Modified Clavien-Dindo-sink classification system for adolescent idiopathic scoliosis

Comparison of Totally Laparoscopic Total Gastrectomy and Laparoscopy-Assisted Total Gastrectomy on Short-Term Outcomes, Inflammatory Response Markers, and Glucose and Lipid Metabolism in Gastric Cancer Patients

Objective

To investigate the therapeutic efficacy of totally laparoscopic total gastrectomy (TLTG) versus laparoscopy-assisted total gastrectomy (LATG) in gastric cancer (GC) treatment, as well as their effects on postoperative inflammation and glucose and lipid metabolic status.

Methods

Clinical data of 68 individuals with GC who underwent LATG (n=31) and TLTG (n=37) from January 2020 to December 2022 were procured. This included intraoperative blood loss, operative time, incision length, number of lymph nodes dissected, postoperative complication rates, and recovery indicators, such as inflammation, glucose metabolism, and lipid metabolism.

Results

The TLTG cohort demonstrated significant advantages in intraoperative blood loss, operative time, and incision length compared to the LATG cohort. Furthermore, TLTG was superior in reducing the incidence of complications. Nevertheless, no substantial variation was observed in the quantity of lymph nodes dissected. Additionally, TLTG showed benefits in postoperative recovery, including better control of the inflammatory response, reduction of complication risks, shorter hospital stay, and alleviation of postoperative pain. TLTG also exhibited a reduced impact on inflammation and demonstrated greater effectiveness in improving postoperative glucose and lipid levels.

Conclusion

TLTG surgery is associated with superior clinical outcomes in the treatment of GC compared to LATG, particularly in reducing surgical trauma and accelerating postoperative recovery. Furthermore, TLTG facilitates the resolution of postoperative inflammatory responses and the amelioration of metabolic disorders. The findings from this investigation advocate for the broader adoption of TLTG in the surgical treatment of GC.

The Clavien-Dindo Classification for Body-Contouring Surgery Complications: Evaluation of 602 Cases

Background: Due to the high frequency of postoperative complications after body-contouring surgeries, the need for a unifying postoperative complication grading system that correlates with outcomes is of key importance. Here we therefore consider the application of the Clavien-Dindo classification to evaluate postoperative complications after body-contouring surgeries. Methods: A retrospective study on 602 patients who underwent body-contouring surgery between 2009 and 2015 at our institution was performed. The length of hospital stays, age, sex, follow-up visits, and postoperative complications were evaluated and classified using the Clavien-Dindo classification. Results: We raised a total of 672 body-contouring procedures on 602 patients (563 female, 39 male). According to the Clavien-Dindo System, the severity of postoperative complications following body-contouring procedures was significantly correlated with the duration of hospitalization (mean 5.8 ± 2.7 days) and the number of follow-up visits (mean 4.4 ± 4.7). Conclusions: The Clavien-Dindo classification offers a valid prediction for postoperative hospital stay and the number of follow-up visits after body-reshaping surgery. By becoming a validated and reliable grading system that correlates patients' outcomes after body-contouring procedures, this classification has the potential to significantly improve patients' healthcare and quality of life.

Severe (>100 Degrees) Thoracic Adolescent Idiopathic Scoliosis - A Comparison of Surgical Approaches

STUDY DESIGN

Retrospective.

OBJECTIVE

Severe curves >100° in adolescent idiopathic scoliosis (AIS) are rare and require careful operative planning. The aim of this study was to assess baseline, perioperative, and 2-year differences between anterior release with posterior instrumentation (AP), posterior instrumentation with posterior column osteotomies (P), and posterior instrumentation with 3-column vertebral osteotomies (VCR).

METHODS

Two scoliosis datasets were queried for primary cases of severe thoracic AIS (≥100°) with 2-year follow-up. Pre- and 2-year postoperative radiographic measures (2D and estimated 3D kyphosis), clinical measurements, and SRS-22 outcomes were compared between three approaches.

RESULTS

Sixty-one patients were included: 16 AP (26%), 38 P (62%), 7 VCR (11%). Average age was 14.4 ± 2.0 years; 75.4% were female. Preoperative thoracic curve magnitude (AP: 112°, P: 115°, VCR: 126°, P = 0.09) and T5-T12 kyphosis (AP: 38°, P: 59°, VCR: 70°, P = 0.057) were similar between groups. Estimated 3D kyphosis was less in AP vs P (-12° vs 4°, P = 0.016). Main thoracic curves corrected to 36° in AP vs 49° and 48° for P and VCR, respectively (P = 0.02). Change in estimated 3D kyphosis was greater in AP vs P and VCR (34° vs 13°, P = 0.009; 34° vs 7°, P = 0.046). One incomplete spinal cord injury had residual deficits (P; 1/61, 1.6%). All SRS-22 domains improved postoperatively.

CONCLUSION

All approaches obtained satisfactory coronal and sagittal correction, but AP had smaller residual coronal deformity and greater kyphosis restoration than the other approaches. This information may help inform the decision of whether to include an anterior release for large thoracic AIS curves.

Is the Child Opportunity Index a Factor in Surgical Outcomes for Adolescent Idiopathic Scoliosis?

BACKGROUND

Low socioeconomic status (SES) has been previously associated with delays in orthopaedic care. However, it is unclear how SES impacts patients with adolescent idiopathic scoliosis (AIS), particularly regarding preoperative major coronal curve angle or surgical outcomes. Utilizing the Child Opportunity Index (COI)-an address-driven measure of pediatric education, health/environment, and SES-we investigated whether COI is associated with differences in preoperative scoliosis magnitude, age at surgery, and AIS surgical outcomes.

METHODS

Consecutive patients with AIS surgically treated at a single center from 2011 to 2017 were reviewed. COI was calculated by inserting a patient's home address into the nationally available COI database to derive a COI value. COI is scored from 0.0 to 100.0 (0.0 is lowest, 100.0 is highest). Specifically, COI is categorized as very low (<20.0), low (20 to 39.9), moderate (40 to 59.9), high (60 to 79.9), and very high (≥80). Those without addresses were excluded. Patients without proper radiographs to assess curve correction were also excluded. A COI threshold of 60.0 was used to separate patients into a low (<60.0) or high COI ( ) group based on published COI guidelines. Outcomes, including preoperative curve magnitude, age at surgery, percentage curve correction, operative time (OT), intraoperative estimated blood loss per level fused, length of stay, and complications, were compared across groups. Pearson correlation analysis was used to assess correlations between COI and preoperative curve magnitude, as well as age.

RESULTS

Four hundred four patients were included in the study, and 263 had 2-year follow-up data. Patients were an average age of 14.9 years old (range: 11.2 to 19.8), had a median COI of 76 (range: 4 to 100), and had a mean preoperative major curve angle of 59 degrees (range: 36 to 93). COI was significantly higher for white patients compared with non-white (80.0 vs 40.0, P < 0.001), and higher for non-Hispanic individuals (79.0 vs 15.0, P < 0.001). Patients with Low COI were associated with a lower OT per level fused ( P = 0.003) and decreased postoperative complication risk ( P = 0.02). COI was not associated with preoperative major coronal curve angle, age at surgery, or any other surgical outcomes.

CONCLUSION

COI was significantly lower for non-white patients and those of Hispanic ethnicity. Patients from low COI backgrounds achieved similar surgical results as those from high COI addresses and had a decreased OT per level fused and complication incidence, though the clinical significance of these differences is unknown. Future prospective studies are needed to determine whether these findings are reproducible across other states and health systems.

LEVEL OF EVIDENCE

Level III-prognostic study.

A New Look at Vertebral Body Tethering (VBT): Through the Modified Clavien-Dindo-Sink (mCDS) Classification

INTRODUCTION

Anterior vertebral body tethering (AVBT) is increasingly popular as an option for surgical treatment of idiopathic scoliosis (IS). While the technology remains new, it is important for families and patients to be able to compare it to the current standard of care, posterior spinal fusion (PSF). The purpose of this study is to describe the complication rate of AVBT in IS using the mCDS and to compare it to the recently reported complication rate of PSF in IS.

METHODS

A multicenter pediatric spine deformity database was queried for all idiopathic scoliosis patients who underwent vertebral body tethering. There were 171 patients with a minimum 9-month follow-up included in this study. Complications were retrospectively graded by 2 attending pediatric spine surgeons using the mCDS classification system.

RESULTS

Data from 171 patients with idiopathic scoliosis was available for analysis, with 156/171 (91%) of patients being female and an average age of 12.2 years old at surgery. There were 156 thoracic tethers (1 with an LIV below L2), 5 lumbar tethers, 9 staged double tethers, and only 1 patient with same-day double tether. Fifty-five (55) (32%) patients experienced a total of 69 complications. The most common complication type for VBT by mCDS was Grade IIIb, encompassing 29/69 (42%) of complications. The second most frequent complication grade was Grade I at 23/69 (33%). Thirty-four (34) out of 69 (49%) of the VBT complications reported required either procedural/surgical intervention or admission to the ICU.

CONCLUSIONS

This is the first study to directly compare the complication profile of VBT to PSF using the mCDS. Forty-nine percent (49%) of the VBT complications reported were at least Grade III, while only 7% of complications in the control PSF cohort from the literature were Grade III or higher. The mCDS complication classification brings light to the early learning experience of a new technique compared to the widely accepted standard of PSF for IS.

LEVEL OF EVIDENCE

III - Retrospective comparative study.

Effect Modification of COVID-19 Symptoms on the Association Between Timing of Surgery and Postoperative Complications in Pediatric Spinal Deformity: A Prospective Cohort Study

OBJECTIVE

The purpose of this study was to explore the optimal timing and associated risks of pediatric spinal deformity surgery during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

All consecutive surgical cases for spinal deformity between September 2022 and May 2023 were included. The population was divided into several categories according to the time from diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection to the day of surgery. Postoperative complications were analyzed using logistic regression, and we simultaneously showed the results from the crude model, minimally adjusted model, and fully adjusted model.

RESULTS

A total of 81 consecutive patients were enrolled. In the fully adjusted model, compared with pre-COVID-19 patients, peri-COVID-19 patients had a 4.5-fold increased risk of postoperative complications (odds ratio = 5.5, 95% confidence interval 1.1-27.2, P = 0.037), early post-COVID-19 patients had a 2.3-fold increased risk (odds ratio= 3.3, 95% confidence interval 0.7-16.1, P = 0.133), and late post-COVID-19 patients were at essentially equal risk. In asymptomatic population, early post-COVID-19 patients and late post-COVID-19 patients appeared to be at equal risk compared with pre-COVID-19 patients. For patients with persistent symptoms, is necessary to wait at least 8 weeks or even longer after SARS-CoV-2 infection. Interaction tests demonstrated that the effect of the timing of surgery on postoperative complications significantly differed in populations with different symptoms.

CONCLUSIONS

Surgery for pediatric spinal deformity should be postponed until 8 weeks after SARS-CoV-2 infection in cases with COVID-19-related symptoms within 2 weeks prior to surgery; whereas, for those who are asymptomatic within 2 weeks prior to surgery, an interval of 4 weeks seemed to be sufficient.

Early Complications After Posterior Spinal Fusion in Patients With Rett Syndrome

BACKGROUND

Neuromuscular scoliosis in Rett syndrome (RS) is common, progressive, and often requires posterior spinal fusion (PSF). While PSF is associated with improved overall outcomes, there is a paucity of information describing complications. We aimed to report the postoperative complications, readmissions, and reoperations for patients with RS undergoing PSF.

METHODS

Female pediatric patients with RS treated by PSF with segmental instrumentation, with or without concurrent pelvis fixation, during January 2012 to August 2022 were included. Preoperative patient characteristics, intraoperative data (estimated blood loss, cell saver, packed red blood cells transfused), postoperative complications according to the Modified Clavien-Dindo-Sink classification within 90 days, unplanned readmissions within 30 days, and unplanned reoperations within 90 days were recorded.

RESULTS

A total of 25 females were included. The mean (SD) age at surgery was 12.9 (1.8) years and the mean follow-up of 38.6 (24.9) months. The mean preoperative major coronal curve was 79 degrees (23 degrees) which decreased to 32 degrees (15 degrees) by the last follow-up ( P <0.001). The median estimated blood loss was 600 mL and length of stay was 7 days. There were 81 total postoperative complications (3.2 complications/patient). Eight (32%) had grade IVa complications (disseminated intravascular coagulopathy, hypotensive shock, respiratory failure, chronic urosepsis). Five (20%) patients experienced seizures, 48% had pulmonary complications, and 56% had gastrointestinal complications. There were 3 readmissions (12%) within 30 days for pneumonia and 2 (8%) reoperations (an incision and drainage and C2-T2 fusion for significant kyphosis) within 90 days. One patient also had their fusion extended to the pelvis 1 year later. There were more nonambulatory patients in the group fused to the pelvis, but otherwise no differences between those fused and unfused to the pelvis.

CONCLUSIONS

This is the largest review of early postoperative complications for patients with RS who underwent PSF. PSF effectively reduced the major coronal curve, but surgeons and families should be aware of a high postoperative seizure and respiratory complication rate, as well as 8% having reoperations within 90 days and 12% being readmitted within 30 days.

LEVEL OF EVIDENCE

Level IV-therapeutic study.

Post-operative steroids in patients with patients with severe cerebral palsy undergoing posterior spinal fusion

INTRODUCTION

Posterior spinal fusion (PSF) represents a large physiologic challenge for children with neuromuscular scoliosis (NMS). Perioperative complications are numerous with many occurring in the post-operative period due to pain and relative immobilization. This study assessed the impact of steroids on patients undergoing PSF for NMS.

METHODS

A retrospective review of consecutive patients managed at a single center with PSF for NMS was reviewed. Clinical and radiographic analysis was used to evaluate baseline demographics, curve characteristics, and post-operative course.

RESULTS

Eighty-nine patients who underwent PSF for NMS were included. Fifty-seven of these patients did not receive post-operative steroids (NS) while 32 patients were treated with post-operative steroids (dexamethasone, WS) for a median of 3 doses (median 6.0 mg/dose every 8 h after surgery). The demographic variables of the cohorts were similar with no difference in curve magnitude, number of vertebrae fused, number of osteotomies, or EBL between groups. A 70% decrease in the median post-operative morphine equivalents was observed in the steroid cohort (0.50 mg/kg WS vs 1.65 mg/kg NS, p value < 0.001). There was an association between post-operative morphine equivalents and length of stay (Spearman's rho = 0.22, p value = 0.04). There was no difference in wound healing, infection, and pulmonary or gastrointestinal complications between groups. No difference was found in pain at discharge, 30-day ED returns, or 30-day OR returns between groups.

CONCLUSIONS

Post-operative dexamethasone resulted in a 70% decrease in morphine equivalent use after PSF for NMS without any increase in perioperative wound infections.

LEVEL OF EVIDENCE

Level 3: case-control series.

Modified Clavien-Dindo-Sink system is reliable for classifying complications following surgical treatment of early-onset scoliosis

PURPOSE

Appropriately measuring and classifying surgical complications is a critical component of research in vulnerable populations, including children with early-onset scoliosis (EOS). The purpose of this study was to assess the inter- and intra-rater reliability of a modified Clavien-Dindo-Sink system (CDS) classification system for EOS patients among a group of pediatric spinal deformity surgeons.

METHODS

Thirty case scenarios were developed and presented to experienced surgeons in an international spine study group. For each case, surgeons were asked to select a level of severity based on the modified CDS system to assess inter-rater reliability. The survey was administered on two occasions to allow for assessment of intra-rater reliability. Weighted Kappa values were calculated, with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.00 considered nearly perfect agreement.

RESULTS

11/12 (91.7%) surgeons completed the first-round survey and 8/12 (66.7%) completed the second. Inter-observer weighted kappa values for the first and second survey were 0.75 [95% CI 0.56-0.94], indicating substantial agreement, and 0.84 [95% CI 0.70-0.98], indicating nearly perfect agreement, respectively. Intra-observer reliability was 0.86 (range 0.74-0.95) between the first and second surveys, indicating nearly perfect agreement .

CONCLUSION

The modified CDS classification system demonstrated substantial to nearly perfect agreement between and within observers for the evaluation of complications following the surgical treatment of EOS patients. Adoption of this reliable classification system as a standard for reporting complications in EOS patients can be a valuable tool for future research endeavors, as we seek to ultimately improve surgical practices and patient outcomes.

LEVEL OF EVIDENCE

Level V.

1- vs. 2-year follow-up after posterior spinal fusion for AIS: what additional information is gained?

PURPOSE

Traditionally, 2-year follow-up data have been the established standard for reporting clinical outcomes following spinal deformity surgery. However, previous studies indicate that 2-year follow-up does not represent long-term outcomes. Currently, there is no clear data that demonstrate a difference in outcomes between the 1 and 2 years postoperative time-periods following posterior spinal fusions (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

A multi-center, prospective database was queried for AIS patients treated with PSF. Clinical outcome scores, assessed by SRS-22, coronal and sagittal radiographic parameters were assessed at time periods: 6 months, 1 year, and 2 years post operatively. Complications and reoperation rates were also assessed. Statistical analysis compared outcomes variables across time-points to assess for significant differences.

RESULTS

694 patients (82.6% female, mean age at surgery 14.9 ± 2.13 years) were identified. Between post-operative year 1 and 2, significant difference in SRS-22 domain scores were present for function domain (4.5 vs. 4.6; p < 0.001), mental health domain (4.3 vs. 4.2; p < 0.001), and total domain score (4.4 vs. 4.4; p = 0.03) but were below the minimal clinically important difference threshold. New complication development was significantly higher within the first year following surgery than the 1-2 year follow-up period (p < 0.001) with greater complication severity within the 0-1 year follow-up period (P = 0.03).

CONCLUSION

There are no clinically important changes in SRS-22 domain scores between 1 and 2 years following PSF for AIS, with higher complications in the first year following PSF. Two-year follow-up data provide little added clinical information while under-estimating the cumulative complication and reoperation rates at long-term follow-up.

No difference in postoperative complication rates or cardiopulmonary function for early versus late scoliosis correction in Duchenne muscular dystrophy

BACKGROUND

Given reduced rates of both pulmonary function decline and scoliosis progression with steroid treatment in Duchenne muscular dystrophy (DMD), the role of early scoliosis surgery has been questioned. The purpose of this study was to compare the postoperative complication rates of early versus late scoliosis correction in DMD.

METHODS

This study was a retrospective cohort, conducted at an academic tertiary level children's hospital. Patients with DMD who underwent posterior scoliosis correction, with preoperative pulmonary function testing [forced vital capacity (FVC)] were included and divided into two groups by preoperative curve angles: ≤ 45° and > 45°. The primary outcome variable was postoperative complications by Clavien-Dindo classification grading. Secondary outcome variables included postoperative complications occurring after the first 90 days, age at surgery, duration of wheelchair dependency preoperatively, pulmonary function, steroid utilization, shortening fraction by echocardiogram, surgery duration, intensive care unit/hospital length of stay, days intubated, infection, and percent curve correction. Two-tailed t-test and Chi-square testing were used for analysis of patient factors and Clavien-Dindo complication grade, respectively.

RESULTS

Thirty-one patients were included with a total follow-up of 8.3 ± 3.2 years, 4.8 ± 2.2 years post-spinal fusion. Steroid treatment (prednisone, deflazacort) was utilized for 21 (67.7%) patients. Primary curve correction was not different between groups (65.0% vs 71.4% [p = 0.37]). There were no significant differences in Clavien-Dindo classification grades between groups (p > 0.05). For the entire cohort, the overall complication rate was higher for patients with steroid treatment (61.9% vs 10.0% [p = 0.008]). Neither forced vital capacity nor fractional shortening on echocardiogram was different between groups at final follow-up (p = 0.6 and p = 0.4, respectively).

CONCLUSION

The comparable risk of perioperative complications for early and late scoliosis correction supports a "watchful waiting" approach, whereby curves less than 45° can be carefully followed while cardiopulmonary function is maintained. Patients undergoing steroid treatment should be counseled regarding the higher risk of postoperative blood transfusion and deep wound infection.

LEVEL OF EVIDENCE

III Retrospective cohort.

Complications following posterior spinal fusion for adolescent idiopathic scoliosis: a retrospective cohort study using the modified Clavien-Dindo-Sink system

PURPOSE

Published complication rates after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) range from 1 to 22%. Complications are often minor and may be underestimated in registries. This study describes complications of PSF for AIS, classifies them according to a Clavien-Dindo-Sink (CDS) system, and investigates risk factors for occurrence of a complication.

METHODS

This retrospective cohort study at two academic centers included all AIS patients aged 10-18 who underwent primary PSF 4/2014-12/2019. Data included demographics, comorbidities, curve magnitude, Lenke classification, levels osteotomized/fused, implant density, 90-day emergency department visits, readmissions, reoperations, and complications as defined by Harms Study Group.

RESULTS

Among 424 patients, mean age was 14.7, mean BMI 22, 77% were female, and 57% had no comorbidities. There were 270 complications (0.64 per patient); 198 patients (47%) had ≥ 1 complication; and 63 patients (15%) had CDS grade ≥ II complications (deviation from standard postoperative course). Complications not related to persistent pain occurred in 103 patients (24%). Ninety-three percent of complications did not require readmission or reoperation (CDS I-II). Within 90 days, 8% presented to an ED, 2% required readmission, and 2% required reoperation. Common complications were back pain > 6 weeks postoperatively (26%), surgical site complications (7%), and ileus/prolonged constipation (3%). Risk factors for experiencing any complication were BMI ≥ 34 (OR 3.44) and Lenke 6 curve (OR 1.95).

CONCLUSION

One in four AIS patients experiences a complication not related to persistent pain after primary PSF, higher than rates published from self-reported registries. Obesity and Lenke 6 curve may increase risk. While most do not require readmission or surgery, 15% of patients have their postoperative course altered by complications.

LEVEL OF EVIDENCE

III-retrospective cohort study.