Thirty-day Postoperative Mortality Research Articles

Total Gastrectomy for Gastric Malignancy: Trends Over 15 Years in Major Morbidity, Mortality, and Patient Selection From The National Surgical Quality Improvement Program.

We examined trends in major morbidity and mortality following total gastrectomy for malignancy in a national cohort. The National Surgical Quality Improvement Program was used to identify patients who underwent total gastrectomy for malignancy from 2007 to 2021. Joinpoint regression was used to determine annual percent changes (APCs) in thirty-day postoperative major morbidity, mortality, and length of stay (LOS). Major morbidity included deep and organ space surgical site infection, venous thromboembolism, cardiac event, pneumonia, acute renal failure, sepsis, and respiratory failure. Of 3515 patients, the median age was 65 years (IQR = 55-73), 59% were male, and 57.9% were White. Major morbidity was 23%, which did not change over time (APC = -1.4, 95% CI = -3.4 to 0.58), nor were there changes in individual morbidities with time. The most common morbidities were organ space surgical site infection (9.2%) and pneumonia (8.5%). Mortality rate in the study cohort was 2.7% and did not change (APC = -6.2, 95% CI = -13.0 to 1.1). LOS (median 9 days) also did not vary with time (APC = -2.3, 95% CI = -7.8 to 3.9). There was an increase in patients with diabetes (21.6% vs. 11.2%, p < 0.05), BMI ≥ 30 (31.1% vs. 18.2%, p < 0.05), and ASA IV-V status (11.6% vs. 3.5%, p < 0.05). Morbidity and mortality following total gastrectomy for malignancy have not significantly changed over the last fifteen years. While this may in part be explained by increased patient comorbidity, efforts should be made to improve patient selection and mitigate postoperative complications to allow for timely adjuvant therapies.

Outcomes after noncardiac surgery in patients with left ventricular assist devices: a systematic review.

The number of patients living with left ventricular assist devices (LVADs) has gradually increased in the past decade. Non-cardiac surgery (NCS) in patients with LVAD poses a unique situation with its inherent challenges. We conducted a comprehensive review to investigate the perioperative complications and mortality associated with emergent or elective NCS in patients with LVAD. A comprehensive literature search for any papers referring to continuous LVAD patients with NCS. All publications with at least five durable LVAD patients who had NCS were eligible for inclusion. Twenty articles matching our criteria were found and included in our study. This systematic review included 6,476 LVAD patients who underwent 6,824 NCS. There were 5-3,216 LVAD patients with NCS in each study. The median age was between 39 and 65 years, and most of the patients (78.8%) were male. Thirty-day postoperative mortality ranged from 0% to 60%. Eight studies reported no death within the 30 days of the operation. Common complications include gastrointestinal (GI) bleeding, intracranial bleeding, infection, acute kidney injury (AKI), urinary tract infection (UTI), stroke, sepsis, pneumonia, and VAD exchange. Emergent abdominal surgery had the highest (up to 60%) mortality rate, and vascular and neurological operations had the highest complication rates. Due to the diverse range of patients in each publication and the combination of outcomes presented in various publications, a meta-analysis was not conducted. In LVAD patients, noncardiac surgery may be performed effectively and safely. LVAD patients who undergo non-cardiac surgery may require more transfusions due to their complex coagulopathies. However, perioperative management of LVAD patients undergoing emergent NCS should be optimized to reduce mortality. https://osf.io/fetsb/.

Spigelian hernias in the adult population: a systematic review of the literature.

Spigelian Hernia (SH) is characterized by the protrusion of abdominal viscera or preperitoneal fat through a defect in the spigelian aponeurosis. The objective of this systematic review was to evaluate current literature on Spigelian Hernias in adult population and elucidate their characteristics and preferable management. MEDLINE and Scopus bibliographical databases were systematically searched (last search: 31st January 2024) for studies concerning SHs. Two hundred and thirty-four articles met predefined inclusion criteria and concerned collectively 1,629 patients with SHs (58.7% females) with an age of 62.32 ± 17.71 (mean ± SD) years and a BMI of 28.56 ± 7.34 (mean ± SD) kg/m2. A minimally invasive approach was opted at 46.8% of cases, while a mesh was implemented at 67.9% of cases. Postoperative length of hospital stay was 2.8 ± 2.9 (mean ± SD) days. Following individual cases analysis, open surgery was preferable at emergency setting (OR: 2.45; 95% CI: 1.36-4.41; p-value: 0.003), and minimally invasive approaches were associated with shorter length of hospital stay [2 (1-9) vs. 5 (1-22) days; p-value: <0.001]. Overall, thirty-day postoperative morbidity and mortality rates reached 7.0% and 0.3% respectively. SH is a rare ventral hernia, and it concerns most frequently overweight women. Open surgical approach is preferred in emergency cases, while laparoscopic surgery is associated with shorter hospitalization. Further comparative studies are necessary to determine optimal surgical approach.

Prognosis Following Surgery for Recurrent Ovarian Cancer and Diagnostic Criteria Predictive of Cytoreduction Success: A Systematic Review and Meta-Analysis.

For women achieving clinical remission after the completion of initial treatment for epithelial ovarian cancer, 80% with advanced-stage disease will develop recurrence. However, the standard treatment of women with recurrent platinum-sensitive diseases remains poorly defined. Secondary (SCS), tertiary (TCS) or quaternary (QCS) cytoreduction surgery for recurrence has been suggested to be associated with increased overall survival (OS). We searched five databases for studies reporting death rate, OS, cytoreduction rates, post-operative morbidity/mortality and diagnostic models predicting complete cytoreduction in a platinum-sensitive disease recurrence setting. Death rates calculated from raw data were pooled based on a random-effects model. Meta-regression/linear regression was performed to explore the role of complete or optimal cytoreduction as a moderator. Pooled death rates were 45%, 51%, 66% for SCS, TCS and QCS, respectively. Median OS for optimal cytoreduction ranged from 16-91, 24-99 and 39-135 months for SCS, TCS and QCS, respectively. Every 10% increase in complete cytoreduction rates at SCS corresponds to a 7% increase in median OS. Complete cytoreduction rates ranged from 9-100%, 35-90% and 33-100% for SCS, TCS and QCS, respectively. Major post-operative thirty-day morbidity was reported to range from 0-47%, 13-33% and 15-29% for SCS, TCS and QCS, respectively. Thirty-day post-operative mortality was 0-6%, 0-3% and 0-2% for SCS, TCS and QCS, respectively. There were two externally validated diagnostic models predicting complete cytoreduction at SCS, but none for TCS and QCS. In conclusion, our data confirm that maximal effort higher order cytoreductive surgery resulting in complete cytoreduction can improve survival.

Factors associated with 30-day mortality and morbidity in patients undergoing emergency colorectal surgery.

The 30-day period following emergency colorectal surgery (ECRS) is associated with high mortality and morbidity. There is a lack of data assessing factors associated with outcomes of ECRS in the Saudi population. Assess factors associated with 30-day postoperative mortality and complications following ECRS. Retrospective cohort study. Single tertiary care center, Riyadh, Saudi Arabia. Demographic characteristics (age, sex, diagnosis, American Society of Anesthesiologists classification, pre-operative septic state, smoking, and comorbidities), operative characteristics (urgency, diverting ostomy, and procedure performed), and postoperative characteristics (length of stay, 30-day mortality, intensive care unit [ICU] admission, ICU length of stay, surgical site infection [SSI], readmission, reoperation, and complications) were collected from electronic medical records. Univariate logistic regression was used to evaluate association with the outcome measures (30-day mortality and postoperative complications). Multivariate logistic regression was applied to evaluate independent variables. Thirty-day postoperative mortality and morbidity. 241 patients. Among 241 patients, 145 (60.2%) were men, and 80 (33.2%) patients were between 50-64 years of age. The most common indication for surgery was malignancy 138 (57%). The overall complication rate was 26.6% and the 30-day mortality rate was 11.2%. Left hemicolectomy was the most commonly performed procedure, performed in 69 (28.6%) patients. Patients between the age of 65-74 had an increased odds of death within 30 days (OR 5.25 [95% CI 1.03-26.5]) on univariate analysis. Preoperative sepsis was associated with a fourfold increase in the likelihood of 30-day mortality (OR 4.44, 95% CI 1.21-16.24, P=.024) on multivariate analysis. The likelihood of hospital re-admission increased by fivefold in patients who developed a postoperative complication (OR 5.33, 95% CI 1.30-21.78, P=.02). Preoperative sepsis was independently associated with 30-day mortality in patients undergoing ECRS, while the likelihood of hospital readmission increased in patients with postoperative complications. Expeditious control of sepsis in the emergency surgical setting by both surgical and medical interventions may reduce the likelihood of postoperative mortality. Establishing discharge protocols for postoperative ECRS patients is advocated. Retrospective design, small sample size, and single setting.

Outcomes of open revascularization for chronic mesenteric ischemia at a tertiary care center in India.

Chronic mesenteric ischemia (CMI) is a rare, debilitating disease associated with higher morbidity and mortality if not treated on time. In the past two decades, there has been a paradigm shift in its management with endovascular modality due to reduced perioperative morbidity and mortality. In the endovascular era, only a few patients require surgical therapy. We conducted this study to report our experience with open surgical revascularization at our hospital. We have conducted a retrospective study after obtaining approval from Institutional Ethics Committee. Data regarding patients who underwent open revascularization for CMI with long-segment occlusion from 2016 to 2021 has been retrieved from the institutional database. The demographic data, clinical presentation, type of surgery and graft used, perioperative mortality and morbidity and length of hospital stay were evaluated. Overall survival and disease-free survival were assessed using Kaplan-Meier analysis. Twenty-one patients underwent open surgical revascularization; 16 were males and five females. The median age was 43years. Fourteen (66.7%) were smokers. The mean duration of follow-up was 28.4 ± 13.6months. Thirty-day postoperative mortality was 0% and morbidity was 28%. The average duration of hospital stay and postoperative weight gain were 6.9 ± 3.7days and 11 ± 4.9 kgs, respectively. One patient died at two years of follow-up due to myocardial infarction and one had a recurrence. Long-term survival at 60months of follow-up was 91.6% and the primary-patency rate was 95.2%. Owing to better long-term and reintervention-free patency, open revascularization should be considered in patients who are fit for surgery, particularly in patients with long-segment mesenteric artery occlusion.

Outcomes for High-Risk Surgical Procedures Across High- and Low-Competition Hospital Markets

Maintaining competition among hospitals is increasingly seen as important to achieving high-quality outcomes. Whether or not there is an association between hospital market competition and outcomes after high-risk surgery is unknown. To evaluate whether there is an association between hospital market competition and outcomes after high-risk surgery. We performed a retrospective study of Medicare beneficiaries who received care in US hospitals. Participants were 65 years and older who electively underwent 1 of 10 high-risk surgical procedures from 2015 to 2018: carotid endarterectomy, mitral valve repair, open aortic aneurysm repair, lung resection, esophagectomy, pancreatectomy, rectal resection, hip replacement, knee replacement, and bariatric surgery. Hospitals were categorized into high-competition and low-competition markets based on the hospital market Herfindahl-Hirschman index. Comparisons of 30-day mortality and 30-day readmissions were risk-adjusted using a multivariate logistic regression model adjusting for patient factors (age, sex, comorbidities, and dual eligibility), year of procedure, and hospital characteristics (nurse ratio and teaching status). Data were analyzed from May 2022 to March 2023. Thirty-day postoperative mortality and readmissions. A total of 2 242 438 Medicare beneficiaries were included in the study. The mean (SD) age of the cohort was 74.1 (6.4) years, 1 328 946 were women (59.3%), and 913 492 were men (40.7%). When examined by procedure, compared with low-competition hospitals, high-competition market hospitals demonstrated higher 30-day mortality for 2 of 10 procedures (mitral valve repair: odds ratio [OR], 1.11; 95% CI, 1.07-1.14; and carotid endarterectomy: OR, 1.06; 95% CI, 1.03-1.09) and no difference for 5 of 10 procedures (open aortic aneurysm repair, bariatric surgery, esophagectomy, knee replacement, and hip replacement; ranging from OR, 0.97; 95% CI, 0.94-1.00, for hip replacement to OR, 1.09; 95% CI, 0.94-1.26, for bariatric surgery). High-competition hospitals also demonstrated 30-day readmissions that were higher for 5 of 10 procedures (open aortic aneurysm repair, knee replacement, mitral valve repair, rectal resection, and carotid endarterectomy; ranging from OR, 1.01; 95% CI, 1.00-1.02, for knee replacement to OR, 1.05; 95% CI, 1.02-1.08, for rectal resection) and no difference for 3 procedures (bariatric surgery: OR, 1.03; 95% CI, 0.99-1.07; esophagectomy: OR, 1.02; 95% CI, 0.99-1.06; and pancreatectomy: OR, 1.00; 95% CI, 0.99-1.01). Hospitals in high-competition compared with low-competition markets cared for patients who were older (mean [SD] age of 74.4 [6.6] years vs 74.0 [6.2] years, respectively; P < .001), were more likely to be racial and ethnic minority individuals (77 322/450 404 [17.3%] vs 23 328/444 900 [5.6%], respectively; P < .001), and had more comorbidities (≥2 Elixhauser comorbidities, 302 415/450 404 [67.1%] vs 284 355/444 900 [63.9%], respectively; P < .001). This study found that hospital market competition was not consistently associated with improved outcomes after high-risk surgery. Efforts to maintain hospital market competition may not achieve better postoperative outcomes.

Factors influencing the choice-of-care pathway and survival in the fetus with hypoplastic left heart syndrome in New Zealand: a population-based cohort study

ObjectivesTo better understand the relative influence of fetal and maternal factors in determining the choice-of-care pathway (CCP) and outcome in the fetus with hypoplastic left heart syndrome (HLHS).DesignA retrospective, population-based...

COVID-19 Vaccination: Does It Alter Postoperative Mortality and Morbidity in Hip Fractures?

Introduction The primary aim of our study was to evaluate the impact of coronavirus disease 2019 (COVID-19) vaccination on mortality in patients with hip fractures by comparing it to those who are unvaccinated. Our secondary objective was to compare the impact on postoperative morbidity parameters like length of hospital stay and complications. Methods A total of 619 hip fractures were divided into the 'Vaccinated group' consisting of 300 patients who had COVID-19 vaccination and the 'Unvaccinated group' consisting of 319 patients who were not vaccinated. Patient demographic variables, Nottingham hip fracture score, American Society of Anesthesiologists (ASA) grade, type of anaesthesia used, and Charlson Comorbidity Index were collected. Our primary outcome measures were 30- and 90-day mortality. Secondary outcome measures included postoperative complications like thromboembolic complications, cardiac, and respiratory complications, etc. Mortality among the COVID-positive patients was also compared between the groups. Results Thirty-day postoperative mortality was higher in the unvaccinated group at 13.2% than in the vaccinated group at 5.3%. A similar increase in 90-day mortality was also observed in the unvaccinated group at 24.8% when compared to 14.7% in the vaccinated group(p<0.001). Despite having a higher baseline prevalence of cardiac comorbidities, the Vaccinated group had fewer post-operative cardiac, thromboembolic, and neurological complications (p>0.05). Moreover, electrolyte imbalance and AKI were also seen in fewer patients in the vaccinated group compared to the control group (p<0.05). Furthermore, it was found that among the vaccinated patients who did have perioperative COVID-19 infection, the 30-day mortality was significantly lower (10%) compared to the control group (31.2%) (p<0.001). Similarly, 90-day mortality was significantly lower (25%) compared to the control group (43.75%) (p<0.001). Conclusion Vaccination against COVID-19 independently reduced mortality and morbidity among patients with hip fractures when compared to those who are not vaccinated. Furthermore, it decreased the risk of acquiring COVID-19, and subsequent postoperative complications. Among those who are infected with COVID-19 despite vaccination, the mortality was significantly lesser.

Differences in the management of patients requiring an emergency resection for colonic cancer in two European populations.

BackgroundPatients with colonic cancer who require emergency colonic cancer surgery often experience poorer outcomes compared with their elective counterparts. In this setting, several treatments approaches are available. In 2009, Danish guidelines recommended treatment with stent for obstruction in left-sided tumours as a bridge to surgery, if expertise is accessible. The aim of this study was to compare the use of elective and emergency resections for colonic cancer and postoperative mortality in two similar demographic populations.MethodsAll patients who underwent a major resection for colonic cancer, between 2005 and 2016 in Denmark and Yorkshire (UK) were identified. The proportion undergoing emergency surgery, the proportion receiving a stent procedure before their resection, and 30-day postoperative mortality were compared between the populations. Logistic regression was used to determine changes in the proportion of those undergoing emergency surgery and 30-day postoperative mortality.ResultsOut of 45 397 patients treated during the study interval, 41 880 were selected. Emergency surgery decreased in Denmark from 16.6 per cent in 2005–07 to 12.9 per cent in 2014–16, but increased in Yorkshire (13.5 per cent to 16.8 per cent). Danish patients with left-sided tumours were less likely to undergo emergency surgery (risk ratio 0.90, 95 per cent c.i. 0.82 to 0.99) and an increase in stent use coincided with a statistically significant decrease in emergency surgery in these patients. Thirty-day postoperative mortality in all resections (elective and emergency) decreased in both populations, but a larger decrease was observed in Denmark (7.7 per cent to 3.0 per cent in Denmark and 7.1 per cent to 3.3 per cent in Yorkshire).ConclusionPatients in Denmark experienced a reduction in the use of emergency resection and increase in stenting procedures, following the policy implemented in some departments of converting potential emergency resections into elective resections.

Lesser-Known Aspects of Deep Brain Stimulation for Parkinson's Disease: Programming Sessions, Hardware Surgeries, Residential Care Admissions, and Deaths

ObjectiveThe long-term treatment burden, duration of community living, and survival of patients with Parkinson's disease (PD) after deep brain stimulation (DBS) implantation are unclear. This study aims to determine the frequency of programming, repeat hardware surgeries (of the intracranial electrode, implantable pulse generator [IPG], and extension-cable), and the timings of residential care and death in patients with PD treated with DBS. Materials and MethodsIn this cross-sectional, population-based study, individual-level data were collected from the Australian government covering a 15-year period (2002–2016) on 1849 patients with PD followed from DBS implantation. ResultsThe mean DBS implantation age was 62.6 years and mean follow-up 5.0 years. Mean annual programming rates were 6.9 in the first year and 2.8 in subsequent years. 51.4% of patients required repeat hardware surgery. 11.3% of patients had repeat intracranial electrode surgery (including an overall 1.1% of patients who were completely explanted). 47.6% of patients had repeat IPG/extension-cable surgery including for presumed battery depletion. 6.2% of patients had early repeat IPG/extension-cable surgery (within one year of any previous such surgery). Thirty-day postoperative mortality was 0.3% after initial DBS implantation and 0.6% after any repeat hardware surgery. 25.3% of patients were admitted into residential care and 17.4% died. The median interval to residential care and death was 10.2 years and 11.4 years, respectively. Age more than 65 years was associated with fewer repeat hardware surgeries for presumed complications (any repeat surgery of electrodes, extension-cables, and early IPG surgery) and greater rates of residential care admission and death. ConclusionsData from a large cohort of patients with PD treated with DBS found that the median life span after surgery is ten years. Repeat hardware surgery, including of the intracranial electrodes, is common. These findings support development of technologies to reduce therapy burden such as enhanced surgical navigation, hardware miniaturization, and improved battery efficiency.

Outcomes after Elective Abdominal Aortic Aneurysm Repair Have Improved Over Time in Patients on Dialysis

Prior studies have demonstrated poor perioperative and long-term survival of patients with end-stage kidney disease (ESKD) on dialysis who undergo abdominal aortic aneurysm repair (AAAR). However, survival in dialysis patients overall has improved over time. We hypothesize that the contemporary rates of perioperative and long-term survival following AAAR in ESKD patients are also improving. Data on AAAR procedures in dialysis patients were collected from the United States Renal Data System between 2008 and 2017. Endovascular (EVAR) and open AAA repair (OAR) were identified by Current Procedural Terminology codes. Patients with a functioning renal transplant, a ruptured aneurysm, and insurance other than Medicare were excluded. Demographics, comorbidities, procedural details, and long-term outcomes were collected. Standard statistical methods were used. We identified 3,374 patients who underwent EVAR (86%, 2,914/3,374) and OAR (14%, 460/3,374). The utilization of OAR decreased significantly from 2008 to 2017 (17.34% vs. 7.43%, P<0.001). Kaplan-Meier survival analysis revealed no significant difference in 5-year survival between OAR and EVAR (24% vs. 17%, P=0.1, Wilcoxon-Breslow test), but open repair was associated with increased long-term survival (Hazards ratio 0.994, confidence interval 0.990-0.999, P=0.017) in an adjusted Cox regression model. The cohort was then divided based on the year of AAAR, group 1: 2008-2010 (1,269/3,374), group 2: 2011-2013 (1,071/3,374), and group 3: 2014-2017 (1,034/3,374). Compared to groups 1 and 2, Group 3 was less likely to have coronary artery device, peripheral vascular disease, recent pneumonia, be nonambulatory, live in a nursing facility, or undergo an OAR and more likely to be younger and dialyze through an arteriovenous fistula/arteriovenous graft at the time of AAA repair. Thirty-day postoperative mortality was significantly lower in group 3 compared to groups 1 and 2 (5.4% [56/1,034] vs. 10.3% [131/1,269]/7.3% [78/1,071], P<0.031). One-year survival by Kaplan-Meier estimate was significantly higher in group 3 (77.7% [803/1,034]) versus groups 1 and 2 (56.7% [719/1,269], 66.9% [716/1,071], P<0.001, log-rank test). Five-year survival was also significantly higher in group 3 (27.3%) compared to groups 1 and 2 (14.2% and 16.5%, P<0.001, log-rank test). In a Cox regression model of long-term mortality adjusted for variables significant on a univariate testing, more recent procedure year was associated with increased survival (Hazards ratio 0.81, [0.77, 0.85], P<0.001). Postoperative and long-term survival following AAA repair have increased over time in ESKD patients on dialysis. This increased survival persists after accounting for differences in patient demographics and type of procedure over time. Elective AAA repair should be considered in carefully selected good-risk patients on dialysis.

Fourteen years of pancreatic surgery for malignancy among ACS-NSQIP centers: Trends in major morbidity and mortality

BackgroundThe American College of Surgeons National Surgical Quality Improvement Program was established to help participating hospitals track and report surgical complications with the goal of improving surgical care. We sought to determine whether this has led to improvements in surgical outcomes for pancreatic malignancies. MethodsPatients with pancreatic malignancies who underwent surgical resection were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2006–2019). Thirty-day postoperative major morbidity and mortality were analyzed by year. Major morbidity included organ and deep surgical site infection, venous thromboembolism, cardiac event, pneumonia, acute renal failure, sepsis, and respiratory failure. ResultsOf the 28,888 patients identified, 51% were male, the median age was 68, 74.3% underwent a pancreaticoduodenectomy, and 25.7% underwent a distal pancreatectomy. Among patients who underwent a pancreaticoduodenectomy, there was a significant increase in major morbidity (annual percent change 0.77, P = .012) driven by increases in organ space surgical site infection (annual percent change 3.52, P < .001) and venous thromboembolism (annual percent change 4.72, P = .005). However, there was a decrease in postoperative mortality (annual percent change -4.58, P = .001). For distal pancreatectomy patients, there was no change in rates of overall major morbidity (annual percent change -1.35, P = .08) or mortality (annual percent change -3.21, P = .25). ConclusionAlthough major morbidity and mortality have not significantly changed for distal pancreatectomy patients, mortality has steadily decreased for patients undergoing pancreaticoduodenectomy, despite an increase in major morbidity. Whether this trend reflects a change in patient selection, an increase in detection of postoperative morbidities and/or an improvement in mitigation of these morbidities warrants further study.

Influence of age on surgical treatment and postoperative outcomes of patients with colorectal cancer in Denmark and Yorkshire, England.

Denmark and Yorkshire are demographically similar and both have undergone changes in their management of colorectal cancer to improve outcomes. The differential provision of surgical treatment, especially in the older age groups, may contribute to the magnitude of improved survival rates. This study aimed to identify differences in the management of colorectal cancer surgery and postoperative outcomes according to patient age between Denmark and Yorkshire. This was a retrospective population-based study of colorectal cancer patients diagnosed in Denmark and Yorkshire between 2005 and 2016. Proportions of patients undergoing major surgical resection, postoperative mortality and relative survival were compared between Denmark and Yorkshire across several age groups (18-59, 60-69, 70-79 and ≥80years) and over time. The use of major surgical resection was higher in Denmark than in Yorkshire, especially for patients aged ≥80years (70.5% versus 50.5% for colon cancer, 49.3% versus 38.1% for rectal cancer). Thirty-day postoperative mortality for Danish patients aged ≥80years was significantly higher than that for Yorkshire patients with colonic cancer [OR (95% CI)=1.22 (1.07, 1.38)] but not for rectal cancer or for 1-year postoperative mortality. Relative survival significantly increased in all patients aged ≥80years except for Yorkshire patients with colonic cancer. This study suggests that there are major differences between the management of elderly patients with colorectal cancer between the two populations. Improved selection for surgery and better peri- and postoperative care in these patients appears to improve long-term outcomes, but may come at the cost of a higher 30-day mortality.

45. Association of race with early outcomes of elective posterior spinal fusion for adolescent idiopathic scoliosis: A propensity score matched analysis

<h3>BACKGROUND CONTEXT</h3> Existing literature demonstrates well-identified racial disparities in spine surgery outcomes. However, previous studies are of significant limitations. <h3>PURPOSE</h3> To investigate the association of race with 30-day perioperative complication rates of elective posterior spinal fusions (PSF) for adolescent idiopathic scoliosis (AIS). <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study. <h3>PATIENT SAMPLE</h3> All pediatric patients with AIS who underwent PSF between 2012-2018 were reviewed from the (ACS-NSQIP) pediatric database. <h3>OUTCOME MEASURES</h3> Thirty-day postoperative morbidity and mortality outcomes were analyzed. Complications included perioperative blood transfusion, venous thromboembolism, unplanned intubation, pneumonia, urinary tract infection, surgical site infection, sepsis, return to operating room, and death. Hospital course data, including operative time, the total length of hospital stay, the proportion of patients needed ICU admission, the proportion of patients discharged to other than home and discharged after the 4th postoperative day were also noted. Readmission data was included. These outcome variables are predefined in the ACS-NSQIP pediatric database, except for the discharge event after the 4th postoperative day, which was considered to be any discharge event occurring after a total hospital stay of 120 hours. <h3>METHODS</h3> Propensity score matching was used to determine whether race (ie, black vs white) had an influence on 30-day perioperative complications. <h3>RESULTS</h3> A total of 4,051 PSF for AIS cases met inclusion criteria and were reviewed. Of these, 3221 (79.5%) patients were white and 830 (20.5%) were black. Patients in the black cohort were more likely to have higher BMI (23.8 vs 21.1), be of female gender (78.2% vs 74.5%), have an ASA class 3 or more (13.7% vs 11.1%), have asthma (8.3% vs 4.9%), have cardiac risk factors (5.1% vs 2.6%), use steroids (3.8% vs 1.1%). In the black cohort, 8% of the cases had up to 6 vertebral segments fused, 64.4% had 7-12 vertebral segments fused and 27.6% had 13 or more vertebral segments fused. In the white cohort, 15.9% of the cases had up 6 vertebral segments fused, 57.2% had 7-12 vertebral segments fused and 26.9% had 13 or more vertebral segments fused. After controlling for differences in baseline factors, except for the higher incidence of venous thromboembolism in the black cohort (2.8% vs 0.1%), (p <0.001), there were no significant differences in morbidity and mortality between the black and white cohorts. <h3>CONCLUSIONS</h3> In contrast to prior literature, our analysis did not identify black race as an independent risk factor for higher perioperative morbidity or mortality in patients undergoing PSF for AIS, except for the higher incidence of venous thromboembolism. We believe that these results are important findings for clinicians and spine surgeons while counseling patients undergoing these types of procedures. It is important to address patient's concerns and to explain that the previously reported inferior perioperative morbidity and mortality outcomes in black patients might be due differences in baseline health status, and not due to the race difference itself. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Spanish Lung Cancer Group SCAT trial: surgical audit to lymph node assessment based on IASLC recommendations

BackgroundThe Spanish Customized Adjuvant Therapy (SCAT) trial assessed the role of individualized adjuvant therapy in clinical N0 incidental pN1 and/or N2 non-small cell lung cancer (NSCLC) completely resected. We assessed surgical topics with an in-depth analysis of quality of lymphadenectomy based on International Association for the Study of Lung Cancer (IASLC) recommendations.MethodsPatients with information about lymphadenectomy available were included (N=451). Prospectively collected data about tumor, type of resection, and postoperative morbidity and quality of lymph node dissection (LND) were retrospectively evaluated. Role of lymph node assessment on survival was analyzed using Kaplan-Meier curves, using regression models to identify prognostic factors.ResultsIn 33.7%, 17.7% and 49.9% of cases, regions 7, 10 and 11 respectively were not assessed. In 21.1% of patients, less than three lymph node regions were biopsied, while in 19.6% of patients less than six lymph nodes were assessed. In 53,4% of patients only one N1 region was evaluated. From patients with positive N2, 8.9% had no N1 regions biopsied. Twenty-nine percent of patients with at least one N2 lymph node resected shown the highest region involved. Thirty-day postoperative mortality was unknown. Five-year overall survival (OS) was 61.7% (95% CI: 55.4–67.4%), 51.5% (95% CI: 39.2–62.4%) and 42.3% (95% CI: 32.1–52.2%) for patients with N1, N2 and N1+N2 disease, respectively (P<0.01). Both number of lymph nodes resected and number of lymph nodes involved by tumor were significantly related to prognosis.ConclusionsIASLC recommendations for surgical resections were not followed in a high proportion of surgical procedures. Hilar and mediastinal lymph node assessment and involvement showed to impact prognosis. Surgical issues such as postoperative mortality could not be evaluated owing to trial design.

Value of Wearable Vital-sign Monitors During Perioperative Period

Perioperative mortality has long been a concern. Although the intraoperative mortality rate has made a 10-fold reduction in the past 3 decades, the thirty-day postoperative mortality rate remains high. Patients die because signs of deterioration are missed. Deterioration of patients is often overlooked or not detected at all. One of the reasons is that the intensity of nursing and the frequency of monitoring vital signs are decreased from the Intensive Care Unit via wards to home. Early detection of physiological instability is crucial to prevent death and disability. Therefore, perioperative continuous monitoring of vital signs and other information is crucial to detect physiological instability and may have the potential benefit to reduce the perioperative mortality and the incidence of major postoperative complications. Wearable continuous vital-sign monitors are expected to achieve this vision. Nowadays this kind of device is available, but further research on it is still needed. This article reviewed the current status of vital-sign monitoring and the value of wearable vital-sign monitors during the perioperative period.

A case series of hilar cholangiocarcinoma: A single surgeon experience over 20-years

ObjectiveTo report our experience in the surgical management of hilar cholangiocarcinoma in a nontransplant center. MethodsWe reviewed the medical charts of patients who underwent surgical resection of hilar cholangiocarcinoma from 1996 to 2016. The preoperative workup as well as the operative techniques were presented. The postoperative mortality and morbidity were detailed with particular emphasis on long survivals. ResultsForty patients met our inclusion criteria,22 patients (55%) had surgical resection with curative intent. Thirty-day postoperative mortality occurred in three cases (13.6%), four patients had grade II, III Clavien-Dindo complications and only one required re-laparotomy (18%).The median follow up duration was 43.4 months. ConclusionHilar cholangiocarcinoma is a rare disease with complete surgical resection presenting the best chance of cure. In addition to the free resection margins, lymph node involvement and the histological type are the most significant factors of prognosis. Histologic type such as primary lymphoma and papillary carcinoma are associated with better survival outcomes. Portal vein embolization should be considered if extended right hepatectomy is contemplated.

Clinical Outcomes, Health Care Costs and Prognostic Factors for Total Knee Arthroplasty: A Multilevel Analysis of a National Cohort Study Using Administrative Claims Data.

Total knee arthroplasty (TKA) is one of the most frequent orthopaedic surgeries. The purpose of this study was to determine the 30-day postoperative mortality rate, total episode-of-care costs, and prognostic factors associated with these outcomes, for adult patients who underwent TKA in Colombia's contributory health care system. A retrospective cohort study of all adult patients enrolled in Colombia's contributory health system, who underwent TKA between January 1, 2012 and November 30, 2015 was performed. Thirty-day postoperative mortality rates, 30-day ICU admissions rates, 30-day hospital readmission rates, 1-year arthroplasty revision rates, and total episode-of-care costs were estimated. Multilevel, generalized linear models were generated, to determine the prognostic factors associated with outcomes presented. A total of 12,453 patients were included. The 30-day mortality rate was 0.13 per 100 surgeries and the ICU admissions rate at 30 days postoperative was 4.44 per 100 surgeries. The 30-day hospital readmission rate was 4.28 per 100 surgeries and the 1-year arthroplasty revision rate was 1.22 per 100 surgeries. The prognostic factors associated with mortality were age, Charlson Index, and type of insurer. The prognostic factors associated with hospital readmission were age category, Charlson Index, and geographic region; younger age and higher Charlson Index were found to be associated with a higher 1-year arthroplasty revision rate. The median of total episode-of-care costs was USD$ 6,190.07 (interquartile range: 2,299-7,282). The multivariate model found that age, the Charlson Index, the Atlantic region, and type of insurer were associated with the costs incurred by the health system. For patients undergoing TKA in Colombia, age, the Charlson Index, insurers, and geographic region are associated with mortality, ICU admissions, 30-day hospital readmissions, 1-year arthroplasty revisions, and total costs incurred by the health system.

Outcome of surgery for acute infective endocarditis: does preoperative stroke have an impact on mortality?

Surgical therapy of infective endocarditis (IE) is challenging and can be associated with high mortality. In this study, we present the early outcomes of patients who underwent cardiac surgery for IE. From 2017 until 2019, 66 patients underwent surgical treatment for IE. Staphylococcus aureus infection was identified in 14 patients (21%). In the same period, about 813 valve replacement procedures were performed with 8% incidence of IE. Mean age was 66 ± 12years and 32% were females. Mean ejection fraction was 55 ± 9%. Seven patients (11%) had stroke due to septic embolism preoperatively. In 20 patients (30%), prosthetic valve endocarditis was an indication for reoperation. Thirty-day postoperative mortality and impact of preoperative stroke were analyzed. Thirty-day mortality was 17% (n = 11). Mean EuroSCORE I was 28 ± 22%. Mean cross clamp time was 63 ± 37min. Fourty patients (61%) underwent one-valve procedure, 25 patients (38%) had double-valve, and one (1%) triple-valve operation. All seven patients with preoperative neurologic dysfunction had unremarkable postoperative course without death or neurologic deterioration. Five of them had no worsening in neurological status, while 2 patients had slight improvement in speech. The comparison between the two groups (patients without preoperative neurological vs. patients with preoperative neurological dysfunction) revealed no significance in the postoperative mortality rate (18% vs. 0% with p = 0.26). Postoperative echocardiography revealed competent valve function in all cases. Surgical treatment for IE still remains a challenge with high morbidity and mortality. Patients with preoperative neurologic dysfunction due to septic embolism have good early postoperative results without increased mortality.