POSSUM: a scoring system for surgical audit

Impact of Enhanced Recovery Protocols on Short-Term Outcomes in Esophagectomy: A Retrospective Cohort Study from Cancer Research Institute, Uttarakhand, India

OBJECTIVE

Surgery for esophageal cancer is associated with high mortality and morbidity, especially in low and middle-income countries. The recent enhanced recovery after surgery guidelines for esophagectomy (2018) which attempt to reduce complications and length of stay (LOS) have rarely been validated in these settings. This study aimed to analyse the effect of this protocol on short-term outcomes in our subset of patients.

METHODS

A retrospective review was conducted to investigate the outcomes of enhanced recovery protocol (ERP) compared to standard pre-protocol care (PP) in patients who underwent esophagectomy for cancer (31 in ERP vs 61 in PP group) at Cancer Research Institute, Uttarakhand, India. The main outcomes measured were 30-day mortality, morbidity and LOS. Risk assessment was stratified as per Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) systems while complications were classified as per the Clavien-Dindo scale.

RESULTS

Preoperative clinical characteristics were similar between groups. Though the predicted POSSUM mortality and morbidity were significantly higher in the ERP group (p = 0.007), 30-day morbidity (19.35% vs 42.62%, p = 0.027) as well as median LOS (12 vs 15 days, p < 0.001) was significantly lower in ERP group. The PP group reported 4 deaths within 30 days as compared to none in the ERP group (p = 0.296). Furthermore, the ERP group reported lower occurrence of pulmonary complications (6.4%vs24.6%,p = 0.046), hemodynamic instability (0%vs14.75%,p = 0.026) as well as need for prolonged postoperative ventilation (> 24 h; 0% vs 11.48%, p = 0.004). Both minor and major complications as assessed by the Clavien-Dindo scale were lower in the group ERP though these differences were not statistically significant (0.059).

CONCLUSIONS

Implementation of ERP improved short-term outcomes; hence can be strongly recommended in patients undergoing esophagectomy.

Investigating the Impact of Patient-Related Factors on Speech Outcomes at 5 Years of Age in Children With a Cleft Palate

To investigate the relationship between patient-related factors (sex, cleft type, cleft extent, and Robin Sequence [RS]) and speech outcome at 5 years of age for children born with a cleft palate ±  lip (CP ± L).

3157 Children (1426 female:1731 male) with a nonsyndromic CP ± L, born between 2006 and 2014 in England, Wales, and Northern Ireland.

Perceptual speech analysis utilized the Cleft Audit Protocol for Speech-Augmented (CAPS-A) rating and UK National Speech Outcome Standards: Speech Standard 1 (SS1)-speech within the normal range, SS2a-no structurally related speech difficulties or history of speech surgery, and SS3-speech without significant cleft-related articulation difficulties.

Odds of achieving SS1 were lower among boys (aOR 0.771 [CI 0.660-0.901]), those with clefts involving the lip and palate (vs palate only) (UCLP-aOR 0.719 [CI 0.591-0.875]; BCLP-aOR 0.360 [CI 0.279-0.463]), and clefts involving the hard palate (incomplete-aOR 0.701 [CI 0.540-0.909]; complete-aOR 0.393 [CI 0.308-0.501]). Similar relationships with these patient factors were observed for SS3. SS2 was affected by the extent of hard palate involvement (complete; aOR 0.449 [CI 0.348-0.580]). Although those with CP and RS were less likely to meet all 3 standards than those without RS, odds ratios were not significant when adjusting for sex and cleft extent.

Sex, cleft type, and extent of hard palate involvement have a significant impact on speech outcome at 5 years of age. Incorporating these factors into risk-adjustment models for service-level outcome reporting is recommended.

Rectal cancer surgery: does low volume imply worse outcome-a single surgeon experience

BACKGROUND

The centralisation of rectal cancer management to high-volume oncology centres has translated to improved oncological and survival outcomes. We hypothesise that individual surgeon caseload, specialisation, and experience may be as significant in determining oncologic and postoperative outcomes in rectal cancer surgery.

METHODS

A prospectively maintained colorectal surgery database was reviewed for patients undergoing rectal cancer surgery between January 2004 and June 2020. Data studied included demographics, Dukes' and TNM staging, neoadjuvant treatment, preoperative risk assessment scores, postoperative complications, 30-day readmission rates, length of stay (LOS), and long-term survival. Primary outcome measures were 30-day mortality and long-term survival compared to national and international standards and best practice guidelines.

RESULTS

In total, 87 patients were included (mean age: 66 years [range: 36-88]). The mean length of stay (LOS) was 16.5 days (SD 6.0). The median ICU LOS was 3 days (range 2-17). Overall, 30-day readmission rate was 16.4%. Twenty-four patients (26.4%) experienced ≥ 1 postoperative complication. The 30-day operative mortality rate was 3.45%. Overall 5-year survival rate was 66.6%. A significant correlation was observed between P-POSSUM scores and postoperative complications (p = 0.041), and all four variants of POSSUM, CR-POSSUM, and P-POSSUM scores and 30-day mortality.

CONCLUSION

Despite improved outcomes seen with centralisation of rectal cancer services at an institutional level, surgeon caseload, experience, and specialisation is of similar importance in obtaining optimal outcomes within institutions.

Preoperative nutritional support in patients undergoing pancreatic surgery affects PREPARE score accuracy

Background

This study aimed to validate the accuracy of the Preoperative Pancreatic Resection (PREPARE) risk score in pancreatic resection patients.

Patients and methods

This prospective study included 216 patients who underwent pancreatic resection between January 2015 and December 2018. All patients in our cohort with weight loss or lack of appetite received dietary advice and preoperative oral nutritional supplementation (600 kcal/day). Demographic, clinicopathological, operative, and postoperative data were collected prospectively. The PREPARE score and the predicted risk of major complications were computed for each patient. Differences in major postoperative complications were analyzed using a multivariate Cox proportional hazards regression model. The predicted and observed risks of major complications were tested using the C-statistic.

Results

The study included 216 patients [117 men (54.2%)] with a median age of 65.0 (30.0-83.0) years. The majority of patients were classified as American Society of Anesthesiologists (ASA)' Physical Status score II (N = 164/216; 75.9%) and as "low risk" PREPARE score (N = 185/216; 85.6%) before the surgery. Only 4 (1.9%) patients were malnourished, with albumin levels of less than 3.5 g/dl. The most common type of pancreatic resection was a pylorus-preserving pancreaticoduodenectomy (N = 122/216; 56.5%). Major morbidity and 30-day mortality rates were 11.1% and 1.9%, respectively. The type of surgical procedure (hazard ratio [HR]: 3.849; 95% confidence interval [CI]: 1.208-12.264) and ASA score (HR: 3.089; 95% CI: 1.067-8.947) were significantly associated with the incidence of major postoperative complications in multivariate analysis. The receiver operating characteristic curve was 0.657 for incremental values and 0.559 for risk categories, indicating a weak predictive model.

Conclusion

The results of the present study suggest that the PREPARE risk score has low accuracy in predicting the risk of major complications in patients with consistent preoperative nutritional support. This limits the use of PREPARE risk score in future preoperative clinical routines.

O-POSSUM and P-POSSUM as predictors of morbidity and mortality in older patients after hip fracture surgery: a meta-analysis

BACKGROUND

The POSSUM model has been widely used to predict morbidity and mortality after general surgery. Modified versions known as O-POSSUM and P-POSSUM have been used extensively in orthopedic surgery, but their accuracy is unclear. This systematic review evaluated the predictive value of these models in older patients with hip fractures.

METHODS

This study was performed and reported based on the "Preferred reporting items for systematic reviews and meta-analyses" guidelines. PubMed, Cochrane, EMBASE, and Web of Science were comprehensively searched for relevant studies, whose methodological quality was evaluated according to the "Methodological index for non-randomized studies" scale. Revman 5 was used to calculate weighted ratios of observed to expected morbidity or mortality.

RESULTS

The meta-analysis included 10 studies, of which nine (2549 patients) assessed the ability of O-POSSUM to predict postoperative morbidity, nine (3649 patients) assessed the ability of O-POSSUM to predict postoperative mortality, and four (1794 patients) assessed the ability of P-POSSUM to predict postoperative mortality. The corresponding weighted ratios of observed to expected morbidity or mortality were 0.84 (95% CI 0.70-1.00), 0.68 (95% CI 0.49-0.95), and 0.61 (95% CI 0.16-2.38).

CONCLUSIONS

While O-POSSUM shows reasonable accuracy in predicting postoperative morbidity in older patients with hip fractures, both P-POSSUM and O-POSSUM substantially overestimate postoperative mortality. The POSSUM model should be optimized further for this patient population.

Frailty Assessment Can Enhance Current Risk Prediction Tools in Emergency Laparotomy: A Retrospective Cohort Study

OBJECTIVE

We set out to assess the performance of the P-POSSUM and NELA risk prediction tool (NELA RPT), and hypothesized that combining them with the Clinical Frailty Scale (CFS) would significantly improve their performance. Emergency laparotomy (EL) is a high-risk surgical intervention, particularly for elderly patients with marked comorbidities and frailty. Accurate risk prediction is crucial for appropriate resource allocation, clinical decision making, and informed consent. Although patient frailty is a significant risk factor, the current risk prediction tools fail to take frailty into account.

METHODS

In this retrospective single-center cohort study, we analyzed all cases entered into the NELA database from the Oxford University Hospitals between 01.01.2018 and 15.06.2021. We analyzed the performance of the P-POSSUM and NELA RPT. Both tools were modified by adding the CFS to the model.

RESULTS

The discrimination of both the P-POSSUM and NELA RPT was good, with a slightly worse performance in the elderly. Adding CFS into the P-POSSUM and NELA RPT models improved both tools in the elderly [AUC from 0.775 to 0.846 (p < 0.05) from 0.814 to 0.864 (p < 0.05), respectively]. The improvement of the NELA RPT across all age groups did not reach statistical significance. The CFS grade was associated with 30-day mortality in patients aged > 65 years. However, in younger patients, this effect was less marked than in the elderly.

CONCLUSION

Our analysis demonstrated a significant improvement in the P-POSSUM and NELA risk models when combined with the CFS. Frailty also increases the 30-day mortality after EL in younger individuals.

Preoperative shock index in major abdominal emergency surgery

Introduction

Major abdominal emergency surgery (MAES) patients have a high risk of mortality and complications. The time-sensitive nature of MAES necessitates an easily calculable risk-scoring tool. Shock index (SI) is obtained by dividing heart rate (HR) by systolic blood pressure (SBP) and provides insight into a patient's haemodynamic status. We aimed to evaluate SI's usefulness in predicting postoperative mortality, acute kidney injury (AKI), requirements for intensive care unit (ICU) and high-dependency monitoring, and the ICU length of stay (LOS).

Method

We retrospectively reviewed 212,089 MAES patients from January 2013 to December 2020. The cohort was propensity matched, and 3960 patients were included. The first HR and SBP recorded in the anaesthesia chart were used to calculate SI. Regression models were used to investigate the association between SI and outcomes. The relationship between SI and survival was explored with Kaplan-Meier curves.

Results

There were significant associations between SI and mortality at 1 month (odds ratio [OR] 2.40 [1.67-3.39], P<0.001), 3 months (OR 2.13 [1.56-2.88], P<0.001), and at 2 years (OR 1.77 [1.38-2.25], P<0.001). Multivariate analysis revealed significant relationships between SI and mortality at 1 month (OR 3.51 [1.20-10.3], P=0.021) and at 3 months (OR 3.05 [1.07-8.54], P=0.034). Univariate and multivariate analysis also revealed significant relationships between SI and AKI (P<0.001), postoperative ICU admission (P<0.005) and ICU LOS (P<0.001). SI does not significantly affect 2-year mortality.

Conclusion

SI is useful in predicting postopera-tive mortality at 1 month, 3 months, AKI, postoperative ICU admission and ICU LOS.

Predicting in-hospital mortality risk for perforated peptic ulcer surgery: the PPUMS scoring system and the benefit of laparoscopic surgery: a population-based study

BACKGROUND

The major treatment for perforated peptic ulcers (PPU) is surgery. It remains unclear which patient may not get benefit from surgery due to comorbidity. This study aimed to generate a scoring system by predicting mortality for patients with PPU who received non-operative management (NOM) and surgical treatment.

METHOD

We extracted the admission data of adult (≥ 18 years) patients with PPU disease from the NHIRD database. We randomly divided patients into 80% model derivation and 20% validation cohorts. Multivariate analysis with a logistic regression model was applied to generate the scoring system, PPUMS. We then apply the scoring system to the validation group.

RESULT

The PPUMS score ranged from 0 to 8 points, composite with age (< 45: 0 points, 45-65: 1 point, 65-80: 2 points, > 80: 3 points), and five comorbidities (congestive heart failure, severe liver disease, renal disease, history of malignancy, and obesity: 1 point each). The areas under ROC curve were 0.785 and 0.787 in the derivation and validation groups. The in-hospital mortality rates in the derivation group were 0.6% (0 points), 3.4% (1 point), 9.0% (2 points), 19.0% (3 points), 30.2% (4 points), and 45.9% when PPUMS > 4 point. Patients with PPUMS > 4 had a similar in-hospital mortality risk between the surgery group [laparotomy: odds ratio (OR) = 0.729, p = 0.320, laparoscopy: OR = 0.772, p = 0.697] and the non-surgery group. We identified similar results in the validation group.

CONCLUSION

PPUMS scoring system effectively predicts in-hospital mortality for perforated peptic ulcer patients. It factors in age and specific comorbidities is highly predictive and well-calibrated with a reliable AUC of 0.785-0.787. Surgery, no matter laparotomy or laparoscope, significantly reduced mortality for scores <  = 4. However, patients with a score > 4 did not show this difference, calling for tailored approaches to treatment based on risk assessment. Further prospective validation is suggested.

Risk Prediction Models for Peri-Operative Mortality in Patients Undergoing Major Vascular Surgery with Particular Focus on Ruptured Abdominal Aortic Aneurysms: A Scoping Review

PURPOSE

The present scoping review aims to describe and analyze available clinical data on the most commonly reported risk prediction indices in vascular surgery for perioperative mortality, with a particular focus on ruptured abdominal aortic aneurysm (rAAA).

MATERIALS AND METHODS

A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English in PubMed, Cochrane and EMBASE databases (last queried, 30 March 2023) were systematically reviewed and analyzed. The Population, Intervention, Comparison, Outcome (PICO) framework used to construct the search strings was the following: in patients with aortic pathologies, in particular rAAA (population), undergoing open or endovascular surgery (intervention), what different risk prediction models exist (comparison), and how well do they predict post-operative mortality (outcomes)?

RESULTS

The literature search and screening of all relevant abstracts revealed a total of 56 studies in the final qualitative synthesis. The main findings of the scoping review, grouped by the risk score that was investigated in the original studies, were synthetized without performing any formal meta-analysis. A total of nine risk scores for major vascular surgery or elective AAA, and 10 scores focusing on rAAA, were identified. Whilst there were several validation studies suggesting that most risk scores performed adequately in the setting of rAAA, none reached 100% accuracy. The Glasgow aneurysm score, ERAS and Vancouver score risk scores were more frequently included in validation studies and were more often used in secondary studies. Unfortunately, the published literature presents a heterogenicity of results in the validation studies comparing the different risk scores. To date, no risk score has been endorsed by any of the vascular surgery societies.

CONCLUSIONS

The use of risk scores in any complex surgery can have multiple advantages, especially when dealing with emergent cases, since they can inform perioperative decision making, patient and family discussions, and post hoc case-mix adjustments. Although a variety of different rAAA risk prediction tools have been published to date, none are superior to others based on this review. The heterogeneity of the variables used in the different scores impairs comparative analysis which represents a major limitation to understanding which risk score may be the "best" in contemporary practice. Future developments in artificial intelligence may further assist surgical decision making in predicting post-operative adverse events.

Surgical management for elderly patients with pancreatic cancer

Pancreatic cancer, one of the diseases of the elderly, has dismal prognosis, demanding major surgery with high risk and life quality problems, especially in the elderly. Therefore, treatment selection, whether or not to undergo surgery, preoperative risk assessment, and perioperative management of the elderly are becoming critical issues. Although the elderly are expected to have higher morbidity and mortality and lower long-term survival outcomes, surgery is becoming safer over time. Appropriate surgical indication selection, patient-centered decision-making, adequate prehabilitation and postoperative geriatric care are expected to improve surgical outcomes in the elderly. Surgeons must have the concept of geriatric care, and efforts based on institutional systems and academic societies are required. If well selected and prepared, the same surgical principle as non-elderly patients can be applied to elderly patients. In this paper, the surgical treatment of elderly patients with pancreatic cancer is reviewed.

Impact of Introducing a PACU24 Concept on the Perioperative Outcome of Patients with Advanced Ovarian Cancer Treated with Cytoreductive Surgery

Introduction

Patients with ovarian cancer who undergo multivisceral surgery usually require intensive care monitoring postoperatively. In view of the ever-fewer numbers of high-care/intensive care beds and the introduction of fast-track treatment concepts, it is increasingly being suggested that these patients should be cared for postoperatively in 24-h Post Anesthesia Care Units (PACU24). No analyses have been carried out to date to investigate whether such a postoperative care concept might be associated with a potential increase in postoperative complications in this patient cohort.

Methods

A PACU24 unit was set up in our institution in 2015 and it has become the primary postoperative care pathway for patients with ovarian cancer who have undergone cytoreductive (debulking) surgery. A structured, retrospective analysis of data from patients treated before (control group) and after (PACU group) the introduction of this care concept was carried out, with a particular focus on postoperative complications and secondary admission to an intensive care unit where necessary.

Results

The data of 42 patients were analyzed for the PACU group and 45 patients for the control group. According to the analysis, the preoperative and surgical data of both groups were comparable (age, ASA, BMI, FIGO stage, duration of surgery, blood loss). The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM score) as a measure for the risk of postoperative complications was higher in the PACU group (11.1% vs. 9.7%, p = 0.001). Patients in the PACU group underwent bowel resection with anastomosis significantly more often (76.3% vs. 33.3%, p < 0.001), although the extent of surgery was otherwise comparable. The total number, type and severity of postoperative complications and the duration of the overall stay in hospital did not differ between the two groups. None of the patients required secondary transfer from the PACU or normal ward to an intensive care unit (ICU).

Summary

Our data support the assumption that the care concept of transferring patients to a PACU24 represents a safe and cost-saving care pathway for the postoperative care of patients even after complex gynecological-oncological procedures.

Combined and intraoperative risk modelling for oesophagectomy: A systematic review

BACKGROUND

Oesophageal cancer is the eighth most common malignancy worldwide and is associated with a poor prognosis. Oesophagectomy remains the best prospect for a cure if diagnosed in the early disease stages. However, the procedure is associated with significant morbidity and mortality and is undertaken only after careful consideration. Appropriate patient selection, counselling and resource allocation is essential. Numerous risk models have been devised to guide surgeons in making these decisions.

AIM

To evaluate which multivariate risk models, using intraoperative information with or without preoperative information, best predict perioperative oesophagectomy outcomes.

METHODS

A systematic review of the MEDLINE, EMBASE and Cochrane databases was undertaken from 2000-2020. The search terms used were [(Oesophagectomy) AND (Model OR Predict OR Risk OR score) AND (Mortality OR morbidity OR complications OR outcomes OR anastomotic leak OR length of stay)]. Articles were included if they assessed multivariate based tools incorporating preoperative and intraoperative variables to forecast patient outcomes after oesophagectomy. Articles were excluded if they only required preoperative or any post-operative data. Studies appraising univariate risk predictors such as preoperative sarcopenia, cardiopulmonary fitness and American Society of Anesthesiologists score were also excluded. The review was conducted following the preferred reporting items for systematic reviews and meta-analyses model. All captured risk models were appraised for clinical credibility, methodological quality, performance, validation and clinical effectiveness.

RESULTS

Twenty published studies were identified which examined eleven multivariate risk models. Eight of these combined preoperative and intraoperative data and the remaining three used only intraoperative values. Only two risk models were identified as promising in predicting mortality, namely the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and POSSUM scores. A further two studies, the intraoperative factors and Esophagectomy surgical Apgar score based nomograms, adequately forecasted major morbidity. The latter two models are yet to have external validation and none have been tested for clinical effectiveness.

CONCLUSION

Despite the presence of some promising models in forecasting perioperative oesophagectomy outcomes, there is more research required to externally validate these models and demonstrate clinical benefit with the adoption of these models guiding postoperative care and allocating resources.

Usefulness of Preoperative Determination of Serum MR-ProAdrenomedullin Levels to Predict the Need for Postoperative Organ Support in Abdominal Oncological Surgery

The need for postoperative organic support is associated with patient outcomes. Biomarkers may be useful for detecting patients at risk. MR-ProADM is a novel biomarker with an interesting profile that can be used in this context. The main objective of this study was to verify whether there was an association between the preoperative serum levels of MR-ProADM and the need for organic support after elective abdominal cancer surgery, and to determine the preoperative MR-ProADM value that predicts the need for postoperative organic support. This was a multicenter prospective observational study conducted by four tertiary hospitals in Spain between 2017 and 2018. Plasma samples were collected for the quantification of MR-ProADM from adults who underwent major abdominal surgery during 2017-2018. The primary outcome was the need for organic support in the first seven postoperative days and its association with the preoperative levels of MR-ProADM, and the secondary outcome was the preoperative levels of MR-ProADM in the study population. This study included 370 patients with a mean age of 67.4 ± 12.9 years. Seventeen percent (63 patients) required some postoperative organic support measures in the first week. The mean preoperative value of MR-ProADM in patients who required organic support was 1.16 ± 1.15 nmol/L. The AUC-ROC of the preoperative MR-ProADM values associated with the need for organic support was 0.67 (95% CI: 0.59-0.75). The preoperative MR-ProADM value, which showed the best compromise in sensitivity and specificity for predicting the need for organic support, was 0.70 nmol/L. The negative predictive value was 91%. A multivariate analysis confirmed that a preoperative level of MR-ProADM ≥ 0.70 nmol/L is an independent factor associated with risk of postoperative organic support (OR 2, 6). Elevated preoperative MR-ProADM levels are associated with the need for postoperative organic support. Therefore, MR-ProADM may be a useful biomarker for perioperative risk assessment.

Interpretable prediction of cardiopulmonary complications after non-small cell lung cancer surgery based on machine learning and SHapley additive exPlanations

Introduction

Lung cancer is a prevalent malignancy globally, with approximately 20% of patients developing cardiopulmonary complications after lobectomy. In order to prevent complications, an accurate and personalized method based on machine learning (ML) is required.

Methods

During the period of 2017-2021, a retrospective analysis was conducted on the medical records of patients who had undergone lobectomy for non-small cell lung cancer (NSCLC). We performed logical regression, decision tree (DT), random forest (RF), gradient boost DT, and eXtreme gradient boosting analyses to establish an ML model. The ten-fold cross-validation was used to evaluate the performance of multiple ML models based on various evaluation metrics, including accuracy, precision, recall, F1 score, and area under the receiver operating (AUC). Additionally, we also calculated the Kappa value of these model. Each model used grid search to optimize hyper-parameters and then used the interpretability method to provide explanations for the model's Decisions.

Results

The study included 718 eligible patients, among whom the incidence of postoperative cardiopulmonary complications was 20.89%. The RF model showed the best comprehensive performance among all models, and its ten-fold cross-validation accuracy, precision, recall, F1 score, and AUC were (OR and 95% confidence interval [CI]) 0.786 (0.738-0.834), 0.803 (0.735-0.872), 0.738 (0.678-0.797), 0.766 (0.714-0.818), 0.856 (0.815-0.898), respectively. The kappa value of the RF model was 0.696 (0.617-0.768). The SHAP method showed that gender, age, and intraoperative blood loss were closely associated with postoperative cardiopulmonary complications.

Conclusion

The application of ML methods for predicting postoperative cardiopulmonary complications based on clinical data of patients with NSCLC showed a good performance. The results indicate that ML combined with the SHAP individualized interpretation method has practical clinical value.

Use of POSSUM (Physiologic and Operative Severity Score for the Study of Mortality and Morbidity) and Portsmouth-POSSUM for Surgical Assessment in Patients Undergoing Emergency Abdominal Surgeries

INTRODUCTION

The POSSUM (Physiologic and Operative Severity Score for the Study of Mortality and Morbidity) and Portsmouth-POSSUM (P-POSSUM) models have been popularly recommended as appropriate for predicting postoperative mortality and morbidity in surgical practice. This study aims to evaluate the efficacy and accuracy of both scoring systems for surgical risk assessment in predicting postoperative mortality and morbidity in patients undergoing emergency abdominal surgeries.

METHODOLOGY

The study was conducted as a part of a post-doctoral fellowship program. A total of 150 patients, undergoing emergency abdominal surgery in a tertiary care hospital in Bhubaneswar, were evaluated using POSSUM and P-POSSUM. Physiological scoring was done prior to surgery and operative scoring was performed intra-operatively. Patients were followed up for 30 days after the operative period. The observed mortality rate was then compared with POSSUM and P-POSSUM predicted mortality rates.

RESULTS

POSSUM predicted a morbidity rate of 116, whereas the actual morbidity rate was 92 (p < 0.05). P-POSSUM predicted a morbidity rate of 109, whereas the actual morbidity rate was 92 (p < 0.05). POSSUM predicted a mortality rate of 23, whereas the actual mortality rate was 21 (p < 0.05). P-POSSUM predicted a mortality rate of 25, whereas the actual mortality rate was 21 (p < 0.05).

CONCLUSIONS

With a reasonably good prediction of morbidity and mortality rate, POSSUM and P-POSSUM scores are both effective scoring systems in clinical practice for use in abdominal surgery.

Nationwide Outcomes of Octogenarians Following Open or Endovascular Management After Ruptured Abdominal Aortic Aneurysms

PURPOSE

Octogenarians are known to have less-favorable outcomes following ruptured abdominal aortic aneurysm (rAAA) repair compared with their younger counterparts. Accurate information regarding perioperative outcomes following rAAA-repair is important to evaluate current treatment practice. The aim of this study was to evaluate perioperative outcomes of octogenarians and to identify factors associated with mortality and major complications after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of a rAAA using nationwide, real-world, contemporary data.

METHODS

All patients that underwent EVAR or OSR of an infrarenal or juxtarenal rAAA between January 1, 2013, and December 31, 2018, were prospectively registered in the Dutch Surgical Aneurysm Audit (DSAA) and included in this study. The primary outcome was the comparison of perioperative outcomes of octogenarians versus non-octogenarians, including adjustment for confounders. Secondary outcomes were the identification of factors associated with mortality and major complications in octogenarians.

RESULTS

The study included 2879 patients, of which 1146 were treated by EVAR (382 octogenarians, 33%) and 1733 were treated by OSR (410 octogenarians, 24%). Perioperative mortality of octogenarians following EVAR was 37.2% versus 14.8% in non-octogenarians (adjusted OR=2.9, 95% CI=2.8-3.0) and 50.0% versus 29.4% following OSR (adjusted OR=2.2, 95% CI=2.2-2.3). Major complication rates of octogenarians were 55.4% versus 31.8% in non-octogenarians following EVAR (OR=2.7, 95% CI=2.1-3.4), and 68% versus 49% following OSR (OR=2.2, 95% CI=1.8-2.8). Following EVAR, 30.6% of the octogenarians had an uncomplicated perioperative course (UPC) versus 49.5% in non-octogenarians (OR=0.5, 95% CI=0.4-0.6), while following OSR, UPC rates were 20.7% in octogenarians versus 32.6% in non-octogenarians (OR=0.5, 95% CI=0.4-0.7). Cardiac or pulmonary comorbidity and loss of consciousness were associated with mortality and major complications in octogenarians. Interestingly, female octogenarians had lower mortality rates following EVAR than male octogenarians (adjusted OR=0.7, 95% CI=0.6-0.8).

CONCLUSION

Based on this nationwide study with real-world registry data, mortality rates of octogenarians following ruptured AAA-repair were high, especially after OSR. However, a substantial proportion of these octogenarians following OSR and EVAR had an uneventful recovery. Known preoperative factors do influence perioperative outcomes and reflect current treatment practice.

The clinical importance of high-sensitivity cardiac troponin measurements for risk prediction in non-cardiac surgery

INTRODUCTION

The global healthcare burden associated with surgery is substantial, with many patients experiencing perioperative complications. Cardiac troponin I and T measured with high-sensitivity assays are cardiac specific biomarkers that associate closely with adverse outcomes in most patient populations. Perioperative physiological stress can induce troponin release from cardiomyocytes, a condition known as perioperative myocardial injury (PMI). PMI is associated with increased risk of poor short- and long-term outcomes, and current European guidelines recommend screening for PMI in at-risk individuals undergoing non-cardiac surgery.

AREAS COVERED

In this review we summarize current knowledge of the prognostic attributes of cardiac troponins, as well as the challenges associated with their application as biomarkers in the perioperative phase.

EXPERT OPINION

Measurement of circulating levels of cardiac troponins identify individuals at increased risk of poor postoperative outcomes. Systematic screening of at-risk individuals undergoing non-cardiac surgery will result in a large proportion of patients in need of further diagnostic workup to establish the exact nature of their PMI. The lack of concrete evidence of clinical benefit and the increased cost associated with such a strategy is concerning and underscore the need for further research.

ERAS programme in a Portuguese tertiary hospital: An audit of the first six months of implementation in elective colorectal surgery

INTRODUCTION AND OBJECTIVES

Enhanced Recovery After Surgery (ERAS) is a multimodal strategy designed to optimize postoperative recovery and reduce morbidity, length of hospital stay, and care costs. The aim of this study was to evaluate compliance and clinical outcomes 6 months of implementation of the program in scheduled colorectal surgery in a tertiary hospital.

MATERIAL AND METHODS

Data from 209 patients who underwent elective colorectal surgery were analysed. The first 102 patients (pre-ERAS group) who underwent surgery between January and May 2018, before the implementation of the program, were compared with the 107 patients treated between May and October 2019, after ERAS implementation. The main outcomes were patient education and counselling, use of intravenous fluids, early mobilization, incidence of postoperative nausea and vomiting, return of bowel function, length of stay, complications, mortality, and overall compliance.

RESULTS

The ERAS program was associated with a significant increase in patient education and counselling (p<0.001) and with a significant reduction in intra- and postoperative IV fluid administration (p=0.007 and p<0.001, respectively) and postoperative nausea or vomiting (17.6% vs 5.0%, p=0.007). Time to recovery of activities of daily living (5.29 vs 2.85 days; p<0.001), time to solid oral intake (6.21 vs 4.35 days; p<0.001), time to first flatus (2.41 vs 1.51 days; p<0.001) and defecation (3.35 vs 1.66 days; p<0.001) decreased with ERAS. There were no statistically significant differences in length of stay, complications, and mortality.

CONCLUSION

This study showed that the ERAS program improved perioperative outcomes and postoperative recovery in patients undergoing colorectal surgery in our hospital.

Perioperative Risk Assessment in Humanitarian Settings: A Scoping Review

BACKGROUND

No validated perioperative risk assessment models currently exist for use in humanitarian settings. To inform the development of a perioperative mortality risk assessment model applicable to humanitarian settings, we conducted a scoping review of the literature to identify reports that described perioperative risk assessment in surgical care in humanitarian settings and LMICs.

METHODS

We conducted a scoping review of the literature to identify records that described perioperative risk assessment in low-resource or humanitarian settings. Searches were conducted in databases including: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, World Health Organization Catalog, and Google Scholar.

RESULTS

Our search identified 1582 records. After title/abstract and full text screening, 50 reports remained eligible for analysis in quantitative and qualitative synthesis. These reports presented data from over 37 countries from public, NGO, and military facilities. Data reporting was highly inconsistent: fewer than half of reports presented the indication for surgery; less than 25% of reports presented data on injury severity or prehospital data. Most elements of perioperative risk models designed for high-resource settings (e.g., vital signs, laboratory data, and medical comorbidities) were unavailable.

CONCLUSION

At present, no perioperative mortality risk assessment model exists for use in humanitarian settings. Limitations in consistency and quality of data reporting are a primary barrier, however, can be addressed through data-driven identification of several key variables encompassed by a minimum dataset. The development of such a score is a critical step toward improving the quality of care provided to populations affected by conflict and protracted humanitarian crises.

Classification of Adverse Events in Adult Surgery

Successful surgery combines quality (achievement of a positive outcome) with safety (avoidance of a negative outcome). Outcome assessment serves the purpose of quality improvement in health care by establishing performance indicators and allowing the identification of performance gaps. Novel surgical quality metric tools (benchmark cutoffs and textbook outcomes) provide procedure-specific ideal surgical outcomes in a subgroup of well-defined low-risk patients, with the aim of setting realistic and best achievable goals for surgeons and centers, as well as supporting unbiased comparison of surgical quality between centers and periods of time. Validated classification systems have been deployed to grade adverse events during the surgical journey: (1) the ClassIntra classification for the intraoperative period; (2) the Clavien-Dindo classification for the gravity of single adverse events; and the (3) Comprehensive Complication Index (CCI) for the sum of adverse events over a defined postoperative period. The failure to rescue rate refers to the death of a patient following one or more potentially treatable postoperative adverse event(s) and is a reliable proxy of the institutional safety culture and infrastructure. Complication assessment is undergoing digital transformation to decrease resource-intensity and provide surgeons with real-time pre- or intraoperative decision support. Standardized reporting of complications informs patients on their chances to realize favorable postoperative outcomes and assists surgical centers in the prioritization of quality improvement initiatives, multidisciplinary teamwork, surgical education, and ultimately, in the enhancement of clinical standards.

Categories of Evidence and Methods in Surgical Decision-Making

Surgical decision-making is a continuum of judgments that take place during the preoperative, intraoperative, and postoperative periods. The fundamental, and most challenging, step is determining whether a patient will benefit from an intervention given the dynamic interplay of diagnostic, temporal, environmental, patient-centric, and surgeon-centric factors. The myriad combinations of these considerations generate a wide spectrum of reasonable therapeutic approaches within the standards of care. Although surgeons may seek evidenced-based practices to support their decision-making, threats to the validity of evidence and appropriate application of evidence may influence implementation. Furthermore, a surgeon's conscious and unconscious biases may additionally determine individual practice.

Elective colorectal cancer surgery in nonagenarians and postoperative outcomes

OBJECTIVES

The population of very elderly patients is increasing, and nonagenarians have significantly higher mortality rates and poorer rates of survival than younger patients. Meanwhile, recent studies have shown colorectal cancer surgery in nonagenarian patients to be feasible regarding postoperative outcomes. This retrospective study aims to evaluate the postoperative outcomes of nonagenarians in the latest clinical settings.

METHODS

Consecutive nonagenarian patients who underwent elective colorectal cancer surgery between 2018 and 2020 retrospectively enrolled (Trial registration number: UMIN000046296 on December 7th, 2021). Clinicopathological data and short-term postoperative outcomes were collected for statistical analysis.

RESULTS

This study included 81 nonagenarian patients (31 males, 50 females). Postoperative complications occurred in 21 patients (25.9%), and 3 patients died within 90 days (3.7%). Multivariate analysis revealed prognostic nutritional index was a significant predictor of postoperative complications (OR 2.99, 95% CI 0.78-9.10, P = 0.048), and performance status ≥ 3 could be an independent risk factor of 90-day mortality (HR 32.30, 95% CI 3.20-326.10, P = 0.032).

CONCLUSIONS

Short-term outcomes after surgical treatment for nonagenarian patients with colorectal cancer were acceptable. Low prognostic nutritional index was closely related to postoperative complications and poor performance status could also lead to 90-day mortality. In aging populations, risk stratification to prevent poorer postoperative outcomes in nonagenarian patients is needed.

Prediction of morbidity and mortality after early cholecystectomy for acute calculous cholecystitis: results of the S.P.Ri.M.A.C.C. study

BACKGROUND

Less invasive alternatives than early cholecystectomy (EC) for acute calculous cholecystitis (ACC) treatment have been spreading in recent years. We still lack a reliable tool to select high-risk patients who could benefit from these alternatives. Our study aimed to prospectively validate the Chole-risk score in predicting postoperative complications in patients undergoing EC for ACC compared with other preoperative risk prediction models.

METHOD

The S.P.Ri.M.A.C.C. study is a World Society of Emergency Surgery prospective multicenter observational study. From 1st September 2021 to 1st September 2022, 1253 consecutive patients admitted in 79 centers were included. The inclusion criteria were a diagnosis of ACC and to be a candidate for EC. A Cochran-Armitage test of the trend was run to determine whether a linear correlation existed between the Chole-risk score and a complicated postoperative course. To assess the accuracy of the analyzed prediction models-POSSUM Physiological Score (PS), modified Frailty Index, Charlson Comorbidity Index, American Society of Anesthesiologist score (ASA), APACHE II score, and ACC severity grade-receiver operating characteristic (ROC) curves were generated. The area under the ROC curve (AUC) was used to compare the diagnostic abilities.

RESULTS

A 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. Chole-risk was validated, but POSSUM PS was the best risk prediction model for a complicated course after EC for ACC (in-hospital mortality: AUC 0.94, p < 0.001; 30-day mortality: AUC 0.94, p < 0.001; in-hospital major morbidity: AUC 0.73, p < 0.001; 30-day major morbidity: AUC 0.70, p < 0.001). POSSUM PS with a cutoff of 25 (defined in our study as a 'Chole-POSSUM' score) was then validated in a separate cohort of patients. It showed a 100% sensitivity and a 100% negative predictive value for mortality and a 96-97% negative predictive value for major complications.

CONCLUSIONS

The Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action.

TRIAL REGISTRATION

ClinicalTrial.gov NCT04995380.

Prediction of morbidity and mortality after early cholecystectomy for acute calculous cholecystitis: results of the S.P.Ri.M.A.C.C. study

Background

Less invasive alternatives than early cholecystectomy (EC) for acute calculous cholecystitis (ACC) treatment have been spreading in recent years. We still lack a reliable tool to select high-risk patients who could benefit from these alternatives. Our study aimed to prospectively validate the Chole-risk score in predicting postoperative complications in patients undergoing EC for ACC compared with other preoperative risk prediction models.

Method

The S.P.Ri.M.A.C.C. study is a World Society of Emergency Surgery prospective multicenter observational study. From 1st September 2021 to 1st September 2022, 1253 consecutive patients admitted in 79 centers were included. The inclusion criteria were a diagnosis of ACC and to be a candidate for EC. A Cochran-Armitage test of the trend was run to determine whether a linear correlation existed between the Chole-risk score and a complicated postoperative course. To assess the accuracy of the analyzed prediction models—POSSUM Physiological Score (PS), modified Frailty Index, Charlson Comorbidity Index, American Society of Anesthesiologist score (ASA), APACHE II score, and ACC severity grade—receiver operating characteristic (ROC) curves were generated. The area under the ROC curve (AUC) was used to compare the diagnostic abilities.

Results

A 30-day major morbidity of 6.6% and 30-day mortality of 1.1% were found. Chole-risk was validated, but POSSUM PS was the best risk prediction model for a complicated course after EC for ACC (in-hospital mortality: AUC 0.94, p < 0.001; 30-day mortality: AUC 0.94, p < 0.001; in-hospital major morbidity: AUC 0.73, p < 0.001; 30-day major morbidity: AUC 0.70, p < 0.001). POSSUM PS with a cutoff of 25 (defined in our study as a ‘Chole-POSSUM’ score) was then validated in a separate cohort of patients. It showed a 100% sensitivity and a 100% negative predictive value for mortality and a 96–97% negative predictive value for major complications.

Conclusions

The Chole-risk score was externally validated, but the CHOLE-POSSUM stands as a more accurate prediction model. CHOLE-POSSUM is a reliable tool to stratify patients with ACC into a low-risk group that may represent a safe EC candidate, and a high-risk group, where new minimally invasive endoscopic techniques may find the most useful field of action.

Trial Registration: ClinicalTrial.gov NCT04995380.

Validation of the Surgical Outcome Risk Tool (SORT) and SORT v2 for Predicting Postoperative Mortality in Patients with Pancreatic Cancer Undergoing Surgery

Background: Pancreatic cancer surgery is related to significant mortality, thus necessitating the accurate assessment of perioperative risk to enhance treatment decision making. A Surgical Outcome Risk Tool (SORT) and SORT v2 have been developed to provide enhanced risk stratification. Our aim was to validate the accuracy of SORT and SORT v2 in pancreatic cancer surgery. Method: Two hundred and twelve patients were included and underwent pancreatic surgery for cancer. The surgeries were performed by a single surgical team in a single tertiary hospital (2016–2022). We assessed a total of four risk models: SORT, SORT v2, POSSUM (Physiology and Operative Severity Score for the enumeration of Mortality and Morbidity), and P-POSSUM (Portsmouth-POSSUM). The accuracy of the model was evaluated using an observed-to-expected (O:E) ratio and the area under the curve (AUC). Results: The 30-day mortality rate was 3.3% (7 patients). Both SORT and SORT v2 demonstrated excellent discrimination traits (AUC: 0.98 and AUC: 0.98, respectively) and provided the best-performing calibration in the total analysis. However, both tools underestimated the 30-day mortality. Furthermore, both reported a high level of calibration and discrimination in the subgroup of patients undergoing pancreaticoduodenectomy, with previous ERCP, and CA19-9 ≥ 500 U/mL. Conclusions: SORT and SORT v2 are efficient risk-assessment tools that should be adopted in the perioperative pathway, shared decision-making (SDM) process, and counseling of patients with pancreatic cancer undergoing surgery.

The Geriatrics at Risk Score (GeRi-Score) for mortality prediction in geriatric patients with proximal femur fracture - a development and validation study from the Registry for Geriatric Trauma (ATR-DGU)

This study developed an easy-to-use mortality prediction tool, which showed an acceptable discrimination and no significant lack of fit. The GeRi-Score was able to predict mortality and could distinguish between mild, moderate and high risk groups. Therefore, the GeRi-Score might have the potential to distribute the intensity of medical care.

PURPOSE

Several mortality-predicting tools for hip fracture patients are available, but all consist of a high number of variables, require a time-consuming evaluation and/or are difficult to calculate. The aim of this study was to develop and validate an easy-to-use score, which depends mostly on routine data.

METHODS

Patients from the Registry for Geriatric Trauma were divided into a development and a validation group. Logistic regression models were used to build a model for in-house mortality and to obtain a score. Candidate models were compared using Akaike information criteria (AIC) and likelihood ratio tests. The quality of the model was tested using the area under the curve (AUC) and the Hosmer-Lemeshow test.

RESULTS

38,570 patients were included, almost equal distributed to the development and to the validation dataset. The AUC was 0.727 (95% CI 0.711 - 0.742) for the final model, AIC resulted in a significant reduction in deviance compared to the basic model, and the Hosmer-Lemeshow test showed no significant lack of fit (p = 0.07). The GeRi-Score predicted an in-house mortality of 5.3% vs. 5.3% observed mortality in the development dataset and 5.4% vs. 5.7% in the validation dataset. The GeRi-Score was able to distinguish between mild, moderate and high risk groups.

CONCLUSIONS

The GeRi-Score is an easy-to-use mortality-predicting tool with an acceptable discrimination and no significant lack of fit. The GeRi-Score might have the potential to distribute the intensity of perioperative medical care in hip fracture surgery and can be used in quality management programs as benchmark tool.

Emerging Concepts Impacting Head and Neck Cancer Surgery Morbidity

All treatment modalities for head and neck cancer carry with them a risk of adverse events. Head and neck surgeons are faced with significant challenges to minimize associated morbidity and manage its sequelae. Recognizing situations in which a surgical complication is an adverse event inherent to the procedure can alleviate the psychologic impact a complication might have on the treatment team and minimize external and internal pressures. Focusing on the complications that can be effectively modified, future complications can be avoided. Also, some surgical morbidities may not be preventable, necessitating the option to reconsider whether the incidents should be labeled toxic reactions rather than a complication. This discussion highlights some of the areas in which additional research is needed to achieve the goal of minimizing the impact of surgical morbidity.

Comparison between Comprehensive Complication Index (CCI®) and Clavien-Dindo Classification for laparoscopic single-stage treatment of choledocholithiasis with concomitant cholelithiasis

PURPOSE

The Clavien-Dindo Classification (CDC) and the Comprehensive Complication Index (CCI®) are both widely used methods for reporting postoperative complications. Several studies have compared the CCI® with the CDC in evaluating postoperative complications of major abdominal surgery. However, there are no published reports comparing both indexes in single-stage laparoscopic common bile duct exploration with cholecystectomy (LCBDE) for the treatment of common bile duct stones. This study aimed to compare the accuracy of the CCI® and the CDC in evaluating the complications of LCBDE.

METHODS

In total, 249 patients were included. Spearman's rank test was used to calculate the correlation coefficient between CCI® and CDC with length of postoperative stay (LOS), reoperation, readmission, and mortality rates. Student t-test and Fisher's exact test were used to study, if higher ASA, age, larger surgical time, history of previous abdominal surgery, preoperative ERCP, and intraoperative cholangitis finding were associated with higher CDC grade or higher CCI® score.

RESULTS

Mean CCI® was 5.17 ± 12.8. CCI® ranges overlap among three CDC grades: II (20.90-36.20), IIIa (26.20-34.60), and IIIb (33.70-52.10). Age > 60 years, ASA ≥ III, and intraoperative cholangitis finding were associated with higher CCI® (p = 0.010, p = 0.044, and p = 0.031) but not with CDC ≥ IIIa (p = 0.158, p = 0.209, and p = 0.062). In patients with complications, LOS presented a significantly higher correlation with CCI® than with CDC (p = 0.044).

CONCLUSION

In LCBDE, the CCI® assesses better the magnitude of postoperative complications in patients older than 60 years, with a high ASA as well as in those who present intraoperative cholangitis. In addition, the CCI® correlates better with LOS in patients with complications.

Effective peer review audit and identification of the surgeon outlier

BACKGROUND

Surgical audit aims to identify ways to maintain and improve the quality of care for patients, in part by assessment of a surgeon's activities and outcomes. However effective data systems to facilitate audit are uncommon. We aimed to assess the effectiveness of a tool for Peer Review Audit.

METHODS

All General Surgeons in Darwin and the Top End were encouraged to self-record their surgical activity, including procedures and adverse events related to procedures, using the College's Morbidity Audit and Logbook Tool (MALT).

RESULTS

A total of 6 surgeons and 3518 operative events were recorded in MALT between 2018 and 2019. De-identified reports of each surgeon's activities, compared directly to the audit group, were created by each surgeon, with correction for complexity of procedures and ASA status. Nine complications Grade 3 and greater were recorded, plus 6 deaths, 25 unplanned returns to theatre (8% failure to rescue rate), 7 unplanned admissions to ICU and 8 unplanned readmissions. One surgeon outlier was identified (>3 standard deviation over group mean) for unplanned returns to theatre. This surgeon's specific cases were reviewed at our morbidity and mortality meeting using the MALT Self Audit Report and changes were implemented as a result, with future progress monitored.

CONCLUSION

The College's MALT system effectively enabled Peer Group Audit. All participating surgeons were readily able to present and validate their own results. A surgeon outlier was reliably identified. This led to effective practice change. The proportion of surgeons who participated was low. Adverse events were likely under-reported.

Building an automated, machine learning-enabled platform for predicting post-operative complications

Objective. In 2019, the University of Florida College of Medicine launched theMySurgeryRiskalgorithm to predict eight major post-operative complications using automatically extracted data from the electronic health record.Approach. This project was developed in parallel with our Intelligent Critical Care Center and represents a culmination of efforts to build an efficient and accurate model for data processing and predictive analytics.Main Results and Significance. This paper discusses how our model was constructed and improved upon. We highlight the consolidation of the database, processing of fixed and time-series physiologic measurements, development and training of predictive models, and expansion of those models into different aspects of patient assessment and treatment. We end by discussing future directions of the model.

Psoas muscle mass index as a predictor of long-term mortality and severity of complications after major intra-abdominal colorectal surgery – A retrospective analysis

STUDY OBJECTIVE

Determine if psoas muscle area measured in routine preoperative computed tomography scans (CT) can be used to identify patients at increased risk of adverse postoperative outcomes after major elective abdominal surgery.

DESIGN

Retrospective analysis of data from a single-centre cohort study conducted in York Hospital between the 1st August of 2015 and the 31st of august of 2020.

SETTING

Preoperative clinic.

PATIENTS

639 patients who attended the preoperative assessment clinic prior to major elective colorectal surgery and had an abdominal CT scan done up to 120 days before surgery.

INTERVENTIONS

None.

MEASUREMENTS

Psoas muscle area at the L3 level was measured in preoperative CT scans and normalised to patient height (psoas muscle index). The lowest sex-stratified tertile of psoas muscle index (PMI) was classed as sarcopenic. The primary outcome was 2-year mortality. Secondary outcomes included postoperative complications assessed using Clavien-Dindo graded major and minor complications, comprehensive complication index (CCI), and length of stay.

MAIN RESULTS

Multivariable regression analysis showed that sarcopenia was associated with 2-year mortality (aOR 1.79, 95% CI 1.03-3.10; p = 0.037) and survival at 2-years was significantly reduced in sarcopenic patients (log-rank test, p = 0.012). Sarcopenia was the only statistically significant predictor of major complications in multivariable logistic regression analysis (aOR 1.69, 95% CI 1.04-2.74, p = 0.034) and associated with an estimated increase of 16.6% in the comprehensive complication index (CCI) score of patients that had complications in multivariable linear regression analysis. Sarcopenia was not associated with length of stay.

CONCLUSIONS

Sarcopenia defined by psoas muscle mass is an independent predictor of 2-year mortality, major complications and severity of complications after major colorectal surgery and may be used for preoperative risk assessment.

Comparison of Adult and Pediatric Cochlear Implant Wound Complications: A Meta-Analysis

OBJECTIVE

To compare age-related differences in wound complications following cochlear implantation (CI).

METHODS

We performed a systematic review of PubMed, Cochrane Database, and Web of Science databases to identify original research evaluating the patient-level factors (demographics and medical history) associated with wound complications following CI. Outcomes were expressed as relative risk (RR) with 95% confidence intervals using the inverse variance method. Studies without comparison groups were described qualitatively.

RESULTS

Thirty-eight studies representing 21,838 cochlear implantations were included. The rate of wound complications ranges from 0% to 22%. Patient age (adult versus pediatric) was the only factor with comparison groups appropriate for meta-analysis. The 10 studies (n = 9547 CI's) included in the meta-analysis demonstrated that adults had a higher incidence of overall wound complications (2.94%) than in children (2.44%) (RR 1.31, 95% CI 1.01-1.69). Adults had a higher incidence of general/unclassified wound complications (2.07%) than in children (1.34%) (RR 1.68, 95% CI 1.12-2.52). There was no difference between adults and children for specific complications such as hematoma, infection, or seroma. Elderly patients (over age 75) have wound complication rates that range from 1% to 4%. No studies contained comparison groups regarding other patient-level factors and CI wound complications.

CONCLUSION

CI wound complication rates reported in the literature are low; however, adults have a higher risk of these complications than pediatric patients. The reported complication rate in elderly adults is low. There is a gap in CI research in consistently reporting wound complications and rigorous research investigating the impact of patient-level factors and wound complications.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:218-226, 2023.

A machine learning-based prediction model for in-hospital mortality among critically ill patients with hip fracture: An internal and external validated study

INTRODUCTION

Few studies have investigated the in-hospital mortality among critically ill patients with hip fracture. This study aimed to develop and validate a model to estimate the risk of in-hospital mortality among critically ill patients with hip fracture.

METHODS

For this study, data from the Medical Information Mart for Intensive Care III (MIMIC-III) Database and electronic Intensive Care Unit (eICU) Collaborative Research Database were evaluated. Enrolled patients (n=391) in the MIMIC-III database were divided into a training (2/3, n=260) and a validation (1/3, n=131) group at random. Using machine learning algorithms such as random forest, gradient boosting machine, decision tree, and eXGBoosting machine approach, the training group was utilized to train and optimize models. The validation group was used to internally validate models and the optimal model could be obtained in terms of discrimination (area under the receiver operating characteristic curve, AUROC) and calibration (calibration curve). External validation was done in the eICU Collaborative Research Database (n=165). To encourage practical use of the model, a web-based calculator was developed according to the eXGBoosting machine approach.

RESULTS

The in-hospital death rate was 13.81% (54/391) in the MIMIC-III database and 10.91% (18/165) in the eICU Collaborative Research Database. Age, gender, anemia, mechanical ventilation, cardiac arrest, and chronic airway obstruction were the six model parameters which were identified using the Least Absolute Shrinkage and Selection Operator (LASSO) method combined with 10-fold cross-validation. The model established using the eXGBoosting machine approach showed the highest area under curve (AUC) value (0.797, 95% CI: 0.696-0.898) and the best calibrating ability, with a calibration slope of 0.999 and intercept of -0.019. External validation also revealed favorable discrimination (AUC: 0.715, 95% CI: 0.566-0.864; accuracy: 0.788) and calibration (calibration slope: 0.805) in the eICU Collaborative Research Database. The web-based calculator could be available at https://doctorwangsj-webcalculator-main-yw69yd.streamlitapp.com/.

CONCLUSION

The model has the potential to be a pragmatic risk prediction tool that is able to identify hip fracture patients who are at a high risk of in-hospital mortality in ICU settings, guide patient risk counseling, and simplify prognosis bench-marking by controlling for baseline risk.

Psoas attenuation and cross-sectional area improve performance of traditional sarcopenia measurements in predicting one-year mortality among elderly patients undergoing emergency abdominal surgery: a pilot study of five computed tomography techniques

BACKGROUND

Risk stratification is challenging in the growing population of geriatric patients requiring emergency surgery. Sarcopenia, which assesses muscle bulk, is a surrogate for frailty and predicts 1-year mortality, but does not incorporate potentially valuable additional information about muscle quality.

OBJECTIVE

To describe five different CT methods of measuring sarcopenia and muscle quality and to determine which method has the greatest sensitivity for predicting 1-year mortality following emergency abdominal surgery in elderly patients.

METHODS

This retrospective study includes 297 patients 70 years and older who underwent "urgent" or "emergent" laparotomy or laparoscopy for acute abdominal disease between 2006 and 2011 at a single quaternary academic medical center. All patients received a CT abdomen and pelvis with intravenous contrast within 1 month of surgery. Five different methods were applied to the psoas muscles on CT: method 1 (total psoas index TPI, which is total psoas area TPA normalized by height), method 2 ("pseudoarea" = anterior-posterior × transverse dimensions), method 3 (average HU), method 4 (TPA × HU), and method 5 ("pseudoarea" × HU).

RESULTS

For all five CT measures, mortality was greatest for the lowest quartile by univariate and adjusted Cox proportional hazard analyses at all time points up to 1-year. The C-statistic was highest for Method 4, using a composite index of TPA and Hounsfield Units, indicating the greatest predictive ability to estimate mortality at all time points.

CONCLUSION

Muscle quality and muscle size can be used in tandem to refine risk assessment of older patients undergoing emergency abdominal surgery. Routine calculation of the composite score of psoas cross-sectional area and HU in the emergency room setting may provide surgeons and patients valuable insight on the risk of 1-year mortality to guide preoperative decision-making and counseling.

CLINICAL IMPACT

Muscle quality and size, both strong independent predictors of surgical outcomes in older patients undergoing emergency abdominal surgery, may be used in tandem to refine risk assessment. A composite score of psoas muscle cross-sectional area and Hounsfield units on CT may provide insight on 1-year mortality in this patient population.

Risk Prediction for Complications in Inflammatory Bowel Disease Surgery: External Validation of the American College of Surgeons' National Surgical Quality Improvement Program Surgical Risk Calculator

BACKGROUND AND AIMS

Many patients with inflammatory bowel disease [IBD] require surgery during their disease course. Having individual risk predictions available prior to surgery could aid in better informed decision making for personalised treatment trajectories in IBD surgery. The American College of Surgeons National Surgical Quality Improvement Program [ACS NSQIP] has developed a surgical risk calculator that calculates risks for postoperative outcomes using 20 patient and surgical predictors. We aimed to validate the calculator for IBD surgery to determine its accuracy in this patient cohort.

METHODS

Predicted risks were calculated for patients operated for IBD between December 2017 and January 2022 at two tertiary centres and compared with actual outcomes within 30 postoperative days. Predictive performance was assessed for several postoperative complications, using metrics for discrimination and calibration.

RESULTS

Risks were calculated for 508 patient trajectories undergoing surgery for IBD. Incidence of any complication, serious complications, reoperation, and readmission were 32.1%, 21.1%, 15.2%, and 18.3%, respectively. Of 212 patients with an anastomosis, 19 experienced leakage [9.0%]. Discriminative performance and calibration were modest. Risk prediction for any complication, serious complication, reoperation, readmission, and anastomotic leakage had a c statistic of 0.605 (95% confidence interval [CI] 0.534-0.640), 0.623 [95% CI 0.558-0.688], 0.590 [95% CI 0.513-0.668], 0.621 [95% CI 0.557-0.685], and 0.574 [95% CI 0.396-0.751], respectively, and a Brier score of 0.240, 0.166, 0.138, 0.152, and 0.113, respectively.

CONCLUSIONS

The accuracy of risks calculated by the ACS NSQIP Surgical Risk Calculator was deemed insufficient for patients undergoing surgery for IBD, generally underestimating postoperative risks. Recalibration or additional variables could be necessary to predict risks in this cohort.

[Integral scales in assessing the risk of postoperative morbidity and mortality]

Annual number of surgeries exceeds 10 million In Russia, and this number is increasing every year. Searching for a scale or index determining the risk of postoperative complications and mortality is an important issue all over the world. The authors analyzed all available risk assessment scales for postoperative morbidity and mortality. The most significant ones in historical aspect and modern perspective grading systems were highlighted. We compared these indices with clinical recommendations and necessary preoperative preparation. Thus, these scales are valuable for surgeons and anesthesiologists to assess the risk, volume of surgical intervention and methods of preoperative management. However, they are not perfect and require improvement. Therefore, development of such scales is a priority objective of medicine in the foreseeable future.

A Synopsis of Artificial Intelligence and its Applications in Surgery

Artificial intelligence (AI) has made steady in-roads into the healthcare scenario over the last decade. While widespread adoption into clinical practice remains elusive, the outreach of this discipline has progressed beyond the physician scientist, and different facets of this technology have been incorporated into the care of surgical patients. New AI applications are developing at rapid pace, and it is imperative that the general surgeon be aware of the broad utility of AI as applicable in his or her day-to-day practice, so that healthcare continues to remain up-to-date and evidence based. This review provides a broad account of the tip of the AI iceberg and highlights it potential for positively impacting surgical care.

Age adjusted Charlson comorbidity index (a-CCI) AS a tool to predict 30-day post-operative outcome in general surgery patients

INTRODUCTION

Age adjusted Charlson comorbidity index (a-CCI) is an established scoring system to predict long-term mortality. However, its role in predicting 30-day post-operative outcome in general surgery patients is not well elucidated.

METHODS

This was a prospective observational study. Consecutive patients operated under general anaesthesia between January 2019 and December 2020 were enrolled. Their a-CCI was calculated and stratified as Grade 0 comorbidities (a-CCI score = 0), Grade A comorbidities (a-CCI score = 1 and 2) and Grade B comorbidities (a-CCI score ≥ 3). Post-operative complications were graded according to Clavien Dindo (CD) grading system and classified as minor complications (CD Grades I and II), major complications (CD Grades III-IV) and mortality (CD Grade V). Binary logistic regression and multi-nominal logistic regression analysis were done and relative risk ratios were calculated.

RESULT

A total of 925 patients were enrolled. The mean age was 42.75 (14-85 ± 10) years. 31% of our patients had complications within 30 days of surgery which included mortality in 2.7%. Compared with patients with Grade 0 comorbidities, the odds of getting complications is 1.2 times more in patients with Grade A comorbidities and 1.84 times more in patients with Grade B comorbidities (P = 0.205, 0.001 respectively). In comparison to patients with Grade 0 co-morbidities, risk of mortality is 3 and 17.86 times more in patients with Grade A and Grade B comorbidities (P = 0.121 and < 0.001 respectively).

CONCLUSION

a-CCI has clinical relevance in general surgical patients and can predict early post-operative outcome. It should be a part of our armamentarium for pre-operative assessment of surgical patients.

Artificial Intelligence and Machine Learning in Prediction of Surgical Complications: Current State, Applications, and Implications

Surgical complications pose significant challenges for surgeons, patients, and health care systems as they may result in patient distress, suboptimal outcomes, and higher health care costs. Artificial intelligence (AI)-driven models have revolutionized the field of surgery by accurately identifying patients at high risk of developing surgical complications and by overcoming several limitations associated with traditional statistics-based risk calculators. This article aims to provide an overview of AI in predicting surgical complications using common machine learning and deep learning algorithms and illustrates how this can be utilized to risk stratify patients preoperatively. This can form the basis for discussions on informed consent based on individualized patient factors in the future.

Elevated Red Blood Cell Distribution Width Is Associated with Poor Prognosis in Fractured Patients Admitted to Intensive Care Units

OBJECTIVES

Red blood cell distribution width (RDW) with prognosis in various infectious diseases. For fractured patients admitted to the intensive care units (ICU), an accurate and fast appraisal is essential. To investigate the association between RDW and prognosis in fractured patients admitted to the ICU utilizing the MIMIC-III database.

METHODS

A retrospective cohort from the MIMIC III database from 2001 and 2012 was constructed. RDW and other information were collected with in-hospital mortality as the primary outcome and 90-day mortality and hospital and intensive care unit (ICU) length of stay (LOS) as secondary outcomes. Univariate and multivariate logistic regression models with propensity score inverse probability of treatment weighting (IPTW) were used to investigate the prognostic value of RDW. A nomogram was built with significant prognostic factors to predict in-hospital mortality, and the performance of the nomogram was evaluated and compared with other severity assessment scores. Subgroup analysis was also conducted.

RESULTS

A total of 2721 fracture patients admitted to the ICU were identified. After IPTW, the group with higher RDW was significantly associated with elevated in-hospital mortality (odds ratio [OR]: 1.68, 95% confidence interval [CI]: 1.19-2.37), 90-day mortality (OR: 1.39, 95% CI: 1.04-1.86), prolonged hospital LOS (OR: 1.25, 95% CI: 1.03-1.50), and ICU LOS significantly (OR: 1.26, 95% CI: 1.05-1.53) in the multivariate logistics model. The nomogram showed optimal discriminative ability and predictive accuracy with an area under the receiver operating characteristic curve of 0.77.

CONCLUSION

RDW independently predicted in-hospital mortality, 90-day mortality, and hospital and ICU LOS in fractured patients admitted to ICU. The nomogram including RDW could also be a promising tool with potential clinical benefits.

Are admission laboratory values in isolation meaningful for predicting surgical outcome in patients with perforated peptic ulcers?

Background

The study aimed to calculate the predictive value of admission laboratory values in patients with perforated peptic ulcers.

Methods

A retrospective, cohort analytical, observational study was performed, including patients with surgically confirmed perforated peptic ulcers over a 5-year period. Demographic data and admission laboratory values were collected from hospital electronic databases. Outcomes measured were in-hospital mortality, intensive care unit (ICU) admission and length of stay. The significance of categorical variables was calculated by chi-square and Fisher's exact test. Logistic regression analysis was performed to determine univariately statistically significant variables.

Results

In total, 188 patients met the inclusion criteria. The median age was 46 (range 15-87) years with a male predominance of 71.3 % (n = 134). The median length of hospital stay was 7 (range 1-94) days and 31.4 % (n = 59) of patients were admitted to the ICU. Post-operative in-hospital mortality was 25.0 % (n = 47). Predicting the categorical outcome of in-hospital mortality, abnormal haemoglobin, platelet count, urea, creatinine and potassium levels were all found to be statistically significant in the univariate analysis. Age (odds ratio [OR] 1.03), haemoglobin (OR 4.36) and creatinine (OR 7.76) levels were significant in the multivariate analysis.

Conclusions

Mortality rate among patients with perforated peptic ulcer disease is still substantial. Admission laboratory values showed statistical significance as outcome indicators and were valuable to assist in predicting the prognosis. An abnormally high serum creatinine level was the strongest single predictor of both mortality and ICU admission.

Key message

Initial laboratory findings of patients admitted for perforated peptic ulcer showed that an abnormally high serum creatinine level was the strongest single predictor of both mortality and ICU admission.

Development of the PIP score: A metric for predicting Intensive Care Unit admission among patients undergoing emergency laparotomy

Background

Emergency laparotomy cases account for a significant proportion of the surgical caseload requiring postoperative intensive care. However, access to Intensive Care Unit (ICU) services has been limited by the scarcity of resources, lack of guidelines, and paucity of triaging tools.

Objective

This study aimed at developing a feasible Post-emergency laparotomy ICU admission Predictive (PIP) scoring tool.

Methodology

A case-control study utilizing the records of 108 patients who underwent emergency laparotomy was conducted. The primary outcome was the postoperative disposition status. Cases were defined as emergency laparotomy patients admitted to the ICU. The control group constituted patients admitted to the general ward. Logistic regression analysis was performed to identify the perioperative predictors of outcome. The PIP score was developed as a composite of each statistically significant variable remaining in the final logistic regression model.

Results

The significant positive predictors of ICU admission included a worsening American Society of Anesthesiologists - Physical Status, decreasing preoperative baseline axillary temperature, increasing preoperative baseline pulse rate, and intraoperative blood-product transfusion. The scoring system incorporating the identified predictors was presented as a numeric scale ranging from zero to four. Two levels of prediction were defined with reference to the optimum cut-off value; a score of <3 (low-intermediate prediction) and a score of ≥3 (high prediction [OR = 37.00, 95% CI = 11.22-122.02, p <0.001]). The score demonstrated an excellent predictive ability on the Receiver Operator Characteristic Curve (Area Under the Curve = 0.91, 95% CI = 0.851-0.973, p <0.001).

Conclusion

The PIP score proves useful as a feasible postoperative triaging adjunct for emergency laparotomy cases. Nonetheless, further validation studies are required.

Development and internal validation of a model for postoperative morbidity in adults undergoing major elective colorectal surgery: the peri-operative quality improvement programme (PQIP) colorectal risk model

Over 1.5 million major surgical procedures take place in the UK NHS each year and approximately 25% of patients develop at least one complication. The most widely used risk-adjustment model for postoperative morbidity in the UK is the physiological and operative severity score for the enumeration of mortality and morbidity. However, this model was derived more than 30 years ago and now overestimates the risk of morbidity. In addition, contemporary definitions of some model predictors are markedly different compared with when the tool was developed. A second model used in clinical practice is the American College of Surgeons National Surgical Quality Improvement Programme risk model; this provides a risk estimate for a range of postoperative complications. This model, widely used in North America, is not open source and therefore cannot be applied to patient populations in other settings. Data from a prospective multicentre clinical dataset of 118 NHS hospitals (the peri-operative quality improvement programme) were used to develop a bespoke risk-adjustment model for postoperative morbidity. Patients aged ≥ 18 years who underwent colorectal surgery were eligible for inclusion. Postoperative morbidity was defined using the postoperative morbidity survey at postoperative day 7. Thirty-one candidate variables were considered for inclusion in the model. Death or morbidity occurred by postoperative day 7 in 3098 out of 11,646 patients (26.6%). Twelve variables were incorporated into the final model, including (among others): Rockwood clinical frailty scale; body mass index; and index of multiple deprivation quintile. The C-statistic was 0.672 (95%CI 0.660-0.684), with a bootstrap optimism corrected C-statistic of 0.666 at internal validation. The model demonstrated good calibration across the range of morbidity estimates with a mean slope gradient of predicted risk of 0.959 (95%CI 0.894-1.024) with an index-corrected intercept of -0.038 (95%CI -0.112-0.036) at internal validation. Our model provides parsimonious case-mix adjustment to quantify risk of morbidity on postoperative day 7 for a UK population of patients undergoing major colorectal surgery. Despite the C-statistic of &lt; 0.7, our model outperformed existing risk-models in widespread use. We therefore recommend application in case-mix adjustment, where incorporation into a continuous monitoring tool such as the variable life adjusted display or exponentially-weighted moving average-chart could support high-level monitoring and quality improvement of risk-adjusted outcome at the population level.

Predictive Performance of NELA Versus P-POSSUM Mortality Scores: Are We Underestimating the Risk of Mortality Following Emergency Laparotomy?

Background In this study, we aimed to compare the performance of the National Emergency Laparotomy Audit (NELA) and Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) mortality risk scores in predicting 30-day and 90-day mortality in patients undergoing emergency laparotomy. Methodology A retrospective cohort study was conducted to compare the predictive performance of preoperative NELA, postoperative NELA, and P-POSSUM predicted mortality scores in patients undergoing emergency laparotomy between 2014 and 2021. The outcomes of interest included the observed 30-day and 90-day mortality. The discrimination of the mortality tools was assessed and compared by determining the area under the curve (AUC) for each tool using the receiver operating characteristic curve analysis. Results A total of 681 patients were included. The observed risk of 30-day and 90-day mortality was 10.4% (71/681) and 14.2% (97/681), respectively. Regarding 30-day mortality, the AUC was 0.791 (0.727-0.855) for the preoperative NELA score, 0.784 (0.721-0.848) for the preoperative P-POSSUM score, and 0.761 (0.699-0.824) for the postoperative NELA score. Regarding 90-day mortality, the AUC was 0.765 (0.708-0.821) for the preoperative NELA score, 0.749 (0.692-0.807) for the preoperative P-POSSUM score, and 0.745 (0.691-0.800) for the postoperative NELA score. The observed/expected ratio for 30-day and 90-day mortality was 3.25 and 4.43 for preoperative NELA, 2.81 and 3.84 for preoperative P-POSSUM, and 2.17 and 2.96 for postoperative NELA, respectively. Pairwise comparisons showed no statistically significant difference in discrimination among the three models. Conclusions Preoperative NELA, postoperative NELA, and P-POSSUM scores underestimated the risk of 30-day and 90-day mortality in patients undergoing emergency laparotomy. No significant difference in predictive performance was found among the three models.

Inter-rater agreement in pPOSSUM scores of geriatric trauma patients: a prospective evaluation

PURPOSE

Risk prediction models are widely used in the perioperative setting to identify high-risk patients who may benefit from additional care and to aid clinical decision-making. pPOSSUM is such a prediction model, however, little is known about the inter-rater agreement when scoring subjective parameters. This study assessed the inter-rater agreement between clinicians of different specialties and work-level when scoring 30 clinical case reports of geriatric hip fracture patients with pPOSSUM.

METHODS

Eighteen clinicians of the department of Surgery (three specialists, four residents), Anaesthesiology (four specialists, two residents) and Emergency Medicine (three specialists, two residents) who were familiar with the pPOSSUM scoring system were asked to calculate the scores. The kappa statistic and the statistical method of Fleiss were used to analyse inter-rater agreement.

RESULTS

The response rate was 100%. Among surgeons, Anaesthesiologists and Emergency department doctors (ED), the overall mean kappa values were 0.42, 0.08 and 0.20, respectively. Among surgery, anaesthesiology and ED residents the overall mean kappa values were 0.21, 0.33 and 0.37, respectively. Within the department of Surgery, Anaesthesiology and Emergency Medicine the overall mean kappa values were 0.23, 0.12 and 0.22, respectively. An overall mean kappa value of 0.19 was seen among all specialists. All residents had an overall mean kappa value of 0.21 and all clinicians had an overall mean kappa value of 0.21.

CONCLUSION

The overall inter-rater agreement of clinicians and interdisciplinary agreement when scoring geriatric hip fracture patients with pPOSSUM was low and prone to subjectivity in our study. A higher work-experience level did not lead to better agreement. When pPOSSUM is calculated without clinical assessment by the same clinician, caution is advised to prevent over-reliance on the pPOSSUM risk prediction model.

LEVEL OF EVIDENCE

III.

The comparison of prognoses between total and distal gastrectomy for gastric cancer in elderly patients ≥ 80 years old

PURPOSE

In Japan, the number of distal gastrectomy for patients ≥ 80 years old is increasing, whereas that of total gastrectomy is decreasing. Surgeons seem to avoid total gastrectomy for elderly patients. Total gastrectomy is reported to have a poorer prognosis than distal gastrectomy, and postoperative pneumonia may be involved in the cause.

METHODS

The medical records of 39 and 108 patients ≥ 80 years old who underwent total and distal gastrectomy, respectively, at 2 affiliated institutions between 2010 and 2019 were retrospectively reviewed. Prognoses were compared between the two groups, focusing on death from pneumonia.

RESULTS

The median overall survival time after total and distal gastrectomy was 21.3 and 74.1 months, respectively, with a significantly poorer prognosis after total gastrectomy than after distal gastrectomy (p < 0.01, hazard ratio [HR] 2.20, 95% confidence interval [CI] 1.37-3.53). The gastric cancer-specific survival time was significantly worse after total gastrectomy than after distal gastrectomy (p < 0.01, HR 2.73, 95% CI 1.29-5.79). The pneumonia-specific survival time was also significantly worse after total gastrectomy than after distal gastrectomy (p = 0.01, HR 3.44, 95% CI 1.25-9.48).

CONCLUSIONS

Patients who underwent total gastrectomy had a poorer prognosis than those who underwent distal gastrectomy, because many patients died of pneumonia early after total gastrectomy.

Defining complexity in anaesthesia: description and validation of the Oxford Anaesthetic Complexity (OxAnCo) score

Increasing demand for surgery and anaesthesia has created an imperative to manage anaesthetic workforce and caseload. This may include changes to distribution of cases amongst anaesthetists of different grades, including non-physician anaesthetists. To achieve this safely, an assessment of case complexity is essential. We present a novel system for scoring complexity of cases in anaesthesia, the Oxford Anaesthetic Complexity score. This integrates patient, anaesthetic, surgical and systems factors, and is different from assessments of risk. We adopted an end-user development approach to the design of the score, and validated it using a dataset of anaesthetic cases. Across 688 cases, the median (IQR [range]) complexity score was 19 (17-22 [15-33]). Cases requiring a consultant anaesthetist had a significantly higher median (IQR [range]) score than those requiring a senior trainee at 22 (20-25 [15-33]) vs. 19(17-21 [15-28]), p < 0.001. Cases undertaken in a tertiary acute hospital had a significantly higher score than those in a district general hospital, the median (IQR [range]) scores being 20 (17-22 [15-33]) vs. 17 (16-19 [17-28]), p < 0.001. Receiver-operating characteristic analysis showed good prediction of complexity sufficient to require a consultant anaesthetist, with area under the curve of 0.84. Any rise in complexity above baseline (score > 15) was strongly predictive of a case too complex for a junior trainee (positive predictive value 0.93). The Oxford Anaesthetic Complexity score can be used to match cases to different grades of anaesthetist, and can help in defining cases appropriate for the expanding non-physician anaesthetist workforce.

Is D2 Lymphadenectomy Necessary in Elderly Gastric Cancer Patients? A Retrospective Study

Objective

We retrospectively analyzed the validity of limited lymphadenectomy (D1 and D1+) in elderly gastric cancer patients.

Summary of background data

According to the aging trend in Japan, patients with gastric cancer are continuing to age. The extent of lymphadenectomy preferable for older patients is unclear.

Methods

The data of 35 and 52 patients ≥80 years old with cT2− or N(+) gastric cancer who underwent gastrectomy with D2 lymphadenectomy and limited lymphadenectomy, respectively, at 2 institutions between 2010 and 2019 were retrospectively reviewed.

Results

The patients who underwent limited lymphadenectomy were older and their Onodera prognostic nutritional indexes were poorer than those who underwent D2 lymphadenectomy, although the differences were not significant. After propensity score matching, 28 patients in each group were analyzed. No significant differences in postoperative complications, initial recurrence sites, or causes of death were observed between the 2 groups except for postoperative respiratory failure, which was more frequent after D2 lymphadenectomy. The median overall survival time after D2 and limited lymphadenectomy was 73.9 and 70.9 months, respectively, with a hazard ratio of 1.32 (P = 0.53).

Conclusions

D1+ or even D1 lymphadenectomy may be acceptable for patients ≥80 years old with advanced gastric cancer.

Illness wellness scale: novel grading system for performance status of patients under surgical care

BACKGROUND

Grading the illness using clinical parameters is essential for the daily progress of inpatients. Existing systems do not incorporate these parameters holistically. The study was designed to internally validate the illness wellness scale, based upon clinical assessment of the patients requiring surgical care, for their risk stratification and uniformity of communication between health care providers.

METHODS

Prospective observational study conducted at a tertiary care hospital. An expert panel devised the scale, and it was modified after feedback from 100 health care providers. A total of 210 patients (150 for internal validation and 60 for inter-observer variability) who required care under the department of surgical disciplines were enrolled. This included patients presenting to surgery OPD, admitted to COVID/non-COVID surgical wards and ICUs, aged ≥16 years.

RESULTS

The response rate of the final illness wellness scale was 95% with 86% positive feedback and a mean of 1.7 on the Likert scale for ease of use (one being very easy and five being difficult). It showed excellent consistency and minimal inter-observer variability with the intra-class correlation coefficient (ICC) above 0.9. In the internal validation cohort (n = 150), univariate and multivariable analysis of factors affecting mortality revealed that categorical risk stratification, age ≥ 60 years, presence or absence of co-morbidities especially hypertension and chronic kidney disease significantly affect mortality.

CONCLUSIONS

The Illness wellness scale is an effective tool for uniformly communicating between health care professionals and is also a strong predictor of risk stratification and mortality in patients requiring surgical care.