Assessment of Surgical Complications With Respect to the Surgical Indication: Proposal for a Novel Index

Preoperative anemia in older individuals undergoing major abdominal surgery is associated with early postoperative morbidity: a prospective observational study

PURPOSE

Preoperative anemia is associated with poor postoperative outcomes. Older patients have limited physiologic reserves, which renders them vulnerable to the stress of major abdominal surgery. We aimed to determine if the severity of preoperative anemia is associated with early postoperative morbidity among older patients undergoing major abdominal surgery.

METHODS

Ethics approval was obtained from SingHealth Centralized Institutional Review Board. This is a prospective observational study conducted in the preoperative anesthesia clinic of a tertiary Singapore hospital from 2017 to 2021. Patient demographic data, comorbidities, and intraoperative details were collected. Outcome measures included blood transfusions, complications according to the Postoperative Morbidity Survey, days alive and out of hospital (DaOH), length of hospital stay, and mortality.

RESULTS

A total of 469 patients were analyzed, 37.5% of whom had preoperative anemia (serum hemoglobin of < 13 g·dL-1 in males and < 12 g·dL-1 in females). Anemia was significantly associated with older age, a higher age-adjusted Comprehensive Complication Index score, a higher incidence of diabetes mellitus, and a higher proportion of patients with an American Society of Anesthesiologists Physical Status of III or IV. The severity of anemia was associated with the presence of early postoperative morbidity at day 5, increased blood transfusions, longer length of hospital stay, and fewer DaOH at 30 days and six months.

CONCLUSION

Anemia is significantly associated with poorer postoperative outcomes in the older population. The impact of anemia on postoperative outcomes could be further evaluated with quality of life indicators, patient-reported outcome measures, and health economic tools.

Efficacy, Safety, and Cost-Effectiveness of Healthium Theruptor Versus 3M Tegaderm Versus Plain Gauze Dressing for Wound Dressings Used in Abdominal and Joint Surgeries: A Prospective, Multicentric, Randomized Study

Background In the realm of surgical and postoperative care, the application of wound dressings is a standard practice to facilitate healing, minimize infection risks, and offer a protective barrier against pathogens for optimal recovery. For instance, Theruptor is an active advanced wound care product with patented microbicidal technology. In the present study, we conducted a randomized clinical trial to compare the clinical efficacy and safety of Healthium Theruptor, 3M Tegaderm, and plain gauze dressings in patients undergoing abdominal and joint surgeries. Methodology This was a multicenter, prospective, three-arm, randomized, double-blind study conducted between April and November 2022 at three different sites in India, viz., All India Institute of Medical Sciences, Jodhpur; Mahatma Gandhi Medical College and Research Institute, Puducherry; and SRM Institute of Science and Technology, Chennai. A total of 210 patients were randomized to receive either of the following three interventions: Theruptor, Tegaderm, and plain gauze dressing (n = 70 each) based on computer-generated randomization sequences using sequentially numbered, opaque, sealed envelopes. Demographic data and surgery details were obtained and recorded at baseline. Parameters such as rate of wound healing, incidence of surgical site infections (SSIs), adverse events, product performance, and pain score were assessed and compared during the weekly follow-up visits until 28 days. In addition, wound assessments using the Stony Brook Scar evaluation scale, Cardiff Wound Impact Questionnaire, and Modified Hollander Wound Evaluation Scale were conducted to provide additional insights on the efficacy of the dressings (days 3, 7, 14, and 28). Lastly, the cost of wound management was assessed at the end of the study. The statistical analysis of the data was performed using a one-way analysis of variance followed by a Bonferroni post-hoc test on GraphPad software. Results All three dressings were equally effective in healing the wound and reducing the incidence of SSIs. The median healing time was estimated to be seven days. Further, no significant difference was observed in wound dehiscence, wound pain, clinical wound parameters, cosmetic assessment, and quality of life among the three groups (p > 0.05) during the follow-up visits. However, the product performance of Theruptor and Tegaderm was significantly better than plain gauze dressing in terms of ease of application (82.87% and 84.13% vs. 71.7%), ease of removal (83.09% and 83.67% vs. 70.79%), comfort to wear (82.59% and 84.47% vs. 72.83%), exudate management (84.35% and 85.7% vs. 77.23%), mean wear time in hours (65.57 and 65.92 vs. 49 hours), and mobility of the patient (p < 0.05). Further, the total cost of wound management with Theruptor dressing was significantly lower than with Tegaderm dressing (₹1117.2 ± 269.86 vs. ₹1474 ± 455.63; p < 0.0001). Conclusions Although all three dressings were equally safe and clinically efficacious, Theruptor was more cost-effective with better product performance. Thus, Theruptor may be a considerate option in the postoperative wound management of abdominal and joint surgeries.

Natural Ending or Surgical Complication: Is It the Time to Reconsider the Clavien-Dindo Classification System?

To date, the Clavien-Dindo classification system represents the most popular assessment tool of postoperative events that ranks surgical complications by the extent of respective required therapeutic interventions. This uniform grading system allows for an objective evaluation of outcomes from a surgical procedure by accurately and standardly defining surgical complications. However, many scientists have meanwhile heavily criticized the Clavien-Dindo classification system as an overly generalized and conservative grading system that requires modification. Herein, we aim to explain the need for reconsideration of the Clavien-Dindo classification system, and discuss the features of an ideal system for the classification of complications that should evaluate not only surgical complications, but also the risk and patient's general performance status.

External Validation of a Risk Model for Severe Complications following Pancreatoduodenectomy Based on Three Preoperative Variables

BACKGROUND

Pancreatoduodenectomy (PD) is the only cure for periampullary and pancreatic cancer. It has morbidity rates of 40-60%, with severe complications in 30%. Prediction models to predict complications are crucial. A risk model for severe complications was developed by Schroder et al. based on BMI, ASA classification and Hounsfield Units of the pancreatic body on the preoperative CT scan. These variables were independent predictors for severe complications upon internal validation. Our aim was to externally validate this model using an independent cohort of patients.

METHODS

A retrospective analysis was performed on 318 patients who underwent PD at our institution from 2013 to 2021. The outcome of interest was severe complications Clavien-Dindo ≥ IIIa. Model calibration, discrimination and performance were assessed.

RESULTS

A total of 308 patients were included. Patients with incomplete data were excluded. A total of 89 (28.9%) patients had severe complications. The externally validated model achieved: C-index = 0.67 (95% CI: 0.60-0.73), regression coefficient = 0.37, intercept = 0.13, Brier score = 0.25.

CONCLUSIONS

The performance ability, discriminative power, and calibration of this model were acceptable. Our risk calculator can help surgeons identify high-risk patients for post-operative complications to improve shared decision-making and tailor perioperative management.

Mucosal immune cell populations and the bacteriome of adenoids and tonsils from people living with HIV on suppressive antiretroviral therapy

Ear, nose, and throat (ENT) conditions are prevalent in people living with HIV (PLWH) and occur at all strata of CD4 counts and despite antiretroviral therapy (ART). ENT conditions are underreported in PLWH. Also, little is known about the adenotonsillar microbiota and its relation to resident adaptive and innate immune cells. To bridge this gap, we characterized immune cell populations and the bacterial microbiota of two anatomical sites (adenoids, tonsils) and the oral cavity. Adenoids and tonsils were obtained from PLWH (n = 23) and HIV-seronegative individuals (SN, n = 16) after nasal surgery and tonsillectomy and processed for flow cytometry. Nasopharyngeal, oropharyngeal swabs, and oral rinses were collected prior to surgery for 16S sequencing. Wilcoxon rank sum test, principal coordinate analysis, permutational multivariate analysis of variance, and linear discriminant analysis (LEfSe) were used to assess differences between PLWH and SN. Spearman’s correlations were performed to explore interactions between the bacteriome and mucosal immune cells. Of the 39 individuals included, 30 (77%) were men; the median age was 32 years. All PLWH were on ART, with a median CD4 of 723 cells. ENT conditions were classified as inflammatory or obstructive, with no differences observed between PLWH and SN. PLWH had higher frequencies of activated CD4+ and CD8+ T cells, increased T helper (Th)1 and decreased Th2 cells; no differences were observed for B cells and innate immune cells. Alpha diversity was comparable between PLWH and SN at all 3 anatomical sites (adenoids, tonsils, and oral cavity). The impact of HIV infection on the bacterial community structure at each site, as determined by Permutational multivariate analysis of variance, was minor and not significant. Two discriminant genera were identified in adenoids using LEfSe: Staphylococcus for PLWH and Corynebacterium for SN. No discriminant genera were identified in the oropharynx and oral cavity. Niche-specific differences in microbial diversity and communities were observed. PLWH shared less of a core microbiota than SN. In the oropharynx, correlation analysis revealed that Th17 cells were inversely correlated with bacterial richness and diversity, Filifactor, Actinomyces and Treponema; and positively correlated with Streptococcus. Our study contributes toward understanding the role of the adenotonsillar microbiota in the pathophysiology of ENT conditions.

Historical Perspective: How the Discovery of HPV Virus Led to the Utilization of a Robot

The treatment of oropharyngeal cancer has undergone many paradigms shifts in recent decades. First considered a surgical disease, improvements in radiotherapy led to its popularization in the 1990s. Subsequently, the discovery of the human papillomavirus (HPV) in the pathogenesis of oropharyngeal cancer, as well as the increase in HPV-associated oropharynx cancer incidence, have prompted a reevaluation of its management. Its sensitivity to standard treatment with a favorable prognosis compared to non HPV-associated oropharyngeal cancer led to a focus on minimizing treatment toxicity. Advances in radiation and surgical techniques, including the use of transoral robotic surgery, gave the rationale to ongoing de-escalation clinical trials in HPV-associated oropharynx cancer.