Rates Of Serious Morbidity Research Articles

Impact of Neoadjuvant Therapy for Pancreatic Cancer: Transatlantic Trend and Postoperative Outcomes Analysis.

The introduction of modern chemotherapy a decade ago has led to increased use of neoadjuvant therapy (NAT) in patients with pancreatic ductal adenocarcinoma (PDAC). A recent North American study demonstrated increased use of NAT and improved operative outcomes in patients with PDAC. The aims of this study were to compare the use of NAT and short-term outcomes in patients with PDAC undergoing pancreatoduodenectomy (PD) among registries from the US and Canada, Germany, the Netherlands, and Sweden. Databases from 2 multicenter (voluntary) and 2 nationwide (mandatory) registries were queried from 2018 to 2020. Patients undergoing PD for PDAC were compared based on the use of upfront surgery vs NAT. Adoption of NAT was measured in each country over time. Thirty-day outcomes, including the composite measure (ideal outcomes), were compared by multivariable analyses. Sensitivity analyses of patients undergoing vascular resection were performed. Overall, 11,402 patients underwent PD for PDAC with 33.7% of patients receiving NAT. The use of NAT increased steadily from 28.3% in 2018 to 38.5% in 2020 (p < 0.0001). However, use of NAT varied widely by country: the US (46.8%), the Netherlands (44.9%), Sweden (11.0%), and Germany (7.8%). On multivariable analysis, NAT was significantly (p < 0.01) associated with reduced rates of serious morbidity, clinically relevant pancreatic fistulae, reoperations, and increased ideal outcomes. These associations remained on sensitivity analysis of patients undergoing vascular resection. NAT before PD for pancreatic cancer varied widely among 4 Western audits yet increased by 26% during 3 years. NAT was associated with improved short-term outcomes.

National trends and feasibility of a robotic surgical approach in the management of patients with inflammatory bowel disease.

Research on the utilization of robotic surgical approaches in the management of inflammatory bowel disease (IBD) is limited. The aims of this study were to identify temporal trends in robotic utilization and compare the safety of a robotic to laparoscopic operative approach in patients with IBD. Patients who underwent minimally invasive surgery (MIS) for IBD were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2013-2021). Temporal trends of robotic utilization were assessed from 2013 to 2021. Primary (30-day overall and serious morbidity) and secondary (unplanned conversion to open) outcomes were assessed between 2019 and 2021, when robotic utilization was highest. Multivariable logistic regression was performed. The use of a robotic approach for colectomies and proctectomies increased significantly between 2013 and 2021 (p < 0.001), regardless of disease type. A total of 6016 patients underwent MIS for IBD between 2019 and 2021. 2234 (37%) patients had surgery for UC [robotic 430 (19.3%), lap 1804 (80%)] and 3782 (63%) had surgery for CD [robotic 500 (13.2%), lap 3282 (86.8%)]. For patients with UC, there was no difference in rates of overall morbidity (22.6% vs. 20.7%, p = 0.39), serious morbidity (11.4% vs. 12.3%, p = 0.60) or conversion to open (1.5% vs. 2.1%, p = 0.38) between the laparoscopic and robotic approaches, respectively. There was no difference in overall morbidity between the two groups in patients with CD (lap 14.0% vs robotic 16.4%, p = 0.15), however the robotic group exhibited higher rates of serious morbidity (7.3% vs. 11.2%, p < 0.01), shorter LOS (3 vs. 4days, p < 0.001) and lower rates of conversion to an open procedure (3.8% vs. 1.6%, p = 0.02). Adjusted analysis showed similar results. The use of the robotic platform in the surgical management of IBD is increasing and is not associated with an increase in 30-day overall morbidity compared to a laparoscopic approach.

Thirty day postoperative outcomes following laparoscopic adrenalectomy for functional adrenal tumors.

Functional adrenal tumors (FATs) are rare and if left untreated, there is a substantial risk of morbidity and mortality due to uncontrolled excess hormone secretion. The three most common FATs are cortisone-producing tumors (hypercortisolism), aldosterone-producing tumors (hyperaldosteronism), and catecholamines-producing tumors (pheochromocytomas). The study aims to evaluate demographic characteristics and 30-day outcomes after laparoscopic adrenalectomy of FATs. Patients who underwent laparoscopic adrenalectomy for FATs were selected from the ACS-NSQIP database (2015-2017), and divided into three groups (hyperaldosteronism, hypercortisolism, and pheochromocytoma). Preoperative demographics, medical comorbidities, and 30-day postoperative outcomes among the three groups were analyzed using the chi-squared test, analysis of variance (ANOVA) and Kruskal-Wallis one-way analysis of variance. Multivariable logistic regression was performed to assess the effects independent variables on the likelihood of increased overall morbidity. Of a total of 2410 patients who underwent laparoscopic adrenalectomy, 345 (14.3%) patients with FATs were included. Patients in the hypercortisolism group were younger, had higher proportion of females, had higher BMI, had a higher proportion of White ethnicity and had a higher proportion of diabetes. The hyperaldosteronism group had a higher proportion of Black ethnicity and a higher proportion of hypertension (HTN) requiring medication. Thirty day postoperative outcomes showed that the pheochromocytoma group had a higher rate of serious morbidity, overall morbidity, and highest readmission rates. There were three deaths, 1 in the pheochromocytoma and 2 in the hypercortisolism groups. Operative time (in minutes) was longer in the hypercortisolism group. Median length of stay was higher in hypercortisolism (2days) and pheochromocytoma (1.5day) groups. Functional adrenal tumors show distinct variations in patient demographics and postoperative outcomes. It is essential to use this information during the preoperative period to optimize patients prior to intervention and counsel patients about potential postoperative outcomes.

Frailty as a Predictor of Surgical Outcomes Following Femoral Hernia Repair.

Femoral hernias are associated with significant morbidity and mortality due to risk of strangulation. Frailty has shown to be strongly associated with adverse outcomes. A modified five-factor frailty index (mFI-5) is a simple validated predictor of postoperative complications and mortality within the ACS-NSQIP® database. This study aims to evaluate the impact of frailty and age on 30-day outcomes after femoral hernia repair. Patients who underwent femoral hernia repair were queried using the ACS-NSQIP database (2017) and divided into two groups based on frailty score (FS): Frail (FS = 1-5) and Non-frail (FS = 0). We evaluated the association between postoperative outcomes and frailty, age, sex, presentation, ASA class, timing of surgery, and surgical approaches. Univariate analysis followed by a multivariable logistic regression model was performed to evaluate postoperative morbidity. Of a total of 1,295 patients, 540 (42.7%) were in the Frail group. No differences in sex and race proportions were observed between groups. The Frail group had a higher rate of serious morbidity (4.4% vs 1.9%, P < .001), overall morbidity (7.8% vs 3.4%, P < .010), readmission rate (5.4% vs 2.3%, P = .003), and median (IQR) hospital length of stay (1 [0, 4] vs 0 [0, 1] days, P < .001). In multivariable analysis, male sex, presentation with complication, emergency surgery, and FS were associated with increased odds of overall morbidity. All deaths were in the Frail group. Frailty, male sex, presentation with obstruction/strangulation, and emergency surgery are independent predictors of increased 30-day morbidity. Thirty-day mortality was noted in the Frail group.

Role of diabetes mellitus in the clinical course and outcome of SARS-CoV-2 infected patients.

Our aim was to study patients with diabetes mellitus and SARS-CoV-2-infection diagnosed during the first pandemic wave in Greece. Cases were retrieved from the national database of SARS-CoV-2 infections. We studied 2624 SARS-CoV-2 infected cases, including 157 with diabetes. Patients with diabetes more often had other comorbidities (68.8 vs. 24.1%; p-value < 0.001). Among patients with diabetes, 149 (94.9%) developed symptomatic disease (COVID-19) compared to 1817 patients (73.7%) without diabetes (p-value < 0.001). A total of 126patients with diabetes and COVID-19 were hospitalized and 41 died (27.5% case-fatality rate compared to 7.5% among patients without diabetes; p-value < 0.001). Patients with diabetes more often were hospitalized, developed complications, were admitted to the intensive care unit (ICU), received invasive mechanical ventilation, and died compared to patients without diabetes (p-values < 0.001 to 0.002 for all comparisons). Multivariate logistic regression analyses revealed that diabetes, having other comorbidities, and older age were significantly associated with higher risk for hospitalization, ICU admission, invasive mechanical ventilation, and death, and that obesity was significantly associated with higher risk for hospitalization, ICU admission, and mechanical intubation, while female gender protected against these outcomes. COVID-19 is associated with increased rates of serious morbidity and adverse outcome in patients with diabetes and represents a severe illness for them.

Society for Maternal-Fetal Medicine Special Statement: A critique of postpartum readmission rate as a quality metric

Hospital readmission is considered a core measure of quality in healthcare. Readmission soon after hospital discharge can result from suboptimal care during the index hospitalization or from inadequate systems for postdischarge care. For many conditions, readmission is associated with a high rate of serious morbidity and potentially avoidable costs. In obstetrics, for postpartum care specifically, hospitals and payers can easily track the rate of maternal readmission after childbirth and may seek to incentivize obstetricians, maternal-fetal medicine specialists, or provider groups to reduce the rate of readmission. However, this practice has not been shown to improve outcomes or reduce harm. There are major concerns with incentivizing providers to reduce postpartum readmissions, including the lack of a standardized metric, a baseline rate of 1% to 2% that is too low to accurately discriminate between random variation and controllable factors, the need for risk adjustment that greatly complicates rate calculations, the potential for bias depending on the duration of the follow-up interval, the potential for the "gaming" of the metric, the lack of evidence that obstetrical providers can influence the rate, and the potential for unintended harm in the vulnerable postpartum population. Until these problems are adequately addressed, maternal readmission rate after a childbirth hospitalization currently has limited utility as a metric for quality or performance improvement or as a factor to adjust provider reimbursement.

Thirty day readmissions and outcomes following radical nephrectomy in renal cell carcinoma: A nationwide analysis.

e16560 Background: Nephrectomy is one of the primary treatments of Stage I-III renal cell carcinoma (RCC), which is usually associated with low rates of serious morbidity and mortality. However, a fraction of patients gets readmitted after the surgery for numerous reasons which can impact their overall prognosis. Methods: We conducted a retrospective cohort study using the 2017 National Readmission Database of adult patients with RCC readmitted within 30 days after an index admission for nephrectomy. We aimed to identify the 30-day readmission rate, mortality, resource utilization, and independent predictors of readmission. Results: A total of 25,307 patients with RCC underwent nephrectomy. The 30-day readmission rate was 8.7%. The top five causes for readmission were sepsis, AKI, STEMI, surgical infections &amp; metastatic disease. Patients requiring readmission were less likely to be discharged home (56.5 vs 81.8%), have private insurance (27.2 vs 34.7), obesity (14.7 vs 20.6%), hypertension (30.9 vs 47.1%), and be admitted to a teaching hospital (75.8 vs 79.2%). They were more likely to be insured with Medicare (58.3 vs 53.3%), have lower income (28.7 vs 26.3%), type 2 diabetes (32.4 vs 26.7%), CKD (44.1 vs 20.7%), malnutrition (9.2 vs 2.1%), undergo chemotherapy (5.2 vs 1.9%). Readmission was associated with higher in-hospital mortality (1.5 vs. 0.1%), CVA (0.6 vs 0.3%), AKI (29.6 vs 16.9%) and pleural effusion (7.8 vs 1.8%). They were also more likely to require mechanical ventilation (3.5 vs 1.8%), parenteral nutrition (1.2 vs 0.4%) and hemodialysis (11.9 vs 4.5%). The in-hospital economic burden of readmission was $128 million in total charges and $31.8 million in total costs. Independent predictors of readmission were disposition to a short-term hospital or skilled nursing facility, length of stay, need for mechanical ventilation and transfusion of blood products, having type 1 diabetes, malnutrition, pleural effusion, and CKD. Younger age and private insurance were associated with preventing readmission. Conclusions: Readmissions after nephrectomy in patients with RCC are associated with increased in-hospital mortality rate and pose a high health care economic burden. We identified few risk factors and patient characteristics associated with post-surgical readmissions; however, further in-depth studies are needed to find preventable risk factors.[Table: see text]

SEVERE ACUTE RESPIRATORY SYNDROME CAUSED BY NEW CORONAVIRUS (COVID-19) AND INFLUENZA VIRUSES IN BRAZIL: DESCRIPTIVE ANALYTICAL OBSERVATIONAL RETROSPECTIVE STUDY/ SÍNDROME RESPIRATÓRIA AGUDA SEVERA CAUSADA PELO NOVO CORONAVÍRUS (COVID-19) E VÍRUS DA INFLUENZA NO BRASIL: ESTUDO RETROSPECTIVO ANALÍTICO OBSERVACIONAL DESCRITIVO

The World Health Organization, monitors diseases that are able of spread rapidly, including infections that may result in severe acute respiratory syndrome. New coronavirus and influenza are etiological agents capable of causing SARS. This is a descriptive analytical observational retrospective study based on secondary data extracted from epidemiological bulletins (EB) among weeks 01 to 48, the Ministry of Health on COVID-19 and Influenza virus, consulted until November 28, 2020. The Ministry of Health received the first notification of a confirmed case of COVID-19 in Brazil on February 26, 2020. From February 26 to November 28, 2020, 6,314,740 cases and, 172,833 deaths from COVID-19 in Brazil were confirmed. Having the highest mortality rate observed in the Midwest region (98.9 / 100 thousand inhabitants). The pandemic has already a high rate of serious morbidity and mortality in older adults and has been shown to be higher than in the influenza pandemic. In Brazil, the numbers have increased and there are already cases of re-infection shared by some health centers. We cannot think that other pandemics will not occur, we must learn from this experience and prepare ourselves with new tests, adequate stocks of personal protective equipment and, the capacity for intensive care.

Trends in obstetric management of extreme preterm birth at 23 to 27 weeks’ gestation in a tertiary obstetric unit: A 10-year retrospective review

ObjectiveTo evaluate maternal and perinatal outcomes in deliveries from 23 + 0 to 26 + 6 weeks gestation in a tertiary hospital. Study DesignA 10-year retrospective analysis was performed which included all women who delivered between 23 + 0 and 26 + 6 weeks gestation in a tertiary obstetric unit from 01/01/2007 to 31/12/2017 inclusive. Data were collected from electronic patient records and individual chart reviews using predetermined variables. Results340 women and 402 infants were included. 84 % (282/340) were singleton pregnancy and 17 % (59/340) had multiple pregnancies. 36.8 % (125/340) of women were delivered by Caesarean section, 11.2 % (14/125) had a classical caesarean section.The leading indications for delivery were preterm premature ruptured membranes (PPROM) 28.2 % (96/340), 8.5 % (29/340) severe pre-eclampsia (PET) and 5.6 % (19/340) were delivered for suspected placental abruption. Of all infants (N = 402), 18.9 % (76/402) were stillborn. 300 infants were admitted to the Neonatal Intensive Care Unit (NICU). The NICU survival to discharge rate was 83.7 % (251/300). The overall perinatal mortality rate (PNMR) was 328.4/1000 and a further late neonatal mortality of 47.3/1000 births. Notably, at the 23 week gestation NNDs are the major contributor to the PNMR and at later gestations stillbirths are the largest contributor. ConclusionPregnant women delivering at extreme preterm gestations are at risk of maternal morbidity. Their infants have high rates of serious morbidity and mortality, with all survivors in this cohort affected by neonatal morbidity. Informed decision-making by providers and parents requires evidence based information on perceived outcomes, ideally individualized to the mother and pregnancy in question. Information from this retrospective cohort study can be used to counsel women and their families on potential morbidity and mortality and to manage expectations.

Biphasic learning curve of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy:technical competence and refinement of patient selection.

BackgroundCytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is routinely used for selected patients with peritoneal metastasis, but can be associated with high complication rates, prolonged hospital stay, and mortality. Our objective was to determine the learning curve of CRS/HIPEC in our institution, representing the largest Asian cohort to date.MethodsA total of 200 consecutive patients with peritoneal metastasis treated with CRS/HIPEC between 2001 and 2016 were grouped into four cohorts of 50 patients and studied. Primary outcomes were severe morbidity (Clavien-Dindo III-V), procedure-related mortality, and duration of ICU and hospital stays. Secondary outcome was duration of surgery.ResultsMedian age was 53 years (10–75). There was no significant age, sex, or histology difference across cohorts. Rates of severe morbidity (23 %), and 60 day inpatient mortality (0.5 %) were comparable to previously reported data. Decreases in rates of serious morbidity, (34 %, 30 %, 12 %, 14 %, p<0.01) and duration of total hospital stay (14, 16, 13, 12 days, p=0.041) were seen across consecutive cohorts. Operation time decreased significantly after the first cohort (10, 7.8, 7.8, 7.2 h, p<0.01), despite increase in average PCI score after the first cohort (8, 14, 12, 13, p=0.063).ConclusionsWhilst 50 cases were adequate for procedural familiarity and decreased average operation time, significant improvement in rate of serious morbidity was observed after 100 operations. We demonstrate a novel biphasic nature to the learning curve, reflecting initial training in which technical competence is achieved, followed by a subsequent period characterized by increasingly complex cases (higher PCI score) and finally refinement of patient selection.

Critical Airway Team: A Retrospective Study of an Airway Response System in a Pediatric Hospital.

Objective Study the performance of a pediatric critical airway response team. Study Design Case series with chart review. Setting Freestanding academic children's hospital. Subjects and Methods A structured review of the electronic medical record was conducted for all activations of the critical airway team. Characteristics of the activations and patients are reported using descriptive statistics. Activation of the critical airway team occurred 196 times in 46 months (March 2012 to December 2015); complete data were available for 162 activations (83%). For 49 activations (30%), patients had diagnoses associated with difficult intubation; 45 (28%) had a history of difficult laryngoscopy. Results Activation occurred at least 4 times per month on average (vs 3 per month for hospital-wide codes). The most common reasons for team activation were anticipated difficult intubation (45%) or failed intubation attempt (20%). For 79% of activations, the team performed an airway procedure, most commonly direct laryngoscopy and tracheal intubation. Bronchoscopy was performed in 47% of activations. Surgical airway rescue was attempted 4 times. Cardiopulmonary resuscitation occurred in 41 activations (25%). Twenty-nine patients died during or following team activation (18%), including 10 deaths associated with the critical airway event. Conclusion Critical airway team activation occurred at least once per week on average. Direct laryngoscopy, tracheal intubation, and bronchoscopic procedures were performed frequently; surgical airway rescue was rare. Most patients had existing risk factors for difficult intubation. Given our rate of serious morbidity and mortality, primary prevention of critical airway events will be a focus of future efforts.

Does having a gastrectomy delay time to feeding and prolong hospital stay in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy?

Aim: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is routinely used to treat selected patients with peritoneal carcinomatosis, but can be associated with prolonged hospital stay, significant morbidity and mortality. Our objective was to assess whether patients undergoing gastrectomy as part of CRS/HIPEC were at increased risk of delayed feeding time and prolonged hospital stay.Methods: Two hundred and fourteen consecutive patients with peritoneal carcinomatosis treated with CRS/HIPEC between 2001 and 2016 were stratified by whether CRS included gastrectomy (n = 19, 9%) and compared. Primary outcomes were time to full feeds and rate of serious morbidity (Clavien–Dindo grades III–V). Secondary outcomes were durations of ICU and hospital stays.Results: Of 214 patients undergoing CRS/HIPEC, those undergoing gastrectomy (19, 8.9%) had increased time to full feeds (8 vs. 5 days, p < 0.01), and duration of ICU (2 vs. 1 days, p < 0.01) and total hospital stays (16 vs. 14 days, p = 0.013). There was no significant increase in serious complications, although increased risk of pneumonia was noted (21% vs. 4.1%, p = 0.011). Undergoing gastrectomy was not independently prognostic in multivariable analysis including high peritoneal tumour load (PCI >12), multiple CRS procedures (number >2) and operation duration (>480 min) in which operative duration remained independently prognostic (p < 0.01).Conclusions: After surgery, early oral refeeding may be beneficial in the majority of patients undergoing CRS/HIPEC. However, patients found to have high peritoneal tumour load with extended surgery and those who underwent gastrectomy should be considered for early post-operative TPN due to the significant risk of delayed time to full feeds.

The Increasing Trends and Serious Morbidity of Primary Cesarean Delivery [4P

INTRODUCTION: To describe the trends over time of primary cesarean delivery (CD) and compare sociodemographic features and morbidity in patients undergoing primary CD. METHODS: A retrospective cohort study was performed using California discharge data. All term, vertex, singleton deliveries from 2001–2009 were analyzed. We excluded cases of malpresentation, preterm delivery, and fetal death. Cases were identified via ICD-9-CM. Logistic regression was performed to adjust for potential confounders. RESULTS: Out of 3,365,055 deliveries, there was a primary CD rate of 15.2%. Primary CD incidence increased considerably during the time period, going from 12.6% in 2001 to 17.0% by 2009. African Americans had the highest primary CD rate (17.9%) while Native Americans (12.9%) and Hispanics (14.0%) had the lowest rates. Advancing maternal age corresponded with dramatically increased primary CD rate. When comparing delivery morbidity in subjects undergoing primary CD compared to VD, primary cesarean delivery was associated with an increased risk of anesthesia-related complications, thromboembolism, and a nearly 10-fold increase in postpartum endometritis. Severe morbidities including coagulopathy, hysterectomy, critical care morbidity were increased 3- to 9-fold. There was a 6-fold relative increase in death in women who had a CD. However, primary CD did have decreased risk of vaginal delivery related morbidity. CONCLUSION: Primary CD rates are increasing. In addition to having risks for future pregnancies, primary CD is associated with increased rates of serious morbidity and mortality at the immediate time of delivery. This data should be used in quality improvement initiatives to stress the importance of primary CD for only appropriately indicated cases.

Maternal and perinatal outcomes of pregnancies delivered at 23 weeks' gestation.

To evaluate the maternal and perinatal outcomes of pregnancies delivered at 23+0 to 23+6 weeks' gestation. This prospective cohort study included women in the Canadian Perinatal Network who were admitted to one of 16 Canadian tertiary perinatal units between August 1, 2005, and March 31, 2011, and who delivered at 23+0 to 23+6 weeks' gestation. Women were included in the network if they were admitted with spontaneous preterm labour with contractions, a short cervix without contractions, prolapsing membranes with membranes at or beyond the external os or a dilated cervix, preterm premature rupture of membranes, intrauterine growth restriction, gestational hypertension, or antepartum hemorrhage. Maternal outcomes included Caesarean section, placental abruption, and serious complication. Perinatal outcomes were mortality and serious morbidity. A total of 248 women and 287 infants were included in the study. The rate of Caesarean section was 10.5% (26/248) and 40.3% of women (100/248) had a serious complication, the most common being chorioamnionitis (38.6%), followed by blood transfusion (4.5%). Of infants with known outcomes, perinatal mortality was 89.9% (223/248) (stillbirth 23.3% [67/287] and neonatal death 62.9% [156/248]). Of live born neonates with known outcomes (n = 181), 38.1% (69/181) were admitted to NICU. Of those admitted to NICU, neonatal death occurred in 63.8% (44/69). Among survivors at discharge, the rate of severe brain injury was 44.0% (11/25), of retinopathy of prematurity 58.3% (14/24), and of any serious neonatal morbidity 100% (25/25). Two subgroup analyses were performed: in one, antepartum stillbirths were excluded, and in the other only centres that indicated they offered fetal monitoring at 23 weeks' gestation were included and antepartum stillbirths were excluded. In each of these, perinatal outcomes similar to the overall group were found. Pregnant women delivering at 23 weeks' gestation are at risk of morbidity. Their infants have high rates of serious morbidity and mortality. Further research is needed to identify strategies and forms of management that not only increase perinatal survival but also reduce morbidities in these extremely low gestational age infants and reduce maternal morbidity.

Effect of umbilical cord milking on morbidity and survival in extremely low gestational age neonates

Delayed umbilical cord clamping benefits extremely low gestational age neonates (ELGANs) but has not gained wide acceptance. We hypothesized that milking the umbilical cord (MUC) would avoid resuscitation delay but improve hemodynamic stability and reduce rates for composite outcome of severe intraventricular hemorrhage, necrotizing enterocolitis, and/or death before discharge. We implemented a joint neonatal/maternal-fetal quality improvement process for MUC starting September 2011. The MUC protocol specified that infants who were born at <30 weeks of gestation undergo MUC 3 times over a duration of <30 seconds at delivery. Obstetric and neonatal data were collected until discharge. We compared the MUC group to retrospective ELGAN cohort delivered at our center between January 2010 and August 2011. Analysis was intention-to-treat. We identified 318 ELGANs: 158 eligible for MUC and 160 retrospective control neonates. No adverse events were reported with cord milking. There was no difference in neonatal resuscitation, Apgar scores, or admission temperature. Hemodynamic stability was improved in the MUC group with higher mean blood pressures through 24 hours of age, despite less vasopressor use (18% vs 32%; P < .01). The initial hematocrit value was higher (50% vs 45%; P < .01), and red cell transfusions were fewer (57% vs 79%; P < .01) in MUC vs control infants. Presence of the composite outcome was significantly less in MUC vs the historic control infants (22% v 39%; odds ratio, 1.81; 95% confidence interval, 1.06-3.10). There were also reductions in intraventricular hemorrhage, necrotizing enterocolitis, and death before hospital discharge. MUC improves early hemodynamic stability and is associated with lower rates of serious morbidity and death among ELGANs.

Volume and outcome relationship in bariatric surgery in the laparoscopic era

The relationship between volume and outcomes in bariatric surgery is well established in the literature. However, the analyses were performed primarily in the open surgery era and in the absence of national accreditation. The recent Metabolic Bariatric Surgery Accreditation and Quality Improvement Program proposed an annual threshold volume of 50 stapling cases. This study aimed to examine the effect of volume and accreditation on surgical outcomes for bariatric surgery in this laparoscopic era. The Nationwide Inpatient Sample was used for analysis of the outcomes experienced by morbidly obese patients who underwent an elective laparoscopic stapling bariatric surgical procedure between 2006 and 2010. In this analysis, low-volume centers (LVC < 50 stapling cases/year) were compared with high-volume centers (HVC ≥ 50 stapling cases/year). Multivariate analysis was performed to examine risk-adjusted serious morbidity and in-hospital mortality between the LVCs and HVCs. Additionally, within the HVC group, risk-adjusted outcomes of accredited versus nonaccredited centers were examined. Between 2006 and 2010, 277,760 laparoscopic stapling bariatric procedures were performed, with 85% of the cases managed at HVCs. The mean number of laparoscopic stapling cases managed per year was 17 ± 14 at LVCs and 144 ± 117 at HVCs. The in-hospital mortality was higher at LVCs (0.17%) than at HVCs (0.07%). Multivariate analysis showed that laparoscopic stapling procedures performed at LVCs had higher rates of mortality than those performed at HVCs [odds ratio (OR) 2.5; 95% confidence interval (CI) 1.3-4.8; p < 0.01] as well as higher rates of serious morbidity (OR 1.2; 95% CI 1.1-1.4; p < 0.01). The in-hospital mortality rate at nonaccredited HVCs was 0.22% compared with 0.06% at accredited HVCs. Multivariate analysis showed that nonaccredited centers had higher rates of mortality than accredited centers (OR 3.6; 95% CI 1.5-8.3; p < 0.01) but lower rates of serious morbidity (OR 0.8; 95% CI 0.7-0.9; p < 0.01). In this era of laparoscopy, hospitals managing more than 50 laparoscopic stapling cases per year have improved outcomes. However, nonaccredited HVCs have outcomes similar to those of LVCs. Therefore, the impact of accreditation on outcomes may be greater than that of volume.

Complications of radical nephrectomy for renal cell carcinoma: a retrospective study comparing transperitoneal and retroperitoneal approaches using a standardized reporting methodology in two Chinese centers

The reporting of complications following transperitoneal and retroperitoneal open radical nephrectomy (RN) is nonstandardized. This study aimed to compare early complications between the two approaches using a standardized reporting methodology in a large contemporary cohort. Between 1996 and 2009, 558 patients underwent open RN for renal cell carcinoma (RCC) in our two centers (424 from Sun Yat-sen University Cancer Center and 134 from the First Affiliated Hospital of Sun Yat-sen University). Records were reviewed for clinicopathologic features and complications. Complications were graded using the Clavien system based on the severity of impact. One hundred and five patients (18.8%) had one or more early complications (168 complications overall). The overall rates of grades I to V complications were 5.6%, 10.8%, 2.2%, 0.4%, and 0.2%, respectively. Patients who underwent transperitoneal RN did not experience more overall or procedure-related complications than those who underwent retroperitoneal RN (P = 0.911 and P = 0.851, respectively). On subgroup analysis, neither grade I/II nor grades III-V complications were significantly different between the transperitonal RN and retroperitoneal RN groups. Multivariate analysis showed that for any grade of complication, age (P = 0.016) and estimated blood loss (P = 0.001) were significant predictors. We concluded that open RN is a safe procedure associated with low rates of serious morbidity and mortality. Compared with retroperitoneal RN, transperitoneal RN was not associated with more complications. Older patient and more blood loss at surgery were independent predictors for higher early postoperative complication rates.

EXCELLENT LONG-TERM ONCOLOGICAL OUTCOME AFTER ELECTIVE TESTIS-SPARING SURGERY FOR LEYDIG CELL TUMORS: A SINGLE-CENTRE EXPERIENCE WITH 19 CASES

When stratifying by highest severity complication, 18% of all P-RPLND patients had only a grade I (i.e. ileus) versus 21% of all PC-RPLND patients (p=NS). PC-RPLND patients had a higher rate of grade II-V complications (16% vs 9%, p=NS). There was 1 mortality due to multiple pulmonary emboli in the PC-RPLND group. CONCLUSIONS: Both P-RPLND and PC-RPLND are associated with low rates of serious morbidity and negligible morbidity in the hands of experienced surgeons. PC-RPLND is associated with longer operative time, higher EBL, a higher rate of overall complications at 37% vs 27% and a higher rate of non-grade I complications.

Snapshots for May 2006

Snapshots for May 2006

Neonatal and Maternal Outcomes in Twin Gestations ???32 Weeks According to the Planned Mode of Delivery

Rates of both perinatal morbidity and mortality are higher in twins than in singleton infants, chiefly because of low birth weight and prematurity as well as twin-twin transfusion syndrome. Malpresentation and mode of delivery remain important factors. Although planned cesarean section may be effective if there is a breech presentation or to prevent locked twins, there is no prevailing opinion about the best mode of delivery. This retrospective cohort study dealt with a total of 164 twins at or after 32 weeks gestation seen at a single center in the years 1999-2002. Cesarean delivery was performed in 29 women (17.7%), the most common indication being fetal malpresentation. In the remaining 135 twins (82.3%), vaginal delivery was attempted, but 26 women required emergent or urgent cesarean section for delivery of both infants. Two women required emergency section for twin B only. Thirteen A twins had instrumental delivery, most often because of fetal distress or failure to progress. One in five women who were to have planned vaginal birth required section delivery; the success rate in the planned vaginal birth group was nearly 80%. There was a single fetal death. Twins A had more serious morbidity in the planned vaginal birth group than with elective cesarean section, but the difference was not significant. Twins B had increased neonatal morbidity regardless of the planned mode of delivery. No women had major life-threatening illness. Two women required a second laparotomy, but rates of serious morbidity did not differ significantly in the planned cesarean section and planned vaginal birth groups (13.8% and 19.3%, respectively). These findings fail to support elective operative delivery for twin gestations at 32 or more weeks gestation. Planned vaginal delivery succeeded in nearly 80% of cases. A prospective, randomized trial may be needed to settle this question.