Risk Of Perioperative Complications Research Articles

Perioperative complication incidence and risk factors for retroperitoneal neuroblastoma in children: analysis of 571 patients

BackgroundSurgery plays an important role in the treatment of neuroblastoma. Perioperative complications may impact the course of neuroblastoma treatment. To date, comprehensive analyses of complications and risk factors have been lacking.MethodsPatients with retroperitoneal neuroblastoma undergoing tumor resection were retrospectively analyzed between 2014 and 2021. The data collected included clinical characteristics, operative details, operative complications and postoperative outcomes. Risk factors for perioperative complications of retroperitoneal neuroblastoma were analyzed.ResultsA total of 571 patients were enrolled in this study. Perioperative complications were observed in 255 (44.7%) patients. Lymphatic leakage (28.4%), diarrhea (13.5%), and injury (vascular, nerve and organ; 7.5%) were the most frequent complications. There were three operation-related deaths (0.53%): massive hemorrhage (n = 1), biliary tract perforation (n = 1) and intestinal necrosis (n = 1). The presence of image-defined risk factors (IDRFs) [odds ratio (OR) = 2.09, P < 0.01], high stage of the International Neuroblastoma Risk Group staging system (INRGSS) (OR = 0.454, P = 0.04), retroperitoneal lymph node metastasis (OR = 2.433, P = 0.026), superior mesenteric artery encasement (OR = 3.346, P = 0.003), and inferior mesenteric artery encasement (OR = 2.218, P = 0.019) were identified as independent risk factors for perioperative complications.ConclusionsDespite the high incidence of perioperative complications, the associated mortality rate was quite low. Perioperative complications of retroperitoneal neuroblastoma were associated with IDRFs, INRGSS, retroperitoneal lymph node metastasis and vascular encasement. Patients with high-risk factors should receive more serious attention during surgery but should not discourage the determination to pursue total resection of neuroblastoma.8e95DYrdivwNpNwDkEtfUxVideo (MP4 94289 KB)

The Role of Invasive Hemodynamic Monitoring in Patients with Severe Mitral Regurgitation Undergoing Herniorrhaphy Operation

Background: Mitral regurgitation (MR) indeed presents challenges during noncardiac surgeries, especially as the severity of MR tends to increase with age and poses a higher risk of perioperative complications. Accurate hemodynamic monitoring becomes crucial in these cases to manage potential complications effectively. However, the standard monitoring in MR conditions during operation, such as TEE, is not always available, but there are other options for invasive monitoring, such as arterial lines, which provide accurate hemodynamic monitoring.&#x0D; Case presentation: A 64-year-old, male, presented with Reponible Lateral Inguinal Hernia with comorbid of severe mitral and tricuspid regurgitation alongside congestive heart failure. The patient was premedicated with fentanyl 25 mcg intravenously, followed by oxygen supplementation with 3 lpm nasal cannula and insertion of the arterial line. Anaesthesia was performed using a lumbar epidural technique, with the insertion of an epidural catheter in the L1-L2 intervertebral space, Reponible Lateral Inguinal Hernia. The local anesthesia agent chosen was plain bupivacaine with a concentration of 0.5% and a volume of 8 ml. The onset of action of epidural anesthesia is achieved within 20 minutes as long as the operation reaches a total blockade as high as T8. The patient is monitored with standard monitors and an artery line during surgery. There were no complaints of shortness of breath, chest heaviness, or chest pain felt by the patient during the operation.&#x0D; Conclusion: Epidural anesthesia technique can provide stable hemodynamics in patients with severe mitral-tricuspid regurgitation and congestive heart failure and hemodynamic monitoring plays an important role postoperatively to prevent further deterioration and maintain stability.

A comparative analysis of perioperative complications and biochemical recurrence between standard and extended pelvic lymph node dissection in prostate cancer patients undergoing radical prostatectomy: a systematic review and meta-analysis.

Pelvic lymph node dissection (PLND) is commonly performed during radical prostatectomy (RP) for prostate cancer staging. This study aimed to comprehensively analyze existing evidence compare perioperative complications associated with standard (sPLND) versus extended PLND templates (ePLND) in RP patients. A meta-analysis of prospective studies on PLND complications was conducted. Systematic searches were performed on Web of Science, Pubmed, Embase, and the Cochrane Library until May 2023. Risk ratios (RRs) were estimated using random-effects models in the meta-analysis. The statistical analysis of the data was carried out using Review Manager software. Nine studies, including three randomized clinical trial and six prospective studies, with a total of 4962 patients were analyzed. The meta-analysis revealed that patients undergoing ePLND had a higher risk of partial perioperative complications, such as lymphedema ( I2 =28%; RR 0.05; 95% CI: 0.01-0.27; P <0.001) and urinary retention ( I2 =0%; RR 0.30; 95% CI: 0.09-0.94; P =0.04) compared to those undergoing sPLND. However, there were no significant difference was observed in pelvic hematoma ( I2 =0%; RR 1.65; 95% CI: 0.44-6.17; P =0.46), thromboembolic ( I2 =57%; RR 0.91; 95% CI: 0.35-2.38; P =0.85), ureteral injury ( I2 =33%; RR 0.28; 95% CI: 0.05-1.52; P =0.14), intraoperative bowel injury ( I2 =0%; RR 0.87; 95% CI: 0.14-5.27; P =0.88), and lymphocele ( I2 =0%; RR 1.58; 95% CI: 0.54-4.60; P =0.40) between sPLND and ePLND. Additionally, no significant difference was observed in overall perioperative complications ( I2 =85%; RR 0.68; 95% CI: 0.40-1.16; P =0.16). Furthermore, ePLND did not significantly reduce biochemical recurrence ( I2 =68%; RR 0.59; 95% CI: 0.28-1.24; P =0.16) of prostate cancer. This analysis found no significant differences in overall perioperative complications or biochemical recurrence between sPLND and ePLND, but ePLND may offer enhanced diagnostic advantages by increasing the detection rate of lymph node metastasis.

Anticoagulation management in elderly patients with proximal femur fractures- overview of current concepts.

Proximal femur fractures (PFF) are common injuries in elderly patients and can have considerable effects on their quality of life, morbidity, and mortality. Due to pre-existing comorbidities, the prevalence of anticoagulated patients is increasing. The right timing for surgery and perioperative anticoagulation treatment remains controversial. This overview aims to summarize current practices in the pre- and postoperative anticoagulation management and the recommended time to surgery in elderly patients with PFF. Time to surgery for anticoagulated patients is often prolonged due to worries about serious perioperative bleeding and higher transfusion demands. But the delay of surgical PFF treatment increases the risk for perioperative complications like pulmonary embolism, pneumonia, deep vein thrombosis and urinary tract infections. Early surgery can be achieved with a consistent and interdisciplinary perioperative anticoagulation management. Antiplatelets do not have to be discontinued and surgery should be performed early without delay. For patients taking vitamin K antagonists (VKA) an INR less than 1.5 is recommended prior to surgery, which can be achieved by pausing VKA intake or by administering vitamin K, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). For the treatment with direct oral anticoagulants (DOAC) a plasma drug level of under 50 pg/mL is considered safe for surgery. If the plasma level can not be determined, a gap of 24 h between the last DOAC dose and surgery is recommended. The systemic administration of tranexamic acid can reduce overall blood loss and transfusion rates in anticoagulated patients with PFF. Surgical treatment of PFF should be performed within 24 h, as delayed surgery increases the risk for perioperative complications. This also applies to anticoagulated patients, when clinically appropriate. International and interdisciplinary guidelines are necessary to ensure early and appropriate treatment of anticoagulated elderly patients with PFF.

A prospective study on indications for tonsillectomy in childhood in Kirkuk

Abstract Background: Childhood tonsillectomy is a common surgery with a risk of life-threatening perioperative complications. Although the appropriate decision of its indications necessitates considerable practical experience, physicians in different medical specialties tend to base their decisions about surgery on various clinical expertise and perspectives. Objectives: This study was conducted to draw attention to the prevalence and actual indications for tonsil surgeries in children. Materials and Methods: This prospective study included 600 children with tonsillitis of both genders, ages ranging from 5 to 15 years old, during the period from October 2020 to August 2022 in Kirkuk, Iraq. Initially, they were divided into two categories: the first included 525 patients (88%) without the need for surgery, while the other category included 75 patients (12%) who underwent tonsil surgery. Patients with tonsillitis undergoing tonsil surgery, 43 (57%) of them had undergone adenotonsillectomy, compared to 32 (43%) children who underwent tonsillectomy. Patients with recurrent tonsillitis amounted to 20 (62%), while patients with tonsillar hypertrophy reached 12 (38%) among those undergoing tonsillectomy. Results: Final obtained data showed that recurrent tonsillitis was significantly more in the age group from 11 to 15 than in the group from 5 to 10 years old. On the contrary, the tonsillar hypertrophy was significantly more in the 5–10 age group than in the other group. Conclusion: This study concluded that a high proportion of children with tonsillitis were cured without surgery, compared to a few frequencies that underwent tonsillectomy due to actual indications. Thus, surgery is not performed for all children with tonsillitis except when really needed to avoid consequences during and after surgery in pediatric patients.

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.

Low Body Mass Index Patients Undergoing an Anterior Lumbar Fusion May Have an Increased Risk of Perioperative Complications.

Previous research has shown that underweight patients may be at a greater risk of experiencing postsurgical complications. The purpose of this study was to investigate the association between body mass index (BMI) and postoperative complications following single-level anterior lumbar fusion (ALF). All single-level elective ALF procedures performed between 2010 and 2020 were identified in the PearlDiver Mariner Database. Patients were separated into 6 groups based on the World Health Organization BMI classifications. Differences in postsurgical complications (ie, deep vein thrombosis, pulmonary embolism, surgical site infection, hardware malfunction, wound dehiscence, and blood transfusion) among BMI categories were assessed using a χ2 contingency test. Results indicated that underweight patients (BMI <20) were at a significantly greater risk of developing deep vein thromboses, experiencing hardware malfunction, and requiring blood transfusion compared with any other BMI classification (P < 0.001). Results also demonstrated that underweight individuals had similar risks of developing surgical site infection and wound dehiscence compared with patients classified as having obesity class III. Underweight patients may be at a greater risk than currently believed of experiencing postoperative complications following single-level ALF procedures. Patients with a BMI of 20 or less should be carefully evaluated prior to surgical intervention to ensure they are optimized for surgery.

Patients With Down Syndrome and Total Hip and Total Knee Arthroplasty: Outcome Measures Show Increased Risk of Perioperative Complications.

Patients with Down syndrome (DS) are being considered for total joint arthroplasty. There is limited literature regarding outcomes of patients with DS after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Data were abstracted from the 2010 to 2021 Q1 PearlDiver M151 database. THA and TKA osteoarthritis adult patients with and without DS were identified. Patients were matched 1:10. Ninety-day postoperative events and 2-year revision rates were compared. For THA, 154 patients with DS were matched with 1,532 patients without DS. For TKA, 150 patients with DS were matched with 1,495 patients without DS. On multivariable logistic regression, THA and TKA patients with DS were at markedly greater odds of postoperative events including any adverse event, sepsis, minor adverse event, urinary tract infection (UTI), acute kidney injury (AKI), and pneumonia. For both THA and TKA, 2-year revision rates were not increased for those with DS. This study represents the largest cohorts for matched patients with DS undergoing THA or TKA through 90 days postoperatively. For both procedures, DS patients were found to have greater risk of several adverse events, but not 2-year revisions. These findings may help guide perioperative risk assessment, patient/family counseling, and care pathways.

Age-Adjusted Modified Frailty Index: Association With Hip Fracture Discharge Functional Dependence

IntroductionHip fractures are a common traumatic injury that carry significant morbidity and mortality, and prognostication of functional outcome is becoming increasingly salient. Across multiple surgical specialties, the five-item and 11-item Modified Frailty Index (mFI-5 and mFI-11) have been found to be convenient, quick, and sensitive tools for identifying patients at risk for perioperative complications. A prior study described the superiority of an Age-Adjusted Modified Frailty Index (aamFI) for predicting perioperative complications compared to the mFI-5 in an elective hip surgery. We sought to externally validate the aamFI in a multicenter hip fracture cohort and hypothesize that these risk scores would not only predict functional dependence (FD) at discharge, but that the aamFI would outperform the mFI-5 and mFI-11. MethodsThe Pennsylvania Trauma Systems Foundation registry was queried from 2010 to 2020 for CPT codes, ICD-9 and ICD-10 codes pertaining to hip fracture patients. Patients with missing locomotion and transfer mobility data were excluded. FD status was determined by discharge locomotion and transfer mobility scores per existing methodology. Univariable and Multivariable analysis as well as receiver operator characteristic curves were used to evaluate and compare the three indices for prediction of functional status at discharge. P value < 0.05 was considered significant. ResultsTwelve thousand seven hundred and forty patients met inclusion criteria (FD: 8183; functional independent 4557). On univariable logistic regression analysis, the mFI-11 (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.47-1.58, P < 0.05), mFI-5 (OR 1.57, 95% CI 1.51-1.63), and aamFI (OR 1.57, 95% CI 1.52-1.62, P < 0.05) were associated with FD. On multivariable logistic regression analysis for predictors of FD, when controlling for age (for the mFI-11 and mFI-5), sex, injury severity score, and admission vitals (systolic blood pressure and respiratory rate), higher mFI-11 and mFI-5 scores independently predicted FD at discharge (OR 1.23, 95% CI 1.18-1.28, P < 0.05 and OR 1.23, 95% CI 1.18-1.29P < 0.05 respectively). Higher aaMFI scores had superior association with functional dependence (OR 1.59, 95% CI 1.54-1.64, P < 0.05). Receiver operator characteristic curves for the mFI-11, mFI-5, and aaMFI showed comparable diagnostic strength (area under curve [AUC] = 0.63 95% CI 0.62-0.64, P < 0.05; AUC = 0.63 95% CI 0.62-0.64, P < 0.05; and AUC = 0.67 95% CI 0.65-0.67, P < 0.05 respectively). ConclusionsThe mFI-11, mFI-5, and aamFI are predictive of functional outcome following hip fracture. By including age, the aamFI retains the ease of use of the mFI-5 while improving its prognostic utility for functional outcome.

The use of thromboelastography and the functional tests with double local hypoxia of the upper limb to assess the risk of thromboembolism in patients undergoing surgery

The use of thromboelastography and the functional tests with double local hypoxia of the upper limb to assess the risk of thromboembolism in patients undergoing surgery

Pre-Anesthesia Transfusion and Peri-Procedure Complications in Patients with Sickle Cell Disease on Hydroxyurea

Introduction Patients with sickle cell disease (SCD) are at increased risk of perioperative complications following general anesthesia including acute chest syndrome (ACS), vaso-occlusive pain episodes (VOE), and infection. The 2013 Transfusion Alternatives Preoperatively in SCD (TAPS) study found preoperative transfusion of patients with SCD, type SS or SB 0 thalassemia, prior to low- or medium-risk surgeries was associated with decreased perioperative complications. The American Society of Hematology 2020 guidelines for transfusion support for SCD suggest preoperative transfusion for those requiring general anesthesia (GA) lasting &amp;gt; 1 hour; however, it was noted that this should be individualized based on factors such as risk of surgery, baseline hemoglobin (Hb), and disease severity. With more broad use of Hydroxyurea (HU) that improves baseline Hb and decreases ACS and VOE frequency, we lack equipoise for when pre-anesthesia transfusion is indicated. We performed a chart review on pediatric patients with SCD at a large SCD center to determine clinician practice of pre-anesthesia transfusion versus no transfusion for patients on HU and the incidence of post-anesthesia complications with and without pre-anesthesia transfusion. Methods We performed an institutional review board approved retrospective chart review of patients with SCD (all genotypes) aged 0 to 22 years who underwent procedures or imaging studies with GA between the years 2019 and 2022 at our institution. Surgical risk score was assigned to all procedures per the TAPS study criteria. We examined the incidence of post-anesthesia complications occurring in the emergency department or hospital within 30 days post-anesthesia. Complications such as VOE, ACS, transfusion-related effects, and infection were recorded as categorical variables. Results We identified 165 patients with SCD who underwent GA at our center between 2019 and 2022: 56 of these patients were on hydroxyurea and 41 were not on hydroxyurea. We excluded 52 patients on chronic transfusion and 16 who had not consented for participation or had anesthesia encounters during a stem cell transplant admission. Among the 56 patients on HU, 34 received pre-anesthesia transfusion (2 by exchange transfusion) and 22 did not. The average Hb of those on HU who received pre-anesthesia transfusion was 8.64 g/dl (SD 1.1 g/dl) and of those who did not receive transfusion it was 9.4 g/dl (SD 1.33 g/dl) (p = 0.03, unpaired t-test). Among patients on HU who received transfusion, 4/34 (12%) had post-anesthesia complications and of those who did not receive transfusion, 6/22 (27%) had complications (p = 0.17, Fisher exact test) (Table). Among the transfused cohort, complications occurred after 2 low-risk procedures (ACS after an electrophysiology study with radiofrequency ablation and streptococcal infection after an abdominal exploratory laparoscopy), 1 medium-risk procedure (hematuria/abdominal pain after laparoscopic cholecystectomy) and 1 high-risk procedure (respiratory failure after coarctation of the aorta repair). Among patients who were not transfused, complications occurred after 2 imaging studies (ACS in the setting of parainfluenza infection after brain MRI and VOE after shoulder MRI), 2 low-risk procedures (ACS after laparoscopic appendectomy and VOE after adenoidectomy), and 2 medium-risk procedures (ACS after laparoscopic cholecystectomy and multiple admissions for 1 patient for ACS and VOE after endoscopic retrograde cholangiopancreatography). Conclusions In patients with SCD -SS or -SB 0 thalassemia on hydroxyurea undergoing procedures with anesthesia at our center, clinicians continued to prescribe pre-anesthesia transfusion for those with a Hb &amp;lt; 9 g/dl. The incidence of complications was higher in patients on HU who did not receive pre-anesthesia transfusion despite an average pre-procedure Hb of &amp;gt; 9 g/dL, but this was not statistically significant in our small sample size. However, these numbers are comparable to the findings of the TAPS study which found that 5/33 (15%) patients in the preoperative transfusion group had clinically important complications compared with 13/33 (39%) patients in the no transfusion group. These findings suggest that despite higher baseline Hb levels in the setting of HU use, patients with sickle cell disease may continue to benefit from pre-anesthesia transfusion but a randomized controlled trial is necessary.

The impact of long-term aspirin use on the patients undergoing shoulder arthroplasty

BackgroundAlthough aspirin is increasingly utilized to reduce the event of severe perioperative complications, the effect of long-term aspirin use (L-AU) on perioperative complications in patients undergoing shoulder arthroplasty (SA) has not been well studied. The goal of the present study is to identify the influence of L-AU on perioperative complications in individuals undergoing SA.MethodsWe selected data from the National Inpatient Sample database between 2010 and 2019, to identify adult patients with SA. Patients were subsequently categorized into L-AU and whole non-L-AU cohorts according to the presence of aspirin use. The demographic and comorbidity characteristics were matched using propensity score matching (PSM). The Pearson chi-square test, Wilcoxon rank test and logistic regression were utilized to assess the association of L-AU with perioperative complications.ResultsFrom 2010 to 2019, a total of 162,418 SA patients satisfied the inclusion criteria, with 22,659 (13.95%) using aspirin on a long-term basis. The vast majority of the patients with pre-existing L-AU were aged 65–74 years, female, White and had Medicare insurance. L-AU before surgery was linked to increased risks of perioperative complications, such as blood transfusion (adjusted odds ratio [aOR]: 1.339), genitourinary disease (aOR: 1.349), acute renal failure (aOR: 1.292), acute myocardial infarction (aOR: 1.494), higher total charge (L-AU vs. the whole non-L-AU vs. matched non-L-AU: $66,727.15 vs. $59,697.08 vs. $59,926.32), and prolonged hospitalization stay (LOS) (aOR: 0.837). However, L-AU was considered a protective factor of acute cerebrovascular disease (aOR: 0.722) and stroke (aOR: 0.725).ConclusionsOur study is based on the largest open-access all-payer inpatient database, revealing a noteworthy finding of aspirin's protective and adverse impact on different postoperative complications in the US population, such as acute cardiovascular disease, and stroke, etc. Further studies assessing the optimum preoperative aspirin duration and dosage to meet the best benefit quantity for patients with planned joint arthroplasties are suggested.

Effect of Smoking on Cancer Surgery Outcomes and Recommendations for Perioperative Smoking Cessation Intervention

Smoking, a common behavior that causes health risks among adults around the world, is closely associated with the risks of developing various kinds of cancers. Nevertheless, the impact of smoking on preoperative risks and postoperative outcomes of cancer surgeries has been largely overlooked. Extensive basic medical and clinical research findings and prognosis data demonstrate that smoking is associated with increased risks of multiple perioperative complications, and that smoking affects the general prognosis of patients. Smoking cessation during the preoperative and perioperative periods effectively reduces these risks and improves the long-term postoperative outcomes of cancer patients. At present, health workers and patients are not giving adequate attention to smoking cessation interventions and the quality of interventions available is poor. Herein, we discussed the necessity of comprehensive and standardized smoking cessation services and made recommendations regarding the implementation of comprehensive and standardized smoking cessation services, providing support for cancer patients to access evidence-based care during the perioperative period.

Relative anemia and perioperative stroke in children with moyamoya

ObjectivesSurgical revascularization for moyamoya arteriopathy decreases long-term stroke risk but carries a risk of perioperative ischemic complications. We aimed to evaluate modifiable stroke risk factors in children undergoing surgical revascularization for moyamoya. Materials and MethodsIn this exploratory, single-center, retrospective cohort study, medical records of pediatric patients undergoing surgical revascularization for moyamoya arteriopathy at our center between 2003 and 2021 were reviewed. Candidate modifiable risk factors were analyzed for association with perioperative stroke, defined as ischemic stroke ≤7 days after surgery. ResultsWe analyzed 53 surgeries, consisting of 39 individual patients undergoing indirect surgical revascularization of 74 hemispheres. Perioperative ischemic stroke occurred following five surgeries (9.4%). There were no instances of hemorrhagic stroke. Larger pre-to-postoperative decreases in hemoglobin (OR 3.90, p=0.017), hematocrit (OR 1.69, p=0.012) and blood urea nitrogen (OR 1.83, p=0.010) were associated with increased risk of perioperative ischemic stroke. Weight-adjusted intraoperative blood loss was not associated with risk of perioperative ischemic stroke (OR 0.94, p=0.796). Among children with sickle cell disease, all of whom underwent exchange transfusion within one week prior to surgery, none experienced perioperative stroke. ConclusionsDecreases in hemoglobin, hematocrit, and blood urea nitrogen between the preoperative and postoperative periods are associated with increased risk of perioperative stroke. These novel findings suggest that dilutional anemia, possibly due to standardly administered hyperhydration, may increase the risk of perioperative stroke in some children with moyamoya. Further work optimizing both mean arterial pressure and oxygen-carrying capacity in these patients, including consideration of alternative blood transfusion thresholds, is necessary.

NCMP-10. DEXAMETHASONE: A TOOL AND A PROBLEM IN GLIOBLASTOMA MANAGEMENT

Abstract Glioblastoma (GBM) patient morbidity and overall survival (OS) are associated with dexamethasone use. We studied dexamethasone-associated hyper-glycemia, leukocytosis, and accompanying complications in the peri-operative period. We also examined the effect of metformin treatment on GBM patient OS. We retrospectively studied 243 GBM patients admitted between 2014-2018. Patients with peri-operative glucose measurements and adequate follow-up to assess for complications were included. Metformin was used for treatment of diabetes or in the management of glucocorticoid-induced hyper-glycemia. Kaplan-Meier curves and log-rank p test were used for univariate analysis. Cox-proportional hazards model was used to generate adjusted hazard ratios for multivariate analysis. Dexamethasone dose was associated with hyper-glycemia and leukocytosis post-operatively. Poor glycemic control was associated with increased odds of 30-day any complication on univariate analysis and 30-day any complication and increased length of stay on multivariate analysis. We then demonstrated that metformin improved OS in methylated O6-methylguanine DNA methyltransferase gene (MGMT) promoter tumor patients (652 days, 95% CI 327 – 897, n = 25 vs 394 days, 95% CI 210 – 513, n = 63; P = .049). Non-diabetic MGMT-methylated tumor patients treated with metformin also had an improved median OS of 736 days, 95% CI 365 – 1036, n = 11 vs 395 days, 95% CI 210 – 513, n = 66; P = .01). Overall, peri-operative hyper-glycemia and higher average dexamethasone use are associated with poor glycemic control and leukocytosis. As a result, dexamethasone can increase the risk of peri-operative complications in GBM patients. Avoiding hyper-glycemia by limiting dexamethasone use or using Metformin may decrease the risk of complications and improve OS.

Outcomes of chronic total occlussion recanalization in patients with prior bypass-surgery: an updated systematic review and meta-analysis of real world registries

Abstract Background Recanalization of chronic total occlusion (CTO) coronary lesions by percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass grafting (CABG) is still considered a challenging scenario due to the complexity of coronary lesions as well as the requirement of CTO PCI advanced techniques. The aim of this study is to compare clinical outcomes of patients undergoing CTO PCI with and without CABG surgery. Methods We conducted a systematic review and meta-analysis of observational studies that compared in-hospital outcomes of CTO PCI in patients with vs. without prior CABG published in Medline from inception until December 2022. The results are synthesized in a quantitative manner with random effects models. Categorical variables were compared using the chi-square test, whereas continuous variables were compared using a 2-sample Student's t-test. Statistical heterogeneity was assessed by I2 statistics: I2 statistic &amp;gt;50% was considered substantial, and I2 &amp;gt;75% was considered considerable. The Review Manager Software version 5.3.5. (The Cochrane Collaboration, 2014) was used to calculate summary statistics (odds ratios [ORs] with 95% confidence intervals [CIs]). Results Eleven observational studies with a total of 35,666 patients were included, of whom 7,005 patients had a history of CABG. Prior CABG patients were older, (68.1 ± 9.0 vs. 64.1 ± 10.7 years; p &amp;lt; 0.001), and had more complex coronary lesions (J-CTO score: 3.2 ± 1.4 vs. 2.5 ± 1.4; p &amp;lt; 0.001). Prior CABG was associated with lower technical success (66.6% vs. 78.5%; OR 0.53 [95% CI: 0.43 to 0.65]; p &amp;lt; 0.00001, I2 = 84%) as well as lower procedural success (OR 0.64 [95% CI: 0.57 to 0.71]; p &amp;lt; 0.00001, I2 = 0%) as compared with patients with no prior CABG (Figure 1A and Figure 1B). Prior CABG patients had a higher incidence of in-hospital mortality (0.7% vs. 0.4%; OR: 2.00 [95% CI: 1.32 to 3.05]; p = 0.001, I2 = 9%, Figure 2A), coronary perforation (3.7% vs. 2.3%; OR: 1.64 [95% CI: 1.15 to 2.33]; p &amp;lt; 0.006, I2 = 74%, Figure 2B), and myocardial infarction (1.7% vs. 0.7%; OR: 2.57 [95% CI: 1.73 to 3.81]; p &amp;lt; 0.00001, I2 = 12%), but a lower incidence of cardiac tamponade (0.2% vs. 0.9%; OR: 0.36 [95% CI: 0.17 to 0.77]; p = 0.09, I2 = 0%, Figure 2C) compared with those without prior CABG. Both groups had a similar incidence of acute cerebrovascular events (0.2% vs. 0.1%; OR: 1.70 [95% CI: 0.75 to 3.88]; p = 0.21, I2 = 0%), major bleeding (1.4% vs. 1.2%; OR: 1.24 [95% CI: 0.96 to 1.61]; p = 0.09, I2 = 0%) and vascular complications (1.4% vs. 0.9%; OR: 1.50 [95% CI: 0.93 to 2.41]; p = 0.10, I2 = 0%). Conclusion Prior CABG patients undergoing CTO PCI presented a higher risk of in-hospital mortality and perioperative procedural complications although the risk of tamponade was lower.Figure 1A and Figure 1BFigure 2A, 2B and 2C

Long-term follow-up of patients with complex coronary artery disease treated with minimally invasive direct coronary artery bypass.

Patients with complex coronary artery disease (CAD) may benefit from surgical myocardial revascularization but weighing the risk of peri-operative complications against the expected merit is difficult. Minimally invasive direct artery bypass (MIDCAB) procedures are less invasive, provide the prognostic advantage of operative revascularization of the left anterior descending artery and may be integrated in hybrid strategies. Herein, the outcomes between patients with coronary 1-vessel disease (1-VD) and patients with 2-VD and 3-VD after MIDCAB procedures were compared in this single-center study. Between 1998 and 2018, 1363 patients underwent MIDCAB at the documented institution. 628 (46.1%) patients had 1-VD, 434 (31.9%) patients 2-VD and 300 (22.0%) patients suffered from 3-VD. Data of patients with 2-VD, and 3-VD were pooled as multi-VD (MVD). Patients with MVD were older (66.2 ± 10.9 vs. 62.9 ± 11.2 years; p < 0.001) and presented with a higher EuroScore II (2.10 [0.4; 34.2] vs. 1.2 [0.4; 12.1]; p < 0.001). Procedure time was longer in MVD patients (131.1 ± 50.3 min vs. 122.2 ± 34.5 min; p < 0.001). Post-operatively, MVD patients had a higher stroke rate (17 [2.3%] vs. 4 [0.6%]; p = 0.014). No difference in 30-day mortality was observed (12 [1.6%] vs. 4 [0.6%]; p = 0.128). Survival after 15 years was significantly lower in MVD patients (p < 0.01). Hybrid procedures were planned in 295 (40.2%) patients with MVD and realized in 183 (61.2%) cases. MVD patients with incomplete hybrid procedures had a significantly decreased long-term survival compared to cases with complete revascularization (p < 0.01). Minimally invasive direct coronary artery bypass procedures are low-risk surgical procedures. If hybrid procedures have been planned, completion of revascularization should be a major goal.

Abstract 15183: Diabetes is Associated With Worse Postoperative Mortality and Morbidity in Bariatric Surgery, Regardless of the Procedure

Introduction: Bariatric surgery is an efficient treatment for obesity. Objectives: We aimed to assess the impact of diabetes on postoperative outcomes of bariatric surgery. Further, we compared the outcomes of different techniques in patients with diabetes. Methods: We used data from the National Inpatient Sample (2015-2019) to identify patients who underwent either sleeve gastrectomy, Roux-en-Y, or gastric banding. Outcomes included postoperative mortality (primary outcome), major bleeding, atrial fibrillation, and acute renal failure. Results: Patients with diabetes had an overall increased risk of perioperative complications when compared to non-diabetic ones for all three types of bariatric surgery. Among patients who underwent sleeve gastrectomy, diabetes was associated with a higher adjusted risk of mortality [aOR 2.07 (1.36-3.16)], atrial fibrillation [aOR 1.07 (1.02-1.11)], and acute renal failure [aOR 1.51 (1.39-1.64)] but a similar risk of major bleeding. Among patients who underwent Roux-en-Y, diabetes did not increase the risk of mortality and bleeding. Still, it was associated with a higher risk of atrial fibrillation [aOR 2.24 (1.25-4.02)] and acute renal failure [aOR 1.36 (1.21-1.62)]. Among patients who underwent gastric banding, diabetes was only associated with a higher risk of major bleeding [aOR 2.94 (1.42-5.88)]. When comparing the 3 techniques in diabetes patients, Roux-en-Y was significantly associated with a higher mortality rate (1.05%, 0.06%, 0%), atrial fibrillation (7.04%, 3.35%,3.48%), and acute renal failure (6.32%, 1.29%, 3.48%) (Roux-en-Y, sleeve, gastric banding; respectively). Major bleedings were more common in Roux-en-Y (1.05%) than in Sleeve (0.5%) (p&lt;0.001). Conclusions: Diabetes is associated with worse postoperative outcomes regardless of the type of bariatric surgery performed. Among diabetes patients, Roux-En-Y was associated with higher mortality and morbidity.

Disparities in access to high-volume parathyroid surgeons in the United States: A call to action

BackgroundParathyroidectomy by a high-volume surgeon is associated with a reduced risk of perioperative complications and of failure to cure primary and secondary hyperparathyroidism. There are limited data on disparities in access to high-volume parathyroid surgeons in the United States. MethodsWe used publicly available 2019 Medicare Provider Utilization and Payment data to identify all surgeons who performed >10 parathyroidectomies for Medicare fee-for-service beneficiaries, anticipating that fee-for-service beneficiaries likely represent only a subset of their high-volume practices. High-volume parathyroid surgeon characteristics and geographic distribution were evaluated. Inequality in the distribution of surgeons was measured by the Gini coefficient. The association between neighborhood disadvantage, based on the Area Deprivation Index, and proximity to high-volume parathyroid surgeons was evaluated using a one-way analysis of variance with Bonferroni-corrected pairwise comparisons. A sensitivity analysis was performed restricting to high-volume parathyroid surgeons within each hospital referral region, evidence-based regional markets for tertiary medical care. ResultsWe identified 445 high-volume parathyroid surgeons who met inclusion criteria with >10 parathyroidectomies for Medicare fee-for-service beneficiaries. High-volume parathyroid surgeons were 71% male sex, and 59.8% were general surgeons. High-volume parathyroid surgeons were more likely to practice in a Metropolitan Statistical Area with a population >1 million than in less populous metropolitan or rural areas. The number of high-volume parathyroid surgeons per 100,000 fee-for-service Medicare beneficiaries in the 53 most populous Metropolitan Statistical Areas ranged from 0 to 4.94, with the highest density identified in Salt Lake City, Utah. In 2019, 50% of parathyroidectomies performed by high-volume parathyroid surgeons were performed by 20% of surgeons in this group, suggesting unequal distribution of surgical care (Gini coefficient 0.41). Patients in disadvantaged neighborhoods were farther from high-volume parathyroid surgeons than those in advantaged neighborhoods (median distance: disadvantaged 27.8 miles, partially disadvantaged 20.7 miles, partially advantaged 12.1 miles, advantaged 8.4 miles; P < .001). This association was also shown in the analysis of distance to high-volume parathyroid surgeons within the hospital referral region (P < .001). ConclusionOlder adults living in disadvantaged neighborhoods have less access to high-volume parathyroid surgeons, which may adversely affect treatment and outcomes for patients with primary and secondary hyperparathyroidism. This disparity highlights the need for actionable strategies to provide equitable access to care, including improved regionalization of high-volume parathyroid surgeon services and easing travel-related burdens for underserved patients.

Evaluating Patient Tolerability for Urological Procedures Under Conscious Sedation: A Prospective Study

PurposeAdministration of general or spinal anesthesia is associated with anesthetic-related complications, long wait times and high costs. Using intravenous conscious sedation and/or local anesthesia is an emerging alternative for a myriad of urologic procedures. Our objective was to prospectively evaluate patient-reported and surgical outcomes of urologic procedures with conscious sedation with or without local anesthesia. MethodsPatients were enrolled from June to Aug 2021 at a tertiary care hospital. All procedures were completed using fentanyl, midazolam or both with patient and procedural data recorded upon completion. Patients were telephoned 4-6 weeks post-procedure with a standardized patient tolerability questionnaire. A multivariable adjusted logistic regression analysis was performed to evaluate whether a patient would opt for conscious sedation again as opposed to general anesthesia. ResultsA total of 196 procedures were performed by 6 attending urologists with an overall success rate of 98.5% and 0% intraoperative complication rate. At 4-6 weeks follow-up, 85.6% of patients reported they would opt for conscious sedation as opposed to general anesthesia. Predictors of opting for conscious sedation in the future was older age (OR: 1.049; p = 0.017) and surgeon perceived level of patient tolerability (OR: 2.124; p < 0.001, scored 1-10). ConclusionPhysician directed, nursing administered IV conscious sedation is a viable alternative for various urologic procedures and has minimal risk of perioperative complications.