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Iacobescu R, Antoniu SA, Popa AD, Pavel-Tanase M, Stratulat TA. Preoperative frailty screening in elderly patients with non-small cell lung cancer surgery: an essential step for a good surgical outcome. Expert Rev Respir Med 2024; 18:99-110. [PMID: 38690646 DOI: 10.1080/17476348.2024.2349579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/26/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION Non-small cell lung cancer (NSCLC) is a disease commonly diagnosed in the elderly, often in advanced stages. However, elderly patients with lung cancer can benefit from surgery, provided that postoperative risks are assessed appropriately before surgery. Frailty is a measure of age-related impaired functional status and a predictor of mortality and morbidity. However, its importance as a preoperative marker is not well defined. AREAS COVERED This systematic review discusses the importance of preoperative frailty screening in elderly patients with NSCLC. A literature search was performed on the MEDLINE database in June 2023, and relevant studies on frailty or preoperative assessment of NSCLC which were published between 2000 and 2023 were retained and discussed in this review. EXPERT OPINION Among the types of existing methods used to assess frailty those on the geriatric assessment seem to be the most appropriate; however, they are unable to fully capture the 'surgical' frailty; thus, other instruments should be developed and validated in NSCLC.
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Affiliation(s)
- Radu Iacobescu
- Medicine II, Nursing/Palliative Care, University of Medicine and Pharmacy, Grigore T. Popa, Iasi, Romania
| | - Sabina Antonela Antoniu
- Medicine II, Nursing/Palliative Care, University of Medicine and Pharmacy, Grigore T. Popa, Iasi, Romania
| | - Alina Delia Popa
- Medicine II, Nursing/Palliative Care, University of Medicine and Pharmacy, Grigore T. Popa, Iasi, Romania
| | - Mariana Pavel-Tanase
- Medicine II, Nursing/Palliative Care, University of Medicine and Pharmacy, Grigore T. Popa, Iasi, Romania
| | - Teodora Alexa Stratulat
- Medicine II, Nursing/Palliative Care, University of Medicine and Pharmacy, Grigore T. Popa, Iasi, Romania
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Akabane S, Miyake K, Iwagami M, Tanabe K, Takagi T. Machine learning-based prediction of postoperative mortality in emergency colorectal surgery: A retrospective, multicenter cohort study using Tokushukai medical database. Heliyon 2023; 9:e19695. [PMID: 37810013 PMCID: PMC10558952 DOI: 10.1016/j.heliyon.2023.e19695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 10/10/2023] Open
Abstract
Background Although prognostic factors associated with mortality in patients with emergency colorectal surgery have been identified, an accurate mortality risk assessment is still necessary to determine the range of therapeutic resources in accordance with the severity of patients. We established machine-learning models to predict in-hospital mortality for patients who had emergency colorectal surgery using clinical data at admission and attempted to identify prognostic factors associated with in-hospital mortality. Methods This retrospective cohort study included adult patients undergoing emergency colorectal surgery in 42 hospitals between 2012 and 2020. We employed logistic regression and three supervised machine-learning models: random forests, gradient-boosting decision trees (GBDT), and multilayer perceptron (MLP). The area under the receiver operating characteristics curve (AUROC) was calculated for each model. The Shapley additive explanations (SHAP) values are also calculated to identify the significant variables in GBDT. Results There were 8792 patients who underwent emergency colorectal surgery. As a result, the AUROC values of 0.742, 0.782, 0.814, and 0.768 were obtained for logistic regression, random forests, GBDT, and MLP. According to SHAP values, age, colorectal cancer, use of laparoscopy, and some laboratory variables, including serum lactate dehydrogenase serum albumin, and blood urea nitrogen, were significantly associated with in-hospital mortality. Conclusion We successfully generated a machine-learning prediction model, including GBDT, with the best prediction performance and exploited the potential for use in evaluating in-hospital mortality risk for patients who undergo emergency colorectal surgery.
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Affiliation(s)
- Shota Akabane
- Department of Urology, Tokyo Women's Medical University, 8-1, Kawadacho, Shinjuku City, Tokyo, Japan
- Department of General Surgery, Shonan Fujisawa Tokushukai Hospital, 1-5-1, Tsujidokandai, Fujisawa, Kanagawa, Japan
- State Major Trauma Unit, Royal Perth Hospital, Victoria Square, Perth, WA, Australia
| | - Katsunori Miyake
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, MI, USA
| | - Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kazunari Tanabe
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women's Medical University, 8-1, Kawadacho, Shinjuku City, Tokyo, Japan
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Malignant Colorectal Polyps: Are Pathology Reports Sufficient for Decision Making? SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2023; 33:22-26. [PMID: 36729667 DOI: 10.1097/sle.0000000000001131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/24/2022] [Indexed: 02/03/2023]
Abstract
AIM This study aims to assess the completeness of pathology reports of T1 colorectal cancers from different healthcare centers and the change of treatment decision after reevaluation of the polyps. MATERIALS AND METHODS In this single-center retrospective cohort study, several pathology reports of endoscopically excised malignant colorectal polyps at diverse healthcare centers in Turkey were reassessed at a comprehensive cancer center in Istanbul. Reassessment was mainly focused on core elements such as the size of invasive carcinoma, histologic type and grade, tumor extension, surgical margin (deep and mucosal), and lymphovascular invasion. RESULTS Sixty-seven endoscopically resected malignant polyps were analyzed. The mean age of patients was 62.2 years and 38 (58%) patients were males. Tumor size, histologic type and grade, surgical margin (deep and mucosal), and lymphovascular invasion were reported in 11%, 100%, 31%, 9%, and 19%, respectively. All 5 prognostic factors were reported only in 1 (1.5%) pathology report. Because of the missing (incomplete) data, the pathologic examination of 59 (88%) patients was determined to be inadequate to make an accurate treatment decision. CONCLUSION Several variables are not considered and frequently missing for decision-making, suggesting the reassessment of the specimen by a second pathologist at a high-volume comprehensive cancer center.
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Maeda K, Kuriyama N, Ito T, Gyoten K, Hayasaki A, Fujii T, Iizawa Y, Murata Y, Tanemura A, Kishiwada M, Mizuno S. Safety and benefits of major hepatectomy with extrahepatic bile duct resection in older perihilar cholangiocarcinoma patients. Langenbecks Arch Surg 2022; 407:2861-2872. [PMID: 35996005 DOI: 10.1007/s00423-022-02654-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/13/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE To evaluate the safety and benefits of major hepatectomy with extrahepatic bile duct resection in older perihilar cholangiocarcinoma patients and to identify possible predictors of surgical mortality. METHODS We retrospectively analyzed the data of 102 consecutive patients who underwent major hepatectomy with extrahepatic bile duct resection for perihilar cholangiocarcinoma in our institution between 2004 and 2021. The patients were included and divided into two groups: older patients ≥ 75 years and non-older patients < 75 years. Patient characteristics, preoperative nutritional and operative risk scores, intraoperative details, postoperative outcomes, and long-term prognosis were compared between the groups. Univariate and multivariate analyses were used to identify the predictors of 90-day mortality after major hepatectomy with extrahepatic bile duct resection. RESULTS Significant differences were identified for some preoperative surgical risk scores, but not for nutritional scores. Older patients had a higher morbidity rate of respiratory complications (p = 0.016), but there were no significant differences in overall (p = 0.735) or disease-specific survival (p = 0.858). A high Dasari's score was identified as an independent predictive factor of 90-day mortality. CONCLUSIONS Major hepatectomy with extrahepatic bile duct resection can be performed for optimally selected older and younger patients with perihilar cholangiocarcinoma, resulting in a good prognosis. However, indications for extended surgery should be recognized. Dasari's preoperative risk score may be a good predictor of 90-day mortality.
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Affiliation(s)
- Koki Maeda
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie, Japan
- Regional Medical Support Center, Mie University Hospital, Tsu city, Mie, Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie, Japan.
| | - Takahiro Ito
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie, Japan
| | - Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie, Japan
| | - Takehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie, Japan
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie, Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie, Japan
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El Asmar A, Hafez K, Fauconnier P, Moreau M, Dal Lago L, Pepersack T, Donckier V, Liberale G. The efficacy of the American College of Surgeons Surgical Risk Calculator in the prediction of postoperative complications in oncogeriatric patients after curative surgery for abdominal tumors. J Surg Oncol 2022; 126:1359-1366. [PMID: 35924711 DOI: 10.1002/jso.27046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/19/2022] [Accepted: 07/25/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The American College of Surgeons (ACS) has developed a Surgical Risk Calculator (SRC) to predict postoperative surgical complications. No studies have reported the performance of the ACS-SRC in oncogeriatric patients. Our objective was to evaluate the predictive performance of the ACS-SRC in these patients, treated with curative surgery for an abdominal malignancy. METHODS This is a retrospective study including 136 patients who underwent elective abdominal oncological surgery, between 2017 and 2019, at our institution. Postoperative complications were classified according to the ACS-SRC, and its predictive performance was analyzed by assessing discrimination and calibration and using receiver operating characteristics and area under the curve (AUC). RESULTS Discrimination was adequate with AUC of 0.7113 (95% confidence interval [CI]: 1.062-1.202, p = 0.0001; Brier 0.198) for serious complications and 0.7230 (95% CI: 1.101-1.756, p = 0.0057; Brier 0.099) for pneumonia; and poor for sepsis, surgical site infection (SSI), and urinary tract infection (UTI) with AUCs of 0.6636 (95% CI: 1.016-1.353, p = 0.0299; Brier 0.142), 0.6167 (95% CI: 1.003-1.266, p = 0.0450; Brier 0.175), and 0.6598 (95% CI: 1.069-2.145, p = 0.0195; Brier 0.082), respectively. CONCLUSION The ACS-SRC is an adequate predictor for serious complications and pneumonia in oncogeriatric patients treated surgically for abdominal cancer. However, the predictive power of the calculator appears to be low for sepsis, UTI, and SSI.
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Affiliation(s)
- Antoine El Asmar
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Karim Hafez
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Pauline Fauconnier
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Michel Moreau
- Data Centre and Statistics Department, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Lissandra Dal Lago
- Department of Oncogeriatrics, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Thierry Pepersack
- Department of Oncogeriatrics, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Vincent Donckier
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Gabriel Liberale
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Moraes CMTDE, Corrêa LDEM, Procópio RJ, Carmo GALDO, Navarro TP. Tools and scores for general and cardiovascular perioperative risk assessment: a narrative review. Rev Col Bras Cir 2022; 49:e20223124. [PMID: 35319563 PMCID: PMC10578796 DOI: 10.1590/0100-6991e-20223124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/29/2021] [Indexed: 11/22/2022] Open
Abstract
The number of surgical procedures in the world is large and in Brazil it has been expressing a growth trend higher than the population growth. In this context, perioperative risk assessment safeguards the optimization of the outcomes sought by the procedures. For this evaluation, anamnesis and physical examination constitute an irreplaceable initial stage which may or may not be followed by complementary exams, interventions for clinical stabilization and application of risk estimation tools. The use of these tools can be very useful in order to obtain objective data for decision making by weighing surgical risk and benefit. Global and cardiovascular risk assessments are of greatest interest in the preoperative period, however information about their methods is scattered in the literature. Some tools such as the American Society of Anesthesiologists Physical Status (ASA PS) and the Revised Cardiac Risk Index (RCRI) are more widely known, while others are less known but can provide valuable information. Here, the main indices, scores and calculators that address general and cardiovascular perioperative risk were detailed.
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Affiliation(s)
| | | | - Ricardo Jayme Procópio
- - Universidade Federal de Minas Gerais, Hospital das Clínicas, Unidade Endovascular - Belo Horizonte - MG - Brasil
| | | | - Tulio Pinho Navarro
- - Universidade Federal de Minas Gerais, Departamento de Cirurgia - Belo Horizonte - MG - Brasil
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Degett TH, Christensen J, Dalton SO, Bossen K, Frederiksen K, Iversen LH, Gögenur I. Prediction of the postoperative 90-day mortality after acute colorectal cancer surgery: development and temporal validation of the ACORCA model. Int J Colorectal Dis 2021; 36:1873-1883. [PMID: 33982139 DOI: 10.1007/s00384-021-03950-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to develop and validate a model to predict 90-day mortality after acute colorectal cancer surgery. METHODS The model was developed in all patients undergoing acute colorectal cancer surgery in 2014-2016 and validated in a patient group operated in 2017 in Denmark. The outcome was 90-day mortality. Tested predictor variables were age, sex, performance status, BMI, smoking, alcohol, education level, cohabitation status, tumour localization and primary surgical procedure. Variables were selected according to the smallest Akaike information criterion. The model was shrunken by bootstrapping. Discrimination was evaluated with a receiver operated characteristic curve, calibration with a calibration slope and the accuracy with a Brier score. RESULTS A total of 1450 patients were included for development of the model and 451 patients for validation. The 90-day mortality rate was 19% and 20%, respectively. Age, performance status, alcohol, smoking and primary surgical procedure were the final variables included in the model. Discrimination (AUC = 0.79), calibration (slope = 1.04, intercept = 0.04) and accuracy (brier score = 0.13) were good in the developed model. In the temporal validation, discrimination (AUC = 0.80) and accuracy (brier score = 0.13) were good, and calibration was acceptable (slope = 1.19, intercept = 0.52). CONCLUSION We developed prediction model for 90-day mortality after acute colorectal cancer surgery that may be a promising tool for surgeons to identify patients at risk of postoperative mortality.
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Affiliation(s)
- Thea Helene Degett
- Center for Surgical Science (CSS), Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600, Koge, Denmark. .,Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark.
| | - Jane Christensen
- Statistics and Data analysis, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Susanne Oksbjerg Dalton
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Clinical Oncology & Palliative Care, Zealand University Hospital, Naestved, Denmark
| | | | - Kirsten Frederiksen
- Statistics and Data analysis, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Lene Hjerrild Iversen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science (CSS), Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600, Koge, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
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Sánchez-Guillén L, Frasson M, Pellino G, Fornés-Ferrer V, Ramos JL, Flor-Lorente B, García-Granero Á, Sierra IB, Jiménez-Gómez LM, Moya-Martínez A, García-Granero E. Nomograms for morbidity and mortality after oncologic colon resection in the enhanced recovery era: results from a multicentric prospective national study. Int J Colorectal Dis 2020; 35:2227-2238. [PMID: 32734415 DOI: 10.1007/s00384-020-03692-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Luis Sánchez-Guillén
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - Matteo Frasson
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain.
| | - Gianluca Pellino
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | | | - José Luis Ramos
- Department of General Surgery, Hospital Universitario de Getafe, Getafe, Spain
| | - Blas Flor-Lorente
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | - Álvaro García-Granero
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
| | | | | | | | - Eduardo García-Granero
- Department of General Surgery, Colorectal Unit, La Fe University Hospital, University of Valencia, Avda Abril Martorell 106, piso 5, torre G, 46023, Valencia, Spain
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Barrio I, Roca-Pardiñas J, Arostegui I. Selecting the number of categories of the lymph node ratio in cancer research: A bootstrap-based hypothesis test. Stat Methods Med Res 2020; 30:926-940. [PMID: 33167789 DOI: 10.1177/0962280220965631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The high impact of the lymph node ratio as a prognostic factor is widely established in colorectal cancer, and is being used as a categorized predictor variable in several studies. However, the cut-off points as well as the number of categories considered differ considerably in the literature. Motivated by the need to obtain the best categorization of the lymph node ratio as a predictor of mortality in colorectal cancer patients, we propose a method to select the best number of categories for a continuous variable in a logistic regression framework. Thus, to this end, we propose a bootstrap-based hypothesis test, together with a new estimation algorithm for the optimal location of the cut-off points called BackAddFor, which is an updated version of the previously proposed AddFor algorithm. The performance of the hypothesis test was evaluated by means of a simulation study, under different scenarios, yielding type I errors close to the nominal errors and good power values whenever a meaningful difference in terms of prediction ability existed. Finally, the methodology proposed was applied to the CCR-CARESS study where the lymph node ratio was included as a predictor of five-year mortality, resulting in the selection of three categories.
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Affiliation(s)
- Irantzu Barrio
- Departamento de Matemática Aplicada, Estadística e Investigación Operativa, Universidad del País Vasco UPV/EHU, Leioa, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Spain
| | - Javier Roca-Pardiñas
- Departamento de Estadística e Investigación Operativa, SiDOR Research Group & CINBIO, Universidade de Vigo, Vigo, Spain
| | - Inmaculada Arostegui
- Departamento de Matemática Aplicada, Estadística e Investigación Operativa, Universidad del País Vasco UPV/EHU, Leioa, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Spain.,BCAM- Basque Center for Applied Mathematics, Bilbo, Spain
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10
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Schwartz PB, Stahl CC, Ethun C, Marka N, Poultsides GA, Roggin KK, Fields RC, Howard JH, Clarke CN, Votanopoulos KI, Cardona K, Abbott DE. Retroperitoneal sarcoma perioperative risk stratification: A United States Sarcoma Collaborative evaluation of the ACS-NSQIP risk calculator. J Surg Oncol 2020; 122:795-802. [PMID: 32557654 PMCID: PMC7744355 DOI: 10.1002/jso.26071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 06/06/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The ACS-NSQIP risk calculator predicts perioperative risk. This study tested the calculator's ability to predict risk for outcomes following retroperitoneal sarcoma (RPS) resection. METHODS The United States Sarcoma Collaborative database was queried for adults who underwent RPS resection. Estimated risk for outcomes was calculated twice in the risk calculator, once using sarcoma-specific CPT codes and once using codes indicative of most comorbid organ resection (eg nephrectomy). ROC curves were generated, with area under the curve (AUC) and Brier scores reported to assess discrimination and calibration. An AUC < 0.6 was considered ineffective discrimination. A negative ▲ Brier indicated improved performance relative to baseline outcome rates. RESULTS In total, 482 patients were identified with a 42.3% 90-day complication rate. Discrimination was poor for all outcomes except "all complications" and "renal failure." Baseline outcome rates were better predictors than calculator estimates except for "discharge to nursing or rehab facility" and "renal failure." Replacing sarcoma-specific CPT codes with resection-specific codes did not improve performance. CONCLUSION The ACS-NSQIP risk calculator poorly predicted outcomes following RPS resection. Changing sarcoma-specific CPT to resection-specific codes did not improve performance. Comorbidities in the calculator may not effectively capture perioperative risk. Future work should evaluate a sarcoma-specific calculator.
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Affiliation(s)
- Patrick B Schwartz
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin
| | - Christopher C Stahl
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin
| | - Cecilia Ethun
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Nicholas Marka
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin
| | - George A Poultsides
- Department of Surgery, Division of Surgical Oncology, Stanford University, Palo Alto, California
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Ryan C Fields
- Department of Surgery, Siteman Cancer Center, Washington University, St. Louis, Missouri
| | - John H Howard
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Callisia N Clarke
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Kenneth Cardona
- Department of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin
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11
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Gijsbers K, de Graaf W, Moons LM, ter Borg F. High practice variation in risk stratification, baseline oncological staging, and follow-up strategies for T1 colorectal cancers in the Netherlands. Endosc Int Open 2020; 8:E1117-E1122. [PMID: 32904821 PMCID: PMC7458727 DOI: 10.1055/a-1192-3545] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/05/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Based on pathology, locally resected T1 colorectal cancer (T1-CRC) can be classified as having low- or high-risk for irradicality and/or lymph node metastasis, the latter requiring adjuvant surgery. Reporting and application of pathological high-risk criteria is likely variable, with inherited variation regarding baseline oncological staging, treatment and surveillance. Methods We assessed practice variation using an online survey among gastroenterologists and surgeons participating in the Dutch T1-CRC Working Group. Results Of the 130 invited physicians, 53 % participated. Regarding high-risk T1-CRC criteria, lymphangio-invasion is used by 100 %, positive or indeterminable margins by 93 %, poor differentiation by 90 %, tumor-free margin ≤ 1 mm by 78 %, tumor budding by 57 % and submucosal invasion > 1000 µm by 47 %. Fifty-two percent of the respondents do not perform baseline staging in locally resected low-risk T1-CRC. In case of unoperated high-risk patients, we recorded 61 different surveillance strategies in 63 participants, using 19 different combinations of diagnostic tests. Endoscopy is used in all schedules. Mean follow-up time is 36 months for endoscopy, 26 months for rectal MRI and 30 months for abdominal CT (all varying 3-60 months). Conclusion We found variable use of pathological high-risk T1-CRC criteria, creating risk for misclassification as low-risk T1-CRC. This has serious implications, as most participants will not proceed to oncological staging in low-risk patients and adjuvant surgery nor radiological surveillance is considered. On the other hand, oncological surveillance in patients with a locally resected high-risk T1-CRC who do not wish adjuvant surgery is highly variable emphasizing the need for a uniform surveillance protocol.
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Affiliation(s)
- Kim Gijsbers
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands,Department of Gastroenterology and Hepatology, UMC Utrecht, Utrecht, The Netherlands
| | - Wilmar de Graaf
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Leon M.G. Moons
- Department of Gastroenterology and Hepatology, UMC Utrecht, Utrecht, The Netherlands
| | - F. ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
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12
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Re-examining the 1-mm margin and submucosal depth of invasion: a review of 216 malignant colorectal polyps. Virchows Arch 2020; 476:863-870. [PMID: 31915959 DOI: 10.1007/s00428-019-02711-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 10/24/2019] [Accepted: 10/29/2019] [Indexed: 02/06/2023]
Abstract
Malignant colorectal polyps have a risk of lymph node metastases between 9 and 24%, but patients who are negative for certain histologic poor prognostic factors have the potential to be treated with polypectomy alone. Retrospective cohort of 216 malignant polyps from 213 patients identified through the British Columbia Colon Screening Program. Complete pathologic reporting (reporting of tumor grade, lymphovascular invasion, margin status, and tumor budding) was present in only 43% of patients. Sixty-one patients had no poor prognostic factors on polypectomy, and 23 (37%) of those underwent surgery. A positive margin cutoff of tumor at cautery showed significantly increased rates of lymph node metastases (p = 0.04) compared to a margin of greater than 0 mm, and polyps with a margin of greater than 0 mm had no risk of residual carcinoma. A submucosal depth of ≥ 2000 μm had an increased rate of lymph node metastases compared to < 2000 μm (p = 0.01). Malignant polyps with either tumor at cautery or a submucosal depth of ≥ 2000 μm, compared to polyps without these risk factors, had a relative risk for lymph node metastases of 16.3. Adoption of submucosal depth and refinement of the cutoffs for positive margin and submucosal depth have the potential to identify high-risk patients and reduce the number of surgeries required in patients with malignant polyps, a group that continues to grow significantly in part due to the introduction of colon screening programs.
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13
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Dilaver NM, Gwilym BL, Preece R, Twine CP, Bosanquet DC. Systematic review and narrative synthesis of surgeons' perception of postoperative outcomes and risk. BJS Open 2019; 4:16-26. [PMID: 32011813 PMCID: PMC6996626 DOI: 10.1002/bjs5.50233] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- N M Dilaver
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK.,Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - B L Gwilym
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
| | - R Preece
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - C P Twine
- Division of Population Medicine, Cardiff University, Cardiff, UK.,Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - D C Bosanquet
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK
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14
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Abstract
Older people are the fastest growing segment of the population and over-represented among people requiring emergency general surgery. Independent of comorbid and procedural factors, perioperative risk increases with increasing age. This effect is amplified with frailty or sarcopenia. Multidisciplinary perioperative care aligned with goals of care is most likely to achieve optimal patient and health system outcomes; however, substantial knowledge gaps exist in emergency general surgery for older people. Anesthesiologists are uniquely positioned to address these knowledge gaps, including optimizing goal-directed intraoperative care, appropriate provision of acute postoperative monitoring, and integration of principles of geriatric medicine in perioperative care.
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15
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Abstract
Complications after colorectal surgery are common. Given the frequency of postoperative complications and their implications on quality of life, it is important to know how to predict and prevent the complications that we encounter. This article aims to provide ways to predict and prevent postoperative complications in colorectal surgery. Here, we review the predictive models, American College of Surgeons National Surgery Quality Improvement Program risk calculator and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity on their practicality and usefulness. Additionally, this review summarizes nonmodifiable and modifiable risk factors in colorectal surgery, which are important for surgeons to understand to minimize and attempt to avoid postoperative complications as well as providing ways to optimize patients preoperatively. Thus, this review will provide information to surgeons to predict and prevent postoperative complications, how to optimize patients preoperatively and ultimately to help reduce their occurrence.
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Affiliation(s)
- Sung Gon Lee
- Department of Surgery, University of Tennessee Graduate School of Medicine, The University of Tennessee Medical Center, Knoxville, Tennessee
| | - Andrew Russ
- Department of Surgery, University of Tennessee Graduate School of Medicine, The University of Tennessee Medical Center, Knoxville, Tennessee
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16
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Gabriel V, Grigorian A, Nahmias J, Pejcinovska M, Smith M, Sun B, Won E, Bernal N, Barrios C, Schubl SD. Risk Factors for Post-Operative Sepsis and Septic Shock in Patients Undergoing Emergency Surgery. Surg Infect (Larchmt) 2019; 20:367-372. [PMID: 30950768 DOI: 10.1089/sur.2018.186] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Sepsis after emergency surgery is associated with a higher mortality rate than elective surgery, and total hospital costs increase by 2.3 times. This study aimed to identify risk factors for post-operative sepsis or septic shock in patients undergoing emergency surgery. Methods: A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program (NSQIP) by identifying patients undergoing emergency surgery between 2012 and 2015 and comparing those who developed post-operative sepsis or septic shock (S/SS) with those who did not. Patients with pre-operative sepsis or septic shock were excluded. Multiple logistic regression was used to identify risk factors for the development of S/SS in patients undergoing non-elective surgery. Results: Of 122,281 patients who met the inclusion criteria, 2,399 (2%) developed S/SS. Risk factors for S/SS were American Society of Anesthesiologists Physical Status (ASA PS) class 2 or higher (odds ratio [OR] 2.57; 95% confidence interval [CI] 2.19-3.02; p < 0.0001), totally dependent (OR 2.00, 95% CI 1.38-2.83; p = 0.00021) or partially dependent (OR 1.62, 95% CI 1.35-2.00; p < 0.0001) functional status, and male gender (OR 1.31; 95% CI 1.18-1.45; p < 0.0001). Compared with colorectal procedures, patients undergoing pancreatic (OR 2.33, CI 1.40-3.87; p = 0.00108) and small intestine (OR 1.27; CI 1.12-1.44; p = 0.00015) surgery were more likely to develop S/SS. Patients undergoing biliary surgery (OR 0.38; CI 0.30-0.48; p < 0.0001) were less likely to develop S/SS. Conclusions: Risk factors for the development of sepsis or septic shock are ASA PS class 2 or higher, partially or totally dependent functional status, and male gender. Emergency pancreatic or small intestinal procedures may confer a higher risk. Greater vigilance and early post-operative screening may be of benefit in patients with these risk factors.
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Affiliation(s)
- Viktor Gabriel
- 1 Department of Surgery, University of California, Irvine, Orange, California
| | - Areg Grigorian
- 1 Department of Surgery, University of California, Irvine, Orange, California
| | - Jeffry Nahmias
- 1 Department of Surgery, University of California, Irvine, Orange, California
| | - Marija Pejcinovska
- 2 Department of Statistics UC Irvine Center for Statistical Consulting, University of California, Irvine, Orange, California
| | - Megan Smith
- 2 Department of Statistics UC Irvine Center for Statistical Consulting, University of California, Irvine, Orange, California
| | - Beatrice Sun
- 3 School of Medicine, University of California, Irvine, Orange, California
| | - Eugene Won
- 1 Department of Surgery, University of California, Irvine, Orange, California
| | - Nicole Bernal
- 4 Division of Trauma, Burns, Acute Care Surgery, and Surgical Critical Care, University of California, Irvine, Orange, California
| | - Cristobal Barrios
- 4 Division of Trauma, Burns, Acute Care Surgery, and Surgical Critical Care, University of California, Irvine, Orange, California
| | - Sebastian D Schubl
- 4 Division of Trauma, Burns, Acute Care Surgery, and Surgical Critical Care, University of California, Irvine, Orange, California
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17
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Vermeer NCA, Backes Y, Snijders HS, Bastiaannet E, Liefers GJ, Moons LMG, van de Velde CJH, Peeters KCMJ. National cohort study on postoperative risks after surgery for submucosal invasive colorectal cancer. BJS Open 2018; 3:210-217. [PMID: 30957069 PMCID: PMC6433330 DOI: 10.1002/bjs5.50125] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 11/06/2018] [Indexed: 12/22/2022] Open
Abstract
Background The decision to perform surgery for patients with T1 colorectal cancer hinges on the estimated risk of lymph node metastasis, residual tumour and risks of surgery. The aim of this observational study was to compare surgical outcomes for T1 colorectal cancer with those for more advanced colorectal cancer. Methods This was a population‐based cohort study of patients treated surgically for pT1–3 colorectal cancer between 2009 and 2016, using data from the Dutch ColoRectal Audit. Postoperative complications (overall, surgical, severe complications and mortality) were compared using multivariable logistic regression. A risk stratification table was developed based on factors independently associated with severe complications (reintervention and/or mortality) after elective surgery. Results Of 39 813 patients, 5170 had pT1 colorectal cancer. No statistically significant differences were observed between patients with pT1 and pT2–3 disease in the rate of severe complications (8·3 versus 9·5 per cent respectively; odds ratio (OR) 0·89, 95 per cent c.i. 0·80 to 1·01, P = 0·061), surgical complications (12·6 versus 13·5 per cent; OR 0·93, 0·84 to 1·02, P = 0·119) or mortality (1·7 versus 2·5 per cent; OR 0·94, 0·74 to 1·19, P = 0·604). Male sex, higher ASA grade, previous abdominal surgery, open approach and type of procedure were associated with a higher severe complication rate in patients with pT1 colorectal cancer. Conclusion Elective bowel resection was associated with similar morbidity and mortality rates in patients with pT1 and those with pT2–3 colorectal carcinoma.
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Affiliation(s)
- N C A Vermeer
- Department of Surgery Leiden University Medical Centre Leiden The Netherlands
| | - Y Backes
- Department of Gastroenterology, University Medical Centre Utrecht Utrecht The Netherlands.,Department of Hepatology, University Medical Centre Utrecht Utrecht The Netherlands
| | - H S Snijders
- Department of Surgery, Groene Hart Ziekenhuis Gouda The Netherlands
| | - E Bastiaannet
- Department of Surgery Leiden University Medical Centre Leiden The Netherlands.,Department of Medical Oncology, Leiden University Medical Centre Leiden The Netherlands
| | - G J Liefers
- Department of Surgery Leiden University Medical Centre Leiden The Netherlands
| | - L M G Moons
- Department of Gastroenterology, University Medical Centre Utrecht Utrecht The Netherlands.,Department of Hepatology, University Medical Centre Utrecht Utrecht The Netherlands
| | - C J H van de Velde
- Department of Surgery Leiden University Medical Centre Leiden The Netherlands
| | - K C M J Peeters
- Department of Surgery Leiden University Medical Centre Leiden The Netherlands
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18
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Hildén M, Wretenberg P, Ekström W. Good overall morbidity prediction with the POSSUM scoring system in patients having a total hip or knee replacement - a prospective study in 227 patients. Clin Interv Aging 2018; 13:1747-1754. [PMID: 30271129 PMCID: PMC6145357 DOI: 10.2147/cia.s165698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Purpose The Physiological and Operation Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and P (Portsmouth)-POSSUM predict the risks of complications and mortality 30 days after surgery. The purpose of this study was to evaluate the POSSUM and P-POSSUM scoring systems in patients who underwent surgery for a total hip or knee replacement. Patients and methods A total of 227 patients with an elective primary total hip or knee replacement were included. The predicted postoperative morbidity was analyzed in these patients and compared with the observed value 30 days after surgery. Logistic regression analysis was used to assess the correlation of variables and outcome. Results The number of patients undergoing total hip or knee replacement was equally distributed with a mean age of 66.4±12.5 years; 57% of patients were females. Postoperative complications occurred in 49 patients, and POSSUM predicted 49 cases with an observed-over-expected ratio of 1.0. The average total POSSUM score was 27.4±4.4 in patients with complications and 26.8±3.5 in patients without complications (P=0.340). Wound infection (n=18), urinary tract infection (n=7), and pulmonary embolus (n=5) were the most common complications. The operation magnitude variable had the highest mean POSSUM score making it the most relevant variable. Age and blood loss and echocardiogram had the largest variance among the assessed variables. Conclusion POSSUM accurately predicted morbidities in patients undergoing elective primary total hip or knee replacement. The risk for wound infection, urinary retention, and pulmonary embolus should be considered during hospitalization. The computerized POSSUM system provides case-mix-adjusted morbidity predictions for groups and, hence, serves as a useful tool for surgical audits and large-scale benchmarking.
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Affiliation(s)
- Mattias Hildén
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital Solna, Stockholm, Sweden,
| | - Per Wretenberg
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital Solna, Stockholm, Sweden,
| | - Wilhelmina Ekström
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital Solna, Stockholm, Sweden,
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19
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Baré M, Mora L, Torà N, Gil MJ, Barrio I, Collera P, Suárez D, Redondo M, Escobar A, Fernández de Larrea N, Quintana JM. CCR-CARESS score for predicting operative mortality in patients with colorectal cancer. Br J Surg 2018; 105:1853-1861. [PMID: 30102425 DOI: 10.1002/bjs.10956] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 06/21/2018] [Accepted: 06/21/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to assess factors associated with outcomes after surgery for colorectal cancer and to design and internally validate a simple score for predicting perioperative mortality. METHODS Patients undergoing surgery for primary invasive colorectal cancer in 22 centres in Spain between June 2010 and December 2012 were included. Clinical variables up to 30 days were collected prospectively. Multiple logistic regression techniques were applied and a risk score was developed. The Hosmer-Lemeshow test was applied and the area under the receiver operating characteristic (ROC) curve (AUC, with 95 per cent c.i.) was estimated. RESULTS A total of 2749 patients with a median age of 68·5 (range 24-97) years were included; the male : female ratio was approximately 2 : 1. Stage III tumours were diagnosed in 32·6 per cent and stage IV in 9·5 per cent. Open surgery was used in 39·3 per cent, and 3·6 per cent of interventions were urgent. Complications were most commonly infectious or surgical, and 25·5 per cent of patients had a transfusion during the hospital stay. The 30-day postoperative mortality rate was 1·9 (95 per cent c.i. 1·4 to 2·4) per cent. Predictive factors independently associated with mortality were: age 80 years or above (odds ratio (OR) 2·76), chronic obstructive pulmonary disease (COPD) (OR 3·62) and palliative surgery (OR 10·46). According to the categorical risk score, a patient aged 80 years or more, with COPD, and who underwent palliative surgery would have a 23·5 per cent risk of death within 30 days of the intervention. CONCLUSION Elderly patients with co-morbidity and palliative intention of surgery have an unacceptably high risk of death.
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Affiliation(s)
- M Baré
- Clinical Epidemiology and Cancer Screening, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - L Mora
- Service of General Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - N Torà
- Clinical Epidemiology and Cancer Screening, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - M J Gil
- General and Digestive Surgery Service, Parc de Salut Mar, Barcelona, Spain
| | - I Barrio
- Universidad del País Vasco UPV/EHU, Leioa, Spain
| | - P Collera
- General and Digestive Surgery Service, Althaia - Xarxa Assistencial Universitaria, Manresa, Spain
| | - D Suárez
- Fundació Parc Taulí, Sabadell, Spain
| | - M Redondo
- Laboratory Service, Hospital Costa del Sol, Málaga, Spain
| | - A Escobar
- Research Unit, Hospital Universitario Basurto, Bilbao, Spain
| | | | - J M Quintana
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Spain
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20
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Madhavan S, Shelat VG, Soong SL, Woon WWL, Huey T, Chan YH, Junnarkar SP. Predicting morbidity of liver resection. Langenbecks Arch Surg 2018; 403:359-369. [PMID: 29417211 DOI: 10.1007/s00423-018-1656-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 01/25/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE Multiple models have attempted to predict morbidity of liver resection (LR). This study aims to determine the efficacy of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and the Physiological and Operative Severity Score in the enUmeration of Mortality and Morbidity (POSSUM) in predicting post-operative morbidity in patients who underwent LR. METHODS A retrospective analysis was conducted on patients who underwent elective LR. Morbidity risk was calculated with the ACS-NSQIP surgical risk calculator and POSSUM equation. Two models were then constructed for both ACS-NSQIP and POSSUM-(1) the original risk probabilities from each scoring system and (2) a model derived from logistic regression of variables. Discrimination, calibration, and overall performance for ACS-NSQIP and POSSUM were compared. Sub-group analysis was performed for both primary and secondary liver malignancies. RESULTS Two hundred forty-five patients underwent LR. Two hundred twenty-three (91%) had malignant liver pathologies. The post-operative morbidity, 90-day mortality, and 30-day mortality rate were 38.3%, 3.7%, and 2.4% respectively. ACS-NSQIP showed superior discriminative ability, calibration, and performance to POSSUM (p = 0.03). Hosmer-Lemeshow plot demonstrated better fit of the ACS-NSQIP model than POSSUM in predicting morbidity. CONCLUSION In patients undergoing LR, the ACS-NSQIP surgical risk calculator was superior to POSSUM in predicting morbidity risk.
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Affiliation(s)
- Sudharsan Madhavan
- Ministry of Health Holdings, 1 Maritime Square, #11-25 HarbourFront Centre, Singapore, 099253, Republic of Singapore
| | - Vishal G Shelat
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Republic of Singapore
| | - Su-Lin Soong
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Republic of Singapore
| | - Winston W L Woon
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Republic of Singapore
| | - Terence Huey
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Republic of Singapore
| | - Yiong H Chan
- Biostatistics Unit, National University Health System, 1E Kent Ridge Road, Singapore, 119228, Republic of Singapore
| | - Sameer P Junnarkar
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Republic of Singapore.
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21
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Jonsson MH, Bentzer P, Turkiewicz A, Hommel A. Accuracy of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity score and the Nottingham risk score in hip fracture patients in Sweden - A prospective observational study. Acta Anaesthesiol Scand 2018; 62:1057-1063. [PMID: 29687439 PMCID: PMC6099275 DOI: 10.1111/aas.13131] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/18/2018] [Accepted: 03/22/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Little is known about accuracy of common risk prediction scores in elderly patients suffering from hip fractures. The objective of this study was to investigate accuracy of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) score, Portsmouth-POSSUM (P-POSSUM) score and the Nottingham Hip Fracture Score (NHFS) for prediction of mortality and morbidity in this patient group. METHODS This was a prospective single centre observational study on 997 patients suffering out-of-hospital cervical, trochanteric or subtrochanteric fracture of the neck of the femur. Calibration and discrimination was assessed by calculating the ratio of observed to expected events (O:E) and areas under receiver operating characteristics curves (ROC). RESULTS The 30-day mortality was 6.2% and complications, as defined by POSSUM, occurred in 41% of the patients. Overall O:E ratios for POSSUM, P-POSSUM and NHFS scores for 30-day mortality were 0.90, 0.98, and 0.79 respectively. The models underestimated mortality in the lower risk bands and overestimated mortality in the higher risk bands. In contrast, POSSUM predicted morbidity well with O:E ratios close to unity in most risk bands. The areas under the ROC curves for the scoring systems was 0.60-0.67. CONCLUSION The POSSUM score and NHFS show moderate calibration and poor discrimination in this cohort. The results suggest that mortality and morbidity in hip fracture patients are largely dependent on factors that are not included in these scores.
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Affiliation(s)
- M. H. Jonsson
- Department of Anaesthesia and Intensive Care MedicineYstad HospitalYstadSweden
- Department of Clinical SciencesLund UniversityLundSweden
| | - P. Bentzer
- Department of Clinical SciencesLund UniversityLundSweden
- Department of Anaesthesia and Intensive CareHelsingborg HospitalHelsingborgSweden
| | - A. Turkiewicz
- Department of Clinical SciencesLund UniversityLundSweden
- Clinical Epidemiology UnitOrthopaedicsLund UniversityLundSweden
| | - A. Hommel
- Department of Clinical SciencesLund UniversityLundSweden
- Clinical Epidemiology UnitOrthopaedicsLund UniversityLundSweden
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22
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Pucher PH, Carter NC, Knight BC, Toh SKC, Tucker V, Mercer SJ. Impact of laparoscopic approach in emergency major abdominal surgery: single-centre analysis of 748 consecutive cases. Ann R Coll Surg Engl 2018; 100:279-284. [PMID: 29364016 PMCID: PMC5958847 DOI: 10.1308/rcsann.2017.0229] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2017] [Indexed: 12/25/2022] Open
Abstract
Background Acute abdominal pathology requiring emergency laparotomy is a common surgical presentation. Despite its widespread implementation in other surgical procedures, laparoscopy, rather than laparotomy, is sparingly used in major emergency surgery. This study reports outcomes and impact of rising use of laparoscopy for a single high-volume district general hospital. Methods Data were retrieved from the prospective National Emergency Laparotomy Audit database for a 30-month period. Patient, procedural, and in-hospital outcome data were collated. Temporal trends were assessed and regression analysis conducted for clinical outcomes. Results A total of 748 consecutive cases were recorded. There was an increasing use of laparoscopy over the study period, with 49% of cases attempted laparoscopically in the final six-month interval. Patients treated laparoscopically were at reduced risk of mortality (odds ratio 0.114, 95% confidence interval 0.024 to 0.550) and experienced reduced length of intensive care stay (regression coefficient –1.571, 95% confidence interval –2.625 to –0.517) in multivariate adjusted analysis. Conclusions Laparoscopy is safe and feasible in a large proportion of cases. It is associated with improved outcomes versus laparotomy.
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Affiliation(s)
- PH Pucher
- Department of General Surgery, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
| | - NC Carter
- Department of General Surgery, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
| | - BC Knight
- Department of General Surgery, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
| | - SKC Toh
- Department of General Surgery, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
| | - V Tucker
- Department of Anaesthesia, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
| | - SJ Mercer
- Department of General Surgery, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
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Arostegui I, Gonzalez N, Fernández-de-Larrea N, Lázaro-Aramburu S, Baré M, Redondo M, Sarasqueta C, Garcia-Gutierrez S, Quintana JM. Combining statistical techniques to predict postsurgical risk of 1-year mortality for patients with colon cancer. Clin Epidemiol 2018; 10:235-251. [PMID: 29563837 PMCID: PMC5846756 DOI: 10.2147/clep.s146729] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Introduction Colorectal cancer is one of the most frequently diagnosed malignancies and a common cause of cancer-related mortality. The aim of this study was to develop and validate a clinical predictive model for 1-year mortality among patients with colon cancer who survive for at least 30 days after surgery. Methods Patients diagnosed with colon cancer who had surgery for the first time and who survived 30 days after the surgery were selected prospectively. The outcome was mortality within 1 year. Random forest, genetic algorithms and classification and regression trees were combined in order to identify the variables and partition points that optimally classify patients by risk of mortality. The resulting decision tree was categorized into four risk categories. Split-sample and bootstrap validation were performed. ClinicalTrials.gov Identifier: NCT02488161. Results A total of 1945 patients were enrolled in the study. The variables identified as the main predictors of 1-year mortality were presence of residual tumor, American Society of Anesthesiologists Physical Status Classification System risk score, pathologic tumor staging, Charlson Comorbidity Index, intraoperative complications, adjuvant chemotherapy and recurrence of tumor. The model was internally validated; area under the receiver operating characteristic curve (AUC) was 0.896 in the derivation sample and 0.835 in the validation sample. Risk categorization leads to AUC values of 0.875 and 0.832 in the derivation and validation samples, respectively. Optimal cut-off point of estimated risk had a sensitivity of 0.889 and a specificity of 0.758. Conclusion The decision tree was a simple, interpretable, valid and accurate prediction rule of 1-year mortality among colon cancer patients who survived for at least 30 days after surgery.
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Affiliation(s)
- Inmaculada Arostegui
- Department of Applied Mathematics, Statistics and Operations Research, University of the Basque Country UPV/EHU, Leioa, Bizkaia, Spain.,Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain.,Basque Center for Applied Mathematics - BCAM, Bilbao, Bizkaia, Spain
| | - Nerea Gonzalez
- Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain.,Research Unit, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - Nerea Fernández-de-Larrea
- Environmental and Cancer Epidemiology Unit, National Center of Epidemiology, Instituto de Salud Carlos III, Madrid, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | | | - Marisa Baré
- Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain.,Clinical Epidemiology and Cancer Screening Unit, Parc Taulí Sabadell-Hospital Universitari, UAB, Sabadell, Barcelona, Spain
| | - Maximino Redondo
- Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain.,Research Unit, Costa del Sol Hospital, Marbella, Malaga, Spain
| | - Cristina Sarasqueta
- Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain.,Research Unit, Donostia Hospital, Donostia-San Sebastián, Gipuzkoa, Spain
| | - Susana Garcia-Gutierrez
- Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain.,Research Unit, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - José M Quintana
- Health Services Research on Chronic Patients Network (REDISSEC), Galdakao, Bizkaia, Spain.,Research Unit, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
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Carvalho-E-Carvalho ME, DE-Queiroz FL, Martins-DA-Costa BX, Werneck-Côrtes MG, Pires-Rodrigues V. The applicability of POSSUM and P-POSSUM scores as predictors of morbidity and mortality in colorectal surgery. ACTA ACUST UNITED AC 2018; 45:e1347. [PMID: 29451643 DOI: 10.1590/0100-6991e-20181347] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 09/21/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE to apply the POSSUM and P-POSSUM scores as a tool to predict morbidity and mortality in colorectal surgery. METHODS we conducted a prospective cohort study of 551 patients submitted to colorectal surgery in a colorectal surgery tertiary referral hospital in Brazil. We grouped patients into pre-established risk categories for comparison between expected and observed morbidity and mortality rates by the POSSUM and P-POSSUM scores. RESULTS in the POSSUM morbidity analysis, the overall expected morbidity was significantly higher than that observed (39.2% vs. 15.6%). The same occurred with patients grouped in categories II (28.9% x 10.5) and III (64.6% x 24.5%). In category I, the expected and observed morbidities were similar (13.7% x 9.1%). Regarding the evaluation of mortality, it was statistically higher than that observed in category III patients and in the total number of patients (11.3% vs. 5.6%). In categories I and II, we observed the same pattern of category III, but without statistical significance. When evaluating mortality by the P-POSSUM score, the overall expected and observed mortality was similar (5.8% x 5.6%). Of the 31 patients who died, 20.2% underwent emergency procedures and sepsis was the main cause of death. CONCLUSION the P-POSSUM score was an accurate tool to predict mortality and could be safely used in this population profile, unlike the POSSUM score.
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A model predicting operative mortality in the UK has only limited value in Denmark. Int J Colorectal Dis 2018; 33:141-147. [PMID: 29279977 DOI: 10.1007/s00384-017-2937-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE Postoperative mortality from colorectal cancer varies between surgical departments. Several models have been developed to predict the operative risk. This study aims to investigate whether the original and the revised Association of Coloproctology of Great Britain and Ireland (ACPGBI) model can predict 30-day mortality after colorectal cancer surgery in Denmark. METHODS Data were collected from the Danish Colorectal Cancer Group database which has > 95% completeness. All patients operated on from January 2007 to December 2013 were included. The individual estimated operative risk was calculated with the original and revised ACPGBI models. Discrimination and calibration were evaluated with a Receiver Operating Characteristic (ROC) curve analysis and a Hosmer-Lemeshow test, respectively. RESULTS In total, 22,807 patients underwent open or laparoscopic colorectal cancer surgery. After excluding 1437 patients because of missing data, 21,370 patients were left for the analyses. The observed 30-day mortality was 5.0%. The original and revised ACPGBI models estimated an operative risk of 7.0 and 4.0%, respectively, with a significant difference in observed and estimated mortality in both models. However, in patients with an estimated risk of at least 26%, i.e., high-risk, good calibration was found with the original ACPGBI model. Discrimination was good with an AUC of 0.83 (95% CI 0.82-0.84) in both models. CONCLUSION The original and revised ACPGBI models are not suitable prediction models for postoperative mortality in the Danish colorectal cancer population. However, the original model might be applicable in predicting mortality in high-risk patients.
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26
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Baré M, Alcantara MJ, Gil MJ, Collera P, Pont M, Escobar A, Sarasqueta C, Redondo M, Briones E, Dujovne P, Quintana JM. Validity of the CR-POSSUM model in surgery for colorectal cancer in Spain (CCR-CARESS study) and comparison with other models to predict operative mortality. BMC Health Serv Res 2018; 18:49. [PMID: 29378647 PMCID: PMC5789585 DOI: 10.1186/s12913-018-2839-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 01/14/2018] [Indexed: 11/10/2022] Open
Abstract
Background To validate and recalibrate the CR- POSSUM model and compared its discriminatory capacity with other European models such as POSSUM, P-POSSUM, AFC or IRCS to predict operative mortality in surgery for colorectal cancer. Methods Prospective multicenter cohort study from 22 hospitals in Spain. We included patients undergoing planned or urgent surgery for primary invasive colorectal cancers between June 2010 and December 2012 (N = 2749). Clinical data were gathered through medical chart review. We validated and recalibrated the predictive models using logistic regression techniques. To calculate the discriminatory power of each model, we estimated the areas under the curve - AUC (95% CI). We also assessed the calibration of the models by applying the Hosmer-Lemeshow test. Results In-hospital mortality was 1.5% and 30-day mortality, 1.7%. In the validation process, the discriminatory power of the CR-POSSUM for predicting in-hospital mortality was 73.6%. However, in the recalibration process, the AUCs improved slightly: the CR-POSSUM reached 75.5% (95% CI: 67.3–83.7). The discriminatory power of the CR-POSSUM for predicting 30-day mortality was 74.2% (95% CI: 67.1–81.2) after recalibration; among the other models the POSSUM had the greatest discriminatory power, with an AUC of 77.0% (95% CI: 68.9–85.2). The Hosmer-Lemeshow test showed good fit for all the recalibrated models. Conclusion The CR-POSSUM and the other models showed moderate capacity to discriminate the risk of operative mortality in our context, where the actual operative mortality is low. Nevertheless the IRCS might better predict in-hospital mortality, with fewer variables, while the CR-POSSUM could be slightly better for predicting 30-day mortality. Trail registration Registered at: ClinicalTrials.gov Identifier: NCT02488161 Electronic supplementary material The online version of this article (10.1186/s12913-018-2839-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marisa Baré
- Clinical Epidemiology and Cancer Screening, Parc Taulí Sabadell-University Hospital, Parc Taulí 1, 08208, Sabadell, Spain. .,Obstetrics, Gynecology and Preventive Medicine Department, Autonomous University of Barcelona-UAB, Cerdanyola del Vallès, Spain. .,Health Services Research on Chronic Patients Network, Sabadell, Spain.
| | - Manuel Jesús Alcantara
- Coloproctology Unit, General and Digestive Surgery Service, Parc Taulí Sabadell- University Hospital, Sabadell, Spain
| | - Maria José Gil
- General and Digestive Surgery Service, Parc de Salut Mar, Barcelona, Spain
| | - Pablo Collera
- General and Digestive Surgery Service, Althaia - Xarxa Assistencial Universitaria, Manresa, Spain
| | - Marina Pont
- Clinical Epidemiology and Cancer Screening, Parc Taulí Sabadell-University Hospital, Parc Taulí 1, 08208, Sabadell, Spain.,Health Services Research on Chronic Patients Network, Sabadell, Spain
| | - Antonio Escobar
- Research Unit, Hospital Universitario Basurto, Bilbao, Spain.,Health Services Research on Chronic Patients Network, Sabadell, Spain
| | - Cristina Sarasqueta
- Unidad de Investigación, Hospital Universitario Donostia/Instituto de Investigación Sanitaria Biodonostia, Donostia, Spain.,Health Services Research on Chronic Patients Network, Sabadell, Spain
| | - Maximino Redondo
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain.,Health Services Research on Chronic Patients Network, Sabadell, Spain
| | - Eduardo Briones
- Unidad de Epidemiología. Distrito Sevilla, Servicio Andaluz de Salud, Sevilla, Spain
| | - Paula Dujovne
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Jose Maria Quintana
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Spain.,Health Services Research on Chronic Patients Network, Sabadell, Spain
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Sohal DPS, Kuderer NM, Shepherd FA, Pabinger I, Agnelli G, Liebman HA, Meyer G, Kalady MF, McCrae K, Lyman GH, Khorana AA. Clinical Predictors of Early Mortality in Colorectal Cancer Patients Undergoing Chemotherapy: Results From a Global Prospective Cohort Study. JNCI Cancer Spectr 2017; 1:pkx009. [PMID: 31360835 PMCID: PMC6649852 DOI: 10.1093/jncics/pkx009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 10/11/2017] [Accepted: 10/19/2017] [Indexed: 02/06/2023] Open
Abstract
Background Early mortality is a major problem in colorectal cancer (CRC). We have shown that Khorana Score is predictive of early mortality in other cancers. Here, we evaluated the value of this score and other prognostic variables in predicting early mortality in CRC. Methods CANTARISK was a prospective, noninterventional, global cohort study in patients with CRC initiating a new chemotherapy regimen. Data were collected at zero, two, four, and six months. Early mortality was defined as death within six months of enrollment. All data were compiled centrally and analyzed after the study closed. Statistically significant univariate associations were tested in multivariable models; adjusted odds ratios (ORs) are presented. Statistical tests were two-sided. Results From 2011 to 2012, 1789 CRC patients were enrolled. The median age was 62 years; 71% were Caucasian. One-third (35%) had a rectal primary, and 65% had metastatic disease. There were 184 (10.3%) patients who died during their first six months in the study. For low, intermediate, and high Khorana Score, there were 8.1%, 11.2% and 32.5% deaths, respectively. In multivariable analyses, Khorana Score was an independent predictor of early death (OR for high/intermediate vs low score = 1.70, P = .0027), in addition to age (OR for each incremental year = 1.03, P = .0014), presence of metastatic disease (OR = 3.28, P < .0001), and Easter Cooperative Oncology Group Performance Status Score of 2 or higher (OR = 3.85, P < .0001). Conclusions This study demonstrates that Khorana Score is predictive of early mortality in CRC patients. Intermediate- or high-risk patients, as defined by this score, may benefit from additional interventions aimed at reducing early mortality.
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Affiliation(s)
- Davendra P S Sohal
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Nicole M Kuderer
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Frances A Shepherd
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Ingrid Pabinger
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Giancarlo Agnelli
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Howard A Liebman
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Guy Meyer
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Matthew F Kalady
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Keith McCrae
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Gary H Lyman
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Alok A Khorana
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
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Moran B, Cunningham C, Singh T, Sagar P, Bradbury J, Geh I, Karandikar S. Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Surgical Management. Colorectal Dis 2017. [PMID: 28632309 DOI: 10.1111/codi.13704] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Brendan Moran
- Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | | | | | | | | | - Ian Geh
- Queen Elizabeth Hospital, Birmingham, UK
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Moonesinghe SR, Grocott MPW, Bennett-Guerrero E, Bergamaschi R, Gottumukkala V, Hopkins TJ, McCluskey S, Gan TJ, Mythen MMG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on measurement to maintain and improve quality of enhanced recovery pathways for elective colorectal surgery. Perioper Med (Lond) 2017; 6:6. [PMID: 28331608 PMCID: PMC5356230 DOI: 10.1186/s13741-017-0062-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 02/27/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND This article sets out a framework for measurement of quality of care relevant to enhanced recovery pathways (ERPs) in elective colorectal surgery. The proposed framework is based on established measurement systems and/or theories, and provides an overview of the different approaches for improving clinical monitoring, and enhancing quality improvement or research in varied settings with different levels of available resources. METHODS Using a structure-process-outcome framework, we make recommendations for three hierarchical tiers of data collection. DISCUSSION Core, Quality Improvement, and Best Practice datasets are proposed. The suggested datasets incorporate patient data to describe case-mix, process measures to describe delivery of enhanced recovery and clinical outcomes. The fundamental importance of routine collection of data for the initiation, maintenance, and enhancement of enhanced recovery pathways is emphasized.
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Affiliation(s)
- S Ramani Moonesinghe
- UCLH NIHR Surgical Outcomes Research Centre and NIAA Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | | | | | - Roberto Bergamaschi
- Department of Surgery, Stony Brook University School of Medicine, New York, USA
| | | | - Thomas J Hopkins
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina USA
| | - Stuart McCluskey
- Department of Anesthesia, University of Toronto, Toronto, ON USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, New York, USA
| | - Michael Monty G Mythen
- Department of Anaesthesia and Perioperative Medicine, University College London, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee USA
| | - Timothy E Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina USA
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Abstract
As the number of older patients with cancer is increasing, oncology disciplines are faced with the challenge of managing patients with multiple chronic conditions who have difficulty maintaining independence, who may have cognitive impairment, and who also may be more vulnerable to adverse outcomes. National and international societies have recommended that all older patients with cancer undergo geriatric assessment (GA) to detect unaddressed problems and introduce interventions to augment functional status to possibly improve patient survival. Several predictive models have been developed, and evidence has shown correlation between information obtained through GA and treatment-related complications. Comprehensive geriatric evaluations and effective interventions on the basis of GA may prove to be challenging for the oncologist because of the lack of the necessary skills, time constraints, and/or limited available resources. In this article, we describe how the Geriatrics Service at Memorial Sloan Kettering Cancer Center approaches an older patient with colon cancer from presentation to the end of life, show the importance of GA at the various stages of cancer treatment, and how predictive models are used to tailor the treatment. The patient's needs and preferences are at the core of the decision-making process. Development of a plan of care should always include the patient's preferences, but it is particularly important in the older patient with cancer because a disease-centered approach may neglect noncancer considerations. We will elaborate on the added value of co-management between the oncologist and a geriatric nurse practitioner and on the feasibility of adapting elements of this model into busy oncology practices.
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Affiliation(s)
| | - Soo Jung Kim
- Memorial Sloan Kettering Cancer Center, New York, NY
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31
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Tabola R, Mantese G, Cirocchi R, Gemini A, Grassi V, Boselli C, Avenia S, Sanguinetti A, Avenia N, Sroczynski M, Wierzbicki J. Postoperative mortality and morbidity in older patients undergoing emergency right hemicolectomy for colon cancer. Aging Clin Exp Res 2016; 29:121-126. [PMID: 27830519 DOI: 10.1007/s40520-016-0643-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/12/2016] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Even with the advances in surgical technique and perioperative care, morbidity and mortality after colorectal cancer surgery remain considerable, and patients (pt) who present as an emergency have an even higher mortality and morbidity rate. METHODS A total of 35 pt with caecum or ascending colon cancer between January 2007 and June 2015, three departments in Italy and in Poland, were included in the study. The intention of surgery in all cases was curative resection with ileo-colic anastomosis. Comparative statistical analysis was performed. RESULTS Acute bowel obstruction was the major complication of CRC that led to an emergency hemicolectomy. Postoperative mortality and morbidity rates were in total 12.5 and 28.1%, respectively. All the deaths happened in Poland. Of the pt, 42.8% had morbidity in Poland and 16.6% in Italy. Out of the pt, 25% presenting with perforation: 25% died, 25% had wound dehiscence, 12.5% had pulmonary oedema, and 12.5% had an intra-abdominal abscess. The mean age of the pt with complications in Poland and in Italy was 79.3 and 72.0 years, respectively. CONCLUSION We observed that particularly lethal combination is older age, perforation with peritonitis and advanced stage of the cancer.
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Affiliation(s)
- Renata Tabola
- Department of Gastrointestinal and General Surgery, Medical University of Wrocław, ul. Curie-Sklodowskiej 66, 50-369, Wrocław, Poland
| | - George Mantese
- Department of Gastrointestinal and General Surgery, Medical University of Wrocław, ul. Curie-Sklodowskiej 66, 50-369, Wrocław, Poland
| | - Roberto Cirocchi
- Department of General and Oncological Surgery, University of Perugia, Località Sant'Andrea delle Fratte 1, 06134, Perugia, Italy.
| | - Alessandro Gemini
- Department of General and Oncological Surgery, University of Perugia, Località Sant'Andrea delle Fratte 1, 06134, Perugia, Italy
| | - Veronica Grassi
- Department of General and Oncological Surgery, University of Perugia, Località Sant'Andrea delle Fratte 1, 06134, Perugia, Italy
| | - Carlo Boselli
- Department of General and Oncological Surgery, University of Perugia, Località Sant'Andrea delle Fratte 1, 06134, Perugia, Italy
| | - Stefano Avenia
- Department of General Surgery, Terni Saint Mary Hospital, University of Perugia, Via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Alessandro Sanguinetti
- Department of General Surgery, Terni Saint Mary Hospital, University of Perugia, Via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Nicola Avenia
- Department of General Surgery, Terni Saint Mary Hospital, University of Perugia, Via Tristano di Joannuccio 1, 05100, Terni, Italy
| | - Maciej Sroczynski
- Department of Minimally Invasive Surgery and Proctology, Medical University of Wroclaw, ul. Borowska 213, 50-556, Wrocław, Poland
| | - Jaroslaw Wierzbicki
- Department of Minimally Invasive Surgery and Proctology, Medical University of Wroclaw, ul. Borowska 213, 50-556, Wrocław, Poland
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Quintana JM, Gonzalez N, Anton-Ladislao A, Redondo M, Bare M, Fernandez de Larrea N, Briones E, Escobar A, Sarasqueta C, Garcia-Gutierrez S, Aguirre U. Colorectal cancer health services research study protocol: the CCR-CARESS observational prospective cohort project. BMC Cancer 2016; 16:435. [PMID: 27391216 PMCID: PMC4939051 DOI: 10.1186/s12885-016-2475-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 06/30/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Colorectal cancers are one of the most common forms of malignancy worldwide. But two significant areas of research less studied deserve attention: health services use and development of patient stratification risk tools for these patients. METHODS DESIGN a prospective multicenter cohort study with a follow up period of up to 5 years after surgical intervention. Participant centers: 22 hospitals representing six autonomous communities of Spain. Participants/Study population: Patients diagnosed with colorectal cancer that have undergone surgical intervention and have consented to participate in the study between June 2010 and December 2012. Variables collected include pre-intervention background, sociodemographic parameters, hospital admission records, biological and clinical parameters, treatment information, and outcomes up to 5 years after surgical intervention. Patients completed the following questionnaires prior to surgery and in the follow up period: EuroQol-5D, EORTC QLQ-C30 (The European Organization for Research and Treatment of Cancer quality of life questionnaire) and QLQ-CR29 (module for colorectal cancer), the Duke Functional Social Support Questionnaire, the Hospital Anxiety and Depression Scale, and the Barthel Index. The main endpoints of the study are mortality, tumor recurrence, major complications, readmissions, and changes in health-related quality of life at 30 days and at 1, 2, 3 and 5 years after surgical intervention. STATISTICAL ANALYSIS In relation to the different endpoints, predictive models will be used by means of multivariate logistic models, Cox or linear mixed-effects regression models. Simulation models for the prediction of discrete events in the long term will also be used, and an economic evaluation of different treatment strategies will be performed through the use of generalized linear models. DISCUSSION The identification of potential risk factors for adverse events may help clinicians in the clinical decision making process. Also, the follow up by 5 years of this large cohort of patients may provide useful information to answer different health services research questions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02488161 . Registration date: June 16, 2015.
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Affiliation(s)
- José M Quintana
- Unidad de Investigación, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain. .,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain.
| | - Nerea Gonzalez
- Unidad de Investigación, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain
| | - Ane Anton-Ladislao
- Unidad de Investigación, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain
| | - Maximino Redondo
- Unidad de Investigación, Hospital Costa del Sol, Málaga, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain
| | - Marisa Bare
- Unidad de Epidemiología Clínica, Corporacio Parc Tauli, Barcelona, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain
| | - Nerea Fernandez de Larrea
- Departamento de Salud, Madrid, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain
| | | | - Antonio Escobar
- Unidad de Investigación, Hospital Basurto, Bilbao, Bizkaia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain
| | - Cristina Sarasqueta
- Unidad de Investigación, Hospital Donosti, Donostia-San Sebastian, Gipuzkoa, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain
| | - Susana Garcia-Gutierrez
- Unidad de Investigación, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain
| | - Urko Aguirre
- Unidad de Investigación, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Galdakao, Bizkaia, Spain
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Nachiappan M, Litake MM. Scoring Systems for Outcome Prediction of Patients with Perforation Peritonitis. J Clin Diagn Res 2016; 10:PC01-5. [PMID: 27134924 DOI: 10.7860/jcdr/2016/16260.7338] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 12/21/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Peritonitis continues to be one of the major infectious problems confronting a surgeon. Mannheim Peritonitis Index (MPI), Physiological and Operative Severity Score for en Umeration of Mortality (POSSUM) and Morbidity and sepsis score of Stoner and Elebute have been devised for risk assessment and for prediction of postoperative outcome. AIM The aim of this study was to find the accuracy of these scores in predicting outcome in terms of mortality in patients undergoing exploratory laprotomy for perforation peritonitis. MATERIALS AND METHODS The prospective study was carried out in 100 diagnosed cases of perforation at our centre in a single unit over a period of 21 months from December 2012 to August 2014. Study was conducted on all cases of peritonitis albeit primary, tertiary, iatrogenic and those with age less than 12 years were excluded from the study. All the relevant data were collected and three scores were computed from one set of data from the patient. The main outcome measure was survival of the patient. The Receiver Operator Characteristics (ROC) curves were obtained for the three scores. Area Under the Curves (AUC) was calculated. Sensitivity and specificity were calculated at a cut off point obtained from the ROC curves. RESULTS POSSUM had an AUC of 0.99, sepsis score had an AUC of 0.98 and MPI had an AUC of 0.95. The cut off point score of 51 for POSSUM had an accuracy of 93.8 and positive predictive value of 70.5, the score of 29 for MPI had an accuracy of 82.8 and positive predictive value of 46 and the score of 22 for sepsis score had an accuracy of 95.9 and positive predictive value of 86.67. CONCLUSION POSSUM score was found to be superior in prediction of mortality as compared to sepsis score of Stoner and Elebute and MPI. POSSUM and MPI over predicted mortality in some cases. None of these scores are strictly preoperative.
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Affiliation(s)
- Murugappan Nachiappan
- Assistant Professor, Department of General Surgery, BJ Medical College and Sassoon General Hospitals , Pune, Maharashtra, India
| | - Manjusha Madhusudhan Litake
- Associate Professor, Department of General Surgery, BJ Medical College and Sassoon General Hospitals , Pune, Maharashtra, India
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Kotzé A, Harris A, Baker C, Iqbal T, Lavies N, Richards T, Ryan K, Taylor C, Thomas D. British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia. Br J Haematol 2015; 171:322-31. [PMID: 26343392 DOI: 10.1111/bjh.13623] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/22/2015] [Accepted: 06/24/2015] [Indexed: 01/28/2023]
Affiliation(s)
- Alwyn Kotzé
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Charles Baker
- University Hospital of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Tariq Iqbal
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Nick Lavies
- Western Sussex Hospitals NHS Trust, Pre-Operative Association Representative, Sussex, UK
| | - Toby Richards
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Kate Ryan
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Craig Taylor
- Dudley Group of Hospitals NHS Foundation Trust, Dudley, UK
| | - Dafydd Thomas
- Abertawe Bro Morgannwg University Health Board, Swansea, UK
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Abstract
The human body's response to surgery is correlated with the extent of tissue damage. The aim of the present study was to, over time, map out parameters concerning inflammation, metabolism, nutrition, breathing function, muscle strength, and well-being in elective colorectal surgery. Eighteen patients were prospectively included: colon resection (n = 9) and rectum resection/amputation (n = 9). Postoperative interleukin 10 (IL-10) rose more in the rectum surgery group on day 0 (P = 0.007) and day 3 (P = 0.025). Furthermore, significant differences between groups were detected regarding albumin, prealbumin, and total iron-binding capacity (TIBC). For albumin and TIBC, this difference was seen even on day 7. C-reactive protein, IL-6, IL-8, glucose, cortisol, insulin, pain, fatigue, nausea, grip strength, and forced expiratory volume in 1 second did not show any differences. No correlation was revealed between measured parameters and postoperative complications. Postoperative levels of IL-10, albumin, prealbumin, and TIBC may be used as determinants of surgical stress after colorectal surgery.
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Scott S, Lund JN, Gold S, Elliott R, Vater M, Chakrabarty MP, Heinink TP, Williams JP. An evaluation of POSSUM and P-POSSUM scoring in predicting post-operative mortality in a level 1 critical care setting. BMC Anesthesiol 2014; 14:104. [PMID: 25469106 PMCID: PMC4247634 DOI: 10.1186/1471-2253-14-104] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 10/28/2014] [Indexed: 12/20/2022] Open
Abstract
Background POSSUM and P-POSSUM are used in the assessment of outcomes in surgical patients. Neither scoring systems’ accuracy has been established where a level 1 critical care facility (level 1 care ward) is available for perioperative care. We compared POSSUM and P-POSSUM predicted with observed mortality on a level 1 care ward. Methods A prospective, observational study was performed between May 2000 and June 2008. POSSUM and P-POSSUM scores were calculated for all postoperative patients who were admitted to the level 1 care ward. Data for post-operative mortality were obtained from hospital records for 2552 episodes of patient care. Observed vs expected mortality was compared using receiver operating characteristic (ROC) curves and the goodness of fit assessed using the Hosmer-Lemeshow equation. Results ROC curves show good discriminative ability between survivors and non-survivors for POSSUM and P-POSSUM. Physiological score had far higher discrimination than operative score. Both models showed poor calibration and poor goodness of fit (Hosmer-Lemeshow). Observed to expected (O:E) mortality ratio for POSSUM and P-POSSUM indicated significantly fewer than expected deaths in all deciles of risk. Conclusions Our data suggest a 30-60% reduction in O:E mortality. We suggest that the use of POSSUM models to predict mortality in patients admitted to level 1 care ward is inappropriate or that a recalibration of POSSUM is required to make it useful in a level 1 care ward setting.
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Affiliation(s)
- Sarah Scott
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, DE22 3DT UK
| | - Jonathan N Lund
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, DE22 3DT UK ; MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Nottingham, NG7 2UH UK
| | - Stuart Gold
- Department of Anesthesia and Critical Care, Royal Derby Hospital, Derby, DE22 3NE UK
| | - Richard Elliott
- Department of Anesthesia and Critical Care, Royal Derby Hospital, Derby, DE22 3NE UK
| | - Mair Vater
- Department of Anesthesia and Critical Care, Royal Derby Hospital, Derby, DE22 3NE UK
| | - Mallicka P Chakrabarty
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, DE22 3DT UK
| | - Thomas P Heinink
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, DE22 3DT UK ; Department of Anesthesia and Critical Care, Royal Derby Hospital, Derby, DE22 3NE UK
| | - John P Williams
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, DE22 3DT UK ; Department of Anesthesia and Critical Care, Royal Derby Hospital, Derby, DE22 3NE UK ; MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Nottingham, NG7 2UH UK
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Wang R, Gao D, Gong W, Liang Z. [Value of modified POSSUM scoring system on predicting operation risk
in elderly NSCLC patients]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2014; 17:669-73. [PMID: 25248708 PMCID: PMC6000503 DOI: 10.3779/j.issn.1009-3419.2014.09.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
背景与目的 对于评价老年患者能否耐受肺癌手术,目前尚无明确标准。本研究旨在探讨改良POSSUM(Physiological and Operative Severity Score for the Umeration of Mortality and Morbidity)评分在预测老年非小细胞肺癌(non-small cell lung cancer, NSCLC)患者术后并发症发生率和病死率中的应用价值,为手术治疗的决策提供重要依据。 方法 2007年12月-2013年12月在解放军总医院接受手术治疗的老年NSCLC患者138例,其中男性88例,女性50例,收集临床资料,各因素对术后实际并发症发生率和病死率的影响,采用二值多元Logistic回归分析。在有、无并发症两组中,采用成组t检验对标准及改良POSSUM评分值进行比较。绘制标准POSSUM和改良POSSUM的受试者工作特征曲线(receiver operating characteristic curve, ROC),计算曲线下面积(area under the curve, AUC),两组间AUC比较采用t检验。计算改良POSSUM评分预测值和实际并发症发生率和病死率的符合度。 结果 共有59例患者出现77例次术后并发症,手术死亡2例。Logistic回归分析,标准POSSUM的18项指标中17项及肺功能、肿瘤分期对术后并发症的发生有统计学意义(P < 0.05),年龄对术后死亡有统计学意义(P < 0.05)。在标准POSSUM评分中,并发症组与无并发症组的评分比较,差异有统计学意义(P < 0.01)。在改良POSSUM评分中,并发症组与无并发症组的评分比较,差异有统计学意义(P < 0.01)。改良POSSUM较标准POSSUM对术后并发症发生有更好的预测价值,两组AUC比较,差异有统计学意义(P < 0.01)。但改良POSSUM对手术死亡的预测值过高。 结论 改良POSSUM评分对老年NSCLC术后并发症发生有较好的预测价值,可为决策手术治疗提供依据。
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Affiliation(s)
- Rong Wang
- Surgery Department of Nan-lou, Chinese PLA General Hospital, Beijing 100853, China
| | - Dewei Gao
- Surgery Department of Nan-lou, Chinese PLA General Hospital, Beijing 100853, China
| | - Weiqin Gong
- Surgery Department of Nan-lou, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhiru Liang
- Surgery Department of Nan-lou, Chinese PLA General Hospital, Beijing 100853, China
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Silvestre J, Rebanda J, Lourenço C, Póvoa P. Diagnostic accuracy of C-reactive protein and procalcitonin in the early detection of infection after elective colorectal surgery - a pilot study. BMC Infect Dis 2014; 14:444. [PMID: 25132018 PMCID: PMC4143543 DOI: 10.1186/1471-2334-14-444] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/12/2014] [Indexed: 02/06/2023] Open
Abstract
Background Colorectal surgery is associated with postoperative infectious complications in up to 40% of cases, but the diagnosis of these complications is frequently misleading, delaying its resolution. Several biomarkers have been shown to be useful in infection diagnosis. Methods We conducted a single-centre, prospective, observational study segregating patients submitted to elective colorectal surgery with primary anastomosis, CRP and PCT were measured daily. We compared infected and non-infected patients. Results From October 2009 to June 2011, a total of 50 patients were included. Twenty-one patients developed infection. PCT and CRP before surgery were equally low in patients with or without postoperative infectious complications. After surgery, both PCT and CRP increased markedly. CRP time-course from the day of surgery onwards was significantly different in infected and non-infected patients (P = 0.001) whereas, PCT time-course was almost parallel in both groups (P = 0.866). Multiple comparisons between infected and non-infected patients from 5th to 9th postoperative days (POD) were performed and CRP concentration was significantly different (P < 0.01, Bonferroni correction), on the 6th, 7th and 8th POD. A CRP concentration > 5.0 mg/dl at the D6 was predictive of infection with a sensitivity of 85% and a specificity of 62% (positive likelihood ratio 2.2, negative likelihood ratio 0.2). Conclusions After a major elective surgical insult both CRP and PCT serum levels increased independently of the presence of infection. Besides serum CRP time-course showed to be useful in the early detection of an infectious complication whereas PCT was unhelpful. Electronic supplementary material The online version of this article (doi:10.1186/1471-2334-14-444) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joana Silvestre
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, CHLO, Lisbon, Portugal.
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Postoperative 30-day mortality in patients undergoing surgery for colorectal cancer: development of a prognostic model using administrative claims data. Cancer Causes Control 2014; 25:1503-12. [PMID: 25104569 DOI: 10.1007/s10552-014-0451-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 07/22/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To develop a prognostic model to predict 30-day mortality following colorectal cancer (CRC) surgery using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked data and to assess whether race/ethnicity, neighborhood, and hospital characteristics influence model performance. METHODS We included patients aged 66 years and older from the linked 2000-2005 SEER-Medicare database. Outcome included 30-day mortality, both in-hospital and following discharge. Potential prognostic factors included tumor, treatment, sociodemographic, hospital, and neighborhood characteristics (census-tract-poverty rate). We performed a multilevel logistic regression analysis to account for nesting of CRC patients within hospitals. Model performance was assessed using the area under the receiver operating characteristic curve (AUC) for discrimination and the Hosmer-Lemeshow goodness-of-fit test for calibration. RESULTS In a model that included all prognostic factors, important predictors of 30-day mortality included age at diagnosis, cancer stage, and mode of presentation. Race/ethnicity, census-tract-poverty rate, and hospital characteristics were independently associated with 30-day mortality, but they did not influence model performance. Our SEER-Medicare model achieved moderate discrimination (AUC = 0.76), despite suboptimal calibration. CONCLUSIONS We developed a prognostic model that included tumor, treatment, sociodemographic, hospital, and neighborhood predictors. Race/ethnicity, neighborhood, and hospital characteristics did not improve model performance compared with previously developed models.
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Korc-Grodzicki B, Downey RJ, Shahrokni A, Kingham TP, Patel SG, Audisio RA. Surgical considerations in older adults with cancer. J Clin Oncol 2014; 32:2647-53. [PMID: 25071124 DOI: 10.1200/jco.2014.55.0962] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The aging of the population is a real concern for surgical oncologists, who are increasingly being asked to treat patients who would not have been considered for surgery in the past. In many cases, decisions are made with relatively little evidence, most of which was derived from trials in which older age was a limiting factor for recruitment. METHODS This review focuses on risk assessment and perioperative management. It describes the relationship between age and outcomes for colon, lung, hepatobiliary, and head and neck cancer, which are predominantly diseases of the elderly and are a major cause of morbidity and mortality. RESULTS Effective surgery requires safe performance as well as reasonable postoperative life expectancy and maintenance of quality of life. Treatment decisions for potentially vulnerable elderly patients should take into account data obtained from the evaluation of geriatric syndromes, such as frailty, functional and cognitive limitations, malnutrition, comorbidities, and polypharmacy, as well as social support. Postoperative care should include prevention and treatment of complications seen more frequently in the elderly, including postoperative delirium, functional decline, and the need for institutionalization. CONCLUSION Surgery remains the best modality for treatment of solid tumors, and chronologic age alone should not be a determinant for treatment decisions. With adequate perioperative risk stratification, functional assessment, and oncologic prognostication, elderly patients with cancer can do as well in terms of morbidity and mortality as their younger counterparts. If surgery is determined to be the appropriate treatment modality, patients should not be denied this option because of their age.
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Affiliation(s)
- Beatriz Korc-Grodzicki
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom.
| | - Robert J Downey
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
| | - Armin Shahrokni
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
| | - T Peter Kingham
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
| | - Snehal G Patel
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
| | - Riccardo A Audisio
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
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Pietri LD, Montalti R, Begliomini B. Anaesthetic perioperative management of patients with pancreatic cancer. World J Gastroenterol 2014; 20:2304-20. [PMID: 24605028 PMCID: PMC3942834 DOI: 10.3748/wjg.v20.i9.2304] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 01/06/2014] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer remains a significant and unresolved therapeutic challenge. Currently, the only curative treatment for pancreatic cancer is surgical resection. Pancreatic surgery represents a technically demanding major abdominal procedure that can occasionally lead to a number of pathophysiological alterations resulting in increased morbidity and mortality. Systemic, rather than surgical complications, cause the majority of deaths. Because patients are increasingly referred to surgery with at advanced ages and because pancreatic surgery is extremely complex, anaesthesiologists and surgeons play a crucial role in preoperative evaluations and diagnoses for surgical intervention. The anaesthetist plays a key role in perioperative management and can significantly influence patient outcome. To optimise overall care, patients should be appropriately referred to tertiary centres, where multidisciplinary teams (surgical, medical, radiation oncologists, gastroenterologists, interventional radiologists and anaesthetists) work together and where close cooperation between surgeons and anaesthesiologists promotes the safe performance of major gastrointestinal surgeries with acceptable morbidity and mortality rates. In this review, we sought to provide simple daily recommendations to the clinicians who manage pancreatic surgery patients to make their work easier and suggest a joint approach between surgeons and anaesthesiologists in daily decision making.
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Mercer S, Guha A, Ramesh V. The P-POSSUM scoring systems for predicting the mortality of neurosurgical patients undergoing craniotomy: Further validation of usefulness and application across healthcare systems. Indian J Anaesth 2014; 57:587-91. [PMID: 24403619 PMCID: PMC3883394 DOI: 10.4103/0019-5049.123332] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIMS Continuous audit of clinical practice is an essential part of making improvements in medicine and enhancing patient care. Validated tools are needed to gather evidence for comparisons. Recently, Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) scores were evaluated in Indian patients undergoing elective craniotomy and it was concluded that P-POSSUM was highly accurate in predicting overall mortality. We wished to study whether this system could be used in a different country and health care system [United Kingdom, UK]. We have evaluated these scores in patients undergoing elective and emergency craniotomies in a tertiary centre in the UK. METHODS Data was collected from all neurosurgical patients who underwent craniotomy overone year. Preoperative variables were collected prior to induction of anaesthesia, and operative variables were also collected. Chi-square test was used for expected and actual mortality differences. Survivor and non-survivor demographics were compared by one-way ANOVA for continuous and Chi-square for categorical variables. RESULTS One hundred and forty-five patients were studied. Mean [SD] physiologic score of the patients was 18.83 [5.07], and mean [SD] operative score was 18.09 [3.75]. P-POSSUM was a better predictor for elective patients and for those undergoing immediate life-saving surgery. CONCLUSION This study confirms and validates the findings of previous work that P-POSSUM is an accurate and reliable tool for estimating in-hospital mortality. It also confirms its usefulness in comparison of results across healthcare systems internationally. Larger scale evaluations may be needed to examine its usefulness in emergency procedures.
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Affiliation(s)
- Sj Mercer
- Department of Anaesthesia and Intensive Care, Mersey Deanery, Liverpool, UK
| | - Arpan Guha
- Department of Neurointensive Care and Anaesthesia, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Vj Ramesh
- Department of Neurointensive Care and Anaesthesia, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
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Dumont F, Mazouni C, Bitsakou G, Morice P, Goéré D, Honoré C, Elias D. A pre-operative nomogram for decision making in oncological surgical emergencies. J Surg Oncol 2014; 109:721-5. [PMID: 24391063 DOI: 10.1002/jso.23557] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 12/16/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND The purpose of the study was to propose a clinical decision-making tool for predicting mortality in patients undergoing emergency abdominal surgery with a palliative intent in the oncology setting. METHODS Identification of all emergency surgical procedures performed in a Department of Oncologic Surgery in a Comprehensive Cancer Center between January 2008 and January 2013. Multivariate logistic and Cox regression models were used to identify factors predicitve of mortality at 3 months and survival probabilities. Models were internally validated using bootstrapping and calibration. RESULTS The mortality rates were 30% at 1 month, 46.7% at 3 months and 83.3% at the end of the study. One model based on the albumin level and the P-POSSUM score (AUC: 0.725) adequately predicted mortality at 3 months. A survival nomogram predicted mortality with a concordance index (CI) of 0.718, using the following factors: WHO performance status (P = 0.02), albumin level (P < 0.01) and P-POSSUM score (P < 0.01). The origin or the extent of the carcinoma did not own sufficient pronostic impact to be selected in this model. CONCLUSIONS Pre-operative mortality risk scores can be developed in a palliative context. Physicians counselling and surgical decision making should be based on the use of these tools.
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Affiliation(s)
- Frédéric Dumont
- Department of Surgical Oncology, Institut Gustave Roussy, Villejuif, France
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Malignancy as a risk factor in single-stage combined approach for simultaneous elective surgical diseases. Int J Surg 2014; 11 Suppl 1:S84-9. [PMID: 24380562 DOI: 10.1016/s1743-9191(13)60024-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To identify morbidity and mortality risk factors in patients with synchronous diseases who underwent single-stage combined (SSC) surgery. METHODS We considered data of 328 patients, each with multiple, elective, synchronous surgical problems treated by a SSC operation. By univariate and multivariate analysis we evaluated many patient-, disease - or treatment-related variables with respect to post-operative mortality, morbidity, and hospital stay. RESULTS Two combined procedures were synchronously performed in 283 patients (86%), 3 combined procedures in 45 patients (14%). Post-operative mortality and morbidity rates were 3% and 24%, respectively, and median duration of hospital stay was 9 days. The occurrence of a surgical oncology procedure emerged as the most important independent risk factor for post-operative mortality and morbidity. CONCLUSIONS The safety of SSC surgery for the treatment of synchronous problems appears similar to that of multi-stage procedures. The understanding of risk factors for this surgical approach could be useful in order to improve patient selection.
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Williams JG, Pullan RD, Hill J, Horgan PG, Salmo E, Buchanan GN, Rasheed S, McGee SG, Haboubi N. Management of the malignant colorectal polyp: ACPGBI position statement. Colorectal Dis 2013; 15 Suppl 2:1-38. [PMID: 23848492 DOI: 10.1111/codi.12262] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- J G Williams
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK.
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Ugolini G, Montroni I, Rosati G, Ghignone F, Bacchi-Reggiani ML, Belluzzi A, Castellani L, Taffurelli M. Can POSSUM accurately predict post-operative complications risk in patients with abdominal Crohn's disease? ANZ J Surg 2013; 84:78-84. [DOI: 10.1111/ans.12297] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2013] [Indexed: 01/24/2023]
Affiliation(s)
- Giampaolo Ugolini
- Department of Medical and Surgical Sciences; University of Bologna, Policlinico S.Orsola-Malpighi; Bologna Italy
| | - Isacco Montroni
- Department of Medical and Surgical Sciences; University of Bologna, Policlinico S.Orsola-Malpighi; Bologna Italy
| | - Giancarlo Rosati
- Department of Medical and Surgical Sciences; University of Bologna, Policlinico S.Orsola-Malpighi; Bologna Italy
| | - Federico Ghignone
- Department of Medical and Surgical Sciences; University of Bologna, Policlinico S.Orsola-Malpighi; Bologna Italy
| | - Maria Letizia Bacchi-Reggiani
- Department of Specialised, Experimental, and Diagnostic Medicine; University of Bologna, Policlinico S.Orsola-Malpighi; Bologna Italy
| | - Andrea Belluzzi
- Department of Specialised, Experimental, and Diagnostic Medicine; University of Bologna, Policlinico S.Orsola-Malpighi; Bologna Italy
| | - Lucia Castellani
- Department of Specialised, Experimental, and Diagnostic Medicine; University of Bologna, Policlinico S.Orsola-Malpighi; Bologna Italy
| | - Mario Taffurelli
- Department of Medical and Surgical Sciences; University of Bologna, Policlinico S.Orsola-Malpighi; Bologna Italy
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Lenzi J, Lombardi R, Gori D, Zanini N, Tedesco D, Masetti M, Jovine E, Fantini MP. Impact of procedure volumes and focused practice on short-term outcomes of elective and urgent colon cancer resection in Italy. PLoS One 2013; 8:e64245. [PMID: 23696873 PMCID: PMC3656123 DOI: 10.1371/journal.pone.0064245] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 04/11/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The relationship between hospital volumes and short-term patients' outcomes of colon cancer (CC) surgery is not well established in the literature. Moreover, evidence about short-term outcomes of urgent compared with elective CC procedures is scanty. The aims of this study are 1) to determine whether caseloads and other hospital characteristics are associated with short-term outcomes of CC surgery; 2) to compare the outcomes of urgent and elective CC surgery. METHODS A total of 14,200 patients undergoing CC surgery between 2005 and 2010 in the General Surgery Units (GSUs) of the hospitals of Emilia-Romagna region, Northern Italy, were identified from the hospital discharge records database. The outcomes of interest were 30-day in-hospital mortality, re-intervention and 30-day re-admission. Using multilevel analysis, we analyzed the relationship of GSU volumes and focused practice, defined as the percentage of CC operations over total operations, with the three outcomes. RESULTS High procedure volumes were associated with a lower risk of 30-day in-hospital mortality, after adjusting for patients' characteristics [aOR (95% CI) = 0.51 (0.33-0.81)]. Stratified analyses for elective and urgent surgery showed that high volumes were associated with a lower 30-day mortality for elective patients [aOR (95% CI) = 0.35 (0.17-0.71)], but not for urgent patients [aOR (95% CI) = 0.72 (0.42-1.24)]. Focused practice was an independent predictor of re-intervention [aOR (95% CI) = 0.67 (0.47-0.97)] and re-admission [aRR (95% CI) = 0.88 (0.78-0.98)]. CONCLUSIONS The present study adds evidence in support of the notion that patients with CC undergoing surgery at high-volume and focused surgical units experience better short-term outcomes.
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Affiliation(s)
- Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Raffaele Lombardi
- General Surgery Unit, Department of Surgery, Maggiore Hospital, Bologna, Italy
| | - Davide Gori
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Nicola Zanini
- General Surgery Unit, Department of Surgery, Maggiore Hospital, Bologna, Italy
| | - Dario Tedesco
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Michele Masetti
- General Surgery Unit, Department of Surgery, Maggiore Hospital, Bologna, Italy
| | - Elio Jovine
- General Surgery Unit, Department of Surgery, Maggiore Hospital, Bologna, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- * E-mail:
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Mcloughlin JM, Lewis JM, Meredith KL. The Impact of Age on Morbidity and Mortality following Esophagectomy for Esophageal Cancer. Cancer Control 2013; 20:144-50. [DOI: 10.1177/107327481302000208] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background In patients with esophageal cancer, treatment decisions often involve a balance between a high-risk procedure and the chance for long-term benefit. The decision can be additionally challenging for elderly patients since some studies have reported an increased incidence of morbidity and mortality in this age group, and data are not clear on the overall benefit of multimodality therapy. Methods To investigate the management and outcomes associated with esophagectomy in elderly patients with esophageal cancer, we performed a review of the literature as well as an analysis of our own institutional data, with a focus on the impact of age on surgical outcomes. We examined type of surgery, neoadjuvant and adjuvant therapy, postoperative complications, length of hospitalization, and mortality as variables in elderly patients with esophageal cancer. Results When assessing the impact of age on the success of esophagectomy, several studies have concluded that advanced age itself is not a predictor of outcomes as much as associated comorbidities are. Our own experience suggests that age is not associated with adverse outcomes when controlling for patient comorbidities. This finding is similar to data reported elsewhere. Conclusions When considering treatment for patients of advanced age, the risks of treatment should be compared with the survival benefits of the therapy prescribed, taking into account additional factors such as poor performance status, existing comorbidities, and residual tumor following neoadjuvant therapy. Many reports, as well as our own experience, have concluded that when adjusted for comorbidities, patient age does not significantly affect outcomes.
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Affiliation(s)
- James M. Mcloughlin
- Department of Surgery of the Division of Surgical Oncology, University of Tennessee, Knoxville, Tennessee
| | - James M. Lewis
- Department of Surgery of the Division of Surgical Oncology, University of Tennessee, Knoxville, Tennessee
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Bos MMEM, Bakhshi-Raiez F, Dekker JWT, de Keizer NF, de Jonge E. Outcomes of intensive care unit admissions after elective cancer surgery. Eur J Surg Oncol 2013; 39:584-92. [PMID: 23490335 DOI: 10.1016/j.ejso.2013.02.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 01/12/2013] [Accepted: 02/06/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Postoperative care for major elective cancer surgery is frequently provided on the Intensive Care Unit (ICU). OBJECTIVE To analyze the characteristics and outcome of patients after ICU admission following elective surgery for different cancer diagnoses. METHODS We analyzed all ICU admissions following elective cancer surgery in the Netherlands collected in the National Intensive Care Evaluation registry between January 2007 and January 2012. RESULTS 28,973 patients (9.0% of all ICU admissions; 40% female) were admitted to the ICU after elective cancer surgery. Of these admissions 77% were planned; in 23% of cases the decision for ICU admission was made during or directly after surgery. The most frequent malignancies were colorectal cancer (25.6%), lung cancer (18.5%) and tumors of the central nervous system (14.3%). Mechanical ventilation was necessary in 24.8% of all patients, most frequently after surgery for esophageal (62.5%) and head and neck cancer (50.2%); 20.7% of patients were treated with vasopressors in the acute postoperative phase, in particular after surgery for esophageal cancer (41.8%). The median length of stay on the ICU was 0.9 days (interquartile ranges [IQR] 0.8-1.5); surgery for esophageal cancer was associated with the longest ICU length of stay (median 2.0 days) with the largest variation (IQR 1.0-4.8 days). ICU mortality was 1.4%; surgery for gastrointestinal cancer was associated with the highest ICU mortality (colorectal cancer 2.2%, pancreatico-cholangiocarcinoma 2.0%). CONCLUSION Elective cancer surgery represents a significant part of all ICU admissions, with a short length of stay and low mortality.
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Affiliation(s)
- M M E M Bos
- Reinier de Graaf Hospital, Department of Internal Medicine, Division of Medical Oncology, Delft, The Netherlands
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Chen T, Wang H, Wang H, Song Y, Li X, Wang J. POSSUM and P-POSSUM as predictors of postoperative morbidity and mortality in patients undergoing hepato-biliary-pancreatic surgery: a meta-analysis. Ann Surg Oncol 2013; 20:2501-10. [PMID: 23435569 DOI: 10.1245/s10434-013-2893-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) models are used extensively to predict postoperative morbidity and mortality in general surgery. The aim was to undertake the first meta-analysis of the predictive value of these models in patients undergoing hepato-biliary-pancreatic surgery. METHODS Eligible articles were identified by searches of electronic databases from 1991 to 2012. All data were specific to hepato-biliary-pancreatic surgery. Predictive value of morbidity and mortality were assessed by calculating weighted observed to expected (O/E) ratios. Subanalysis was also performed. RESULTS Sixteen studies were included in final review. The morbidity analysis included nine studies on POSSUM with a weighted O/E ratio of 0.78 [95 % confidence interval (CI) 0.68-0.88]. The mortality analysis included seven studies on POSSUM and nine studies on P-POSSUM (Portsmouth predictor equation for mortality). Weighted O/E ratios for mortality were 0.35 (95 % CI 0.17-0.54) for POSSUM and 0.95 (95 % CI 0.65-1.25) for P-POSSUM. POSSUM had more accuracy to predict morbidity after pancreatic surgery (O/E ratio 0.82; 95 % CI 0.72-0.92) than after hepatobiliary surgery (O/E ratio 0.66; 95 % CI 0.57-0.74), in large sample size studies (O/E ratio 0.90; 95 % CI 0.85-0.96) than in small sample size studies (O/E ratio 0.69; 95 % CI 0.59-0.79). CONCLUSIONS POSSUM overpredicted postoperative morbidity after hepato-biliary-pancreatic surgery. Predictive value of POSSUM to morbidity was affected by the type of surgery and the sample size of studies. Compared with POSSUM, P-POSSUM was more accurate for predicting postoperative mortality. Modifications to POSSUM and P-POSSUM are needed for audit in hepato-biliary-pancreatic surgery.
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Affiliation(s)
- Tao Chen
- Department of General Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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