30-day Postoperative Morbidity Research Articles

Safety of lymphadenectomy during video-assisted thoracic surgery lobectomy: analysis from a national database.

The Italian VATS Group database was accessed to evaluate whether preoperative and intraoperative factors may affect the safety of lymphadenectomy (LA) during video-assisted thoracic surgery lobectomy. All video-assisted thoracic surgery lobectomy procedures performed between 1 January 2014 and 30 March 2017 for non-small-cell lung cancer with cN0 or cN1 disease were identified in the database. LA safety was evaluated based on intraoperative (operative time, bleeding and conversion rate) and postoperative (30-day morbidity and mortality, chest drain duration and length of stay) outcomes and was correlated with the number of resected lymph nodes and the rates of nodal upstaging. Continuous variables were presented as mean ± standard deviation and compared using the unpaired t-test; the χ2 test was used for categorical variables. Univariable analysis was performed on selected variables. Significant variables (P < 0.30) were entered into a Cox multivariable logistic regression model, using the overall and specific occurrence of complications as dependent variables. The Spearman's rank correlation coefficient was applied as needed. A total of 3181 cases (2077 men, 65.3%; mean age of 69 years) met the enrolment criteria. Final pathology was consistent with adenocarcinoma (n = 2262, 67.5%), squamous cell (n = 520, 15.5%), typical (n = 184, 5.5%) and atypical carcinoid (n = 48, 1.4%) and other (n = 335, 10%). The mean number of resected lymph nodes was 13.42 ± 8.24; nodal upstaging occurred in 308 of 3181 (9.68%) cases. Six hundred and fifty-five complications were recorded in 404 (12.7%) patients; in this series, no mortality was observed. Univariable and multivariable analyses did not show any association between the extension of LA and intraoperative or postoperative outcomes. The number of resected lymph nodes and nodal upstagings showed a minimal correlation with intraoperative outcomes and a moderate correlation with postoperative air leak (ρ = 0.35 and ρ = 0.48, respectively), arrhythmia (ρ = 0.29 and ρ = 0.35, respectively), chest drain duration (ρ = 0.35 and ρ = 0.51, respectively) and length of stay (ρ = 0.35). Based on the VATS Group data, video-assisted thoracic surgery LA proved to be safe and displayed good outcomes even when performed with an extended approach.

Thirty-day postoperative morbidity and mortality in elderly women with breast cancer: an analysis of the NSQIP database.

Postoperative complication rates for elderly women undergoing breast cancer surgery have not been well studied. We describe the postoperative complication rates of elderly (≥ 70 years) women with breast cancer and compare them with young (40-69 years) women. Data were extracted from the National Surgical Quality Improvement Program database (2004-2014). We included women with invasive breast cancer who underwent surgery. Outcomes were 30-day postoperative morbidity and mortality(complications), which were compared between young and elderly women. Morbidity was categorized using the Surgical Risk Preoperative Assessment System (SURPAS) clusters. We identified 100,037 women of which 26.7% were elderly. Compared to young women, elderly women were more likely to have more comorbidities and undergo breast-conserving surgery, but less likely to undergo lymph node surgery, breastreconstruction, and neoadjuvant chemotherapy. While the 30-day overall morbidity rate was not significantly different between young and elderly women (3.9 vs. 3.8%, p = 0.2), elderly women did have significantly higher rates of pulmonary, cardiac (arrest and myocardial infarction), venous thromboembolic, and neurological morbidity. Specific morbidities that showed significantly lower rates among elderly women included wound disruption and deep and organ space surgical site infection. Any cause death was significantly higher in elderly compared to young women (0.2 vs. 0.05%, p < 0.001). While some specific 30-day postoperative morbiditieswere more often seen in elderly women, theoverall 30-day postoperative complicationrate was very low. These data support the safety of breast cancer surgery in well-selected elderly patients.

Does prolonged operative time impact postoperative morbidity in patients undergoing robotic-assisted rectal resection for cancer?

Several studies have shown a correlation between longer operative times and higher rates of postoperative morbidity for open and laparoscopic surgery for rectal cancer. The aim of the study was to determine the impact of prolonged operative time on early postoperative morbidity in patients undergoing robotic-assisted rectal cancer resection. The study was a retrospective review of a prospectively maintained database conducted in two centers of the same institution. A total of 260 consecutive patients undergoing with robotic-assisted resection for rectal cancer between 2007 and 2016 were included. Patients were divided into two groups regarding median operative time: > 300min (prolonged operative time; n = 133) and ≤ 300min (control; n = 127). Patient characteristics, operative and postoperative data were compared between groups. Univariate and multivariate analyses were performed to determine whether prolonged operative time was a predictive factor of 30-day postoperative morbidity. Prolonged operative time was noted more frequently in males (p = 0.02), patients with higher BMI (p < 0.01), more severe comorbidities (p < 0.01), in tumors of the mid-rectum, and in surgery performed after neoadjuvant chemoradiation or upon surgeons' learning curve. The two groups had similar overall postoperative morbidity (32 vs. 41%; p = 0.16) and severe morbidity (6 vs. 6%; p = 0.92) rates. Prolonged operative time was associated with longer hospital stay (3.8 ± 2.5 vs. 5.0 ± 3.7days; p = 0.004) in univariate analysis. Prolonged operative time was not independently associated with postoperative morbidity or with increased hospital stay on multivariate analysis. In our study, prolonged operative time was not associated with an over-risk of morbidity in patients undergoing robotic resection for rectal cancer. These results suggest that more difficult robotic procedures do not lead to increased postoperative morbidity.

Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes

Our knowledge of the types of intraoperative patient safety events, their harm to patients, and relationship to postoperative complications is sparse. This study examined intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) voluntarily reported by providers using two programs at our hospital: surgical debriefing and incident reporting. Among the 3020 surgical procedures assessed, 142 iMEs and 103 iAEs were reported, yielding an overall rate of 8%. Of these events, 135 (55%) were obtained from incident reporting and 110 (45%) from surgical debriefing. The overall association between intraoperative events (iMEs and iAEs) and 30-day postoperative morbidity was significant (adjusted odds ratio = 1.08 with 95% confidence interval (CI) of (1.03, 1.13). This association was stronger when we included only the iAEs (1.47, 95% CI (1.35, 1.58)). Our findings suggest that hospitals should consider using both programs to obtain a more complete picture of intraoperative patient safety and to reduce postoperative morbidity.

Risk Factors for Readmissions Following Anterior Lumbar Interbody Fusion.

Retrospective study of prospectively collected data. To analyze the incidence and risk factors for readmissions following anterior lumbar interbody fusion. No study has yet reported readmission rates for a specific lumbar surgical approach. There is evidence to indicate differences in perioperative complication rates between anterior versus posterior lumbar interbody fusion techniques, which may translate into differences in readmission rates. The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent anterior lumbar interbody fusion. Patients were separated into groups of those with and without 30-day readmissions. Univariate analysis and multivariate logistic regression were used to analyze the effect of different risk factors on 30-day readmissions. Multivariate analysis showed that morbid obesity (odds ratio 15.6, P = 0.002) and alcohol use (odds ratio 16.9, P = 0.004) independently predicted unplanned 30-day readmission. Sex, pulmonary comorbidity, cardiac comorbidity, and steroid use were not found to be significant independent predictors of unplanned 30-day readmission in anterior lumbar interbody fusion. Adult patients undergoing anterior lumbar interbody fusion who were morbidly obese and had history of alcohol use are at increased risk for 30-day readmissions. Future studies should look to directly compare readmission rates and risk factors between alternative lumbar interbody surgical approaches with longer follow-up and more clinical and radiological parameters investigated. 3.

The Surgical Apgar Score predicts outcomes of emergency abdominal surgeries both in fit and frail older patients

The Surgical Apgar Score (SAS) is a simple and rapid scoring system predicting postoperative mortality and morbidity. However, it remains unknown whether it might be useful in fit and frail older patients undergoing abdominal emergency surgery. MethodsConsecutive patients ≥65 years, needing emergency abdominal surgery were enrolled in this prospective study. Additionally to the SAS, the G8 screening score was used to determine the frailty status. The logistic regression analysis was conducted investigating the association between the scores and 30-day postoperative outcomes. ResultsThe study sample comprised 315 older patients (165 female, 150 male) with a median age of 77 (range 65–100) years old. The prevalence of frailty was 60.3%. The most frequent surgical indications were acute cholecystitis, followed by ileus, complicated diverticulitis, ulcer perforation, complication of gastric cancer and other causes. The decreasing SAS was significantly associated with the increasing likelihood of both 30-day postoperative major complications (p < 0.01) and death (p < 0.01) both in fit and frail older patients. Multivariate analyses have identified the G8, frailty screening test, and the SAS score as independent factors that predict postoperative adverse events. The model combining both scores increased the discriminatory ability for 30-day postoperative major morbidity and mortality. ConclusionThe SAS confirmed to be a simple and powerful predictor of 30-day postoperative morbidity and mortality both in fit and frail older patients undergoing emergency abdominal surgery. The department allocation algorithm based of the combination of the G8 and the SAS may be considered as an option to improve the outcomes of older patients undergoing abdominal emergency surgery.

Frailty and emergency surgery in the elderly: protocol of a prospective, multicenter study in Italy for evaluating perioperative outcome (The FRAILESEL Study).

Improvements in living conditions and progress in medical management have resulted in better quality of life and longer life expectancy. Therefore, the number of older people undergoing surgery is increasing. Frailty is often described as a syndrome in aged patients where there is augmented vulnerability due to progressive loss of functional reserves. Studies suggest that frailty predisposes elderly to worsening outcome after surgery. Since emergency surgery is associated with higher mortality rates, it is paramount to have an accurate stratification of surgical risk in such patients. The aim of our study is to characterize the clinicopathological findings, management, and short-term outcome of elderly patients undergoing emergency surgery. The secondary objectives are to evaluate the presence and influence of frailty and analyze the prognostic role of existing risk-scores. The final FRAILESEL protocol was approved by the Ethical Committee of "Sapienza" University of Rome, Italy. The FRAILESEL study is a nationwide, Italian, multicenter, observational study conducted through a resident-led model. Patients over 65years of age who require emergency surgical procedures will be included in this study. The primary outcome measures are 30-day postoperative mortality and morbidity rates. The Clavien-Dindo classification system is used to categorize complications. The secondary outcome measures include length of hospital stay, length of stay in intensive care unit, and predictive value for morbidity and mortality of several frailty and surgical risk-scores. The results of the FRAILESEL study will be disseminated through national and international conference presentations and peer-reviewed journals. The study is also registered at ClinicalTrials.gov (ClinicalTrials.gov identifier: NCT02825082).

Multivisceral Resection for Locally Invasive Colorectal Liver Metastases: Outcomes of a Matched Cohort Analysis

Local invasion of adjacent viscera by colorectal liver metastases (CRLM) is no longer considered an absolute contraindication to curative hepatic resection. A growing number of observational analyses have illustrated the feasibility of such resections; however, the evidence base is at best heterogeneous with a lack of evidence comparing similar patient groups. We aimed to evaluate the outcomes of hepatectomy for CRLM when combined with other viscera and compare to a matched cohort of isolated hepatic resections. Methods: From 2005 to 2015, 523 patients underwent hepatic resection for CRLM at our institution, 19 of whom underwent hepatectomy with extrahepatic resection. A 3: 1 matched cohort analysis was performed between those who underwent isolated hepatectomy (control group) and those who underwent hepatectomy with extrahepatic resection (combined group). Clinicopathological data were reviewed along with 30-day postoperative morbidity and mortality. Furthermore, overall survival for the multivisceral cohort was compared to all other isolated hepatectomies over the same time period. Results: Nineteen patients underwent liver resection accompanied by either/or diaphragmatic resection (n = 13), major vein resection and reconstruction (n = 5), and visceral resection (n = 3). Maximum tumor size was significantly larger in the combined group (60.58 vs. 15.34 mm p < 0.0001). Postoperative morbidity was similar in both groups (p = 0.41). Following multivisceral resection, 1-, 3- and 5-year survival rates were 75, 56.6, and 25.7% respectively. Overall survival showed no significant difference between combined and control groups (p = 0.78). Similarly, when compared to the total cohort of isolated liver resections (n = 504), no significant difference in overall mortality was noted. Conclusion: In patients presenting with concomitant CRLM and extrahepatic extension where R0 margins can be achieved, this present study supports the rationale to proceed to ­surgery with comparable morbidity and mortality rates to ­isolated hepatectomy.

Immune effects after uniportal nonintubated video-thoracoscopic operations

Background: We hypothesized that uniportal video-assisted thoracic surgery (VATS) under nonintubated anesthesia may have a lesser immunological impact than same procedures under general anesthesia. Methods: Between December 2005 and October 2016, a total of consecutive 878 patients underwent VATS operations under nonintubated anesthesia. In a subset of 542 patients we assessed lymphocyte subpopulations at 1, 7 and 14 days postoperatively and matched with a control group of 106 patients who underwent uniportal intubated surgery. Results: Global time spent in the operative room was significantly longer in intubated group (85±41 vs. 118±34 minutes; P=0.03). The total lymphocytes count showed a lesser drop in the nonintubated group at post-operative day 7 (P=0.04) and 14 (P=0.05) with a significant lesser reduction of natural killer lymphocytes at day 7 (P=0.03) and 14 (P=0.04). 30-day mortality (0.9% vs. 4.7%; P=0.04), major morbidity (9.5% vs. 19%; P=0.03) and hospital stay (4.2±2.8 vs. 6.1±2.6 days; P=0.04) were significantly lower in the nonintubated group. Survival rate in the subset of patients operated for malignant effusion was significantly higher in the nonintubated group (P=0.03). Conclusions: Uniportal nonintubated operations demonstrated a significant lower impact on immunological response compared to the traditional procedure in general anesthesia. This impacted postoperative 30-day mortality, major morbidity and hospital stay. We also found a significant influence on long-term survival in a consistent subset of patients operated for malignant pleural effusion.

P640 Risk of post-operative complications among Crohn’s disease patients treated pre-operatively with vedolizumab. A matched case–control study

Although biologic agents have revolutionised the medical management of moderate-to-severe Crohn’s disease (CD), many patients still require surgery. Vedolizumab, a biologic agent directed towards gut-specific α4β7 integrins, has recently been used to treat CD. There is considerable controversy regarding the potential adverse effects of vedolizumab on surgical outcomes. The aim of this study was to evaluate 30-day post-operative morbidity in patients with CD receiving vedolizumab prior to colorectal surgery. A prospectively maintained database evaluating the role of clinical, serologic and genetic markers with clinical phenotypes in CD was queried for patients treated with vedolizumab prior to surgery. Selected patients were then age and gender matched 1: 3: 3 into three pre-operative treatment groups: (a) vedolizumab, (b) anti-tumour necrosis factor (anti-TNF), and (c) no biologics. Demographic information, characteristics of the disease and its treatment, and perioperative outcomes were tabulated. Thirty-day post-operative complications among patient groups were compared using univariate and multivariable analysis. Eighty-one age and gender matched patients were included, 13 of whom were treated with vedolizumab, 39 who were treated with anti-TNF and 29 who were treated with no biologics. Three patient groups were also well matched in number of prior CD surgeries, pre-operative steroid use, smoking, indications for surgery, use of a stoma and length of the resected specimen. The overall incidence of post-operative complications was not different among patients pre-operatively receiving vedolizumab, anti-TNF or no biologics (30.8% vs. 20.5% vs. 33.3%; p = 0.72). There was also no significant difference in the development of surgical site infection (7.7% vs. 12.8% vs. 10.3%; p = 0.87), post-operative ileus (30.8% vs. 10.3% vs. 17.2%; p = .21), mean (SD) length of postoperative hospital stay (4.8 ± 3.2 vs. 4.5 ± 3.2 vs. 4.7 ± 2.3 days; p = 0.95) or readmission rate (0 vs. 2.6% vs. 3.4%; p = 0.80) in patients receiving pre-operative vedolizumab, anti-TNF, or no biologics, respectively. On multivariable analysis of the entire cohort, only previous bowel obstruction increased the 30-day morbidity (p = 0.02). However, vedolizumab was not associated with any postoperative outcome, including overall 30-day morbidity (OR: 1.07, 95% CI: 0.79–1.46; p = 0.66), surgical site infection (OR: 0.96, 95% CI: 0.76–1.22; p = 0.75) or ileus (OR: 1.14, 95% CI: 0.90–1.46; p = 0.27). In this matched case–control study, pre-operative vedolizumab exposure did not affect the risk of 30-day post-operative complications in CD. Pre-operative treatment with vedolizumab in CD appears to be safe.

High Neutrophil to Lymphocyte Ratio Is Associated With Symptomatic and Ruptured Thoracic Aortic Aneurysm.

The predictive value of the neutrophil to lymphocyte ratio (NLR) has been demonstrated in several cardiovascular diseases. The aim of our study was to investigate the association between the preoperative NLR and aneurysm characteristics as well as 30-day postoperative morbidity and mortality in patients with thoracic aortic aneurysm (TAA) undergoing aortic surgical repair. Consecutive patients (n = 75) with TAA were retrospectively included over a 10-year period. Clinical characteristics, aneurysm characteristics, and 30-day postoperative outcome were recorded. The median age of patients was 71 (67-80) years. The median preoperative NLR was 3.5 (2.3-5.8). The proportion of asymptomatic TAA was significantly lower in patients with an NLR > 3.5 compared with those with an NLR < 3.5 (52.6% vs 75.7%; P = .054). The proportion of patients with pain or with ruptured TAA was significantly higher in patients with an NLR > 3.5 compared with those with NLR < 3.5 (42.1% vs 16.2%; P = .022 and 26.3% vs 2.7%; P = .007, respectively). No significant difference was observed regarding the 30-day overall postoperative mortality and morbidity. The preoperative NLR did not correlate with TAA diameter. A high preoperative NLR is significantly associated with symptomatic and ruptured TAA, suggesting a potential interest as a marker and/or player in the disease.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for the Elderly: Is It Reasonable? A Meta-Analysis.

Whether cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is safe and worthwhile for elderly patients remains unclear. This meta-analysis of outcomes after CRS plus HIPEC for the elderly aimed to generate a higher level of evidence and precise indications for these patients. A systematic literature search for studies reporting postoperative outcomes after CRS plus HIPEC for elderly patients was performed in the MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Web of Knowledge Conference Proceedings Citation Index-Science, and Google Scholar databases. The included studies evaluated the overall 30-day postoperative morbidity, 90-day postoperative mortality, grade 3 or higher postoperative morbidity, rates of anastomotic leaks, reoperation and readmission, and length of hospital stay. The inclusion criteria were met by 13 retrospective studies involving 2544 patients. Considering only comparative studies, the 90-day postoperative mortality was significantly increased for elderly patients [odds ratio (OR), 0.49; 95% confidence interval (CI), 0.27-0.88; I 2=79%]. The 30-day grade 3 or higher postoperative morbidity was increased in the patients 70years of age or older (14.5%; 95% CI 8.1-24.4 vs. 32.3%; 95% CI 22.4-44.0%; p=0.004; I 2=85%). The overall 30-day postoperative morbidity, rates of anastomotic leaks, reoperation and readmission, and length of hospital stay were not affected by age. Treatment of the elderly with CRS plus HIPEC was associated with increased severe postoperative morbidity and mortality. However, these conclusions should be weighted given the existence of major biases in the included studies. Age alone probably would not be a formal contraindication, but frailty should be taken into account. Further prospective studies are needed.

Procedure-based postoperative risk prediction using NSQIP data

BackgroundThe National Surgical Quality Improvement Program (NSQIP) has proposed using procedure-based hierarchical models to predict adverse outcomes, but it is not clear whether this approach was used to develop the NSQIP “Surgical Risk Calculator”. We therefore wished to demonstrate how procedure-based hierarchical models can be constructed and to describe their results. MethodsNSQIP data from 2015 were used to construct statistical models predicting 30-day postoperative mortality and morbidity, using two-level logistic regression with preoperative patient-level variables as fixed effects and procedure-specific codes as a random intercept. Model performance was validated using NSQIP data from 2014. ResultsNSQIP for 2015 contained records for 885,502 patients, of whom 8986 died (1.0%) and 104,836 suffered a complication (11.8%). Complete model specifications and results are presented, including odds ratios for patient-level variable effects and random procedure effects. Most comorbidities were associated with increased morbidity and mortality, but overweight and obesity were associated with lower risk. Odds ratios for individual procedures ranged from 0.117 to 10.85 for mortality and from 0.615 to 8.09 for morbidity. Validation C-statistics were 0.940 for the mortality model and 0.833 for the morbidity model; Brier Scores were 0.0086 and 0.085, respectively. Graphs for 20 quantiles showed good conformity of observed and predicted risk. ConclusionsProcedure-based hierarchical logistic regression models of NSQIP outcomes had satisfactory overall performance statistics. Model specifications and results are provided for criticism and improvement, and several possible refinements are suggested.

Metabolic syndrome is associated with increased postoperative complications and use of hospital resources in patients undergoing laparoscopic adrenalectomy

Rates of obesity and metabolic syndrome continue to rise worldwide; however, the impact of metabolic syndrome on outcomes following adrenalectomy has not been described. In this study, we sought to investigate the effects of metabolic syndrome on postoperative 30-day morbidity, mortality, and utilization of hospital resources in a large cohort of patients undergoing elective laparoscopic adrenalectomy. Patients who underwent laparoscopic adrenalectomy from 2005 to 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients with body mass index ≥30 kg/m2 who also had diabetes and hypertension requiring medications were defined as having metabolic syndrome. Univariate and multivariable analyses were performed for the outcomes of 30-day mortality/morbidity, major complications, and utilization of hospital resources (prolonged duration of stay ≥3 days and requirement for perioperative blood transfusion). Of the 3,502 patients included in the study, 395 had metabolic syndrome (11.3%). Patients with metabolic syndrome were older (P < .001) and had a greater percentage of preoperative comorbidities (P < .05) than patients without metabolic syndrome. On unadjusted analysis, metabolic syndrome was associated with an increased risk for mortality/morbidity, major complications, duration of stay, operative time, and risk for blood transfusion (all P < .001). On multivariable analysis, metabolic syndrome was an independent predictor of overall mortality/morbidity (odds ratio, 1.86; P < .001), major complications (odds ratio, 1.99; P < .001), pulmonary complications (odds ratio, 1.83; P = .049), the need for blood transfusion (odds ratio, 1.94; P = .04), and prolonged length of stay (odds ratio odds ratio, 1.34; P = .02). The presence of metabolic syndrome increased the risk for postoperative complications after laparoscopic adrenalectomy and was associated with 2-fold risk for blood transfusion and 34% increased odds of a prolonged hospital stay.

Does a Combination of Laparoscopic Approach and Full Fast Track Multimodal Management Decrease Postoperative Morbidity?: A Multicenter Randomized Controlled Trial.

The aim of this study was to assess whether association of laparoscopic approach and full fast track multimodal (FFT) management can reduce postoperative morbidity after colorectal cancer surgery, as compared to laparoscopic approach with limited fast-track program (LFT). Recent advances in colorectal cancer surgery are introduction of laparoscopy and FFT implementation. Patients eligible for elective laparoscopic colorectal cancer surgery were randomized into 2 groups: FFT or LFT care (with only early oral intake and mobilization starting on Day 1). Primary outcome was postoperative 30-day morbidity, according to Clavien-Dindo classification. Two hundred seventy patients were randomized and 263 were analyzed: 130 in FFT group and 133 in LFT group, including 106 colon (FFT: n = 52 and LFT: n = 54) and 157 rectal cancer (FFT: n = 78 and LFT: n = 79). Postoperative 30-day mortality was nil. Overall postoperative 30-day morbidity did not show any difference between the groups (FFT: 35% vs LFT: 29%, P = 0.290), neither regarding the overall population, nor in the colon (FFT: 23% vs LFT: 19%, P = 0.636) or rectal (FFT: 44% vs LFT: 35%, P = 0.330) cancer subgroups. Severe postoperative morbidity was also not different between groups (FFT: 12% vs LFT: 8%, P = 0.266). After multivariate regression analysis, only early intravenous catheter removal (on day 2) [odds ratio: 0.390; 95% confidence interval: (95% CI 0.181-0.842); P = 0.017] and the absence of intraoperative lidocaine intravenous perfusion (odds ratio: 0.182, 95% CI 0.042-0.788; P = 0.019) were identified as independent predictive factors of reduced postoperative morbidity. Addition of FFT multimodal management to laparoscopic approach with early oral intake and mobilization does not reduce postoperative morbidity after colorectal cancer surgery.

Association of a Prophylactic Surgical Approach to Stage IV Small Intestinal Neuroendocrine Tumors With Survival

Primary tumor resection and mesenteric lymph node dissection in asymptomatic patients with stage IV small intestinal neuroendocrine tumors (SI-NETs) are controversial. To determine the association of locoregional surgery (LRS) performed at diagnosis with outcomes in patients with asymptomatic SI-NETs and distant metastases. This cohort study included asymptomatic patients with stage IV SI-NETs diagnosed from January 1, 1985, through December 31, 2015, and identified using the prospective database of SI-NETs from Uppsala University Hospital, Uppsala, Sweden. Patients included were treated at a tertiary referral center and followed up until May 31, 2016, with data from the Swedish National Patient Register. The 363 patients with stage IV SI-NETs without abdominal symptoms were divided between those who underwent prophylactic up-front surgery within 6 months from diagnosis combined with oncologic treatment (hereafter referred to as LRS group [n = 161]) and those who underwent nonsurgical treatment or delayed surgery as needed combined with oncologic treatment (hereafer referred to as delayed LRS group [n = 202]). Prophylactic up-front surgery within 6 months from diagnosis combined with oncologic treatment vs nonsurgical treatment or delayed surgery as needed combined with oncologic treatment. Overall survival (OS), length of hospital stay (LOS), postoperative morbidity and mortality, and reoperation rates measured from baseline. Propensity score matching was performed between the 2 groups. The 363 patients included 173 women (47.7%) and 190 men (52.3%), with a mean (SD) age at diagnosis of 62.4 (11.1) years. Two isonumerical groups with 91 patients in each resulted after propensity score matching. The LRS and delayed LRS groups were comparable in median OS (7.9 years [range, 5.1-10.7 years] vs 7.6 years [range, 5.8-9.5 years]; hazard ratio [HR], 0.98; 95% CI, 0.70-1.37; log-rank P = .93) and cancer-specific survival (7.7 years [range, 4.5-10.8 years] vs 7.6 years [range, 5.6-9.7 years]; HR, 0.99; 95% CI, 0.71-1.40; log-rank P = .99). No difference was found in 30-day mortality (0 patients in both matched groups) or postoperative morbidity (2 [2.2%] vs 1 [1.1%]; P > .99), median LOS (73 days [range, 2-270 days] vs 76 days [range, 0-339 days]; P = .64) or LOS due to local tumor-related symptoms (7.0 days [range, 0-90 days] vs 11.5 days [range, 0-69 days]; P = .81), or incisional hernia repairs (4 patients [4.4%] in both groups; P > .99). Patients in the LRS group underwent more reoperative procedures (13 [14.3%]) compared with those in the delayed LRS group (3 [3.3%]) owing to intestinal obstruction (P < .001). Prophylactic up-front LRS conferred no survival advantage in asymptomatic patients with stage IV SI-NETs. Delayed surgery as needed was comparable in all examined outcomes and was associated with fewer reoperations for intestinal obstruction. The value of a priori LRS in the presence of distant metastases is challenged and needs to be elucidated in a randomized clinical study.

Nutritional optimization during neoadjuvant therapy prior to surgical resection of esophageal cancer-a narrative review.

This narrative review aims to evaluate the evidence for the different nutritional approaches employed during neoadjuvant therapy in patients with locoregional esophageal cancer. Patients with esophageal cancer are often malnourished and difficult to optimize nutritionally. While evidence suggests that neoadjuvant therapy can offer a survival advantage, associated toxicity can exacerbate poor nutritional status. There is currently no accepted standard of care regarding optimal nutritional approach. A systematic literature search was undertaken. Studies describing the utilization of an additional nutritional intervention in patients with esophageal cancer receiving neoadjuvant therapy prior to esophagectomy were included. Primary outcome measure was 30-day postoperative mortality after esophagectomy. Secondary outcome measures were loss of weight during neoadjuvant therapy, completion rate of intended neoadjuvant therapy, complications from nutritional intervention, 30-day postoperative morbidity after esophagectomy and quality of life during neoadjuvant treatment. Given the heterogeneity of retrieved articles results was presented as a narrative review. Twenty-five studies were included of which 16 evaluated esophageal stenting, four feeding jejunostomy, three gastrostomy, one nasogastric feeding, and one comparative study of esophageal stenting to feeding jejunostomy. 30-day postoperative mortality was only reported in two of the 26 included studies limiting comparison between nutritional strategies. All studies of esophageal stents reported improvements in dysphagia with reported weight change ranging from -5.4 to +6 kg and one study reported 30-day postoperative mortality after esophagectomy (10%). In patients undergoing esophageal stenting for their neoadjuvant treatment overall migration rate was 29.9%. Studies of laparoscopically inserted jejunostomy were all retrospective reviews that demonstrated an increase in weight ranging from 0.4 to 11.8 kg and similarly no study reported 30-day postoperative mortality. Only one comparative study was included that compared esophageal stents to jejunostomy. This study reported no significant difference between the two groups in respect to complication rates (stents 22% vs. jejunostomy 4%, P=0.11) or increase in weight (stents 4.4 kg vs. jejunostomy 4.2 kg, P=0.59). Quality of life was also poorly reported. This review demonstrates the uncertainty on the optimal nutritional approach for patients with resectable esophageal cancer undergoing neoadjuvant treatment prior to esophagectomy. A prospective, multicenter, observational cohort study is needed to determine current practice and inform a prospective clinical trial.

Temporal Trends, Determinants, and Outcomes of Inpatient versus Outpatient Arteriovenous Fistula Operations

As high healthcare costs are increasing scrutinized, a movement toward reducing patient hospital admissions and lengths of stay has emerged, particularly for operations that may be performed safely in the outpatient setting. Our aim is to describe recent temporal trends in the proportion of dialysis access procedures performed on an inpatient versus outpatient basis and to determine the effects of these changes on perioperative morbidity and mortality. The 2005-2008 American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary arteriovenous fistula (AVF) procedures using current procedural terminology codes. Changes in the proportions of inpatient versus outpatient operations performed by year, as well as the associated 30-day postoperative morbidity and mortality, were analyzed using univariable statistics and multivariable logistic regression. Two thousand nine hundred fifty AVF procedures were performed over the study period. Overall, 71.7% (n=2,114) were performed on an outpatient basis. Inpatient procedures were associated with higher 30-day morbidity (10.5% vs. 4.5%) and mortality (2.8% vs. 0.7%) than outpatient procedures (both, P<0.001). There was a significant increase in the proportion of procedures performed on an outpatient basis over time (2005: 56% vs. 2008: 75%; P<0.001). There were no changes in postoperative morbidity or mortality for inpatient or outpatient AVF over time (P≥0.36). Independent determinants of having an inpatient procedure included younger age (OR 0.99), increasing ASA class (ASA IV OR 1.56), congestive heart failure (OR 3.32), recent ascites (OR 3.25), poor functional status (OR 3.22), the presence of an open wound (OR 1.91), and recent sepsis (OR 6.06) (all, P<0.01). Acute renal failure (OR 2.60) and current dialysis (OR 1.44) were also predictive (P<0.001). After correcting for baseline differences between groups, the adjusted OR for both morbidity (aOR 1.93, 95% CI 1.38-2.69) and mortality (aOR 2.85, 95% CI 1.36-5.95) remained significantly higher for inpatient versus outpatient AVF. Dialysis access operations are increasingly being performed on an outpatient basis, with stable perioperative outcomes. Inpatient procedures are associated with worse outcomes, likely because they are reserved for patients with acute illnesses, serious comorbidities, and poor functional status. Overall, for appropriately selected patients, the movement toward performing more elective dialysis access operations on an outpatient basis is associated with acceptable outcomes.

Frailty and emergency surgery in the elderly: Protocol of a prospective, multicenter study in Italy for evaluating perioperative outcome (The FRAILESEL Study)

Introduction: Improvements in living conditions and progress in medical management have resulted in better ​quality of life and longer life expectancy. Therefore, the number of older people undergoing surgery is increasing. Frailty is often described as a syndrome in aged patients where there is augmented vulnerability due to progressive loss of functional reserves. Studies suggest that frailty predisposes elderly to worsening outcome after surgery. Since emergency surgery is associated with higher mortality rates, it is paramount to have an accurate stratification of surgical risk in such patients. The aim of our study is to characterize the clinico-pathological findings, management, and short-term outcome of elderly patients undergoing emergency surgery. The secondary objectives are to evaluate the presence and influence of frailty and analyze the prognostic role of existing risk-scores. The final FRAILESEL protocol was approved by the Ethical Committee of “Sapienza” University of Rome, Italy. Methods and analysis: The FRAILESEL study is a nationwide, Italian, multicenter, observational study conducted through a resident-led model. Patients over 65 years of age who require emergency surgical procedures will be included in this study. The primary outcome measures are 30-day postoperative mortality and morbidity rates. The Clavien-Dindo classification system will be used to categorize complications. Secondary outcome measures include length of hospital stay, length of stay in intensive care unit, and the predictive value for morbidity and mortality of several frailty and surgical risk scores. The results of the FRAILESEL study will be disseminated through national and international conference presentations and peer-reviewed journals. The study is also registered at ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT02825082).

Goal-directed Fluid Therapy Does Not Reduce Primary Postoperative Ileus after Elective Laparoscopic Colorectal Surgery: A Randomized Controlled Trial.

Inadequate perioperative fluid therapy impairs gastrointestinal function. Studies primarily evaluating the impact of goal-directed fluid therapy on primary postoperative ileus are missing. The objective of this study was to determine whether goal-directed fluid therapy reduces the incidence of primary postoperative ileus after laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program. Randomized patient and assessor-blind controlled trial conducted in adult patients undergoing laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program. Patients were assigned randomly to receive intraoperative goal-directed fluid therapy (goal-directed fluid therapy group) or fluid therapy based on traditional principles (control group). Primary postoperative ileus was the primary outcome. One hundred twenty-eight patients were included and analyzed (goal-directed fluid therapy group: n = 64; control group: n = 64). The incidence of primary postoperative ileus was 22% in the goal-directed fluid therapy and 22% in the control group (relative risk, 1; 95% CI, 0.5 to 1.9; P = 1.00). Intraoperatively, patients in the goal-directed fluid therapy group received less intravenous fluids (mainly less crystalloids) but a greater volume of colloids. The increase of stroke volume and cardiac output was more pronounced and sustained in the goal-directed fluid therapy group. Length of hospital stay, 30-day postoperative morbidity, and mortality were not different. Intraoperative goal-directed fluid therapy compared with fluid therapy based on traditional principles does not reduce primary postoperative ileus in patients undergoing laparoscopic colorectal surgery in the context of an Enhanced Recovery After Surgery program. Its previously demonstrated benefits might have been offset by advancements in perioperative care.