Single High-volume Center Research Articles

The role of cardiac surgeon in transvenous lead extraction: Experience from 3462 procedures.

The professional society guidelines recommend that transvenous lead extraction (TLE) operating teams collaborate closely with cardiac surgeons in the management of life-threatening complications. We assessed the role of cardiac surgeons participating in 3462 TLE procedures at a high-volume center between 2006 and 2021. The roles for cardiac surgery in TLE can be categorized into five areas: emergency surgical interventions for the management of cardiac laceration and severe bleeding (1.184%), cardiac surgery complementing partially successful TLE or vegetation removal (0.693%), delayed surgical treatment of TLE-related tricuspid valve dysfunction (0.751%), epicardial pacemaker implantation through sternotomy during emergency, complementing or delayed surgical interventions (0.607%), and delayed epicardial lead implantation (0.491%). Isolated damage to the wall of the right atrium was the most common cause of cardiac tamponade (53.66% of emergency surgeries) followed by injury to the right ventricle and vena cava (both 7.317%). Emergency cardiac surgery for the management of severe hemorrhagic complications is still the most common treatment option. The remaining areas include surgery complementing partially successful TLE: repair of tricuspid valve or epicardial ventricular lead placement to achieve permanent cardiac resynchronization. The experience at a single high-volume TLE center indicates the necessity of close collaboration with the cardiac surgeons whose roles appear broader than the mere surgical standby. Mortality in patients who survived cardiac surgery during TLEdoes not differ from the survival of other patients after TLE without complications requiring surgical intervention.

MO816: Bone Turnover Markers as Risk Factors of Severe Hypocalcemia After Parathyroidectomy for Secondary Hyperparathyroidism

Abstract BACKGROUND AND AIMS Hungry bone syndrome is a common postoperative complication after parathyroidectomy (PTx) for severe secondary hyperparathyroidism (SHPT). We aimed to evaluate whether preoperative levels of serum alkaline phosphatase (AP) and β-crosslaps (CTX) are associated with the development of severe hypocalcemia after PTx for SHPT in dialysis-dependent patients. METHOD The retrospective study included 127 severe SHPT dialysis-dependent patients who underwent subtotal (SPTx) or total parathyroidectomy with autotransplantation of parathyroid tissue (PTx + AT) in a single high-volume centre of endocrine surgery between 2011 and 2014. Severe postoperative hypocalcemia was defined as an ionized serum calcium level <0.9 mmol/L on a day 3 after surgery. RESULTS Severe hypocalcemia was observed in 83 (65.4%) patients after PTx. Comparing to those with mild hypocalcemia, hypoCa patients were significantly younger (mean age 44.2 ± 11.3 years versus 49.7 ± 10.4 years in a non-hypoCa group; P = .0089). Patients in two groups did not differ in terms of gender (P = .198), dialysis vintage (P = .24) and type of surgery (TPTx + AT or SPTx; P = .127). Preoperative PTH level was significantly higher in hypoCa group comparing to non-hypo Ca group [134 (Q1–Q3: 103–190) pmol/L versus 93.9 (Q1–Q3: 74.6–124.3) pmol/L, respectively; P < .0001]. In univariate analysis preoperative AP level was associated with the risk of postoperative severe hypocalcemia [363.2 (Q1–Q3: 180.9–726.3) IU in hypoCa group versus 142.1 (Q1–Q3: 97.2–223.7) IU in non-hypoCa group; P < 0.0001) (Figure 1). AP level above the cut-off value of 238.5 IU/L caused a 5-fold increase risk of severe hypocalcemia. We observed a moderate negative correlation between preoperative AP level and serum ionized calcium level on the third postoperative day after PTx {ρ = –0.637 [95% confidence interval (95% CI) –0.51 to –0.74]; P < .0001}. In contrast, preoperative CTX level was not associated with postoperative severe hypocalcemia [5.34 (Q1–Q3: 4.06–6.03) µg/L in hypoCa group versus 4.6 (Q1–Q3: 3.42–5.69) µg/L in non-hypoCa group; P = .191] (Figure 2). Moreover, the correlation between preoperative AP and CTX levels was weak, even though it was statistically significant [ρ = 0.27 (95% CI 0.08–0.44); P = .006]; and we observed no statistically significant correlation between preoperative CTX and PTH levels (P = .07). The multivariate logistic regression revealed AP level as the only independent risk factor of severe hypocalcemia development after PTx [ОR 1.006 (95% CI 1.002–1.009) per each IU; P = .005]. CONCLUSION We identified serum AP level, but not CTX, as an independent risk factor of severe hypocalcemia development after surgical treatment of SHPT. The correlation between CTX and other bone turnover markers (PTH, AP) is weak in dialysis-dependent patients with severe SHPT.

CA-536-02 PULSED FIELD ABLATION FOR PAROXYSMAL AND PERSISTENT ATRIAL FIBRILLATION USING AN OPTIMIZED BIPHASIC WAVEFORM: REAL CLINICAL DATA FROM SINGLE CENTER

Catether ablation of atrial fibrillation (AF) using thermal energies such as radiofreqency or cryothermy is associated with indiscriminate tissue destruction. Pulsed field ablation (PFA) with adapted sub-second electric - fields create pores in cell membranes - caused irreversible electroporation. Analysis conteined Farawave™ catheter PFA in single center high-volume center.

Robotic Ablation for Atrial Fibrillation: A High Volume Single Center Experience

Robotic Ablation for Atrial Fibrillation: A High Volume Single Center Experience

Machine learning algorithms as early diagnostic tools for pancreatic fistula following pancreaticoduodenectomy and guide drain removal: A retrospective cohort study

ObjectiveClinically relevant postoperative pancreatic fistula (CR-POPF) remains the major cause of morbidity following pancreaticoduodenectomy (PD). Several model score systems such as the Fistula Risk Score (FRS) have been developed to predict CR-POPF using preoperative and intraoperative data. Machine learning (ML) algorithms are increasingly applied in the medical field and they could be used to assess the risk of CR-POPF, identify clinically meaningful data and guide drain removal. MethodsData from consecutive patients who underwent PD between January 1, 2010 and March 31, 2021 at a single high-volume center was collected retrospectively in this study. Demographics, clinical features, intraoperative parameters, and laboratory values were used to conduct the ML model. Four different ML algorithms (CatBoost, lightGBM, XGBoost and Random Forest) were used to train this model with cross-validation. ResultsA total of 2421 patients with 62 clinical parameters were enrolled in this ML model. The majority of patients (76.3%) underwent open PD while others underwent robot-assisted PD. CR-POPF occurred in 424 (17.5%) patients. The CatBoost algorithm outperformed other algorithms with a mean area under the receiver operating characteristic curve (AUC) of 0.81 (95% confidence interval: 0.80–0.82) from the 5-fold cross-validation procedure. In the test dataset, the CatBoost algorithm also achieved the best mean-AUC of 0.83. The most important value was mean drain fluid amylase (DFA) in the first seven postoperative days (POD). The performance of models that used only preoperative data and intraoperative data was marginally lower than that of models that used combined data. ConclusionOur ML algorithms could be applied as early diagnostic tools for CR-POPF in patients who underwent PD. Such real-time clinical decision support tools can identify patients with a high risk of CR-POPF, help in developing the perioperative management plan and guide the optimal timing of drain removal.

Is it safe to expand the indications for split liver transplantation in adults? A single-center analysis of 155 in-situ splits.

IntroductionSplit liver transplantation (SLT) enables two recipients to be transplanted using a single donor liver; typically, an adult and a child. Despite equivalent long‐term outcomes to whole grafts in selected adults, the use of these grafts in high‐risk adult recipients with high model for end‐stage liver disease (MELD) scores (≥30), a poor pre‐transplant clinical status (ICU or hospital‐bound), acute liver failure or retransplantation remains controversial.MethodsWe retrospectively analyzed all deceased donor adult liver transplants performed between July 2002 and November 2019 at a single high‐volume center and performed a propensity score‐matched analysis. A subgroup analysis was performed to assess utility of these grafts for high‐risk recipients.ResultsA total of 1090 adult liver transplants were performed, including 155 SLT (14%). Graft survival at 1‐, 3‐ and 5‐years were comparable between recipients of split and whole liver grafts (82%, 79% and 74% vs. 86%, 81% and 77%, respectively, log rank P = .537), as was patient survival at 1‐, 3‐ and 5‐years. Recipients of split grafts were more likely to have biliary complications and hepatic artery thrombosis, but equivalent long‐term survival. Recipients with high MELD scores or a poor pre‐transplant clinical status had similar patient and graft survival and complication profiles irrespective of whether they received split or whole grafts.ConclusionsSLT is an important method for addressing donor shortages and provides comparable long‐term outcomes in adult recipients despite an increase in short‐term complications. SLT use in high‐risk recipients should be considered to allow for sickest‐first allocation policies.

Stepwise Improvements in Esophagectomy Outcomes During a Quarter Century

The practice of surgery is a constant quest for improvement. In this issue of The Annals of Thoracic Surgery, in their retrospective analysis of esophagectomy outcomes at a single high-volume center during a 25-year period, Slaman and colleagues1 show how a systematic approach to surgical care can result in incremental progress. The 5-year survival rate after esophagectomy at their institution increased from 32.5% to 47.7%. The rates of R0 resection, hospital length of stay, and intensive care unit stay also significantly improved.

35: DOES CARDIOPULMONARY TESTING HELP PREDICT LONG-TERM SURVIVAL AFTER OESOPHAGECTOMY?

Abstract Background and aim Oesophagectomy is associated with a high rate of morbidity and mortality. Preoperative cardiopulmonary fitness has been correlated with outcomes within major surgery. Variables derived from CPET have been associated with postoperative outcomes. It is unclear whether preoperative cardiorespiratory fitness of patients undergoing oesophagectomy is associated with long-term survival. The aim of this study was to evaluate whether any of the cardiopulmonary exercise testing (CPET) variables that are routinely derived in patients with oesophageal cancer may aid in predicting long-term survival after oesophagectomy. Methods Patients undergoing CPET followed by trans-thoracic oesophagectomy for oesophageal cancer with curative intent between January 2013 and January 2017 from single high-volume centre were retrospectively analysed. The relationship between predictive co-variables including CPET variables, and survival was studied with a Cox proportional hazard model. Receiver operation curve (ROC) analysis was conducted to find cut-off values for CPET variables predictive of 3-year survival. Results A total of 313 patients were analyzed. The ventilatory equivalent for carbon dioxide (VE/VCO2) at anaerobic threshold was the only CPET variable independently predictive of long-term survival in multivariable analysis (HR 1.049, 95% CI 1.011–1.088, P = 0.011). Pathological stage III and IV disease was the other co-variable found to be independently predictive of survival. ROC analysis of the VE/VCO2 failed to demonstrate a predictive cut-off value of 3-year survival (AUC = 0.564, 95% CI 0.499–0.629, P = 0.056). Conclusion A high VE/VCO2 before oesophagectomy for malignant disease is an independent predictor of long-term survival and may be an important variable for consideration when counselling patients.

Direct anterior approach hip arthroplasty: How to reduce complications - A 10-years single center experience and literature review.

BACKGROUNDThe direct anterior approach for total hip arthroplasty (DAA-THA) is increasing in popularity due to some advantages such as less surgical trauma, minimal dissection of soft tissues, shorter rehabilitation times, faster return to daily activities, lower incidence of dislocation. On the other hand, the literature reports a high rate of intraoperative complications, with many different rates and complication types in the published papers. AIMTo analyze our complications comparing results with the literature; to report measures that we have taken to reduce complications rate.METHODSAll DAA-THA patients with one year minimum follow up who were operated at a single high-volume centre, between January 2010 and December 2019 were included in this retrospective study. All surgeries were performed using cementless short anatomical or straight stems and press fit cups. Patients’ follow-up was performed, at 6 wk, 3 mo, then annually post-surgery with clinical and radiological evaluation. Primary outcomes were stem revision for aseptic loosening and all-cause stem revision. Second outcome was intra-operative and post-operative complications identification.RESULTSA total of 394 patients underwent DDA-THA from January 2010 and December 2019, for a total of 412 hips; twelve patients lost to follow-up and one patient who died from causes not related to surgery were excluded from the study. The average age at the time of surgery was 61 years (range from 28 to 78 years). Mean follow-up time was 64.8 mo (range 12-120 mo). Seven stems were revised. One cortical perforation, one trochanteric and lateral cortical wall intraoperative fracture, one diaphyseal fracture, three clinically symptomatic early subsidence and one late aseptic loosening. We also observed 3 periprosthetic fractures B1 according to the Vancouver Classification. Other minor complications not requiring stem revision were 5 un-displaced fractures of the calcar region treated with preventive cerclage, one early infection, one case of late posterior dislocation, 18 case of asymptomatic stem subsidence, 6 cases of lateral cutaneous femoral nerve dysesthesia.CONCLUSIONDAA is associated to good outcomes and lower incidence of dislocation. Complication rate can be reduced by mindful patient selection, thorough preoperative planning, sufficient learning curve and use of intraoperative imaging.

Bronchial Complications and Survival Outcomes in Post-Lung Transplant

<h3>Purpose</h3> This study contrasts the current standard practice of continuous suturing to interrupted suturing during lung transplantation (LTx). We compared survival outcomes between groups, and further categorized the differences in the rate, type, and treatment of bronchial complications. <h3>Methods</h3> There were 889 LTx at our high-volume single center from Feb2012 to Jun2021. Continuous suturing was executed using 3/0 polypropylene suture on an SH needle. Interrupted implemented the same technique for the membranous portion of the anastomosis, and multiple interrupted 3/0 polypropylene sutures for the cartilaginous portion. Kaplan-Meier curves and log-rank tests compared survival, and Cox regression analysis examined impact on survival. Clinical parameters and demographics were compared, with p values <0.05 considered significant. <h3>Results</h3> Of 889 patients, 548 received continuous suturing while 341 received interrupted suturing. Demographics and clinical parameters between groups were: age (p = 0.029), gender (p = 0.9), race (p = 0.63), etiology (p = 0.261), lung allocation score (p = 0.25), BMI (p = 0.049), single versus double LTx (p < 0.0001). Bronchial complications occurred at similar rates (p = 0.38), as did types of complications (ischemia/necrosis, dehiscence, stenosis, malacia) except for dehiscence (4.5% continuous, 0.7% interrupted). ECMO was utilized in 54 vs 28 patients (continuous vs. interrupted; p = 0.12). Complications were treated similarly (p = 0.69) with dilation + stent being the most common treatment. Kaplan-Meier survival curve showed no significant difference in survival (p = 0.177). Cox regression analysis showed no difference between techniques, with bronchial complications, ECMO usage, and diagnosis having a statistically significant effect on survival. <h3>Conclusion</h3> Our study found similar survival outcomes, bronchial complication rates, and complication treatments between techniques, demonstrating comparable outcomes for both techniques.

Heart Transplant Challenges and Long-Term Outcome in Saudi Arabia: Single High-Volume Center

<h3>Purpose</h3> Heart transplant (HT) remain a gold standard therapy for patient with ESHD. Other obstacles than organ shortage are identified in our study, reporting 30 years outcome <h3>Methods</h3> Between 1989 and 2019, 341 patients underwent HT. Due to missing, 70 patients were excluded. Mean age of our recipient is 35 ±15 years, 74.7% male. Causes were Dilated cardiomyopathy 62.7% while 23.2% ischemic cardiomyopathy and restrictive cardiomyopathy 4%. Mean time on waiting list was 98 days.17.5% of our cohort were in INTERMACS 1 and 2 classes, where 24.3% were in class 3. Mechanical circulatory support (temporary or long term) was used in 14.7% of the patients before transplant. Pre-operative renal and hepatic impairment were found in 24% and 5% respectively <h3>Results</h3> Mean ischemic time was 185 minutes.10% of our recipients required short term mechanical support post-operatively. Early mortality happened in 14%. post-operative stroke was diagnosed in 4.7% of the patients. Long term survival of discharged patient is 86% in the follow up. Comparing first intraoperative Echocardiography with last follow up Echocardiography showing normal LV function in 72% while in follow up 63.5% are having normal LV function. Moreover, for right ventricle only 14.7% were having normal RV function and 8.4% were having sever RV dysfunction at first post-op Echo, however in last follow up normal RV function was found in 43% while sever RV dysfunction was found in only 3% <h3>Conclusion</h3> Despite the high-risk patient profile, we have observed acceptable outcome. Dramatic improvement in the RV function was observed in long-term follow-up

New-Onset Diabetes in Patients Post-Heart Transplantation; the Role of Hypertension and Novel Diabetic Medications

<h3>Purpose</h3> New-onset post-transplantation diabetes mellitus (DM) is common among heart transplant (HT) recipients and has been shown to be associated with higher rates of renal dysfunction and death or re-transplantation. There are limited data to describe the use of novel anti-diabetic therapies in this population. We aimed to describe the prevalence of newly diagnosed DM and DM treatment patterns in HT patients at a single high-volume transplant center<b>.</b> <h3>Methods</h3> Patients undergoing HT between 1/2010-12/2017 were retrospectively reviewed. Patients undergoing repeat HT were excluded from the analysis. New-onset DM was defined by HbA1c >= 6.5% or initiation of anti-diabetic therapy. Data were collected from the electronic medical record. <h3>Results</h3> 280 transplant patients were identified with a median follow-up of 5.1 (IQR 2.6-8.1) years. 95 (33.9%) had pre-transplant DM. Of the 185 remaining patients, 45 (24.3%) developed post-HT DM with a median time to diagnosis of 109 (IQR 20-439) days. Median age of those with new-onset DM was 54 (IQR 47-61) years and 37.8% were female. Risk of PTDM was 18.2% at 1 year, 20.0% at 2 years, 23.8% at 5 years, and 33.1% at 10 years (<b>Fig 1a</b>). Hypertension was independently associated with post-HT DM (p = 0.014, <b>Fig 1b</b>). Among all patients with DM in the post-transplant period (N=140), 10 (7.1%) were started on a sodium-glucose cotransporter-2 inhibitor (SGLT2i) and 17 (12.1%) were treated with a glucagon-like peptide-1 receptor agonist (GLP-1 RA). Adverse events with SGLT2i included polyuria in 2 patients, and adverse events with GLP-1 RA included gastrointestinal disturbance in 2 patients, palpitations in 1 patient, and discontinuation for unknown reasons in 1 patient. <h3>Conclusion</h3> DM is a common co-morbidity among HT recipients, with a high rate of pre-existing DM and post-HT DM. Utilization of the newest anti-diabetic agents with known cardiovascular benefits remains low in this cohort.

Impact of true or false lumen renal perfusion after type B aortic dissection on renal volume.

The aim of this study was to analyse the influence of true, false, and combined lumen perfusion of renal arteries on mid- and long-term kidney volume in patients with type B aortic dissection (TBAD). Retrospective analysis of patients diagnosed with a TBAD between 2008 and 2015 in a single high-volume European center. The origin of the renal arteries was evaluated on a dedicated 3D workstation (TeraRecon Inc., San Mateo, CA, USA) and coded as either arising from the true lumen (TL), false lumen (FL) or from a combination of both (CL). Additional evaluated anatomical parameters were renal volume, length, width, and depth of the kidneys. Measurements were recorded at the time of diagnosis (T0) and at 1-month (T1), 6-months (T2), 18-months (T3) and 36-month of follow-up time (T4). A total of 131 renal arteries and kidneys were evaluated in 69 patients. Mean age was 64±13 years and 77% were male. The absolute number and percentage of assessed renal arteries/kidneys was 131 (100%) at T0, 89 (68%) at T1, 73 (56%) at T2, 57 (44%) at T3 and 43 (44%) at T4. At the time of diagnosis, 71.6% renal arteries originated from the TL, 19.1% from the FL and 9.2% from a CL. TEVAR was performed in 92.7% patients and nine patients had additional renal artery stenting. At T0 the mean renal volume was 212.1±70.9cm3, 178±61.2 in women versus 222.2±70.6 in men (P=0.002). Forty-three percent of the patients had a renal volume reduction ≥15% from T0 to their last available CTA. Mixed model analysis showed a significant overall renal volume reduction of 13.7cm3 from T0 to T4 (P<0.05). No significant differences in renal-volume reduction were observed depending on origin of the renal artery, though an estimated reduction of renal volume from T0 to T4 of 40.8 cm3 was seen when the kidneys were perfused by a CL, while TL perfusion only caused a reduction of 15.6 cm3 and no relevant volume change over time was observed when the renal artery originated from FL. Alongside a renal volume reduction, mixed model analysis also showed a significant serum-creatinine increase, from 0.8618mg/at T0 to 1.38±0.56 mg/dL at T4 (P<0.001), as well as a significant glomerular filtration rate reduction over time, from > 60mL/min at T0 to 49±13 mL/min at T4 (P<0.001). A negative correlation was observed between creatinine values and renal volume change, while a positive correlation was observed between GFR and renal volume change (P<0.001). There is a significant mid-term renal-volume reduction in patients with TBAD, independent of the origin of the renal arteries. Albeit not statistically significant, combined renal artery perfusion may lead to a greater volume reduction, potentially secondary to a relevant dynamic compression by the dissection membrane. Further multicentre studies are warranted to determine the effect on long-term renal function and on possible preventive strategies.

COVID-19 opens the door for right iliac fossa pain treatment pathway.

The COVID-19 pandemic has increased the risks of surgery and management of common surgical conditions has changed, with greater reliance on imaging and conservative management. The negative appendectomy rate (NAR) in the UK has previously remained high. The aim of this study was to quantify pandemic-related changes in the management of patients with suspected appendicitis, including the NAR. A retrospective study was performed at a single high volume centre of consecutive patients aged over five years presenting to general surgery with right iliac fossa pain in two study periods: for two months before lockdown and for four months after lockdown. Pregnant patients and those with previous appendectomy, including right colonic resection, were excluded. Demographic, clinical, imaging and histological data were captured, and risk scores were calculated, stratifying patients into higher and lower risk groups. Data were analysed by age, sex and risk subgroups. The mean number of daily referrals with right iliac fossa pain or suspected appendicitis reduced significantly between the study periods, from 2.92 before lockdown to 2.07 after lockdown (p<0.001). Preoperative computed tomography (CT) rates increased significantly from 22.9% to 37.2% (p=0.002). The NAR did not change significantly between study periods (25.5% prior to lockdown, 11.1% following lockdown, p=0.159). Twelve (75%) out of sixteen negative appendectomies were observed in higher risk patients aged 16-45 years who did not undergo preoperative CT. The NAR in patients undergoing CT was 0%. Greater use of preoperative CT should be considered in risk stratified patients in order to reduce the NAR.

Incidence and risk factor analysis of complications after sentinel node biopsy for penile cancer

To determine the incidence and types of complications after dynamic sentinel node biopsy (DSNB) in patients with penile cancer (PeCa) and identify risk factors for the occurrence of postoperative complications. We evaluated 644 patients with PeCa (1284 DSNB procedures) with at least one clinically node negative (cN0) groin who underwent DSNB between 2011 and 2020 at a single high-volume centre. The 30- and 30-90-day postoperative complications were collected according to the modified Clavien-Dindo classification and the standardised methodology proposed by the European Association of Urology panel. Uni- and multivariable generalised linear mixed models were used to identify risk factors for the occurrence of complications per groin. A 30-day postoperative complication occurred in 14% of groins (n = 186), of which 94% were mild to moderate. Wound infection and lymphocele formation were most common. A 30-90-day postoperative complication occurred in 3.4% of the groins, all of which were mild or moderate (Grade I-II). The number of removed lymph nodes (LNs) per groin was the main independent predictor for any 30-day complications and Grade ≥II complications (odds ratio 1.40; P < 0.001). There was an increase in the probability of postoperative complications with the number of LNs removed after accounting for all confounders. Despite being less morbid than (modified) inguinal LN dissection, DSNB is still associated with a considerable risk of postoperative mild-to-moderate complications. This risk increases with increasing number of LNs removed. Further procedural refinement aimed at removing the true sentinel node(s) only, may help further reduce the morbidity of surgical staging in PeCa.

Minimally invasive distal pancreatectomy: Chronologic changes in the trends and clinical outcomes through a 15-year, single-center experience with 2212 patients.

We identified the chronologic changes in the clinical outcomes of minimally invasive distal pancreatectomy (MIDP) for left-sided pancreatic tumors in a single high-volume center over a period of 15years. Between 2005 and 2019, 2212 patients underwent planned MIDP. Chronologic changes were analyzed according to 5-year intervals (P1, P2, P3). Furthermore, we assessed the prognostic factors of open conversion and postoperative complications. Minimally invasive distal pancreatectomy has steadily increased during the last 15years when compared to open distal pancreatectomy, from 10.8% to 84.9%. Also, MIDP for pancreatic ductal adenocarcinoma (PDAC) has been steadily increasing from 5.6% to 68.4%. According to the 5-year intervals, lengths of hospital stay decreased, but age and American Society of Anesthesiologists (ASA) ≥3 increased; conversely, the rates of Clavien-Dindo classification ≥grade 3 (9.5%) and postoperative pancreatic fistula (39.7%) showed no differences. The 90-day mortality and open conversion rates were 0.2% and 3.5%, respectively. Multivariate logistic regression analysis revealed malignancy and extended pancreatectomy were risk factors for open conversion. Furthermore, the poor prognostic factors for severe complications were malignancy, extended pancreatectomy, and ASA ≥3. Minimally invasive distal pancreatectomy has become a popular procedure not only for benign cases but also for malignant ones. However, well-organized training, experience and skill are necessary, especially for poor-performance patients and extensively malignant conditions.

Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Non-Protected Left Main Coronary Artery Disease: 1-Year Outcomes in a High Volume Single Center Study.

Introduction: There is clear evidence of a significant reduction in all major cardiovascular adverse events (MACE) by coronary artery bypass grafting (CABG) in left main coronary artery stenosis (LMCS), but revascularization by percutaneous coronary artery intervention (PCI) shows an increasingly important role as an alternative to CABG. Several recent trials aiming to test the difference in mortality between the two types of revascularization found conflicting data. The aim of this study is to determine whether PCI is non-inferior to CABG with respect to the occurrence of MACE at 1 year in patients with significant LMCS. Material and methods: We prospectively enrolled 296 patients with chronic or acute coronary syndromes and significant LM stenosis. The angiography that recommended the revascularization procedure was used for the calculation of the Syntax II score, in order to classify the patients as low-, intermediate- or high-risk. Low- and high-risk patients were revascularized with either PCI or CABG, according to current guidelines, and were included in the subgroup S1. The second subgroup (S0) included intermediate-risk patients (Syntax II score 23–32), in whom the type of revascularization was chosen depending on the decision of the heart team or the patient preference. Patients were monitored according to the chosen mode of revascularization—PCI or CABG. LM revascularization was performed in all the patients. Clinical endpoints included cardiac death, myocardial infarction, need for revascularization and stroke. Patients were evaluated at 1 year after revascularization. Event rates were estimated using the Kaplan–Meier analysis in time to the first event. Results: At 1-year follow-up, a primary endpoint occurred in 35/95 patients in the CABG group and 37/201 in the PCI group. There were no significant differences between the 2 treatment strategies in the 1-year components of the end-point. However, a tendency to higher occurrence of cardiac death (HR = 1.48 CI (0.55–3.9), p = 0.43), necessity of repeat revascularization (HR = 1.7, CI (0.81–3.6), p = 0.16) and stroke (HR = 1.52, CI (1.15–2.93), p = 0.58) were present after CABG. Contrariwise, although without statistical significance, MI was more frequent after PCI (HR = 2, CI (0.78–5.2), p = 0.14). The Kaplan–Meier estimates in subgroups demonstrated the same tendency to higher rates for cardiac death, repeat revascularization and stroke after CABG, and higher rates of MI after PCI. Although without statistical significance, patients with an intermediate-risk showed a slightly lower risk of MACE after PCI than CABG. With the exception of dyslipidemia and gender, other cardiovascular risk factors were in favor of CABG (CKD, obesity). Conclusion: In patients with LMCS, PCI with drug-eluting stents was non-inferior to CABG with respect to the composite of cardiac death, myocardial infarction, repeat revascularization and stroke at 1 year, even in patients with intermediate Syntax II risk score.

A genomic classifier for prostate cancer correlates with adverse pathologic features: Transcriptomic features of cribriform and intraductal carcinoma of the prostate.

268 Background: Invasive cribriform and intraductal carcinoma (CF/IDC) portends an unfavorable prognosis for patients diagnosed with prostate cancer (CaP). Limited studies with small sample sizes have explored whether genomic classifiers are associated with IDC and/or CF status. We investigated the correlation between Decipher genomic risk score and IDC/CF status and assessed PCa transcriptomic features. Methods: We performed a retrospective review of CaP patients who had Decipher testing at a single high volume center between 2009-2020. The highest grade index lesion from radical prostatectomy specimens was identified by GU pathologists and used for Decipher testing. Genitourinary pathologists reviewed prostatectomy specimens for the presence of CF and IDC features. Patients were divided into three groups based on pathologic features, absent CF/IDC (CF-/IDC-), CF positive only (CF+/IDC-), and CF/IDC positive (CF+/IDC+). Categorical clinical, genomic, and pathologic variables were assessed using the Pearson Chi-Square test, quantitative with the Kruskal-Wallis test. Multivariable logistic regression was used to identify predictors of high-risk Decipher GC scores. The Kaplan-Meier method with log-rank was used to compare biochemical recurrence free survival. Differential gene expression and gene network analysis was used to identify genes and pathways associated with IDC/CF features. Results: 463 patients were included with a median follow-up of 25 months. Patients who were CF+/IDC+ had higher GC scores (CF+/IDC+: 0.77 vs. CF+/IDC-: 0.71 vs. CF-/IDC-: 0.61, p&lt;0.001). Patients who were CF+/IDC+ had a higher percentage of Gleason grade group &gt;3 (CF+/IDC+: 79% vs. CF+/IDC-: 52% vs. CF-/IDC-: 52%, p&lt;0.001). On multivariate logistic regression, predictors of high-risk GC score were presence of CF+/IDC+ features on final pathology (OR: 3.94, p&lt;0.001) and pathologic Gleason grade group &gt;3 (OR: 1.58, p=0.04). Transcriptomic analysis revealed that the hallmark androgen response pathway was significantly upregulated in CF+/IDC+ patients (Log fold change: 15.7, p&lt;0001). Conclusions: This is the largest series investigating the association of a clinically validated genomic classifier and pathologic features such as cribriform and intraductal carcinoma. These findings have implications for the use of genomic classifiers in settings where expert GU pathology is not readily available and in potentially unmasking adverse histology at the time of biopsy.[Table: see text]

Gender-Associated Outcomes Following Percutaneous Coronary Intervention With a Third-Generation, Ultrathin-Strut Drug-Eluting Stent: A Real-World, Single-Center Experience.

IntroductionIn recent years, the new third-generation ultrathin bioresorbable-polymer sirolimus-eluting stent (BP-SES), characterized by some of the thinnest struts among commercially available devices (60–80 μm) and an amorphous silicon carbide coating, has been introduced for the treatment of coronary artery disease (CAD). The present study aimed to assess different clinical outcomes and safety of this drug-eluting stent in male and female patients in a real-world setting.MethodsThe present study is a retrospective analysis including all patients treated with BP-SES between January 2017 and December 2019 at a single high-volume center. Follow-up data, including stress test results and clinical setting, were collected during outpatient visits or by telephone contact. Patients symptomatic for angina or with a positive stress test were addressed to CT scan/coronary angiogram. The main study outcome was target lesion failure (TLF), defined as a composite of cardiovascular death, target vessel myocardial infarction, or target lesion revascularization.ResultsOverall, 66 (15.9%) female and 349 (84.1%) male patients were included; women were older (median age 70 vs. 66, P = 0.003) and with a lower body mass index (BMI) (25.0 vs. 26.1, P = 0.010) compared to men, with no other relevant differences in baseline characteristics. Indication for percutaneous coronary intervention (PCI) was acute coronary syndrome in 86 (20.7%) of the cases, with no significant differences between male and female patients. A total of 558 lesions were treated with BP-SES stents, 90 in women and 468 in men (1.36 vs. 1.34 lesions per patient, P = 0.83); cumulative stent length (33.6 vs. 38.4 mm, P = 0.078), and mean stent diameter (2.92 vs. 3.0 mm, P = 0.39) did not differ in women compared to men. Technical and clinical successes were achieved in all patients. Stent thrombosis (ST) occurred in 2 (0.5%) patients, both men. TLF occurred in 10 (2.9%) men and 2 (3.0%) women after a median follow-up of 402 days, without significant differences at log-rank analysis (2.34 events per 100 patient-years in men, 2.53 in women; P = 0.80).ConclusionUltrathin struts BP-SES showed to be a safe and effective option for the treatment of CAD in both women and men, with a very low ST rate and favorable long-term outcomes.

Open Radical Cystectomy versus Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Early Outcomes of a Single-Center Randomized Controlled Trial.

Radical cystectomy (RC) with urinary diversion (UD) is still considered a complex surgery associated with significant morbidity. Open RC (ORC) remains the reference option of treatment, even if adoption of robot-assisted RC (RARC) is rapidly increasing. To date, all the available randomized controlled trials were characterized by an extracorporeal approach in performing UD, undermining potential benefits of a totally minimally invasive procedure. In this study, we aimed to report perioperative and 6-month outcomes from the first RCT comparing ORC and RARC with totally intracorporeal UD. Patients were eligible for randomization if they had a diagnostic transurethral resection of bladder tumor with cT2-4, cN0, cM0 or recurrent high-grade nonmuscle-invasive bladder cancer and no anesthesiological contraindications to robotic surgery. Patients were enrolled with a covariate adaptive randomization process based on the following variables: body mass index, American Society of Anesthesiologists® score, baseline hemoglobin, planned UD, neoadjuvant chemotherapy and cT stage. The primary end point was to demonstrate the superiority of RARC with intracorporeal UD in terms of a 50% transfusion rate reduction. Overall, 116 consecutive patients (58 RARC, 58 ORC) were enrolled. Among primary endpoint, overall perioperative transfusion rates were significantly lower in the RARC cohort (RARC: 22% vs ORC: 41%; p=0.046). This prospective randomized trial observed 22% and 41% overall perioperative transfusion rates in patients treated by RARC and ORC, respectively, confirming a significant benefit in favor of RARC with intracorporeal UD. However, perioperative complications, hospital stay and 6-month health-related quality of life were largely comparable between groups. Oncologic and functional outcomes will be assessed at longer followup to observe potential differences between arms.