New Onset Geriatric Syndromes and One-year Outcomes Following Elective Gastrointestinal Cancer Surgery.

OBJECTIVE: To assess whether older adults who develop geriatric syndromes following elective gastrointestinal surgery have poorer 1-year outcomes. BACKGROUND: Within 10 years, 70% of all cancers will occur in older adults ≥65 years old. The rise in older adults requiring major surgery has brought attention to age-related complications termed geriatric syndromes. However, whether postoperative geriatric syndromes are associated with long-term outcomes is unclear. METHODS: A population-based retrospective cohort study using the New York State Cancer Registry and the Statewide Planning and Research Cooperative System was performed including patients >55 years with pathologic stage I-III esophageal, gastric, pancreatic, colon, or rectal cancer who underwent elective resection between 2004 and 2018. Those aged 55 to 64 served as the reference group. The exposure of interest was a geriatric syndrome [fracture, fall, delirium, pressure ulcer, depression, malnutrition, failure to thrive, dehydration, or incontinence (urinary/fecal)] during the surgical admission. Patients with any geriatric syndrome within 1 year of surgery were excluded. Outcomes included incident geriatric syndrome, 1-year days alive and out of the hospital, and 1-year all-cause mortality. RESULTS: In this study, 37,998 patients with a median age of 71 years without a prior geriatric syndrome were included. Of those 65 years or more, 6.4% developed a geriatric syndrome. Factors associated with an incident geriatric syndrome were age, alcohol/tobacco use, comorbidities, neoadjuvant therapy, ostomies, open surgery, and upper gastrointestinal cancers. An incident geriatric syndrome was associated with a 43% higher risk of 1-year mortality (hazard ratio, 1.43; 95% confidence interval, 1.27-1.60). For those aged 65+ discharged alive and not to hospice, a geriatric syndrome was associated with significantly fewer days alive and out of hospital (322 vs 346 days, P < 0.0001). There was an indirect relationship between the number of geriatric syndromes and 1-year mortality and days alive and out of the hospital after adjusting for surgical complications. CONCLUSIONS: Given the increase in older adults requiring major surgical intervention, and the establishment of geriatric surgery accreditation programs, these data suggest that morbidity and mortality metrics should be adjusted to accommodate the independent relationship between geriatric syndromes and long-term outcomes.

The accumulation of ERAS (enhanced recovery after surgery) components reduces post-colectomy length of stay at small and low volume hospitals.

In small hospitals, where the majority of colectomy surgery is performed in the United States, adopting more individual ERAS components improves outcomes. The accumulation of individual ERAS components influences outcome more than an "ERAS designation" and this can be used by small hospitals to improve outcomes.

Survival after left ventricular assist device with and without temporary right ventricular support.

BACKGROUND: Right ventricular (RV) failure after the insertion of a left ventricular assist device (LVAD) historically results in poor outcomes. Patients requiring temporary RV support after LVAD insertion are a heterogeneous group of patients consisting of those in cardiogenic shock after myocardial infarction, to those with chronic decompensated heart failure. For patients requiring biventricular support, we have used a hybrid system consisting of a HeartMate II LVAD and CentriMag right ventricular assist device (RVAD). The purpose of this study was to determine the 1-year survival in patients requiring isolated LVAD and patients requiring biventricular support. METHODS: All patients who underwent HeartMate II LVAD alone or in conjunction with a temporary CentriMag RVAD were examined from 2006 to 2011. Preoperative demographics, operative outcomes, and survival were analyzed. RESULTS: A total of 139 patients required HeartMate II insertion; 34 (24%) required biventricular support at the time of HeartMate II implantation. The mean duration of biventricular support was 17 ± 11.9 days (range, 6 to 56 days) with 91.8% (n = 31) of RVADs successfully explanted. Survival to hospital discharge was not different between groups (95.2 versus 88.2%; p = 0.2). However, 1-year survival was significantly greater in patients who required isolated HeartMate II LVAD (87% versus 77%; p = 0.03). CONCLUSIONS: Biventricular support using a HeartMate II LVAD and CentriMag RVAD resulted in limited mortality at hospital discharge. However biventricular dysfunction does not have a favorable outcome at 1 year when compared with patients requiring isolated HeartMate II.

The effect of repeat sternotomy during right ventricular outflow tract reconstruction.

OBJECTIVE: Right ventricular outflow tract (RVOT) reconstruction necessitates frequent reoperation. To understand the early outcomes, we analyzed our results to provide the intra- and postoperative morbidity and mortality. We hypothesized that multiple previous sternotomies do not influence the morbidity, mortality, or survival. DESIGN: We performed a retrospective review of patients who underwent reoperative RVOT reconstruction at the University of Rochester Medical Center and SUNY Upstate Medical Center from January 1, 2000 to December 31, 2009. Patients were divided into three groups based upon the number of previous sternotomies: Group 1 with one, Group 2 with two, and Group 3 with three or more previous sternotomies. RESULTS: 220 patients had reoperative RVOT reconstruction, 103 in Group 1, 71 in Group 2, and 46 in Group 3. There was no difference in the percentage of inadvertent cardiotomy between groups (Group 1: 2%, Group 2: 1%, Group 3: 2%; P =.9) The number of previous sternotomies had no effect upon infection, arrhythmia, or the percentage of patients who received a red blood cell transfusion (Group 1: 56%, Group 2: 49% Group 3: 43%; P =.3). Perioperative mortality for the entire group was 3/220 (1.4%), with no difference between groups. At a mean follow-up of 39 months, there was a survival of 98% for Groups 1 and 3 and 97% for Group 2 (P =.7). CONCLUSION: Reoperative RVOT reconstruction can safely be performed with limited morbidity and mortality. The number of previous sternotomies does not influence the rate of cardiotomy, red blood cell transfusion, or early outcome.

Surgical strategy for aortic coarctation repair resulting in physiologic arm and leg blood pressures.

OBJECTIVE: The goal of aortic coarctation repair is laminar aortic blood flow resulting in a negative or absent arm:leg blood pressure (BP) gradient. Despite satisfactory relief of coarctation, associated arch hypoplasia can result in residual obstruction and postoperative upper body hypertension. INTERVENTION: We devised a surgical strategy to create a tension-free anastomosis with a diameter as large as both the adjacent proximal and distal aorta using a radically extended end-to-end anastomosis via sternotomy and/or thoracotomy. Sternotomy is chosen when there is significant transverse arch hypoplasia defined as a distal transverse arch ≤ diameter of the left carotid artery, presence of a common brachiocephalic trunk, or coexisting intracardiac lesion requiring repair. Thoracotomy is used in all other cases. RESULTS: From 2000 to 2008, 95 consecutive patients were repaired using this approach, 35 with sternotomy and 60 with thoracotomy. At a mean follow-up of 50 ± 23 months, mean systolic BP was 94 ± 10 mm Hg, and 84% of patients had no residual arm:leg BP gradient. Mean arm:leg BP gradient was not statistically different between groups (-8.5 ± 15 sternotomy and -7.0 ± 10 mm Hg thoracotomy, P= .7). With Doppler echocardiography, 96% of patients demonstrated normal early diastolic reversal of blood flow in the descending thoracic aorta. CONCLUSIONS: For aortic coarctation repair in infancy, a strategy designed to directly address aortic arch hypoplasia results in excellent intermediate-term results with normal BP, physiologic arm:leg BP relationship, and near normal descending aortic blood flow velocities by Doppler.

Carpentier edwards porcine valved conduit for right ventricular outflow tract reconstruction.

BACKGROUND: The optimal conduit for right ventricular outflow tract (RVOT) reconstruction is uncertain, with varying degrees of longevity reported for pericardial, homograft, and xenograft valves utilized in this position. METHODS: A retrospective review of children and adults with congenital heart disease who underwent RVOT reconstruction with the Carpentier Edwards™ (CE) porcine valved conduit was conducted from 2001 to 2009 at the University of Rochester and SUNY Upstate Medical Centers. Clinical data were analyzed for each subject according to conduit size, and all of the Doppler derived transconduit gradients from postoperative echocardiograms were analyzed. RESULTS: Two hundred and eighteen patients received a single CE conduit for RVOT reconstruction with conduit size ranging from 12 to 30 mm. Perioperative mortality was 1.8% (4/218). Follow-up data were available for 95% of subjects with duration of follow-up ranging from 1 to 9 years. The increase in transconduit gradient over time was inversely proportional to conduit size. For the entire series, freedom from reoperation was 70.3% at 8.2 years. Patients receiving 25 and 30 mm conduits demonstrated no gradient development over this period of follow-up. CONCLUSIONS: In this series, the CE conduit showed excellent longevity at intermediate term follow-up, with slower progression of conduit stenosis as measured by RVOT gradient change compared with previous reports.

An inexpensive cardiac bypass cannulation simulator: facing challenges of modern training.

The importance of surgical simulation has grown in the quickly changing climate of modern surgical training. As the expectation of basic skills acquisition has shifted to forums outside the operating room, residency programs have struggled to provide realistic teaching simulations for their trainees. We have developed and tested a realistic and low-cost porcine cannulation model. This model provided a platform for both technical and cognitive skills acquisition at the first session of the cardiothoracic or "CT Surgery Boot Camp" during the summer of 2008.