Postoperative morbidity and mortality for malignant colon obstruction: the American College of Surgeon calculator reliability

Management of obstructed colorectal carcinoma in an emergency setting: An update

Colorectal carcinoma is common, particularly on the left side. In 20% of patients, obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced (stage II, III or even IV). Diagnosis is based on clinical presentation, plain abdominal radiogram, computed tomography (CT), CT colonography and positron emission tomography/CT. The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes remains unknown. For the most common left-sided obstruction, the first choice should be either emergency surgery or endoscopic decompression by self-expendable metal stents or tubes. The operative plan should be either one-stage or two-stage resection. One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma (colostomy or ileostomy). Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity. Two-stage resection (Hartmann's procedure) is safer and the most widely used despite temporally affecting quality of life. Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing. For the less common right-sided obstruction, one-stage surgical resection is more beneficial than endoscopic decompression. The role of minimally invasive surgery (laparoscopic or robotic) is a subject of debate. Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rupture and subsequent septic complications. The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates. Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes. Management plans are crucial and must be individualized to better fit each case.

Mortality Risk Stratification in Emergency Surgery for Obstructive Colon Cancer-External Validation of International Scores, American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (SRC), and the Dedicated Score of French Surgical Association (AFC/OCC Score)

BACKGROUND

The increased rates of postoperative mortality after emergency surgery for obstructive colon cancer (OCC) require the use of risk-stratification scores. The study purpose is to external validate the surgical risk calculator (SRC) and the AFC/OCC score and to create a score for risk stratification.

PATIENTS AND METHODS

Overall, 435 patients with emergency surgery for OCC were included in this retrospective study. We used statistical methods suitable for the aimed purpose.

RESULTS

Postoperative mortality was 11.72%. SRC performance: strong discrimination (AUC = 0.864) and excellent calibration (11.80% predicted versus 11.72% observed); AFC/OCC score performance: adequate discrimination (AUC = 0.787) and underestimated mortality (6.93% predicted versus 11.72% observed). We identified nine predictors of postoperative mortality: age > 70 years, CHF, ECOG > 2, sepsis, obesity or cachexia, creatinine (aN) or platelets (aN), and proximal tumors (AUC = 0.947). Based on the score, we obtained four risk groups of mortality rate: low risk (0.7%)-0-2 factors, medium risk (12.5%)-3 factors, high risk (40.0%)-4 factors, very high risk (84.4%)-5-6 factors.

CONCLUSIONS

The two scores were externally validated. The easy identification of predictors and its performance recommend the mortality score of the Clinic County Emergency Hospital of Galați/OCC for clinical use.

The Pre-Operative GRADE Score Is Associated with 5-Year Survival among Older Patients with Cancer Undergoing Surgery

We aimed to assess the prognostic value of the pre-operative GRADE score for long-term survival among older adults undergoing major surgery for digestive or non-breast gynaecological cancers. Between 2013 and 2019, 136 consecutive older adults with cancer were prospectively recruited from the PF-EC cohort study before major cancer surgery and underwent a geriatric assessment. The GRADE score includes weight loss, gait speed at the threshold of 0.8 m/s, cancer site and cancer extension. The primary outcome was post-operative 5-year mortality. Patients were classified as low risk (GRADE ≤ 8) or high risk (GRADE > 8) on the basis of the median score. A Cox multivariate proportional hazards regression model was performed to assess the association between pre-operative factors and 5-year mortality expressed by adjusted hazard ratio (aHR) and 95% CI. The median age was 80 years, 52% were men, 73% had colorectal cancer. The 30-day post-operative severe complication rate (Clavien-Dindo ≥ 3) was 37%. The 5-year post-operative mortality rate was 34.5%. A GRADE score ≥ 8 (aHR = 2.64 [1.34-5.21], p = 0.0002) was associated with post-operative mortality after adjustment for Body Mass Index < 21 kg/m² and Instrumental Activities of Daily Living <3/4. By combining very simple geriatric and cancer parameters, the pre-operative GRADE score provides a discriminant prognosis and could help to choose the most suitable treatment strategy for older cancer patients, avoiding under or over-treatment.

What is the Accuracy of the ACS-NSQIP Surgical Risk Calculator in Emergency Abdominal Surgery? A Meta-Analysis

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator provides an estimation of 30-d post-operative complications including mortality. This tool has the potential to both aid in decision-making for patients and their families and also in optimizing the clinical management of high-risk patients. However, it's utility in patients requiring emergency abdominal surgery has shown to be inconsistent outside of NSQIP participating institutions. This study undertook a meta-analysis to assess the calculator's accuracy in predicting mortality in these patients.

METHODS

A literature search of PubMed, Medline and Cochrane databases was conducted between October 2019 to April 2020. The PubMed, Medline and Cochrane Databases were searched for relevant studies. The search strategy included studies from January 2013 to April 2020. Studies including elective surgery were excluded. A random effects model was used and fitted using restricted maximum likelihood estimation. The O:E ratio was used to validate the calculator's accuracy in predicting mortality.

RESULTS

Six studies were included in the meta-analysis, with a total of 1835 patients undergoing emergency intra-abdominal surgery. The summary estimate of the O:E ratio of the ACS-NSQIP surgical risk calculator in predicting 30-d post-operative mortality was 1.06 (95% CI 0.74-1.51). There was significant heterogeneity between studies with a Cochrane Q of 11.96 (P = 0.04) and I² = 57.5%.

CONCLUSIONS

The ACS-NSQIP surgical risk calculator is a reliable predictor of mortality in this external cohort and has potential to be utilised in the multi-disciplinary care of patients undergoing emergency abdominal surgery.

Scoring Systems May be Effective in Predicting Mortality Associated with Palliative Emergency Gastrointestinal Surgery: A Retrospective Observational Study

Background

Palliative emergency gastrointestinal surgery is associated with significant morbidity and mortality and weighing up the benefits and harms during the decision-making may be challenging. There are very few studies on surgery in palliative patient population. The aim of this retrospective study was to evaluate morbidity and mortality after palliative emergency gastrointestinal surgery and the usability of scoring systems in predicting the outcome.

Methods

Consecutive adult patients undergoing palliative emergency surgery at a tertiary hospital during the period 2015 to 2016 were included. Pre- and post-operative functional status, morbidity and mortality of patients were assessed. The predictive value of the American Society of Anesthesiologists (ASA) classification, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP SRC) and Palliative index (PI) in estimating morbidity and mortality were determined.

Results

A total of 93 patients (age 69 [28–92] years, 51% female) were included. Typical indications for surgery were bowel obstruction (52%) and securing food intake (30%). Pre-operatively two patients (2.2%) were totally dependent in daily activities, while post-operatively the respective share was 34% at discharge from hospital. The incidence of post-operative complications was 37% and 14% died during the hospital stay. One-, three-month and one-year mortality rates were 41%, 63% and 87%, respectively. While ASA score, PI score and ACS NSQIP did not predict post-operative morbidity, both ASA score and ACS NSQIP SRC predicted post-operative mortality.

Conclusions

Palliative emergency laparotomy is associated with significant post-operative mortality and morbidity. Scorings, such as ASA score and ACS NSQIP SRC predict mortality in this patient population.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

The Need for Accurate Risk Assessment in a High-Risk Patient Population: A NSQIP Study Evaluating Outcomes of Cholecystectomy in the Patient With Cancer

BACKGROUND

Cholecystectomy is considered a low-risk procedure with proven safety in many high-risk patient populations. However, the risk of cholecystectomy in patients with active cancer has not been established.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried to identify all patients with disseminated cancer who underwent cholecystectomy from 2005 to 2016. Postcholecystectomy outcomes were defined for patients with cancer and those without by comparing several outcomes measures. A multivariate model was used to estimate the odds of 30-d mortality.

RESULTS

We compared outcomes in 3097 patients with disseminated cancer to a matched cohort of patients without cancer. Patients with cancer had more comorbidities at baseline: dyspnea (10.5% versus 7.0%, P < 0.0001), steroid use (10.1% versus 3.0%, P < 0.0001), and loss of >10% body weight in 6-mo prior (9.3% versus 1.6%, P < 0.0001). Patients with cancer sustained higher rates of wound (2.3% versus 5.6%, P < 0.0001), respiratory (1.4% versus 3.9%, P < 0.0001), and cardiovascular (2.0% versus 6.8%, P < 0.0001) complications. In addition, patients with disseminated cancer experienced a longer length of stay and higher 30-d mortality. Multivariate modeling showed that the odds of 30-d mortality was 3.3 times greater in patients with cancer.

CONCLUSIONS

Compared to patients without cancer, those with disseminated cancer are at higher risk of complication and mortality following cholecystectomy. Traditional treatment algorithms should be used with caution and care decisions individualized based on the patient's disease status and treatment goals.

The American College of Surgeon's surgical risk calculator's ability to predict disposition in older gynecologic oncology patients undergoing laparotomy

OBJECTIVES

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator calculates risk of postoperative complications utilizing clinically apparent preoperative variables. If validated for patients with gynecologic cancers, this can be an effective tool in to use for shared decision-making, especially in the older (70+ years of age) patient population for whom surgical risks and potential loss of independence is increased. The primary objective of this study was to evaluate the ability of the ACS NSQIP surgical risk calculator to predict discharge to a post-acute care among older (age 70+ years) gynecologic oncology patients undergoing laparotomy. The secondary objectives were to assess its ability to predict postoperative complications and death.

METHODS

This was a retrospective cohort study of gynecologic oncology patients 70+ years of age undergoing laparotomy. Surgical procedures, 21 preoperative variables, postoperative complications, and patient disposition were abstracted from the medical record. Risk scores for seven postoperative complications and discharge to post-acute care were calculated. The association between risk scores and outcomes were assessed using logistic regression and predictive ability was evaluated using the c-statistic and Brier score.

RESULTS

204 surgeries were performed on 200 patients between January 1, 2009 and December 31, 2013. The mean age was 76.3 ± 5.1 years; 87% were independent at baseline. A total of 79 (41%) were discharged to post-acute care. The calculator's ability to predict discharge to post-acute care was reasonable (c- statistic =0.708, Brier = 0.205). Although the calculator did not accurately predict all postoperative complications, the calculator's ability to predict death was strong (c-statistic = 0.811, Brier = 0.015).

CONCLUSION

For older patients with an elevated calculated risk of discharge to post acute care the possibility of discharge to post-acute care should be discussed preoperatively. For patients with a higher risk of death, non-surgical management options should be considered when available.