Specific Postoperative Complications Research Articles

Safety and short-term outcomes of sleeve gastrectomy and Roux-en-Y gastric bypass following removal of adjustable gastric banding

Background: The practice of bariatric surgery was studied using the German Bariatric Surgery Registry (GBSR). The focus of the study was to evaluate whether revision sleeve gastrectomy (R-SG) or Roux-en-Y Gastric Bypass (R-RYGB) has a major benefit in terms of perioperative risk in patients after failed Adjustable Gastric Banding (AGB). Methods: The data collection includes patients who underwent SG or RYGB as revision surgery after failed AGB between 2005 and 2019. Outcome criteria were perioperative complications, comorbidities, 30-day mortality, and operative time. Results: The study analyzed data from 1395 patients after revision SG and RYGB. 907 patients after R-RYGB, and 488 after R-SG. Intraoperative and overall postoperative complication rates were not significantly different between the two groups (p=0.321 and 0.621). The specific postoperative complication rate was significantly lower in R-SG than in R-RYGB (p=0.049). The mean operative time differed significantly between the two groups in favor of R-SG (160.3 min vs. 128.3 min; p<0.001). There was no significant difference in 30-day mortality between the two groups (p=0.952). Conclusion: The study shows that R-SG and R-RYGB are safe and feasible as revision procedures and have acceptable complication and mortality rates. However, in our study, we cannot make a recommendation in favor of any of the surgical methods. Proper patient selection is essential to avoid possible adverse effects. Concerning the long-term results, further studies with higher methodological quality are necessary.

Comparison of Postoperative Complications and Reoperation Rates Following Surgical Management of Cervical Spondylotic Myelopathy in the Privately Insured Patient Population.

This was a large database study. The objective of this study was to compare the incidence of complications and reoperation rates between the most common surgical treatments for cervical spondylotic myelopathy (CSM): anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), and posterior laminectomy and fusion (Lamifusion). CSM is a major contributor to disability and reduced quality of life worldwide. Humana insurance database was queried for CSM diagnoses between 2007 and 2016. The initial population was divided based on the surgical treatment and matched for age, sex, and Charlson Comorbidity index. Specific postoperative complications or revisions were analyzed at individual time points. Pearson χ2 analysis with Yate continuity correction was used. Lamifusion had significantly higher rates of wound infection/disruption than ACDF or ACCF (5.03%, 2.19%, 2.29%; P=0.0008, 0.002, respectively) as well as iatrogenic deformity (4.75%, 2.19%, 2.10%; P=0.0036, 0.0013). Lamifusion also had a significantly higher rate of shock and same-day transfusion than ACDF (4.75%, 2.01%, P=0.0005), circulatory complications (2.01%, <1%, P=0.0183), and C5 palsy (4.84%, 1.74%, P≤0.0001). Compared with ACDF, Lamifusion had higher rates of hardware complication (3.29%, 2.01%, P=0.0468), and revision surgery (8.23% 5.85%, P=0.0395). Lamifusion had significantly lower rates of dysphagia than either ACDF (3.93% vs. 6.58%, P=0.0089) or ACCF (3.93% vs. 8.59%, P<0.0001). When comparing ACCF to ACDF, ACCF had significantly higher rates of circulatory complications (2.38%, <1%, P=0.0053), shock/same-day transfusion (3.2%, 2.0%, P=0.59), C5 palsy (3.47%, 1.74%, P=0.0108), and revision surgery (9.51%, 5.85%, P=0.0086). The data shows that posterior Lamifusion has higher overall rate of complications compared with ACDF or ACCF. Furthermore, when comparing the anterior approaches, ACDF was associated with lower rate of complication and revision. ACCF had the highest overall rate of revision surgery.

Autologous Scleral Pocket Technique for Ahmed Glaucoma Valve Implantation with Pars Plana Tube Insertion for Neovascular Glaucoma

Specific postoperative complications, such as tube exposure and conjunctival erosion, have occurred despite the favorable surgical outcomes of tube shunt surgeries for refractory glaucoma. The new autologous scleral pocket technique is performed by inserting the tube into the vitreous cavity without using a donor scleral patch. The purpose of this study was to evaluate the surgical results of Ahmed glaucoma valve (AGV) implantation using this technique for neovascular glaucoma (NVG), which is one of the representative refractory types of glaucoma. This observational retrospective case series included 15 consecutive eyes of 15 patients with NVG who had undergone AGV implantation at Kobe University between January 2018 and December 2019. The mean preoperative intraocular pressure (IOP) was 37.2 ± 13.8 mmHg and the glaucoma drug score was 4.2 ± 2.2. The mean IOP and glaucoma drug score at 1 year postoperatively decreased to 15.0 ± 4.6 mmHg and 1.3 ± 2.0, respectively (p < 0.001). No significant change in the corneal endothelial cell density following surgery was observed (p = 0.09); however, one patient required an additional trabeculectomy at 7 months postoperatively. No cases of tube exposure or conjunctival erosion were observed at 1 year postoperatively. These results indicated the effectiveness and safety of this technique in patients with NVG.

Risk Assessment in Thyroid Lobectomy and Total Thyroidectomy using Over 100 Thousand Cases.

To assess risk factors and non-thyroid specific postoperative complications for thyroid lobectomy compared to total thyroidectomy. A retrospective, cross-sectional study of adults undergoing a lobectomy or total thyroidectomy using the National Surgical Quality Improvement Program database between 2005 and 2017. Patients not treated by otolaryngologists or general surgeons and with unknown demographic variables were excluded. A total of 106 915 patients were analyzed, 64 763 total thyroidectomies and 42 152 lobectomies. Multivariable analysis demonstrated that total thyroidectomy patients were half as likely to return to the operating room (OR = 0.491 (95%CI 0.445-0.542), P < .001). Within this cohort, patients at greater risk for reoperation had a history of hypertension (OR = 1.225 (95%CI 1.090-1.376), P < .001), a malignant pathology (OR = 1.921 (95%CI 1.734-2.128), P < .001), and smoked (OR = 1.237 (95%CI 1.087-1.407), P = .001). Conversely, diabetes and body mass index did not impact the rate of reoperation when assessing total thyroidectomy and lobectomy. The most frequent non-thyroid specific complications in total thyroidectomy were unplanned intubation (0.5%), urinary tract infection (0.3%), and superficial surgical site infection (0.3%). In thyroid lobectomy, the most common complications were superficial surgical site infection (0.3%) and urinary tract infection (0.2%). Our multi-institutional study indicates specific risk factors for returning to the operating room that may warrant closer follow up after surgery for total thyroidectomy or thyroid lobectomy. We also identified the most common post-operative complications. During pre-operative planning, these findings should be considered by thyroid surgeons to help mitigate risk to patients.

Trends and consequences of surgical conversion in the United States.

The aim of this study was to identify national utilization trends of robotic surgery for elective colectomy, conversion rates over time, and the specific impact of conversion on postoperative morbidity. Conversion to open represents a hard endpoint for minimally invasive surgery (MIS) and is associated with worse outcomes when compared to MIS or even traditional open procedures. All adult patients who underwent either laparoscopic or robotic elective colectomy from 2013 to 2018 as reported in the American College of Surgeons Quality Improvement Program (ACS-NSQIP) database were included. National trends of both robotic utilization and conversion rates were analyzed, overall and according to underlying disease (benign disease, inflammatory bowel disease (IBD), cancer), or the presence of obesity (body mass index (BMI) ≥ 30kg/m2). Demographic and surgical risk factors for surgical conversion to open were identified through multivariable regression analysis. Further assessed were overall and specific postoperative 30-day complications, which were risk adjusted and compared between converted patients and the remaining cohort. Of 66,652 included procedures, 5353 (8.0%) were converted to open. Conversion rates were 8.5% for laparoscopic and 4.9% for robotic surgery (p < 0.0001). A decline in conversion rates over the 6-year inclusion period was observed overall and for patients with obesity. This trend paralleled an increased utilization of the robotic platform. Several surrogates for advanced disease stages for cancer, diverticulitis, and IBD and prolonged surgical duration were identified as independent risk factors for unplanned conversion, while robotic approach was an independent protective factor (OR 0.44, p < 0.0001). Patients who had unplanned conversion were more likely to experience postoperative complications (OR 2.36; 95% CI [2.21-2.51]), length of hospital stay ≥ 6days (OR 2.86; 95% CI [2.67-3.05], and 30-day mortality (OR 2.28; 95% CI [1.72-3.02]). This nationwide study identified a decreasing trend in conversion rates over the 6-year inclusion period, both overall and in patients with obesity, paralleling increased utilization of the robotic platform. Unplanned conversion to open was associated with a higher risk of postoperative complications.

Echinococcosis of the liver: evolution of surgical treatment

To analyze the development of surgical approaches for hepatic echinococcosis. We have analyzed diagnosis and treatment of 349 patients with liver echinococcosis; 97 patients were treated at the Botkin Clinical Hospital for the period from 2009 to 2019 and 252 patients were treated in surgical hospitals of Moscow city for the period from 2014 to 2019. General and specific postoperative complications, relapses and surgical approaches were assessed. The number of echinococcectomies performed in surgical hospitals of Moscow is 3 times higher compared to the Botkin Hospital. The number of liver resections is comparable in both groups. The number of pericystectomies is more than 2 times higher in the Botkin Hospital. PAIR technique was more common in surgical hospitals of Moscow. Evolution of surgical treatment from open echinococcectomy to anatomical liver resections and subsequent pericystectomy with PAIR technique becomes another round of evolutionary spiral in the development of surgical treatment of liver echinococcosis.

Relationship Between Postoperative Complications and the Prognosis of Gastric Carcinoma Patients Who Underwent Surgical Resection: A Systematic Review and Meta-Analysis.

Background:Whether the presence of postoperative complications was associated with poor prognosis of gastric carcinoma (GC) patients remain controversial. This meta-analysis was designed and reported to compare the survival difference between patients with complications and non-complications.Methods:Cochrane Library, PubMed and Embase databases were comprehensively searched for published literatures to review current evidence on this topic. The survival data were extracted, and a random-effect or fixed-effect model was used to analyze the correlation between postoperative complications and oncologic outcome of GC patients.Results:Of all studies identified, 32 were eligible for this pooled analysis, with a total of 32,067 GC patients. The incidence of postoperative complications was approximately 12.5% to 51.0%. Among them, infectious complications varied from 3.0% to 28.6%, anastomotic leakage varied from 1.1% to 8.7% and postoperative pneumonia varied from 1.6% to 12.8%. The presence of postoperative complications resulted in a significant poorer overall survival (OS) of gastric carcinoma patients (hazard ratio [HR]:1.49, 95% confidence interval [CI]: 1.33-1.67, P < 0.001). Additionally, the pooled results showed a significant correlation between infectious complications and decreased OS (HR: 1.61, 95%CI: 1.38-1.88, P < 0.001). Concerning specific postoperative complications, we found that both anastomotic leakage (HR: 2.36, 95%CI: 1.62-3.42, P < 0.001) and postoperative pneumonia (HR: 1.74, 95%CI: 1.22-2.49, P = 0.002) impaired the OS of gastric carcinoma patients.Conclusion:Postoperative complications were significantly correlated to recurrence and poor survival in gastric carcinoma patients. To gain a better surgical outcome and long-term oncological outcome, postoperative complications should be minimized as much as possible.

Decreased Complications After Total Laryngectomy Using a Clinical Care Pathway.

Background: Complications following total laryngectomy can lead to increased hospital length of stay (LOS) and increased health care costs. Our objective was to determine the efficacy of a clinical care pathway for improving outcomes for patients following total laryngectomy.Methods: This quality improvement study included all adult patients undergoing total laryngectomy—either primary or salvage—at a tertiary referral center between January 2013 and December 2018. The primary outcome was hospital LOS measured in postoperative days. The total and specific postoperative complication frequencies were evaluated, as well as 30-day readmission rates and intensive care unit (ICU) LOS.Results: Sixty-three patients were included in the study: 29 (46.0%) patients before the pathway implementation and 34 (54.0%) patients after pathway implementation. Demographic characteristics between the groups were similar. The prepathway cohort had a higher rate of total complications compared to the postpathway group (relative risk=0.5; 95% CI 0.3-1.0), although the differences in individual complications were similar. The median LOS of 10 days was the same for the 2 cohorts. The median ICU LOS was 1 day greater in the postpathway cohort, but no difference was seen in rates of ICU readmission in the 2 groups. The 30-day readmission rate also was not significant between the 2 groups.Conclusion: Implementation of a postoperative order set pathway for patients undergoing laryngectomy is associated with decreased overall complication rates. Use of a clinical care pathway may improve outcomes in patients undergoing total laryngectomy.

The Relative Impact of Specific Postoperative Complications on Older Patients Undergoing Hip Fracture Repair

Hip fractures affect a vulnerable population and are associated with high rates of morbidity, mortality, and resource utilization. Although postoperative complications are a known driver of mortality and resource utilization, the comparative impacts of specific complications on outcomes is unknown. This study assessed which complications are associated with the highest effects on mortality and resource utilization for older patients who undergo hip fracture repair. Patients ≥ 65 years of age who underwent hip fracture repair during 2016-2017 included in the Hip Fracture Targeted ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database populated the data set. Prolonged hospitalization (≥ 75th percentile) and 30-day mortality and readmission were the primary outcomes. Population attributable fractions (PAFs) were used to quantify the anticipated reduction in the primary outcomes that would result from complete prevention of 10 postoperative complications. Of 17,755 patients across 117 hospitals, 70.9% were female, 26.0% were over age 90, 22.8% had an American Society of Anesthesiologists (ASA) score of 4-5, and 53.9% presented with an intertrochanteric fracture. Postoperative delirium affected 29.8% of patients and was associated with death (PAF 18.0%; 95% confidence interval [CI] = 13.2-22.5), prolonged hospitalization (PAF 14.3%; 95% CI = 12.7-15.8), and readmission (PAF 15.0%; 95% CI = 11.3-18.6). Pneumonia affected 4.1% of patients and was associated with death (PAF 10.9%; 95% CI = 8.9-12.8), prolonged hospitalization (PAF 4.0%; 95% CI = 3.5-4.5), and readmission (PAF 9.1%; 95% CI = 7.5-10.7). The impact of the other eight complications was comparatively small. Postoperative delirium and pneumonia are the highest-impact complications for older hip fracture repair patients. These complications should be prioritized in quality improvement efforts that target this patient population.

Is Laparoscopic Bariatric Surgery Safe and Effective in Patients over 60 Years of Age?" an Updated Systematic Review and Meta-Analysis.

To evaluate, mid-term outcomes between elderly patients (EP, i.e., age > 60years old) and young patients (YP, i.e., age < = 60years old) who underwent laparoscopic bariatric surgery. Studies comparing EP versus YP for bariatric surgery published until April 2020 were selected and submitted to a systematic review and meta-analysis. After LSG, overall morbidity and specific post-operative complication rates (i.e., leak, abscess, hemorrhage, and reoperation) were significantly more frequent in EP compared with those in YP. Surgical outcomes were similar between EP and YP after LRYGB. Both procedures achieved weight loss, but it was statistically greater in YP compared with that in EP. In summary, this meta-analysis suggests that laparoscopic bariatric surgery is a safe and effective treatment in EP compared with that in YP.

Increased Rates of Septic Shock, Cardiac Arrest, and Mortality Associated With Chronic Steroid Use Following Anterior Cervical Discectomy and Fusion for Cervical Stenosis.

Anterior cervical discectomy and fusion (ACDF) is an established treatment modality for cervical spondylosis. Many patients are on immunosuppressant therapy in the management of various inflammatory spinal pathologies and other comorbid conditions. The impact of chronic steroid use on postoperative complications has not been examined in cervical fusion procedures. The objective of this study was to identify specific postoperative complications associated with steroid/immunosuppressant use following ACDF for cervical stenosis. A multi-institutional surgical registry was queried to identify 5377 patients with ACDF diagnosed with cervical stenosis. Patients were stratified into cohorts with a history of steroid/immunosuppressant use for chronic conditions (n = 198, 3.3%) versus those who did not (n = 5179, 96.7%). Propensity-score matching without replacement was implemented to control for preoperative demographics and comorbidities. Pearson χ2 and Fischer exact tests were used in comparing the prevalence of demographics, comorbidities, and complication rates. Upon propensity matching, increased rates of pulmonary embolisms (0.51% vs 0.00%, P = .025), cardiac arrest requiring resuscitation (1.01% vs 0.10%, P = .020), septic shock (0.51% vs 0.00%, P = .025), and mortality (1.52% vs 0.20%, P = .009) in the postoperative 30-day period in patients on chronic steroid/immunosuppressant use were observed. The results indicate that steroid use/immunosuppression in patients with ACDF has a higher associated rate of pulmonary embolisms, cardiac arrest, septic shock, and mortality. The risk of mortality and these other complications should be carefully considered prior to operative intervention. Future research may investigate steroid-tapering protocols that reduce the rate of infection and other postoperative complications in the subset of immunosuppressed ACDF patients. By elucidating the complication rates of ACDF patients on steroids for cervical stenosis, orthopedic surgeons can better stratify patients for risk of postoperative morbidity. Surgeons may have deeper risk-benefit discussions with these specific patients before they elect to have the operation.

Unstable Hemostasis and Specific Postoperative Complications (Literature Review)

Perioperative bleeding occupies a leading place among all surgical complications and, despite the rapid developmentof surgery, remains relevant to this day. In addition to an increase in mortality, bleeding can cause the developmentof other postoperative complications, which lead to disability of patients and to a decrease in the quality of life in all agegroups. Most perioperative bleeding are caused by technical errors. This article reviews the problem of perioperativebleeding from the point of view of impaired coagulation capabilities of the body. The main etiopathogenetic featuresof hemostasis during the development of this complication are considered. The analysis of postoperative complications,which were directly or indirectly caused by bleeding during or after surgery, is presented. The prevalence of thesecomplications in various areas of surgery has been demonstrated. More detailed study of the hemostasis system andthe identification of predictors of hemostasis difficulties before the surgery may cause an improvement in the resultsof surgical treatment and reduce the number of postoperative complications and the duration of hospital stay. Accordingly, this will lead to a decrease in the cost of treatment and an increase in patient satisfaction with the medicalcare. In connection with the above, there is a great interest among surgeons and anesthesiologists in preventing thedevelopment of perioperative bleeding.

Complications d’une ostéotomie autocentrée coulissante de la tubérosité tibiale antérieure pour pathologie fémoro-patellaire : faible incidence de pseudarthrose et de fracture

BackgroundA tibial tubercle osteotomy (TTO) is a commonly performed procedure in young and active patients with patellofemoral complaints. Previous small patient series demonstrated a relatively high risk of complications, which appear to be technique dependent. The purpose of this large case series is to quantify the risk of procedure specific postoperative complications related to a uniform self-centering TTO technique in a large cohort, performed by two different surgeons in one center. HypothesisWe hypothesize that nonunion or fracture occurs in less than 1% of the procedures. Patients and methodsFive hundred and twenty-nine knees in four hundred and forty-seven patients who underwent a self-centering TTO with at least one year of follow up were included. We performed a retrospective cohort review. Tibial fracture, osteotomy nonunion, neurovascular complications, infection and wound complications that required surgical intervention were defined as major complications, miscellaneous complications were defined minor. ResultsThe major finding in this study is the low incidence of non-union (0.6%) and tibial fracture (0.4%). In total, 9 (1.7%) major complications were reported. Minor complications included superficial wound infection in five patients, two patients had a venous thromboembolism (VTE). ConclusionA self-centering TTO is a relatively safe technique with a low number of nonunion and fracture. Level of evidenceLevel IV, retrospective cohort study.

Risk of major cardiovascular and cerebrovascular complications after elective surgery in patients with sleep-disordered breathing: A retrospective cohort analysis.

There is limited and conflicting data on whether sleep-disordered breathing (SDB) is associated with postoperative major cardiovascular and cerebrovascular events (MACCE), and mortality. To determine whether SDB is associated with increased risks of MACCE, mortality and length of hospital stay. Retrospective cohort analysis from the Nationwide Inpatient Sample. Adults who underwent elective abdominal, orthopaedic, prostatic, gynaecological, thoracic, transplant, vascular or cardiac surgery in the United States of America between 2011 and 2014. The study cohort included 1813 974 surgical patients, of whom 185 615 (10.2%) had SDB. Emergency or urgent surgical procedures were excluded. The incidences of MACCE, respiratory and vascular complications, in-hospital mortality and mean length of hospital stay were stratified by SDB. Linear and logistic regression models were constructed to determine the independent association between SDB and outcomes of interest. The incidences of MACCE [25.3 vs. 19.8%, odds ratio (OR) 1.20, P < 0.001] and respiratory complications (11.75 vs. 8.0%, OR 1.43, P < 0.001) were significantly higher in patients with SDB than in those without SDB. SDB was associated with higher rates of atrial fibrillation (14.7 vs. 10.8%, P < 0.001), other arrhythmias (6.0 vs. 5.4%, P < 0.001) and congestive heart failure (9.8 vs. 7.1%, P < 0.001). SDB patients had a lower rate of myocardial infarction (3.1 vs. 3.4%, OR 0.69, P < 0.001), lower mortality (0.6 vs. 1.3%, P < 0.001) and shorter length of hospital stay (4.8 vs. 5.2 days, P < 0.001). SDB was associated with increased risks of MACCE, and respiratory and vascular complications, but had a lower incidence of in-hospital mortality and shorter length of hospital stay.

Complications of a self-centering sliding tibial tubercle osteotomy for patellofemoral complaints; low incidence of non-union and fracture

BackgroundA tibial tubercle osteotomy (TTO) is a commonly performed procedure in young and active patients with patellofemoral complaints. Previous small patient series demonstrated a relatively high risk of complications, which appear to be technique dependent. The purpose of this large case series is to quantify the risk of procedure specific postoperative complications related to a uniform self-centering TTO technique in a large cohort, performed by two different surgeons in one center. HypothesisWe hypothesize that non-union or fracture occurs in less than 1% of the procedures. Patients and methodsFive hundred and twenty-nine knees in four hundred and forty-seven patients who underwent a self-centering TTO with at least one year of follow-up were included. We performed a retrospective cohort review. Tibial fracture, osteotomy non-union, neurovascular complications, infection and wound complications that required surgical intervention were defined as major complications, miscellaneous complications were defined minor. ResultsThe major finding in this study is the low incidence of non-union (0.6%) and tibial fracture (0.4%). In total 9 (1.7%) major complications were reported. Minor complications included superficial wound infection in five patients, two patients had a venous thrombo-embolism (VTE). ConclusionA self-centering TTO is a relatively safe technique with a low number of non-union and fracture. Level of evidenceLevel IV, retrospective cohort study.

Clinical outcome of staged surgery after primary amputation for mangled extremity.

Amputation for a mangled extremity is an effective and reliable life-saving treatment method, which requires a relatively shorter duration for treatment than limb salvage. However, only a few studies have focused on treatment with amputation. Herein, we report good clinical outcomes achieved through staged surgery performed after amputation. This study included 47 patients (38 men, 9 women; average age, 52.4years) diagnosed with mangled extremity, who underwent primary amputation between March 2014 and January 2019. The patients were divided into the initial closure (IC) groups (including 26 patients who underwent IC after amputation) and staged surgery (SS) (including 21 patients who underwent SS after amputation) groups. The presence of complications including necrosis and infection, consequent additional surgery, duration of hospitalization and expense for treatment, and functional scores of upper and lower extremities were assessed. No specific postoperative complication was found in the SS group. However, additional surgeries were performed in the IC group because of complications including three cases of infection and two cases of necrosis. The differences between the hospitalization period, treatment cost, and functional examination conducted 1year after surgery of the two groups were not statistically significant. The patients in the IC group who underwent additional surgery were hospitalized for a longer period and presented with lower functional scores due to delayed rehabilitation. Staged surgery is a definitive and safe treatment option that can effectively reduce complications including infection and necrosis in patients with mangled extremity.

The role of bursectomy in the surgical management of gastric cancer: a meta-analysis and systematic review

In order to delineate the exact role of bursectomy (BS) in gastric cancer surgery, we designed and conducted the present meta-analysis. This meta-analysis adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. A systematic literature review of the electronic databases (Medline, Scopus, Web of Science) was performed. Trial sequential analysis (TSA) was introduced for the validation of the pooled analyses. The level of evidence was attributed based on the GRADE approach. Overall, nine studies and 3599 patients were included in our meta-analysis. BS did not lead to an increase in the overall morbidity rate (OR 1.17, 95% CI 0.97-1.42, p = 0.09). Equivalence was, also, identified in all specific postoperative complications. Similarly, mortality rates were comparable (p = 0.69). Moreover, BS was related to a significantly higher operative time (p < 0.001) and perioperative blood loss (p = 0.002). Finally, resection of the omental bursa was not associated with improved R0 excision rates (p = 0.92), lymph node harvest (p = 0.1) or survival outcomes (OS p = 0.15 and DFS p = 0.97). BS displayed a suboptimal perioperative performance without any significant oncological efficacy. Due to certain limitations and the low level of evidence, further high-quality RCTs are required.

Robot-Assisted Pancreatic Surgery—the Russian Experience.

Surgical procedures that involve working in small anatomical spaces can be successfully performed using robot-assisted surgery. We did a retrospective study of the results of 86 robot-assisted pancreatic operations performed in the Abdominal Department No.1 of the A.V. Vishnevsky Institute of Surgery, Moscow. Seventy (81.4%) patients were female, and 16 (18.6%) were male; the average age was 49 (37; 59). The following robot-assisted surgeries were performed: 17 pancreaticoduodenectomies, 45 distal pancreatectomies, 16 tumor enucleations, 6 median resections, and 2 total duodenopancreatectomies. The duration of robot-assisted surgical operations varied depending on the extent of the surgery: for a pancreaticoduodenectomy (PD), it was 400 (360–550) min; for a distal pancreatectomy, it was 210 (180–250) min. Estimated blood loss in a PD was 200 (150–500) ml; in a distal pancreatectomy, it was 100 (50–300) ml. Conversions happened in 6 cases: 2 of them in PD and 4 in distal pancreatectomies. The postoperative length of stay was 15 ± 9 days and depended on the extent of the surgery. The maximum length (16 days) was after robot-assisted pancreaticoduodenectomies (14–25), the minimum (12 days) after organ-preservation surgery (8; 15). Pancreatic fistula А and В occurred in 35 (40.7%) patients and hemorrhages in 6 (7.0%) cases; there were 2 cases of 30-day mortality (2.3%). Robotic assistance can be successfully used in pancreatic surgery. Robot-assisted procedures ensure the precision of lymphadenectomy and anastomoses formation, and the postoperative lengths of stay are more comfortable for patients due to minimal tissue injury. The use of the robot-assisted approach in pancreatic surgery does not guarantee that specific postoperative complications will not occur.

Chlorhexidine Versus Iodine Vaginal Preparation Prior to Hysterectomy; A Randomized Controlled Trial [11B

INTRODUCTION: Currently we lack sufficient data for The American College of Obstetricians and Gynecologists to make recommendations regarding vaginal preparation solutions for hysterectomy. We designed a randomized controlled trial to compare the effectiveness of Chlorhexidine and Iodine. METHODS: Following Institutional Review Board approval, subjects undergoing hysterectomy via vaginal or endoscopic approach were randomized to 4% Chlorhexidine or 10% Iodine vaginal preparation. Vaginal cultures were obtained prior to preparation, then 30, 60 and 90 minutes thereafter. Primary outcome was the percent of samples with ≥5,000 bacteria (“positive culture”) at 90 minutes. Secondary outcomes included percent of samples ≥5,000 at 30 and 60 minutes, clearance of specific pathogens, postoperative complications, and surgical site infection rate. RESULTS: Eighty-five patients were randomized, average age 59.8 years (11.4) and median Charlson index score of 2 (0,6). Baseline percent ≥5,000 was no different (95.5% vs 100%; P=.495); 35.3% were positive for bacterial vaginosis. The Chlorhexidine group demonstrated a lower percentage of positive cultures at 90 minutes (47.6% vs 85.4%; P&lt;.001), 30 minutes (27.3% vs 51.2%; P=.024) and 60 minutes (22.7% vs 70.7%; P&lt;.001). Regarding specific pathogens, at 90 minutes, fewer subjects were positive for Staphylococcus in the Chlorhexidine group (5 vs 19; P=.035). There was no difference in the rate of urinary tract infection (15.9% vs 14.6%; P=.870), and no surgical site infections were documented. CONCLUSION: Chlorhexidine clears bacteria from the vagina more effectively and maintains a more aseptic surgical environment for 90 minutes. Gynecologic surgeons may consider switching to 4% Chlorhexidine from 10% Iodine for their vaginal preparation solution.

Association of hospital volume with patient selection, risk of complications, and mortality from failure to rescue after open abdominal aortic aneurysm repair

ObjectiveThe association of higher hospital volume with lower mortality after open abdominal aortic aneurysm (OAAA) repair is well known; however, the underlying mechanism for improved outcomes is poorly understood. Better patient selection, lower risk of complications, and improved ability to rescue patients after adverse events are assumed mechanisms, but few data exist to validate this hypothesis. The purpose of this analysis was to determine the association of hospital volume with patient selection, incidence of complications, and failure to rescue (FTR) after adverse events resulting from OAAA repair. MethodsThe Vizient (Irving, Tex) database (>95% of all academic hospitals) was reviewed for OAAA repairs (elective, n = 2827; nonelective, n = 1622) performed from 2012 to 2014. Presentation type (elective vs nonelective) was considered in all analyses. Elixhauser comorbidity index and van Walraven weighted scores were assigned to patients and volume-outcome relationships explored. By use of logistic regression, risk-adjusted complications (including preventable complications; Agency for Healthcare Research and Quality patient safety indicators [PSIs]) and FTR rates were determined. Predicted risk scores were assigned to delineate hospital volume association with these outcomes. ResultsOverall, no relationship between hospital volume and composite patient comorbidity severity score was identified (Elixhauser comorbidity index and van Walraven weighted scores: Pearson [ρ, 0.02], P = .2; [ρ, −0.01], P = .4; Spearman correlation coefficient [ρ, 0.02], P = .4; [ρ, −0.02], P = .2). The lack of correlation persisted in considering elective vs nonelective status. However, for elective cases, differences in specific comorbidities were noted because high-volume hospitals were more likely to repair patients with a history of peripheral vascular disease (P = .01), diabetes (P = .07), obesity (P = .004), and alcohol abuse (P = .05). Lower volume hospitals more frequently repaired patients with hypothyroidism (P = .05), fluid and electrolyte disorders (P = .007), and chronic blood loss anemia (P = .05). No specific individual comorbidity differences were detected for nonelective cases. In examining hospital volume effects on the likelihood for development of any complication (45%), PSIs (12%), and FTR (9%), a significant risk reduction was noted in high-volume institutions. Specifically, a nonlinear relationship between hospital volume and risk of any complication (P = .0004), PSI (P = .0004), and FTR (P =. 0003) was present. In exploring the risk of specific complications or PSI events, greater hospital volume was strongly correlated to a lower likelihood of multiple adverse outcomes. ConclusionsAlthough high-volume institutions performing OAAA repair do not necessarily operate on patients with more comorbidities, there are important differences in the patients selected compared with lower volume hospitals. The risk for development of multiple specific postoperative complications as well as for preventable adverse events preceding FTR is significantly lower in high-volume centers. These findings provide benchmarks for multiple selected quality indicators and further support national initiatives to incentivize regionalization of OAAA care.