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Karabulut A, Umman V, Oral G, Erginoz E, Carkman MS. Assessing the effectiveness of ACS surgical risk calculator versus P-POSSUM in predicting mortality and morbidity for major hepatobiliary surgery: An observational study. Medicine (Baltimore) 2024; 103:e38973. [PMID: 38996128 PMCID: PMC11245204 DOI: 10.1097/md.0000000000038973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 06/27/2024] [Indexed: 07/14/2024] Open
Abstract
Risk assessment is difficult yet would provide valuable data for both the surgeons and the patients in major hepatobiliary surgeries. An ideal risk calculator should improve workflow through efficient, timely, and accurate risk stratification. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator (SRC) and Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) are surgical risk stratification tools used to assess postoperative morbidity. In this study, preoperative data from 300 patients undergoing major hepatobiliary surgeries performed at a single tertiary university hospital were retrospectively collected from electronic patient records and entered into the ACS-SRC and P-POSSUM systems, and the resulting risk scores were calculated and recorded accordingly. The ACS-NSQIP-M1 (C-statistics = 0.725) and M2 (C-statistics = 0.791) models showed better morbidity discrimination ability than P-POSSUM-M1 (C-statistics = 0.672) model. The P-POSSUM-M2 (C-statistics = 0.806) model showed better differentiation success in morbidity than other models. The ACS-NSQIP-M1 (C-statistics = 0.888) and M2 (C-statistics = 0.956) models showed better mortality discrimination than P-POSSUM-M1 (C-statistics = 0.776) model. The P-POSSUM-M2 (C-statistics = 0.948) model showed better mortality differentiation success than the ACS-NSQIP-M1 and P-POSSUM-M1 models. The use of ACS-SRC and P-POSSUM calculators for major hepatobiliary surgeries offers quantitative data to assess risks for both the surgeon and the patient. Integrating these calculators into preoperative evaluation practices can enhance decision-making processes for patients. The results of the statistical analyses indicated that the P-POSSUM-M2 model for morbidity and the ACS-NSQIP-M2 model for mortality exhibited superior overall performance.
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Affiliation(s)
- Ali Karabulut
- Department of General Surgery, Istanbul University Cerrahpasa – Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Veysel Umman
- Department of General Surgery, Izmir University of Economics, School of Medicine, Izmir, Turkey
| | - Gunes Oral
- Department of General Surgery, Istanbul University Cerrahpasa – Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Ergin Erginoz
- Department of General Surgery, Istanbul University Cerrahpasa – Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Mehmet Sinan Carkman
- Department of General Surgery, Istanbul University Cerrahpasa – Cerrahpasa School of Medicine, Istanbul, Turkey
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Cho J, Park J, Jeong E, Shin J, Ahn S, Park MG, Park RW, Park Y. Machine Learning Approach Using Routine Immediate Postoperative Laboratory Values for Predicting Postoperative Mortality. J Pers Med 2021; 11:jpm11121271. [PMID: 34945743 PMCID: PMC8706001 DOI: 10.3390/jpm11121271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Several prediction models have been proposed for preoperative risk stratification for mortality. However, few studies have investigated postoperative risk factors, which have a significant influence on survival after surgery. This study aimed to develop prediction models using routine immediate postoperative laboratory values for predicting postoperative mortality. Methods: Two tertiary hospital databases were used in this research: one for model development and another for external validation of the resulting models. The following algorithms were utilized for model development: LASSO logistic regression, random forest, deep neural network, and XGBoost. We built the models on the lab values from immediate postoperative blood tests and compared them with the SASA scoring system to demonstrate their efficacy. Results: There were 3817 patients who had immediate postoperative blood test values. All models trained on immediate postoperative lab values outperformed the SASA model. Furthermore, the developed random forest model had the best AUROC of 0.82 and AUPRC of 0.13, and the phosphorus level contributed the most to the random forest model. Conclusions: Machine learning models trained on routine immediate postoperative laboratory values outperformed previously published approaches in predicting 30-day postoperative mortality, indicating that they may be beneficial in identifying patients at increased risk of postoperative death.
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Affiliation(s)
- Jaehyeong Cho
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Korea; (J.C.); (J.P.)
| | - Jimyung Park
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Korea; (J.C.); (J.P.)
| | - Eugene Jeong
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA;
| | - Jihye Shin
- Division of Cancer Control & Policy, National Cancer Control Institute, Goyang-si 10408, Korea;
| | - Sangjeong Ahn
- Department of Pathology, Catholic Kwandong University International St. Mary’s Hospital, Incheon 21431, Korea;
| | - Min Geun Park
- Department of Surgery, Catholic Kwandong University International St. Mary’s Hospital, Incheon 21431, Korea;
| | - Rae Woong Park
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Korea; (J.C.); (J.P.)
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon 16499, Korea
- Correspondence: (R.W.P.); (Y.P.)
| | - Yongkeun Park
- Department of Surgery, Catholic Kwandong University International St. Mary’s Hospital, Incheon 21431, Korea;
- Correspondence: (R.W.P.); (Y.P.)
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3
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Dutton J, Zardab M, De Braal VJF, Hariharan D, MacDonald N, Hallworth S, Hutchins R, Bhattacharya S, Abraham A, Kocher HM, Yip VS. The accuracy of pre-operative (P)-POSSUM scoring and cardiopulmonary exercise testing in predicting morbidity and mortality after pancreatic and liver surgery: A systematic review. Ann Med Surg (Lond) 2020; 62:1-9. [PMID: 33489107 PMCID: PMC7804364 DOI: 10.1016/j.amsu.2020.12.016] [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: 11/09/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 11/10/2022] Open
Abstract
Background Cardiopulmonary exercise-testing (CPET) and the (Portsmouth) Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity ((P)-POSSUM) are used as pre-operative risk stratification and audit tools in general surgery, however, both have been demonstrated to have limitations in major hepatopancreatobiliary (HPB) surgery. Materials and methods The aim of this review is to determine if CPET and (P)-POSSUM scoring systems accurately predict morbidity and mortality. Eligible articles were identified with an electronic database search. Analysis according to surgery type and tool used was performed. Results Twenty-five studies were included in the final review. POSSUM predicted morbidity demonstrated weighted O/E ratios of 0.75(95%CI0.57–0.97) in hepatic surgery and 0.85(95%CI0.8–0.9) in pancreatic surgery. P-POSSUM predicted mortality in pancreatic surgery demonstrated an O/E ratio of 0.75(95%CI0.27–2.13) and 0.94(95%CI0.57–1.55) in hepatic surgery. In both pancreatic and hepatic surgery an anaerobic threshold(AT) of between 9 0.5–11.5 ml/kg/min was predictive of post-operative complications, and in pancreatic surgery ventilatory equivalence of carbon dioxide(˙VE/˙VCO2) was predictive of 30-day mortality. Conclusion POSSUM demonstrates an overall lack of predictive fit for morbidity, whilst CPET variables provide some predictive power for post-operative outcomes. Development of a new HPB specific risk prediction tool would be beneficial; the combination of parameters from POSSUM and CPET, alongside HPB specific markers could overcome current limitations. Current pre-operative scoring for pancreatic and liver surgery is inaccurate. In pancreatic and liver surgery anaerobic threshold scores were predictive of complications. In pancreatic surgery ventilatory equivalence of carbon dioxide was predictive of mortality. P-POSSUM is inaccurate for predicting mortality and morbidity in pancreatic surgery.
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Affiliation(s)
| | | | | | | | - N MacDonald
- Department of Anaesthesia, The Royal London Hospital, Barts Health NHS Trust Whitechapel, E1 1BB, UK
| | - S Hallworth
- Department of Anaesthesia, The Royal London Hospital, Barts Health NHS Trust Whitechapel, E1 1BB, UK
| | | | | | | | | | - V S Yip
- Barts and London HPB Centre, UK
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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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Maker AV, Hu V, Kadkol SS, Hong L, Brugge W, Winter J, Yeo CJ, Hackert T, Büchler M, Lawlor RT, Salvia R, Scarpa A, Bassi C, Green S. Cyst Fluid Biosignature to Predict Intraductal Papillary Mucinous Neoplasms of the Pancreas with High Malignant Potential. J Am Coll Surg 2019; 228:721-729. [PMID: 30794864 DOI: 10.1016/j.jamcollsurg.2019.02.040] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/01/2019] [Accepted: 02/02/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current standard-of-care technologies, such as imaging and cyst fluid analysis, are unable to consistently distinguish intraductal papillary mucinous neoplasms (IPMNs) of the pancreas at high risk of pancreatic cancer from low-risk IPMNs. The objective was to create a single-platform assay to identify IPMNs that are at high risk for malignant progression. STUDY DESIGN Building on the Verona International Consensus Conference branch duct IPMN biomarker review, additional protein, cytokine, mucin, DNA, and microRNA cyst fluid targets were identified for creation of a quantitative polymerase chain reaction-based assay. This included messenger RNA markers: ERBB2, GNAS, interleukin 1β, KRAS, MUCs1, 2, 4, 5AC, 7, prostaglandin E2R, PTGER2, prostaglandin E synthase 2, prostaglandin E synthase 1, TP63; microRNA targets: miRs 101, 106b, 10a, 142, 155, 17, 18a, 21, 217, 24, 30a, 342, 532, 92a, and 99b; and GNAS and KRAS mutational analysis. A multi-institutional international collaborative contributed IPMN cyst fluid samples to validate this platform. Cyst fluid gene expression levels were normalized, z-transformed, and used in classification and regression analysis by a support vector machine training algorithm. RESULTS From cyst fluids of 59 IPMN patients, principal component analysis confirmed no institutional bias/clustering. Lasso (least absolute shrinkage and selection operator)-penalized logistic regression with binary classification and 5-fold cross-validation used area under the curve as the evaluation criterion to create the optimal signature to discriminate IPMNs as low risk (low/moderate dysplasia) or high risk (high-grade dysplasia/invasive cancer). The most predictive signature was achieved with interleukin 1β, MUC4, and prostaglandin E synthase 2 to accurately discriminate high-risk cysts from low-risk cysts with an area under the curve of up to 0.86 (p = 0.002). CONCLUSIONS We have identified a single-platform polymerase chain reaction-based assay of cyst fluid to accurately predict IPMNs with high malignant potential for additional studies.
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Affiliation(s)
- Ajay V Maker
- Department of Surgery, University of Illinois at Chicago, and the Creticos Cancer Center, AIMMC, Chicago, IL.
| | - Vincent Hu
- Department of Bioinformatics, University of Illinois at Chicago, Chicago, IL
| | - Shrihari S Kadkol
- Department of Pathology, University of Illinois at Chicago, Chicago, IL
| | - Lenny Hong
- Department of Pathology, University of Illinois at Chicago, Chicago, IL
| | - William Brugge
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jordan Winter
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Büchler
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Rita T Lawlor
- Department of Diagnostics and Public Health, Section of Pathology and ARC-Net Centre for Applied Research on Cancer, University of Verona, Verona, Italy
| | - Roberto Salvia
- Department of Surgery, Istituto del Pancreas, University and Hospital Trust of Verona, Verona, Italy
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology and ARC-Net Centre for Applied Research on Cancer, University of Verona, Verona, Italy
| | - Claudio Bassi
- Department of Surgery, Istituto del Pancreas, University and Hospital Trust of Verona, Verona, Italy
| | - Stefan Green
- Department of DNA Services, University of Illinois at Chicago, Chicago, IL
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Rodriguez-Lopez M, Tejero-Pintor FJ, Perez-Saborido B, Barrera-Rebollo A, Bailon-Cuadrado M, Pacheco-Sanchez D. Severe morbidity after pancreatectomy is accurately predicted by preoperative pancreatic resection score (PREPARE): A prospective validation analysis from a medium-volume center. Hepatobiliary Pancreat Dis Int 2018; 17:559-565. [PMID: 30316626 DOI: 10.1016/j.hbpd.2018.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 09/18/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Major morbidity in pancreatic surgery remains high. Different scores for predicting complications have been described. Preoperative pancreatic resection (PREPARE) score is based on objective preoperative variables and offers good predictive accuracy for Clavien ≥ III complications. This study aimed to validate this score and analyze other preoperative variables in a prospective study performed in a medium-volume center. METHODS A total of 50 pancreatic resections were included. Preoperative variables were registered and PREPARE was calculated. The main outcome was severe morbidity (Clavien ≥ III) up to 30 days after discharge. The secondary outcomes were length of stay (LOS) and readmission. Statistical validation was performed to compare severe morbidity rate among the scores categories. Association with other preoperative variables (not included in PREPARE) was also tested. RESULTS Of the 50 pancreatic resections, the severe morbidity was 34.0%, with median LOS of 11 days. Readmission rate was 25.5%. Severe morbidity rates according to PREPARE categories were 18.5% in low-risk group, 41.7% in intermediate-risk group, and 63.6% in high-risk group, respectively (P = 0.023). The accuracy was 72% (Hosmer-Lemeshow, P = 0.86). ROC curve was obtained both for PREPARE score expressed as incremental values and categorized as the three risk groups, showing an area under curve (AUC) of 0.736 (95% CI: 0.586-0.887; P = 0.007) and 0.712 (95% CI: 0.555-0.869; P = 0.015), respectively. PREPARE was significant in multivariate analysis. Median LOS was statistically higher as PREPARE category increases (9, 11 and 15 days in low-, intermediate- and high-risk groups, respectively; P = 0.009). Readmission was not associated with any variables. CONCLUSIONS PREPARE behaves as an independent risk factor for severe morbidity after pancreatic surgery. Score validation shows good accuracy prediction. Increasing PREPARE category is also associated with longer LOS.
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Affiliation(s)
- Mario Rodriguez-Lopez
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain.
| | | | - Baltasar Perez-Saborido
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - Asterio Barrera-Rebollo
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - Martin Bailon-Cuadrado
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
| | - David Pacheco-Sanchez
- General and Digestive Surgery Department, Rio-Hortega University Hospital, Valladolid 47012, Spain
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Sato N, Hasegawa Y, Saito A, Motoi F, Ariake K, Katayose Y, Nakagawa K, Kawaguchi K, Fukudo S, Unno M, Sato F. Association between chronological depressive changes and physical symptoms in postoperative pancreatic cancer patients. Biopsychosoc Med 2018; 12:13. [PMID: 30288172 PMCID: PMC6162953 DOI: 10.1186/s13030-018-0132-1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 09/11/2018] [Indexed: 02/07/2023] Open
Abstract
Background Pancreatic cancer (PC) has poorer prognosis and higher surgical invasiveness than many other cancers, with associated psychiatric symptoms including depression and anxiety. Perioperative depression has not been investigated in PC patients regarding surgical stress and relevant interventions. Methods We evaluated chronological depressive changes and subjective physical symptoms in surgically treated PC patients preoperatively and at 3 and 6 months postoperatively. Enrolled patients undergoing pancreatic tumor surgery completed questionnaires based on the Self-Rating Depression Scale (SDS) and Functional Assessment of Cancer Therapy for Patients with Hepatobiliary Cancer (FACT-Hep) preoperatively, and at 3 and 6 months postoperatively. Responses were analyzed with JMP® Pro using one-way and two-way ANOVA, Spearman’s rank correlation coefficient, and multiple regression analysis. Results Malignancy was diagnosed in 73 of 101 patients postoperatively; SDS score was significantly higher in these patients than in those with benign tumors at all timepoints: malignant/benign, 41.8/37.9 preoperatively (p = 0.004); 43.5/37.8 3 months postoperatively (p = 0.006); and 42.9/37.7 6 months postoperatively (p = 0.020). SDS scores were significantly higher in patients < 65 years old with malignancy at 3 months than at 6 months postoperatively (44.6/42.5, p = 0.046) and in patients with malignancy who underwent pancreaticoduodenectomy at 3 months postoperatively than preoperatively (43.4/41.1; p = 0.028). SDS scores moderately correlated with 8 physical symptom-related FACT-Hep items 3 months postoperatively (p < 0.05), showing low-to-moderate correlation with 16 physical symptom-related FACT-Hep items at 6 months postoperatively (p < 0.05). Multiple regression analysis of FACT-Hep symptoms significantly correlated with SDS scores revealed the following significant variables: “lack of energy” (p < 0.000) and “pain” (p = 0.018) preoperatively (R2 = 0.43); “able to perform usual activities” (p = 0.031) and “lack of energy” (p < 0.000) at 3 months postoperatively (R2 = 0.51); and “stomach swelling or cramps” (p = 0.034) and “bowel control” (p = 0.049) at 6 months postoperatively (R2 = 0.52). Conclusions PC patients experience persistently high levels of depression preoperatively through 6 months postoperatively, with associated subjective symptoms including pain and gastrointestinal symptoms. Trial registration UMIN Clinical Trials Registry 000009592, Registered 20 December 2012.
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Affiliation(s)
- Naoko Sato
- 1Department of Oncology Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan.,5Department of Oncology Nursing, Tohoku University, 2-1 Seiryo-machi, Aoba-ku, Sendai, 980-8575 Japan
| | - Yoshimi Hasegawa
- 2Department of Nursing, Tohoku University School of Health Sciences, Sendai, Japan
| | - Asami Saito
- 1Department of Oncology Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fuyuhiko Motoi
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kyohei Ariake
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Katayose
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Nakagawa
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Kawaguchi
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shin Fukudo
- 4Department of Behavioral Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fumiko Sato
- 1Department of Oncology Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
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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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9
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Kobayashi S, Segami K, Hoshino H, Nakahara K, Katayama M, Koizumi S, Otsubo T. Risk factors for failure of early recovery from pancreatoduodenectomy despite the use of enhanced recovery after surgery protocols and a physical aging score to predict postoperative risks. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:231-239. [PMID: 29412516 DOI: 10.1002/jhbp.540] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are beneficial for pancreatoduodenectomy (PD). Our aim was to evaluate risk factors associated with ERAS protocol failure after PD. METHODS Clinical variables of 187 patients managed using ERAS protocols between April 2011 and April 2017, including non-early recovery (non-ER) patients, with complications or requiring a hospital stay ≥15 days, and early recovery (ER) patients, were compared. A physical aging (PA) score was devised to predict postoperative risks. RESULTS Independent risk factors of complications were a pre-albumin level ≤18 mg/dl (odds ratio (OR) 2.197; 95% confidence interval (CI) 1.052-4.622), and an American Society of Anesthesiologists (ASA) score ≥II (OR 2.195; 95% CI 1.052-4.746). Independent risk factors for hospital stay ≥15 days (P < 0.001) were age ≥70 years (OR 2.438; 95% CI 1.122-5.299) and an ASA score ≥II (OR 2.348; 95% CI 1.109-4.968). The PA score included age, ASA score, and pre-albumin level. The complication rate for each PA score was as follows: score "0", 12.1%; score "1", 18.2%; score "2", 26.9%; score "3", 30.8%; and score "≥4", 47.2%. CONCLUSIONS Advanced age, poor nutrition, and serious illnesses can cause ERAS protocol failure. The PA score is effective for predicting postoperative progress.
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Affiliation(s)
- Shinjiro Kobayashi
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kohei Segami
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hiroyuki Hoshino
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kazunari Nakahara
- Department of Gastroenterology and Hepatology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Masafumi Katayama
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Satoshi Koizumi
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Takehito Otsubo
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
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Nair AS. Surgical Apgar Score for predicting patient outcome after hepatopancreaticobiliary surgeries. Saudi J Anaesth 2018; 12:155-156. [PMID: 29416485 PMCID: PMC5789487 DOI: 10.4103/sja.sja_267_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Abhijit S Nair
- Department of Anaesthesia and Pain Medicine, Basavatarakam Indo-American Cancer Hospital and Research Centre, Hyderabad, Telangana, India
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11
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Nair A, Bharuka A, Rayani BK. The Reliability of Surgical Apgar Score in Predicting Immediate and Late Postoperative Morbidity and Mortality: A Narrative Review. Rambam Maimonides Med J 2018; 9:RMMJ.10316. [PMID: 29035696 PMCID: PMC5796735 DOI: 10.5041/rmmj.10316] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Surgical Apgar Score is a simple, 10-point scoring system in which a low score reliably identifies those patients at risk for adverse perioperative outcomes. Surgical techniques and anesthesia management should be directed in such a way that the Surgical Apgar Score remains higher to avoid postoperative morbidity and mortality.
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Affiliation(s)
- Abhijit Nair
- To whom correspondence should be addressed. E-mail:
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12
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Can we better predict the biologic behavior of incidental IPMN? A comprehensive analysis of molecular diagnostics and biomarkers in intraductal papillary mucinous neoplasms of the pancreas. Langenbecks Arch Surg 2017; 403:151-194. [DOI: 10.1007/s00423-017-1644-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/24/2017] [Indexed: 02/07/2023]
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13
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Bournet B, Vignolle-Vidoni A, Grand D, Roques C, Breibach F, Cros J, Muscari F, Carrère N, Selves J, Cordelier P, Buscail L. Endoscopic ultrasound-guided fine-needle aspiration plus KRAS and GNAS mutation in malignant intraductal papillary mucinous neoplasm of the pancreas. Endosc Int Open 2016; 4:E1228-E1235. [PMID: 27995180 PMCID: PMC5161125 DOI: 10.1055/s-0042-117216] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 08/19/2016] [Indexed: 12/11/2022] Open
Abstract
Background:KRAS and GNAS mutations are common in intraductal papillary mucinous neoplasia of the pancreas (IPMN). The aims of this study were to assess the role of pre-therapeutic cytopathology combined with KRAS and GNAS mutation assays within cystic fluid sampled by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to predict malignancy of IPMN. Patients and methods: We prospectively included 37 IPMN patients with clinical and/or imaging predictors of malignancy (men: 24; mean age: 69.5 years). Cytopathology (performed on cystic fluid and/or IPMN nodules), KRAS (Exon 2, codon 12) and GNAS (Exon 8, codon 201) mutations assays (using TaqMan® allelic discrimination) were performed on EUS-FNA material. The final diagnosis was obtained from IPMN resections (n = 18); surgical biopsies, EUS-FNA analyses, and follow-up (n = 19): 10 and 27 IPMN were benign and malignant, respectively. Results: Sensitivity, specificity, positive and negative predictive values, and accuracy of cytopathology alone to diagnose IPMN malignancy were 55 %, 100 %, 100 %, 45 %, and 66 %, respectively. When KRAS-mutation analysis was combined with cytopathology these values were 92 %, 50 %, 83 %, 71 %, and 81 %, respectively. GNAS assays did not improve the performances of cytopathology alone or those of cytopathology plus a KRAS assay. Conclusions: In patients with a likelihood of malignant IPMN at pre-therapeutic investigation, testing for KRAS mutations in cystic fluid sampling by EUS-FNA improved the results of cytopathology for the diagnosis of malignancy whereas GNAS mutation assay did not.
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Affiliation(s)
- Barbara Bournet
- Department of Gastroenterology and INSERM UMR 1037, CHU Toulouse Rangueil, University of Toulouse, Toulouse, France,INSERM UMR 1037, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - Alix Vignolle-Vidoni
- INSERM UMR 1037, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - David Grand
- Department of Pathology, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - Céline Roques
- Department of Pathology, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - Florence Breibach
- Department of Pathology, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - Jérome Cros
- Department of Pathology, Beaujon Hospital, University of Paris Diderot, Clichy, France
| | - Fabrice Muscari
- Department of Digestive Surgery, CHU Toulouse Rangueil, University of Toulouse, Toulouse, France
| | - Nicolas Carrère
- INSERM UMR 1037, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France,Department of Digestive Surgery, CHU Toulouse Purpan, University of Toulouse, Toulouse, France
| | - Janick Selves
- INSERM UMR 1037, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France,Department of Pathology, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - Pierre Cordelier
- INSERM UMR 1037, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - Louis Buscail
- Department of Gastroenterology and INSERM UMR 1037, CHU Toulouse Rangueil, University of Toulouse, Toulouse, France,INSERM UMR 1037, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France,Corresponding author Louis Buscail, MD, PhD Department of Gastroenterology and INSERM U1037CHU Rangueil1 avenue Jean PoulhèsTSA 5003231059 Toulouse Cedex 9France+33 5 61 32 30 55+33 5 61 32 22 29
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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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Risk Model for Distal Gastrectomy When Treating Gastric Cancer on the Basis of Data From 33,917 Japanese Patients Collected Using a Nationwide Web-based Data Entry System. Ann Surg 2015; 262:295-303. [PMID: 25719804 DOI: 10.1097/sla.0000000000001127] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To establish a risk model for distal gastrectomy in Japanese patients with gastric cancer. BACKGROUND Risk stratification for distal gastrectomy in Japanese patients with gastric cancer improves surgical outcomes. METHODS The National Clinical Database was constructed for risk determination in gastric cancer-related gastrectomy among Japanese individuals. Data from 33,917 gastric cancer cases (1737 hospitals) were used. The primary outcomes were 30-day and operative mortalities. Data were randomly assigned to risk model development (27,220 cases) and test validation (6697 cases) subsets. Stepwise selection was used for constructing 30-day and operative mortality logistic models. RESULTS The 30-day, in-hospital, and operative mortality rates were 0.52%, 1.16%, and 1.2%, respectively. The morbidity was 18.3%. The 30-day and operative mortality models included 17 and 21 risk factors, respectively. Thirteen variables overlapped: age, need for total assistance in activities of daily living preoperatively or within 30 days after surgery, cerebrovascular disease history, more than 10% weight loss, uncontrolled ascites, American Society of Anesthesiologists score (≥ class 3), white blood cell count more than 12,000/μL or 11,000/μL, anemia (hemoglobin: males, <13.5 g/dL; females, <12.5 g/dL; or hematocrit: males, <37%; females <32%), serum albumin less than 3.5 or 3.8 g/dL, alkaline phosphatase more than 340 IU/L, serum creatinine more than 1.2 mg/dL, serum Na less than 135 mEq/L, and prothrombin time-international normalized ratio more than 1.25 or 1.1. The C-indices for the 30-day and operative mortalities were 0.785 (95% confidence interval, 0.705-0.865; P < 0.001) and 0.798 (95% confidence interval, 0.746-0.851; P < 0.001), respectively. CONCLUSIONS The risk model developed using nationwide Japanese data on distal gastrectomy in gastric cancer can predict surgical outcomes.
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Assessing surgical quality: comparison of general and procedure-specific morbidity estimation models for the risk adjustment of pancreaticoduodenectomy outcomes. World J Surg 2015; 38:2412-21. [PMID: 24705780 DOI: 10.1007/s00268-014-2554-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The use of outcomes to evaluate surgical quality implies the need for detailed risk adjustment. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a generally applicable risk adjustment model suitable for pancreatic surgery. A pancreaticoduodenectomy (PD)-specific intraoperative pancreatic risk assessment (IPRA) estimates the risk of postoperative pancreatic fistula (POPF) and associated morbidity based on factors that are not incorporated into POSSUM. OBJECTIVE The aim of the study was to compare the risk estimations of POSSUM and IPRA in patients undergoing PD. METHODS An observational single-center cohort study was conducted including 195 patients undergoing PD in 2008-2010. POSSUM and IPRA data were recorded prospectively. Incidence and severity of postoperative morbidity was recorded according to established definitions. The cohort was grouped by POSSUM and IPRA risk groups. The estimated and observed outcomes and morbidity profiles of POSSUM and IPRA were scrutinized. RESULTS POSSUM-estimated risk (62 %) corresponded with observed total morbidity (65 %). Severe morbidity was 17 % and in-hospital-mortality 3.1 %. Individual and grouped POSSUM risk estimates did not reveal associations with incidence (p = 0.637) or severity (p = 0.321) of total morbidity or POPF. The IPRA model identified patients with high POPF risk (p < 0.001), but was even associated with incidence (p < 0.001) and severity (p < 0.001) of total morbidity. CONCLUSION The risk factors defined by a PD-specific model were significantly stronger predictive indicators for the incidence and severity of postoperative morbidity than the factors incorporated in POSSUM. If available, reliable procedure-specific risk factors should be utilized in the risk adjustment of surgical outcomes. For pancreatic surgery, generally applicable tools such as POSSUM still have to prove their relevance.
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Maemura K, Mataki Y, Kurahara H, Mori S, Higo N, Sakoda M, Iino S, Nakajo A, Ishigami S, Ueno S, Takao S, Shinchi H, Natsugoe S. Pancreaticogastrostomy after Pancreaticoduodenectomy Using Twin Square Wrapping with Duct-to-Mucosa Anastomosis. Eur Surg Res 2015; 55:109-18. [DOI: 10.1159/000433425] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 05/15/2015] [Indexed: 11/19/2022]
Abstract
Background/Purpose: This study aimed to evaluate the feasibility and safety of a novel pancreaticogastrostomy technique for diminishing pancreatic fistulas after pancreaticoduodenectomy using gastric wrapping of the pancreatic stump with a twin square-shaped horizontal mattress and a suture fixing the main pancreatic duct to the gastric mucosa anastomosis [twin square wrapping (TSW) method]. Methods: Fifty-three patients undergoing pancreaticogastrostomy after pancreaticoduodenectomy were included in the study and chronologically divided into a conventional group (n = 32) and a TSW group (n = 21). The perioperative factors and the postoperative outcomes were retrospectively analyzed. Results: The operating time for the pancreatic anastomosis, the total operating time, and the blood loss volume in the TSW group were lower than in the conventional group, but without a statistically significant difference. The TSW group had a significantly lower postoperative white blood cell count and C-reactive protein level, with a reduced intra-abdominal fluid accumulation as assessed by computed tomography on postoperative day 7, had a lower incidence of postoperative complications and pancreatic fistulas, and achieved a shorter duration of drain placement and shorter postoperative hospital stays as compared to the conventional group. Conclusions: The TSW technique should be considered for reducing pancreatic fistulas by diminishing the postoperative inflammatory response and improving patient outcomes without increasing the operating time.
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Daudé M, Muscari F, Buscail C, Carrère N, Otal P, Selves J, Buscail L, Bournet B. Outcomes of nonresected main-duct intraductal papillary mucinous neoplasms of the pancreas. World J Gastroenterol 2015; 21:2658-2667. [PMID: 25759534 PMCID: PMC4351216 DOI: 10.3748/wjg.v21.i9.2658] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 10/12/2014] [Accepted: 12/08/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare characteristics and outcomes of resected and nonresected main-duct and mixed intraductal papillary mucinous neoplasms of the pancreas (IPMN).
METHODS: Over a 14-year period, 50 patients who did not undergo surgery for resectable main-duct or mixed IPMN, for reasons of precluding comorbidities, age and/or refusal, were compared with 74 patients who underwent resection to assess differences in rates of survival, recurrence/occurrence of malignancy, and prognostic factors. All study participants had dilatation of the main pancreatic duct by ≥ 5 mm, with or without dilatation of the branch ducts. Some of the nonsurgical patients showed evidence of mucus upon perendoscopic retrograde cholangiopancreatography or endoscopic ultrasound and/or after fine needle aspiration. For the surgical patients, pathologic analysis of resected specimens confirmed a diagnosis of IPMN with involvement of the main pancreatic duct or of both branch ducts as well as the main pancreatic duct. Clinical and biologic follow-ups were conducted for all patients at least annually, through hospitalization or consultation every six months during the first year of follow-up, together with abdominal imaging analysis (magnetic resonance cholangiopancreatography or computed tomography) and, if necessary, endoscopic ultrasound with or without fine needle aspiration.
RESULTS: The overall five-year survival rate of patients who underwent resection was significantly greater than that for the nonsurgical patients (74% vs 58%; P = 0.019). The parameters of age (< 70 years) and absence of a nodule were associated with better survival (P < 0.05); however, the parameters of main pancreatic duct diameter > 10 mm, branch duct diameter > 30 mm, or presence of extra pancreatic cancers did not significantly influence the prognosis. In the nonsurgical patients, pancreatic malignancy occurred in 36% of cases within a mean time of 33 mo (median: 29 mo; range: 8-141 mo). Comparison of the nonsurgical patients who experienced disease progression with those who did not progress showed no significant differences in age, sex, symptoms, subtype of IPMN, or follow-up period; only the size of the main pancreatic duct was significantly different between these two sub-groups, with the nonsurgical patients who experienced progression showing a greater diameter at the time of diagnosis (> 10 mm).
CONCLUSION: Patients unfit for surgery have a 36% greater risk of developing pancreatic malignancy of the main-duct or mixed IPMN within a median of 2.5 years.
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MESH Headings
- Adenocarcinoma, Mucinous/mortality
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/surgery
- Adenocarcinoma, Mucinous/therapy
- Adenocarcinoma, Papillary/mortality
- Adenocarcinoma, Papillary/pathology
- Adenocarcinoma, Papillary/surgery
- Adenocarcinoma, Papillary/therapy
- Adult
- Aged
- Aged, 80 and over
- Cholangiopancreatography, Endoscopic Retrograde
- Cholangiopancreatography, Magnetic Resonance
- Disease Progression
- Endoscopic Ultrasound-Guided Fine Needle Aspiration
- Endosonography
- Female
- Humans
- Kaplan-Meier Estimate
- Male
- Middle Aged
- Neoplasm Recurrence, Local
- Pancreatectomy/adverse effects
- Pancreatectomy/mortality
- Pancreatic Neoplasms/mortality
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Pancreatic Neoplasms/therapy
- Predictive Value of Tests
- Proportional Hazards Models
- Retrospective Studies
- Risk Factors
- Time Factors
- Tomography, X-Ray Computed
- Treatment Outcome
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Wang H, Wang H, Chen T, Liang X, Song Y, Wang J. Evaluation of the POSSUM, P-POSSUM and E-PASS scores in the surgical treatment of hilar cholangiocarcinoma. World J Surg Oncol 2014; 12:191. [PMID: 24961847 PMCID: PMC4079624 DOI: 10.1186/1477-7819-12-191] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 06/08/2014] [Indexed: 02/08/2023] Open
Abstract
Background The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model, its Portsmouth (P-POSSUM) modification and the Estimation of physiologic ability and surgical stress (E-PASS) are three surgical risk scoring systems used extensively to predict postoperative morbidity and mortality in general surgery. The aim was to undertake the first study of the predictive value of these models in patients undergoing surgical treatment of hilar cholangiocarcinoma. Methods A retrospective analysis was performed on data collected prospectively over a 10-year interval from January 2003 to December 2012. The morbidity and mortality risks were calculated using the POSSUM, P-POSSUM and E-PASS equations. Results One hundred patients underwent surgical treatment of hilar cholangiocarcinoma. Complications were seen in 52 of 100 patients (52.0%). There were 10 postoperative in-hospital deaths (10.0%). Of 31 preoperative and intraoperative variables studied, operative type (P = 0.000), preoperative serum albumin (P = 0.003) and aspartate aminotransferase (P = 0.029) were found to be factors multivariate associated with postoperative complications. Intraoperative blood loss (P = 0.015), Bismuth-Corlette classification (P = 0.033) and preoperative hemoglobin (P = 0.041) were independent factors multivariate associated with in-hospital death. The POSSUM system predicted morbidity risk effectively with no significant lack of fit (P = 0.488) and an area under the ROC curve (AUC) of 0.843. POSSUM, P-POSSUM and E-PASS scores showed no significant lack of fit in calculating the mortality risk (P >0.05) and all yielded an AUC value exceeding 0.8. POSSUM had significantly more accuracy in predicting morbidity after major and major plus operations (O:E (observed/expected) ratio 0.98 and AUC 0.901) than after minor and moderate operations (O:E ratio 1.13 and AUC 0.759). Conclusions POSSUM, P-POSSUM and E-PASS scores effectively predict morbidity and mortality in surgical treatment of hilar cholangiocarcinoma. However, improvements are still needed in the future because none of these scoring systems yielded an AUC value exceeding 0.9 for operations with all different levels of severity. Only POSSUM had more accuracy in predicting postoperative morbidity after operations with higher severity. Trial registration This study was undertaken after obtaining approval from the ethics committee of School of Medicine, Shanghai Jiao Tong University with a trial registration number of http://09411960800.
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Affiliation(s)
| | | | | | | | | | - Jian Wang
- Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 S, Dongfang Road, Shanghai 200127, China.
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Charalampakis V, Wiglesworth A, Formela L, Senapati S, Akhtar K, Ammori B. POSSUM and p-POSSUM overestimate morbidity and mortality in laparoscopic bariatric surgery. Surg Obes Relat Dis 2014; 10:1147-53. [PMID: 25205569 DOI: 10.1016/j.soard.2014.04.023] [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] [Received: 01/05/2014] [Revised: 03/02/2014] [Accepted: 04/09/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite their wide use in surgical audit, the application of the Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and the Portsmouth predictor of mortality (p-POSSUM) in bariatric surgery has been limited. The aim of this study was to evaluate the usefulness of POSSUM and p-POSSUM in bariatric comparative audit. METHODS Data were retrospectively collected on consecutive patients who underwent laparoscopic gastric by-pass (LRYGB) and sleeve gastrectomy (SG) at a teaching institute. POSSUM and p-POSSUM equations were applied. The observed to expected ratios for morbidity and mortality were calculated. A Student's t test was performed to assess if a relationship could be found between the observed and the predicted outcomes. RESULTS Between 2008 and 2013, 504 patients (370 female) with a mean (range) age of 46 (17-69) years underwent LRYGB (n = 383) and SG (n = 121). The operative morbidity was 10.9% and mortality was .2%. POSSUM overpredicted morbidity (30.56%), and no relationship between morbidity risk and the development of complications was found (P = .152). There was a grouping of patients in the low-risk mortality groups for both POSSUM and p-POSSUM. Both equations overpredicted mortality (5.95% and 1.62%, respectively). CONCLUSION Both POSSUM and p-POSSUM equations overpredicted morbidity and mortality in this only study in the literature of modern bariatric practice that employed a large representative patient sample receiving the commonest procedures. A multicenter study is needed to address the low incidence of events and enable modification of those equations for use in bariatric surgical audit.
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Affiliation(s)
| | - Amanda Wiglesworth
- Department of Surgery at Salford Royal Foundation Trust, Manchester, United Kingdom; The University of Manchester, Manchester, United Kingdom
| | - Laura Formela
- Department of Surgery at Salford Royal Foundation Trust, Manchester, United Kingdom
| | - Siba Senapati
- Department of Surgery at Salford Royal Foundation Trust, Manchester, United Kingdom
| | - Khurshid Akhtar
- Department of Surgery at Salford Royal Foundation Trust, Manchester, United Kingdom
| | - Basil Ammori
- Department of Surgery at Salford Royal Foundation Trust, Manchester, United Kingdom; The University of Manchester, Manchester, 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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“Total arterial devascularization first” technique for resection of pancreatic head cancer during pancreaticoduodenectomy. ACTA ACUST UNITED AC 2013; 33:687-691. [DOI: 10.1007/s11596-013-1181-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 09/12/2013] [Indexed: 12/31/2022]
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Invited commentary on "a systematic review of POSSUM and P-POSSUM as predictors of postoperative morbidity and mortality in patients undergoing pancreatic surgery". Am J Surg 2013; 205:473-4. [PMID: 23388424 DOI: 10.1016/j.amjsurg.2012.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 07/17/2012] [Indexed: 11/22/2022]
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