Reduction In Major Complications Research Articles

Systematic review and meta-analysis of short-term outcomes: robot-assisted versus laparoscopic surgery for gastric cancer patients with visceral obesity.

The objective of this meta-analysis was to assess the comparative efficacy of robot-assisted and laparoscopic surgery in treating gastric cancer among patients characterized by a high visceral fat area (VFA). In April 2024, we conducted a comprehensive literature review using major international databases, such as PubMed, Embase, and Google Scholar. We restricted our selection to articles written in English, excluding reviews, protocols without published data, conference abstracts, and irrelevant content. Our analysis focused on continuous data using 95% confidence intervals (CIs) and standard mean differences (SMDs), while dichotomous data were assessed with odds ratios (ORs) and 95% CIs. We set the threshold for statistical significance at P < 0.05. Data extraction included baseline characteristics, primary outcomes (such as operative time, major complications, lymph node yield, and anastomotic leakage), and secondary outcomes. The meta-analysis included three cohort studies totaling 970 patients. The robotic-assisted group demonstrated a significantly longer operative time compared to the laparoscopic group, with a weighted mean difference (WMD) of - 55.76min (95% CI - 74.03 to - 37.50; P < 0.00001). This group also showed a reduction in major complications, with an odds ratio (OR) of 2.48 (95% CI 1.09-5.66; P = 0.03) and fewer occurrences of abdominal infections (OR 3.17, 95% CI 1.41-7.14; P = 0.005), abdominal abscesses (OR 3.83, 95% CI 1.53-9.57; P = 0.004), anastomotic leaks (OR 4.09, 95% CI 1.73-9.65; P = 0.001), and pancreatic leaks (OR 8.93, 95% CI 2.33-34.13; P = 0.001). However, no significant differences were observed between the groups regarding length of hospital stay, overall complications, estimated blood loss, or lymph node yield. Based on our findings, robot-assisted gastric cancer surgery in obese patients with visceral fat appears to be correlated with fewer major complications compared to laparoscopic surgery, while maintaining similar outcomes in other surgical aspects. However, it is important to note that robot-assisted procedures do tend to have longer operative times.

The association of marital status with kidney cancer surgery morbidity - a retrospective cohort study.

To better understand whether the marital status impacts 90-day postoperative outcomes following kidney cancer surgery. We performed a retrospective cohort study of adult patients undergoing elective partial or radical nephrectomy to manage kidney masses from 2003 to 2017 using the Premier Hospital Database, a national hospital discharge dataset. Multinomial logistic regression models controlling for a wide range of clinicodemographic, surgical, and hospital characteristics were used to assess an association between marital status and postoperative complications. The primary outcome was 90-day complications, including minor complications (Clavien grades 1-2), non-fatal major complications (Clavien grades 3-4), and mortality (Clavien grade 5). Secondary outcomes included patient disposition and readmission rates. The study cohort comprised 106,752 patients, of which 61,188 (57.32%) were married. The overall incidence of minor complications, major complications, and death was 24.04%, 6.00%, and 0.71%, respectively. Marriage was associated with a significantly lower incidence of minor (RR 0.97; 95% CI: 0.94-0.99) complications following open or radical nephrectomy and major complications (RR 0.89; 95% CI: 0.84-0.95) for all surgical types and approaches. There was no association between marital status and mortality (RR 0.94; 95% CI: 0.81-1.10). Marriage is associated with a significant reduction in major complications following kidney cancer surgery, likely because it is associated with greater social support, which is beneficial in the postoperative phase of care. Marital status and social support may play a role in the preoperative decision-making process and counseling for patients considering kidney cancer surgery.

Role of Desmopressin Acetate before Percutaneous Ultrasound-Guided Kidney Biopsy in Patients with Kidney Dysfunction

Abstract Introduction: The most common complication of percutaneous kidney biopsy is bleeding, which can be seen in up to one-third of cases. The aim of this study was to evaluate the effect of prebiopsy administration of intranasal desmopressin acetate in reducing the incidence of biopsy-related bleeding complications. Methods: This was a prospective randomized double-blind pilot study conducted at our center from January 2021 to September 2022. Consecutive adult patients who underwent native percutaneous kidney biopsy with an estimated glomerular filtration rate (eGFR) ≤45 ml/min/1.73 m2 were randomized into a placebo (saline intranasal spray) group versus intranasal desmopressin group. The bleeding complications were compared between the two groups. Results: A total of 80 patients who underwent kidney biopsy at our center from January 2021 to September 2022 with eGFR ≤45 ml/min/1.73 m2 were included (40 patients in desmopressin group and 40 patients in non-desmopressin group) in the study. The mean age of the patients was 44 ± 12 years with a mean eGFR of 20.82 ± 12.64 ml/min/1.73 m2. Intranasal desmopressin administration before kidney biopsy was associated with a significantly higher number of minor bleeding complications (P = 0.02) and no significant reduction in major complications (P = 0.15) when compared with a group that did not receive desmopressin. Other complications like hypotension, flushing, and vasovagal syncope were not statistically significantly associated with the use of desmopressin. Conclusions: Our study did not find any utility of prophylactic desmopressin use before kidney biopsy in patients with kidney dysfunction.

Outcomes of Negative Pressure Wound Therapy on Immediate Breast Reconstruction after Mastectomy.

This is a retrospective single-institution study evaluating the ciNPT device, 3M Prevena Restor BellaForm, on breast reconstruction patients. The study was performed between July 1, 2019 and October 30, 2020, with 125 patients (232 breasts). Seventy-seven patients (142 breasts) did not receive the ciNPT dressing, and 48 patients (90 breasts) received the ciNPT dressing. Primary outcomes were categorized by major or minor complications. Age, BMI, and final drain removal were summarized using medians and quartiles, and were compared with nonparametric Mann-Whitney test. Categorical variables were compared using chi-square or Fisher exact test. There was a statistically significant reduction in major complications in the ciNPT group versus the standard dressing group (P = 0.0247). Drain removal time was higher in the ciNPT group. Our study shows that ciNPT may help reduce major complication rates in implant-based breast reconstruction patients.

Machine perfusion techniques for liver transplantation - A meta-analysis of the first seven randomized-controlled trials

Machine perfusion is increasingly being tested in clinical transplantation. Despite this, the number of large prospective clinical trials remains limited. The aim of this study was to compare the impact of machine perfusion vs. static cold storage (SCS) on outcomes after liver transplantation. A systematic search of MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted to identify randomized-controlled trials (RCTs) comparing "post-transplant" outcomes following machine perfusion vs. SCS. Data were pooled using random effect models. Risk ratios (RRs) were calculated for relevant outcomes. The quality of evidence was rated using the GRADE-framework. Seven RCTs were identified (four on hypothermic oxygenated [HOPE] and three on normothermic machine perfusion [NMP]), including a total number of 1,017 patients. Both techniques were associated with significantly lower rates of early allograft dysfunction (NMP: n= 41/282, SCS: n= 74/253, RR 0.50, 95% CI 0.30-0.86, p=0.01, I2= 39%; HOPE: n= 45/241, SCS: n= 97/241, RR 0.48, 95% CI 0.35-0.65, p<0.00001, I2= 5%). The HOPE approach led to a significant reduction in major complications (Clavien Grade ≥IIIb; HOPE: n= 90/241; SCS: n= 117/241, RR 0.76, 95% CI 0.63-0.93, p=0.006, I2= 0%), "re-transplantation" (HOPE: n= 1/163; SCS: n= 11/163; RR 0.21, 95% CI 0.04-0.96, p=0.04; I2= 0%) and graft loss (HOPE: n= 7/163; SCS: n= 19/163; RR 0.40, 95% CI 0.17-0.95, p=0.04; I2= 0%). Both perfusion techniques were found to 'likely' reduce overall biliary complications and non-anastomotic strictures. Although this study provides the highest current evidence on the role of machine perfusion, outcomes remain limited to a 1-year follow-up after liver transplantation. Comparative RCTs and large real-world cohort studies with longer follow-up are required to enhance the robustness of the data further, thereby supporting the introduction of perfusion technologies into routine clinical practice. CRD42022355252. For a decade, two dynamic perfusion concepts have increasingly been tested in several transplant centres worldwide. We undertook the first systematic review and meta-analysis and identified seven published RCTs, including 1,017 patients, evaluating the effect of machine perfusion (hypothermic and normothermic perfusion techniques) compared to static cold storage in liver transplantation. Both perfusion techniques were associated with lower rates of early allograft dysfunction in the first week after liver transplantation. Hypothermic oxygenated perfusion led to a reduction in major complications, lower "re-transplantation" rates and better graft survival. Both perfusion strategies were found to 'likely' reduce overall biliary complications and non-anastomotic biliary strictures. This study provides the highest current evidence on the role of machine perfusion. Outcomes remain limited to a 1-year post-transplant follow-up. Larger cohort studies with longer follow-up and clinical trials comparing the perfusion techniques are required. This is especially relevant to provide clarity and optimise implementation processes further to support the commissioning of this technology worldwide.

A leadless ventricular pacemaker providing atrioventricular synchronous pacing in the real-world setting: acute results from the Micra AV post-approval registry

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Medtronic, inc. Introduction Advances in leadless pacemaker technology have enabled accelerometer based atrioventricular synchronous (AVS) pacing by sensing atrial mechanical contraction. However, acute safety performance of these devices in real-world clinical practice has not been assessed. Objectives To report the acute performance of the Micra AV transcatheter pacemaker from the worldwide Micra AV post-approval registry (PAR). Methods The Micra AV PAR is an ongoing prospective single-arm observational study designed to assess the safety and effectiveness of the Micra AV system in the real-world setting. Patients enrolled in the Micra AV PAR will be followed for 3 years. For the present interim analysis, baseline characteristics, total AV synchrony index (sum of %AM-VP, %AM-VS, and AV conduction mode switch percentage), and major complications occurring within 30-days of implant were summarized and compared to a historical cohort of 2,667 transvenous dual chamber (TV-DC) pacing patients. Results The device was successfully implanted in 797 of 802 patients (99.4%) at 99 centers. Mean age was 74.1±15.1 years and 42.3% were female. The most common pacing indication was AV block (55.7%). Comorbidities included diabetes (29.7%), CAD (22.8%), and heart failure (12.1%), with 31.3% precluded from transvenous device therapy. Micra AV patients were on average older (74.1 vs. 71.1 yrs, P&amp;lt;0.0001) and had a significantly higher incidence of renal disease (22.3% vs. 9.8%, P&amp;lt;0.0001). Major complications occurred in 2.6% of Micra AV patients and in 7.1% TV-DC patients (P&amp;lt;0.001, Figure). The reduction in major complications was largely driven by the absence of pneumothoraces and lead dislodgements among Micra AV patients. Of the 309 patients programmed to VDD mode with at least 30 days of device follow-up, the median AV synchrony index was 86.0% (IQR: 69.2% - 97.2%). Mean A4 amplitude was 2.1±1.6 m/s2 post-implant and 2.2±1.7 m/s2 at follow-up (P=0.57) in 308 patients with paired assessments. Conclusions The Micra AV leadless pacemaker was implanted with a high rate of success in patients with a high co-morbidity burden, with a significantly lower rate of acute complications relative to dual-chamber transvenous pacemakers despite patients being older and having a higher incidence of renal disease. Longer-term performance will continue to be assessed in this ongoing trial.

CI-452769-2 PERFORMANCE OF LEADLESS PACEMAKERS IN EXTENDED FOLLOW-UP: 5 YEAR RESULTS FROM THE MICRA VR TRANSCATHETER PACING SYSTEM POST-APPROVAL REGISTRY

Prior reports have demonstrated a favorable safety and efficacy profile of the Micra leadless pacemaker over mid-term follow-up; however, long-term outcomes in real-world clinical practice remain unknown. We report 5-year outcomes of the Micra VR leadless pacemaker from the worldwide post-approval registry (PAR). All Micra VR PAR patients (n=1809) undergoing implant attempt were included. Endpoints included system- or procedure-related major complications and system revision rate for any cause through 60 months post-implant. Rates were compared through 36 months post-implant to a reference dataset of 2667 patients implanted with a transvenous pacemaker using Fine-Gray competing risk models. Patients were followed for a median of 48.9 (IQR: 21.6-59.8) months with active patients followed for a median of 59.7 (IQR: 54.2-64.9) months. Median age was 79 (IQR: 71-84) years at implant and patients had multiple comorbidities, including renal dysfunction (21.5%) and heart failure (15.4%). The major complication rate at 60 months was 4.3% (95% CI: 3.4%-5.4%) and was 4.1% at 36 months, which was significantly lower than the 8.5% rate observed for transvenous systems (HR: 0.47, 95% CI: 0.36-0.61; P<0.001; Figure). The all-cause system revision rate at 60 months was 4.9% (95% CI: 3.9%-6.1%). System revisions among Micra patients were mostly for device upgrades (40.2%) or elevated thresholds (28.0%). The most frequent action was to program the device OOO (78.0%), while 10 devices were successfully explanted 2-1442 days post-implant. No infection requiring Micra removal was noted over the duration of follow-up. At 36 months, the system revision rate was significantly lower with Micra vs. transvenous systems (3.3% vs 6.6%, P<0.001). Extended performance data of the Micra leadless pacemaker remains in-line with previously reported data with a 53% reduction in major complications through 36-months relative to transvenous pacemakers. The rate of system revisions was low through 5 years and importantly, no infections requiring Micra removal were observed. Performance will continue to be evaluated in this ongoing trial.

Percutaneous Nephrolithotomy Access: A Meta-Analysis Comparing Access by Urologist vs Radiologist.

Introduction: Percutaneous nephrolithotomy is a minimally invasive procedure indicated for the management of staghorn calculi or renal calculi >2.0 cm. Percutaneous renal access is a critical step in this procedure and can be performed by either urologists or interventional radiologists. The purpose of this study is to perform a meta-analysis to compare outcomes between urologist and interventional radiologist-mediated access. Methods: An electronic literature search was conducted to identify studies comparing urologist- and interventional radiologist-acquired access. Studies must have included both urologist- and intervention radiologist-acquired access data but were excluded if (1) not in English; (2) abstract without full text; (3) unable to determine who acquired access; and (4) only included either urologist or interventional radiologist data. Meta-analysis comparison was generated with the Review Manager 5.4 software. Results: After screening the abstracts and title, 55 relevant studies were identified. Nine articles were utilized in the meta-analysis. Urologist-acquired access was associated with a greater stone-free rate (risk ratio [RR] = 1.10; 95% confidence interval [CI], 1.01-1.20), a reduction in major complications (RR = 0.69; 95% CI, 0.53-0.92), and a shorter hospital stay (mean difference -0.40; 95% CI, -0.64 to -0.16) in comparison with radiologist-acquired access. Urologist-acquired access was associated with greater blood loss (mean difference 0.46; 95% CI, 0.32-0.60) when compared with interventional radiology-acquired access. No significant differences were found with regard to unusable access, multiple tracts, supracostal access, ancillary procedure requirement, operative time, minor complications, and transfusions. Conclusions: Urologist-acquired access may be associated with a higher stone-free rate and a reduction in major complications, whereas interventional radiologist-mediated access may be associated with a reduction in blood loss, despite similar transfusion rates.

Abstract 9556: From Low Volume to High Volume: Successful Reduction in Major Complications While Building Transvenous Lead Extraction Center Volume

Introduction: Transvenous lead extraction (TLE) is associated with better outcomes in high-volume (HiV, &gt;30 TLE/year) than low-volume centers. Little data exist regarding transitioning to a HiV TLE center. We examined the impact of strategic interventions at a tertiary care center transitioning to a HiV TLE center. Hypothesis: Systematic interventions to increase TLE volume and quality are expected to decrease the rate of major complications without adversely affecting procedural success rates. Methods: Consecutive patients undergoing TLE with leads &gt;1 year post implantation from 2012-2021 were reviewed. The primary endpoints were TLE success and major complications including TLE-related mortality, vascular laceration, pericardial effusion, and emergent cardiothoracic surgery. Outcomes were compared between TLE completed in 2012-2018 prior to the intervention (n=125) and TLE after intervention 2019-2021 (n=127). Results: There were 252 consecutive TLE procedures included involving 398 leads. Strategic interventions were implemented in 2018 (Figure). Annual mean TLE volume increased from 19.5 TLE (29.7 leads) to 42.4 TLE (69.7 leads). Baseline characteristics including age (62.4±14.7 vs. 61.9±17.4), gender (52.4% vs. 47.7% male), and infectious indications (33.6% vs. 35.4%) were similar (P&gt;0.05 for all). With the transition to a HiV center, there was no significant change in complete procedural success (84.0% vs. 85.8%, P=0.73) and clinical success (94.4% vs. 96.1%, P=0.57). Major complications significantly decreased from 10/125 (8.0%) to 3/127 (2.4%) after the interventions in 2018 (P=0.049). Conclusions: Multidisciplinary improvements in pre-procedural risk stratification, scheduling, and technique resulted in a successful transition to a HiV TLE center with a reduction in major complications and a high procedural success rate.

Complication rates of direct puncture and pull-through techniques for percutaneous endoscopic gastrostomy: Results from a large multicenter cohort.

Background and study aims Two different techniques for percutaneous endoscopic gastrostomy (PEG) have been developed: classical pull-through and direct puncture techniques. This study compared the complication rate for both techniques in a large retrospective patient cohort. Patients and methods Clinical data from patients who received a PEG in four high-volume centers for endoscopy were included retrospectively between January 2016 and December 2018. Patient characteristics and complication rates were correlated in univariate and multivariate analyses. Results Data from 1014 patients undergoing a PEG insertion by the pull-through technique were compared to 183 patients for whom the direct puncture technique was used. The direct puncture technique was associated with a 50 % reduction in minor and 85.7 % reduction in major complications when compared to the pull-through technique. Multivariate analysis of these data revealed an odds ratio of 0.067 (0.02-0.226; P < 0.001) for major complications in the direct puncture group. Conclusions Compared to the pull-through technique, the direct puncture technique resulted in a significant reduction in complications. Despite the retrospective design of this study, these results suggest that the direct puncture technique may be preferable to improve patient safety.

Volatile versus Total Intravenous Anesthesia for Coronary Artery Bypass Graft Surgery: Analysis of 1586 MYRIAD Trial Patients Managed with the Same Perioperative Protocol

Background: This study investigated the influence of volatile anesthesia (VA) on major complications and mortality in patients undergoing coronary artery bypass graft surgery (CABG). Methods: This post-hoc analysis included 1586 patients from the MYRIAD trial managed using the same perioperative protocol at a single institution. Patients were randomized to receive either volatile anesthesia (sevoflurane, isoflurane, or desflurane) or total intravenous anesthesia (TIVA). The assessed study outcomes were the rate of complications, including: myocardial infarction, stroke, acute kidney injury, prolonged ventilation (&gt;24 h), receipt of high-dose inotropic support (inotropic score &gt;10), and need for mechanical circulatory support. The duration of intensive care unit (ICU) stay, length of hospitalization, hospital readmission during follow-up, 30-days and 1-year mortality were also analyzed. Results: 1586 patients were enrolled between September 2014–September 2017 and randomly assigned to the volatile anesthesia group (n = 794) and the TIVA group (n = 792). The median patient age was 63 years, with a median ejection fraction of 60%. There were no significant differences in the rates of major complications, duration of ICU stay, and hospitalization between the groups. The median total dose of fentanyl was 12.0 mcg/kg in volatile group and 14.4 mcg/kg in TIVA group (p &lt; 0.001). One-year mortality rates were 2.5% (n = 20) and 3.2% (n = 25) in the volatile and TIVA groups, respectively. Two patients were lost at the 30-day and 1-year follow-ups in the volatile group compared to four patients in TIVA group. Regression analysis showed that cardiopulmonary bypass (CPB) duration, fentanyl dose, and baseline serum creatinine level were associated with 30-days mortality, while ejection fraction was associated with 1-year mortality. Conclusions: The use of VA in patients undergoing CABG did not result in a reduction in major complications or mortality compared with TIVA. A higher dose of fentanyl was used in the TIVA group and was associated with an increase in the 30-days mortality. These findings warrant further investigation. Clinical Trial Registration: ClinicalTrials.gov (NCT02105610).

60% Reduction of reoperations and complications for elderly patients with hip fracture through the implementation of a six-item improvement programme

IntroductionHip fractures are common, serious and costly fractures in the elderly population. Several guidelines seeking to ensure best practice have been introduced. Although our institution complied with national guidelines for...

Desmopressin Acetate Before Percutaneous Ultrasound-Guided Kidney Biopsy in Patients with Renal Failure - Is it Really Beneficial?

The most common complication of percutaneous renal biopsy is bleeding, which can be seen in up to one-third of cases. The aim of this study was to evaluate the effect of prebiopsy administration of intranasal desmopressin acetate in reducing the incidence of biopsy-related bleeding complications in patients with significant renal dysfunction who underwent renal biopsy. This was a retrospective, observational study of percutaneous native renal biopsies performed at our center from July 2014 to June 2018. Bleeding complication rates of patients with renal failure (estimated glomerular filtration rate [eGFR] <30 mL/minute/1.73 m2) who received desmopressin and those who did not receive desmopressin were compared. Desmopressin administration before renal biopsy in patients with eGFR <30 mL/minute/1.73 m2 was associated with a significant reduction of bleeding complications (major and minor together; P = 0.025) and no significant reduction in major complications (P = 0.616) or intervention rates (P = 0.251) when compared with a group that did not receive desmopressin. While prebiopsy intranasal desmopressin use was associated with a significant reduction of overall bleeding complications including major and minor complications, there was no reduction in the rate of other major complications and interventions.

Short stump and high anastomosis pull-through (SHiP) procedure for delayed coloanal anastomosis with no protective stoma for low rectal cancer

Despite advances in coloanal anastomosis techniques, satisfactory procedures completed without complications remain lacking. We investigated the effectiveness of our recently developed ‘Short stump and High anastomosis Pull-through’ (SHiP) procedure for delayed coloanal anastomosis without a stoma. In this retrospective study, we analysed functional outcomes, morbidity, and mortality rates and local recurrence of 37 patients treated using SHiP procedure, out of the 282 patients affected by rectal cancer treated in our institution between 2012 and 2020. The inclusion criterion was that the rectal cancer be located within 4 cm from the anal margin. One patient died of local and pulmonary recurrence after 6 years, one developed lung and liver metastases after 2 years, and one experienced local recurrence 2.5 years after surgery. No major leak, retraction, or ischaemia of the colonic stump occurred; the perioperative mortality rate was zero. Five patients (13.51%) had early complications. Stenosis of the anastomosis, which occurred in nine patients (24.3%), was the only long-term complication; only three (8.1%) were symptomatic and were treated with endoscopic dilation. The mean Wexner scores at 24 and 36 months were 8.3 and 8.1 points, respectively. At the 36-month check-up, six patients (24%) had major LARS, ten (40%) had minor LARS, and nine (36%) had no LARS. The functional results in terms of LARS were similar to those previously reported after immediate coloanal anastomosis with protective stoma. The SHiP procedure resulted in a drastic reduction in major complications, and none of the patients had a stoma.

Semi-closed-circuit vacuum-assisted MiniPCNL system in pediatric patients

Surgical treatment of kidney stones has changed over the years. The use of Mini Percutaneous Nephrolithotomy (MiniPCNL) instrumentation is associated with a reduction of major complications but it lengthens the operative time (OT). This limit may be overcome by a semi-closed-circuit vacuum-assisted MiniPCNL system, characterized by a continuous inflow and a suction-controlled outflow. We present our initial experience in pediatric patients who underwent PCNL using a 12 Fr nephroscope and a 16-Fr-large nephrostomy sheath, equipped with a lateral arm connected to suction. We used Holmium laser lithotripsy and performed lapaxy by drawing back slowly the nephroscope inside the sheath until the opening of the lateral aspiration arm, without using other devices. The stone-free rate (SFR) was assessed at 4 weeks. We included 12 procedures in 8 patients with a median age of 119 months and a median weight of 27Kg. The median OT was 108min and the SFR was 80%. No intra-operative complications occurred, while minor post-operative complications occurred after 4/12 procedures. These preliminary data in pediatric population showed the employed system is a safe and effective approach to treat complex kidney stones with a satisfactory SFR and a low OT.

Innovation in health care: continuous wireless monitoring to improve management of critically ill atients: LIMS study preliminary results

Abstract Background Wireless vital parameter continuous monitoring (WVPCM) is compared to regular nurse monitoring in order to provide data on the clinical and economic impact of critically ill patients (CIPs) in Internal Medicine Units (IMU). Study Design Pilot prospective randomized controlled open-label multi-center study with WIN@Hospital wearable wireless system creating alerts on portable devices (ipad). Experimental Arm: CIPs with MEWS (Modified Early Warning Score) ≥3 and/or NEWS (National Early Warning Score) ≥5 at admission underwent WCPCM over the first 72 h. Active Comparator: CIPs with MEWS ≥3 and/or NEWS ≥5 at admission undergoing regular nurse monitoring. Method Primary outcomes: Reduction of major complications (MC) from 15% to 5%. Secondary outcomes: One day reduction in length of stay (LOS); reduced nurse monitoring time; accurate patient stratification and definition of end stage disease. Results Preliminary results: Enrolled 145 and evaluable 125 patients (51 M/74 F), mean age 80.5 years, Comorbidity: Cumulative Illness Rating Scale CIRS-CI: 4, CIRS SI: 1.8. About 38% scored a BRASS (Blaylock Risk Assessment Screening Score) ≥20 indicating need for discharge planning requiring step-down care. More than 50% of patients present IIA index &amp;gt;3 indicating high dependency from nursing assistance. Nurses saved a minimum of 49,6 minutes to a maximum of 58,1 minutes on time spent monitoring each patient per day. A trend towards reduction of major complications in the experimental group appears to be seen (31% versus 45%). Decrease in re-admissions (7% versus 11%) and mortality (7.3% versus 23.9%) has been observed. Arrhythmic and ischemic complications detection doubled in the experimental arm. More than 30% of the patients meet the criteria defining end stage disease. Conclusion WVPCM, detecting early deterioration in CIPs, may facilitate timely response in at-risk patients, increasing safety and reducing costs. Telemedicine Network Funding Acknowledgement Type of funding source: None

Crisis of confidence in cardiothoracic trainees: National trends in the use of minimally invasive esophagectomy

Esophagectomy is highly morbid. Although overall survival has improved with centralization of care, postoperative morbidity has been quoted as approaching 60%.1,2 However, a recent multicenter randomized controlled trial reported a 77% reduction in major complications with hybrid minimally invasive esophagectomy compared with an open approach.3 Furthermore, randomized data support lower pulmonary morbidity following minimally invasive esophagectomy.4 Despite these convincing data, a survey of recent cardiothoracic graduates suggested a crisis of confidence in performing minimally invasive esophagectomy.

Laparoscopic bowel resection of deep infiltrating endometriosis. Comparative outcomes of a public teaching hospital and a referral private hospital.

Purpose To compare the operative outcomes of laparoscopic surgical treatment for bowel endometriosis in a public teaching hospital versus in a private referral hospital.Methods The indications for surgery, type and time of operation, length of hospital stay, need for a temporary stoma, rate of conversion to open surgery, and postoperative complications were evaluated.Results One hundred eighty-one patients were included (150 patients, 82.9%, in a private hospital). In the private hospital, there were more patients with infertility [56% vs. 29%; P=0.01] as an indication for surgery) and segmental resection was more common in the private hospital (48% vs. 29%, p=0.05). The average operative time (211.9±83.4 minutes vs. 128 ± 55 minutes, p<0.001) as well as the length of hospital stay (3.97±1.7 days vs. 1.56±0.85 days, p<0.001) was higher in the public hospital; the rate of conversion to open surgery was significantly lower in the private hospital (2% vs. 32.3%, p<0.001). Operations performed at the public hospital were associated with higher rates of postoperative complications (Clavien-Dindo II and II) (38.7% x 11.3%, p=0.021; OR 3.2, CI 95% 1.2-8.0).Conclusion Laparoscopic surgery in private centers was associated with reductions in major complications, surgical times, lengths of stay and rates of conversion to open surgery compared to that in public teaching hospitals.

Benefits of minimally-invasive surgery for sigmoid and rectal cancer in older adults compared with younger adults: Do older adults have the most to gain?

IntroductionRandomized trials demonstrated oncologic safety and short-term benefits of laparoscopy. We investigated if the benefit of laparoscopy on short-term outcomes is greater for older adults compared with younger adults. MethodsWe identified all older (≥70 years old) and younger (<70) adults with primary sigmoid and rectal cancer treated with resection between 2002 and 2018 from an institutional database. We compared 30-day postoperative outcomes using multivariable logistic regression with an interaction term between age group and surgical approach. Primary outcomes were death, major (Clavien-Dindo III-IV) and minor (Clavien-Dindo I-II) complications, and wound complications. ResultsWe included 792 patients, 293 (37%) older and 499 (63%) younger. Use of laparoscopy was similar between age groups: 120/293 (41%) older, 204/499 (41%) younger (p = .98). All patients had 30-day follow-up. Compared with open resection, minimally-invasive resection was associated with a greater reduction in deaths in older adults than in younger adults (absolute difference in older adults 7.0% less versus 2.1% less in younger adults; adjusted odds ratio [aOR] older 3.01, 95% confidence interval [CI] 1.31–7.33; aOR younger 0.31, 95% CI 0.05–1.24; interaction p = .01). Similarly, minimally-invasive resection was associated with a greater reduction in major complications in older adults than in younger adults (absolute difference in older adults 6.4% less versus 2.4% less in younger adults; aOR older 1.91, 95% CI 1.07–3.41; aOR younger 0.70, 95% CI 0.34–1.38; interaction p = .03). ConclusionsMinimally-invasive compared with open surgery demonstrated a differential benefit on postoperative death and major complications between younger and older adults.

Opioid tolerance impacts compliance with enhanced recovery pathway after major abdominal surgery

BackgroundOpioid tolerant patients have been shown to have poor postoperative outcomes. Enhanced recovery pathways are evidence-based interventions that focus on optimizing recovery, and their effectiveness depends on the degree of compliance with the pathway. We wish to determine pathway compliance and its impact on postoperative outcomes in opioid tolerant patients undergoing abdominal surgery on an enhanced recovery pathway. MethodsFrom December 2014 to June 2017, 646 patients undergoing major abdominal surgery on an enhanced recovery pathway were included. Patients <18 years and having emergency surgery were excluded. Compliance was measured to 14 perioperative pathway standards and high-compliance was defined as adhering to ≥75% standards. Opioid tolerance was defined as any patient taking a prescribed opioid medication equivalent to 60 mg of oral morphine per day for 1 week prior to surgery. The Colorectal Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity was used for risk-adjusted analyses. Outcomes of interest include length of stay, major complications (Clavien-Dindo ≥2), 30-day readmission rates, and mortality. ResultsOverall, 114 (18%) patients were opioid tolerant and 532 (82%) were not opioid tolerant. Opioid tolerant patients were less likely to be highly compliant with enhanced recovery pathway standards than non-tolerant patients (35% vs 54%; P < .001); particularly postoperative care standards. On adjusted analysis, opioid tolerance was associated with a 2-fold increase in readmissions following major abdominal surgery. Examining only those patients with opioid tolerance, adjusted analysis demonstrated that high compliance with the enhanced recovery pathway standards was independently associated with a 26% reduction in length of stay, over a 90% reduction in major complications, and mitigated the effect on readmissions. ConclusionThe authors provide evidence that opioid tolerance is associated with less favorable outcomes in patients undergoing major abdominal surgery on an enhanced recovery pathway, and this is likely due to a lack of pathway compliance. Establishing strategies to improve compliance in this challenging patient cohort may serve to mitigate the negative impact of opioid tolerance.