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Festen S, van der Wal-Huisman H, van der Leest AHD, Reyners AKL, de Bock GH, de Graeff P, van Leeuwen BL. The effect of treatment modifications by an onco-geriatric MDT on one-year mortality, days spent at home and postoperative complications. J Geriatr Oncol 2020; 12:779-785. [PMID: 33342722 DOI: 10.1016/j.jgo.2020.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/30/2020] [Accepted: 12/02/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Decision-making in older patients with cancer can be complex, as benefits of treatment should be weighed against possible side-effects and life-expectancy. A novel care pathway was set up incorporating geriatric assessment into treatment decision-making for older cancer patients. Treatment decisions could be modified following discussion in an onco-geriatric multidisciplinary team (MDT). We assessed the effect of treatment modifications on outcomes. MATERIALS AND METHODS This retrospective study was performed in the surgical department of a University Hospital. Patients of 70 years and older with a solid malignancy were included. All patients underwent a nurse-led geriatric assessment (GA) and were discussed in an onco-geriatric MDT. This could result in a modified or an unchanged treatment advice compared to the regular tumor board. Primary outcome was one-year mortality. Secondary outcomes were post-operative complications and days spent in hospital in the first year after inclusion. RESULTS For the 184 patients in the analyses, the median age was 77.5 years and 41.8% were female. For 46 patients (25%), the treatment advice was modified by the onco-geriatric MDT. There was no significant difference in one-year mortality between the unchanged and modified group (29.7% versus 26.1%, p = 0.7). There were, however, significantly fewer days spent in hospital (median 5 vs 8.5 days p = 0.02) and fewer grade II or higher postoperative complications (13.3% versus 35.5% p = 0.005) in the modified group. CONCLUSION Incorporating geriatric assessment in decision-making did not lead to excess one-year mortality, but did result in fewer complications and days spent in hospital.
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Affiliation(s)
- Suzanne Festen
- University of Groningen, University Medical Center Groningen, University Center for Geriatric Medicine, Hanzeplein 1, 9700 RB Groningen, the Netherlands.
| | - Hanneke van der Wal-Huisman
- University of Groningen, University Medical Center Groningen, Department of Surgery, Hanzeplein 1, 9700 RB Groningen, the Netherlands.
| | - Annya H D van der Leest
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Hanzeplein 1, 9700 RB Groningen, the Netherlands.
| | - Anna K L Reyners
- University of Groningen, University Medical Center Groningen, Department of Medical Oncology and Department of Internal Medicine, Hanzeplein 1, 9700 RB Groningen, the Netherlands.
| | - Geertruida H de Bock
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Hanzeplein 1, 9700 RB Groningen, the Netherlands.
| | - Pauline de Graeff
- University of Groningen, University Medical Center Groningen, University Center for Geriatric Medicine, Hanzeplein 1, 9700 RB Groningen, the Netherlands.
| | - Barbara L van Leeuwen
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Hanzeplein 1, 9700 RB Groningen, the Netherlands.
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Dynamic frailty: Objective physiological assessment to guide management in necrotizing pancreatitis. Surgery 2020; 169:1078-1085. [PMID: 33339652 DOI: 10.1016/j.surg.2020.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/13/2020] [Accepted: 10/23/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Physical frailty as a measure of physiological reserve is an important yet understudied topic in necrotizing pancreatitis. We measured frailty metrics in patients with necrotizing pancreatitis at baseline and at 1 month to assess dynamic change. We hypothesized that greater baseline frailty and steeper decline in frailty biomarkers are associated with worse outcomes in necrotizing pancreatitis. METHODS A retrospective analysis of an institutional, necrotizing pancreatitis-specific database was performed. First order outcomes were organ failure, infected necrosis, step-up approach failure, and mortality. Baseline frailty assessment included measurement of comorbid diseases (modified frailty index), nutritional status (prognostic nutritional index), and radiologic sarcopenia (psoas muscle index, Hounsfield unit average calculation). Dynamic frailty was evaluated using psoas muscle index and Hounsfield unit average calculation. Significant associations between baseline and dynamic frailty with outcomes were analyzed. RESULTS Three hundred and forty-one patients were included in this study. Most patients were male (65%) with biliary etiology of necrotizing pancreatitis (46%). Baseline comorbid diseases and baseline sarcopenia were not associated with first order outcomes. Lower baseline prognostic nutritional index was associated with organ failure (P < .001) and infected necrosis (P < .001). After 30 days, 25% of patients became sarcopenic. Larger declines in all sarcopenia metrics were associated with organ failure, infected necrosis, and/or death (P < .05). Lower psoas area and density were independent risk factors for organ failure and infected necrosis. CONCLUSION Dynamic changes in sarcopenia-focused frailty metrics were significantly and consistently associated with organ failure, infected necrosis, and death. Further development of a dynamic frailty index to objectively guide decision-making in necrotizing pancreatitis is warranted.
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Grenda TR, Chang AC. Commentary: Quantifying "fit for esophagectomy"-Grasping for more metrics. J Thorac Cardiovasc Surg 2020; 161:833-834. [PMID: 33317784 DOI: 10.1016/j.jtcvs.2020.11.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Tyler R Grenda
- Division of Thoracic Surgery, Sidney Kimmel Medical College, Philadelphia, Pa
| | - Andrew C Chang
- Section of Thoracic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Mich.
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54
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Frailty is a better predictor than age for outcomes in geriatric patients with rectal cancer undergoing proctectomy. Surgery 2020; 168:504-508. [DOI: 10.1016/j.surg.2020.05.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/21/2020] [Accepted: 05/12/2020] [Indexed: 12/18/2022]
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Famularo S, Di Sandro S, Giani A, Bernasconi DP, Lauterio A, Ciulli C, Rampoldi AG, Corso R, De Carlis R, Romano F, Braga M, Gianotti L, De Carlis L. Treatment of hepatocellular carcinoma beyond the Milan criteria. A weighted comparative study of surgical resection versus chemoembolization. HPB (Oxford) 2020; 22:1349-1358. [PMID: 31932243 DOI: 10.1016/j.hpb.2019.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 09/21/2019] [Accepted: 12/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Optimal treatment of hepatocellular carcinoma (HCC) beyond the Milan criteria (MC) is debated. The aim of the study was to assess overall-survival (OS) and disease-free-survival (DFS) for HCC beyond MC when treated by trans-arterial-chemoembolization (TACE) or surgical resection (SR). METHOD between 2005 and 2015, all patients with a first diagnosis of HCC beyond MC(1 nodule>5 cm, or 3 nodules>3 cm without macrovascular invasion) were evaluated. Analyses were carried out through Kaplan-Meier, Cox models and the inverse probability weighting (IPW) method to reduce allocation bias. Sub-analyses have been performed for multinodular and single large tumors compared with a MC-IN cohort. RESULTS 226 consecutive patients were evaluated: 118 in SR group and 108 in TACE group. After IPW, the two pseudo-populations were comparable for tumor burden and liver function. In the SR group, 1-5 years OS rates were 72.3% and 35% respectively and 92.7% and 39.3% for TACE (p = 0.500). The median DFS was 8 months (95%CI:8-9) for TACE, and 11 months (95%CI:9-12) for SR (p < 0.001). TACE was an independent predictor for recurrence (HR 1.5; 95%CI: 1.1-2.1; p = 0.015). Solitary tumors > 5 cm and multinodular disease had comparable OS and DFS as Milan-IN group (p > 0.05). CONCLUSION Surgery allowed a better control than TACE in patient bearing HCC beyond MC. This translated into a significant benefit in terms of DFS but not OS.
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Affiliation(s)
- Simone Famularo
- School of Medicine and Surgery, University of Milano - Bicocca, Italy; Department of Surgery, ASST - San Gerardo Hospital, Monza, Italy
| | - Stefano Di Sandro
- Department of General Surgery and Transplantation - ASST - Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandro Giani
- School of Medicine and Surgery, University of Milano - Bicocca, Italy; Department of Surgery, ASST - San Gerardo Hospital, Monza, Italy
| | - Davide P Bernasconi
- School of Medicine and Surgery, University of Milano - Bicocca, Italy; Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy
| | - Andrea Lauterio
- Department of General Surgery and Transplantation - ASST - Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Cristina Ciulli
- School of Medicine and Surgery, University of Milano - Bicocca, Italy; Department of Surgery, ASST - San Gerardo Hospital, Monza, Italy
| | - Antonio G Rampoldi
- Department of Radiology, ASST - Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Rocco Corso
- Department of Radiology, ASST - San Gerardo Hospital, Monza, Italy
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation - ASST - Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Surgical Sciences, University of Pavia, Pavia, Italy
| | - Fabrizio Romano
- School of Medicine and Surgery, University of Milano - Bicocca, Italy; Department of Surgery, ASST - San Gerardo Hospital, Monza, Italy; International Center for Digestive Health, University of Milan-Bicocca, Milan, Italy
| | - Marco Braga
- School of Medicine and Surgery, University of Milano - Bicocca, Italy; Department of Surgery, ASST - San Gerardo Hospital, Monza, Italy; International Center for Digestive Health, University of Milan-Bicocca, Milan, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano - Bicocca, Italy; Department of Surgery, ASST - San Gerardo Hospital, Monza, Italy; International Center for Digestive Health, University of Milan-Bicocca, Milan, Italy.
| | - Luciano De Carlis
- School of Medicine and Surgery, University of Milano - Bicocca, Italy; Department of General Surgery and Transplantation - ASST - Grande Ospedale Metropolitano Niguarda, Milan, Italy; International Center for Digestive Health, University of Milan-Bicocca, Milan, Italy
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56
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Vidal PP, Vienne-Jumeau A, Moreau A, Vidal C, Wang D, Audiffren J, Bargiotas I, Barrois R, Buffat S, Dubost C, Ghidaglia JM, Labourdette C, Mantilla J, Oudre L, Quijoux F, Robert M, Yelnik AP, Ricard D, Vayatis N. An opinion paper on the maintenance of robustness: Towards a multimodal and intergenerational approach using digital twins. Aging Med (Milton) 2020; 3:188-194. [PMID: 33103039 PMCID: PMC7574634 DOI: 10.1002/agm2.12115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 12/29/2022] Open
Abstract
The increasing number of frail elderly people in our aging society is becoming problematic: about 11% of community‐dwelling older persons are frail and another 42% are pre‐frail. Consequently, a major challenge in the coming years will be to test people over the age of 60 years to detect pre‐frailty at the earliest stage and to return them to robustness using the targeted interventions that are becoming increasingly available. This challenge requires individual longitudinal monitoring (ILM) or follow‐up of community‐dwelling older persons using quantitative approaches. This paper briefly describes an effort to tackle this challenge. Extending the detection of the pre‐frail stages to other population groups is also suggested. Appropriate algorithms have been used to begin the tracing of faint physiological signals in order to detect transitions from robustness to pre‐frailty states and from pre‐frailty to frailty states. It is hoped that these studies will allow older adults to receive preventive treatment at the correct institutions and by the appropriate professionals as early as possible, which will prevent loss of autonomy. Altogether, ILM is conceived as an emerging property of databases (“digital twins”) and not the reverse. Furthermore, ILM should facilitate a coordinated set of actions by the caregivers, which is a complex challenge in itself. This approach should be gradually extended to all ages, because frailty has no age, as is testified by overwork, burnout, and post‐traumatic syndrome.
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Affiliation(s)
- Pierre-Paul Vidal
- Institute of Information and Control Hangzhou Dianzi University Zhejiang China.,Centre Borelli CNRS Paris University Paris France
| | | | - Albane Moreau
- Centre Borelli CNRS Paris University Paris France.,Service de Neurologie Hôpital d'Instruction des Armées de Percy Service de Santé des Armées Clamart France
| | - Catherine Vidal
- Centre Borelli CNRS Paris University Paris France.,ENT Department Salpetriere Hospital Paris France
| | - Danping Wang
- Institute of Information and Control Hangzhou Dianzi University Zhejiang China.,Plateforme Sensorimotricité Paris University - CNRS - INSERM Paris France
| | | | | | - Remi Barrois
- Centre Borelli CNRS Paris University Paris France
| | | | - Clément Dubost
- Centre Borelli CNRS Paris University Paris France.,Hôpital d'instruction des armées Bégin Saint-Mandé France
| | | | | | | | - Laurent Oudre
- L2TI Sorbonne Paris Nord University Villetaneuse France
| | | | - Matthieu Robert
- Centre Borelli CNRS Paris University Paris France.,Service d'ophtalmologie AP-HP Hôpital Universitaire Necker-Enfants Malades Paris France
| | - Alain P Yelnik
- Centre Borelli CNRS Paris University Paris France.,PRM Department GH St Louis Lariboisière F. Widal Paris University Paris France
| | - Damien Ricard
- Centre Borelli CNRS Paris University Paris France.,Service de Neurologie Hôpital d'Instruction des Armées de Percy Service de Santé des Armées Clamart France.,École d'application du Val-de-Grâce Service de Santé des Armée Paris France
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Simon HL, Paula T, Luz MM, Nemeth SK, Moug SJ, Keller DS. Frailty in older patients undergoing emergency colorectal surgery: USA National Surgical Quality Improvement Program analysis. Br J Surg 2020; 107:1363-1371. [DOI: 10.1002/bjs.11770] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/24/2020] [Accepted: 05/14/2020] [Indexed: 12/21/2022]
Abstract
Abstract
Background
Frailty is associated with advancing age and may result in adverse postoperative outcomes. A suspected growing elderly population needing emergency colorectal surgery stimulated this study of the prevalence and impact of frailty.
Methods
Elderly patients (defined as aged at least 65 years by Medicare and the United States Census Bureau) who underwent emergency colorectal resection between 2012 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program population database. The five-item modified frailty index (mFI-5) score was calculated, and patients stratified into groups 0, 1 or 2 +. Main outcome measures were the prevalence of frailty, and its impact on 30-day postoperative morbidity, mortality, reoperation, duration of hospital stay (LOS), discharge destination and readmission.
Results
A total of 10 025 patients were identified with a median age 75 years, of whom 41·8 per cent were men. The majority (87·7 per cent) had an ASA fitness grade of III or greater and 3129 (31·2 per cent) were frail (mFI-5 group 2+). Major morbidity occurred in one-third of patients and the postoperative mortality rate was 15·9 per cent. Some 52·0 per cent of patients had a prolonged hospital stay and 11·0 per cent were readmitted. Although most patients (88·0 per cent) lived independently before surgery, only 45·4 per cent were discharged home directly. Frailty (mFI-5 2+) predicted mortality, overall and major morbidity, reoperation, prolonged LOS, discharge to an institution and readmission, but frailty was independent of sex.
Conclusion
Frailty is associated with morbidity, mortality and loss of independence in elderly patients needing emergency colorectal surgery.
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Affiliation(s)
| | - T Paula
- Division of Colorectal Surgery, USA
| | - M M Luz
- Division of Colorectal Surgery, USA
| | - S K Nemeth
- Columbia HeartSource, Center for Innovation and Outcomes Research, USA
| | - S J Moug
- Department of Surgery, Royal Alexandra Hospital, Paisley, UK
| | - D S Keller
- Division of Colorectal Surgery, USA
- Herbert Irving Comprehensive Cancer Center, Department of Surgery, Columbia University Medical Center, New York, USA
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Giani A, Famularo S, Riva L, Tamini N, Ippolito D, Nespoli L, Conconi P, Sironi S, Braga M, Gianotti L. Association between specific presurgical anthropometric indexes and morbidity in patients undergoing rectal cancer resection. Nutrition 2020; 75-76:110779. [PMID: 32268263 DOI: 10.1016/j.nut.2020.110779] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Baseline body composition has been associated with dismal outcomes in patients undergoing a variety of major abdominal operations. Whether specific anthropometric indexes can predict morbidity after rectal resection has been poorly investigated. The aims of this study were to assess whether there is a relationship between body mass index and the different computed tomography-assessed body composition indexes, and whether the analysis of different body compartments could be predictive of short-term outcomes in patients undergoing curative surgery for rectal cancer. METHODS Computed tomography-derived measures of skeletal muscle and adipose tissue areas of patients undergoing surgery for rectal cancer between January 2009 and December 2016 were used to calculate population-specific thresholds of sarcopenia, subcutaneous adiposity, visceral adiposity, visceral obesity, sarcopenic obesity, and myosteatosis. Association between the aforementioned body composition features were related with overall complication, infection, and anastomotic leak. RESULTS During the study period, 311 patients received surgery and 173 were eligible for an accessible preoperative computed tomography imaging. After surgery, 59 (34.1%) patients experienced a complication, 29 an infection, and 10 an anastomotic failure. The overall morbidity rate was observed more frequently in patients with sarcopenia than in those without sarcopenia (39% versus 17.5%; P = 0.002) and infections (41.4% versus 21.5% respectively; P = 0.024). The presence of myosteatosis also was associated with a higher incidence of overall morbidity (33.9% versus 20.2% in patients without myoteatosis; P = 0.048). Anastomotic failure occurred in 6 of 10 patients with visceral obesity and in 24 of 112 (21.4%) patients without this condition (P = 0.007). CONCLUSIONS Some anthropometric indexes are accurate predictors of specific types of morbidity. These findings may allow a more accurate preoperative risk stratification.
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Affiliation(s)
- Alessandro Giani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Simone Famularo
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Luca Riva
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Radiology, San Gerardo Hospital, Monza, Italy
| | - Nicolò Tamini
- Department of Surgery, San Gerardo Hospital, Monza, Italy
| | | | - Luca Nespoli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Paola Conconi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Sandro Sironi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Marco Braga
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Surgery, San Gerardo Hospital, Monza, Italy.
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Abstract
Patients with frailty experience substantial physical and emotional distress related to their condition and face increased morbidity and mortality compared with their nonfrail peers. Palliative care is an interdisciplinary medical specialty focused on improving quality of life for patients with serious illness, including those with frailty, throughout their disease course. Anesthesiology providers will frequently encounter frail patients in the perioperative period and in the intensive care unit (ICU) and can contribute to improving the quality of life for these patients through the provision of palliative care. We highlight the opportunities to incorporate primary palliative care, including basic symptom management and straightforward goals-of-care discussions, provided by the primary clinicians, and when necessary, timely consultation by a specialty palliative care team to assist with complex symptom management and goals-of-care discussions in the face of team and/or family conflict. In this review, we apply the principles of palliative care to patients with frailty and synthesize the evidence regarding methods to integrate palliative care into the perioperative and ICU settings.
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Affiliation(s)
- Rita C. Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Lee KC, Streid J, Sturgeon D, Lipsitz S, Weissman JS, Rosenthal RA, Kim DH, Mitchell SL, Cooper Z. The Impact of Frailty on Long-Term Patient-Oriented Outcomes after Emergency General Surgery: A Retrospective Cohort Study. J Am Geriatr Soc 2020; 68:1037-1043. [PMID: 32043562 PMCID: PMC7234900 DOI: 10.1111/jgs.16334] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/11/2019] [Accepted: 12/14/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Few studies examine the impact of frailty on long-term patient-oriented outcomes after emergency general surgery (EGS). We measured the prevalence of frailty among older EGS patients and examined the impact of frailty on 1-year outcomes. DESIGN Retrospective cohort study using 2008 to 2014 Medicare claims. SETTING Acute care hospitals. PARTICIPANTS Patients 65 years or older who received one of the five EGS procedures with the highest mortality burden (partial colectomy, small bowel resection, peptic ulcer disease repair, adhesiolysis, or laparotomy). MEASUREMENTS A validated claims-based frailty index (CFI) identified patients who were not frail (CFI < .15), pre-frail (.15 ≤ CFI < .25), mildly frail (.25 ≤ CFI < .35), and moderately to severely frail (CFI ≥ .35). Multivariable Cox regression compared 1-year mortality. Multivariable Poisson regression compared rates of post-discharge hospital encounters (hospitalizations, intensive care unit stay, emergency department visit) and home time over 1 year after discharge. All regression models adjusted for age, sex, race, admission from facility, procedure, sepsis, inpatient palliative care delivery, trauma center designation, hospital bed size, and teaching status, and they were clustered by patient and hospital referral region. RESULTS Among 468 459 older EGS adults, 37.4% were pre-frail, 12.4% were mildly frail, and 3.6% were moderately to severely frail. Patients with mild frailty experienced a higher risk of 1-year mortality compared with non-frail patients (hazard ratio = 1.97; confidence interval [CI] = 1.94-2.01). In the year after discharge, patients with mild and moderate to severe frailty had more hospital encounters compared with non-frail patients (7.8 and 11.5 vs 2.0 per person-year; incidence rate ratio [IRR] = 4.01; CI = 3.93-4.08 vs IRR = 5.89; CI = 5.70-6.09, respectively). Patients with mild and moderate to severe frailty also had fewer days at home in the year after discharge compared with non-frail patients (256 and 203 vs 302 mean days; IRR = .97; CI = .96-.97 vs IRR = .95; CI = .94-.95, respectively). CONCLUSION Older EGS patients with frailty are at increased risk for poor 1-year outcomes and decreased home time. Targeted interventions for older EGS patients with frailty during the index EGS hospitalization are urgently needed to improve long-term outcomes. J Am Geriatr Soc 68:1037-1043, 2020.
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Affiliation(s)
- Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Surgery, University of California, San Diego, California
| | | | - Dan Sturgeon
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stuart Lipsitz
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joel S Weissman
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Dae H Kim
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Rosiello G, Palumbo C, Knipper S, Deuker M, Stolzenbach LF, Tian Z, Gandaglia G, Fossati N, Montorsi F, Shariat SF, Saad F, Briganti A, Karakiewicz PI. Preoperative frailty predicts adverse short-term postoperative outcomes in patients treated with radical prostatectomy. Prostate Cancer Prostatic Dis 2020; 23:573-580. [DOI: 10.1038/s41391-020-0225-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/02/2020] [Accepted: 03/06/2020] [Indexed: 12/30/2022]
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Ofori-Asenso R, Chin KL, Sahle BW, Mazidi M, Zullo AR, Liew D. Frailty Confers High Mortality Risk across Different Populations: Evidence from an Overview of Systematic Reviews and Meta-Analyses. Geriatrics (Basel) 2020; 5:geriatrics5010017. [PMID: 32178338 PMCID: PMC7151473 DOI: 10.3390/geriatrics5010017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/02/2020] [Accepted: 03/09/2020] [Indexed: 01/03/2023] Open
Abstract
We performed an overview of systematic reviews and meta-analyses to summarize available data regarding the association between frailty and all-cause mortality. Medline, Embase, CINAHL, Web of Science, PsycINFO, and AMED (Allied and Complementary Medicine) databases were searched until February 2020 for meta-analyses examining the association between frailty and all-cause mortality. The AMSTAR2 checklist was used to evaluate methodological quality. Frailty exposure and the risk of all-cause mortality (hazard ratio [HR] or relative risk [RR]) were displayed in forest plots. We included 25 meta-analyses that pooled data from between 3 and 20 studies. The number of participants included in these meta-analyses ranged between <2000 and >500,000. Overall, 56%, 32%, and 12% of studies were rated as of moderate, low, and critically low quality, respectively. Frailty was associated with increased risk of all-cause mortality in 24/24 studies where the HR/RRs ranged from 1.35 [95% confidence interval (CI) 1.05-1.74] (patients with diabetes) to 7.95 [95% CI 4.88-12.96] (hospitalized patients). The median HR/RR across different meta-analyses was 1.98 (interquartile range 1.65-2.67). Pre-frailty was associated with a significantly increased risk of all-cause mortality in 7/7 studies with the HR/RR ranging from 1.09 to 3.65 (median 1.51, IQR 1.38-1.73). These data suggest that interventions to prevent frailty and pre-frailty are needed.
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Affiliation(s)
- Richard Ofori-Asenso
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3181, Australia; (K.L.C.); (D.L.)
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2 2300 Universitetsparken, Copenhagen, Denmark
- Correspondence: ; Tel.: +61411092470
| | - Ken Lee Chin
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3181, Australia; (K.L.C.); (D.L.)
- Melbourne Medical School, University of Melbourne, Parkville, VIC 3010, Australia
| | - Berhe W. Sahle
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC 3053, Australia;
| | - Mohsen Mazidi
- Twin Research and Genetic Epidemiology, Kings College London, London SE1 7EH, UK;
| | - Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, RI 02912, USA;
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3181, Australia; (K.L.C.); (D.L.)
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63
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Tamini N, Giani A, Famularo S, Montuori M, Giardini V, Gianotti L. Should radical surgery for rectal cancer be offered to elderly population? A propensity-matching analysis on short- and long-term outcomes. Updates Surg 2020; 72:801-809. [PMID: 32036561 DOI: 10.1007/s13304-020-00717-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 01/26/2020] [Indexed: 02/08/2023]
Abstract
Elderly patients with rectal tumor are often undertreated if compared to younger ones. The reasons for this attitude are not fully clear.The aim of this study was to determine the feasibility of radical treatments for rectal cancer in subjects with an age ≥ 75 years (group 1) and to compare short- and long-term outcomes of these patients with patients with an age of less that 75 years (group 2). 311 consecutive patients who underwent radical surgery for rectal cancer were evaluated. A propensity-matching analysis on short- and long-term outcomes was conducted to compare older and younger patients. Overall postoperative complication rate was 23.8% (19/80) in the group 2 and 33.8% (27/80) in group 1 (p = 0.162). OS at 1, 3 and 5 years was 96.2%, 88.4% and 75.9% in under 75 and 92.5%, 64.3% and 50.6% in over 75 group, respectively (p = 0.001). However, TSS was considered, no significant difference was found. Major complications were comparable within groups: 10 (12.5%) versus 11 (13.8%) in groups 2 and 1, respectively (p = 0.633). This study suggests that major rectal cancer surgery with curative intent should not be denied to an elderly population on the basis of age alone. Specific oncologic features and comorbidities are better long-term mortality predictors than aging.
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Affiliation(s)
- Nicolò Tamini
- Department of Surgery, San Gerardo Hospital, ASST Monza, Via Pergolesi 33, 20900, Monza, Italy.
| | - Alessandro Giani
- Department of Surgery, San Gerardo Hospital, ASST Monza, Via Pergolesi 33, 20900, Monza, Italy.,School of Medicine and Surgery, University of Milano, Bicocca, Monza, Italy
| | - Simone Famularo
- Department of Surgery, San Gerardo Hospital, ASST Monza, Via Pergolesi 33, 20900, Monza, Italy.,School of Medicine and Surgery, University of Milano, Bicocca, Monza, Italy
| | - Mauro Montuori
- School of Medicine and Surgery, University of Milano, Bicocca, Monza, Italy
| | - Vittorio Giardini
- Department of Surgery, San Gerardo Hospital, ASST Monza, Via Pergolesi 33, 20900, Monza, Italy
| | - Luca Gianotti
- Department of Surgery, San Gerardo Hospital, ASST Monza, Via Pergolesi 33, 20900, Monza, Italy.,School of Medicine and Surgery, University of Milano, Bicocca, Monza, Italy
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64
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Rosiello G, Palumbo C, Deuker M, Stolzenbach LF, Tian Z, Larcher A, Capitanio U, Montorsi F, Shariat SF, Kapoor A, Saad F, Briganti A, Karakiewicz PI. Preoperative frailty predicts adverse short‐term postoperative outcomes in patients treated with radical nephroureterectomy. J Surg Oncol 2020; 121:688-696. [DOI: 10.1002/jso.25840] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 01/03/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Giuseppe Rosiello
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal Quebec Canada
- Department of Urology and Division of Experimental OncologyURI, Urological Research Institute, IRCCS San Raffaele Scientific Institute Milan Italy
| | - Carlotta Palumbo
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal Quebec Canada
- Urology Unit, ASST Spedali Civili of Brescia, Department of Medical and Surgical SpecialtiesRadiological Science and Public Health, University of Brescia Brescia Italy
| | - Marina Deuker
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal Quebec Canada
- Department of UrologyUniversity Hospital Frankfurt Frankfurt am Main Germany
| | - Lara Franziska Stolzenbach
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal Quebec Canada
- Martini‐Klinik Prostate Cancer Center, University Hospital Hamburg‐Eppendorf Hamburg Germany
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal Quebec Canada
| | - Alessandro Larcher
- Department of Urology and Division of Experimental OncologyURI, Urological Research Institute, IRCCS San Raffaele Scientific Institute Milan Italy
| | - Umberto Capitanio
- Department of Urology and Division of Experimental OncologyURI, Urological Research Institute, IRCCS San Raffaele Scientific Institute Milan Italy
| | - Francesco Montorsi
- Department of Urology and Division of Experimental OncologyURI, Urological Research Institute, IRCCS San Raffaele Scientific Institute Milan Italy
| | - Shahrokh F. Shariat
- Department of UrologyComprehensive Cancer Center, Medical University of Vienna Vienna Austria
- Institute of Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University Moscow Russia
| | - Anil Kapoor
- Division of Urology, Department of SurgeryJuravinski Cancer Centre, McMaster University Hamilton Ontario Canada
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal Quebec Canada
| | - Alberto Briganti
- Department of Urology and Division of Experimental OncologyURI, Urological Research Institute, IRCCS San Raffaele Scientific Institute Milan Italy
| | - Pierre I. Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal Quebec Canada
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65
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Ke JXC, MacDonald DB, McIsaac DI. Perioperative Acute Care of Older Patients Living with Frailty. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00355-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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66
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The Comprehensive Complication Index is Related to Frailty in Elderly Surgical Patients. J Surg Res 2019; 244:218-224. [DOI: 10.1016/j.jss.2019.06.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/03/2019] [Accepted: 06/05/2019] [Indexed: 01/07/2023]
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Gianotti L, Sandini M. The 2019 ESPEN Arvid Wretlind lecture perioperative nutritional and metabolic care: Patient-tailored or organ-specific approach? Clin Nutr 2019; 39:2347-2357. [PMID: 31732291 DOI: 10.1016/j.clnu.2019.10.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIM The perioperative severe changes in the nutritional and metabolic homeostasis are, by some means, proportional to the extent of tissue injury and magnitude of operative trauma. An adequate qualitative and quantitative replacement of nutritional substrates are of utmost importance to facilitate proper tissue healing and recovery and maintenance of organ function after surgery. METHODS The present manuscript has been planned to put the most recent research of the Milano-Bicocca University surgical working group in the context of a more personalized nutritional therapy and metabolic care for surgical patients. Particular prominence has been given to major pancreatic resections because these surgeries are among the most complex and challenging operations for the degree of parenchyma resection and tissue dissection, the consequent overall injury, and the fairly high rate of major complications resulting in a catabolic response. RESULTS Anthropometric parameters and particularly sarcopenia, visceral obesity - and their relative proportion -, are strongly associated with poor outcome after pancreatic surgery. Adequate perioperative nutritional therapy is of utmost importance in affecting morbidity. Long-term nutritional and metabolic sequelae, caused by exocrine pancreatic insufficiency, need to be promptly recognized and treated with an adequate enzyme supplementation. CONCLUSIONS There is strong evidence sustaining the necessity of proper perioperative metabolic and nutritional care into the management of patients undergoing major pancreatic surgery.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy.
| | - Marta Sandini
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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68
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How to incorporate geriatric assessment in clinical decision-making for older patients with cancer. An implementation study. J Geriatr Oncol 2019; 10:951-959. [DOI: 10.1016/j.jgo.2019.04.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 02/22/2019] [Accepted: 04/04/2019] [Indexed: 12/27/2022]
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Dent E, Martin FC, Bergman H, Woo J, Romero-Ortuno R, Walston JD. Management of frailty: opportunities, challenges, and future directions. Lancet 2019; 394:1376-1386. [PMID: 31609229 DOI: 10.1016/s0140-6736(19)31785-4] [Citation(s) in RCA: 697] [Impact Index Per Article: 139.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 07/03/2019] [Accepted: 07/10/2019] [Indexed: 12/13/2022]
Abstract
Frailty is a complex age-related clinical condition characterised by a decline in physiological capacity across several organ systems, with a resultant increased susceptibility to stressors. Because of the heterogeneity of frailty in clinical presentation, it is important to have effective strategies for the delivery of care that range across the continuum of frailty severity. In clinical practice, we should do what works, starting with frailty screening, case identification, and management of frailty. This process is unarguably difficult given the absence of an adequate evidence base for individual and health-system interventions to manage frailty. We advocate change towards individually tailored interventions that preserve an individual's independence, physical function, and cognition. This change can be addressed by promoting the recognition of frailty, furthering advancements in evidence-based treatment options, and identifying cost-effective care delivery strategies.
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Affiliation(s)
- Elsa Dent
- Torrens University Australia, Adelaide, SA, Australia; Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.
| | | | - Howard Bergman
- Department of Family Medicine, McGill University, Montréal, QC, Canada
| | - Jean Woo
- Department of Medicine, Chinese University of Hong Kong, Hong Kong, Special Administrative Region, China
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology and Global Brain Health Institute, Trinity College, Dublin, Ireland; Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Jeremy D Walston
- Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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70
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More Severe Deficits in Performance Status at Time of Liver Transplant is Associated With Significantly Higher Risk of Death Following Liver Transplantation. J Clin Gastroenterol 2019; 53:e392-e399. [PMID: 30762610 DOI: 10.1097/mcg.0000000000001187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
GOAL To evaluate the impact of Karnofsky Performance Status score (KPSS) at the time of liver transplantation (LT) on post-LT survival. BACKGROUND While the Model for End-Stage Liver Disease (MELD) score is used to prioritize individuals for LT, it does not specifically incorporate functional status into patient assessment for LT. METHODS Using 2005 to 2016 United Network for Organ Sharing data, all adults (age 18 y and above) undergoing LT were identified. The association of KPSS at the time of LT (KPSS 1: functional status 80% to 100%, KPSS 2: 60% to 70%, KPSS 3: 40% to 50%, KPSS 4: 10% to 30%) with post-LT survival was evaluated using Kaplan-Meier methods and adjusted multivariate logistic regression models. RESULTS Among 66,397 LT recipients (68% male, 72% non-Hispanic white, 22% hepatocellular carcinoma, median age: 55 to 57), women were more likely to be KPSS 4 at the time of LT compared with men (27.95% vs. 22.79%; P<0.001) and African Americans (25.43% vs. 23.03%; P<0.001) and Hispanics (31.69% vs. 23.03%; P<0.001) were more likely to be KPSS 4 than non-Hispanic whites. Worse KPSS at LT correlated with higher post-LT mortality [compared with KPSS 1: Hazard Ratio (HR) for KPSS 2: 1.16, 95% confidence interval (CI): 1.10-1.22; HR for KPSS 3: 1.40; 95% CI: 1.32-1.49; HR for KPSS 4: 1.67; 95% CI: 1.55-1.79]. This increased mortality seen with worse KPSS was observed among all liver disease etiologies and in patients with and without hepatocellular carcinoma. CONCLUSIONS Worse functional status at the time of LT is strongly associated with higher risk of mortality following LT, emphasizing the importance of optimizing performance status in the preoperative period.
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71
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Gianotti L, Fumagalli Romario U, De Pascale S, Weindelmayer J, Mengardo V, Sandini M, Cossu A, Parise P, Rosati R, Bencini L, Coratti A, Colombo G, Galli F, Rausei S, Casella F, Sansonetti A, Maggioni D, Costanzi A, Bernasconi DP, De Manzoni G. Association Between Compliance to an Enhanced Recovery Protocol and Outcome After Elective Surgery for Gastric Cancer. Results from a Western Population-Based Prospective Multicenter Study. World J Surg 2019; 43:2490-2498. [PMID: 31240434 DOI: 10.1007/s00268-019-05068-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The association between compliance to an enhanced recovery protocol (ERAS) and outcome after surgery for gastric cancer has been poorly investigated, particularly in Western patients. The aim of the study was to evaluate whether the rate of adherence to the ERAS program was correlated with outcome and time of discharge. METHODS A prospective, observational, multicenter study was designed to be performed at Italian referral centers for gastric surgery. The protocol was discussed and approved by the Italian Research Group on Gastric Cancer. Twenty-three ERAS domains were applied. A multivariate logistic regression was used to assess the association between ERAS compliance and overall and major complication rates. The Poisson regression model (measured as mean ratios) was used to assess the association of ERAS compliance rate and length of stay (LOS). RESULTS Eight centers participated and 290 subjects with a median age of 73 years were enrolled. The overall rates of adherence to pre-, intra-, and postoperative ERAS items were 69.8%, 60.3%, and 82.5%, respectively. At the multivariate model, there was an association between overall rate of morbidity and an overall ERAS compliance rate greater than 70% (OR 0.413; 95% CI 0.235-0.7240; P 0.002). A similar association was found for major complications (OR 0.328; 95% CI 0.151-0.709; P 0.005). The Poisson regression showed that in patients with ERAS compliance rate >70%, LOS was reduced of approximately 20% (mean ratio 0.812; 95% CI 0.694-0.950; P 0.009). CONCLUSIONS These results suggest a moderate compliance to an ERAS program and a significant association between adherence and outcomes.
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Affiliation(s)
- Luca Gianotti
- Department of Surgery, School of Medicine and Surgery, San Gerardo Hospital, Milano - Bicocca University, Monza, Italy
| | | | | | | | - Valentina Mengardo
- General and Esophagogastric Surgery, University of Verona, Verona, Italy
| | - Marta Sandini
- Department of Surgery, School of Medicine and Surgery, San Gerardo Hospital, Milano - Bicocca University, Monza, Italy
| | - Andrea Cossu
- Digestive Surgery, San Raffaele Hospital, San Raffaele Vita e Salute University, Milan, Italy
| | - Paolo Parise
- Digestive Surgery, San Raffaele Hospital, San Raffaele Vita e Salute University, Milan, Italy
| | - Riccardo Rosati
- Digestive Surgery, San Raffaele Hospital, San Raffaele Vita e Salute University, Milan, Italy
| | - Lapo Bencini
- Oncologic and Robotic Surgery, Department of Oncology, Azienda Ospedaliero - Universitaria Careggi, Florence, Italy
| | - Andrea Coratti
- Oncologic and Robotic Surgery, Department of Oncology, Azienda Ospedaliero - Universitaria Careggi, Florence, Italy
| | - Giovanni Colombo
- Department of Surgery, School of Medicine and Surgery, San Gerardo Hospital, Milano - Bicocca University, Monza, Italy
| | | | - Stefano Rausei
- Department of Surgery, ASST Valle Olona, Gallarate, Italy
| | - Francesco Casella
- General Surgery, Vannini-Figlie di San Camillo Hospital, Rome, Italy
| | - Andrea Sansonetti
- General Surgery, Vannini-Figlie di San Camillo Hospital, Rome, Italy
| | - Dario Maggioni
- General Surgery 3, ASST-Monza, Desio Hospital, Desio, Italy
| | | | - Davide P Bernasconi
- Centre of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
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72
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Analysis of risk factors for hemorrhage and related outcome after pancreatoduodenectomy in an intermediate-volume center. Updates Surg 2019; 71:659-667. [DOI: 10.1007/s13304-019-00673-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 07/27/2019] [Indexed: 02/06/2023]
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73
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Surgical risk and benefits of laparoscopic surgery for elderly patients with gastric cancer: a multicenter prospective cohort study. Gastric Cancer 2019; 22:845-852. [PMID: 30539321 DOI: 10.1007/s10120-018-0898-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 11/05/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic gastrectomy (LG) might have greater clinical benefits for elderly patients as less invasive surgery; however, there is still little evidence to support its benefit. We evaluated the surgical outcomes of elderly patients in a nationwide prospective cohort study. METHODS One hundred and sixty-nine participating institutions were identified by stratified random sampling, and were adjusted for hospital volume, type and location. During 1 year from 2014 to 2015, consecutive patients who underwent gastrectomy for gastric cancer were prospectively enrolled. 'Elderly' was defined as ≥ 75 years of age, based on the prevalence of comorbidities and the activities of daily living of patients of this age. We compared the surgical outcomes of LG to those of open gastrectomy (OG) in non-elderly and elderly patients. The primary outcome was the incidence of severe morbidities (Grade ≥ 3). RESULTS Eight thousand nine hundred and twenty-seven patients were enrolled [non-elderly, n = 6090 (OG, n = 2602; LG, n = 3488); elderly, n = 2837 (OG, n = 1471; LG, n = 1366)]. Grade ≥ 3 complications occurred in 161 (10.9%) patients who underwent OG and 98 (7.2%) who underwent LG (p < 0.001). After adjusting for confounding factors, we confirmed that laparoscopic surgery was not an independent risk factor (odds ratio = 0.81, 0.60-1.09). OG was associated with a significantly longer median length of postoperative stay in comparison to LG (16 versus 12 days, p < 0.001). There were no significant differences in the incidence of other postoperative comorbidities. CONCLUSION The safety of LG in elderly patients was demonstrated. LG shortened the length of postoperative hospital stay.
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74
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Enhanced recovery after colorectal surgery: the clinical and economic benefit in elderly patients. Eur Surg 2019. [DOI: 10.1007/s10353-019-0595-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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75
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Famularo S, Di Sandro S, Giani A, Angrisani M, Lauterio A, Romano F, Gianotti L, De Carlis L. The impact of age and ageing on hepatocarcinoma surgery: Short- and long-term outcomes in a multicentre propensity-matched cohort. Liver Int 2019; 39:894-904. [PMID: 30790410 DOI: 10.1111/liv.14075] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Management of malignancy in elderly patients is challenging. We aimed to assess the impact of age and ageing on overall survival (OS), recurrence-free survival (RFS), tumour-specific survival (TSS) and potential years of life lost (PYLL) after surgery for hepatocarcinoma (HCC). METHODS Consecutive patients treated for HCC between 2005 and 2015 were evaluated. Patients were divided according to age-decade. Afterwards, elderly patients (≥75 years) were compared with patients < 75 years. A 1:1 propensity matching was used to reduce the risk of bias. Survival was estimated by Kaplan-Meier method and Cox regression analysis. RESULTS Four hundred and thirty-nine patients were stratified: group 1 (age ≤ 55, n = 72), group 2 (age: 56-65, n = 133), group 3 (age: 66-74, n = 141) and group 4 (age ≥ 75, n = 93). Group 1 had the highest median PYLL (27.6, IQR 24.6-32.5) while group 4 the lowest (2.0, IQR 0-9.6; P < 0.001). Comparing elderly vs younger, there were no significant differences in terms of OS (P = 0.054), TSS (P = 0.321) and RFS (P = 0.240). Ageing was the only variable associated with post-operative complications (OR: 2.51; 95% CI: 1.23-5.13; P = 0.025) and liver-related morbidity was an independent predictor of OS. (HR 2.49, 95% CI: 1.34-4.64, P = 0.004). CONCLUSION Ageing per se is not an absolute contraindication for liver resection, given the acceptable oncologic long-term prognosis, but the worse short-term outcomes in the elderly should induce an accurate patient selection.
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Affiliation(s)
- Simone Famularo
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,General and Transplant Surgery Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Di Sandro
- General and Transplant Surgery Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandro Giani
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Marco Angrisani
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Andrea Lauterio
- General and Transplant Surgery Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Romano
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Luciano De Carlis
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,General and Transplant Surgery Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy
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76
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Ko FC. Preoperative Frailty Evaluation: A Promising Risk-stratification Tool in Older Adults Undergoing General Surgery. Clin Ther 2019; 41:387-399. [PMID: 30799232 PMCID: PMC6585449 DOI: 10.1016/j.clinthera.2019.01.014] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/24/2019] [Accepted: 01/29/2019] [Indexed: 11/21/2022]
Abstract
PURPOSE General surgical procedures are among the most commonly performed operations in the United States. Despite advances in surgical and anesthetic techniques and perioperative care, complications after general surgery in older adults remain a significant cause of increased morbidity, mortality, and health care costs. Frailty, a geriatric syndrome characterized by multisystem physiologic decline and increased vulnerability to stressors and adverse clinical outcomes, has emerged as a plausible predictor of adverse outcomes after surgery in older patients. Thus, the goal of this topical review is to evaluate the evidence on the association between preoperative frailty and clinical outcomes after general surgery and whether frailty evaluation may have a role in surgical risk-stratification in vulnerable older patients. METHODS A PubMed database search was conducted between September and October 2018 to identify relevant studies evaluating the association between frailty and clinical outcomes after general surgery. Key words (frailty and surgery) and Medical Subject Heading term (general surgery) were used, and specific inclusion and exclusion criteria were applied. FINDINGS The available evidence from meta-analyses and cohort studies suggest that preoperative frailty is significantly associated with adverse clinical outcomes after emergent or nonemergent general surgery in older patients. Although these studies are limited by a high degree of heterogeneity of frailty assessments, types of surgery, and primary outcomes, baseline frailty appears to increase risk of postoperative complications and morbidity, hospital length of stay, 30-day mortality, and long-term mortality after general surgical procedures in older adults. IMPLICATIONS Evidence supports the further development of preoperative frailty evaluation as a risk-stratification tool in older adults undergoing general surgery. Research is urgently needed to quantify and differentiate the predictive ability of validated frailty instruments in the context of different general surgical procedures and medical acuity and in conjunction with existing surgical risk indices widely used in clinical practice. Practical applicability of frailty instrument as well as geriatrics-centered outcomes need to be incorporated in future studies in this line of research. Furthermore, clinical care pathways that integrate frailty assessment, geriatric medicine focused perioperative and postoperative management, and patient-centered interdisciplinary care models should be investigated as a comprehensive intervention approach in older adults undergoing general surgery. Finally, early implementation of palliative care should occur at the outset of hospital encounter in frail older patients who present with indications for emergent general surgery.
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Affiliation(s)
- Fred C Ko
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Geriatric Research Education and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, NY, USA.
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Khan AI, Reiter DA, Sekhar A, Sharma P, Safdar NM, Patil DH, Psutka SP, Small WC, Bilen MA, Ogan K, Master VA. MRI quantitation of abdominal skeletal muscle correlates with CT-based analysis: implications for sarcopenia measurement. Appl Physiol Nutr Metab 2019; 44:814-819. [PMID: 30615474 DOI: 10.1139/apnm-2018-0473] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Sarcopenia is associated with poor outcomes in a variety of conditions, including malignancy. Abdominal skeletal muscle area (SMA) segmentation using computed tomography (CT) has been shown to be an accurate surrogate for identifying sarcopenia. While magnetic resonance imaging (MRI) segmentation of SMA has been validated in cadaver limbs, few studies have validated abdominal SMA segmentation using MRI at lumbar level mid-L3. Our objective was to assess the reproducibility and concordance of CT and MRI segmentation analyses of SMA at mid-L3. This retrospective analysis included a random sample of 10 patients with renal cell carcinoma (RCC) and CT abdomen/pelvis, used to assess intra-observer variability of SMA measurements using CT. An additional sample of 9 patients with RCC and both CT and T2-weighted (T2w) MRI abdomen/pelvis was used to assess intra-observer variability of SMA using MRI and concordance of SMA between MRI and CT. SMA was segmented using Slice-O-Matic. SMA reproducibility was assessed using intraclass correlation coefficient (ICC). SMA concordance was analyzed using Bland-Altman plot and Pearson correlation coefficient. The intra-observer variability of CT and MRI SMA at mid-L3 was low, with ICC of 0.998 and 0.985, respectively. Bland-Altman analysis revealed bias of 0.74% for T2w MRI over CT. The Pearson correlation coefficient was 0.997 (p < 0.0001), demonstrating strong correlation between CT and T2w MRI. Abdominal SMA at mid-L3 is reproducibly segmented for both CT and T2w MRI, with strong correlation between the 2 modalities. T2w MRI can be used interchangeably with CT for assessment of SMA and sarcopenia. This finding has important clinical implications.
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Affiliation(s)
- Amir Ishaq Khan
- a Emory University School of Medicine, Atlanta, GA 30322, USA
| | - David A Reiter
- b Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Aarti Sekhar
- b Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Puneet Sharma
- b Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Nabile M Safdar
- b Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Dattatraya H Patil
- c Department of Urology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Sarah P Psutka
- d Department of Urology, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - William C Small
- b Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Mehmet A Bilen
- e Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Kenneth Ogan
- c Department of Urology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Viraj A Master
- c Department of Urology, Emory University School of Medicine, Atlanta, GA 30322, USA
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van der Windt DJ, Bou-Samra P, Dadashzadeh ER, Chen X, Varley PR, Tsung A. Preoperative risk analysis index for frailty predicts short-term outcomes after hepatopancreatobiliary surgery. HPB (Oxford) 2018; 20:1181-1188. [PMID: 30005992 DOI: 10.1016/j.hpb.2018.05.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/10/2018] [Accepted: 05/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Risk Analysis Index (RAI) for frailty is a rapid survey for comorbidities and performance status, which predicts mortality after general surgery. We aimed to validate the RAI in predicting outcomes after hepatopancreatobiliary surgery. METHODS Associations of RAI, determined in 162 patients prior to undergoing hepatopancreatobiliary surgery, with prospectively collected 30-day post-operative outcomes were analyzed with multivariate logistic and linear regression. RESULTS Patients (age 62 ± 14, 51% female) had a median RAI of 7, range 0-25. With every unit increase in RAI, length of stay increased by 5% (95% CI: 2-7%), odds of ICU admission increased by 10% (0-20%), ICU length of stay increased by 21% (9-34%), and odds of discharge to a nursing facility increased by 8% (0-17%) (all P < 0.05). Particularly in patients who suffered a first post-operative complication, RAI was associated with additional complications (1.6 unit increase in Comprehensive Complication Index per unit increase in RAI, P = 0.002). In a direct comparison in a subset of 74 patients, RAI and the ACS-NSQIP Risk Calculator performed comparably in predicting outcomes. CONCLUSION While RAI and ACS-NSQIP Risk Calculator comparatively predicted short-term outcomes after HPB surgery, RAI has been specifically designed to identify frail patients who can potentially benefit from preoperative prehabilitation interventions.
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Affiliation(s)
- Dirk J van der Windt
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Patrick Bou-Samra
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Xilin Chen
- Pittsburgh Surgical Outcomes Research Center (PittSORCe), University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick R Varley
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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79
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Sarcopenia: ultrasound today, smartphones tomorrow? Eur Radiol 2018; 29:1-2. [DOI: 10.1007/s00330-018-5833-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 09/27/2018] [Accepted: 10/12/2018] [Indexed: 12/12/2022]
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80
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Thomas RA, Empey JA, Seth S, Crozier J. Guess the weight: the accuracy of estimated weight for surgical admissions - a comparison study. Scott Med J 2018; 64:56-61. [PMID: 30336742 DOI: 10.1177/0036933018805657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS An accurate body weight is vital for safe dosing of many drugs. Weight is often unavailable for emergency admissions and an estimation is used. Emergency Department staff are poor at estimating patient weight, but no data existed for surgical admissions. This study assesses the reliability of weight estimation by patients and healthcare workers. METHODS AND RESULTS All emergency surgical patients admitted during one week were approached. If consented, four healthcare workers (consultant, foundation doctor, nurse, support worker) independently estimated their weight. The patients then gave their estimate. Actual weight was measured and data analysed. Seventy-two consecutive surgical admissions were included, aged 16-95 and 52% male. Healthcare workers correctly (within ±10% margin) estimated the weight for only 57% of patients. Further statistical analysis confirmed that staff are inaccurate estimators and patients are better at estimating their own weight (p < 0.006). CONCLUSIONS Staff are poor at estimating weight and the study was unable to show statistical superiority of any professional group when guessing weights. There was also a tendency for staff to increasingly under-estimate as weight increases. Patients are the most accurate estimators, but self-reporting is still too unreliable for drug dosing and should stop.
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Affiliation(s)
- Rachel Ab Thomas
- 1 Specialty Registrar, Department of Surgery, Forth Valley Royal Hospital, Larbert, UK
| | - Julie-Ann Empey
- 2 Foundation Doctor, Department of Surgery, Forth Valley Royal Hospital, Larbert, UK
| | - Subodh Seth
- 3 Associate Specialist, Department of Surgery, Forth Valley Royal Hospital, Larbert, UK
| | - Joseph Crozier
- 4 Consultant, Department of Surgery, Forth Valley Royal Hospital, Larbert, UK
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81
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Gianotti L, Besselink MG, Sandini M, Hackert T, Conlon K, Gerritsen A, Griffin O, Fingerhut A, Probst P, Abu Hilal M, Marchegiani G, Nappo G, Zerbi A, Amodio A, Perinel J, Adham M, Raimondo M, Asbun HJ, Sato A, Takaori K, Shrikhande SV, Del Chiaro M, Bockhorn M, Izbicki JR, Dervenis C, Charnley RM, Martignoni ME, Friess H, de Pretis N, Radenkovic D, Montorsi M, Sarr MG, Vollmer CM, Frulloni L, Büchler MW, Bassi C. Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS). Surgery 2018; 164:1035-1048. [PMID: 30029989 DOI: 10.1016/j.surg.2018.05.040] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal nutritional therapy in the field of pancreatic surgery is still debated. METHODS An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group. RESULTS The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement. CONCLUSION The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy.
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marta Sandini
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Kevin Conlon
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Arja Gerritsen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Oonagh Griffin
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Abe Fingerhut
- University of Graz Hospital, Surgical Research Unit, Graz, Austria
| | - Pascal Probst
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Antonio Amodio
- Unit of Gastroenterology, University of Verona Hospital Trust, Verona, Italy
| | - Julie Perinel
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Mustapha Adham
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Massimo Raimondo
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Horacio J Asbun
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Asahi Sato
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kyoichi Takaori
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Marco Del Chiaro
- Pancreatic Surgery Unit - Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) - Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christos Dervenis
- University of Cyprus and Department of Surgical Oncology and HPB Surgery Metropolitan Hospital, Athens, Greece
| | - Richard M Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marc E Martignoni
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | | | - Dejan Radenkovic
- Clinic for Digestive Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marco Montorsi
- Department of Surgery, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Michael G Sarr
- Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Markus W Büchler
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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