Preoperative ASA Score Research Articles

Factors associated with an increased risk of postoperative blood transfusions in patients undergoing total hip arthroplasty – A mini-review

Introduction: Elective total hip arthroplasty is a common surgery performed around the world. Many patients undergoing elective total hip arthroplasty are elderly, with a large proportion being anaemic preoperatively. The aim of this mini-review is to discuss the numerous factors associated with blood transfusions after total hip arthroplasty, with particular emphasis on preoperative anaemia. Methods: This is a mini-review of the literature regarding factors associated with increased rates of postoperative blood transfusions and methods and strategies to reduce the incidence of postoperative blood transfusions after elective total hip arthroplasty. Results: Preoperative anaemia is a common condition in patients undergoing elective total hip arthroplasty. Preoperative anaemia, age, and increasing ASA score are all associated with increased rates of postoperative blood transfusions. Conclusion: Preoperative anaemia, increased age and ASA score are all associated statistically with increased rates of postoperative blood transfusions in patients undergoing elective total hip arthroplasty.

OGC O01 - Stomach Cancer Elective Surgery Morbidity and Mortality at 90-Days (HOLD Study): A Prospective, International Collaborative Cohort Study

Abstract Background Data on multinational 90-day mortality and morbidity rates after surgery for gastric cancer is limited in the literature. This study aimed to understand the 90-day mortality and morbidity outcomes according to GASTRODATA Registry for elective gastric cancer surgery patients and identify risk factors. Method We conducted an international prospective study on ≥18 years patients undergoing elective surgery for gastric cancer with curative intent from 01 April 2022 to 30 September 2022. Known metastatic disease, concurrent secondary cancers, gastrointestinal stromal tumour (GIST) and Siewert type I/II oesophagogastric junction malignancies were excluded. Univariate and multivariate logistic regression was used to identify variables associated to 90-day outcome. Results 380 collaborators from 47 countries submitted data on 1538 patients. Mean age was 64.2 years and 58.5% were males. 90-day morbidity rate was 38.2% (n=587) and mortality rate was 2.9% (n=45). Pre-operative higher CCI or ASA score, pre-operative weight loss >10%, and surgical determinants such as type of gastric resection, positive specimen margin, number of harvested lymph nodes, longer surgery duration and post operative pathological IV staging (p value<0.05) were identified as predictors of postoperative severe complications and mortality. Conclusion Elective gastric cancer surgery has a 90-day morbidity of 38.2% and 90-day mortality of 2.9%, globally. This study identified several factors associated with higher morbidity and exemplified the importance of a unified language on surgical morbidity, pre-habilitation and ongoing audits to enhance patient outcomes.

Determinants of Neurological Outcome Following Elective and Emergency Open Thoracoabdominal Aortic Aneurysm Repair-A Retrospective Multi-Center Study.

Background/Objectives: This study aimed to evaluate and establish the incidence of all types of neurological complications at our high-volume reference center for open TAAA repair in the Netherlands and Germany. Additionally, we sought to identify predictors for various neurological complications. Methods: This retrospective study was conducted in accordance with the STROBE guidelines, with the aim of reporting neurological outcomes for all patients who underwent open thoracoabdominal aortic aneurysm repair at two centers (Maastricht-Aachen) from 2000 to 2023, and to examine the association between these outcomes and pre- and perioperative parameters. The primary endpoints of the study were all-cause mortality, spinal cord ischemia (SCI), stroke, intracerebral bleeding (ICB), critical illness polyneuropathy/myopathy (CIP/CIM), and recurrent laryngeal nerve paralysis. Results: A total of 577 patients were operated on for open TAAA repair in two centers. The total in-hospital mortality rate was 20.6%, while the elective cases in-hospital mortality rate was 14.6%. In all, 28.2% of patients experienced neurological complications. The spinal cord ischemia rate was 7.5%, intracerebral bleeding 3.6%, stroke 5.9%, critical illness polyneuropathy 3.5%, and laryngeal nerve paresis 5.7%. Crawford extent II was significantly associated with increased neurological complications (OR 2.05, 95% CI 1.39-3.03, p = 0.003), while Crawford extent III and IV were significantly associated with fewer postoperative neurological complications (OR 0.61 (0.38-0.98) p = 0.04) (OR 0.52 (0.30-0.92) p = 0.02). Preoperative ASA score > 3 (OR 1.76, 95% CI 1.16-2.67, p = 0.007), COPD (OR 1.82, 95% CI 1.19-2.78, p = 0.006), massive intraoperative transfusion (OR 1.48, 95% CI 1.01-2.17, p = 0.04), and reinterventions during hospital stay (OR 1.98, 95% CI 1.36-2.89, p < 0.001) and surgery time (p =< 0.001) were significantly associated with neurological complications. Patients with neurological complications had higher rates of other postoperative morbidities. Conclusions: Neurological complications after open TAAA repair remain a significant concern, with identified risk factors associated with increased morbidity, mortality, and resource utilization. Identifying at-risk patients could potentially lead to a reduction in neurological complications.

Recovery of health-related quality of life after laparoscopic versus open distal pancreatectomy.

Limited data comparing recovery of health-related quality of life (HRQoL) after laparoscopic (LDP) versus open distal pancreatectomy (ODP) are available. The aim of this study was to assess the impact of laparoscopy on postoperative HRQOL after DP using the Patient-Reported Outcomes Measurement Information System (PROMIS). Data from consecutive patients who underwent DP (2020-2022) enrolled in a prospective clinical trial were reviewed. Patients completed PROMIS-29 plus 2 profile preoperatively, at postoperative day (POD) 15, 30, 90, and 180. Linear regression analysis adjusting for confounders including preoperative PROMIS scores, age, gender, ASA score, diagnosis, and multivisceral resection was used to estimate mean between-group differences (MD) in postoperative PROMIS domains T scores. Overall, 202 patients (118 laparoscopic, 86 open) underwent DP (median age 66years, pancreatic cancer 41%, multivisceral resection 10%, median LOS 6days). At POD15, LDP was associated with higher physical function (MD 5.6) and participation in social roles and activities scores (MD 3.8), reduced fatigue (MD -2.7) and sleep disturbance (MD -3.8) compared to ODP. At POD30, LDP patients had higher physical function (MD 5.2) and participation in social roles and activities scores (MD 6.0), reduced fatigue (MD -3.5), and anxiety (MD -4.0) compared to ODP. No between-group differences were found in HRQoL domains at POD90 and 180. Six months after surgery, the proportions of patients who had not recovered to preoperative physical function, participation in social roles and activities, fatigue, pain interference, sleep disturbance, cognitive function, depression, and anxiety were 31%, 31%, 28%, 20%, 15%, 14%, 8%, and 7%, respectively. According to PROMIS, LDP resulted in improved physical and social functioning and reduced anxiety and fatigue up to 30days after surgery compared to ODP. At 6months after surgery, recovery of physical domains is still incomplete in up to 30% of patients.

Surgical treatment of spondylodiscitis in critically ill septic patients

PurposeSurgical procedures in critically ill patients with spondylodiscitis are challenging and there are several controversies. Here, we present our experience with offering surgical intervention early in critically ill septic patients with spondylodiscitis.MethodAfter we introduced a new treatment paradigm offering early but limited surgery, eight patients with spondylodiscitis complicated by severe sepsis and multiple organ failure underwent urgent surgical treatment over a 10-year period. Outcome was assessed according to the Barthel index at 12-month follow-up and at the last available follow-up (mean 89 months).ResultsThere were 7 men and 1 woman, with a mean age of 62 years. The preoperative ASA score was 5 in 2 patients, and 4 in 6 patients. Six of them presented with high-grade paresis, and in all of them, spondylodiscitis with intraspinal and/or paravertebral abscesses was evident in MR imaging studies. All patients underwent early surgery (within 24 h after admission). The median time in intensive care was 21 days. Out of the eight patients, seven survived. One year after surgery, five patients had a good outcome (Barthel index: 100 (1); 80 (3); and 70 (1)). At the last follow-up (mean 89 months), 4 patients had a good functional outcome (Barthel index between 60 and 80).ConclusionEarly surgical treatment in critically ill patients with spondylodiscitis and sepsis may result in rapid control of infection and can provide favorable long-term outcome. A general strategy of performing only limited surgery is a valid option in such patients who have a relatively high risk for surgery.

Blood-Transfusion Risk Factors after Intramedullary Nailing for Extracapsular Femoral Neck Fracture in Elderly Patients

Extracapsular femoral neck fractures (eFNF) are the third most common type of fracture in traumatology. Intramedullary nailing (IMN) is one of the most frequently used ortho-pedic treatments for eFNF. Blood loss is one of the main complications of this treatment. This study aimed to identify and evaluate the perioperative risk factors that lead to blood transfusion in frail patients with eFNF who undergo IMN. From July 2020 to December 2020, 170 eFNF-affected patients who were treated with IMN were enrolled and divided into two groups according to blood transfusion: NBT (71 patients who did not need a blood transfusion), and BT (72 patients who needed blood transfusion). Gender, age, BMI, pre-operative hemoglobin levels, in-ternational normalized ratio (INR) level, number of blood units transfused, length of hospital stay, surgery duration, type of anesthesia, pre-operative ASA score, Charlson Comorbidity Index, and mortality rate were assessed. Cohorts differed only for pre-operatively Hb and surgery time (p < 0.05). Patients who have a lower preoperative Hb level and longer surgery time have a high blood-transfusion risk and should be closely followed peri-operatively.

EARLY PROMS FOLLOWING TOTAL HIP ARTHROPLASTY WITH AND WITHOUT COMPUTER NAVIGATION SYSTEM: A STUDY FROM THE AUSTRALIAN NATIONAL JOINT REPLACEMENT REGISTRY

Total hip arthroplasty (THA) is an effective treatment for symptomatic hip osteoarthritis (OA). While computer-navigation technologies in total knee arthroplasty show survivorship advantages and are widely used, comparable applications within THA show far lower utilisation. Using national registry data, this study compared patient reported outcome measures (PROMs) in patients who underwent THA with and without computer navigation.Data from Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) PROMs program included all primary THA procedures performed for OA up to 31 December 2020. Procedures using the Intellijoint HIP® navigation system were identified and compared to procedures using other computer navigation systems or conventional instrumentation only. Changes in PROM scores between pre-operative and 6-month post-operative time points were analysed using multiple regression model, adjusting for pre-operative score, patient age, gender, ASA score, BMI, surgical approach, and hospital type.There were 65 primary THA procedures that used the Intellijoint HIP® system, 90 procedures used other types of computer navigation, and the remaining 5,284 primary THA procedures used conventional instrumentation. The estimated mean changes in the EuroQol visual analogue scale (EQ VAS) score and Oxford Hip score did not differ significantly when Intellijoint® was compared to conventional instruments (estimated differences of 2.4, 95% CI [-1.7, 6.5], p = 0.245, and −0.5, 95% CI [-2.5, 1.4], p = 0.592, respectively). The proportion of patients who were satisfied with their procedure was also similar when Intellijoint® was compared to conventional instruments (rate ratio 1.06, 95% CI [0.97, 1.16], p = 0.227).The preliminary data demonstrate no significant difference in PROMs when comparing the Intellijoint HIP® THA navigation system with both other navigation systems and conventional instrumentation for primary THAs performed for OA. Level of evidence: III (National registry analysis)

Prolonged antibiotics after ovarian cancer debulking with intestinal surgery are not associated with improved infectious outcomes (302)

<b>Objectives:</b> While limited data support prolonged antibiotic therapy for infectious prophylaxis following intestinal surgery in epithelial ovarian cancer (EOC), the practice is often performed. The purpose of this study was to determine whether prolonged antibiotic therapy is associated with decreased incidence of postoperative incisional infections in patients with EOC undergoing cytoreductive surgery (CRS) with colorectal resection. <b>Methods:</b> An IRB-approved, retrospective single-institution cohort study was performed in women with EOC who underwent CRS with colorectal resection from 2008 to 2017. Superficial surgical site infections (SSI) and combined superficial and deep pelvic/intra-abdominal abscesses were assessed independently and defined according to the Centers for Disease Control (CDC). The impact of extended antibiotics (piperacillin/tazobactam x 72 hours) was assessed using univariate models. Cox regression was used to determine the impact of infectious outcomes on progression-free survival (PFS) and overall survival (OS). <b>Results:</b> Of 268 eligible patients, 161 (60.1%) patients received additional antibiotic therapy, and 107 (39.9%) patients received standard antibiotic therapy only. There was no difference seen in the age, race, preoperative ASA score, residual disease, or medical comorbid conditions between the groups. Stage of disease at the time of surgery, histopathologic diagnosis, type of chemotherapy given (neoadjuvant vs adjuvant) were not significantly different among patients who received additional antibiotics (p >0.05) compared to those who did not. Patients who underwent a transverse colectomy were less likely to receive additional antibiotics than other colorectal resections (p=0.032). There were no differences in the rate of superficial SSI or combined superficial-deep SSI or intra-abdominal infections between those who received standard versus prolonged antibiotics (p=0.35). Extended/prolonged antibiotics did not significantly alter PFS (HR: 1.06, p=0.68) or OS (HR: 1.12, p=0.49). <b>Conclusions:</b> In our retrospective study, additional antibiotics did not reduce incisional infectious morbidity in women with EOC undergoing CRS with colorectal resection. Specifically, the addition of extended antibiotics did not improve outcomes in SSI or superficial and deep abscesses. Given the recent association of antibiotic use with poor outcomes after platinum-based chemotherapy and immunotherapy, antibiotic stewardship should be encouraged. Further study of the potential benefit, or lack thereof, of prolonged antibiotics in gynecologic oncology is warranted.

Is sequential bilateral robotic total knee arthroplasty a safe procedure? A matched comparative pilot study.

To our knowledge, no papers have reported the results of robotic-assisted surgery for sequential bilateral Total Knee Arthroplasty (TKA). Indeed, sequential bilateral TKA present several benefits, as one single anesthesia, surgical episode, hospitalization, and rehabilitation. The purpose of our study was to evaluate peri-operative outcomes and compare the complication rates, clinical outcomes, and implant positioning of sequential bilateral TKA performed with a robotic-assisted system versus a conventional technique. All patients who underwent a sequential bilateral robotic-assisted primary TKA (raTKA) in our institution between November 2019 and February 2021 were included. Twenty patients met the inclusion criteria and were matched with 20 sequential bilateral TKA performed with a conventional technique. The two groups were comparable for the demographic data and the preoperative parameters, including preoperative anticoagulation and ASA score. The minimum follow-up was 6 months. The operative time was significantly longer in the robotic group (< 0.0001), with a mean additional time of 29min. There was no significant difference between both groups for postoperative blood loss, rate of blood transfusion, or postoperative pain. The average length of stay was 5 days. There was one early complication in the robotic group due to the tibial trackers. The functional outcomes were similar between both groups, except for the functional KSS score, which was better at 6 months in the robotic group (p < 0.0001). The restoration of the knee alignment and the distal femoral anatomy were significantly better in the robotic group than in the conventional group. Despite a longer operative time, the peri-operative parameters of sequential bilateral TKA were similar between robotic and conventional techniques. Further, sequential bilateral raTKA was at least as safe as a conventional technique, without additional risk of medical complications.

Preoperative prognostic factors for obstructive colorectal cancer.

The aim of the study was to determine the preoperative predictive factors of overall survival, relapse-free survival, and peritoneal carcinomatosis in obstructive colorectal cancer. Data from patients undergoing emergency surgery for obstructive colorectal cancer at our center between 2004 and 2016 were extracted retrospectively from our health records. Several preoperative parameters were used to predict survival and peritoneal carcinomatosis using univariate and multivariate analysis, and ROC curves. A total of 107 patients with obstructive colorectal cancer were included. Five-year relapse-free and overall survival rates were 14% and 28%, respectively, with 15% peritoneal carcinomatosis. Univariate analysis showed that age ≥ 83years old, preoperative ASA score ≥ 3, initial hemodynamic instability, and CRP > 18.3mg/L was significantly associated with worse relapse-free and overall survival. In a multivariate analysis, only age > 83years (HR = 1.75; HR = 2.16, for relapse-free and overall survival status, respectively) and hemodynamic instability (HR = 7.29; HR = 6.55) were confirmed in the multivariate model. Global peritoneal carcinomatosis was significantly associated with synchronous liver metastases in the multivariate model (OR = 4.56), and synchronous peritoneal carcinomatosis only was significantly associated with platelet to lymphocyte ratio (PLR) > 269 and synchronous liver metastases in the multivariate model (OR = 0.003; OR = 7.26). Synchronous liver metastases are prognostic risk factor for global and synchronous peritoneal carcinomatosis whereas PLR > 269 was a significant protective factor for synchronous peritoneal carcinomatosis only for obstructive colorectal cancer. Age > 83years and initial hemodynamic instability were key preoperative prognostic risk factors for worse relapse-free and overall survival. Prognostic usefulness of blood cell ratios for mortality and peritoneal carcinomatosis warrants further investigation.

Pancreaticoduodenectomy with Complex Vascular Reconstruction Is Safe and Oncologically Justified

Introduction: The aim of this study was to analyze the experience in two transplant centers of patients undergoing pancreaticoduodenectomy (PD) with or without vascular reconstruction. Method: We retrospectively reviewed prospectively collected data of all consecutive patients undergoing pancreaticoduodenectomy (PD) for cancer, between 1/1/2013 and 1/31/2018. The overall cohort (n=197) was divided into those with vascular reconstruction (Group1, n=38) and without vascular reconstruction (Group2, n=159). Results: The two groups were similar in terms of age, sex distribution, and pre-operative ASA score. One post-operative portal vein thrombosis was seen in each group (NS). Peri-operative mortality occurred in one patient in Group 2 due to post-op bleeding. Hospital length of stay (8d vs 7d, p=0.14), ICU length of stay (2d vs 1d, p=0.47), and blood loss (350cc vs 300cc) were similar in both groups. The length of surgery was longer in Group 1 (438 minutes vs 341, p<0.0001). Both groups had similar rates of Clavien grade 3 or higher morbidity (15.8% in Group1 and 15.7% in Group2, p=0.83). R0 resection rate was lower in Group 1 (73.7% vs 92.5%, p=0.001). However, the local recurrence rates did not differ between the two groups - 17 (44.7%) in Group 1 and 71 in Group 2 (44.7%, p=0.992). Kaplan-Meier analysis showed no difference in overall and disease-free survival, and also when limiting the pathology to only pancreatic ductal adenocarcinoma. Conclusions: Our experience shows that complex vascular reconstruction in PD can be achieved safely when done by experienced teams, and with comparable cancer outcomes in selected patients.

Surgical treatment of bone metastasis from osteophilic cancer. Results in 401 peripheral and spinal locations

IntroductionPeripheral and spinal bone metastases arise mainly from 5 osteophilic cancers: lung, prostate, kidney, breast and thyroid. Few studies combined results for the two types metastatic location (peripheral and spinal). Therefore we performed a multicenter retrospective study of surgically managed peripheral and spinal bone metastases to assess: (1) global function at a minimum 1 year's follow-up and; (2) factors affecting survival. HypothesisGlobal function is improved by surgery, with acceptable survival. Material and methodBetween 2015 and 2016, 386 patients were operated on in 11 centers for 401 metastases: 231 peripheral, and 170 spinal. Mean age was 62.6±12.5 years in the 212 female patients (54%) versus 66.4±11.5 years in the 174 males (46%) (p=0.001). Pre- to postoperative comparison was made on pain on VAS (visual analog scale), WHO (World Health Organization) score, Karnofsky score, walking and global upper-limb function. Survival was estimated at 4 years’ follow-up. ResultsThe most frequent locations were in the femur (n=146, 36%) and thoracic spine (n=107, 27%). The primary cancer was revealed by the metastasis in 82 patients (21%). There were 55 general complications (14%) and 48 local complications (12%). Twenty-one patients (5.4%) died during the first month. VAS and Karnofsky sores improved: respectively, 6.6±2.3 vs. 3.4±2.1 (p<0.001) and 65±14 vs. 72±20 (p=0.01). Walking, upper-limb function and Frankel grade improved in respectively 49/86 (57%), 19/29 (66%) and 31/84 (37%) patients. Median survival was 13.3 months (95% CI: 10.8–17.1), and was related to the primary (log-rank, p<0.001): lung 6.5 months (95% CI: 5.2–8.9), prostate 11.1 months (95% CI: 5.3–43.6), kidney 12.9 months (95% CI: 8.4–22.6), breast 26.5 months (95% CI: 19.0–34.0), and thyroid 49.0 months (95% CI: 12.2–NA). On multivariate analysis, independent factors for death comprised internal fixation rather than prosthesis (OR=2.20; 95% CI: 1.59–3.04 (p<0.001)), high preoperative ASA score (OR=1.78; 95% CI: 1.40–2.28 (p<0.001)), preoperative chemotherapy (OR=1.26; 95% CI: 1.13–1.41 (p<0.001)) and major visceral metastasis (lung, brain, liver) (OR=11.80; 95% CI: 5.21–26.71 (p<0.001)). ConclusionAlthough function improved only slightly, pain relief and maintained autonomy suggest enhanced comfort in life, confirming the study hypothesis only partially. Factors affecting survival and clinical results argue for preventive surgery when possible, before general health status deteriorates. Level of evidenceIV; retrospective observational.

Percutaneous nephrolithotomy in patients with chronic kidney disease

Introduction and objective: Urolithiasis can impair renal function by obstruction, infection, its association with comorbidities, high recurrence rate and need for multiple surgical interventions. Treatment of patients with chronic kidney disease (CKD) may be challenging due to the increased risk for intra- and postoperative complications, higher ASA score and association with comorbidities. The objective of this study is to compare the preoperative characteristics, efficacy and safety of PCNL in patients with normal or mildly impaired renal function and patients with chronic kidney disease. Material and methods: Prospectively collected data on 1656 PCNL procedures, performed in the Department of Urology and Nephrology at Military Medical Academy, Sofia, Bulgaria between 2011 and 2021 was analyzed. Patients were divided in 2 groups: Group 1 (1244 patients with normal or mildly impaired renal function, eGFR &gt; 60 mL/min/1.73 m2 ) and Group 2 (412 patients with moderately impaired renal function and end stage renal disease, eGFR &lt; 60 mL/min/1.73 m2 ) Results: Patients with CKD were more likely to be older, be female, with higher incidence of comorbidities and higher preoperative ASA score, higher rate of recurrent stones, solitary kidney and staghorn stones. PCNL efficacy after single procedure and at 3rd postoperative month was lower for CKD patients (respectively 79,6% vs 83,4%, р=0.086, and 85,9% vs 90,1%, р=0.018). There were no statistically significant differences in postoperative hemoglobin drop (14,0±10,2 vs 14,2±10,4, р=0.772) and overall complications rate (14,6% vs 12,1%, р=0.793) between the two groups. Conclusions: The results of this study suggest that PCNL is an effective and safe procedure in patients with chronic kidney disease. Although, CKD patients had larger and more complex stones, higher comorbidity rate, and higher incidence of recurrent stones and infection, these factors had no negative impact on PCNL outcomes compared to patients with normal or mildly impaired renal function.

Early intraoperative and postoperative complications of C1-C2 fixation using the Goel-Harms technique : How often? Which? Why?

Fractures of the axis are among the most frequent spinal injuries. Posterior C1-C2 fixation according to Goel-Harms is an accepted alternative to the more traditional procedures: initial stability has been shown and there is awide range of indications but there is apaucity of data on possible complications. Such knowledge, however, is essential in order to improve outcomes.Thus, the aim of the study was:1.to describe the frequency, type and severity of early postoperative complications following C1-C2 fixation according to Goel-Harms,2.to investigate whether there is acorrelation between frequency and severity of complications,3.to detect risk factors for complications.Patients included in this study were treated surgically using the C1-C2 fixation according to Goel-Harms between March 2011 and July 2018. Data were taken from our hospital database and checked via OPS 10 code "S12.1". We analyzed age, sex, ASA score, blood loss, operating time and complications. These data were extracted from clinical data sheets.A total of 134 patients were detected, 54% female, mean age 75years and mean ASA score3. There were 122 complications. All these complications were observed in 50% of the patients. These were mainly minor complications (32%), and 18% severe complications. Mortality was 2%. We found that patients with more severe complications also had significantly more complications when compared to patients with minor complications (Fisher's exact test, p = 0.001). Preoperative ASA score was the only risk factor to significantly influence the number (p = 0.001) and severity (p = 0.002) of postoperative complications. Each increase of the preoperative ASA score increased the risk to get one more complication by a factor of 2.55 (odds ratio 2.55) and increased the risk to get asevere complication by a factor of 2.43 (odds ratio 2.43). Intraoperative blood loss, patient age and duration of surgery, however, were not identified as risk factors for complications.

Minimally invasive surgery for choledochal cysts: Laparoscopic versus robotic approaches.

Backgrounds/AimsMinimally invasive surgery is a widely accepted approach in hepatobiliary surgery and choledochal cyst excision has also been performed by minimally invasive methods, including laparoscopic and robotic approaches. However, only a few studies have compared laparoscopic and robotic surgery. Therefore, we performed a comparative study between two groups, including cost aspects.MethodsWe retrospectively analyzed minimally invasive choledochal cyst excision at Severance Hospital in Seoul, South Korea from January 2005 to December 2018. A total of 39 patients that underwent minimally invasive choledochal cyst excision were identified. The 23 patients (58.9%) and 16 patients (41.1%) were enrolled in laparoscopic and robotic approach, respectively. We compared the patient’s characteristics, and perioperative outcomes between laparoscopic and robotic surgery groups.ResultsA comparative analysis between the two groups showed no differences in preoperative clinical characteristics. There were no significant differences in operative time, estimated blood loss, and postoperative complications, including biliary complication. The preoperative ASA score (p=0.021) and hospital stays (p=0.011) were the only clinical variables that differed between the two groups. All of the variables included in the cost analysis showed statistically significant differences (total hospital charge: p=0.035, patient’s bill: p≤0.001, operation: p=0.002, anesthesia: p=0.001, postoperative management: p=0.001).ConclusionsThe overall clinical outcomes between the laparoscopic and robotic approach to choledochal cyst were comparable. The surgical approach should be balanced based on the surgeons’ skill, patients’ general condition, disease extent, and economic status.

Preoperative low hematocrit is an adverse prognostic biomarker in ovarian cancer.

The study aimed to investigate the prognostic value of preoperative hematocrit (HCT) on the survival of epithelial ovarian cancer (EOC) patients. Patients who underwent primary debulking surgery (PDS) in our institution, from January 2010 to December 2015, were enrolled. The preoperative HCT, hemoglobin (Hb), tumor stage, ascites volume, age, albumin, BMI, ASA score, diabetes and other factors were collected and analyzed to find the risk factors for poor prognosis of EOC patients using Cox regression. Survival analysis was conducted with Kaplan-Meier method and log-rank test. 192 patients met the inclusion criteria. HCT < 35% (P = 0.031, HR: 1.715, 95% CI 1.050-2.802) was an independent risk factor for poor overall survival in patients. The mean survival time was 83.7months in patients with preoperative HCT ≥ 35% and 61.7months in patients with HCT < 35% (P = 0.002). Patients with low HCT (< 35%) had a poor prognosis compared with patients with normal HCT, specifically in the patients of stage III/IV, age ≥ 65years, BMI ≥ 25.0kg/m2, ascites volume ≤ 500mL, ASA score < 3, albumin ≥ 35g/L and nondiabetic. Low HCT was more likely to occur in patients with advanced stage (III/IV), anemia (Hb < 110g/mL), low albumin (< 35g/L), high ASA score (≥ 3) and platelet > 400 × 109/L. Preoperative low HCT was a valuable predictor for EOC patients' poor prognosis, specifically in obese, nondiabetic, elder, advanced stage but having relatively good performance status patients.

Mayo Adhesive Probability (MAP) score of non-donated kidney aids in predicting post-operative renal function following donor nephrectomy

BackgroundTo examine the association of preoperative Mayo Adhesive Probability (MAP) scores in the donor (MAPd) and non-donor kidneys (MAPnd) with post-donation renal function.MethodsThree hundred thirty-one patients undergoing hand assisted laparoscopic donor nephrectomy (HALDN) were reviewed. MAPd and MAPnd were obtained. Estimated glomerular filtration rate (eGFR) was recorded preoperatively and at 1 day, 1 month, and 6 months postoperatively.ResultsTwo hundred females and 131 males were evaluated with median BMI 26.4 kg/m2 (range 17.1–39.6) and median age 45 years (range 19–78). MAPd score was 0 for 231 patients (69.8%) and > 0 for 100 patients (30.2%). MAPnd score was 0 for 234 patients (70.7%) and > 0 for 97 patients (29.3%). The median preoperative eGFR was 86.6 ml/min/1.73m2 (range 48.8–138.4). After adjusting for preoperative eGFR, BMI, ASA score, and kidney sidedness, postoperative eGFR was associated with MAP score in the non-donated kidney (p = 0.014) but not in the donated kidney (p = 0.24). Compared to donors with MAPnd = 0, donors with a MAPnd > 0, mean eGFR was − 2.33 ml/min/1.73m2 lower at postoperative day 1 (95% CI − 4.24 to − 0.41, p = 0.018), − 3.02 ml/min/1.73m2 lower at 1 month (95% CI − 5.11 to − 0.93, p = 0.005), and − 2.63 ml/min/1.73m2 lower at 6 months postoperatively (95% CI − 5.01 to − 0.26, p = 0.030).ConclusionsMAP score > 0 in the non-donated kidney is associated with worse renal function in the 6 months following HALDN.

How safe and effective is laparoscopic decortication of simple renal cysts in elderly patients?

Objective: To investigate the assessment of feasibility and safety of laparoscopic decortication of simple renal cysts in elderly patients.Methods: The data of 114 patients who underwent laparoscopic decortication for simple renal cyst between October 2011 and May 2019 were retrospectively evaluated. Patients’ age, gender and ASA scores; operation time; cyst size and location; complications; hospital stays and success rates of operations were recorded.Results: The mean age of the patients were 73.8 ± 8.2 years. Forty-eight (42.1%) of the patients were female and 66 (57.9%) were male. Cysts were localized on the right side in 61 (53.5%) patients and on the left side in 53 (46.5%) patients; and mean cyst size was 72.83 ± 31.13 mm. Also, they were localized on the anterior in 88 (77.2%) patients and on the posterior of the kidney in 26 (22.8%) patients. Preoperative ASA score distributions were ASA-I in 12 patients (10.5%), ASA-II in 31 patients (27.2%), ASA-III in 68 patients (59.7%), and ASA-IV in 3 patients (2.6%). Mean operative time was 41.4 ± 5.6 min. Clavien grade 1 complications were observed in 5 (10.4%) patients. Median hospitalization time was 1 day. No recurrence was occurred in any patient in the postoperative period.Conclusions: Although laparoscopic surgery has some risks and complications for elderly patients, laparoscopic decortication can be applied safely and effectively in treatment of simple renal cyst in that patient population.

Patients undergoing shoulder surgery have high preoperative expectations.

The primary aims of this study were to (1) assess the preoperative expectations of patients undergoing shoulder surgery, and (2) determine the relationship between preoperative patient demographics, PROs, and preoperative patient expectations. It was hypothesized that younger patients with worse function and worse health status had higher expectations of shoulder surgery. Data from a total of 319 patients (319 shoulders) from 2015-2018 were analyzed. Patients completed a series of questionnaires covering demographics and patient-reported outcome measures. Expectations of treatment were evaluated using the Musculoskeletal Outcomes Data Evaluation and Management System. Bivariate analyses were performed to determine the significance of identified associations. The study population consisted of 186 males and 133 females. The mean age was 46.9 (± 17.2), and the mean BMI was 30.1 (± 6.8). Overall, patients had high expectations of shoulder surgery, with a mean score of 84.7 (± 19.3). The most commonly performed procedure in the study population was arthroscopic rotator cuff repair. There was a significant association between pre-treatment expectations and ethnicity, previous shoulder surgery, employment status, income level, tobacco use, preoperative opioid use, depression, and ASA score. The findings suggest that patients undergoing shoulder surgery have high overall preoperative expectations, which were significantly associated with ethnicity, surgical history, opioid use, and employment status, and with multiple patient-reported outcome measures including physical function, pain interference, fatigue, and depression. Nevertheless, by discussing expectations preoperatively, orthopaedic surgeons can help patients develop high but realistic expectations to improve outcomes and satisfaction. IV.

Comparison of external fixation and intramedullary nailing in geriatric patients with intertrochanteric fractures of the femur

Aim: The healing time of femoral intertrochanteric fractures in the elderly population is prolonged due to the presence of osteoporosis. However, mortality is high because of major causes such as embolism due to long-term bed rest. It is particularly important that these patients be operated and given the freedom to move in the early postoperative period. In this study, we aimed to compare the clinical outcomes of Proximal Femoral Nail (PFN) and External Fixation (EF) in older patients with intertrochanteric fractures of the femur (ITFF).Methods: This study included 72 patients aged 65 years or older who were diagnosed with ITFF and underwent PFN (n=38) or EF (n=34) between 2011 and 2017. Patient data including demographic characteristics, preoperative ASA score, surgical technique, postoperative complications, and functional outcomes at final follow-up, Harris Hip Score (HHS) and Mean Mobility Score (MMS) scores were recorded for each patient.Results: The results indicated that both PFN and EF provided equally satisfactory functional outcomes in the patients. EF was found to have major advantages including significantly lower operative times, lower intraoperative blood loss, and administration of sedation only in high-risk patients. PFN was also found to have remarkable advantages such as lower reoperation risk, reduced mortality, and lower risk of superficial wound infection.Conclusion: Although both PFN and EF were found to have remarkable advantages, PFN seems to be more advantageous in terms of complications. Meaningfully, PFN could be more reliable and effective in the treatment of extracapsular ITFF in old-age patients.