Perioperative Mortality Research Articles

227. CAUSES OF IN-HOSPITAL MORTALITY FOLLOWING TRANSTHORACIC ESOPHAGECTOMY FOR CANCER

Abstract Background Rates of peri-operative mortality following esophagectomy for cancer have markedly decreased over the last few decades, with a 90-day mortality rate below 5% considered a benchmark for quality of care. Although studies have focused on mortality rates, little is known about the causality. The aim of this study was to perform a multicenter, in-depth analysis of peri-operative mortality following esophagectomy for cancer. Methods Data was obtained multicenter, from prospective databases, between January 2010 – June 2020. All patients with a lethal postoperative course (Clavien-Dindo V) following elective transthoracic esophagectomy were included. Data collection included baseline characteristics, preoperative comorbidities, surgical procedures, postoperative complications and their management. In each participating center, two surgeons independently reassessed patient work-up and the management of intra-operative and postoperative complications to finally classify the management of each section as adequate, non-adequate or undetermined. Statistics encompassed descriptive analysis. Results One-hundred and twenty-one out of 3899 patients died in-hospital following oesophagectomy; a mortality rate of 3.1%. Patients deceased on a median of 32 days after surgery (IQR: 18-60). In preoperative work up: 24 patients (19.7%) had a Charlson-Comorbidity-Index (CCI) of 5 of higher; with cardiac comorbidity reported most often, in 39% of patients. Reassessment revealed work-up was not adequate in two patients (1.4%). During surgery, 6 patients (4.6%) suffered complications, all managed adequately in reassessment. Following surgery, a total of 343 major complications were identified in the 121 patients (mean 2.4 ± 1.2) with anastomotic leakage (AL) reported most often, in 65 patients (53.7%). AL was reported as cause of death in 44 patients (36.5 %). In eight patients (6.6 %) postoperative management was reassessed to be non-adequate, in these cases recognition and initiation of treatment for AL (n=7) or conduit necrosis (n=1) was delayed. Conclustion In contrast to other published series, reassessment of this homogenous patient cohort with a lethal clinical course in expert centers revealed only a low rate of preventable mortality with respect to the preoperative patient selection and postoperative complication management. However, anastomotic leakage was identified to be the leading cause of death following esophagectomy contributing to a significantly prolonged clinical course and lethal outcome. As the development of surgical procedures with complex anastomotic techniques is inevitably associated with an increasing leakage rate expressed by prolonged learning curves, modification of complication management might be considered in order to reduce overall death rates.

200.3: Substantial decline in perioperative mortality risk for living kidney donors.

200.3: Substantial decline in perioperative mortality risk for living kidney donors.

Cushing syndrome from an ACTH-producing pheochromocytoma or paraganglioma: structured review of 94 cases.

Adrenocorticotropic hormone-producing pheochromocytomas/paragangliomas are rare neuroendocrine tumors that co-secrete excess catecholamines and adrenocorticotropic hormone, resulting in Cushing syndrome (CS). This review aims to summarize important patient characteristics, investigations, and outcomes in all cases reported in the English literature. A literature search was conducted to identify all English-language case reports and case series describing adrenocorticotropic hormone-producing pheochromocytomas/paragangliomas. Relevant characteristics were systematically recorded. Cases that did not provide definitive evidence of an adrenocorticotropin (ACTH)-producing pheochromocytoma/paraganglioma were excluded. Our search strategy identified 93 published cases that met the inclusion criteria. We additionally reported one patient for a total of 94 cases. Details related to patient characteristics, laboratory data, and outcomes were commonly underreported. The median age was 47 years, and females accounted for 72% of cases. A cushingoid appearance was reported in 82% of patients, and hypertension in 86%. Infections were reported in 23% of patients. Urinary metanephrines were elevated at least three-fold above normal in 74% of cases. ACTH levels were high in 88% of patients and inappropriately normal in 12%. The median 24-hour urinary cortisol was 21-fold the upper limit of normal. Adrenalectomy was performed in nearly all patients, with 88% achieving a cure for both catecholamine and glucocorticoid excess. A total of 11 patients died. Metastases were uncommon (6%). Adrenocorticotropic hormone-producing pheochromocytomas/paragangliomas are associated with considerable morbidity and mortality. It should be considered in the diagnostic workup of all patients with ectopic CS. Surgical cure is achieved in most patients, and infections are the leading cause of peri-operative mortality.

348. MANAGEMENT OF AORTO-ESOPHAGEAL FIFISTULA SECONDARY AFTER THORACIC ENDOVASCULAR AORTIC REPAIR

Abstract Background Aorto-esophageal fifistula (AEF) is rare with highly fatal conditions and occurs most frequently secondary as a result of oesophageal malignancies, aortic aneurysms, thoracic trauma, and other thoracic surgerys. We evaluated the incidence of AEF after thoracic endovascular aortic repair (TEVAR), and investigated their clinical features, determinants, therapeutic options and results. Raising awareness and vigilance of AEF and developing individualized diagnosis and treatment measures are the key to improve the prognosis. Methods We conducted a voluntary survey in three centres with a thoracic endovascular programme. Results Of the patients who underwent TEVAR between 2010 and 2020,11/423 developed AEF. Aortic pseudoaneurysm was associated with the development of AEF among indications to TEVAR (P<0.05). Besides, emergent and complicated procedures resulted in increased risk of AEF (P<0.05). Five patients were treated conservatively, all of whom died within 30 days. Six patients underwent AEF surgical treatment, with a perioperative mortality of 33% (2/6). At a mean follow-up of 18.7+13.6 months, overall survival was 33% (2/6). Conclusion The incidence of AEF after TEVAR is not negligible and long-term follow-up is required especially for patients submitted to emergent and complicated procedures. Both surgical and endovascular treatment of AEF are associated with high mortality. However, once AEF develops, conservative treatment does not appear to be an optimal management. Timely operation has positive correlation with increase of long-term survival rate of patients.

Single-center clinical experience of extended sleeve lobectomy (ESL) versus standard sleeve lobectomy (SL).

Sleeve lobectomy (SL) and extended SL (ESL), which aim to preserve pulmonary function and enhance the quality of life of patients while ensuring oncological outcomes, are valuable surgical options for the treatment of centrally located non-small cell lung cancer (NSCLC). This study aimed to compare perioperative adverse events and long-term survival between SL and ESL in NSCLC patients, providing a comprehensive review of surgical outcomes, complications, and survival to assess the roles of SL and ESL in thoracic oncology. This single-center retrospective study assessed the outcomes of NSCLC patients who underwent SL or ESL from June 2014 to January 2022. The patients were selected based on specific inclusion criteria, and statistical analyses were conducted to examine the postoperative outcomes, overall survival (OS), and disease-free survival (DFS) of the patients. A total of 218 patients met the inclusion criteria. Among 218 patients, 33 underwent ESL and 185 underwent SL. Compared to SL, ESL was associated with longer operative times and higher R0 resection rates (93.9% vs. 78.8%, P=0.047). Despite the higher complexity of ESL compared to SL, there were no significant differences in the perioperative complications or mortality rates between the groups. Survival analysis was conducted on the propensity score matching (PSM) data, the results demonstrated superior OS and DFS in the ESL group compared to the SL group. Advanced age, more advanced nodal (N) status, and non-R0 resection were significant predictors of poorer prognosis. ESL is a feasible and effective alternative for treating centrally located NSCLC, with better R0 resection rates and comparable survival outcomes to SL, without increasing the risk of grade III-IV complications. Further studies with larger cohorts need to be conducted to validate these findings and refine the surgical techniques.

Potential value and advances in research on bone mineral density (BMD) measurement in the auxiliary clinical assessment of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer death worldwide and its prognosis is highly heterogeneous, being related not only to underlying chronic liver disease but also to the severity of cancer cachexia. Nutritional factors play a crucial role in influencing the prognosis of HCC. Despite musculoskeletal imbalance being consistently reported as a predictor of perioperative mortality in patients with HCC, this condition is often overlooked in clinical management. Bone mineral density (BMD), which serves as a marker of nutritional status, can be assessed through CT by measuring the pixel density of the vertebral bone. Recent clinical studies have indicated that BMD serves not only as a significant risk factor for development of HCC in cirrhotic patients but also potentially functions as an independent prognostic indicator for post-treatment outcomes in patients with HCC. Preoperative abdominal CT scans provide a convenient and cost-effective method to measure BMD, offering significant assistance in prognostic evaluation of patients with HCC. A thorough grasp of the liver-bone connection, along with the conduct of higher-quality studies and the establishment of standardized methods and cutoff values for BMD measurement, could enhance approaches to manage HCC.

The jailed coiling technique: An endovascular solution for saccular aneurysms with suboptimal fixation sites.

To evaluate the midterm results of patients with saccular aneurysms treated with the jailed coiling technique. A retrospective review of 17 patients treated with the jailed coiling technique over a 7 year period, between 2018 and 2024 at our institution. Treatment entails placing an endograft across the neck of the saccular aneurysm followed by coiling of the aneurysm through an extraluminal catheter. Debranching procedures of the aortic arch were performed when necessary in order to create a sealing zone of >5mm. Data collected included demographics, anatomical features of the lesions and sealing zones, indication for intervention, method of treatment and technical success, sac expansion, and reinterventions. 17 patients (median age 69, 14 males) were treated for saccular aneurysms with short, suboptimal sealing zones (aortic arch 13, distal thoracic aorta 2, celiac trunk 1, brachiocephalic artery 1). Among the aortic arch aneurysms, six required preoperative debranching procedures of the aortic arch in order to create a short landing zone of 5mm, making them eligible for the procedure. Technical success was obtained in all patients. One perioperative mortality occurred. Mean follow-up among those treated for arch aneurysms was 32 months (range 1-71 months). One patient who was treated for an aortic arch aneurysm had a persistent endoleak. No sac enlargement was observed. None of the patients required interventions and none experienced aneurysm related mortality. The jailed coiling technique is a safe and effective method to treat saccular arterial aneurysms with suboptimal, short sealing zones. It can be utilized for saccular aneurysms located within the aortic arch and for aneurysms located in other locations where coiling or stent grafting is not an option. The procedure can be performed with minimal morbidity with a high percentage of success. Long term durability of the repair needs to be determined.

Comparison of a risk calculator with frailty indices in patients undergoing lung cancer resection.

Perioperative risk stratification is an essential component of preoperative planning for cancer surgery. While frailty has gained attention for its utility in risk stratification, no studies have directly compared it to existing risk calculators. Therefore, the objective of this study was to compare the risk stratification of the American College of Surgeons Surgical Risk Calculator (ACS-SRC), the Revised Risk Analysis Index (RAI-rev), and the Modified Frailty Index (5-mFI). The primary outcomes were 30-day postoperative morbidity, 30-day postoperative mortality, unplanned readmission, unplanned reoperation, and discharge disposition other-than-home. Patients undergoing anatomic lung resection for primary, non-small cell lung cancer were identified within the American College of Surgeons National Quality Improvement Program (ACS NSQIP) database. The ACS-SRC, RAI-rev, and 5-mFI tools were used to predict adverse postoperative events. Tools were compared for discrimination in the primary outcomes. 9663 patients undergoing anatomic lung resection for cancer between 2012 and 2014 were included. The cohort was 53.1% female. Median age at diagnosis was 67 (interquartile range = 59-74) years. Cardiothoracic surgeons performed 89% and general surgeons performed 11.0% of the operations. Perioperative morbidity and mortality rates were 10.9% (n = 1048) and 1.6% (n = 158). Rates of 30-day postoperative unplanned readmission and reoperation were 7.5% (n = 725) and 4.8% (n = 468). The ACS-SRC had the highest discrimination for all measured outcomes, as measured by the area under the receiver operating curve (AUC) and corresponding confidence interval (95% confidence interval [CI]). This included perioperative mortality (AUC = 0.74, 95% CI = 0.71-0.78), compared to RAI-rev (AUC = 0.66, 95% CI = 0.62-0.69) and 5-mFI (AUC = 0.61, 95% CI = 0.57-0.65; p < 0.001). The RAI-rev and 5-mFI had similar discrimination for all measured outcomes. ACS-SRC was the perioperative risk stratification tool with the highest predictive discrimination for adverse, 30-day, postoperative events for patients with cancer treated with anatomic lung resection.

Comparison of perioperative bleeding risk between direct oral anticoagulants in transurethral resection of prostate.

To evaluate the perioperative morbidity and mortality associated with direct oral anticoagulants (DOACs) and warfarin for patients receiving transurethral resection of prostate (TURP). This was a single-centre, retrospective cohort analysis of patients who underwent TURP for benign prostate hyperplasia from April 2019 to December 2023. The primary objective was to evaluate the perioperative bleeding and thromboembolic risk between anticoagulated (AC) vs no-AC patients. The secondary objective was to evaluate perioperative bleeding and thromboembolic risk between different formulations of DOACs. Patient demographics, prior treatment, prostate size, baseline bleeding risk, and operative details were collected. Bleeding and thromboembolic-related morbidity were captured within a 3-month postoperative period. Perioperative management of AC therapy was recorded, and all patients had their AC therapy withheld. Cohort characteristic between the AC vs no-AC, and DOAC groups were analysed with two-sided t-test, and chi-square test. Further logistic regression analyses were carried out to identified significant variables between the groups. These significant variables were used for adjustment in inverse probability-weighted treatment effect analysis to evaluate bleeding risk. There were 629 patients in the cohort, and 113 (18%) patients were receiving AC therapy. The AC patients were at 1.6 times statistically significant increased risk of acute bleeding, and 11 times increased risk of prolonged haematuria for >14 days. When compared to apixaban, patients on rivaroxaban conferred a statistically significant increased risk of acute bleeding by 2.21 times. Patients receiving AC therapy had a statistically significant increased risk of stroke in the perioperative setting (no-AC vs AC: 0.4% vs 2.7%, P = 0.01). This is the first study to evaluate risk of bleeding for TURP patients receiving DOACs. The AC patients are more likely to experience haematuria and stroke in the perioperative period despite withholding therapy. Apixaban appears to cause less bleeding-related complications than rivaroxaban.

Gender-Specific Long-Term Results After Elective Open Abdominal Aortic Aneurysm Repair Depending on the Site of Distal Anastomosis.

Analysis of gender-specific differences in short- and long-term outcome after elective open abdominal aortic aneurysm repair (OAR) regarding the distal anastomosis. In this retrospective cohort study, data from 4853 patients of a German health insurance company undergoing OAR for infrarenal abdominal aortic aneurysms (AAAs) between 2010 and 2016 were analysed. The patients were followed through 2018. A total of 4050 (83.5%) men and 803 (16.6%) women underwent OAR. Women were older than men (72.9 ± 8.7 vs 69.8 ± 8.5years; P < .001). A tube graft was used in 2644 (54.5%) patients, an aorto-biiliac bifurcated graft in 1657 (34.1%) and an aorto-bifemoral bifurcated graft in 552 (11.4%). Perioperative mortality was not significantly different between men (5.7%) and women (6.5%) in the total patient population (P = .411). This was true for aorto-aortic tube grafting (P = .361), aorto-biiliac reconstructions (P = 1.000) and aorto-bifemoral reconstructions (P = .345). Kaplan-Meier estimated long-term survival of men after 9years was better than that of women (55.0% vs 43.8%; P = .006). However, separated by the site of the distal anastomosis, this was only true for aorto-aortic reconstructions (survival men vs women 56.0% vs 42.1%; P = .005), not for aorto-biiliac and aorto-bifemoral reconstructions. In the multivariate Cox regression analysis, age over 80years, heart failure, aorto-bifemoral reconstruction, chronic kidney disease stage 3-5, chronic obstructive pulmonary disease, peripheral artery disease, arterial hypertension, but not gender (P = .531), had a negative impact on long-term survival. If possible, an aorto-aortic tube graft should be preferred to aorto-biiliac and aorto-bifemoral reconstructions in OAR. Patients selected for aorto-bifemoral artery reconstruction exhibit higher perioperative morbidity and mortality as well as worse long-term survival compared to patients selected for an intra-abdominal reconstruction. In the multivariate regression analysis, gender was not an independent risk factor for either short- or long-term outcomes.

Thirty-Year Trends in Perioperative Mortality Risk for Living Kidney Donors

This study uses a national registry study to characterize temporal trends in perioperative mortality in donors and risk factors associated with this event.

Identifying barriers and facilitators to follow-up after endovascular aortic repair (EVAR): Qualitative study design and protocol

Endovascular aortic repair (EVAR) is now first line therapy for most patients with abdominal aortic aneurysms (AAA) as it reduces perioperative morbidity and mortality compared to open surgery. However, up to 40 % of patients do not undergo recommended follow-up, increasing risk of subsequent rupture. Risk factors for loss to follow-up have been studied retrospectively, however, qualitative studies assessing perceived barriers and facilitators to follow-up have not been performed and there are few qualitative protocols within the vascular surgery literature. This article presents a qualitative descriptive study protocol aimed at understanding and improving post-operative follow-up adherence after EVAR developed through an iterative process based on the Theoretical Domains Framework of behavior change. Steps include:•Selection of target behavior and study design•Development of study materials, sampling/recruitment strategy, and data collection•Qualitative data analysis and reporting findingsWe demonstrate the feasibility of this study by pilot testing of the semi-structured interview guides on a small group of patients, healthcare providers, and key personnel. This protocol aims to describe key stakeholder experiences within the healthcare system that will ultimately serve as the basis for future multi-institutional research piloting intervention strategies to improve EVAR follow-up.

Bi-National Outcomes of Redo Surgical Aortic Valve Replacement in the Era of Valve-in-Valve Transcatheter Aortic Valve

Implantation of bioprosthetic valves is more common as the population ages and there is a shift towards implanting bioprosthetic aortic valves in an increasingly younger surgical population. Bioprosthetic heart valve insertion, however, carries the long-term risk of valve failure through structural valve degeneration. Re-operative surgical aortic valve replacement has historically been the only definitive management option for patients with prosthetic valve dysfunction, however, data on the short- and long-term outcomes following re-operative surgery in Australia and New Zealand is limited. Data on all patients who underwent redo aortic valve surgery, over a 20-year period (up to 2021) was obtained from the Australian and New Zealand Society of Cardiothoracic Surgery Registry. A total of 1,199 patients (770 males; 64.2% and 429 females; 35.8%) were included in the overall analysis. The 30-day mortality was 6.4% with operative urgency status the most important risk factor for peri-operative mortality. The long-term survival rate of 1,145 patients was 90.5% (95% confidence interval [CI] 88.8%-92.3%), 77% (95% CI 73.9%-80.2%) and 57.2% (95% CI 55.2%-62.8%) at 1-, 5- and 10-years post-procedure, respectively, with a median survival of 12.7 years. Pre-existing chronic kidney disease was strongly associated with poorer long-term survival. For patients under 70 years of age the 1-, 5- and 10-year survival rates were 92.9% (95% CI 90.9%-95.1%), 83.6% (95% CI 80.1%-87.3%) and 73.1% (95% CI 67.4%-79.3%), respectively. The results from this registry study indicate that in Australia and New Zealand, a repeat surgical aortic valve replacement can result in a relatively low mortality rate, serving as a reference point for medical procedures in these regions.

Endovascular Aortic Repair With the E-Tegra Device: Preliminary Outcomes From a Multicenter National Registry.

Endovascular aortic repair (EVAR) is currently expanding its feasibility thanks to design innovations, but hostile proximal necks and narrow iliac arteries are still a constraint, as expressed by the Instructions for Use (IFU) of most devices. Our aim is to report the preliminary results of the E-Tegra endograft in infrarenal abdominal aortic aneurysms (AAAs) performed in 15 high-volume centers. The e-Tegra Italian endoGraft REgistry (TIGRE) is a prospectively maintained database of consecutive EVAR with the E-Tegra stent-graft across 15 participating centers between March 2021 and March 2023. The registry records baseline clinical data, anatomic measurements of the abdominal aorta, perioperative and postoperative outcomes, with a scheduled follow-up period of 3 years for all patients. This is a preliminary analysis of the first results updated to January 2024. The primary endpoints are technical and clinical success, perioperative mortality, freedom from endograft rupture, and aortic-related mortality. The secondary endpoints are freedom from reintervention, and any type of endoleak (EL). The results were analyzed in relation with the anatomic characteristics of the AAAs, namely, iliac axes tortuosity and proximal neck hostility. The registry included 147 consecutive EVAR (138 elective and 9 in emergent setting), 7 of which were associated with an iliac branch implantation. Ninety patients had at least 1 criterion of anatomical hostility, and 25 were treated outside the device IFU. Primary technical success was achieved in 146 cases (99.3%) and assisted success in 147 (100%), with no perioperative mortality. After a median follow-up period of 20 months, no aneurysm-related mortality occurred. Reinterventions were 5: 2 for type IB EL and 3 for type II ELs with aneurysm sac increase. Five more type II ELs with aneurysm sac stability are under observation. No differences in terms of reinterventions were noted between aneurysms with standard and hostile anatomy. The E-Tegra endograft is safe and effective in treating AAAs with standard and hostile anatomy, with a low rate of complications and reinterventions, although longer-term outcomes and larger numbers are needed to compare its performances related to specific anatomic criteria. This multi-center nationwide Registry reports a real-world experience of EVAR performed with the E-Tegra abdominal endograft across 15 high-volume Centers, providing early- and mid-term device-specific results, which will help vascular surgeons in endograft selection. In particular, this study focuses on clinical results obtained in treating aneurysms with hostile anatomy, analyzing the performances of the E-Tegra endograft in cases of hostile proximal necks and narrow or tortuous iliac axes.

The Enzen Trial: Analysis of EVAR Endoprosthesis Zenith and Endurant for Infrarenal Aortoiliac Aneurysms Regarding Outcomes, Endoleaks, and Reinterventions.

The main objective of this paper is to analyze the outcomes regarding endoleaks, reinterventions, and death related to aneurysm complications in patients submitted to endovascular repair (EVAR) for abdominal aortoiliac aneurysm (AAA) using Endurant II (Medtronic) and Zenith Flex (Cook) endografts. This was a prospective, consecutive cohort study of patients with AAA who underwent EVAR between January 2019 and December 2022. Two groups of patients were evaluated: Group Endurant (patients submitted to EVAR with the use of Endurant II) and Group Zenith (patients submitted to EVAR with the use of Zenith Flex). A total of 156 patients were evaluated. Group Zenith (67 patients, 42.9%) and Group Endurant (89 patients, 57.1%). The perioperative mortality was 5.1%, eight patients (six patients Group Zenith, and two patients Group Endurant, p=0.054). There were 28 patients (17.9%) submitted to urgent repair of the aneurysm (expansion or rupture), with no differences among the groups. There were 36 cases (23.1%) of later endoleak, with a higher incidence in Zenith group (23 patients, 34.3%) than Endurant group (13 patients, 14.6%, p=0.002), most of them Type II endoleak (21 patients, 13.4%). There were 12 cases of Type I endoleak, also with a higher prevalence in Zenith group (13.4%) than Endurant group (3.4%, p=0.002). Moreover, regarding limb graft occlusion (LGO), there were nine patients (5.8%), with a higher prevalence in Zenith group (9%) than Endurant group (3.4%, p=0.045). The overall survival in a Kaplan-Meier at 720 days was 82.3% in the Zenith group and 89.1% in the Endurant group, with no statistical significance among the groups (p=0.09). The freedom from reintervention rates in a Kaplan-Meier at 720 days was 82.8% in the Zenith group and 93.2% in the Endurant group (p=0.001). In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, LGO and reinterventions than patients submitted to Endurant II endografts. The linear regression analysis showed that the presence of endoleaks, type of endograft device (Zenith graft) and limb graft occlusion were related to higher reintervention rates. In this present study, Zenith endograft had higher rates of endoleaks, aneurysms related mortality, limb graft occlusions and reinterventions than patients submitted to Endurant II endografts. The main impact and the innovation that this article provides is an opportunity to evaluate and choose the best endograft suitable for the patient with AAA during EVAR.

Comparative Retrospective Cohort Study of Carotid-Subclavian Bypass versus In Situ Fenestration for Left Subclavian Artery Revascularization during Zone 2 Thoracic Endovascular Aortic Repair: A Single-Center Experience.

Background: Thoracic endovascular aortic repair (TEVAR) has become the first-line therapy for descending aortic disease. Recent studies have demonstrated that preventive revascularization of the left subclavian artery (LSA) in zone 2 TEVAR cases reduces the risk of neurological complications. However, there is no uniform consensus on the choice of revascularization techniques. Although carotid-subclavian bypass is considered the gold standard method, in situ fenestration techniques have also shown encouraging results. This study aims to compare the carotid-LSA bypass with in situ fenestration (ISF) for LSA revascularization and to discuss our treatment approach. Methods: We conducted a retrospective review of all patients undergoing zone 2 TEVAR with in situ fenestration (ISF) or carotid-subclavian artery bypasses for LSA revascularization at our institution between February 2011 and February 2024. Preoperative patient characteristics and primary outcomes, such as operative mortality, transient ischemic attack, stroke, and spinal cord ischemia, were analyzed between the groups. Results: During the 13-year study period, 185 patients underwent TEVAR procedures. Of these, 51 patients had LSA revascularization with zone 2 TEVAR; 32 patients underwent carotid-subclavian artery bypasses, and 19 underwent in situ fenestration. The technical success rate was 100%. Statistically, there was no significant difference between the groups in terms of primary outcomes such as stroke, transient ischemic attack, spinal cord ischemia, and death (p > 0.05). Conclusions: In situ fenestration (ISF) may be an effective and feasible method for LSA revascularization. With precise patient selection and in experienced hands, ISF appears to be associated with similar perioperative outcomes and mortality rates to the carotid-subclavian bypass.

Total laparoscopic radical resection of hilar cholangiocarcinoma: preliminary experience of a single center

BackgroundThe aim of this study was to describe our preliminary experience in the procedure of laparoscopic radical resection of hilar cholangiocarcinoma and to evaluate its feasibility, safety, and clinical efficacy.MethodsA retrospective analysis was conducted on 44 patients with hilar cholangiocarcinoma who underwent laparoscopic surgery at our hospital from August 2019 to September 2023. Clinical data were collected from these patients, including 13 cases of Bismuth type I, 17 cases of Bismuth type II, 5 cases of Bismuth type IIIa, and 9 cases of Bismuth type IIIb.ResultsLaparoscopic radical resection of hilar cholangiocarcinoma was successfully performed in 38 patients (86.3%). Among the remaining patients, 3 required vascular reconstruction to complete radical surgery and were converted to laparotomies, while 3 others underwent T-tube drainage only due to unresectable metastases. The median operation time was 285 min (range, 190–450), and the median estimated blood loss was 360 mL (range, 260–1200). The postoperative hospital stay duration was 14.3 ± 3.6 days. No perioperative mortality was observed. Postoperative pathological examination revealed negative microscopic margins (R0) in 39 cases and positive microscopic margins (R1) in 2 cases. Postoperative complications occurred in 8 patients (18.1%), with 4 cases (9.0%) of Grade I, 3 cases (6.8%) of Grade II, 1 case (2.2%) of Grade IIIa, and no Grade IIIb or IV complications. The median overall survival for patients who underwent radical R0 resection was 30.4 months (range, 5.3–43.6). The Disease-free survival rates were 73.6% at 1 year, 61.2% at 2 years, and 40.1% at 3 years.ConclusionTotal laparoscopic radical resection of hilar cholangiocarcinoma can be performed safely, feasibly, and effectively by experienced surgeons after an accurate preoperative evaluation.

Colombian surgical outcomes study insights on perioperative mortality rate, a main indicator of the lancet commission on global surgery – a prospective cohort study

Surgical care holds significant importance in healthcare, especially in low and middle-income countries, as at least 50% of the 4.2 million deaths within the initial 30 days following surgery take place in these countries. The Lancet Commission on Global Surgery proposed six indicators to enhance surgical care. In Colombia, studies have been made using secondary data. However, strategies to reduce perioperative mortality have not been implemented. This study aims to describe the fourth indicator, perioperative mortality rate (POMR), with primary data in Colombia. A multicentre prospective cohort study was conducted across 54 centres (hospitals) in Colombia. Each centre selected a 7-day recruitment period between 05/2022 and 01/2023. Inclusion criteria involved patients over 18 years of age undergoing surgical procedures in operating rooms. Data quality was ensured through a verification guideline and statistical analysis using mixed-effects multilevel modelling with a case mix analysis of mortality by procedure-related, patient-related, and hospital-related conditions. 3807 patients were included with a median age of 48 (IQR 32-64), 80.3% were classified as ASA I or II, and 27% of the procedures had a low-surgical complexity. Leading procedures were Orthopedics (19.2%) and Gynaecology/Obstetrics (17.7%). According to the Clavien-Dindo scale, postoperative complications were distributed in major complications (11.7%, 10.68-12.76) and any complication (31.6%, 30.09-33.07). POMR stood at 1.9% (1.48-2.37), with elective and emergency surgery mortalities at 0.7% (0.40-1.23) and 3% (2.3-3.89) respectively. The POMR was higher than the ratio reported in previous national studies, even when patients had a low-risk profile and low-complexity procedures. The present research represents significant public health progress with valuable insights for national decision-makers to improve the quality of surgical care. This work was supported by Universidad del Rosario and Fundación Cardioinfantil-Instituto de Cardiología grant number CTO-057-2021, project-ID IV-FGV017.

ONE-STAGE VERSUS TWO-STAGE REVISION HIP ARTHROPLASTY: CAN WE CONFIRM THE DATA FROM META-ANALYSIS IN REAL-WORLD REGISTRY DATA?

Studies and meta-analyses worldwide show an increased use of one-stage revisions for treating periprosthetic hip infections, often yielding comparable or better outcomes than two-stage revisions. However, it remains unclear if these successful results can be consistently achieved nationwide besides large centers.This observational cohort study used data from the German Arthroplasty Registry (EPRD) to compare the mortality and re-revision rates between one-stage (n=8183) and two-stage (n=657) first-time revision total hip arthroplasty (RTHA). Kaplan-Meier estimates were applied to evaluate the re-revision rate and cumulative mortality for RTHA.There was a significant difference in mortality between one-stage and two-stage RTHA (p=0.02). One-year post-surgery, the mortality rate was 9.4% for one-stage revisions and 5.5% for two-stage revisions. At the five-year follow-up, the mortality rate for one-stage revisions was 25.5%, compared to 20.0% for two-stage revisions. No significant differences (p=0.30) were found in re-revision rates between one-stage and two-stage revisions after one year (one-stage 16.5% vs. two-stage 13.5%) or five years (one-stage 21.6% vs. two-stage 20.8%). For multiple revisions, the mortality differences were even larger (p&lt;0.001), with a one-year mortality rate of 12.8% for one-stage RTHA and 5.7% for two-stage RTHA.Despite the excellent results of one-stage RTHA in the literature from individual large centers, it shows a significantly higher mortality rate with equal re-revision rate compared to two-stage revision in the nationwide care besides large centers. Significant differences can already be seen within the first year, indicating an increased perioperative mortality for one-stage revision, which might be explained by longer surgery duration, blood-loss and patient selection or maybe a lack of experience concerning proper surgical debridement for one-stage revision. This illustrates the need to establish centers for joint-revision surgery that provide interdisciplinary care and high case numbers to improve perioperative outcomes.

Non-Cardiac Perioperative Mortality Factors at a Single Urban Veterans Affairs Medical Center.

Background: The Veterans affairs (VA) surgical quality improvement program was established to evaluate the quality of VA surgical care to over nine million United States Veterans. Patient demographics vary by region, with urban areas correlating with higher mortality rates. This study attempts to determine the factors associated with 30-day mortality at a single VA medical center in an urban setting. Methods: Patients included in the study were at least 18 years of age and underwent a surgical procedure between January 2013 and June 2023. Baseline demographics included preoperative comorbidities, American Society of Anesthesiology (ASA) class, and preoperative lab values. Clinical outcomes included postoperative mortality within 30 days of the procedure. Chi-square, t-test, ANOVA, and multivariate logistic regressions were used to determine relationships, using P < .05 to determine significance. Results: A total of 11,547 patients with complete data were included, of which 92 patients (0.8%) died within 30 days of surgery. A higher preoperative hematocrit was protective against 30-day mortality. A perioperative transfusion, bleeding disorder, chronic obstructive pulmonary disease (COPD), history of a myocardial infarction, higher ASA class, and an emergency procedure all increased the likelihood of perioperative mortality. Conclusions: Veterans who seek surgical care at Veterans Health Administration centers receive high quality care with a low mortality rate. Identifying risk factors for perioperative mortality provides the opportunity to stratify those veterans at highest risk.