Salvage Patients Research Articles

Income and Insurance-Based Disparities in Primary Soft Tissue Sarcoma of the Extremities.

Soft tissue sarcomas (STSs) are rare but can be devastating. Paradigm shifts in adjuvant treatment have expanded the availability of limb salvage; however, a subset of patients still require amputation. The aim of this study was to examine the impact of patient, disease, and practice-related factors on rates of amputation in STS. All adults undergoing resection for STS of the extremities were tabulated from the 2004-2021 National Cancer Database (NCDB). Multivariable models were utilized to evaluate risk factors for undergoing amputation. Of 31 805 patients, 1880 (6%) underwent amputation. Those who underwent amputation were younger (57 vs. 60, p < 0.001), more commonly Black (12% vs. 9%, p < 0.00), and more frequently Medicaid insured (11% vs. 6%, p < 0.001). Amputation patients experienced a longer time from diagnosis to surgery, compared to limb salvage patients (46 [23-91] vs. 37 days [9-93], p < 0.001). Amputation was associated with a significantly greater hazard of overall mortality over 10 years following resection (HR 1.66, p < 0.001). We report significant race-, income-, and insurance-based disparities in amputation risk and overall survival for patients with STS of the extremities. We also report a significantly increased risk of amputation for patients with delayed clinical presentation. Multidisciplinary sarcoma care teams should be aware of these disparities.

High-Intensity Focused Ultrasound Ablation for Primary or Salvage Prostate Cancer Therapy: Initial Outcomes in the Veteran Healthcare Setting

High-Intensity Focused Ultrasound (HIFU) provides comparable oncologic, erectile, and urinary outcomes to standard-of-care options for localized prostate cancer. This study reports the largest United States series of HIFU in veterans for both primary and salvage therapies. We retrospectively analyzed the outcomes of 43 veterans treated at the Michael E. DeBakey Veterans Affairs Medical Center from 2018 to 2022. Primary endpoints included prostate-specific antigen (PSA) reduction and local recurrence rates. Secondary endpoints included 30-day complications, Sexual Health Inventory for Men (SHIM), and American Urological Association Symptom Score (AUASS). In our study, 31 veterans (72.1%) received primary treatment and 12 (27.9%) received salvage therapy, with a median follow-up of 23 and 25 months, respectively. Median PSA nadir was 0.16 for primary and 0.12 for salvage groups, with PSA reduction stable over 30 months. Local recurrence occurred in 16.1% of primary and 16.6% of salvage patients. SHIM scores and AUASS were not statistically different before and after HIFU therapy. Short- and intermediate-term results suggest HIFU is a safe and effective treatment option with excellent potency and preserved urinary function, as well as adequate oncological control for primary and salvage therapies for localized prostate cancer in veterans.

Outcomes of Salvage Surgery for Esophageal Carcinoma: A Nationwide Cohort Study from the Dutch Upper GI Cancer Audit.

Salvage esophagectomy is more complex and associated with higher postoperative morbidity and mortality than standard resection. This study aimed to investigate short-term outcomes and theinfluence of hospital volume on these outcomes of salvage surgery for esophageal cancer. The study enrolled all patients undergoing esophagectomy for esophageal cancer registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) between 2012 and 2022. The patients were classified as salvage or non-salvage by registering surgeons. Salvage surgery is defined in the DUCA as surgery after definitive chemoradiotherapy. Postoperative mortality (30-day/in-hospital) and morbidity were compared between the salvage and non-salvage patients using multilevel logistic regression analyses. Hospital variation in the use of salvage esophagectomy was investigated using funnel plots. The influence of hospital volume (≤ 40 to > 40 cases) and salvage volume (< 6 to ≥ 6 cases) on outcomes for salvage patients were investigated. Using backward elimination, relevant baseline characteristics influencing salvage outcomes were identified. Between 2012 and 2022, 7749 patients underwent esophagectomy, 251 (3%) of whom underwent salvage resection, varying from 0 to 8% between centers. Severe complications (43% vs 28%; odds ratio [OR], 1.81; 95 % confidence interval [CI], 1.40-2.34) and 30-day/in-hospital mortality (11% vs 3%; OR, 3.65; 95% CI, 2.38-5.61) were higher after salvage surgery than after non-salvage surgery. Salvage patients treated in high-volume centers had a lower risk of 30-day/in-hospital mortality than those treated in low-volume centers (9% vs 19%; OR, 0.42; 95% CI, 0.18-0.99), with no relation between salvage volume and outcome. Male sex, older age (> 75 years), and squamous cell carcinoma were associated with worse short-term outcomes of salvage surgery. Salvage surgery is associated with worse short-term outcomes than non-salvage esophagectomy. Outcomes after salvage surgery were favorable in high-volume esophagectomy centers.

A Comparative Analysis of Patient-Reported Outcomes Following Free Tissue Transfer, Partial Foot Amputation, and Below-Knee Amputation in High-Risk Limb Salvage Patients.

The surgical decision for limb-salvage with free tissue transfer (FTT), partial foot amputation (PFA), or below-knee amputation (BKA) for complex lower extremity (LE) wounds hinges on several factors, including patient choice and baseline function. However, patient-reported outcome measures (PROMs) on LE function, pain, and QoL for chronic LE wound interventions are limited. Thus, the study aim was to compare PROMs in patients who underwent FTT, PFA, or BKA for chronic LE wounds. PROMs were collected via QR code for all adult chronic LE wound patients who presented to a tertiary wound center between June 2022 and June 2023. A cross-sectional analysis of patients who underwent FTT, PFA, or BKA was conducted. The 12-Item Short Survey (SF-12), PROM Information System Pain Intensity (PROMIS-3a), and Lower Extremity Functional Scale (LEFS) were completed at 1, 3, and 6 months and 1, 3, and 5 years postoperatively. Patient demographics, comorbidities, preoperative characteristics, and amputation details were collected. Of 200 survey sets, 71 (35.5%) underwent FTT, 51 (25.5%) underwent PFA, and 78 (39.0%) underwent BKA. Median postoperative time points of survey completion between FTT (6.2 months, IQR: 23.1), PFA (6.8 months, IQR: 15.5), and BKA (11.1 months, IQR: 21.3) patients were comparable (P = 0.8672). Most patients were male (n = 92, 76.0%) with an average age and body mass index (BMI) of 61.8 ± 12.6 years and 30.3 ± 7.0 kg/m2, respectively. Comorbidities for FTT, PFA, and BKA patients included diabetes mellitus (DM; 60.6% vs 84.2% vs 69.2%; P = 0.165), peripheral vascular disease (PVD; 48.5% vs 47.4% vs 42.3%; P = 0.790), and chronic kidney disease (CKD; 12.1% vs 42.1% vs 30.8%; P = 0.084). No significant differences were observed between FTT, PFA, and BKA patients in mean overall PROMIS-3a T-scores (49.6 ± 14.8 vs 54.2 ± 11.8 vs 49.6 ± 13.7; P = 0.098), LEFS scores (37.5 ± 18.0 vs 34.6 ± 18.3 vs 38.5 ± 19.4; P = 0.457), or SF-12 scores (29.6 ± 4.1 vs 29.5 ± 2.9 vs 29.0 ± 4.0; P = 0.298). Patients receiving FTT, PFA, or BKA for chronic LE wounds achieve comparable levels of LE function, pain, and QoL postoperatively. Patient-centered functionally based surgical management for chronic LE wounds using interdisciplinary care, preoperative medical optimization, and proper patient selection optimizes postoperative PROMs.

332. OUTCOMES OF SALVAGE SURGERY FOR ESOPHAGEAL CARCINOMA: A NATIONWIDE COHORT STUDY

Abstract Background Compared to a standard resection, salvage esophagectomy is a more complex procedure and associated with increased postoperative morbidity and mortality. This study aimed to investigate short-term outcomes of salvage surgery for esophageal carcinoma and the influence of hospital volume and baseline characteristics on outcomes. Methods All patients undergoing esophagectomy for esophageal cancer registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) between 2012-2022 in the Netherlands were included. Patients were classified as salvage or non-salvage by registering surgeons. The definition was: surgery after definitive chemoradiotherapy. Postoperative mortality (30-day/-in-hospital) and morbidity were compared between salvage and non-salvage patients using multilevel logistic regression analyses. Hospital variation in the use of salvage esophagectomy was investigated using funnel plots. The influence of annual hospital volume (&amp;lt;40-&amp;gt;40) and annual salvage volume (&amp;lt;6-&amp;gt;6) on outcomes of salvage patients were investigated. Using backward elimination, relevant baseline characteristics influencing outcomes after salvage surgery were identified. Results Between 2012-2022, 7,749 patients underwent esophagectomy, of whom 251 (3%) underwent salvage resection, varying from 0%-8% of esophagectomies between centers. Salvage surgery was associated with an increased risk of 30-day/in-hospital mortality (11% vs. 3%; OR:3.65; 95%CI:2.38-5.61) and severe complications (43% vs. 28%; OR:1.81; 95%CI:1.40-2.34). Salvage patients treated in high-volume esophagectomy centers (&amp;gt;40) had a decreased risk of 30-day/in-hospital mortality compared to low-volume centers (9% vs. 19%; OR:0.42; 95%CI:0.18-0.99), with no relation found between annual salvage volume and outcome. Certain baseline characteristics, foremost men, elderly (&amp;gt;75 years) and squamous cell carcinomas, were associated with worse short-term outcomes of salvage surgery. Conclusion Salvage surgery for esophageal carcinoma is infrequently but increasingly performed in the Netherlands, with wide hospital variation in its use. Salvage surgery is associated with worse short-term outcomes when compared with non-salvage esophagectomy. Outcomes after salvage surgery were favorable in high-volume esophagectomy centers, suggesting a volume-outcome relationship for salvage surgery.

Thoracoscopic salvage esophagectomy with prophylactic mediastinal lymph node dissection after definitive chemoradiotherapy for patients with esophageal cancer.

Salvage esophagectomy for residual tumor and localized relapses after definitive chemoradiotherapy (dCRT) for patients with esophageal cancer is associated with a high rate of postoperative complications and in-hospital mortality. In addition, there are many controversial issues associated with salvage esophagectomy, such as the acceptability of minimally invasive surgery and the need for prophylactic dissection of mediastinal lymph nodes. The aim of this study was to evaluate the safety and usefulness of thoracoscopic salvage esophagectomy with prophylactic mediastinal lymph node dissection. The study included 31 patients who underwent thoracoscopic salvage esophagectomy with prophylactic mediastinal lymph node dissection after dCRT between 2013 and 2022 (salvage patients) and 610 nonsalvage patients who underwent conventional thoracoscopic esophagectomy during the same time period. Differences between the median ages and sexes of the 2 patient groups were not significant. The dominant location of tumors in the salvage patients was the upper thoracic esophagus. More salvage patients had clinical T4 disease. The salvage patients had a lower median number of retrieved mediastinal lymph nodes than the nonsalvage patients. The differences between the rates of R0, postoperative complications, and in-hospital deaths in the 2 patient groups were not significant. The 3-year overall survival (OS) rates for the salvage patients were 73%, with 3-year OS rates for R0 vs non-R0 of 81% vs 0%, p < 0.01 and pN0 vs pN1-3 of 89% vs 49%, p < 0.01. Regarding short-term outcomes, prophylactic mediastinal lymph node dissection for patients undergoing thoracoscopic salvage esophagectomy was as safe as prophylactic dissection for patients undergoing conventional thoracoscopic esophagectomy. R0 surgery and pN0 are important factors for long-term survival in patients undergoing thoracoscopic salvage esophagectomy.

Effect of HER2-low expression on the efficacy of CDK4/6 inhibitors in breast cancer: A meta-analysis.

e13034 Background: The effect of human epidermal growth factor receptor 2 (HER2)-low expression on the efficacy of CDK4/6 inhibitors in breast cancer is unclear. Therefore, the aim of this meta-analysis was to determine the effect of HER2-low on the efficacy of CDK4/6 inhibitors in advanced breast cancer. Methods: We searched 10 databases and meeting minutes up to July 15, 2023, to identify studies that reported median progression-free survival (mPFS) and overall survival (OS) among HR+/HER2-low breast cancer patients and HER2-zero breast cancer patients receiving treatment with CDK4/6 inhibitors. We calculated pooled hazard ratios (HRs) and 95% confidence intervals (CIs). Results: A total of 9 retrospective studies involving 1494 patients were included. HER2-low breast cancer patients accounted for 52.48% of the sample, and HER2-zero breast cancer patients accounted for 47.52% of the sample. The mPFS was significantly worse for HR+/HER2-low breast cancer patients treated with CDK4/6 inhibitors combined with endocrine therapy than for HER2-zero breast cancer patients (risk ratio = 1.29, 95% CI: 1.15-1.44, p &lt; 0.00001). There was no significant difference in the median overall survival (mOS) between patients with HER2-low breast cancer and patients with HER2-zero breast cancer (risk ratio = 1.07, 95% CI: 0.69-1.66%, p = 0.78). The mPFS was significantly worse for HR+/HER2-low breast cancer patients receiving first-line treatment with CDK4/6 inhibitors combined with endocrine therapy (risk ratio = 1.25, 95% CI: 1.07-1.47, p = 0.0002). Conclusions: The mPFS of patients with advanced HER2-low breast cancer and first-line salvage patients receiving CDK4/6 inhibitors combined with endocrine therapy was significantly inferior to that observed in HER2-zero breast cancer patients. However, there were no discernible differences in the mOS between the two patient groups.

2446: Relapse in Endometrial Cancer: impact of salvage treatment and patients characteristics

2446: Relapse in Endometrial Cancer: impact of salvage treatment and patients characteristics

D58. A Comparative Analysis of Patient-reported Outcomes Following Free Tissue Transfer, Partial Foot Amputation, and Below-knee Amputation in High-risk Limb Salvage Patients

D58. A Comparative Analysis of Patient-reported Outcomes Following Free Tissue Transfer, Partial Foot Amputation, and Below-knee Amputation in High-risk Limb Salvage Patients

Impact of cell salvage on hematocrit and post-partum anemia in low hemorrhage risk elective cesarean delivery

BackgroundPostpartum anemia is a significant contributor to peripartum morbidity. The utilization of cell salvage in low risk cases and its impact on postpartum anemia has not been investigated. We therefore aimed to examine the impact of autologous blood transfusion/cell salvage in routine cesarean delivery on postoperative hematocrit and anemia. Study design and methodsRetrospective cohort study from a perfusion database from a large academic center where cell salvage is performed at the discretion of the obstetrical team. Data from 99 patients was obtained. All patients were scheduled elective cesarean deliveries that took place on the labor and delivery floor. Thirty patients in the cohort had access to cell salvage where autologous blood was transfused after surgery. Pre-procedural hemoglobin/hematocrit measurements were obtained along will postpartum samples that were collected on post-partum day one. ResultsThe median amount of blood returned to cell salvage patients was 250 mL [206–250]. Hematocrit changes in cell salvage patients was significantly smaller than controls (−1.85 [−3.87, −0.925] vs −6.4 [−8.3, −4.75]; p < 0.001). The odds of developing new anemia following surgery were cut by 74% for the cell salvage treatment group, compared to the odds for the control group (OR = 0.26 (0.07–0.78); p = 0.028) DiscussionDespite losing more blood on average, patients with access to cell salvage had higher postoperative HCT, less postpartum anemia, and no difference in complications related to transfusion. The utilization of cell salvage for routine cesarean delivery warrants further research.

A 20-year-old man with hemopneumothorax caused by penetrating thoracic trauma: a case report

Link of Video Abstract: https://youtu.be/IgxLxMUB4Xk Background: 20–25% of trauma-related deaths are caused by thoracic injuries, which also contribute to 25–50% of patient deaths. An increasing number of critically injured but potentially salvageable patients are reporting to trauma centers as a result of the rising occurrence of penetrating chest injuries and the advancements in prehospital and perioperative care. Up to 80% of patients with penetrating chest injuries can be treated conservatively; in other situations, a sternotomy/thoracotomy (3%) or tube thoracostomy (18%) may be required. This case report aims to present a case of hemopneumothorax as a consequence of penetrating thoracic trauma. Case presentation: A 20-year-old male patient referred to Dr. Soetomo General Hospital a tertiary referral hospital massive hemopneumothorax dextra post water seal drainage to be underwent surgical resuscitation by open thoracotomy procedure then right internal mammary ligation and pericardial repair surgery. Patient’s condition steadily improved after the operation. Chest penetrating thoracic trauma caused by applying a mechanical force directly and abruptly to a focused location can cause penetrating injuries. By stretching and crushing tissue, a knife or projectile causes damage, which is often limited to the tissues in the route of penetration. The Patient with significant chest injuries needs to be managed with adequate analgesics and chest physiotherapy. Conclusion: Clear treatment algorithms and uniform assessment in chest penetrating trauma are essential for effective management. A substantial number of patients can be saved by conducting the primary survey and beginning with interventions that can save patient lives.

A Comparative Analysis of Patient-Reported Outcomes Following Free Tissue Transfer Versus Partial Foot Amputation in High-Risk Limb Salvage Patients

A Comparative Analysis of Patient-Reported Outcomes Following Free Tissue Transfer Versus Partial Foot Amputation in High-Risk Limb Salvage Patients

Stent Grafts Across the Elbow Joint for Access Salvage.

Covered stent grafts (SGs) are currently being used in a wide variety of situations to maintain function and patency of hemodialysis access circuits. Stent grafts are rarely placed across the elbow joint (EJ), however, due to fear of stent fracture. This study reports on the experience and patency rates with SGs across the EJ. From April 2020 to August 2023, all procedures with SGs placed across the EJ were retrospectively analyzed. A total of 21 patients with SGs placed across the EJ were included in the study. The Covera Vascular Covered Stent (BD, Franklin Lakes, New Jersey, USA) was used in all cases. Of these, 18 were arteriovenous (AV) fistulae, and 3 were AV grafts. Stent grafts were placed for various pathologies, including residual stenosis, perforation, aneurysm, and thrombosis. Follow-up outcomes were obtained from angiographic images on follow-up angiography and included primary patency, primary assisted patency, and secondary patency. The primary patency of the target lesion was 85% (CI=70%-100%) and 85% (CI=70%-100%) at 6 and 12 months, respectively. The primary assisted patency was 85% (CI=70%-100%) and 85% (CI=70%-100%) at 6 and 12 months, respectively. Secondary patency of the access circuit was 95% (CI=86%-100%) at 6 months and 89% (CI=75%-100%) at 12 months. The average follow-up duration was 393 days (range=27-768 days). There were no instances of stent fracture during follow-up. Stent grafts should be placed across the EJ for good short-term and mid-term patency rates. The placement of stent grafts across the elbow joint in hemodialysis patients for access salvage is controversial due to the fear of stent fracture or occlusion. This retrospective study evaluated the placement of stent grafts for access salvage in 21 patients for various etiologies. Good patency rates were seen out to 12 months and no stent fractures were observed. Although longer term data is needed, stent grafts should be considered an acceptable option for access salvage when treating lesions that cross the elbow joint.

Manual vs Mechanical Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest on a Ski Slope: A Pilot Study.

The quality of cardiopulmonary resuscitation (CPR) is critical in increasing the probability of survival with a good neurologic outcome after out-of-hospital cardiac arrest. In an austere environment with a potentially salvageable patient, bystanders or first responders may need to provide chest compressions for a prolonged duration or during physically challenging transportation scenarios. Consequently, they may be at risk of fatigue or injury, and chest compression quality may deteriorate. The study sought to assess whether or not access to and utilization of a mechanical compression device (Lund University Cardiopulmonary Assist System) was feasible and not inferior to manual compressions while extricating and transporting a patient from a ski slope. Variable 3-person ski patrol teams responded to a simulated patient with out-of-hospital cardiac arrest in a nonshockable rhythm. Using a mannequin and CPR quality monitor, performance during manual CPR was compared with that of a mechanical compression device. This is a prospective, crossover analysis of CPR quality during extrication from a ski slope. Across 8 total runs, chest compression fraction, which is the proportion of time without spontaneous circulation during which compressions occurred, and high-quality CPR, as measured by appropriate rate and depth, were compared between the 2 groups. Extrication times between the 2 groups were also measured. There was no difference in compression fraction between the manual (91.4%; 95% CI [86.8-96.1]) and mechanical arms (92.8%; 95% CI [88.8-96.8]) (P=0.67). There was an increase in the time performing high-quality CPR in the mechanical group (58.5%; 95% CI [45.8-71.2]) vs that in the manual group (25.6%; 95% CI [13.5-37.8]) (P<0.001). There was a statistically significant difference in the extrication times between the 2 groups, 7.6 ± 0.5 min in the manual group vs 8.6 ± 0.4 min in the mechanical group (P=0.014). Mechanical CPR devices are noninferior for use in ski areas during initial resuscitation and transportation. Compared with manual CPR, mechanical CPR would likely improve the fraction of time performing high-quality CPR.

Cost-effectiveness of combination therapy of polatuzumab vedotin plus rituximab, cyclophosphamide, doxorubicin, and prednisolone for previously untreated diffuse large B-cell lymphoma in Japan

AimThe POLARIX trial showed that Pola + R-CHP (polatuzumab vedotin plus rituximab, cyclophosphamide, doxorubicin, and prednisolone) prolongs progression-free survival (PFS) in patients with previously untreated diffuse large B-cell lymphoma (DLBCL) compared with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone), the conventional standard of care, with a similar safety profile. However, Pola + R-CHP has not been evaluated from the viewpoint of health economics in Japan. This study evaluates the cost-effectiveness of Pola + R-CHP for previously untreated DLBCL from a Japanese public healthcare payer’s perspective.MethodsA partitioned survival analysis model was constructed to estimate lifetime costs and effectiveness of Pola + R-CHP and R-CHOP in previously untreated DLBCL who had an International Prognostic Index score (IPI) score of ≥2. A parametric survival model was applied to data analyzed in the POLARIX trial to estimate the lifetime overall survival (OS) and PFS for each treatment. The parameters required for the model were based on the results of a literature search and expert opinion.ResultsThe incremental cost-effectiveness ratio (ICER) of Pola + R-CHP vs. R-CHOP was JPY2,710,238 per quality-adjusted life year (QALY), less than the ICER of JPY7.5 million per QALY that is considered to be cost-effective based on the threshold of the Japanese cost-effectiveness evaluation system. One-way sensitivity analysis showed that the parameters influencing the results of the analysis were median PFS and the total cost per regimen of salvage chemotherapy, patient weight, and patient age. Probabilistic sensitivity analysis showed that the probability of Pola + R-CHP having superior cost-effectiveness was 99.2% when the reference value was JPY7.5 million. The results of scenario analysis suggested that prolongation of PFS was an important factor in the evaluation of cost-effectiveness in previously untreated DLBCL with or without prolongation of OS.ConclusionsThis study suggests that Pola + R-CHP is a cost-effective treatment for previously untreated DLBCL in Japan under the public health insurance system.

SP7.4 Autologous blood transfusion reduces the requirement for peri-operative allogenic blood transfusion in patients undergoing major hepatobiliary surgery

Abstract Aims Major HPB surgery is associated with a high risk of major blood loss. We aimed to assess whether autologous transfusion of blood salvaged intra-operatively reduces the requirement for post-operative allogenic transfusion. This is clinically important because blood is a scarce resource and allogenic transfusion is associated with the potential for morbidity. Methods We analysed data from a prospective database of 501 patients undergoing major HPB resection (2015–2022). Patients who received cell salvage (n=264) were compared with those who did not (n=237). Non-autologous transfusion was assessed from the time of surgery to 5 days post-surgery, and blood loss tolerance was calculated using the Lemmens-Bernstein-Brodosky formula. Multivariate analysis was used to identify factors associated with the need for allogenic blood transfusion. Results 32% of lost blood volume was replaced through autologous transfusion in patients receiving cell salvage. Although cell salvage patients experienced significantly higher intra-operative blood loss compared with the non-cell salvage group (1360ml vs 971ml, p=0.0005), they received significantly less allogenic red blood cell units (1.5 vs 0.92 units/patient, p=0.03). In addition, more of the non-cell salvage patients required low-level transfusion (≤3 units). Use of cell salvage and correction of blood loss tolerance are both independently associated with avoidance of transfusion. There was no difference in major morbidity, 30 or 90-day mortality between the groups. Conclusions Use of cell salvage was associated with a reduction in allogenic blood transfusion. Further work is needed to understand whether this is a cost-effective means of reducing allogenic transfusion to support the routine use of intraoperative cell salvage in major HPB surgery.

Comparative effectiveness of decompressive craniectomy versus craniotomy for traumatic acute subdural hematoma (CENTER-TBI): an observational cohort study

Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy. We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014-2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582). Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12-26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p<0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre=0.9 [95% CI 0.7-1.1], n=200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0-3.4), n=200]). We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling. Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.

Does Frailty Predict Outcomes in Patients Undergoing Free or Pedicled Flap Procedures for Lower Extremity Limb Salvage? An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database.

Older and frailer patients are increasingly undergoing free or pedicled tissue transfer for lower extremity (LE) limb salvage. This novel study examines the impact of frailty on postoperative outcomes in LE limb salvage patients undergoing free or pedicled tissue transfer. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2010-2020) was queried for free and pedicled tissue transfer to the LE based on Current Procedural Terminology and the International Classification of Diseases9/10 codes. Demographic and clinical variables were extracted. The five-factor modified frailty index (mFI-5) was calculated using functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients were stratified by mFI-5 score: no frailty (0), intermediate frailty (1), and high frailty (2 + ). Univariate analysis and multivariate logistic regression were performed. In total, 5,196 patients underwent free or pedicled tissue transfer for LE limb salvage. A majority were intermediate (n = 1,977) or high (n = 1,466) frailty. High frailty patients had greater rates of comorbidities-including those not in the mFI-5 score. Higher frailty was associated with more systemic and all-cause complications. On multivariate analysis, the mFI-5 score remained the best predictor of all-cause complications-with high frailty associated with 1.74 increased adjusted odds when compared with no frailty (95% confidence interval: 1.47-2.05). While flap type, age, and diagnosis were independent predictors of outcomes in LE flap reconstruction, frailty (mFI-5) was the strongest predictor on adjusted analysis. This study validates the mFI-5 score for preoperative risk assessment for flap procedures in LE limb salvage. These results highlight the likely importance of prehabilitation and medical optimization prior to limb salvage.

A Comparative Analysis of Functional and Patient-Reported Outcomes Following Lisfranc and Chopart Amputations in High-Risk Limb Salvage Patients

Midfoot amputations provide an opportunity for limb salvage through preservation of a weightbearing limb. However, the longevity of midfoot amputations is threatened by restrictions in surface area and risks of skin breakdown. To better inform decisions surrounding the level of amputation, we sought to compare outcomes of high-risk individuals who underwent Lisfranc or Chopart amputations. A single-center retrospective cohort study was performed from November 2013 to September 2022 of adult patients who underwent Lisfranc or Chopart amputations. Patients were stratified into cohorts based on the amputation type. Outcomes included postoperative rates of re-amputation, functional status, mortality and patient-reported outcome measures in the form of Lower Extremity Functional Scale scores. Sixty-six patients were identified; of which, 45 underwent Lisfranc amputation, and 21 underwent Chopart amputation. Median Charlson Comorbidity Index was 7, signifying a substantial comorbidity burden. By median follow-up of 14 (Interquartile range: 28) months, 31 patients (36%) progressed to higher-level amputation, and most patients were ambulatory (n=38, 58%). Overall rates of re-amputation, ambulatory status, and mortality were comparable between groups. Re-amputation to another midfoot amputation was more common among the Lisfranc cohort (n=16, 36% vs n=1, 5%), whereas re-amputation to BKA was more prevalent among the Chopart cohort (Chopart: n=7, 33% vs Lisfranc: n=7, 16%; p=.011). Average Lower Extremity Functional Scale scores were similar between groups and corresponded to a maximal function of 48%. Lisfranc and Chopart amputations have the potential to be efficacious limb salvage options in high-risk patient populations in conjunction with intraoperative biomechanical optimization and optimal preoperative patient selection.

Identifying Patients in Whom the Follow-Up Scheme after Robot-Assisted Radical Prostatectomy Could Be Optimized in the First Year after Surgery: Reducing Healthcare Burden.

The currently advised follow-up scheme of PSA testing after robot-assisted radical prostatectomy (RARP) is strict and might pose a burden to our healthcare system. We aimed to optimize the 1-year follow-up scheme for patients who undergo RARP. All patients with histologically-proven prostate cancer (PCa) who underwent RARP between 2018 and August 2022 in the Prostate Cancer Network in the Netherlands were retrospectively evaluated. We excluded patients who underwent salvage RARP and patients who had <1 year of PSA follow-up. Postoperative PSA values were collected. Biochemical persistence (BCP) was defined as PSA level >0.10 ng/mL at 0-4 months after RARP, whereas biochemical recurrence (BCR) was defined as PSA level >0.2 ng/mL at any time point after RARP. We aimed to identify a group of patients who had a very low risk of BCR at different time points after surgery. Of all 1155 patients, BCP was observed in 151 (13%), of whom 79 (6.8%) had PSA ≥ 0.2 ng/mL. BCR further developed in 51 (4.7%) and 37 (3.4%) patients at 5-8 and 9-12 months after RARP, respectively. In 12 patients, BCR was found at 5-8 months after RARP in the absence of BCP. These patients represented 1.2% (12/1004) of the entire group. In other words, 98.8% (992/1004) of patients who had an unmeasurable PSA level at 0-4 months after RARP also had an unmeasurable PSA level 5-8 months after surgery. Limitations are the retrospective design and incomplete follow-up. Patients with an unmeasurable PSA level at 3-4 months after RARP may not need to be retested until 12 months of follow-up, as almost 100% of patients will not have the biochemically recurrent disease at 5-8 months of follow-up. This will reduce PSA testing substantially at the cost of hardly any missed patients with recurrent disease.