1
|
Harris J, Ahluwalia V, Xu K, Romeo D, Fritz C, Rajasekaran K. The efficacy of the National Surgical Quality Improvement Program surgical risk calculator in head and neck surgery: A meta-analysis. Head Neck 2024; 46:1718-1726. [PMID: 38576311 DOI: 10.1002/hed.27765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/16/2024] [Accepted: 03/26/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND The National Surgical Quality Improvement Program surgical risk calculator (SRC) estimates the risk for postoperative complications. This meta-analysis assesses the efficacy of the SRC in the field of head and neck surgery. METHODS A systematic review identified studies comparing the SRC's predictions to observed outcomes following head and neck surgeries. Predictive accuracy was assessed using receiver operating characteristic curves (AUCs) and Brier scoring. RESULTS Nine studies totaling 1774 patients were included. The SRC underpredicted the risk of all outcomes (including any complication [observed (ob) = 35.9%, predicted (pr) = 21.8%] and serious complication [ob = 28.7%, pr = 17.0%]) except mortality (ob = 0.37%, pr = 1.55%). The observed length of stay was more than twice the predicted length (p < 0.02). Discrimination was acceptable for postoperative pneumonia (AUC = 0.778) and urinary tract infection (AUC = 0.782) only. Predictive accuracy was low for all outcomes (Brier scores ≥0.01) and comparable for patients with and without free-flap reconstructions. CONCLUSION The SRC is an ineffective instrument for predicting outcomes in head and neck surgery.
Collapse
Affiliation(s)
- Jacob Harris
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vinayak Ahluwalia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine Xu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dominic Romeo
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian Fritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
2
|
Johnson EP, Monsour R, Hafez O, Kotha R, Ackerman RS. Major Perioperative Cardiac Risk Assessment: A Review for Cardio-Oncologists and Perioperative Physicians. Clin Pract 2024; 14:906-914. [PMID: 38804403 PMCID: PMC11130950 DOI: 10.3390/clinpract14030071] [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: 04/08/2024] [Revised: 05/06/2024] [Accepted: 05/14/2024] [Indexed: 05/29/2024] Open
Abstract
The Revised Cardiac Risk Index (RCRI) and the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) preoperative risk assessment tools are the most widely used methods for quantifying the risk of major negative perioperative cardiac outcomes that a patient may face during and after noncardiac surgery. However, these tools were created to include as wide a range of surgical factors as possible; thus, some predictive accuracy is sacrificed when it comes to certain surgical subpopulations. In this review, we explore the various surgical oncology patient populations for whom these assessment tools can be reliably applied and for whom they demonstrate poor reliability.
Collapse
Affiliation(s)
- Emily P. Johnson
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA;
| | - Robert Monsour
- Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA;
| | - Osama Hafez
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (R.K.); (R.S.A.)
| | - Rohini Kotha
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (R.K.); (R.S.A.)
| | - Robert S. Ackerman
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (R.K.); (R.S.A.)
| |
Collapse
|
3
|
Bursztyn N, Slomowitz E, Assaf D, Yahia EH, Kent I, Wasserberg N, Avital S, White I. Comparison of Post-Operative Outcomes of Right Colectomy between Crohn's Disease and Adenocarcinoma of the Right Colon: A Retrospective Cohort Study. J Clin Med 2024; 13:2809. [PMID: 38792351 PMCID: PMC11122225 DOI: 10.3390/jcm13102809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/29/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
(1) Background: Crohn's disease (CD) and right-sided colorectal-carcinoma (CRC) are two common indications for right colectomies. Many studies have tried to identify risk factors associated with post-operative complications for both CD and CRC. However, data directly comparing the outcomes of the two are sparse. This study aims to compare the 30-day post-operative outcome after a right colectomy for CD versus CRC. Its secondary aim is to identify the factors associated with these outcomes for each group. (2) Methods: A retrospective cohort study of 123 patients who underwent a right colectomy for CD or CRC in a single institution between March 2011 and March 2016. (3) Results: There were no significant differences between the groups when comparing the overall complication rate, the median Clavien-Dindo score, reoperation rates and the length of hospitalization. The leak rate was higher in the Crohn's group (13.95% (6/43) vs. 3.75% (3/80)), p = 0.049), although the stoma rate was the same (4/43 9.5%; 7/80 9.9%). (4) Conclusions: This study has shown that post-operative complication rate is similar for right colectomy in CD and CRC. However, Crohn's disease patients did have a higher leak rate.
Collapse
Affiliation(s)
- Naama Bursztyn
- School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Internal Medicine A, Shamir Medical Center, Be’er Ya’akov 70300, Israel
| | - Edden Slomowitz
- School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Colorectal Unit, Department of Surgery, Beilinson Hospital, Rabin Medical Center, Petach-Tikva 49100, Israel
| | - Dan Assaf
- School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Department of Surgery, Sheba Medical Center, Tel-Aviv 39040, Israel
| | - Ehab Haj Yahia
- School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Department Surgery B, Meir Medical Center, Kfar Saba 44281, Israel
| | - Ilan Kent
- School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Department of Surgery, Sheba Medical Center, Tel-Aviv 39040, Israel
| | - Nir Wasserberg
- School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Colorectal Unit, Department of Surgery, Beilinson Hospital, Rabin Medical Center, Petach-Tikva 49100, Israel
| | - Shmuel Avital
- School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Department Surgery B, Meir Medical Center, Kfar Saba 44281, Israel
| | - Ian White
- School of Medicine, Tel Aviv University, Tel-Aviv 69978, Israel
- Colorectal Unit, Department of Surgery, Beilinson Hospital, Rabin Medical Center, Petach-Tikva 49100, Israel
| |
Collapse
|
4
|
Koh YX, Tan IEH, Zhao Y, Chong HM, Ang BH, Tan HL, Chua DW, Loh WL, Tan EK, Teo JY, Au MKH, Goh BKP. Evaluation of the American College of Surgeons risk calculator in hepatectomy for metastatic colorectal cancer in a Southeast Asian population. Langenbecks Arch Surg 2024; 409:152. [PMID: 38703240 DOI: 10.1007/s00423-024-03331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/20/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE This study evaluated the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) calculator in predicting outcomes after hepatectomy for colorectal cancer (CRC) liver metastasis in a Southeast Asian population. METHODS Predicted and actual outcomes were compared for 166 patients undergoing hepatectomy for CRC liver metastasis identified between 2017 and 2022, using receiver operating characteristic curves with area under the curve (AUC) and Brier score. RESULTS The ACS-NSQIP calculator accurately predicted most postoperative complications (AUC > 0.70), except for surgical site infection (AUC = 0.678, Brier score = 0.045). It also exhibited satisfactory performance for readmission (AUC = 0.818, Brier score = 0.011), reoperation (AUC = 0.945, Brier score = 0.002), and length of stay (LOS, AUC = 0.909). The predicted LOS was close to the actual LOS (5.9 vs. 5.0 days, P = 0.985). CONCLUSION The ACS-NSQIP calculator demonstrated generally accurate predictions for 30-day postoperative outcomes after hepatectomy for CRC liver metastasis in our patient population.
Collapse
Affiliation(s)
- Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore.
- Duke-National University of Singapore Medical School, Singapore, Singapore.
- Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore, Singapore.
| | - Ivan En-Howe Tan
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Yun Zhao
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Hui Min Chong
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Boon Hwee Ang
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Hwee Leong Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Darren Weiquan Chua
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore, Singapore
| | - Wei-Liang Loh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Ek Khoon Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore, Singapore
| | - Jin Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
- Finance, SingHealth Community Hospitals, Singapore, 168582, Singapore
- Finance, Regional Health System & Strategic Finance, Singapore Health Services, Singapore, 168582, Singapore
| | - Brian Kim Poh Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore, Singapore
| |
Collapse
|
5
|
Tan HJ, Spratte BN, Deal AM, Heiling HM, Nazzal EM, Meeks W, Fang R, Teal R, Vu MB, Bennett AV, Blalock SJ, Chung AE, Gotz D, Nielsen ME, Reuland DS, Harris AH, Basch E. Clinical Decision Support for Surgery: A Mixed Methods Study on Design and Implementation Perspectives From Urologists. Urology 2024:S0090-4295(24)00307-8. [PMID: 38697362 DOI: 10.1016/j.urology.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/08/2024] [Accepted: 04/20/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE To assess urologist attitudes toward clinical decision support (CDS) embedded into the electronic health record (EHR) and define design needs to facilitate implementation and impact. With recent advances in big data and artificial intelligence (AI), enthusiasm for personalized, data-driven tools to improve surgical decision-making has grown, but the impact of current tools remains limited. METHODS A sequential explanatory mixed methods study from 2019 to 2020 was performed. First, survey responses from the 2019 American Urological Association Annual Census evaluated attitudes toward an automatic CDS tool that would display risk/benefit data. This was followed by the purposeful sampling of 25 urologists and qualitative interviews assessing perspectives on CDS impact and design needs. Bivariable, multivariable, and coding-based thematic analysis were applied and integrated. RESULTS Among a weighted sample of 12,366 practicing urologists, the majority agreed CDS would help decision-making (70.9%, 95% CI 68.7%-73.2%), aid patient counseling (78.5%, 95% CI 76.5%-80.5%), save time (58.1%, 95% CI 55.7%-60.5%), and improve patient outcomes (42.9%, 95% CI 40.5%-45.4%). More years in practice was negatively associated with agreement (P <.001). Urologists described how CDS could bolster evidence-based care, personalized medicine, resource utilization, and patient experience. They also identified multiple implementation barriers and provided suggestions on form, functionality, and visual design to improve usefulness and ease of use. CONCLUSION Urologists have favorable attitudes toward the potential for clinical decision support in the EHR. Smart design will be critical to ensure effective implementation and impact.
Collapse
Affiliation(s)
- Hung-Jui Tan
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC.
| | - Brooke N Spratte
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Hillary M Heiling
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Elizabeth M Nazzal
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - William Meeks
- American Urological Association Data Management and Statistical Services
| | - Raymond Fang
- American Urological Association Data Management and Statistical Services
| | - Randall Teal
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, NC
| | - Maihan B Vu
- Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Antonia V Bennett
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Susan J Blalock
- Pharmaceutical Outcomes & Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Arlene E Chung
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Bioinformatics, Duke University, Durham, NC
| | - David Gotz
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; School of Information and Library Science, University of North Carolina, Chapel Hill, NC
| | - Matthew E Nielsen
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Daniel S Reuland
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Alex Hs Harris
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | - Ethan Basch
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC; Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
6
|
Read M, Nguyen T, Swan K, Arnaoutakis DJ, Dua A, Toloza E, Shames M, Bailey C, Latz CA. Cutdown is Associated with Higher 30-day Unplanned Readmissions and Wound Complications than Percutaneous Access for EVAR. Ann Vasc Surg 2024; 106:1-7. [PMID: 38599484 DOI: 10.1016/j.avsg.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/13/2024] [Accepted: 02/19/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND A 2023 Cochrane review showed no difference in bleeding/wound infection complications, short-term mortality and aneurysm exclusion between the percutaneous and cut-down approach for femoral access in endovascular aortic aneurysm repair (EVAR). In contrast, single-center studies have shown bilateral cutdown resulting in higher readmission rates due to higher rates of groin wound infections. Whether 30-day readmission rates vary by type of access during EVAR procedures is unknown. The goal of this study was to ascertain which femoral access approach for EVAR is associated with the lowest risk of 30-day readmission. METHODS The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing EVAR for aortic disease from 2012-2021. All ruptures and other emergency cases were excluded. Cohorts were divided into bilateral cutdown, unilateral cutdown, failed percutaneous attempt converted to open and successful percutaneous access. The primary 30-day outcomes were unplanned readmission and wound complications. Univariate analyses were performed using the Fisher's exact test, Chi-Square test and the Student's t-test. Multivariable analysis was performed using logistic regression. RESULTS From 2012 to 2021, 14,002 patients met study criteria. Most (7,395 [53%]) underwent completely percutaneous access, 5,616 (40%) underwent bilateral cutdown, 849 (6%) underwent unilateral cutdown, and 146 (1%) had a failed percutaneous access which was converted to open. Unplanned readmissions by access strategy included 7.6% for bilateral cutdown, 7.3% for unilateral cutdown, 7.8% for attempted percutaneous converted to cutdown, and 5.7% for completely percutaneous access (P < 0.001, Figure 1). After multivariable analysis, unplanned readmissions compared to percutaneous access yielded: percutaneous converted to cutdown adjusted odds ratio (AOR): 1.38, 95% CI [0.76-2.53], P = 0.29; unilateral cutdown AOR: 1.18, 95% CI [0.92-1.51], P = 0.20; bilateral cutdown AOR: 1.26, 95% CI [1.09-1.43], P = 0.001. Bilateral cutdown was also associated with higher wound complications compared to percutaneous access (AOR: 4.41, CI [2.86-6.79], P < 0.001), as was unilateral cutdown (AOR: 3.04, CI [1.46-6.32], P = 0.003). CONCLUSIONS Patients undergoing cutdown for EVAR are at higher risk for 30-day readmission compared to completely percutaneous access. If patient anatomy allows for percutaneous EVAR, this access option should be prioritized.
Collapse
Affiliation(s)
- Meagan Read
- Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, FL; Division of GI Oncology, Moffitt Cancer Center, Tampa, FL
| | - Trung Nguyen
- Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, FL
| | - Kevin Swan
- Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, FL
| | - Dean J Arnaoutakis
- Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, FL
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Eric Toloza
- Division of GI Oncology, Moffitt Cancer Center, Tampa, FL
| | - Murray Shames
- Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, FL
| | - Charles Bailey
- Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, FL
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, FL.
| |
Collapse
|
7
|
Hatipoglu E, Erginoz E, Askar A, Erguney S. Accuracy of the ACS NSQIP Surgical Risk Calculator for Predicting Postoperative Complications in Gastric Cancer Following Open Gastrectomy. Am Surg 2024; 90:640-647. [PMID: 37823864 DOI: 10.1177/00031348231206581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
INTRODUCTION The prediction of complications before gastric surgery is of utmost importance in shared decision making and proper counseling of the patient in order to minimize postoperative complications. Our aim was to evaluate the predictive validity of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk calculator in gastric cancer patients who underwent gastrectomy. METHODS Preoperative assessment data of 432 patients were retrospectively reviewed and manually entered into the calculator. The accuracy of the calculator was evaluated using Pearson's chi-squared test, C-statistic, Brier score, and Hosmer-Lemeshow test. RESULTS The lowest Brier scores were observed in urinary tract infection, renal failure, venous thromboembolism, pneumonia, and cardiac complications. Best results were obtained for predicting sepsis, discharge to rehabilitation facility, and death (low Brier scores, C-statistic >.7, and Hosmer-Lemeshow P > .05). CONCLUSION The calculator had a strong performance in predicting sepsis, discharge to the rehabilitation facility, and death. However, it performed poor in predicting the most commonly observed events (any or serious complication and surgical site infection).
Collapse
Affiliation(s)
- Engin Hatipoglu
- Department of General Surgery, Istanbul University Cerrahpaşa - Cerrahpaşa School of Medicine, Istanbul, Turkey
| | - Ergin Erginoz
- Department of General Surgery, Istanbul University Cerrahpaşa - Cerrahpaşa School of Medicine, Istanbul, Turkey
| | - Ahmet Askar
- Department of General Surgery, Istanbul University Cerrahpaşa - Cerrahpaşa School of Medicine, Istanbul, Turkey
| | - Sabri Erguney
- Department of General Surgery, Istanbul University Cerrahpaşa - Cerrahpaşa School of Medicine, Istanbul, Turkey
| |
Collapse
|
8
|
Laane CL, Van Lieshout EM, Van Heeswijk RA, De Jong AI, Verhofstad MH, Wijffels MM. Validity of the ACS NSQIP surgical risk calculator as a tool to predict postoperative outcomes in subacute orthopedic trauma diagnoses. Heliyon 2024; 10:e25796. [PMID: 38375267 PMCID: PMC10875421 DOI: 10.1016/j.heliyon.2024.e25796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 01/27/2024] [Accepted: 02/02/2024] [Indexed: 02/21/2024] Open
Abstract
Purpose This retrospective study aimed to validate the ACS NSQIP Surgical Risk Calculator (SCR) to predict 30-day postoperative outcomes in patients with one of the following subacute orthopedic trauma diagnoses; multiple rib fractures, pelvic ring/acetabular fracture, or unilateral femoral fracture. Methods Data of patients with these diagnoses treated between January 1, 2015 and September 19, 2020 were extracted from the patients' medical files. Diagnostic performance, discrimination, calibration, and accuracy of the ACS NSQIP SRC to predict specific outcomes developing within 30 days after surgery was determined. Results The total cohort of the three diagnoses consisted of 435 patients. ACS NSQIP SRC underestimated the risk for serious complications, especially in patients with multiple rib fractures (8.3% predicted vs 17.2% observed) or pelvic ring/acetabular fracture (6.1% vs 19.8%). Underestimation was more pronounced for the composite outcome 'any complication'. Sensitivity ranged from 16.7% to 100% and specificity from 41.1% to 97.1%. Specificity exceeded sensitivity for pelvic ring/acetabular and femoral fractures. Discrimination was good for predicting death (femoral fracture), fair for readmission (femoral fracture), serious complication (multiple rib fractures), and any complication (multiple rib fractures), but poor in all other outcomes and diagnoses. Calibration and accuracy were adequate for all three diagnoses (p-value for Hosmer-Lemeshow test >0.05 and Brier scores <0.25). Conclusion Performance of the ACS NSQIP SRC in the studied cohort was variable for all three diagnoses. Although it underestimated the risk of most outcomes, calibration and accuracy seemed generally adequate. For most outcomes, adequate diagnostic performance and discrimination could not be confirmed.
Collapse
Affiliation(s)
| | - Esther M.M. Van Lieshout
- Corresponding author. Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Roos A.M. Van Heeswijk
- Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Amber I. De Jong
- Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Michael H.J. Verhofstad
- Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mathieu M.E. Wijffels
- Trauma Research Unit Dept. of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| |
Collapse
|
9
|
Kuiper BI, Janssen LMJ, Versteeg KS, Ten Tusscher BL, van der Spoel JI, Lubbers WD, Kazemier G, Loer SA, Schober P, van Halm VP. Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery? BMC Anesthesiol 2024; 24:9. [PMID: 38166642 PMCID: PMC10759340 DOI: 10.1186/s12871-023-02394-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/20/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND International guidelines recommend preoperative multidisciplinary team (MDT) assessment for high-risk surgical patients. Preoperative MDT meetings can help to improve surgical care, but there is little evidence on whether they improve patient outcomes. METHODS This paper aims to share our experience of MDT meetings for high-risk surgical patients to underline their added value to the current standard of care. An observational study of a retrospective cohort of preoperative high-risk MDT meetings of a tertiary referral hospital between January 2015 and December 2020. For 249 patients the outcomes preoperative data, MDT decisions, and patient outcomes were collected from electronic health records. MAIN RESULTS A total of 249 patients were discussed at high-risk MDT meetings. Most of the patients (97%) were assessed as having an American Society of Anesthesiology score ≥ 3, and 219 (88%) had a European Society of Cardiology and European Society of Anaesthesiology risk score of intermediate or high. After MDT assessment, 154 (62%) were directly approved for surgery, and 39 (16%) were considered ineligible for surgery. The remaining 56 (23%) patients underwent additional assessments before reconsideration at a high-risk MDT meeting. The main reason for patients being discussed at the high-risk MDT meeting was to assess the risk-benefit ratio of surgery. Ultimately, 184 (74%) patients underwent surgery. Of the operated patients, 122 (66%) did not have a major complication in the postoperative period, and 149 patients (81%) were alive after one year. CONCLUSIONS This cohort study shows the vulnerability and complexity of high-risk patients but also shows that the use of an MDT assessment contributes too improved peri- and postoperative treatment strategies in high-risk patients. Most patients underwent surgery after careful risk assessment and, if deemed necessary, preoperative and perioperative treatment optimization to reduce their risk.
Collapse
Affiliation(s)
- B I Kuiper
- Department of Surgery, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - L M J Janssen
- Department of Anesthesiology, Amsterdam UMC location VUmc, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands.
| | - K S Versteeg
- Department of Internal medicine, section geriatrics, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - B L Ten Tusscher
- Department of Intensive Care Medicine, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - J I van der Spoel
- Department of Intensive Care Medicine, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| | - W D Lubbers
- Department of Anesthesiology, Amsterdam UMC location VUmc, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
| | - G Kazemier
- Department of Surgery, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - S A Loer
- Department of Anesthesiology, Amsterdam UMC location VUmc, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
| | - P Schober
- Department of Anesthesiology, Amsterdam UMC location VUmc, De Boelelaan 1117, Amsterdam, 1081 HV, The Netherlands
| | - V P van Halm
- Department of Cardiology, Amsterdam UMC location VUmc, Amsterdam, The Netherlands
| |
Collapse
|
10
|
Velmahos CS, Paschalidis A, Paranjape CN. The Not-So-Distant Future or Just Hype? Utilizing Machine Learning to Predict 30-Day Post-Operative Complications in Laparoscopic Colectomy Patients. Am Surg 2023; 89:5648-5654. [PMID: 36992631 DOI: 10.1177/00031348231167397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
BACKGROUND Complex machine learning (ML) models have revolutionized predictions in clinical care. However, for laparoscopic colectomy (LC), prediction of morbidity by ML has not been adequately analyzed nor compared against traditional logistic regression (LR) models. METHODS All LC patients, between 2017 and 2019, in the National Surgical Quality Improvement Program (NSQIP) were identified. A composite outcome of 17 variables defined any post-operative morbidity. Seven of the most common complications were additionally analyzed. Three ML models (Random Forests, XGBoost, and L1-L2-RFE) were compared with LR. RESULTS Random Forests, XGBoost, and L1-L2-RFE predicted 30-day post-operative morbidity with average area under the curve (AUC): .709, .712, and .712, respectively. LR predicted morbidity with AUC = .712. Septic shock was predicted with AUC ≤ .9, by ML and LR. CONCLUSION There was negligible difference in the predictive ability of ML and LR in post-LC morbidity prediction. Possibly, the computational power of ML cannot be realized in limited datasets.
Collapse
|
11
|
Magin JC, Wrobel JR, An X, Acton J, Doyal A, Jia S, Krakowski JC, Schoenherr J, Serrano R, Flynn D, McLean D, Grant SA. Venous Excess Ultrasound (VExUS Grading to Assess Perioperative Fluid Status for Noncardiac Surgeries: a Prospective Observational Pilot Study. POCUS JOURNAL 2023; 8:223-229. [PMID: 38099161 PMCID: PMC10721303 DOI: 10.24908/pocus.v8i2.16792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Objectives: Perioperative fluid administration impacts the rate of complications following surgery. VExUS grading system is a standardized point of care ultrasound (POCUS)-based, comprehensive method to assess volume status. VExUS could serve as a tool to guide fluid management, if validated perioperatively. The primary aim was to assess the success rate of obtaining required windows for VExUS grading , as well as the feasibility within a perioperative setting among noncardiac surgery. Further, this study describes the incidence of perioperative venous congestion and associations with 30-day postoperative complications. Methods: This observational study was conducted in non-critically ill adults undergoing noncardiac surgery. Patients were scanned preoperatively, in the post anesthesia care unit (PACU), and 24 hours postoperatively for venous congestion. Researchers retrospectively captured 30-day complications for multivariate analyses. Results: The cohort included 69 participants. Ninety-one percent of scans over all timepoints were successfully completed. Pre-operatively, 57 (83%) scans were Grade 0, and 11 (16%) were Grade 1. Venous congestion was observed in 29 (44%) patients in the PACU (n=66). 22 (33%) patients were Grade 1, while 7 (11%) were Grade 2. At 24 hours (n=63), 31 patients (49%) had venous congestion: 20 (32%) Grade 1 and 11 (17%) Grade 2. Of the pre-operative Grade 0, 28 (50%) had at least one postoperative scan with venous congestion. No patients were Grade 3 at any timepoint. The 30-day complication rate was 32% (n=22). Eleven (16%) patients developed acute kidney injury (AKI). There was no statistically significant association between VExUS grading and all-cause complications or AKI. Conclusion: This study demonstrates that perioperative VExUS scoring is a feasible tool among a variety of noncardiac surgeries. We highlight that venous congestion is common and increases postoperatively within non-ICU populations. Larger studies are needed to assess the relationship between VExUS grading and postoperative complications.
Collapse
Affiliation(s)
- Justin C Magin
- University of North Carolina School of MedicineChapel Hill, NCUSA
| | - Jacob R Wrobel
- University of North Carolina School of MedicineChapel Hill, NCUSA
| | - Xinming An
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Jacob Acton
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Alexander Doyal
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Shawn Jia
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - James C Krakowski
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Jay Schoenherr
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Ricardo Serrano
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - David Flynn
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Duncan McLean
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| | - Stuart A Grant
- Department of Anesthesiology, University of North CarolinaChapel Hill, NCUSA
| |
Collapse
|
12
|
Dosis A, Helliwell J, Syversen A, Tiernan J, Zhang Z, Jayne D. Estimating postoperative mortality in colorectal surgery- a systematic review of risk prediction models. Int J Colorectal Dis 2023; 38:155. [PMID: 37261539 DOI: 10.1007/s00384-023-04455-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/02/2023]
Abstract
PURPOSE Risk prediction models are frequently used to support decision-making in colorectal surgery but can be inaccurate. Machine learning (ML) is becoming increasingly popular, and its application may increase predictive accuracy. We compared conventional risk prediction models for postoperative mortality (based on regression analysis) with ML models to determine the benefit of the latter approach. METHODS The study was registered in PROSPERO(CRD42022364753). Following the PRISMA guidelines, a systematic search of three databases (MEDLINE, EMBASE, WoS) was conducted (from 1/1/2000 to 29/09/2022). Studies were included if they reported the development of a risk model to estimate short-term postoperative mortality for patients undergoing colorectal surgery. Discrimination and calibration performance metrics were compared. Studies were evaluated against CHARMS and TRIPOD criteria. RESULTS 3,052 articles were screened, and 45 studies were included. The total sample size was 1,356,058 patients. Six studies used ML techniques for model development. Most studies (n = 42) reported the area under the receiver operating characteristic curve (AUROC) as a measure of discrimination. There was no significant difference in the mean AUROC values between regression models (0.833 s.d. ± 0.52) and ML (0.846 s.d. ± 0.55), p = 0.539. Calibration statistics, which measure the agreement between predicted estimates and observed outcomes, were less consistent. Risk of bias assessment found most concerns in the data handling and analysis domains of eligible studies. CONCLUSIONS Our study showed comparable predictive performance between regression and ML methods in colorectal surgery. Integration of ML in colorectal risk prediction is promising but further refinement of the models is required to support routine clinical adoption.
Collapse
Affiliation(s)
| | | | | | - Jim Tiernan
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | |
Collapse
|
13
|
Brovman EY, Zorrilla-Vaca A, Urman RD. Regional Anesthesia for Lobectomy and Risk of Pulmonary Complications: A National Safety Quality Improvement Program Propensity-Matching Analysis. J Cardiothorac Vasc Anesth 2023; 37:547-554. [PMID: 36609074 DOI: 10.1053/j.jvca.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 12/03/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine whether general anesthesia (GA) in conjunction with regional anesthetic (RA) techniques are associated with favorable pulmonary outcomes versus GA alone among patients undergoing lobectomy by either video-assisted thoracoscopic surgery (VATS) or open thoracotomy. DESIGN A retrospective cohort (2014-2017). SETTING The American College of Surgeons National Surgical Quality Improvement Program. PARTICIPANTS Adult patients undergoing lobectomy by either VATS or open thoracotomy. INTERVENTIONS Two groups of patients were identified based on the use of GA alone or GA in conjunction with RA (RA+GA) techniques (either neuraxial or peripheral nerve blocks). Both groups were propensity-matched based on pulmonary risk factors. The authors' primary outcome was composite postoperative pulmonary complication (PPC), including pneumonia, reintubation, and failure to wean from the ventilator. MEASUREMENTS AND MAIN RESULTS A total of 4,134 VATS (2,067 in GA and 2,067 in RA+GA) and 3,112 thoracotomies (1,556 in GA and 1,556 in RA+GA) were included in the final analysis. Regional anesthetic, as an adjuvant to GA, did not affect the incidence of PPC among patients undergoing lobectomy by VATS (odds ratio [OR] 1.07, 95% CI 0.81-1.43, p = 0.622), as well as in those undergoing lobectomy via thoracotomy (OR 1.19, 95% CI 0.93-1.51, p = 0.174). There was no statistically significant difference between groups in terms of readmission rates, length of stay, and mortality at 30 days. CONCLUSIONS The RA techniques were not associated with a lower incidence of pulmonary complications in lobectomy surgery.
Collapse
Affiliation(s)
- Ethan Y Brovman
- Department of Anesthesiology, and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Andres Zorrilla-Vaca
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Perioperative Research, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
14
|
Franklin CDH, House AK, Pfeiffer CN. Complications and postoperative non-steroidal anti-inflammatory use of three extracapsular cruciate ligament repair techniques performed in a general practice clinic environment. J Small Anim Pract 2023; 64:21-30. [PMID: 36324226 DOI: 10.1111/jsap.13557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 08/26/2022] [Accepted: 09/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To report complications and postoperative non-steroidal anti-inflammatory use associated with fabellotibial suture, Tightrope and Ligafiba Isotoggle procedures performed on dogs of varying weights within a general practice setting. MATERIALS AND METHODS Clinical records of eligible patients from 2009 to 2018 were retrospectively extracted from five general practice clinics. Data for signalment, patient weight, surgery performed, complications, postoperative use of non-steroidal anti-inflammatory drugs, and timing thereof were extracted and analysed using multinomial logistic regression. Predicted probability tables were generated for complications and non-steroidal anti-inflammatory drug use. RESULTS The study included 370 surgeries, with 97 fabellotibial suture, 158 Tightrope and 42 Ligafiba Isotoggle procedures in patients less than 15 kg, and 43 fabellotibial suture, 16 Tightrope and 30 Ligafiba Isotoggle procedures in patients at least 15 kg. The proportion of patients that can be expected to have no complications was greatest for older dogs (9 years) weighing less than 15 kg (fabellotibial suture, 91%; Tightrope/Ligafiba Isotoggle, 88%), and the highest major medical and surgical complication risks were expected in young dogs (1 year) weighing over 15 kg (fabellotibial suture, 28%; Tightrope/Ligafiba Isotoggle, 59%). The predicted risk of requiring repeated non-steroidal anti-inflammatory drug prescriptions in the 18-month postoperative period for an 15 kg patient was 37% to 39%. CONCLUSION Weight and age were significant factors influencing complications and postoperative non-steroidal anti-inflammatory drug use in fabellotibial suture, Tightrope and Ligafiba Isotoggle surgical patients in a general practice setting. CLINICAL SIGNIFICANCE Clinicians should consider the possibility of complications and requirement for ongoing non-steroidal anti-inflammatory drug use before performing extracapsular procedures in patients weighing more than 15 kg.
Collapse
Affiliation(s)
- C D H Franklin
- Peninsula Vet Emergency and Referral Hospital, Mornington, Australia
| | - A K House
- Peninsula Vet Emergency and Referral Hospital, Mornington, Australia
| | - C N Pfeiffer
- Melbourne Veterinary School, University of Melbourne, Parkville, Australia
| |
Collapse
|
15
|
Collins CR, Abel MK, Shui A, Intinarelli G, Sosa JA, Wick EC. Preparing for participation in the centers for Medicare and Medicaid Services' bundle care payment initiative-advanced for major bowel surgery. Perioper Med (Lond) 2022; 11:54. [PMID: 36494765 PMCID: PMC9733045 DOI: 10.1186/s13741-022-00286-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/07/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND As healthcare costs rise, there is an increasing emphasis on alternative payment models to improve care efficiency. The bundled payment represents an alternative reimbursement model gaining popularity within the surgical sphere. We aimed to assess where the largest opportunities for care improvement lay and how best to identify patients at high risk of suffering costly complications. METHODS We utilized itemized CMS claims data for a retrospective cohort of patients between 2014 and 2016 who met inclusion criteria for the Major Bowel Bundled Payment Program and performed a cost analysis to identify opportunities for improved care efficiency. Based on the results of this cost analysis, we identified readmissions as a target for improvement. We then assessed whether the American College of Surgeons' National Surgical Quality Improvement Program surgical risk calculator (ACS NSQIP SRC) could accurately identify patients within our bundled payment population who were at high risk of readmission using a logistic regression model. RESULTS Our study cohort included 252 patients. Readmissions accounted for 12.8% of the average total care episode cost with a coefficient of variation of 2.72, thereby representing the most substantial, non-fixed cost for our bundled payment patients. Patients readmitted within their 90-day care episode were 2.53 times more likely to be high-cost (>$60,000) than patients not readmitted. However, the ACS NSQIP SRC did not accurately predict patients at high risk of readmission within the first 30 days with an AUROC of 0.58. CONCLUSIONS Our study highlights the importance of reducing readmissions as a central component of improving care for bowel surgery bundled payment patients. Preventing such readmissions requires accurate identification of patients at high risk of readmission; however, current risk prediction models lack the adaptability necessary for this task.
Collapse
Affiliation(s)
- Caitlin R. Collins
- grid.266102.10000 0001 2297 6811Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA 94143 USA
| | - Mary Kathryn Abel
- grid.266102.10000 0001 2297 6811School of Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Amy Shui
- grid.266102.10000 0001 2297 6811Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA USA
| | - Gina Intinarelli
- grid.266102.10000 0001 2297 6811Office of Population Health, University of California, San Francisco, San Francisco, CA USA
| | - Julie Ann Sosa
- grid.266102.10000 0001 2297 6811Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA 94143 USA
| | - Elizabeth C. Wick
- grid.266102.10000 0001 2297 6811Department of Surgery, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA 94143 USA
| |
Collapse
|
16
|
Intraoperative Assessment of Surgical Stress Response Using Nociception Monitor under General Anesthesia and Postoperative Complications: A Narrative Review. J Clin Med 2022; 11:jcm11206080. [PMID: 36294399 PMCID: PMC9604770 DOI: 10.3390/jcm11206080] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/16/2022] Open
Abstract
We present a narrative review focusing on the new role of nociception monitor in intraoperative anesthetic management. Higher invasiveness of surgery elicits a higher degree of surgical stress responses including neuroendocrine-metabolic and inflammatory-immune responses, which are associated with the occurrence of major postoperative complications. Conversely, anesthetic management mitigates these responses. Furthermore, improper attenuation of nociceptive input and related autonomic effects may induce increased stress response that may adversely influence outcome even in minimally invasive surgeries. The original role of nociception monitor, which is to assess a balance between nociception caused by surgical trauma and anti-nociception due to anesthesia, may allow an assessment of surgical stress response. The goal of this review is to inform healthcare professionals providing anesthetic management that nociception monitors may provide intraoperative data associated with surgical stress responses, and to inspire new research into the effects of nociception monitor-guided anesthesia on postoperative complications.
Collapse
|
17
|
Hamade S, Alshiek J, Javadian P, Ahmed S, McLeod FN, Shobeiri SA. Evaluation of the American College of Surgeons National Surgical Quality Improvement Program Risk Calculator to predict outcomes after hysterectomies. Int J Gynaecol Obstet 2022; 158:714-721. [PMID: 34929052 DOI: 10.1002/ijgo.14075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/08/2021] [Accepted: 12/17/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the American College of Surgeons (ACS) surgical risk calculator's reliability in predicting outcomes in hysterectomies. METHODS This is a prospective cohort study at a large community-based hospital. Twenty-one preoperative and postoperative criteria were abstracted from the electronic medical record and entered into the online ACS calculator to determine a risk score. Logistical regression was used to determine the association between risk score and actual outcome. The prediction capability was analyzed with c-statistic, Hosmer-Lemeshow, and Brier score. RESULTS A total of 634 hysterectomies were performed during the study period from January to April 2019. Patients were predominantly 55 years old, white (53%) and overweight (body mass index 30). Predicted perioperative adverse events were significantly higher than actual adverse events across all domains. In all, 54/634 (8.5%) patients experienced postoperative urinary tract infection. C-statistics for return to operating room, renal failure, and readmission were 0.607 (95% C Statistic index [CI] 0.370-0.845), 0.882 (95% CI 0.802-0.962), 0.637 (95% CI 0.524-0.750), respectively. Brier scores approached one in all categorical domains. CONCLUSION The ACS surgical risk calculator holds the promise of predicting postoperative complications or length of stay for patients undergoing hysterectomy. Further adjustment to this tool is required before it can be advocated for use in the clinical setting.
Collapse
Affiliation(s)
- Sara Hamade
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Jonia Alshiek
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
- Technion Medical School, Hillel Yafe Medical Center, Hadera, Israel
| | - Pouya Javadian
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Sushma Ahmed
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Francine N McLeod
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - S Abbas Shobeiri
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia, USA
| |
Collapse
|
18
|
Hite MA, Gaertner WB, Garcia B, Flume PA, Maxwell PJ, George VV, Curran T. Abdominal Surgical Procedures in Adult Patients With Cystic Fibrosis: What Are the Risks? Dis Colon Rectum 2022; 65:e805-e815. [PMID: 35030557 PMCID: PMC9259049 DOI: 10.1097/dcr.0000000000002162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND With advances in medical care, patients with cystic fibrosis are more commonly living into adulthood, yet there are limited data describing the need for GI surgery and its outcomes in adult cystic fibrosis patients. OBJECTIVE We aim to use a national administrative database to evaluate trends in abdominal GI surgery and associated postoperative outcomes among adult cystic fibrosis patients. DESIGN This was a national retrospective cohort study. SETTING A national all-payor administrative database from 2000 to 2014 was used. PATIENTS Patients included adults (age ≥18 years) with cystic fibrosis undergoing abdominal GI surgery. MAIN OUTCOME MEASURES The primary outcome was trend over time in number of surgical admissions. Secondary outcomes included morbidity and mortality by procedure type. RESULTS We identified 3075 admissions for abdominal surgery, of which 28% were elective. Major GI surgical procedures increased over the study period ( p < 0.01), whereas appendectomy and cholecystectomy did not demonstrate a clear trend ( p = 0.90). The most common procedure performed was cholecystectomy ( n = 1280; 42%). The most common major surgery was segmental colectomy ( n = 535; 18%). Obstruction was the most common surgical indication ( n = 780; 26%). For major surgery, in-hospital mortality was 6%, morbidity was 37%, and mean length of stay was 15.9 days (SE 1.2). LIMITATIONS The study is limited by a lack of granular physiological and clinical data within the administrative data source. CONCLUSIONS Major surgical admissions for adult patients with cystic fibrosis are increasing, with the majority being nonelective. Major surgery is associated with significant morbidity, mortality, and prolonged length of hospital stay. These findings may inform perioperative risk for adult patients with cystic fibrosis in need of GI surgery. See Video Abstract at http://links.lww.com/DCR/B850 . PROCEDIMIENTOS QUIRRGICOS ABDOMINALES EN PACIENTES ADULTOS CON FIBROSIS QUSTICA CULES SON LOS RIESGOS ANTECEDENTES:Con los avances en la medicina, los pacientes con fibrosis quística viven más comúnmente hasta la edad adulta, pero hay datos escasos que describan la necesidad de cirugía gastrointestinal y sus resultados en pacientes adultos con fibrosis quística.OBJETIVO:Nuestro objetivo es utilizar una base de datos administrativa nacional para evaluar las tendencias en la cirugía gastrointestinal abdominal y los resultados posoperatorios asociados entre los pacientes adultos con fibrosis quística.DISEÑO:Estudio de cohorte retrospectivo nacional.AJUSTE:Base de datos administrativa nacional de todas las instituciones pagadoras desde 2000 a 2014.PACIENTES:Todos los pacientes adultos (edad> 18) con fibrosis quística sometidos a cirugía gastrointestinal abdominal.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la tendencia a lo largo del tiempo en el número de ingresos quirúrgicos. Los resultados secundarios incluyeron morbilidad y mortalidad por tipo de procedimiento.RESULTADOS:Identificamos 3.075 ingresos por cirugía abdominal de los cuales el 28% fueron electivos. Los procedimientos quirúrgicos gastrointestinales mayores aumentaron durante el período de estudio (p <0,01) mientras que la apendicectomía y la colecistectomía no demostraron una tendencia clara (p = 0,90). El procedimiento realizado con mayor frecuencia fue la colecistectomía (n = 1.280; 42%). La cirugía mayor más común fue la colectomía segmentaria (n = 535; 18%). La obstrucción fue la indicación quirúrgica más común (n = 780; 26%). Para la cirugía mayor, la mortalidad hospitalaria fue del 6%, la morbilidad del 37% y la estadía media de 15,9 días (EE 1,2).LIMITACIONES:El estudio está limitado por la falta de datos clínicos y fisiológicos granulares dentro de la fuente de datos administrativos.CONCLUSIONES:Los ingresos quirúrgicos mayores de pacientes adultos con fibrosis quística están aumentando y la mayoría no son electivos. La cirugía mayor se asocia con una morbilidad y mortalidad significativas y una estancia hospitalaria prolongada. Estos hallazgos pueden informar el riesgo perioperatorio para pacientes adultos con fibrosis quística que necesitan cirugía gastrointestinal. Consulte Video Resumen en http://links.lww.com/DCR/B850 . (Traducción-Dr. Felipe Bellolio ).
Collapse
Affiliation(s)
- Melissa A. Hite
- Division of Colon and Rectal Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Wolfgang B. Gaertner
- Division of Colon and Rectal Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Bryan Garcia
- Division of Pulmonology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Patrick A. Flume
- Division of Pulmonology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Pinckney J. Maxwell
- Division of Colon and Rectal Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Virgilio V. George
- Division of Colon and Rectal Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Thomas Curran
- Division of Colon and Rectal Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
19
|
Raso KL, Suen M, Turner J, Khatri S, Lin Y, Wildbore C, Becerril-Martinez G, Le Page P, Tan SY, Egger S, Vardy J. Prehabilitation before gastrointestinal cancer surgery (Prehab-GI): Protocol for an implementation study. (Preprint). JMIR Res Protoc 2022; 12:e41101. [PMID: 36972114 PMCID: PMC10131732 DOI: 10.2196/41101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/03/2022] [Accepted: 11/18/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Surgery remains the standard curative treatment for early-stage colorectal and upper gastrointestinal cancer. Reduced preoperative functional capacity, nutritional status, and psychological well-being are associated with poor postoperative outcomes. Prehabilitation aims to improve preoperative functional reserves through physical, nutritional, and psychological interventions. Yet, how it transitions from a trial setting to being integrated into a real-world health setting is unknown. OBJECTIVE The primary aim is to evaluate the implementation of a multimodal (supervised exercise, nutrition, and nursing support) prehabilitation program into standard care for patients with gastrointestinal cancer (colorectal and upper gastrointestinal cancer) scheduled for curative intent surgery. The secondary aim is to determine the impact of a multimodal prehabilitation program on functional capacity, nutritional and psychological status, and surgical outcomes. METHODS This is an implementation study that will investigate a multimodal prehabilitation intervention, in a nonblinded, nonrandomized, single-group, pre-post design. Patients diagnosed with colorectal and upper gastrointestinal cancer scheduled for potentially curative intent surgery at Concord Repatriation General Hospital, with ≥14 intervention days prior to surgery and are medically cleared to exercise will be eligible. The study will be evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance Evaluation Framework. RESULTS The protocol was approved in December 2019 by the Concord Repatriation General Hospital Human Research Ethics Committee (reference number 2019/PID13679). Recruitment commenced in January 2020. In response to the COVID-19 pandemic, recruitment was paused in March 2020 and reopened in August 2020 with remote or telehealth intervention adaptations. Recruitment ended on December 31, 2021. Over the 16-month recruitment period, a total of 77 participants were recruited. CONCLUSIONS Prehabilitation represents an opportunity to maximize functional capacity and improve surgical outcomes. The study will provide guidance and contribute to the evidence on the integration of prehabilitation into standard care using adaptive models of health care delivery including telehealth. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ACTR 12620000409976; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378974&isReview=true. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/41101.
Collapse
Affiliation(s)
- Kristy-Lee Raso
- Department of Nutrition and Dietetics, Concord Repatriation General Hospital, Concord, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Michael Suen
- Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Concord, Australia
| | - Jane Turner
- Concord Cancer Centre, Concord Repatriation General Hospital, Concord, Australia
| | - Sonia Khatri
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Concord, Australia
- Concord Cancer Centre, Concord Repatriation General Hospital, Concord, Australia
| | - Yanlan Lin
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Concord, Australia
| | - Carolyn Wildbore
- Concord Cancer Centre, Concord Repatriation General Hospital, Concord, Australia
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, Australia
| | - Guillermo Becerril-Martinez
- Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, Australia
| | - Philip Le Page
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, Australia
| | - Sim Yee Tan
- Department of Nutrition and Dietetics, Concord Repatriation General Hospital, Concord, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
- Concord Cancer Centre, Concord Repatriation General Hospital, Concord, Australia
| | - Sam Egger
- The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council New South Wales, Sydney, Australia
| | - Janette Vardy
- Sydney Medical School, University of Sydney, Sydney, Australia
- Concord Cancer Centre, Concord Repatriation General Hospital, Concord, Australia
| |
Collapse
|
20
|
Prado L, Stopenski S, Grigorian A, Schubl S, Barrios C, Kuza C, Matsushima K, Clark D, Nahmias J. Predicting Unplanned Intensive Care Unit Admission for Trauma Patients: The CRASH Score. J Surg Res 2022; 279:505-510. [PMID: 35842975 DOI: 10.1016/j.jss.2022.06.039] [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: 02/27/2022] [Revised: 05/10/2022] [Accepted: 06/11/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Unplanned transfer of trauma patients to the intensive care unit (ICU) carries an associated increase in mortality, hospital length of stay, and cost. Trauma teams need to determine which patients necessitate ICU admission on presentation rather than waiting to intervene on deteriorating patients. This study sought to develop a novel Clinical Risk of Acute ICU Status during Hospitalization (CRASH) score to predict the risk of unplanned ICU admission. METHODS The 2017 Trauma Quality Improvement Program database was queried for patients admitted to nonICU locations. The group was randomly divided into two equal sets (derivation and validation). Multiple logistic regression models were created to determine the risk of unplanned ICU admission using patient demographics, comorbidities, and injuries. The weighted average and relative impact of each independent predictor were used to derive a CRASH score. The score was validated using area under the curve. RESULTS A total of 624,786 trauma patients were admitted to nonICU locations. From 312,393 patients in the derivation-set, 3769 (1.2%) had an unplanned ICU admission. A total of 24 independent predictors of unplanned ICU admission were identified and the CRASH score was derived with scores ranging from 0 to 32. The unplanned ICU admission rate increased steadily from 0.1% to 3.9% then 12.9% at scores of 0, 6, and 14, respectively. The area under the curve for was 0.78. CONCLUSIONS The CRASH score is a novel and validated tool to predict unplanned ICU admission for trauma patients. This tool may help providers admit patients to the appropriate level of care or identify patients at-risk for decompensation.
Collapse
Affiliation(s)
- Louis Prado
- Department of Surgery, University of California, Irvine, Orange, California
| | - Stephen Stopenski
- Department of Surgery, University of California, Irvine, Orange, California
| | - Areg Grigorian
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Sebastian Schubl
- Department of Surgery, University of California, Irvine, Orange, California
| | - Cristobal Barrios
- Department of Surgery, University of California, Irvine, Orange, California
| | - Catherine Kuza
- Department of Anesthesia, University of Southern California, Los Angeles, California
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Damon Clark
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Orange, California.
| |
Collapse
|
21
|
CADISH LA, FORD CB, Wu JM, Anger JT. Mortality and Reoperation Following Midurethral Sling Versus Urethral Bulking in Older Women. Urology 2022; 165:144-149. [PMID: 35460678 PMCID: PMC9940270 DOI: 10.1016/j.urology.2022.03.033] [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: 12/02/2021] [Revised: 03/22/2022] [Accepted: 03/31/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine differences in mortality, retreatment rates, and comorbidities that may be risk factors for retreatment among Medicare beneficiaries (age 65+) undergoing midurethral sling vs urethral bulking. MATERIALS AND METHODS This was a retrospective cohort study using the 5% limited data set from the Center for Medicare and Medicaid Services between 2010 and 2018. Beneficiaries age 65 or older who underwent sling or bulking without concomitant surgery from 2011 to 2014 were included and followed until reoperation or retreatment, loss of Medicare, death, or December 31, 2018. Repeat procedures for ongoing stress incontinence or complication were included. Associations between index treatment and need for a secondary procedure were evaluated using Cox proportional hazards models. RESULTS Median follow-up time was 5.7 years for 1,700 patients undergoing sling and 5.2 years for 875 patients undergoing bulking. Within 5 years, 10.2% of sling patients and 23.2% of bulking patients had died. When controlling for age, race, and comorbidities, bulking patients were 1.73 times more likely than sling patients to die during the study period. Bulking patients were significantly more likely to have 12 of the 16 of the medical comorbidities evaluated. By 5 years, 6.7% of sling patients had been retreated for stress urinary incontinence (SUI) compared with 24.6% of bulking patients. Apart from hypertension, none of the comorbidities evaluated was associated with a difference in the risk of a subsequent surgical procedure. Members of racial and ethnic minority groups were less likely to be retreated. CONCLUSION Older adults undergoing bulking are notably sicker and have shorter life expectancy as compared with those undergoing sling, suggesting these factors heavily guide patient selection. Comorbidities do not predispose patients to reoperation or retreatment.
Collapse
Affiliation(s)
- Lauren A. CADISH
- Urogynecology, Department of Obstetrics and Gynecology, Providence Saint John’s Health Center, Santa Monica, CA
| | - Cassie B. FORD
- Department of Population Health Science, Duke University School of Medicine, Durham, NC
| | - Jennifer M. Wu
- Section of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, NC
| | | |
Collapse
|
22
|
Wang J, Lu S, Meng Y, Zhou X, Fu W. Beta adrenergic blockade and clinical outcomes in patients with colorectal cancer: A systematic review and meta-analysis. Eur J Pharmacol 2022; 929:175135. [DOI: 10.1016/j.ejphar.2022.175135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/27/2022] [Accepted: 06/30/2022] [Indexed: 11/26/2022]
|
23
|
Liu XY, Zhang B, Kang B, Cheng YX, Yuan C, Tao W, Wei ZQ, Peng D. The Effect of Complications on Oncological Outcomes of Colorectal Cancer Patients After Primary Surgery: A Propensity Score Matching Analysis. Front Oncol 2022; 12:857062. [PMID: 35719908 PMCID: PMC9203956 DOI: 10.3389/fonc.2022.857062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/04/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose The purpose of this study is to explore the oncologic outcomes of complications on colorectal cancer (CRC) patients who underwent primary surgery using a propensity score matching (PSM) analysis. Methods A retrospective study was conducted from Jan 2011 to Jan 2020 in a clinical center. The overall survival (OS) and disease-free survival (DFS) were compared among the no complications group, the major complications group and the minor complications group. Results A total of 4250 CRC patients who underwent radical primary surgery were included in the current study. Among them, 927 (21.8%) patients suffered complications. After 1:1 ratio PSM, there were 98 patients in the major complications group and in the minor complications group, and 911 patients in the overall complications group and in the no complications group. There was no significant difference in terms of baseline information after PSM (p>0.05). Complications were independent predictors of OS (p=0.000, HR=1.693, 95% CI=1.476-1.941) and DFS (p=0.000, HR=1.555, 95% CI=1.367-1.768). In terms of specific tumor stage, the no complications group had better OS on all stages (p=0.006) and stage III (p=0.003) CRC than the complications group after PSM. Furthermore, the no complications group had better DFS on all stages (p=0.005) and stage III (p=0.021) CRC than the complications group after PSM. However, there was no significant difference between the minor complications group and the major complications group in different tumor stages (p>0.05). Conclusion Complications were associated with poor prognosis of CRC and surgeons should be cautious of the adverse events.
Collapse
Affiliation(s)
- Xiao-Yu Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bin Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bing Kang
- Department of Clinical Nutrition, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu-Xi Cheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chao Yuan
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Tao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zheng-Qiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dong Peng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
24
|
Gillis C, Martinez MC, Mina DS. Tailoring prehabilitation to address the multifactorial nature of functional capacity for surgery. J Hum Nutr Diet 2022; 36:395-405. [PMID: 35716131 DOI: 10.1111/jhn.13050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/07/2022] [Indexed: 11/30/2022]
Abstract
Mounting evidence suggests that recovery begins before the surgical incision. The pre-surgery phase of recovery - the preparation for optimal surgical recovery - can be reinforced with prehabilitation. Prehabilitation is the approach of enhancing the functional capacity of the individual to enable them to withstand a stressful event. With this narrative review, we apply the Wilson & Cleary conceptual model of patient outcomes to specify the complex and integrative relationship of health factors that limit functional capacity before surgery. To have the greatest impact on patient outcomes, prehabilitation programs require individualized and coordinated care from medical, nutritional, psychosocial, and exercise services. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Chelsia Gillis
- School of Human Nutrition, McGill University.,Anesthesia Department, McGill University
| | | | - Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto.,Department of Anesthesia and Pain Management, University Health Network
| |
Collapse
|
25
|
Argillander T, van der Hulst H, van der Zaag-Loonen H, van Duijvendijk P, Dekker J, van der Bol J, Bastiaannet E, Verkuyl J, Neijenhuis P, Hamaker M, Schiphorst A, Aukema T, Burghgraef T, Sonneveld D, Schuijtemaker J, van der Meij W, van den Bos F, Portielje J, Souwer E, van Munster B. Predictive value of selected geriatric parameters for postoperative outcomes in older patients with rectal cancer – A multicenter cohort study. J Geriatr Oncol 2022; 13:796-802. [DOI: 10.1016/j.jgo.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 03/23/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
|
26
|
Barber EL, Garg R, Strohl A, Roque D, Tanner E. Feasibility and Prediction of Adverse Events in a Postoperative Monitoring Program of Patient-Reported Outcomes and a Wearable Device Among Gynecologic Oncology Patients. JCO Clin Cancer Inform 2022; 6:e2100167. [PMID: 35427184 PMCID: PMC9848580 DOI: 10.1200/cci.21.00167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE The objective of this study was to test the feasibility of implementing a postoperative monitoring program for women with gynecologic cancers composed of patient-reported outcomes (PROs) and a wearable activity monitor. METHODS We prospectively enrolled patients undergoing gynecologic cancer surgery to this single-arm study. Enrolled patients completed PROs (Patient-Reported Outcomes Measurement Information System physical function, sleep disturbance, anxiety, fatigue, and pain intensity) at baseline and one-week intervals for 4 weeks. They also wore a wearable accelerometer device that measured steps, heart rate, and intensity of physical activity. The primary outcome was feasibility. The secondary outcome was prediction of unscheduled contacts with the health care system on a given postoperative day. RESULTS We enrolled 34 women. Three patients were unevaluable. The mean age was 58 years. The mean body mass index was 31 kg/m2; 17 patients were White (54.8%), 12 patients were Black (38.7%), and two patients (6.5%) were Asian. The overall wear time was 83.8%, and patients responded to 80.4% of the PRO instruments. Twenty-two patients (71%) had an unscheduled contact with the health care system postoperatively (median 1.5, 0.0-8.0). The day of an unscheduled health care utilization event was predicted with acceptable discrimination (area under the receiver operating characteristic curve 0.75; 95% CI, 0.67 to 0.81). PROs of fatigue and physical function were most predictive followed by wearable device outputs of lightly active minutes and average daily heart rate. CONCLUSION Implementation of a postoperative monitoring program of patient-reported outcomes and a wearable device was feasible. The specific day of an unscheduled contact with the health care system was predicted with acceptable discrimination.
Collapse
Affiliation(s)
- Emma L. Barber
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL,Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL,Surgical Outcomes and Quality Improvement Center, Institute for Public Health in Medicine, Chicago, IL,Emma L. Barber, MD, MS, Department of Gynecologic Oncology, Northwestern University, 250 E Superior Suite 05-138, Chicago, IL 60611; e-mail:
| | - Ravi Garg
- Surgical Outcomes and Quality Improvement Center, Institute for Public Health in Medicine, Chicago, IL
| | - Anna Strohl
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University Hospitals, Cleveland, OH
| | - Dario Roque
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL,Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Edward Tanner
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL,Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| |
Collapse
|
27
|
Numakura K, Nakai Y, Kojima T, Osawa T, Narita S, Nakayama M, Kitamura H, Nishiyama H, Shinohara N. Overview of clinical management for older patients with renal cell carcinoma. Jpn J Clin Oncol 2022; 52:665-681. [PMID: 35397166 DOI: 10.1093/jjco/hyac047] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
The rapidly increasing pool of older patients being diagnosed with and surviving their cancer is creating many challenges. Regarding localized renal cell carcinoma, surgery is considered as gold standard treatment options even in older men, whereas active surveillance and ablation therapy are alternative options for a proportion of these patients. With regard to advanced disease, anti-vascular endothelial growth factor tyrosine kinase inhibitors (VEGFR-TKI) and immune check point inhibitor are standard treatment modalities, although treatment choice from multiple regimens and prevention of adverse events need to be considered. Better assessment techniques, such as comprehensive geriatric assessment to meet the unique needs of older patients, are a central focus in the delivery of high-quality geriatric oncology care. Through this process, shared decision-making should be adopted in clinical care to achieve optimal goals of care that reflect patient and caregiver hopes, needs and preferences. It is necessary to continue investigating oncological outcomes and complications associated with treatment in this population to ensure appropriate cancer care. In this narrative review, we completed a literature review of the various treatments for renal cell carcinoma in older patients that aimed to identify the current evidence related to the full range of the treatments including active surveillance, surgery, ablation therapy and systemic therapy. Prospectively designed studies and studies regarding geriatric assessment were preferentially added as references. Our goals were to summarize the real-world evidence and provide a decision framework that guides better cancer practices for older patients with renal cell carcinoma.
Collapse
Affiliation(s)
| | - Yasutomo Nakai
- Department of Urology, Osaka International Cancer Institute, Osaka, Japan
| | | | - Takahiro Osawa
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| | | | - Masashi Nakayama
- Department of Urology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroshi Kitamura
- Department of Urology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | | | - Nobuo Shinohara
- Department of Urology, Hokkaido University Hospital, Sapporo, Japan
| |
Collapse
|
28
|
van der Hulst HC, Dekker JWT, Bastiaannet E, van der Bol JM, van den Bos F, Hamaker ME, Schiphorst A, Sonneveld DJ, Schuijtemaker JS, de Jong RJ, Portielje JE, Souwer ET. Validation of the ACS NSQIP surgical risk calculator in older patients with colorectal cancer undergoing elective surgery. J Geriatr Oncol 2022; 13:788-795. [DOI: 10.1016/j.jgo.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 03/16/2022] [Accepted: 04/06/2022] [Indexed: 11/26/2022]
|
29
|
Pourlotfi A, Ahl Hulme R, Bass GA, Sjölin G, Cao Y, Matthiessen PL, Mohseni S. Statin Therapy Is Associated With Decreased 90-Day Postoperative Mortality After Colon Cancer Surgery. Dis Colon Rectum 2022; 65:559-565. [PMID: 34784312 DOI: 10.1097/dcr.0000000000001933] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There have been conflicting reports regarding a protective effect of statin therapy after colon cancer surgery. OBJECTIVE This study aimed to evaluate the association between statin therapy and the postoperative mortality following elective colon cancer surgery. DESIGN This population-based cohort study is a retrospective analysis of prospectively collected data from the Swedish Colorectal Cancer Register. SETTINGS Patient inclusion was achieved through a nationwide register. PATIENTS All adult patients undergoing elective surgery for colon cancer between January 2007 and September 2016 were included in the study. Patients who had received and collected a prescription for statins pre- and postoperatively were allocated to the statin-positive cohort. MAIN OUTCOME MEASURES The primary and secondary outcomes of interest were 90-day all-cause mortality and 90-day cause-specific mortality. RESULTS A total of 22,337 patients underwent elective surgery for colon cancer during the study period, of whom 6,494 (29%) were classified as statin users. Statin users displayed a significant survival benefit despite being older, having a higher comorbidity burden, and being less fit for surgery. Multivariate analysis illustrated significant reductions in the incidence risk for 90-day all-cause mortality (Incidence Rate Ratio = 0.12, p < 0.001) as well as 90-day cause-specific deaths due to sepsis, due to multiorgan failure, or resulting from a cardiovascular and respiratory origin. LIMITATIONS The limitations of this study include its observational retrospective design, restricting the ability to perform standardized follow-up of statin therapy. Confounding from other uncontrolled variables cannot be excluded. CONCLUSIONS Statin users had a significant postoperative benefit regarding short-term mortality following elective colon cancer surgery in the current study; however, further research is needed to ascertain whether this relationship is causal. See Video Abstract at http://links.lww.com/DCR/B738. LA TERAPIA CON ESTATINAS SE ASOCIA CON UNA DISMINUCIN DE LA MORTALIDAD POSOPERATORIA A LOS DAS DESPUS DE LA CIRUGA DE CNCER DE COLON ANTECEDENTES:Ha habido informes contradictorios con respecto al efecto protector de la terapia con estatinas después de la cirugía de cáncer de colon.OBJETIVO:Este estudio tuvo como objetivo evaluar la asociación entre la terapia con estatinas y la mortalidad postoperatoria después de la cirugía electiva por cáncer de colon.DISEÑO:Este estudio de cohorte poblacional es un análisis retrospectivo de datos recopilados prospectivamente del Registro Sueco de Cáncer Colorrectal.AJUSTES:La inclusión de pacientes se logró mediante la inclusión a través de un registro a nivel nacional.PACIENTES:Se incluyeron en el estudio todos los pacientes adultos sometidos a cirugía electiva por cáncer de colon en el período de enero de 2007 y septiembre de 2016. Los pacientes que habían recibido y recogido una receta de estatinas antes y después de la operación fueron asignados a la cohorte positiva de estatinas.PRINCIPALES MEDIDAS DE DESENLACES:Los desenlaces primarios y secundarios de interés fueron la mortalidad por cualquier causa a los 90 días y la mortalidad por causas específicas a los 90 días.RESULTADOS:Un total de 22.337 pacientes se sometieron a cirugía electiva por cáncer de colon durante el período de estudio, de los cuales 6.494 (29%) se clasificaron como usuarios de estatinas. Los usuarios de estatinas mostraron un beneficio significativo en la supervivencia a pesar de ser mayores, de tener una mayor carga de comorbilidad y de estar menos acondicionado para la cirugía. El análisis multivariado ilustró reducciones significativas en el riesgo de incidencia de mortalidad por cualquier causa a 90 días (índice de tasa de incidencia = 0,12, p < 0,001), así como muertes específicas ena 90 días debidas a sepsis, falla multiorgánica o dea enfermedades de origen cardiovascular y respiratorio.LIMITACIONES:Las limitaciones de este estudio incluyen su diseño observacional retrospectivo, que restringe la capacidad de realizar un seguimiento estandarizado de la terapia con estatinas. No se puede excluir confusión a partir de otras variables no controladas.CONCLUSIONES:Los usuarios de estatinas tuvieron un beneficio posoperatorio significativo con respecto a la mortalidad a corto plazo después de cirugía electiva por cáncer de colon en el estudio actual, sin embargo, se necesita más investigación para confirmar si eexiste una relación es causal. Consulte Video Resumen en http://links.lww.com/DCR/B738.
Collapse
Affiliation(s)
- Arvid Pourlotfi
- Department of Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Rebecka Ahl Hulme
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Gary A Bass
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Gabriel Sjölin
- Department of Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Peter L Matthiessen
- Department of Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Shahin Mohseni
- Department of Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| |
Collapse
|
30
|
Gillis C, Ljungqvist O, Carli F. Prehabilitation, enhanced recovery after surgery, or both? A narrative review. Br J Anaesth 2022; 128:434-448. [PMID: 35012741 DOI: 10.1016/j.bja.2021.12.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/03/2021] [Accepted: 12/05/2021] [Indexed: 12/12/2022] Open
Abstract
This narrative review presents a biological rationale and evidence to describe how the preoperative condition of the patient contributes to postoperative morbidity. Any preoperative condition that prevents a patient from tolerating the physiological stress of surgery (e.g. poor cardiopulmonary reserve, sarcopaenia), impairs the stress response (e.g. malnutrition, frailty), and/or augments the catabolic response to stress (e.g. insulin resistance) is a risk factor for poor surgical outcomes. Prehabilitation interventions that include exercise, nutrition, and psychosocial components can be applied before surgery to strengthen physiological reserve and enhance functional capacity, which, in turn, supports recovery through attaining surgical resilience. Prehabilitation complements Enhanced Recovery After Surgery (ERAS) care to achieve optimal patient outcomes because recovery is not a passive process and it begins preoperatively.
Collapse
Affiliation(s)
- Chelsia Gillis
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada.
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada
| |
Collapse
|
31
|
Kim H, Kim CH. Association Between Preoperative Depression and Readmission Rate Following Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2021; 36:3807-3813. [PMID: 34244031 DOI: 10.1016/j.arth.2021.06.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 05/29/2021] [Accepted: 06/17/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To date, no meta-analysis of the relationship between hospital readmission after total joint arthroplasty (TJA) and preoperative depression has been conducted. Hence, this systematic review and meta-analysis aimed to evaluate the association of preoperative depression with the readmission rate following TJA. METHODS We systematically searched MEDLINE, EMBASE, and Cochrane Library for studies published before March 28, 2021, which compared readmission rates in patients with or without preoperative depression who underwent TJA. The primary outcome was the relationship between preoperative depression and 30-day and 90-day readmission rates after TJA. We also performed surgery type subgroup analyses for total hip arthroplasty, total knee arthroplasty (TKA), total shoulder arthroplasty, and total ankle arthroplasty. RESULTS We included 9 studies with 395,815 TJA cases, of which 49,402 were diagnosed with preoperative depression and 346,413 were not. In pooled TJA analysis, the 30-day and 90-day readmission rates were significantly higher in the depression group than in the no-depression group (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.26-2.73, P = .002 and OR 1.27, 95% CI 1.14-1.43,; P < .001, respectively). In the subgroup analyses, the 90-day readmission rate was higher in the depression group than in the no-depression group after TKA (OR 1.28, 95% CI 1.15-1.42, P < .001). There were no differences in other surgery types. CONCLUSION Based on available evidence, preoperative depression increases the readmission rate after TJA, particularly TKA. As depression is a modifiable risk factor, screening for depression and referring patients for proper psychiatric management are important. LEVEL OF EVIDENCE Level III, meta-analysis.
Collapse
Affiliation(s)
- Harin Kim
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chul-Ho Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
32
|
Hulme RA, Forssten MP, Pourlotfi A, Cao Y, Bass GA, Matthiessen P, Mohseni S. The Association Between Revised Cardiac Risk Index and Postoperative Mortality Following Elective Colon Cancer Surgery: A Retrospective Nationwide Cohort Study. Scand J Surg 2021; 111:14574969211037588. [PMID: 34605315 DOI: 10.1177/14574969211037588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Despite improvements in the perioperative care during the last decades for oncologic colon resection, there is still a substantial risk for postoperative complications and mortality. Opportunities exist for improvement in preoperative risk stratification in this patient population. We hypothesize that the Revised Cardiac Risk Index, a user-friendly tool, could better identify patients with high postoperative mortality risks. METHODS A retrospective analysis of operated patients between the years 2007 and 2017 was undertaken, using the prospectively recorded Swedish Colorectal Cancer Registry, which has a 99.5% national coverage for all cases of colon cancer. Patients were cross-referenced with the Swedish National Board of Health and Welfare dataset, a government registry of mortality and comorbidity data. Revised Cardiac Risk Index (RCRI) scores were calculated for each patient and stratified into four groups (RCRI 1, 2, 3, ⩾ 4). A Poisson regression model with robust standard errors of variance was employed to correlate the 90-day postoperative survival with each level of the Revised Cardiac Risk Index. RESULTS A total of 24,198 patients met the study inclusion criteria. 90-day postoperative mortality increased from 2.4% in patients with RCRI 1 to 10.1% in patients with RCRI ⩾ 4 (p < 0.001). Adjusted 90-day postoperative mortality increased linearly with an increasing RCRI, where an RCRI of 2, 3, and ≥ 4 respectively led to a 46%, 80%, and 167% increased risk of mortality compared to RCRI 1 (p < 0.001). CONCLUSIONS A strong association between an increasing Revised Cardiac Risk Index score and increased 90-day postoperative mortality risk was detected. The Revised Cardiac Risk Index may facilitate risk stratification of patients undergoing elective colon cancer surgery.
Collapse
Affiliation(s)
- Rebecka Ahl Hulme
- School of Medical Sciences, Örebro University, Örebro, Sweden Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Arvid Pourlotfi
- Department of Surgery, Örebro University Hospital, Örebro, Sweden School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Gary Alan Bass
- School of Medical Sciences, Örebro University, Örebro, Sweden Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA
| | - Peter Matthiessen
- School of Medical Sciences, Örebro University, Örebro, Sweden Division of Colorectal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, 701 85 Örebro, Sweden
| |
Collapse
|
33
|
Souwer ETD, Bastiaannet E, Steyerberg EW, Dekker JWT, Steup WH, Hamaker MM, Sonneveld DJA, Burghgraef TA, van den Bos F, Portielje JEA. A Prediction Model for Severe Complications after Elective Colorectal Cancer Surgery in Patients of 70 Years and Older. Cancers (Basel) 2021; 13:cancers13133110. [PMID: 34206349 PMCID: PMC8268502 DOI: 10.3390/cancers13133110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/09/2021] [Accepted: 06/14/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Older patients have an increased risk of morbidity and mortality after colorectal cancer (CRC) surgery. Existing CRC surgical prediction models have not incorporated geriatric predictors, limiting applicability for preoperative decision-making. The objective was to develop and internally validate a predictive model based on preoperative predictors, including geriatric characteristics, for severe postoperative complications after elective surgery for stage I-III CRC in patients ≥70 years. PATIENTS AND METHODS A prospectively collected database contained 1088 consecutive patients from five Dutch hospitals (2014-2017) with 171 severe complications (16%). The least absolute shrinkage and selection operator (LASSO) method was used for predictor selection and prediction model building. Internal validation was done using bootstrapping. RESULTS A geriatric model that included gender, previous DVT or pulmonary embolism, COPD/asthma/emphysema, rectal cancer, the use of a mobility aid, ADL assistance, previous delirium and polypharmacy showed satisfactory discrimination with an AUC of 0.69 (95% CI 0.73-0.64); the AUC for the optimism corrected model was 0.65. Based on these predictors, the eight-item colorectal geriatric model (GerCRC) was developed. CONCLUSION The GerCRC is the first prediction model specifically developed for older patients expected to undergo CRC surgery. Combining tumour- and patient-specific predictors, including geriatric predictors, improves outcome prediction in the heterogeneous older population.
Collapse
Affiliation(s)
- Esteban T. D. Souwer
- Department of Internal Medicine, Haga Hospital, 2545 AA Den Haag, The Netherlands
- Department of Medical Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (E.B.); (J.E.A.P.)
- Correspondence:
| | - Esther Bastiaannet
- Department of Medical Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (E.B.); (J.E.A.P.)
| | - Ewout W. Steyerberg
- Department of Medical Statistics, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Jan Willem T. Dekker
- Department of Surgery, Reinier De Graaf Gasthuis, 2625 AD Delft, The Netherlands;
| | - Willem H. Steup
- Department of Surgery, Haga Hospital, 2545 AA Den Haag, The Netherlands;
| | - Marije M. Hamaker
- Department of Geriatric Medicine, Diakonessenhuis, 3582 KE Utrecht, The Netherlands;
| | | | - Thijs A. Burghgraef
- Department of Surgery, Meander Medisch Centrum, 3813 TZ Amersfoort, The Netherlands;
| | - Frederiek van den Bos
- Department of Geriatric Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Johanna E. A. Portielje
- Department of Medical Oncology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (E.B.); (J.E.A.P.)
| |
Collapse
|
34
|
Stopenski S, Grigorian A, Inaba K, Lekawa M, Matsushima K, Schellenberg M, Kim D, de Virgilio C, Nahmias J. Prehospital Variables Alone Can Predict Mortality After Blunt Trauma: A Novel Scoring Tool. Am Surg 2021; 87:1638-1643. [PMID: 34128401 DOI: 10.1177/00031348211024192] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We sought to develop a novel Prehospital Injury Mortality Score (PIMS) to predict blunt trauma mortality using only prehospital variables. STUDY DESIGN The 2017 Trauma Quality Improvement Program database was queried and divided into two equal sized sets at random (derivation and validation sets). Multiple logistic regression models were created to determine the risk of mortality using age, sex, mechanism, and trauma activation criterion. The PIMS was derived using the weighted average of each independent predictor. The discriminative power of the scoring tool was assessed by calculating the area under the receiver operating characteristics (AUROC) curve. The PIMS ability to predict mortality was then assessed by using the validation cohort. The score was compared to the Revised Trauma Score (RTS) using the AUROC curve, including a subgroup of patients with normal vital signs. RESULTS The derivation and validation groups each consisted of 163 694 patients. Seven independent predictors of mortality were identified, and the PIMS was derived with scores ranging from 0 to 20. The mortality rate increased from 1.4% to 43.9% and then 100% at scores of 1, 10, and 19, respectively. The model had very good discrimination with an AUROC of .79 in both the derivation and validation groups. When compared to the RTS, the AUROC were similar (.79 vs. .78). On subgroup analysis of patients with normal prehospital vital signs, the PIMS was superior to the RTS (.73 vs. .56). CONCLUSION The PIMS is a novel scoring tool to predict mortality in blunt trauma patients using prehospital variables. It had improved discriminatory power in blunt trauma patients with normal vital signs compared to the RTS.
Collapse
Affiliation(s)
- Stephen Stopenski
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine, Orange, CA, USA.,Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Michael Lekawa
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Dennis Kim
- Department of Surgery, Harbor - UCLA Medical Center, Torrance, CA, USA
| | | | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Orange, CA, USA
| |
Collapse
|
35
|
Gillis C, Richer L, Fenton TR, Gramlich L, Keller H, Culos-Reed SN, Sajobi TT, Awasthi R, Carli F. Colorectal cancer patients with malnutrition suffer poor physical and mental health before surgery. Surgery 2021; 170:841-847. [PMID: 33966805 DOI: 10.1016/j.surg.2021.04.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND To determine whether there is an association between preoperative nutritional status and preoperative physical function, patient-reported quality of life, and body composition in colorectal cancer patients awaiting elective surgery. METHODS We conducted a pooled analysis of individual baseline patient data (n = 266) collected from 5 prehabilitation trials in colorectal cancer surgery. All data were collected approximately 4 weeks before surgery. Each patient's nutritional status was evaluated using the Patient-Generated Subjective Global Assessment: scores 4-8 indicated need for nutritional treatment, whereas ≥9 indicated critical need for a nutrition intervention. Physical function was measured with the 6-minute walk test; patient-reported quality of life was captured with the SF-36; body mass and composition were determined using multifrequency bioelectrical impedance. RESULTS Mean Patient-Generated Subjective Global Assessment score was 5.3 (standard deviation: 3.9). Approximately two-thirds of patients had a Patient-Generated Subjective Global Assessment of 4-8 or ≥9 (n = 162/266). The 6-minute walk test was progressively worse with higher Patient-Generated Subjective Global Assessment scores (PG-SGA <4: 471(119) m; PG-SGA 4-8: 417(125) m; PG-SGA ≥9: 311(125) m, P < .001). Every component of the SF-36 was lower in those with a Patient-Generated Subjective Global Assessment ≥9 compared to Patient-Generated Subjective Global Assessment <4, indicating that malnourished patients suffer worse quality of life. Interestingly, only the male patients with a Patient-Generated Subjective Global Assessment ≥9 presented with statistically significant lower body mass, reduced fat-free mass index, and a lower percent body fat relative to those with Patient-Generated Subjective Global Assessment <4, in part due to the higher variability among the females. CONCLUSION The consequences of malnutrition are far-reaching and are strongly associated with the physical and mental health of colorectal cancer patients awaiting elective resection.
Collapse
Affiliation(s)
- Chelsia Gillis
- Department of Anesthesia, McGill University, Montreal, Canada.
| | - Lauren Richer
- Department of Anesthesia, McGill University, Montreal, Canada
| | - Tanis R Fenton
- Department of Community Health Sciences, Institute of Public Health, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada; Nutrition Services, Alberta Health Services, Calgary, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Heather Keller
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada; Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - S Nicole Culos-Reed
- Faculty of Kinesiology and Department of Oncology, Cumming School of Medicine, University of Calgary; Psychosocial Resources, Tom Baker Cancer Centre, Cancer Care, Alberta Health Services, Calgary, Alberta, Canada
| | - Tolulope T Sajobi
- Cumming School of Medicine, Department of Community Health Sciences and O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Rashami Awasthi
- Department of Anesthesia, McGill University, Montreal, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University, Montreal, Canada
| |
Collapse
|
36
|
Schlick CJR, Ellis RJ, Merkow RP, Yang AD, Bentrem DJ. Development and validation of a risk calculator for post-discharge venous thromboembolism following hepatectomy for malignancy. HPB (Oxford) 2021; 23:723-732. [PMID: 32988755 PMCID: PMC7990740 DOI: 10.1016/j.hpb.2020.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/16/2020] [Accepted: 09/09/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-discharge venous thromboembolism (VTE) chemoprophylaxis decreases VTEs following cancer surgery, however identifying high-risk patients remains difficult. Our objectives were to (1) identify factors available at hospital discharge associated with post-discharge VTE following hepatectomy for malignancy and (2) develop and validate a post-discharge VTE risk calculator to evaluate patient-specific risk. METHODS Patients who underwent hepatectomy for malignancy from 2014 to 2017 were identified from the ACS NSQIP hepatectomy procedure targeted module. Multivariable logistic regression identified factors associated with post-discharge VTE. A post-discharge VTE risk calculator was constructed, and predicted probabilities of post-discharge VTE were calculated. RESULTS Among 11 172 patients, 95 (0.9%) developed post-discharge VTE. Post-discharge VTE was associated with obese BMI (OR 2.29 vs. normal BMI [95%CI 1.31-3.99]), right hepatectomy/trisegmentectomy (OR 1.63 vs. partial/wedge [95%CI 1.04-2.57]), and several inpatient postoperative complications: renal insufficiency (OR 5.29 [95%CI 1.99-14.07]), transfusion (OR 1.77 [95%CI 1.12-2.80]), non-operative procedural intervention (OR 2.97 [95%CI 1.81-4.86]), and post-hepatectomy liver failure (OR 2.22 [95%CI 1.21-4.08]). Post-discharge VTE risk ranged from 0.3% to 30.2%. Twenty iterations of 10-fold cross validation identified internal validity. CONCLUSIONS Risk factors from all phases of care, including inpatient complications, are associated with post-discharge VTE following hepatectomy. Identifying high-risk patients may allow for personalized risk-based post-discharge chemoprophylaxis prescribing.
Collapse
Affiliation(s)
- Cary Jo R. Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ryan J. Ellis
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Ryan P. Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Anthony D. Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - David J. Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Surgery Service, Jesse Brown VA Medical Center, Chicago, IL, USA
| |
Collapse
|
37
|
Emergency General Surgery (EGS) Risk Stratification Scores. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-020-00281-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
|
38
|
Maleki MR, Doosty F, Yarmohammadian MH, Rasi V, Tanner EI. Designing an Elderly Hospital Admission Risk Prediction Model in Iran's Hospitals. Int J Prev Med 2021; 12:22. [PMID: 34084319 PMCID: PMC8106286 DOI: 10.4103/ijpvm.ijpvm_433_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 02/20/2019] [Indexed: 01/08/2023] Open
Abstract
Background: The identification of elderly at risk of new functional disabilities in activities of daily living at admission to the hospital may facilitate referral for purposive interventions to prevent decline and institutionalization. This study was aimed at designing a risk prediction model for identifying the elderly at risk of admission in Iran's hospitals. Materials and Methods: This is a cross-sectional descriptive study conducted in 2017. In order to formulate and validate a prediction model, the study was done in two development and validation cohort study. Functional decline was defined as a decline of at least one point on the Katz ADL index at follow-up compared with preadmission status. Results: In development cohort, the mean age was 71 years including 54% of men and 46% women, 22% of men and 17% of women experienced functional decline after 3 months. In the validation cohort, the mean age was 70 years, including 49% of men and 51% women, 19% of men and 15% of women, functional decline after 3 months was observed. Conclusion: On the basis of the findings, aging at risk of hospital admission can be identified by easy designed model with four questions: (1) Is the patient's age more than 85 years? (2) Does the patient's mini mental status <22? (3) Does the patient need help for using general transporting? (4) Has the patient lost weight <5% over the past 6 months and body mass index <18.5? And also geriatrics experts can use the designed model as a predictive tool in order to improve the quality level of healthcare services to elderly as a vulnerable and high risk group. The important point of model is easy to use even for nonspecialists.
Collapse
Affiliation(s)
- Mohammad R Maleki
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Farzaneh Doosty
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad H Yarmohammadian
- Health Management and Economic Research Center, Health Services Administration, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Vahid Rasi
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Elizabeth Ibby Tanner
- Interprofessional Education and Practice, Center for Innovative Care in Aging Johns Hopkins School of Nursing, Baltimore, United States of America
| |
Collapse
|
39
|
Latz CA, Boitano L, Wang LJ, Pendleton AA, DeCarlo C, Sumpio B, Schwartz S, Srivastava S, Dua A. Contemporary Endovascular 30-Day Outcomes for Critical Limb Threatening Ischemia Relative to Surgical Bypass Grafting. Vasc Endovascular Surg 2021; 55:441-447. [PMID: 33602047 DOI: 10.1177/1538574421989516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Data from 2011-2014 showed lower extremity bypass(LEB) outperforming infrainguinal endovascular intervention(IEI) regarding major adverse limb events(MALE) but noted no significant difference in major adverse cardiac events(MACE) in propensity matched cohorts. This study aimed to determine if more recent(2015-2018) endovascular outcomes data have improved relative to surgical bypass. METHODS Patients who underwent intervention for chronic limb threatening ischemia (CLTI) from 2015-2018 were identified using the American College of Surgeons National Quality Improvement Program(NSQIP) Vascular Surgery module. The cohort was categorized as undergoing lower extremity bypass(LEB) or infrainguinal endovascular intervention(IEI). Primary 30-day outcomes included major adverse cardiac events(MACE), major adverse limb events(MALE), and major amputation. Inverse probability weighting was used for multivariable analysis. RESULTS A total of 10,783 patients underwent an infrainguinal intervention for CLTI from 2015-2018. Of these, 6,003(55.7%) underwent LEB and 4,780(44.3%) underwent IEI. Forty percent of the cohort was considered "high anatomic risk" by Objective Performance Goals(OPG) standards, and 13.6% were considered "high clinical risk." The IEI cohort vs. the LEB cohort experienced a Myocardial infarction(MI)/Stroke rate of 1.8% vs. 3.6%(p < .001), and had a mortality rate of 2.0% vs. 1.7%(p = .22), which yielded a composite MACE of 3.4% vs. 4.8%(p = .001). The rate of reintervention for IEI vs LEB was 4.4% vs. 5.3%(p = .04), the loss of patency (without re-intervention) rate was 1.8% vs. 1.8%(p = 1.0), and the major amputation rate was 4.1% vs. 3.5%(p = .15), which resulted in a MALE rate of 9.1% vs. 8.8%(p = .50). Following inverse probability weighting, comparing the IEI to the referent LEB, MALE AOR = 1.17, 95% CI[1.01 -1.36], p = .036, MACE AOR = 0.61, 95% CI[0.49-0.74], p < .001, and major amputation AOR = 1.31, 95% CI[1.05 -1.62], p = .016. CONCLUSION Endovascular outcomes continue to demonstrate inferiority in major amputation and overall MALE. However, endovascular intervention has a significantly reduced incidence of MACE. Overall, these results demonstrate an improvement in endovascular MACE rates in recent years relative to surgical bypass.
Collapse
Affiliation(s)
- Christopher Alan Latz
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Laura Boitano
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Linda J Wang
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Anna A Pendleton
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Brandon Sumpio
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Samuel Schwartz
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Sunita Srivastava
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
40
|
Gaitanidis A, Breen K, Naar L, Mikdad S, El Moheb M, Kongkaewpaisan N, El Hechi M, Kaafarani HMA. Performance of the Emergency Surgery Score (ESS) Across Different Emergency General Surgery Procedures. J Surg Res 2021; 261:152-158. [PMID: 33429224 DOI: 10.1016/j.jss.2020.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/02/2020] [Accepted: 12/08/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The Emergency Surgery Score (ESS) has been previously validated as a reliable tool to predict postoperative outcomes in emergency general surgery (EGS). The purpose of this study is to assess the differential performance of the ESS in specific EGS procedures. METHODS The American College of Surgeons' National Surgical Quality Improvement Program database was retrospectively analyzed for patients undergoing EGS between 2007 and 2017. Patients who underwent the following EGS procedures were identified: laparoscopic appendectomy, laparoscopic cholecystectomy, surgery for small bowel obstruction (SBO), colectomy, and incarcerated ventral or inguinal hernia repair. The performance of the ESS in predicting mortality in each procedure was assessed using receiver operating characteristic analyses. RESULTS A total of 467,803 patients underwent EGS (mean age 50 ± 19.9 y, females 241,330 [51.6%]), of which 191,930 (41%) underwent laparoscopic appendectomy, 40,353 (8.6%) underwent laparoscopic cholecystectomy, and 35,152 (7.5%) patients underwent surgery for SBO. The ESS correlated extremely well with mortality for patients who underwent laparoscopic appendectomy (area under the curve (AUC) 0.91), laparoscopic cholecystectomy (AUC 0.91), lysis of adhesions for SBO (AUC 0.83), colectomy (AUC 0.83), and incarcerated hernia repair (AUC 0.85). CONCLUSIONS ESS performance accurately predicts mortality across a wide range of EGS procedures, and its use should be encouraged for preoperative patient counseling and for nationally benchmarking the quality of care of EGS.
Collapse
Affiliation(s)
- Apostolos Gaitanidis
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Kerry Breen
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Leon Naar
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Sarah Mikdad
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Majed El Hechi
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts.
| |
Collapse
|
41
|
Preoperative Assessment of Geriatric Surgical Patients: Update on Clinical Scales Used for Elective General and Digestive Surgery. Surg Laparosc Endosc Percutan Tech 2021; 31:368-375. [PMID: 33399357 DOI: 10.1097/sle.0000000000000896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/16/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Higher life expectancy in the general population entails a growing interest in the surgical management of diseases affecting elderly patients. Preoperative assessment when planning surgery needs to carefully evaluate physical and functional status of the patient. This review aims to describe the most commonly used scales in the evaluation of elderly patients scheduled for surgery and provides a useful tool to decide the scales that would be better to assess these specific patients. METHODS According to the PRISMA statement of publications published, we have carried out a systematic review focused on elderly patients who underwent surgical procedures in General and Surgery. Using Medline, Embase, and Cochrane library, a systematic search of the literature from 1992 to 2018 was performed. This enabled us to retrieve information from the selected articles on scales to evaluate medical fitness, functional status, or both, in the elderly or frail patients. RESULTS We reviewed 102 articles and selected the most frequently used assessment scales or indexes. After this extensive analysis, we selected 4 functional scales (Katz Index, Barthel Scale, Karnofsky Performance Score, and Vulnerable Elders Survey), 4 clinical scales (American Society of Anaesthesiologists Index, Charlson Comorbidity Index, Pfeiffer Test, and Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity Scale) and finally, 2 mixed scales (American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator and Edmonton Frail Scale). CONCLUSIONS No consensus on the use of a unified assessment scale for elderly patients exists. However, with this review, we provide a brief guideline about the most useful and used scales to perform a comprehensive assessment of geriatric patients undergoing surgery.
Collapse
|
42
|
Latz CA, Boitano LT, Wang LJ, DeCarlo C, Pendleton AA, Waller HD, Lee CJ, Dua A. Perioperative outcomes for carotid revascularization on asymptomatic dialysis-dependent patients meet Society for Vascular Society guidelines. J Vasc Surg 2020; 74:195-202. [PMID: 33340696 DOI: 10.1016/j.jvs.2020.11.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The current Society for Vascular Surgery practice guidelines recommend carotid revascularization for asymptomatic disease in patients with at least a 3-year life expectancy and stenosis >60% when the expected perioperative stroke and death rate is <3%. Based on this recommendation, it was previously determined that asymptomatic patients who require dialysis would not meet the perioperative stroke and death thresholds nor the long-term survival benchmarks to justify carotid surgery. To determine whether carotid surgery for patients requiring dialysis is appropriate, the present study compared the perioperative outcomes after carotid revascularization for dialysis-dependent patients relative to nondialysis patients in a contemporary, national cohort. METHODS The targeted vascular module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who undergone carotid endarterectomy or carotid artery stenting for asymptomatic carotid disease from 2011 to 2018. The cohort was categorized as requiring or not requiring dialysis. The primary 30-day outcomes included mortality and the composite of stroke/death and stroke/death/myocardial infarction (MI). Univariate analyses were performed using the Fisher exact test and Wilcoxon rank sum test. Multivariable analyses were used to assess the independent associations of the estimated glomerular filtration rate and dialysis dependence with the stroke/death rate. RESULTS A total of 17,579 patients met the inclusion criteria. Of these patients, 226 (1.3%) required dialysis at revascularization. No difference was found in the degree of severe stenosis (80%-99%) demonstrated by 69% of the dialysis cohort and 72% of the nondialysis cohort (P = .9). Of the dialysis and nondialysis cohorts, 5% and 3.6% underwent carotid artery stenting (P = .3). The dialysis-dependent patients were younger (68 vs 71 years; P < .001) and were more likely to have insulin-dependent diabetes (47% vs 12%; P < .001), congestive heart failure (8.4% vs 1.4%; P < .001), and severe chronic obstructive pulmonary disease (15% vs 10%; P = .03). In the dialysis and nondialysis cohort, 2 (0.9%) and 88 (0.5%) patients died (P = .3); 4 (1.8%) and 247 (1.4%) experienced strokes (P = .6); and 3 (1.3%) and 185 (1.1%) patients experienced MI (P = .5), respectively. The composite outcomes of stroke/death and stroke/death/MI was 2.2% (n = 5) and 1.8% (n = 319; P = .6) and 3.5% (n = 8) and 2.8% (n = 479; P = .4) in the dialysis and nondialysis cohorts, respectively. After multivariable analysis, neither the estimated glomerular filtration rate (adjusted odds ratio, 1.0; 95% confidence interval, 1.00-1.01; P = .26) nor dialysis dependence (adjusted odds ratio, 0.21; 95% confidence interval, 0.03-1.57; P = .13) was independently associated with the composite outcome of stroke/death. CONCLUSIONS The 30-day carotid revascularization outcomes for asymptomatic disease in dialysis-dependent patients met the Society for Vascular Surgery guidelines in this national cohort and might be better than previously surmised. Hence, vascular surgeons could consider carotid revascularization for select dialysis-dependent patients with the appropriate expected longevity and perioperative risk.
Collapse
Affiliation(s)
- Christopher A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Linda J Wang
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anna A Pendleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Harold D Waller
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Cheong J Lee
- Division of Vascular Surgery, NorthShore University Health System, Evanston, Ill
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| |
Collapse
|
43
|
Aceto P, Bassi P, Sollazzi L, Racioppi M, Fortunato G, Di Gianfrancesco L, Marusco I, Ragonese M, Cataldo A, Palermo G. Implementation of frailty preoperative assessment to predict outcome in patients undergoing urological surgery: a systematic review and meta-analysis. BJU Int 2020; 127:507-517. [PMID: 33259147 DOI: 10.1111/bju.15314] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND A common limit of the widely used risk scores for preoperative assessment is the lack of information about aspects linked to frailty that may affect outcome, especially in the setting of elderly patients undergoing urological surgery. Frailty has recently been introduced as an additional characteristic to be assessed for better identifying patients at risk of negative outcomes. OBJECTIVE To examine the evidence for recent advances in preoperative assessment in patients undergoing urological surgery focussing on the detrimental effect of frailty on outcome, including major (mPCs) and total postoperative complications (tPCs), discharge to a facility, and mortality. The secondary aim was to establish which cut-off scores of the modified Frailty Index (mFI, 11 items) and/or simplified FI (sFI, five items) predicted PCs. METHODS We searched PubMed, the Excerpta Medica database (EMBASE), Cochrane Library and clinicaltrial.gov from inception to 31 May 2020. Studies reporting relationships between the investigated outcomes and patients' frailty were included. We estimated odds ratios (ORs) through a random effect model by using Revman 5.4. RESULTS Frailty, assessed by different tools, was associated with a significantly higher rate of 30-day (OR 1.73, 95% confidence interval [CI] 1.58-1.89) and 90-day (OR 2.09, 95% CI 1.14-3.82) mPCs and 30-day tPCs (OR 2.10, 95% CI 1.76-2.52). A mFI of ≥2 was associated with a higher rate of 30-day mPCs (OR 1.79, 95% CI 1.69-1.89) and greater 30-day mortality (OR 3.46, 95% CI 2.10-5.49). A pre-planned post hoc analysis also revealed that a sFI of ≥3 was predictive of mPCs (OR 3.30, 95% CI 2.12-5.12). CONCLUSIONS Frailty assessment may help to predict PCs and mortality in patients undergoing major urological surgery. Either a mFi of ≥2 or sFI of ≥3 should be considered potential 'red flags' for preoperative risk assessment and decision-making. There is not enough evidence to confirm the necessity to perform frailty assessment in minor urological surgery.
Collapse
Affiliation(s)
- Paola Aceto
- Dipartimento di Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Università Cattolica del Sacro Cuore, Roma, Italia
| | - Pierfrancesco Bassi
- Università Cattolica del Sacro Cuore, Roma, Italia.,Dipartimento di Scienze Mediche e Chirurgiche, Clinica Urologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Liliana Sollazzi
- Dipartimento di Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Università Cattolica del Sacro Cuore, Roma, Italia
| | - Marco Racioppi
- Università Cattolica del Sacro Cuore, Roma, Italia.,Dipartimento di Scienze Mediche e Chirurgiche, Clinica Urologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Giusy Fortunato
- Dipartimento di Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Luca Di Gianfrancesco
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Urologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Irene Marusco
- Dipartimento di Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Mauro Ragonese
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Urologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Andrea Cataldo
- Dipartimento di Scienze Dell'Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Giuseppe Palermo
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Urologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| |
Collapse
|
44
|
Samy A, Abdalla A, Rizk A. Evaluation of short-term loop colostomy in dogs using conventional and supporting subcutaneous silicone drain techniques. J Adv Vet Anim Res 2020; 7:685-691. [PMID: 33409313 PMCID: PMC7774783 DOI: 10.5455/javar.2020.g468] [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: 06/07/2020] [Revised: 08/19/2020] [Accepted: 08/25/2020] [Indexed: 11/30/2022] Open
Abstract
Objective: This study aimed at evaluating the supporting and non-supporting loop colostomy techniques in dogs. Materials and Methods: In this study, 12 adult healthy mongrel dogs were used to carry out a short-term (21 days) temporary flank loop colostomy. The dogs were divided into two groups (n = 6). In the first group (Con group), conventional stoma fixation was operated without loop support. In the second group [subcutaneous silicone drain (SSD) group], an SSD was used as a supporting bridge. The stoma was fixed by a modified, interrupted seromuscular vertical mattress suture pattern. Both peristomal and stomal complications were recorded. Results: Results showed that a total of seven dogs (58%) suffered complications. There was a significant tendency toward less peristomal (p = 0.012) and stomal complications (p = 0.001) in the SSD group. The intensity of pain was significantly (p < 0.05) different between the two groups in the first week post surgery. Comfort with stoma care was significantly (p = 0.015) better in the SSD group, experiencing the best results. Conclusion: It is concluded that an appropriate stoma location, using a soft supporting bridge, stoma fixation using modified interrupted neuromuscular vertical mattress sutures, and proper appliance fixation by adhesive tapes and a tight T-shirt may overcome the complications of short-term loop colostomy in dogs and introduce a satisfaction for stoma care.
Collapse
Affiliation(s)
- Alaa Samy
- Department of Surgery, Anesthesiology and Radiology, Faculty of Veterinary Medicine, Mansoura University, Mansoura, Egypt
| | - Abdelnasser Abdalla
- Department of Internal Medicine, Infectious and Fish Diseases, Mansoura Veterinary Teaching Hospital, Mansoura University, Mansoura, Egypt
| | - Awad Rizk
- Department of Surgery, Anesthesiology and Radiology, Faculty of Veterinary Medicine, Mansoura University, Mansoura, Egypt
| |
Collapse
|
45
|
Sentí S, Gené C, Troya J, Pacho C, Nuñez R, Parrales M, Jimenez I, Fernandez-Llamazares J, Julian JF, Parés D. Comprehensive geriatric assessment: Influence on clinical results after colorectal surgery in advanced age patients. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 44:472-480. [PMID: 33199132 DOI: 10.1016/j.gastrohep.2020.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/08/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The objective of this work was to analyse the postoperative clinical results of patients surgically treated for colorectal cancer in relation to the results of the preoperative comprehensive geriatric evaluation. METHODS Observational study in which postoperative morbidity and mortality at 30 and 90 days were analysed in a cohort of patients surgically treated for colorectal cancer according to age groups: group 1) between 75 and 79 years old; group 2) between 80 and 84 years old, and group 3) ≥85 years old. In addition to the anaesthetic risk assessment, patients were assessed with the Karnofsky, Barthel and Pfeiffer indexes. Mortality at 30 and 90 days after surgery was analysed in relation to the results of the comprehensive evaluation. RESULTS A total of 227 patients with colorectal cancer were included in the study period: 91 in group 1, 89 in group 2 and 47 in group 3. There were statistically significant differences in mortality at 30 days (p=0,029) but not at 90 days after surgery, according to age groups. Mortality at 90 days was significantly higher in patients with worse scores on the Karnofsky and Barthel scales. CONCLUSIONS Comprehensive geriatric assessment using different scales is a good tool to assess postoperative mortality in the mid-term postoperative period.
Collapse
Affiliation(s)
- Sara Sentí
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Clara Gené
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - José Troya
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Cristina Pacho
- Unidad de Geriatría de Agudos, Servicio Medicina Interna, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Raquel Nuñez
- Unidad de Geriatría de Agudos, Servicio Medicina Interna, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Mauricio Parrales
- Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Irene Jimenez
- Unidad de Atención al Ciudadano, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Jaume Fernandez-Llamazares
- Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Joan-Francesc Julian
- Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - David Parés
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España.
| |
Collapse
|
46
|
Schlick CJR, Yuce TK, Yang AD, McGee MF, Bentrem DJ, Bilimoria KY, Merkow RP. A postdischarge venous thromboembolism risk calculator for inflammatory bowel disease surgery. Surgery 2020; 169:240-247. [PMID: 33077197 DOI: 10.1016/j.surg.2020.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/26/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Guidelines recommend extended chemoprophylaxis for venous thromboembolism in high-risk patients having operations for inflammatory bowel disease. Quantifying patients' risk of venous thromboembolism, however, remains challenging. We sought (1) to identify factors associated with postdischarge venous thromboembolism in patients undergoing colorectal resection for inflammatory bowel disease and (2) to develop a postdischarge venous thromboembolism risk calculator to guide prescribing of extended chemoprophylaxis. METHODS Patients who underwent an operation for inflammatory bowel disease from 2012 to 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program for colectomy and proctectomy procedure targeted modules. Postdischarge venous thromboembolism included pulmonary embolism or deep vein thrombosis diagnosed after discharge from the index hospitalization. Multivariable logistic regression estimated the association of patient/operative factors with postdischarge venous thromboembolism. A postdischarge venous thromboembolism risk calculator was subsequently constructed. RESULTS Of 18,990 patients, 199 (1.1%) developed a postdischarge venous thromboembolism within the first 30 postoperative days. Preoperative factors associated with postdischarge venous thromboembolism included body mass index (1.9% with body mass index ≥35 vs 0.8% with body mass index 18.5-24.9; odds ratio 2.34 [95% confidence interval 1.49-3.67]), steroid use (1.3% vs 0.7%; odds ratio 1.91 [95% confidence interval 1.37-2.66]), and ulcerative colitis (1.5% vs 0.8% with Crohn's disease; odds ratio 1.76 [95% confidence interval 1.32-2.34]). Minimally invasive surgery was associated with postdischarge venous thromboembolism (1.2% vs 0.9% with open; odds ratio 1.42 [95% confidence interval 1.05-1.92]), as was anastomotic leak (2.8% vs 1.0%; odds ratio 2.24 [95% confidence interval 1.31-3.83]) and ileus (2.1% vs 0.9%; odds ratio 2.60 [95% confidence interval 1.91-3.54]). The predicted probability of postdischarge venous thromboembolism ranged from 0.2% to 14.3% based on individual risk factors. CONCLUSION Preoperative, intraoperative, and postoperative factors are associated with postdischarge venous thromboembolism after an operation for inflammatory bowel disease. A postdischarge venous thromboembolism risk calculator was developed which can be used to tailor extended venous thromboembolism chemoprophylaxis by individual risk.
Collapse
Affiliation(s)
- Cary Jo R Schlick
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Tarik K Yuce
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anthony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Michael F McGee
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - David J Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Surgery Service, Jesse Brown VA Medical Center, Chicago, IL
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL.
| |
Collapse
|
47
|
Latz CA, Wang LJ, Boitano L, DeCarlo C, Sumpio B, Schwartz S, Lee CJ, Dua A. Contemporary Endovascular Outcomes for Critical Limb Ischemia Are Still Failing to Meet Society for Vascular Surgery Objective Performance Goals. Vasc Endovascular Surg 2020; 55:33-38. [PMID: 33030116 DOI: 10.1177/1538574420964623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The Society for Vascular Surgery (SVS) created Objective Performance Goals (OPGs) for critical limb ischemia (CLI) in 2009. It was previously shown that endovascular therapy for CLI was not meeting these benchmarks. The OPG for all peripheral interventions is <8% for major adverse cardiac events (MACE), <8% for major adverse limb events (MALE), and <3% for major amputation. The goal of this study is to evaluate if outcomes have improved for CLI in recent years, specifically 2015-2018. METHODS The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried to identify patients who underwent endovascular intervention for critical limb ischemia from 2011-2018. Cohorts were divided into 2011-2014 and 2015-2018. Primary 30-day outcomes were MACE, MALE, and major amputation. Univariate analyses were performed using the Fisher's exact test and the Wilcoxon rank-sum test. Multivariate analysis comparing groups was performed using inverse probability weights and trend over time analysis was performed using logistic regression with year of intervention as a continuous variable. RESULTS From 2011 to 2018, 7,168 patients underwent an endovascular intervention for CLI. 28% were classified as "OPG high anatomic risk," and 17% were classified as "OPG high clinical risk." The 2015-2018 cohort vs. the 2011-14 cohort experienced MACE in 3.3% vs. 2.7% (p = .23), MALE in 9.1% vs. 8.9% (p = 0.83), and amputation in 4.0% vs. 4.2% (p = 0.71). When only high anatomic risk patients were considered (n = 1988), MACE was experienced in 2.4% vs. 2.2% (p = 0.87), MALE by 9.5% vs. 10.6% (p = 0.47) and amputation by 5.1% vs. 6.0% (p = 0.40). When only high clinical risk patients were considered (n = 1224), MACE was experienced in 5.2% vs. 3.9% (p = 0.33), MALE by 8.0% vs. 7.4% (p = 0.74) and amputation by 3.9% vs. 3.7% (p = 0.88). Comparing 2015-2018 to the reference 2011-2014, MALE adjusted odds ratio (AOR) = 0.99, 95% CI [0.83-1.18], MACE AOR = 1.19 95% CI [0.88-1.60], and major amputation AOR = 0.91 95% CI [0.70-1.17]. There were no decreases in the trend over time for MALE (AOR per year 0.97, CI [.94-1.02], major amputation (AOR per year: 0.97, CI [0.91-1.03], nor for MACE (AOR per year: 1.05, CI [.98-1.13]). CONCLUSION Outcomes following endovascular interventions for CLI continue to underperform when compared to OPG benchmarks for MALE and amputations. There is no decrease over time for these target outcomes. Target MACE events remain acceptable despite the increasing clinical complexity of patients being treated.
Collapse
Affiliation(s)
- Christopher A Latz
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Linda J Wang
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Laura Boitano
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Brandon Sumpio
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Samuel Schwartz
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Cheong J Lee
- Division of Vascular Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
48
|
Gillis C, Fenton TR, Gramlich L, Sajobi TT, Culos-Reed SN, Bousquet-Dion G, Elsherbini N, Fiore JF, Minnella EM, Awasthi R, Liberman AS, Boutros M, Carli F. Older frail prehabilitated patients who cannot attain a 400 m 6-min walking distance before colorectal surgery suffer more postoperative complications. Eur J Surg Oncol 2020; 47:874-881. [PMID: 33041092 DOI: 10.1016/j.ejso.2020.09.041] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/30/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Recent efforts to prehabilitate intermediately frail and frail (Fried frailty criteria ≥2) elective colorectal cancer patients did not influence clinical nor functional outcomes. The objective of this secondary analysis was to describe the subset of intermediately frail and frail prehabilitated patients who could not attain a minimum 400 m (a prognostic cut-point used in other patient populations) 6-min walking distance (6MWD) before elective surgery. MATERIALS AND METHODS Secondary analysis of a randomized controlled trial. Patients participated in multimodal prehabilitation at home and in-hospital for approximately four weeks before colorectal surgery. Primary outcome was incidence of postoperative complications within 30 days of hospital discharge. RESULTS Sixty percent of the patients who participated in prehabilitation did not reach a minimum walking distance of 400 m in 6 min before surgery. Compared to the group that attained ≥400 m 6MWD (n = 19), the <400 m group (n = 28) were older, had higher percent body fat, lower physical function, lower self-reported physical activity, higher American Society of Anesthesiologists (ASA) classification, and twice as many were in critical need of a nutrition intervention at baseline. No group differences were observed regarding frailty status (P = 0.775). Sixty-one percent of the <400 m 6MWD group experienced at least one complication within 30 days of surgery compared to 21% in the ≥400 m group (P = 0.009). CONCLUSION Several preoperative characteristics were identified in the <400 m 6MWD group that could be useful in screening and targeting future prehabilitative treatments. Future trials should investigate use of a 400 m standard for the 6MWD as a minimal treatment target for prehabilitation.
Collapse
Affiliation(s)
- Chelsia Gillis
- Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Canada; Nutrition Lead, Peri Operative Program, McGill University, Montreal, Calgary, Alberta, Canada
| | - Tanis R Fenton
- Department of Community Health Sciences, Institute of Public Health, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Canada; Nutrition Services, Alberta Health Services, Calgary, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Tolulope T Sajobi
- Cumming School of Medicine, Department of Community Health Sciences & O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - S Nicole Culos-Reed
- Faculty of Kinesiology and Department of Oncology, Cumming School of Medicine, University of Calgary. Psychosocial Resources, Tom Baker Cancer Centre, Cancer Care, Alberta Health Services, Calgary, Alberta, Canada
| | | | - Noha Elsherbini
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Julio F Fiore
- Department of Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Enrico M Minnella
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada
| | - Rashami Awasthi
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada
| | - A Sender Liberman
- Department of Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Marylise Boutros
- Department of Surgery, McGill University Health Center, Montreal, QC, Canada
| | - F Carli
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada.
| |
Collapse
|
49
|
Keller DS, Reif de Paula T, Kiran RP, Nemeth SK. Evaluating the association of the new National Surgical Quality Improvement Program modified 5-factor frailty index with outcomes in elective colorectal surgery. Colorectal Dis 2020; 22:1396-1405. [PMID: 32291861 DOI: 10.1111/codi.15066] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/03/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The 5-factor modified frailty index (mFI-5) is a new, NSQIP-based, predictive tool for mortality and postoperative complications. The mFI-5's predictive ability has been validated within the large-scale NSQIP database but applicability in institutional databases has not been investigated. We sought to assess the association between the mFI-5 and morbidity/mortality at the institutional level. METHODS A divisional database was queried for 2017 elective colorectal resections and an mFI-5 calculated. The main outcome measure was the association and predictive value of the mFI-5 with major morbidity/mortality and minor complications. Univariable analyses were performed via the Cochran-Armitage Test and Cramer's V. Logistic regression evaluated the relationship between the mFI-5 and morbidity/mortality while accounting for demographics and pre-operative risk factors. Receiver operating characteristic (ROC) curves were plotted to visualize the predictive strength for outcomes. RESULTS Four hundred and twelve patients were analyzed. 8.7% had major morbidity/mortality and 31.6% minor complications. The mFI-5 categorized patients into 0 (n = 335), 1 (n = 58), and 2+ (n = 19) groups. Univariable analysis showed a higher mFI-5 was associated significantly with major morbidity/mortality (P = 0.004), but not minor (P = 0.281). Multivariable logistic regression showed a strong association between an mFI-5 score of 2+ with major complications (Major: OR = 4.616, CI [1.442-14.776], P = 0.010). ROC curves showed the mFI-5 was poor for predicting outcomes and performed better when other risk factors were added to the model. CONCLUSION The mFI-5 tool has an independent association with major morbidity/mortality in an institutional dataset for elective colorectal surgery, but is not predictive. Its predictive ability is enhanced when other patient-specific risk factors are incorporated.
Collapse
Affiliation(s)
- D S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - T Reif de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - R P Kiran
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - S K Nemeth
- Department of Surgery, Columbia HeartSource, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, New York, USA
| |
Collapse
|
50
|
Bennett S, Søreide K, Gholami S, Pessaux P, Teh C, Segelov E, Kennecke H, Prenen H, Myrehaug S, Callegaro D, Hallet J. Strategies for the delay of surgery in the management of resectable hepatobiliary malignancies during the COVID-19 pandemic. Curr Oncol 2020; 27:e501-e511. [PMID: 33173390 PMCID: PMC7606047 DOI: 10.3747/co.27.6785] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective We aimed to review data about delaying strategies for the management of hepatobiliary cancers requiring surgery during the covid-19 pandemic. Background Given the covid-19 pandemic, many jurisdictions, to spare resources, have limited access to operating rooms for elective surgical activity, including cancer, thus forcing deferral or cancellation of cancer surgeries. Surgery for hepatobiliary cancer is high-risk and particularly resource-intensive. Surgeons must critically appraise which patients will benefit most from surgery and which ones have other therapeutic options to delay surgery. Little guidance is currently available about potential delaying strategies for hepatobiliary cancers when surgery is not possible. Methods An international multidisciplinary panel reviewed the available literature to summarize data relating to standard-of-care surgical management and possible mitigating strategies to be used as a bridge to surgery for colorectal liver metastases, hepatocellular carcinoma, gallbladder cancer, intrahepatic cholangiocarcinoma, and hilar cholangiocarcinoma. Results Outcomes of surgery during the covid-19 pandemic are reviewed. Resource requirements are summarized, including logistics and adverse effects profiles for hepatectomy and delaying strategies using systemic, percutaneous and radiation ablative, and liver embolic therapies. For each cancer type, the long-term oncologic outcomes of hepatectomy and the clinical tools that can be used to prognosticate for individual patients are detailed. Conclusions There are a variety of delaying strategies to consider if availability of operating rooms decreases. This review summarizes available data to provide guidance about possible delaying strategies depending on patient, resource, institution, and systems factors. Multidisciplinary team discussions should be leveraged to consider patient- and tumour-specific information for each individual case.
Collapse
Affiliation(s)
- S Bennett
- Canada: Department of Surgery, University of Toronto, Toronto, ON (Bennett, Callegaro, Hallet); Department of Radiation Oncology, University of Toronto, Toronto, ON (Myrehaug); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON (Hallet)
| | - K Søreide
- Norway: Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, and Department of Clinical Medicine, University of Bergen, Bergen
| | - S Gholami
- United States: Division of Surgical Oncology, Department of Surgery, University of California, Davis, CA (Gholami); Virginia Mason Cancer Institute, Seattle, WA (Kennecke)
| | - P Pessaux
- France: Department of Surgery, Institut Hospitalo-Universitaire de Strasbourg, Strasbourg
| | - C Teh
- Philippines: Institute of Surgery, St. Luke's Medical Center, Quezon City; Department of Surgery, Makati Medical Center, Makati; and Department of General Surgery, National Kidney and Transplant Institute, Quezon City
| | - E Segelov
- Australia: Monash University and Monash Health, Melbourne
| | - H Kennecke
- United States: Division of Surgical Oncology, Department of Surgery, University of California, Davis, CA (Gholami); Virginia Mason Cancer Institute, Seattle, WA (Kennecke)
| | - H Prenen
- Belgium: Department of Oncology, University Hospital Antwerp, Antwerp
| | - S Myrehaug
- Canada: Department of Surgery, University of Toronto, Toronto, ON (Bennett, Callegaro, Hallet); Department of Radiation Oncology, University of Toronto, Toronto, ON (Myrehaug); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON (Hallet)
| | - D Callegaro
- Canada: Department of Surgery, University of Toronto, Toronto, ON (Bennett, Callegaro, Hallet); Department of Radiation Oncology, University of Toronto, Toronto, ON (Myrehaug); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON (Hallet)
- Italy: Department of Surgery, Fondazione irccs Istituto Nazionale Tumori, Milan
| | - J Hallet
- Canada: Department of Surgery, University of Toronto, Toronto, ON (Bennett, Callegaro, Hallet); Department of Radiation Oncology, University of Toronto, Toronto, ON (Myrehaug); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON (Hallet)
| |
Collapse
|