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BACKGROUND: Several registries focus on patients undergoing minimally invasive liver surgery (MILS). This study compared transatlantic registries focusing on the variables collected and differences in baseline characteristics, indications, and treatment in patients undergoing MILS. Furthermore, key variables were identified. METHODS: The five registries for liver surgery from North America (ACS-NSQIP), Italy, Norway, the Netherlands, and Europe were compared. A set of key variables were established by consensus expert opinion and compared between the registries. Anonymized data of all MILS procedures were collected (January 2014-December 2019). To summarize differences for all patient characteristics, treatment, and outcome, the relative and absolute largest differences (RLD, ALD) between the smallest and largest outcome per variable among the registries are presented. RESULTS: In total, 13,571 patients after MILS were included. Both 30- and 90-day mortality after MILS were below 1.1% in all registries. The largest differences in baseline characteristics were seen in ASA grade 3-4 (RLD 3.0, ALD 46.1%) and the presence of liver cirrhosis (RLD 6.4, ALD 21.2%). The largest difference in treatment was the use of neoadjuvant chemotherapy (RLD 4.3, ALD 20.6%). The number of variables collected per registry varied from 28 to 303. From the 46 key variables, 34 were missing in at least one of the registries. CONCLUSION: Despite considerable variation in baseline characteristics, indications, and treatment of patients undergoing MILS in the five transatlantic registries, overall mortality after MILS was consistently below 1.1%. The registries should be harmonized to facilitate future collaborative research on MILS for which the identified 46 key variables will be instrumental.
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Laparoscopia , Neoplasias Hepáticas , Humanos , Neoplasias Hepáticas/cirurgia , Hepatectomia/métodos , Laparoscopia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Sistema de RegistrosRESUMO
BACKGROUND: The incidence of intrahepatic cholangiocarcinoma (ICC) continues to rise, and hepatectomy is the only cure. Perioperative outcomes following hepatectomy for colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC) are better described than for ICC. The aim was to compare post-hepatectomy outcomes for ICC to CRLM and HCC. METHODS: The 2014-2020 ACS NSQIP hepatectomy PUF was utilized. Patients with ICC, CRLM, and HCC were identified and others excluded. Demographic, disease, and procedural characteristics were collected. Univariable and multivariable analyses (Chi-Square for categorical variables; Kruskal-Wallis for continuous variables) were performed for mortality, serious morbidity, bile leak, post-hepatectomy liver failure (PHLF), and 30-day readmission. RESULTS: 17,789 patients underwent hepatectomy including 2377 for ICC, 10,195 for CRLM, and 5217 for HCC. Patients undergoing hepatectomy for ICC vs. HCC vs. CRLM were noted to have higher 30-day mortality (4.8% vs. 2.5% vs. 1.0%, respectively p < 0.05). ICC was associated with higher overall and serious morbidity, bile leak, severe PHLF, and readmission. Multivariable analyses confirmed higher odds ratios for mortality and morbidity (p < 0.05) in patients with ICC. CONCLUSION: Hepatectomy for ICC is associated with worse short-term outcomes than for CRLM or HCC. Surgeons should be aware of these risks during surgical planning.
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INTRODUCTION: Roux-en-Y Gastric Bypass (RYGB) has been associated with increased weight loss but more complications when compared with sleeve gastrectomy (SG). However, a direct comparison between RYGB and SG has never been performed in patients with a history of solid organ transplantation. The aim of this study was to determine the association between procedure type and surgical outcomes. MATERIALS AND METHODS: Patients with a history of solid organ transplantation were identified in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project Participant Use File database from 2017 to 2018. Procedure type (SG versus RYGB) was used to stratify patients. Propensity score matching and multivariable logistic regressions were used, and outcomes were compared. RESULTS: Of 678 cases identified, 80% (n = 542) underwent an SG and 20% (n = 136) had an RYGB. Patients differed significantly (P < 0.05) by multiple demographic variables. Multivariable regression revealed RYGB to be associated with higher overall morbidity (odds ratio [OR] 1.98; P = 0.012), morbidity related to surgery (OR 2.47; P = 0.002), unplanned readmissions (OR 2.48; P = 0.002), and readmissions related to surgery (OR 2.32; P = 0.016). After propensity score matching, RYGB, compared with SG, was also associated with higher morbidity (14% versus 7.4%; P = 0.077) and readmissions (13% versus 6.6%; P = 0.099) related to surgery, although this did not reach statistical significance. CONCLUSIONS: In patients with a history of solid organ transplant, RYGB was associated with increased morbidity and readmissions compared with SG.
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Cirurgia Bariátrica , Derivação Gástrica , Obesidade Mórbida , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/métodos , Gastrectomia/efeitos adversos , Gastrectomia/métodos , Derivação Gástrica/efeitos adversos , Derivação Gástrica/métodos , Humanos , Morbidade , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The Pringle Maneuver (PM) is considered to be safe and effective. However, data regarding perioperative outcomes after a PM are conflicting. Therefore, the aim of this analysis is to compare the outcomes of patients who have and have not undergone a PM in North America. METHODS: Patients undergoing major (≥3 segments) or partial hepatectomy (≤2 segments) were identified in the 2014-17 ACS-NSQIP hepatectomy database. Patients with and without a PM were compared. Propensity matching was utilized, and subgroup analyses by liver texture, hepatectomy extent and pathology were performed. RESULTS: Prior to matching, 3706 (24%) of 15,748 hepatectomy patients underwent a PM. The PM was utilized in 1445 (27%) of major and 2261 (22%) of partial hepatectomies. After matching, 3295 patients with and 3295 without a PM were compared. Operative time was significantly increased for patients undergoing a PM (246 vs. 225 min, p < 0.001). Subgroup analyses revealed post-hepatectomy liver failure and septic shock to be significantly increased (both p < 0.05) for patients undergoing a PM during a partial hepatectomy or in patients with metastatic disease. CONCLUSION: Patients undergoing a partial hepatectomy and those with metastatic disease have worse outcomes when a Pringle Maneuver is performed.
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Falência Hepática , Neoplasias Hepáticas , Perda Sanguínea Cirúrgica , Hepatectomia/efeitos adversos , Humanos , Neoplasias Hepáticas/cirurgia , Duração da CirurgiaRESUMO
BACKGROUND: Corticosteroids have been a mainstay of immunosuppression in patients after solid organ transplantation. Due to deleterious effects, there is a push to minimize steroid use. The impact of corticosteroid use on prior solid organ transplant patients undergoing metabolic and bariatric surgery (MBS) is unknown. The aim of this study was to determine if corticosteroid use independently impacts surgical outcomes after MBS in solid organ transplant patients. MATERIALS AND METHODS: A retrospective analysis was performed on patients undergoing sleeve gastrectomy and Roux-en-Y gastric bypass in the 2017 Metabolic and Bariatric Surgery Accreditation Quality and Improvement Project Participant Use File database. Patients with a history of solid organ transplantation were identified and further stratified by corticosteroid use. Univariable and multivariable regression for multiple postoperative outcomes were performed. RESULTS: Overall findings are summarized in visual abstract. Of 382 prior solid organ transplant patients, 42% (n = 160) were on corticosteroids. Patients on corticosteroids had significantly higher overall morbidity (16% versus 9%, P < 0.05). After multivariable analysis, corticosteroid use had a two-fold increase in overall morbidity (odds ratio 2.05, P = 0.0034) but without an increased risk for overall morbidity related to MBS (odds ratio 2.06, P = 0.061). CONCLUSIONS: Solid organ transplant patients undergoing MBS on corticosteroids have a significantly increased rate of overall morbidity (P < 0.05) but not morbidity related to bariatric surgery.
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Corticosteroides/efeitos adversos , Cirurgia Bariátrica/estatística & dados numéricos , Obesidade/cirurgia , Transplante de Órgãos , Complicações Pós-Operatórias/cirurgia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Recent data suggest that routine drainage is unnecessary in patients undergoing hepatectomy, but many surgeons continue to utilize drains. We compared the outcomes of patients undergoing early versus routine drain removal after hepatectomy. METHODS: Patients having drains placed during major (≥3 segments) or partial hepatectomy (≤2 segments) were identified in the 2014-16 ACS-NSQIP database. Propensity matching between early (POD 0-3) and routine (POD 4-7) drain removal and multivariable regressions were performed. RESULTS: Early drain removal was performed in 661 (40%) of patients undergoing a partial hepatectomy and 211 (22%) of major hepatectomy patients. After matching, 719 early and 719 routine drain removal patients were compared. Early drain removal patients had lower overall (12 vs 19%, p < 0.001) and serious (9 vs 13%, p < 0.03) morbidity as well as fewer bile leaks (2.1% vs 5.0%, p < 0.003). Length of stay was two days shorter (4 vs 6 days, p < 0.01) and readmissions were less frequent (5.4 vs 8.1%, p = 0.02) for patients undergoing early drain removal. CONCLUSION: Early drain removal is associated with fewer overall and serious complications, shorter length of stay and fewer readmissions. Early drain removal after hepatectomy is an underutilized management strategy.
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Hepatectomia , Complicações Pós-Operatórias , Remoção de Dispositivo/efeitos adversos , Drenagem/efeitos adversos , Humanos , Tempo de Internação , Complicações Pós-Operatórias/etiologia , Fatores de TempoRESUMO
BACKGROUND: Racial disparities are known to negatively impact survival in patients with pancreatic adenocarcinoma. However, data regarding the Hispanic ethnicity are scarce in the pancreatic cancer literature. Therefore, the aim of this study is to analyze whether race and ethnicity are independent predictors of survival in patients with pancreatic adenocarcinoma in Florida. METHODS: A retrospective study was performed utilizing all patients diagnosed with pancreatic adenocarcinoma between 1983 and 2013 in the Florida Cancer Data System (FCDS). Statistical analysis was performed using Cox proportional hazard regression models, and Kaplan-Meier survival analysis. RESULTS: Of 36,756 patients identified with pancreatic adenocarcinoma in the FCDS, 9.1% were Hispanic and 91% were non-Hispanic. Ethnicity was associated with improved survival among Hispanics compared to non-Hispanics (HR 0.86, 95% CI 0.82-0.90, both p = 0.001). Furthermore, 90% of patients were White, and 9% were Black. Compared to Whites, Blacks had a significantly decreased survival (HR 1.07, 95% CI 1.03-1.13, p = 0.003). CONCLUSION: In Florida patients with pancreatic adenocarcinoma, Hispanic ethnicity is associated with improved survival compared to Non-Hispanics. Additionally, Blacks present at an earlier age and later stage of diagnosis with worse survival compared to Whites and Others.
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Adenocarcinoma , Neoplasias Pancreáticas , Adenocarcinoma/terapia , Etnicidade , Florida , Disparidades em Assistência à Saúde , Humanos , Neoplasias Pancreáticas/terapia , Estudos Retrospectivos , População BrancaRESUMO
Topoisomerase IB (Top1) is a key eukaryotic nuclear enzyme that regulates the topology of DNA during replication and gene transcription. Anticancer drugs that block Top1 are either well-characterized interfacial poisons or lesser-known catalytic inhibitor compounds. Here we describe a new class of cytotoxic redox-stable cationic Au(3+) macrocycles which, through hierarchical cluster analysis of cytotoxicity data for the lead compound, 3, were identified as either poisons or inhibitors of Top1. Two pivotal enzyme inhibition assays prove that the compounds are true catalytic inhibitors of Top1. Inhibition of human topoisomerase IIα (Top2α) by 3 was 2 orders of magnitude weaker than its inhibition of Top1, confirming that 3 is a type I-specific catalytic inhibitor. Importantly, Au(3+) is essential for both DNA intercalation and enzyme inhibition. Macromolecular simulations show that 3 intercalates directly at the 5'-TA-3' dinucleotide sequence targeted by Top1 via crucial electrostatic interactions, which include π-π stacking and an Au···O contact involving a thymine carbonyl group, resolving the ambiguity of conventional (drug binds protein) vs unconventional (drug binds substrate) catalytic inhibition of the enzyme. Surface plasmon resonance studies confirm the molecular mechanism of action elucidated by the simulations.
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Ouro/química , Compostos Macrocíclicos/química , Inibidores da Topoisomerase I/química , Catálise , Cristalografia por Raios X , HumanosRESUMO
BACKGROUND: Some patients undergo thyroidectomy while hospitalized for a related or independent indication. Outcomes have not been described in this group. METHODS: The 2016-2018 thyroidectomy-targeted NSQIP datasets were queried for patients admitted for ≥1 day preoperatively. 1:1 propensity score matching was employed to compare the outcomes of admitted patients to outpatients, including surgical and thyroidectomy-specific outcomes. Multivariable logistic regression determined factors associated with poor outcomes. RESULTS: Of 18,078 patients, 312 were admitted at least 1 day prior to surgery. Inpatients had higher ASA classifications and rates of several comorbidities compared to the general population. After propensity score matching, inpatients had higher rates of overall complications, unplanned reoperation, and bleeding. They also experienced higher rates of thyroidectomy-specific complications such as hypocalcemia and neck hematoma. By multivariable regression, admission prior to surgery was associated with development of any complications. CONCLUSION: Thyroidectomy in hospitalized patients carries an increased risk of complications. Patients requiring thyroidectomy while already hospitalized should be counseled accordingly.
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BACKGROUND: Patients with liver disease undergoing colectomy have higher rates of complications and mortality. The Albumin-Bilirubin score is a recently developed system, established to predict outcomes after hepatectomy, that accounts for liver dysfunction. METHODS: All patients undergoing colectomy were identified in the 2015-2018 American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database. Demographics and outcomes were compared between patients with Albumin-Bilirubin Grade 1 vs. 2/3. Multivariable regression was performed for outcomes including colorectal-specific complications. Areas under the receiver operative characteristic curves were calculated to determine accuracy of the Albumin-Bilirubin score. RESULTS: Of 86,273 patients identified, 48% (N = 41,624) were Albumin-Bilirubin Grade 1, 45% (N = 38,370) Grade 2 and 7% (N = 6,279) Grade 3. Patents with Grade 2/3 compared to Grade 1 had significantly increased mortality (7.2% vs. 0.9%, p < 0.001) and serious morbidity (31% vs. 12%, p < 0.001). Colorectal-specific complications including anastomotic leak (3.7% vs. 2.8%, p < 0.001) and prolonged ileus (26% vs. 14%, p < 0.001) were higher in patients with Grade 2/3. Grade 2/3 had increased risk of mortality (odds ratio 3.07, p < 0.001) and serious morbidity (1.78, p < 0.001). Albumin-Bilirubin had excellent accuracy in predicting mortality (area under the curve 0.81, p < 0.001) and serious morbidity (0.70, p < 0.001). CONCLUSION: Albumin-Bilirubin is easily calculated using only serum albumin and total bilirubin values. Grade 2/3 is associated with increased rates of mortality and morbidity following colectomy. Albumin-Bilirubin can be applied to risk-stratify patients prior to colectomy.
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Bilirrubina , Colectomia , Hepatopatias , Complicações Pós-Operatórias , Albumina Sérica , Humanos , Colectomia/métodos , Colectomia/efeitos adversos , Masculino , Feminino , Bilirrubina/sangue , Pessoa de Meia-Idade , Idoso , Albumina Sérica/análise , Albumina Sérica/metabolismo , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/epidemiologia , Hepatopatias/cirurgia , Hepatopatias/sangue , Hepatopatias/mortalidade , Estudos Retrospectivos , Curva ROC , Fístula Anastomótica/sangue , Fístula Anastomótica/etiologia , Fístula Anastomótica/epidemiologia , Íleus/etiologia , Íleus/sangue , Valor Preditivo dos Testes , Resultado do TratamentoRESUMO
The structures, spectroscopy, and cytotoxicity of four novel nominally square-planar gold(III) chelates 1-4 with the general formula cis-AuCl2(X), where the ligand X is an anionic bidentate pyridyl- or isoquinolylamido chelating agent, are described. The Au-N(amido), Au-N(pyridyl), and Au-N(isoquinolyl) distances are 2.002(9)-2.016(3), 2.01(1)-2.037(3), and 2.037(3) Å, respectively. Density functional theory simulations afforded accurate gold(III) coordination geometries for 1-4 (bond distances and angles to within 5% of the X-ray values), while accurate transition energies were limited to those calculated in the UV spectral region. The complexes had variable stability in dimethyl sulfoxide: compound 3 (relatively rigid) was indefinitely stable, compounds 1 and 2 (conformationally flexible) slowly demetalated over 30 days, and 4 (extensively aromatic) formed an insoluble precipitate after 10 days (72 h in an aqueous buffer). The isoquinolylamido derivative 4 was sufficiently cytotoxic in the NCI-60 screen to undergo full five-dose testing. Notably low GI50 (1.8, 2.3, and 3.2 µM) and IC50 (4.0, 9.8, and 15 µM) values were recorded for the OVCAR-3, IGROV1, and SW-620 cell lines, respectively. Hierarchical cluster analysis employing the National Cancer Institute (NCI) data for known anticancer drugs and 4 revealed that compound 4 is mechanistically identical with the topoisomerase IIα (Top2) poison zorubicin and statistically similar to the topoisomerase IB (Top1) poisons camptothecin and 9-methoxycamptothecin. The Top2-catalyzed decatenation reaction of kinetoplast DNA was studied as a function of the concentration of 4: the compound acts as an interfacial poison of Top2 at low concentrations (<1 µM) and a catalytic inhibitor of the enzyme above 5 µM. Gel mobility shift assays (plasmid DNA substrate) showed that the catalytic inhibition of Top2 likely correlates with DNA binding by 4 at concentrations >5 µM. Compound 4 is also a catalytic inhibitor of Top1 at higher concentrations, consistent with DNA binding by the complex.
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Compostos Organoáuricos/química , Compostos Organoáuricos/farmacologia , Inibidores da Topoisomerase/química , Inibidores da Topoisomerase/farmacologia , Amidas/química , Amidas/farmacologia , Antineoplásicos/química , Antineoplásicos/farmacologia , Linhagem Celular Tumoral , Cristalografia por Raios X , DNA/metabolismo , DNA Topoisomerases Tipo I/metabolismo , DNA Topoisomerases Tipo II/metabolismo , Humanos , Isoquinolinas/química , Isoquinolinas/farmacologia , Modelos Moleculares , Neoplasias/tratamento farmacológicoRESUMO
BACKGROUND: Racial disparities in care exist for diseases with heterogeneous treatment guidelines. The impact of these disparities on outcomes after parathyroidectomy for secondary(2HPT) and tertiary hyperparathyroidism(3HPT) was explored. METHODS: The 2015-2019 NSQIP datasets were used. Patients who underwent parathyroidectomy for 2HPT and 3HPT were identified and analyzed separately. Patients were stratified by race (white vs. non-white); demographics, comorbidities, and outcomes were compared. Studied outcomes included 30-day morbidity, mortality, unplanned reoperation, readmission, and postoperative length of stay(LOS). RESULTS: There were 1,150 patients with 2HPT and 262 with 3HPT. For 2HPT, 65.5% were non-white; morbidity, reoperation, and prolonged LOS(>3days) occurred disproportionately more often in non-white patients. Non-white race was independently associated with morbidity; higher ASA class and alkaline phosphatase levels were associated with prolonged LOS. For 3HPT, 53.1% were non-white; a prolonged LOS(>1day) occurred disproportionately more often in non-white patients. Higher alkaline phosphatase levels were independently associated with prolonged LOS. CONCLUSION: Race and markers of advanced disease negatively impact outcomes after parathyroidectomy for 2HPT and 3HPT. Attention to racial disparities and earlier referral may positively impact outcomes.
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Hiperparatireoidismo Secundário , Hiperparatireoidismo , Humanos , Paratireoidectomia , Fosfatase Alcalina , Hiperparatireoidismo/cirurgia , Morbidade , Reoperação , Hiperparatireoidismo Secundário/cirurgia , Estudos RetrospectivosRESUMO
BACKGROUND: Preoperative opioid use has shown association with worse outcomes after surgery. However, little is known about the effect of preoperative benzodiazepines with and without opioids. The aim of this study was to determine the influence of preoperative substance use on outcomes after abdominal surgery. STUDY DESIGN: Patients undergoing abdominal operations including ventral hernia, colectomy, hysterectomy, cholecystectomy, appendectomy, nephrectomy, and hiatal hernia were identified in an opioid surgical steward program by a regional NSQIP consortium between 2019 and 2021. American College of Surgeons NSQIP data were linked with custom substance use variables created by the collaborative. Univariable and multivariable analyses were performed for 30-day outcomes. RESULTS: Of 4,439 patients, 64% (n = 2,847) were women, with a median age of 56 years. The most common operations performed were hysterectomy (22%), ventral hernia repair (22%), and colectomy (21%). Preoperative opioid use was present in 11% of patients (n = 472), 10% (n = 449) were on benzodiazepines, and 2.3% (n = 104) were on both. Serious morbidity was significantly (p < 0.001) increased in patients on preoperative opioids (16% vs 7.9%) and benzodiazepines (14% vs 8.3%) compared with their naïve counterpart and this effect was amplified in patients on both substances (20% vs 7.5%). Multivariable regression analyses reveal that preoperative substance use is an independent risk factor (p < 0.01) for overall morbidity and serious morbidity. CONCLUSIONS: Preoperative opioid and benzodiazepine use are independent risk factors that contribute to postoperative morbidity. This influence on surgical outcomes is exacerbated when patients are on both substances.
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Hérnia Ventral , Transtornos Relacionados ao Uso de Opioides , Humanos , Feminino , Pessoa de Meia-Idade , Masculino , Analgésicos Opioides/uso terapêutico , Benzodiazepinas/uso terapêutico , Hérnia Ventral/cirurgia , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento , Estudos RetrospectivosRESUMO
BACKGROUND: Perioperative blood transfusions and operative time are surgical quality indicators. The aim of this analysis is to determine which of these variables drives post-hepatectomy outcomes. METHODS: Patients undergoing major or partial hepatectomy were identified in the 2014-2018 American College of Surgeons National Surgical Quality Improvement Program hepatectomy targeted database. Prolonged operative time was defined as ≥ 240 minutes. Multivariable logistic regressions were performed for multiple postoperative outcomes. RESULTS: Of 20 521 hepatectomies, 18% of patients received a perioperative transfusion, and the median operative time was 218 minutes. Patients receiving a transfusion had a significant (P < .001) increase in mortality (5.1% vs. .7%) and serious morbidity (43% vs. 16%). Prolonged operative time was associated with significantly (P < .001) increased mortality (2.4% vs. .8%) and serious morbidity (29% vs. 14%). Those with primary hepatobiliary cancer had the highest rates of postoperative morbidity and mortality compared to patients with metastatic and benign disease when a transfusion occurred. On multivariable regression analyses, perioperative transfusions conferred a higher risk (P < .001) than prolonged operative time for mortality (OR 5.02 vs. 1.47) and serious morbidity (OR 2.56 vs. 1.50). CONCLUSIONS: Perioperative blood transfusions are a more robust predictor of post-hepatectomy outcomes than increased operative time, especially in patients with primary hepatobiliary cancer.
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Transfusão de Sangue , Hepatectomia , Hepatectomia/efeitos adversos , Humanos , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Melhoria de Qualidade , Fatores de RiscoRESUMO
BACKGROUND: The albumin-bilirubin score (ALBI) has recently been shown to have increased accuracy in predicting post-hepatectomy liver failure and mortality compared with the Model for End-Stage Liver Disease (MELD). However, the use of ALBI as a predictor of postoperative mortality for other surgical procedures has not been analyzed. The aim of this study was to measure the predictive power of ALBI compared with MELD-sodium (MELD-Na) across a wide range of surgical procedures. STUDY DESIGN: Patients undergoing cardiac, pulmonary, esophageal, gastric, gallbladder, pancreatic, splenic, appendix, colorectal, adrenal, renal, hernia, and aortic operations were identified in the 2015-2018 American College of Surgeons NSQIP database. Patients with missing laboratory data were excluded. Univariable analysis and receiver operator characteristic curves were performed for 30-day mortality and morbidity. Areas under the curves were calculated to validate and compare the predictive abilities of ALBI and MELD-Na. RESULTS: Of 258,658 patients, the distribution of ALBI grades 1, 2, 3 were 51%, 42%, and 7%, respectively. Median MELD-Na was 7.50 (interquartile range 6.43 to 9.43). Overall 30-day mortality rate was 2.7% and overall morbidity was 28.6%. Increasing ALBI grade was significantly associated with mortality (ALBI grade 2: odds ratio [OR] 5.24; p < 0.001; ALBI grade 3: OR 25.6; p < 0.001) and morbidity (ALBI grade 2: OR 2.15; p < 0.001; ALBI grade 3: OR 6.12; p < 0.001). On receiver operator characteristic analysis, ALBI outperformed MELD-Na with increased accuracy in several operations. CONCLUSIONS: ALBI score predicts mortality and morbidity across a wide spectrum of surgical procedures. When compared with MELD-Na, ALBI more accurately predicts outcomes in patients undergoing pulmonary, elective colorectal, and adrenal operations.
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Bilirrubina/sangue , Doença Hepática Terminal/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Albumina Sérica Humana/análise , Sódio/sangue , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Idoso , Comorbidade , Conjuntos de Dados como Assunto , Doença Hepática Terminal/sangue , Doença Hepática Terminal/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Testes de Função Hepática/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Curva ROC , Medição de Risco/métodos , Índice de Gravidade de DoençaRESUMO
BACKGROUND: Race has been shown to impact receipt of and outcomes following hepatobiliary surgery. We sought to determine if racial disparities in the management of hepatocellular carcinoma persist. METHODS: Information on patients with hepatocellular carcinoma diagnosed between 2012 and 2016 was obtained from the Surveillance, Epidemiology, and End Results database. The sample was stratified by race/ethnicity, and associations between tumor characteristics, treatment, and survival were assessed. RESULTS: Of 33,672 patients, the mean age was 65 years, and 77% were male. By race, 17,150 (51%) were white, 4755 (14%) black, 6850 (20%) Hispanic, and 4917 (15%) Asian. When assessing the likelihood of treatment versus no treatment for tumors less than 5 cm, no difference was observed between whites and blacks in any year, but Hispanics were less likely than whites to receive treatment in most years. Asians were more likely to receive treatment every year. When assessing the likelihood of transplant versus surgical resection, blacks were less likely than whites to undergo transplant in all years except 2016. Hispanics were equally likely, while Asians were less likely to undergo transplant in all years. For years 2012 to 2016 collectively, Asians had better 5-year survival rates than other races after undergoing ablation and resection. No difference in the risk of death was observed among blacks, whites, or Hispanics after undergoing ablation, resection, or transplant. CONCLUSION: Racial disparities for blacks and Hispanics have improved. Although Asians were less likely to undergo transplant, they had better survival after undergoing resection or ablation.
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Carcinoma Hepatocelular , Neoplasias Hepáticas , Idoso , Carcinoma Hepatocelular/cirurgia , Etnicidade , Hispânico ou Latino , Humanos , Neoplasias Hepáticas/cirurgia , Masculino , Taxa de Sobrevida , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Minimally invasive hepatectomy has been shown to be associated with improved outcomes when compared with open surgery. However, data comparing laparoscopic and robotic hepatectomy is lacking and limited to single-center studies. METHODS: Patients undergoing major (≥ 3 segments) or partial (≤ 2 segments) hepatectomy were identified in the 2014-2017 ACS-NSQIP hepatectomy targeted database. Patients undergoing laparoscopic and robotic approaches were compared, and propensity score matching was utilized to adjust for bias. RESULTS: Of 3152 minimally invasive hepatectomies (MIHs), 86% (N = 2706) were partial and 14% (N = 446) were major. The laparoscopic approach was utilized in 92% of patients (N = 2905) and 8% were performed robotically (N = 247). The percentage of MIHs increased over time (p < 0.01). After matching, 240 were identified in each cohort. Compared with the robotic approach, patients undergoing laparoscopic hepatectomy had a significantly higher conversion rate (23% vs. 7.4%) but had shorter operative time (159 vs. 204 min) (p < 0.001). Laparoscopic cases undergoing an unplanned conversion to open were associated with increased morbidity (p < 0.001), but this difference was not observed in robotic cases. Both MIH approaches had low mortality (1.0%, p = 1.00), overall morbidity (17%, p = 0.47), and very short length of stay (3 days, p = 0.80). CONCLUSION: Minimally invasive hepatectomy is performed primarily for partial hepatectomies. Laparoscopic hepatectomy is associated with a significantly higher conversion rate, and converted cases have worse outcomes. Both minimally invasive approaches are safe with similar mortality, morbidity, and a very short length of stay. Graphical Abstract.
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Laparoscopia , Procedimentos Cirúrgicos Robóticos , Hepatectomia/efeitos adversos , Humanos , Tempo de Internação , América do Norte/epidemiologia , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: As the obesity epidemic worsens, the prevalence of fatty liver disease has increased. However, minimal data exist on the impact of combined fatty liver and metabolic syndrome on hepatectomy outcomes. Therefore, the aim of this analysis is to measure the outcomes of patients who do and do not have a fatty liver undergoing hepatectomy in the presence and absence of the metabolic syndrome. METHODS: Patients with fatty and normal livers undergoing major hepatectomy (≥3 segments) were identified in the 2014 to 2018 American College of Surgeon National Surgical Quality Improvement Program database. Patients undergoing partial hepatectomy and those with missing liver texture data were excluded. Propensity matching was used and adjusted for multiple variables. A subgroup analysis stratified by the metabolic syndrome (body mass index ≥30 kg/m2, hypertension and diabetes) was performed. Demographics and outcomes were compared by χ2 and Mann-Whitney tests. RESULTS: Of 2,927 hepatectomies, 30% of patients (N = 863) had a fatty liver. The median body mass index was 28.6, and the metabolic syndrome was present in 6.3% of patients (N = 184). After propensity matching, 863 patients with fatty and 863 with normal livers were compared. Multiple outcomes were significantly worse in patients with fatty livers (P <.05), including serious morbidity (32% vs 24%), postoperative invasive biliary procedures (15% vs 10%), organ space infections (11% vs 7.8%), and pulmonary complications. Patients with fatty livers and the metabolic syndrome had significantly increased postoperative cardiac arrests, pulmonary embolisms, and mortality (P < .05). CONCLUSION: Fatty liver disease is associated with significantly worse outcomes after major hepatectomy. The metabolic syndrome confers an increased risk of postoperative mortality.
Assuntos
Fígado Gorduroso/complicações , Hepatectomia/mortalidade , Síndrome Metabólica/complicações , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Current guidelines recommend laparoscopic cholecystectomy be offered for patients with acute cholecystitis except those deemed as high risk. Few studies have examined the impact of frailty on outcomes for patients undergoing laparoscopic cholecystectomy. Therefore, the aim of this study was to determine the association of frailty with postoperative morbidity and mortality in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. METHODS: Patients undergoing laparoscopic cholecystectomy for acute cholecystectomy were identified from 2005 to 2010 in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP). The Modified Frailty Index (mFI) was used a surrogate for frailty, and patients were stratified as non-frail (mFI 0), low frailty (mFI 1-2), intermediate frailty (mFI 3-4) and high frailty (mFI ≥ 5). Univariable and multivariable analyses were performed. Receiver operator curves (ROC) and an area under the curve (AUC) were generated to determine accuracy of mFI in predicting postoperative morbidity and mortality. RESULTS: Of the 6898 patients undergoing laparoscopic cholecystectomy, 3245 (47%) patients were non-frail. There were 2913 (42%) patients with low-frailty, 649 (9%) patients with intermediate frailty, and 91 (2%) with high frailty. Clavien IV complications were higher for intermediate frail patients (OR 1.81, 95% CI 1.00-3.28, p = 0.050) and high-frail patients (OR 4.59, 95% CI 1.98-10.7, p < 0.001). Additionally, mortality was higher for patients with intermediate frailty (OR 4.69, 95% CI 1.37-16.0, p = 0.014) and high frailty (OR 12.2, 95% CI 2.67-55.5, p = 0.001). The mFI had excellent accuracy for mortality (AUC = 0.83) and Clavien IV complications (AUC = 0.73). CONCLUSION: Frailty is associated with postoperative morbidity and mortality in patients undergoing laparoscopic cholecystectomy for acute cholecystitis.