CONUT Score Predicts Early Morbidity After Liver Transplantation: A Collaborative Study

Introduction: Liver transplantation (LT) is burdened by the risk of post-operative morbidity. Identifying patients at higher risk of developing complications can help allocate resources in the perioperative phase. Controlling Nutritional Status (CONUT) score, based on lymphocyte count, serum albumin, and cholesterol levels, has been applied to various surgical specialties, proving reliable in predicting complications and prognosis. Our study aims to investigate the role of the CONUT score in predicting the development of early complications (within 90 days) after LT.Methods: This is a retrospective analysis of 209 patients with a calculable CONUT score within 2 months before LT. The ability of the CONUT score to predict severe complications, defined as a Comprehensive Complication Index (CCI) ≥42.1, was examined. Inverse Probability Treatment Weighting was used to balance the study population against potential confounders.Results: Patients with a CCI ≥42.1 had higher CONUT score values (median: 7 vs. 5, P-value < 0.0001). The CONUT score showed a good diagnostic ability regarding post-LT morbidity, with an AUC = 0.72 (95.0%CI = 0.64–0.79; P-value < 0.0001). The CONUT score was the only independent risk factor identified for a complicated post-LT course, with an odds ratio = 1.39 (P-value < 0.0001). The 90-day survival rate was 98.8% and 87.5% for patients with a CONUT score <8 and ≥8, respectively.Conclusions: Pre-operative CONUT score is a helpful tool to identify patients at increased post-LT morbidity risk. Further refinements in the score composition, specific to the LT population, could be obtained with prospective studies.

Opioid-free versus opioid-based anesthesia in pancreatic surgery

Background Opioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear. Methods Perioperative data from 77 consecutive patients who underwent pancreatic resection were included and retrospectively reviewed. Patients received either an OBA with intraoperative remifentanil (n = 42) or an OFA (n = 35). OFA included a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infiltration and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48 h after extubation, length of stay, adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes. Results Compared to OBA, NRS (3 [2–4] vs 0 [0–2], P < 0.001) and opioid consumption (36 [24–52] vs 10 [2–24], P = 0.005) were both less in the OFA group. Length of stay was shorter by 4 days with OFA (14 [7–46] vs 10 [6–16], P < 0.001). OFA (P = 0.03), with postoperative pancreatic fistula (P = 0.0002) and delayed gastric emptying (P < 0.0001) were identified as only independent factors for length of stay. The comprehensive complication index (CCI) was the lowest with OFA (24.9 ± 25.5 vs 14.1 ± 23.4, P = 0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups. Conclusions In this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.

Does a prior hysterectomy complicate transvaginal/transumbilical hybrid NOTES cholecystectomy?—a comparative analysis of prospectively collected data

Purpose Hysterectomy alters the anatomy of the posterior vaginal vault used as access for transvaginal/transumbilical hybrid NOTES cholecystectomy (NC), creating potential consequences for the feasibility and complication rate of the procedure. Therefore, the aim of our retrospective analysis of prospectively collected data was to analyze the postoperative course after NC in previously hysterectomized (PH) patients compared with patients who had not undergone hysterectomy (NH). Methods A total of 126 NH patients and 50 PH patients aged over 42 who had an NC from 12/2008 to 04/2021 were compared regarding age, body mass index (BMI), ASA classification, number of percutaneous trocars, need for intraoperative urinary bladder catheterization, length of procedure, conversion rate, and intraoperative and postoperative complication rate according to the Clavien/Dindo classification, Comprehensive Complication Index (CCI), mortality, and hospital length of stay. Results PH patients were older than NH patients (63.0 vs 51.5 years; P < 0.001) but did not differ significantly in ASA classification (P = 0.595) and BMI (26.8 vs 27.9 kg/m2; P = 0.480). They required more percutaneous trocars (P = 0.047) and longer procedure time (66.0 vs. 58.5 min; P = 0.039). Out of all 287 scheduled NC only one had to be “converted” to traditional laparoscopic cholecystectomy. Intraoperative and postoperative complication rates, Clavien/Dindo classification, CCI, need for intraoperative urinary bladder catheterization, and length of stay did not differ significantly. Conclusion Our results indicate an increased degree of difficulty of NC in PH patients, although there is no major impact on intraoperative and postoperative complication rates. Urinary bladder perforation is a specific access-related complication in PH patients.

The Costs of Complications and Unplanned Readmissions after Pancreatoduodenectomy for Pancreatic and Periampullary Tumors: Results from a Single Academic Center

Background/Objectives: Complications after pancreatoduodenectomy (PD) lead to unplanned readmissions (UR), with a two- to threefold increase in admission costs. In this study, we aimed to create an understanding of the costs of complications and UR in this patient group. Furthermore, we aimed to generate a detailed cost overview that can be used to build a theoretical model to calculate the cost efficacy for prehabilitation. Methods: A retrospective cohort analysis was performed using the Dutch Pancreatic Cancer Audit (DPCA) database of patients who underwent a PD at our institute between 2013 and 2017. The total costs of the index hospital admission and UR related to the PD were collected. Results: Of the 160 patients; 35 patients (22%) had an uncomplicated course; 87 patients (54%) had minor complications, and 38 patients (24%) had severe complications. Median costs for an uncomplicated course were EUR 25.682, and for a complicated course, EUR 32.958 (p = 0.001). The median costs for minor complications were EUR 30.316, and for major complications, EUR 42.664 (p = 0.001). Costs were related to the Comprehensive Complication Index (CCI). The median costs of patients with one or more UR were EUR 41.199. Conclusions: Complications after PD led to a EUR 4.634–EUR 16.982 (18–66%) increase in hospital costs. A UR led to a cost increase of EUR 12.567 (44%). Since hospital costs are directly related to the CCI, reduction in complications will lead to cost-effectiveness.

P-EGS17 Evaluation of Different Surgical Risk Prediction Models in Predicting Morbidity and Mortality in Emergency Giant Hiatus and Diaphragmatic Hernia Repairs

Background Emergency presentation of giant hiatus and diaphragmatic hernias are associated with significant morbidity and mortality, and predicting perioperative risks can be difficult. There are several preoperative risk evaluation models used commonly in emergency general surgery. Not only can they help clinicians stratify risk, but they can also be valuable tools to outline surgical risks to patients and families. This study aimed to evaluate the suitability of different risk prediction models when predicting morbidity and mortality in emergency giant hiatus and diaphragmatic hernia repairs. Methods This was a retrospective cohort study of all emergency hiatus and diaphragmatic hernia repairs at a tertiary upper gastrointestinal centre from 2010 to 2021. The outcomes were compared to the predicted mortality and morbidity of different risk prediction models. The mortality models SORT (Surgical Outcome Risk Tool), NELA (National Emergency Laparotomy Audit) and ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Programme) were compared using the area under the curve (AUC). Morbidity was evaluated by calculating the comprehensive complication index (CCI). CCI was compared to P-POSSUM (Portsmouth – Physiological and Operative Severity Score) and ACS-NSQIP predicted morbidity using Spearman correlation. Results 108 patients were included in the analysis. 49.1% were female, and 50.9% were male. The median age was 69 (IQR 59-78). The 30-day mortality rate was 6.93%. ACS-NSQIP had the highest predictive power for mortality (AUC = 0.845), in comparison to NELA (AUC=0.809) and SORT (AUC = 0.740). Both ACS-NSQIP and P-POSSUM showed moderate correlation to CCI (rho = 0.489, p &lt; 0.001 and 0.446, p &lt; 0.001 respectively). Conclusions ACS-NSQIP is a better predictor of both mortality and morbidity in emergency giant hiatus and diaphragmatic hernia repairs when compared to NELA, P-POSSUM and SORT. ACS-NSQIP may have a role in pre-assessment and consenting of emergency giant hiatus and diaphragmatic hernia repairs. Multi-centre prospective studies could be used to validate these findings.

P-O10 Mortality and Morbidity Reporting Quality

Background Mortality and morbidity (M&M) meetings in surgery are an important quality assurance process. These meetings contribute to learning, education and improvements in patient care. In order to achieve these outcomes effectively, M&M meeting require robust structure and process including accurate documentation of complications. Our hepato-pancreatico-biliary (HPB) unit conducts and records weekly M&M meetings based on consultant reported complications. However as there was no standardized documentation method of complications there was possible under-reporting. This realisation acted as a basis to investigate the robustness of our current reporting methodology of surgical complications and recommend changes in practice to achieve quality improvement. Methods Patients were selected retrospectively (May 20 - Sep 20) from M&M recording excel sheet which is maintained through our weekly meetings. Patient undergoing major HPB cancer resections were included. Day case procedures were excluded. Complications reported on excel sheet were compared against any additional mis-reported complications through review of online discharge letters, discharge summaries & investigations. The primary aim of this quality improvement project was to identify mis-reported complications. The secondary aims were to compare any change in Comprehensive complication Index (CCI) following addition of mis-reported complications. Results Total number of patients included in the study were n = 46. Postoperative surgical complications were recorded for n = 27 patients. 19 patients were identified to have unreported complications. Total number of unreported complications were 34. This amounted to average unreported complication per case at 1.78. Average CCI score was 14.4 before inclusion of unreported complications. There was a significant rise in average CCI score to 35.8; an increase of 21.6 CCI score after inclusion of unreported complications. Conclusions Unreported complications following major HPB cancer resection impact the quality of learning and education process in M&M meetings. It is essential to make complications reporting a robust process to prevent mis-reporting. We recommended use of Clavein-Dindo complications grading form as part of surgical clerking. This would help real time recording of surgical complications during postoperative journey of patients, help capture even minor complications. It would also be recommended to get these forms countersigned by responsible consultants before discharge of patients.

Learning Curve of Ex Vivo Liver Resection and Autotransplantation in Treating End-Stage Hepatic Alveolar Echinococcosis: A RA-CUSUM Analysis

Background: This retrospective study aimed to evaluate the safety and learning curve of ex vivo liver resection and autotransplantation (ELRA).Methods: A total of 102 consecutive end-stage HAE patients who underwent ELRA between 2014 and 2020 in West China Hospital were enrolled. The primary endpoint was major postoperative complications (comprehensive complication index, CCI &gt; 26). The ELRA learning curve was evaluated using risk-adjusted cumulative sum (RA-CUSUM) methods. The learning phases were determined based on RA-CUSUM analysis and tested for their association with intra- and post-operative endpoints.Results: The median surgery time was 738 (659–818) min, with a median blood loss of 2,250 (1,600–3,000) ml. The overall incidence of major morbidity was 38.24% (39/102). Risk-adjusted cumulative sum analysis demonstrated a learning curve of 53 ELRAs for major postoperative complications. The learning phase showed a significant association with the hemodynamic unstable time (HR −30.29, 95% CI −43.32, −17.25, P &lt; 0.0001), reimplantation time (HR −13.92, 95% CI −23.17, −4.67, P = 0.004), total postoperative stay (HR −6.87, 95% CI −11.33, −2.41, P = 0.0033), and postoperative major morbidity (HR 0.25, 95% CI 0.09, 0.68, p = 0.007) when adjusted for age, disease course, liver function, and remote metastasis.Discussion:Ex vivo liver resection and autotransplantation is feasible and safe with a learning curve of 53 cases for major postoperative complications.