Risk Of Perioperative Complications Research Articles

A survey to determine the zone of equipoise for the Proximal FEmur Resection or Internal Fixation fOR Metastases (PERFORM) randomized controlled trial.

The objective of this study was to establish a zone of clinical equipoise for the Proximal FEmur Resection or Internal Fixation fOR Metastases (PERFORM) randomized controlled trial, which will compare resection and endoprosthetic reconstruction to internal fixation for skeletal metastases of the proximal femur. A survey was developed, piloted, and distributed to self-declared interested stakeholders in the PERFORM trial. The survey targeted orthopedic oncologists and was designed to assess patient and bone lesion characteristics that drive surgical decision-making in the treatment of skeletal metastases in the proximal femur. An Ethics Waiver was obtained at the lead academic institution and data was collected in the REDCap survey database. Responses were complete from 76 surgeons across North America, South America, Europe, Asia, and Africa. Response rate from self-declared interested stakeholders was 70%, with additional responses collected from a broader international audience. Responses indicate that a study population for which either resection and endoprosthetic reconstruction or internal fixation are acceptable options include (1) life expectancy at least 6months, (2) bone loss of no more than 75% and no less than 25%, and (3) minimal to moderate risk for perioperative complications. Ninety-three percent of respondents indicated that they would be interested in participating in the PERFORM trial. A preliminary zone of equipoise for the PERFORM trial includes patients with 25-75% bone loss, low to moderate risk of operative complications, and life expectancy of at least 6months. Further stakeholder discussions have finalized the PERFORM trial protocol prior to study initiation.

Abstract 4135092: Prolonged Procedure Time and Its Association with Peri-Procedural Complications in Endovascular Therapy for Symptomatic Lower Extremity Arterial Disease

Background: Prolonged operative times in surgical procedures have been significantly associated with an increased risk of complications. However, the impact of prolonged procedure time of peri-procedural complications in patients undergoing endovascular therapy (EVT) for symptomatic lower extremity arterial disease (LEAD) has not been systematically evaluated. Aims: To determine the association between prolonged procedure time and peri-procedural complications in patients undergoing EVT for symptomatic LEAD. Methods: Data from a nationwide EVT registry in Japan (J-EVT) between 2021 and 2022 were analyzed. The outcome measure was peri-procedural complications defined as a composite of perioperative death, major bleeding, contrast nephropathy, myocardial infarction, ischemic stroke, and major amputation. Procedure time was categorized into four clinically relevant groups (≤59, 60–119, 120–179, and ≥180 minutes). The logistic regression model was developed to investigate the risk of peri-procedural complications across subgroups of procedure time with the shortest subgroup (≤59 minutes) set as the reference category. Results: A total of 47,301 patients (average age: 75±9 years, male: 69.0%, chronic limb-threatening ischemia [CLTI]: 51.0%) undergoing EVT for symptomatic LEAD were analyzed. Notable comorbidities included diabetes mellitus at 60.6% and dialysis at 29.9%, respectively. A history of coronary artery disease was noted in 40.7% of the participants. The median procedure time (interquartile range) was 110 (74–161) minutes. A total of 431 patients (0.9%) experienced perioperative complications. The perioperative complications included 48 deaths, 277 cases of major bleeding, 28 cases of contrast nephropathy, 10 myocardial infarctions, 16 ischemic strokes and 72 major amputations. After adjusting for patient and limb characteristics, and hospital and operator volumes, the odds ratios for perioperative complications were 1.21 (P=0.45) for 60–119 minutes, 2.36 (P=0.001) for 120–179 minutes, and 5.31 (P<0.001) for ≥180 minutes with the shortest subgroup (<59 min) set as the reference. Conclusions: Prolonged procedure time of EVT for symptomatic LEAD was significantly associated with an increased risk of perioperative complications.

Anesthetic Management in Obstructive Sleep Apnea: A Narrative Review

Obstructive Sleep Apnea (OSA) introduces substantial difficulties in the management of anesthesia, largely due to its implications for airway management, sensitivity to sedative agents, and an elevated risk of complications during the perioperative period. This narrative review seeks to offer an in-depth exploration of the contemporary approaches to anesthesia management in patients diagnosed with OSA. It covers the entire continuum of care, including preoperative, intraoperative, and postoperative phases. The review underscores the critical importance of an accurate and thorough diagnosis of OSA, which is essential for formulating effective anesthetic strategies. Risk stratification is emphasized as a key element in identifying the specific challenges posed by each patient’s condition and tailoring the anesthesia plan accordingly. By examining current practices and recommendations, the review aims to provide insights into how individualized anesthetic plans can be designed to reduce the risk of perioperative complications and enhance patient safety

Smokeless Tobacco Use is Associated with a Lower Risk of Perioperative Complications and Revision Surgery after Anatomic and Reverse Total Shoulder Arthroplasty Compared to Cigarette Smokers

Smokeless Tobacco Use is Associated with a Lower Risk of Perioperative Complications and Revision Surgery after Anatomic and Reverse Total Shoulder Arthroplasty Compared to Cigarette Smokers

Glucagon-like Peptide-1 Receptor Agonist Use is Associated With Increased Risk of Perioperative Complication and Readmission Following Shoulder Arthroplasty

Glucagon-like peptide-1 (GLP-1) receptor agonists, increasingly used for diabetes management and weight loss, have been linked to lower readmission rates after knee and hip arthroplasty. However, their impact on total shoulder arthroplasty (TSA) outcomes remains unclear. This study investigates the effects of GLP-1 receptor agonists on major complications and revisions following TSA. A retrospective query of the TriNetX database from 2010 to 2023 was performed to identify patients who underwent anatomic or reverse TSA and were prescribed GLP-1 receptor agonists. GLP-1 receptor agonist users were 1:1 propensity score-matched to controls for demographic factors and comorbidities, yielding 1,259 patients in each group. Outcomes included 90-day postoperative medical complications and readmission and revision surgery at 2 years. Odds ratios (ORs), 95% confidence intervals, and P values were calculated. After Bonferroni correction, P < 0.005 was considered significant. GLP-1 receptor agonist users (n = 1,259) experienced significantly higher rates of deep vein thrombosis (1.6% vs. 0.9%; OR 3.0; P = 0.001), myocardial infarction (1.60% vs. 0.9%; OR 2.84; P = 0.003), pneumonia (3.34% vs 1.50%; OR 2.25; P = 0.003), transfusion (7.1% vs. 4.3%; OR 1.7; P = 0.003), and readmission (8.1% vs 5.2%; OR 1.6; P = 0.004) in the 90-day postoperative period compared to patients not taking GLP-1 receptor agonists. There were no differences in the rates of stroke, pulmonary embolism, postoperative anemia, or renal failure. In patients with a minimum 2-year follow-up (n = 776), there was no difference in revision rate (3.2% vs 1.8%; OR 1.8; P = 0.07). GLP-1 receptor agonist use during TSA was associated with an increased risk of deep vein thrombosis, myocardial infarction, pneumonia, need for transfusion, and readmission. Further investigation into the perioperative risk assessment and medical optimization of patients utilizing GLP-1 receptor agonists may be warranted.

Сравнение методик пункционно-дилатационной трахеостомии Фрова и Григгс у пациентов с избыточной массой тела и ожирением: рандомизированное контролируемое исследование

INTRODUCTION: Tracheostomy is one of the most frequently performed operations in intensive care patients. This is due to the fact that in the population of intensive care patients, puncture tracheostomy has a number of advantages compared to surgical tracheostomy (ST). This determines the urgency of finding ways to reduce the risk of perioperative complications during puncture tracheostomy in intensive care patients, especially in overweight and obese patients. OBJECTIVE: To study the advantages and limitations of puncture dilation tracheostomy (PDT) performed using the Frova method under ultrasound control in intensive care patients with overweight and obesity, in comparison with the Griggs PDT method under fibrobronchoscopic (FBS) control. MATERIALS AND METHODS: The presented prospective study was conducted in the departments of anesthesiology and intensive care of the A.I. Burnasyan Federal Medical Biophysical Center FMBA from 2017 to 2021, which included 92 overweight and obese patients whose body mass index (BMI) was more than 25 kg/m2 and required tracheostomy. Two groups were identified: group (n = 48) — Frova tracheostomy under ultrasound control, group (n = 44) — Griggs tracheostomy under FBS control. RESUITS: Performing PDT using the Frova technique under ultrasound control is feasible and safe in intensive care patients with overweight and obesity, whereas with grade 3 obesity with a BMI of more than 41 kg/m2 and/or with a thickness of pretracheal soft tissues of more than 40 mm, PDT using the Frova technique should be abandoned and should be considered as absolute contraindications for performing PDT using the Frova method under ultrasound control. CONCLUSIONS: PDT using the Frova method under ultrasound control, when compared with the Griggs method with FBS control, can significantly reduce the incidence of intraoperative desaturation, arterial hypotension, intraoperative severe hemorrhagic complications, postoperative soft tissue infection around a tracheostomy wound.

Концепция периоперационного риска: обзор литературы

INTRODUCTION: Perioperative risk refers to the likelihood of adverse events occurring during and after surgery. For the purpose of defining and classifying adverse events and predicting them, a comprehensive search of Pubmed and Lens.org was made according to the author expert opinion. OBSERVATIONS: Traditionally, two main types of postoperative adverse events have been investigated: complications and mortality. However, over the past decade, there has been a growing trend to expand the range of adverse events analyzed, from intraoperative critical events and the quality of recovery from anesthesia to the development of intensive care syndrome, assessing quality of life, disability, and survival over time. An important aspect associated with adverse events and outcomes is the provision of additional resources for a long-term stay for patients with acute respiratory viral infections and inpatient care after discharge, among other things. The review formulates its own concept of perioperative risk, based on a critical analysis of literature, with an emphasis on the need to create an ideal tool, such as a calculator, that must undergo external validation. This tool should include available, modifiable variables, and accurately determine the full range of adverse events and outcomes during the intra- and early postoperative periods, as well as delayed events. The concept shall also focus on identifying and characterizing patients with a high risk of perioperative complications.

The impact of body mass index for atrial fibrillation ablation; real-world data on outcomes and quality of life

Abstract Background Pulmonary vein isolation (PVI) is a cornerstone in the management of atrial fibrillation (AF). Increasing numbers of overweight and obese patients undergo PVI, despite the association between a higher body mass index (BMI) and adverse ablation outcomes. The risks of perioperative complications and quality of life have hardly been studied for the different bodyweight groups. Purpose The purpose of this study is to clarify the impact of BMI on PVI outcomes, including both perioperative complications and change in quality of life after PVI. Methods This is an observational, multicentre cohort study of prospectively collected data, covering all 15 ablation centres in the Netherlands. The study included all patients who underwent their first catheter-PVI between January 2015 and December 2021. Patients with a BMI below 18.5 kg/m2, missing BMI data, or prior ablations were excluded. Patients were categorized by BMI; normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25-29.9 kg/m2) and obesity (BMI ≥30 kg/m2). The primary outcome was repeat ablation within one year. A logistic regression model was used to adjust for patient characteristics. A generalized additive model was fitted to visualize the correlation between BMI and the risk of repeat ablation. Secondary outcomes were repeat ablation within 3 years, a composite of the periprocedural complications, and change in quality of life, assessed using the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) questionnaire before and at one year after PVI. Results A total of 20,725 patients (33% female) were included; 72% had a paroxysmal AF pattern. Of all patients, 30% were normal weight, 47% overweight and 23% obese. Within the first year post-index PVI, obese patients had a higher incidence of repeat ablation than normal-weighing and overweight patients (17.8% versus 15.6% and 16.1%, P &amp;lt;0.05). Obesity independently predicted an increased risk of repeat ablation within 1 year (odds ratio 1.15; 95%-confidence interval 1.01-1.31, P =0.03). This increased risk was also apparent for repeat ablations within 3 years (hazards ratio 1.15; 95%-confidence interval 1.06-1.25; P &amp;lt;0.01). The composite complication rate was 3.8% in normal weighing, 3.0% in overweight, and 4.6% in obese patients, with weight class not being an independent predictor. All weight groups had a substantial improvement in quality of life one year after ablation. Post PVI, summarized AFEQT score was still lower in obese patients (81), than in normal weight (88; P &amp;lt;0.01) and overweight patients (88; P &amp;lt;0.01). Conclusions In a nation-wide contemporary cohort, obesity is an independent predictor for undergoing a repeat ablation within both 1 and 3 years. This relation is not apparent for overweight individuals. Catheter ablation can safely be performed in all weight classes. Despite an overall lower quality of life among obese individuals, substantial improvements in quality of life occur in all weight groups.Visual abstract

A Survey to Determine the Zone of Equipoise for the Proximal FEmur Resection or Internal Fixation fOR Metastases (PERFORM) Randomized Controlled Trial.

The objective of this study was to establish a zone of clinical equipoise for the P roximal F E mur R esection or Internal F ixation f OR M etastases (PERFORM) randomized controlled trial, which will compare resection and endoprosthetic reconstruction to internal fixation for skeletal metastases of the proximal femur. A survey was developed, piloted, and distributed to self-declared interested stakeholders in the PERFORM trial. The survey targeted orthopaedic oncologists and was designed to assess patient and bone lesion characteristics that drive surgical decision making in the treatment of skeletal metastases in the proximal femur. An Ethics Waiver was obtained at the lead academic institution and data was collected in the REDCap survey database. Responses were complete from 76 surgeons across North America, South America, Europe, Asia and Africa. Responses indicate that a study population for which either resection and endoprosthetic reconstruction or internal fixation are acceptable options include: (1) life expectancy at least 6 months, (2) bone loss of no more than 75% and no less than 25%, and (3) minimal to moderate risk for peri-operative complications. Ninety-three percent of respondents indicated that they would be interested in participating in the PERFORM trial. A preliminary zone of equipoise for the PERFORM trial includes patients with 25-75% bone loss, low to moderate risk of operative complications, and life expectancy of at least 6 months. Further stakeholder discussions will finalize the PERFORM trial protocol prior to study initiation.

Effects of Chronic Obstructive Pulmonary Disease on the Outcomes of Fenestrated-Branched Endovascular Aortic Aneurysm Repair.

Chronic obstructive pulmonary disease (COPD) is common in patients with aortic aneurysms. Severe COPD is associated with an increased risk of aneurysm rupture and perioperative complications. This study assesses the outcomes of COPD and non-COPD patients after fenestrated-branched endovascular aortic aneurysm repair (FBEVAR). A single institution, retrospective study of FBEVAR patients between 2011 and 2020 compared outcomes between COPD and non-COPD patients. COPD patients were stratified by Global Initiative for Chronic Obstructive Lung Disease criteria and oxygen dependence. Outcome measures included 30-day mortality, pulmonary complications, major adverse events (MAE), and mid-term survival. 387 patients (71% male, age 72 years, interquartile range [68-79]) underwent FBEVAR. 181 patients (47%) had COPD. Smoking history was more frequent in COPD patients (P = .022). Among COPD patients, 20.4% were oxygen-dependent. Technical success, defined as successful delivery of the main aortic endograft and all intended side branches, was 98.4%. 30-day mortality (P = .83) and MAE rates (P = .87) were similar between groups. While not statistically significant, COPD patients had more frequent pulmonary complications (6.1% vs. 2.4%, P = .13) and were more frequently discharged on oxygen (P = .002). There were no differences in intensive care unit or hospital length of stay between groups (P = .29; P = .85, respectively). 5-year survival was similar between groups (P = .10). Oxygen-dependent COPD and severe-very severe COPD were associated with decreased mid-term survival (Hazard Ratio 2.39, P = .048). FBEVAR is safe and effective for treating complex aortic pathology in COPD patients, including oxygen-dependent patients. Patients with more severe COPD were more frequently discharged on oxygen. Mid-term survival was slightly reduced in patients with oxygen-dependent and severe-very severe COPD. Level 3, non-randomized controlled cohort/follow-up study.

Algorithm for Managing Patients Hospitalized in the Surgical Wards Due to COVID-19-Related Acute Abdominal Pathology

AIM OF THE STUDY. Was to improve the outcomes of treatment of patients with COVID-19-related acute abdominal pathology by developing and implementing an algorithm for the diagnosis and treatment of those patients.MATERIAL AND METHODS. The study involved 200 patients who were randomized into two groups. This research was retrospective, based on the analysis of the medical histories of patients hospitalized with clinical manifestations of acute abdominal pathology that developed against the background of COVID-19. All medical histories in emergency departments and centers of the Republic of Uzbekistan were analyzed in the period from the beginning of the declaration of the pandemic (March 2020) to July 2022 inclusive.RESULTS. In the context of an infectious disease pandemic (COVID–19 as an example), it is very important to develop an algorithm for managing patients with acute surgical pathology. This algorithm should include a diagnostic component with the purpose of timely diagnosis of acute surgical pathology and hospitalization in the surgical department. The next step is to identify patients with a high risk of perioperative complications and adverse outcomes. The final component of the algorithm is the correction of possible risk factors for adverse outcomes.CONCLUSION. The duration of hospitalization of patients who underwent surgery for acute abdominal pathology was significantly longer during the pandemic compared to that of in the post-pandemic period (10.35±7.01 vs. 5.83±3.85 days, p&lt;0.001), which may be due to both changes in the structure of the pathology and a larger number of complicated forms. The application of the developed algorithm will optimize the management of patients with COVID-19-related acute surgical pathology, guarantee rapid decision-making while minimizing the risk of infection, reduce the risk of complications and adverse outcomes.

Second-Generation Supraglottic Airway Devices Versus Endotracheal Intubation in Adults Undergoing Abdominopelvic Surgery: A Systematic Review and Meta-Analysis

BACKGROUND: Second-generation supraglottic airway (SGA) devices are widely used, but thought to have inferior safety performance to endotracheal tubes (ETTs), but might be equally efficacious while improving patient-centered outcomes. We compared second-generation SGAs with ETTs for perioperative safety, efficacy, and quality of recovery in adults undergoing abdominopelvic surgery under general anesthesia. Our primary objective was to assess safety in the form of major airway complications. Secondary objectives were other safety, efficacy, and quality of recovery outcomes. METHODS: We searched 4 databases for randomized controlled trials of adult patients having abdominopelvic surgery comparing second-generation SGAs and ETTs. After 2-person screening and data extraction, pairwise meta-analysis was conducted and the grading of recommendations, assessment, development, and evaluation (GRADE) approach was applied to assess the certainty of evidence. RESULTS: A total of 51 studies, randomizing 5110 patients, were included. Second-generation SGAs significantly reduced the risk of major perioperative airway complications (risk ratio [RR], 0.41; 95% confidence interval [CI], 0.23–0.71; P = .007; low certainty), with no clear clinically relevant difference in regurgitation or pulmonary aspiration (low certainty). SGAs significantly increased the risk of inadequate ventilation (RR, 3.36; 95% CI, 1.43–7.89; P = .011; very low certainty); however, postoperative sore throat (RR, 0.52; 95% CI, 0.38–0.70; P &lt; .001; moderate certainty), hoarseness (RR, 0.32; 95% CI, 0.231–0.48; P &lt; .001; low certainty), coughing at the emergence of anesthesia (RR, 0.17; 95% CI, 0.08–0.36; P &lt; .001; low certainty), and postoperative nausea and vomiting (RR, 0.64; 95% CI, 0.42–0.98; P = .042; very low certainty) were all less frequent with SGAs. No other clinically relevant differences were observed for other remaining outcomes. CONCLUSIONS: Second-generation SGAs reduce the risk of major airway complications compared with ETTs in adults undergoing abdominopelvic procedures under general anesthesia, with no reported clinically relevant differences in the risk of regurgitation or pulmonary aspiration. Additionally, they improve the quality of postoperative recovery with lower risk of sore throat, hoarseness, and postoperative nausea and vomiting. These data provide an opportunity for clinicians to reassess the implications of conservative airway management, and potentially expand the role of second-generation SGAs in routine clinical practice.

Curve-centered plaques raise the risk of peri-operative neurological and cardiovascular complications during angioplasty and stenting for severe carotid stenosis.

Carotid artery stenting is an alternative interventional treatment to carotid endarterectomy. However, preprocedural considerations and anatomical risk factor analyses for carotid artery stenting are currently insufficient. Therefore, we investigated the high-risk anatomical appearance of carotid artery stenting from the neurointerventionist perspective to predict periprocedural complications. We retrospectively reviewed patients with carotid stenosis who underwent carotid artery stenting at a comprehensive stroke center between January 2012 and December 2021. We compared the demographic characteristics, medical history, and anatomical appearance of the stenotic segment in patients with and without complications. We analyzed a total of 148 patients (64 women [43.2%]; median age, 73.0 [interquartile range, 65.5-79.0]). Complications occurred in 39 of the 148 patients, primarily minor and transient. Of baseline or procedural characteristics, a high initial National Institutes of Health Stroke Scale score (p = 0.04), symptomatic stenosis (p = 0.01), and curve-centered plaque of the proximal ICA (p = 0.01) were significantly associated with carotid artery stenting complications in unadjusted analysis. Curve-centered plaque remained an independent risk factor for carotid artery stenting complications after adjustment (odds ratio 2.23[1.02-4.88], p = 0.04). High-risk vascular anatomical features, such as curve-centered plaque, are associated with a high frequency of periprocedural complications of carotid artery stenting. Tailored patient selection for carotid stenosis is crucial to prevent complications. Patients with curve-centered plaque should consider alternative treatment options such as carotid endarterectomy to achieve optimal clinical results.

Tubeless ureteroenteric anastomosis in robot-assisted radical cystectomy with intracorporeal urinary diversion does not increase the risk of anastomotic stenosis or postoperative complications.

The objective is to demonstrate that omitting ureteral stent placement in robotic intracorporeal urinary diversion does not lead to increased risk of perioperative complications, namely ureteral strictures or anastomotic leaks. We retrospectively reviewed the records of 68 consecutive patients who underwent robotic radical cystectomy with ileal conduit creation or orthotopic neobladder by a single surgeon between January 2020 and September 2023. Chronologically, the first cohort of patients had ureteral stents placed to bridge the ureteroenteric anastomosis, and in the second cohort, stenting was omitted. Cohort 1 consisted of 28 patients with surgeries performed between January 2020 and April 2021, while cohort 2 had 40 patients who underwent surgery from April 2021 to September 2023. The cohorts were well matched with regard to patient age, gender, ASA score and rate of neoadjuvant chemotherapy. The choice of urinary diversion was left to surgeon and patient preference, and there was no significant difference in the proportion of ileal conduits versus orthotopic neobladders within each cohort. Estimated blood loss, total operative time, inpatient length of stay and pathologic T and N staging did not statistically differ between the cohorts. Overall, there was no difference in the rates of postoperative ileus, ureteral stricture, anastomotic leak, infectious complications, and 30-day readmission rates between the groups. Tubeless ureteroenteric anastomosis in patients undergoing robotic radical cystectomy with intracorporeal diversion does not appear to increase the risk of anastomotic strictures or postoperative complications. Further prospective evaluation is warranted.

Laparoscopic Transabdominal Needle-free Emergency Cerclage in the Early Second Trimester of Pregnancy after Failed Transvaginal Cerclage: Two Case Reports and a Review of the Literature.

The aim of the study was to describe the preventive option and safety of laparoscopic transabdominal emergency cerclage in pregnant women with advanced cervical shortening after failed vaginal cerclage or in whom vaginal cerclage is no longer possible. Laparoscopic isthmo-cervical emergency cerclage was carried out in two patients at 13+0 and 15+5 weeks of gestation (GW) respectively. Both patients had cervical shortening and it was no longer possible to expose the cervix after conization or re-conization. The attempts to carry out transvaginal cerclage were unsuccessful. The technical aspects, feasibility, safety, and pregnancy outcomes after laparoscopic transabdominal cerclage are presented here, based on two case reports. The cerclages were placed after blunt dissection of the uterine vessels and careful introduction of a KELLY forceps through the avascular space between the ascending and descending branches of the uterine vessels without using a needle. The operating times were 93 and 134 minutes (min), respectively. The estimated blood loss during the procedure was less than 50ml and neither perioperative nor postoperative complications occurred. The subsequent course of both pregnancies was uneventful and fetal development in both cases was normal. In the first case, the baby was delivered by secondary cesarean section following premature rupture of membranes in week 35+4 of gestation. The baby had a birthweight of 2786g, APGAR scores of 8/9/10 and an umbilical cord arterial pH of 7.36. In the second case, delivery was by primary cesarean section in week 39+5 of gestation. The infant had a birth weight of 4160g, APGAR scores of 5/9/10 and an umbilical cord arterial pH of 7.20. Laparoscopic transabdominal cerclage is a safe and effective treatment option, even early in the second trimester of pregnancy, for patients in whom transvaginal cerclage is no longer possible due to anatomical factors. The method is technically very feasible and is associated with positive obstetric outcomes. The overall risk of perioperative complications is within acceptable limits.

Outcomes of donation after circulatory death (DCD) and ex-vivo lung perfusion (EVLP) lung transplantation

BackgroundDonation after circulatory death (DCD) and ex-vivo lung perfusion (EVLP) have been adopted to expand the donor pool in lung transplantation, but outcomes data have been conflicting. This study explores mid-term outcomes of DCD lung transplantation in the modern era, with a focus on EVLP and risk factors for graft failure. MethodsThe United Network for Organ Sharing (UNOS) database was queried for adult lung transplants from 1/1/2015 to 3/1/2023. Loss to follow-up, multiorgan and prior lung transplants were excluded. DCD vs DBD (donation after brain death) lung transplants were compared, with subgroup analysis +/- EVLP. Outcomes were survival and postoperative complications. Overall survival was analyzed separately for an early era (2015-2018) and modern era (2019-2023). ResultsThe study included 1103 DCD (221 with EVLP, and 882 without) and 17973 donation after brain death (DBD) lung transplants (524 with EVLP, and 17449 without). Median follow-up was 3 years. DCD donors were less likely to be CDC high risk (19.3% vs 24.1%, p<0.001), have purulence on bronchoscopy (13.3% vs 18.3%, p<0.001) or infiltrates on chest x-ray (66.7% vs 67.8%, p=0.013). EVLP was more likely to be used for DCD transplants (20.0% vs 2.9%, p<0.001).After transplant, DCD recipients were more likely to be reintubated (24.3% vs 18.5%, p<0.001) and require ECMO within 72 hours (14.9% vs 7.8%, p<0.001), and DCD donation was an independent risk factor for these complications on multivariable logistic regression. Overall survival did not differ significantly between DCD and DBD transplants on adjusted survival analysis in the early or modern era (p=0.774 and p=0.468 respectively). On multivariable Cox regression, DCD and EVLP were not independent risk factors for mortality.On subgroup analysis, the DCD+EVLP cohort had significantly worse survival in the modern era, which remained significant after adjusting for donor and recipient factors (p=0.005). EVLP was an independent risk factor for graft failure in the DCD cohort (HR 1.33, 95% CI 1.00-1.77, p=0.047), but did not significantly affect DBD graft survival (p=0.870). Risk factors for graft failure and mortality in the DCD+EVLP cohort included pulmonary hypertension (HR 77.5, 95% CI 6.15-979, p<0.001), transfusion prior to transplant (HR 2.60, 95% CI 1.07-6.31, p=0.035), elevated creatinine (HR 2.82, 95% CI 1.34-5.90, p=0.006), and higher allocation score (HR 1.02, 95% CI 1.00-1.04, p=0.017) ConclusionStudy findings suggest increased risks of mortality and perioperative complications following transplantation with DCD lungs that have undergone EVLP. DCD lung transplantation without EVLP confers equivalent survival but with some increase in perioperative complications. Further investigation and careful recipient selection is warranted to optimize the use of these extended criteria donors in the modern era.

Outcomes of Surgical Valve Replacements for Radiation-Induced Valvulopathy

Objective(s)Cancer patients who receive radiation therapy to the thorax often develop radiation-induced heart disease (RIHD) decades later. Prior chest radiation is associated with elevated perioperative risk of complications and mortality following cardiac surgery. Whether the type of valve (mechanical vs. bioprosthetic) used affects outcomes in patients with RIHD is unknown. MethodsThis retrospective review analyzed the characteristics and post-operative outcomes of patients with a prior history of chest radiation for Hodgkin or non-Hodgkin lymphoma who underwent surgical valve replacement at a single institution between 2000 and 2021. Both 30-day peri-operative outcomes and long-term survival were assessed. ResultsMechanical valve patients tended to be younger, have more valves replaced, and have undergone prior coronary artery bypass grafting (CABG) than bioprosthetic valve recipients. Valve type alone did not alter perioperative complications or overall survival. Median survival was 11.0 years in mechanical and 10.9 years in bioprosthetic valve patients (P = 0.930). Twelve patients underwent valve reinterventions (6 mechanical, 6 bioprosthetic), and three underwent transplant. Single valve (AV or MV) recipients fared better with median survival of 13.3 years compared to 6.2 years in those who underwent combined AVR+MVR (P<0.0001). ConclusionsPatients with RIHD who undergo surgical valve replacement have similarly suboptimal short- and long-term outcomes regardless of mechanical vs. bioprosthetic valve type. Those who required combined aortic and mitral valve replacement had especially high 10-year overall mortality. Further investigation in a larger dataset including transcatheter approaches is warranted.

The Relationship Between Age and 30-Day Outcomes Following Unicompartmental Versus Total Knee Arthroplasty

BackgroundAn enhanced understanding of the short-term complication profile following unicompartmental knee arthroplasty (UKA) versus total knee arthroplasty (TKA) can improve surgical decision-making and subsequent patient outcomes. This study aimed to determine if the difference in risk of 30-day morbidity and mortality between UKA and TKA varied as a function of patient age. MethodsThis retrospective study of a national quality improvement database using data from 2014 to 2020 included 403,342 patients undergoing UKA (n = 12,324) or TKA (n = 391,018). A generalized additive model (GAM) evaluated non-linear relationships between primary outcome and predictors (age, procedure type, and procedure type x age interaction) using a 1:5 UKA to TKA matched sample. Probabilities and odds ratios (95% CI [confidence interval]) estimated the relative risk of complications across the age spectrum. ResultsIn the GAM, TKA patients relative to UKA had 1.30 higher odds (95% CI 1.19 to 1.43, P < 0.001) of 30-day morbidity and mortality. There was a significant, non-linear relationship between age and the primary outcome (P = 0.02), such that the odds were lowest at younger ages. They increased slowly until about age 65 years, at which point the slope became steeper. The interaction terms for age and procedure type were not significant (P = 0.30). The 30-day probability for short-term complications of a 65-, 75-, and 85-year-old undergoing UKA was 2.1% (95% CI, 1.8 to 2.3), 2.4% (95% CI, 2.0 to 2.8), and 3.2% (95% CI, 2.3 to 4.1), respectively. Conversely, the probability of a 65-, 75-, and 85-year-old undergoing TKA was 2.9% (95% CI, 2.7 to 3.0), 3.6% (95% CI, 3.3 to 3.8), and 5.5% (95% CI, 4.7 to 6.3). ConclusionsPatients undergoing UKA had a quantifiable lower likelihood of morbidity or mortality than TKA at all ages. These data can provide individualized risk for UKA and TKA across the age spectrum and could be helpful in counseling patients regarding their risk for perioperative complications.

Cerebrovascular Disease in Surgical Patients

It is well established that patients with a personal history of a cerebrovascular accident (stroke or transient ischemic attack) are at increased risk for perioperative cardiovascular complications, including recurrent stroke. Although the individual patient risk for perioperative stroke is typically low, the overall prevalence is significant, appears to be increasing, and has the potential for devastating complications including death. The perioperative provider must not only be knowledgeable of the elevated risk for patients with a history of stroke undergoing surgery, but also be familiar with perioperative risk reduction strategies. This article provides a general overview of cerebrovascular disease in surgical patients with much of the content being presented at the 2023 Perioperative Medicine Summit in Orlando, Florida.

Development and validation of deep learning models for identifying the brand of pedicle screws on plain spine radiographs.

In spinal revision surgery, previous pedicle screws (PS) may need to be replaced with new implants. Failure to accurately identify the brand of PS-based instrumentation preoperatively may increase the risk of perioperative complications. This study aimed to develop and validate an optimal deep learning (DL) model to identify the brand of PS-based instrumentation on plain radiographs of spine (PRS) using anteroposterior (AP) and lateral images. A total of 529 patients who received PS-based instrumentation from seven manufacturers were enrolled in this retrospective study. The postoperative PRS were gathered as ground truths. The training, validation, and testing datasets contained 338, 85, and 106 patients, respectively. YOLOv5 was used to crop out the screws' trajectory, and the EfficientNet-b0 model was used to develop single models (AP, Lateral, Merge, and Concatenated) based on the different PRS images. The ensemble models were different combinations of the single models. Primary outcomes were the models' performance in accuracy, sensitivity, precision, F1-score, kappa value, and area under the curve (AUC). Secondary outcomes were the relative performance of models versus human readers and external validation of the DL models. The Lateral model had the most stable performance among single models. The discriminative performance was improved by the ensemble method. The AP + Lateral ensemble model had the most stable performance, with an accuracy of 0.9434, F1 score of 0.9388, and AUC of 0.9834. The performance of the ensemble models was comparable to that of experienced orthopedic surgeons and superior to that of inexperienced orthopedic surgeons. External validation revealed that the Lat + Concat ensemble model had the best accuracy (0.9412). The DL models demonstrated stable performance in identifying the brand of PS-based instrumentation based on AP and/or lateral images of PRS, which may assist orthopedic spine surgeons in preoperative revision planning in clinical practice.