Can the physiologic ability and surgical stress (E-PASS) scoring system predict operative morbidity after distal pancreatectomy?

Estimation of Physiologic Ability and Surgical Stress scoring system for predicting complications following abdominal surgery: A meta-analysis spanning 2004 to 2022

BACKGROUND

Postoperative complications remain a paramount concern for surgeons and healthcare practitioners.

AIM

To present a comprehensive analysis of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system's efficacy in predicting postoperative complications following abdominal surgery.

METHODS

A systematic search of published studies was conducted, yielding 17 studies with pertinent data. Parameters such as preoperative risk score (PRS), surgical stress score (SSS), comprehensive risk score (CRS), postoperative complications, postoperative mortality, and other clinical data were collected for meta-analysis. Forest plots were employed for continuous and binary variables, with χ2 tests assessing heterogeneity (P value).

RESULTS

Patients experiencing complications after abdominal surgery exhibited significantly higher E-PASS scores compared to those without complications [mean difference and 95% confidence interval (CI) of PRS: 0.10 (0.05-0.15); SSS: 0.04 (0.001-0.08); CRS: 0.19 (0.07-0.31)]. Following the exclusion of low-quality studies, results remained valid with no discernible heterogeneity. Subgroup analysis indicated that variations in sample size and age may contribute to heterogeneity in CRS analysis. Binary variable meta-analysis demonstrated a correlation between high CRS and increased postoperative complication rates [odds ratio (OR) (95%CI): 3.01 (1.83-4.95)], with a significant association observed between high CRS and postoperative mortality [OR (95%CI): 15.49 (3.75-64.01)].

CONCLUSION

In summary, postoperative complications in abdominal surgery, as assessed by the E-PASS scoring system, are consistently linked to elevated PRS, SSS, and CRS scores. High CRS scores emerge as risk factors for heightened morbidity and mortality. This study establishes the accuracy of the E-PASS scoring system in predicting postoperative morbidity and mortality in abdominal surgery, underscoring its potential for widespread adoption in effective risk assessment.

Estimation of Physiologic Ability and Surgical Stress (E-PASS) Predicts Postoperative Major Complications After Hepato-Pancreato Biliary Surgery in the Elderly

BACKGROUND

As society ages, an increasing number of elderly patients require hepato-pancreato-biliary (HPB) surgery. We investigated the risk factors for complications in elderly patients undergoing HPB surgery using surgical risk scoring models.

METHODS

We retrospectively investigated 184 elderly patients (≥ 65 years old) who underwent HPB surgery, including the liver, pancreas, bile duct, and/or gallbladder resection, with exemption to simple cholecystectomy between January 2017 and December 2019. The surgical risk scoring models used included the Estimation of Physiological Ability and Surgical Stress (E-PASS), Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), and Geriatric 8 (G8). We evaluated the correlations between the scores and severe complications. Complications were classified as severe (Clavien-Dindo classification [C-D] ≥ III) or non-severe (C-D ≤ II).

RESULTS

Complications occurred in 78 patients (24 C-D ≥ III, 54 C-D ≤ II). Preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) were significantly higher in patients with C-D ≥ IIIa than in those with C-D ≤ II. Multiple logistic regression analysis revealed that PRS (P = 0.01) and SSS (P = 0.04) were independent predictive factors for severe complications. However, the POSSUM and G8 models showed no significant correlations to severe complications.

CONCLUSION

E-PASS is a useful model for predicting complications in elderly patients undergoing HPB surgery.

Accurate prediction of severe postoperative complications after pancreatic surgery: POSSUM vs E-PASS

BACKGROUND/PURPOSE

Few reports have evaluated the differences in the predictive accuracy between the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and estimation of physiologic ability and surgical stress (E-PASS) in pancreatic surgery. Thus, we evaluated the accuracy and similarity of POSSUM and E-PASS for the prediction of severe postoperative complications (PCs) after pancreatic surgery.

METHODS

We enrolled 343 consecutive patients who underwent pancreatic surgery in our department between April 2006 and September 2017. The difference in predictive values of POSSUM and E-PASS for the occurrence of PCs ≥ Clavien-Dindo grade IIIa (PCs-CD ≥ IIIa) was nonparametrically compared. The predictive accuracy and similarity of each tool was examined using the receiver operating characteristic (ROC) curve and linear regression analyses.

RESULTS

Forty-five patients developed PCs-CD ≥ IIIa. E-PASS had a significantly higher predictive value for estimating PCs-CD ≥ IIIa occurrence (P = .002) than did POSSUM. The area under the curve value in ROC analysis was significantly higher in E-PASS than in POSSUM (0.643 vs 0.543, P = .014), with a weak positive correlation in the predictive value between E-PASS and POSSUM (R²  = .333, P < .001).

CONCLUSION

Estimation of physiologic ability and surgical stress was useful for predicting severe PCs after pancreatic surgery and had a higher accuracy than POSSUM.

Irrigation and passive drainage of pancreatic stump after distal pancreatectomy in high-risk patients: an innovative approach to reduce pancreatic fistula

INTRODUCTION

Postoperative pancreatic fistula (POPF) represents the most common form of morbidity after distal pancreatectomy (DP). The aim of this study was to illustrate an innovative technique of irrigation and passive drainage to reduce clinically relevant POPF (CR-POPF) incidence in high-risk patients undergoing DP.

MATERIAL AND METHODS

Twelve consecutive high-risk patients received irrigation and passive drainage of the pancreatic stump with a Salem sump drainage after DP. The Salem sump was irrigated with 100 ml/h of Ringer solution for 2 postoperative days (POD). In the case of low-drain amylase and lipase levels on POD 3, the irrigation was reduced to 50 ml/h. Persistence of low-drain pancreatic enzymes on POD 4 allowed for interruption of irrigation and subsequent removal of drainage from POD 7 onward in the absence of evidence of any pancreatic fistula.

RESULTS

Overall, 16.6% of the patients experienced a grade 3 or higher surgical complication. We experienced only one case of POPF: the fistula was classified as grade B and it was managed with radiologic drainage of the fluid collection. We did not experience any case of re-operation nor in-hospital mortality.

CONCLUSIONS

Irrigation with passive drainage of the pancreatic stump after DP is an interesting approach for CR-POPF prevention in high-risk patients.

Prehabilitation for Hepatopancreatobiliary Surgical Patients: Interim Analysis Demonstrates a Protective Effect From Neoadjuvant Chemotherapy and Improvement in the Frailty Phenotype

BACKGROUND

Prehabilitation encompasses multidisciplinary interventions to improve health and lessen incidence of surgical deterioration by reducing physiologic stress and functional decline. This study presents an interim analysis to demonstrate prehabilitation for hepatopancreatobiliary (HPB) surgical patients.

METHODS

In 2018, a structured prehabilitation pilot program was implemented. Eligibility required HPB malignancy, neoadjuvant chemotherapy, and residence within hour drive. Patients were enrolled into the 4-month program. The fitness component was composed of timed up and go test and grip strength with exercise recommendations. Nutrition involved evaluation of sarcopenic obesity, glucose management, and smoking and alcohol counseling. Psychological services included psychosocial assessments and advanced care planning, with social work referrals. Component were evaluated monthly by a physician using laboratory results, nutritional data and questionnaires, psychological assessments, and validated fitness tests. Nurse navigators spoke with patients weekly to monitor compliance.

RESULTS

At 12 months, nineteen patients were enrolled. Ten completed prehabilitation, neoadjuvant chemotherapy and underwent their surgical procedure. There were no differences found after prehabilitation in functional status, physical performance, psychosocial assessments, or nutrition. Frailty, as assessed by Fried frailty criteria, improved significantly after prehabilitation (P < .0001). Symptom severity and laboratory values did not change. Length of stay was 6.5 days and all patients were discharged to home. There was 1 readmission for transient ischemic attack and 90-day mortality rate was 0%.

DISCUSSION

Prehabilitation to improve recovery is a promising concept encompassing a wide array of multidisciplinary assessments and interventions. It may demonstrate a protective effect on physiologic decline from chemotherapy and may reverse frailty phenotypes.

Modified frailty index predicts early outcomes after colorectal surgery: an ACS-NSQIP study

AIM

Frailty is defined as a decrease in physiological reserve with increased risk of morbidity following significant physiological stressors. This study examines the predictive power of the five-item modified frailty index (5-mFI) in predicting outcomes in colorectal surgery patients.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Database was queried from 2011 to 2016 to determine the predictive power of 5-mFI in patients who had colorectal surgery.

RESULTS

Of 295 490 patients, 45.8% had a score of 0, 36.2% had a score of 1 and 18% had a score of ≥ 2. On univariate analysis, frailer patients had significantly greater incidences for overall morbidity, serious morbidity, mortality, prolonged length of hospital stay, discharge to a facility other than home, reoperation and unplanned readmission. These findings were consistent on multivariate analysis where the frailest patients had greater odds of postoperative overall morbidity (OR 1.39; 95% CI 1.35-1.43), serious morbidity (OR 1.39; 95% CI 1.33-1.45), mortality (OR 2.00; 95% CI 1.87-2.14), prolonged length of hospital stay (OR 1.24; 95% CI 1.20-1.27), discharge destination to a facility other than home (OR 2.80; 95% CI 2.70-2.90), reoperation (OR 1.17; 95% CI 1.11-1.23) and unplanned readmission (OR 1.31; 95% CI 1.26-1.36). Weighted kappa statistics showed strong agreement between the 5-mFI and 11-mFI (kappa = 0.987, P < 0.001).

CONCLUSIONS

The 5-mFI is a valid and easy to use predictor of 30-day postoperative outcomes after colorectal surgery. This tool may guide the surgeon to proactively recognize frail patients to instigate interventions to optimize them preoperatively.

Sarcopenia and Inflammatory Bowel Disease: A Systematic Review

BACKGROUND

Sarcopenia is associated with increased morbidity and mortality in oncologic and transplant surgery. It has a high incidence in chronic inflammatory states including inflammatory bowel disease (IBD). The validity of existing data in IBD and of sarcopenia's correlation with surgical outcomes is limited.

METHODS

We performed a systematic review to assess the correlation of sarcopenia with the requirement for surgery and surgical outcomes in patients with IBD. Observational studies of patients with IBD in whom an assessment of sarcopenic status/skeletal muscle index was undertaken, a proportion of whom proceeded to surgical management, were selected.

RESULTS

A total of 5 studies with a combined 658 IBD patients met the inclusion criteria. The majority (70%) had a diagnosis of Crohn's disease. Median (range) body mass index and skeletal muscle index were reported in 4 studies and were 16.58 (13.66-22.50) kg/m2 and 44.52 (42.90-50.64) cm2/m2, respectively. Forty-two percent of IBD patients had sarcopenia. Notably, none of the studies assessed both the anatomical and functional component required for a correct assessment of sarcopenia. Three studies noted that sarcopenic IBD patients had a higher probability of requiring surgery. The rate of major complications (Clavien-Dindo grade ≥IIIa) was significantly higher in patients with sarcopenia. Improved perioperative nutrition management may mitigate the risk of complications.

CONCLUSION

Many IBD patients are young, may be malnourished, and commonly require emergent surgery. There is considerable heterogeneity in the assessment of sarcopenia. Sarcopenia is common in the IBD population and can predict the need for surgical intervention. Sarcopenia correlates with an increased rate of major postoperative complications. Improved perioperative intervention may diminish this risk. A formal assessment, screening by a dedicated IBD dietician, and preoperative physical therapy may facilitate early intervention.

How to better identify patients at high risk of postoperative complications?

PURPOSE OF REVIEW

Preoperative risk assessment and perioperative factors may help identify patients at increased risk of postoperative complications and allow postoperative management strategies that improve patient outcomes. This review summarizes historical and more recent scoring systems for predicting patients with increased morbidity and mortality in the postoperative period.

RECENT FINDINGS

Most prediction scores predict postoperative mortality with, at best, moderate accuracy. Scores that incorporate surgery-specific and intraoperative covariates may improve the accuracy of traditional scores. Traditional risk factors including increased ASA physical status score, emergent surgery, intraoperative blood loss and hemodynamic instability are consistently associated with increased mortality using most scoring systems.

SUMMARY

Preoperative clinical risk indices and risk calculators estimate surgical risk with moderate accuracy. Surgery-specific risk calculators are helpful in identifying patients at increased risk of 30-day mortality. Particular attention should be paid to intraoperative hemodynamic instability, blood loss, extent of surgical excision and volume of resection.

Feasibility of a Modified E-PASS and POSSUM System for Postoperative Risk Assessment in Patients with Spinal Disease

OBJECTIVE

This retrospective case control study aimed to evaluate the feasibility of using Estimation of Physiological Ability and Surgical Stress (E-PASS) and Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) systems in patients undergoing spinal surgical procedures. Degenerative spine disease has increased in incidence in aging societies, as has the number of older adult patients undergoing spinal surgery. Many older adults are at a high surgical risk because of comorbidity and poor general health.

METHODS

We retrospectively reviewed 217 patients who had undergone spinal surgery at a single tertiary care. We investigated complications within 1 month after surgery. Criteria for both skin incision in E-PASS and operation magnitude in the POSSUM system were modified to fit spine surgery. We calculated the E-PASS and POSSUM scores for enrolled patients, and investigated the relationship between postoperative complications and both surgical risk scoring systems. To reinforce the predictive ability of the E-PASS system, we adjusted equations and developed modified E-PASS systems.

RESULTS

The overall complication rate for spinal surgery was 22.6%. Forty-nine patients experienced 58 postoperative complications. Nineteen major complications, including hematoma, deep infection, pleural effusion, progression of weakness, pulmonary edema, esophageal injury, myocardial infarction, pneumonia, reoperation, renal failure, sepsis, and death, occurred in 17 patients. The area under the receiver operating characteristic curve (AUC) for predicted postoperative complications after spine surgery was 0.588 for E-PASS and 0.721 for POSSUM. For predicted major postoperative complications, the AUC increased to 0.619 for E-PASS and 0.842 for POSSUM. The AUC of the E-PASS system increased from 0.588 to 0.694 with the Modified E-PASS equation.

CONCLUSIONS

The POSSUM system may be more useful than the E-PASS system for estimating postoperative surgical risk in patients undergoing spine surgery. The preoperative risk scores of E-PASS and POSSUM can be useful for predicting postoperative major complications. To enhance the predictability of the scoring systems, using of modified equations based on spine surgery-specific factors may help ensure surgical outcomes and patient safety.

Modified frailty index predicts postoperative outcomes in older gastrointestinal cancer patients

BACKGROUND AND OBJECTIVES

Frailty disproportionately impacts older patients with gastrointestinal cancer, rendering them at increased risk for poor outcomes. A frailty index may aid in preoperative risk stratification. We hypothesized that high modified frailty index (mFI) scores are associated with adverse outcomes after tumor resection in older, gastrointestinal cancer patients.

METHODS

Patients (60-90 years old) who underwent gastrointestinal tumor resection were identified in the 2005-2012 NSQIP Participant Use File. mFI was defined by 11 previously described, preoperative variables. Frailty was defined by an mFI score >0.27. The postoperative course was evaluated using univariate and multivariate analysis.

RESULTS

41 455 patients (mean age 72.4 years, 47.4% female) were identified. The most prevalent form of cancer was colorectal (69.3%, n = 28 708) and 2.8% of patients were frail (n = 1,164). Frail patients were significantly more likely to have increased length of stay (11.7 vs 9.0 days), major complications (29.1% vs 17.9%), and 30-day mortality (5.6% vs 2.5%), (all P < 0.001). Multivariate analysis identified mFI as an independent predictor of major complications (OR 1.52, 95%CI 1.39-1.65, P < 0.001) and 30-day mortality (OR 1.48, 95%CI 1.24-1.75, P < 0.001).

CONCLUSIONS

mFI was associated with the incidence of postoperative complications and mortality in older surgical patients with gastrointestinal cancer.

Modified Frailty Index Predicts Morbidity and Mortality After Pancreaticoduodenectomy

BACKGROUND

Pancreatic cancer is a disease of older adults, who may present with limited physiologic reserve. The authors hypothesized that a frailty index can predict postoperative outcomes after pancreaticoduodenectomy (PD).

METHODS

All patients who underwent PD were identified in the 2005-2012 NSQIP Participant Use File. Patients undergoing emergency procedures, those with an American Society of Anesthesiologists (ASA) classification of five, and those with a diagnosis of preoperative sepsis were excluded from the study. A modified frailty index (mFI) was defined by 11 variables within the National Surgical Quality Improvement Program (NSQIP) previously used for the Canadian Study of Health and Aging-Frailty Index. An mFI score of 0.27 or higher was defined as a high mFI. Uni- and multivariate analyses were performed to evaluate postoperative outcomes.

RESULTS

This study enrolled 9986 patients (age 65 ± 12 years, 48.8% female) who underwent PD. Of these patients, 6.4% (n = 637) had a high mFI (>0.27). Increasing mFI was associated with higher prevalence of postoperative morbidity (p < 0.001) and 30-days mortality (p < 0.001). In the univariate analysis, high mFI was associated with increased morbidity (odds ratio [OR] 1.68; 95% confidence interval [CI] 1.43-1.97; p < 0.001) and 30-days mortality (OR 2.45; 95% CI 1.74-3.45; p < 0.001). After adjustment for age, sex, ASA classification, albumin level, and body mass index (BMI), high mFI remained an independent preoperative predictor of postoperative morbidity (OR 1.544; 95% CI 1.289-1.850; p < 0.0001) and 30-days mortality (OR 1.536; 95% CI 1.049-2.248; p = 0.027).

CONCLUSIONS

High mFI is associated with postoperative morbidity and mortality after PD and can aid in preoperative risk stratification.

Validation of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) score for maintenance hemodialysis patients undergoing elective abdominal surgery

AIMS

This study assessed the validity of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) score in maintenance hemodialysis patients undergoing elective abdominal surgery.

METHODS

We retrospectively reviewed the medical records of 73 hemodialysis patients who underwent elective gastrointestinal surgery. The main outcomes analyzed were the E-PASS score and postoperative course, which were defined by mortality and morbidity. The discriminative capability of the E-PASS score was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

The overall mortality rate observed was 2.7% (2 patients) and the morbidity rate was 36.9%. There were no significant differences in the comprehensive risk score, preoperative score or surgical stress score for patients with or without complications (p = 0.556, 0.639 and 0.168, respectively). Subsequent ROC curve analysis demonstrated poor predictive accuracy for morbidity. When the results in our study population were compared with those in Haga's study population, our population exhibited a highly significant rightward shift (p < 0.001).

CONCLUSION

The E-PASS score was a poor predictor of complications because maintenance hemodialysis patients already have relatively high risk factors. This scoring system should not be applied in such a special group with high risk factors.

Evaluation of the POSSUM, P-POSSUM and E-PASS scores in the surgical treatment of hilar cholangiocarcinoma

Background

The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model, its Portsmouth (P-POSSUM) modification and the Estimation of physiologic ability and surgical stress (E-PASS) are three surgical risk scoring systems used extensively to predict postoperative morbidity and mortality in general surgery. The aim was to undertake the first study of the predictive value of these models in patients undergoing surgical treatment of hilar cholangiocarcinoma.

Methods

A retrospective analysis was performed on data collected prospectively over a 10-year interval from January 2003 to December 2012. The morbidity and mortality risks were calculated using the POSSUM, P-POSSUM and E-PASS equations.

Results

One hundred patients underwent surgical treatment of hilar cholangiocarcinoma. Complications were seen in 52 of 100 patients (52.0%). There were 10 postoperative in-hospital deaths (10.0%). Of 31 preoperative and intraoperative variables studied, operative type (P = 0.000), preoperative serum albumin (P = 0.003) and aspartate aminotransferase (P = 0.029) were found to be factors multivariate associated with postoperative complications. Intraoperative blood loss (P = 0.015), Bismuth-Corlette classification (P = 0.033) and preoperative hemoglobin (P = 0.041) were independent factors multivariate associated with in-hospital death. The POSSUM system predicted morbidity risk effectively with no significant lack of fit (P = 0.488) and an area under the ROC curve (AUC) of 0.843. POSSUM, P-POSSUM and E-PASS scores showed no significant lack of fit in calculating the mortality risk (P >0.05) and all yielded an AUC value exceeding 0.8. POSSUM had significantly more accuracy in predicting morbidity after major and major plus operations (O:E (observed/expected) ratio 0.98 and AUC 0.901) than after minor and moderate operations (O:E ratio 1.13 and AUC 0.759).

Conclusions

POSSUM, P-POSSUM and E-PASS scores effectively predict morbidity and mortality in surgical treatment of hilar cholangiocarcinoma. However, improvements are still needed in the future because none of these scoring systems yielded an AUC value exceeding 0.9 for operations with all different levels of severity. Only POSSUM had more accuracy in predicting postoperative morbidity after operations with higher severity.

Trial registration

This study was undertaken after obtaining approval from the ethics committee of School of Medicine, Shanghai Jiao Tong University with a trial registration number of http://09411960800.

Value of general surgical risk models for predicting postoperative morbidity and mortality in pancreatic resections for pancreatobiliary carcinomas

BACKGROUND

The present study evaluated the utility of general surgical risk models to predict postoperative morbidity and mortality in the specialty field of pancreatic resections for pancreatobiliary carcinomas.

METHODS

We investigated Estimation of Physiologic Ability and Surgical Stress (E-PASS), its modified version (mE-PASS), and Portsmouth Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in 231 patients undergoing pancreatoduodenectomy or distal pancreatectomy (Group A). We also analyzed E-PASS and mE-PASS in another cohort of the same procedures (Group B, n = 313).

RESULTS

Areas under the receiver operating characteristic curve (AUC) for detecting in-hospital mortality in Group A were moderate at 0.75 for E-PASS, 0.69 for mE-PASS, and 0.69 for P-POSSUM. The predicted mortality rates of the models significantly correlated with severity of postoperative complications (ρ = 0.17, P = 0.011 for E-PASS; ρ = 0.15, and P = 0.027 for P-POSSUM). The AUCs were also moderate in Group B at 0.68 for E-PASS and 0.69 for mE-PASS. The predicted mortality rates significantly correlated with severity of postoperative complications (ρ = 0.18, P = 0.0018 for E-PASS; ρ = 0.17, and P = 0.0022 for mE-PASS).

CONCLUSIONS

The present study suggests that the predictive powers of general risk models may be moderate in pancreatic resections. A novel model would be desirable for these procedures.

Predictive value of E-PASS and POSSUM systems for postoperative risk assessment of spinal surgery

Object

The Estimation of Physiological Ability and Surgical Stress (E-PASS) and Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) systems are surgical risk scoring systems that take into account both the patient's preoperative condition and intraoperative variables. While they predict postoperative morbidity and mortality rates for several types of surgery, spinal surgeries are currently not included. The authors assessed the usefulness of E-PASS and POSSUM algorithms and compared the predictive ability of both systems in patients with spinal disorders considered for surgery.

Methods

The E-PASS system includes a preoperative risk score, a surgical stress score, and a comprehensive risk score that is determined by both the preoperative risk score and surgical stress score. The POSSUM system is composed of a physiological score and an operative severity score; its total score is based on both the physiological score and operative severity score. The authors calculated the E-PASS and POSSUM scores for 601 consecutive patients who had undergone spinal surgery and investigated the relationship between the individual scores of both systems and the incidence of postoperative complications. They also assessed the correctness of the predicted morbidity rate of both systems.

Results

Postoperative complications developed in 64 patients (10.6%); there were no in-hospital deaths. All EPASS scores (p ≤ 0.001) and the operative severity score and total score of the POSSUM (p < 0.03) were significantly higher in patients with postoperative complications than in those without postoperative complications. The morbidity rates correlated linearly and significantly with all E-PASS scores (p ≤ 0.001); their coefficients (preoperative risk score, ρ = 0.179; surgical stress score, ρ = 0.131; and comprehensive risk score, ρ = 0.198) were higher than those for the POSSUM scores (physiological score, ρ = 0.059; operative severity score, ρ = 0.111; and total score, ρ = 0.091). The area under the receiver operating characteristic curve for the predicted morbidity rate was 0.668 for the E-PASS and 0.588 for the POSSUM system.

Conclusions

As E-PASS predicted morbidity more correctly than POSSUM, it is useful for estimating the postoperative risk of patients considered for spinal surgery.

Pancreatic cancer in the remnant pancreas following primary pancreatic resection

PURPOSE

To clarify the clinical features of cancer in the pancreatic remnant.

METHODS

We retrospectively reviewed the clinical and pathological findings of 10 patients who developed remnant pancreatic cancer in our hospital between 2002 and 2012. The KRAS sequences in both the initial pancreatic tumor and remnant pancreatic cancer were examined in two patients.

RESULTS

Eight patients underwent a second pancreatectomy for remnant pancreatic cancer (resected group), while two patients were not operated on and underwent chemotherapy (unresected group). The remnant pancreatic cancer developed at the cut end of the pancreas (pancreaticogastrostomy site) in four patients. In the resected group, four patients died 17 months after the emergence of the remnant pancreatic cancer and four patients survived during the median 40.5-month observation period. The median survival of the unresected group after the emergence of the remnant pancreatic cancer was 10 months. The findings of the KRAS sequencing and immunohistological staining of the remnant pancreatic cancer for MUC1 and MUC2 in the two patients were consistent with those of the initial pancreatic tumor in one patient, and not consistent in the other.

CONCLUSIONS

Our results suggest that both local recurrence and a new primary cancer can develop in the pancreatic remnant, and repeated pancreatectomy can prolong survival.

Impact of sarcopenia on outcomes following resection of pancreatic adenocarcinoma

INTRODUCTION

Assessing patient-specific risk factors for long-term mortality following resection of pancreatic adenocarcinoma can be difficult. Sarcopenia--the measurement of muscle wasting--may be a more objective and comprehensive patient-specific factor associated with long-term survival.

METHODS

Total psoas area (TPA) was measured on preoperative cross-sectional imaging in 557 patients undergoing resection of pancreatic adenocarcinoma between 1996 and 2010. Sarcopenia was defined as the presence of a TPA in the lowest sex-specific quartile. The impact of sarcopenia on 90-day, 1-year, and 3-year mortality was assessed relative to other clinicopathological factors.

RESULTS

Mean patient age was 65.7 years and 53.1 % was male. Mean TPA among men (611 mm²/m²) was greater than among women (454 mm²/m²). Surgery involved pancreaticoduodenectomy (86.0 %) or distal pancreatectomy (14.0 %). Mean tumor size was 3.4 cm; 49.9 % and 88.5 % of patients had vascular and perineural invasion, respectively. Margin status was R0 (59.0 %) and 77.7 % patients had lymph node metastasis. Overall 90-day mortality was 3.1 % and overall 1- and 3-year survival was 67.9 % and 35.7 %, respectively. Sarcopenia was associated with increased risk of 3-year mortality (HR = 1.68; P < 0.001). Tumor-specific factors such as poor differentiation on histology (HR = 1.75), margin status (HR = 1.66), and lymph node metastasis (HR = 2.06) were associated with risk of death at 3-years (all P < 0.001). After controlling for these factors, sarcopenia remained independently associated with an increased risk of death at 3 years (HR = 1.63; P < 0.001).

CONCLUSIONS

Sarcopenia was a predictor of survival following pancreatic surgery, with sarcopenic patients having a 63 % increased risk of death at 3 years. Sarcopenia was an objective measure of patient frailty that was strongly associated with long-term outcome independent of tumor-specific factors.

Using the E-PASS scoring system to estimate the risk of emergency abdominal surgery in patients with acute gastrointestinal disease

PURPOSE

The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system, which quantifies a patient's reserve and surgical stress, is used to predict morbidity and mortality in patients before elective gastrointestinal surgery. We conducted this study to clarify whether the E-PASS scoring system is useful for assessing the risks of emergency abdominal surgery.

METHODS

The subjects of this retrospective study were 51 patients who underwent emergency gastrointestinal surgery at a public general hospital. The main outcomes were the E-PASS scores and the postoperative course, defined by mortality and morbidity.

RESULTS

Postoperative complications developed in 15 of the 51 patients (29.4%). The E-PASS score was significantly higher in the patients with postoperative complications than in those without (0.61 ± 0.31 vs 0.20 ± 0.35, respectively; n = 36). The morbidity rates were significantly lower in the patients with a value less than 0.5 than in those with a value more than 0.5 (17.1% and 56.3%, respectively; P < 0.01). There were 7 operative deaths among the 16 patients with a high score, versus none among the 9 patients with a low score (P < 0.01). Three patients underwent laparoscopic-assisted bowel resection with a good postoperative course, with scores of less than 0.5.

CONCLUSIONS

The E-PASS scoring system is useful for surgical decision making and evaluating whether patients will tolerate emergency gastrointestinal surgery. Minimally invasive therapy would assist in lowering the risk of complications.

Prognosis of patients with hepatocellular carcinoma after hepatic resection: are elderly patients suitable for surgery?

AIM

The indication for hepatectomy is still controversial in elderly patients with hepatocellular carcinoma (HCC). We examined the clinicopathological features and survival of 188 HCC patients who underwent hepatectomy.

PATIENTS/METHODS

Patients were divided into four age groups: Age(<50) group (young patients <50 years of age, n = 9), Age(50-69) group (between 50-69 years, n = 110), Age(70-79) group (70-79 years, n = 57), and Age(≥80) group (≥80 years, n = 12). Physiologic ability and surgical stress (E-PASS) score, including preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) were assessed.

RESULTS

Proportion of patients of Age(70-79) and Age(≥80) groups increased significantly in the last 5 years (P < 0.01). Co-morbidity, performance status, and American Society of Anesthesiologists score significantly increased with age (P < 0.05). Proportions of patients with irregular findings and necro-inflammatory activity were significantly lower in Age(70-79) and Age(≥80) groups than in other groups (P < 0.05). Systemic postoperative complications were high in Age(70-79) and Age(≥80) groups. PRS increased significantly with age (P < 0.05). Multivariate analysis identified PRS ≥0.32 and age ≥70 years as significant determinants of systemic complications (P < 0.05). There were no significant differences in postoperative survivals among the groups.

CONCLUSIONS

Careful follow-up and proper decision on hepatectomy upon assessment of PRS are important in elderly HCC patients.