Operative Risk In Patients Research Articles

Increased Regional Market Competition is Associated with a Lower Threshold for Revascularization in Asymptomatic Carotid Artery Stenosis

Revascularization practices with respect to asymptomatic carotid stenosis (ACAS) are known to vary widely among proceduralists. In addition, regional market competition has been previously shown to drive more aggressive practices in a number of surgical procedures. The aim of our study was to examine the association of regional market competition with revascularization thresholds for ACAS. All patients undergoing carotid revascularization in the Vascular Quality Initiative carotid endarterectomy and stenting databases (2016-2020) were included. High-grade carotid stenosis was defined as ≥80%. We calculated the Herfindahl-Hirschman Index (HHI; a measure of physician market competition) for each U.S region as defined by the U.S Department of Health and Human Services. Logistic regression was used to examine the association of degree of carotid stenosis at revascularization with HHI stratified by symptomatology, adjusting for age, sex, race, insurance, and revascularization modality. Of 92,243 carotid interventions, 57,094 (61.9%) were performed for ACAS and 35,149 (38.1%) were performed for symptomatic carotid stenosis (SCAS). ACAS patients undergoing revascularization for moderate-grade stenosis were significantly less likely to be aspirin (85.6% vs. 86.3%), clopidogrel (41.3% vs. 45.1%), dual anti-platelet therapy (35.9% vs. 39.2%) and systemic anticoagulants (10.9 vs. 11.7%) compared to high-grade stenosis (all P<0.05). Multivariable analysis demonstrated that decreased local market competition was independently associated with a lower odds of revascularization for moderate versus high-grade ACAS (odds ratio OR: 0.99 per 10 point increase in HHI, 95% confidence interval CI: 0.98-0.99). There was no association of local market competition with degree of carotid stenosis at time of revascularization among patients with SCAS (OR: 1.00 per 10 point increase in HHI, 95% CI: 0.99-1.00). Among ACAS patients, patients with moderate-grade stenosis had a higher odds ratio of in-hospital stroke or death compared to patients with high-grade stenosis (OR: 1.22, 95% CI 1.03-1.45). This association was not redemonstrated in the SCAS group (OR: 0.92, 95% CI: 0.80-1.06). Increased local market competition is associated with a lower threshold for revascularization of ACAS. There is no association between regional market competition and revascularization threshold for SCAS. These findings, combined with the significantly increased risk of perioperative stroke/death among moderate-grade ACAS patients, suggest that competition among proceduralists may result in a higher tolerance for increased operative risk in patients who might otherwise be reasonable candidates for surveillance.

Surgical treatment of post-infarction papillary muscle rupture: systematic review and meta-analysis.

Papillary muscle rupture (PMR) is a rare but potentially fatal complication following acute myocardial infarction (AMI). Surgical treatment is considered the standard of care. This systematic review and meta-analysis aims to evaluate the early outcomes after surgical correction of post-AMI PMR. Electronic databases were searched from January 1990 to December 2020. Studies reporting patients undergoing mitral valve surgery for post-AMI PMR were analysed. The primary outcome assessed was operative mortality. Differences were expressed as risk ratio (RR) with 95% confidence interval (CI) to assess the relationships between predefined surgical variables and clinical prognosis. A total of 1,851 adult patients, from 12 observational studies, were identified. Operative mortality was 21%. Meta-analysis revealed reduced operative risk in patients undergoing mitral valve repair (MVr) as compared to replacement (MVR) (RR, 0.33; 95% CI: 0.14 to 0.79; P=0.01), and an increased risk of operative mortality in patients with complete PMR (RR, 2.54; 95% CI: 1.12 to 5.74; P=0.03). No significant differences in terms of operative mortality were observed between patients with or without pre/peri-operative intra-aortic balloon pump (IABP) support and between subjects who underwent mitral valve surgery with or without concomitant coronary artery bypass grafting (CABG). Mitral valve surgery for post-AMI PMR carries a high operative mortality. Patients with complete PMR and subjects undergoing MVR have increased risks of operative mortality. The preoperative use of IABP and concomitant CABG seem not to influence the early postoperative course in this context.

Perioperative Transjugular Intrahepatic Portosystemic Shunt Is Associated With Decreased Postoperative Complications in Decompensated Cirrhotics Undergoing Abdominal Surgery.

Operative risk in patients with cirrhosis is related to the severity of liver disease and nature of procedure. Pre and postoperative portal decompression via transjugular intrahepatic portosystemic shunt (TIPS) are logical approaches to facilitate surgery and improve postoperative outcomes. We compared postoperative outcomes of decompensated cirrhotics undergoing abdominal surgery either with or without perioperative TIPS placement. We performed a retrospective review of 41 decompensated cirrhotic patients who had abdominal surgery from 2010-2019 at the University of Alabama at Birmingham. Patients were stratified based on having received either perioperative TIPS or no TIPS. Demographics, laboratory data, perioperative TIPS status and postoperative complications were compared between the 2 groups using Fisher exact test and Student 2 sample t-test. Group 1 consisted of 28 patients who had TIPS procedure, with 21 being preoperative and 7 being postoperative. Group 2 had 13 patients who had abdominal surgery without TIPS. When compared to those with perioperative TIPS, patients without TIPS had a significantly increased incidence of postoperative ascites (33% vs 77%, P = .0026), infection (18% vs 54%, P = .028), and acute kidney injury (AKI) (14% vs 46%, P = .0485). Additionally, postoperative Model of End Stage Liver Disease Sodium score was significantly higher in patients without TIPS (22 ± 4.74) when compared to those who had TIPS (17.14 ± 5.48) (P = .009). Perioperative TIPS placement in decompensated cirrhotics was associated with decreased postoperative ascites, infection, and AKI when compared to those without TIPS. Further studies are needed to validate our findings.

Increased Regional Market Competition Lowers Threshold For Revascularization In Asymptomatic Carotid Artery Stenosis

INTRODUCTION AND OBJECTIVES Revascularization practices for asymptomatic carotid stenosis(ACAS) vary widely among physicians. Our study examines the association of regional market competition with ACAS revascularization thresholds. METHODS We included all patients undergoing carotid revascularization in the VQI endarterectomy and stenting databases(2016-2020). High-grade stenosis was defined as ≥80%. We calculated the Herfindahl-Hirschman Index(HHI; measuring physician market competition) for US regions. Logistic regression was used to examine the association between degree of stenosis at revascularization with HHI stratified by symptomatology, adjusting for revascularization modality and traditional risk factors. RESULTS Of 92,243 carotid interventions, 61.9% were performed for ACAS and 38.1% for symptomatic carotid stenosis(SCAS). Patients undergoing revascularization for moderate-grade ACAS(vs. high-grade) were less likely to be on aspirin(85.6% vs. 86.3%) and clopidogrel(41.3% vs. 45.1%, both p<0.05), but equally likely to be on statins (85.6% vs. 85.7%, p=0.70). There were significant regional differences in the proportion of carotid revascularization procedures performed for moderate-grade ACAS(Figure). After adjusting for baseline differences between groups, market competition was independently associated with higher odds of revascularization for moderate versus high-grade ACAS(OR:1.02 per 10pt ΔHHI, 95%CI:1.01-1.03). There was no association of market competition with degree of carotid stenosis at time of revascularization among SCAS patients(OR:1.00 per 10pt ΔHHI, 95%CI:1.00-1.01). ACAS patients with moderate-grade stenosis had higher odds of in-hospital stroke or death compared to high-grade stenosis patients(OR:1.28, 95%CI:1.05-1.56). CONCLUSIONS Increased local market competition is associated with a lower revascularization threshold for ACAS but not SCAS. These findings, combined with the increased risk of perioperative stroke/death among moderate-grade ACAS patients, suggest that competition among physicians may result in a higher tolerance for increased operative risk in patients who might otherwise be reasonable candidates for surveillance. Revascularization practices for asymptomatic carotid stenosis(ACAS) vary widely among physicians. Our study examines the association of regional market competition with ACAS revascularization thresholds. We included all patients undergoing carotid revascularization in the VQI endarterectomy and stenting databases(2016-2020). High-grade stenosis was defined as ≥80%. We calculated the Herfindahl-Hirschman Index(HHI; measuring physician market competition) for US regions. Logistic regression was used to examine the association between degree of stenosis at revascularization with HHI stratified by symptomatology, adjusting for revascularization modality and traditional risk factors. Of 92,243 carotid interventions, 61.9% were performed for ACAS and 38.1% for symptomatic carotid stenosis(SCAS). Patients undergoing revascularization for moderate-grade ACAS(vs. high-grade) were less likely to be on aspirin(85.6% vs. 86.3%) and clopidogrel(41.3% vs. 45.1%, both p<0.05), but equally likely to be on statins (85.6% vs. 85.7%, p=0.70). There were significant regional differences in the proportion of carotid revascularization procedures performed for moderate-grade ACAS(Figure). After adjusting for baseline differences between groups, market competition was independently associated with higher odds of revascularization for moderate versus high-grade ACAS(OR:1.02 per 10pt ΔHHI, 95%CI:1.01-1.03). There was no association of market competition with degree of carotid stenosis at time of revascularization among SCAS patients(OR:1.00 per 10pt ΔHHI, 95%CI:1.00-1.01). ACAS patients with moderate-grade stenosis had higher odds of in-hospital stroke or death compared to high-grade stenosis patients(OR:1.28, 95%CI:1.05-1.56). Increased local market competition is associated with a lower revascularization threshold for ACAS but not SCAS. These findings, combined with the increased risk of perioperative stroke/death among moderate-grade ACAS patients, suggest that competition among physicians may result in a higher tolerance for increased operative risk in patients who might otherwise be reasonable candidates for surveillance.

Abstract 9431: Preoperative Serum Gdf-15, Endothelin-1 Levels, and Intraoperative Factors as Short-Term Operative Risks for Patients Undergoing Cardiovascular Surgery

Introduction: The Society of Thoracic Surgeons (STS) risk score is widely used for the risk assessment of cardiac surgery. Serum biomarkers such as growth differentiation factor-15 (GDF-15) and endothelin-1 (ET-1) are also used to evaluate risk. Hypothesis: To investigate the relationships between preoperative serum GDF-15, ET-1 levels, and intraoperative factors and short-term operative risks including acute kidney injury (AKI) for patients undergoing cardiovascular surgery. Methods: Total 145 patients were included in this study (92 males and 53 females, age 68.4 ± 13.2 years). The preoperative STS score was determined, and the serum GDF-15 and ET-1 levels were measured by Enzyme-Linked Immunosorbent Assay. These were related to postoperative risks, including AKI, defined according to the Acute Kidney Injury Network (AKIN) classification criteria. Results: AKI developed in 23% of patients. The GDF-15 and ET-1 levels correlated with the STS score. The STS score and GDF-15 and ET-1 levels all correlated with preoperative eGFR, Alb, Hb, and BNP levels; perioperative data (urine output); ICU stay period; and postoperative admission days. Patients with AKI had longer circulatory pulmonary bypass (CPB) time, and male patients with AKI had higher ET-1 levels than those without AKI. The risk of developing AKI increased with increasing preoperative ET-1 level at baseline (OR for 1 pg/mL increase in ET-1, 2.177; 95% CI, 1.034-4.584; p = 0.041) and CPB time (OR for 1 h increase in CPB time, 4.194; 95% CI, 2.005-8.773; p &lt; 0.001), even adjusted by age, sex, and BMI. In addition, multivariable logistic regression analysis showed that the risk of 30-day mortality plus morbidity increased with increasing preoperative GDF-15 level at baseline, CPB time, and RCC transfusion, even adjusted for age, gender, and BMI. Conclusion: The present study provides evidence that preoperative GDF-15 and ET-1 levels as well as intraoperative factors such as CPB time may be helpful to identify short-term operative risk for patients undergoing cardiovascular surgery.

Is the pulmonary pressure directly correlated with the operative risk in patients with isolated tricuspid valve surgery?

Severe pulmonary hypertension is a relative contraindication for isolated tricuspid valve (TV) surgery. However, some patients may still benefit from TV surgery. We hypothesized that pulmonary pressure alone is an inadequate predictor of outcomes post-TV surgery, and that aorto-pulmonary pressure quotient (AoP/PAP) is a better predictor. From 2005 to 2019, a total of 122 patients (mean age: 68.5±10.5 years; 43.3% male) with isolated TV regurgitation and preoperative right heart catheterization referred to our institution for isolated TV surgery were included. Patients with concomitant procedures were excluded from this analysis. All data were retrospectively analyzed. Follow-up was 97% complete. The mean follow-up time was 4.3±3.6 years. The mean preoperative New York Heart Association (NYHA) class was 2.9±0.7, left ventricular ejection fraction was 52.3±11.3%, creatinine level was 124.8±102.6μmol/l, mean pulmonary artery pressure was 25.5±9.4mmHg, mean MELD-XI score 13.5±4.2, and mean AoP/PAP was 4.1±1.9 mmHg. Thirty-day mortality was 10.9%, and 5-years survival was 56.6±4.9%. Cox regression analysis revealed age (P=0.001; HR: 1.058; CI 95%: 1.023-1.094), the mean arterial pressure (P=0.002; HR: 0.969; CI 95%: 0.950-0.988) and systolic pulmonary artery pressure (P=0.035; HR: 1.054; CI 95%: 1.004-1.107), as well as mean AoP/PAP>4 (P=0.001; HR: 6.678; CI 95%: 2.197-20.294) as predictors for long-term mortality. Regardless of the degree of pulmonary hypertension, a mean AoP/PaP quotient ≤4 impacts the postoperative survival of patients undergoing isolated TV surgery. However, further research is still required to verify this finding.

Meta‐analysis of surgical treatment for postinfarction left ventricular free‐wall rupture

BackgroundLeft ventricular free‐wall rupture (LVFWR) is one of the most lethal complications after acute myocardial infarction (AMI). The optimal therapeutic strategy is controversial. The current meta‐analysis sought to examine the outcome of patients surgically treated for post‐AMI LVFWR.MethodsA comprehensive literature review was performed to identify articles reporting outcomes of subjects who underwent LVFWR surgical repair. The primary endpoint was operative mortality. A meta‐analysis was performed to assess the associations of predefined variables of interest and clinical prognosis.ResultsOf the 3132 retrieved articles, 11 nonrandomized studies, enrolling a total of 363 patients, fulfilled the inclusion criteria and were included in this analysis. The mean age of patients was 68 years. The operative mortality rate was 32% (n = 115). Meta‐analysis revealed reduced operative risk in patients with oozing type rupture, as compared to blowout type (risk ratios [RR]: 0.47; 95% confidence interval [CI]: 0.33–0.67; p < .0001); RR was also significantly reduced in subjects in whom LVFWR was treated with sutureless technique, as compared to those undergoing sutured repair (RR: 0.59; 95% CI: 0.41–0.83; p = .002). Increased risk of operative mortality was demonstrated in patients who required postoperative extracorporeal membrane oxygenation (ECMO) support (RR: 2.39; 95% CI: 1.59–3.60; p < .0001).ConclusionsSurgical treatment of postinfarction LVFWR has a high operative mortality rate. Blowout rupture, sutured repair and postoperative ECMO support are factors associated with increased risk of operative mortality.

Development of a claims-based EuroSCORE II in patients with aortic stenosis needing surgical or transcatheter aortic valve replacement using electronic hospital records: a nationwide study

Abstract Background Prediction of operative risk in patients with aortic stenosis (AS) undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) remains a challenge, particularly in high-risk patients. The EuroSCORE II is now commonly used to improve risk prediction. Large analyses from administrative database have provided opportunities for conducting health research in the field of structural heart disease interventions but may have a lack of granularity and do not routinely include EuroSCORE II, which may result in a risk of uncontrolled biases. We sought to approximate the EuroSCORE II using only administrative claims data to enable the operative risk to be assessed without clinical or paraclinical performance measures. Methods Based on the administrative hospital-discharge database, we collected information for all patients with AS treated with SAVR or TAVI between 2010 and 2019 in France. A total of 78,085 SAVR and 60,821 patients with AS treated with transcatheter aortic valve replacement (TAVR) were found in the database. For each patient, the EuroSCORE II was estimated using the formulas available at the EuroSCORE website. Age, gender, extracardiac arteriopathy, poor mobility, previous cardiac surgery, chronic lung disease, active endocarditis, diabetes on insulin, recent MI, dialysis are items available in the PMSI database using the ICD-10 or CCAM codes. For renal impairment, NYHA class, LVEF, pulmonary hypertension, “critical preoperative state” and urgent intervention, different proxies were built based on ICD-10 codes likely to represent increasing severity of these items. Results In the cohort of patients with SAVR, mean estimated EuroSCORE II was 3.3±1.1 while all-cause death at day 30 after SAVR was 3.8%. In the cohort of patients with TAVI, mean estimated EuroSCORE II was 3.8±1.0 while all-cause death at day 30 after TAVI was 5.5%. In the whole cohort, the area under the curve (AUC) of the estimated EuroSCORE II for predicting the risk of all-cause death at day 30 was 0.72 (95% CI 0.71–0.73) and was higher in patients treated with SAVR (AUC 0.76, 95% CI 0.75–0.77) than in those treated with TAVI (AUC 0.67, 95% CI 0.65–0.68, p&amp;lt;0.00001 for DeLong test). The observed versus predicted risks of all-cause death at day 30 post-TAVI OR SAVR within risk deciles are shown in Figure 1. Calibration of the prediction score was satisfying across the 10 deciles and a predicted 30-day mortality rate of approximately 15%. Conclusions Claims data alone can be used to identify individuals with AS at operative risk when they are considered for SAVR or TAVI. The Claims-based EuroSCORE II might be used in research with large datasets for confounding adjustment or risk prediction. It provides hospitals and health systems with a low-cost, systematic way to identify a group of patients who are at greater risk of adverse outcomes with these interventions and for whom a more specific approach might be useful. Figure 1 Funding Acknowledgement Type of funding source: None

The 6-min walk test in the functional evaluation of patients with lung cancer qualified for lobectomy.

The American College of Chest Physicians guidelines recommend low-technology exercise tests in the functional evaluation of patients with lung cancer considered for resectional surgery. However, the 6-min walk test (6MWT) is not included, because the data on its clinical value are inconsistent. Our goal was to evaluate the 6MWT in assessing the risk of cardiopulmonary complications in candidates for lung resection. We performed a retrospective assessment of clinical data and pulmonary function test results in 947 patients, mean age 65.3 (standard deviation 9.5) years, who underwent a single lobectomy for lung cancer. In 555 patients with predicted postoperative values ≤60%, the 6MWT was performed. The 6-min walking distance (6MWD) and the distance-saturation product (DSP), which is the product of the 6MWD in metres, and the lowest oxygen saturation registered during the test were assessed. A total of 363 patients with predicted postoperative values <60% and a 6MWT distance (6MWD) ≥400 m or DSP ≥ 350 m% had a lower rate of cardiopulmonary complications than patients with shorter 6MWD or lower DSP values [odds ratio (OR) 0.53, 95% confidence interval (CI) 0.35-0.81] and 0.47 (95% CI 0.30-0.73), respectively. This result was also true for patients with predicted postoperative values <40%, ORs 0.33 (95% CI 0.14-0.79) and 0.25 (95% CI 0.10-0.61), respectively. The 6MWT is useful in the assessment of operative risk in patients undergoing a single lobectomy for lung cancer. It helps to stratify the operative risk, which is lower in patients with 6MWD ≥400 m or DSP ≥350 m% than in patients with a shorter 6MWD or lower DSP values.

Endocarditis after percutaneous edge-to-edge in a heart transplant recipient: management through the HeartPort technique.

In the case illustrated in this study, a heart transplant recipient received percutaneous mitral edge-to-edge for secondary mitral regurgitation on the basis of increased reoperative risk. After development of mitral endocarditis, reoperation and mitral valve replacement were successfully performed through the HeartPort technique. We discuss the technical aspects, including the positioning of the Intraclude® device and the access to the mitral valve in this context. We address the decision-making issues (role of minimally invasive surgery to reduce operative risk in patients with one or more previous sternotomies).

Pulmonary valve and right ventricular outflow tract surgery in adults: 23-year experience.

Surgery of the pulmonary valve, right ventricular outflow tract, and pulmonary artery falls under the domain of paediatric cardiac surgery. However, 97 adult patients underwent such operations in our institution from 1993 to 2016. This study aims to analyse preoperative risk factors, intraoperative data, postoperative outcomes, and long-term survival to identify the potential predictors of mortality and high-risk patients. We divided our patient cohort into three groups in accordance with surgical indications: 17 patients with pulmonary valve endocarditis (group A), 70 patients with congenital defects involving the pulmonary valve (group B), and 10 patients who underwent pulmonary valve surgery for other indications, such as tumour or other acquired valvular disease (group C). Gender distribution was comparable in all the three groups, with about 40% of the total number of patients being female. The mean age was 35.9 ± 15.7 years. Sixty (61.9%) patients had a history of cardiac surgery. Various concomitant cardiac surgical procedures were necessary in 49 (50.5%) cases. There were two (11.8%) in-hospital deaths in group A, two (2.9%) in group B, and none in group C. Within the mean follow-up time of 6.6 ±7.2 years, three (17.7%) patients in group A, two (2.9%) in group B, and four (40%) in group C died. Adult patients with pulmonary valve disease are often previously heart-operated and often need concomitant procedures. The operative risk in patients with pulmonary valve endocarditis is high. Surgery of congenital defects of the pulmonary valve is safe and can be performed with excellent outcomes.

Results of Open Surgical Repair in Patients With Marfan Syndrome and Distal Aortic Dissection

In patients with Marfan syndrome (MFS), distal aortic dissection can necessitate thoracoabdominal aortic aneurysm (TAAA) repair in survivors of acute DeBakey type I dissection and those with DeBakey type III dissection. We examined outcomes of surgical repair of TAAA in patients with MFS with distal aortic dissection. Data were analyzed for 127 consecutive TAAA repairs performed between January 2004 and June 2014 in patients with MFS and distal aortic dissection-DeBakey types I (n= 73) and III (n= 54). The median time from dissection onset to TAAA repair was 5.2 years (interquartile range [IQR]: 2.1 to 9.8 years) for the overall group and was longer in patients with DeBakey I (6.5 years, IQR: 3.5 to 13.9 years) than patients with DeBakey III (2.9 years, IQR: 0.6 to 6.0 years, p < 0.001). Eleven patients (9%) had acute or subacute dissection at the time of repair. Sixty-six patients (52%) underwent Crawford extent II TAAA repair. A composite end point, adverse event, was defined as operative death or permanent stroke, renal failure, paraplegia, or paraparesis. Eight patients had adverse events (6%), including 5 operative deaths (4%). There was no permanent stroke and 1 case each of permanent paraplegia andparaparesis. At discharge, 2 early survivors (2%) had renal failure. Extent II repairs did not have substantially different outcomes from other repairs. In these patients with MFS with aortic dissection, open TAAA repair incurred reasonable operative risk, but improvements are needed to reduce rates of renal failure. Extent II TAAA repair does not appear to increase operative risk in patients with MFS.

PTU-131 Cardiopulmonary exercise testing predicts prolonged hospital stay following oesophago-gastric cancer surgery

<h3>Introduction</h3> Preoperative cardiopulmonary exercise testing (CPEX) has been shown to be useful in assessing operative risks in patients undergoing major surgery. The aim of this study was to assess the value of CPEX in predicting complications and prolonged hospital stay in patients undergoing oesophago-gastric cancer resection. <h3>Method</h3> Between November 2013 and November 2014, 68 patients (52 men, 16 women) with a median age of 67 (range 32–82) years underwent CPEX before potentially curative resections for oesophago-gastric cancer. CPEX variables measured included oxygen uptake at the estimated lactate threshold (AT) and at peak exercise (VO2 max). Patients were mobilised on the first postoperative day with epidural analgesia and all oesophagectomy patients had feeding jejunostomies with feed starting on postoperative day one. Postoperative morbidity and mortality was determined using the Clavien-Dindo classification. <h3>Results</h3> The mean AT was 12.6 ± 3.1 ml kg^-1min^-1(mean ± SD) and the mean VO2 max was 20.5 ± 5.5 ml kg^-1min^-1. Serious post-operative complications (Clavien-Dindo score ≥3) occurred in 18 (26.5%) patients. There was no significant association between all variables of CPEX and the development of post-operative complications. Median length of hospital stay was 11 (range 6–78) days. VO2 max and body mass index (BMI) was associated with increased length of hospital stay (weight coefficient: -0.271; 95% C. I: -1.049 – -0.071; p = 0.025 and weight coefficient: 0.259; 95% C. I: 0.045–1.054; p = 0.033 respectively) on univariate linear regression analysis. Only VO2 max retained independent association with length of hospital stay on multivariate analysis. <h3>Conclusion</h3> CPEX is a poor predictor of post-operative complications in patients undergoing curative oesophago-gastric cancer resection. However, a lower VO2 max may be useful in identifying patients ‘at risk’ of prolonged length of hospital stay. <h3>Disclosure of interest</h3> None Declared.

Value of estimation of physiologic ability and surgical stress in prediction of operative risk of hip fracture

Objective To use estimation of physiologic ability and surgical stress (E-PASS) to assay operative risks in patients with hip fracture and to discuss its application value.Methods Sixtyfour patients with hip fractures were subjected to the retrospective review.There were 38 males and 26 females,at mean age of 54.3 years (range,19-84 years).The operative risk was assayed by E-PASS and postoperative complications as well as case fatality were detected and compared.Results Postoperative complications developed in 16 patients (25％).E-PASS score was significantly higher for the patients with postoperative complications than in those without [(0.64 ± 0.31) points vs (0.22 ± 0.31) points,P ＜ 0.05].Incidence of complications was significantly lower for patients with a E-PASS score ＜ 0.6 than for those with a E-PASS score ＞ 0.6 (19％ vs 50％,P ＜ 0.01).There were 2 deaths among 16 patients with a E-PASS score ＞ 0.6.The remaining 48 patients with a E-PASS score ＜ 0.6 obtained satisfactory recovery.Conclusion E-PASS is effective for predicting operative risk and is instructive for surgery decision in treatment of hip fractures. Key words: Hip fractures; Surgical procedures, operative; Estimation of physiologic ability and surgical stress

Heart valve surgery: EuroSCORE vs. EuroSCORE II vs. Society of Thoracic Surgeons score.

This is a validation study comparing the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II with the previous additive (AES) and logistic EuroSCORE (LES) and the Society of Thoracic Surgeons' (STS) risk prediction algorithm, for patients undergoing valve replacement with or without bypass in Pakistan. Clinical data of 576 patients undergoing valve replacement surgery between 2006 and 2013 were retrospectively collected and individual expected risks of death were calculated by all four risk prediction algorithms. Performance of these risk algorithms was evaluated in terms of discrimination and calibration. There were 28 deaths (4.8%) among 576 patients, which was lower than the predicted mortality of 5.16%, 6.96% and 4.94% by AES, LES and EuroSCORE II but was higher than 2.13% predicted by STS scoring system. For single and double valve replacement procedures, EuroSCORE II was the best predictor of mortality with highest Hosmer and Lemmeshow test (H-L) p value (0.346 to 0.689) and area under the receiver operating characteristic (ROC) curve (0.637 to 0.898). For valve plus concomitant coronary artery bypass grafting (CABG) patients actual mortality was 1.88%. STS calculator came out to be the best predictor of mortality for this subgroup with H-L p value (0.480 to 0.884) and ROC (0.657 to 0.775). For Pakistani population EuroSCORE II is an accurate predictor for individual operative risk in patients undergoing isolated valve surgery, whereas STS performs better in the valve plus CABG group.

Laparoscopic Cholecystectomy in Cirrhotic Patients

Background: Cholelithiasis is very common in cirrhotic patients (15-30%), occurring 1 to 3 times more often than in general population. The presence of cirrhosis, hepatocellular failure and/or portal hypertension increases the risk of postoperative complications in any type of surgery, especially biliary. Methods: A review of the literature over the last 8 years (2005-2013) was performed by searching the Medline database using the following keywords “Laparoscopic Cholecystectomy” and “cirrhosis”. We selected 11 studies that were considered well-documented and contained comparable data. We analyze the demographics, cholecystectomy indication and duration, incidence of perioperative complications and time of hospitalization in cirrhotic and noncirrhotic patients. Results: Analysis of the literature revealed a total of 842 cirrhotic patients that undergone laparoscopic cholecystectomy in group of 11 published studies. The incidence of acute cholecystitis as indication for LC (Laparoscopic Cholecystectomy) was extremely variable (3.6% to 52.38%). The ratio women to men were 1.06: 407 patients (48.34%) were men and 435 were women (51.66%). Mean of mean age reported by each series was of 53.77 years (range 21-86). Child-Pugh class was reported by 10 studies for a total of 577 patients, most of them being Child-Pugh class A (443 cases, 76.78%) and B (119 cases, 23.22%). The average operating time of reported mean values was of 94.14 minutes. Average overall morbidity rate was of 24.87%; a single study reported 75% morbidity, all other studies indicating rates of maximum 35%. The length of hospital stay was of 3.47 days (range: 1.87 to 7.2). Conclusions: LC, although initially contraindicated in cirrhotic patients, has gradually replaced open cholecystectomy as standard surgical procedure. The operative risk in patients with liver disease depends on the degree of preexistent hepatic dysfunction, nature of the procedure and comorbid conditions.

A prospective cohort study to reduce operative risk in stage I gastric cancer patients with metabolic syndrome: Preoperative exercise versus surgery alone.

e15112 Background: Although obesity influences the technical difficulty of surgery, a reasonable marker of abdominal obesity is not confirmed and effective intervention has never been applied to reduce the operative risk in patients with abdominal obesity. Methods: To reduce the surgical difficulty and risk in gastric cancer patients with abdominal obesity, a preoperative exercise protocol was designed for stage I gastric cancer patients who were diagnosed to have metabolic syndrome (MetS). Results: In total, 51 patients (33 who underwent surgery alone, 18 who were treated with preoperative exercise) were registered in this study. Visceral fat areas (VFA) were estimated by CT scan, and they were associated most strongly with waist, followed by HDL cholesterol, and BMI. In the exercise group, all patients completed protocol treatment, without disease progression and &gt; grade2 exercise-associated adverse events. VFA of the exercise group were larger than that of the surgery alone group at registration (221cm2 /180cm2, p=0.028), then reduced after exercise to non-significant level with surgery alone group (201cm2 /180cm2, p=0.264). There were no significant differences of intraoperative blood loss (262mL/201mL: p=0.465) and incidence of perioperative morbidity (27.7%/29%, p=1.000) between exercise and non-exercise groups. Multivariate logistic regression analysis detected intraoperative blood loss (&gt; 380mL) as significant risk factor (p=0.023) for perioperative morbidity. Conclusions: Waist was surrogate marker for VFA in this study, thus can be a candidate of simple indicator of abdominal obesity. Preoperative interventional exercise did not directly reduce operative risk of gastric cancer with MetS; however, it was associated indirectly with risk reduction by improving surgical difficulty.

Comparison of Six Risk Scores for In-hospital Mortality in Chinese Patients Undergoing Heart Valve Surgery

To compare six risk scores with regard to their validity to predict in-hospital mortality after heart valve surgery in a single-centre patient population of China. From January 2006 to December 2011, 3479 consecutive patients who underwent heart valve surgery at our centre were collected and scored according to the EuroSCORE II, VA risk score, NNE risk score, Ambler risk score, NYC risk score, and STS risk score. Calibration of the six risk scores was assessed by the Hosmer-Lemeshow (H-L) test. Discrimination was tested by calculating the area under the receiver operating characteristic (ROC) curve. Observed mortality was 3.32% overall. The STS score showed good calibration in predicting in-hospital mortality (H-L: P = 0.126). The EuroSCORE II, VA score, NNE score, and NYC score underpredicted observed mortality (H-L: P < 0.0001, P < 0.0001, P = 0.001, and P < 0.0001, respectively) and the Ambler score overpredicted observed mortality (H-L: P = 0.005). The discriminative power (i.e. the area under the ROC curve) for in-hospital mortality was highest for the STS score (0.706), followed by the EuroSCORE II model (0.693), NNE score (0.684), NYC score (0.682), Ambler score (0.677) and VA score (0.643). Compared with the EuroSCORE II, VA score, NNE score, NYC score, and the Ambler score, the STS score gives an accurate prediction for individual operative risk in patients undergoing heart valve surgery at our centre. Therefore, the use of the STS score for risk evaluation maybe suitable in patients undergoing heart valve surgery at our centre in the future.

Asymptomatic Severe Aortic Stenosis with Left Ventricular Dysfunction: Watchful Waiting or Valve Replacement?

Aortic stenosis (AS) is the most common valvular heart disorder in older adults. Patients with severe AS are generally treated nonsurgically if asymptomatic and referred to aortic valve replacement when symptoms develop. However, patients with severe asymptomatic AS with left ventricular dysfunction may benefit from early aortic valve replacement. Although operative mortality in patients with severe AS and left ventricular dysfunction is greater than in patients with preserved left ventricular function, the overall mortality risk is substantially lower than that of watchful waiting. Operative risk in patients with severe AS and left ventricular dysfunction is often overestimated and, consequently, most are not referred to surgery despite clinical data in support of early aortic valve replacement. Asymptomatic patients with echocardiographic confirmation of severe AS and left ventricular dysfunction should be referred for aortic valve replacement.

Validation of EuroSCORE II in Chinese Patients Undergoing Heart Valve Surgery

To assess the performance of the The European System for Cardiac Operative. Risk Evaluation II (EuroSCORE II) in Chinese patients undergoing heart valve surgery at our centre. From January 2006 to December 2011, 3479 consecutive patients who underwent heart valve surgery at our centre were collected and scored according to the original EuroSCORE and EuroSCORE II models. All patients were divided into single valve surgery and multiple valve surgery subgroups. The entire cohort and each subgroup were analysed. Calibration of the original EuroSCORE and EuroSCORE II models was assessed by the Hosmer-Lemeshow (H-L) test. Discrimination was tested by calculating the area under the receiver operating characteristic (ROC) curve. Observed mortality was 3.32% overall, compared to expected mortality 3.84% for the original additive EuroSCORE (H-L: P = 0.013), 3.33% for the original logistic EuroSCORE (H-L: P = 0.08), and 2.52% for the EuroSCORE II (H-L: P < 0.0001). The EuroSCORE II model showed good calibration in predicting in-hospital mortality for patients undergoing single valve surgery (H-L: P = 0.103) and poor calibration for patients undergoing multiple valve surgery (H-L: P < 0.0001). The discriminative power of the original EuroSCORE model (area under the ROC curve of 0.684 and 0.673 for the additive and logistic model, respectively) and EuroSCORE II model (area under the ROC curve of 0.685) for the entire cohort was poor. The discriminative power of the EuroSCORE II model was good for the single valve surgery group (area under the ROC curve of 0.792) and was poor for the multiple valve surgery group (area under the ROC curve of 0.605). The EuroSCORE II model gives an accurate prediction for individual operative risk in patients undergoing single valve surgery but an imprecise prediction in patients undergoing multiple valve surgery at our centre. Therefore, the use of the EuroSCORE II model for risk evaluation may be suitable in patients undergoing single valve surgery, and the creation of a new model which accurately predicts outcomes in patients undergoing multiple valve surgery is possibly required at our centre in the future.