Šlenfuktas, Vygintas

Surgical services were poorly prepared for the COVID-19 pandemic, leading to widescale disruption to elective activity. This study aimed to identify actionable priorities to strengthen pandemic preparedness of surgical and hospital systems.

There is low-certainty evidence on the impact of extended pharmacological prophylaxis on venous thromboembolism-associated morbidity and mortality. The aim of this study was to determine the efficacy and safety of extended prophylaxis after major abdominopelvic surgery for the prevention of clinically relevant venous thromboembolism after hospital discharge.

Background. Pulmonary complications are the most common cause of death after surgery. This study aimed to derive and externally validate a novel prognostic model that can be used before elective surgery to estimate the risk of postoperative pulmonary complications and to support resource allocation and prioritisation during pandemic recovery.

Cardiovascular complications after major surgery are associated with increases in morbidity and mortality. There is confusion over definitions of cardiac injury or complications, and variability in the assessment and management of patients. This international prospective cohort study aimed to define the incidence and timing of these complications and to investigate their impact on 30-day all-cause mortality. We performed a prospective, international cohort study between January 2022 and May 2022. Data were collected on consecutive patients undergoing major abdominal surgery in 446 hospitals from 28 countries across Europe. The primary outcome measure was cardiovascular complications as defined by the Standardised Endpoints for Perioperative Medicine-Core Outcome Measures for Perioperative and Anaesthetic Care initiative up to 30 days after surgery. The secondary outcome was 30-day postoperative mortality. This study included 24,203 patients, of whom 611 (2.5%) developed cardiovascular complications. In total, 458 (1.9%) patients died within 30 days of surgery, of which 123 (26.9%) deaths were judged to be cardiac-related. Mortality rates were higher in patients who developed postoperative cardiovascular complications than in those who did not (19.8% vs. 1.4%), which persisted after risk adjustment (hazard ratio (95%CI) 4.15 (3.14-5.48)). We estimated an absolute risk reduction (95%CI) of 0.4 (0.3-0.5) in mortality in the absence of all cardiovascular complications. This would confer a relative risk reduction in mortality of 21.1% if all cardiovascular complications were prevented. Postoperative cardiovascular complications are relatively common and occur early after major abdominal surgery. However, over 1 in 5 postoperative deaths were attributable to these complications, highlighting an important area for future randomised trials.

Background: Multimorbidity poses a global challenge to healthcare delivery. This study aimed to describe the prevalence of multimorbidity, common disease combinations and outcomes in a contemporary cohort of patients undergoing major abdominal surgery. Methods: This was a pre-planned analysis of a prospective, multicentre, international study investigating cardiovascular complications after major abdominal surgery conducted in 446 hospitals in 29 countries across Europe. The primary outcome was 30-day postoperative mortality. The secondary outcome measure was the incidence of complications within 30 days of surgery. Results: Of 24,227 patients, 7006 (28.9%) had one long-term condition and 10,486 (43.9%) had multimorbidity (two or more long-term health conditions). The most common conditions were primary cancer (39.6%); hypertension (37.9%); chronic kidney disease (17.4%); and diabetes (15.4%). Patients with multimorbidity had a higher incidence of frailty compared with patients ≤ 1 long-term health condition. Mortality was higher in patients with one long-term health condition (adjusted odds ratio 1.93 (95%CI 1.16-3.23)) and multimorbidity (adjusted odds ratio 2.22 (95%CI 1.35-3.64)). Frailty and ASA physical status 3-5 mediated an estimated 31.7% of the 30-day mortality in patients with one long-term health condition (adjusted odds ratio 1.30 (95%CI 1.12-1.51)) and an estimated 36.9% of the 30-day mortality in patients with multimorbidity (adjusted odds ratio 1.61 (95%CI 1.36-1.91)). There was no improvement in 30-day mortality in patients with multimorbidity who received pre-operative medical assessment. Conclusions: Multimorbidity is common and outcomes are poor among surgical patients across Europe. Addressing multimorbidity in elective and emergency patients requires innovative strategies to account for frailty and disease control. The development of such strategies, that integrate care targeting whole surgical pathways to strengthen current systems, is urgently needed for multimorbid patients. Interventional trials are warranted to determine the effectiveness of targeted management for surgical patients with multimorbidity.

The optimal treatment of anastomotic leak after rectal cancer resection is unclear. This worldwide cohort study aimed to provide an overview of four treatment strategies applied.

Objective Parathyroid carcinoma (PC) is considered a rare malignancy which accounts for less than 1% of hyperparathyroidism cases in reported literature. In B. C. James study there were only 348 cases of PC reported in SEER database 2000-2012, which compose 0,36 (per 1 million) incidence rate. PC occurrence is equal in men and women, while benign parathyroid diseases incidence is higher in women with ratio 3-4:1. Diagnostic criteria were established in 1973 by A. Schantz and B. Castleman which include thick fibrous bands, mitotic activity, vascular and capsular invasion in pathomorphological tests. The variations and pathognomic features are debated as there have been reported large series of patients with metastatic tumours of which as many as 50% were initially misdiagnosed as benign tumours, therefore preoperative diagnosis and staging is often incorrect or not available. Imaging techniques such as sestamibi scintigraphy and neck ultrasound are only used in localizing the parathyroid tissue preoperatively and >3cm size mass may raise suspicion of PC as denoted in Cetani study, however these techniques are in no way diagnostic of PC. This lead to diagnostic markers application such as Ki-67, Cyclin D1, which are more specific to PC than parathyroid adenoma. The course of disease is indolent and most deaths occur due to untreated complications of hypercalcemia. Ten cases of PC were treated in our hospital during the period of 17 years. This review focuses on our experience with the diagnosis, treatment and survival of the patients. Our aim was to review the demographics, diagnostics, treatment and outcomes of the patients, who were surgically treated for parathyroid carcinoma in the Hospital of Lithuanian University of Health Sciences Kauno Klinikos. As large part of contemporary literature on the topic is referencing the older studies from the year 2000 and before, we think that a more recent standpoint can contribute to better understanding the PC. Methods The model of the study was retrospective. Data on demographics, initial symptoms, preoperative diagnostic blood tests and instrumental procedures, surgical operations, complications, postoperative blood tests, and histology of tumours was collected. The data concerning patients‘ survival was acquired from the Lithuanian National Cancer Institute’s Cancer Registry. Results There were 10 patients who were treated surgically for parathyroid carcinoma. During the study period patients with PC accounted for 2,2 percent of all the patients with parathyroid gland pathology treated surgically in our clinic. Among PC patients there were 7 females, age distribution was from 54 – 74, mean – 64 years. Eighty percent of admitted patients suffered from complications. The most prevalent symptoms were renal function impairment, nephrolithiasis and subsequent pyelonephritis. Three patients had suffered from spontaneous bone fractures. Other common complaints included joint pain and malaise, hoarseness of voice.. Five patients had palpable disease at time of admission. One patient was asymptomatic (Table 1). Preoperative blood tests showed increased serum calcium 2,62-3,4 mmol/l (normal range (NR) – 2,15-2,55 mmol/l), ionized calcium 1,15- 1,57 mmol/l (NR – 0,98-1,13 mmol/l), and PTH 23,91 – 210 pmol/l (NR – 1,2-5,3 pmol/l), which plunged to normal range after surgical treatment. All patients were tested with ultrasound and scintigraphy. Five fine needle aspirational (FNA) punctures of nodules were performed (Table 3). None of the tests were diagnostic of parathyroid carcinoma preoperatively, nevertheless 5 out of 5 cytology showed features of malignancy. En-bloc parathyroidectomies were performed on all patients with various extents of thyroid gland removal. The diagnoses of PC were confirmed with histologic tests. Most prevalent features included vascular invasion (70%), capsular invasion (60%) and presence of fibrous bands (60%). There were no cases with distant metastases at initial surgery and lymphonodectomies were not performed. Data from Cancer registry showed, that 8 out of 10 patients were alive (survivability ranging from 4 months to 16 years postoperatively). Two of the patients have deceased due to carcinoma of pancreas and thyroid gland 2 and 4 years respectively after the operation. Conclusions Parathyroid carcinoma has complex diagnostics and staging because of its rarity and lack of studies. Majority of PC patients present with hypercalcemia and its complications – renal insufficiency, nephrolithiasis. Palpable neck mass is prevalent in half of the patients. Lesser than 3,5 mmol/l values of serum calcium should not lessen the suspicion of PC. The outcome of non-metastasized PC is favourable when en-bloc resection of the tumour is performed. Brief description of the abstract Objective: Review the diagnostics, treatment and outcomes of the patients, who were surgically treated for parathyroid carcinoma in the Hospital of LUHS Kauno klinikos from 2003 to 2019. Conclusions: Majority of PC patients present with hypercalcemia and its complications – renal insufficiency, nephrolithiasis. Lesser than 3,5 mmol/l values of serum calcium should not lessen the suspicion of PC. The outcome of non-metastasized PC is favourable when en-bloc resection of the tumour is performed.

To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL).

Background: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58-5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23-0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised.

We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05-1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4-7 days or ≥ 8 days of 1.25 (1.04-1.48), p = 0.015 and 1.31 (1.11-1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care.