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Ye B, Xie J, Xi K, Huang Z, Liao Y, Chen Z, Ji W. The value of a risk model combining specific risk factors for predicting postoperative severe morbidity in biliary tract cancer. Front Oncol 2024; 13:1309724. [PMID: 38375202 PMCID: PMC10876292 DOI: 10.3389/fonc.2023.1309724] [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: 10/16/2023] [Accepted: 12/29/2023] [Indexed: 02/21/2024] Open
Abstract
Purpose Several surgical risk models are widely utilized in general surgery to predict postoperative morbidity. However, no studies have been undertaken to examine the predictive efficacy of these models in biliary tract cancer patients, and other perioperative variables can also influence morbidity. As a result, the study's goal was to examine these models alone, as well as risk models combined with disease-specific factors, in predicting severe complications. Methods A retrospective study of 129 patients was carried out. Data on demographics, surgery, and outcomes were gathered. These model equations were used to determine the morbidity risks. Severe morbidity was defined as the complication comprehensive index ≥ 40. Results Severe morbidity was observed in 25% (32/129) patients. Multivariate analysis demonstrated that four parameters [comprehensive risk score ≥1, T stage, albumin decrease value, and international normalized ratio (INR)] had a significant influence on the probability of major complications. The area under the curve (AUC) of combining the four parameters was assessed as having strong predictive value and was superior to the Estimation of Physiologic Ability and Surgical Stress System (E-PASS) alone (the AUC value was 0.858 vs. 0.724, p = 0.0375). The AUC for the modified E-PASS (mE-PASS) and Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) in patients over the age of 70 was classified as no predictive value (p = 0.217 and p = 0.063, respectively). Conclusion The mE-PASS and POSSUM models are ineffective in predicting postoperative morbidity in patients above the age of 70. In biliary tract cancer (BTC) patients undergoing radical operation, a combination of E-PASS and perioperative parameters generates a reasonable prediction value for severe complications.
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Affiliation(s)
- BaoLong Ye
- Department of Gastrointestinal and Hernia Surgery, Ganzhou Hospital-Nanfang Hospital, Southern Medical University, Ganzhou, China
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Gastrointestinal and Hernia Surgery, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - JunFeng Xie
- Department of Gastrointestinal and Hernia Surgery, Ganzhou Hospital-Nanfang Hospital, Southern Medical University, Ganzhou, China
- Department of Gastrointestinal and Hernia Surgery, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
| | - KeXing Xi
- Department of Gastrointestinal and Hernia Surgery, Ganzhou Hospital-Nanfang Hospital, Southern Medical University, Ganzhou, China
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - ZhiShun Huang
- Department of Gastrointestinal and Hernia Surgery, Ganzhou Hospital-Nanfang Hospital, Southern Medical University, Ganzhou, China
- Department of Gastrointestinal and Hernia Surgery, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
| | - YanNian Liao
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - ZiWen Chen
- Department of Gastrointestinal and Hernia Surgery, Ganzhou Hospital-Nanfang Hospital, Southern Medical University, Ganzhou, China
- Department of Gastrointestinal and Hernia Surgery, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
| | - Wu Ji
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Kapoor D, Perwaiz A, Singh A, Kumar AN, Chaudhary A. Factors predicting 30-day mortality after pancreaticoduodenectomy-the impact of elevated aspartate aminotransferase. Langenbecks Arch Surg 2023; 408:130. [PMID: 36991246 DOI: 10.1007/s00423-023-02865-w] [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] [Accepted: 03/19/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE High preoperative bilirubin levels and cholangitis are associated with poor peri-operative outcomes following pancreaticoduodenectomy (PD). However, the impact of deranged preoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels on immediate postoperative outcomes is relatively unexplored. We hypothesized that deranged AST and ALT lead to worse postoperative outcomes after PD. The aim of this study was to assess the factors contributing to postoperative mortality (POM) following PD, and to study the impact of deranged aminotransferases. METHODS This is a retrospective analysis of 562 patients. Risk factors for POM were computed using a multivariate logistic regression model. RESULTS The rate of POM was 3.9%. On univariate analysis, the American Society of Anaesthesiologists grades, diabetes mellitus, cardiac comorbidity, preoperative biliary stenting, elevated serum bilirubin, AST, elevated serum creatinine, clinically relevant pancreatic fistula (CRPF), and grade B+C post-pancreatectomy hemorrhage (PPH) were associated with 30-day mortality. On multivariate analysis, preoperative elevated AST was independently predictive of 30-day POM (OR = 6.141, 95%CI 2.060-18.305, p = 0.001). Other factors independently predictive of POM were elevated serum creatinine, preoperative biliary stenting, CRPF and grade B and C PPH. The ratio of AST/ALT > 0.89 was associated with 8 times increased odds of POM. CONCLUSION Elevated preoperative AST emerged as a predictor of 30-day POM after PD, with an 8-times increased odds of death with an AST/ALT ratio > 0.89.
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Affiliation(s)
- Deeksha Kapoor
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India
| | - Azhar Perwaiz
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India
| | - Amanjeet Singh
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India
| | - Arun N Kumar
- Department of Data Science, Alke Research Private Limited, Bengaluru, Karnataka, India
| | - Adarsh Chaudhary
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
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Perioperative risk of pancreatic head resection-nomogram-based prediction of severe postoperative complications as a decisional aid for clinical practice. Langenbecks Arch Surg 2022; 407:1935-1947. [PMID: 35320379 PMCID: PMC9399026 DOI: 10.1007/s00423-021-02426-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 12/29/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE To develop nomograms for pre- and early-postoperative risk assessment of patients undergoing pancreatic head resection. METHODS Clinical data from 956 patients were collected in a prospectively maintained database. A test (n = 772) and a validation cohort (n = 184) were randomly generated. Uni- and multi-variate analysis and nomogram construction were performed to predict severe postoperative complications (Clavien-Dindo Grades III-V) in the test cohort. External validation was performed with the validation cohort. RESULTS We identified ASA score, indication for surgery, body mass index (BMI), preoperative white blood cell (WBC) count, and preoperative alkaline phosphatase as preoperative factors associated with an increased perioperative risk for complications. Additionally to ASA score, BMI, indication for surgery, and the preoperative alkaline phosphatase, the following postoperative parameters were identified as risk factors in the early postoperative setting: the need for intraoperative blood transfusion, operation time, maximum WBC on postoperative day (POD) 1-3, and maximum serum amylase on POD 1-3. Two nomograms were developed on the basis of these risk factors and showed accurate risk estimation for severe postoperative complications (ROC-AUC-values for Grades III-V-preoperative nomogram: 0.673 (95%, CI: 0.626-0.721); postoperative nomogram: 0.734 (95%, CI: 0.691-0.778); each p ≤ 0.001). Validation yielded ROC-AUC-values for Grades III-V-preoperative nomogram of 0.676 (95%, CI: 0.586-0.766) and postoperative nomogram of 0.677 (95%, CI: 0.591-0.762); each p = 0.001. CONCLUSION Easy-to-use nomograms for risk estimation in the pre- and early-postoperative setting were developed. Accurate risk estimation can support the decisional process, especially for IPMN-patients with an increased perioperative risk.
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Zhang JY, Huang J, Zhao SY, Liu X, Xiong ZC, Yang ZY. Risk Factors and a New Prediction Model for Pancreatic Fistula After Pancreaticoduodenectomy. Risk Manag Healthc Policy 2021; 14:1897-1906. [PMID: 34007227 PMCID: PMC8121671 DOI: 10.2147/rmhp.s305332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/15/2021] [Indexed: 01/03/2023] Open
Abstract
Aim In order to find the risk factors of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) according to the latest definition and grading system of International Study Group of Pancreatic Surgery (ISGPS) (version 2016) and propose a nomogram for predicting POPF. Methods We conducted a retrospective analysis of 232 successive cases of PD performed at our hospital by the same operator from August 2012 to June 2020. POPF was diagnosed in accordance with the latest definition of pancreatic fistula from the ISGPS. The risk factors of POPF were analyzed by univariate and multivariate logistic regression analysis. A nomogram model to predict the risk of POPF was constructed based on significant factors. Results There were 18 cases of POPF, accounting for 7.8% of the total. Among them, 17 cases were classified into ISGPF grade B and 1 case was classified into ISGPF grade C. In addition, 35 cases were classified into biochemical leak. Univariate and multivariate analysis showed that hypertension, non-diabetes, no history of abdominal surgery, antecolic gastrojejunostomy and soft pancreas were independent risk factors of POPF. Based on significant factors, a nomogram is plotted to predict the risk of POPF. The C-index of this nomogram to assess prediction accuracy was 0.916 (P < 0.001) indicating good prediction performance. Conclusion Hypertension, non-diabetes, no history of abdominal surgery, antecolic gastrojejunostomy and soft pancreas were independent risk factors of POPF. Meanwhile, a nomogram for predicting POPF with good test performance and discriminatory capacity was constituted.
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Affiliation(s)
- Jia-Yu Zhang
- Graduate School of Peking Union Medical College, Beijing, 100730, People's Republic of China.,Department of General Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Jia Huang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
| | - Su-Ya Zhao
- Beijing University of Chinese Medicine, Beijing, 100029, People's Republic of China
| | - Xin Liu
- Graduate School of Tianjin Medical University, Tianjin, 300041, People's Republic of China
| | - Zhen-Cheng Xiong
- Institute of Medical Technology, Peking University Health Science Center, Beijing, 100029, People's Republic of China
| | - Zhi-Ying Yang
- Graduate School of Peking Union Medical College, Beijing, 100730, People's Republic of China.,Department of General Surgery, China-Japan Friendship Hospital, Beijing, 100029, People's Republic of China
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The effect of high intraoperative blood loss on pancreatic fistula development after pancreatoduodenectomy: An international, multi-institutional propensity score matched analysis. Surgery 2021; 170:1195-1204. [PMID: 33931208 DOI: 10.1016/j.surg.2021.03.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/18/2021] [Accepted: 03/16/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND The association between intraoperative estimated blood loss and outcomes after pancreatoduodenectomy has, thus far, been rarely explored. METHODS In total, 7,706 pancreatoduodenectomies performed at 18 international institutions composing the Pancreas Fistula Study Group were examined (2003-2020). High estimated blood loss (>700 mL) was defined as twice the median. Propensity score matching (1:1 exact-match) was employed to adjust for variables associated with high estimated blood loss and clinically relevant pancreatic fistula occurrence. The study was powered to detect a 33% clinically relevant pancreatic fistula increase in the high estimated blood loss group, with α = 0.05 and β = 0.2. RESULTS The propensity score model included 966 patients with high estimated blood loss and 966 patients with lower estimated blood loss; all covariate imbalantces were solved. Patients with high estimated blood loss patients experienced higher clinically relevant pancreatic fistula rates (19.4 vs 12.6%, odds ratio 1.66; P < .001), as well as higher severe complication rates (27.8 vs 15.6%), transfusions (50.1 vs 14.3%), reoperations (9.2 vs 4.0%), intensive care unit transfers (9.9 vs 4.8%) and 90-day mortality (4.7 vs 2.0%, all P < .001). High estimated blood loss was an independent predictor for clinically relevant pancreatic fistula (odds ratio 1.78, 95% confidence interval 1.37-2.32), as were prophylactic Octreotide administration (odds ratio 1.95, 95% confidence interval 1.46-2.61) and soft pancreatic texture (odds ratio 5.32, 95% confidence interval 3.74-5.57; all P < .001). Moreover, a second model including 1,126 pancreatoduodenectomies was derived including vascular resections as additional confounder (14.0% vascular resections performed in each group). On multivariable regression, high estimated blood loss was confirmed an independent predictor for clinically relevant pancreatic fistula reduction (odds ratio 1.80, 95% confidence interval 1.32-2.44; P < .001), whereas vascular resection was not (odds ratio 0.64, 95% confidence interval 0.34-1.88; P = .156). CONCLUSION This study better establishes the relationship between estimated blood loss and outcomes after pancreatoduodenectomy. Despite inherent contributions to blood loss, its minimization is an actionable opportunity for clinically relevant pancreatic fistula reduction and performance optimization in pancreatoduodenectomy. Accordingly, practical insights are offered to achieve this goal.
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Casciani F, Trudeau MT, Asbun HJ, Ball CG, Bassi C, Behrman SW, Berger AC, Bloomston MP, Callery MP, Christein JD, Falconi M, Fernandez-Del Castillo C, Dillhoff ME, Dickson EJ, Dixon E, Fisher WE, House MG, Hughes SJ, Kent TS, Malleo G, Partelli S, Salem RR, Stauffer JA, Wolfgang CL, Zureikat AH, Vollmer CM. Surgeon experience contributes to improved outcomes in pancreatoduodenectomies at high risk for fistula development. Surgery 2021; 169:708-720. [PMID: 33386129 DOI: 10.1016/j.surg.2020.11.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pancreatoduodenectomies at high risk for clinically relevant pancreatic fistula are uncommon, yet intimidating, situations. In such scenarios, the impact of individual surgeon experience on outcomes is poorly understood. METHODS The fistula risk score was applied to identify high-risk patients (fistula risk score 7-10) from 7,706 pancreatoduodenectomies performed at 18 international institutions (2003-2020). For each case, surgeon pancreatoduodenectomy career volume and years of practice were linked to intraoperative fistula mitigation strategy adoption and outcomes. Consequently, best operative approaches for clinically relevant pancreatic fistula prevention and best performer profiles were identified through multivariable analysis models. RESULTS Eight hundred and thirty high-risk pancreatoduodenectomies, performed by 64 surgeons, displayed an overall clinically relevant pancreatic fistula rate of 33.7%. Clinically relevant pancreatic fistula rates decreased with escalating surgeon career pancreatoduodenectomy (-49.7%) and career length (-41.2%; both P < .001), as did transfusion and reoperation rates, postoperative morbidity index, and duration of stay. Great experience (≥400 pancreatoduodenectomies performed or ≥21-year-long career) was a significant predictor of clinically relevant pancreatic fistula prevention (odds ratio 0.52, 95% confidence interval 0.35-0.76) and was more often associated with pancreatojejunostomy reconstruction and prophylactic octreotide omission, which were both independently associated with clinically relevant pancreatic fistula reduction. A risk-adjusted performance analysis also correlated with experience. Moreover, minimizing blood loss (≤400 mL) significantly contributed to clinically relevant pancreatic fistula prevention (odds ratio 0.40, 95% confidence interval 0.22-0.74). CONCLUSION Surgeon experience is a key contributor to achieve better outcomes after high-risk pancreatoduodenectomy. Surgeons can improve their performance in these challenging situations by employing pancreatojejunostomy reconstruction, omitting prophylactic octreotide, and minimizing blood loss.
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Affiliation(s)
- Fabio Casciani
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | - Maxwell T Trudeau
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Chad G Ball
- Department of Surgery, University of Calgary, Canada
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | | | - Adam C Berger
- Department of Surgery, Jefferson Medical College, Philadelphia, PA
| | - Mark P Bloomston
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mark P Callery
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John D Christein
- Department of Surgery, University of Alabama at Birmingham School of Medicine, AL
| | | | | | - Mary E Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Euan J Dickson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, United Kingdom
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Canada
| | | | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Steven J Hughes
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Tara S Kent
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | | | - Ronald R Salem
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | | | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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Dutton J, Zardab M, De Braal VJF, Hariharan D, MacDonald N, Hallworth S, Hutchins R, Bhattacharya S, Abraham A, Kocher HM, Yip VS. The accuracy of pre-operative (P)-POSSUM scoring and cardiopulmonary exercise testing in predicting morbidity and mortality after pancreatic and liver surgery: A systematic review. Ann Med Surg (Lond) 2020; 62:1-9. [PMID: 33489107 PMCID: PMC7804364 DOI: 10.1016/j.amsu.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 11/10/2022] Open
Abstract
Background Cardiopulmonary exercise-testing (CPET) and the (Portsmouth) Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity ((P)-POSSUM) are used as pre-operative risk stratification and audit tools in general surgery, however, both have been demonstrated to have limitations in major hepatopancreatobiliary (HPB) surgery. Materials and methods The aim of this review is to determine if CPET and (P)-POSSUM scoring systems accurately predict morbidity and mortality. Eligible articles were identified with an electronic database search. Analysis according to surgery type and tool used was performed. Results Twenty-five studies were included in the final review. POSSUM predicted morbidity demonstrated weighted O/E ratios of 0.75(95%CI0.57–0.97) in hepatic surgery and 0.85(95%CI0.8–0.9) in pancreatic surgery. P-POSSUM predicted mortality in pancreatic surgery demonstrated an O/E ratio of 0.75(95%CI0.27–2.13) and 0.94(95%CI0.57–1.55) in hepatic surgery. In both pancreatic and hepatic surgery an anaerobic threshold(AT) of between 9 0.5–11.5 ml/kg/min was predictive of post-operative complications, and in pancreatic surgery ventilatory equivalence of carbon dioxide(˙VE/˙VCO2) was predictive of 30-day mortality. Conclusion POSSUM demonstrates an overall lack of predictive fit for morbidity, whilst CPET variables provide some predictive power for post-operative outcomes. Development of a new HPB specific risk prediction tool would be beneficial; the combination of parameters from POSSUM and CPET, alongside HPB specific markers could overcome current limitations. Current pre-operative scoring for pancreatic and liver surgery is inaccurate. In pancreatic and liver surgery anaerobic threshold scores were predictive of complications. In pancreatic surgery ventilatory equivalence of carbon dioxide was predictive of mortality. P-POSSUM is inaccurate for predicting mortality and morbidity in pancreatic surgery.
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Affiliation(s)
| | | | | | | | - N MacDonald
- Department of Anaesthesia, The Royal London Hospital, Barts Health NHS Trust Whitechapel, E1 1BB, UK
| | - S Hallworth
- Department of Anaesthesia, The Royal London Hospital, Barts Health NHS Trust Whitechapel, E1 1BB, UK
| | | | | | | | | | - V S Yip
- Barts and London HPB Centre, UK
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8
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Hayashi H, Kawabata Y, Nishi T, Kishi T, Nakamura K, Kaji S, Fujii Y, Tajima Y. Accurate prediction of severe postoperative complications after pancreatic surgery: POSSUM vs E-PASS. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:156-164. [PMID: 33058549 DOI: 10.1002/jhbp.839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/08/2020] [Accepted: 09/20/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND/PURPOSE Few reports have evaluated the differences in the predictive accuracy between the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and estimation of physiologic ability and surgical stress (E-PASS) in pancreatic surgery. Thus, we evaluated the accuracy and similarity of POSSUM and E-PASS for the prediction of severe postoperative complications (PCs) after pancreatic surgery. METHODS We enrolled 343 consecutive patients who underwent pancreatic surgery in our department between April 2006 and September 2017. The difference in predictive values of POSSUM and E-PASS for the occurrence of PCs ≥ Clavien-Dindo grade IIIa (PCs-CD ≥ IIIa) was nonparametrically compared. The predictive accuracy and similarity of each tool was examined using the receiver operating characteristic (ROC) curve and linear regression analyses. RESULTS Forty-five patients developed PCs-CD ≥ IIIa. E-PASS had a significantly higher predictive value for estimating PCs-CD ≥ IIIa occurrence (P = .002) than did POSSUM. The area under the curve value in ROC analysis was significantly higher in E-PASS than in POSSUM (0.643 vs 0.543, P = .014), with a weak positive correlation in the predictive value between E-PASS and POSSUM (R2 = .333, P < .001). CONCLUSION Estimation of physiologic ability and surgical stress was useful for predicting severe PCs after pancreatic surgery and had a higher accuracy than POSSUM.
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Affiliation(s)
- Hikota Hayashi
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Yasunari Kawabata
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Takeshi Nishi
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Takashi Kishi
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Kosuke Nakamura
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Shunsuke Kaji
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Yusuke Fujii
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Yoshitsugu Tajima
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, Izumo, Japan
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Adamenko O, Ferrari C, Schmidt J. Irrigation and passive drainage of pancreatic stump after distal pancreatectomy in high-risk patients: an innovative approach to reduce pancreatic fistula. Langenbecks Arch Surg 2020; 405:1233-1241. [PMID: 33084924 PMCID: PMC7686191 DOI: 10.1007/s00423-020-02012-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/11/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) represents the most common form of morbidity after distal pancreatectomy (DP). The aim of this study was to illustrate an innovative technique of irrigation and passive drainage to reduce clinically relevant POPF (CR-POPF) incidence in high-risk patients undergoing DP. MATERIAL AND METHODS Twelve consecutive high-risk patients received irrigation and passive drainage of the pancreatic stump with a Salem sump drainage after DP. The Salem sump was irrigated with 100 ml/h of Ringer solution for 2 postoperative days (POD). In the case of low-drain amylase and lipase levels on POD 3, the irrigation was reduced to 50 ml/h. Persistence of low-drain pancreatic enzymes on POD 4 allowed for interruption of irrigation and subsequent removal of drainage from POD 7 onward in the absence of evidence of any pancreatic fistula. RESULTS Overall, 16.6% of the patients experienced a grade 3 or higher surgical complication. We experienced only one case of POPF: the fistula was classified as grade B and it was managed with radiologic drainage of the fluid collection. We did not experience any case of re-operation nor in-hospital mortality. CONCLUSIONS Irrigation with passive drainage of the pancreatic stump after DP is an interesting approach for CR-POPF prevention in high-risk patients.
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Affiliation(s)
- Olga Adamenko
- Hirslanden Hospitals, Kappelistrasse 7, 8002, Zürich, Switzerland
| | - Carlo Ferrari
- Hirslanden Hospitals, Kappelistrasse 7, 8002, Zürich, Switzerland.
- Università degli Studi di Milano, Via Festa del Perdono 7, Milan, 20122, Italy.
| | - Jan Schmidt
- Hirslanden Hospitals, Kappelistrasse 7, 8002, Zürich, Switzerland
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Van Beijsterveld CAFM, Bongers BC, Den Dulk M, Van Kuijk SMJ, Dejong CHC, Van Meeteren NLU. Exploring the relation between preoperative physical functioning and the impact of major complications in patients following pancreatic resection. HPB (Oxford) 2020; 22:716-727. [PMID: 31740275 DOI: 10.1016/j.hpb.2019.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 09/14/2019] [Accepted: 09/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to evaluate the association between preoperative level of physical functioning and time to recovery of physical functioning, postoperative complications, and the impact of postoperative major complications in patients undergoing elective pancreatic resection. Additionally, prediction models to identify high-risk patients for developing a major complication were externally validated. METHODS Perioperative data of patients who underwent pancreatic resection were analysed. Primary outcomes were time to recovery of physical functioning and postoperative major complications. Impact of a major complication was explored by evaluating its effect on time to recovery of physical functioning. Risk-prediction models were retrieved following a systematic review. RESULTS Multivariable analysis (n = 63) showed that ASA grade III (OR 3.498) and preoperative platelet count (OR 1.005) were associated with major complications, whereas aerobic capacity (OR 0.347) was associated with time to recovery of physical functioning. Age, preoperative aerobic capacity, functional mobility, and perceived level of functional capacity were associated with the impact of a major complication. The AUC of two risk prediction models were 0.556 and 0.701. CONCLUSION Preoperative parameters of physical function were associated with postoperative outcomes and may be useful in outcome prediction, although future approaches should not only register the incidence of major complications but also take the impact of a complication on a patient's physical functioning into account.
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Affiliation(s)
- Christel A F M Van Beijsterveld
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands; Department of Physical Therapy, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, the Netherlands.
| | - Bart C Bongers
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands; SOMT University of Physiotherapy, PO Box 585, 3800 AN, Amersfoort, the Netherlands; Department of Nutrition and Movement Sciences, Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
| | - Marcel Den Dulk
- Department of Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, the Netherlands; Department of Surgery, University Hospital RWTH-Aachen, 52074, Aachen, Germany
| | - Sander M J Van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, the Netherlands
| | - Cornelius H C Dejong
- Department of Surgery, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, the Netherlands; Department of Surgery, University Hospital RWTH-Aachen, 52074, Aachen, Germany; Department of Surgery, Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
| | - Nico L U Van Meeteren
- Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands; Top Sector Life Sciences and Health (Health∼Holland), P.O. Box 93035, 2509 AA, The Hague, the Netherlands
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11
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Tan E, Song J, Lam S, D'Souza M, Crawford M, Sandroussi C. Postoperative outcomes in elderly patients undergoing pancreatic resection for pancreatic adenocarcinoma: A systematic review and meta-analysis. Int J Surg 2019; 72:59-68. [PMID: 31580919 DOI: 10.1016/j.ijsu.2019.09.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/11/2019] [Accepted: 09/26/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND Pancreatic cancer is a disease of the elderly. Surgical resection is usually offered to patients in early stage disease; however, pancreatic resection in the elderly is controversial. METHODS MEDLINE, EMBASE and Cochrane Library, were searched for studies comparing short- and long-term outcomes of elderly (above the age of 70) with non-elderly patients (below the age of 70) following pancreatic resection for pancreatic adenocarcinoma over the period from the inception of electronic database to 2017. Twelve articles documenting 4860 patients were included. A meta-analysis of data on patient characteristics, operative techniques, and perioperative outcomes were analysed. Our primary endpoint was postoperative mortality, defined as 30-day mortality or in-hospitalisation mortality. RESULTS There were 919 patients in the elderly group and 3941 patients in the non-elderly group. Elderly patients had worse ASA scores (p < 0.001) and more cardiovascular comorbidities (p = 0.002). Tumour size, T-stage, N-stage and tumour grade were similar between the elderly and non-elderly group (p > 0.05). Fewer elderly patients received a concomitant venous resection with their pancreatectomy (RR0.80, p = 0.003, I2 = 0%), achieved a negative margin status (RR0.76, p = 0.02, I2 = 28%) and underwent adjuvant chemotherapy treatment (RR0.69, p < 0.001, I2 = 42%). Overall complication (RR1.15, p < 0.001, I2 = 47%), in particular, respiratory complications (RR2.33, p = 0.004, I2 = 39%), was higher in the elderly group. There was no difference in postoperative pancreatic fistula formation, postoperative haemorrhage, intraabdominal abscess and length of hospital stay between both groups (p > 0.05). Postoperative mortality was similar between both groups (p = 0.17). Subgroup analysis according to the time of enrolment (<2000, ≥2000) showed a significant subgroup effect (Chi2 = 3.44, p = 0.06, I2 = 70.9%) and revealed that postoperative mortality in the elderly group improved over time (Before 2000: n = 1654, subtotal RR2.27, p = 0.02, I2 = 0%; From 2000 onwards: n = 3206, subtotal RR1.00, p = 0.99, I2 = 0%). CONCLUSION Fewer elderly patients received chemotherapy and portal vein resection to achieve a clear margin. Pancreatic resection of pancreatic adenocarcinoma can be performed safely on elderly patients with acceptable risks in experienced centres by specialist hepatobiliary surgeons. Age alone should not be the only determinant for the selection of patients for surgical treatment of pancreatic adenocarcinoma.
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Affiliation(s)
- Elinor Tan
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia; Surgical Outcomes Research Centre (SOuRCe), The University of Sydney, Darlington, NSW, 2006, Australia; Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia.
| | - Jialu Song
- Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia
| | - Susanna Lam
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia; Surgical Outcomes Research Centre (SOuRCe), The University of Sydney, Darlington, NSW, 2006, Australia
| | - Mario D'Souza
- Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia; Sydney Local Health District Clinical Research Centre, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Michael Crawford
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Charbel Sandroussi
- Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia; Surgical Outcomes Research Centre (SOuRCe), The University of Sydney, Darlington, NSW, 2006, Australia; Faculty of Medicine and Health, The University of Sydney, Darlington, NSW, 2006, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, 145-147 Missenden Road, Camperdown, NSW, 2050, Australia
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12
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van Boxel GI, McLure S, Jones K, Jones G. Inter-operator variability in pPOSSUM scores: a note of caution. Br J Hosp Med (Lond) 2019; 80:343-347. [PMID: 31180764 DOI: 10.12968/hmed.2019.80.6.343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE Predicting perioperative morbidity and mortality can be achieved by several risk predicting algorithms. In the UK, the National Emergency Laparotomy Audit, mandated for all patients undergoing emergency laparotomy, uses pPOSSUM as its risk prediction tool. However, there is no literature reporting the inter-operator variability in calculating the score. Inter-rater variability was assessed based on 10 real general surgical cases that went on to have an emergency laparotomy. METHODS Forty clinicians, 10 each of registrars and consultants in anaesthetics and general surgery, were asked to calculate the pPOSSUM based on the clinical information typically available at the time of making the decision to proceed to emergency laparotomy for the same 10 National Emergency Laparotomy Audit cases. All participants were surveyed to assess their understanding and use of the pPOSSUM score. RESULTS More than 80% of respondents stated that they use pPOSSUM in daily clinical practice. There was variability in the calculated scores between the groups analysed. Two subgroups were evident: one in which the calculated mean pPOSSUM was similar between participants but did not reflect the true value, and the other which was accurate, but demonstrated high inter-rater variability. CONCLUSIONS This is the first study to investigate inter-operator variability in pPOSSUM scores. Previous reports on the validity of the tool fail to account for subjective variation. At a time where pPOSSUM has become a routine part of clinical practice, this variability needs to be accounted for and taken into consideration in the decision-making process.
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Affiliation(s)
- Gijsbert I van Boxel
- Surgical Registrar, Department of General Surgery, Royal Berkshire Hospital, Reading RG1 5AN
| | - Stewart McLure
- Core Trainee in Anaesthetics, Department of Anaesthetics, Royal Berkshire Hospital, Reading
| | - Keaton Jones
- Surgical Registrar, Department of General Surgery, Oxford University Hospitals Foundation Trust, Oxford
| | - Gregory Jones
- Consultant, Department of General Surgery, Royal Berkshire Hospital, Reading
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13
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Sato N, Hasegawa Y, Saito A, Motoi F, Ariake K, Katayose Y, Nakagawa K, Kawaguchi K, Fukudo S, Unno M, Sato F. Association between chronological depressive changes and physical symptoms in postoperative pancreatic cancer patients. Biopsychosoc Med 2018; 12:13. [PMID: 30288172 PMCID: PMC6162953 DOI: 10.1186/s13030-018-0132-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 09/11/2018] [Indexed: 02/07/2023] Open
Abstract
Background Pancreatic cancer (PC) has poorer prognosis and higher surgical invasiveness than many other cancers, with associated psychiatric symptoms including depression and anxiety. Perioperative depression has not been investigated in PC patients regarding surgical stress and relevant interventions. Methods We evaluated chronological depressive changes and subjective physical symptoms in surgically treated PC patients preoperatively and at 3 and 6 months postoperatively. Enrolled patients undergoing pancreatic tumor surgery completed questionnaires based on the Self-Rating Depression Scale (SDS) and Functional Assessment of Cancer Therapy for Patients with Hepatobiliary Cancer (FACT-Hep) preoperatively, and at 3 and 6 months postoperatively. Responses were analyzed with JMP® Pro using one-way and two-way ANOVA, Spearman’s rank correlation coefficient, and multiple regression analysis. Results Malignancy was diagnosed in 73 of 101 patients postoperatively; SDS score was significantly higher in these patients than in those with benign tumors at all timepoints: malignant/benign, 41.8/37.9 preoperatively (p = 0.004); 43.5/37.8 3 months postoperatively (p = 0.006); and 42.9/37.7 6 months postoperatively (p = 0.020). SDS scores were significantly higher in patients < 65 years old with malignancy at 3 months than at 6 months postoperatively (44.6/42.5, p = 0.046) and in patients with malignancy who underwent pancreaticoduodenectomy at 3 months postoperatively than preoperatively (43.4/41.1; p = 0.028). SDS scores moderately correlated with 8 physical symptom-related FACT-Hep items 3 months postoperatively (p < 0.05), showing low-to-moderate correlation with 16 physical symptom-related FACT-Hep items at 6 months postoperatively (p < 0.05). Multiple regression analysis of FACT-Hep symptoms significantly correlated with SDS scores revealed the following significant variables: “lack of energy” (p < 0.000) and “pain” (p = 0.018) preoperatively (R2 = 0.43); “able to perform usual activities” (p = 0.031) and “lack of energy” (p < 0.000) at 3 months postoperatively (R2 = 0.51); and “stomach swelling or cramps” (p = 0.034) and “bowel control” (p = 0.049) at 6 months postoperatively (R2 = 0.52). Conclusions PC patients experience persistently high levels of depression preoperatively through 6 months postoperatively, with associated subjective symptoms including pain and gastrointestinal symptoms. Trial registration UMIN Clinical Trials Registry 000009592, Registered 20 December 2012.
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Affiliation(s)
- Naoko Sato
- 1Department of Oncology Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan.,5Department of Oncology Nursing, Tohoku University, 2-1 Seiryo-machi, Aoba-ku, Sendai, 980-8575 Japan
| | - Yoshimi Hasegawa
- 2Department of Nursing, Tohoku University School of Health Sciences, Sendai, Japan
| | - Asami Saito
- 1Department of Oncology Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fuyuhiko Motoi
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kyohei Ariake
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Katayose
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Nakagawa
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Kawaguchi
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shin Fukudo
- 4Department of Behavioral Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fumiko Sato
- 1Department of Oncology Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
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14
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Blay-Domínguez E, Lajara-Marco F, Bernáldez-Silvetti PF, Veracruz-Gálvez EM, Muela-Pérez B, Palazón-Banegas MÁ, Salinas-Gilabert JE, Lozano-Requena JA. O-POSSUM score predicts morbidity and mortality in patients undergoing hip fracture surgery. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018. [DOI: 10.1016/j.recote.2018.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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15
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Kobayashi S, Segami K, Hoshino H, Nakahara K, Katayama M, Koizumi S, Otsubo T. Risk factors for failure of early recovery from pancreatoduodenectomy despite the use of enhanced recovery after surgery protocols and a physical aging score to predict postoperative risks. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:231-239. [PMID: 29412516 DOI: 10.1002/jhbp.540] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are beneficial for pancreatoduodenectomy (PD). Our aim was to evaluate risk factors associated with ERAS protocol failure after PD. METHODS Clinical variables of 187 patients managed using ERAS protocols between April 2011 and April 2017, including non-early recovery (non-ER) patients, with complications or requiring a hospital stay ≥15 days, and early recovery (ER) patients, were compared. A physical aging (PA) score was devised to predict postoperative risks. RESULTS Independent risk factors of complications were a pre-albumin level ≤18 mg/dl (odds ratio (OR) 2.197; 95% confidence interval (CI) 1.052-4.622), and an American Society of Anesthesiologists (ASA) score ≥II (OR 2.195; 95% CI 1.052-4.746). Independent risk factors for hospital stay ≥15 days (P < 0.001) were age ≥70 years (OR 2.438; 95% CI 1.122-5.299) and an ASA score ≥II (OR 2.348; 95% CI 1.109-4.968). The PA score included age, ASA score, and pre-albumin level. The complication rate for each PA score was as follows: score "0", 12.1%; score "1", 18.2%; score "2", 26.9%; score "3", 30.8%; and score "≥4", 47.2%. CONCLUSIONS Advanced age, poor nutrition, and serious illnesses can cause ERAS protocol failure. The PA score is effective for predicting postoperative progress.
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Affiliation(s)
- Shinjiro Kobayashi
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kohei Segami
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Hiroyuki Hoshino
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Kazunari Nakahara
- Department of Gastroenterology and Hepatology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Masafumi Katayama
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Satoshi Koizumi
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
| | - Takehito Otsubo
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan
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16
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Blay-Domínguez E, Lajara-Marco F, Bernáldez-Silvetti PF, Veracruz-Gálvez EM, Muela-Pérez B, Palazón-Banegas MÁ, Salinas-Gilabert JE, Lozano-Requena JA. O-POSSUM score predicts morbidity and mortality in patients undergoing hip fracture surgery. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 62:207-215. [PMID: 29191635 DOI: 10.1016/j.recot.2017.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 09/13/2017] [Accepted: 10/28/2017] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The aim of this study is to evaluate the O-POSSUM score capacity to predict the morbidity and mortality of patients undergoing hip fracture surgery. MATERIAL AND METHODS We retrospectively reviewed the clinical records of patients older than 65years old, operated on for hip fractures between January 2012 and December 2013. Of 229 patients, the mean age was 82.3years and 170 were women. We collected comorbidities, type of surgery, and expected morbidity and mortality O-POSSUM values. RESULTS After a minimum follow up of one year, 38 deaths were reported and 77 patients had complications. The expected mortality according to the O-POSSUM was 35 patients and expected morbidity 132. CONCLUSION By comparing the observed results with those predicted, the O-POSSUM scale is reliable in predicting mortality and overestimates morbidity.
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Affiliation(s)
- Elena Blay-Domínguez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Vega Baja, Orihuela, Alicante, España.
| | - Francisco Lajara-Marco
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Vega Baja, Orihuela, Alicante, España
| | | | | | - Beatriz Muela-Pérez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Vega Baja, Orihuela, Alicante, España
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17
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Roberts KJ, Prasad P, Steele Y, Marcon F, Faulkner T, Cilliers H, Dasari B, Abradelo M, Marudanayagam R, Sutcliffe RP, Muiesan P, Mirza DF, Isaac J. A reduced time to surgery within a 'fast track' pathway for periampullary malignancy is associated with an increased rate of pancreatoduodenectomy. HPB (Oxford) 2017; 19:713-720. [PMID: 28566239 DOI: 10.1016/j.hpb.2017.04.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 02/13/2017] [Accepted: 04/16/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Pancreatoduodenectomy (PD) typically follows preoperative biliary drainage (PBD) despite PBD being potentially harmful. This study evaluated a pathway to avoid PBD within the framework of the UK's NHS. METHOD A prospective observational study of jaundiced patients undergoing PD for periampullary cancer. A pathway to provide early surgery without PBD was introduced at the start of the study period. RESULTS Over 12 months 61 and 32 patients underwent surgery with and without PBD respectively; 95% of patients in the PBD group had been stented before referral. The time from CT scan to surgery was shorter in the no PBD group (16 vs 65 days, p < 0.0001). Significantly more patients underwent PD in the no PBD group (31/32 vs 46/61, p = 0.009) and venous resection (10/31 vs 4/46, p = 0.014). The sensitivity of initial CT scan to define borderline resectable disease was worse in the PBD group (91 vs 50%, p = 0.042). CONCLUSIONS Early surgery to avoid PBD is possible within the NHS. By reducing the time to surgery it appears that more patients undergo potentially curative resection. It is desirable to understand why surgery without PBD is not performed routinely as are the development of strategies to support its more widespread practice.
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Affiliation(s)
- Keith J Roberts
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK.
| | - Pooja Prasad
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Yvonne Steele
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Francesca Marcon
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Thomas Faulkner
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Hentie Cilliers
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Bobby Dasari
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Manuel Abradelo
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Ravi Marudanayagam
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Robert P Sutcliffe
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Paolo Muiesan
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - Darius F Mirza
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
| | - John Isaac
- Departments of Pancreatic Surgery and Anaesthesia, University Hospitals Birmingham, UK
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18
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Velez-Serrano JF, Velez-Serrano D, Hernandez-Barrera V, Jimenez-Garcia R, Lopez de Andres A, Garrido PC, Álvaro-Meca A. Prediction of in-hospital mortality after pancreatic resection in pancreatic cancer patients: A boosting approach via a population-based study using health administrative data. PLoS One 2017; 12:e0178757. [PMID: 28591154 PMCID: PMC5462391 DOI: 10.1371/journal.pone.0178757] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 05/18/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND One reason for the aggressiveness of the pancreatic cancer is that it is diagnosed late, which often limits both the therapeutic options that are available and patient survival. The long-term survival of pancreatic cancer patients is not possible if the tumor is not resected, even among patients who receive chemotherapy in the earliest stages. The main objective of this study was to create a prediction model for in-hospital mortality after a pancreatectomy in pancreatic cancer patients. METHODS We performed a retrospective study of all pancreatic resections in pancreatic cancer patients in Spanish public hospitals (2013). Data were obtained from records in the Minimum Basic Data Set. To develop the prediction model, we used a boosting method. RESULTS The in-hospital mortality of pancreatic resections in pancreatic cancer patients was 8.48% in Spain. Our model showed high predictive accuracy, with an AUC of 0.91 and a Brier score of 0.09, which indicated that the probabilities were well calibrated. In addition, a sensitivity analysis of the information available prior to the surgery revealed that our model has high predictive accuracy, with an AUC of 0.802. CONCLUSIONS In this study, we developed a nation-wide system that is capable of generating accurate and reliable predictions of in-hospital mortality after pancreatic resection in patients with pancreatic cancer. Our model could help surgeons understand the importance of the patients' characteristics prior to surgery and the health effects that may follow resection.
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Affiliation(s)
| | - Daniel Velez-Serrano
- Department of Statistics and Operations Research, Complutense University, Madrid, Spain
| | | | - Rodrigo Jimenez-Garcia
- Department of Preventive Medicine & Public Health, Rey Juan Carlos University, Madrid, Spain
| | - Ana Lopez de Andres
- Department of Preventive Medicine & Public Health, Rey Juan Carlos University, Madrid, Spain
| | - Pilar Carrasco Garrido
- Department of Preventive Medicine & Public Health, Rey Juan Carlos University, Madrid, Spain
| | - Alejandro Álvaro-Meca
- Department of Preventive Medicine & Public Health, Rey Juan Carlos University, Madrid, Spain
- * E-mail:
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Cusworth BM, Krasnick BA, Nywening TM, Woolsey CA, Fields RC, Doyle MM, Liu J, Hawkins WG. Whipple-specific complications result in prolonged length of stay not accounted for in ACS-NSQIP Surgical Risk Calculator. HPB (Oxford) 2017; 19:147-153. [PMID: 27939807 PMCID: PMC5462337 DOI: 10.1016/j.hpb.2016.10.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/06/2016] [Accepted: 10/28/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator was developed to help counsel patients regarding estimated postoperative risk for a variety of surgical complications. This retrospective single institutional study examined the calculator's ability to accurately predict complications and length of hospital stay (LOS) in patients who had undergone a Pancreaticoduodenectomy (PD) at our institution. METHODS 165 patients at Washington University School of Medicine who underwent a PD from 8/2011 to 7/2013 were included. Surgical complication risk as determined by the ACS-NSQIP Surgical Risk Calculator were compared to actual 30 day complications. PD complications not accounted for by the calculator were compared to those without PD-specific complications. RESULTS Overall predicted LOS was significantly shorter than actual duration of hospitalization (median 8.5 vs. 8.0 days; p < 0.001). 38% patients (n = 62) with Whipple-specific complication demonstrated a significant increase in LOS (8.0 vs. 12.2 days; p < 0.0001). DISCUSSION A large proportion of complications experienced after PD are pancreas-specific, accounting for the difference in predicted vs. actual LOS and providing rationale for future development of PD specific risk models.
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Affiliation(s)
- Brian M Cusworth
- Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8109, St. Louis, MO 63119, USA
| | - Bradley A Krasnick
- Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8109, St. Louis, MO 63119, USA
| | - Timothy M Nywening
- Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8109, St. Louis, MO 63119, USA
| | - Cheryl A Woolsey
- Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8109, St. Louis, MO 63119, USA
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8109, St. Louis, MO 63119, USA; Alvin J. Siteman Cancer Center, 4921 Parkview Place, St. Louis, MO 63110, USA
| | - Maria M Doyle
- Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8109, St. Louis, MO 63119, USA
| | - Jingxia Liu
- Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8109, St. Louis, MO 63119, USA
| | - William G Hawkins
- Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8109, St. Louis, MO 63119, USA; Alvin J. Siteman Cancer Center, 4921 Parkview Place, St. Louis, MO 63110, USA.
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Fassoulaki A, Chondrogiannis K, Staikou C. Physiological and operative severity score for the enumeration of mortality and morbidity scoring systems for assessment of patient outcome and impact of surgeons' and anesthesiologists' performance in hepatopancreaticobiliary surgery. Saudi J Anaesth 2017; 11:190-195. [PMID: 28442958 PMCID: PMC5389238 DOI: 10.4103/1658-354x.203025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Context: The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a scoring system used to predict morbidity and mortality. Aims: We compared the physiological and operative risk, the expected morbidity and mortality, and the observed postoperative mortality among patients operated by different surgeons and anesthetized by different anesthesiologists. Settings and Design: This was a retrospective, single center study. Subjects and Methods: The anesthetic records of 159 patients who underwent hepatopancreaticobiliary surgery were analyzed for the physiological and operative severity, POSSUM morbidity, POSSUM and Portsmouth POSSUM (P-POSSUM) mortality scoring systems, observed mortality in 30-days, 3, 6, and 12 months postoperatively, duration of surgery, and units of packed red blood cells (PRBC) transfused. These variables were compared among patients operated by five different surgeons and anesthetized by seven different anesthesiologists. Statistical Analysis: One-way analysis of variance was used for normally and Kruskal–Wallis test for nonnormally distributed responses. Differences in percentages of postoperative mortality were assessed by Chi-squared test. Results: The physiological severity, POSSUM morbidity, POSSUM and P-POSSUM mortality scores, and observed mortality at 1, 3, 6, and 12 months postoperatively did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. Duration of surgery (P < 0.001), PRBC units transfused (P = 0.002), and operative severity (P = 0.001) differed significantly among patients operated by different surgeons. Conclusions: The physiological severity score, POSSUM and P-POSSUM scores did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. The different operative severity scores did not influence the observed mortality in the postoperative period.
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Affiliation(s)
- Argyro Fassoulaki
- Department of Anesthesiology, Aretaieio Hospital, Medical School, University of Athens, Athens, Greece
| | | | - Chryssoula Staikou
- Department of Anesthesiology, Aretaieio Hospital, Medical School, University of Athens, Athens, Greece
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Pancreatic Surgery in the Older Population: A Single Institution's Experience over Two Decades. Curr Gerontol Geriatr Res 2016; 2016:8052175. [PMID: 28018428 PMCID: PMC5149609 DOI: 10.1155/2016/8052175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/13/2016] [Indexed: 12/03/2022] Open
Abstract
Objectives. Surgery is the most effective treatment for pancreatic cancer. However, present literature varies on outcomes of curative pancreatic resection in the elderly. The objective of the study was to evaluate age as an independent risk factor for 90-day mortality and complications after pancreatic resection. Methods. Nine hundred twenty-nine consecutive patients underwent 934 pancreatic resections between March 1995 and July 2014 in a tertiary care center. Primary analyses focused on outcomes in terms of 90-day mortality and postoperative complications after pancreatic resection in these two age groups. Results. Even though patients aged 75 years or older had significantly more postoperative morbidities compared with the younger patient group, the age group was not associated with increased risk of 90-day mortality after pancreatic resection. Discussion. The study suggests that age alone should not preclude patients from undergoing curative pancreatic resection.
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Jaap K, Hunsinger M, Dove J, Mcginty K, Stefanowicz E, Fera J, Wild J, Shabahang M, Blansfield J. Morphometric Predictors of Morbidity after Pancreatectomy. Am Surg 2016. [DOI: 10.1177/000313481608201230] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pancreatic surgery has historically been associated with high morbidity and mortality. One model that could predict outcomes is the assessment of preoperative morphometrics. The objective of this study was to compare different clinical and morphometric features of patients undergoing pancreatectomy to predict morbidity. This is a retrospective chart review of patients undergoing pancreatectomy from December 2004 to October 2013. Morphometric parameters on preoperative CT scans were measured and patients were grouped to examine their association with postoperative morbidity. A total of 180 patients were included in this study (90 males and 90 females). At the time of diagnosis, patients had an average age of 66.7 years (range = 24–90), and median body mass index of 27.4 kg/m2 (range = 16–58 kg/m2). Sixty-one patients (33.9%) experienced surgical complications. Of the individual morphometric variables examined, sarcopenia was the best predictor of length of stay and surgical complications. On multivariate analysis, there was a strong statistically significant correlation of sarcopenia with surgical complications (odds ratio = 3.524, P = 0.0049). No other morphometric variables predicted morbidity. Sarcopenia is a useful predictor for postoperative morbidity after pancreatectomy. The results of this study suggest that noninvasive preoperative testing can be used to quantify postoperative complications after pancreatic surgery.
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Affiliation(s)
- Kathryn Jaap
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Marie Hunsinger
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - James Dove
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Katrina Mcginty
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Edward Stefanowicz
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Jillian Fera
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Jeffrey Wild
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Mohsen Shabahang
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Joseph Blansfield
- From the Department of General Surgery, Geisinger Medical Center, Danville, Pennsylvania
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WHipple-ABACUS, a simple, validated risk score for 30-day mortality after pancreaticoduodenectomy developed using the ACS-NSQIP database. Surgery 2016; 160:1279-1287. [DOI: 10.1016/j.surg.2016.06.040] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/28/2016] [Indexed: 01/27/2023]
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24
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Eskander MF, Bliss LA, Tseng JF. Pancreatic adenocarcinoma. Curr Probl Surg 2016; 53:107-54. [DOI: 10.1067/j.cpsurg.2016.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/04/2016] [Indexed: 12/17/2022]
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25
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Tevis SE, Weber SM, Kent KC, Kennedy GD. Nomogram to Predict Postoperative Readmission in Patients Who Undergo General Surgery. JAMA Surg 2015; 150:505-10. [PMID: 25902340 DOI: 10.1001/jamasurg.2014.4043] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
IMPORTANCE The Centers for Medicare and Medicaid Services have implemented penalties for hospitals with above-average readmission rates under the Hospital Readmissions Reductions Program. These changes will likely be extended to affect postoperative readmissions in the future. OBJECTIVES To identify variables that place patients at risk for readmission, develop a predictive nomogram, and validate this nomogram. DESIGN, SETTING, AND PARTICIPANTS Retrospective review and prospective validation of a predictive nomogram. A predictive nomogram was developed with the linear predictor method using the American College of Surgeons National Surgical Quality Improvement Program database paired with institutional billing data for patients who underwent nonemergent inpatient general surgery procedures. The nomogram was developed from August 1, 2006, through December 31, 2011, in 2799 patients and prospectively validated from November 1, 2013, through December 19, 2013, in 255 patients at a single academic institution. Area under the curve and positive and negative predictive values were calculated. MAIN OUTCOMES AND MEASURES The outcome of interest was readmission within 30 days of discharge following an index hospitalization for a surgical procedure. RESULTS Bleeding disorder (odds ratio, 2.549; 95% CI, 1.464-4.440), long operative time (odds ratio, 1.601; 95% CI, 1.186-2.160), in-hospital complications (odds ratio, 16.273; 95% CI, 12.028-22.016), dependent functional status, and the need for a higher level of care at discharge (odds ratio, 1.937; 95% CI, 1.176-3.190) were independently associated with readmission. The nomogram accurately predicted readmission (C statistic = 0.756) in a prospective evaluation. The negative predictive value was 97.9% in the prospective validation, while the positive predictive value was 11.1%. CONCLUSIONS AND RELEVANCE Development of an online calculator using this predictive model will allow us to identify patients who are at high risk for readmission at the time of discharge. Patients with increased risk may benefit from more intensive postoperative follow-up in the outpatient setting.
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Affiliation(s)
- Sarah E Tevis
- Department of Surgery, University of Wisconsin, Madison
| | | | - K Craig Kent
- Department of Surgery, University of Wisconsin, Madison
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Butterfield R, Stedman W, Herod R, Aneman A. Does adding ICU data to the POSSUM score improve the prediction of outcomes following surgery for upper gastrointestinal malignancies? Anaesth Intensive Care 2015; 43:490-6. [PMID: 26099762 DOI: 10.1177/0310057x1504300412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Surgery for upper gastrointestinal malignancy carries a high postoperative mortality and morbidity risk. The importance of preoperative physiological reserve and intraoperative events in determining clinical outcomes is recognised in the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) score that comprises variables relevant to both phases. Whether adding variables linked to ICU admission characteristics improves the predictive capacity of POSSUM is unclear, especially in an Australian/New Zealand healthcare context. This study aimed to evaluate the predictive capacity of the POSSUM score for 30-day mortality and in-hospital morbidity in 80 patients undergoing resection of oesophageal (28%), gastric (26%) or pancreatic (46%) malignancies and admitted to ICU. The 30-day mortality was 8.8% and 65% of patients developed some postoperative complication. Receiver operating characteristics generated an area under the curve (95% CI) to predict mortality by Portsmouth POSSUM of 0.87 (0.77 to 0.93) and morbidity by POSSUM of 0.67 (0.55 to 0.77). Multiple regression analysis including biochemical variables and vital signs on admission to ICU identified renal function parameters, fluid balance and need for cardiorespiratory support beyond the first postoperative day as independent factors associated with mortality and morbidity (in addition to the POSSUM score) but the inclusion of these variables in a logistic regression model did not significantly improve the predictive capacity for mortality (to area under the curve 0.93 [0.85 to 0.97]) or morbidity (to area under the curve 0.67 [0.55 to 0.78]). In conclusion, the POSSUM score provides clinically useful predictive capacity in patients undergoing surgery for upper gastrointestinal malignancies. The incorporation of ICU admission variables to the pre- and intraoperative POSSUM variables did not significantly enhance the precision.
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Affiliation(s)
- R Butterfield
- Senior Registrar, Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, New South Wales
| | - W Stedman
- Consultant VMO, Intensive Care Unit, Princess Alexandria Hospital, Brisbane, Queensland
| | - R Herod
- Senior Registrar, Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, New South Wales
| | - A Aneman
- Senior Staff Specialist, Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District and Associate Professor, University of New South Wales, Western Sydney Clinical School, Sydney, New South Wales
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Assessing surgical quality: comparison of general and procedure-specific morbidity estimation models for the risk adjustment of pancreaticoduodenectomy outcomes. World J Surg 2015; 38:2412-21. [PMID: 24705780 DOI: 10.1007/s00268-014-2554-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The use of outcomes to evaluate surgical quality implies the need for detailed risk adjustment. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a generally applicable risk adjustment model suitable for pancreatic surgery. A pancreaticoduodenectomy (PD)-specific intraoperative pancreatic risk assessment (IPRA) estimates the risk of postoperative pancreatic fistula (POPF) and associated morbidity based on factors that are not incorporated into POSSUM. OBJECTIVE The aim of the study was to compare the risk estimations of POSSUM and IPRA in patients undergoing PD. METHODS An observational single-center cohort study was conducted including 195 patients undergoing PD in 2008-2010. POSSUM and IPRA data were recorded prospectively. Incidence and severity of postoperative morbidity was recorded according to established definitions. The cohort was grouped by POSSUM and IPRA risk groups. The estimated and observed outcomes and morbidity profiles of POSSUM and IPRA were scrutinized. RESULTS POSSUM-estimated risk (62 %) corresponded with observed total morbidity (65 %). Severe morbidity was 17 % and in-hospital-mortality 3.1 %. Individual and grouped POSSUM risk estimates did not reveal associations with incidence (p = 0.637) or severity (p = 0.321) of total morbidity or POPF. The IPRA model identified patients with high POPF risk (p < 0.001), but was even associated with incidence (p < 0.001) and severity (p < 0.001) of total morbidity. CONCLUSION The risk factors defined by a PD-specific model were significantly stronger predictive indicators for the incidence and severity of postoperative morbidity than the factors incorporated in POSSUM. If available, reliable procedure-specific risk factors should be utilized in the risk adjustment of surgical outcomes. For pancreatic surgery, generally applicable tools such as POSSUM still have to prove their relevance.
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Bliss LA, Witkowski ER, Yang CJ, Tseng JF. Outcomes in operative management of pancreatic cancer. J Surg Oncol 2014; 110:592-8. [PMID: 25111970 DOI: 10.1002/jso.23744] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 06/18/2014] [Indexed: 12/18/2022]
Abstract
Pancreatic cancer is a highly lethal malignancy that often presents at an advanced stage. Surgical resection can prolong survival and offers the only potential for cure. However, pancreatectomy is associated with significant morbidity and mortality. This article reviews perioperative outcomes, post-resection long-term survival, and innovations in the surgical management of pancreatic cancer.
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Affiliation(s)
- Lindsay A Bliss
- Department of Surgery and Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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29
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Rückert F, Kuhn M, Scharm R, Endig H, Kersting S, Klein F, Bahra M, Rückert W, Wilhelm TJ, Niedergethmann M, Grützmann R. Evaluation of POSSUM for Patients Undergoing Pancreatoduodenectomy. J INVEST SURG 2014; 27:338-48. [DOI: 10.3109/08941939.2014.932475] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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30
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Wang H, Wang H, Chen T, Liang X, Song Y, Wang J. Evaluation of the POSSUM, P-POSSUM and E-PASS scores in the surgical treatment of hilar cholangiocarcinoma. World J Surg Oncol 2014; 12:191. [PMID: 24961847 PMCID: PMC4079624 DOI: 10.1186/1477-7819-12-191] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 06/08/2014] [Indexed: 02/08/2023] Open
Abstract
Background The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model, its Portsmouth (P-POSSUM) modification and the Estimation of physiologic ability and surgical stress (E-PASS) are three surgical risk scoring systems used extensively to predict postoperative morbidity and mortality in general surgery. The aim was to undertake the first study of the predictive value of these models in patients undergoing surgical treatment of hilar cholangiocarcinoma. Methods A retrospective analysis was performed on data collected prospectively over a 10-year interval from January 2003 to December 2012. The morbidity and mortality risks were calculated using the POSSUM, P-POSSUM and E-PASS equations. Results One hundred patients underwent surgical treatment of hilar cholangiocarcinoma. Complications were seen in 52 of 100 patients (52.0%). There were 10 postoperative in-hospital deaths (10.0%). Of 31 preoperative and intraoperative variables studied, operative type (P = 0.000), preoperative serum albumin (P = 0.003) and aspartate aminotransferase (P = 0.029) were found to be factors multivariate associated with postoperative complications. Intraoperative blood loss (P = 0.015), Bismuth-Corlette classification (P = 0.033) and preoperative hemoglobin (P = 0.041) were independent factors multivariate associated with in-hospital death. The POSSUM system predicted morbidity risk effectively with no significant lack of fit (P = 0.488) and an area under the ROC curve (AUC) of 0.843. POSSUM, P-POSSUM and E-PASS scores showed no significant lack of fit in calculating the mortality risk (P >0.05) and all yielded an AUC value exceeding 0.8. POSSUM had significantly more accuracy in predicting morbidity after major and major plus operations (O:E (observed/expected) ratio 0.98 and AUC 0.901) than after minor and moderate operations (O:E ratio 1.13 and AUC 0.759). Conclusions POSSUM, P-POSSUM and E-PASS scores effectively predict morbidity and mortality in surgical treatment of hilar cholangiocarcinoma. However, improvements are still needed in the future because none of these scoring systems yielded an AUC value exceeding 0.9 for operations with all different levels of severity. Only POSSUM had more accuracy in predicting postoperative morbidity after operations with higher severity. Trial registration This study was undertaken after obtaining approval from the ethics committee of School of Medicine, Shanghai Jiao Tong University with a trial registration number of http://09411960800.
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Affiliation(s)
| | | | | | | | | | - Jian Wang
- Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 S, Dongfang Road, Shanghai 200127, China.
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Haga Y, Wada Y, Saitoh T, Takeuchi H, Ikejiri K, Ikenaga M. Value of general surgical risk models for predicting postoperative morbidity and mortality in pancreatic resections for pancreatobiliary carcinomas. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:599-606. [PMID: 24648305 DOI: 10.1002/jhbp.105] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The present study evaluated the utility of general surgical risk models to predict postoperative morbidity and mortality in the specialty field of pancreatic resections for pancreatobiliary carcinomas. METHODS We investigated Estimation of Physiologic Ability and Surgical Stress (E-PASS), its modified version (mE-PASS), and Portsmouth Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in 231 patients undergoing pancreatoduodenectomy or distal pancreatectomy (Group A). We also analyzed E-PASS and mE-PASS in another cohort of the same procedures (Group B, n = 313). RESULTS Areas under the receiver operating characteristic curve (AUC) for detecting in-hospital mortality in Group A were moderate at 0.75 for E-PASS, 0.69 for mE-PASS, and 0.69 for P-POSSUM. The predicted mortality rates of the models significantly correlated with severity of postoperative complications (ρ = 0.17, P = 0.011 for E-PASS; ρ = 0.15, and P = 0.027 for P-POSSUM). The AUCs were also moderate in Group B at 0.68 for E-PASS and 0.69 for mE-PASS. The predicted mortality rates significantly correlated with severity of postoperative complications (ρ = 0.18, P = 0.0018 for E-PASS; ρ = 0.17, and P = 0.0022 for mE-PASS). CONCLUSIONS The present study suggests that the predictive powers of general risk models may be moderate in pancreatic resections. A novel model would be desirable for these procedures.
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Affiliation(s)
- Yoshio Haga
- Institute for Clinical Research, National Hospital Organization Kumamoto Medical Center, 1-5 Ninomaru, Chuo-ku, Kumamoto, 860-0008, Japan; Department of International Medical Cooperation, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
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Tzeng CWD, Tran Cao HS, Lee JE, Pisters PWT, Varadhachary GR, Wolff RA, Abbruzzese JL, Crane CH, Evans DB, Wang H, Abbott DE, Vauthey JN, Aloia TA, Fleming JB, Katz MHG. Treatment sequencing for resectable pancreatic cancer: influence of early metastases and surgical complications on multimodality therapy completion and survival. J Gastrointest Surg 2014; 18:16-24; discussion 24-5. [PMID: 24241967 DOI: 10.1007/s11605-013-2412-1] [Citation(s) in RCA: 146] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 11/01/2013] [Indexed: 02/03/2023]
Abstract
Barriers to multimodality therapy (MMT) completion among patients with resectable pancreatic adenocarcinoma include early cancer progression and postoperative major complications (PMC). We sought to evaluate the influence of these factors on MMT completion rates of patients treated with neoadjuvant therapy (NT) and surgery-first (SF) approaches. We evaluated all operable patients treated for clinically resectable pancreatic head adenocarcinoma at our institution from 2002 to 2007. Rates of MMT completion, 90-day PMC, and overall survival (OS) were evaluated. Ninety-five of 115 (83 %) NT and 29/50 (58 %) SF patients completed MMT. Patients who completed MMT lived longer than those who did not (36 vs. 11 months, p < 0.001). The most common reason that NT (11 %) and SF (26 %) patients failed to complete MMT was early disease progression. The rates of PMC among NT and SF patients were similar. Among SF patients, 69 % with no PMC completed MMT versus 29 % after PMC (p = 0.040). PMC were associated with decreased OS in SF patients but not in NT patients. The impact of early cancer progression and PMC upon completion of MMT is reduced by delivery of nonoperative therapies prior to pancreaticoduodenectomy. NT sequencing is a practical treatment strategy, particularly for patients at high biological or perioperative risk.
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Lee DY, Schwartz JA, Wexelman B, Kirchoff D, Yang KC, Attiyeh F. Outcomes of pancreaticoduodenectomy for pancreatic malignancy in octogenarians: an American College of Surgeons National Surgical Quality Improvement Program analysis. Am J Surg 2013; 207:540-8. [PMID: 24560585 DOI: 10.1016/j.amjsurg.2013.07.042] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 06/18/2013] [Accepted: 07/06/2013] [Indexed: 01/03/2023]
Abstract
BACKGROUND Most series analyzing outcomes of pancreaticoduodenectomy in octogenarians are limited by a small sample size. The investigators used the American College of Surgeons National Surgical Quality Improvement Program database for an analysis of the impact of advanced age on outcomes after pancreatic cancer surgery. METHODS The National Surgical Quality Improvement Program database from 2005 to 2010 was accessed to study the outcomes of 475 pancreaticoduodenectomies performed in patients ≥80 years of age compared with 4,102 patients <80 years of age using chi-square and Student's t tests. A multivariate logistic regression was used to analyze factors associated with 30-day mortality and the occurrence of major complications. RESULTS Octogenarians had significantly more preoperative comorbidities compared with patients <80 years of age. On multivariate analysis, age ≥80 years was associated with an increased likelihood of experiencing 30-day mortality and major complications compared with patients <80 years of age. On subgroup analysis, septuagenarians had a similar odds ratio of experiencing mortality or complications compared with octogenarians, whereas patients <70 years of age were at lower risk. CONCLUSIONS Although octogenarians have an increased risk for mortality and major complications compared with patients <80 years of age, on subgroup analysis, they do not differ from septuagenarians.
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Affiliation(s)
- David Y Lee
- Department of Surgery, St. Luke's-Roosevelt Hospital Center, 1000 10th Avenue, New York, NY 10019, USA.
| | - Jamie A Schwartz
- Department of Surgery, St. Luke's-Roosevelt Hospital Center, 1000 10th Avenue, New York, NY 10019, USA
| | - Barbara Wexelman
- Department of Surgery, St. Luke's-Roosevelt Hospital Center, 1000 10th Avenue, New York, NY 10019, USA
| | - Daniel Kirchoff
- Department of Surgery, St. Luke's-Roosevelt Hospital Center, 1000 10th Avenue, New York, NY 10019, USA
| | - Kevin C Yang
- Department of Surgery, St. Luke's-Roosevelt Hospital Center, 1000 10th Avenue, New York, NY 10019, USA
| | - Fadi Attiyeh
- Department of Surgery, St. Luke's-Roosevelt Hospital Center, 1000 10th Avenue, New York, NY 10019, USA
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Chandrabalan VV, McMillan DC, Carter R, Kinsella J, McKay CJ, Carter CR, Dickson EJ. Pre-operative cardiopulmonary exercise testing predicts adverse post-operative events and non-progression to adjuvant therapy after major pancreatic surgery. HPB (Oxford) 2013; 15:899-907. [PMID: 23458160 PMCID: PMC4503288 DOI: 10.1111/hpb.12060] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 11/12/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgery followed by chemotherapy is the primary modality of cure for patients with resectable pancreatic cancer but is associated with significant morbidity. The aim of the present study was to evaluate the role of cardiopulmonary exercise testing (CPET) in predicting post-operative adverse events and fitness for chemotherapy after major pancreatic surgery. METHODS Patients who underwent a pancreaticoduodenectomy or total pancreatectomy for pancreatic head lesions and had undergone pre-operative CPET were included in this retrospective study. Data on patient demographics, comorbidity and results of pre-operative evaluation were collected. Post-operative adverse events, hospital stay and receipt of adjuvant therapy were outcome measures. RESULTS One hundred patients were included. Patients with an anaerobic threshold less than 10 ml/kg/min had a significantly greater incidence of a post-operative pancreatic fistula [International Study Group for Pancreatic Surgery (ISGPS) Grades A-C, 35.4% versus 16%, P = 0.028] and major intra-abdominal abscesses [Clavien-Dindo (CD) Grades III-V, 22.4% versus 7.8%, P = 0.042] and were less likely to receive adjuvant therapy [hazard ratio (HR) 6.30, 95% confidence interval (CI) 1.25-31.75, P = 0.026]. A low anaerobic threshold was also associated with a prolonged hospital stay (median 20 versus 14 days, P = 0.005) but not with other adverse events. DISCUSSION CPET predicts a post-operative pancreatic fistula, major intra-abdominal abscesses as well as length of hospital stay after major pancreatic surgery. Patients with a low anaerobic threshold are less likely to receive adjuvant therapy.
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Affiliation(s)
- Vishnu V Chandrabalan
- Academic Department of Surgery, University of GlasgowGlasgow, UK,Correspondence, Vishnu V. Chandrabalan, Academic Unit of Surgery, School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow G31 2ER, UK. Tel: +44 141 211 5435. Fax: +44 141 552 3229. E-mail:
| | | | - Roger Carter
- Department of Respiratory Medicine, Glasgow Royal InfirmaryGlasgow, UK
| | - John Kinsella
- Section of Anaesthesia, Glasgow Royal InfirmaryGlasgow, UK
| | - Colin J McKay
- West of Scotland Pancreatic Unit, Glasgow Royal InfirmaryGlasgow, UK
| | - C Ross Carter
- West of Scotland Pancreatic Unit, Glasgow Royal InfirmaryGlasgow, UK
| | - Euan J Dickson
- West of Scotland Pancreatic Unit, Glasgow Royal InfirmaryGlasgow, UK
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McAuliffe JC, Parks K, Kumar P, McNeal SF, Morgan DE, Christein JD. Computed tomography attenuation and patient characteristics as predictors of complications after pancreaticoduodenectomy. HPB (Oxford) 2013; 15:709-15. [PMID: 23458275 PMCID: PMC3948539 DOI: 10.1111/hpb.12037] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 11/24/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Morbidity after pancreaticoduodenectomy (PD) remains high. Computed tomography (CT) of intra-abdominal tissue has not been thoroughly evaluated to establish associations with the occurrence of complications after PD. The current study sought to determine whether differences in non-enhanced visceral attenuation predicted complications after PD. METHODS Outcomes in patients undergoing PD were analysed according to the Clavien system for classifying complications and the International Study Group on Pancreatic Fistula system for classifying postoperative pancreatic fistula (POPF). Preoperative non-enhanced CT scans were evaluated by a blinded investigator for attenuation of abdominal viscera and fat thickness. Data on pancreatic firmness and pancreatic duct size were collected. Univariate and multivariate analyses were performed. RESULTS A total of 134 patients underwent PD for malignant and benign disease. Rates of morbidity, mortality and POPF at 90 days were 61%, 4% and 23%, respectively. Patients with a body mass index of > 25 kg/m(2) had higher rates of POPF (P = 0.05) and complications (P < 0.01). In multivariate analysis, patients were more likely to develop any complication as CT attenuation decreased for paraspinus muscle (P < 0.01), spleen (P < 0.03) and liver (P = 0.01) parenchyma. CONCLUSIONS Postoperative complications after PD remain prevalent. Decreased CT attenuation of abdominal viscera is an independent predictor of morbidity after PD and suggests a high-risk patient physiology for pancreatic resection.
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Affiliation(s)
- John C McAuliffe
- Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294-0016, USA
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Abstract
Tumorigenesis of pancreatic cancer (PC) and the pathophysiology of type 2 diabetes mellitus (DM2) are emerging as intertwined pathways. As the operative morbidity and mortality of pancreatectomy has improved, incidence has increased and survival has remained mostly unchanged. The diagnosis of DM2 suggests pancreatic dysfunction and possible early carcinogenesis. DM2 is a significant comorbidity predicting worse outcomes in patients undergoing pancreatic resection as part of the treatment of PC. This article examines this phenomena and suggests possible approaches to screening and diagnosis.
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Affiliation(s)
- John C McAuliffe
- Department of Surgery, The Kirklin Clinic, UAB Medical Center, 1802 6th Avenue South, Birmingham, AL 35294, USA
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Chen T, Wang H, Wang H, Song Y, Li X, Wang J. POSSUM and P-POSSUM as predictors of postoperative morbidity and mortality in patients undergoing hepato-biliary-pancreatic surgery: a meta-analysis. Ann Surg Oncol 2013; 20:2501-10. [PMID: 23435569 DOI: 10.1245/s10434-013-2893-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) models are used extensively to predict postoperative morbidity and mortality in general surgery. The aim was to undertake the first meta-analysis of the predictive value of these models in patients undergoing hepato-biliary-pancreatic surgery. METHODS Eligible articles were identified by searches of electronic databases from 1991 to 2012. All data were specific to hepato-biliary-pancreatic surgery. Predictive value of morbidity and mortality were assessed by calculating weighted observed to expected (O/E) ratios. Subanalysis was also performed. RESULTS Sixteen studies were included in final review. The morbidity analysis included nine studies on POSSUM with a weighted O/E ratio of 0.78 [95 % confidence interval (CI) 0.68-0.88]. The mortality analysis included seven studies on POSSUM and nine studies on P-POSSUM (Portsmouth predictor equation for mortality). Weighted O/E ratios for mortality were 0.35 (95 % CI 0.17-0.54) for POSSUM and 0.95 (95 % CI 0.65-1.25) for P-POSSUM. POSSUM had more accuracy to predict morbidity after pancreatic surgery (O/E ratio 0.82; 95 % CI 0.72-0.92) than after hepatobiliary surgery (O/E ratio 0.66; 95 % CI 0.57-0.74), in large sample size studies (O/E ratio 0.90; 95 % CI 0.85-0.96) than in small sample size studies (O/E ratio 0.69; 95 % CI 0.59-0.79). CONCLUSIONS POSSUM overpredicted postoperative morbidity after hepato-biliary-pancreatic surgery. Predictive value of POSSUM to morbidity was affected by the type of surgery and the sample size of studies. Compared with POSSUM, P-POSSUM was more accurate for predicting postoperative mortality. Modifications to POSSUM and P-POSSUM are needed for audit in hepato-biliary-pancreatic surgery.
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Affiliation(s)
- Tao Chen
- Department of General Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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A systematic review of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity and its Portsmouth modification as predictors of post-operative morbidity and mortality in patients undergoing pancreatic surgery. Am J Surg 2013; 205:466-72. [PMID: 23395580 DOI: 10.1016/j.amjsurg.2012.06.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Revised: 05/20/2012] [Accepted: 06/08/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model and its Portsmouth modification (P-POSSUM) are used extensively to predict postoperative mortality and morbidity in general surgery. The aim of this study was to undertake the first systematic review of the predictive value of these models in patients undergoing pancreatic surgery. METHODS Eligible articles were identified by searches of electronic databases for those published from 1991 to 2012. Two independent reviewers assessed each study against inclusion and exclusion criteria. All data were specific to pancreatic surgery. Predictive value of morbidity and mortality were assessed by calculating observed/expected ratios. RESULTS Nine studies were included in the final review. The morbidity analysis included 8 studies (1,734 patients) of POSSUM with a weighted observed/expected ratio of .85. The mortality analysis included 5 studies (936 patients) of POSSUM and 4 studies (716 patients) of P-POSSUM. Weighted observed/expected ratios for mortality were .35 for POSSUM and 1.39 for P-POSSUM. CONCLUSIONS POSSUM overpredicted postoperative morbidity in patients undergoing pancreatic surgery. Both POSSUM and P-POSSUM failed to offer significant predictive value for mortality in pancreatic surgery, and more data collection in large populations undergoing pancreatic surgery are needed.
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Ying L, Bo B, Huo-Yan W, Hong Z. Evaluation of a Modified POSSUM Scoring System for Predicting the Morbidity in Patients Undergoing Lumbar Surgery. Indian J Surg 2013; 76:212-6. [PMID: 25177119 DOI: 10.1007/s12262-013-0840-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 01/16/2013] [Indexed: 10/27/2022] Open
Abstract
For most spine surgeons, operative intervention is common for the treatment of lumbar disc herniation, lumbar stenosis, lumbar fracture or lumbar spondylolisthesis. However, with the increase in lumbar surgery, the complication rate increases accordingly. Whereas the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system has been widely used to predict morbidity in various surgical fields, the application of this system in lumbar surgery has not been reported. From January 2008 to January 2010, we recruited 158 patients (85 males and 73 females) with operation for lumbar disc herniation, lumbar stenosis, lumbar fracture, or lumbar spondylolisthesis. All patients were analyzed to compare the morbidity by a modified POSSUM scoring system. According to the modified POSSUM, the expected morbidity was 51 cases (32.3 %), whereas the observed mortality was 42 cases (26.6 %). The overall observed-to-expected ratio was 0.82, and the chi-squared test indicated no statistically significant difference between the expected and observed morbidities (χ (2) = 1.23, P = 0.27), suggesting that the modified POSSUM can accurately estimate the outcome. The modified POSSUM scoring system we developed is a useful tool for predicting and evaluating morbidity in lumbar surgery. Further studies are required to investigate whether this scoring system can predict mortality.
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Affiliation(s)
- Li Ying
- Department of Orthopaedics, Guangdong Hospital of Integrated Traditional and Western Medicine, Foshan, Guangdong 528200 People's Republic of China
| | - Bai Bo
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou Medical College, Guangzhou, Guangdong 510120 People's Republic of China
| | - Wu Huo-Yan
- Department of Orthopaedics, Guangdong Hospital of Integrated Traditional and Western Medicine, Foshan, Guangdong 528200 People's Republic of China
| | - Zhuang Hong
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405 People's Republic of China
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Lewis RS, Vollmer CM. Risk scores and prognostic models in surgery: pancreas resection as a paradigm. Curr Probl Surg 2013; 49:731-95. [PMID: 23131540 DOI: 10.1067/j.cpsurg.2012.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Lewis R, Drebin JA, Callery MP, Fraker D, Kent TS, Gates J, Vollmer CM. A contemporary analysis of survival for resected pancreatic ductal adenocarcinoma. HPB (Oxford) 2013; 15:49-60. [PMID: 23216779 PMCID: PMC3533712 DOI: 10.1111/j.1477-2574.2012.00571.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Accepted: 08/15/2012] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Survival after a resected pancreatic ductal adenocarcinoma (PDAC) appears to be improving. Yet, in spite of advancements, prognosis remains disappointing. This study analyses a contemporary experience and identifies features associated with survival. METHODS Kaplan-Meier analysis was conducted for 424 PDAC resections performed at two institutions (2001-2011). Multivariate analysis was performed to elicit characteristics independently associated with survival. RESULTS The median, 1-, and 5-year survivals were 21.3 m, 76%, and 23%, with 30/90-day mortalities of 0.7%/1.7%. 76% of patients received adjuvant therapy. Patients with major complications (Clavien Grade IIIb-IV) survived equivalently to patients with no complications (P = 0.33). The median and 5-year survival for a total pancreatectomy was 32.2 m/49%; for 90 'favourable biology' patients (R0/N0/M0) was 37.3 m/40%; and for IPMN (9% of series) was 21.2 m/46%. Elderly (>75 yo) and nonelderly patients had similar survival. Favorable prognostic features by multivariate analysis include lower POSSUM physiology score, R0 resection, absence of operative transfusion, G1/G2 grade, absence of lymphovascular invasion, T1/T2 stage, smaller tumor size, LN ratio <0.3, and receipt of adjuvant therapy. CONCLUSION This experience with resected PDAC shows decreasing morbidity and mortality rates along with modestly improving long-term survival, particularly for certain subgroups of patients. Survival is related to pathological features, pre-operative physiology, operative results and adjuvant therapy.
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Affiliation(s)
- Russell Lewis
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, 19104, USA
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Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg 2012; 216:1-14. [PMID: 23122535 DOI: 10.1016/j.jamcollsurg.2012.09.002] [Citation(s) in RCA: 831] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 09/05/2012] [Accepted: 09/05/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistulas (CR-POPF) are serious inherent risks of pancreatic resection. Preoperative CR-POPF risk assessment is currently inadequate and rarely disqualifies patients who need resection. The best evaluation of risk occurs intraoperatively, and should guide fistula prevention and response measures thereafter. We sought to develop a risk prediction tool for CR-POPF that features intraoperative assessment and reveals associated clinical and economic significance. STUDY DESIGN Based on International Study Group of Pancreatic Fistula classification, recognized risk factors for CR-POPF (small duct, soft pancreas, high-risk pathology, excessive blood loss) were evaluated during pancreaticoduodenectomy. An optimal risk score range model, selected from 3 different constructs, was first derived (n = 233) and then validated prospectively (n = 212). Clinical and economic outcomes were evaluated across 4 ranges of scores (negligible risk, 0 points; low risk, 1 to 2; intermediate risk, 3 to 6; high risk, 7 to 10). RESULTS Clinically relevant postoperative pancreatic fistulas occurred in 13% of patients. The incidence was greatest with excessive blood loss. Duct size <5 mm was associated with increased fistula rates that rose with even smaller ducts. These factors, together with soft pancreatic parenchyma and certain disease pathologies, afforded a highly predictive 10-point Fistula Risk Score. Risk scores strongly correlated with fistula development (p < 0.001). Notably, patients with scores of 0 points never developed a CR-POPF, while fistulas occurred in all patients with scores of 9 or 10. Other clinical and economic outcomes segregated by risk profile across the 4 risk strata. CONCLUSIONS A simple 10-point Fistula Risk Score derived during pancreaticoduodenectomy accurately predicts subsequent CR-POPF. It can be readily learned and broadly deployed. This prediction tool can help surgeons anticipate, identify, and manage this ominous complication from the outset.
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Affiliation(s)
- Mark P Callery
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Witkowski ER, Smith JK, Tseng JF. Outcomes following resection of pancreatic cancer. J Surg Oncol 2012; 107:97-103. [PMID: 22991309 DOI: 10.1002/jso.23267] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 08/27/2012] [Indexed: 12/11/2022]
Abstract
Pancreatic cancer is an aggressive and highly lethal malignancy. Surgical resection is a modest tool, but it provides the only potential for curative therapy and often prolongs survival. This article reviews the progress made on both local and national levels towards an era of safer pancreatic surgery, while discussing both perioperative outcomes and long-term survival after resection.
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Affiliation(s)
- Elan R Witkowski
- Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Ragulin-Coyne E, Carroll JE, Smith JK, Witkowski ER, Ng SC, Shah SA, Zhou Z, Tseng JF. Perioperative mortality after pancreatectomy: A risk score to aid decision-making. Surgery 2012; 152:S120-7. [DOI: 10.1016/j.surg.2012.05.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 05/11/2012] [Indexed: 01/26/2023]
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Peng P, Hyder O, Firoozmand A, Kneuertz P, Schulick RD, Huang D, Makary M, Hirose K, Edil B, Choti MA, Herman J, Cameron JL, Wolfgang CL, Pawlik TM. Impact of sarcopenia on outcomes following resection of pancreatic adenocarcinoma. J Gastrointest Surg 2012; 16:1478-86. [PMID: 22692586 PMCID: PMC3578313 DOI: 10.1007/s11605-012-1923-5] [Citation(s) in RCA: 416] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 05/30/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Assessing patient-specific risk factors for long-term mortality following resection of pancreatic adenocarcinoma can be difficult. Sarcopenia--the measurement of muscle wasting--may be a more objective and comprehensive patient-specific factor associated with long-term survival. METHODS Total psoas area (TPA) was measured on preoperative cross-sectional imaging in 557 patients undergoing resection of pancreatic adenocarcinoma between 1996 and 2010. Sarcopenia was defined as the presence of a TPA in the lowest sex-specific quartile. The impact of sarcopenia on 90-day, 1-year, and 3-year mortality was assessed relative to other clinicopathological factors. RESULTS Mean patient age was 65.7 years and 53.1 % was male. Mean TPA among men (611 mm²/m²) was greater than among women (454 mm²/m²). Surgery involved pancreaticoduodenectomy (86.0 %) or distal pancreatectomy (14.0 %). Mean tumor size was 3.4 cm; 49.9 % and 88.5 % of patients had vascular and perineural invasion, respectively. Margin status was R0 (59.0 %) and 77.7 % patients had lymph node metastasis. Overall 90-day mortality was 3.1 % and overall 1- and 3-year survival was 67.9 % and 35.7 %, respectively. Sarcopenia was associated with increased risk of 3-year mortality (HR = 1.68; P < 0.001). Tumor-specific factors such as poor differentiation on histology (HR = 1.75), margin status (HR = 1.66), and lymph node metastasis (HR = 2.06) were associated with risk of death at 3-years (all P < 0.001). After controlling for these factors, sarcopenia remained independently associated with an increased risk of death at 3 years (HR = 1.63; P < 0.001). CONCLUSIONS Sarcopenia was a predictor of survival following pancreatic surgery, with sarcopenic patients having a 63 % increased risk of death at 3 years. Sarcopenia was an objective measure of patient frailty that was strongly associated with long-term outcome independent of tumor-specific factors.
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Affiliation(s)
- Peter Peng
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Omar Hyder
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amin Firoozmand
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter Kneuertz
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard D. Schulick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Donghang Huang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Martin Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenzo Hirose
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Barish Edil
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael A. Choti
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph Herman
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John L. Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Timothy M. Pawlik
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Surgery, Johns Hopkins University School of Medicine, Harvey 611 600 N. Wolfe Street, Baltimore, MD 21287, USA
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Assifi MM, Lindenmeyer J, Leiby BE, Grunwald Z, Rosato EL, Kennedy EP, Yeo CJ, Berger AC. Surgical Apgar score predicts perioperative morbidity in patients undergoing pancreaticoduodenectomy at a high-volume center. J Gastrointest Surg 2012; 16:275-81. [PMID: 22033701 DOI: 10.1007/s11605-011-1733-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 10/12/2011] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Pancreaticoduodenectomy (PD) remains a procedure that carries considerable morbidity. Numerous studies have evaluated factors to predict patients at risk. The aim of this study was to determine whether the surgical Apgar score (SAS) predicts perioperative morbidity and mortality. METHODS We examined 553 patients undergoing successful PD between January 2000 and December 2010. Postoperative complications were graded using the Clavien scale, and the SAS (range, 0-10) was determined. The Cochran-Armitage test for trend was used to determine the association between grouped SAS scores (0-2, 3-4, 5-6, 7-8, and 9-10) and each of the outcomes. RESULTS The average patient age was 64 years, and there was an even distribution of males and females. There were 11 perioperative deaths (2%), 186 grade 2 or higher complications (34%), and 86 major complications (grades 3-5, 16%). Additionally, 61 patients developed pancreatic fistulae (11%). Statistical analysis determined that SAS was a significant predictor of grade 2 or higher complications (p < 0.0001), major morbidity (p = 0.01), and pancreatic fistula (p = 0.04) but not mortality (p = 0.20). CONCLUSIONS We demonstrate that the SAS is a significant predictor of perioperative morbidity for patients undergoing PD. This score should be used to identify patients at higher risk in order to prioritize use of postoperative critical care beds and hospital resources.
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Affiliation(s)
- M Mura Assifi
- Department of Surgery and Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, 1100 Walnut Street, MOB, Suite 500, Philadelphia, PA 19107, USA
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Villodre C, Carbonell S, Espinosa J, Bravo JA, Zubiaga L, Rojas S, Abad R, Campos L, Alcázar C, Franco M, Estrada JL, Zapater P, Mena L, Lluís F. Evaluación del riesgo quirúrgico de 1.000 episodios consecutivos con el sistema POSSUM. Comparación entre cirugía gastrointestinal programada y urgente. Cir Esp 2012; 90:24-32. [DOI: 10.1016/j.ciresp.2011.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Revised: 05/30/2011] [Accepted: 06/19/2011] [Indexed: 11/24/2022]
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A root-cause analysis of mortality following major pancreatectomy. J Gastrointest Surg 2012; 16:89-102; discussion 102-3. [PMID: 22065319 DOI: 10.1007/s11605-011-1753-x] [Citation(s) in RCA: 171] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 10/13/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Although mortality rates from pancreatectomy have decreased worldwide, death remains an infrequent but profound event at an individual practice level. Root-cause analysis is a retrospective method commonly employed to understand adverse events. We evaluate whether emerging mortality risk assessment tools sufficiently predict and account for actual clinical events that are often identified by root-cause analysis. METHODS We assembled a Pancreatic Surgery Mortality Study Group comprised of 36 pancreatic surgeons from 15 institutions in 4 countries. Mortalities after pancreatectomy (30 and 90 days) were accrued from 2000 to 2010. For root-cause analysis, each surgeon "deconstructed" the clinical events preceding a death to determine cause. We next tested whether mortality risk assessment tools (ASA, POSSUM, Charlson, SOAR, and NSQIP) could predict those patients who would die (n = 218) and compared their prognostic accuracy against a cohort of resections in which no patient died (n = 1,177). RESULTS Two hundred eighteen deaths (184 Whipple's resection, 18 distal pancreatectomies, and 16 total pancreatectomies) were identified from 11,559 pancreatectomies performed by surgeons whose experience averaged 14.5 years. Overall 30- and 90-day mortalities were 0.96% and 1.89%, respectively. Individual surgeon rates ranged from 0% to 4.7%. Only 5 patients died intraoperatively, while the other 213 succumbed at a median of 29 days. Mean patient age was 70 years old (38% were >75 years old). Malignancy was the indication in 90% of cases, mostly pancreatic cancer (57%). Median operative time was 365 min and estimated blood loss was 700 cc (range, 100-16,000 cc). Vascular repair or multivisceral resections were required for 19.7% and 15.1%, respectively. Seventy-seven percent had a variety of major complications before death. Eighty-seven percent required intensive care unit care, 55% were transfused, and 35% were reoperated upon. Fifty percent died during the index admission, while another 11% died after a readmission. Almost half (n = 107) expired between 31 and 90 days. Only 11% had autopsies. Operation-related complications contributed to 40% of deaths, with pancreatic fistula being the most evident (14%). Technical errors (21%) and poor patient selection (15%) were cited by surgeons. Of deaths, 5.5% had associated cancer progression-all occurring between 31 and 90 days. Even after root-cause scrutiny, the ultimate cause of death could not be determined for a quarter of the patients-most often between 31 and 90 days. While assorted risk models predicted mortality with variable discrimination from nonmortalities, they consistently underestimated the actual mortality events we report. CONCLUSION Root-cause analysis suggests that risk prediction should include, if not emphasize, operative factors related to pancreatectomy. While risk models can distinguish between mortalities and nonmortalities in a collective fashion, they vastly miscalculate the actual chance of death on an individual basis. This study reveals the contributions of both comorbidities and aggressive surgical decisions to mortality.
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Regenbogen SE. Intraoperative Performance Evaluation in Colorectal Surgery. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Estimation of physiologic ability and surgical stress score does not predict immediate outcome after pancreatic surgery. Pancreas 2011; 40:723-9. [PMID: 21654545 DOI: 10.1097/mpa.0b013e318212c02c] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The Estimation of Physiologic Ability and Surgical Stress score was designed to predict postoperative morbidity and mortality in general surgery. Our study aims to evaluate its use and accuracy in estimating postoperative outcome after elective pancreatic surgery. METHODS Between 2002 and 2007, approximately 304 patients requiring pancreatic resection at our institution were recorded prospectively and evaluated retrospectively. The patients' preoperative risk score, surgical stress score (SSS), and comprehensive risk score (CRS) were calculated and compared with the severity of postoperative morbidity, where mortality was regarded as the most severe postoperative complication. RESULTS Observed and predicted mortality rates were 2.9% and 2.0%, respectively. Mean CRS was higher in patients who died than in patients that survived, but this difference was not statistically significant (P = 0.20). Preoperative risk score, SSS, and CRS did not differ between patients with and without complications (preoperative risk score: P = 0.32; SSS: P = 0.22; CRS: P = 0.13). Estimation of Physiologic Ability and Surgical Stress particularly underpredicted morbidity in patients with a CRS between 0.0 and less than 0.5. CONCLUSIONS The Estimation of Physiologic Ability and Surgical Stress scoring system is an ineffective predictor of complications after pancreatic resection. Further refinements to the score calculation are warranted to provide accurate prediction of immediate surgical outcome after pancreatic surgery.
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