The Pre-Operative GRADE Score Is Associated with 5-Year Survival among Older Patients with Cancer Undergoing Surgery

We aimed to assess the prognostic value of the pre-operative GRADE score for long-term survival among older adults undergoing major surgery for digestive or non-breast gynaecological cancers. Between 2013 and 2019, 136 consecutive older adults with cancer were prospectively recruited from the PF-EC cohort study before major cancer surgery and underwent a geriatric assessment. The GRADE score includes weight loss, gait speed at the threshold of 0.8 m/s, cancer site and cancer extension. The primary outcome was post-operative 5-year mortality. Patients were classified as low risk (GRADE ≤ 8) or high risk (GRADE > 8) on the basis of the median score. A Cox multivariate proportional hazards regression model was performed to assess the association between pre-operative factors and 5-year mortality expressed by adjusted hazard ratio (aHR) and 95% CI. The median age was 80 years, 52% were men, 73% had colorectal cancer. The 30-day post-operative severe complication rate (Clavien-Dindo ≥ 3) was 37%. The 5-year post-operative mortality rate was 34.5%. A GRADE score ≥ 8 (aHR = 2.64 [1.34–5.21], p = 0.0002) was associated with post-operative mortality after adjustment for Body Mass Index < 21 kg/m2 and Instrumental Activities of Daily Living <3/4. By combining very simple geriatric and cancer parameters, the pre-operative GRADE score provides a discriminant prognosis and could help to choose the most suitable treatment strategy for older cancer patients, avoiding under or over-treatment.

P-O17 The Royal Stoke Green Pathway: a method to undertake safe UGI surgery during the COVID pandemic

Background During the first wave of the COVID pandemic surgical services we paralysed globally, with cancellation of an estimated 28-million operations during the first 12 weeks. Worryingly, surgical patient with COVID were reported to have unacceptably high peri-operative mortality, approaching 25%. However, there was an urgent clinical need to progress with category 1 and 2 operations, to prevent disease progression and avoidable morbidity and mortality from non-COVID pathologies. During the second and subsequent waves of the pandemic it was vital to protect patients from peri-operative COVID whilst undertaking urgent surgery safely. Methods Our centre developed a ring-fenced 'Green Pathway' for category 1 and 2 patients requiring surgery. Patients were treated in physically separate area of the hospital, with no interaction between COVID and non-COVID patients, healthcare staff or facilities. Patients self-isolated for 14-days prior to admission, and had pre- and peri-operative COVID RT-PCR tests. We assessed outcomes for patients immediately prior to the introduction of the Green Pathway (1/10/2020) and following implementation (31/12/2020) to assess safety. Textbook outcomes for pancreatoduodenectomy were compared to assess safety and quality. Other data suggests that UGI surgery couldn't continue in other hospitals from December 2020. Results There were 47 admissions to surgical HDU following category 1 and 2 upper GI operations during the study; 31 pre-pathway (PP) implementation, and 16 green pathway (GP) patients. Median age 66-years (43-78 range) PP vs 65-years (range 42-74) GP, median ASA 3 vs 2. Median HDU length of stay (LOS) 5-days vs 7-days, and median hospital LOS 11.5-days vs 9-days for PP vs GP respectively. There were 6 cases of peri-operative COVID in PP cohort, and 1 in GP (contract following discharge). There was no mortality within either cohort. For the subgroup of patients undergoing PD: 10 patients PP, 6 patients GP, textbook outcomes were achieved in 90% vs 67% PP vs GP. Conclusions The implementation of the Green Pathway at our institution enabled continuation of surgery for patients with category 1 and 2 operations during the COVID pandemic with a significant reduction in peri-operative COVID infection, no mortality and no increase in length of stay. The TO rate was lower with the GP (not statistically significant), but our 4-year institution TO rate is 70.3%, comparing favourably to other studies. This pathway has enabled safe continuation of urgent surgery during the pandemic and could be a model for adoption in other centres especially if there is resurgence of COVID cases during the coming winter.

Early Outcomes of Emergency Surgery for Left-Sided Mechanical Valve Thrombosis

Background: Valve thrombosis is a potentially lethal complication of mechanical cardiac valves. We examined the clinical characteristics as well as the early outcomes of patients undergoing emergency surgery for left-sided mechanical valve thrombosis. Methods: Between January 2012 and May 2020, 104 consecutive patients were offered an emergency redo surgery for acute mechanical valve thrombosis. Ninety-seven of these patients were included in the current study. Results: The mean age was 34.2 ± 10.3 years. Most of the patients were females (61 patients), and 27 patients (27.8%) were pregnant. The mitral valve was the site of thrombosis in 81 patients. Inadequate anticoagulation was found in 60.8% of patients. The overall early mortality was 32.9% (32 patients) with an operative mortality of 25.7%. Outcomes in the pregnant subgroup tended to be worst with a maternal mortality in the range of 37%, and with fetal and neonatal survival as low as 33.3%. Conclusion: The overall mortality in cases of mechanical valve thrombosis warranting surgery remains high. Since inadequate anticoagulation seems to be one of the major precipitating factors, the current study highlights the need for improvements in anticoagulation practices. The use of tissue valves should also be contemplated more seriously in some younger patients, especially females expressing the desire for future pregnancies.

Preoperative beta-blocker in ventricular dysfunction patients: need a more granular quality metric

Background The use of preoperative beta-blockers has been accepted as a quality standard for patients undergoing coronary artery bypass graft (CABG) surgery. However, conflicting results from recent studies have raised questions concerning the effectiveness of this quality metric. We sought to determine the influence of preoperative beta-blocker administration before CABG in patients with left ventricular dysfunction. Methods The authors analyzed all cases of isolated CABGs in patients with left ventricular ejection fraction less than 50%, performed between 2012 January and 2017 June, at 94 centres recorded in the China Heart Failure Surgery Registry database. In addition to the use of multivariate regression models, a 1–1 propensity scores matched analysis was performed. Results Of 6116 eligible patients, 61.7% received a preoperative beta-blocker. No difference in operative mortality was found between two cohorts (3.7% for the non-beta-blockers group vs. 3.0% for the beta-blocker group; adjusted odds ratio [OR] 0.82 [95% CI 0.58–1.15]). Few differences in the incidence of other postoperative clinical end points were observed as a function of preoperative beta-blockers except in stroke (0.7% for the non-beta-blocker group vs. 0.3 for the beta-blocker group; adjusted OR 0.39 [95% CI 0.16–0.96]). Results of propensity-matched analyses were broadly consistent. Conclusions In this study, the administration of beta-blockers before CABG was not associated with improved operative mortality and complications except the incidence of postoperative stroke in patients with left ventricular dysfunction. A more granular quality metric which would guide the use of beta-blockers should be developed.

Aortic Bicuspidy: Clinical Profile and Surgery

Objective: To study the anatomic-clinical profile of aortic bicuspidy and the outcome of surgery. Patients and Methods: During an 18-year period, 448 patients had aortic valve replacement. Of these, 24 (5.3%) had aortic bicuspidy (AB). The diagnosis of AB was made by echocardiography or during surgery. All patients underwent surgery under extracorporeal circulation. Results: The mean age was 45.2 ± 11.8 years, 14 patients (58.3%) had aortic stenosis and 10 cases (41.7%) had aortic insufficiency, 4 of whom had infective endocarditis. All patients had aortic valve replacement. The operative mortality rate was zero. The mean times of the cardiopulmonary bypass (CPB) and aortic clamping were 99.2 ± 35.4 min and 65.8 ± 24.9 min, respectively. Conclusion: Aortic bicuspidy progresses rapidly and becomes symptomatic in young adults. Despite excellent surgical results, early detection is desirable before complications occur.

Reoperative Aortic Arch Surgery under Mild Systemic Hypothermia: Two-Center Experience

Background The aim of the study was to assess the indications, surgical strategies, and outcomes after reoperative aortic arch surgery performed generally under mild hypothermia. Methods Ninety consecutive patients (60 males, mean age, 55 ± 16 years) underwent open reoperative aortic arch surgery after previous cardiac aortic surgery. The indications included chronic-progressive arch aneurysm (55.5%), chronic aortic dissection (17.8%), contained arch rupture (16.7%), and graft infection (10%). The reoperation was performed through a repeat sternotomy (96%) or clamshell thoracotomy (4%) using antegrade cerebral perfusion under mild systemic hypothermia (28.9 ± 2.5°C) in all except three patients. Results The surgery comprised hemiarch or total arch replacement in 41 (46%) and 49 (54%) patients, respectively. The distal extension included classic or frozen elephant trunk technique, each in 12 patients, and total descending aorta replacement in 4 patients. Operative mortality was 6 (6.7%) among all patients, with age identified as the only independent predictor of operative mortality (p = 0.05). Permanent and transient neurologic deficits occurred in 1% and 9% of the patients, respectively. Estimated survival at 8 years was 59 ± 8% with advanced heart failure predictive for late mortality (p = 0.014). Freedom from second reoperation or intervention on the aorta was 78 ± 6% at 8 years, with most of these events occurring downstream in patients with chronic degenerative aneurysms. Conclusion Aortic arch reoperations performed using antegrade cerebral perfusion under mild systemic hypothermia offer favorable operative outcomes with an exceptionally low rate of neurologic morbidity without any difference between hemiarch and complex arch procedures.

EP.FRI.454 National Emergency Laparotomy Audit: are we compliant with pre-operative mortality risk documentation?

The National Emergency Laparotomy Audit (NELA) set out key performance indicators in patients undergoing emergency laparotomy, one of which is the assessment of individuals pre-operative risk of mortality. This should be made explicit to the patient and recorded clearly on the consent form and in the medical record.1 Pre-operative mortality risk can be calculated through clinical assessment or using the NELA risk scoring tool. Omission of a this can lead to patients missing out on accepted standards of care and belies gaining informed consent. A snapshot audit of patients added to the NELA database was performed between 01/08/2020 and 31/10/2020. Data collected included the pre-operative mortality risk percentage (if calculated) and whether the patient was taken to theatre. This figure was correlated against the patient's physical notes or scanned copies on Medway. A target level of ≥ 85% of patients having their pre-operative mortality risk calculated and the this figure being documented appropriately. 49 patients were uploaded to the NELA database and 80% (n = 39) had a calculated risk. 55% of these patients (n = 27) proceeded to theatre, however correlation with physical notes and scanned documents on Medway revealed none had the correct documentation as per NELA standards. A questionnaire circulated to trainees and consultants exploring their understanding of pre-operative mortality risk documentation. Of the 7 respondents, 4 stated they rarely or never documented the pre-operative mortality risk as per NELA guidance. Ideas for improving the documentation process included a NELA pathway document, visual aids (e.g. poster) and a pre-operative mortality risk sticker.

TP5.2.12 30-Day mortality in vascular surgery during the COVID pandemic: 1st wave outcomes

Aims To assess the 30-day mortality rate in patients undergoing vascular procedures in a single vascular centre during the first wave of the Covid-19 pandemic. Methods Retrospective analysis of all vascular operations undertaken at our unit from 11th March 2020 to 16th November 2020. Thirty-day mortality rate, ASA grade, 30-day Covid-19 PCR test positivity and cause of death were assessed. Mortality rate was compared to previous five-year average with a Chi- Square test. Results Within the observed period, 237 vascular operations were performed (49% operative reduction). 57 patients (24%) were operated electively through the “Green pathway” (day case) and there were no perioperative positive Covid-19 tests. 180 patients were operated through the “Amber” (elective Inpatient) or “Red” (emergency) pathway. Eight inpatients (4.4%) died within 30 days from surgery, similar to the average 30-day mortality observed in the previous years (5.9% p &gt; 0.05). Three patients (1.42%) tested positive preoperatively but were all asymptomatic from Covid-19. One patient who died tested positive for Covid-19 but was asymptomatic from a respiratory aspect and died of cardiovascular disease. Conclusion We found no difference in 30-day post-operative mortality rate during the initial wave of Covid-19. Only 3 patients undergoing emergency operations tested positive. This study does reinforce the “Green pathway” strategy for elective patients to ensure minimising exposure to Covid-19 but we also did not witness any difference in mortality rate in the “Amber” or “Red” pathway. The impact of the second or third “wave” on current numbers will need to be studied further.