Rates Of Major Perioperative Complications Research Articles

MP47-08 PERCUTANEOUS THERMAL ABLATION IS SAFE AND FEASIBLE FOR IPSILATERAL LOCAL RECURRENCE OF DISEASE AFTER PARTIAL NEPHRECTOMY FOR RENAL CELL CARCINOMA

You have accessJournal of UrologyCME1 Apr 2023MP47-08 PERCUTANEOUS THERMAL ABLATION IS SAFE AND FEASIBLE FOR IPSILATERAL LOCAL RECURRENCE OF DISEASE AFTER PARTIAL NEPHRECTOMY FOR RENAL CELL CARCINOMA Justin Refugia, Tarek Taha, Ayelet Wandel, Nidal Edkaedek, Alexander Tsivian, Parth Thakker, Jacob Bundy, Sarah Connolly, Michael Miller, and Matvey Tsivian Justin RefugiaJustin Refugia More articles by this author , Tarek TahaTarek Taha More articles by this author , Ayelet WandelAyelet Wandel More articles by this author , Nidal EdkaedekNidal Edkaedek More articles by this author , Alexander TsivianAlexander Tsivian More articles by this author , Parth ThakkerParth Thakker More articles by this author , Jacob BundyJacob Bundy More articles by this author , Sarah ConnollySarah Connolly More articles by this author , Michael MillerMichael Miller More articles by this author , and Matvey TsivianMatvey Tsivian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003293.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Utilization of non-surgical modalities to manage local recurrence (LR) of renal mass after partial nephrectomy (PN) is paramount. Recurrence has been reported up 3.2% during the surveillance period. Repeat PN for an ipsilateral recurrence, while feasible, can be technically challenging with upwards of a 19.6% major perioperative complication rate. Percutaneous thermal ablation (PTA) for LR is a nephron-sparing procedure that is a viable option in this setting. In this study, we present our experience with LR of renal mass after PN to assess perioperative and oncologic outcomes. METHODS: We reviewed a retrospective case series of patients in two institutions who had LR after PN for RCC and were managed with PTA. LR was defined as enhancing renal mass ipsilateral to prior PN. The primary objectives were post-ablation recurrence free survival (RFS) and complication rate. A descriptive analysis was performed of the data collected. Kaplan-Meier survival analysis was performed to assess recurrence free survival after TA for LR. RESULTS: We identified 27 patients between 2012 and 2022 that were treated percutaneously with cryoablation (37%), radiofrequency ablation (33%) or microwave ablation (30%). The patients had a combined 34 tumors removed by PN, primarily T1a (70%) or T1b (15%), with clear cell (59%) or papillary (29%) subtype. There were positive surgical margins at PN in 33% of patients. LR occurred at median of 4 years after PN with a median size of 1.7 cm. Five tumors (17%) recurred at the PN site and the remainder were de novo tumors. Two patients (7%) developed perinephric hematoma immediately post-procedure that was managed conservatively (Clavien-Dindo Grade 1). Surveillance imaging was performed according to international management guidelines. Following PTA, there were 4 ipsilateral recurrences (13%) at a median of 14 months. One patient required repeat ablation for an ipsilateral tumor. RFS after PTA for LR was 93%, 79%, and 63% at 1 years, 2 years, and 5 years, respectively. CONCLUSIONS: Our data demonstrate that local therapy with PTA for local recurrence after PN is safe and feasible. Further comparisons of local therapies for management of LR after partial nephrectomy may reinforce the use of PTA for small renal masses. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e646 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Justin Refugia More articles by this author Tarek Taha More articles by this author Ayelet Wandel More articles by this author Nidal Edkaedek More articles by this author Alexander Tsivian More articles by this author Parth Thakker More articles by this author Jacob Bundy More articles by this author Sarah Connolly More articles by this author Michael Miller More articles by this author Matvey Tsivian More articles by this author Expand All Advertisement PDF downloadLoading ...

Corrélation entre l’utilisation d’une tige remplissante et le syndrome d’implantation du ciment chez les personnes âgées ostéoporotiques souffrant d’une fracture du col du fémur traitée par arthroplastie de hanche cimentée : une étude cas-témoin rétrospective chez 128 patients

BackgroundBone cement implantation syndrome (BCIS) is a serious and potentially fatal complication especially in patients with osteoporotic femoral neck fracture (OFNF) undergoing cemented hip arthroplasty (CHA). Recent studies showed that the shape-closed femoral stem profile could lead to a significant increase of the intramedullary pressure during cementation and prosthesis insertion. This study aimed to 1) correlate the use of shaped-closed femoral stem and other perioperative risk factors with severe grade of BCIS (grade 2 or 3: BCIS gr2/3, and 2) identify the prevalence of BCIS in the elderly patients with OFNF and treated with CHA. HypothesisLarge wedge-shaped (or “shape-closed”) femoral stem design would significantly associate with BCIS gr2/3 in the elderly patients who sustained OFNF and underwent CHA. Patients and methodsA total of 128 OFNF patients, who aged over 75 years and underwent CHA were retrospectively reviewed and then allocated into 2 groups: SC Group (use shape-closed femoral stem, n=40) and FC Group (use force-closed femoral stem, n=88). BCIS was grading in all patients according to Donaldson classification. Perioperative data between the patients with BCIS-gr2/3 and those with BCIS grade 0 or 1 (BCIS-gr0/1) were compared. Multiple logistic regression analysis was used to identify predictive factors for BCIS-gr2/3. ResultsThe prevalence of overall BCIS and BCIS-gr2/3 was 32.8 % (n=42) and 6.2 % (n=8), respectively. The total in-hospital and 1-year mortality rates were 2.3 % and 4.7 %, respectively. The major perioperative complication in patients with BCIS-gr2/3 was significantly higher compared to those in patients with BCIS-gr0/1 (62.5 % vs. 10.0 %, p=0.001). Multivariate analysis showed that age >90 years (OR 9.4, 95 % CI: 1.4-62.9, p=0.02), preinjury Parker mobility score <4 (OR=48.8; 95 % 2.7-897.2, p=0.008) and shape-closed femoral stem used (OR=19.1; 95 %CI, 1.8–204.5, p=0.01) were the significant independent predictors for BCIS-gr2/3 in these patients. ConclusionBCIS in OFNF patients undergoing CHA is common and associates with a high major perioperative complication rate. Our initial hypothesis is validated as the patients at risk for BCIS-gr2/3 are those whose CHA procedures use a shape-closed femoral stem design and with extreme age, and having poor preinjury ambulatory status. Therefore, we recommended using cementless stem as the first option in OFNF. However, if CHA is needed, strict guideline for cement insertion should be followed with force-closed stem application to avoid the risk of BCIS-gr2/3. Level of evidenceIII; Retrospective case-control study.

Correlation between shape-closed femoral stem design and bone cement implantation syndrome in osteoporotic elderly femoral neck fracture undergoing cemented hip arthroplasty: A retrospective case-control study in 128 patients

BackgroundBone cement implantation syndrome (BCIS) is a serious and potentially fatal complication especially in patients with osteoporotic femoral neck fracture (OFNF) undergoing cemented hip arthroplasty (CHA). Recent studies showed that the shape-closed femoral stem profile could lead to a significant increase of the intramedullary pressure during cementation and prosthesis insertion. This study aimed to (1) correlate the use of shaped-closed femoral stem and other perioperative risk factors with severe grade of BCIS grade 2 or 3: BCIS gr2/3, and (2) identify the prevalence of BCIS in the elderly patients with OFNF and treated with CHA. HypothesisLarge wedge-shaped (or “shape-closed”) femoral stem design would significantly associate with BCIS gr2/3 in the elderly patients who sustained OFNF and underwent CHA. Patients and methodsA total of 128 OFNF patients, who aged over 75years and underwent CHA were retrospectively reviewed and then allocated into 2 groups: SC Group (use shape-closed femoral stem, n=40) and FC Group (use force-closed femoral stem, n=88). BCIS was grading in all patients according to Donaldson classification. Perioperative data between the patients with BCIS-gr2/3 and those with BCIS grade 0 or 1 (BCIS-gr0/1) were compared. Multiple logistic regression analysis was used to identify predictive factors for BCIS-gr2/3. ResultsThe prevalence of overall BCIS and BCIS-gr2/3 was 32.8% (n=42) and 6.2% (n=8), respectively. The total in-hospital and 1-year mortality rates were 2.3% and 4.7%, respectively. The major perioperative complication in patients with BCIS-gr2/3 was significantly higher compared to those in patients with BCIS-gr0/1 (62.5% vs. 10.0%, p=0.001). Multivariate analysis showed that age>90years (OR=9.4, 95% CI: 1.4–62.9, p=0.02), preinjury Parker mobility score<4 (OR=48.8; 95% CI: 2.7–897.2, p=0.008) and shape-closed femoral stem used (OR=19.1; 95% CI: 1.8–204.5, p=0.01) were the significant independent predictors for BCIS-gr2/3 in these patients. ConclusionBCIS in OFNF patients undergoing CHA is common and associates with a high major perioperative complication rate. Our initial hypothesis is validated as the patients at risk for BCIS-gr2/3 are those whose CHA procedures use a shape-closed femoral stem design and with extreme age, and having poor preinjury ambulatory status. Therefore, we recommended using cementless stem as the first option in OFNF. However, if CHA is needed, strict guideline for cement insertion should be followed with force-closed stem application to avoid the risk of BCIS-gr2/3. Level of evidenceIII; retrospective case-control study.

Triple valve surgery: long-term follow-up from a single centre.

The aims of this study were to analyze early and late outcomes of TVS and identify predictors of short and long- term poor prognosis. Single centre retrospective study with 130 patients who underwent TVS between 2007 and 2020. Most of the patients were female (72.3%), mean age of 64.4 years; 61.1% were in New York Heart Association class III/IV, with a EuroSCORE II of 7.5%. Univariable and Multivariable analyses were undertaken to identify predictors of perioperative mortality and morbidity and long-term mortality. In-hospital mortality was 10.8%, of which 7.6% were due to a cardiac cause. Diabetes Mellitus was an in- dependent predictor of increased perioperative mortality. This group had 27.7% rate of major perioperative complications. Elevated systolic pulmonary pressure and obesity were predictors of early morbidity. All-cause mortality was 43.1% for 14 years. The survival at 1, 5 and 10 years was 83%, 60% and 43%, respectively. Diabetes Mellitus was a risk factor for long-term mortality. Patients undergoing TVS have a high surgical risk making TVS an operation associated with high mor- tality and morbidity. This research suggests Diabetes Mellitus, pulmonary hypertension and obesity as risk factors for mortality in TVS.

The central role of cannulation in determining outcomes after surgery for acute type A aortic dissection: where do we stand?

In their work, Ramaprabhu et al. [1] retrospectively analysed patients with acute type A aortic dissection (ATAAD) who underwent emergent surgery (n = 107) during a 10-year period at a single institution (from January 2008 to March 2018). The study cohort was divided into 2 groups for purposes of data analysis: group 1: direct ascending aorta cannulation (AscAo, n = 47; median age, 69 years; females 34%) versus group 2: non-aortic cannulation (non-AscAo, n = 60; median age 62 years; females 20%). The authors found no statistically significant differences in rates of major perioperative complications (such as stroke or acute kidney injury), postoperative lactate levels and long-term survival. Notwithstanding the clinical relevance of the work by Ramaprabhu et al., their findings must be put into a broader clinical perspective and viewed within the context of some notable limitations to the study methodology. First and foremost, the authors point out that the site of arterial cannulation was decided individually based on the surgeon's preference and anatomy of the dissection. Indeed, they state that owing to the ease and relatively rapid initiation of cardiopulmonary bypass, they had lately preferred to use AscAo cannulation over a guidewire under echocardiographic guidance. However, the non-AscAo cannulation was performed using several different techniques including femoral artery cannulation, axillary artery cannulation, and even double cannulation with axillary artery plus femoral artery cannulation. However, the relatively limited sample size could not allow further comparisons between the latter techniques, which remains an unaddressed question.

Contemporary indications for open abdominal aortic aneurysm repair in the endovascular era

ObjectiveDespite the emergence of endovascular aneurysm repair (EVAR) as the most common approach to abdominal aortic aneurysm repair, open aneurysm repair (OAR) remains an important option. This study seeks to define the indications for OAR in the EVAR era and how these indicatioxns effect outcomes. MethodsA retrospective cohort study was performed of all OAR at a single institution from 2004 to 2019. Preoperative computed tomography scans and operative records were assessed to determine the indication for OAR. These reasons were categorized into anatomical contraindications, systemic factors (connective tissue disorders, contraindication to contrast dye), and patient or surgeon preference (patients who were candidates for both EVAR and OAR). Perioperative and long-term outcomes were compared between the groups. ResultsWe included 370 patients in the analysis; 71.6% (265/370) had at least one anatomic contraindication to EVAR and 36% had two or more contraindications. The most common anatomic contraindications were short aortic neck length (51.6%), inadequate distal seal zone (19.2%), and inadequate access vessels (15.7%). The major perioperative complication rate was 18.1% and the 30-day mortality was 3.0%. No single anatomic factor was identified as a predictor of perioperative complications. Sixty-one patients (16.5%) underwent OAR based on patient or surgeon preference; these patients were younger, had lower incidences of coronary artery disease and chronic obstructive pulmonary disease, and were less likely to require suprarenal cross-clamping compared with patients who had anatomic and/or systemic contraindications to EVAR. The patient or surgeon preference group had a lower incidence of perioperative major complications (8.2% vs 20.1%; P = .034), shorter length of stay (6 days vs 8 days; P < .001) and no 30-day mortalities. The multivariable adjusted risk for 15-year mortality was lower for patient or surgeon preference patients (adjusted hazard ratio, 0.44; 95% confidence interval, 0.24-0.80; P = .007) compared with those anatomic or systemic contraindications. ConclusionsWithin a population of patients who did not meet instruction for use criteria for EVAR, no single anatomic contraindication was a marker for worse outcomes with OAR. Patients who were candidates for both aortic repair approaches but elected to undergo OAR owing to patient or surgeon preference have very low 30-day mortality and morbidity, and superior long-term survival rates compared with those patients who underwent OAR owing to anatomic and/or systemic contraindications to EVAR.

Neuraxial and general anesthesia for outpatient total joint arthroplasty result in similarly low rates of major perioperative complications: a multicentered cohort study

BackgroundNeuraxial anesthesia when compared with general anesthesia has shown to improve outcomes following lower extremity total joint arthroplasty. It is unclear whether these benefits are present in outpatient surgery given...

Contemporary Indications for Open Abdominal Aortic Aneurysm Repair in the Endovascular Era

Despite the emergence of endovascular abdominal aortic aneurysm repair (EVAR) as the most common approach to repair, open aneurysm repair (OAR) remains a critical option. We sought to define the indications for OAR in the EVAR era and how these indications affect the outcomes. We performed a retrospective review of all OAR cases at a single institution from 2004 to 2020. Preoperative computed tomography scans and operative records were assessed to determine the indications for OAR. These reasons were categorized into anatomic contraindications, systemic factors (ie, connective tissue disorders, contraindication to contrast dye), and patient and/or surgeon preference (candidates for both EVAR and OAR). The perioperative and long-term outcomes were compared. A total 370 patients were included in the analysis. Of the 370 patients, 265 (71.6%) had at least one anatomic contraindication to EVAR (36% had two or more contraindications). The most common anatomic contraindications were a short aortic neck length (51.6%), an inadequate distal seal zone (19.2%), and inadequate access vessels (15.7%). The major perioperative complication rate was 18.1%, and the 30-day mortality was 3.6%. No single anatomic factor was identified as a predictor of perioperative complications. Sixty-one patients (16.5%) had undergone OAR by patient and/or surgeon preference. These patients were younger, had a lower incidence of coronary artery disease and chronic obstructive pulmonary disease, and were less likely to require suprarenal cross-clamping than were the patients who had had anatomic and/or systemic contraindications to EVAR. The patient/surgeon preference group had a lower incidence of perioperative major complications (8.2% vs 20.1%; P = .034), a shorter length of stay (6 vs 8 days; P < .001), and no 30-day mortality. The multivariable adjusted risk for 15-year mortality was lower for the patient/surgeon preference group (19.7% vs 39.5%; adjusted hazard ratio, 0.44; 95% confidence interval, 0.24-0.80; P = .007) than for the anatomic/systemic contraindications group (Table). Within a population of patients who did not meet the instructions for use criteria for EVAR, no single anatomic contraindication was a marker for worse outcomes after OAR. Patients who were candidates for both aortic repair approaches but who had elected to undergo OAR had 30-day mortality of 0% and superior perioperative morbidity and long-term survival rates.TableShort- and long-term outcomes stratified by OAR indicationVariableSurgeon/patient preference (n = 61)Anatomical/systemic contraindication (n = 309)P valueEstimated blood loss, mL1177 ± 9531656 ± 1653.060ICU LOS, days2 (1-2)2 (1-4).14Hospital LOS, days6 (6-9)8 (6-11)<.00130-day mortality0 (0)11 (3.6).22Long-term outcomes, adjusted 15-Year death12 (19.7)122 (39.5).007ICU, Intensive care unit; LOS, length of stay; OAR, open aneurysm repair.Data presented as mean ± standard deviation, median (interquartile range), or number (%). Open table in a new tab

MP42-01 A MATCHED ANALYSIS OF CONVENTIONAL MULTI-PORT VERSUS SP SINGLE-SITE ROBOTIC PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy III (MP42)1 Sep 2021MP42-01 A MATCHED ANALYSIS OF CONVENTIONAL MULTI-PORT VERSUS SP SINGLE-SITE ROBOTIC PARTIAL NEPHRECTOMY Joon Chae Na, Sylvia Alip, Nak-Hoon Son, Jinu Kim, Won Sik Jang, Yong Seung Lee, Koon Ho Rha, and Woong Kyu Han Joon Chae NaJoon Chae Na More articles by this author , Sylvia AlipSylvia Alip More articles by this author , Nak-Hoon SonNak-Hoon Son More articles by this author , Jinu KimJinu Kim More articles by this author , Won Sik JangWon Sik Jang More articles by this author , Yong Seung LeeYong Seung Lee More articles by this author , Koon Ho RhaKoon Ho Rha More articles by this author , and Woong Kyu HanWoong Kyu Han More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002063.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A purpose built single-site robotic SP platform has recently been introduced and our institute is currently using this novel platform conducting truly single-site robotic partial nephrectomy. In this study we aimed to compare its initial results with the conventional multi-port robotic partial nephrectomy. METHODS: Patients who underwent single-site robotic partial nephrectomy (SP group) were matched to those who underwent multi-port robotic partial nephrectomy (MP group) during the same period by the same surgeon from Dec, 2018 to Apr, 2020. Patients were matched 1:3 according to RENAL nephrometry score, horizontal location of tumor(anterior/posterior), and vertical location of tumor(upper/mid/lower), sex and BMI. RESULTS: There were 21 patients in the SP group, and 62 matched patients in the MP group. The SP group had a longer overall operation time, console time, and warm ischemic time compared to the MP group. None of the patients included in the study had a complication greater than Clavien-Dindo system grade 1, and all were recurrence free at a mean follow-up of 12.5 (SD 5.8) months. Mean changes in eGFR showed no statistically significant differences in both groups at one week, three months, six months, and one year post-operatively. CONCLUSIONS: True single-site robotic partial nephrectomy using the SP platform can be safely performed without an increase of major perioperative complication rates. Although there was an increase in operative time, especially ischemic time, the oncological and functional outcomes were equivalent to the conventional multi-port robotic approach. This maybe attributed to the precise enucleoresection made possible by the articulating instruments of the SP platform. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e770-e770 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joon Chae Na More articles by this author Sylvia Alip More articles by this author Nak-Hoon Son More articles by this author Jinu Kim More articles by this author Won Sik Jang More articles by this author Yong Seung Lee More articles by this author Koon Ho Rha More articles by this author Woong Kyu Han More articles by this author Expand All Advertisement Loading ...

Thoracofemoral bypass outcomes in the Vascular Quality Initiative

ObjectiveThoracofemoral bypass (TFB) has been used infrequently but is an alternative for select patients with aortoiliac occlusive disease. Limited data are available in the reported data regarding TFB, with all studies small, single-center series. We aimed to describe the perioperative and long-term survival, patency, and rate of major perioperative complications after TFB in a large national registry. MethodsThe Vascular Quality Initiative suprainguinal bypass module was used to identify patients who had undergone TFB for occlusive disease from 2009 to 2019. A descriptive analysis was performed to provide the rates of survival, patency, major complications, and freedom from major amputation in the perioperative period and at 1 year of follow-up. Major complications were compared by procedure indication, with categorical variables analyzed using χ2 tests and continuous variables using analysis of variance. Kaplan-Meier curve analysis was used to estimate survival at the 1- and 5-year follow-up intervals and freedom from major amputation at 1 year. ResultsA total of 154 TFB procedures were identified. Of the 154 patients, 59 (38.3%) had undergone previous inflow bypass and 22 (14.2%) had undergone previous leg bypass. The procedure indications included claudication (n = 66; 42.9%), rest pain (n = 59; 38.3%), tissue loss (n = 19; 12.3%), and acute limb ischemia (n = 10; 6.5%). Major complications (eg, wound infection, respiratory, major stroke, new dialysis, cardiac, embolic, major amputation, occlusion) occurred in 31.2% of the cohort. When examined by indication, the acute limb ischemia and claudication cohorts had an increased rate of major complications (acute limb ischemia, 60.0%; claudication, 34.8%; critical limb ischemia, 24.4%; P = .05). The survival rate at 30 days was 95.5%, with a Kaplan-Meier estimated 1-year survival rate of 92.7% ± 2.2%. Primary patency at discharge from the index hospitalization was 92.9% and 89.0% at 1 year. Postoperative major amputation was required for 1 patient during the index hospitalization, for a Kaplan-Meier estimated freedom from major amputation at 1 year of 97.1% ± 2.2%. Two patients developed in-hospital bypass occlusion and three patients developed occlusion within 1 year, for an overall freedom from occlusion rate of 96.8% at 1 year. ConclusionsTFB is associated with a high rate of perioperative major complications; however, the long-term survival and patency after TFB remained acceptable when performed for limb salvage. The high perioperative complication rates of TFB procedures performed for claudication suggest TFB should be used rarely in this population. These data can be used to counsel patients and aid in decision making before operative intervention.

Perioperative complication rates following neoadjuvant therapy in pancreatic adenocarcinoma.

688 Background: Whether upfront resection or total neoadjuvant therapy is superior for the treatment of potentially resectable pancreatic adenocarcinoma (PDAC) remains controversial. The impact of neoadjuvant treatment on major perioperative complication rates for patients (pts) undergoing resection for PDAC is commonly debated. We hypothesized that rates would be comparable among patients receiving neoadjuvant chemoradiation (neo-CRT), neoadjuvant chemotherapy alone (neo-CHT), or upfront surgery. Methods: This is a retrospective study of 208 pts with PDAC who underwent resection within a multidisciplinary pancreatico-biliary program at an academic tertiary referral center between 2011-2018. Data were abstracted from the medical record, an institutional cancer registry and NSQIP databases. Outcomes were assessed using χ2, Fisher’s exact test and two-tailed Student’s t-tests. Results: 208 pts were identified: 33 locally advanced, borderline or upfront resectable pts underwent neo-CRT, 35 borderline or resectable pts underwent neoadjuvant-CHT, and 140 resectable pts did not undergo neoadjuvant therapy. There were no statistically significant differences in major perioperative complication rates between groups. Overall rates were 36.4%, 34.3%, and 26.4% for pts who underwent neo-CRT, neo-CHT alone, or upfront resection, respectively (p = 0.38). No significant difference were observed in complication rates (35.3% v. 26.4%; p = 0.19) or median hospital length of stay (10 days v. 10 days; p = 0.87) in pts who received any neoadjuvant therapy versus upfront resection. There were two perioperative deaths in the neo-CRT group (6.1%), zero in the neo-CHT group, and four in the upfront resection group (2.9%); p = 0.22. Conclusions: There were no significant differences in major perioperative complication rates, hospital length of stay, or post-operative mortality in pts who underwent neoadjuvant therapy (neo-CRT or neo-CHT alone) versus upfront surgery. Notably, neo-CRT had comparable perioperative complication rates to neo-CHT alone, which suggests neoadjuvant radiation therapy may not pose additional surgical risk.

ESTUDO CRÍTICO EPIDEMIOLÓGICO DO TRATAMENTO CIRÚRGICO DA ESTENOSE CAROTÍDEA EM MUNICÍPIO DE MÉDIO PORTE NO ESTADO DO PARANÁ

Context: The treatment of carotid stenosis aims to prevent the possible ischemic brain damage. Carotid stenosis surgery is not without risk. Objectives: Evaluate and discuss in comparison with the literature, the results of patients submitted to open carotid stenosis surgery in four hospitals in a medium-sized municipality in the state of XXXXXX. Method: Retrospective study, carried out by the survey of 68 electronic medical records, in four hospitals from January 2014 to July 2018. Data referring to the variables: age, symptomatology, sex, time between symptoms and surgery, degree of stenosis, comorbidities, outcomes and surgical indication were compared with the literature. Results: The mean age was 69.3 years, 60 symptomatic, 46 males, with a mean of 70.2 years and 14 females with 66.5 years. Eight asymptomatic, 7 males with a mean of 71.1 years and a female with 57 years. Fifty-two were operated on early and 8 after ninety days. All submitted to endarterectomy, with general anesthesia and only two without shunt. Seven patients (10.3%) had major complications within 30 days, four (5.9%) stroke, 1 (1.5%) AMI and 4 (5.9%) died, two of the perioperative stroke group . Conclusion: Asymptomatic patients undergoing the procedure had no major perioperative complications. Those with severe deficits and delayed surgery did not benefit from the surgery. The rates of major perioperative complications are similar to those found in the national literature and higher than in controlled studies.

Lower Extremity Venous Stent Placement: A Large Retrospective Single-Center Analysis.

To study short-term and long-term outcomes of lower extremity venous stents placed at a single center and to characterize changes in vein diameter achieved by stent placement. A database of all patients who received lower extremity venous stents between 1996 and 2018 revealed 1,094 stents were placed in 406 patients (172 men, 234 women; median age, 49 y) in 513 limbs, including patients with iliocaval stents (9.4% acute thrombosis, 65.3% chronic thrombosis, 25.3% nonthrombotic lesions). Primary, primary assisted, and secondary patency rates were assessed for lower extremity venous stents at 1, 3, and 5 years using Kaplan-Meier analyses and summary statistics. Subset analyses and Cox regression were performed to identify risk factors for patency loss. Vein diameters and Villalta scores before and up to 12 months after stent placement were compared. Complication and mortality rates were calculated. Primary, primary assisted, and secondary patency rates at 5 years were 57.3%, 77.2%, and 80.9% by Kaplan-Meier methods and 78.6%, 90.3%, and 92.8% by summary statistics. Median follow-up was 199 days (interquartile range, 35.2-712.0 d). Patency rates for the subset of patients (n= 46) with ≥ 5 years of follow-up (mean ± SD 9.1 y ± 3.4) were nearly identical to cohort patency rates at 5 years. Patients with inferior vena cava stent placement (hazard ratio 2.11, P < .0001) or acute thrombosis (hazard ratio 3.65, P < .0001) during the index procedure had significantly increased risk of losing primary patency status. Vein diameters were significantly greater after stent placement. There were no instances of stent fracture, migration, or structural deformities. In patients with chronic deep vein thrombosis, Villalta scores significantly decreased after stent placement (from 15.7 to 7.4, P < .0001). Perioperative mortality was < 1%, and major perioperative complication rate was 3.7%. Cavo-ilio-femoral stent placement for venous occlusive disease achieves improvement of vein disease severity scores, increase in treated vein diameters, and satisfactory long-term patency rates.

Minimally invasive approaches to the inguinal nodes in cN0 patients.

In penile cancer, lymphadenectomy can have staging and possibly therapeutic values. However, many physicians and patients are reluctant when it comes to inguinal lymph node dissection (ILND) due to high rate of surgical morbidities. In recent years, minimally invasive surgical approaches have shown success in reducing perioperative morbidities. Newer surgical modalities, including videoscopic inguinal lymphadenectomy and robotic-assisted inguinal lymphadenectomy, have been explored to reduce the morbidities of ILND while not compromising oncologic outcomes. Data on this topic is limited but available data suggest that these minimally invasive techniques are safe and associated with less perioperative morbidities. There is no study to directly compare the oncological outcome between these different techniques. However, number of dissected lymph nodes is used a surrogate for oncologic outcomes. Different treatment approaches including open, laparoscopic, and robotic seem to be similar and effective in terms of nodal yield. Laparoscopic and robotic approaches are successful in dissecting inguinal lymph nodes and are associated with lower rate of major perioperative complications. Individual patient's characteristics as well as surgeon's experience should be considered when trying to decide the optimum surgical modality for ILND.

Comparison of the Transarterial and Transthoracic Approaches in Nontransfemoral Transcatheter Aortic Valve Implantation

Transfemoral approach stands as the reference access-route for transcatheter aortic valve implantation (TAVI). Nonetheless, alternatives approaches are still needed in a significant proportion of patients. This study aimed at comparing outcomes between transthoracic-approach (transapical or transaortic) and transarterial-approach (transcarotid or subclavian) TAVI. Data from 191 consecutive patients who underwent surgical-approach TAVI from May 2009 to September 2017 were analyzed. Patients were allocated in 2 groups according to the approach. The primary end point was the 30-day composite of death of any cause, need for open surgery, tamponade, stroke, major or life-threatening bleeding, stage 2 or 3 acute kidney injury, coronary obstruction, or major vascular complications. During the study period, 104 patients underwent transthoracic TAVI (transapical: 60.6%, transaortic: 39.4%) whereas 87 patients underwent transarterial TAVI (subclavian: 83.9%, transcarotid: 16.1%). Logistic EuroSCORE I tended to be higher in transthoracic-TAVI recipients. In-hospital and 30-day composite end point rates were 25.0% and 11.5% (p = 0.025), and 26.0% and 14.9% (p = 0.075) for the transthoracic and transarterial cohorts, respectively. Propensity score-adjusted logistic regression demonstrated no significant detrimental association between the 30-day composite end point and transthoracic access (odds ratio 2.12 95% confidence interval 0.70 to 6.42; p = 0.18). Transarterial TAVI was associated with a shorter length of stay (median: 6 vs 7 days, p <0.001). TAVI approach was not an independent predictor of midterm mortality. In conclusion, nontransfemoral transarterial-approach TAVI is safe, feasible, and associated with comparable rates of major perioperative complications, and midterm mortality compared with transthoracic-approach TAVI.

Perioperative Complications During Living Donor Nephrectomy: Results From a Multicenter Cohort Study.

Background:While living kidney donation is considered safe in healthy individuals, perioperative complications can occur due to several factors.Objective:We explored associations between the incidence of perioperative complications and donor characteristics, surgical technique, and surgeon’s experience in a large contemporary cohort of living kidney donors.Design:Living kidney donors enrolled prospectively in a multicenter cohort study with some data collected retrospectively after enrollment was complete (eg, surgeon characteristics).Setting:Living kidney donor centers in Canada (n = 12) and Australia (n = 5).Patients:Living kidney donors who donated between 2004 and 2014 and the surgeons who performed the living kidney donor nephrectomies.Measurements:Operative and hospital discharge medical notes were collected prospectively, with data on perioperative (intraoperative and postoperative) information abstracted from notes after enrollment was complete. Complications were graded using the Clavien-Dindo system and further classified into minor and major. In 2016, surgeons who performed the nephrectomies were invited to fill an online survey on their training and experience.Methods:Multivariable logistic regression models with generalized estimating equations were used to compare perioperative complication rates between different groups of donors. The effect of surgeon characteristics on the complication rate was explored using a similar approach. Poisson regression was used to test rates of overall perioperative complications between high- and low-volume centers.Results:Of the 1421 living kidney donor candidates, 1042 individuals proceeded with donation, where 134 (13% [95% confidence interval (CI): 11%-15%]) experienced 142 perioperative complications (55 intraoperative; 87 postoperative). The most common intraoperative complication was organ injury and the most common postoperative complication was ileus. No donors died in the perioperative period. Most complications were minor (90% of 142 complications [95% CI: 86%-96%]); however, 12 donors (1% of 1042 [95% CI: 1%-2%]) experienced a major complication. No statistically significant differences were observed between donor groups and the rate of complications. A total of 43 of 48 eligible surgeons (90%) completed the online survey. Perioperative complication rates did not vary significantly by surgeon characteristics or by high- versus low-volume centers.Limitations:Operative and discharge reporting is not standardized and varies among surgeons. It is possible that some complications were missed. The online survey for surgeons was completed retrospectively, was based on self-report, and has not been validated. We had adequate statistical power only to detect large effects for factors associated with a higher risk of perioperative complications.Conclusions:This study confirms the safety of living kidney donation as evidenced by the low rate of major perioperative complications. We did not identify any donor or surgeon characteristics associated with a higher risk of perioperative complications.Trial registration(s):NCT00319579: A Prospective Study of Living Kidney Donation (https://clinicaltrials.gov/ct2/show/NCT00319579)NCT00936078: Living Kidney Donor Study (https://clinicaltrials.gov/ct2/show/NCT00936078)

Revision adult spinal deformity surgery: Does the number of previous operations have a negative impact on outcome?

To study the effect of the number of previous operations on the outcome of revision adult spinal deformity (ASD) surgery. One hundred and thirty-seven consecutive patients who underwent revision ASD surgery were classified as follows: those who had one previous operation (group 1), had two previous operations (group 2) and had three or more previous operations (group 3). Perioperative complications and additional surgeries were reviewed. Back pain, leg pain, ODI scores and radiographic measurements were obtained. Preoperatively, the patients in group 3 had worse ODI (60.0 vs. 48.1 and 47.9, p < 0.01) but not back pain or leg pain. Group 2 and group 3 had worse coronal plumb line (38.4 and 35.8mm vs. 18.2mm, p < 0.05) and SVA (99.7 and 153.9mm vs. 67.8mm, p < 0.05). Group 3 had worse PI-LL mismatch (40.1° vs. 25.3° and 26.2°, p = 0.08). Minor and major perioperative complication rates were 27.5% in group 1, 31.1% in group 2 and 39.0% in group 3 (p > 0.05). At mean 30-month follow-up, the additional surgery rates were 7.8, 17.8 and 22.0%, respectively (p = 0.07). The patients in all groups had improved back pain, leg pain and ODI scores. The net improvements on back pain, leg pain and ODI were not statistically different between the groups. Revision ASD patients who had two or more previous operations present with more coronal and sagittal imbalance and worse functional status. Patients who had three or more previous operations have relatively higher reoperation rate but similar perioperative complication rate and similar clinic improvements. These slides can be retrieved under Electronic Supplementary Material.

Results of Phase 1 study on cytoreductive radical prostatectomy in men with newly diagnosed metastatic prostate cancer

BackgroundPreclinical and retrospective data suggest that cytoreductive radical prostatectomy may benefit a subset of men who present with metastatic prostate cancer (mPCa). Herein, we report the results of the first planned Phase 1 study on cytoreductive surgery.MethodsFrom four institutions, 36 patients consented to the study. However, four did not complete surgery because of rapid disease progression (n = 3) and another because of an intraoperatively discovered pericolonic abscess. Men with newly diagnosed clinical mPCa to lymph nodes or bones were eligible. The primary endpoint was the rate of major perioperative complications (Clavien-Dindo Grade 3 or higher) occurring within 90 days of surgery.ResultsThe mean age at surgery was 64.0 years. The 90-day overall complication rate was 31.2% (n = 10), of which two (6.25%) were considered major complications: one acute tubular necrosis requiring temporary dialysis and one death. In men with more than 6 months of follow-up, 67.9% had prostate specific antigen nadir ≤0.2 ng/mL, while one patient experienced a rapid rise in prostate specific antigen and another a widely disseminated disease that resulted in death 5 months after surgery. Altogether, these results demonstrate that cytoreductive radical prostatectomy is safe and surgically feasible in selected patients who present with mPCa . Yet, there may be a small subset of patients in whom surgery may cause a significant harm.ConclusionTherefore, cytoreductive surgery in men with mPCa should be limited to clinical trials until robust data are available.

Risk Factors for 30-Day Unplanned Readmission and Major Perioperative Complications After Spine Fusion Surgery in Adults: A Review of the National Surgical Quality Improvement Program Database.

Retrospective review of a prospective cohort. The aim of the study was to determine the patient characteristics and surgical procedure factors related to increased rates of 30-day unplanned readmission and major perioperative complications after spinal fusion surgery, and the association between unplanned readmission and major complications. Reducing unplanned readmissions can reduce the cost of healthcare. Payers are implementing penalties for 30-day readmissions after discharge. There is limited data regarding the current rates and risk factors for unplanned readmission and major complications related to spinal fusion surgery. Spine fusion patients were identified using the 2012 and 2013 American College of Surgeons National Surgical Quality Improvement Program Participant User File. Rates of readmissions within 30 days after spine fusion surgery were calculated using the person-years method. Cox proportional hazards models were used to assess the independent associations of spine surgical procedure types, diagnoses, patient profiles, and major perioperative complications with unplanned related readmissions. Independent risk factors for major complications were assessed by multivariable logistic regression. Of the 18,602 identified patients, there was a 5.2% overall major perioperative complication rate. There was a rate of 4.4% per 30 person-days for unplanned readmissions related to index surgery. Independent risk factors for both readmissions and major perioperative complications included combined anterior and posterior surgery, diagnosis of solitary tumor, older age, and higher American Society of Anesthesiologists class. Patients with deep/organ surgical site infection carried higher risk of having unplanned readmission, followed by pulmonary embolism, acute renal failure, and stroke/cerebral vascular accident with neurological deficit. This study provides benchmark rates of 30-day readmission based on diagnosis and procedure codes from a high-quality database for adult spinal fusion patients and showed increased rates of 30-day unplanned readmission and major perioperative complications for patients with specific risk factors. Targeted preoperative planning on modifiable risk factors with proportional reimbursement may promote higher-quality healthcare. 3.

Outcomes After Resection of T4 Non-Small Cell Lung Cancer Using Cardiopulmonary Bypass

Complete, en bloc resection offers the greatest chance of long-term survival in T4 non-small cell lung cancer (NSCLC). The use of cardiopulmonary bypass (CPB) to achieve an en bloc resection is controversial because of potentially increased bleeding, lung dysfunction, and tumor dissemination. We reviewed our institutional experience to assess CPB's effect on survival. All patients who underwent resection for T4 NSCLC at our institution between 1980 and 2013 were retrospectively reviewed and stratified according to whether they did (CPB group, n= 20) or did not (No CPB group, n= 355) undergo CPB. Primary outcomes of interest were overall and disease-free survival and perioperative complications. Baseline characteristics and medical therapy were similar between the groups. Median overall survival for all patients was 31 months, with 1-, 3-, 5-, and 10-year survival of 73%, 47%, 40%, and 26%, respectively. Median disease-free survival for all patients was 19 months, with 1-, 3-, 5-, and 10-year disease-free survival of 61%, 40%, 33%, and 21%, respectively. No difference was found in overall or disease-free survival at 1, 3, 5, and 10 years between the No CPB and CPB groups (p= 0.89 and p= 0.88). In addition, no differences were found in the rates of major perioperative complications. The use of CPB allows for complete, en bloc resection in otherwise inoperable patients with T4 NSCLC and offers similar overall and disease-free survival to patients resected without CPB. All thoracic surgeons who manage T4 NSCLC should consider the use of CPB if it is necessary to achieve a complete, en bloc resection.