A review of risk scoring systems utilised in patients undergoing gastrointestinal surgery

More than 30 Years of POSSUM: Are Scoring Systems Still Relevant Today for Colorectal Surgery?

BACKGROUND

The Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) weights the patient's individual health status and the extent of the surgical procedure to estimate the probability of postoperative complications and death of general surgery patients. The variations Portsmouth-POSSUM (P-POSSUM) and colorectal POSSUM (CR-POSSUM) were developed for estimating mortality in patients with low perioperative risk and for patients with colorectal carcinoma, respectively. The aim of the present study was to evaluate the significance of POSSUM, P-POSSUM, and CR-POSSUM in two independent colorectal cancer cohorts undergoing surgery, with an emphasis on laparoscopic procedures.

METHODS

For each patient, an individual physiological score (PS) and operative severity score (OS) was attributed to calculate the predicted morbidity and mortality, respectively. Logistic regression analysis was used to evaluate the possible correlation between the subscores and the probability of postoperative complications and mortality.

RESULTS

The POSSUM equation significantly overpredicted postoperative morbidity, and all three scoring systems considerably overpredicted in-hospital mortality. However, the POSSUM score identified patients at risk of anastomotic leakage, sepsis, and the need for reoperation. Logistic regression analysis demonstrated a strong correlation between the subscores and the probability of postoperative complications and mortality, respectively.

CONCLUSION

Our results suggest that the three scoring systems are too imprecise for the estimation of perioperative complications and mortality of patients undergoing colorectal surgery in the present day. Since the subscores proved valid, a revision of the scoring systems could increase their reliability in the clinical setting.

Surgical Apgar Score can accurately predict the severity of post-operative complications following emergency laparotomy

BACKGROUND

The Surgical Apgar Score (SAS) describes a feasible and objective tool for predicting surgical outcomes. However, the accuracy of the score and its correlation with the complication severity has not been well established in many grounds of low resource settings.

OBJECTIVE

To determine the accuracy of Surgical Apgar Score in predicting the severity of post-operative complications among patients undergoing emergency laparotomy at Muhimbili National Hospital.

METHODS

A prospective cohort study was conducted for a period of 12 months; patients were followed for 30 days, the risk of complication was classified using the Surgical Apgar Score (SAS), severity of complication was estimated using the Clavien Dindo Classification (CDC) grading scheme and Comprehensive Complication Index (CCI). Spearman correlation and simple linear regression statistic models were applied to establish the relationship between Surgical Apgar Score (SAS) and Comprehensive Complication Index (CCI). The Accuracy of SAS was evaluated by determining its discriminatory capacity on Receiver Operating Characteristics (ROC) curve, data normality was tested by Shapiro-Wilk statistic 0.929 (p < 0.001).Analysis was done using International Business Machine Statistical Product and Service Solution (IBM SPSS) version 27.

RESULTS

Out of the 111 patients who underwent emergency laparotomy, 71 (64%) were Male and the median age (IQR) was 49 (36, 59).The mean SAS was 4.86 (± 1.29) and the median CCI (IQR) was 36.20 (26.2, 42.40). Patients in the high-risk SAS group (0-4) were more likely to experience severe and life-threatening complications, with a mean CCI of 53.3 (95% CI: 47.2-63.4), compared to the low-risk SAS group (7-10) with a mean CCI of 21.0 (95% CI: 5.3-36.2). A negative correlation was observed between SAS and CCI, with a Spearman r of -0.575 (p < 0.001) and a regression coefficient b of -11.5 (p < 0.001). The SAS demonstrated good accuracy in predicting post-operative complications, with an area under the curve of 0.712 (95% CI: 0.523-0.902, p < 0.001) on the ROC.

CONCLUSION

This study has demonstrated that SAS can accurately predict the occurrence of complications following emergency laparotomy at Muhimbili National Hospital.

Implementation of the Surgical Apgar Score in Laboratory Animal Science: A Showcase Pilot Study in a Porcine Model and a Review of the Literature

INTRODUCTION

In an attempt to further improve surgical outcomes, a variety of outcome prediction and risk-assessment tools have been developed for the clinical setting. Risk scores such as the surgical Apgar score (SAS) hold promise to facilitate the objective assessment of perioperative risk related to comorbidities of the patients or the individual characteristics of the surgical procedure itself. Despite the large number of scoring models in clinical surgery, only very few of these models have ever been utilized in the setting of laboratory animal science. The SAS has been validated in various clinical surgical procedures and shown to be strongly associated with postoperative morbidity. In the present study, we aimed to review the clinical evidence supporting the use of the SAS system and performed a showcase pilot trial in a large animal model as the first implementation of a porcine-adapted SAS (pSAS) in an in vivo laboratory animal science setting.

METHODS

A literature review was performed in the PubMed and Embase databases. Study characteristics and results using the SAS were reported. For the in vivo study, 21 female German landrace pigs have been used either to study bleeding analogy (n = 9) or to apply pSAS after abdominal surgery in a kidney transplant model (n = 12). The SAS was calculated using 3 criteria: (1) estimated blood loss during surgery; (2) lowest mean arterial blood pressure; and (3) lowest heart rate.

RESULTS

The SAS has been verified to be an effective tool in numerous clinical studies of abdominal surgery, regardless of specialization confirming independence on the type of surgical field or the choice of surgery. Thresholds for blood loss assessment were species specifically adjusted to >700 mL = score 0; 700-400 mL = score 1; 400-55 mL score 2; and <55 mL = score 3 resulting in a species-specific pSAS for a more precise classification.

CONCLUSION

Our literature review demonstrates the feasibility and excellent performance of the SAS in various clinical settings. Within this pilot study, we could demonstrate the usefulness of the modified SAS (pSAS) in a porcine kidney transplantation model. The SAS has a potential to facilitate early veterinary intervention and drive the perioperative care in large animal models exemplified in a case study using pigs. Further larger studies are warranted to validate our findings.

Scoring systems for the management of oncological hepato-pancreato-biliary patients

Oncological scoring systems in surgery are used as evidence-based decision aids to best support management through assessing prognosis, effectiveness and recurrence. Currently, the use of scoring systems in the hepato-pancreato-biliary (HPB) field is limited as concerns over precision and applicability prevent their widespread clinical implementation. The aim of this review was to discuss clinically useful oncological scoring systems for surgical management of HPB patients. A narrative review was conducted to appraise oncological HPB scoring systems. Original research articles of established and novel scoring systems were searched using Google Scholar, PubMed, Cochrane, and Ovid Medline. Selected models were determined by authors. This review discusses nine scoring systems in cancers of the liver (CLIP, BCLC, ALBI Grade, RETREAT, Fong's score), pancreas (Genç's score, mGPS), and biliary tract (TMHSS, MEGNA). Eight models used exclusively objective measurements to compute their scores while one used a mixture of both subjective and objective inputs. Seven models evaluated their scoring performance in external populations, with reported discriminatory c-statistic ranging from 0.58 to 0.82. Selection of model variables was most frequently determined using a combination of univariate and multivariate analysis. Calibration, another determinant of model accuracy, was poorly reported amongst nine scoring systems. A diverse range of HPB surgical scoring systems may facilitate evidence-based decisions on patient management and treatment. Future scoring systems need to be developed using heterogenous patient cohorts with improved stratification, with future trends integrating machine learning and genetics to improve outcome prediction.

Comparison of the Clavien-Dindo and Comprehensive Complication Index systems for grading of surgical complications after colorectal resections

INTRODUCTION

Postoperative complications are associated with prolonged hospital stay and a rise in costs of treatment. The Comprehensive Complication Index (CCI) was developed as a scoring system that does not only take the most severe complication into account but all complications after surgery. Our aim was to compare the Clavien-Dindo scoring system with the CCI in predicting length of hospital stay (LOHS) and in-hospital costs after colorectal resections.

METHODS

Complications occurring after surgical procedures, performed between October 2012 and September 2013, were prospectively recorded. During this period 164 patients developed complication(s). Only patients that underwent a colorectal resection were included. Multivariable linear regression analysis was performed to find independent predictors of in-hospital costs and LOHS.

RESULTS

64 patients (age (range): 69 (10-91) years, M/F: 36/28) were retained. 46 (71.9%) patients had a Clavien-Dindo score ≥ IIIb. Median (IQR) CCI was 40 (30.2-53.9). Mean (±SD) in-hospitals costs for all patients were €12,920 ± €10,229. The adjusted difference (95% CI, p-value) in in-hospital costs for minor and major (Clavien-Dindo ≥ IIIb) complications was 10,021 (€4283 to €15,759, p = 0.001). A 10 point increase in CCI increased in-hospital costs by €2040. Multivariable analysis retained CCI > 40 as the only independent risk factor for increased in-hospital costs (Standard Beta Coeffic (p-value): 8063 (p = 0.022).

CONCLUSION

CCI is a better predictor of in-hospital costs than Clavien-Dindo score to classify complications after colorectal resections, as it captures all complications. Further research is warranted to extrapolate our findings to other sub-specialities of surgery.

Management of postoperative complications during laparoscopic anterior rectal resection

Laparoscopic anterior resection (LAR) is currently a routine practice in specialized high-volume centers, with equivalent oncological outcomes in historical, open surgery. Appropriate pelvic dissection can be measured by the adequacy of circumferential margin (CRM) and distal margin, both are risk factors of local recurrence. Among the various operative procedures for colorectal cancer, low anterior resection (LAR) for rectal cancer is one of the most demanding procedures because it requires resection of cancer with surrounding mesorectal tissue and reconstruction with anastomosis in the narrow pelvis while preserving the autonomic nerves of the urogenital organs particularly in the male pelvis. Low anterior resection is associated with a relatively high incidence of postoperative morbidities, including anastomotic leakage and other operative site infections, and asymptomatic patients infected with COVID-19 submitted to elective could be at higher risk which sometimes result in post operative mortality. Therefore, recognition of the incidence and risk factors of postoperative complications following low anterior resection is essential to prevent it. The importance of some risk factors such as age, nutrition status of the patient, experience of the surgeon and many other factors that influence outcome of colorectal surgery which could be modified pre operatively to prevent post operative complications. In the other hand long term post operative complications may promote tumor recurrence and decrease survival. The severity of these complications was evaluated by Clavien-Dindo classification (Table1) initiated in 1992 is based on the type of therapy needed to correct the complication. The principle of the classification is simple, reproducible, flexible, and applicable. The Clavien-Dindo Classification(1) appears reliable and may represent a compelling tool for quality assessment in surgery. Post-operative complications can also be classified according to time-line related to surgery as such, early postoperative complications can be defined where morbidity rates occurred within 30 days of the procedure (25%-32%)- (Table 2) or long-term as those that take place between the 30th post-operative day to 3 years following. The aims of this review are to provide an overview of the current literature on post operative complications of rectal surgery and to describe risk factors and strategies to prevent, treat or reduce complications.

Nomograms for morbidity and mortality after oncologic colon resection in the enhanced recovery era: results from a multicentric prospective national study

PURPOSE

Predicting postoperative complications and mortality is important to plan the surgical strategy. Different scores have been proposed before to predict them but none of them have been yet implemented into the routine clinical practice because their difficulties and low accuracy with new surgical strategies and enhanced recovery. The main aim of this study is to identify risk factors for postoperative morbidity and mortality after colonic resection (CR) without protective stomas, in order to develop a comprehensive, up-to-date, simple, reliable, and applicable model for the preoperative assessment of patients with colon cancer.

METHODS

Multivariable analysis was performed to identify risk factors for 60-day morbidity and mortality. Coefficients derived from the regression model were used in the nomograms to predict morbidity and mortality.

RESULTS

Three thousand one hundred ninety-three patients from 52 hospitals were included into the analysis. Sixty-day postoperative complications rate was 28.3% and the mortality rate was 3%. In multivariable analysis the independent risk factors for postoperative complications were age, male gender, liver and pulmonary diseases, obesity, preoperative albumin, anticoagulant treatment, open surgery, intraoperative complications, and urgent surgery. Independent risk factors for mortality were age, preoperative albumin anticoagulant treatment, and intraoperative complications.

CONCLUSIONS

Risk factors for morbidity and mortality after CR for cancer were identified and two easy predictive tools were developed. Both of them could provide important information for preoperative consultation and surgical planning in the time of enhance recovery.

Usage of Probiotics and its Clinical Significance at Surgically Treated Patients Sufferig from Colorectal Carcinoma

Introduction:

Colorectal Cancer (CRC) is the third most common malignant disease and the fourth most common cause of death associated with malignancy. Adenocarcinomas account for 95% of all cases of colon cancer. Treatment usually includes a surgical resection which is preceded or followed by chemotherapy and radiotherapy depending on the stage. There is constant interest in the microbiological ecosystem of the intestine, which is considered to be crucial for the onset and progression of the disease as well as the development of postoperative complications. Iatrogenic factors associated with the treatment of CRC may result in pronounced expression of virulence of the bacterial intestinal flora and fulminant inflammatory response of the host which ultimately leads to adverse treatment results. The modulation of intestinal microflora by probiotics seems to be an effective method of reducing complications in surgical patients. The question is whether ordering probiotics can lead to more favourable treatment outcomes for our patients who are operated due to colorectal adenocarcinoma, and whether this should become common practice.

Aim:

To demonstrate the clinical significance of probiotic administration in patients treated for colorectal adenocarcinoma and the results compared with relevant studies.

Patients and Methods:

In a randomized controlled prospective study conducted at the Clinic of General and Abdominal Surgery of the UCCS in the period of 01 January 2017 until 31 December 2017, there were a total of 78 patients with colorectal adenocarcinoma. Patients were divided into two groups: a group treated with oral probiotics (n = 39) according to the 2x1 scheme starting from the third postoperative day lasting for the next thirty days, followed by 1x1 lasting for two weeks in each subsequent month to one year, and the control group (n = 39) which was not routinely treated with probiotics.

Results:

A statistically significant difference in the benefit of using probiotics was found during postoperative hospitalization and the occurrence of fatal outcome in the first six months. All complications were more present in the group of patients untreated with probiotic, with statistical significance shown only in the case of ileus. Probiotic has a statistically significant reduction in postoperative complications in the localization of tumours on the rectum -33.3% and the ascending colon -16.7%.

Conclusion:

There is a significant benefit of administering probiotics in surgically treated patients for colorectal adenocarcinoma.

Functional performance and 30-day postoperative mortality after emergency laparotomy-a retrospective, multicenter, observational cohort study of 1084 patients

BACKGROUND

Despite the importance of predicting adverse postoperative outcomes, functional performance status as a proxy for frailty has not been systematically evaluated in emergency abdominal surgery. Our aim was to evaluate if the Eastern Cooperative Oncology Group (ECOG) performance score was independently associated with mortality following high-risk emergency abdominal surgery, in a multicentre, retrospective, observational study of a consecutive cohort.

METHODS

All patients aged 18 or above undergoing high-risk emergency laparotomy or laparoscopy from four emergency surgical centres in the Capitol Region of Denmark, from January 1 to December 31, 2012, were included. Demographics, preoperative status, ECOG performance score, mortality, and surgical characteristics were registered. The association of frailty with postoperative mortality was evaluated using multiple regression models. Likelihood ratio test was applied for goodness of fit.

RESULTS

In total, 1084 patients were included in the cohort; unadjusted 30-day mortality was 20.2%. ECOG performance score was independently associated with 30-day mortality. Odds ratio for mortality was 1.70 (95% CI (1.0, 2.9)) in patients with ECOG performance score of 1, compared with 5.90 (95% CI (1.8, 19.0)) in patients with ECOG performance score of 4 (p < 0.01). Likelihood ratio test suggests improvement in fit of logistic regression modelling of 30-day postoperative mortality when including ECOG performance score as an explanatory variable.

CONCLUSIONS

This study found ECOG performance score to be independently associated with the postoperative 30-day mortality among patients undergoing high-risk emergency laparotomy. The utility of including functional performance in a preoperative risk assessment model of emergency laparotomy should be evaluated.

Systematic review and narrative synthesis of surgeons' perception of postoperative outcomes and risk

BACKGROUND

The accuracy with which surgeons can predict outcomes following surgery has not been explored in a systematic way. The aim of this review was to determine how accurately a surgeon's 'gut feeling' or perception of risk correlates with patient outcomes and available risk scoring systems.

METHODS

A systematic review was undertaken in accordance with PRISMA guidelines. A narrative synthesis was performed in accordance with the Guidance on the Conduct of Narrative Synthesis In Systematic Reviews. Studies comparing surgeons' preoperative or postoperative assessment of patient outcomes were included. Studies that made comparisons with risk scoring tools were also included. Outcomes evaluated were postoperative mortality, general and operation-specific morbidity and long-term outcomes.

RESULTS

Twenty-seven studies comprising 20 898 patients undergoing general, gastrointestinal, cardiothoracic, orthopaedic, vascular, urology, endocrine and neurosurgical operations were included. Surgeons consistently overpredicted mortality rates and were outperformed by existing risk scoring tools in six of seven studies comparing area under receiver operating characteristic (ROC) curves (AUC). Surgeons' prediction of general morbidity was good, and was equivalent to, or better than, pre-existing risk prediction models. Long-term outcomes were poorly predicted by surgeons, with AUC values ranging from 0·51 to 0·75. Four of five studies found postoperative risk estimates to be more accurate than those made before surgery.

CONCLUSION

Surgeons consistently overestimate mortality risk and are outperformed by pre-existing tools; prediction of longer-term outcomes is also poor. Surgeons should consider the use of risk prediction tools when available to inform clinical decision-making.

A novel scoring system to analyze combined effect of lifestyle factors on pancreatic cancer risk: a retrospective case-control study

Although several risk factors for the onset of pancreatic ductal adenocarcinoma (PDAC) have been identified, currently, no scoring system to systemically evaluate the risk of PDAC has been established. In this study, we aimed to use a population of over 1200 patients to build a novel scoring system, and evaluated combined effects of risk factors for PDAC patients.A set of 4904 participants including 1274 PDAC patients and 3630 non-cancer individuals were recruited for the single-center study over 17-year period (1997~2013). Systematic logical analysis were presented for case and control groups, and a risk rating system was constructed to assess combined risk factors. Seven independent risk factors were identified with the increased risk of PDAC, were selected into the risk score. A merged risk assessment model was established, demonstrating significantly increased PDAC risk in following a number of rising scores. Individuals with scores from 1 to more than 4, the responding OR (95% CI) were 3.06 (2.57~3.65), 7.08 (5.63~8.91), 22.4 (14.2~35.4), and 31.4 (12.7~77.5), respectively. The integer-based risk score in the study can be used for risk stratification to accurately evaluate PDAC occurrence at an early stage. This scoring system provides an accurate risk assessment of PDAC risk.

The Parkland grading scale for cholecystitis

BACKGROUND

Gallbladders (GBs) with severe inflammation have longer operative times and an increased risk for complications. We propose a grading system using intraoperative images to better stratify GB inflammation.

METHODS

After reviewing the intraoperative images of GBs obtained during several hundred laparoscopic cholecystectomies, we developed a five-tiered grading system based on anatomy and inflammatory changes. Fifty intraoperative photographs were taken prior to dissection and then distributed to 11 surgeons who rated each GB's severity per the grading system. The two-way random effects Intraclass Correlation Coefficient (ICC) was used to assess the reliability among the raters.

RESULTS

The ICC among the raters of GB severity was 0.804 (95% CI: 0.733 to 0.867; p = 0.0001). Nineteen GB images had greater than 82% agreement and 16 were clustered around GBs with severe inflammation (grades 3-5).

CONCLUSION

This study proposes a simple, reliable grading system that characterizes GB complexity based on inflammation and anatomy.

Physiological and operative severity score for the enumeration of mortality and morbidity scoring systems for assessment of patient outcome and impact of surgeons' and anesthesiologists' performance in hepatopancreaticobiliary surgery

Context:

The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a scoring system used to predict morbidity and mortality.

Aims:

We compared the physiological and operative risk, the expected morbidity and mortality, and the observed postoperative mortality among patients operated by different surgeons and anesthetized by different anesthesiologists.

Settings and Design:

This was a retrospective, single center study.

Subjects and Methods:

The anesthetic records of 159 patients who underwent hepatopancreaticobiliary surgery were analyzed for the physiological and operative severity, POSSUM morbidity, POSSUM and Portsmouth POSSUM (P-POSSUM) mortality scoring systems, observed mortality in 30-days, 3, 6, and 12 months postoperatively, duration of surgery, and units of packed red blood cells (PRBC) transfused. These variables were compared among patients operated by five different surgeons and anesthetized by seven different anesthesiologists.

Statistical Analysis:

One-way analysis of variance was used for normally and Kruskal–Wallis test for nonnormally distributed responses. Differences in percentages of postoperative mortality were assessed by Chi-squared test.

Results:

The physiological severity, POSSUM morbidity, POSSUM and P-POSSUM mortality scores, and observed mortality at 1, 3, 6, and 12 months postoperatively did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. Duration of surgery (P < 0.001), PRBC units transfused (P = 0.002), and operative severity (P = 0.001) differed significantly among patients operated by different surgeons.

Conclusions:

The physiological severity score, POSSUM and P-POSSUM scores did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. The different operative severity scores did not influence the observed mortality in the postoperative period.

New surgical scoring system to predict postoperative mortality

Purpose

There is still no easy and highly useful method to comprehensively assess both preoperative and intraoperative patient statuses to predict postoperative outcomes. We attempted to develop a new scoring system that would enable a comprehensive assessment of preoperative and intraoperative patient statuses instantly at the end of anesthesia, predicting postoperative mortality.

Methods

The study included 32,555 patients who underwent surgery under general or regional anesthesia from 2008 to 2012. From the anesthesia records, extracted factors, including patient characteristics and American Society of Anesthesiologists physical status classification (ASA-PS), and three intraoperative indexes (the lowest heart rate, lowest mean arterial pressure, and estimated volume of blood loss) are used to calculate the surgical Apgar score (sAs). The sAs and ASA-PS, and surgical Apgar score combined with American Society of Anesthesiologists physical status classification (SASA), which combines the sAs and ASA-PS into a single adjusted scale, were compared and analyzed with postoperative 30-day mortality.

Results

Increased severity of the sAs, ASA-PS and SASA was correlated with significantly higher mortality. The risk of death was elevated by 3.65 for every 2-point decrease in the sAs, by 6.4 for every 1-point increase in the ASA-PS, and by 9.56 for every 4-point decrease in the SASA. The ROC curves of the sAs and ASA-PS alone also individually demonstrated high validity (AUC = 0.81 for sAs and 0.79 for ASA-PS, P < 0.001). The SASA was even more valid (AUC = 0.87, P < 0.001).

Conclusions

The sAs and ASA-PS were shown to be extremely useful for predicting 30-day mortality after surgery. An even higher predictive ability was demonstrated by the SASA, which combines these simple and effective scoring systems.

Development of a risk stratification system for the occurrence of prolonged postoperative ileus after colorectal surgery: a prospective risk factor analysis

BACKGROUND

Management strategies for prolonged postoperative ileus (PPOI) are principally conservative and it is therefore valuable to shift attention to prevention. This study aimed to identify prospectively the perioperative risk factors for the development of PPOI and create a tool to predict its occurrence.

METHODS

Patients undergoing elective colorectal surgery at Auckland District Health Board between September 2012 and June 2014 were enrolled. In total, 92 variables were investigated prospectively with uniform application of a standardized definition of PPOI. Logistic regression and area under receiver operating characteristic curves (AUC) were used to generate risk stratification models.

RESULTS

PPOI occurred in 88 of 327 patients (26.9%). Independent predictors of PPOI were male gender (odds ratio [OR], 3.01), decreasing preoperative albumin (OR, 1.11 per g/L unit), open or converted technique (OR, 6.37 [vs laparoscopic]), increasing wound size (OR, 1.09 [per cm]), operative difficulty (OR, 1.28 [per unit on 10-point Likert scale]), operative bowel handling (OR, 1.38 [per unit on 10-point Likert scale]), red cell transfusion (OR, 1.84 [per unit]), intravenous crystalloid administration (OR, 1.55 [per liter]), and delayed first mobilization (OR, 1.39 [per day]). The I-Score assimilated preoperative and intraoperative variables to generate a score out of 6 with a 7-fold increase in risk from low-risk to high-risk strata and fair predictive capacity (AUC, 0.742; 95% CI, 0.684-0.799).

CONCLUSION

Independent predictors for the development of PPOI have been identified prospectively and used to construct a novel risk stratification model.

Safety of hepatectomy for elderly patients with hepatocellular carcinoma

The number of elderly patients with hepatocellular carcinoma (HCC) has been increasing. Characteristics of elderly HCC patients are a higher proportion of females, a lower rate of positive hepatitis B surface antigen, and a higher rate of positive hepatitis C antibodies. Careful patient selection is vital for performing hepatectomy safely in elderly HCC patients. Treatment strategy should be decided by not only considering tumor stage and hepatic functional reserve, but also physiological status, including comorbid disease. Various assessment tools have been applied to predict the risk of hepatectomy. The reported mortality and morbidity rates after hepatectomy in elderly HCC patients ranged from 0% to 42.9% and from 9% to 51%, respectively. Overall survival rate after hepatectomy in elderly HCC patients at 5 years ranged from 26% to 75.9%. Both short-term and long-term results after hepatectomy for strictly selected elderly HCC patients are almost the same as those for younger patients. However, considering physiological characteristics and the high prevalence of comorbid disease in elderly patients, it is important to assess patients more meticulously and to select them strictly if scheduled to undergo major hepatectomy.

Innovative bridging of the rural-urban divide: comparison of scope, safety, and impact of collaborative rural surgery camps and an urban surgical program

BACKGROUND

In medically under-resourced regions worldwide, non-permanent surgery programs or camps have been conducted to expand access to surgical services. Surgery camp programs have been reported in rural India, primarily in the ophthalmic and obstetric fields; however, the provision of general surgical services in these settings is largely unknown.

METHODS

A 12-month retrospective review of non-ambulatory procedures performed at a rural hospital surgery camp program and at an urban hospital in Maharashtra, India, was completed to characterize relative differences in procedural activity, frequency and severity of perioperative complications, and to evaluate efficacy of care.

RESULTS

A total of 449 cases performed in rural hospital surgery camps were compared with 344 cases performed in an urban hospital during the course of the study period. The majority of rural surgical cases were elective and of intermediate complexity. Approximately 4% of rural cases were complex-major compared to 17% of urban cases. Intraoperative complications occurred in 0.2% rural cases compared to 5.5% of urban cases; p = 0.01. Postoperative complications were predominantly low grade in both groups. The postoperative complication rate was higher among rural surgical patients (43.4%; 23.5%; p < 0.01), though the Surgical Risk Score was significantly lower in this group (p < 0. 01). Rural surgery camp activity over 12 months achieved diagnostic and/or therapeutic goals in 92.2% of procedures and rendered 1.74-2.69 disability-adjusted life-years (DALYs) averted per patient.

CONCLUSIONS

Rural general surgery camps can safely and effectively provide a wide range of surgical services under appropriate collaborative and clinical conditions. Surgery camps may be a safe, temporizing solution to unmet needs until substantial gains in rural healthcare are realized.

Prognostic factors for morbidity and mortality in elderly patients undergoing acute gastrointestinal surgery: a systematic review

BACKGROUND

Elderly patients undergoing acute gastrointestinal (GI) surgery experience increased morbidity and mortality compared with younger and elective patients. Prognostic factors can be used to counsel patients of these risks and, if modifiable, to minimize them. We reviewed the literature on prognostic factors for adverse outcomes in elderly patients undergoing acute GI surgery.

METHODS

We searched PubMed and Embase using a strategy developed in collaboration with an expert librarian. Studies examining independent associations between prognostic factors and morbidity or mortality in patients aged 65 and older undergoing acute GI surgery were selected. We extracted data using a standardized form and assessed study quality using the QUIPS tool.

RESULTS

Nine cohort studies representing 2958 patients satisfied our selection criteria. All studies focused on postoperative mortality. Thirty-four prognostic factors were examined, with significant variability across studies. There was limited or conflicting evidence for most prognostic factors. Meta-analysis was only possible for the American Society of Anesthesiologists (ASA) score, which was found to be associated with mortality in 4 studies (pooled odds ratio 2.77, 95% confidence interval 0.92-8.41).

CONCLUSION

While acute GI surgery in elderly patients is becoming increasingly common, the literature on prognostic factors for morbidity and mortality in this patient population lags behind. Further research is needed to help guide patient care and potentially improve outcomes.

Major incidents and complications in otherwise healthy patients undergoing elective procedures: results based on 1.37 million anaesthetic procedures

BACKGROUND

Improved anaesthesia safety has made severe anaesthesia-related incidents, complications, and deaths rare events, but concern about morbidity and mortality in anaesthesia continues. This study examines possible severe adverse outcomes or death recorded in a large national surveillance system based on a core data set (CDS).

METHODS

Cases from 1999 to 2010 were filtered from the CDS database. Cases were defined as elective patients classified as ASA physical status grades I and II (without relevant risk factors) resulting in death or serious complication. Four experts reviewed the cases to determine anaesthetic involvement.

RESULTS

Of 1 374 678 otherwise healthy, ASA I and II patients in the CDS database, 36 met the study inclusion criteria resulting in a death or serious complication rate of 26.2 per million [95% confidence interval (CI), 19.4-34.6] procedures, and for those with possible direct anaesthetic involvement, 7.3 per million cases (95% CI, 3.9-12.3).

CONCLUSIONS

This is the first study assessing severe incidents and complications from a national outcome-tracking database. Annual identification and review of cases, perhaps with standardized database queries in the respective departments, might provide more detailed information about the cascades that lead to unfortunate outcomes.

Nonspecific changes in clinical laboratory indicators in unselected terminally ill patients and a model to predict survival time based on a prospective observational study

BACKGROUND

The clinical prediction of survival is among the most challenging tasks because it refers to the process whereby the medical team assimilates clinical data using subjective methods. The purpose of this prospective observational study was to develop a model for evaluating survival time using objective laboratory parameters.

METHODS

Albumin (ALB), creatinine (CRE), C-reactive protein (CRP) and the neutrophilic leukocyte count (NEU) were measured using automated analysers. A total of 177 subjects with any one positive item of 4 items were included in the study. Age on the observation date and date of death were recorded.

RESULTS

ALB, CRE, CRP and the NEU were all significant predictors of survival time (p < 0.05). The median survival time of patients with anyone of the 4 items positive would be over 1 year; if any 2 items were positive, the median survival time was approximately 1 year; if any 3 items were positive, the median survival time was approximately 4 months and if 4 items were positive, the median survival time was approximately 20 days.

CONCLUSIONS

This study suggests that a model using ALB, CRE, CRP and the NEU is potentially useful in the objective evaluation of survival time in terminally ill patients.

How to improve the performance of intraoperative risk models: an example with vital signs using the surgical apgar score

BACKGROUND

Computerized reviews of patient data promise to improve patient care through early and accurate identification of at-risk and well patients. The significance of sampling strategy for patient vital signs data is not known. In the instance of the surgical Apgar score (SAS), we hypothesized that larger sampling intervals would improve the specificity and overall predictive ability of this tool.

METHODS

We used electronic intraoperative data from general and vascular surgical patients in a single-institution registry of the American College of Surgeons National Surgical Quality Improvement Program. The SAS, consisting of lowest heart rate, lowest mean arterial blood pressure, and estimated blood loss between incision and skin closure, was calculated using 5 methods: instantaneously and using intervals of of 5 and 10 minutes with and without interval overlap. Major complications including death were assessed at 30 days postoperatively.

RESULTS

Among 3000 patients, 272 (9.1%) experienced major complications or death. As the sampling interval increased from instantaneous (shortest) to 10 minutes without overlap (largest), the sensitivity, positive predictive value, and negative predictive value did not change significantly, but significant improvements were noted for specificity (79.5% to 82.9% across methods, P for trend <0.001) and accuracy (76.0% to 79.3% across methods, P for trend <0.01). In multivariate modeling, the predictive utility of the SAS as measured by the c-statistic nearly increased from Δc = +0.012 (P = 0.038) to Δc = +0.021 (P < 0.002) between the shortest and largest sampling intervals, respectively. Compared with a preoperative risk model, the net reclassification improvement and integrated discrimination improvement for the shortest versus largest sampling intervals of the SAS were net reclassification improvement 0.01 (P = 0.8) vs 0.06 (P = 0.02), and for integrated discrimination improvement, they were 0.008 (P < 0.01) vs 0.015 (P < 0.001).

CONCLUSIONS

When vital signs data are recorded in compliance with American Society of Anesthesiologists' standards, the sampling strategy for vital signs significantly influences performance of the SAS. Computerized reviews of patient data are subject to the choice of sampling methods for vital signs and may have the potential to be optimized for safe, efficient patient care.

The surgical Apgar score is strongly associated with intensive care unit admission after high-risk intraabdominal surgery

BACKGROUND

Understanding intensive care unit (ICU) triage decisions for high-risk surgical patients may ultimately facilitate resource allocation and improve outcomes. The surgical Apgar score (SAS) is a simple score that uses intraoperative information on hemodynamics and blood loss to predict postoperative morbidity and mortality, with lower scores associated with worse outcomes. We hypothesized that the SAS would be associated with the decision to admit a patient to the ICU postoperatively.

METHODS

We performed a retrospective cohort study of adults undergoing major intraabdominal surgery from 2003 to 2010 at an academic medical center. We calculated the SAS (0-10) for each patient based on intraoperative heart rate, mean arterial blood pressure, and estimated blood loss. Using logistic regression, we assessed the association of the SAS with the decision to admit a patient directly to the ICU after surgery.

RESULTS

The cohort consisted of 8501 patients, with 72.7% having an SAS of 7 to 10 and <5% an SAS of 0 to 4. A total of 8.7% of patients were transferred immediately to the ICU postoperatively. After multivariate adjustment, there was a strong association between the SAS and the decision to admit a patient to the ICU (adjusted odds ratio 14.41 [95% confidence interval {CI}, 6.88-30.19, P < 0.001] for SAS 0-2, 4.42 [95% CI, 3.19-6.13, P < 0.001] for SAS 3-4, and 2.60 [95% CI, 2.08-3.24, P < 0.001] for SAS 5-6 compared with SAS 7-8).

CONCLUSIONS

The SAS is strongly associated with clinical decisions regarding immediate ICU admission after high-risk intraabdominal surgery. These results provide an initial step toward understanding whether intraoperative hemodynamics and blood loss influence ICU triage for postsurgical patients.

Clinical and microbiological efficacy of tigecycline for complicated skin-soft-tissue and intra-abdominal infections in a Turkish university hospital

OBJECTIVE

Tigecycline, a new glycylcycline antimicrobial agent, is indicated for the treatment of complicated skin structure infection (cSSTI), intra-abdominal infection (cIAI) and community acquired pneumonia. We aimed to evaluate the clinical and microbiological data together about tigecycline therapy.

METHODS

Patients with cIAIs and cSSTIs were included in a prospective, observational follow-up. Patient follow-up forms were developed and clinical and microbiological data were recorded.

RESULTS

Of the 107 patients, 67 had cSSTIs, 40 had cIAIs. Tigecycline was used empirically in 37.5% of cIAIs and in 50.7% of cSSTIs. In 85.0% of the patients with cIAI and in 73.1% of the patients with cSSTI, clinical and/or microbiological response could be achieved. A drug change was made in 26.9% and 7.5% of the patients with cSSTI and cIAI respectively. Superinfection was detected in 14.9% of the cSSTI and 7.5% of the cIAI patients.

CONCLUSION

As a result, tigecycline can be safely used in the treatment of different infections. Compared with cSSTIs, the treatment response is better and the duration of treatment is shorter in cIAIs. However, MIC value must be determined at any rate if tigecycline is to be used in the treatment of Acinetobacter (MDR Acinetobacter, in particular) infections. Clinical cure and microbiological eradication rate of tigecycline therapy changes according to different clinical diagnosis and microorganism.

Development of a prognostic score using the complete blood cell count for survival prediction in unselected critically ill patients

Objective. The purpose of this study was to develop a new prognostic scoring system for critically ill patients using the simple complete blood cell count (CBC). Methods. CBC measurements in samples from 306 patients in an intensive care unit were conducted with automated analyzers, including levels of neutrophils, lymphocytes, erythrocytes, hemoglobin, and platelets. The time of sampling and the time of death were recorded. Z values were calculated according to the measured values, reference mean values, and standard deviations. The prognostic score was equivalent to the median of the Z value of each of the measured parameters. Results. There was a significant correlation between survival time and neutrophil, lymphocyte, and platelet levels (P < 0.05). Prognostic scores were calculated from the Z value of these three parameters. Survival times decreased as the prognostic score increased. Conclusions. This study suggests that a model that uses levels of neutrophils, lymphocytes, and platelets is potentially useful in the objective evaluation of survival time or disease severity in unselected critically ill patients.

Validation of the surgical Apgar score in a neurosurgical patient population

Object

The surgical Apgar score (SAS) reliably predicts postoperative death and complications and has been validated in a large cohort of general and vascular surgery patients. However, there has been limited study of the utility of the score in the neurosurgical population. The authors tested the hypothesis that the SAS would predict postoperative complications and length of stay after neurosurgical procedures.

Methods

A cohort of 918 intracranial and spine surgery patients treated over a 3-year period were retrospectively evaluated. The 10-point SAS was calculated and postoperative 30-day mortality and complications rates, intensive care unit (ICU) stay, and hospital stay were assessed by 2 independent raters. Univariate analysis and multivariate logistic regression were performed.

Results

There were 145 patients (15.8%) with at least 1 complication and 24 patients (2.6%) who died within 30 days of surgery. Surgical Apgar scores were significantly associated with the likelihood of postoperative complications (p < 0.001) and death (p = 0.002); scores varied inversely with postoperative complication and mortality risk in a multivariate analysis. Low SASs also predicted prolonged ICU and hospital stay. Patients with scores of 0–2 stayed a mean of 18.9 days (p < 0.001) and patients with scores of 3–4 stayed an average of 14.3 days (p < 0.001) compared with 4.1 days in patients with scores of 9–10.

Conclusions

The application of the surgical Apgar score to a neurosurgical cohort predicted 30-day postoperative mortality and complication rates as well as extended ICU and hospital stay. This readily calculated score may help neurosurgical teams efficiently direct postoperative care to those at highest risk of death and complications.

Anesthesia and perioperative management of colorectal surgical patients - A clinical review (Part 1)

Colorectal surgery is commonly performed for colorectal cancer and other pathology such as diverticular and inflammatory bowel disease. Despite significant advances, such as laparoscopic techniques and multidisciplinary recovery programs, morbidity and mortality remain high and vary among surgical centers. The use of scoring systems and assessment of functional capacity may help in identifying high-risk patients and predicting complications. An understanding of perioperative factors affecting colon blood flow and oxygenation, suppression of stress response, optimal fluid therapy, and multimodal pain management are essential. These fundamental principles are more important than any specific choice of anesthetic agents. Anesthesiologists can significantly contribute to enhance recovery and improve the quality of perioperative care.

Development and cross-validation of the in-hospital mortality prediction in advanced cancer patients score: a preliminary study

PURPOSE

Acute palliative care units (APCUs) provide intensive symptom support and transition of care for advanced cancer patients. Better understanding of the predictors of in-hospital mortality is needed to facilitate program planning and patient care. In this prospective study, we identified predictors of APCU mortality, and developed a four-item In-hospital Mortality Prediction in Advanced Cancer Patients (IMPACT) predictive model.

METHODS

Between April and July 2010, we documented baseline demographics, the Edmonton Symptom Assessment Scale (ESAS), 80 clinical signs including known prognostic factors, and 26 acute complications on admission in consecutive APCU patients. Multivariate logistic regression analysis was used to identify factors for inclusion in a nomogram, which was cross-validated with bootstrap analysis.

RESULTS

Among 151 consecutive patients, the median age was 58, 13 (9%) had hematologic malignancies, and 52 (34%) died in the hospital. In multivariate analysis, factors associated with in-hospital mortality were advanced education (odds ration [OR]=11.8, p=0.002), hematologic malignancies (OR=8.6, p=0.02), delirium (OR=4.3, p=0.02), and high ESAS global distress score (OR=20.8, p=0.01). In a nomogram based on these four factors, total scores of 6, 10, 14, 17, and 21 corresponded to a risk of death of 10%, 25%, 50%, 75%, and 90%, respectively. The model has 92% sensitivity and 88% specificity for predicting patients at low/high risk of dying in the hospital, and a receiver-operator characteristic curve concordance index of 83%.

CONCLUSIONS

Higher education was associated with increased utilization of the interdisciplinary palliative care unit until at the end of life. Patients with higher symptom burden, delirium, and hematologic malignancies were also more likely to require APCU care until death.

Surgical Apgar score predicts perioperative morbidity in patients undergoing pancreaticoduodenectomy at a high-volume center

OBJECTIVES

Pancreaticoduodenectomy (PD) remains a procedure that carries considerable morbidity. Numerous studies have evaluated factors to predict patients at risk. The aim of this study was to determine whether the surgical Apgar score (SAS) predicts perioperative morbidity and mortality.

METHODS

We examined 553 patients undergoing successful PD between January 2000 and December 2010. Postoperative complications were graded using the Clavien scale, and the SAS (range, 0-10) was determined. The Cochran-Armitage test for trend was used to determine the association between grouped SAS scores (0-2, 3-4, 5-6, 7-8, and 9-10) and each of the outcomes.

RESULTS

The average patient age was 64 years, and there was an even distribution of males and females. There were 11 perioperative deaths (2%), 186 grade 2 or higher complications (34%), and 86 major complications (grades 3-5, 16%). Additionally, 61 patients developed pancreatic fistulae (11%). Statistical analysis determined that SAS was a significant predictor of grade 2 or higher complications (p < 0.0001), major morbidity (p = 0.01), and pancreatic fistula (p = 0.04) but not mortality (p = 0.20).

CONCLUSIONS

We demonstrate that the SAS is a significant predictor of perioperative morbidity for patients undergoing PD. This score should be used to identify patients at higher risk in order to prioritize use of postoperative critical care beds and hospital resources.

Laparoscopic colorectal resection for cancer: effects of conversion on long-term oncologic outcomes

BACKGROUND

The effects of conversion to open surgery during laparoscopic resection for colorectal cancer on long-term oncologic outcomes still are unclear.

METHODS

All 450 laparoscopic colorectal resections for cancer performed at a single center between 1994 and 2008 and included in a prospectively maintained database were considered. Patients who required conversion to open surgery (CONV) were matched 1:2 with laparoscopically completed cases (LAP) and 1:5 with open surgery cases (OPEN) for age, American Society of Anesthesiologists (ASA) score, year of surgery, tumor location, and tumor stage. Fisher's exact, chi-square, and Wilcoxon tests were used as appropriate. Kaplan-Meier curves were compared to analyze survival.

RESULTS

In this study, 31 CONV cases were independently compared with 62 LAP and 155 OPEN cases. Compared with the LAP and OPEN patients, the CONV patients were characterized by a numerically higher rate of preoperative comorbidity (61.3% vs LAP, 51.6; P = 0.4 and OPEN, 48.4%; P = 0.2), male gender (77.4% vs LAP, 59.7%; P = 0.09 and OPEN, 58.1%; P = 0.05), and a significantly higher mean body mass index (29.6 vs LAP, 26.8; P = 0.012 and OPEN, 28.8; P = 0.3). The pathologic tumor stage, location, and chemotherapy and radiotherapy rates were comparable among the groups. After a median follow-up period of 4.1, 4.2, and 4.6 years, the 5-year disease-free survival rate was significantly lower for the CONV patients (40.2%) than for the LAP (70.7%, P = 0.01) or the OPEN (63.3%, P = 0.04) patients. However, the 5-year cancer-specific survival rates were similar among the CONV (94.4%), LAP (86.1%, P = 0.36), and OPEN (84.9%, P = 0.14) patients.

CONCLUSIONS

Conversion to open surgery does not affect oncologic outcomes, although CONV patients have increased comorbidity rates affecting long-term mortality.

Postoperative mortality and complications

Recent publications not only underline the risks of age and disease during surgery but also help us quantify the risks with greater precision. Importantly, patient factors often have a stronger association with postoperative mortality than surgical factors. Important factors preoperatively are: age, American Society of Anaesthesiologist (ASA) physical status, emergency surgery, and plasma albumin concentration. There is emerging work on quantifying frailty as a further risk factor for perioperative complication and mortality as well as need for higher level of care after discharge from hospital. Important postoperative complications include sepsis and kidney injury. Preventing, detecting and managing complications and mortality is the greatest challenge facing those caring for surgical patients, including anaesthetists. Evidence for the long term effects of perioperative complications adds further importance to minimizing perioperative complications. Newer approaches in patient care, particularly co-management during the postoperative phase by different specialities are emerging. Managing high-risk patients should also be enhanced with greater surveillance and more rapid and appropriate response; ensuring we do not fail to rescue our patients.

Decisions to operate: the ASA grade 5 dilemma

INTRODUCTION

Deciding to operate on high risk patients suffering catastrophic surgical emergencies can be problematic. Patients are frequently classed as American Society of Anesthesiologists (ASA) grade 5 and, as a result, aggressive but potentially lifesaving intervention is withheld. The aim of our study was to review the short-term outcomes in patients who were classed as ASA grade 5 but subsequently underwent surgery despite this and to compare the ASA scoring model to other predictors of surgical outcome.

METHODS

All patients undergoing emergency surgery with an ASA grade of 5 were identified. Patient demographics, indications for surgery, intraoperative findings and outcomes were recorded. In addition to the ASA scores, retrospective Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P POSSUM) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated and compared to the observed outcomes.

RESULTS

Nine patients (39%) survived to discharge. ASA grade was a poor predictor of outcome. P POSSUM and APACHE II scores correlated significantly with each other and with observed outcomes when predicting surgical mortality. The median stay for survivors in the intensive care unit was nine days.

CONCLUSIONS

In times of an ageing population, the number of patients suffering catastrophic surgical events will increase. Intervention, with little hope of a cure, a return to independent living or an acceptable quality of life, leads to unnecessary end-of-life suffering for patients and their relatives, and consumes sparse resources. The accuracy and reliability of ASA grade 5 as an outcome predictor has been questioned. P POSSUM and APACHE II scoring systems are significantly better predictors of outcome and should be used more frequently to aid surgical decision-making in high risk patients.

Assessment of the Surgical Apgar Score in a Swedish setting

BACKGROUND

Predicting major post-operative complications is an important task for which simple and reliable methods are lacking. A simple scoring system based on intraoperative heart rate, blood pressure and blood loss was recently developed to fill this gap. This system, the Surgical Apgar Score, shows promising results both in terms of validity and in terms of usefulness. The goal of this study was to study both these components in a Scandinavian setting.

METHODS

Pre-operative patient characteristics and intraoperative variables were recorded for 224 patients undergoing general and vascular surgery between 26 October and 17 December 2009. Major complications were evaluated during a 30-day follow-up. The relationship between Surgical Apgar Score and major complication was analysed using χ(2)-tests and the relative risk between different scoring patient groups was analysed.

RESULTS

The study showed a strong correlation between the Surgical Apgar Score and major complication (P<0.001). 61.5% of the lowest-scoring patients sustained a major complication compared with only 6.4% in the highest-scoring group. This is equivalent to a relative risk of 7.14 (95% CI: 2.88-17.5, P<0.001).

CONCLUSIONS

The Surgical Apgar Score is valid in a Scandinavian setting. We also note that there were no practical issues in collecting the score. Together with patient pre-operative risk, the score has great potential to guide clinicians when making post-operative decisions and give immediate feedback about the surgical procedure. The next step should be to educate surgical staff about the score.

Elderly POSSUM, a dedicated score for prediction of mortality and morbidity after major colorectal surgery in older patients

BACKGROUND

Several scores have been developed to evaluate surgical unit mortality and morbidity. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and derivatives use preoperative and intraoperative factors, whereas the Surgical Risk Scale (SRS) and Association Française de Chirurgie (AFC) score use four simple factors. To allow for advanced age in patients undergoing colorectal surgery, a dedicated score-the Elderly (E) POSSUM-has been developed and its accuracy compared with these scores.

METHODS

From 2002 to 2004, 1186 elderly patients, at least 65 years old, undergoing major colorectal surgery in France were enrolled. Accuracy was assessed by calculating the area under the receiver operating characteristic curve (AUC) (discrimination) and calibration.

RESULTS

The mortality and morbidity rates were 9 and 41 per cent respectively. The E-POSSUM had both a good discrimination (AUC = 0.86) and good calibration (P = 0.178) in predicting mortality and a reasonable discrimination (AUC = 0.77) and good calibration (P = 0.166) in predicting morbidity. The E-POSSUM was significantly better at predicting mortality and morbidity than the AFC score (P(c) = 0.014 and P(c) < 0.001 respectively).

CONCLUSION

The E-POSSUM is a good tool for predicting mortality, and the only efficient scoring system for predicting morbidity after major colorectal surgery in the elderly.

Complications in colorectal surgery: risk factors and preventive strategies

BACKGROUND

Open or laparoscopic colorectal surgery comprises of many different types of procedures for various diseases. Depending upon the operation and modifiable and non-modifiable risk factors the intra- and postoperative morbidity and mortality rate vary. In general, surgical complications can be divided into intraoperative and postoperative complications and usually occur while the patient is still in the hospital.

METHODS

A literature search (1980-2009) was carried out, using MEDLINE, PubMed and the Cochrane library.

RESULTS

This review provides an overview how to identify and minimize intra- and postoperative complications. The improvement of different treatment strategies and technical inventions in the recent decade has been enormous. This is mainly attributable to the increase in the laparoscopic approach, which is now well accepted for many procedures. Training of the surgeon, hospital volume and learning curves are becoming increasingly more important to maximize patient safety, surgeon expertise and cost effectiveness. In addition, standardization of perioperative care is essential to minimize postoperative complications.

CONCLUSION

This review summarizes the main perioperative complications of colorectal surgery and influencable and non-influencable risk factors which are important to the general surgeon and the relevant specialist as well. In order to minimize or even avoid complications it is crucial to know these risk factors and strategies to prevent, treat or reduce intra- and postoperative complications.