Major Morbidity Rate Research Articles

Operative management and outcomes of gallbladder cancer in Australia: a multi‐institutional, retrospective, observational cohort analysis

AbstractBackgroundData on optimal extent of resection for various stages of gallbladder cancer are lacking. This study aims to evaluate disease‐free (DFS) and overall survival (OS) after simple (SC) versus radical cholecystectomy (RC) for gallbladder cancer in the Australian context, and assesses factors associated with post‐operative morbidity.MethodsMulti‐centre, retrospective cohort analysis including all gallbladder cancer patients who underwent resection across six Australian institutions between January 2010 and January 2020.ResultsOf 63 patients included, 31 underwent SC and 32 had RC. Liver and other organ resection correlated with prolonged median DFS (41.9 vs. 13.1 months, HR 0.492 [95% CI 0.245–0.987], P = 0.042) and OS on univariate analysis of all patients (55.8% survived five years follow‐up at study conclusion vs. median 18.4 months, HR 0.66 [95% CI 0.446–0.972], P = 0.036) but failed to demonstrate effect on multivariable analysis (OS HR 0.31 [95% CI 0.09–1.04], P = 0.057). RC was associated with a higher 30‐day complication rate (n = 21 [65.6%] vs. n = 15 [48.4%], P = 0.310) compared to SC, although not statistically significant. There was no significant difference in the major morbidity rate (Clavien‐Dindo ≥ Grade III) observed after SC (n = 7 [22.6%]) compared with RC (n = 6 [18.7%], P = 0.754). Neoadjuvant therapy was not utilized and adjuvant treatment used infrequently.ConclusionExtended gallbladder cancer resection was associated with prolonged OS and DFS but also considerable post‐operative morbidity. Further studies are warranted to determine the optimal extent of surgical resection by stage of gallbladder cancer.

Results of complete cytoreductive strategy in patients with peritoneal metastases of colorectal origin with or without extraperitoneal metastases: A bicentric analysis

BackgroundIncreased survival can be achieved in patients with colorectal cancer peritoneal metastases (CRPM) treated with cytoreductive surgery. The benefit of this strategy remains uncertain when CRPM are associated with extraperitoneal metastases (EPM). The aim of this study was to compare short- and long-term outcomes of patients treated with CRS for CRPM, with or without EPM. MethodsThis study included 413 consecutive patients who underwent CRS for CRPM: 120 with EPM (EPM+) and 293 without (EPM-). Patients with isolated ovarian metastases were included in EPM-group (n = 83). ResultsEPM were mainly located to the liver (66 %,n = 79), retroperitoneal lymph nodes (33 %,n = 40); less frequently to the spleen (9 %,n = 12), lung (9 %,n = 10) or pleura (1 %,n = 1). Ovarian metastases were present in 126 patients (83 in EMP-, 43 in EPM+). Peritoneal carcinomatosis index (PCI) was similar in EPM- (8 [4–14]) and EPM+ (8 [3–13],p = 0.335) groups, as postoperative mortality (3 % vs 3 %,p = 1) and major morbidity rates (28 % vs 35 %,p = 0.223). Median overall survival (mOS) and disease-free survival were significantly higher in the EPM-group (58m vs 39m, and 16m vs 10m,p = 0.003). We highlighted 3 prognostic groups 1) EPM-with PCI<10 (mOS 93m), 2) EPM+ with PCI<10 (mOS 57m), 3) EPM-with 10<PCI<15 (mOS 35m) or EPM+ with 10<PCI<15 (mOS 31m) or PCI>15 regardless EPM (mOS 26m, p < 0.001). ConclusionComplete cytoreductive surgery seems to be feasible in patients with EPM, without increase in postoperative morbidity and mortality compared to patients without EPM. This strategy provides prolonged survival in selected patients with limited peritoneal metastases from colorectal cancer.

Failure to Rescue After Resection of Perhilar Cholangiocarcinoma in an International Multicenter Cohort.

Failure to rescue (FTR) is defined as the inability to prevent death after the development of a complication. FTR is a parameter in evaluating multidisciplinary postoperative complication management. The aim of this study was to evaluate FTR rates after major liver resection for perihilar cholangiocarcinoma (pCCA) and analyze factors associated with FTR. Patients who underwent major liver resection for pCCA at 27 centers were included. FTR was defined as the presence of a Dindo grade III or higher complication followed by death within 90 days after surgery. Liver failure ISGLS grade B/C were scored. Multivariable logistic analysis was performed to identify predictors of FTR and reported using odds ratio and 95% confidence intervals. In the 2186 included patients, major morbidity rate was 49%, 90-day mortality rate 13%, and FTR occurred in 24% of patients with a grade III or higher complication. Across centers, major complication rate varied from 19 to 87%, 90-day mortality rate from 5 to 33%, and FTR ranged from 11 to 50% across hospitals. Age [1.04 (1.02-1.05) years], ASA 3 or 4 [1.40 (1.01-1.95)], jaundice at presentation [1.79 (1.16-2.76)], right-sided resection [1.45 (1.06-1.98)], and annual hospital volume < 6 [1.44 (1.07-1.94)] were positively associated with FTR. When liver failure is included, the odds ratio for FTR is 9.58 (6.76-13.68). FTR occurred in 24% of patients after resection for pCCA. Liver failure was associated with a nine-fold increase of FTR and hospital volume below six was also associated with an increased risk of FTR.

Implementation of a Multidisciplinary Enhanced Recovery After Surgery (ERAS) Program for Cytoreductive Surgery (CRS) With Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) can be associated with prolonged hospital stays. A novel Enhanced Recovery After Surgery (ERAS) based on ERAS Society guidelines was designed and implemented. The primary outcome was ERAS compliance. Secondary outcomes included length of stay (LOS) and postoperative complications. A retrospective study on patients who underwent CRS/HIPEC between 2018 and 2022, with ERAS implementation in 2022. Health records were reviewed. Statistical analysis included descriptive statistics, Wilcoxon tests, Student t-test, and χ2 and binomial negative regression. Health Ethics Research Board approval was obtained. Eighty patients underwent CRS/HIPEC: 59 in the pre-ERAS group and 21 in the post-ERAS group. Groups were similar in age, comorbidities, and Peritoneal Carcinomatosis Index. ERAS compliance increased from 32.8% to 70.8% (p < 0.001). Median LOS decreased from 14 to 9 days (p < 0.001). Comparing pre-ERAS to post-ERAS showed no significant difference in the major morbidity rate (13.6% vs. 9.5%) or 30-day readmission (9.4% vs. 4.8%) and no mortalities. Controlling for patient characteristics, the mean LOS decreased by 6.94 days (p < 0.001). Implementation of an ERAS CRS/HIPEC program is safe and allows for improved compliance to ERAS protocols and a significant reduction in LOS.

Impact of patient age on outcome of minimally invasive versus open pancreatoduodenectomy: a propensity score matched study

BackgroundPancreatoduodenectomy in elderly patients may be associated with increased postoperative mortality, but studies in minimally invasive pancreatoduodenectomy (MIPD) are scarce. MethodsInternational multicenter retrospective study including patients aged >60 years undergoing MIPD (robot-assisted and laparoscopic) and open pancreatoduodenectomy (OPD), were categorized by age: 60–69, 70–79, and 80+ years. In each category, propensity score matching (PSM) was performed (1:1 ratio) between MIPD and OPD. Primary outcome was 30-day/in-hospital mortality. ResultsAmong 3820 patients, we matched 1468 patients aged 60–69, 1154 patients aged 70–79, and 196 patients aged 80+ years. In patients aged 60–69 and 70–79 years, MIPD was associated with longer operative time, less blood loss and a longer length of stay. Major morbidity was higher after MIPD with similar 30-day/in-hospital mortality. The R0 resection rate was higher after MIPD. In patients aged 80+ years, besides a longer operative time in MIPD, outcomes were comparable between both groups. ConclusionThis study found no evidence that increasing age worsens mortality of MIPD. MIPD was associated with longer operative time, higher rate of major morbidity, prolonged length of stay versus less blood loss and a higher R0 resection in patients aged 60–69 and 70–79 years. These differences continue in patients aged 80+ years, but became less evident.

ThP4.9 - The role of preoperative nutritional assessment in postoperative outcomes of hepato-pancreato-biliary patients: A bicenter prospective observational study

Abstract Aims Preoperative nutritional status of patients who undergo surgery due to hepato-pancreato-biliary (HPB) cancer has been considered as a prognostic factor of their postoperative course. The aim of the present study was to investigate the association of preoperative nutritional assessment with the postoperative morbidity and mortality in such patients. Methods Patients undergoing surgery due to HPB cancer from March 2022 until March 2023 at two university surgical departments were included in the present study. Patients’ demographics and postoperative parameters, such as complications’ severity according to Clavien-Dindo classification and mortality, along with malignancy stage were reported. Preoperative nutritional assessment was conducted according to the Global Leadership Initiative on Malnutrition (GLIM) criteria and the Controlling Nutritional Status (CONUT) score. The present study was registered in ClinicalTrials.gov (NCT05795374). Results The present study included 66 patients with a mean age of 63 ± 12 years old. The high risk of malnutrition according to the GLIM criteria was associated with major (Clavien-Dindo≥3) postoperative complications (74% vs 32%, p=0.026) and increased 30-day mortality (80% vs 23%, p=0.021). Moreover, malnutrition according to the CONUT tool was correlated to increased 30-day mortality (66% vs 45%, p=0.016). Conclusions Preoperative malnutrition seems to be associated with higher rates of postoperative mortality and major morbidity in patients undergoing surgery due to HPB cancer.

Social Vulnerability Index Is Associated With Major Morbidity After Lung Resection

BackgroundLittle is known about the prognostic impact of the Social Vulnerability Index (SVI) in patients with early-stage non-small cell lung cancer (NSCLC) who are undergoing video-assisted thoracoscopic lung resection. MethodsPatients who underwent lung resection for stage IA-IIB NSCLC at a single institution between 2010 and 2021 were included in the study. The Society of Thoracic Surgeons definition of major morbidity, consisting of 14 postoperative events, was used. The SVI was determined by geocoding the permanent addresses of Illinois residents and using the Centers for Disease Control and Prevention calculator for a census-tract level SVI. Univariate and multivariate logistic regression analyses were used to examine the association between the SVI and major morbidity. Cut-point analysis was performed to determine the SVI cutoff that most strongly correlated with major morbidity. ResultsA total of 551 patients met inclusion criteria, and 65% (356 of 551) of these patients underwent lobectomy. The SVI cutoff was determined to be 0.831 (P = .010). In the high-SVI cohort , 58% (26 of 45) were Black, compared with 9% (45 of 506) in the low-SVI cohort (P < .001). For high-SVI patients, the major morbidity rate was 27% vs 9% for low-SVI patients (P = .0174), and the 1-year mortality rate was 8.9% vs. 3.0% for those with a low SVI (P = .061). On univariate analysis, high SVI status was associated with 30-day major morbidity (odds ratio, 2.84; CI, 1.28-6.29; P = .010). On multivariate analysis, after controlling for age, race, sex, tumor histologic type, procedure type, preoperative comorbidities, smoking history, and forced expiratory volume in 1 second, this association persisted (odds ratio, 3.16; CI, 1.11-8.99; P = .031). ConclusionsA high SVI is associated with major morbidity after video-assisted thoracoscopic lung resection for NSCLC.

604. REAL-WORLD MANAGEMENT AND OUTCOMES OF PATIENTS WITH NON METASTATIC ESOPHAGEAL SQUAMOUS CELL CARCINOMA IN THE FREGAT DATABASE

Abstract Background International guidelines for locally advanced esophageal squamous cell carcinoma (ESCC) recommend both neoadjuvant chemoradiotherapy (nCRT) followed by planned surgery (P-surg) or definitive chemoradiotherapy (dCRT) with salvage surgery (S-surg). However, the optimal treatment remains unknown, and the ongoing pragmatic NEEDS randomized trial is assessing the efficacy of an organ-preserving strategy after dCRT (Nilsson, Front Oncol 2022). Real-world data on the management of non-metastatic ESCC is limited. This study aims to describe the treatment strategies and prognosis of patients with non-metastatic ESCC in a real-world setting. Methods We conducted a retrospective cohort study of patient treated for non-metastatic ESCC between 2014 and 2022. Data were extracted from the FREGAT database. For the entire population, different treatment strategies were described. We compared patients who received nCRT with those who received dCRT under real-life conditions (“Real-life” population) and according to the NEEDS randomized trial criteria (“NEEDS-like” population). Five-year overall survival (OS) and relapse-free survival (RFS) were compared between nCRT and dCRT patients using a Cox proportional hazard model adjusting for major confounders. In operated patients, the impact of surgery on OS and RFS was assessed using a time-dependent Cox proportional hazard model. Postoperative outcomes were compared between P-surg and S-surg using Fisher’s exact test. Results From 971 patients diagnosed with non-metastatic ESCC, 867 (89.3%) received a curative treatment including dCRT (41.0%), nCRT (28.0%), primary esophagectomy (9.8%), neoadjuvant chemotherapy (3.4%), or endoscopic resection (1.0%). Fifty-nine patients (6,1%) received supportive care or chemotherapy alone. Forty-five patients (4.6%) died during or before treatment. In the “real-life” population (n=659), 269 patients received nCRT and 390 patients received dCRT. A total of 229 patients (93.5%) in nCRT group underwent P-surg and S-surg was performed in 44 patients (11.3%) in dCRT group. After adjustment, dCRT was associated with a significantly poorer 5-year OS and RFS (respectively HR=1.83, 95%CI 1.44-2.33; HR=1.98, 95%CI 1.57-2.49). A complete clinical response (cCR) was observed in 21.6% and 29.5% of the nCRT and dCRT groups, respectively. Among cCR undergoing resection, 35.8% had residual disease on pathological specimen. Time between CRT and surgery was 58 days (IQR44-72) vs. 109 days (IQR71-278) for P-surge and S-Surg respectively. The 90-day mortality, major morbidity (Clavien-Dindo III/IV) and pulmonary complication rates were similar in both groups, except for a higher risk of anastomotic leakage after S-surg (p=0.05). In the “NEEDS-like” population (n=598), findings were consistent and comparable to those observed in the “real-life” population. Conclusion Among non-mestastatic ESCC included in the FREGAT database, 10.6% had a non-curative approach or died prematurely. Most patients underwent dCRT, with S-surg rate of only 11.3%. Neoadjuvant CRT followed by P-surg was associated with the best outcome in terms of OS and RFS in both “rela life” and “Needs-like” populations. In operated patients, postoperative outcomes were similar after nCRT and dCRT, except for a higher incidence of anastomotic leakage after S-surg. This study highlighted the therapeutic strategies used and their results in real-life conditions for non-metastatic ESCC inside the FREGAT database. The treatment option of nCRT followed by P-surg appears to remain the optimal curative treatment regimen.

A Man with Sudden Onset Leg Pain and Weakness

Case Presentation: An 89-year-old male who had been holding dabigatran in the setting of transcarotid artery revascularization presented to the emergency department with sudden onset leg pain and weakness. Computed tomography angiography revealed acute aortic occlusion and thrombosis of the bilateral common iliac arteries. He underwent aortoiliac and femoral embolectomies and stenting of the bilateral common iliac arteries and returned to his baseline functional status. Discussion: Acute aortic occlusion is a rare but often devastating vascular emergency characterized by obstruction of the aorta by an embolus or thrombosis. Diagnosis can be challenging as it may be mistaken for spinal pathology, which can lead to delays in diagnosis. Despite advances in diagnostic modalities and interventions, acute aortic occlusion often results in high rates of major morbidity and mortality.

Surgical Outcome After Distal Pancreatectomy With and Without Portomesenteric Venous Resection in Patients with Pancreatic Adenocarcinoma: A Transatlantic Evaluation of Patients in North America, Germany, Sweden, and The Netherlands (GAPASURG)

BackgroundPancreatic adenocarcinoma located in the pancreatic body might require a portomesenteric venous resection (PVR), but data regarding surgical risks after distal pancreatectomy (DP) with PVR are sparse. Insight into additional surgical risks of DP-PVR could support preoperative counseling and intraoperative decision making. This study aimed to provide insight into the surgical outcome of DP-PVR, including its potential risk elevation over standard DP.MethodsWe conducted a retrospective, multicenter study including all patients with pancreatic adenocarcinoma who underwent DP ± PVR (2018–2020), registered in four audits for pancreatic surgery from North America, Germany, Sweden, and The Netherlands. Patients who underwent concomitant arterial and/or multivisceral resection(s) were excluded. Predictors for in-hospital/30-day major morbidity and mortality were investigated by logistic regression, correcting for each audit.ResultsOverall, 2924 patients after DP were included, of whom 241 patients (8.2%) underwent DP-PVR. Rates of major morbidity (24% vs. 18%; p = 0.024) and post-pancreatectomy hemorrhage grade B/C (10% vs. 3%; p = 0.041) were higher after DP-PVR compared with standard DP. Mortality after DP-PVR and standard DP did not differ significantly (2% vs. 1%; p = 0.542). Predictors for major morbidity were PVR (odds ratio [OR] 1.500, 95% confidence interval [CI] 1.086–2.071) and conversion from minimally invasive to open surgery (OR 1.420, 95% CI 1.032–1.970). Predictors for mortality were higher age (OR 1.087, 95% CI 1.045–1.132), chronic obstructive pulmonary disease (OR 4.167, 95% CI 1.852–9.374), and conversion from minimally invasive to open surgery (OR 2.919, 95% CI 1.197–7.118), whereas concomitant PVR was not associated with mortality.ConclusionsPVR during DP for pancreatic adenocarcinoma in the pancreatic body is associated with increased morbidity, but can be performed safely in terms of mortality.

The Society of Thoracic Surgeons 2024 Risk Models for Lung Cancer Resection: Continued Refinement and Improved Outcomes

BackgroundThe Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) has been used to develop risk models for patients undergoing pulmonary resection for cancer. Leveraging a contemporary and more inclusive cohort, this study sought to refine these models. MethodsThe study population consisted of adult patients in the STS GTSD who underwent pulmonary resection for cancer between 2015 and 2022. Unlike in previous models, nonelective operations were included. Separate risk models were derived for operative mortality, major morbidity, and composite morbidity or mortality. Logistic regression with backward selection was used with predictors retained in models if P < .10. All derived models were validated using 9-fold cross-validation. Model discrimination and calibration were assessed for the overall cohort and for surgical procedure, demographic, and risk factor subgroups. ResultsData from 140,927 patients at 337 participating centers were included in the study. Overall operative mortality rate was 1.1%, major morbidity was 7.3%, and composite morbidity or mortality was 7.6%. Novel predictors of short-term outcomes included interstitial lung disease, diffusing capacity of lung for carbon monoxide, and payer status. Overall discrimination was superior to previous STS pulmonary resection models for operative mortality (C-statistic = 0.80) and for composite morbidity or mortality (C-statistic = 0.70). Model discrimination was comparable and model calibration was excellent across all procedure- and demographic-specific subcohorts. ConclusionsAmong STS GTSD participants, major morbidity and operative mortality rates remained low after pulmonary resection. The newly derived pulmonary resection risk models demonstrate superior performance compared with previous models, with broader real-life applicability and clinical face validity.

Intraoperative intraductal ultrasonography of the main pancreatic duct during pancreatoduodenectomy: technical description of a pilot series.

The intraoperative risk stratification during pancreatoduodenectomy is gaining increasing significance. The main pancreatic duct wall is of particular importance as it represents the element of anchor of the anastomotic stiches. This study aims to describe the safety, feasibility, and reproducibility of a novel intraductal ultrasonography of the main pancreatic (MPD)-Wirsung duct (IWU) during pancreatoduodenectomy (PD).A prospective series of 58 patients underwent PD with anastomosis between the MPD and the jejunum. Just before the reconstructive phase, the remaining pancreatic stump underwent complete IWU with definition of Wirsung thickness (WT) at the anastomotic site, using a radial ultrasound probe of 1.7mm in diameter.No IWU-related complications were reported. The median WT of the MPD was 1.1mm (SD 0.2). The rates of postoperative pancreatic fistula (POPF), major morbidity, and mortality were 17, 5, and 0%, respectively.The use of IWU during PD demonstrated safety and feasibility. IWU represents a new tool aimed at determining structural characteristics of the MPD that could impact on the surgical strategy of the pancreatic anastomosis. Further validation and comparative analysis with the current standard of care are warranted within a prospective controlled framework.

Surgical outcomes of major vascular resection for retroperitoneal liposarcoma from a high‑volume sarcoma center: a propensity score matching analysis

PurposeRadical resection of retroperitoneal liposarcoma (RLPS) may necessitate vascular resection and reconstruction. The study was conducted to assess surgical outcomes of surgery for RLPS with major vascular involvement.MethodsPatients with RLPS who underwent surgical resection at the Sarcoma Center of Peking University Cancer Hospital between April 2011 and December 2022 were identified from a prospectively maintained database. Patients were classified into two groups: vascular resection and non-vascular resection groups. A propensity score matching analysis was performed to eliminate baseline differences between the groups. Surgical details and postoperative outcomes were analyzed. Furthermore, prognostic factors for local recurrence-free survival (LRFS) and overall survival (OS) were assessed.ResultsOverall, 199 patients were identified and the median follow-up period was 48 (interquartile range [IQR] 45–69) months. Vascular resection was performed in 42 (21%) patients, 25 of whom had vascular infiltration. A total of 39 patients had vascular replacement and 3 patients underwent partial resection (side-wall resection). Vascular resection was burdened by higher rates of major morbidity (38% vs. 14%, p < 0.001) and 30-day mortality (7.1% vs. 1.3%, p = 0.005). After propensity-matched analysis, patients who underwent vascular resection had 5-year LRFS and OS rates comparable to those without vascular involvement. Major vascular resection was not an independent risk factor for LRFS or OS.ConclusionsAlthough accompanied by increased risks of major morbidity and mortality, the major vascular resection enabled radical resection in patients with advanced RLPS, affording comparable 5-year LRFS and OS rates compared to those who did not.

Effect of donor warm ischemia time during graft extraction in right lobe robotic donor hepatectomy on recipient outcomes—A propensity score matched analysis

One of the concerns specific to minimally invasive donor hepatectomy (MIDH) is the prolonged time required for graft extraction after completion of the donor hepatectomy (donor warm ischemia time [DWIT]). There has never been an objective evaluation of minimally invasive donor hepatectomy-DWIT on allograft function in living donor liver transplantation. We evaluated the effect of DWIT following robotic donor hepatectomy (RDH) on recipient outcomes and compared them with a matched cohort of open donor hepatectomy (ODH). Demographic, perioperative, and recipient’s postoperative outcome data for all right lobe (RL)-RDH performed between September 2019 and July 2023 were analyzed and compared with a propensity score matched cohort (1:1) of RL-ODH from the same time period. Of a total of 103 RL-RDH and 446 RL-ODH, unmatched and propensity score matched analysis (1:1) revealed a significantly longer DWIT in the RDH group as compared to the ODH group (9.33 ± 3.95 vs 2.87 ± 2.13, P < .0001). This did not translate into any difference in the rates of early allograft dysfunction (EAD), biliary complications, major morbidity, or overall 1-and 3-month survival. The receiver operating characteristic curve analysis threshold for DWIT-early allograft dysfunction was 9 minutes (area under receiver operating characteristic: 0.67, sensitivity = 80%, specificity = 53.8%). We show that prolonged DWIT within an acceptable range in RDH does not have deleterious effects on short-term recipient outcomes. Further long-term studies are required to confirm our findings, especially with regard to nonanastomotic biliary complications.

Is conventional functional liver remnant volume higher than 40% still sufficient to prevent post-hepatectomy liver failure in jaundiced patients with hilar cholangiocarcinoma? A single-center experience in China.

Our study aims to evaluate the predictive accuracy of functional liver remnant volume (FLRV) in post-hepatectomy liver failure (PHLF) among surgically-treated jaundiced patients with hilar cholangiocarcinoma (HCCA). We retrospectively reviewed surgically-treated jaundiced patients with HCCA between June, 2000 and June, 2018. The correlation between FRLV and PHLF were analyzed. The optimal cut off value of FLRV in jaundiced HCCA patients was also identified and its impact was furtherly evaluated. A total of 224 jaundiced HCCA patients who received a standard curative resection (43 patients developed PHLF) were identified. Patients with PHLF shared more aggressive clinic-pathological features and were generally in a more advanced stage than those without PHLF. An obvious inconsistent distribution of FLRV in patients with PHLF and those without PHLF were detected. FLRV (continuous data) had a high predictive accuracy in PHLF. The newly-acquired cut off value (FLRV = 53.5%, sensitivity = 81.22%, specificity = 81.4%) showed a significantly higher predictive accuracy than conventional FLRV cut off value (AUC: 0.81 vs. 0.60, p < 0.05). Moreover, patients with FLRV lower than 53.5% also shared a significantly higher major morbidity rate as well as a worse prognosis, which were not detected for FLRV of 40%. For jaundiced patients with HCCA, a modified FLRV of 53.5% is recommended due to its great impact on PHLF, as well as its correlation with postoperative major morbidities as well as overall prognosis, which might help clinicians to stratify patients with different therapeutic regimes and outcomes. Future multi-center studies for training and validation are required for further validation.

Morbidity following robot-assisted surgery in a gynecological oncology setting: A cohort study.

The objective of the study was to provide a comprehensive description of perioperative morbidity associated with robot-assisted surgery (RAS) in a gynecological oncology setting in order to improve the preoperative counseling of women and support shared decision-making. All women scheduled for intended RAS between January 2015 and December 2022 were prospectively included in an electronic morbidity database for the analyses of perioperative complications. In total, 2225 women were included. Sixty-four patients (2.9%) experienced an intraoperative complication. Intraoperative complications were associated with a higher rate of conversion to laparotomy (15.6% vs. 1.8%, p < 0.001), a higher rate of major postoperative morbidity (9.3% vs. 2.4%, p < 0.001), and a higher rate of reoperation (9.3% vs. 1.7%, p < 0.001), compared to cases without intraoperative complications. Thirty-day postoperative morbidity was evaluated according to the Memorial Sloan-Kettering Cancer Center Surgical Secondary Events Grading System. Grade 3-5 events were considered major. A total of 57 patients (2.6%) experienced a major event after surgery, postoperative rupture of the vaginal vault being the most common complication requiring surgical intervention. Conversion to laparotomy occurred in 49 cases (2.2%) and was associated with higher intraoperative blood loss (300 mL vs. 25 mL, p < 0.001), a higher rate of postoperative major events (20.4% vs. 2.2%, p < 0.001), and a higher rate of reoperation (11.8% vs. 1.6%, p < 0.001). Our study demonstrates low rates of major perioperative morbidity and conversion to laparotomy after RAS performed by trained high-volume surgeons in a gynecological oncology setting.

Standardization and short-term outcomes of robot-assisted minimally invasive esophagectomy in the semi-prone position

Robot-assisted minimally invasive esophagectomy (RAMIE) has recently been developed and is increasingly performed for thoracic esophageal and esophagogastric junction (EGJ) cancers. At our institute, we performed RAMIE in the semi-prone position using the da Vinci Xi system with two- or three-field lymphadenectomy in 91 patients with resectable thoracic esophageal or EGJ cancers between October 2018 and March 2023. During this period, we improved and standardized the surgical procedures to perform precise and safe mediastinal lymphadenectomies and minimize postoperative complications. The rates of major operative morbidities (C-D grade, ≥ I) were acceptable (recurrent laryngeal nerve paralysis, 6.6%; pneumonia, 9.9%; atelectasis, 6.7%; anastomotic leak, 14.3%). Both operative and 30-day mortality rates were 0%. In this technical note, we present our standardized surgical techniques for RAMIE in the semi-prone position for esophageal and EGJ cancers.

Association of different doses of antenatal corticosteroids exposure with early major outcomes and early weight loss percentage in extremely preterm infants or extremely low birthweight infants: a multicentre cohort study

ObjectivesTo determine the dose-dependent associations between antenatal corticosteroids (ANS) exposure and the rates of major morbidities, and the early weight loss percentage (EWLP) in hospital among extremely preterm infants (EPI)...

Non-hiatal diaphragmatic hernias: results of transabdominal and transthoracic surgical approaches at a fourth-level hospital.

The objective of this study is to elucidate the clinical and demographic profiles, as well as perioperative outcomes, of patients undergoing surgery for non-hiatal diaphragmatic hernias. Additionally, it aims to analyse these outcomes based on the surgical approach employed (transthoracic versus transabdominal). This retrospective, observational study was conducted at a single center and involved patients diagnosed with non-hiatal diaphragmatic hernia who underwent either emergency or elective surgery between July 2007 and March 2023. Clinical characteristics and perioperative outcomes of these patients were compared using appropriate statistical tests.The research protocol for this observational, retrospective, and comparative study followed the Declaration of Helsinki's ethical requirements. The need for Clinical Research Ethics Committee approval was waived according to our institutional law because the study was a retrospective cohort study based on anonymous data of patients. Informed consent was waived because this study involved the secondary analysis of patient medical records. Additionally, this study followed the STROBE guidelines for reporting observational studies. The analysis included 22 patients being 59.1% men, with median age of 61years. The predominant clinical presentation was restrictive lung disease (40.9%). The majority of cases (68%) had traumatic aetiology with a median defect size of 4cm (range of 3-8cm). Elective surgery was performed in 15 cases (68.1%) and transthoracic approach was employed in 13 patients (54.5%). Postoperative major morbidity reached 27.2% and mortality within 30days was 9.1%. Emergency surgeries accounted for 44.4% of transabdominal interventions, compared to 23% in the transthoracic subgroup (p = 0.376). There were no statistically significant differences between the transabdominal and trasnthoracic approaches in terms of global postoperative complications (88.8% vs. 84.6%, p = 1), major complications (44.4% vs 15.4%, p = 0.734), mortality (11.1% v 7.6%, p = 1) and recurrence (11.1% vs 7.6%, p = 1). Postoperative stay was significantly shorter in the transthoracic subgroup (6days vs. 14days, p = 0.011). Non-hiatal diaphragmatic hernias are characterized by significant postoperative major morbidity and mortality rates, standing at 27.2% and 9.1%, respectively, accompanied by a recurrence rate of 9.1%. Both transthoracic and transabdominal approaches demonstrate comparable short- and long-term outcomes.

Assessing quality of hepato-pancreato-biliary surgery: nationwide benchmarking.

Clinical auditing is a powerful tool to evaluate and improve healthcare. Deviations from the expected quality of care are identified by benchmarking the results of individual hospitals using national averages. This study aimed to evaluate the use of quality indicators for benchmarking hepato-pancreato-biliary (HPB) surgery and when outlier hospitals could be identified. A population-based study used data from two nationwide Dutch HPB audits (DHBA and DPCA) from 2014 to 2021. Sample size calculations determined the threshold (in percentage points) to identify centres as statistical outliers, based on current volume requirements (annual minimum of 20 resections) on a two-year period (2020-2021), covering mortality rate, failure to rescue (FTR), major morbidity rate and textbook/ideal outcome (TO) for minor liver resection (LR), major LR, pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). In total, 10 963 and 7365 patients who underwent liver and pancreatic resection respectively were included. Benchmark and corresponding range of mortality rates were 0.6% (0 -3.2%) and 3.3% (0-16.7%) for minor and major LR, and 2.7% (0-7.0%) and 0.6% (0-4.2%) for PD and DP respectively. FTR rates were 5.4% (0-33.3%), 14.2% (0-100%), 7.5% (1.6%-28.5%) and 3.1% (0-14.9%). For major morbidity rate, corresponding rates were 9.8% (0-20.5%), 28.1% (0-47.1%), 36% (15.8%-58.3%) and 22.3% (5.2%-46.1%). For TO, corresponding rates were 73.6% (61.3%-94.4%), 54.1% (35.3-100), 46.8% (25.3%-59.4%) and 63.3% (30.7%-84.6%). Mortality rate thresholds indicating a significant outlier were 8.6% and 15.4% for minor and major LR and 14.2% and 8.6% for PD and DP. For FTR, these thresholds were 17.9%, 31.6%, 22.9% and 15.0%. For major morbidity rate, these thresholds were 26.1%, 49.7%, 57.9% and 52.9% respectively. For TO, lower thresholds were 52.5%, 32.5%, 25.8% and 41.4% respectively. Higher hospital volumes decrease thresholds to detect outliers. Current event rates and minimum volume requirements per hospital are too low to detect any meaningful between hospital differences in mortality rate and FTR. Major morbidity rate and TO are better candidates to use for benchmarking.