Predictor Of Overall Morbidity Research Articles

The prognostic role of aspartate transaminase to platelet ratio index on outcomes after nonemergent major hepatectomy

IntroductionNoninvasive screening methods to identify patients preoperatively with abnormal liver texture remain limited. Aspartate transaminase to platelet ratio index has been validated to predict fibrosis in patients with hepatitis C; however, its use as a predictor of postoperative outcomes in patients without viral hepatitis remains unknown. MethodsWe queried the American College of Surgeons National Surgical Quality Improvement Program dataset to identify patients who underwent a major hepatectomy between 2014 and 2021. We excluded patients who underwent emergent operations, patients with viral hepatitis, and patients with ascites. Aspartate transaminase to platelet ratio index was calculated using the following equation: (aspartate transaminase/40)/(platelet count) × 100. An aspartate transaminase to platelet ratio index ≥0.7 was used to identify patients with significant fibrosis. Univariable analysis was performed to identify factors associated with aspartate transaminase to platelet ratio index ≥0.7, perioperative transfusion, serious morbidity, overall morbidity, and 30-day mortality. Multivariable logistic regression analysis was performed to identify adjusted predictors of these outcomes. ResultsOf the 8,933 patients who met inclusion criteria, 1,170 (13.1%) patients had an aspartate transaminase to platelet ratio index ≥0.7. A perioperative blood transfusion was administered to 2,497 (28.0%). The number of patients who experienced overall morbidity, serious morbidity, and mortality were 3,195 (35.8%), 2,665 (29.8%), and 238 (2.7%), respectively. Aspartate transaminase to platelet ratio index ≥0.7 was an independent predictor of transfusion (odds ratio: 1.51 [1.32–1.72], P < .001), overall morbidity (1.16 [1.01–1.33], P = .032), and mortality (1.56 [1.12–2.13], P = .006). Transfusion was an independent predictor of overall morbidity (2.50 [2.26–2.76], P < .001), serious morbidity (2.51 [2.26–2.79], P < .001), and mortality (3.28 [2.49–4.33], P < .001). ConclusionAn aspartate transaminase to platelet ratio index ≥0.7 is associated with perioperative transfusion, overall morbidity, and 30-day mortality. The aspartate transaminase to platelet ratio index may serve as a noninvasive tool to risk stratify patients before elective major hepatectomy.

"The Prognostic Role of Aspartate Transaminase to Platelet Ratio Index (APRI) on Outcomes Following Non-emergent Minor Hepatectomy".

Fibrosis and cirrhosis are associated with worse outcomes after hepatectomy. Aspartate transaminase to platelet ratio index (APRI) is associated with fibrosis and cirrhosis in hepatitis C patients. However, APRI has not been studied to predict outcomes after hepatectomy in patients without viral hepatitis. We reviewed the ACS-NSQIP dataset to identify patients who underwent a minor hepatectomy between 2014 and 2021. We excluded patients with viral hepatitis or ascites as well as patients who underwent emergent operations or biliary reconstruction. APRI was calculated using the following equation: (AST/40)/(platelet count) × 100. APRI ≥0.7 was used to identify significant fibrosis. Univariable analysis was performed to identify factors associated with APRI ≥0.7, transfusion, serious morbidity, overall morbidity, and 30-day mortality. Multivariable logistic regression was performed to identify adjusted predictors of these outcomes. Of the 18,069 patients who met inclusion criteria, 1630 (9.0%) patients had an APRI ≥0.7. A perioperative blood transfusion was administered to 2139 (11.8%). Overall morbidity, serious morbidity, and mortality were experienced by 3162 (17.5%), 2475 (13.7%), and 131 (.7%) patients, respectively. APRI ≥0.7 was an independent predictor of transfusion (adjusted OR: 1.48 [1.26-1.74], P < .001), overall morbidity (1.17 [1.02-1.33], P = .022), and mortality (1.97 [1.22-3.06], P = .004). Transfusion was an independent predictor of overall morbidity (3.31 [2.99-3.65], P < .001), serious morbidity (3.70 [3.33-4.11], P < .001), and mortality (5.73 [4.01-8.14], P < .001). APRI ≥0.7 is associated with perioperative transfusion, overall morbidity, and 30-day mortality. APRI may serve as a noninvasive tool to risk stratify patients prior to elective minor hepatectomy.

Aspartate Transaminase to Platelet Ratio Index (APRI) and Albumin-Bilirubin Grade (ALBI) Predict Postoperative Morbidity Following Hepatectomy for Hepatocellular Carcinoma: A Multicenter Cohort Study

Background and aims: Postoperative morbidity following hepatectomy remains high, and understanding its risk factors is important to improve perioperative outcomes. We aimed to identify the role of two non-invasive markers - albumin-bilirubin (ALBI) and aspartate transaminase to platelet ratio index (APRI) - in predicting postoperative morbidity following hepatectomy for hepatocellular carcinoma (HCC). Methods: A multicenter data of patients undergoing hepatectomy for HCC at 8 centers were retrospectively analyzed. These patients were divided into normal and high groups according to preoperative ALBI and APRI scores. ALBI and APRI's predictive accuracy of postoperative 30-day overall and major morbidity were evaluated by the area under the receiver operating characteristic curve (AUC) and compared with two conventional scores: Child-Pugh grade and model for end-stage liver disease (MELD). Results: In 2,301 patients, 866 (37.6%) and 400 (17.4%) were in the high ALBI and APRI groups, respectively. There were significant differences of postoperative overall morbidity between the normal and high ALBI groups (26.2% vs. 40.1%, P < 0.001), as well as between the normal and high APRI groups (29.2% vs. 42.4%, P < 0.001). The AUCs of the ALBI and APRI scores for predicting overall morbidity are greater than those of Child-Pugh grade and MELD score. Multivariable analyses revealed that ALBI and APRI were independent predictors of overall morbidity in both preoperative and postoperative prediction models. Similar results existed in predicting postoperative major morbidity. Conclusion: Preoperative ALBI and APRI could predict postoperative 30-day overall and major morbidity following hepatectomy for HCC before or after surgery.

Altitude and its inverse association with abdominal obesity in an Andean country: a cross-sectional study.

Background: Abdominal obesity represents an accurate predictor of overall morbidity and mortality, which is worrisome because it is also continuously increasing across Andean countries. However, its relationship with altitude remains unclear. The objective of this study was to assess the association between altitude and abdominal obesity in Peru, and how sociodemographic variables impact this association. Methods: We estimated the prevalence of abdominal obesity in Peru and analyzed its association with altitude using the data from the 2012-2013 National Household Survey (ENAHO). During this survey, a representative sample of Peruvians was screened for abdominal obesity, using waist circumference as a proxy, and the Adult Treatment Panel III guidelines cutoffs. Results: Data were analyzed from a sample of 20,489 Peruvians (51% male). The prevalence of abdominal obesity was estimated at 33.6% (95% CI: 32.5 to 34.6%). In Peru, altitude was significantly and inversely associated with abdominal obesity, decreasing with higher altitudes: 1500-2999 meters above mean sea level (MAMSL) vs <1500 MAMSL, adjusted prevalence rate [aPR]= 0.86 (95% CI: 0.75 to 0.97); ≥3000 MAMSL vs <1500 MAMSL, aPR= 0.98 (95% CI: 0.87 to 1.11), when adjusting by age, gender and residence area (rural/urban). However, this association was significantly modified by age and gender ( p< 0.001). Conclusion: Abdominal obesity is highly prevalent in Peru and decreases significantly with altitude, but age and gender modify this association. Thus, abdominal obesity appears to affect older women from low altitudes more than younger men from high altitudes.

Altitude and its inverse association with abdominal obesity in an Andean country: a cross-sectional study

Background: Abdominal obesity represents an accurate predictor of overall morbidity and mortality, which is worrisome because it is also continuously increasing across Andean countries. However, its relationship with altitude remains unclear. The objective of this study was to assess the association between altitude and abdominal obesity in Peru, and how sociodemographic variables impact this association. Methods: We estimated the prevalence of abdominal obesity in Peru and analyzed its association with altitude using the data from the 2012-2013 National Household Survey (ENAHO). During this survey, a representative sample of Peruvians was screened for abdominal obesity, using waist circumference as a proxy, and the Adult Treatment Panel III guidelines cutoffs. Results: Data were analyzed from a sample of 20 489 Peruvians (51% male). The prevalence of abdominal obesity was estimated at 33.6% (95% CI: 32.5 to 34.6%). In Peru, altitude was significantly and inversely associated with abdominal obesity, decreasing with higher altitudes: 1500-2999 meters above mean sea level (MAMSL) vs <1500 MAMSL, adjusted prevalence rate [aPR]= 0.90 (95% CI: 0.84 to 0.96); ≥3000 MAMSL vs <1500 MAMSL, aPR= 0.78 (95% CI: 0.72 to 0.84), when adjusting by age, gender and residence area (rural/urban). However, this association was significantly modified by age and gender ( p< 0.001). Conclusion: Abdominal obesity is highly prevalent in Peru and decreases significantly with altitude, but age and gender modify this association. Thus, abdominal obesity appears to affect older women from low altitudes more than younger men from high altitudes.

Altitude and its inverse association with abdominal obesity in an Andean country: a cross-sectional study

Background: Abdominal obesity represents an accurate predictor of overall morbidity and mortality, which is worrisome because it is also continuously increasing across Andean countries. However, its relationship with altitude remains unclear. The objective of this study was to assess the association between altitude and abdominal obesity in Peru, and how sociodemographic variables impact this association. Methods: We estimated the prevalence of abdominal obesity in Peru and analyzed its association with altitude using the data from the 2012-2013 National Household Survey (ENAHO). During this survey, a representative sample of Peruvians was screened for abdominal obesity, using waist circumference as a proxy, and the Adult Treatment Panel III guidelines cutoffs. Results: Data were analyzed from a sample of 20,489 Peruvians (51% male). The prevalence of abdominal obesity was estimated at 33.6% (95% CI: 32.5 to 34.6%). In Peru, altitude was significantly and inversely associated with abdominal obesity, decreasing with higher altitudes: 1500-2999 meters above mean sea level (MAMSL) vs &lt;1500 MAMSL, adjusted prevalence rate [aPR]= 0.86 (95% CI: 0.75 to 0.97); ≥3000 MAMSL vs &lt;1500 MAMSL, aPR= 0.98 (95% CI: 0.87 to 1.11), when adjusting by age, gender and residence area (rural/urban). However, this association was significantly modified by age and gender (p&lt; 0.001). Conclusion: Abdominal obesity is highly prevalent in Peru and decreases significantly with altitude, but age and gender modify this association. Thus, abdominal obesity appears to affect older women from low altitudes more than younger men from high altitudes.

Frailty Predicts Morbidity and Mortality after Colectomy for Clostridium difficile Colitis

Frailty has been noted as a powerful predictive preoperative tool for 30-day postoperative complications. We sought to evaluate the association between frailty and postoperative outcomes after colectomy for Clostridium difficile colitis. The National Surgical Quality and Improvement Program cross-institutional database was used for this study. Data from 470 patients with a diagnosis of C. difficile colitis were used in the study. Modified frailty index (mFI) is a previously described and validated 11-variable frailty measure used with the National Surgical Quality and Improvement Program to assess frailty. Outcome measures included serious morbidity, overall morbidity, and Clavien IV (requiring ICU) and Clavien V (mortality) complications. The median age was 70 years and body mass index was 26.9 kg/m2. 55.6 per cent of patients were females. 98.5 per cent of patients were assigned American Society of Anesthesiologists Class III or higher. The median mFI was 0.27 (0-0.63). Because mFI increased from 0 (non-frail) to 0.55 and above, the overall morbidity increased from 53.3 per cent to 84.4 per cent and serious morbidity increased from 43.3 per cent to 78.1 per cent. The Clavien IV complication rate increased from 30.0 per cent to 75.0 per cent. The mortality rate increased from 6.7 per cent to 56.2 per cent. On a multivariate analysis, mFI was an independent predictor of overall morbidity (AOR: 13.0; P < 0.05), mortality (AOR: 8.8; P = 0.018), cardiopulmonary complications (AOR: 6.8; P = 0.026), and prolonged length of hospital stay (AOR: 6.6; P = 0.045). Frailty is associated with increased risk of complications in C. difficile colitis patients undergoing colectomy. mFI is an easy-to-use tool and can play an important role in the risk stratification of these patients who generally have significant morbidity and mortality to begin with.

Determining the optimal time for radical cystectomy after neoadjuvant chemotherapy.

To determine whether the recovery window (RW) between neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) affects 90-day postoperative morbidity and incidence of lymph node metastasis. We reviewed patients treated with NAC and RC from 1995 to 2013 for ≤cT4 N0 M0 bladder cancer. The association of the RW with 90-day perioperative morbidity and lymph node metastasis was determined. Generalised linear models were used to determine predictors of each endpoint. Patients were stratified into four RWs by 21-day intervals (18-42; 43-63; 64-84; and ≥85 days) from last day of NAC to RC. We evaluated 306 patients with RW information during the study period. The median (range) RW was 46 (18-199) days. There was no difference in overall morbidity, re-admission, or major complication rates amongst the four RWs. In the multivariable analysis extravesical disease was an independent predictor of overall morbidity (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.16-3.26; P = 0.011). Age (OR 1.05, 95% CI: 1.02-1.09; P = 0.004), and surgical duration ≥7 h (OR 2.87, 95% CI: 1.52-5.42; P = 0.001) were independent predictors of major complications. Only surgical duration ≥7 h was a predictor of re-admission (OR 2.24; 95% CI: 1.26-3.98; P = 0.006). A RW of ≥85 days had the highest incidence of node-positive disease (pN+; 40%). In a separate multivariable model that included clinical predictors for pN+, a RW of ≥85 days was an independent predictor of nodal metastasis (OR 2.92, 95% CI: 1.20-7.09; P = 0.018). Patients treated with NAC for bladder cancer can undergo RC between 18 and 84 days (2.5-12 weeks) after NAC with no difference in the risk of perioperative morbidity. Delaying surgery beyond 12 weeks was associated with a significant risk of lymph node metastasis.

Base Excess as a Predictor of Complications in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy.

Base excess is important in assessing metabolic status. Postoperative management in patients undergoing cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies can be a challenge, and we therefore sought to investigate perioperative predictors of overall morbidity in CRS/HIPEC patients at our institution. Patients who underwent CRS/HIPEC from 2012 to 2016 were identified retrospectively from a prospectively collected institutional database. Patient demographics and perioperative variables were obtained and the comprehensive complication index (CCI) was calculated for each patient in order to assess perioperative morbidity. Stepwise linear regression analyses were performed, with CCI as the outcome variable. A total of 72 CRS/HIPEC patients had recorded base excesses in the first 48h postoperatively. Mean immediate postoperative base excess was -6.0mmol/L (interquartile range [IQR] -8 to -4.1), mean delta base excess at 48h was +4.3mmol/L (IQR +2.1 to +6.2), and mean CCI was 25.2 (IQR 8.7-36.7). On multivariate analysis, delta base excess was the only significant predictor of CCI, demonstrating a protective effect (p=0.001). In patients who experienced less than the mean delta base excess of +4.3mmol/L, lower delta base excess was an independent predictor of complications (p<0.001). Delta base excess is an independent predictor of morbidity in patients undergoing CRS/HIPEC. A delta base excess of greater than +4.3mmol/L at 48h may be an appropriate goal for resuscitation of CRS/HIPEC patients in the immediate postoperative period. Standardized protocols to correct the base deficit in CRS/HIPEC patients during the early postoperative period can potentially help mitigate perioperative morbidity.

Analysis of the impact of pre-operative biliary drainage and intraoperative drain placement on outcomes after pancreaticoduodenectomy using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database

Objective: We analyzed the outcomes of patients who had preoperative biliary drainage and/or intraoperative drains placed during pancreaticoduodenectomy compared to their non-intervention controls using ACS-NSQIP data. Methods: Retrospective review of 2014 NSQIP data was performed on patients undergoing pancreaticoduodenectomy. Demographic characteristics, length of stay, operative time, and 30-day postoperative complications were compared between study groups. Results: Patients without preoperative biliary drainage [1406/2968 (47%)] had more pancreatic fistulas (20.6% vs 15.9%, p=0.001), less SSI (6.5% vs 12.5%, p<0.001), less wound disruption (1.2% vs 2.2%, p=0.043), more pulmonary embolus (1.7% vs 0.6%, p=0.006), less transfusion requirement (18.1% vs 24.6%, p<0.001), less postoperative sepsis (7.5% vs 11.5%, p<0.001), shorter operative time (370 min vs 380 min, p=0.029) and decreased overall morbidity (53.6% vs 59.9%, p=0.001) compared to controls. Patients who did not have a drain placed at surgery (ND) [393/3108 (13%)] had less pancreatic fistulas (9.2% vs 19.5%, p<0.001), less transfusion requirements (15.4% vs 22.2%, p<0.001), more pneumonia (8.7% vs 4.1%, p<0.001), more post-operative shock (5.6% vs 3.5%, p=0.037), shorter LOS (9.7 d vs 11.3 d, p=0.003), shorter operative time (361 min vs 377 min, p=0.024) and decreased overall morbidity (47.6% vs 58.2%, p<0.001) compared to controls. Multivariate analysis revealed intraoperative drain placement (OR 2.03, p<0.001) and preoperative biliary drainage (OR 1.35, p=0.002) as independent predictors of overall morbidity. Conclusion: In this retrospective review of ACS-NSQIP data, both preoperative biliary drainage and intraoperative drainage of anastomoses in pancreaticoduodenectomies were independent predictors of overall morbidity.

Preoperative anemia and outcomes in patients undergoing surgery for inflammatory bowel disease

BackgroundAnemia is the most common extraintestinal manifestation in patients with inflammatory bowel disease (IBD), and has been linked to severity of the disease. The aim of the study was to assess the impact of anemia on postoperative outcomes in patients with IBD. MethodsWe retrospectively reviewed patients with IBD from the NSQIP database over an 8-year period. Patients were grouped based on the presence of anemia. The impact of anemia on postoperative morbidity, mortality and length of stay was assessed. ResultsA total of 15,761 patients met our criteria. Half of the patients were anemic upon presentation. Anemic patients were more likely to have a history of steroid use, present with sepsis and require an emergency operation. In multivariate analysis, anemia was a significant predictor of overall morbidity, serious morbidity and increased length of stay. ConclusionsAnemic patients with IBD present more often with sepsis and require emergency surgery compared to their peers. In addition, anemia serves as an independent predictor of overall complications, serious morbidity and increased length of stay following abdominal operations.

Congenital Diaphragmatic Hernia Defect Size and Infant Morbidity at Discharge.

Survival for infants with congenital diaphragmatic hernia (CDH) has gradually improved, yet substantial burden of disease remains. Although larger CDH defect sizes increase mortality, the association between defect size and morbidity has not been reported. Our objective was to evaluate the association of defect size with pulmonary, neurologic, and gastrointestinal morbidity at the time of hospital discharge. An international, prospective cohort study was performed. Patient demographics, intraoperative defect size, and clinical outcomes were reviewed. The primary outcome was morbidity at the time of discharge, which entailed supplemental oxygen requirement, abnormal neurologic clinical and radiographic findings, gastroesophageal reflux, supplemental nutrition, or pulmonary-, neurologic-, or gastrointestinal-related medications. A total of 3665 patients were included in the study cohort. Overall survival was 70.9%, and 84.0% of survivors were discharged from the hospital (16.0% transferred). Median age at discharge was 38 days (interquartile range [IQR] 23-69) and ranged from 22 (IQR 16-32) days for "A" (smallest) defects to 89 (IQR 64-132) days for "D" (largest) defects (P < .001). Of those discharged from the hospital, 1522 (74.2%) had pulmonary (n = 660, 30.2%), neurologic (n = 446, 20.4%), or gastrointestinal (n = 1348, 61.7%) morbidities, and multiple morbidities were diagnosed in 701 (34.7%) patients. On multivariable regression analyses incorporating key patient characteristics, defect size was consistently the greatest predictor of overall morbidity, hospital length of stay, and duration of ventilation. Infants with CDH are commonly discharged with ≥1 major morbidities. The size of the diaphragmatic defect appears to be the most reliable indicator of a patient's hospital course and discharge burden of disease.

Impact of Resident Involvement on Morbidity in Adult Patients Undergoing Fusion for Spinal Deformity.

A retrospective study of prospectively collected data. The aim of this study was to determine whether patients undergoing spinal deformity surgery with resident involvement are at an increased risk of morbidity. Resident involvement has been investigated in other orthopedic procedures but has not been studied in adult spinal deformity surgery. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) 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 (CPT) codes were used to query the database for adults who underwent fusion for spinal deformity between 2005 and 2012. Patients were separated into propensity score matched groups of those with and without resident involvement. Univariate analysis and multivariate logistic regression were used to analyze the effect of resident involvement on the incidence of postoperative morbidity and other surgical outcomes. Resident involvement was an independent predictor of overall morbidity [odds ratio (OR) 2.2, P < 0.0001], wound complication (OR 2.5, P = 0.0252), intra-/postoperative transfusion (OR 2.3, P < 0.0001), and length of stay > 5 days (OR 2.0, P < 0.0001). However, resident involvement was not an independent predictor for other complications, such as mortality. Resident participation was associated with significantly longer operative times. As a result, higher rate of certain morbidity, but not mortality, was found, specifically for complications that have been previously associated with long operative duration. 3.

Frailty is a Predictor of Adverse Outcomes after Hepatic Resections for Hepatocellular Carcinoma

Adjusted odds ratio (95% CI) 3.01 (1.18-7.68) 3.16 (1.22-8.17) 3.09 (1.22-7.84) 3.69 (1.42-9.60) respectively. The majority of patients (53.1%) were male. There were 72.5% of patients who had an American Society of Anesthesiologists score 3, and the median mFI was 0.09 (range 0e0.64). As the mFI increased from 0 (no frailty-associated variables) to 0.36 (4 of 11) or higher, the rate of overall morbidity increased from 32.5% to 54.2%. The proportion of Clavien class IV complications increased from 7.2% to 25.4% and the mortality rate increased from 1.5% to 11.0%. All results were significant at p<0.01. On multivariate analysis, mFI was an independent predictor of overall morbidity (adjusted odds ratio [AOR] 3.2, p<0.01), Clavien class IV complications (AOR 11.3, p<0.01), and mortality (AOR 18.7, p<0.01).

Impact of obesity on postoperative outcome of hepatic resection for colorectal metastases

Outcomes in obese patients who underwent liver resection have been analyzed, but series are heterogeneous and data are controversial. The aim of this study was to analyze short-outcome in obese patients undergone hepatectomy for colorectal metastases. A retrospective analysis on 1,021 consecutive hepatectomies between January 2000 and April 2014 for colorectal metastases was carried out. World Health Organization Classification of obesity (body mass index >30 kg/m(2)) was used to identify 140 obese patients. Outcomes were compared among obese and nonobese patients. Obese patients were mainly male (78%) and were associated more frequently with hypertension (51% vs 29%, P < .001), ischemic heart disease (9% vs 3%, P = .007), and diabetes (23% vs 10%, P < .001) compared with nonobese patients. Approximately 30% of patients underwent major hepatectomy in the 2 groups. Associated resections were performed in 36% of obese and 37% of nonobese patients. Median parenchymal transection time (80 ± 64 minutes vs 70 ± 50 minutes, P = .013) and blood loss (300 ± 420 vs 200 ± 282, P = .001) were greater in obese patients. Postoperative mortality was nil in obese patients and 0.6% in nonobese patients. Overall morbidity was greater in obese patients (41% vs 31%, P = .012) mainly related to pulmonary complications (16% vs 9%, P = .012). Reinterventions were more frequent in obese patients (3.6% vs 1.2%, P = .004). Median hospital stay was comparable. At pathologic examination, hepatic steatosis was greater in obese (69% vs 43%, P < .001). At multivariate analysis, age >65 years (odds ratio [OR] 1.43, 95% confidence interval [95% CI] 1.09-1.88), obesity (OR 1.64, 95% CI 1.13-2.38), major hepatectomies (OR 1.65, 95% CI 1.31-2.33), and associated resections (OR 1.67, I95% CI 1.27-2.20) were independent predictors of overall morbidity (P < .001). Among obese patients, there was a positive correlation between age and severity of complications (R = 0.173, P = .041). Obese patients undergoing hepatectomy for colorectal metastases should be approached with caution because of an increased risk of postoperative morbidity.

MP65-05 DETERMINING THE OPTIMAL TIMING FOR RADICAL CYSTECTOMY AFTER NEOADJUVANT CHEMOTHERAPY

You have accessJournal of UrologyBladder Cancer: Invasive III1 Apr 2015MP65-05 DETERMINING THE OPTIMAL TIMING FOR RADICAL CYSTECTOMY AFTER NEOADJUVANT CHEMOTHERAPY Chinedu Mmeje, Cooper Benson, Graciela Nogueras-Gonzalez, Isuru Jayaratna, Neema Navai, Jianjun Gao, Arlene Siefker-Radtke, Ashish Kamat, Colin Dinney, and Jay Shah Chinedu MmejeChinedu Mmeje More articles by this author , Cooper BensonCooper Benson More articles by this author , Graciela Nogueras-GonzalezGraciela Nogueras-Gonzalez More articles by this author , Isuru JayaratnaIsuru Jayaratna More articles by this author , Neema NavaiNeema Navai More articles by this author , Jianjun GaoJianjun Gao More articles by this author , Arlene Siefker-RadtkeArlene Siefker-Radtke More articles by this author , Ashish KamatAshish Kamat More articles by this author , Colin DinneyColin Dinney More articles by this author , and Jay ShahJay Shah More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2295AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We present the largest series reviewing complications and pathologic outcomes following neoadjuvant chemotherapy (NAC) and radical cystectomy (RC), to determine whether the interval between chemotherapy and surgery (ICS) affects 90-day post-operative morbidity and lymph node metastasis. METHODS We analyzed 338 patients treated with NAC followed by RC from January 1995 through December 2013. The association of ICS with 90-day surgical morbidity, incidence of major complication, 90-day readmission, and lymph node metastasis was determined. Generalized linear models were used to determine potential predictors of each endpoint. Patients were stratified into four groups by ICS days (18 - 42;43 - 64;64 - 85;> 85). Complications were classified using the Clavien system. RESULTS The overall morbidity of the cohort was 59%, with 66% being minor, and 34% being major complications. The median ICS was 46 days (18 - 199 days). There was no difference in the overall morbidity, readmission, or major complication rates among the four groups. Patients with an ICT > 85 days had the highest incidence of lymph node metastasis (40%), though this was not found to be significant (p = 0.1). On multivariate analysis including predictors of perioperative morbidity, extravesical (pT3 - 4) disease (OR = 1.97; p = 0.01) was an independent predictor of overall morbidity, while age at cystectomy (OR = 1.05; p = 0.004), and surgical time ≥ 7 hrs (OR = 2.87; p = 0.001) were independent predictors of major complications. Only surgical time ≥ 7 hrs (OR = 2.24; p = 0.006) was found to be a predictor of readmission. In a separate multivariate analysis that included risk factors for pathological node positivity, the predictors for lymph node metastasis included variant histology (OR = 2.06; p = 0.026) and extravesical disease (OR = 2.76; p = 0.002). Patients with an ICT > 85 days had a higher risk of node metastasis though this was not significant. CONCLUSIONS Patients can undergo RC anytime between 2.5 - 12 weeks after NAC with no difference in risk of surgical complications or nodal metastasis. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e808-e809 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chinedu Mmeje More articles by this author Cooper Benson More articles by this author Graciela Nogueras-Gonzalez More articles by this author Isuru Jayaratna More articles by this author Neema Navai More articles by this author Jianjun Gao More articles by this author Arlene Siefker-Radtke More articles by this author Ashish Kamat More articles by this author Colin Dinney More articles by this author Jay Shah More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Determining the optimal timing for radical cystectomy after neoadjuvant chemotherapy.

339 Background: We present the largest series reviewing complications and pathologic outcomes following neoadjuvant chemotherapy (NAC) and radical cystectomy (RC), to determine whether the interval between chemotherapy and surgery (ICS) affects 90-day post-operative morbidity and lymph node metastasis. Methods: We analyzed 338 patients treated with NAC followed by RC from January 1995 through December 2013. The association of ICS with 90-day surgical morbidity, incidence of major complication, 90-day readmission, and lymph node metastasis was determined. Generalized linear models were used to determine potential predictors of each endpoint. Patients were stratified into four groups by ICS days (18 – 42; 43 – 64; 64 – 85; &gt; 85). Complications were classified using the Clavien system. Results: The overall morbidity of the cohort was 59%, with 66% being minor, and 34% being major complications. The median ICS was 46 days (18 – 199 days). There was no difference in the overall morbidity, readmission, or major complication rates among the four groups. Patients with an ICT &gt; 85 days had the highest incidence of lymph node metastasis (40%), though this was not found to be significant (p = 0.1). On multivariate analysis including predictors of perioperative morbidity, extravesical (pT3 – 4) disease (OR = 1.97; p = 0.01) was an independent predictor of overall morbidity, while age at cystectomy (OR = 1.05; p = 0.004), and surgical time ≥ 7 hrs (OR = 2.87; p = 0.001) were independent predictors of major complications. Only surgical time ≥ 7 hrs (OR = 2.24; p = 0.006) was found to be a predictor of readmission. In a separate multivariate analysis that included risk factors for pathological node positivity, the predictors for lymph node metastasis included variant histology (OR = 2.06; p = 0.026) and extravesical disease (OR = 2.76; p = 0.002). Patients with an ICT &gt; 85 days had a higher risk of node metastasis though this was not significant. Conclusions: Patients can undergo RC anytime between 2.5 – 12 weeks after NAC with no difference in risk of surgical complications or nodal metastasis.

Impulsivity predicts time to reach euthymia in adults with bipolar disorder.

Specific demographic and illness characteristics have been identified as predictors of overall morbidity and treatment course among individuals with bipolar disorder. However, the role of specific cognitive limitations on disease severity and treatment response is unclear. The present study evaluated whether impulsiveness during acute mania was a significant predictor of achieving euthymia within one year following psychiatric hospitalization. Participants were 94 adult inpatients (60 manic) with bipolar I disorder. Baseline symptom severity was assessed using the Young Mania Rating Scale and the Montgomery-Åsberg Depression Rating Scale. Impulsivity was measured with the Stop Signal Task, Degraded Stimulus Continuous Performance Task, Delayed Response Task, and Barratt Impulsiveness Scale-11. Individual predictors of time to reach euthymia included fewer depressive symptoms and better impulse control at baseline, later age at illness onset, shorter illness duration, and the absence of comorbid attention-deficit hyperactivity disorder. Self-reported impulsivity was a significant independent predictor of time to euthymia, even after accounting for relevant clinical variables. Better trait impulse control may be associated with better treatment responsiveness among adults with bipolar disorder.

Complications Following Reduction Mammaplasty

Reduction mammaplasty is an established and effective technique to treat symptomatic macromastia. Variable rates of complications have been reported, and there is a continued need for better outcome assessment studies. The authors investigate predictors of postoperative complications following reduction mammaplasty using the National Surgery Quality Improvement Program (NSQIP) data sets. The 2005-2010 American College of Surgeons NSQIP databases were reviewed to identify primary encounters for reduction mammaplasty using Current Procedural Terminology code 19318. Two complication types were recorded: major complications (deep infection and return to operating room) and any complication (all surgical complications). Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. A multivariate regression analysis was used to identify independent predictors of complications. A total of 3538 patients were identified with an average age of 43 years and body mass index of 31.6 kg/m(2). Most patients underwent outpatient surgery (80.5%) with an average operative time of 180 minutes. The incidence of overall surgical complications was 5.1%. The following factors were independently associated with any surgical complications: morbid obesity (odds ratio [OR], 2.1; P < .001), active smoking (OR, 1.7; P < .001), history of dyspnea (OR, 2.0; P < .001), and resident participation (OR, 1.8; P = .01). The incidence of major surgical complications was 2.1%. Factors associated with major complications included active smoking (OR, 2.7; P < .001), dyspnea (OR, 2.6; P < .001), resident participation (OR, 2.1; P < .001), and inpatient surgery (OR, 1.8; P = .01). This study demonstrates overall incidence of complications in 1 in 20 patients and a 1 in 50 incidence of a major surgical complication. Noteworthy findings include the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. These data can assist surgeons in preoperative counseling and enhance perioperative decision making.

Ventral hernia repairs in the oldest-old: high-risk regardless of approach

Ventral hernia repairs (VHR) are among the most common procedures performed by general surgeons. Even though the US population is aging, outcomes of VHR in the elderly and oldest-old (≥80 years) are not well documented. Our study aims to evaluate the short-term outcomes of VHR in the oldest-old patients. The National Surgical Quality Improvement Program (NSQIP) database was queried for all patients who underwent VHR based on Current Procedural Terminology codes between 2005 and 2011. Chi square, Fisher's exact and two-tailed Student's t test were used to compare baseline characteristics and outcomes. Binary logistic regression was used to control for confounding variables. Odds ratios (OR) with 95 % confidence intervals (CI) were reported when applicable. We identified 123,151 patients who underwent a VHR; 4,917 (4 %) were ≥80 years of age. The incidence of laparoscopy increased from 19.8 % in 2009-23.2 % in 2011 (p < 0.001). 30-day unadjusted mortality was 1.7 versus 0.1 % for younger patients (p < 0.001). After controlling for baseline differences, age ≥80 years was an independent predictor of overall morbidity (OR 1.4, 95 % CI 1.3-1.6, p < 0.001), serious morbidity (OR 1.6, 95 % CI 1.4-1.8, p < 0.001) and mortality (OR 3.5, 95 % CI 2.5-4.6, p < 0.001). Oldest-old patients undergoing laparoscopic VHR had a lower incidence of surgical site infection (SSI) compared with patients with open repair (1 vs. 3.4 %, p = 0.001). Mortality, serious morbidity and overall morbidity were not significantly different. VHR in the oldest-old carried significantly higher 30-day overall morbidity, serious morbidity and mortality, compared with younger patients. The use of laparoscopy was associated with improved SSI. Mortality and morbidity were associated with emergency surgery, wound classification and baseline comorbidities, but not surgical approach.