survival after gastric resection was developed and externally validated in Korea and Japan. However, this gastric cancer nomogram is derived from large-volume centers, and the applicability of the nomogram in smaller centers must be proven. The purpose of this study is to externally validate the gastric cancer nomogram using a dataset from a medium-volume center in Korea.Materials and MethodsWe retrospectively analyzed 610 patients who underwent radical gastrectomy for gastric cancer from August 1, 2005 to December 31, 2011. Age, sex, number of metastatic lymph nodes (LNs), number of examined LNs, depth of invasion, and location of the tumor were investigated as variables for validation of the nomogram. Both discrimination and calibration of the nomogram were evaluated.ResultsThe discrimination was evaluated using Harrell's C-index. The Harrell's C-index was 0.83 and the discrimination of the gastric cancer nomogram was appropriate. Regarding calibration, the 95% confidence interval of predicted survival appeared to be on the ideal reference line except in the poorest survival group. However, we observed a tendency for actual survival to be constantly higher than predicted survival in this cohort.ConclusionsAlthough the discrimination power was good, actual survival was slightly higher than that predicted by the nomogram. This phenomenon might be explained by elongated life span in the recent patient cohort due to advances in adjuvant chemotherapy and improved nutritional status. Future gastric cancer nomograms should consider elongated life span with the passage of time.

Endoscopic Ultrasound-Guided Biliary Drainage Using Self-Expandable Metal Stent for Malignant Biliary Obstruction.

Purpose. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been increasingly reported worldwide. However, studies concerning EUS-BD from Mainland China are sporadic. This study aims to investigate the feasibility, efficacy, and safety of EUS-BD using SEMS in a single center from Mainland China. Methods. Between November 2011 and August 2015, 24 patients underwent EUS-BD using a standardized algorithm. Results. Three patients underwent rendezvous technique (RV), 4 underwent hepaticogastrostomy (HGS), and 17 underwent choledochoduodenostomy (CDS). The technical and clinical success rates were 95.8% (23/24) and 100% (23/23), respectively. Mean procedure time for the CDS group (35.9 ± 5.0 min) or HGS group (39.3 ± 5.0 min) was significantly shorter than that for the RV group (64.7 ± 9.1 min) (P < 0.05). Complications (13%) included (1) cholangitis and (2) postprocedure hemorrhage. During the follow-up periods (mean 6.4 months), 22 (91.7%) patients died of tumor progression with mean stent patency of 5.8 ± 2.2 months. Stent occlusion occurred in 2 (8.7%) patients. Conclusion. EUS-BD using SEMS is a feasible, effective, and safe alternative for biliary decompression after failed ERCP. EUS-RV may not be the first-line choice for EUS-BD in a medium volume center. Further evaluation and experience of this method are needed.

Management and Outcome of Periprocedural Cardiac Perforation and Tamponade with Radiofrequency Catheter Ablation of Cardiac Arrhythmias: A Single Medium-Volume Center Experience.

IntroductionCardiac tamponade (CT) is a life-threatening complication of radiofrequency ablation (RFA). The course and outcome of CT in low-to-medium volume electrophysiology centers are underreported.MethodsWe analyzed the incidence, management and outcomes of CT in 1500 consecutive RFAs performed in our center during 2011–2016.ResultsOf 1500 RFAs performed in 1352 patients (age 55 years, interquartile range: 41–63), 569 were left-sided procedures (n = 406 with transseptal access). Conventional RFA or irrigated RFA was performed in 40.9% and 59.1% of procedures, respectively. Ablation was performed mostly for atrioventricular nodal reentrant tachycardia (25.4%), atrial fibrillation (AF; 18.5%), atrial flutter (18.4%), accessory pathway (16.5%) or idiopathic ventricular arrhythmia (VA; 12.3%), and rarely for structural VA (2.1%). CT occurred in 12 procedures (0.8%): 10 AF ablations, 1 idiopathic VA and 1 typical atrial flutter ablation. Factors significantly associated with CT were older age, pre-procedural oral anticoagulation, left-sided procedures, transseptal access, AF ablation, irrigated RFA and longer fluoroscopy time (on univariate analysis), and AF ablation (on multivariable analysis). The perforation site was located in the left atrium (n = 7), right atrium (n = 3), or in the left ventricle or coronary sinus (n = 1 each). Upon pericardiocentesis, two patients underwent urgent cardiac surgery because of continued bleeding. There was no fatal outcome. During the follow-up of 19 ± 14 months, eight patients were arrhythmia free.ConclusionIncidence of RFA-related CT in our medium-volume center was low and significantly associated with AF ablation. The outcome of CT was mostly favorable after pericardiocentesis, but readily accessible cardiothoracic surgery back-up should be mandatory in RFA centers.

Regionalization of Pediatric Surgery: Trends Already Underway.

This study aims to characterize the delivery of pediatric surgical care based on hospital volume stratified by disease severity, geography, and specialty. Longitudinal regionalization over the 10-year study period is noted and further explored. The Kids' Inpatient Database (KID) was queried from 2000 to 2009 for patients <18 years undergoing noncardiac surgery. Hospitals nationwide were grouped into commutable regions and identified as high-volume centers (HVCs) if they had more than 1000 weighted procedures per year. Regions that had at least one HVC and one or more additional lower volume center were included for analysis. Low-risk, high-risk neonatal, and surgical subspecialties were analyzed separately. A total of 385,242 weighted pediatric surgical admissions in 33 geographical regions and 224 hospitals were analyzed. Overall, HVCs comprised 33 (14.7%) hospitals, medium-volume center (MVC) 33 (14.7%), and low-volume center (LVC) 158 (70.5%). The four low-risk procedures analyzed were increasingly regionalized: appendectomy (52% in HVCs in 2000 to 60% in 2009, P < 0.001), fracture reduction (63% to 68%, P < 0.001), cholecystectomy (54% to 63%, P < 0.001), and pyloromyotomy (65% to 85%, P < 0.001). Neonatal surgery showed significant regionalization trends for tracheoesophageal fistula (66% to 87%, P < 0.001) and gastroschisis (76% to 89%, P < 0.001). This is the first large-scale, multi-region analysis to demonstrate that pediatric surgical care has transitioned to HVCs over a recent decade, particularly for low-risk patients. It is important for practitioners and policymakers alike to understand such volume trends in order to ensure hospital capacity while maintaining an optimal quality of care.

Outcomes of Patients After Arterial Switch Operation: 18 Years of Experience in a Single Medium-Volume Center.

The objective of this paper was to describe the outcomes in patients submitted to arterial switch operation and to analyze the predictors of in-hospital mortality and further need of re-operation at a single-center institution. Between September 1995 and January 2014, 128 consecutive arterial switch operations were performed. Surgical mortality during this period was analyzed retrospectively, and a follow-up analysis of the survivors was conducted. Surgical era, cardiopulmonary bypass time (p=0.001), and diagnosis category (p=0.025) influenced in-hospital mortality. The estimated overall survival for the 91 hospital survivors was 96.8, 96.4, and 96.2% at 5, 10, and 15years, respectively. The median follow-up time was 67months (range 0.71-222months). Three patients (5%) presented severe aortic regurgitation. Right ventricle outflow tract systolic gradient by echocardiography was above 60mmHg in 2%. Late re-interventions occurred in 12 (13%) patients with mean time of 64±34months after the initial procedure. Actuarial freedom from re-interventions at 5, 10, and 15years was 96.4, 69.7, and 61.9%, respectively. Arterial switch operation remains the procedure of choice in patients with transposition of great arteries. It can be performed even in middle-volume institutions, leading to the same middle- and long-term outcomes of high-volume institutions. Early high mortality rate may occur due not only to learning curve, but also to cardiopulmonary bypass time and ventricular septal defect closure.

Nationwide outcomes of nontrauma splenectomy

Due to the impact of LeapFrog and many scientific publications, regionalization for solid-organ operations gained momentum in the early 2000s. This study examines the effects of regionalization for medically indicated, nontrauma splenectomies (NTSs) in the USA. The Nationwide Inpatient Sample (NIS) data were analyzed for NTS based on International Classification of Disease Ninth Revision Clinical Modification codes for 1998–1999 (the 1990s) and 2008–2009 (the 2000s). The hospitals in the NIS were stratified by volume and divided into high volume (HV), medium volume, and low-volume (LV) terciles based on the annual volume of splenectomies performed (<5, 5–10, and 11+, respectively). Demographics, comorbidities, complications, admission status, and in-patient mortality were recorded. Univariate and multivariate statistical analyses were utilized. NIS recorded 4,293 NTS performed in the 1990s and 3,384 in the 2000s. Despite the decrease in operative volume, regionalization did not occur: in the first decade 30, 37, and 33 % of cases occurred in LV center (LVC), medium volume center, and HV center (HVC), respectively, compared with 34, 30, and 36 % in the second decade (p < 0.001). Patients were older in low-volume hospitals (LVC) than in high-volume hospitals (HVC) in both decades (in the 1990s: 45.3 vs. 52.7 years, p < 0.001; in the 2000s: 49.1 vs. 54.5 years, p < 0.001). The Charlson Comorbidity Index scores were not different in LVC compared with HVC in both decades (the 1990s: 1.31 vs. 1.23, p = 0.73; the 2000s: 1.54 vs. 1.41, p = 0.72). In both decades, LVC had more emergent admissions than HVC (20.3 vs. 16.8 %, p = 0.03; 28.8 vs. 19.5 %, p < 0.001). Complication rates were higher in LVC in both decades (the 1990s: 16.9 vs. 13.6 %, p = 0.02; the 2000s: 19.8 vs. 15.5 %, p = 0.006). Mortality was not different for HVC and LVC in both decades (the 1990s: 3.75 vs. 4.27, p = 0.49; the 2000s: 2.94 vs. 4.03, p = 0.15). NTS has not been affected by regionalization, which is dissimilar to other solid-organ abdominal procedures. Indeed, the benefit of regionalization for splenectomy has not been established.

Preparing for Prospective Clinical Trials: A National Initiative of an Excellence Registry for Consecutive Pancreatic Cancer Resections

Despite significant improvements in perioperative mortality as well as response rates to multimodality treatment, results after surgical resection of pancreatic adenocarcinoma with respect to long-term outcomes remain disappointing. Patient recruitment for prospective international trials on adjuvant and neoadjuvant regimens is challenging for various reasons. We set out to assess the preconditions and potential to perform perioperative trials for pancreatic cancer within a well-established Austrian nationwide network of surgical and medical oncologists (Austrian Breast & Colorectal Cancer Study Group). From 2005 to 2010 five high-volume centers and one medium-volume center completed standardized data entry forms with 33 parameters (history and patient related data, preoperative clinical staging and work-up, surgical details and intraoperative findings, postoperative complications, reinterventions, reoperations, 30-day mortality, histology, and timing of multimodality treatment). Outside of the study group, in Austria pancreatic resections are performed in three “high-volume” centers (>10 pancreatic resections per year), three “medium-volume” centers (5–10 pancreatic resections per year), and the rest in various low-volume centers (<5 pancreatic resections per year) in Austria. Nationwide data for prevalence of and surgical resections for pancreatic adenocarcinoma were contributed by the National Cancer Registry of Statistics of Austria and the Austrian Health Institute. In total, 492 consecutive patients underwent pancreatic resection for ductal adenocarcinoma. All postoperative complications leading to hospital readmission were treated at the primary surgical department and documented in the database. Overall morbidity and pancreatic fistula rate were 45.5 % and 10.1 %, respectively. Within the entire cohort there were 9.8 % radiological reinterventions and 10.4 % reoperations. Length of stay was 16 days in median (0–209); 12 of 492 patients died within 30 days after operation, resulting in a 30-day mortality rate of 2.4 %. Seven of the total 19 deaths (36.8 %) occurred after 30 days, during hospitalization at the surgical department, resulting in a hospital mortality rate of 3.9 % (19/492). With a standardized histopathological protocol, there were 70 % (21/30) R0 resections, 30 % (9/30) R1 resections, and no R2 resections in Vienna and 62.7 % (32/51) R0 resections, 35.3 % (18/51) R1 resections, and 2 % (1/51) R2 resections in Salzburg. Resection margin status with nonstandardized protocols was classified as R0 in 82 % (339/411), R1 in 16 % (16/411), and R2 in 1.2 % (5/411). Perioperative chemotherapy was administered in 81.1 % of patients (8.3 % neoadjuvant; 68.5 % adjuvant; 4.3 % palliative); chemoradiotherapy (1.6 % neoadjuvant; 3 % adjuvant; 0.2 % palliative), in 4.9 % of patients. The six centers that contributed to this registry initiative provided surgical treatment to 40 % of all Austrian patients, resulting in a median annual recruitment of 85 (51–104) patients for the entire ABCSG-group and a median of 11.8 (0–38) surgeries for each individual department. Surgical quality data of the ABCSG core pancreatic group are in line with international standards. With continuing centralization the essential potential to perform prospective clinical trials for pancreatic adenocarcinoma is given in Austria. Several protocol proposals aiming at surgical and multimodality research questions are currently being discussed

INTERMACS Level at the Time of Transplant Assessment Predicts Overall Mortality and Probability of Advanced Therapy

Purpose INTERMACS scale predicts mortality in patients undergoing ventricular assist device (VAD) implantation and heart transplantation (HTx). This study evaluated the association of INTERMACS levels at the time of HTx assessment with overall mortality and the probability of receiving HTx or VAD. Methods and Materials We included 360 consecutive HTx candidates from a single medium-volume transplant center from 2000 to 2012. Patients were categorized by INTERMACS level 1,2,3,4 or 5-7 based on clinical status at first assessment. Multivariable parametric model was used to analyze the association between INTERMACS level and overall mortality (including waitlist, post-HTx and post-VAD mortality) entering time of HTx and VAD as time-varying covariates. We used competing-risk analysis to assess the probability of HTx or VAD. Results The mean age was 47±13 years and 66% were male. Thirty(9%), 23(6%), 34(9%), 33(9%) and 240(67%) patients were INTERMACS 1,2,3,4 and 5-7 respectively. During a median follow up of 3.5 years, 75 patients received a VAD, 219 a HTx and 113 died (41 waitlist, 12 post-VAD and 60 post-HTx deaths). INTERMACS at initial assessment was an independent predictor of overall mortality after adjusting for age, sex, ischemic cardiomyopathy, creatinine, HTx and VAD. Mortality at 1 year was 14% in INTERMACS 1 patients and there was a 17% risk reduction for each INTERMACS level improvement (HR 0.83, 95%CI 0.72-0.96). Mortality risk was similar in patients receiving HTx or VAD (p=0.86). However, the probability of undergoing HTx was significantly lower in patients with worse INTERMACS (HR 0.87, 95%CI 0.76-0.99) while VAD implantation was higher (HR 1.56, 95%CI 1.35-1.79). Conclusions INTERMACS level at initial HTx assessment is an independent predictor of overall mortality. Survival was similar in patients receiving VAD or HTx. However, patients with worse INTERMACS level had higher overall mortality and lower chances of undergoing HTx. These results may help physicians to make informed decisions when considering advanced therapies.

Chirurgie des Magenkarzinoms in einer Schwerpunktklinik

The aim of the study was to evaluate prognostic factors for the surgical treatment of gastric cancer in a medium volume center. The investigation focused in particular on morbidity and mortality. From January 2005 to August 2011 a total of 74 patients with gastric cancer were surgically treated in our medium volume center. The study of these patients included morbidity, mortality, UICC (International Union Against Cancer) stage, Laurén classification, surgical therapy procedure, American Society of Anesthesiologists (ASA) classification and duration of surgery. After surgery 11 patients suffered from complications with a morbidity of 14.9% and a mortality of 1.4% (n=1). No significant differences could be detected during the study period. In comparison to other studies the morbidity and mortality rates signify similar to better data than complications of high volume centers which might be due to the small group of surgeons who are specialized in gastric surgery.

Increased Short- and Long-term Mortality at Low-volume Pediatric Heart Transplant Centers

The relationship between volume and outcome in many complex surgical procedures is well established. No published data has examined this relationship in pediatric cardiac transplantation, but low-volume adult heart transplant programs seem to have higher early mortality. The United Network for Organ Sharing (UNOS) provided center-specific data for the 4647 transplants performed on patients younger than 19 years old, 1992 to 2007. Patients were stratified into 3 groups based on the volume of transplants performed in the previous 5 years at that center: low [<19 transplants, n = 1135 (24.4%)], medium [19–62 transplants, n = 2321(50.0%)], and high [≥63 transplants, n= 1191 (25.6%)]. A logistic regression model for postoperative mortality was developed and observed-to-expected (O:E) mortality rates calculated for each group. Unadjusted long-term survival decreased with decreasing center volume (P<0.0001). Observed postoperative mortality was higher than expected at low-volume centers [O:E ratio 1.39, 95% confidence interval (CI) 1.05–1.83]. At low volume centers, high-risk patients (1.34, 0.85–2.12)--especially patients 1 year old or younger (1.60, 1.07–2.40) or those with congenital heart disease (1.36, 0.94–1.96)--did poorly, but those at high-volume centers did well (congenital heart disease: 0.90, 0.36–1.26; age<1 year: 0.75, 0.51–1.09). Similar results were obtained in the subset of patients transplanted after 1996. In multivariate logistic regression modeling, transplantation at a low-volume center was associated with an odds ratio for postoperative mortality of 1.60 (95% CI, 1.14–2.24); transplantation at a medium volume center had an odds ratio of 1.24 (95% CI, 0.92–1.66). The volume of transplants performed at any one center has a significant impact on outcomes. Regionalization of care is one option for improving outcomes in pediatric cardiac transplantation.

Risk factors and outcome of pancreatic fistula after consecutive pancreaticoduodenectomy with pancreaticojejunostomy for patients with malignant tumor

Objective: Pancreatic fistula (PF) is a common complication after pancreaticoduodenectomy (PD) and there is no consensus regarding the criteria to define PF. The study was undertaken to determine the risk factors for PF according to the definition of the International Study Group on Pancreatic Fistula (ISGPF) and to delineate its impact on patient outcome. Methods: Between March 1994 and May 2009, data from 153 consecutive patients with malignant tumors underwent a PD with pancreaticojejunostomy in the Peking University People’s Hospital were recorded prospectively. A total of 24 factors were examined with univariate analysis and multivariate logistic regression analysis was used to estimate relative risks, and their 95% confidence intervals (95% CI) and odds ratio (OR). Results: Our institution belonged to medium-volume center and PF occurred in 30 patients (19.6%). Pancreatic texture, early postoperative hemorrhage and pancreatic pathologies correlated with PF rates significantly in univariate analyses. But in multivariate regression, soft gland (OR, 4.934; 95% CI, 1.132−7.312) and early postoperative hemorrhage with conservative therapy (OR, 4.130; 95% CI, 1.057−21.112) were predictive. The mean postoperative length of stay in patients with PF was longer (32.7±23.9 versus 60.5±56.2 days) than patients without PF (P=0.001). Overall 30-day mortality was not affected by the development of PF (P=0.657). There was no difference in reoperation rates between patients with and without PF (10.0% versus 6.5%, P=0.787). Concerning the sum of postoperative complications, there were 36 complications for 30 patients with PF, while 64 for 123 patients without PF. When patients with distal cholangiocarcinoma, ampullary and duodenal cancer were considered as a whole for survival analysis, the median survival for patients with PF was 20 months, whereas the median survival for patients without PF was 26 months. Kaplan-Meier survival curves for patients with and without PF were not statistically different (P=0.903). Conclusion: Soft texture and early postoperative hemorrhage with conservative therapy are independent correlates of increased rate of PF. Anastomotic technique for pancreaticojejunostomy does not have impact on the development of PF in our experience. PF contributes to early postoperative morbidity and the length of hospital stay, but it dose not affect postoperative 30-day mortality, reoperation rate and overall survival.

Predictors of outcome in a multicenter port-access valve registry

Background. The aim of this study was to examine the predictors of outcome in patients undergoing isolated valve operation using port-access techniques. Methods. Logistic regression analysis was performed in a prospective, multi-institutional registry of patients undergoing isolated aortic valve replacement (AVR, n = 252), mitral repair (MVP, n = 491), or mitral replacement (MVR, n = 568) using port-access techniques from 1997 to 1999. Results. Endoaortic balloon occlusion was used in 2% (AVR), 93% (MVP), and 90% (MVR) of cases. Conversion to full sternotomy occurred in 3.8% of all cases. For all patients, early mortality was 50 of 1,311 (3.8%) and onset of new atrial fibrillation occurred in 140 of 1,311 (11%) patients. The determinants of 30-day mortality were redo, age, and MVR or AVR. The determinants of reoperation for bleeding were age, reoperation, and MVR. Age was a predictor for stroke, and age and low or medium volume center were predictors of new atrial fibrillation. Conclusions. Excellent short-term results can be obtained using port-access techniques in isolated mitral or aortic valve operations. Patient outcome is not related to institutional case volume, and the primary determinants of outcome after port-access valve procedures are generally patient-related factors.