Open versus robotic-assisted partial nephrectomy: a multicenter comparison study of perioperative results and complications

Purpose

To compare surgical results, morbidity and positive surgical margins rate of patients undergoing robotic partial nephrectomy (RPN) versus open partial nephrectomy (OPN).

Methods

This is an observational multicenter study promoted by the “Associazione GIovani Laparoscopisti Endoscopisti” (AGILE) no-Profit Foundation, which involved six Italian urologic centers. All clinical, surgical, and pathological variables of patients treated with OPN or RPN for renal tumors were gathered in a prospectively maintained database. Tumor nephrometry was measured with PADUA score, and complications were stratified with modified Clavien system. Differences between RPN and OPN group were assessed with univariate analysis. Perioperative variables independently associated with complications were assessed with multivariate analysis.

Results

A total of 198 and 105 patients were enrolled in OPN and RPN group, respectively. Both had similar demographics, indications to surgery, tumor nephrometry, renal function, WIT (18.7 vs. 18.2 min; p = NS), positive margin rate (5.6 vs. 5.7 %; p = NS), intraoperative complications, and postoperative medical complications. Compared to OPN, RPN group was significantly more morbid (p = 0.04), included tumors with smaller size (p = 0.002), had longer operative time (p < 0.001), lower blood loss, surgical postoperative complications (5.7 vs. 21.2 %, p < 0.001), Clavien 3–4 surgical complications (1 vs. 9.1 %, p = 0.001), and shorter hospitalization. The surgical approach resulted independently correlated with surgical complications on multivariate analysis.

Conclusion

In the present series, RPN was associated with a significant reduction of blood loss, surgical complications, including the reintervention rate for urinary fistula and postoperative bleeding, and with a shorter hospitalization.     

Correlation of the RENAL nephrometry score with warm ischemia time after robotic partial nephrectomy

Purpose

The RENAL nephrometry score (RNS) was developed to quantify complexity of renal tumors in a reproducible manner. We aim to determine whether individual categories of the RNS have different impact on the warm ischemia time (WIT) for patients undergoing robotic partial nephrectomy (RPN).

Methods

In a retrospective analysis of a prospectively maintained database, we identified 251 consecutive patients who underwent RPN between January 2007 and June 2010. RNS was determined in 187 with available imaging. Univariable analysis and multivariable linear regression analysis were performed to identify which factors were more significantly associated with WIT.

Results

Overall RNS was of low (4–6), moderate (7–9), and high complexity (10–12) in 84 (45 %), 80 (43 %), and 23 (12 %) patients, respectively. There was no association between gender (p = 0.6), BMI (p = 0.3), or anterior/posterior location (A) (p = 0.8), and WIT. On univariable analysis, longer WIT was associated with size (R) >4 cm (p < 0.0001), entirely endophytic properties (E) (p = 0.005), tumor <4 mm from the collecting system/sinus (N) (p < 0.0001), and location between the polar lines (L) (p = 0.004). Total RNS and WIT were highly correlated (Spearman correlation coefficient = 0.54, p < 0.0001). There was a significant trend of higher WIT with increased tumor complexity (p for trend <0.0001). After multivariable analysis, only R (p = 0.0003), E (p = 0.003), and N (p = 0.00002) components of the RNS were significantly associated with WIT.

Conclusions

The A and L subcategories of the RNS have no significant impact on the WIT of patients undergoing RPN. WIT is significantly dependent upon the other subcategories, as well as the overall RNS. These findings can be used to preoperatively predict which tumor characteristics will likely affect WIT and may be useful in preoperative counseling as well as planning of approach.     

Robotic partial nephrectomy shortens warm ischemia time, reducing suturing time kinetics even for an experienced laparoscopic surgeon: a comparative analysis

Objectives

Laparoscopic and robotic partial nephrectomy (LPN and RPN) are strongly related to influence of tumor complexity and learning curve. We analyzed a consecutive experience between RPN and LPN to discern if warm ischemia time (WIT) is in fact improved while accounting for these two confounding variables and if so by which particular aspect of WIT.

Methods

This is a retrospective analysis of consecutive procedures performed by a single surgeon between 2002–2008 (LPN) and 2008–2012 (RPN). Specifically, individual steps, including tumor excision, suturing of intrarenal defect, and parenchyma, were recorded at the time of surgery. Multivariate and univariate analyzes were used to evaluate influence of learning curve, tumor complexity, and time kinetics of individual steps during WIT, to determine their influence in WIT. Additionally, we considered the effect of RPN on the learning curve.

Results

A total of 146 LPNs and 137 RPNs were included. Considering renal function, WIT, suturing time, renorrhaphy time were found statistically significant differences in favor of RPN (p < 0.05). In the univariate analysis, surgical procedure, learning curve, clinical tumor size, and RENAL nephrometry score were statistically significant predictors for WIT (p < 0.05). RPN decreased the WIT on average by approximately 7 min compared to LPN even when adjusting for learning curve, tumor complexity, and both together (p < 0.001).

Conclusions

We found RPN was associated with a shorter WIT when controlling for influence of the learning curve and tumor complexity. The time required for tumor excision was not shortened but the time required for suturing steps was significantly shortened.     

External validation of the preoperative anatomical classification for prediction of complications related to nephron-sparing surgery

Purpose

Ficarra et al. (Eur Urol 56:786–793, 2009) published a preoperative anatomical classification (PADUA) to assess the impact of anatomical parameters of renal tumors on complication rate of nephron-sparing surgery (NSS). The objective of this study is to provide a bi-center external validation of this classification using the technique of hilar arterial clamping during open and laparoscopic NSS and to correlate the PADUA score to the ischemia time.

Methods

240 consecutive tumors treated with open and laparoscopic NSS were reclassified according to the PADUA classification. Complications were graded according to the modified Clavien system (Dindo et al. in Ann Surg 240:205–213, 2004). Chi-square tests and multivariate logistic regression models addressed the predictive value of PADUA classification on overall complication rate and grade.

Results

Mean patient age was 62.2 ± 13.3 years. Eastern Cooperative Oncology Group performance was 0 in 76%, 1 in 22% and 2 in 2%. 61 (25%) were treated laparoscopically. The median PADUA score was 7.5 (range 6–13). Mean surgery and ischemia time was 189 ± 95 and 24 ± 22 min, respectively. Overall complication rate was 23% (n = 54). On univariate analysis, the PADUA score correlated with complication rate (p < 0.001) of open and laparoscopic NSS. On multivariate, only the PADUA score correlated with complication rate (p = 0.0056). Ischemic time correlated with the PADUA score and was significantly higher in PADUA score ≥ 10 (p = 0.034).

Conclusions

The PADUA score is a reliable tool to preoperatively predict the risk of complications. In addition, it might be beneficial for a more objective patient selection for laparoscopic surgery and teaching NSS.     

Transperitoneal versus retroperitoneal robotic partial nephrectomy: matched-pair comparisons by nephrometry scores

Purpose

The purpose of this study was to compare perioperative outcomes of transperitoneal (TP) and retroperitoneal (RP) robot-assisted partial nephrectomy (RPN) by matched analysis using nephrometry systems.

Methods

A total of 107 patients who underwent RPN by a single surgeon from December 2008 to June 2012 were analyzed; 57 patients underwent TP RPN and 50 patients underwent RP RPN. Baseline demographic characteristics, perioperative outcomes and changes in renal function were collected by retrospective review of medical records. Matched-pair comparisons were done using RENAL score and C-index.

Results

No significant difference was observed between TP and RP RPN in patient age, body mass index, gender, laterality, clinical stage, tumor size, RENAL score or ASA score. The TP RPN had more cystic renal masses (TP vs. RP = 33 vs. 12 %, p = 0.012) and RP RPN had shorter median operation times (150 vs. 120 min, p = 0.015) and shorter mean warm ischemic times (26.2 vs. 22.6 min, p = 0.040) than TP RPN. In the matched-pair analysis, RP RPN showed shorter operation times with similar warm ischemic times. Estimated blood loss and visual analog pain scales showed no significant differences between groups. A total of 12 (11.4 %) postoperative complications occurred, all Clavien class I or II with no significant difference in incidence.

Conclusions

Retroperitoneal robot-assisted partial nephrectomy showed shorter operation time and generally equivalent perioperative results to TP RPN. RP RPN is a viable treatment option for treating posterior or lateral renal masses.     

Analysis of Surgical Complications of Renal Tumor Enucleation with Standardized Instruments and External Validation of Padua Classification

Purpose

To assess surgical results and morbidity of tumor enucleation (TE), and to evaluate their correlation with PADUA nephrometric score.

Methods

We prospectively gathered data, including accurate analysis of tumor nephrometry, from 244 consecutive patients treated with TE for clinically localized renal cell carcinoma. All surgical results were collected, and perioperative complications were stratified for severity according to Clavien system. Correlation between preoperative variables and surgical results/complications was assessed with uni- and multivariate analysis.

Results

Mean (range) tumor size was 3.6 (0.8–10.0) cm, and mean (range) warm ischemia time was 16.8 (5–35) min. Overall, perioperative complications occurred in 45 patients (18.4 %), and of those 8 were medical and 37 were surgical (4 Clavien grade 1, 25 grade 2, and 8 grade 3) complications. Urine leakage rate was 2.0 %. No grade 4/5 complications occurred in this series. At univariate analysis PADUA score, endophytic tumor growth, tumor diameter, involvement of UCS and renal sinus resulted associated with warm ischemia time (p < 0.0001 each) and surgical complications (p = 0.0007, p = 0.049, p = 0.021, p = 0.036, and p = 0.029, respectively). At logistic regression, nephrometry score resulted independently associated with overall complications (related risk for each increased point 1.54; p = 0.017), surgical complications (related risk 1.58; p = 0.016), and Clavien grade 3 surgical complications (related risk 2.99; p = 0.008).

Conclusions

The TE technique was associated with a 15.2 % surgical complication rate with a 3.3 % reintervention rate (including ureteral stenting and superselective renal artery embolization). Tumor nephrometry and surgical indication resulted independent predictors of Clavien grade 3 complications. The PADUA score is a reliable tool to predict surgical results and morbidity of TE.     

A comparison of pathologic outcomes of matched robotic and open partial nephrectomies

Purpose

Open partial nephrectomy (OPN) and robotic partial nephrectomy (RPN) are widely utilized techniques for small renal masses. The lack of tactile feedback and limitations of laparoscopy may result in differences in the surgical specimen that may impact oncologic outcome. We present postoperative pathological outcomes data in a cohort of patients matched for nephrometry score, tumor size, gender and age.

Materials and methods

We reviewed 81 patients who underwent partial nephrectomy between January 2003 and March 2010. Twenty-seven underwent RPN and 54 received OPN. Two OPN cases were matched for nephrometry score, tumor size, gender and age for each RPN. Postoperative pathological specimens were reviewed by a urologic pathologist regarding margin status, pathologic stage, histology, renal capsule violation, among other variables.

Results

Sixty-two (76.5 %) patients were found to have renal cell carcinoma on final pathology. Frozen sectioning with tumor bed sampling was intra-operatively employed in 70 cases (86.4 %). The overall positive margin occurrence was 1 of 81 patients, which occurred during an RPN for a hilar tumor and converted to radical nephrectomy to achieve negative clinical margins. Additionally, 14.8 % of OPN patients had renal capsule violation as compared to 3.7 % of RPN cases (p = 0.34). Importantly, the mean distance to the proximal margin edge for RPN specimens (2.77 mm) was equivalent to OPN (3.01 mm), p = 0.46.

Conclusion

When matched for nephrometry score, tumor size, gender and age, RPN produces similar pathological outcomes to OPN.     

Robotic and open partial nephrectomy for complex renal tumors: a matched-pair comparison with a long-term follow-up

Objectives

To compare the surgical, functional and oncological outcomes of patients undergoing robotic partial nephrectomy (RPN) or open partial nephrectomy (OPN) for moderately or highly complex tumors (RENAL nephrometry score ≥7).

Methods

A retrospective, matched-pair analysis was performed for 380 patients who underwent either RPN (n = 190) or OPN (n = 190) for a complex renal mass in different institutions. Surgical data, pathological variables, complications and functional and oncological outcomes were reviewed.

Results

RPN is associated with less estimated blood loss (EBL) (196.8 vs 240.8 ml; p < 0.001), shorter length of hospital stay (7.8 vs 9.2 days; p < 0.001) and lower rate of postoperative complications (15.8 vs 28.9 %; p = 0.002). Patients undergoing RPN required more direct cost. In multivariable models, surgical approach was the significant predictor for the occurrence of postoperative minor complications and postoperative wound pain. Median follow-up for RPN and OPN was 49 months and 52 months, respectively. The decline of estimated glomerular filtration at the last available follow-up (RPN: 8.7 %; OPN: 10 %) was similar (p = 0.125). The 5-year recurrence-free survival rate was 95.1 % for RPN and 92.7 % for OPN (p = 0.48).

Conclusions

RPN provides acceptable and comparable results in terms of perioperative, functional and oncological outcomes compared to OPN for complex renal tumors with RENAL score ≥7. Moreover, RPN is a less invasive approach with the benefit of shorter length of hospital stay, less EBL and lower rate of postoperative complications.

     

Tumor diameter accurately predicts perioperative outcomes in T1 renal cancer treated with robot-assisted partial nephrectomy

Purpose

To compare diameter as a continuous variable with categorical R.E.N.A.L. nephrometry score (RNS) in predicting surgical outcomes of robotic partial nephrectomy (RPN).

Methods

We retrospectively reviewed consecutive patients receiving RPN at our institution between July 2007 and June 2014 (n = 286). Three separate multivariate analyses were performed to assess the relationship between RNS components (R = radius, E = endophyticity, N = nearness to collecting system, L = location relative to polar lines), total RNS, and diameter as a continuous variable with operating time, warm ischemia time (WIT), and estimated blood loss (EBL). Each linear regression model’s quality of fit to the data was assessed with coefficients of determination (R ²).

Results

Continuous tumor diameter and total RNS were each significantly correlated to operative time, EBL, and WIT (p < 0.001). Categorical R related to operative time (R = 2 vs. R = 1, p = 0.001; R = 3 vs. R = 1, p = 0.001) and WIT (R = 2 vs. R = 1, p = 0.003; R = 3 vs. R = 1, p = 0.016), but not to EBL. For each of these outcomes, diameter outperformed both R and total RNS, as assessed by R ². Age, body mass index, Charlson Comorbidity Index, and anterior versus posterior location did not correlate with surgical outcomes.

Conclusions

In this series of RPN from a high-volume center, surgical outcomes more closely related to tumor diameter than RNS. While RNS provides surgeons a standardized tool for preoperative planning of renal masses, tumor size may be employed as a more familiar measurement when counseling patients on potential outcomes.

     

Robotic partial nephrectomy versus laparoscopic partial nephrectomy: a single laparoscopic trained surgeon’s experience in the development of a robotic partial nephrectomy program

Objectives

We evaluated whether the surgical approach during the implementation of a robotic kidney surgery program influenced perioperative and oncologic outcomes.

Methods

We prospectively evaluated a single institution experience with minimally invasive partial nephrectomy between 2006 and 2010. The study cohort comprised 86 consecutively treated patients who underwent laparoscopic partial nephrectomy (LPN, N = 59) or robotic-assisted (RPN, N = 27) partial nephrectomy by a single surgeon.

Results

There was no difference between the LPN and RPN cohort in terms of gender, age, operative side, American Society of Anesthesiology score, or preoperative estimated glomerular filtration rate (eGFR). An early unclamping technique was used for 22 (82%) patients in the RPN cohort and 6 (10%) patients in the LPN cohort. (P < 0.001). Warm ischemia time was lower in the RPN cohort (mean 18.5 vs. 28.0 min, P = <0.001) as result of majority undergoing early unclamping. There was no difference in operative time, estimated blood loss, length of stay, transfusion rate, positive surgical margin, or postoperative decrease in eGFR. There was no difference in mean eGFR decrease after early unclamping (16%) versus traditional clamping (22%); however, 11 (29%) patients had greater than 50% decrease in eGFR after traditional clamping versus 0 patients after early unclamping (P = 0.014).

Conclusion

Patients undergoing RPN during implementation of a robotic kidney surgery program when compared with LPN appear to have equivalent perioperative outcomes and oncologic efficacy. RPN patients had surgery later in our minimally invasive partial nephrectomy experience, and these results may not be generalizable to laparoscopic and/or robotic naïve surgeons.

     

Partial nephrectomy: Is there an advantage of the self-retaining barbed suture in the perioperative period? A matched case–control comparison

Objective

To evaluate the efficacy of the self-retaining barbed suture (SRBS) in renal defect repair during partial nephrectomy (PN), by assessing perioperative outcomes.

Methods

From June 2010 on we have been using the SRBS for superficial layer closure during open and laparoscopic PN in two European centers. These data were collected prospectively and matched with historical PN cases performed with conventional suture. Cases were matched for PADUA score, surgical approach (laparoscopic or open) and the center where surgery was performed. Comparisons were made in patient characteristics and perioperative outcomes including warm ischemia time (WIT), changes in hemoglobin (Hb), changes in estimated glomerular filtration rate (eGFR) and perioperative complications between the SRBS and non-SRBS groups. Statistical tests of significance were performed using Student’s t test and chi-square test for continuous and categorical variables, respectively.

Results

Thirty-one consecutive cases of PN under WIT were performed with SRBS. These cases were matched with cases from the historical database of PN performed with conventional suture. The rate of perioperative complications was statistically significantly lower in the SRBS cohort (6.5 vs. 22.6?%, p?=?0.038). Mean ischemia time was 19.6?min (SD, 7.5) in the SRBS group versus 21.8?min (SD, 9.5) in the conventional suture group (p?=?0.312). There were no significant differences between groups for postoperative changes in creatinine, eGFR and Hb. Limitations of this study include the absence of randomization and the relative small sample size.

Conclusions

SRBS can be safely used during partial nephrectomy. SRBS reduces significantly the number of perioperative complications.     

Role of Survivin Gene Promoter Polymorphism (−31G>C) in Susceptibility and Survival of Esophageal Cancer in Northern India

Background and Aim

Survivin is an upregulated inhibitor of apoptosis protein in esophageal cancer (EC), and a promoter region polymorphism (?31G>C) in the survivin gene has been reported as a modulator of gene expression. We aim to explore the role of survivin ?31G>C polymorphism in susceptibility and survival of EC patients in northern Indian population.

Materials and Methods

A case–control study was performed in 500 subjects (250 EC patients and 250 controls), and genotyping was done by polymerase chain reaction (PCR) restriction fragment length polymorphism (RFLP) method.

Results

Survivin CC genotype was found to be significantly associated with EC susceptibility [odds ratio (OR) = 2.29; 95% confidence interval (CI) = 1.27–4.14; P = 0.006], particularly in males (OR = 4.91; 95% CI = 2.19–11.02; P = 0.0001) having squamous cell carcinoma (SCC) histopathology (OR = 2.4; 95% CI = 1.36–4.21; P = 0.002) at middle third esophagus location (OR = 2.60; 95% CI = 1.40–4.82; P = 0.002). Patients carrying CC genotype were found to have higher susceptibility to lymph node metastasis (OR = 2.82; 95% CI = 1.46–5.48; P = 0.002). However, on survival analysis, no prognostic role of survivin ?31G>C polymorphism was detected. In case-only analysis, no gene–environment interaction was observed.

Conclusion

Survivin promoter region polymorphism (?31G>C) is associated with susceptibility and clinical characteristics but not prognosis of esophageal cancer in northern Indian population.     

Atherosclerosis within the non-neoplastic margin of partial nephrectomy specimens: implications for medical management

Purpose

To describe the frequency and severity of atherosclerosis contained within the non-neoplastic tissue of partial nephrectomy (PN) specimens.

Methods

Archived open PN specimens were evaluated for histological evidence of atherosclerosis. Clinically significant atherosclerosis was defined as arterial luminal narrowing of >25 % due to fibrointimal thickening. Histological findings were correlated with clinical data including history of major medical comorbidities and preoperative statin use.

Results

The study cohort was comprised of 114 patients (71 men and 43 women). The mean age at the time of surgery was 59.3 years, and 69 (60.5 %) patients had a history of at least one major medical comorbidity including hypertension (54.5 %), diabetes (16.7 %) and coronary artery disease (12.3 %). Clinically significant atherosclerosis was observed in 29 (25.4 %) patients. These individuals were older (p = 0.001), and three times more likely to have greater than one major medical comorbidity (p = 0.002). In addition, only 17 (58.6 %) were prescribed a statin at the time of surgery.

Conclusions

Atherosclerosis is frequently observed in the non-neoplastic tissue of PN specimens. Patients found to have atherosclerosis can potentially benefit from intensive lifestyle modification and medical therapy with lipid-lowering medications. These measures would likely have the greatest clinical impact on those patients without an existing history of major medical comorbidities.     

Analysis of the efficacy of direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) according to the prognostic factors in patients with colorectal perforation

Purpose

Direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) has been reported to improve the outcomes in patients with colorectal perforation. We retrospectively identified prognostic factors in patients with colorectal perforation and considered the efficacy of PMX-DHP based on these prognostic factors.

Methods

One hundred and fifty-six patients who underwent surgery for colorectal perforation in our department between November 1995 and March 2011 were enrolled in this study. The clinicopathological factors were compared between the survivor and non-survivor groups.

Results

There were 28 patients (17.9 %) who died within 28 days after surgery. According to the multivariate analysis, an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 17 or more was a significant independent prognostic factor (P = 0.002, odds ratio = 5.39). There was a significant difference in the survival rates between the patients with APACHE II scores of 16 or less and those with scores of 17 or more who had received the PMX-DHP (+) (P < 0.0001).

Conclusion

The APACHE II score is useful as a prognostic factor in patients with colorectal perforation, and the survival rate was 50 % or lower among the patients with APACHE II scores of 17 or higher. Therefore, PMX-DHP appears to have limited efficacy in serious cases.     

Statistical Analysis of Surgical Site Infection After Head and Neck Reconstructive Surgery

Background

Surgical site infections (SSIs) occur at a rate exceeding 40 % after head and neck reconstruction and are due in part to the clean-contaminated surgical field, in which cutaneous fields interact with oral or pharyngeal fields. The aim of this study was to clarify the most important risk factors for SSI and to identify effective strategies for preventing SSI.

Methods

In 2011 and 2012, 197 patients who underwent head and neck reconstructive surgery were studied at National Cancer Center Hospital East, Japan. The SSI rate, risk factors for SSI, and biological aspects of SSI were evaluated prospectively.

Results

A total of 42 patients (21.3 %) had SSIs, and 62 bacterial species were identified at infection sites. Significant risk factors for SSI identified with multivariate analysis were hypoalbuminemia [P = 0.002, odds ratio (OR) = 3.37], reconstruction with vascularized bone transfer (P = 0.006, OR = 3.99), and a poor American Society of Anesthesiologists Physical Status score (P = 0.041, OR = 3.00). Most bacteria identified were species that persist around cutaneous and pharyngeal fields, but multidrug-resistant bacteria were rare.

Conclusions

The SSI rate at our hospital is lower than rates in previous studies. To minimize SSI, intervention to improve the patient’s perisurgical nutritional status and a more appropriate mandible reconstructive strategy should be considered.     

Clinical Outcomes After Unplanned Extubation in a Surgical Intensive Care Population

Background

Clinical outcome after unplanned extubation (UE) in patients admitted to the surgical intensive care unit (SICU) has not been fully investigated. In this study we assessed in-hospital mortality of patients with UE and determined whether UE is a predictor of in-hospital mortality. Finally, we sought to identify predictors of reintubation after UE in mechanically ventilated patients in the SICU.

Methods

Medical charts of patients (n = 4,407) admitted to the SICU between October 2007 and December 2011 were reviewed retrospectively.

Results

Eighty-five episodes of UE occurred in 81 patients. Patients with UE required emergency surgery more frequently and had higher ICU and hospital mortality rates, reintubation rate, and APACHE II scores and longer mechanical ventilation (MV) and ICU stay than patients without UE (P < 0.05 for all associations). Multivariate analysis revealed that reintubation (odds ratio [95 % confidence interval]: 4.14 [2.58–6.67]; P < 0.001), APACHE II scores (1.14 [1.12–1.17]; P < 0.001), emergency surgery (1.73 [1.18–2.53]; P = 0.005), and chronic neurologic disease (2.11 [1.30–3.41]; P = 0.002) were associated with hospital mortality. Reintubation was necessary in 17 patients. On multivariate analysis, a score on the Richmond Agitation–Sedation Scale (RASS, 0.48 [0.31–0.76]; P = 0.001), PaO₂/FiO₂ ratio (0.99 [0.99–1.00]; P = 0.048), and MV duration before UE (1.46 [1.08–1.98]; P = 0.014) were independently associated with reintubation after UE.

Conclusions

Our results indicated that although patients with UE had high in-hospital mortality, UE was not directly associated with in-hospital mortality. Reintubation, chronic neurologic disease, emergency operation, and higher APACHE II score were related to increased in-hospital mortality. A low RASS score, a low PaO₂/FiO₂ ratio, and long MV duration before UE were related to reintubation after UE.     

Histological Damage of Colonic Epithelium is Associated with Clinical Severity and Outcome in Colectomized Critically Ill Patients

Background

Severe intestinal mucosal damage and organ failure has been associated in experimental models. Our purpose was to determine whether there is any association between histopathological findings and postoperative mortality among ICU patients undergoing emergency colectomies for various illnesses.

Methods

In a retrospective case control study, total colectomy specimens from 50 patients in a mixed ICU were analysed: 18 had sepsis, 11 vascular operations, and 21 Clostridium difficile colitis. Overall thickness, the width of epithelial defects, and presence of cryptal damage were assessed. Extent of necrosis and amount of neutrophils were separately evaluated in the layers of the colonic wall. Clinical features, including sequential organ failure assessment (SOFA) scores and survival, were registered.

Results

The histopathological findings for the three clinical entities were similar, except for the abundance of characteristic pseudomembranes in the Clostridium group. Mucosal height (maximum) showed a negative correlation with SOFA score on admission (ρ = ?0.296, P = 0.037), and with preoperative blood lactate level (ρ = ?0.316; P = 0.027). The nonsurvivors had wider enterocyte defects (60 vs. 40.8, P = 0.002) and more severe crypt damage (61 vs. 27 %; P = 0.024) than the survivors.

Conclusions

The histopathological damage involves all layers of the colon wall among ICU patients being largely similar in sepsis, C. difficile infection, and ischemia after vascular operations. Mucosal epithelial damage is associated with clinical severity of the illness and mortality.     

Analysis of perioperative factors associated with increased cost following abdominal wall reconstruction (AWR)

Background

Ventral hernias are a common, challenging, and expensive problem for both the general and reconstructive surgeons; therefore, the aim of this study is to critically assess perioperative factors related to cost in abdominal wall reconstructions (AWR).

Methods

A retrospective review of AWR patients from 2007 and 2012 was performed. Analysis of perioperative factors associated with total cost of reconstruction was performed. Linear regression analyses were used to assess independent predictors of total cost.

Results

134 consecutive AWR performed by a single surgeon over a 5-year period at an academic teaching center were included. The average total cost of AWR was $61,251 ± 55,624. Linear regression analysis demonstrated that diabetes (P = 0.026), increased American Society of Anesthesiologists score (P = 0.002), preoperative anemia (P = 0.001), and hernias derived from trauma (P = 0.015) were independently associated with added cost in AWR when controlling for confounding variables. In addition, patients requiring intra-abdominal procedures (P = 0.012) and those receiving an AWR using Acellular Dermal Matrix (P = 0.015) accrued significantly greater cost. Interestingly, preoperative placement of an epidural (P = 0.011) was independently associated with significant cost savings and reduced medical morbidity. Major surgical complications (P < 0.001) and length of stay (P < 0.001) were independently associated with increased cost following AWR.

Conclusion

We present a critical assessment of cost in AWR at a major academic teaching hospital and quantify the impact of reconstruction in the setting of medical morbidities and reconstructive complexities. The data from this study can be used to adjust reimbursement schemes and to critically assess the cost–benefit of performing AWR.     

Prognostic Significance of CD151 Expression in Esophageal Squamous Cell Carcinoma with Aggressive Cell Proliferation and Invasiveness

Background

CD151 is a member of the tetraspanins and has recently been reported as a promoter of the malignant progression of cancer. The purpose of this study was to clarify the clinicopathological outcome and prognostic significance of the immunohistochemical expression of CD151 in esophageal squamous cell carcinoma (ESCC).

Methods

We evaluated the significance of CD151 expression by immunohistochemistry in 138 surgically resected ESCC and the association of CD151 expression with clinicopathological features.

Results

Seventy-five (51.7%) ESCC showed a positive expression of CD151, which indicated a significant association with tumor depth (P = 0.004), lymph node metastasis (P = 0.002), distant metastasis (P = 0.025), and lymphatic invasion (P = 0.046), as well as the Ki-67 labeling index (P = 0.011). The 5-year survival rate of ESCC patients with CD151-positive expression was significantly lower than with CD151-negative expression (positive, 43.1%; negative, 63.8%; P = 0.003). Multivariate analysis showed that positive CD151 expression was not an independent factor for poor survival (P = 0.096).

Conclusions

CD151 expression is associated with tumor proliferation and invasiveness in ESCC.     

Laparoscopic partial nephrectomy: risk stratification according to patient and tumor characteristics

Purpose

Laparoscopic partial nephrectomy (LPN) is the treatment of choice for localized tumors in many centers. We aimed to evaluate differences in complication rates and outcome stratified by risk categories, depending on patient or tumor characteristics.

Methods

Eighty-one patients who underwent LPN for localized renal tumors between 2004 and 2007 were evaluated. Clinical and pathological data, including localization, size and infiltration depth (classified according to PADUA and RENAL score), at initial radiologic imaging were analyzed. Results were correlated with complications during or after surgery, operative time, warm ischemia time and clinical outcome.

Results

Overall complication rate was 13.6% for LPN (11 patients, Clavien-Dindo classification: II–III). No significant correlations were found for patient-based risk classification models (age?>?70?years, ASA-status?>2, BMI?>?30). A higher mean operative time was observed in centrally located tumors (P?=?0.045). Increased hemoglobin loss was observed in central (P?=?0.007), PADUA?>?8 (P?=?0.006) and RENAL?>?7 (P?=?0.002) tumors. Impaired renal function (creatinine increase in postoperative controls) was associated with tumor diameter?>?4?cm (P?=?0.023). Only central tumor growth had a significant predictive value for postoperative complications (P?=?0.007). In patients with central tumor growth (P?=?0.002), PADUA?>?8 (P?=?0.041) and RENAL?>?7 (P?=?0.044) scores, hospital stay was prolonged.

Conclusions

Uni and multifactorial scoring systems have been developed for LPN to identify potentially high-risk patients. In our series, only central tumor growth pattern enabled the prediction of increased operation time, hemoglobin loss, hospitalization as well as postoperative complications.