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BACKGROUND: The relationship between the number and type of postoperative complications and mortality in the setting for surgery for acute type A aortic dissection (ATAAD) remains underexplored despite its critical role in the failure-to-rescue (FTR) metric. METHODS: This retrospective study used data from the Society of Thoracic Surgeons Adult Cardiac Surgical Database on ATAAD surgeries performed between January 2018 and December 2022. Patients were categorized based on their number of major complications. The primary outcome was FTR. We used multilevel regression and classification and regression tree models. RESULTS: We included 19,243 patients (33% females), with a median age of 61 years. Regarding complications, 47.7% of patients had 0, 20.2% had 1, 12.7% had 2, and 19.4% experienced 3 or more. The most frequently reported complications were prolonged mechanical ventilation (30.3%), unplanned reoperation (19.5%), and renal failure (17.2%). Cardiac arrest occurred in 7.1% of cases. FTR increased from 13% in patients with 1 complication to >30% in those with 4 or more complications. Cardiac arrest (adjusted odds ratio [aOR], 10.9) and renal failure (aOR, 5.3) had the highest odds for mortality, followed by limb ischemia (aOR, 2.7), stroke (aOR, 2.6), and gastrointestinal complications (aOR, 2.4). Hospitals in the top performance quartile consistently showed lower FTR rates across all levels of complication. CONCLUSIONS: The study validates a dose-response association between postoperative complications and mortality in patients undergoing surgery for ATAAD. Top-performing hospitals consistently show lower FTR rates independent of the number of complications. Future research should focus on the timing of complications and interventions to reduce the burden of complications.
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OBJECTIVE: To determine the relationship between volume of cases and failure-to-rescue (FTR) rate after surgery for acute type A aortic dissection (ATAAD) across the United States. METHODS: The Society of Thoracic Surgeons adult cardiac surgery database was used to review outcomes of surgery after ATAAD between June 2017 and December 2021. Mixed-effect models and restricted cubic splines were used to determine the risk-adjusted relationships between ATAAD average volume and FTR rate. FTR calculation was based on deaths associated with the following complications: venous thromboembolism/deep venous thrombosis, stroke, renal failure, mechanical ventilation >48 hours, sepsis, gastrointestinal complications, cardiopulmonary resuscitation, and unplanned reoperation. RESULTS: In total, 18,192 patients underwent surgery for ATAAD in 832 centers. The included hospitals' median volume was 2.2 cases/year (interquartile range [IQR], 0.9-5.8). Quartiles' distribution was 615 centers in the first (1.3 cases/year, IQR, 0.4-2.9); 123 centers in the second (8 cases/year, IQR, 6.7-10.2); 66 centers in the third (15.6 cases/year, IQR, 14.2-18); and 28 centers in the fourth quartile (29.3 cases/year, IQR, 28.8-46.0). Fourth-quartile hospitals performed more extensive procedures. Overall complication, mortality, and FTR rates were 52.6%, 14.2%, and 21.7%, respectively. Risk-adjusted analysis demonstrated increased odds of FTR when the average volume was fewer than 10 cases per year. CONCLUSIONS: Although high-volume centers performed more complex procedures than low-volume centers, their operative mortality was lower, perhaps reflecting their ability to rescue patients and mitigate complications. An average of fewer than 10 cases per year at an institution is associated with increased odds of failure to rescue patients after ATAAD repair.
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Mortality and morbidity for high-risk surgical patients are often high, especially in low-resource settings. Enhanced peri-operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before-and-after cohort study aimed to assess the effectiveness of a postoperative 48-hour enhanced care pathway for high-risk surgical patients ('high-risk surgical bundle') who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high-risk post-anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in-hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high-risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high-risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30-0.72). The high-risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49-0.80]) and surgical re-interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30-0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high-risk surgical patients in a resource-constrained setting could reduce in-hospital mortality.
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Assistência Perioperatória , Brasil/epidemiologia , Estudos de Coortes , Mortalidade Hospitalar , Humanos , Estudos RetrospectivosRESUMO
OBJECTIVE: Recent data from major noncardiac surgery suggest that outcomes in frail patients are better predicted by a hospital's volume of frail patients specifically, rather than overall surgical volume. We sought to evaluate this "frailty volume-frailty outcome relationship" in patients undergoing cardiac surgery. METHODS: We studied 72,818 frail patients undergoing coronary artery bypass grafting or valve replacement surgery from 2010 to 2014 using the Nationwide Readmissions Database. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Multilevel logistic regression was used to assess the independent effect of frailty volume by quartile on mortality, surgical complications, failure to rescue, nonhome discharge, 30-day readmissions, length of stay, and hospital costs in frail patients. RESULTS: In comparing the highest volume quartiles with the lowest, both overall cardiac surgical volume and volume for frail patients were significantly associated with shorter length of stay and reduced costs. However, frailty volume was also independently associated with significantly reduced in-hospital mortality (odds ratio, 0.79; 95% confidence interval, 0.67-0.94; P = .006) and failure to rescue (odds ratio, 0.83; 95% confidence interval, 0.70-0.98; P = .03), whereas no such association was seen between overall volume and either mortality (odds ratio, 0.94; 95% confidence interval, 0.74-1.10; P = .43) or failure to rescue (odds ratio, 0.98; 95% confidence interval, 0.83-1.17; P = .85). Neither frailty volume nor overall volume showed any significant relationship with the rate of 30-day readmissions. CONCLUSIONS: In frail patients undergoing cardiac surgery, surgical volume of frail patients was a significant independent of predictor of in-hospital mortality and failure to rescue, whereas overall surgical volume was not. Thus, the "frailty volume-outcome relationship" superseded the traditional "volume-outcome relationship" in frail patients with cardiac disease.
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Procedimentos Cirúrgicos Cardíacos , Idoso Fragilizado/estatística & dados numéricos , Fragilidade , Cardiopatias , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Fragilidade/diagnóstico , Fragilidade/epidemiologia , Cardiopatias/epidemiologia , Cardiopatias/cirurgia , Custos Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Prognóstico , Fatores de Risco , Estados Unidos/epidemiologiaRESUMO
Introdução: Cerca de 30% das pacientes com câncer do colo uterino evoluirão com falha terapêutica, seja persistência ou recorrência, e a depender do tratamento prévio o resgate cirúrgico completo pode ter benefício no controle da doença. Objetivos: Avaliar o perfil das pacientes que evoluíram com falha do tratamento do câncer do colo uterino localmente avançado e que foram submetidas ao tratamento cirúrgico de resgate. Materiais e métodos: Foram avaliadas características clínicas, cirúrgicas e patológicas de 46 mulheres, portadoras de câncer do colo uterino localmente avançado, que evoluíram com persistência ou recidiva tumoral e foram submetidas a cirurgia de resgate, na Santa Casa de Misericórdia de Maceió, no período entre março de 2013 a dezembro de 2020. Resultados: A mediana de idade do grupo estudado foi de 47,5 anos (26-69), com predomínio de tipo histológico carcinoma de células escamosas (89,1%) e grau histológico 2 (42,3%). A maioria das pacientes (n=45, 97,8%) foram submetidas a radioterapia no tratamento primário. Apresentaram persistência e recorrência 43,5% e 56,5% dos casos, respectivamente, sendo a região pélvica central o sítio anatômico mais comum desta falência (73,8%). Apesar de todas as pacientes terem sido submetidas a colposcopia e colpocitologia, o diagnóstico da falha do tratamento e a indicação do resgate cirúrgico foram baseados na ressonância magnética da pelve (97,8%). O intervalo livre de doença mediano antes do resgate cirúrgico foi 14,5 meses. Das 46 pacientes levadas ao resgate cirúrgico 5 (10,86%) foram submetidas a cirurgia com caráter paliativo e 41 (89,1%) curativo, sendo realizado histerectomia, simples ou radical, em 48,7%, linfadenectomia isolada, pélvica e/ou retroperitoneal, em 21,9%, e exenteração pélvica em 29,2%. A morbidade e mortalidade cirúrgica foram de 30,4% e 6,5%, respectivamente. Em 41,5% dos casos curativos, os espécimes cirúrgicos não apresentavam sinais de malignidade. No último seguimento foi observado que 65,2% das pacientes estavam vivas e 52,1% estavam vivas e sem evidência de doença. A sobrevida livre de doença e sobrevida global em 2 anos foram de 66,3% e de 55,2%, respectivamente. Conclusão: O resgate cirúrgico das pacientes portadoras de câncer do colo uterino que evoluíram com falha do tratamento inicial é factível, principalmente quando esta ocorre na região pélvica central ou linfonodal isolada, com aceitável morbimortalidade. Cirurgias menos radicais que a exenteração pélvica apresentaram menor taxa de complicações e maior sobrevida livre de doença.
Introduction: About 30% of patients with cervical cancer develop therapeutic failure, whether persistence or recurrence, and depending on previous treatment, complete salvage surgery may improve the disease control. Objectives: To evaluate the clinical and pathological factors and outcomes of patients who developed treatment failure for locally advanced cervical cancer and were submitted to surgical resection. Methods: We evaluated the clinical and pathological characteristics of 46 women with locally advanced cervical cancer who had persistent or recurrent disease and underwent salvage surgery, in Santa Casa de Misericórdia de Maceió, from March 2013 to December 2020 were evaluated. Results: The median age was 47.5 years (range, 26-69), with a predominance of squamous cell carcinoma (89.1%) and histological grade 2 (42.3%). Most patients (n=45, 97.8%) underwent radiotherapy in the primary treatment. They presented persistence and recurrence in 43.5% and 46.5% of the cases, respectively, with the central pelvic region being the most common anatomical site of failure (73.8%). Although all patients underwent colposcopy and colpocytology, the diagnosis of treatment failure and indication for surgical salvage were mostly based on magnetic resonance imaging (97.8%). The median disease-free interval before surgical salvage was 14.5 months. Of the 46 patients that underwent salvage surgery, 5 (10.86%) underwent palliative surgery, and 41 (89.1%) curative; with hysterectomy, simple or radical, in 48.7%; isolated lymphadenectomy, pelvic and/or retroperitoneal, in 21.9%; and pelvic exenteration in 29.2%. Overall surgical morbidity and mortality were 30.4% and 6.5%, respectively. In 41,5% of surgical specimens, there were no evidence of residual malignancy. In the last follow-up, we observed that 65.2% of the patients were alive and 52.1% were alive and without evidence of disease. The 2-year disease-free survival and overall survival were 66,3% and 55.2%, respectively. CONCLUSION: Surgical salvage of patients with cervical cancer who developed primary treatment failure is feasible, especially when it occurs in the central pelvic region or isolated lymph node, with acceptable morbidity and mortality. Less radical surgeries than pelvic exenteration have lower complication rates and better disease-free survival.
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Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Neoplasias do Colo do Útero/cirurgia , Falha da Terapia de Resgate , Análise de Sobrevida , Recidiva Local de NeoplasiaRESUMO
INTRODUCTION: The failure to rescue (FTR) rate is the probability of death after a major complication and was defined in elective surgical cohorts. In elective surgery, the precedence rate (proportion of deaths preceded by major complications) approaches 100%, but recent studies in trauma report rates of only 20-25%. We hypothesised that use of high quality data would result precedence rates in higher than those derived from national datasets, and we further sought to characterise the nature of those deaths not preceded by major complications. METHODS: Prospectively collected data from 2006 to 2010 from a single level I trauma centre were used. Patients age >16 years with AIS ≥2 who survived beyond the trauma bay were included. Complications, mortality, FTR, and precedence rates were calculated. Chart abstraction was performed for registry deaths without recorded complications to verify the absence of complications and determine the cause of death, after which outcomes were re-calculated. RESULTS: A total of 8004 patients were included (median age 41 (IQR 25-75), 71% male, 82% blunt, median ISS 10 (IQR 5-18)). Using registry data the precedence rate was 55%, with 132/293 (45%) deaths occurring without antecedent major complications. On chart abstraction, 11/132 (8%) patients recorded in the registry as having no complication prior to death were found to have major complications. Complication and FTR rates after chart abstraction were statistically significantly different than those derived from registry data alone (complications 16.5% vs. 16.3, FTR 12.3 vs.13, p=0.001), but this difference was unlikely to be clinically meaningful. Patients dying without complications predominantly (87%) had neurologic causes of demise. CONCLUSIONS: Use of data with near-complete ascertainment of complications results in precedence rates much higher than those from national datasets. Patients dying without precedent complications at our centre largely succumbed to progression of neurologic injury. Attempts to use FTR to compare quality between centres should be limited to high quality data. LEVEL OF EVIDENCE: Level III. RETROSPECTIVE COHORT STUDY: Outcomes.