Preoperative Comorbid Conditions Research Articles

Comparison of Outcomes in Below-Knee Amputation Between Vascular, General, and Orthopedic Surgeons

IntroductionGeneral surgeons (GS), orthopedic surgeons (OS), and vascular surgeons (VS) can perform below-knee amputation (BKA) operations. We compared the outcomes of BKA patients among the three specialties. MethodsAdult patients who underwent a BKA were identified from the 2016–2018 National Surgical Quality Improvement Project database. Statistical data for orthopedic and vascular BKA cases were then compared with GS cases using logistic regression analysis. Outcomes included mortality, length of hospital stay, and complications. ResultsThere were 9619 BKA cases. VS had the highest volume of BKA with 58.9% of the cases, compared to GS at 22.9% and OS at 18.1%. 4.4% of general surgery patients had severe frailty compared to OS (3.3%) and VS (3.4%, P < 0.001). VS has the lowest rates of emergency cases (11.9% versus 16.1 for GS versus 15.8% versus OS) and the most favorable wound classification (38.3%, versus 48.7% for GS and VS). Peripheral vascular disease was notably highest in VS (34.0% versus. 20.6% for GS and 9.9% for OS, P < 0.001). Compared to GS, VS was more likely to have a prolonged length of stay (odds ratio) (OR)(1.409), 95% CI 1.265-1.570) while OS was less likely (OR 0.650, 95% CI 0.561-0.754). OS had a lower risk of complications (OR 0.781, 95% CI 0.674-0.904). Mortality was not significantly different among the three specialties. ConclusionsThe National Surgical Quality Improvement Project retrospective analysis of BKA cases suggested that mortality was not statistically different when performed by VS, GS, and OS. There were fewer overall complications when OS performed a BKA, but this is more likely a result of operating upon a generally healthier patient population with lower incidence of preoperative comorbid conditions.

Comorbid Conditions and Complications in Body Contouring Surgery: A Retrospective Review.

Body contouring procedures have significantly increased in popularity in the United States. The authors sought to understand, categorize, and classify patients' experiences with postoperative complications following common body contouring procedures. PearlDiver (PearlDiver Technologies, Colorado Springs, CO), a database with over 90 million patients, was queried to identify patients who had undergone body contouring procedures between 2010 and 2021 using current procedural terminology (CPT) codes. The authors identified patients who underwent panniculectomy, abdominoplasty, brachioplasty, thighplasty, mastopexy, breast augmentation, augmentation mastopexy, breast reduction, and liposuction for analysis. They reviewed combined procedures and analyzed risk factors associated with the most common complications. There were 243,886 patients included in the study. The majority of patients were female, between 50 and 59 years old, and had their procedures performed in the southern United States. There were an average of 25,352 procedures per year. The majority of cases involved breast surgeries. The most common preoperative comorbid conditions diagnosed 1 year before surgery were hypertension, obesity, and diabetes. The most common postoperative complications within 90 days were wound dehiscence, hematoma, and urinary tract infection. A logistic regression evaluating the association of the preoperative comorbid conditions with postoperative complications found that patients with obesity, tobacco use, diabetes, and hypertension had an increased risk of developing wound dehiscence, hematoma, and surgical-site infection. The data suggest that patients with obesity, tobacco use, diabetes, and hypertension undergoing body contouring surgery are at greater risk of developing wound dehiscence, hematomas, and surgical-site infections. Understanding this data is imperative for providers to adequately identify associated risk factors, stratify patients, and provide adequate perioperative counseling.

Thoracoabdominal aortic aneurysmectomy in the high-risk patient

ObjectiveThe study objective was to provide a review of outcomes and management strategies for high-risk scenarios in the open repair of thoracoabdominal aortic aneurysms. MethodsSeries examining the open repair of thoracoabdominal aortic aneurysms were reviewed to identify well-described high-risk scenarios and summarize expected outcomes and management strategies in the current era. ResultsThe efforts of many have led to improved outcomes for patients undergoing the inherently challenging open repair of thoracoabdominal aortic pathologies. Several well-described high-risk scenarios include those related to preoperative comorbid conditions (preoperative pulmonary dysfunction, low ejection fraction, and renal dysfunction), anatomically high-risk cases (extent II repairs), and those with acute presentations (rupture, mycotic aneurysms, acute complicated type B aortic dissection). Several operative and perioperative techniques have been developed to mitigate the risk in these formidable cases. ConclusionsChallenges remain for several high-risk scenarios in thoracoabdominal aortic aneurysm repair. Judicious patient selection, meticulous surgical, and critical care strategies have greatly decreased the risk for many high-risk patients.

52. Patients with additional medical comorbidities failed to maintain MCID+ status at five years following adult spinal deformity surgery

<h3>BACKGROUND CONTEXT</h3> Evidence on long-term maintenance of health status in adult spinal deformity (ASD) patients who improve above MCID threshold (MCID+) at 2 years following surgery is limited. <h3>PURPOSE</h3> This study aims to: (1) evaluate whether patients who reached MCID+ status at two years postoperatively will maintain MCID+ status at 5 years, (2) identify risk factors associated with maintaining MCID+ status, and (3) Assess whether maintaining MCID+ status at 5 years is associated with satisfaction with surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective review. <h3>PATIENT SAMPLE</h3> Patients who underwent adult spinal deformity (ASD) surgery with minimum 5-year follow-up who achieved 2-year MCID in ODI were identified. <h3>OUTCOME MEASURES</h3> Maintenance of MCID+ status at 5 years for Oswestry Diability Index (ODI). <h3>METHODS</h3> Patients who maintained MCID+ status at 5 years and those who did not formed the comparison groups. Multivariable logistic regression, controlling for age, complications after two years and two-year alignment, was used to identify risk factors associated with the inability to maintain MCID+ status. In a separate multivariable logistic regression, whether maintaining MCID+ status was associated with 5-year surgical satisfaction was assessed. <h3>RESULTS</h3> Of 633 eligible patients, 339 had 5-year data. Of 133 with both 2- and 5-year data, 70 who achieved 2-year MCID in ODI were included. 30% (21) failed to maintain MCID+ status at 5 years. Preoperatively, 33% (23) were narcotic users, 47% (33) were frail and mean surgical invasiveness was 96.6±36.02. On multivariable logistic regression, preoperative variables were assessed: CCI > 3 (OR 5.75; p=0.026), ASA grade > 2 (OR 5.25; p=0.015), anemia (OR 19.74; p=0.009), and cancer (OR 6.46; p=0.015) were associated with increased odds of failure to maintain MCID+ status at 5-year follow-up. Patients who failed to maintain MCID+ status at 5 years had a higher odds of being unsatisfied with the surgery (OR 15.66; p=0.001). Frailty and surgical invasiveness had no significant impact on MCID+ status at 5 years. <h3>CONCLUSIONS</h3> Preoperative comorbid conditions significantly impact patient's long-term ability to maintain the positive gains in health-related quality of life measures from the surgery. Surgeons should continue to monitor and treat the chronic conditions to ensure maintenance of long-term recovery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

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.

Long-term age-stratified survival following endovascular and open abdominal aortic aneurysm repair

ObjectiveThe long-term survival differences between endovascular repair (EVAR) and open repair for abdominal aortic aneurysms (AAAs) and specifically the impact of age on these differences remain a topic of debate. Therefore, we compared the long-term mortality between EVARand open abdominal aneurysm repair for patients of different ages. MethodsThis was a retrospective cohort study of prospectively collected data from patients undergoing elective EVAR or open repair for infrarenal AAAs within the Vascular Quality Initiative multinational clinical registry (2003-2021). The primary outcome was long-term all-cause mortality comparing EVAR and open repair for patients aged less than 65 years, between 65 and 79 years, and those aged 80 and older. In addition, we investigated the interaction between repair modality and 10-year hazard of mortality for sex, aneurysm diameter, and several preoperative comorbid conditions within each age category. To account for the nonrandom assignment of treatment, we used propensity scores and inverse probability weighted Cox proportional hazard analysis. ResultsWe identified 48,074 patients undergoing elective infrarenal abdominal aneurysm repair (89% EVAR) within the study period, including 7940 patients aged less than 65, 29,555 aged between 65 and 79, and 10,579 aged 80 years or more. EVAR was associated with a higher propensity score-adjusted long-term hazard of mortality compared with open repair in the cohort aged less than 65 years (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.04-1.86; P = .026). The mortality was similar in the age cohort between 65 and 79 (HR, 0.94; 95% CI, 0.79-1.10; P = .43), whereas EVAR was associated with a lower hazard of mortality in the cohort aged 80 years or more (HR, 0.63; 95% CI, 0.46-0.86; P = .004). In patients aged less than 65 years, the hazard of mortality was higher with EVAR compared with open repair in those with female sex (HR, 4.40; 95% CI, 1.75-11.0), an aneurysm diameter of more than 65 mm (HR, 2.19; 95% CI, 1.11-4.34), and an absence of coronary artery disease (HR, 1.26; 95% CI, 0.83-1.91), congestive heart failure (HR, 1.41; 95% CI, 1.03-1.92), and renal dysfunction (HR, 1.46; 95% CI, 1.04-2.05). In the patient cohort aged 80 and older, a lower hazard of mortality for EVAR versus open repair was observed for male patients or those with small aneurysms or certain comorbidities. ConclusionsIn a selected group of young patients with a substantial life expectancy, the long-term mortality is higher with EVAR compared with open repair for infrarenal AAAs. Long-term mortality with EVAR is similar in the middle cohort and lower in the elderly cohort compared with open repair.

Female Gender Is Associated With Worse Outcomes Following Complex Fenestrated Or Branched Endovascular Aortic Repair

<h3>INTRODUCTION AND OBJECTIVES</h3> Gender discrepancies during aortic repair are noted to disproportionally affect females. Recent examination of complex fenestrated and branched endovascular aneurysm repair (FBEVAR) at high-volume centers noted equivalent mortality among genders following repair. Whether similar results extend to real-world practice is unknown. <h3>Methods</h3> Utilizing the Vascular Quality Initiative (VQI) database from 2012-2020, all juxtarenal and type IV aneurysms (sealing zones 5-8) who underwent elective FBEVAR were included. Urgent, symptomatic, ruptured and staged cases were excluded. Demographics, comorbid conditions and technical factors were compared between genders. Our outcomes included in-hospital mortality, any complications, and retreatments. Multivariable logistic regression was used to adjust for patient and procedural factors. <h3>RESULTS</h3> There were 1547 males (77.5%) and 449 females (22.5%) included in our analysis. There were noted differences in pre-operative co-morbid conditions, medical optimization, and technical aspects of the procedure (Table 1). However, no difference was noted in proximal or distal sealing stent, number of fenestrations, or immediate post-procedure endoleak. Overall women had a higher incidence of in-hospital mortality, 5.6% versus 1.9% in men (P<0.001). On multivariable logistic regression female gender was an independent predictor of increased complications (OR 1.672 95% CI: 1.202-2.324, P=0.002), retreatment (OR 2.765, 95% CI: 1.745-4.070, P<0.001), and mortality (OR 2.296, 95% CI: 1.301-4.053, P=0.004).Image, table 1Image, table 1 <h3>CONCLUSIONS</h3> Females undergoing FBEVAR had similar extent of disease, number of fenestrations, and incidence of immediate endoleak but worse COPD and lower rates of optimal medical therapy. Despite adjustment for patient and procedural factors, female sex remained associated with worse outcomes. These data strongly support the need to incorporate the increased risks of repair for females when contemplating FBEVAR.

Modified Frailty Index (mFI) predicts 30-day complications after microsurgical breast reconstruction

Frailty lacks a universal definition. The modified Frailty Index (mFI) using patient comorbidities can be used to measure frailty. We hypothesized that mFI predicts 30-day complications after microsurgical breast reconstruction. American College of Surgeons’ (ACS) National Surgical Quality Improvement Project (NSQIP) was investigated to identify patients undergoing microsurgical breast reconstruction between 2005–2014 using Current Procedure Terminology (CPT) code, 19364. We used mFI as a measure of frailty. The patients were assigned a frailty score based on the number of preoperative comorbid conditions as defined by the mFI. Other risk indices used include age, BMI, wound class, ASA class. Stratification was performed in ascending order for each. The outcome measure was aggregate 30-day complications. Regression analysis was performed followed by Receptor Operating Characteristic (ROC) curve to determine the accuracy of each risk index in predicting 30-day complications. Of the 3237 patients 24% experienced complications. Univariate logistic regression analysis found odds ratio of complications for frailty score 1 = 22.1 (CI = 17.9–27.3, p < 0.01), and 2 = 28 (CI = 18.3–43, p < 0.01) compared to frailty score = 0. ROC curve demonstrated mFI with the highest concordance score (c-score = 0.816). Multivariable logistic regression found frailty as the strongest independent predictor of 30-day aggregate complications adjusted OR = 22.24, CI = 17.77–27.82, p < 0.01 when compared to other risk indices. The modified Frailty Index is a simple, reliable, and objective tool that can be used to predict postoperative complications after microsurgical breast reconstruction. The application of this tool can help microsurgeons preoperatively identify patients who are at high risk. Abbreviations: ACS: American College of Surgeons; ASA: American Society of Anesthesiologists; BMI: body mass index; CHF: congestive heart failure; CPT: current procedural terminology; COPD: chronic obstructive pulmonary disease; CVA: cerebrovascular accident; DM: diabetes mellitus; IRB: institutional review board; mfi: modified frailty index; MI: myocardial infarction; NSQIP: national surgical quality improvement program; PVD: peripheral vascular disease; ROC: receptor operating characteristic; TIA: transient ischemic attach

Omentopexy during laparoscopic sleeve gastrectomy: Is it effective in reducing postoperative gastrointestinal symptoms. A retrospective cohort study

BackgroundPostoperative gastrointestinal symptoms are common in patients undergoing sleeve gastrectomy. This study is aimed to assess the effectiveness of omentopexy during laparoscopic sleeve gastrectomy in reducing gastrointestinal symptoms. MethodsA retrospective analysis of patients who underwent laparoscopic sleeve gastrectomy with and without omentopexy in the period between January 2016 to September 2017. All procedures were performed by three surgeons utilizing the same surgical technique. Data extracted included patient socio-demographics’, preoperative body mass index (BMI), hospitalization period, treatments and post-operative gastrointestinal symptoms. It contained the GERD-Health Related Quality of Life Questionnaire (GERD-HRQL) measuring symptom severity in gastro esophageal reflux disease (GERD). Data were analyzed at 6, 12 and 18 months with reference to weight loss. ResultsA total of 140 patients were included in this study, 70 in each group arm. Age, preoperative BMI, pre-operative co-morbid conditions like hypertension, diabetes, and asthma were considered as confounding variables among the two groups. None of the previous factors were statistically significantly different among both groups. The outcomes of both groups were compared in terms of postoperative nausea, vomiting, regurgitation, intra-hospital stay, medication use, early return to work, and EWL%. None of the previous outcomes except for days of hospital stay and ondansetron use was found to be significantly different between both groups. ConclusionOmentopexy does not change the outcome for laparoscopic sleeve gastrectomy in terms of gastrointestinal symptoms or weight loss results.

Preoperative Opioid Prescription Patients Do Not Suffer Distinct Outcomes After Bariatric Surgery: a Matched Analysis of Outcomes.

While over 200 million opioid prescriptions are written annually for chronic pain in the USA, little has been written on the impact of opioids on bariatric surgery, specifically on the effects of prescription opioid use on weight loss post laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). We completed a matched-cohort, retrospective review in 1176 consecutive patients undergoing primary bariatric surgery at a single institution. Patients were grouped into chronic prescription opioid users (POU), defined as ongoing opioid use for > 3months at the time of surgery, and opioid-naïve controls (CON), defined as no opioid use prior to surgery. About 130 POU and 130 CON patients were then matched according to preoperative comorbid conditions and demographics. Percent total weight loss was similar at 3weeks, 3months, 6months, 1year, and 2years in POU and CON-9.6 ± 5.8 vs 8.9 ± 4.5 (p = 0.057), 18.4 ± 7.2 vs 18.5 ± 7.2% (p = 0.901), 28.0 ± 9.4 vs 27.9 ± 12.9% (p = 0.894), 30.3 ± 13.0 vs 32.8 ± 9.0% (p = 0.387), and 31.4 ± 12.7 vs 36.9 ± 21.3% (p = 0.369), respectively. The 30-day readmission, reoperation, venothrombotic event rate, bleeding rate, and infection rate were similar in POU compared to CON patients. Complications and weight loss outcomes are similar for prescription opioid users compared to opioid-naïve controls following bariatric surgery. Chronic prescription opioid use is not a contraindication to bariatric surgery.

Obstructive Sleep Apnea and Ambulatory Surgery: Who Is Truly at Risk?

Obstructive Sleep Apnea and Ambulatory Surgery: Who Is Truly at Risk?

Lower Socioeconomic Status Is Associated with Groin Wound Complications after Revascularization for Peripheral Artery Disease

Surgical site infections (SSIs) after lower extremity revascularization are a common cause of increased morbidity in patients with peripheral artery disease (PAD). Understanding the multifaceted risk factors for SSIs may suggest closer monitoring for certain patients. The objective of this study is to evaluate the risk factors associated with incidence of SSIs, including patient demographics, operative factors, and socioeconomic status. A retrospective review of a prospectively maintained database was queried for all patients who underwent any femoral exposure for the purposes of treating PAD from 2014 to 2017 at a single, academic, public hospital. Patient demographics, procedural data, and a variety of socioeconomic parameters were collected from chart review. Zip code geocoding was also used to obtain surrogates for local socioeconomic factors. The primary outcome measure was SSI within 90days of operation. A total of 136 patients were identified, of which 19 (14%) developed an SSI. The only demographic variable associated with an increased risk of infection was body mass index (24.8 vs 30.1, P<0.05). Major preoperative comorbid conditions, smoking status, and insurance status were not associated with an increased risk of complications. In addition, the type of procedure performed [infrainguinal bypass (n=68), femoral endarterectomy (n=36), aortofemoral bypass (n=17), femoral-femoral bypass (n=8), axillofemoral bypass (n=7)] was not associated with any trend toward SSI. Estimated blood loss (292 vs 463mL, P<0.05), postoperative glucose (169 vs 212, P<0.05), and postoperative white blood cell count (13.6 vs 18.3, P<0.05) were the only periprocedural variables associated with SSIs. Lower mean household income, mean family income, and per capita income were all associated with an increased risk of postoperative infection (all P<0.05). Socioeconomic factors, including poorer household income, are strongly associated with an increased risk of postoperative SSIs after lower extremity revascularization. Modifiable variables, such as preoperative optimization and procedural conduct, also display an effect on the development of an SSI. As a result, health care providers should maintain a high index of suspicion for the development of SSI in patients with lower socioeconomic status.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BackgroundThe African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. MethodsASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. ResultsThe model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. ConclusionsThis simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. Clinical trial registrationNCT03044899.

Five-year outcomes of laparoscopic sleeve gastrectomy as a primary procedure for morbid obesity: A prospective study.

AIMTo prospectively evaluate the postoperative morbi-mortality and weight loss evolution of patients who underwent a laparoscopic sleeve gastrectomy (LSG) as a primary bariatric procedure during 5 years of follow-up.METHODSSince 2006, data from patients undergoing a highly restrictive primary LSG have been prospectively registered in a database and analysed. Preoperative co-morbid conditions, operating time, hospital stay, early and late complications rate and evolution of weight loss after 5 years of follow-up were analysed.RESULTSA total of 156 patients were included, 74.3% of whom were women. The mean age was 43.2 ± 13.1 years and the mean body mass index (BMI) was 41.5 ± 7.9 kg/m2. Seventy patients (44.8%) presented a BMI under 40 kg/m2. The mortality rate was 0%. The leakage rate was 1.2%, and the total 30-d morbidity rate was 5.1% (8/156). With a mean follow-up of 32.7 ± 28.5 (range 6-112) mo, the mean percent of excess of weight loss (%EWL) was 82.0 ± 18.8 at 1 year, 76.7 ± 21.3 at 3 years and 60.3 ± 28.9 at 5 years. The mean percent of excess of BMI loss (%EBMIL) was 94.9 ± 22.4 at 1 year, 89.4 ± 27.4 at 3 years and 74.8 ± 29.4 at 5 years. Patients with preoperative BMI less than 40 kg/m2 achieved greater weight loss than did the overall study population. Diabetes remitted in 75% of the patients and HTA improved in 71.7%. CPAP masks were withdrawn in all patients with obstructive sleep apnoea.CONCLUSIONLSG built with a narrow 34 F bougie and starting 3 cm from the pylorus proved to be safe and highly effective in terms of weight loss as a stand-alone procedure, particularly in patients with a preoperative BMI lower than 40 kg/m2.

Abstract 115: Is Routine Patching Necessary Following Carotid Endarterectomy (CEA)?

Objectives: Large medicare databases and meta-analyses recommend routine patching following carotid endarterectomy (CEA). Routine patching reduces perioperative stroke, carotid thrombosis, and restenosis. This 30 year experience evaluates the long term outcome of CEA with selective patching and without routine postoperative duplex examination. Methods: An IRB-approved retrospective review of all CEAs peformed by two surgeons over a 30 year period (1984-2014). Pre-operative imaging studies, operative reports, physical findings, co-morbid conditions, and pre- and postoperative medications were evaluated. Results: Over a 30-year period, 439 CEAs were performed for symptomatic carotid disease using a selective patch technique depending on gender, internal carotid artery diameter, cardiovascular risk factors, and preoperative arteriogram. In this group of 439 patients, 17 (3.9%) had patch closure of the carotid artery and the other 422 (96.1%) had primary closure. There were 2 (0.47%) perioperative strokes in the primary closure group and 4 (0.95%) patients in this group developed symptomatic carotid restenosis at a mean follow-up of 49.5 months (range 1 to 237 months). There was 1 (5.8%) carotid thrombosis in the patch closure group who also had a perioperative stroke and was serologically positive for a hypercoagulable disorder. The 4 patients who developed symptomatic restenosis had arteriographically proven &gt; 90% stenosis and required repeat CEA. The remaining 418 (99.0%) patients having primary closure remained neurologically asymptomatic (mean follow-up 10.3 years, range 2.5 to 17 years). There was 1 (0.23%) operative death that occurred following the induction of general anesthesia. Conclusions: In this experience, there is no statistically significant difference in restenosis in the primary closure group and selective patch group following CEA. Although this data set is a small, single center, two surgeon, retrospective review, it does not support the generally well accepted view of routine patching following CEA

One thousand patients with symptomatic aortic valve disease and malignancy: Can they withstand aortic valve replacement?

&lt;p&gt;Aortic valve disease is the third most common cardiovascular disease among the elderly. Once it becomes symptomatic, the short-term prognosis is poor. These patients often have comorbid conditions such as malignancies. The main question is to identify if such patients can undergo aortic valve replacement (AVR) which is the only way to improve prognosis. One thousand patients underwent valve replacement in a 7-year time span. A retrospective file study was performed to evaluate the presence of malignancies, other pre-operative comorbid conditions, severity of heart diseases, operative data and post-operative complications. Statistical analyses were performed using chi-square and Mann-Whitney U-test. Malignancies were found in 137 patients. With respect to comorbid conditions, there were no significant differences between cancer and non-cancer patients, except for a higher mean transvalvular gradient (&lt;em&gt;P&lt;/em&gt; = 0.027) and less obesity (&lt;em&gt;P&lt;/em&gt; = 0.033) or hyperlipidemia (&lt;em&gt;P&lt;/em&gt; = 0.052). Post-operative results showed a trend of delirium cases in cancer patients (&lt;em&gt;P&lt;/em&gt; = 0.071), and there was a borderline shorter length of hospital stay (&lt;em&gt;P&lt;/em&gt; = 0.087). There were no significant differences in other post-operative complications or mortality, which was 5.8% for cancer patients and 4.5% for non-cancer patients (&lt;em&gt;P&lt;/em&gt; = 0.704). Elderly patients with a history of malignancies can withstand major cardiac surgeries such as AVR. They did not exhibit comorbid conditions or major post-operative complications. Mortality was also comparable. If such patients have an acceptable cancer prognosis, they should not be denied the life-saving AVR. However, the decision to offer AVR should be made by a multidisciplinary team involving cardiologists, cardiac surgeons and oncologists. Once such decision is made, it should not be delayed.&lt;/p&gt;&lt;p&gt; &lt;/p&gt;

Comparative Effectiveness of Median Sternotomy vs Minimal Access Cardiopulmonary Bypass and Circulatory Arrest for Resection of Renal Cell Carcinoma with Inferior Vena Caval Extension

Introduction: The use of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA) is an adjunctive surgical technique that can be employed for the resection of renal cell carcinoma (RCC) with venous thrombus extension superior to the level of the hepatic veins. Median Sternotomy (MS) or Minimal Access (MA) incisions may be used to establish CPB during the resection of these extensive tumors. We review our experience with both incisional approaches and compareoperative details, perioperative complications, and recurrence free survival. Materials and Methods: From 1986 to 2012, 70 radical nephrectomies with concomitant inferior vena cava (IVC) thrombectomies were performed at our institution using MS (23 patients) and MA (47 patients) techniques. Preoperative patient characteristics, pathologic data, and organ specific postoperative complications and follow-up data were compared between groups. Estimates of overall and recurrence-free survival were constructed using Kaplan-Meier curves and compared using log-rank testing. Results: There were no significant differences with respect to patient demographics or preoperative comorbid conditions between the MA and MS groups. The MA group showed a significant reduction (p < 0.05) in the duration of postoperative mechanical ventilation, length of stay, operative time, and number of blood transfusions compared to MS patients. Overall and organ-system specific complications demonstrated a decreased incidence of wound infection (37.9% v. 12.5%, p = 0.0135) and sepsis (14.3% v. 0%, p = 0.0137) in patients undergoing MA approach. Perioperative mortality was significantly reduced in the MA group (30.4% v. 8.5% p = 0.0179). Recurrence-free survival in the MS group was 0.59 years and 1.2 years in the MA group (p = 0.06). Conclusions: Minimal access surgical approaches for CPB and DHCA during the resection of RCC with extensive tumor thrombus provide similar oncologic control with decreased duration of mechanical ventilation, length of stay and infection related complications. Our findings suggest that MA techniques provide significant advantages over MS.

A retrospective analysis of massive blood transfusion and post-operative complications in patients undergoing supra-major orthopaedic oncosurgeries.

Background and Aims:Anaesthetic management of patients undergoing supra-major orthopaedic oncosurgeries is challenging. We wanted to evaluate the effects of pre-operative co-morbid conditions, intraoperative blood loss and transfusion, haemodynamic instability on post-operative complications and hospital outcomes in patients after such surgeries.Methods:We collected data from the patient files, anaesthesia records and the electronic medical records about pre-operative morbidities, intraoperative management, complications, blood loss, fluid therapy and blood products transfused. We also collected data on post-operative complications, intensive care unit (ICU) and hospital length of stay (LOS) and status at discharge. Data were summarised using percentages for categorical data and mean and median for continuous data.Results:The mean blood loss was 4567.44 ml (range 1200–16,000 ml); 95% of all patients received blood transfusion. Twenty patients needed massive blood transfusion. Fresh frozen plasma was needed in 17 patients while 1 patient needed single donor platelets. Haemodynamic instability was present in 38 patients, of which 8 needed continuous vasopressor infusion. Nineteen patients were ventilated post-operatively. Coagulopathy occurred in 22 patients while thrombocytopaenia was seen in 6 patients. The median ICU LOS was 3 (1–6) days, and median hospital stay was 17 (6–53) days. All patients were discharged alive.Conclusion:Supra-major orthopaedic oncosurgeries are associated with massive intraoperative blood loss and transfusion. Common complications include anaemia, coagulopathy and hyperbilirubinaemia and prolonged ICU stay. Meticulous care, anticipating the complications with timely treatment can lead to excellent outcomes.

Delayed repair of obstructing ventral hernias is associated with higher mortality and morbidity

BackgroundPatients presenting with ventral hernia-related obstruction are commonly managed with emergent ventral hernia repair (VHR). Selected patients with resolution of obstruction may be managed in a delayed manner. This study sought to assess the effect of delay on VHR outcomes. MethodsThe American College of Surgeons’ National Surgical Quality Improvement Program database from 2005 to 2011 was queried using diagnosis codes for ventral hernia with obstruction. Those who underwent repair over 24 hours after admission were classified as delayed repair. Preoperative comorbid conditions, American Society of Anesthesiology (ASA) scores, and 30-day outcomes were evaluated. ResultsWe identified 16,881 patients with a mean age of 58 ± 15 years and body mass index of 36 ± 10. Delayed repair occurred in 27.7% of the patients. After controlling for comorbidities and ASA score, delayed VHR was independently associated with mortality (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.41 to 2.48, P < .001), morbidity (OR 1.4, 95% CI 1.24 to 1.50, P < .001), surgical site infection (OR 1.2, 95% CI 1.03 to 1.35, P = .016), and concurrent bowel resection (OR 1.2, 95% CI 1.03 to 1.34, P = .016). ConclusionsVHR for obstructed patients is frequently performed over 24 hours after admission. After adjusting for comorbid conditions and ASA score, delayed VHR is independently associated with worse outcomes. Prompt repair after appropriate resuscitation should be the management of choice.

Endovascular Repair of Ruptured Abdominal Aortic Aneurysm: Are Outcomes Improving?

This study evaluated whether increased experience with endovascular abdominal aortic aneurysm (AAA) repair (EVAR) for ruptured AAA (rAAA) has improved patient outcomes. The National Surgical Quality Improvement Program (NSQIP) database was queried, from the years 2005 to 2011, to identify patients who underwent EVAR for rAAA. A total of 803 EVAR procedures were performed for rAAA. Procedures performed between 2005 and 2007 were placed into the early EVAR (E-EVAR) group and those performed between 2008 and 2011 were placed into the late EVAR (L-EVAR) group. Patient demographics, comorbidities, perioperative data, and outcomes were compared. More EVAR procedures were performed for rAAA in the L-EVAR group than in the E-EVAR group (124 vs 679, P < .01). The groups were similar with regards to demographics and preoperative comorbid conditions. There was a lower rate of acute renal failure (9% vs 15%, P = .03), pneumonia (11% vs 18%, P = .03), and deep venous thrombosis (0% vs 2%, p4 units) (16% vs 4%, P < .01). The L-EVAR group had shorter operative times (173 vs 187 minutes, P < .01) despite the trend toward hemodynamic instability. Mortality on the day of surgery (10% vs 10%, P = .82) and 30-day mortality (26% vs 24%, P = .69) were not significantly different between E-EVAR and L-EVAR. There has been an increase in the use of EVAR for hemodynamically unstable patients with rAAA, with acceptable immediate and 30-day mortality rates. The findings may be attributed to an improvement in EVAR devices and/or the surgeons' comfort level with the use of EVAR for rAAA. These data suggest that EVAR is an effective treatment for rAAA even in the setting of an unstable patient.