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Johns AJ, Yoon PS, Sabo AJ, Huynh TT, Farmer DL, Navarro SM, Farkas LM. Experience of a single academic institution with the National Accreditation Program for Rectal Cancer and the resulting improvement in care. Colorectal Dis 2023; 25:2155-2159. [PMID: 37789561 DOI: 10.1111/codi.16766] [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: 07/21/2022] [Revised: 04/29/2023] [Accepted: 09/06/2023] [Indexed: 10/05/2023]
Abstract
AIM The American College of Surgeons Committee on Cancer developed the National Accreditation Program for Rectal Cancer (NAPRC) to reduce variations in rectal cancer care, standardize clinical practice and encourage multidisciplinary approaches. The aim of this study was to analyse if accreditation achieved a higher quality of care at one hospital. METHOD The University of California Davis Medical Center was accredited in 2019. A retrospective review of rectal adenocarcinoma patients was performed between the years 2013 and 2018. Patients presenting from 2013 to 2015 were discussed at a gastrointestinal tumour board while patients in 2018 had an accredited rectal cancer tumour board. Patients from 2016 to 2017 were excluded as the programme was still developing. Compliance to the NAPRC standards was compared between the cohorts. RESULTS One hundred and thirty patients were evaluated, 88 (68%) in the prerectal tumour board cohort and 42 (32%) in the rectal tumour board cohort. The prerectal tumour board cohort often failed to meet attendance standards. All patients in the rectal tumour board cohort met all criteria. Similarly, clinical service compliance improved in the rectal tumour board cohort for 13 metrics, 10 of which were statistically significant. Although a high proportion of patients in both groups experienced quality surgery, i.e. complete total mesorectal excision and negative margins, the lack of complete pathological reporting in the prerectal tumour board cohort limited analysis. CONCLUSION Multidisciplinary rectal cancer tumour boards are associated with improved compliance with recommended care by the NAPRC. Patients discussed at a rectal cancer tumour board were more likely to receive appropriate staging, coordinated care and have better clinical documentation.
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Affiliation(s)
- Alexandra J Johns
- University of California Davis Medical Center, Sacramento, California, USA
| | - Paul S Yoon
- University of California Davis Medical Center, Sacramento, California, USA
| | - Anthony J Sabo
- University of California Davis Medical Center, Sacramento, California, USA
| | - Timothy T Huynh
- University of California Davis Medical Center, Sacramento, California, USA
| | - Diana L Farmer
- University of California Davis Medical Center, Sacramento, California, USA
| | - Shannon M Navarro
- University of California Davis Medical Center, Sacramento, California, USA
| | - Linda M Farkas
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Molenaar CJL, Minnella EM, Coca-Martinez M, ten Cate DWG, Regis M, Awasthi R, Martínez-Palli G, López-Baamonde M, Sebio-Garcia R, Feo CV, van Rooijen SJ, Schreinemakers JMJ, Bojesen RD, Gögenur I, van den Heuvel ER, Carli F, Slooter GD. Effect of Multimodal Prehabilitation on Reducing Postoperative Complications and Enhancing Functional Capacity Following Colorectal Cancer Surgery: The PREHAB Randomized Clinical Trial. JAMA Surg 2023; 158:572-581. [PMID: 36988937 PMCID: PMC10061316 DOI: 10.1001/jamasurg.2023.0198] [Citation(s) in RCA: 76] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 11/19/2022] [Indexed: 03/30/2023]
Abstract
Importance Colorectal surgery is associated with substantial morbidity rates and a lowered functional capacity. Optimization of the patient's condition in the weeks prior to surgery may attenuate these unfavorable sequelae. Objective To determine whether multimodal prehabilitation before colorectal cancer surgery can reduce postoperative complications and enhance functional recovery. Design, Setting, and Participants The PREHAB randomized clinical trial was an international, multicenter trial conducted in teaching hospitals with implemented enhanced recovery after surgery programs. Adult patients with nonmetastasized colorectal cancer were assessed for eligibility and randomized to either prehabilitation or standard care. Both arms received standard perioperative care. Patients were enrolled from June 2017 to December 2020, and follow-up was completed in December 2021. However, this trial was prematurely stopped due to the COVID-19 pandemic. Interventions The 4-week in-hospital supervised multimodal prehabilitation program consisted of a high-intensity exercise program 3 times per week, a nutritional intervention, psychological support, and a smoking cessation program when needed. Main Outcomes and Measures Comprehensive Complication Index (CCI) score, number of patients with CCI score more than 20, and improved walking capacity expressed as the 6-minute walking distance 4 weeks postoperatively. Results In the intention-to-treat population of 251 participants (median [IQR] age, 69 [60-76] years; 138 [55%] male), 206 (82%) had tumors located in the colon and 234 (93%) underwent laparoscopic- or robotic-assisted surgery. The number of severe complications (CCI score >20) was significantly lower favoring prehabilitation compared with standard care (21 of 123 [17.1%] vs 38 of 128 [29.7%]; odds ratio, 0.47 [95% CI, 0.26-0.87]; P = .02). Participants in prehabilitation encountered fewer medical complications (eg, respiratory) compared with participants receiving standard care (19 of 123 [15.4%] vs 35 of 128 [27.3%]; odds ratio, 0.48 [95% CI, 0.26-0.89]; P = .02). Four weeks after surgery, 6-minute walking distance did not differ significantly between groups when compared with baseline (mean difference prehabilitation vs standard care 15.6 m [95% CI, -1.4 to 32.6]; P = .07). Secondary parameters of functional capacity in the postoperative period generally favored prehabilitation compared with standard care. Conclusions and Relevance This PREHAB trial demonstrates the benefit of a multimodal prehabilitation program before colorectal cancer surgery as reflected by fewer severe and medical complications postoperatively and an optimized postoperative recovery compared with standard care. Trial Registration trialregister.nl Identifier: NTR5947.
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Affiliation(s)
| | - Enrico Maria Minnella
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Miquel Coca-Martinez
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Department of Anesthesia, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Marta Regis
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Rashami Awasthi
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | | | | | - Raquel Sebio-Garcia
- Physical Medicine and Rehabilitation Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carlo Vittorio Feo
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
- Unit of Provincial General Surgery, Azienda Unità Sanitaria Locale Ferrara, Ferrara, Italy
| | | | | | - Rasmus Dahlin Bojesen
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Surgery, Zealand University Hospital, Køge, Denmark
| | - Edwin R. van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Francesco Carli
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Taffurelli G, Montroni I, Ghignone F, Zattoni D, Garutti A, Di Candido F, Mazzotti F, Frascaroli G, Tamberi S, Ugolini G. Frailty assessment can predict textbook outcomes in senior adults after minimally invasive colorectal cancer surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:626-632. [PMID: 36396488 DOI: 10.1016/j.ejso.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/21/2022] [Accepted: 11/03/2022] [Indexed: 11/09/2022]
Abstract
AIM Colorectal cancer (CRC) surgery can be associated with suboptimal outcomes in older patients. The aim was to identify the correlation between frailty and surgical variables with the achievement of Textbook Outcome (TO), a composite measure of the ideal postoperative course, by older patients with CRC. METHOD All consecutive patients ≥70years who underwent elective CRC-surgery between January 2017 and November 2021 were analyzed from a prospective database. To obtain a TO, all the following must be achieved: 90-day survival, Clavien-Dindo (CD) < 3, no reintervention, no readmission, no discharge to rehabilitation facility, no changes in the living situation and length of stay (LOS) ≤5days/≤14days for colon and rectal surgery respectively. Frailty and surgical variables were related to the achievement of TO. RESULTS Four-hundred-twenty-one consecutive patients had surgery (97.7% minimally invasive), 24.9% for rectal cancer, median age 80 years (range 70-92), median LOS of 4 days (range 1-96). Overall, 288/421 patients (68.4%) achieved a TO. CD 3-4 complications rate was 6.4%, 90-day mortality rate was 2.9%. At univariate analysis, frailty and surgical variables (ileostomy creation, p = 0.045) were related to. However, multivariate analysis showed that only frailty measures such as flemish Triage Risk Screening Tool≥2 (OR 1.97, 95%CI: 1.23-3.16; p = 0.005); Charlson Index>6 (OR 1.61, 95%CI: 1.03-2.51; p = 0.036) or Timed-Up-and-Go>20 s (OR 2.06, 95%CI: 1.01-4.19; p = 0.048) independently predicted an increased risk of not achieving a TO. CONCLUSION The association between frailty and comprehensive surgical outcomes offers objective data for guiding family counseling, managing expectations and discussing the possible loss of independence with patients and caregivers.
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Affiliation(s)
- Giovanni Taffurelli
- Colorectal and General Surgery Unit, Ospedale per gli Infermi Faenza and Ospedale Santa Maria delle Croci Ravenna, AUSL Romagna, Italy.
| | - Isacco Montroni
- Colorectal and General Surgery Unit, Ospedale per gli Infermi Faenza and Ospedale Santa Maria delle Croci Ravenna, AUSL Romagna, Italy
| | - Federico Ghignone
- Colorectal and General Surgery Unit, Ospedale per gli Infermi Faenza and Ospedale Santa Maria delle Croci Ravenna, AUSL Romagna, Italy
| | - Davide Zattoni
- Colorectal and General Surgery Unit, Ospedale per gli Infermi Faenza and Ospedale Santa Maria delle Croci Ravenna, AUSL Romagna, Italy
| | - Anna Garutti
- Department of Medical Oncology, Ospedale per gli Infermi, Faenza, AUSL Romagna, Italy
| | - Francesca Di Candido
- Colorectal and General Surgery Unit, Ospedale per gli Infermi Faenza and Ospedale Santa Maria delle Croci Ravenna, AUSL Romagna, Italy
| | - Federico Mazzotti
- Colorectal and General Surgery Unit, Ospedale per gli Infermi Faenza and Ospedale Santa Maria delle Croci Ravenna, AUSL Romagna, Italy
| | - Giacomo Frascaroli
- Colorectal and General Surgery Unit, Ospedale per gli Infermi Faenza and Ospedale Santa Maria delle Croci Ravenna, AUSL Romagna, Italy
| | - Stefano Tamberi
- Department of Medical Oncology, Ospedale per gli Infermi, Faenza, AUSL Romagna, Italy
| | - Giampaolo Ugolini
- Colorectal and General Surgery Unit, Ospedale per gli Infermi Faenza and Ospedale Santa Maria delle Croci Ravenna, AUSL Romagna, Italy; University of Bologna, Italy
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Predictive value of the Naples prognostic score on postoperative outcomes in patients with rectal cancer. Langenbecks Arch Surg 2023; 408:113. [PMID: 36859650 DOI: 10.1007/s00423-023-02851-2] [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: 07/20/2022] [Accepted: 02/21/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE The Naples prognostic score (NPS) is a prognostic index based on the nutritional and inflammatory status. However, its utility in predicting postoperative complications (POCs) has not been examined in rectal cancer (RC). We evaluated the predictive value of the preoperative NPS for POCs in RC. METHODS We retrospectively analyzed 235 patients who underwent surgery for RC. The NPS was calculated based on serum albumin, serum total cholesterol, the neutrophil-to-lymphocyte ratio (NLR) and the lymphocyte-to-monocyte ratio (LMR). Severe POCs were defined as Clavien-Dindo classification grade ≥ III. The optimal cut-off value of the NPS was determined by a receiver operator characteristic (ROC) curve analysis. The NPS, NLR, LMR, platelet-to-lymphocyte ratio (PLR), C-reactive protein (CRP)-to-albumin ratio (CAR), Glasgow prognostic score (GPS), Onodera prognostic nutritional index (PNI) and controlling nutritional status score (CONUT) were investigated as inflammation-based and/or nutritional markers. Predictors of severe POCs were analyzed by logistic regression modeling. RESULTS Severe POCs were observed in 64 patients (27.2%). Male sex, operation time (> 257 min), blood loss (≥ 30 mL), albumin (< 4.0 g/dL), CRP (≥ 1.0 mg/dL), total cholesterol (≤ 180 mg/dL), NPS (≥ 2), LMR (≥ 3.48), PLR (≥ 103.6), CAR (> 0.025), GPS (≥ 1), PNI (< 48.1) and CONUT (≥ 2) were significantly associated with severe POCs. The multivariate analysis revealed that male sex, operation time (> 257 min), and a high NPS (≥ 2) were independent predictors of severe POCs. The ROC curve analysis revealed that the NPS had the greatest predictive value among the inflammation-based and/or nutritional markers. CONCLUSION The NPS is a valuable predictor of severe POCs in RC.
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Ben Abdelkrim M, Elghali MA, Moussa A, Ben Abdelaziz A. Contextual Validation of the Prediction of Postoperative Complications of Colorectal Surgery by the " ACS NSQIP ® Risk Calculator" in a Tunisian Center. Cancer Inform 2022; 21:11769351221135153. [PMID: 36386277 PMCID: PMC9661577 DOI: 10.1177/11769351221135153] [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: 05/05/2022] [Accepted: 10/08/2022] [Indexed: 08/29/2023] Open
Abstract
CONTEXT Models for predicting individual risks of surgical complications are advantageous for operative decision making and the nature of postoperative management procedures. OBJECTIVE Validate the "ACS NSQIP® Risk Calculator" in the prediction of postoperative complications during colorectal cancer surgery, operated during the years 2015 to 2019. METHODS this is a prognostic validation study of the "ACS NSQIP®" applied retrospectively to patients operated on for colorectal cancer in the surgical department of Farhat Hached hospital, during the 2015 and 2019 5-year term. Three levels of adjustment. Discrimination and calibration were carried out mainly by ROC curves (AUC ⩾ 0.8). RESULTS In this study, 129 patients were included with a sex ratio of 1.22 and a median age of 62 years. The most common operative procedure was low segmental colectomy with colorectal anastomosis. Thirty-seven patients (28.7%) had at least one postoperative complication. The prediction and cuts-off points values of mortality (AUC = 0.858; CI95% [0.570-0.960]; Cuts-off points = 1.8%), cardiac complications (AUC = 0.824; CI95% [0.658-0.990]; Cuts-off points = 1.8%), thromboembolic complications (AUC = 0.802; CI95% [0.617-0.987]; Cuts-off point = 3.1%), and renal insufficiency (AUC = 0.802; CI95% [ 0.623-0.981]; Cuts-off point = 1.2%) were adjusted according to level 1 of the calculator. CONCLUSION This work contextualized the prediction of postoperative complications in colorectal surgery in the university general surgery department of Farhat Hached in Sousse (Tunisia), making it possible to improve the quality and safety of surgical care. The application of the Tunisian mini calculator is recommended as well as the generalization of validation following the development of a generic calculator for all operating procedures.
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Affiliation(s)
- Mehdi Ben Abdelkrim
- Department of General and Digestive Surgery CHU Farhat Hached, Sousse, Tunisia
- Research Laboratory “Measuring and Supporting the Performance of Health Establishments”: LR19SP01
| | - Mohamed Amine Elghali
- Department of General and Digestive Surgery CHU Farhat Hached, Sousse, Tunisia
- Research Laboratory “Measuring and Supporting the Performance of Health Establishments”: LR19SP01
- Faculty of medicine of Sousse, University of Sousse
| | - Amany Moussa
- Department of General and Digestive Surgery CHU Farhat Hached, Sousse, Tunisia
| | - Ahmed Ben Abdelaziz
- Research Laboratory “Measuring and Supporting the Performance of Health Establishments”: LR19SP01
- Faculty of medicine of Sousse, University of Sousse
- Direction of Information Systems, CHU Sahloul, Sousse
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Hyer JM, Beane JD, Spolverato G, Tsilimigras DI, Diaz A, Paro A, Dalmacy D, Pawlik TM. Trends in Textbook Outcomes over Time: Are Optimal Outcomes Following Complex Gastrointestinal Surgery for Cancer Increasing? J Gastrointest Surg 2022; 26:50-59. [PMID: 34506022 DOI: 10.1007/s11605-021-05129-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/17/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of composite measures like "textbook outcome" (TO) may provide a more accurate measure of surgical quality. We sought to determine if TO has improved over time and to characterize the association of achieving a TO with trends in survival among patients undergoing complex gastrointestinal surgery for cancer. METHODS Medicare beneficiaries who underwent pancreas, liver, or colon resection for a cancer diagnosis between 2004 and 2016 were identified using the SEER-Medicare database. Rates of TO (no complication, extended length of stay, 90-day readmission, or 90-day mortality) were assessed over time. RESULTS Among 94,329 patients, 6765 (7.2%), 1985 (2.1%), and 85,579 (90.7%) patients underwent resection for primary pancreatic, hepatic, or colon cancer, respectively. In total, 53,464 (56.7%) patients achieved a TO; achievement of TO varied by procedure (pancreatectomy: 48.1% vs. hepatectomy: 55.2% vs. colectomy: 57.4%, p < 0.001). The proportion of patients achieving a textbook outcome increased over time for all patients (2004-2007, 53.3% vs. 2008-2011, 56.5% vs. 2012-2016, 60.1%) (5-year increase: OR 1.16 95%CI 1.13-1.18) (p < 0.001). Survival at 1-year following pancreatic, liver, or colon resection for cancer had improved over time among both patients who did and did not achieve a postoperative TO. TO was independently associated with a marked reduction in hazard of death (HR 0.44, 95%CI 0.43-0.45). The association of TO and survival was consistent among patients stratified by procedure. CONCLUSION Less than two-thirds of patients undergoing complex gastrointestinal surgery for a malignant indication achieved a TO. The likelihood of achieving a TO increased over time and was associated with improved survival.
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Affiliation(s)
- J Madison Hyer
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Joal D Beane
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Gaya Spolverato
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Alessandro Paro
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Djhenne Dalmacy
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Dencker EE, Bonde A, Troelsen A, Varadarajan KM, Sillesen M. Postoperative complications: an observational study of trends in the United States from 2012 to 2018. BMC Surg 2021; 21:393. [PMID: 34740362 PMCID: PMC8571843 DOI: 10.1186/s12893-021-01392-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 10/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative complications continue to constitute a major issue for both the healthcare system and the individual patient and are associated with inferior outcomes and higher healthcare costs. The objective of this study was to evaluate the trends of postoperative complication rates over a 7-year period. METHODS The NSQIP datasets from 2012 to 2018 were used to assess 30-day complication incidence rates including mortality rate following surgical procedures within ten surgical subspecialties. Multivariable logistic regression was used to associate complication rates with dataset year, while adjusting for relevant confounders. RESULTS A total of 5,880,829 patients undergoing major surgery were included. Particularly the incidence rates of four complications were found to be decreasing: superficial SSI (1.9 to 1.3%), deep SSI (0.6 to 0.4%), urinary tract infection (1.6 to 1.2%) and patient unplanned return to the operating room (3.1 to 2.7%). Incidence rate for organ/space SSI exhibited an increase (1.1 to 1.5%). When adjusted, regression analyses indicated decreased odds ratios (OR) through the study period years for particularly deep SSI OR 0.92 [0.92-0.93], superficial SSI OR 0.94 [0.94-0.94] and acute renal failure OR 0.96 [0.95-0.96] as the predictor variable (study year) increased (p < 0.01). However, OR's for organ/space SSI 1.05 [1.05-1.06], myocardial infarction 1.01 [1.01-1.02] and sepsis 1.01 [1.01-1.02] increased slightly over time (all p < 0.01). CONCLUSIONS Incidence rates for the complications exhibited a stable trend over the study period, with minor in or decreases observed.
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Affiliation(s)
- Emilie Even Dencker
- Department of Surgical Gastroenterology and Transplantation C-TX, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen Ø, 2100, Rigshospitalet, Denmark.,Center for Surgical Translational and Artificial Intelligence Research (CSTAR), Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Alexander Bonde
- Department of Surgical Gastroenterology and Transplantation C-TX, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen Ø, 2100, Rigshospitalet, Denmark.,Center for Surgical Translational and Artificial Intelligence Research (CSTAR), Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Anders Troelsen
- Department of Orthopedics, Copenhagen University Hospital, Hvidovre, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Hvidovre, Denmark
| | | | - Martin Sillesen
- Department of Surgical Gastroenterology and Transplantation C-TX, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen Ø, 2100, Rigshospitalet, Denmark. .,Center for Surgical Translational and Artificial Intelligence Research (CSTAR), Copenhagen University Hospital, Rigshospitalet, Denmark. .,Institute of Clinical Medicine, University of Copenhagen, Hvidovre, Denmark.
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Knoll W, Fergusson N, Ivankovic V, Wang TF, Caiano L, Auer R, Carrier M. Extended thromboprophylaxis following major abdominal/pelvic cancer-related surgery: A systematic review and meta-analysis of the literature. Thromb Res 2021; 204:114-122. [PMID: 34175749 DOI: 10.1016/j.thromres.2021.06.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Postoperative venous thromboembolism (VTE) is a significant source of morbidity and mortality in cancer patients undergoing major abdominopelvic surgery. Many guidelines recommend the use of extended duration postoperative low molecular weight heparin (LMWH) thromboprophylaxis, although the evidence for its overall safety and efficacy is unclear. AIMS We sought to assess the 30-day postoperative rates of VTE and bleeding complications following major abdominopelvic cancer surgery and to explore the potential risks and benefits of extended duration thromboprophylaxis with LMWH in such setting. METHODS A systematic search of the literature was conducted. Observational studies and RCTs of adult patients that underwent abdominopelvic cancer surgery were included. Pooled proportions for the outcome measures and pooled relative risks for the extended duration thromboprophylaxis analyses were generated. RESULTS A total of 68 studies (1,631,118 patients) were included in the analysis. The 30-day postoperative rate of VTE was 1.7% (95%CI: 1.5 to 1.9, I2 = 98%). The postoperative rate of clinically-relevant bleeding complications was 3.5% (95%CI: 1.6 to 6.1, I2 = 99%). Extended duration thromboprophylaxis was associated with a significant reduction in the incidence of clinical VTE (1.0% vs 2.1%; Risk ratio (RR) 0.48, 95%CI: 0.31 to 0.74; I2 = 0), without a significant increase in clinically-relevant bleeding (4.0% vs. 4.9%; RR 1.0, 95%CI: 0.66 to 1.5, I2 = 0). CONCLUSIONS The overall risk of symptomatic VTE within 30 days of surgery was relatively low. Extended LMWH thromboprophylaxis following major abdominopelvic cancer surgery was associated with a reduced incidence of clinical VTE without an increase in clinically-relevant bleeding.
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Affiliation(s)
- William Knoll
- Faculty of Medicine, Queen's University, Kingston, Canada; Department of Medicine University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Nathan Fergusson
- Department of Medicine University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Victoria Ivankovic
- Department of Medicine University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Tzu-Fei Wang
- Department of Medicine University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lucia Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Rebecca Auer
- Department of Surgery, University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Canada.
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Leeds IL, Drabo EF, Lehmann LS, Safar B, Johnston FM. On All Accounts: Cost-Effectiveness Analysis of Limited Preoperative Optimization Efforts Before Colon Cancer Surgery. Dis Colon Rectum 2021; 64:744-753. [PMID: 33955409 PMCID: PMC8835996 DOI: 10.1097/dcr.0000000000001926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Reports suggest that preoperative optimization of a patient's serious comorbidities is associated with a reduction in postoperative complications. OBJECTIVE The purpose of this study was to assess the cost and benefits of preoperative optimization, accounting for total costs associated with postoperative morbidity. DESIGN This study is a decision tree cost-effectiveness analysis with probabilistic sensitivity analysis (10,000 iterations). SETTING This is a hypothetical scenario of stage II colon cancer surgery. PATIENT The simulated 65-year-old patient has left-sided, stage II colon cancer. INTERVENTION Focused preoperative optimization targets high-risk comorbidities. OUTCOMES Total discounted (3%) economic costs (US $2018), effectiveness (quality-adjusted life-years), incremental cost-effectiveness ratio (incremental cost-effectiveness ratio, cost/quality-adjusted life-years gained), and net monetary benefit. RESULTS We calculated the per individual expected health care sector total cost of preoperative optimization and sequelae to be $12,395 versus $15,638 in those not optimized (net monetary benefit: $1.04 million versus $1.05 million). A nonoptimized patient attained an average 0.02 quality-adjusted life-years less than one optimized. Thus, preoperative optimization was the dominant strategy (lower total costs; higher quality-adjusted life-years). Probabilistic sensitivity analysis demonstrated 100% of simulations favoring preoperative optimization. The breakeven cost of optimization to remain cost-effective was $6421 per patient. LIMITATIONS Generalizability must account for the lack of standardization among existing preoperative optimization efforts, and decision analysis methodology provides guidance for the average patient or general population, and is not patient-specific. CONCLUSIONS Although currently not comprehensively reimbursed, focused preoperative optimization may reduce total costs of care while also reducing complications from colon cancer surgery. See Video Abstract at http://links.lww.com/DCR/B494. EN TODO CASO ANLISIS DE RENTABILIDAD DE LOS ESFUERZOS LIMITADOS DE OPTIMIZACIN PREOPERATORIA ANTES DE LA CIRUGA DE CNCER DE COLON ANTECEDENTES:Los informes sugieren que la optimización preoperatoria de las comorbilidades graves de un paciente se asocia con una reducción de las complicaciones postoperatorias.OBJETIVO:El propósito de este estudio fue evaluar el costo y los beneficios de la optimización preoperatoria, teniendo en cuenta los costos totales asociados con la morbilidad postoperatoria.DISEÑO:Análisis de costo-efectividad de árbol de decisión con análisis de sensibilidad probabilístico (10,000 iteraciones).AJUSTE ENTORNO CLINICO:Escenario hipotético Cirugía de cáncer de colon en estadio II.PACIENTE:Paciente simulado de 65 años con cáncer de colon en estadio II del lado izquierdo.INTERVENCIÓN:Optimización preoperatoria enfocada dirigida a comorbilidades de alto riesgo.RESULTADOS:Costos económicos totales descontados (3%) (US $ 2018), efectividad (años de vida ajustados por calidad [AVAC]), relación costo-efectividad incremental (ICER, costo / AVAC ganado) y beneficio monetario neto (NMB).RESULTADOS:Calculamos que el costo total esperado por sector de atención médica individual de la optimización preoperatoria y las secuelas es de $ 12,395 versus $ 15,638 en aquellos no optimizados (NMB: $ 1.04 millones versus $ 1.05 millones, respectivamente). Un paciente no optimizado alcanzó un promedio de 0.02 AVAC menos que uno optimizado. Por lo tanto, la optimización preoperatoria fue la estrategia dominante (menores costos totales; mayores AVAC). El análisis de sensibilidad probabilístico demostró que el 100% de las simulaciones favorecían la optimización preoperatoria. El costo de equilibrio de la optimización para seguir siendo rentable fue de $ 6,421 por paciente.LIMITACIONES:La generalización debe tener en cuenta la falta de estandarización entre los esfuerzos de optimización preoperatorios existentes y esa metodología de análisis de decisiones proporciona una guía para el paciente promedio o la población general, no específica del paciente.CONCLUSIONES:Si bien actualmente no se reembolsa de manera integral, la optimización preoperatoria enfocada puede reducir los costos totales de la atención y al mismo tiempo reducir las complicaciones de la cirugía de cáncer de colon. Consulte Video Resumen en http://links.lww.com/DCR/B494.
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Affiliation(s)
- Ira L. Leeds
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emmanuel F. Drabo
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lisa Soleymani Lehmann
- VA New England Healthcare System, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M. Johnston
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Stringfield SB, Fleshman JW. Specialization improves outcomes in rectal cancer surgery. Surg Oncol 2021; 37:101568. [PMID: 33848763 DOI: 10.1016/j.suronc.2021.101568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 01/23/2023]
Affiliation(s)
- Sarah B Stringfield
- Baylor University Medical Center, Department of Surgery, 3500 Gaston Ave, Dallas, TX, 75246, USA.
| | - James W Fleshman
- Baylor University Medical Center, Department of Surgery, 3500 Gaston Ave, Dallas, TX, 75246, USA
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Pathologic complete response is associated with decreased morbidity following rectal cancer resection. Am J Surg 2020; 222:390-394. [PMID: 33261851 DOI: 10.1016/j.amjsurg.2020.11.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND There are conflicting data regarding the relationship between pathologic complete response (pCR) and post-operative complications following rectal cancer resection. The objective of this study was to compare the rates of morbidity among pCR patients and non-pCR patients and to identify factors that predict pCR morbidity in a large national database. METHODS This is a retrospective study using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted proctectomy data (2016-18). Patients with neoadjuvant chemoradiation therapy followed by proctectomy were included, and divided into pCR and non-pCR groups according to final stage. The groups were compared with Student's t-test, Chi-squared or Fisher's exact test. Multivariate logistic regression models were constructed to estimate the association between pCR status and post-operative morbidity while adjusting for key covariates. RESULTS 244 pCR and 1656 non-pCR patients were included. pCR patients had higher body mass index (28.1 ± 6.2 vs. 29.1 ± 5.9 kg/m2; p = 0.01) and lower pre-operative stage (T stage, p = 0.03; N stage, p < 0.001). The groups were equivalent with respect to surgical approach, type of surgery, and operative time (p > 0.05). Post-operative complications in pCR patients were less frequent than in non-pCR patients (23.0% vs. 29.3%; p = 0.04). This association was robust to adjustment for confounders in logistic regression, as patients with pCR had decreased odds of post-operative morbidity (OR 0.66, CI [0.43, 0.96], p = 0.04). CONCLUSION pCR is associated with fewer post-operative complications compared to non-pCR, suggesting that pCR is not a marker of severe pelvic fibrosis. This difference may be due to underlying tumor biology, and associated increased technical challenges resecting larger, non-responsive tumors.
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