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El-Asmar JM, Ayoub CH, Kfoury P, Abou-Mrad A, El-Hajj A. Surgical Complications Requiring Reoperation in Open Versus Minimally Invasive Radical Nephrectomy: A Contemporary Analysis of the National Surgical Quality Improvement Program. World J Surg 2023; 47:856-862. [PMID: 36587175 DOI: 10.1007/s00268-022-06869-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND To explore reoperation rates for different radical nephrectomy (RN) approaches that are experiencing a shift from open radical nephrectomy (ORN) toward minimally invasive surgery (MIS), we aimed to compare reoperation rates along with their culprit etiologies between the different types of surgical approaches for RN. METHODS The national surgical quality improvement program dataset was used to select patients who underwent RN between the years 2012-2019. A 1:1 propensity score matched analysis was used. Reoperation rates and causes were then compared between open and MIS approach. RESULTS The propensity matched cohort included 15,294 patients. Reoperation rates due to large bowel injury (0.01 vs. 0.14%), vascular injury (0.07 vs. 0.22%), and other abdominal (0.5 vs. 0.77%) were more common in ORN as compared to MIS (MIS vs. ORN, respectively, p < 0.034). Reoperation due to hernia (0.14 vs. 0.03%) was more common in MIS as compared to ORN (p = 0.027). No difference was seen for small bowel injury and incision/wound debridement. General reoperation (1.61 vs. 2.22%) and mortality (0.57 vs. 1.47%) were also more common in ORN as compared to MIS (p < 0.008). CONCLUSION Reoperation due to large bowel injury, vascular injury, and other abdominal was more likely to occur in ORN. Whereas reoperation due to hernia was more likely to occur in MIS. Surgical approach was an independent risk factor for immediate and early reoperation rates in RN patients. These results could be used to counsel patients pre-operatively on possible surgical approaches and complications.
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Affiliation(s)
- Jose M El-Asmar
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Riad El Solh, PO BOX: 11-0236, Beirut, 1107 2020, Lebanon
| | - Christian Habib Ayoub
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Riad El Solh, PO BOX: 11-0236, Beirut, 1107 2020, Lebanon
| | - Peter Kfoury
- American University of Beirut Medical School, American University of Beirut, Beirut, Lebanon
| | - Anthony Abou-Mrad
- American University of Beirut Medical School, American University of Beirut, Beirut, Lebanon
| | - Albert El-Hajj
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Riad El Solh, PO BOX: 11-0236, Beirut, 1107 2020, Lebanon.
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Lim K, Riveros C, Ranganathan S, Xu J, Patel A, Slawin J, Ordonez A, Aghazadeh M, Morgan M, Miles BJ, Esnaola N, Klaassen Z, Allenson K, Brooks M, Wallis CJD, Satkunasivam R. Morbidity and mortality of multivisceral resection with radical nephrectomy for locally advanced renal cell carcinoma: An analysis of the National Surgical Quality Improvement Program (NSQIP) database. Urol Oncol 2023; 41:209.e1-209.e9. [PMID: 36801191 DOI: 10.1016/j.urolonc.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/09/2022] [Accepted: 01/09/2023] [Indexed: 02/21/2023]
Abstract
INTRODUCTION Locally advanced renal cell carcinoma (RCC) can rarely invade into adjacent abdominal viscera without clinical evidence of distant metastases. The role of multivisceral resection (MVR) of involved adjacent organs at the time of radical nephrectomy (RN) remains poorly described and quantified. Using a national database, we aimed to evaluate the association between RN+MVR and 30-day postoperative complications. METHODS AND MATERIALS We conducted a retrospective cohort study of adult patients undergoing RN for RCC with and without MVR between 2005 and 2020 using the ACS-NSQIP database. The primary outcome was a composite of any of the following 30-day major postoperative complications: mortality, reoperation, cardiac event, and neurologic event. Secondary outcomes included individual components of the composite primary outcome, as well as infectious and venous thromboembolic complications, unplanned intubation and ventilation, transfusion, readmission, and prolonged length of stay (LOS). Groups were balanced using propensity score matching. Likelihood of complications was assessed by conditional logistic regression adjusted for unbalanced total operation time. Postoperative complications were compared by Fisher's exact test among subtypes of resection. RESULTS A total of 12,417 patients were identified: 12,193 (98.2%) undergoing RN alone and 224 (1.8%) undergoing RN+MVR. Patients undergoing RN+MVR were more likely to experience major complications (odds ratio [OR] 2.46; 95% confidence interval [CI] 1.28-4.74). However, there was no significant association between RN+MVR and postoperative mortality (OR 2.49; 95% CI 0.89-7.01). RN+MVR was associated with higher rates of reoperation (OR 7.85; 95% CI 2.38-25.8), sepsis (OR 5.45; 95% CI 1.83-16.2), surgical site infection (OR 4.41; 95% CI 2.14-9.07), blood transfusion (OR 2.24; 95% CI 1.55-3.22), readmission (OR 1.78; 95% CI 1.11-2.84), infectious complications (OR 2.62; 95% CI 1.62-4.24), and longer hospital stay (5 days [IQR 3-8] vs. 4 days [IQR 3-7]; OR 2.31 [95% CI 2.13-3.03]). There was no heterogeneity in the association between subtype of MVR and major complication rate. CONCLUSION Undergoing RN+MVR is associated with an increased risk of 30-day postoperative morbidity, including infectious complications, reoperation, blood transfusion, prolonged LOS, and readmission.
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Affiliation(s)
- Kelvin Lim
- Department of Urology, Houston Methodist Hospital, Houston, TX
| | - Carlos Riveros
- Department of Urology, Houston Methodist Hospital, Houston, TX
| | | | - Jiaqiong Xu
- Center for Health Data Science and Analytics, Houston Methodist Research Institute, Houston, TX
| | - Ashmi Patel
- Department of Urology, Houston Methodist Hospital, Houston, TX
| | - Jeremy Slawin
- Department of Urology, Houston Methodist Hospital, Houston, TX
| | - Adriana Ordonez
- Center for Health Data Science and Analytics, Houston Methodist Research Institute, Houston, TX
| | - Monty Aghazadeh
- Department of Urology, Houston Methodist Hospital, Houston, TX
| | - Monica Morgan
- Department of Urology, Houston Methodist Hospital, Houston, TX
| | - Brian J Miles
- Department of Urology, Houston Methodist Hospital, Houston, TX
| | - Nestor Esnaola
- Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Zachary Klaassen
- Division of Urology, Medical College of Georgia, Augusta University, Augusta, GA
| | - Kelvin Allenson
- Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Michael Brooks
- Department of Urology, Houston Methodist Hospital, Houston, TX
| | - Christopher J D Wallis
- Division of Urology and Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Urology, University of Toronto, Toronto, Ontario, Canada; Division of Urology, Mount Sinai Hospital, Toronto, Ontario, Canada
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Latz CA, Lella S, Boitano LT, DeCarlo C, Feldman Z, Png CYM, Mohebali J, Dua A, Conrad M. Short- and long-term outcomes after concurrent splenectomy during thoracoabdominal aortic aneurysm repair. J Vasc Surg 2021; 74:1109-1116. [PMID: 33887425 DOI: 10.1016/j.jvs.2021.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 03/15/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Splenectomy is often performed during open thoracoabdominal aortic aneurysm (TAAA) repair, because capsular tears are common and can be associated with significant bleeding. It is unknown whether splenectomy affects the short- or long-term outcomes after TAAA repair. METHODS All open type I to IV TAAA repairs performed from 1987 to June 2015 were evaluated using a single institutional database. The primary endpoints were in-hospital death, major adverse events (MAE) and long-term survival. The secondary endpoint was hospital length of stay (LOS). All repairs performed for aneurysm rupture were excluded. Univariate analysis was conducted using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Logistic and linear multivariable regression were used for the in-hospital endpoints, and survival analyses were performed using Cox proportional hazards modeling and Kaplan-Meier techniques. RESULTS A total of 649 patients met the study inclusion criteria. Of the 649 patients, 150 (23%) underwent concurrent splenectomy (CS) and six required emergency splenectomy secondary to bleeding postoperatively, leading to 156 cases of total in-hospital splenectomy. The perioperative mortality rate was 5.2% in the CS group and 5.2% in the non-CS group (P = 1.0). MAE were experienced by 48% of the CS patients compared with 34% of the non-CS patients (P = .003). Multivariable analysis revealed splenectomy was not independently predictive of perioperative death (adjusted odds ratio, 0.95; 95% confidence interval [CI], 0.41-2.23; P = .9). However, splenectomy was independently associated with any MAE (adjusted odds ratio, 1.78; 95% CI, 1.19-2.65; P = .005). Splenectomy was also associated with a longer length of stay (+5.39 days; 95% CI, 1.86-8.92; P = .003). No survival difference was found between the cohorts in the total splenectomy cohort in the unadjusted (log-rank P = 1.0) or adjusted (splenectomy adjusted hazard ratio, 1.02; 95% confidence interval, 0.78-1.35; P = .9). CONCLUSIONS CS during open TAAA repair did not lead to increased perioperative mortality but did lead to significantly increased perioperative morbidity and longer hospital lengths of stay. We found no difference in long-term survival outcomes when CS was performed. Splenectomy during TAAA repair did not affect long-term survival.
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Affiliation(s)
- Christopher A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Srihari Lella
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Zach Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - C Y Maximilian Png
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
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Kalapara AA, Frydenberg M. The role of open radical nephrectomy in contemporary management of renal cell carcinoma. Transl Androl Urol 2020; 9:3123-3139. [PMID: 33457285 PMCID: PMC7807349 DOI: 10.21037/tau-19-327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Radical nephrectomy (RN) remains a cornerstone of the management of localised renal cell carcinoma (RCC). RN involves the en bloc removal of the kidney along with perinephric fat enclosed within Gerota's fascia. Key principles of open RN include appropriate incision for adequate exposure, dissection and visualisation of the renal hilum, and early ligation of the renal artery and subsequently renal vein. Regional lymph node dissection (LND) facilitates local staging but its therapeutic role remains controversial. LND is recommended in patients with high risk clinically localised disease, but its benefit in low risk node-negative and clinically node-positive patients is unclear. Concomitant adrenalectomy should be reserved for patients with large tumours with radiographic evidence of adrenal involvement. Despite a recent downtrend in utilisation of open RN due to nephron-sparing and minimally invasive alternatives, there remains a vital role for open RN in the management of RCC in three domains. Firstly, open RN is important to the management of large, complex tumours which would be at high risk of complications if treated with partial nephrectomy (PN). Secondly, open RN plays a crucial role in cytoreductive nephrectomy (CN) for metastatic RCC, in which the laparoscopic approach achieves similar results but is associated with a high reoperation rate. Finally, open RN is the current standard of care in the management of inferior vena caval (IVC) tumour thrombus. Management of tumour thrombus requires a multidisciplinary approach and varies with cranial extent of thrombus. Higher level thrombus may require hepatic mobilisation and circulatory support, whilst the presence of bland thrombus may warrant post-operative filter insertion or ligation of the IVC.
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Affiliation(s)
| | - Mark Frydenberg
- Department of Surgery, Monash University, Melbourne, Australia.,Cabrini Institute, Cabrini Health, Melbourne, Australia
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Chatterjee S, LeMaire SA, Green SY, Price MD, Amarasekara HS, Zhang Q, Pirko CJ, Preventza O, de la Cruz KI, Todd SR, Coselli JS. Is incidental splenectomy during thoracoabdominal aortic aneurysm repair associated with reduced survival? J Thorac Cardiovasc Surg 2020; 160:641-652.e2. [DOI: 10.1016/j.jtcvs.2019.07.133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 01/06/2023]
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Delafontaine JL, Moreci R, Samra NS. Acute splenic rupture following laparoscopic pneumoperitoneum: A case report. Trauma Case Rep 2019; 22:100211. [PMID: 31338406 PMCID: PMC6620620 DOI: 10.1016/j.tcr.2019.100211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction Splenic rupture after laparoscopic surgery is a very rare complication. In this study, we report a case of a splenic laceration that occurred during a laparoscopic gastrostomy tube placement. The theorized mechanism in this case was acute disruption of a peri-splenic hematoma. Case report A 64-year-old African-American male presented after a motor vehicle accident with multiple injuries and was admitted to a surgical intensive care unit, where he declined from ICU days 6 through 11. The patient underwent tracheostomy and laparoscopic gastrostomy tube placement given his significant neurologic deficits. Intraoperatively, the patient developed hypotension, leading to the discovery of hemoperitoneum and necessitating an emergent open splenectomy. Conclusion Splenic rupture following laparoscopic procedures is a very rare phenomenon. In this case, we believe the splenic rupture was secondary to an acute disruption of a previously hemostatic splenic hematoma involving the abdominal wall during creation of capnoperitoneum.
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Affiliation(s)
- Jean-Luc Delafontaine
- Department of Surgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, USA
| | - Rebecca Moreci
- Louisiana State University School of Medicine, Shreveport, LA, USA
| | - Navdeep S Samra
- Department of Trauma, Acute Care Surgery, and Surgical Critical Care, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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Saxena A, Liauw W, Morris DL. Splenectomy is an independent risk factor for poorer perioperative outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: an analysis of 936 procedures. J Gastrointest Oncol 2017; 8:737-746. [PMID: 28890825 DOI: 10.21037/jgo.2017.07.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND There is a paucity of data on the impact of splenectomy on peri-operative outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). We report the largest series to date which addresses this topic. METHODS Nine hundred and thirty six consecutive patients underwent CRS/HIPEC from 1996 to 2016 at a high-volume institution in Sydney, Australia. Of these, 418 (45%) underwent splenectomy. Peri-operative complications were graded according to the Clavien-Dindo Classification. The association of splenectomy with 19 peri-operative outcomes was assessed using univariate and multivariate analyses. RESULTS In-hospital mortality was 1.8%. Patients undergoing splenectomy had a higher disease burden (peritoneal cancer index ≥17) (71% vs. 22%, P<0.001) and underwent a longer operation (≥9 hours) (73% vs. 34%, P<0.001). Even after accounting for confounding factors, splenectomy was independently associated with an increased risk of grade III/IV morbidity [relative risk (RR), 1.94; 95% confidence interval (CI), 1.29-2.91; P=0.01], infective complications (RR, 1.63; 95% CI, 1.09-2.44; P=0.018), pancreatic leak (RR, 5.2; 95% CI, 1.81-14.89, P=0.002) and intra-abdominal collection (RR, 1.86; 95% CI, 1.23-2.84, P=0.004). It was also an independent risk factor for long hospital stay (≥28 days) (RR, 1.98; 95% CI, 1.25-3.11; P=0.003). Splenectomy was not associated with in-hospital mortality (RR, 1.68; 95% CI, 0.32-9.32, P=0.556). CONCLUSIONS Splenectomy is an independent risk factor for poorer peri-operative outcomes. Minimizing the likelihood of inadvertent splenic injury through careful dissection and routine vaccination can improve outcomes.
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Affiliation(s)
- Akshat Saxena
- UNSW Department of Surgery, St George Hospital, Kogarah, New South Wales, Australia
| | - Winston Liauw
- UNSW Department of Surgery, St George Hospital, Kogarah, New South Wales, Australia
| | - David L Morris
- UNSW Department of Surgery, St George Hospital, Kogarah, New South Wales, Australia
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Giri SK, Abdelrahman M, Flood HD. Experience with sliding-clip splenorrhaphy for splenic injury during radical nephrectomy. Can Urol Assoc J 2015; 9:E476-9. [PMID: 26279719 PMCID: PMC4514495 DOI: 10.5489/cuaj.2732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We report our experience with sliding-clip splenorrhaphy (SCS), a novel splenic conservation technique, for iatrogenic splenic injury (ISI) during a left radical nephrectomy (RN). We also reviewed the literature on ISI. METHODS We retrospectively reviewed data from patients who had RN between January 2005 and December 2013 at our institution. The technique used was similar to sliding-clip renorrhaphy. Our Medline literature identified articles containing "splenic injury during nephrectomy," "iatrogenic splenic injury." "iatrogenic splenectomy," and "splenorrhaphy." Our primary outcome measures included incidence of splenic injury and splenic conservation rate and splenectomy. RESULTS Among the 370 RN, 140 were left sided. ISI injury occurred in 6 left RN (incidence 1.6% for all nephrectomies, 4.2% for left-sided nephrectomies). All 6 cases had open procedure and for the left-sided procedure. Splenic conservation was attempted in 4 patients using SCS and 3 out of 4 were successfully repaired. Altogether 3 patients had splenectomy (incidence 0.8% for all nephrectomies, 2.1% for left-sided nephrectomies). Our literature review revealed that the incidence of iatrogenic splenectomy during left nephrectomy varies from 1.3% to 13.2%. CONCLUSIONS SCS is an acceptable novel splenic conservation technique due to its ease of use and success in selected patients with ISI. There is little evidence on the true incidence of ISI especially on splenic conservation during nephrectomy. Every attempt at splenic conservation is likely to improve immediate- and long-term patient outcomes.
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Affiliation(s)
- Subhasis K. Giri
- University Hospital Limerick, St. Nessan’s Road, Limerick, Ireland
| | | | - Hugh D. Flood
- University Hospital Limerick, St. Nessan’s Road, Limerick, Ireland
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