Rate Of Major Postoperative Complications Research Articles

Readmission Rate After 2-level Lumbar Decompression: A Propensity-matched Cohort Study Comparing Inpatient and Outpatient Settings.

Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2012-2015. Compare the 30-day readmission and postoperative major complications rates of 2-level lumbar decompression performed in the ambulatory and the inpatient settings. In recent years, there is an increasing trend toward ambulatory spine surgery. However, there remains a concern regarding risks of readmission and postoperative morbidity after discharge. The ACS-NSQIP database from 2012 to 2015 was queried for adult patients who underwent elective 2-level lumbar decompression (CPT code 63047 accompanied with code 63048). A cohort of ambulatory lumbar decompression cases was matched 1:1 with an inpatient cohort after controlling for patient demographics, comorbidities, and complexity of the procedure. The primary outcome was the 30-day readmission rate. Secondary outcomes included a composite of 30-day postoperative major complications and hospital length of stay for hospitalized patients. A total of 7505 patients met our study criteria. The ambulatory 2-level lumbar decompression surgery rate increased significantly over the study period from 28% in 2012 to 49% in 2015 (P<0.001). In the matched sample, there was no statistically significant difference in the 30-day readmission rate (odds ratio, 0.82; 95% confidence interval, 0.64-1.04; P=0.097) between the two cohorts; however, the ambulatory cohort had a lower 30-day postoperative major complication rate (odds ratio, 0.55; 95% confidence interval, 0.38-0.79; P=0.002). After 2-level lumbar decompression performed on inpatient versus outpatient basis, the 30-day readmission rate is similar. However, the 30-day postoperative complication rate is significantly lower in the ambulatory setting. The reasons for these differences need further exploration. Level III.

A lower cut-off for lymph node harvest predicts for poorer overall survival after rectal surgery post neoadjuvant chemoradiotherapy

BackgroundA lymph node harvest (LNH) of < 12 is a predictor for poor prognosis in rectal cancer patients. However, neoadjuvant chemoradiotherapy (NACRT) is known to decrease LNH; hence, a cut-off of 12 is inappropriate in such patients. This paper aims to establish a LNH cut-off predictive for disease-free and overall survival in NACRT patients.MethodsA retrospective review of patients who underwent elective surgery for rectal cancer from 2006 to 2013 was performed. All patients with R1/2 resections and presence of metastases and those operated on for recurrence were excluded. Patient demographics, clinical features, operative details, LNH, 30-day mortality and disease-free and overall survival were recorded. P values of < 0.05 were considered significant.ResultsA total of 257 patients were studied, with 174 (68%) males and a median age of 66 years. Ninety-four (37%) patients received long-course NACRT, and 122 (48%) patients were stage 2 and below. Median LNH was 17, which was reduced in the NACRT group (14 versus 23, P < 0.01). Average length of stay was 9 ± 8 days, with a major post-operative complication rate of 4%. Using hazard ratio plots for the NACRT subgroup, LNH cut-offs of 16.5 and 8.5 were obtained for disease-free survival (DFS) and overall survival (OS) respectively. Survival analysis showed that a LNH cut-off of 8.5 was a significant predictor of OS (P < 0.001).ConclusionLNH is reduced in patients receiving NACRT before rectal cancer surgery. A LNH of 9 and above is associated with improved overall survival. We propose that this can be used as a tool for prognosis.

Marijuana use does not affect the outcomes of bariatric surgery.

The decriminalization of marijuana and legalization of derived products requires investigation of their effect on healthcare-related outcomes. Unfortunately, little data are available on the impact of marijuana use on surgical outcomes. We aimed to determine the effect of marijuana use on 30-day complications and 1-year weight loss following laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). At a large academic center, 1176 consecutive patients undergoing primary bariatric surgery from 2012 to 2017 were identified and separated into cohorts according to marijuana use. The only exclusions were 19 patients lost to follow-up. Propensity score matching, using logistic regression according to preoperative age, gender, BMI, and comorbid conditions, yielded 73 patient pairs for the control and study arms. All patients were followed two years postoperatively. Excess BMI lost did not differ between marijuana users and controls at 3weeks (23.0% vs 18.9%, p = 0.095), 3months (42.0% vs 38.1%, p = 0.416), 6months (60.6% vs 63.1%, p = 0.631), 1year (78.2% vs 77.3%, p = 0.789), or 2years (89.1% vs 74.5%, p = 0.604). No differences in the rate of major 30-day postoperative complications, including readmission, infection, thromboembolic events, bleeding events and reoperation rates, were found between groups. Follow-up rate at two years was lower in marijuana users (12.3% vs 27.4%, p = 0.023). This study suggests marijuana use has no impact on 30-day complications or weight loss following bariatric surgery, and should not be a contraindication to bariatric surgery.

48: Association of Hispanic ethnicity with complications after benign hysterectomy

Hispanic patients have previously been shown to have a below-average complication rate following hysterectomy, but little is known about specific risks for this group.1 Our primary objective was to identify differences in rates of specific complications experienced by Hispanic patients following hysterectomy for benign indications as compared to non-Hispanic white patients. Our secondary objective was to compare route of hysterectomy and length of stay (LOS) between these groups. We performed a cohort study using National Surgical Quality Improvement Program (NSQIP) data. Our primary exposure was Hispanic race, with non-Hispanic white patients as the control. The NSQIP database contains prospectively-gathered, patient-level perioperative data from inpatient hospitals throughout the United States. Patients with gynecologic cancer diagnoses or who underwent staging procedures were excluded. Demographic data, postoperative complication rates, route of hysterectomy and LOS were compared between groups. Postoperative complication data were stratified by surgical route. Proportions were analyzed using two-sample tests, Student t-tests and contingency tables. 102,050 women were included. 15.0% were Hispanic and 85.0% were non-Hispanic white. Hispanic patients were more likely to have class 1 or 2 obesity (59.7 vs 49.8%), diabetes (10.9 vs 6.7%), and anemia (hematocrit <33: 14.1 vs 6.5%); p<0.01 for all. Hispanic patients were more likely to undergo abdominal hysterectomy (30.0 vs 19.1%, p<0.01) and to remain inpatient for 2-6 days (38.8 vs 24.0%, p<0.01). Hispanic patients were more likely to require blood transfusion following all routes of hysterectomy including abdominal hysterectomy (8.3 vs 5.9%, p= <0.01), laparoscopic hysterectomy (1.9 vs 0.6%, p= <0.01), vaginal hysterectomy (2.9 vs 1.4%, p= <0.01) and laparoscopic-assisted vaginal hysterectomy (2.4 vs 1.3%, p= <0.01). This difference remained significant only in patients without preoperative anemia when stratified by hematocrit. Hispanic patients had a decreased or equal rate of surgical site infection, pneumonia, pulmonary embolism, stroke, urinary tract infection, cardiac arrest, myocardial infarction, deep venous thrombosis, septic shock, death, unplanned reoperation, or readmission as compared with non-Hispanic white patients. Hispanic women were more likely to undergo open hysterectomy, had an increased length of stay, were more likely to have preoperative anemia and had a higher transfusion rate. Despite a higher rate of open surgery, Hispanic patients had a decreased or equivalent rate of major postoperative complications.1.Jacoby, V, Fujimoto, VY, Giudice, LC, Kupperman, M and Washington, AE. Racial and Ethnic Disparities in Benign Gynecologic Conditions and Associated Surgeries. Am J Obstet Gynecol. 2010 June; 202(6): 514-521.

Impact of neoadjuvant chemotherapy on surgical and pathological results of gastric cancer patients: A case-control study.

Neoadjuvant chemotherapy (NACT) followed by radical surgery represents a treatment option for patients with advanced gastric cancer (GC). This case-control study aimed to evaluate the clinicopathological characteristics and surgical outcomes of GC patients who received NACT, and its impact on survival. We retrospectively reviewed all patients with GC who underwent gastrectomy. A total of 45 cases with NACT were matched with consecutive 45 patients who underwent upfront gastrectomy for the following characteristics: gender, age, gastrectomy type, lymphadenectomy extent, American Society of Anesthesiologists class, histological type, cT and cN. NACT group had smaller tumors (4.9 vs 6.8 cm P = .006), lower lymphatic invasion rate (40% vs 73.3%, P = .001), lower venous invasion rate (18% vs 46.7%, P = .003) and lower perineural invasion rate (35% vs 77.8%, P < .0001). The ypTNM stage was lower in patients treated with NACT (P < .001). The major postoperative complication (POC) rate was lower in NACT patients (6.7% vs 24.4%, P = .02), as was hospital length of stay (10.8 vs 17 days, P = .005). NACT allowed nodal and tumor downstaging. In addition, patients who underwent NACT had fewer POC and shorter length of hospital stay.

Primary Sarcoma of Descending Aorta.

Primitive aortic sarcomas are rare tumors characterized by resistance to medical treatment and a poor prognosis with high metastatic rates and local recurrences. Surgery remains the mainstay treatment and is based on challenging and technically demanding resections with high rate of major intraoperative and postoperative complications. We report the case of a patient with primitive intimal sarcoma of the aorta, who underwent a descending aortic resection and reconstruction with a prosthetic tube.

The utility of fibrinogen level as a predictor of complications after laparoscopic gynecologic surgery: a prospective observational study

BackgroundComplications after laparoscopic gynecological surgery may increase patients’ morbidity and mortality; therefore, their timely diagnosis and early treatment would help clinicians to avoid life-threatening situations. We aimed to evaluate the predictive role of fibrinogen for diagnosing complications after laparoscopic gynecologic surgery for benign and malignant conditions.Patients and methodsAll patients who underwent elective laparoscopic gynecologic surgery between June 2013 and December 2017 at the Department of Gynecologic Oncology, Azienda Ospedaliera Brotzu, Cagliari, were prospectively included. Post-operative complications were assessed and graded according to the Clavien-Dindo classification. Fibrinogen and white blood cell level were determined preoperatively, on the first post-operative day and at the appearance of symptoms indicative of an irregular post-operative course or at the time of re-hospitalization for persistent symptoms. The postoperative changes (calculated from the first postoperative day) were correlated with the occurrence and severity of complications and their predictive role was assessed.ResultsWe enrolled 1016 patients: 36% underwent surgery for benign pathologies (mainly voluminous fibromatous uteri and severe deep endometriosis) and 64% for gynecologic malignancies. The overall complication rate was of 3.45%, the rate of major postoperative complications was 2.85%. A postoperative fibrinogen increase ≥ 20% had a high diagnostic accuracy to identify postoperative complications early (AUC 0.931, sensitivity 89%, and specificity 99%). The magnitude of postoperative fibrinogen change was associated with complication severity.ConclusionsOur findings demonstrated that fibrinogen increase can enable the early detection of postoperative complications after laparoscopic gynecological surgery. Further prospective and multi-center studies are warranted to confirm these results.

The Impact of Epidural Analgesia on Perioperative Morbidity or Mortality after Open Abdominal Aortic Aneurysm Repair

Epidural analgesia (EA) is frequently used as an adjuvant to general anesthesia (GA) for improved postoperative analgesia and reduced rates of cardiac, pulmonary, and renal complications. However, only a few studies have examined EA-GA specifically during open abdominal aortic aneurysm (AAA) repair. The effects of EA-GA specifically during open AAA repair regarding postoperative outcomes are unknown. This study was performed to evaluate postoperative outcomes in patients undergoing open AAA repair with EA-GA versus GA alone. We performed a retrospective analysis for patients undergoing surgery between January 1, 2014 and December 31, 2016 using the National Surgical Quality Improvement Program (NSQIP) database. Propensity score matching was used to establish cohorts for analysis. Multivariable logistic regression was performed to determine significant perioperative outcomes for each anesthesia type. A total of 2,171 patients underwent open AAA repair in our date range; we excluded emergent and ruptured AAA. A total of 2,145 patients were included in our analysis, of whom 653 patients received EA-GA and 1,492 patients received GA only. Major postoperative outcomes included mortality, pulmonary cardiac and renal complications, infections, thrombosis, and blood transfusion requirement (including Cell-Saver usage). Additional overall outcomes included hospital length of stay, return to the operating room, and readmission. Patients in EA+GA and GA alone groups were comparable regarding demographics, functional status, and comorbidities. Decreased odds of readmission was observed in EA+GA compared with GA (0.49, 95% CI [0.28-0.86]; P=0.014); and increased odds of receiving a blood transfusion was observed in those who underwent EA+GA (1.63, 95% CI [1.23-2.14]; P=0.001). No difference was observed between patients who had an AAA repair with EA+GA versus GA alone with regard to mortality, return to operating room, major pulmonary, cardiac, renal, or infectious complications. EA+GA was not associated with decreased mortality or decreased rates of major postoperative pulmonary, cardiac, or renal complications. EA+GA was associated with increased transfusion requirements and decreased rates of hospital readmission.

Laparoscopic Parenchymal-Sparing Hepatectomy for Multiple Colorectal Liver Metastases Improves Outcomes and Salvageability: A Propensity Score-Matched Analysis.

Parenchymal-sparing hepatectomy (PSH) is regarded as the standard of care for colorectal liver metastases (CRLMs) in open surgery. However, the surgical and oncological benefits of laparoscopic PSH compared with laparoscopic major hepatectomy (MH) have not been fully documented. A total of 269 patients who underwent initial laparoscopic liver resections with curative intent for CRLMs between 2004 and 2017 were enrolled. Preoperative patient characteristics and tumor burden were adjusted with propensity score matching, and laparoscopic PSH was compared with laparoscopic MH after matching. PSH was performed in 148 patients, while MH was performed in 121 patients. After propensity score matching, 82 PSH and 82 MH patients showed similar preoperative characteristics. PSH was associated with lower rates of major postoperative complications compared with MH (6.1 vs. 15.9%; p = 0.046). Recurrence-free survival (RFS) and liver-specific RFS rates were comparable between both groups (p = 0.595 and 0.683). Repeat hepatectomy for liver recurrence was more frequently performed in the PSH group (63.9 vs. 36.4%; p = 0.022), and the PSH group also showed a trend toward a higher overall survival (OS) rate (5-year OS 79.4 vs. 64.3%; p = 0.067). Multivariate analyses revealed that initial MH was one of the risk factors to preclude repeat hepatectomy after liver recurrence (hazard ratio 2.39, p = 0.047). Laparoscopic PSH provided surgical and oncological benefits for CRLMs, with less complications, similar recurrence rates, and increased salvageability through repeat hepatectomy, compared with laparoscopic MH. PSH should be the standard approach, even in laparoscopic procedures.

Acellular Dermal Matrix Performance Compared with Latissimus Dorsi Myocutaneous Flap in Expander-Based Breast Reconstruction.

Background:Latissimus dorsi myocutaneous flap (LDMF) with tissue expander provides excellent results in breast reconstruction. Acellular dermal matrix (ADM) has been used in expander-based reconstruction (EBR) with good results. This study assesses how ADM compares to LDMF in EBR.Methods:The cohorts comprised 124 patients (218 breasts) who had EBR using ADM between 2006 and 2012, and 242 patients (266 breasts) who had EBR using LDMF between 1994 and 2012. Postoperative complications, reoperations, Breast-Q scores, and objectively assessed aesthetic outcomes were compared.Results:Median age was 55 years for both ADM (range 23–84) and LDMF (range 26–88) groups. No statistically significant differences were noted between the groups in the rates of major postoperative complications (P > 0.3). Forty-nine of the 218 (22.5%) in the ADM group and 67 of 266 (25.2%) in the LDMF group had a total of 63 and 84 reoperations, respectively (P = 0.52), with no significant differences in the reoperations rate (P > 0.3). No significant differences were observed in the Breast-Q scores. Some categorical differences were noted in the aesthetic outcomes; however, the difference between the overall outcomes was not significant (P = 0.54).Conclusion:Our study revealed no statistically significant differences in the complications or reoperation rates, patient satisfaction, or overall aesthetic outcomes when comparing the use of ADM to LDMF in EBR. In conclusion, this study supports the hypothesis that ADM performs as well as LDMF in EBR.

A structured pathway for accelerated postoperative recovery reduces hospital stay and cost of care following microvascular breast reconstruction without increased complications

Accelerated recovery protocols have proved effective in many surgical procedures but are infrequently applied in breast reconstruction. In this study, we evaluate the impact of a structured pathway for accelerated postoperative recovery in patients undergoing microvascular breast reconstruction at a high-volume center. We describe our care pathway for patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our center. We compared length of stay (LOS), complication rates, readmission rates, and cost of inpatient care before (pre-protocol (Pre-P)) and after (post-protocol (Post-P)) the implementation of the protocol. Patients in the Post-P group (n = 198) had a significant reduction in mean LOS as compared to those in the Pre-P (n = 183) group (3.6 +/- 0.85 vs. 4.7 +/-1.04 days, p = 0.006). There was no significant difference in the rates of major (Pre-P 16.9% vs. Post-P 14.7%, p = 0.71) or minor (Pre-P 21.3% vs. 17.1%, p = 0.22) postoperative complications between groups. The readmission rates were also similar (Pre-P 6.5% vs. Post-P 4.5, p = 0.69). Implementation of the protocol resulted in a significant reduction in the mean cost of in-patient care. A simple protocol for accelerated and streamlined postoperative recovery effectively reduces LOS and patient care costs following DIEP flap breast reconstruction without compromising patient safety.

Sciatic and Femoral Nerve Resection During Extended Radical Surgery for Advanced Pelvic Tumours: Long-term Survival, Functional, and Quality-of-life Outcomes.

To report survival, functional, and quality-of-life (QoL) outcomes after extended radical resection for advanced pelvic tumors with en bloc sciatic or femoral nerve resection. Advanced pelvic tumors involving the sciatic or femoral nerve have traditionally been considered inoperable. Small studies have suggested acceptable functional outcomes can be achieved after pelvic exenteration with en bloc sciatic nerve resection. Consecutive patients who underwent extended radical pelvic surgery with en bloc resection of the sciatic or femoral nerves at a single center were included. Of 713 radical pelvic resections, 68 patients (9.5%) had en bloc sciatic or femoral nerve resection. Complete sciatic, partial sciatic, and complete femoral nerve resection was performed in 26 (38%), 38 (56%), and 4 patients (6%), respectively. Overall and major postoperative complication rates were 63% and 40%, respectively. R0 resection was achieved in 65% of patients, which translated to 55% and 76% overall and local recurrence-free 5-year survival in those with colorectal cancer. Twenty-two (96%) and 25 (92%) patients could mobilize independently after complete and partial sciatic nerve resection, respectively. Physical QoL was significantly lower at 6 months after surgery compared with baseline (P = 0.041), but returned to baseline at 12 months (P = 0.163). There was no difference in mental or overall QoL at 6 or 12 months compared with baseline. En bloc sciatic and femoral nerve resection can be performed during extended radical pelvic resections with morbidity and survival outcomes comparable with existing exenteration literature, including in patients with recurrent rectal cancer. Physical QoL may be impaired after surgery, but returns to baseline by 12 months.

Perioperative complications and outcome after surgery for treatment of gastric carcinoma in dogs: A Veterinary Society of Surgical Oncology retrospective study of 40 cases (2004-2018).

To describe the clinical characteristics, perioperative complications, and outcomes in dogs surgically treated for gastric carcinoma. Multi-institutional retrospective case series. Forty client-owned dogs with histologically confirmed gastric carcinoma. Medical records were reviewed for preoperative diagnostics, surgery, histopathology, postoperative complications, adjuvant chemotherapy, disease progression, and survival. Variables were assessed for associations with outcome by using Cox proportional hazards regression analysis. Surgical treatment included partial gastrectomy (28 dogs), Billroth I (9 dogs), subtotal gastrectomy (2 dogs), and submucosal resection (1 dog). Major postoperative complications occurred in 8 of 40 dogs, including septic peritonitis secondary to dehiscence in 4 dogs. The median progression free interval was 54 days, and the median survival time (MST) was 178 days (range, 1-1902). According to multivariable analysis results, experiencing an intraoperative complication was associated with an increased risk of death (hazard ratio [HR] 3.5, 95% CI 1.1-9.8, P = .005), and administration of adjuvant chemotherapy correlated with an improved survival (HR 0.4, 95% CI 0.2-0.9, P = .03). In this population of dogs, MST exceeded historically reported data, major postoperative complication rates were comparable to established literature, and administration of adjuvant chemotherapy was associated with improved survival. Results from this study may be used to counsel owners more accurately regarding prognosis for dogs undergoing surgical excision for gastric carcinoma.

Role of D2 gastrectomy in gastric cancer with clinical para-aortic lymph node metastasis

BACKGROUNDOwing to the technical difficulty of pathological diagnosis, imaging is still the most commonly used method for clinical diagnosis of para-aortic lymph node metastasis (PALM) and evaluation of therapeutic effects in gastric cancer, which leads to inevitable false-positive findings in imaging. Patients with clinical PALM may have entirely different pathological stages (stage IV or not), which require completely different treatment strategies. There is no consensus on whether surgical intervention should be implemented for this group of patients. In particular, the value of D2 gastrectomy in a multidisciplinary treatment (MDT) approach for advanced gastric cancer with clinical PALM remains unknown.AIMTo investigate the value of D2 gastrectomy in a MDT approach for gastric cancer patients with clinical PALM.METHODSIn this real-world study, clinico-pathological data of all gastric cancer patients treated at the Cancer Hospital, Chinese Academy of Medical Sciences between 2011 and 2016 were reviewed to identify those with clinically enlarged PALM. All the clinico-pathological data were prospectively documented in the patient medical record. For all the gastric cancer patients with advanced stage disease, especially those with suspicious distant metastasis, the treatment methods were determined by a multidisciplinary team.RESULTSIn total, 48 of 7077 primary gastric cancer patients were diagnosed as having clinical PALM without other distant metastases. All 48 patients received chemotherapy as the initial treatment. Complete or partial response was observed in 39.6% (19/48) of patients in overall and 52.1% (25/48) of patients in the primary tumor. Complete response of PALM was observed in 50.0% (24/48) of patients. After chemotherapy, 45.8% (22/48) of patients received D2 gastrectomy, and 12.5% (6/48) of patients received additional radiotherapy. The postoperative major complication rate and mortality were 27.3% (6/22) and 4.5% (1/22), respectively. The median overall survival and progression-free survival of all the patients were 18.9 and 12.1 mo, respectively. The median overall survival of patients who underwent surgical resection or not was 50.7 and 12.8 mo, respectively. The 3-year and 5-year survival rates were 56.8% and 47.3%, respectively, for patients who underwent D2 resection. Limited PALM and complete response of PALM after chemotherapy were identified as favorable factors for D2 gastrectomy.CONCLUSIONFor gastric cancer patients with radiologically suspicious PALM that responds well to chemotherapy, D2 gastrectomy could be a safe and effective treatment and should be adopted in a MDT approach for gastric cancer with clinical PALM.

Intraoperative and major postoperative complications and survival of dogs undergoing surgical management of epiglottic retroversion: 50 dogs (2003-2017).

To report intraoperative and major postoperative complications in dogs treated surgically for epiglottic retroversion (ER), compare the incidence of major postoperative complications between procedures, and report survival of surgically treated dogs. Multi-institutional retrospective study. Fifty dogs treated with 78 procedures. Medical records of dogs diagnosed and surgically treated for ER from 2003 to 2017 at 11 institutions were reviewed. Complications were divided into intraoperative and major postoperative complications. Intraoperative complications occurred during 2 of 78 (2.6%) procedures. Thirty-six major postoperative complications were documented in 22 dogs after 36 of 74 (48.7%) procedures. Postoperative complications occurred after 7 of 12 (58.3%) nonincisional epiglottopexy, 23 of 43 (53.5%) incisional epiglottopexy, 2 of 4 (50%) partial epiglottectomy, 2 of 12 (16.7%) subtotal epiglottectomy, and 2 of 3 (66.7%) other surgical procedures. Epiglottopexy failure was the most common major postoperative complication. The incidence of major postoperative complications did not differ between procedures (P = .1239), although, when combined, epiglottopexy procedures (30/55) had a higher incidence of complications than epiglottectomy procedures (4/16; P = .048). Thirty (60%) dogs were alive at a median of 928 days (range, 114-2805), 8 (16%) were lost to follow-up after 411 days (range, 43-1158), and 12 (24%) were dead/euthanized after 301.5 days (range, 3-1212). Median survival time was not reached after a median of 716 days. Although intraoperative complications were uncommon, major postoperative complications were common, especially after epiglottopexy procedures. Although surgical treatment of ER is associated with a high rate of major postoperative complications, especially epiglottopexy procedures, long-term survival can be achieved.

Laparoscopic versus open liver resection for hepatocellular carcinoma in elderly patients: a multi-centre propensity score-based analysis.

The frequency of liver resection in elderly patients has been increasing. However, data are limited regarding the safety of laparoscopic liver resection (LLR) compared with that of open liver resection (OLR) for hepatocellular carcinoma (HCC) in elderly patients. The present study aimed to compare short-term outcomes between LLR and OLR in elderly patients with HCC using propensity score matching. The study included 630 patients (age, ≥ 75years) who underwent liver resection for HCC at nine liver centres between April 2010 and December 2017. Patients were divided into LLR and OLR groups, and perioperative outcomes were compared between the groups. In addition, subgroup analysis was performed according to age (75-79 and ≥ 80years). Of the 630 patients, 221 and 409 were included in the LLR and OLR groups, respectively. After propensity score matching, 155 patients were included in each group. Intraoperative blood loss and the transfusion, post-operative overall complication and major complication rates were lower in the matched LLR than the matched OLR group (P < 0.001, P = 0.004, P < 0.001 and P < 0.001, respectively). Moreover, post-operative pulmonary and cardiovascular complications were less frequent in the matched LLR group (P = 0.008 and P = 0.014, respectively). In subgroup analysis, among octogenarians, the post-operative major complication rate was lower and hospital stay was shorter in the matched LLR than the matched OLR group (P < 0.001 and P < 0.001, respectively). LLR for HCC is associated with good short-term outcomes in patients aged ≥ 75years compared with OLR. LLR is safe and feasible in selected octogenarians with HCC.

Evaluation of postoperative complication rates in cats undergoing perineal urethrostomy performed in dorsal recumbency.

Medical records were reviewed for cats that underwent a perineal urethrostomy performed in dorsal recumbency for the treatment of urethral obstruction. Information, including signalment, reason for presentation, number of previous obstructions, surgery time, and perioperative and postoperative complications, were collected through a review of medical records and owner follow-up. The objective was to evaluate short- and long-term complications in cats that underwent perineal urethrostomy performed in dorsal recumbency for treatment of urethral obstruction. No major or life-threatening complications, such as urethral stricture, re-obstruction, euthanasia due to lower urinary signs or chronic urinary tract infection, were reported. Short-term complications were limited to dysuria in 2/12 (16.7%) cats. Long-term follow-up was available for nine cats. The most common long-term complication seen in this population of cats was a single recurrence of urinary tract infection in 3/9 (33.3%) cats that resolved after a short course of empirical antibiotic therapy. Performing perineal urethrostomy in dorsal recumbency is safe and may have advantages to ventral recumbency due to improved visualization, allowing for more efficient dissection and improved accuracy in tissue apposition during closure. We believe this has been a major contributor to our reported reduced major postoperative complication rate.

Impact of Synchronous Versus Metachronous Onset of Colorectal Peritoneal Metastases on Survival Outcomes After Cytoreductive Surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC): A Multicenter, Retrospective, Observational Study

BackgroundCareful selection of patients with colorectal peritoneal metastases (PM) for cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is crucial. It remains unknown whether the time of onset of colorectal PM (synchronous vs metachronous) influences surgical morbidity and survival outcomes after CRS with HIPEC.MethodsPatients with histologically proven colorectal PM who underwent CRS with HIPEC between February 2006 and December 2017 in two Dutch tertiary referral hospitals were retrospectively included from a prospectively maintained database. The onset of colorectal PM was classified as synchronous (PM diagnosed at the initiational presentation with colorectal cancer) or metachronous (PM diagnosed after initial curative colorectal resection). Major postoperative complications (Clavien–Dindo grade ≥ 3), overall survival (OS), and disease-free survival (DFS) were compared between patients with synchronous colorectal PM and those with metachronous colorectal PM using Kaplan–Meier analyses, proportional hazard analyses, and a multivariate Cox regression analysis.ResultsThe study enrolled 433 patients, of whom 231 (53%) had synchronous colorectal PM and 202 (47%) had metachronous colorectal PM. The major postoperative complication rate and median OS were similar between the patients with synchronous colorectal PM and those with metachronous colorectal PM (26.8% vs 29.7%; p = 0.693 and 34 vs 33 months, respectively; p = 0.819). The median DFS was significantly decreased for the patients with metachronous colorectal PM and those with synchronous colorectal PM (11 vs 15 months; adjusted hazard ratio, 1.63; 95% confidence interval, 1.18–2.26).ConclusionsMetachronous onset of colorectal PM is associated with early recurrence after CRS with HIPEC compared with synchronous colorectal PM, without a difference in OS or major postoperative complications. Time to onset of colorectal PM should be taken into consideration to optimize patient selection for this major procedure.

P086 HANDSEWN ANASTOMOSIS AFTER ILEOCOLIC RESECTION FOR CROHN’S DISEASE: A LOST ART?

Ileocolic resection (ICR) is the most common surgical procedure for Crohn’s disease (CD). Reconstruction is most commonly achieved with stapled side-to-side (SSTS) or hand-sewn (HS) ileocolic anastomosis (ICA), depending on tissue quality, surgeon experience, and surgeon preference. We aimed to compare short-term complications and long-term recurrence-free survival of CD between patients who underwent SSTS vs.HS anastomoses in our institution. This study was a retrospective analysis of a prospectively maintained database over a 5-year period. All patients who underwent ICR and ICA for terminal ileal CD from 01/2012–12/2016 were included. HS group included 53 end-to-end, 5 side-to-side, and 1 end-to-side cases. Surgeries were done for 26 surgeons. Patients who had a stoma or other types of anastomoses were excluded. The two groups were compared in a univariate analysis. Recurrence (Rutgeerts≥i2 or active disease on CT/MRI) rates were assessed using Kaplan-Meier curves and a log-rank test. Cox-proportional hazard and linear regression models with propensity score inverse probability of treatment weighting were used to further evaluate postoperative outcomes and recurrence of CD. Numbers represent median or proportion as noted. 261 patients were analyzed: 59 in the HS group and 202 in the SSTS group. Patients in the HS group had a longer course of disease (16 vs.9 years, p=0.005), were more likely to have previous surgeries (59 vs.42%, p=0.02), perianal disease (39 vs.23%, p=0.02) and redo ICA (56 vs.33%, p=0.001). There was no difference between the groups in preoperative or postoperative use of medications. More HS patients were ASA class 3 (65 vs.40%, p=0.004), and HS operations were longer (157 vs.133min., p<0.001), with more blood loss (150 vs.50ml, p<0.001), and fewer were laparoscopic (41 vs.65%, p<0.001). Patients who underwent HS compared to STSS had surgeons with more years of experience, 16 vs.11 years, p<0.001, respectively. For postoperative outcomes, HS patients had longer lengths of stay (6 vs.5 days, p=0.02). The Kaplan-Meier analysis for recurrence showed no difference in recurrence rates. After propensity score weighting and adjustment for covariates, HS patients had less than 1/3 of the odds of Clavien-Dindo≥3 complication compared to SSTS group (OR0.29 [0.09-0.92], p=0.03). At our center after ICR for CD, HS anastomoses, compared to SSTS anastomoses, were independently associated with a lower rate of major postoperative complications, despite being performed in more complex patients. In addition, no difference in recurrence rates between groups was observed. Thus, colorectal surgeons should be facile and confident in performing HS procedures, especially in difficult situations (advanced or recurrent disease, previous surgeries, and high morbidity patients), lest HS become a lost art.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Perioperative Goal-Directed Therapy during Kidney Transplantation: An Impact Evaluation on the Major Postoperative Complications.

Background: Kidney transplantation is considered the first-choice therapy in end-stage renal disease (ESRD) patients. Despite recent improvements in terms of outcomes and graft survival in recipients, postoperative complications still concern the health-care providers involved in the management of those patients. Particularly challenging are cardiovascular complications. Perioperative goal-directed fluid-therapy (PGDT) and hemodynamic optimization are widely used in high-risk surgical patients and are associated with a significant reduction in postoperative complication rates and length of stay (LOS). The aim of this work is to compare the effects of perioperative goal-directed therapy (PGDT) with conventional fluid therapy (CFT) and to determine whether there are any differences in major postoperative complications rates and delayed graft function (DGF) outcomes. Methods: Prospective study with historical controls. Two groups, a PGDT and a CFT group, were used: The stroke volume (SV) optimization protocol was applied for the PGDT group throughout the procedure. Conventional fluid therapy with fluids titration at a central venous pressure (CVP) of 8–12 mmHg and mean arterial pressure (MAP) >80 mmHg was applied to the control group. Postoperative data collection including vital signs, weight, urinary output, serum creatinine, blood urea nitrogen, serum potassium, and assessment of volemic status and the signs and symptoms of major postoperative complications occurred at 24 h, 72 h, 7 days, and 30 days after transplantation. Results: Among the 66 patients enrolled (33 for each group) similar physical characteristics were proved. Good functional recovery was evident in 92% of the CFT group, 98% of the PGDT group, and 94% of total patients. The statistical analysis showed a difference in postoperative complications as follows: Significant reduction of cardiovascular complications and DGF episodes (p < 0.05), and surgical complications (p < 0.01). There were no significant differences in pulmonary or other complications. Conclusions: PGDT and SV optimization effectively influenced the rate of major postoperative complications, reducing the overall morbidity and thus the mortality in patients receiving kidney transplantation.