Surgical Mortality Research Articles

Is intensive care necessary after major thoracic surgery? A propensity score-matched study.

This study aims to compare the surgical results, complications, mortality rates, and inpatient costs in two patient groups followed, whether in the intensive care unit or general ward after a major thoracic procedure and to examine clinical and surgical factors related to the development of complications. Between January 2018 and June 2021, a total of 485 patients (150 males, 335 females; mean age: 58.3±13.2 years; range, 22 to 86 years) who underwent a major thoracic surgery in our clinic were retrospectively analyzed. The patients were divided into two groups as the intensive care unit patients (n=254) and general ward patients (n=231). In the former group, the patients were followed in the intensive care unit for a day, while in the general ward group, the patients were taken directly to the ward. The groups were compared after propensity score matching. All patients were analyzed for risk factors of morbidity development. After propensity score matching, 246 patients were enrolled including 123 patients in each group. There was no statistically significant difference between the groups in any features except for late morbidity, and inpatient costs were higher in the intensive care unit group (p<0.05). In the multivariate analysis, age, American Society of Anesthesiologists Class 3, and secondary malignancy were found to be associated with morbidity (p<0.05). In experienced centers, it is both safe and costeffective to follow almost all of the major thoracic surgery patients postoperatively in the general ward.

Influence of hepatic dysfunction in patients who underwent tricuspid valve surgery.

Hepatic dysfunction (HD) is frequently associated with chronic tricuspid regurgitation (TR), and is a risk factor for TR surgery. Late referral of patients with TR is associated with the progression of TR and HD, as well as an increase in surgical morbidity and mortality. Many patients with severe TR suffer from HD; however, their clinical impact is not well documented. This retrospective review was conducted between October 2008 and July 2017. In total, 159 consecutive patients underwent surgery for TR; 101 with moderate to severe TR were included. We divided patients into N (normal liver function; n=56) and HD (HD; n=45) groups. HD was defined as clinically or radiologically diagnosed liver cirrhosis, or a preoperative Model for End-Stage Liver Disease (MELD)-XI score ≥13. Perioperative data were compared between groups, and changes in the MELD score following TR surgery were estimated in the HD group. Long-term survival rates were analyzed, and analyses were performed to obtain the assessment tool and cutoff value to determine the degree of HD affecting late mortality. The preoperative demographics of both groups were similar, excluding the presence of HD. The EuroSCORE II, MELD score, and prothrombin time international normalization ratio were significantly higher in the HD group, and although early mortality was comparable between groups [N group: 0%, HD group: 2.2% (n=1); P=0.446], intensive care unit and hospital stays were significantly longer in the HD group. The MELD score in the HD group temporarily increased immediately after surgery, and then decreased. The long-term survival rates were significantly lower in the HD group. The most suitable tool for predicting late mortality was the MELD-XI score, with a cutoff value of 13 points. Surgery for patients with severe TR can be performed with relatively low morbidity and operative mortality, regardless of associated HD. MELD scores significantly improved after TR surgery in patients with HD. Even with favorable early outcomes, compromised long-term survival with HD suggests the need to develop an assessment tool that can evaluate the appropriate timing for TR surgery.

MP07-02 PREDICTING RISK FOR PATIENTS UNDERGOING SACROCOLPOPEXY FROM FRAILTY INDEXES

You have accessJournal of UrologyCME1 Apr 2023MP07-02 PREDICTING RISK FOR PATIENTS UNDERGOING SACROCOLPOPEXY FROM FRAILTY INDEXES Rishabh Simhal, Kerith Wang, Maria D'Amico, Courtney Capella, Radhika Ragam, Joon Yau Leong, Yash Shah, Whitney Smith, Patrick Shenot, and Alana Murphy Rishabh SimhalRishabh Simhal More articles by this author , Kerith WangKerith Wang More articles by this author , Maria D'AmicoMaria D'Amico More articles by this author , Courtney CapellaCourtney Capella More articles by this author , Radhika RagamRadhika Ragam More articles by this author , Joon Yau LeongJoon Yau Leong More articles by this author , Yash ShahYash Shah More articles by this author , Whitney SmithWhitney Smith More articles by this author , Patrick ShenotPatrick Shenot More articles by this author , and Alana MurphyAlana Murphy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Sacrocolpopexy (SCP) is a definitive treatment option for pelvic organ prolapse (POP). Because there are less invasive, albeit less definitive treatment options, a frailty index that best predicts outcomes and mortality for patients desiring SCP is useful to aid in decision making. METHODS: Open and minimally invasive SCPs performed from 2006 to 2020 were identified inthe National Surgical Quality Improvement Program (NSQIP) database. Frailty was determined by the NSQIP modified frailty index (mFI-5), a validated 5-item score including points for diabetes, impaired functional status, COPD, CHF, and hypertension, and by the revised surgical Risk Analysis Index (RAI-rev), a validated score accounting for patient comorbidities, age, and functional status. As previously published, patients with mFI-5 scores of 2 or more and RAI-rev scores of 26 or more were considered “frail.” Univariate logistic regression and t-test analyses were performed for mFI-5 and RAI-rev as predictors of surgical complications, 30-day readmissions, 30-day mortality, and hospital length of stay (LOS). RESULTS: 9,082 SCPs were identified in the database. In total, 5.2% of patients experienced minor complications (superficial SSIs, pneumonia, UTIs, bleeding requiring transfusion, or AKIs), and 1.4% of patients experienced major complications (sepsis, DVT, stroke, reintubation, renal failure, myocardial infarction, pulmonary embolism, septic shock, wound dehiscence, deep wound infections, or cardiac arrest). The 30-day readmission and mortality rates were 2.7% and 0.02%, respectively. On univariate logistic regression, a frail mFI-5 score was not predictive of minor complications, major complications, 30-day readmissions or mortality. However, a frail compared to a non-frail mFI-5 was associated with a higher LOS (1.6 vs 1.4, p=.008). A frail compared to a non-frail RAI-rev was predictive of major complications [OR 2.52; 95% CI 1.34-4.72; p=0.004], 30-day readmissions [OR 2.62, 95% CI 1.61-4.26; p=.0001], 30-day mortality [OR 26.8; 95% CI 1.67-428.88; p=0.02], and LOS (1.8 vs 1.4 days, p=.0008). CONCLUSIONS: The RAI-rev is a better predictor than the mFI-5 for major complications, readmission rate, mortality, and hospital LOS and may help in the decision making and risk counseling for patients POP considering an SCP. Source of Funding: n/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e84 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rishabh Simhal More articles by this author Kerith Wang More articles by this author Maria D'Amico More articles by this author Courtney Capella More articles by this author Radhika Ragam More articles by this author Joon Yau Leong More articles by this author Yash Shah More articles by this author Whitney Smith More articles by this author Patrick Shenot More articles by this author Alana Murphy More articles by this author Expand All Advertisement PDF downloadLoading ...

MP31-10 MANAGEMENT OF MYCOTIC PSEUDOANEURYSMS IN RENAL TRANSPLANT PATIENTS - A LITERATURE REVIEW AND PROPOSAL FOR A NOVEL MANAGEMENT PATHWAY

You have accessJournal of UrologyCME1 Apr 2023MP31-10 MANAGEMENT OF MYCOTIC PSEUDOANEURYSMS IN RENAL TRANSPLANT PATIENTS - A LITERATURE REVIEW AND PROPOSAL FOR A NOVEL MANAGEMENT PATHWAY Alexandra Bain, Gerrit Winkelaar, and Max Levine Alexandra BainAlexandra Bain More articles by this author , Gerrit WinkelaarGerrit Winkelaar More articles by this author , and Max LevineMax Levine More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003264.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Vascular complications represent the main cause of early graft loss in renal transplantations—with less than 1% of these cases developing mycotic pseudoaneurysms. The morbidity and mortality associated with this complication is significant with an overall mortality rate of 15-20% and a graft loss rate of 55-70%. Currently the gold standard treatment for mycotic pseudoaneurysms is undefined. Recently there have been three renal transplant patients at the University of Alberta Hospital who developed mycotic pseudoaneurysms with different surgical repairs and outcomes. We performed a quality assurance review and a literature review of the surgical management of mycotic pseudoaneurysms. Based on this review, we have proposed a novel management pathway which may help reduce post-operative complications. METHODS: The databases MEDLINE and SCOPUS were searched for all case reports describing management of mycotic pseudoaneurysms in renal transplant patients between years 1990-2022. RESULTS: Twenty-two articles were reviewed which described forty-one case reports of mycotic pseudoaneurysms in renal transplant recipients. Repair techniques included patch repair in 61% of cases (25/41), endovascular stenting in 22% of cases (9/41), and extra-anatomical bypass in 12% of cases (5/41), 5% of patients (2/41) had a post-mortem diagnosis. The failure rates of patch repair resulting in death or repeat surgery was 44% (11/25), failure rates for stents was 22% (2/9), failure rates of extra-anatomical bypass was 0%. Every patient who required a takeback operative procedure was managed with an extra-anatomical bypass. Overall patient mortality was 17% (7/41), overall graft loss rate was 68% (28/41). CONCLUSIONS: Considering the high failure rates of patch repairs and endovascular stents, we suggest the first-line strategy for repair should be an extra-anatomical bypass with the assistance of Vascular Surgery when possible. If an extra-anatomical bypass cannot be performed, we suggest a wide surgical debridement with autologous in-line reconstruction. These surgical approaches may help decrease the incidence of surgical failure rates and mortalities. Having a standardized management pathway utilized by Transplant Urology and Vascular Surgery may allow for improved patient surgical outcomes and graft survival outcomes in the future. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e433 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexandra Bain More articles by this author Gerrit Winkelaar More articles by this author Max Levine More articles by this author Expand All Advertisement PDF downloadLoading ...

Safety of expedited-surgery protocols in anticoagulant-treated patients with hip fracture: a systematic review and meta-analysis.

Perioperative management of patients with hip fracture patients receiving oral anticoagulants requires navigating the risks associated with surgical delay and perioperative hemostasis. The aim of this systematic review and meta-analysis was to evaluate the effect of expedited-surgery protocols on time to surgery and perioperative outcomes in anticoagulant-treated patients with hip fracture. We searched MEDLINE, Embase and CENTRAL from inception to May 5, 2020, to identify English-language studies reporting outcomes after expedited hip fracture surgery in patients receiving vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) before hospital admission. We performed a meta-analysis using Mantel-Haenszel weighting for dichotomous variables and inverse variance weighting for continuous variables. Among the 4253 citations identified, 14 studies were included. In the 6 studies eligible for meta-analysis, compared to hip fracture surgery before implementation of a VKA-reversal protocol, surgery after implementation of such a protocol was associated with a significant reduction in time to surgery (mean difference 45.31 h, 95% confidence interval [CI] 15.81 h to 74.80 h). Expedited surgery (within 48 h) in patients who received DOACs preoperatively was not associated with increased surgical duration (mean difference -7.29 min, 95% CI -22.5 min to 7.95 min) or 30-day mortality (odds ratio [OR] 1.30, 95% CI 0.49 to 3.89) compared to patients who did not receive anticoagulants (control patients). However, expedited surgery in DOAC-treated patients was associated with an increased blood transfusion risk compared to control patients (OR 0.58, 95% CI 0.36 to 0.96). Implementing a VKA-reversal protocol for patients with hip fracture is effective in decreasing time to surgery, without an increased bleeding risk. Performing hip fracture surgery within 48 hours in DOAC-treated patients is also safe, with a small increase in blood transfusion risk.

Obesity in Pediatric Congenital Heart Disease: The Role of Age, Complexity, and Sociodemographics.

The prevalence of obesity in children with congenital heart disease (CHD) is greater than 25%, putting these patients at-risk for increased surgical morbidity and mortality. Our goal was to determine the association between CHD complexity, sociodemographic factors, and obesity. Our hypothesis was that among CHD patients, the odds of obesity would be highest in older children with simple CHD, and in all children with a lower socioeconomic status. We conducted a retrospective cohort study, reviewing electronic medical records of children aged 2-17years from over 50 outpatient pediatric clinics in Houston, TX. Children were classified as simple or moderate/complex CHD, and obesity was defined by BMI ≥ 95th percentile for age and sex. Logistic regression was used to determine the association between sociodemographic factors and CHD complexity with obesity. We identified 648 CHD and 369,776 non-CHD patients. Children with simple CHD had a similar odds of obesity as non-CHD children. Children with CHD had a higher prevalence of obesity if they were older, male, Black, Hispanic, and publicly insured. Children with moderate/complex CHD had lower odds of obesity [OR 0.24 (95% CI 0.07-0.73)], however their predicted probability of obesity approached that of the general population as they aged. Additionally, there was an incremental relationship with poverty and obesity [1.01 (1.01-1.01)]. Awareness of which patients with CHD are at highest risk of obesity may help in targeting interventions to assist at-risk patients maintain a healthy lifestyle.

COMPARISON OF PREOPERATIVE BOWEL PREPARATION MODELS OF PATIENTS WHO UNDERWENT SURGERY FOR COLORECTAL CANCER

Background&#x0D; The most prevalent cancer in society is colorectal cancer (CRC). Studies aiming to lower surgical morbidity and mortality have found a significant contribution from preoperative bowel preparation. Models for bowel preparation included mechanical cleaning, the use of antibiotics, and control groups. We compared preoperative bowel preparation for elective colorectal cancer and evaluated its effects in this study.&#x0D; Material and Methods&#x0D; Preoperative bowel preparation model was used to prospectively split 144 patients (n=144) with colorectal cancer into four groups. Patients in the first group (Group I) underwent mechanical bowel preparation (MBP), followed by oral antibiotic therapy (OAB) and MBP in the second group (Group II), intravenous antibiotic therapy (IVAB), MBP, and OAB in the third group (Group III), and no bowel preparation in the fourth group (Group IV). Demographic information, anastomotic leakage, surgical site infection, intraabdominal abscess, postoperative ileus, and death were compared between patients.&#x0D; Results&#x0D; Groups I, II, III, and IV of the study each had 35 patients, 38 patients, 35 patients, and 36 patients, respectively. There was no statistically significant difference between the four groups when the groups were evaluated by age, gender, and ASA (American Society of Anesthesiologists) score (p&gt; 0.05). There were significant differences between surgical site infection (SSI), intraabdominal abscess, and anastomosis leaking (p0.05). Mortality and postoperative ileus did not differ significantly (p &gt; 0.05).&#x0D; Conclusion&#x0D; We consider that the bowel preparation approach of mechanical colon cleansing and antibiotic administration is appropriate for patients who have had surgery owing to elective CRC.

Myosteatotic and sarcopenic obesity impact postoperative outcomes more robustly than visceral obesity in general surgery patients, with differences by sex

Computed tomography (CT) defined myosteatotic, sarcopenic, and visceral obesity are associated with adverse surgical outcomes and mortality in patients with malignancies. These occult conditions may also be widely prevalent in today's general surgery patients who tend to be overweight/obese. This study identified the predominant obesity phenotypes in 906 patients aged 18-85 years who were scheduled for laparoscopic resection for benign abdominal or colorectal disease at Vanderbilt University Medical Center between 2010 and 2017. Sex and body mass index (BMI) specific cut-points were used to identify myosteatotic, sarcopenic, and visceral obesity phenotype from abdominal CT scan morphometrics. Multivariable regression modeling determined relationships between sex, obesity phenotype, and postoperative outcomes. The myosteatostic+sarcopenic obesity phenotype associated with longer surgery duration and increased the likelihood for major complication (OR 1.34, 95%CI 1.01-1.74) and ICU admission (OR 1.39, 95%CI 1.04-1.90). Having myosteatotic obesity doubled the likelihood for hospital stay >7 days and discharge to a nursing home (OR 2.11, 95%CI 1.43,3.11), increasing the likelihood for readmission within 90 days. Obesity was more prevalent in females, but myosteatotic, sarcopenic, and visceral obesity were more prevalent in males, regardless of age or BMI. Males had more major complications (23.6% vs 17.7%, P=0.03), particularly wound dehiscence or infection, and a 2-day longer hospital stay. This study shows that sarcopenic and myosteatotic obesity phenotypes are highly prevalent, especially in male general surgery patients, regardless of age or BMI. Importantly, sarcopenic and myosteatostic obesity may be more detrimental than visceral obesity; these phenotypes robustly associated with adverse postoperative outcomes. Future work could use these findings for design of phenotype-specific interventions to reduce patient risk and prevent outcomes that are harmful and costly.

Minimally invasive surgery for anterior flail chest injury in the acute phase: series of 10 cases.

Anterior flail chest frequency represents a significant case of ventilator insufficiency. Surgical stabilization of acute phase of trauma is considered to effectively shorten the period of ventilation compared to conservative treatment using mechanical ventilation. We have applied minimally invasive surgery to stabilize the injured chest wall. Surgical stabilization of predominantly anterior flail chest segments was performed using one or two bars as per the Nuss procedure, during the acute phase of chest trauma. Data from all patients were examined. Ten patients received surgical stabilization using the Nuss method between 1999 and 2021. All patients had already been mechanically ventilated prior to surgery. The mean period from trauma to surgery was 4.2days (range, 1-8days). The number of bars used was one for 7 patients, and two for 3 patients. The mean operation time was 60min (range, 25-107min). All patients were extubated from artificial respiration without surgical complications or mortality. Mean total ventilation period was 6.5days (range, 2-15days). All bars were removed in a subsequent surgery. No collapses or fracture recurrences were observed. This method is simple and effective for fixed anterior dominant frail segment.

Repeat pulmonary thromboendarterectomy outcomes: A 15-year single-center retrospective review

ObjectiveChronic thromboembolic pulmonary hypertension is potentially curable via pulmonary thromboendarterectomy. A minority of patients experience recurrence of their symptoms and are eligible for repeat pulmonary thromboendarterectomy. However, little data exist regarding risk factors and outcomes for this patient population. MethodsWe performed a retrospective review of the University of California San Diego chronic thromboembolic pulmonary hypertension quality improvement database, including all patients who underwent pulmonary thromboendarterectomy from December 2005 to December 2020. Of the 2019 cases performed during this period, 46 were repeat pulmonary thromboendarterectomy procedures. Demographics, preoperative and postoperative hemodynamics, and surgical complications were compared between the repeat pulmonary thromboendarterectomy group and 1008 first pulmonary thromboendarterectomy group. ResultsRepeat pulmonary thromboendarterectomy recipients were more likely to be younger, to have an identified hypercoagulable state, and to have higher preoperative right atrial pressure. Etiologies of recurrent disease include incomplete initial endarterectomy, discontinuation of anticoagulation (noncompliance or for medical reasons), and anticoagulation treatment failure. Patients who received repeat pulmonary thromboendarterectomy had significant hemodynamic improvement, but less pronounced compared with patients who received first pulmonary thromboendarterectomy. Repeat pulmonary thromboendarterectomy was associated with an increased risk of postoperative bleeding, reperfusion lung injury, residual pulmonary hypertension, and increased ventilator, intensive care unit, and hospital days. However, hospital mortality was similar between the groups (2.2% vs 1.9%). ConclusionsThis is the largest reported series of repeat pulmonary thromboendarterectomy surgery. Despite an increase in postoperative complications, this study demonstrates that repeat pulmonary thromboendarterectomy surgery can result in significant hemodynamic improvement with acceptable surgical mortality in an experienced center.

Doctors' knowledge and perceptions of perioperative nutrition support; results from a large Australian tertiary referral Centre.

Nutritional optimisation in the perioperative period is essential in the prevention and treatment of malnutrition, a state of poor bodily function caused by a lack of nutritional intake, thereby altering body composition.1 Although identification and treatment of malnutrition is well recognized as a key component of Enhanced Recovery After Surgery (ERAS) guidelines, it is still highly prevalent, and significantly associated with poor outcomes. Studies have shown that up to 50% of patients undergoing abdominal surgery are malnourished.2-5 These patients are further at risk due to reduced recognition, combined with poor clinician understanding of treatment strategies due to their lack of knowledge and experience.6-10 To identify how we can improve on surgical nutrition management within our surgical units, we performed a survey within a large tertiary referral hospital in Melbourne, Australia. The project was approved by the Western Health Office of Research (QA2020.13_61439). A purpose-built, 23-item anonymous online REDCap survey was distributed to all doctors (including interns, residents, registrars, fellows and consultants) working across all general surgical units at Western Health. As our recruitment strategy involved advertising the survey at the weekly surgical morbidity and mortality meeting and via email distribution, response rate calculation was not feasible. The survey, developed by a team of senior academic dietitians and surgeons, included Likert scale ‘agree/disagree’ questions as well as clinical multiple-choice questions to assess doctor's perceptions and knowledge of perioperative nutritional support within general surgery. Of the 50 respondents, the majority were junior doctors (11 [22%] interns and 17 [34%] residents), 11 were registrars (22%) and a further 11 were consultant surgeons (22%). Only 24% (12) of respondents reported any prior training on perioperative nutritional support. While all respondents agreed on the importance of perioperative nutrition training (100%) and 94% (47) agreed on the need for nutritional assessment both before and after abdominal surgery, only 46% (23) felt confident in being able to initiate enteral or parenteral support according to evidence based guidelines. This was reflected when only approximately half of respondents correctly identified the correct timing to commence enteral (62%; 31) and total parenteral nutrition (50%; 25). Early identification of patients with nutritional deficits is important to ensure appropriate and timely interventions, however only a small proportion (20%; 10) of doctors surveyed were confident in identifying malnutrition and only 34% (17) were able to identify the common risks of malnutrition in a surgical patient. Only 38% (19) of doctors understood that the commonly used ‘fast from midnight’ order was unnecessary.11 These findings correspond with the nutritional knowledge gaps that have been observed across the world amongst medical students, junior medical staff and surgeons.6-10 Many hospitalized patients suffer from malnutrition, and those undergoing abdominal surgery, especially emergency cases, are at risk of deterioration owing to prolonged fasting and slow return to adequate nutritional intake. A recent British audit showed that patients undergoing emergency surgery are more likely to fast for longer periods of time (more than 12 h for clear fluids, and 24 h for food) compared with elective patients.11 Whilst we have shown the majority of doctors understand the importance of nutrition optimisation, they may not be equipped with the knowledge of when and how to do so. The implementation of ERAS protocols which include nutrition components can help standardize nutrition supplementation.12 A recent study also showed a lack of nutrition related education in British postgraduate training curriculums, suggesting a potential solution of implementing nutritional based objectives in all postgraduate training programs.7, 13 We recommend that doctors should be encouraged to make use of available hospital resources, in particular involvement of dietitians and the multidisciplinary team to help with early identification of patients at risk of malnutrition. Embedded education in both undergraduate and postgraduate training could help improve on doctors understanding and management of nutritional deficiencies. Open access publishing facilitated by The University of Melbourne, as part of the Wiley - The University of Melbourne agreement via the Council of Australian University Librarians. Howard H. Y. Tang: Formal analysis; writing – original draft; writing – review and editing. Danielle Taylor: Data curation; investigation; methodology; writing – review and editing. Irene Deftereos: Conceptualization; methodology; writing – review and editing. Aurora Ottaway: Methodology; writing – review and editing. Justin M. C. Yeung: Conceptualization; supervision; visualization; writing – review and editing.

Analysis of potential clinical management issues in unreported mortality data from an Australian health service.

We have previously reported incomplete data submission to the Victorian Audit of Surgical Mortality (VASM) by a large health service. We have further examined the source health service clinical data to assess whether any clinical management issues (CMI) occurred and should have been reported. The previous study identified 46 deaths that should have been reported to VASM. The hospital records of these patients were further analysed. Data recorded included the patient's age, gender, admission type and clinical course. Any potential clinical management issues were recorded and classified using the VASM definitions (area of consideration or concern, adverse event). Median age of the deceased patients was 72 (range 17-94), with 17 (37%) being female. Patients were under the care of nine different specialties with general surgery being the most common (18/46). Only four (8.7%) of the cases were electively admitted. 17 (37%) patients had at least one CMI with 10 (21.7%) classified as adverse events. Most deaths were not considered preventable. The proportion of CMI in the unreported deaths was consistent with the previously reported VASM data, however current findings show a high percentage of adverse events. The underreporting may be due to inexperienced medical staff or coders, poor quality notes or confusion about what should be reported. These findings reinforce the importance of data collection and reporting at the health service level, and a number of important lessons and opportunities to improve patient safety have been lost.

Early and Long-term Complications of Robotic Assisted Laparoscopy in Infants and Children

BackgroundRobotic-assisted laparoscopy still lacks wide acceptance in infants and children. We developed the service and report the largest single institution experience of complications over a period of 11 years. MethodsBetween March 2006 and May 2017, consecutive infants and children who underwent robotic assisted laparoscopy under the care of two laparoscopic surgeons were studied. Data for patients, surgeons, year of surgery, operation, and timing, nature, grades of complications were assessed. ResultsA total of 601 robotic procedures (45 different types) were carried out in 539 patients. Of these 31 (5.8%) were converted, none for operative complications. These and another 4 with complicated co-morbidity were excluded, leaving 504 patients for further analysis. There were 60 (11.9%) complications in 57 (11.3%) patients. Mean (SD) age was 7.7 years −/+5.1 with the youngest being 4 weeks. Concomitant or bilateral robotic and non-robotic procedures took place in 8.1% and 13.3% of patients respectively. Significant medical co-morbidity and abdominal scarring were present in 29% and 14.9% of patients respectively. Complications occurred in theatre 1.6%, hospital 5.6%, 28 days 1.2%, and late 3.6%. Mean follow up was 7.6 years −/+ 3.1 SD. Over-all postoperative complication rate was 10.3%: CD grade I 6.5% (33), II 0.6% (3), and IIIa/b 3.2% (16) which included 1.4% (7) re-do surgery. Most (11/16) grade III occurred late. There were no bleeding, grade IV or V complications, surgical mortality, or technology related complications. ConclusionsComplications are low even during the learning phase and while developing the new technique. Most complications occurred early and were minor. Most high-grade complications presented late. Levels of Evidence2B

Surgical, survival and quality of life outcomes in over 1000 pelvic exenterations: lessons learned from a large Australian case series

To determine surgical, survival and quality of life outcomes across different tumour streams and lessons learned over 28 years. Consecutive patients undergoing pelvic exenteration at a single, high volume, referral hospital, between 1994 and 2022 were included. Patients were grouped according to their tumour type at presentation as follows, advanced primary rectal cancer, other advanced primary malignancy, locally recurrent rectal cancer, other locally recurrent malignancy and non-malignant indications. The main outcomes included, resection margins, postoperative morbidity, long-term overall survival, and quality of life outcomes. Non-parametric statistics and survival analyses were performed to compare outcomes between groups. Of the 1023 pelvic exenterations performed, 981 (95.9%) unique patients were included. Most patients underwent pelvic exenteration due to locally recurrent rectal cancer (N= 321, 32.7%) or advanced primary rectal cancer (N= 286, 29.2%). The rates of clear surgical margins (89.2%; P< 0.001) and 30-days mortality were higher in the advanced primary rectal cancer group (3.2%; P= 0.025). The 5-year overall survival rates were 66.3% in advanced primary rectal cancer and 44.6% in locally recurrent rectal cancer. Quality of life outcomes differed across groups at baseline, but generally had good trajectories thereafter. International benchmarking revelled excellent comparative outcomes. The results of this study demonstrate excellent outcomes overall, but significant differences in surgical, survival and quality of life outcomes across patients undergoing pelvic exenteration due to different tumour streams. The data reported in this manuscript can be utilized by other centres as benchmarking as well as proving both subjective and objective outcome details to support informed decision-making for patients.

Marching Ahead through the Pandemic: Continuing Anesthesia Services in COVID Era-Our Experience from a Tertiary Care Cancer Centre.

Swati BhanIntroduction This paper aims to provide an overview of the administrative and clinical preparations done in a tertiary care cancer hospital in continuing operation theatre (OT) services through the COVID pandemic. Methods Retrospective data collection, data for the past 1.5 years (COVID period) March 2020 to August 2021 were compared to surgical output for a similar duration of time before the COVID era (September 2018-February 2020). Results A total of 1,022 surgeries were done under anesthesia in the COVID period as against 1,710 surgeries done in a similar time frame in the pre-COVID era. Overall, we saw a 40%drop in the total number of cases. Thorax, abdominal, and miscellaneous surgeries (soft tissue sarcomas, urology, and gyneconcology) saw a maximum fall in numbers; however, head and neck cases saw an increase in numbers during the pandemic. Surgical morbidity and mortality were similar in the COVID and pre-COVID era. No cases of severe COVID infection were reported among the healthcare staff working in OT. Discussion We could successfully continue our anesthesia services with minimal risk to healthcare staff throughout the pandemic by adopting major guidelines in a pragmatic and practical approach with minor changes to suit our setup.

Cost-effectiveness of SAPIEN 3 transcatheter aortic valve implantation in low surgical mortality risk patients in Spain

Cost-effectiveness of SAPIEN 3 transcatheter aortic valve implantation in low surgical mortality risk patients in Spain

Surgical interhospital transfer mortality: national analysis.

Interhospital transfers of surgical patients are an independent risk factor for mortality. The Australian and New Zealand Audit of Surgical Mortality (ANZASM) aims to improve surgical care through assessment of all cases of surgical mortality. This study aimed to describe common clinical management issues that contributed to interhospital transfer patient mortality. Data for all surgical patient mortality in Australia (except New South Wales) that underwent interhospital transfer between 1 January 2010 and 31 December 2019 were extracted from ANZASM. The surgeons' reports and assessors' evaluations were examined to identify clinical management issues. Thematic analysis was performed to develop pertinent themes and subthemes. Some 8679 patients were identified over the 10-year period. Of these, 2171 (25.0 per cent) had 3259 clinical management issues identified. Prominent themes were operative design (n = 466, 14.3 per cent), decision to operate (n = 425, 13.0 per cent), medical conditions (n = 344, 10.6 per cent), diagnosis (n = 326, 10 per cent), transfer (n = 293, 10.0 per cent), intraoperative issues (n = 278, 8.5 per cent), inadequate assessment (n = 238, 7.3 per cent), communication (n = 224, 6.9 per cent), delay in recognizing complications (n = 180, 5.5 per cent), coagulopathy (n = 151, 4.6 per cent), insufficient monitoring (n = 127, 3.9 per cent), infection (n = 107, 3.3 per cent), and hospital resources (n = 100, 3.1 per cent). Assessors considered 58.4 per cent of clinical management issues (n = 1903) probably or definitely preventable. This study identified 13 themes of potentially avoidable management issues present in surgical mortality following interhospital transfers. Quality-improvement initiatives targeting these areas may improve surgical patient outcomes.

Impact of a digital surgical workflow including Digital Device Briefing Tool on morbidity and mortality in a patient population undergoing primary stapled colorectal anastomosis for benign or malignant colorectal disease: protocol for a multicentre prospective cohort study

IntroductionWith growing emphasis on surgical safety, it appears fundamental to assess the safety of colorectal resection involving primary stapled anastomosis. Surgical stapling devices can considerably foster patient safety in colorectal...

Temporal validation of a multivariable surgical mortality prediction model (NZRisk): a New Zealand national cohort study

ObjectivesClinical risk calculators (CRCs), such as NZRisk, are used daily by clinicians to guide clinical decisions and explain individual risk to patients. The utility and robustness of these tools depends...

Volume- and quality-controlled certification system promotes centralization of complex hepato-pancreatic-biliary surgery.

Centralization of complex surgeries has made little progress when it only considers the minimum number of surgical procedures. We aim to assess the impact of certification system of Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) on centralization and surgical quality of advanced hepato-pancreatic-biliary (HPB) surgery. The National Clinical Database was used to review 20 111 patients who underwent pancreatoduodenectomy (PD) and 9666 who underwent advanced hepatectomy defined as hepatectomy of more than one section during 2019 and 2020. JSHPBS certifies hospitals based on the annual number of advanced HPB surgeries and the surgical quality. Minimum numbers of surgeries for board-certified A and B institutions are 50 and 30, respectively. Short-term outcomes were compared among institutions. In 2020, 69.4% (7007/10090) and 72.9% (3433/4710) of patients underwent PD and advanced hepatectomy at board-certified institutions. In-hospital mortality rates after PD was 0.9% at certified A institutions, 1.4% at B institutions, and 2.7% at non-certified institutions (p < .001). The odds ratio (OR) of risk-adjusted mortality after PD compared with non-certified institutions was 0.39 (confidence interval [CI]: 0.30-0.50, p < .001) at certified A institutions, and 0.54 at certified B institutions (CI: 0.40-0.73, p < .001). In-hospital mortality rates after advanced hepatectomy was 1.7% at certified A institutions, 2.3% at B institutions, and 3.2% at non-certified institutions (p < .001). The OR of risk-adjusted mortality after advanced hepatectomy compared with non-certified institutions was 0.57 at certified A institutions (CI: 0.41-0.78, p < .001). The volume- and quality-controlled certification system of JSHBPS reduces surgical mortality after advanced HPB surgeries.