Severe Perioperative Complications Research Articles

Retrospective Comparison of SADI-S Versus RYGB in Chinese with Diabetes and BMI< 35kg/m2: a Propensity Score Adjustment Analysis.

As a modification of the duodenal switch (DS), single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) has recently become very popular and is successful for weight loss and T2DM remission. However, current studies have been mostly aimed at patients with severe obesity. In this study, we firstly compare primary SADI-S to the Roux-en-Y gastric bypass (RYGB) in Chinese with diabetes and BMI< 35 kg/m2. Using a propensity score (PS) matching analysis, we analyzed all patients with diabetes and BMI< 35 kg/m2 who underwent primary SADI-S or RYGB. All surgeries were conducted by a single surgeon at a Chinese center from June 2017 to January 2019. Twenty-six patients who underwent SADI-S and 65 patients who underwent RYGB were included in our analysis. Of these, 26 (100%) of patients in the SADI-S group and 43 (66%) of patients in the RYGB group completed the 24-month follow-up. No severe perioperative complication was observed in either group. There was a statistically higher percentage of total weight loss with SADI-S at the 2-year follow-up when compared to RYGB (p = 0.017 after PS correction). After PS adjustment, 76.5% of patients in the SADI-S group and 82.4% of patients in the RYGB group achieved complete remission of T2DM (p = 1.000). Nutritional outcomes were similar in the two groups. In Chinese with diabetes and BMI< 35 kg/m2, with comparable T2DM remission and nutritional outcomes, primary SADI-S allows for better weight loss than RYGB. Compared with RYGB, SADI-S is also a safe, effective, and feasible treatment for these patients.

Bowel resection performed by gynecologists - Outcomes and learning curves. Activity profile in a Gynecology Department: 7-year observational cohort

ObjectiveBowel resection is frequently used when performing oncological surgery to obtain complete cytoreduction or to remove endometriosis in case of intestinal invasion. Acquiring the surgical skills to perform this kind of procedure is crucial to offer to our patients an optimal management. The aim of this study is to describe a 7-years surgical experience in bowel resections of a gynecologic surgeon and to determine his learning curves. Study DesignThis is a monocentric retrospective cohort study reporting digestive resection performed between January 2013 and April 2020 in the Gynecology Department of Strasbourg University Hospital. Ninety-one consecutive patients were assigned in two groups: gynecological cancer (n = 44) and deep infiltrating endometriosis (DIE) (n = 47). The main outcome measure was the postoperative complications rate at 30 days, based on the modified Clavien-Dindo severity system. Learning curves were evaluated using cumulative sum (CUSUM) analysis of operative time and risk-adjusted cumulative sum (RA-CUSUM) analysis of severe perioperative complications. Identification of predictive factors for operation duration and severe perioperative complication occurrence was conducted using multivariate analysis. ResultsMinor complications were found in 25% of cases. Major complication rate (Clavien-Dindo ≥ IIIa) was 14% in total and only involved patients operated for cancer. The CUSUM curve for operative time peaked at the 35th case and showed a downward slope after the 45th case. Significant predictive factors of operating time were cytoreductive tumoral surgery, size of the bowel resection and laparoscopic surgery, while learning phase 3 significantly decreased it. The RA-CUSUM curve for severe perioperative complications (Clavien-Dindo ≥ IIIa) showed a progressive decrease in the complication rate as the number of interventions increases without showing clear inflection points. Only cardiopulmonary pathologies were found as significant predictive factor of severe complications. ConclusionProficiency in performing highly complex surgery was achieved after approximately 45 cases, cancer and DIE all together. Acceptable rates of severe perioperative complications were observed even during the initial learning period and are comparable with those found in the literature concerning bowel resection performed by gynecologic oncologists but also by general and digestive surgeons.

Safety and effectiveness of left atrial appendage occlusion in patients with atrial fibrillation and end-stage renal disease undergoing long-term hemodialysis

Objective: To evaluate the safety and effectiveness of left atrial appendage occlusion (LAAO) in patients with atrial fibrillation and end-stage renal disease undergoing long-term hemodialysis. Methods: Six patients with AF and end-stage renal disease(ESRD)on long term hemodialysis who underwent LAAO from March 2017 to March 2021 in Beijing Anzhen Hospital were enrolled. Baseline characteristics such as age, sex, types of arrhythmia, stroke and bleeding score, and continuous dialysis time were collected. Four patients underwent LAAO, two patients underwent the combined procedure of catheter ablation and LAAO. Perioperative treatment and serious complications were recorded. Transesophageal echocardiography was repeated at 45 days and 60 days after the procedure. Telephone follow-up was conducted at 3, 6 and 12 months after the procedure, and every 6 months thereafter. Thromboembolism and major bleeding events and survival were evaluated. Results: The average age was (66.7±17.0) years old, and 5 were male (5/6). There were 4 patients with paroxysmal AF (4/6), and 2 patients with persistent AF (2/6). The mean CHA2DS2-VASc score was (4.8±1.5), and the HAS-BLED score was (3.5±1.4). The duration of hemodialysis was 2.6 (1.1, 8.3) years. Successfully Watchman implantation was achieved in all patients. There were no severe perioperative complications, and no device related thrombosis or leaks were observed by transesophageal echocardiography. During a mean of 22.0 (12.0, 32.0) months follow-up, there was no thromboembolism or major bleeding events. A total of 2 patients died, one from sudden cardiac death, and another one from heart failure. Conclusions: LAAO may be a safe and effective therapeutic option for prevention of thromboembolism in patients with atrial fibrillation and end-stage renal disease undergoing long-term hemodialysis, further studies with larger patient cohort are needed to confirm our results.

Preoperative heart rate variability analysis is as a potential simple and easy measure for predicting perioperative delirium in esophageal surgery

BackgroundDelirium is one of the most common but severe perioperative complications. Autonomic activity evaluated by heart rate variability (HRV) has been recently reported as a useful tool for prediction and for early detection of delirium in acute care medicine, especially in postoperative intensive care unit (ICU) patients. We hypothesized that HRV, by 3-lead electrocardiogram (ECG), one day prior to surgery might correlate with the presence of postoperative delirium. Materials and methodsThis study was cohort prospective pilot study. We measured preoperative HRV and postoperative delirium in patients who underwent surgery for elective esophageal cancer. ECG of the participants was performed for 10 min 6–12 h preceding surgery. Postoperatively, patients were admitted to the ICU or critical care unit and stayed for at least 3 days. Delirium was diagnosed by psychiatrist rounds twice a day. ResultsDelirium was assessed for 3 days after surgery and 30 patients performed the study. Seven patients developed delirium during their ICU stay, while the remaining twenty-three did not. After HRV analysis, the preoperative high frequency power in delirium patients was significantly lower than that in non-delirium patient. Other parameters of HRV, including lower frequency power, total power and the ratio showed no statistically significant difference between the groups. ConclusionThe results of current study demonstrated that preoperative measurement of HRV may be a useful predictor of delirium. Further investigation could pave the way to a non-invasive, minimally stressful method of predicting postoperative delirium.

Perioperative outcomes in obese women with uterine cancer

Objectives: Obesity is a known independent risk factor for endometrial cancer that is continuing to increase in incidence throughout the United States. There is limited data on perioperative outcomes among women with endometrial cancer and obesity, especially in the era of increasing prevalence of minimally invasive surgery. We examined the association between obesity and perioperative outcomes in patients who underwent hysterectomy for uterine cancer. Methods: The National Surgical Quality Improvement Program (NSQIP) database was utilized to identify women with uterine cancer who underwent hysterectomy between the years of 2007 and 2018. Patients were classified into body mass index (BMI) groups: normal (<25), overweight (25-29.9), and obese (≥30). Analyses were also performed that stratified the obese BMI group into 30-39.9, 40-49.9, and ≥50. Multivariable logistic regression models were developed to determine clinical and demographic factors associated with perioperative morbidity and mortality. The associations between BMI group and route of hysterectomy and performance of lymph node dissection were examined using log-linear regression models. Results: A total of 42,075 endometrial cancer patients including 15.2% who were normal weight, 20.1% who were overweight and 64.8% who were obese were identified. Compared to normal BMI and overweight patients, obese patients were more likely to undergo minimally invasive hysterectomy (73.7% for obese, 72.0% for overweight, 71.6% for normal BMI; P=0.0018) and were less likely to have a lymph node dissection during surgery (53.3% for obese, 60.0% for overweight, 58.9% for normal BMI; P<0.0001). There were no differences in perioperative outcomes based on three BMI groups (normal, overweight, and obese with BMI ≥30). However, compared to women with normal BMI, those with BMI ≥50 were more likely to have any complications (6.8% vs 4.4%; aRR 1.30; 95% CI, 1.07-1.58), severe (Clavian IV) complications (3.3% vs. 1.8%; aRR 1.53; 95% CI, 1.15-2.04), readmission (6.8% vs. 4.4%; aRR 1.37; 95% CI, 1.12-1.66), and reoperation (2.4% vs 1.2%; aRR 1.76; 95% CI, 1.24-2.49). Perioperative mortality was not statistically different among any of the obese cohorts compared to those with normal BMI. Conclusions: Obese women with endometrial cancer who undergo hysterectomy are more likely to have minimally invasive procedures and less likely to have lymph node dissections. Those with BMI ≥50 are at higher risk for severe perioperative complications and reoperation. Obesity is a known independent risk factor for endometrial cancer that is continuing to increase in incidence throughout the United States. There is limited data on perioperative outcomes among women with endometrial cancer and obesity, especially in the era of increasing prevalence of minimally invasive surgery. We examined the association between obesity and perioperative outcomes in patients who underwent hysterectomy for uterine cancer. The National Surgical Quality Improvement Program (NSQIP) database was utilized to identify women with uterine cancer who underwent hysterectomy between the years of 2007 and 2018. Patients were classified into body mass index (BMI) groups: normal (<25), overweight (25-29.9), and obese (≥30). Analyses were also performed that stratified the obese BMI group into 30-39.9, 40-49.9, and ≥50. Multivariable logistic regression models were developed to determine clinical and demographic factors associated with perioperative morbidity and mortality. The associations between BMI group and route of hysterectomy and performance of lymph node dissection were examined using log-linear regression models. A total of 42,075 endometrial cancer patients including 15.2% who were normal weight, 20.1% who were overweight and 64.8% who were obese were identified. Compared to normal BMI and overweight patients, obese patients were more likely to undergo minimally invasive hysterectomy (73.7% for obese, 72.0% for overweight, 71.6% for normal BMI; P=0.0018) and were less likely to have a lymph node dissection during surgery (53.3% for obese, 60.0% for overweight, 58.9% for normal BMI; P<0.0001). There were no differences in perioperative outcomes based on three BMI groups (normal, overweight, and obese with BMI ≥30). However, compared to women with normal BMI, those with BMI ≥50 were more likely to have any complications (6.8% vs 4.4%; aRR 1.30; 95% CI, 1.07-1.58), severe (Clavian IV) complications (3.3% vs. 1.8%; aRR 1.53; 95% CI, 1.15-2.04), readmission (6.8% vs. 4.4%; aRR 1.37; 95% CI, 1.12-1.66), and reoperation (2.4% vs 1.2%; aRR 1.76; 95% CI, 1.24-2.49). Perioperative mortality was not statistically different among any of the obese cohorts compared to those with normal BMI. Obese women with endometrial cancer who undergo hysterectomy are more likely to have minimally invasive procedures and less likely to have lymph node dissections. Those with BMI ≥50 are at higher risk for severe perioperative complications and reoperation.

Early experience of pure minimally invasive donor hepatectomy by junior surgeon

Although the pure minimally invasive donor hepatectomy (PMIDH) has been increasingly performed, it is still reported by experienced surgeons. Here we reported the early experience of PMIDM by junior surgeon. From April 2019 to November 2020, PMIDHs were performed for 19 patients by single novice surgeon (H.D.H) at Yonsei University College of Medicine. Clinical characteristics, perioperative outcomes of donors and clinical features of recipients were analyzed. Eighteen of 19 donors had pure laparoscopic liver resection. Right, left hemihepatectomies and left lateral sectionectomies were performed for 15, 1 and 3 donors, respectively. Mean total operation time was 460.63 ± 70.89 minutes and median operative bleeding was 200 mL (50-1,600 mL). Median hospital stay was 8 (7-11) days. In terms of laparoscopic donor right hemihepatectomy, mean total operation time was 464.21 ± 43.52 minutes. Median amount of bleeding during operation was 225 mL (50-1,600 mL). Mean estimated total liver volume was 1,228.26 ± 217.01 (935.80-1,584.90) and mean real graft weight was 764.86 ± 153.46 (529.00-1,077.00). The robotic donor right hemihepatectomy was performed for one donor. Total operation time was 663 minutes with 550 mL of operative bleeding. There was no conversion to open surgery. Only the first donor had transfusion during operation. There was no severe perioperative complication more than grade III according to classification of Clavien-Dindo surgical complication. Although the PMIDH may need high level of surgical skill, it appears to be a safe and feasible procedure by junior surgeon in properly selected donors.

Does the power of the laser devices matter for a successful HoLEP procedure? A prospective comparative study.

The objectives of this prospective study were to evaluate the efficiency, safety and applicability of medium-power (MP) holmium laser devices in the endoscopic enucleation of the enlarged prostate (HoLEP) compared with high-power (HP) laser devices. From October 2019 to July 2020, a total of 120 consecutive patients planned for HoLEP were divided randomly into two groups formed in terms of the power of the device used. While patients in group 1 were treated with a MP device (50W) at 39.6W (2.2J/18Hz), patients in group 2 were treated with HP (100W) device at 42W (1.2J/35Hz). Preoperative patient characteristics, perioperative measures and 3-month functional outcomes were evaluated in both groups with an emphasis on enucleation efficiency (EE) and haemoglobin decrease in a comparative manner. All patients underwent successful HoLEP surgery with no severe perioperative and postoperative complications. No statistically significant differences were observed in terms of preoperative patient characteristics and perioperative measures in the two groups. The median EE values in groups 1 and 2 were 1.15 (interquartile range [IQR]: 0.33-2.2) and 1.11 (IQR: 0.4-2.8), respectively (P=.775). Haemoglobin decrease values in groups 1 and 2 were 1.3 (IQR: 0.1-4) and 1.4 (IQR: 0.4-3.1), respectively (P=.736). There was no difference in terms of either catheterisation time or hospital stay in the groups. In the model created to predict haemoglobin decrease, only biopsy was detected to be the independent predictive factor among the data from laser device, biopsy and antithrombotic use. Functional outcomes markedly improved in all patients without any statistically significant difference between the groups in the 3-month follow-up. Our comparative study indicated that HoLEP can be performed safely and effectively with MP laser devices without any technical difficulties and with comparable results achieved in HP laser devices.

Does aggressive surgery only benefit patients with less advanced ovarian cancer?

5556 Background: The recent SCORPION trial showed that aggressive primary debulking surgery (PDS) did not improve survival outcomes in patients with advanced ovarian cancer and was associated with a high incidence of perioperative morbidity. We compared survival outcomes and morbidity between patients who underwent highly aggressive and less aggressive surgery at our hospital; patients with high tumor loads were treated with neoadjuvant chemotherapy (NACT), followed by aggressive surgery. Methods: This retrospective study included 209 patients with a surgical complexity score (SCS) ≥8, who underwent aggressive surgery between January 2008 and December 2018. PDS, followed by chemotherapy was performed in this study, and NACT followed by interval debulking surgery (IDS) was performed in patients with excessively high tumor loads, a poor general condition, or unresectable lesions in whom PDS was contraindicated. Based on the median SCS, patients were categorized into highly aggressive surgery and less aggressive surgery groups, and we performed an intergroup comparison of progression-free survival (PFS), overall survival (OS), and perioperative morbidity. Results: The median SCS was 13 in all cohorts. The less aggressive surgery group (SCS &lt; 13) and the highly aggressive surgery group (SCS≥13) included 83 and 126 patients, respectively. The peritoneal cancer index in the highly aggressive surgery group was higher than that in the less aggressive surgery group (20 vs. 9). Notably, 52 patients (63%) underwent PDS in the less aggressive surgery group, and 104 patients (83%) underwent IDS after NACT in the highly aggressive surgery group. No intergroup difference was observed in patients without any residual disease (less aggressive surgery group: 74 patients [89%] vs. highly aggressive surgery group: 118 patients [94%], p = 0.245). The median PFS in the less- and highly aggressive surgery groups was 32 months (95% confidence interval [CI] 24–45) and 31 months (95% CI 27–34) (log-rank test, p = 0.622; Wilcoxon test, p = 0.926), respectively. The median OS in the less- and highly aggressive surgery groups was 99 months (95% CI 59–not reached) and 75 months (95% CI 56–106) (log-rank test, p = 0.390; Wilcoxon test, p = 0.799), respectively. Severe perioperative complications (Clavien-Dindo grade ≥IIIb) occurred in 4 patients (4.8%) and 8 patients (6.4%) in the less- and highly aggressive surgery groups, respectively (p = 0.767). Conclusions: Aggressive surgery benefits both patients with less advanced and advanced ovarian cancer. Selection of the optimal timing of debulking surgery may lead to better survival outcomes without an increase in perioperative morbidity in patients with high tumor loads, who undergo highly aggressive surgery.

A case of sigmoidectomy for sigmoid colon cancer with severe pulmonary arterial hypertension associated with mixed tissue connected disease: A case report.

IntroductionPatients with mixed connective tissue disease (MCTD) have higher rates of pulmonary arterial hypertension (PAH) than the general population. PAH is a risk for perioperative respiratory and heart failure, and marked edema of colonic stoma after sigmoidectomy. We report a case of sigmoidectomy for sigmoid colon cancer in a patient with PAH associated with MCTD for whom perioperative treatment was planned to control pulmonary arterial pressure (PAP), and a surgical strategy to avoid complications attributable to PAH and MCTD was employed.Case presentationA 52-year-old woman with sigmoid cancer and severe PAH associated with MCTD underwent surgery. We controlled PAH by using intravenous epoprostenol. We selected open surgery without laparoscopy and Hartmann's operation. After surgery, severe perioperative complications were not detected, and the patient discharged from hospital 17 days after the operation.DiscussionDuring surgery under general anesthesia, the mortality rate of PAH is high because of heart and respiratory failure. We planned to switch the PAH treatment from an oral agent to intravenous epoprostenol only in the preoperative period, and selected open surgery. We ligated the inferior mesenteric artery (IMA) and inferior mesenteric vein (IMV) below the branch of LCA to avoid marked edema of stoma. Consequently, we could avoid severe intraoperative and postoperative complications.ConclusionsControlling PAP using epoprostenol, open surgery, stoma and the ligation level for the IMA and IMV preventing are important to avoid perioperative complications of sigmoid colon cancer complicated by severe PAH.

Perioperative complications in cleft palate repair with Robin sequence following Tuebingen palatal plate treatment

Our study aimed to evaluate perioperative complications following our institutional pre- and intraoperative management in cleft palate repair with Robin sequence (RS).RS patients who underwent cleft palate repair between 2000 and 2020 were retrospectively analysed. RS children with complete documentation and whose initial treatment involved the Tuebingen palatal plate (TPP) were included. Clinical records and operative charts were reviewed with regard to clinical characteristics as well as the neonatal and perioperative course. Results before and after adjustment of the anesthesiology protocol in 2014 were compared.143 RS patients (41% male, 59% female) were included. Median pretherapeutic mixed-obstructive apnea index (MOAI) after birth was 9.4/hour (IQR 20.0). TPP treatment was associated with normalisation of the MOAI and adequate weight gain until surgery. At surgery, median age was 10 months (IQR 3), MOAI 0.1/h (IQR 0.5), and weight 8.7 kg (IQR 1.7). In 93% of cases (n = 133), the postoperative course was uneventful. Refinement of the anesthesiology protocol showed positive effects on the perioperative course and led to a reduction in perioperative events (10.7% vs. 2.9%). No severe perioperative complications occurred.We recommend the adoption of TPP treatment in the therapy of RS children. Our favourable results show that early TPP treatment minimizes perioperative complications in cleft palate repair by effectively and sustainably correcting upper airway obstruction.

Research progress in influence of perioperative hypotension on postoperative outcome of patients.

With the advancement of disease treatments, the number of patients undergoing surgery worldwide is increasing. However, many patients still experience severe perioperative complications. Perioperative hypotension is one of the common side effects during surgery. Physiologically, perioperative hypotension can lead to insufficient perfusion of important organs and result in acute and chronic irreversible organ injury, which cause serious consequences for the patient's postoperative hospitalization and even the long-term outcome. Therefore, in order to optimize perioperative circulation management and improve the quality of life for patients after surgery, it is of great importance to investigate the relationship between perioperative hypotension and postoperative myocardial injury, ischemic stroke, postoperative delirium, acute kidney injury, and postoperative mortality. Individualized circulation management and reasonable application of vasoactive drugs may be the key point to early prevention and correct treatment of perioperative hypotension, which is of great significance for reducing perioperative related morbidity and mortality and improving the prognosis for the surgical patients.

Perioperative FLOT plus anti-PD-L1 avelumab (FLOT-A) in resectable oesophagogastric adenocarcinoma (OGA): Interim safety analysis results from the ICONIC trial.

201 Background: ICONIC is a single-arm phase II trial investigating the safety and efficacy of perioperative FLOT-A in resectable OGA. Following a 3+3 design safety run-in phase, standard dose FLOT with 10mg/kg IV avelumab (dose level 0) q2weeks was taken forward into the main study. The aims of this pre-planned interim analysis were to assess perioperative safety and R0 resection rates. Methods: The interim analysis occurred once the 15th patient treated at dose level 0 reached 30 days post-surgery. Results: At data cut-off, 15 patients had received at least one cycle of FLOT-A and had undergone resection. The median age of patients was 63y (range: 25 – 73). 71% had an ECOG PS of 0. 60% of tumours were staged as T3 at baseline and 40% T2; 67% were N0, 7% N1 and 27% N2. Due to 5-FU related cardiac toxicity, two patients switched to alternative chemotherapy without 5-FU and avelumab. 13/15 patients (87%) completed 4 cycles of pre-operative FLOT-A; of these, five patients had avelumab omitted for one cycle for toxicity evaluation and management. 9/15 patients (60%) experienced a G3/4 adverse event (AE). These were FLOT-A-related in 8/15 patients (53.3%). The commonest G3/4 AEs were febrile neutropenia, neutropenia and diarrhoea. Median time from last chemotherapy to surgery was 6.4 weeks. No delays or failure to proceed to surgery occurred due to avelumab-related complications. 7% of patients had an American Society of Anaesthesiologists (ASA) preoperative risk score of I, 47% a score of II and 47% a score of III. 73% of patients had operations involving a thoracic approach (10 minimally invasive Ivor-Lewis oesophagogastrectomy with two field radical lymphadenectomy, 1 left thoracoabdominal oesophagogastrectomy and 4 gastrectomy with D2 lymphadenectomy). Median time to extubation was 6h (IQR: 4-24). The median Acute Physiology and Chronic Health Evaluation (APACHE) score at day 1 post-op was 12 (IQR: 10-15) with a median of 3 days (IQR: 2-4) of CCU care. No unexpected complications were reported intra-operatively or during post-operative recovery in FLOT-A treated patients. 5/14 evaluable patients at data cut-off (35.7%) had Clavien-Dindo grade II post-operative complications and 3/14 (21.4%) grade IIIa complications; of these 1 patient had an anastomotic leak that was treated endoscopically. There were no emergency re-operations. All 15 patients achieved R0 resections and were discharged home after a median of 13d (IQR: 11-16) in hospital. Conclusions: To date, FLOT-A has not led to unexpected or unusually severe perioperative complications in the context of major complex upper GI surgery for resectable OGA. Clinical trial information: NCT03399071.

Exploration of the connection between severe perioperative complications and preoperative basic diseases of surgical patients with non-small cell lung cancer

Objective: To explore the connection between severe perioperative complications and preoperative basic diseases of surgical patients with non-small cell lung cancer (NSCLC). Methods: We retrospectively analyzed the data of surgical patients with NSCLC from January 1, 2016 to December 31, 2018 in Cancer Hospital, Chinese Academy of Medical Sciences (CAMS). The single factor analysis and logistic multivariate regression analysis were conducted to explicate the correlation of the risk factors especially preoperative basic diseases with severe perioperative complications. Results: A total of 12, 650 cases meeting our inclusion and exclusion criteria were included, of whom 5, 409 (42.76%) cases had various preoperative basic diseases and 140 (1.11%)cases occurred severe perioperative complications. Pulmonary and intrathoracic complications and circulatory system complications dominantly accounted for the severe perioperative complications, with incidence of 0.64% and 0.25%, respectively. The gender, age, tumor differentiation, surgical method, surgical approach, and preoperative basic diseases were significantly associated with the occurrence of severe perioperative complications in surgical patients with NSCLC according to the single factor analysis outcomes (P<0.05). Patients with pulmonary disease (P=0.02), heart disease (P=0.03) and diabetes (P=0.02) were more likely to occur severe complications according to the multivariate analysis outcomes. Conclusions: The forms of severe perioperative complications of surgical patients with NSCLC are various. Patients with pulmonary disease, heart disease and diabetes are likely to occur severe complications, besides patients with male sex, elder age, poorly differentiated tumor, and undergoing open thoracotomy. We should take more effective measures to avoid severe complications when deal with these patients.

Abordagem clínico-cirúrgica de desvio portossistêmico congênito em pequenos animais: quais as novidades?

Foi realizada uma revisão sobre a fisiopatogenia, sinais clínicos, diagnóstico e principais tratamentos e técnicas para o desvio portossistêmico em pequenos animais. As fontes pesquisadas foram: CAB, MEDILINE por um período retrospectivo de 20 anos e acervos da Biblioteca da Faculdade de Medicina Veterinária e Zootecnia (FMVZ) da Universidade de São Paulo (USP). O desvio portossistêmico congênito (DPSC) é uma das anormalidades vasculares mais comuns em cães, as raças de pequeno porte apresentam maior incidência. Os DPSCs em cães e gatos são comunicações vasculares que ocorrem do sistema venoso portal para o sistema venoso sistêmico, ou seja, fazem uma via secundária. Há dois tipos de DPSCs, intra-hepático e extra-hepático, observados com frequência em raças de grande porte e miniaturas, respectivamente. O diagnóstico é baseado no histórico de animais jovens com retardo de crescimento, letargia, convulsão ou distúrbio de comportamento principalmente após alimentação, retorno demorado de anestesia ou sedação, crise de encefalopatia hepática, em raças predispostas. A confirmação do vaso anômalo é realizada pela ultrassonografia com doppler, angiografia por tomografia computadorizada ou por ressonância magnética. O manejo clínico pode aliviar sinais clínicos de encefalopatia hepática, porém em longo prazo, é questionável, pois o fluxo sanguíneo portal continua desviado para a circulação sistêmica, comprometendo a distribuição de fatores hepatotróficos ao fígado e ocorrendo uma contínua atrofia do mesmo. O único tratamento definitivo é o cirúrgico, idealmente com técnica que atenue progressivamente o vaso anômalo e evite a hipertensão portal aguda. Dentre as técnicas de tratamento cirúrgico descritas o uso de ameroide constrictor apresenta-se como uma das formas mais seguras a obtenção do fechamento do desvio. Entretanto, os portadores de DPSC podem sofrer de complicações perioperatórias graves e necessitam de abordagem clínicocirúrgica específica, associado a um diagnóstico por imagem precisa para a correta localização do vaso anômalo e sucesso cirúrgico.

P0308IMPACT OF MAJOR SURGICAL OPERATIONS ON CLINICAL OUTCOME IN DIALYSIS PATIENTS

Abstract Background and Aims We aimed to study the impact of major surgical operations on clinical outcome in patients with end-stage kidney disease treated with haemodialysis (HD) or peritoneal dialysis (PD). Method We retrospectively evaluated the records of all patients on HD and PD, who had been treated for at least 3 months at our outpatient clinics between January 1, 2014 and December 31, 2018. In addition to clinical and laboratory parameters, data on all major surgical operations were recorded. Results Among the 202 patients, 133 (66%) were on HD and 69 (34%) on PD. The mean age (±SD) was 58.3±14.5 years, 48% were female and 28% had diabetes mellitus. Forty-seven patients (23%) had a major surgical operation. The operation types were cardiovascular in 14 patients, orthopaedic in 11, gastrointestinal in 8, genitourinary in 6, parathyroidectomy in 5 and brain, pulmonary and breast in 1 patient each. Operations were emergent in 10 patients (21%) and elective in the others (79%). Among the whole study population, 59 patients (29%) died during the study period. In Kaplan-Meier analysis (Figure), mean (95% CI) survival time in operated patients was 43 months (37 to 49 months), while it was 49 months (46 to 52 months) in the others (p=0.023). Fifteen out of 23 deaths (65%) among the operated patients occurred in the first month after surgery. Severe perioperative complications (arrhythmias, hypervolemia, hypotension, bleeding, acute coronary syndrome, respiratory failure and cerebrovascular event) were recorded in 17 (36%) of the operated patients, of whom 16 died (p=0.001). Although did not reach a significant level, mortality rate tended to be higher after emergent operations than that after elective operations. Cox regression analyses revealed that age (RR 1.033, 95% CI 1.010-1.057, p=0.005), diabetes (RR 2.581, 95% CI 1.474-4.521, p=0.001), preoperative C-reactive protein level (RR 1.005, 95% CI 1.002-1.007, p&amp;lt;0.0001) and having a major surgical operation (RR 1.868, 95% CI 1.068-3.268, p=0.028) were the independent predictors of mortality. Conclusion Although prospective studies with a higher patient number are needed to confirm, our study shows that, in addition to age, diabetes and inflammatory status, having a major surgical operation is an independent risk factor for mortality in dialysis patients. The prevention and management of perioperative complications properly may result in more favourable outcomes in these patients.

Neovagina Creation: A Novel Improved Laparoscopic Vecchietti Procedure in Patients with Mayer-Rokitansky-Küster-Hauster Syndrome

To report a new improved laparoscopic Vecchietti vaginoplasty in patients with congenital vaginal agenesis and to investigate its efficacy and safety. A retrospective descriptive and case-control study. Single academic institution. Women who were diagnosed with Mayer-Rokitansky-Küster-Hauster (MRKH) syndrome and underwent our new improved laparoscopic Vecchietti procedure from July 2010 to June 2019 were selected as the study group. The eligible participants had congenital vaginal agenesis with normal 46,XX karyotype and ovarian function. Age-matched, nulliparous, sexually active women were selected as the control group. Women with MRKH syndrome in the study group underwent the novel improved laparoscopic Vecchietti procedure. All participants in both groups were required to complete Female Sexual Function Index and Female Genital Self-Image Scale questionnaires. The effects of our procedure, including the anatomic and functional efficacy of the neovagina, were the primary outcomes. The secondary outcomes consisted of the perioperative complications, surgical morbidities, and long-term postoperative discomfort. A total of 79 patients with MRKH syndrome underwent our new improved Vecchietti vaginoplasty, of whom 44 (55.7%) were diagnosed as Type I MRKH syndrome, whereas 35 (44.3%) were Type II MRKH syndrome. At a 30-month follow-up after surgery, an anatomic neovagina measuring 10.44 cm in length and 1.30 cm in width was achieved. All 79 patients obtained anatomic success with 92.41% of functional efficacy. Compared with 81 age-matched, nulliparous women in the control group, there was no statistical difference regardless of individual measure or total Female Sexual Function Index scores (p >.05). The Female Genital Self-Image Scale assessment showed a significantly lower score in patients undergoing the vaginoplasty (20.14 ± 3.05 vs 22.95 ± 2.12; p <.001). There were no severe perioperative complications except 1 mild bladder injury and 1 transient fever. Our novel improved laparoscopic Vecchietti vaginoplasty is a relatively safe and effective method for surgical treatment of congenital vaginal agenesis. It may be an alternative to neovagina creation for reaching satisfying anatomic and functional efficacy and improving patients' sexual function.

Total Laparoscopic Hysterectomy for Diagnosis and Treatment of Cervical Cystic Lesions: A Case Series

Objective: Cervical cystic lesions are often observed in gynecological clinical practice. Many are caused by benign diseases such as lobular endocervical glandular hyperplasia (LEGH), and it is important to differentiate these lesions from those due to malignant diseases such as minimal deviation adenocarcinoma (MDA). In cases in which fertility preservation is not a concern, the final pathology is often confirmed by hysterectomy. To investigate the feasibility and safety of laparoscopic surgery for cervical cystic lesions, we retrospectively examined cases in which total laparoscopic hysterectomy (TLH) was performed for diagnosis and treatment. Methods: The subjects were 28 women who underwent TLH from April 2012 to March 2017 at Keio University Hospital. The pre- and post-operative courses of these patients were examined. Results: The average age was 49.4 (range 39 - 65) years and the mean body mass index was 21.7 (16.8 - 30.5) kg/m2. The average operation time was 159 (101 - 314) min and the average bleeding volume was 106.8 (0 - 600) g. There were no severe perioperative complications. The average hospital stay was 8.4 (7 - 14) days. In postoperative pathological diagnosis, 13 cases had benign diseases such as Nabot cysts, there were 14 cases of LEGH, and one patient was diagnosed with MDA. In the MDA case, additional bilateral salpingo-oophorectomy and pelvic lymph node dissection were performed at a later date. No metastasis was observed in these excised specimens. Conclusions: Our results suggest that TLH for cervical cystic lesions can be performed safely. However, it is important to consider the TLH indication before surgery based on the possibility of malignant disease.

Femtosecond laser-assisted versus phacoemulsification cataract surgery (FEMCAT): a multicentre participant-masked randomised superiority and cost-effectiveness trial

Cataract surgery is one of the most common operations in health care. Femtosecond laser-assisted cataract surgery (FLACS) enables more precise ocular incisions and lens fragmentation than does phacoemulsification cataract surgery (PCS). We hypothesised that FLACS might improve outcomes in cataract surgery compared with PCS despite having higher costs. We did a participant-masked randomised superiority clinical trial comparing FLACS and PCS in two parallel groups (permuted block randomisation stratified on centres via a centralised web-based application, allocation ratio 1:1, block size of 2 or 4 for unilateral cases and 2 or 6 for bilateral cases). Five French University Hospitals enrolled consecutive patients aged 22 years or older who were eligible for unilateral or bilateral cataract surgery. Participants, outcome assessors, and technicians carrying out examinations were masked to the surgical treatment allocation until the last follow-up visit and a sham laser procedure was set up for participants randomly assigned to the PCS arm. The primary clinical endpoint was the success rate of surgery, defined as a composite of four outcomes at a 3-month postoperative visit: absence of severe perioperative complication, a best-corrected visual acuity (BCVA) of 0·0 LogMAR (logarithm of the minimum angle of resolution) or better, an absolute refractive error of 0·75 dioptres or less, and unchanged postoperative corneal astigmatism power (≤0·5 dioptres) and axis (≤20°). The primary economic endpoint was the incremental cost per additional patient who had treatment success at 3 months. Primary outcomes were assessed in all randomly assigned patients who met all eligibility criteria (missing data considered as failure). We used mixed logistic regression models or mixed linear regression models for statistical comparisons, adjusted on centres and whether cataract surgery was bilateral or unilateral. The study is registered with ClinicalTrials.gov, NCT01982006. Of the 907 patients (1476 eyes) randomly assigned between Oct 9, 2013, and Oct 30, 2015, 870 (704 eyes in FLACS group and 685 eyes in the PCS group) were analysed. We identified no significant difference in the success rate of surgery between the FLACS and PCS groups (FLACS: 41·1% [289 eyes]; PCS: 43·6% [299 eyes]); adjusted odds ratio 0·85, 95% CI 0·64-1·12, p=0·250). The incremental cost-effectiveness ratio was €10 703 saved per additional patient who had treatment success with PCS compared with FLACS. We observed no severe adverse events during the femtosecond laser procedure, and most of the complications in the FLACS group related to the primary outcome measures occurred during the phacoemulsification phase or postoperatively. Despite its advanced technology, femtosecond laser was not superior to phacoemulsification in cataract surgery and, with higher costs, did not provide an additional benefit over phacoemulsification for patients or health-care systems. French Ministry of Social Affairs and Health.

Customized anterior craniocervical reconstruction via a modified high-cervical retropharyngeal approach following resection of a spinal tumor involving C1-2/C1-3.

The surgical treatment of an upper cervical spinal tumor (UCST) at C1-2/C1-3 is challenging due to anterior exposure and reconstruction. Limited information has been published concerning the effective approach and reconstruction for an anterior procedure after C1-2/C1-3 UCST resection. The authors attempted to introduce a novel, customized, anterior craniocervical reconstruction between the occipital condyles and inferior vertebrae through a modified high-cervical retropharyngeal approach (mHCRA) in addressing C1-2/C1-3 spinal tumors. Seven consecutive patients underwent 2-stage UCST resection with circumferential reconstruction. Posterior decompression and occiput-cervical instrumentation was conducted at the stage 1 operation, and anterior craniocervical reconstruction using a 3D-printed implant was performed between the occipital condyles and inferior vertebrae via an mHCRA. The clinical characteristics, perioperative complications, and radiological outcomes were reviewed, and the rationale for anterior craniocervical reconstruction was also clarified. The mean age of the 7 patients in the study was 47.6 ± 19.0 years (range 12-72 years) when referred to the authors' center. Six patients (85.7%) had recurrent tumor status, and the interval from primary to recurrence status was 53.0 ± 33.7 months (range 24-105 months). Four patients (57.1%) were diagnosed with a spinal tumor involving C1-3, and 3 patients (42.9%) with a C1-2 tumor. For the anterior procedure, the mean surgical duration and average blood loss were 4.1 ± 0.9 hours (range 3.0-6.0 hours) and 558.3 ± 400.5 ml (range 100-1300 ml), respectively. No severe perioperative complications occurred, except 1 patient with transient dysphagia. The mean pre- and postoperative visual analog scale scores were 8.0 ± 0.8 (range 7-9) and 2.4 ± 0.5 (range 2.0-3.0; p < 0.001), respectively, and the mean improvement rate of cervical spinal cord function was 54.7% ± 13.8% (range 42.9%-83.3%) based on the modified Japanese Orthopaedic Association scale score (p < 0.001). Circumferential instrumentation was in good position and no evidence of disease was found at the mean follow-up of 14.8 months (range 7.3-24.2 months). The mHCRA provides optimal access to the surgical field at the C0-3 level. Customized anterior craniocervical fixation between the occipital condyles and inferior vertebrae can be feasible and effective in managing anterior reconstruction after UCST resection.

Learning curve of high-complexity surgery for advanced ovarian cancer

ObjectiveWe investigated the learning curve for a monodisciplinary surgical team consisting of gynecologic oncologists performing cytoreductive surgery for advanced ovarian cancer, involving high-complexity procedures with bowel resection and upper abdominal surgery. MethodsWe investigated 271 consecutive patients with ovarian, fallopian tube, and peritoneal carcinoma undergoing cytoreductive surgery for stage III/IV disease. All operations were performed by a team consisting of only gynecologic oncologists. Patients were classified into 2 groups depending on the surgical complexity score (a cumulative score based on complexity and number of procedures performed). Learning curves for patients with moderate (4–7, 63 patients) and high scores (8–18, 208 patients) were evaluated using cumulative sum (CUSUM) analysis of operative time, total blood loss, and perioperative complications. ResultsOperative time and total blood loss showed a learning curve. The CUSUM curve for operative time peaked at the 28th and 51st case in the moderate- and high-score groups, respectively. The CUSUM curve for total blood loss peaked at the 16th and 55th case in the moderate- and high-score groups, respectively. The CUSUM curve for complications (Clavien-Dindo ≥ IIIb) showed a downward slope after the 6th case in the high-score group and remained within the acceptable range throughout the study. ConclusionProficiency in performing high-complexity surgery was achieved after approximately 50 cases and this number is greater than the number of cases required to perform moderate-complexity surgery. Acceptable rates of severe perioperative complications were observed even during the initial learning period in cases of high-complexity surgery.