Surgical Mortality Research Articles

Abstract 4143228: Uncovering Hidden Disparities in Surgical Mortality among Texas Medicaid-Insured Infants with Critical Congenital Heart Disease

Background: Data shows that publicly insured patients with critical congenital heart disease (CCHD) have higher surgical mortality than privately insured patients. However, little is known about disparities within Medicaid-insured cohorts. We hypothesized that disparities in surgical mortality exist within the Medicaid population, with the highest mortality being among the most socially vulnerable patients. Methods: We conducted a retrospective cohort study using Texas Birth Defects Registry records of infants with CCHD born 2010-2014 who underwent cardiac surgery <1 year old (CCHDs). Patients with CCHD as defined by the Centers for Disease Control or ductal dependent anatomy were included, and records for study inclusion were reviewed by a pediatric cardiologist. Cases were linked with death certificates and the Medicaid database, and Medicaid patients were stratified into Primary (PM) and Secondary (SM) cohorts. The PM cohort was comprised of patients with the highest scores (most socioeconomically vulnerable) based on the census tract derived Social Vulnerability Index (SVI). The primary predictor was race/ethnicity and primary outcome was infant mortality. Descriptive sociodemographics were analyzed using chi-square. Infant mortality was analyzed using stratified univariable Cox Proportional-Hazards models. Results: We identified 2525 infants with CCHD S , of whom 14.5% had PM and 56.9% had SM. The Medicaid-cohort had more single ventricle, chromosomal, and extracardiac defects than the Non-Medicaid (NM) cohort (p<0.0001). Compared to the SM cohort, CCHD S infants with PM were more likely to be born preterm, and be born to mothers who are non-White, have < a high school education (p<0.0001, respectively), and who drove further to surgical facility (p<0.005). Cox regression showed no racial/ethnic mortality disparities in the PM cohort. In the SM cohort, infant mortality was 2.2x higher among Black patients (HR 2.21, CI 1.41-3.45). In the NM cohort, Hispanic patients had nearly 2x (HR 1.93, CI 1.12-3.33) and Black patients had 3x (HR 3.01, CI 1.42-5.96) higher risk of infant mortality than White CCHDs infants. Conclusions: We completed one of the largest analyses of Medicaid-insured CCHD S infants using a novel SVI stratification. Despite worse SVI, racial/ethnic disparities in CCHD S mortality were not observed among PM-insured patients. Future database work should include stratified Medicaid populations to accurately interpret outcomes in patients with CCHD.

Abstract 4138252: Association between Pressure-Adjusted Heart Rate and Mortality in Cardiogenic Shock

Introduction: Among patients with cardiogenic shock (CS), high right atrial pressure (RAP) and low mean arterial pressure (MAP) are associated with in-hospital mortality. Pressure-adjusted heart rate (PAHR), defined as heart rate * RAP-to-MAP ratio (HR * [RAP/MAP]), integrates these parameters and has been used to identify cardiovascular dysfunction in critical illness. Higher PAHR values associate with higher surgical ICU mortality, but the prognostic significance of PAHR has not been assessed in cardiac intensive care unit (CICU) patients with CS. Hypothesis: We hypothesized that higher PAHR values are associated with higher risk of in-hospital mortality in patients with CS. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multinational registry of CICUs coordinated by the TIMI Study Group. Among CS admissions (2018-2023) undergoing invasive hemodynamic assessment within 24h of CICU admission, we calculated PAHR (in bpm) and assessed its relationship with in-hospital mortality. Patients on temporary mechanical circulatory support were excluded. Odds ratios were adjusted for age, sex, vasoactive-inotropic score (VIS), SCAI stage, and preceding cardiac arrest. Subgroup analyses stratifying by CS subtype were performed. Results: Among the 1411 CS admissions in the analysis cohort (mean age 61 years, 31% women), 18% had AMI-CS, 75% had HF-CS, and 7% had secondary CS. At the time of assessment (median 1.4h after CICU admission), 75% were on vasoactive support (median VIS 3.8). Median HR was 92 (Q1-Q3 77-109) bpm, RAP 15 (Q1-Q3 10-19) mmHg, MAP 75 (Q1-Q3 67-87) mmHg, and PAHR 17 (Q1-Q3 11-24) bpm. A stepwise gradient of higher in-hospital mortality with increasing PAHR values (p-trend <0.001; Fig ) was observed. In adjusted models, a higher PAHR was associated with higher in-hospital mortality (aOR per 10-bpm, 1.35 [95% CI, 1.15-1.58]), and had stronger prognostic associations with mortality than its individual hemodynamic components (Fig) . Conclusion: Higher PAHR is strongly associated with in-hospital mortality in CS patients. PAHR, a simple parameter which is readily calculable without needing a pulmonary artery catheter, may aid in identifying CS patients at higher risk of death.

Updated risk prediction model for pancreaticoduodenectomy using data from the National Clinical Database in Japan

AbstractAimRisk prediction models for mortality, severe postoperative complications, and postoperative pancreatic fistula in patients undergoing pancreaticoduodenectomy were established using data from the National Clinical Database more than a decade ago, and the surgical outcomes of pancreaticoduodenectomy have improved over the years. The aim of this study is to update the risk prediction model for pancreaticoduodenectomy using National Clinical Database data.MethodsBetween 2019 and 2021, the data of 35 365 patients who underwent pancreaticoduodenectomy and who were registered in the National Clinical Database were retrospectively analyzed. According to the registration year, the patients were divided into two cohorts: the development cohort (2019–2020; n = 23 654) and the validation cohort (2021; n = 11 711). Logistic regression analyses were performed to create risk models for surgical mortality, severe postoperative complications, and grade C postoperative pancreatic fistula.ResultsOverall, the rates of surgical mortality, severe postoperative complications, and grade C postoperative pancreatic fistula were 1.8%, 2.2%, and 1.3%, respectively. Logistic regression analyses revealed 28, 28, and 14 risk factors for surgical mortality, severe postoperative complications, and grade C postoperative pancreatic fistula, respectively. The area under the receiver operating characteristic curve of the risk model in the development cohort was 0.759 for surgical mortality, 0.712 for severe complications, and 0.699 for postoperative pancreatic fistula, comparable to the validation cohort. The calibration plots were favorable in both cohorts.ConclusionThe updated risk model for pancreaticoduodenectomy will be useful to predict surgical mortality, severe postoperative complications, and grade C postoperative pancreatic fistula.

Cost-effectiveness analysis of transcatheter aortic valve implantation versus surgical aortic valve replacement in patients with severe aortic stenosis at low risk of surgical mortality in Sweden

Background: Transcatheter aortic valve implantation (TAVI) has shown similar or improved clinical outcomes compared with surgical aortic valve replacement (SAVR) in patients with symptomatic severe aortic stenosis at low risk for surgical mortality. This cost-utility analysis compared TAVI with SAPIEN 3 versus SAVR in symptomatic severe aortic stenosis patients at low risk of surgical mortality from the perspective of the Swedish healthcare system. Methods: A published, two-stage, Markov-based cost-utility model that captured clinical outcomes from the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated according to Recommended Therapies (SWEDEHEART) registry (2018–2020) was adapted from the perspective of the Swedish healthcare system using local general population mortality, utility and costs data. The model had a lifetime horizon. Model outputs included changes in direct healthcare costs and health-related quality of life from using TAVI as compared with SAVR. Results: TAVI with SAPIEN 3 resulted in lifetime costs per patient of 940,541 Swedish krona (SEK) and lifetime quality-adjusted life years (QALYs) per patient of 7.16, whilst SAVR resulted in lifetime costs and QALYs per patient of 821,380 SEK and 6.81 QALYs, respectively. Compared with SAVR, TAVI offered an incremental improvement of +0.35 QALY per patient at an increased cost of +119,161 SEK per patient over a lifetime horizon, resulting in an incremental cost-effectiveness ratio of 343,918 SEK per QALY gained. Conclusion: TAVI with SAPIEN 3 is a cost-effective option versus SAVR for patients with symptomatic severe aortic stenosis at low risk for surgical mortality treated in the Swedish healthcare setting. These findings may inform policy decisions in Sweden for the management of this patient group.

Calcific Aortic Stenosis

ImportanceCalcific aortic stenosis (AS) restricts the aortic valve opening during systole due to calcification and fibrosis of either a congenital bicuspid or a normal trileaflet aortic valve. In the US, AS affects 1% to 2% of adults older than 65 years and approximately 12% of adults older than 75 years. Worldwide, AS leads to more than 100 000 deaths annually.ObservationsCalcific AS is characterized by aortic valve leaflet lipid infiltration and inflammation with subsequent fibrosis and calcification. Symptoms due to severe AS, such as exercise intolerance, exertional dyspnea, and syncope, are associated with a 1-year mortality rate of up to 50% without aortic valve replacement. Echocardiography can detect AS and measure the severity of aortic valve dysfunction. Although progression rates vary, once aortic velocity is higher than 2 m/s, progression to severe AS occurs typically within 10 years. Severe AS is defined by an aortic velocity 4 m/s or higher, a mean gradient 40 mm Hg or higher, or a valve area less than or equal to 1.0 cm2. Management of mild to moderate AS and asymptomatic severe AS consists of patient education about the typical progression of disease; clinical and echocardiographic surveillance at intervals of 3 to 5 years for mild AS, 1 to 2 years for moderate AS, and 6 to 12 months for severe AS; and treatment of hypertension, hyperlipidemia, and cigarette smoking as indicated. When a patient with severe AS develops symptoms, surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) is recommended, which restores an average life expectancy; in patients aged older than 70 years with a low surgical risk, 10-year all-cause mortality was 62.7% with TAVI and 64.0% with SAVR. TAVI is associated with decreased length of hospitalization, more rapid return to normal activities, and less pain compared with SAVR. However, evidence supporting TAVI for patients aged younger than 65 years and long-term outcomes of TAVI are less well defined than for SAVR. For patients with symptomatic severe AS, the 2020 American College of Cardiology/American Heart Association guideline recommends SAVR for individuals aged 65 years and younger, SAVR or TAVI for those aged 66 to 79 years, and TAVI for individuals aged 80 years and older or those with an estimated surgical mortality of 8% or higher.ConclusionsCalcific AS is a common chronic progressive condition among older adults and is diagnosed via echocardiography. Symptomatic patients with severe AS have a mortality rate of up to 50% after 1 year, but treatment with SAVR or TAVI reduces mortality to that of age-matched control patients. The type and timing of valve replacement should be built on evidence-based guidelines, shared decision-making, and involvement of a multidisciplinary heart valve team.

Percutaneous Closure of Postmyocardial Infarction Ventricular Septal Rupture – A Single Center Experience from the Eastern Part of India

Abstract Background: Postinfarction ventricular septal rupture (VSR) is a rare but lethal mechanical complication of an acute myocardial infarction (AMI). It results in 90%–95% mortality within 2 months of diagnosis without any kind of intervention. Given high surgical mortality, transcatheter closure has emerged as a potential strategy and as an alternative to high-risk surgical closure. Indian data on percutaneous device closure of post-AMI VSR are limited; hence, we report our resource-limited single-center experience with different kinds of occluder devices for closure of post-AMI VSR. Methods and Results: In this single-center, retrospective cohort study, patients who underwent transcatheter closure of postmyocardial infarction (MI) VSR between 2018 and 2024 at Health World Hospitals in Durgapur, West Bengal, were included. The primary outcome was a mortality rate of 30 days. The study population was eleven primary cases of post-MI VSR. The mean age of the population was 61 years. The majority of the patients had anterior wall MI (54.5%), and the remaining had inferior wall MI. Different kinds of devices (Amplatzer atrial septal occlude, post-MI VSD device, and Konar-Multifunctional Occluder) were used to close VSR. Successful closure was performed in 9 patients (81%) with minimal residual shunt in 2 patients. Of 9 cases, 3 patients expired; one was lost to follow-up, and the rest are doing well at 30-day follow-up. Conclusion: Transcatheter closure of PMI VSRs can be performed with different kinds of devices with high technical success, relatively low procedural complication rates, and a good 30-day survival even in a setup outside the metropolis with limited availability of devices, as an alternative to very high-risk surgical closure.

Preoperative Consultations and Their Effect on Surgical Delays and Mortality in Hip Fracture Surgery.

The impact of preoperative consultations on mortality and morbidity rates, and their association with delays and hospital stays for surgery, remains a topic of discussion. This study aims to elucidate the necessity of consultations for those undergoing femoral neck fracture surgery, examining their influence on delays, hospital durations, and their correlation with mortality rates. The study examined data from 320 emergency department patients with femoral neck fractures undergoing hip arthroplasty surgery at our hospital between 2011 and 2021, using digital medical records. Patients were consulted in relevant departments for risk optimization. They were categorized into two groups based on the time of surgery: Group 1 (operated within 48 h) and Group 2 (delayed surgery). The analysis included days from admission to surgery, total hospital stay, and time from surgery to discharge. Mortality rates, with a minimum 2-year follow-up, were assessed using digital records, patient contact, or a death notification system. Statistical analyses involved Mann-Whitney U, Kruskal-Wallis, post hoc analysis, Pearson's chi-squared, and Fisher-Freeman-Halton tests (α = 0.05). SPSS v25.0 software was used. Patients with consultation requests experience significantly delayed surgery compared to those without (p < 0.001). Statistically significant differences were observed between consulted and nonconsulted groups in time until surgery (p < 0.001), time from surgery to discharge (p < 0.001), and overall length of hospital stay (p < 0.001). However, there is no statistically significant difference in 30-day and 1-year mortality between consulted and nonconsulted patients, both departmentally and overall. This study found that advanced age and high ASA scores were the main factors causing surgical delays in hip fracture patients. While modifiable comorbidities could reduce hospital stays, they did not significantly affect postoperative mortality. Streamlining elective consultations and reducing organizational delays could help prevent delayed surgeries and improve outcomes.

Mid-Term Results of Pulmonary Valve-Sparing Repair for Tetralogy of Fallot With Pulmonary Stenosis.

The transannular patch remains the most common procedure performed for patients with Tetralogy of Fallot (TOF) with pulmonary stenosis. Pulmonary regurgitation has a negative impact on early and late outcomes. To address this issue pulmonary valve-sparing repair (PVSR) has been developed. Our study goal is to evaluate the mid-term outcomes (five years) of PVSR at our institution. The data were collected retrospectively from June 2014 to June 2022. A total of 390 patients had total repair of TOF. Among these, PVSR was performed in 154 (39.4%) patients. The mid-term outcomes on the status of the pulmonary valve gradient, degree of pulmonary regurgitation, reintervention rate, and mid-term survival after PVSR were investigated. The median age at time of TOF repair was 12 (interquartile range [IQR]: 8-48) months and the median weight was 7.9 (IQR: 3.1-49.5) kg. The mean preoperative right ventricular outflow tract (RVOT) gradient was 77 ± 19.6 mm Hg. All patients had a pulmonary valve Z score of more than -2.5. The post-repair mean RV/LV pressure ratio was 0.49 ± 0.12. There was no surgical mortality. The median follow-up was 3 years (6 months to 8 years). The reintervention rate on the pulmonary valve was 4/154 (2.6%) at five years. The freedom from reintervention and from developing moderate pulmonary valve regurgitation at 5 years was 95% (151/154) and 77% (119/154), respectively. Pulmonary valve-sparing repair gives good mid-term outcomes in a specific group of patients with TOF. Reintervention rates are very low and the peak gradient across the pulmonary valve came down in the majority of patients during mid-term follow up. An RVOT gradient more than 40mm Hg at discharge predicts a high risk of need for reintervention. We continue to monitor our patients for the long term outcome.

Early result of minimally invasive cardiac myxoma resection at University Medical Center, Ho Chi Minh City

Objective: The study aimed to evaluate various clinical and paraclinical characteristics, as well as early surgical outcomes of minimally invasive cardiac myxoma resection at University Medical Center HCMC. Subjects and methods: This is a retrospective descriptive case series study involving all patients diagnosed with cardiac myxomas who underwent minimally invasive surgery at University Medical Center HCMC from January 2020 to June 2024. Results: There were 31 patients, consisting of 22 females and 9 males. The mean age was 56,2 ± 10,7 years old (from 37 to 77 years old). The clinical manifestations were diverse: asymptomatic (45,2%), cerebral embolism (6,4%), fatigue (29,0%), dyspnea (35,5%), palpitations (12,9%), and dizziness (12,9%). Echocardiographic results: 90,3% left atrial myxoma, 9,7% right atrial myxoma. The tumor attachment sites: interatrial septum (93,6%), left atrial wall (6,4%). The average tumor size was 36,3 ± 15,1 mm. All tumors were completely resected (100%). Additional surgical procedures: mitral valve repair (3,2%), interatrial septum repair (6,4%). Cardiopulmonary bypass time was 82,4 ± 31,1 minutes (from 49 to 199 minutes), cross - clamp time was 39,2 ± 17,6 minutes (from 18 to 85 minutes), with 3 cases not requiring cardiac arrest. Ventilation time was 13,2 ± 6,3 hours (from 6,7 to 32,4 hours), intensive care unit stay was 52,6 ± 28,1 hours (from 13 to 113,7 hours), postoperative recovery time was 6,9 ± 2,3 days (from 4 to 16 days). Early outcomes: 3 cases of atrial fibrillation with rapid ventricular response, treated medically (9,7%), 1 case of acute kidney injury (3,2%), 4 cases of pleural effusion (12,9%), 3 cases of pneumothorax (9,7%), 1 case of right external iliac artery thrombosis requiring surgical thrombectomy (3,2%), and 2 cases of deep vein thrombosis (6,4%). No surgical site infections, cerebrovascular accidents, or mortality within 30 days post-surgery were reported. Conclusion: Minimally invasive cardiac myxoma resection demonstrates a low complication rate, with no reported tumor recurrence or early postoperative mortality. This technique offers a safe and effective alternative to traditional median sternotomy and may be gradually adopted and implemented in lower - level healthcare facilities.

Variation in care in individuals hospitalised with abdominal aortic aneurysm in nine high-income countries: a cross-sectional cohort study

Abstract Background Abdominal aortic aneurysms (AAA) can be safely repaired using either endovascular aneurysm repair (EVAR) or open repair when intact, but after rupture morbidity and mortality are extremely high. Treatment patterns and outcomes for intact AAA are likely to differ between countries due to differences in AAA screening policies, health system capacity and payment approaches, and other factors, such as demographics and lifestyle, but are poorly studied. Methods We conducted a retrospective serial cross-sectional cohort study of adults aged ≥66 years hospitalised for with an intact AAA and repair procedure in the same admission between 2011 and 2019 in nine countries (US, Canada, England, Denmark, Netherlands, Switzerland, Taiwan, South Korea and Israel) using population-representative administrative data. We investigated age-sex standardised (to the 2019 US population) repair rates (open repair or EVAR) and health system performance measures, including hospital length of stay (LOS), 30-day readmission, and all-cause mortality (30 days and 1 year). Results The number of intact AAA hospital admissions between 2011 and 2019 ranged from 1,290 in Israel to 199,764 in the US. The rates of intact AAA repair per 1000 population varied between countries and over time, from 0.11 per 1000 (South Korea) to 0.69 per 1000 (US) in 2011 and from 0.14 per 1000 (Taiwan) to 0.57 per 1000 (the Netherlands) in 2019. Most countries saw a decline in the rate of AAA repair over the study period. The proportion repaired using open repair vs EVAR also varied widely across the countries. In the US, Israel and Taiwan open repair was used in 11% or fewer cases whereas in the remaining countries we observed open repair in 25.1 % (South Korea) to 56.7% (Denmark) of cases. (Figure 1) Mortality was generally higher following open repairs compared to EVAR in all countries. In 2019, following EVAR, 30-day mortality varied from 0.6% (8.1% at 1 year) in South Korea to 2.3% (11.7% at 1 year) in Israel and following open repair varied from 2.9 (4.4% at 1 year) in England to 7.6% (15.1% at 1 year) in the US. (Figure 2) Mean hospital LOS in 2019 ranged from 2.5 days (US) to 12.2 days (South Korea), following EVAR and from 9.1 days (Taiwan) to 21.5 days (South Korea) following open repair. The 30-day readmission rate in 2019 ranged from 8.1% (US) to 31.8% in Israel following EVAR and from 11.4% (US) to 22.2% (South Korea) following open repair. Conclusions We observed substantial between-country variation in surgical approaches, mortality, and health system performance measures for AAA. Further research is needed to understand and plan optimal, evidence-based AAA screening and treatment strategies.Rates of EVAR and open repairAdjusted 30-day all-cause mortality

Clinical outcomes according to clinical and surgical risk scores for tricuspid regurgitation

Abstract Background TRIO score, the clinical risk score in significant tricuspid regurgitation (TR), and TRI-SCORE, the surgical mortality risk for tricuspid valve (TV) surgery, have been proposed. We aimed to investigate the correlation and distribution of two risk scores, and to define the clinical benefit of TV surgery in patients with low or intermediate TRIO score and TRI-SCORE. Methods In a total of 10,054 patients diagnosed with moderate to severe TR between January 2008 to December 2020, TRIO score and TRI-SCORE were stratified into low, intermediate, and high-risk groups. Patients of all etiologies of TR were included and patients who underwent prior tricuspid valve surgery were excluded. The clinical outcome was all-cause death. Results TRI-SCORE and TRIO scores were moderately correlated (r =0.39, p&amp;lt;0.001). 9,104 (90.6%) patients (age 67 ± 14 years, 42% male) had low or intermediate TRI and TRIO score. During 12.6 ± 10.1 years, 885 (9.7%) underwent TV surgery and 1,268 (13.9%) experienced clinical outcomes. Kaplan-Meier analysis revealed significant differences in clinical outcomes according to TV surgery in both low and intermediate TRIO score patients (log-rank, p&amp;lt;0.001) and sub-analyzed them according to the TRI-SCORE group (Figure). In multivariable Cox regression analysis, TV surgery (HR 0.37, 95% CI 0.28-0.49, p&amp;lt;0.001) were significantly associated with clinical outcomes after adjusting confounding factors. Conclusions TV surgery is clinically beneficial in moderate to severe TR patients with a low or intermediate TRIO score and TRI-SCORE.

Comparison of mortality scores performance in transcatheter aortic valve replacement: suiting up to percutaneous intervention

Abstract Introduction As transcatheter aortic valve replacement (TAVR) is increasingly relevant for patients with severe symptomatic aortic stenosis, having a reliable procedure specific risk-prediction tool is paramount to provide high-quality care. Surgical scores as the EuroScore II and the Society of Thoracic Surgeons (STS) score II have been widely used to identify patients with high surgical risk in whom percutaneous treatment might be more favorable. However, current literature lacks a consensual specific predictive model for short-term and mid-term prognosis in patients undergoing transcatheter aortic valve implantation (TAVI). Purpose We aimed to access short and midterm (30 days and one year) mortality and to access the ability of a directly adapted score in estimating mortality in a real-world population. Methods We conducted a retrospective observational study in patients who implanted TAVR in a single center. Surgical mortality scores – EUROSCORE II and STS score II – and adapted score Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) transcatheter valve therapy (TVT) score were used to estimate mortality. Predictive abilities of these three scores were compared using area under the receiver operating characteristics (ROC) curve for 30-day and one year mortality. Results From January 2018 to December 2021, 416 patients were submitted to TAVR procedure in our center. The mean age was 83+-6 years old and 229 (55%) were female. 94% had hypertension, 80% dyslipidemia, 40% diabetes mellitus, 35% coronary artery disease, 32% chronic kidney disease. Mean ejection fraction was 56%. During a mean follow-up (FUP) of 816 ± 492 days, 30-day mortality was 1,7% and after 1 year mortality rate was 12,2% (higher than reported in PARTNER 3 trial, 8,5%). The Mean EuroSCORE was 3,4±3,2, mean STS-II 3,9±1,8 and mean value for STS/ACC-TVT score was 3,55±1,34. ROC curve analysis showed a significantly higher discriminative power of STS/ACC-TVT (AUC 0,749, 95% CI 0,681-0,818) compared with surgical scores (p=0,001) – figure 1. We also divided population into quartiles and compared the mortality rate at 30 days and 1 year in each quartile using either STSII or STS/ACC-TVT; As can be seen in figure 2, mortality rates correlated better with the STS/ACC-TVT score than with the STS score. Conclusion A score adapted to a TAVI population showed better predictive capacity than traditional surgical scores. Less preponderance of previous surgical status, relevance of access site and more adapted weight of age might explain the best performance of STS/ACC-TVT score. Surgical scores are helpful in choosing treatment option, but adapted scores are better to predict pos-TAVR mortality.

HEPATECTOMIA CONVENCIONAL EM DOIS ESTÁGIOS VERSUS ALPPS: UMA REVISÃO DE LITERATURA SOBRE O TRATAMENTO DE METÁSTASE HEPÁTICA COLORRETAL

This study compared the outcomes of two modalities of hepatectomies for the treatment of colorectal liver metastasis. The research is justified by the high morbidity and mortality associated with hepatic surgical interventions, as these require a delicate approach and intricate techniques, posing a challenge in the surgical field. The aim was to highlight the operative technique with greater efficacy, outlining its associated benefits and risks, in order to identify the definitively superior aspects within the literature among the analyzed modalities. The methodology involved a literature review of 46 articles, written in Portuguese and English, available in various databases from 2019 to 2024. The results indicated that ALPPS had limited advantages compared to HDE, demonstrating greater surgical efficacy, while the rates of perioperative complications and short-term outcomes were comparable between the two techniques, with no evidence of differences in reducing morbidity and mortality. Conversely, there were discrepancies in determining the overall survival rates between the two techniques, underscoring the need for further studies on the topic and the exploration of less invasive methods with lower rates of surgical morbidity and mortality.

Transcatheter aortic valve implantation with SAPIEN 3 versus surgical aortic valve replacement in patients with symptomatic severe aortic stenosis at low risk of surgical mortality: a cost-utility analysis for Switzerland.

The 2021 European Society of Cardiology Guidelines on valvular heart disease recommend transcatheter aortic valve implantation (TAVI) for patients with symptomatic severe aortic stenosis at low surgical risk and age ≥75 years who are suitable for a transfemoral approach (recommendation class IA) based on two large randomised controlled trials (PARTNER 3 and Evolut Low Risk) comparing transcatheter aortic valve implantation with surgical aortic valve replacement (SAVR). Whether such an approach is cost-effective in Switzerland remains unclear. The aim of this cost-utility analysis was to compare transcatheter aortic valve implantation with SAPIEN 3 versus surgical aortic valve replacement in symptomatic severe aortic stenosis patients at low risk of surgical mortality from the perspective of Swiss compulsory health insurance using data from the PARTNER 3 trial (reflecting specifically the safety and efficacy of the SAPIEN 3 TAVI device). A previously published two-stage Markov-based model that captured clinical outcomes from the PARTNER 3 trial was adapted from the perspective of the Swiss compulsory health insurance system, using local or geographically close general population mortality and utility data, unit costs and medical resource use from publicly available sources and based on expert opinion. The model had a lifetime horizon with a 3% yearly discounting factor. The cost-utility analysis estimated changes in both direct healthcare costs and health-related quality-adjusted life years for transcatheter aortic valve implantation compared with surgical aortic valve replacement in patients with symptomatic severe aortic stenosis at low risk of surgical mortality. Overall, transcatheter aortic valve implantation with SAPIEN 3 resulted in lifetime costs per patient of CHF 79,534 and quality-adjusted life years per patient of 9.64, compared with surgical aortic valve replacement lifetime costs and quality-adjusted life years per patient of CHF 76,891 and 8.96, respectively. Compared with surgical aortic valve replacement, transcatheter aortic valve implantation was estimated to offer an incremental improvement of +0.68 quality-adjusted life years per patient at an increased cost of +CHF 2643 per patient over a lifetime horizon. The incremental cost-effectiveness ratio was CHF 3866 per quality-adjusted life year gained and remained below CHF 50,000 per quality-adjusted life year gained across several sensitivity analyses. This analysis suggests that transcatheter aortic valve implantation using the SAPIEN 3 device is likely to be a highly cost-effective alternative for symptomatic severe aortic stenosis patients at a low risk of surgical mortality, treated in the contemporary Swiss setting. These findings may help to inform a holistic approach when making policy decisions for the management of this patient group.

Unveiling patterns in pediatric appendectomy: A comparative study on healthcare resource capacity and surgical decisions in Brazil.

Appendicitis is the most prevalent surgical emergency in children. This study examined hospital infrastructure, surgical techniques, patient demographics, and hospitalization parameters to assess the provision of safe and adequate care within the Brazilian public healthcare system. Pediatric hospitalizations for acute appendicitis in 2022 were extracted from the Brazilian national database. We included all hospitalizations for patients aged 0-16years with a primary ICD-10 diagnosis of acute appendicitis who underwent an operation. Parameters of interest were the type of surgical approach, mortality, and total cost of hospitalization. Facilities were defined as basic-facility, full-facility, and pediatric according to the level of pediatric resources available. In 2022, there were 29,983 pediatric appendectomies due to acute appendicitis. Of these, 90.2% were open appendectomies. Most occurred in basic-facility general hospitals (53.0%), followed by full-facility (35.2%) and pediatric hospitals (11.8%). Full-facility hospitals had a higher median cost (USD126.3, IQR 99.5-154.4) compared to basic (USD96.8, IQR 87.6-130.1) and pediatric hospitals (USD103.0, IQR 91.9-117.5), though the cost difference between basic and pediatric was not significant (p=0.367). Death was a rare event across all levels of hospital infrastructure and for all types of procedures performed. The majority of hospitalizations for acute appendicitis occurred in hospitals with minimal pediatric infrastructure. Open appendectomies remain the most predominant procedure across all hospital types.

Implementation of the WHO surgical safety checklist in resource-limited Somalia: a new standard in surgical safety

BackgroundSurgical safety remains a critical global health concern, with complications from surgical procedures resulting in significant morbidity and mortality, particularly in low- and middle-income countries. The World Health Organization (WHO) Surgical Safety Checklist (SSC) has been shown to reduce surgical complications and mortality rates. However, its implementation and impact in resource-limited settings like Somalia remain understudied. This study aimed to evaluate the implementation of the WHO SSC in selected hospitals in Mogadishu, Somalia, and assess its impact on surgical safety practices.MethodsA pre- and post-intervention study was conducted in 15 randomly selected hospitals in Mogadishu, Somalia. The intervention involved a comprehensive training program on the WHO SSC for surgical teams. Data on hospital characteristics, surgical details, and adherence to the SSC were collected over two periods: pre-intervention (April 12th to May 4th, 2024) and post-intervention (May 12th to June 3rd, 2024). The primary outcome was the adherence to the SSC, categorized as good (> 60%) or poor (≤ 60%). Descriptive statistics, McNemar’s test, and binary logistic regression were used for data analysis.ResultsAdherence to the WHO SSC significantly improved post-intervention, with 98.8% of surgical cases demonstrating good adherence compared to 37% pre-intervention (p < 0.001). The mean adherence score increased from 51.6% (SD = 29.6) to 94.1% (SD = 8.2). Significant improvements were observed for most individual checklist items, including patient identity confirmation, surgical site marking, anesthesia machine checks, and pulse oximeter use (p < 0.001). Team dynamics and communication also improved significantly post-intervention. Hospital type, size, years of service, funding source, surgical department, surgery type, urgency, and staff numbers were associated with checklist adherence pre-intervention.ConclusionThe implementation of a comprehensive training intervention significantly improved adherence to the WHO Surgical Safety Checklist in resource-limited hospitals in Mogadishu, Somalia. The findings highlight the feasibility and effectiveness of the SSC in enhancing surgical safety practices, team communication, and patient outcomes in challenging healthcare environments. Tailored implementation strategies, ongoing training, and cultural adaptation are crucial for the successful adoption of the SSC in resource-constrained settings.

Travel burden and bypassing closest site for surgical cancer treatment for urban and rural oncology patients.

We examined the relationship between travel burden for surgical cancer care and rurality, geographic bypass of the nearest surgical facility, cancer type, and mortality outcomes. Using Medicare claims and enrollment data (2016-2018) from beneficiaries with cancer of the colon, rectum, lung, or pancreas, we measured travel times to: the nearest surgical facility and facility used. For those who bypassed the nearest, we examined travel time and rurality in relation to surgical rates. Using multivariable regression modeling, we estimated associations of bypass with 90-day postoperative- and one-year mortality; rurality was examined as an effect modifier. Among 211,025 beneficiaries with cancer, 25.5% resided in non-metropolitan areas. About 66% of metropolitan/micropolitan, and 78% of small town/rural patients bypassed their closest facility. Increasing rurality was significantly associated with increased likelihood of bypass (Referent=metropolitan, OR; 95%CI: micropolitan 1.10; 1.04-1.16, small town/rural 2.08; 1.96-2.20. Bypassing the nearest facility was associated with decreased likelihood of both 90-day postoperative mortality (OR=0.79; 95%CI 0.74-0.85) and 1-year mortality (OR=0.81; 95%CI 0.77-0.86). The greatest decrement in 1-year mortality was for pancreatic cancer across all rural-urban categories (OR; 95%CI: metropolitan 0.63; 0.53-0.76; micropolitan 0.53; 0.29-0.97); small town/rural 0.46; 0.25-0.86). Most Medicare beneficiaries with lung, colon, rectal, or pancreatic cancer bypassed the closest facility providing surgical cancer care, especially rural patients. Bypassing was associated with a lower likelihood of 90-day postoperative, and 1-year mortality. Understanding determinants of bypassing, particularly among rural patients, may reveal potential mechanisms to improve cancer outcomes and reduce rural cancer disparities.

Postoperative complications in the pediatric population. Malnutrition or phase angle? Which one do we use?

Malnutrition increases post-operative risks like infections and prolonged stays. Pediatric assessment challenges require using anthropometric measurements and phase angle, which reflects body cell mass and health outcomes. Phase angle varies by maturation stages, making it crucial for pre-surgical evaluations alongside BMI. This study aimed to determine the relationship between nutritional status, phase angle, and postoperative complications in pediatric patients who underwent surgery. Prospective study with patients aged 3-17 undergoing major non-ambulatory surgery. Anthropometric measurements (weight, height, BMI Z-scores) hand grip strength, dietary intake and body composition via bioimpedance to assess phase angle were recorded. Postoperative complications were monitored, including surgical site infections, morbidity (pneumonia, inotropic support, infections, thromboembolism), and mortality. Surgical risks and pre- and postoperative conditions were documented. After the application of the selection criteria, a total of 391 patients who underwent surgery were included; 60% (n = 235) were within the range of the preschool and school-age groups. During the follow-up period, 51 (13%) patients developed at least one postoperative complication, with surgical site infections being the most common. Moreover, as phase angle decreased, the length of stay (LOS) increased in all the participants. Among children aged ≤12 years old, malnutrition was a risk factor for complications [OR 3.86 (1.61-9.27 95%CI)], whereas among adolescents, phase angle served as a protective factor [OR 0.63 (0.42-0.94 95%CI)]. Significant associations were observed between nutritional status, by BMI z-score, and post-surgical complications in younger patients. Additionally, in adolescents, the phase angle emerged as a protective factor against these complications.

Outcomes reported in elective colorectal cancer surgery research for older patients: A scoping review.

Colorectal cancer rates are increasing in older populations, who often have comorbidities and face higher surgical risks and mortality rates. Therefore, surgical outcomes, such as 5-year mortality rates, may not be appropriate, necessitating a focus on postoperative quality of life. However, determining optimal postoperative outcome measures for older colorectal cancer patients poses a challenge. This scoping review aimed to explore currently available data describing postoperative outcomes used to assess older patients undergoing elective colorectal cancer surgery. We conducted a comprehensive literature search of major electronic databases from inception to March 2023. Studies exploring frail or older individuals with colorectal cancer undergoing elective surgical procedures, and which reported postoperative outcomes, were included. Outcomes were categorized as surgery-specific versus person-centred and summarized using narrative synthesis. The type and rate of surgery-specific outcomes were tabulated. Of 1366 identified citations, 16 studies focused on person-centred outcomes and 66 reported exclusively on surgery-specific outcomes. Nine 'person-centred outcome' studies reported discharge destination, primarily home discharge. Postoperative delirium ranged from 8.2% to 18.1% in six studies. Four studies explored geriatric syndromes, three analysed activities of daily living, and three studies reported significant quality of life improvement. The 66 'surgery-specific outcome' studies assessed mortality (N = 61); length of stay (N = 40); postoperative complications (N = 47); readmission (N = 18); reoperation (N = 16); and survival (N = 42). Person-centred outcomes are underreported, but crucial for guiding patient management. Older patients require adequate information about their postoperative recovery period to enhance wellbeing. Future research must address this gap to improve care for older people undergoing elective colorectal cancer surgery.

Development and validation of a novel tool for identification and categorization of non-technical errors associated with surgical mortality.

Up to half of all surgical adverse events are due to non-technical errors, making non-technical skill assessment and improvement a priority. No specific tools are available to retrospectively identify non-technical errors that have occurred in surgical patient care. This original study aimed to develop and provide evidence of validity and inter-rater reliability for the System for Identification and Categorization of Non-technical Error in Surgical Settings (SICNESS). A literature review, modified Delphi process, and two pilot phases were used to develop and test the SICNESS tool. For each pilot, 12 months of surgical mortality data from the Australian and New Zealand Audit of Surgical Mortality were assessed by two independent reviewers using the SICNESS tool. Main outcomes included tool validation through modified Delphi consensus, and inter-rater reliability for: non-technical error identification and non-technical error categorization using Cohen's κ coefficient, and overall agreement using Fleiss' κ coefficient. Version 1 of the SICNESS was used for pilot 1, including 412 mortality cases, and identified and categorized non-technical errors with strong-moderate inter-rater reliability. Non-technical error exemplars were created and validated through Delphi consensus, and a novel mental model was developed. Pilot 2 included an additional 432 mortality cases. Inter-rater reliability was near perfect for leadership (κ 0.92, 95% c.i. 0.82 to 1.00); strong for non-technical error identification (κ 0.89, 0.84 to 0.93), communication and teamwork (κ 0.89, 0.79 to 0.99), and decision-making (κ 0.85, 0.79 to 0.92); and moderate for situational awareness (κ 0.79, 0.71 to 0.87) and overall agreement (κ 0.69, 0.66 to 0.73). The SICNESS is a reliable and valid tool, enabling retrospective identification and categorization of non-technical errors associated with death, occurring in real surgical patient interactions.