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Alselaim NA, Alsemari MA, Alyabsi M, Al-Mutairi AM. Factors associated with 30-day mortality and morbidity in patients undergoing emergency colorectal surgery. Ann Saudi Med 2023; 43:364-372. [PMID: 38071441 PMCID: PMC11182427 DOI: 10.5144/0256-4947.2023.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The 30-day period following emergency colorectal surgery (ECRS) is associated with high mortality and morbidity. There is a lack of data assessing factors associated with outcomes of ECRS in the Saudi population. OBJECTIVES Assess factors associated with 30-day postoperative mortality and complications following ECRS. DESIGN Retrospective cohort study. SETTING Single tertiary care center, Riyadh, Saudi Arabia. PATIENTS AND METHODS Demographic characteristics (age, sex, diagnosis, American Society of Anesthesiologists classification, pre-operative septic state, smoking, and comorbidities), operative characteristics (urgency, diverting ostomy, and procedure performed), and postoperative characteristics (length of stay, 30-day mortality, intensive care unit [ICU] admission, ICU length of stay, surgical site infection [SSI], readmission, reoperation, and complications) were collected from electronic medical records. Univariate logistic regression was used to evaluate association with the outcome measures (30-day mortality and postoperative complications). Multivariate logistic regression was applied to evaluate independent variables. MAIN OUTCOME MEASURE Thirty-day postoperative mortality and morbidity. SAMPLE SIZE 241 patients. RESULTS Among 241 patients, 145 (60.2%) were men, and 80 (33.2%) patients were between 50-64 years of age. The most common indication for surgery was malignancy 138 (57%). The overall complication rate was 26.6% and the 30-day mortality rate was 11.2%. Left hemicolectomy was the most commonly performed procedure, performed in 69 (28.6%) patients. Patients between the age of 65-74 had an increased odds of death within 30 days (OR 5.25 [95% CI 1.03-26.5]) on univariate analysis. Preoperative sepsis was associated with a fourfold increase in the likelihood of 30-day mortality (OR 4.44, 95% CI 1.21-16.24, P=.024) on multivariate analysis. The likelihood of hospital re-admission increased by fivefold in patients who developed a postoperative complication (OR 5.33, 95% CI 1.30-21.78, P=.02). CONCLUSION Preoperative sepsis was independently associated with 30-day mortality in patients undergoing ECRS, while the likelihood of hospital readmission increased in patients with postoperative complications. Expeditious control of sepsis in the emergency surgical setting by both surgical and medical interventions may reduce the likelihood of postoperative mortality. Establishing discharge protocols for postoperative ECRS patients is advocated. LIMITATIONS Retrospective design, small sample size, and single setting.
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Affiliation(s)
- Nahar A. Alselaim
- From the Department of Surgery, King Abdulaziz Medical City, College of Medicine, King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia
| | | | - Mesnad Alyabsi
- From the Department of Population Health Research, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abrar M. Al-Mutairi
- From the Research Unit, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Portale G, Spolverato YC, Tonello AS, Bartolotta P, Frigo G, Simonetto M, Gregori D, Fiscon V. Which video technology brings the higher cognitive burden and motion sickness in laparoscopic colorectal surgery: 3D, 2D-4 K or 3D-4 K? a propensity score study. Int J Colorectal Dis 2023; 38:190. [PMID: 37428283 DOI: 10.1007/s00384-023-04491-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Technological development has offered laparoscopic colorectal surgeons new video systems to improve depth perception and perform difficult task in limited space. The aim of this study was to assess the cognitive burden and motion sickness for surgeons during 3D, 2D-4 K or 3D-4 K laparoscopic colorectal procedures and to report post-operative data with the different video systems employed. METHODS Patients were assigned to either 3D, 2D-4 K or 3D-4 K video and two questionnaires (Simulator Sickness Questionnaire-SSQ- and NASA Task Load Index -TLX) were used during elective laparoscopic colorectal resections (October 2020-August 2022) from two operating surgeons. Short-term results of the operations performed with the three different video systems were also analyzed. RESULTS A total of 113 consecutive patients were included: 41 (36%) in the 3D Group (A), 46 (41%) in the 3D-4 K Group and 26 (23%) in the 2D-4 K Group (C). Weighted and adjusted regression models showed no significant difference in cognitive load amongst the surgeons in the three groups of video systems when using the NASA-TLX. An increased risk for slight/moderate general discomfort and eyestrain in the 3D-4 K group compared with 2D-4 K group (OR = 3.5; p = 0.0057 and OR = 2.8; p = 0.0096, respectively) was observed. Further, slight/moderate difficulty focusing was lower in both 3D and 3D-4 K groups compared with 2D-4 K group (OR = 0.4; p = 0.0124 and OR = 0.5; p = 0.0341, respectively), and higher in the 3D-4 K group compared with 3D group (OR = 2.6; p = 0.0124). Patient population characteristics, operative time, post-operative staging, complication rate and length of stay were similar in the three groups of patients. CONCLUSIONS 3D and 3D-4 K systems, when compared with 2D-4 K video technology, have a higher risk for slight/moderate general discomfort and eyestrain, but show lower difficulty focusing. Short post-operative outcomes do not differ, whichever imaging system is used.
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Affiliation(s)
- Giuseppe Portale
- Department of General Surgery, Azienda Euganea ULSS 6, Via Casa di Ricovero, 40; 35013, Cittadella, Padua, Italy.
| | - Ylenia Camilla Spolverato
- Department of General Surgery, Azienda Euganea ULSS 6, Via Casa di Ricovero, 40; 35013, Cittadella, Padua, Italy
| | | | - Patrizia Bartolotta
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35121, Padua, Italy
| | - Gianfranco Frigo
- Department of Cardiology, Azienda Euganea ULSS 6, Cittadella, Italy
| | - Marco Simonetto
- Department of Neurology, Azienda Euganea ULSS 6, Cittadella, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, 35121, Padua, Italy
| | - Valentino Fiscon
- Department of General Surgery, Azienda Euganea ULSS 6, Via Casa di Ricovero, 40; 35013, Cittadella, Padua, Italy
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Portale G, Cavallin F, Cipollari C, Spolverato Y, Di Miceli D, Zuin M, Mazzeo A, Morabito A, Sava T, Fiscon V. Preoperative Prognostic Nutritional Index was not predictive of short-term complications after laparoscopic resection for rectal cancer. Langenbecks Arch Surg 2023; 408:263. [PMID: 37402015 DOI: 10.1007/s00423-023-02962-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 05/29/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND AND AIM Prognostic Nutritional Index (PNI) is a useful tool to predict short-term results in patients undergoing surgery for gastrointestinal cancer. Few studies have addressed this issue in colorectal cancer or specifically in rectal cancer. We evaluated the prognostic relevance of preoperative PNI on morbidity of patients undergoing laparoscopic curative resection for rectal cancer (LCRRC). METHODS PNI data and clinico-pathological characteristics of LCRRC patients (June 2005-December 2020) were evaluated. Patients with metastatic disease were excluded. Postoperative complications were evaluated using the Clavien-Dindo classification. RESULTS A total of 182 patients were included in the analysis. Median preoperative PNI was 36.5 (IQR 32.8-41.2). Lower PNI was associated with females (p=0.02), older patients (p=0.0002), comorbidity status (p<0.0001), and those who did not receive neoadjuvant treatment (p=0.01). Post-operative complications occurred in 53 patients (29.1%), by the Clavien-Dindo classification: 40 grades I-II and 13 grades III-V. Median preoperative PNI was 35.0 (31.8-40.0) in complicated patients and 37.0 (33.0-41.5) in uncomplicated patients (p=0.09). PNI showed poor discriminative performance regarding postoperative morbidity (AUC 0.57) and was not associated with postoperative morbidity (OR 0.97) at multivariable analysis. CONCLUSIONS Preoperative PNI was not associated with postoperative morbidity after LCRRC. Further research should focus on different nutritional indicators or hematological/immunological biomarkers.
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Affiliation(s)
- Giuseppe Portale
- Department of General Surgery, Azienda ULSS 6 'Euganea' Padova, Via Casa di Ricovero, 40, 35013, Cittadella, Padua, Italy.
| | | | - Chiara Cipollari
- Department of General Surgery, Azienda ULSS 6 'Euganea' Padova, Via Casa di Ricovero, 40, 35013, Cittadella, Padua, Italy
| | - Ylenia Spolverato
- Department of General Surgery, Azienda ULSS 6 'Euganea' Padova, Via Casa di Ricovero, 40, 35013, Cittadella, Padua, Italy
| | - Diletta Di Miceli
- Department of General Surgery, Azienda ULSS 6 'Euganea' Padova, Via Casa di Ricovero, 40, 35013, Cittadella, Padua, Italy
| | - Matteo Zuin
- Department of General Surgery, Azienda ULSS 6 'Euganea' Padova, Via Casa di Ricovero, 40, 35013, Cittadella, Padua, Italy
| | - Antonio Mazzeo
- Department of General Surgery, Azienda ULSS 6 'Euganea' Padova, Via Casa di Ricovero, 40, 35013, Cittadella, Padua, Italy
| | - Alberto Morabito
- Department of Oncology, Azienda ULSS 6 'Euganea', Cittadella, Italy
| | - Teodoro Sava
- Department of Oncology, Azienda ULSS 6 'Euganea', Cittadella, Italy
| | - Valentino Fiscon
- Department of General Surgery, Azienda ULSS 6 'Euganea' Padova, Via Casa di Ricovero, 40, 35013, Cittadella, Padua, Italy
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Portale G, Spolverato YC, Bartolotta P, Gregori D, Mazzeo A, Rettore C, Cancian L, Fiscon V. Skeletal Muscle Mass and Surgical Morbidity After Laparoscopic Rectal Cancer Resection. J Laparoendosc Adv Surg Tech A 2023. [PMID: 37130330 DOI: 10.1089/lap.2023.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
Background: Sarcopenia is a useful tool in predicting short-term results in patients undergoing surgery for gastrointestinal cancer. However, there are few studies addressing this issue in colorectal cancer, and even less specifically focused on rectal cancer. We evaluated the prognostic relevance of preoperative skeletal mass index on postoperative morbidity in patients undergoing laparoscopic curative resection for rectal cancer. Methods: Skeletal mass index data and clinicopathological characteristics of rectal cancer patients in a 15-year period (June 2005-December 2020) were evaluated; patients with metastatic disease at surgery were excluded; postoperative complications within 30 days were evaluated using the Clavien-Dindo classification. Results: A total of 166 patients were included in the study. The overall prevalence of sarcopenia was 60%. BMI, Hb, or albumin were not associated with sarcopenia. Hospital stay was not correlated with sarcopenia. Postoperative complications occurred in 51 patients (31%); by the Clavien-Dindo classification 31 (61%) grade I, 10 (14.5%) grade II, and 10 (14.5%) grade III. Overall complications were not significantly different in sarcopenic and nonsarcopenic patients (P = .10). Considering only patients with complications, sarcopenia was found to be a predictor of more severe postoperative morbidity (odds ratio 12.7, P = .021). On multivariable analysis, sarcopenia was not associated with postoperative morbidity. Conclusions: Skeletal muscle status in rectal cancer patients undergoing curative resection was not associated with overall postoperative morbidity, although there was a correlation between sarcopenia and more severe complications. Further studies in a larger cohort of patients are needed before conclusions can be drawn on the relationship between muscular depletion and surgical outcomes in rectal cancer patients.
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Affiliation(s)
- Giuseppe Portale
- Department of General Surgery, Azienda Euganea ULSS 6, Cittadella, Italy
| | | | - Patrizia Bartolotta
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Antonio Mazzeo
- Department of General Surgery, Azienda Euganea ULSS 6, Cittadella, Italy
| | - Carlo Rettore
- Department of Radiology, Azienda Euganea ULSS 6, Cittadella, Italy
| | - Luca Cancian
- Department of Radiology, Azienda Euganea ULSS 6, Cittadella, Italy
| | - Valentino Fiscon
- Department of General Surgery, Azienda Euganea ULSS 6, Cittadella, Italy
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Portale G, Zuin M, Spolverato YC, Bartolotta P, Gregori D, Rettore C, Cancian L, Morabito A, Sava T, Fiscon V. Prognostic effect of sarcopenia in patients undergoing laparoscopic rectal cancer resection. ANZ J Surg 2023. [PMID: 36757847 DOI: 10.1111/ans.18269] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND The importance of body composition, in particular skeletal muscle mass, as risk factor affecting survival of cancer patients has recently gained increasing attention. The relationship between sarcopenia and oncological outcomes has become a topic of research in particular in patients with gastrointestinal cancer. However, there are few studies addressing this issue in colorectal cancer, and even less specifically focused on rectal cancer, in particular in Western countries. The aim of this study was to evaluate the prognostic relevance of preoperative skeletal mass index (SMI) on long-term outcomes in patients undergoing laparoscopic curative resection for rectal cancer. METHODS SMI data and clinicopathological characteristics of rectal cancer patients in a 15-year period (June 2005-December 2020) were evaluated; patients with metastatic disease at surgery were excluded; overall and disease-free survival as well as recurrence were evaluated. RESULTS Hundred and sixty-five patients were included in the study. Sarcopenia was identified in 30 (18%) patients. Multivariate analysis identified sarcopenia (HR = 3.28, CI = 1.33-8.11, P = 0.015), along with age (HR = 1.06, CI = 1.02-1.10, P = 0.002) and stage III (HR = 2.63, CI = 1.13-6.08, P < 0.03) as independent risk factors for overall survival. CONCLUSION Long-term results of rectal cancer patients undergoing curative resection are affected by their preoperative skeletal muscle status. Larger studies including comprehensive data on muscle strength along with SMI are awaited to confirm these results on both Eastern and Western rectal cancer patient populations before strategies to reverse muscle depletion can be extensively applied.
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Affiliation(s)
- Giuseppe Portale
- Department of General Surgery, Azienda Euganea ULSS 6, Cittadella, Italy
| | - Matteo Zuin
- Department of General Surgery, Azienda Euganea ULSS 6, Cittadella, Italy
| | | | - Patrizia Bartolotta
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Carlo Rettore
- Department of Radiology, Azienda Euganea ULSS 6, Cittadella, Italy
| | - Luca Cancian
- Department of Radiology, Azienda Euganea ULSS 6, Cittadella, Italy
| | - Alberto Morabito
- Department of Oncology, Azienda Euganea ULSS 6, Cittadella, Italy
| | - Teodoro Sava
- Department of Oncology, Azienda Euganea ULSS 6, Cittadella, Italy
| | - Valentino Fiscon
- Department of General Surgery, Azienda Euganea ULSS 6, Cittadella, Italy
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Cizginer S, Prohl EG, Monteiro JFG, Yildiz F, Jones RN, Schechter S, Patterson R, Klipfel A, Katlic MR, Daiello LA, Mujahid N, Neupane I, Cioffi WG, Ducharme M, Vrees MD, McNicoll L. Integrated postoperative care model for older colorectal surgery patients improves outcomes and reduces healthcare costs. J Am Geriatr Soc 2023; 71:1452-1461. [PMID: 36721263 DOI: 10.1111/jgs.18216] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/27/2022] [Accepted: 11/26/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Older surgical patients have an increased risk for postoperative complications, driving up healthcare costs. We determined if postoperative co-management of older surgery patients is associated with postoperative outcomes and hospital costs. METHODS Retrospective data were collected for patients ≥70 years old undergoing colorectal surgery at a community teaching hospital. Patient outcomes were compared between those receiving postoperative surgery co-management care through the Optimization of Senior Care and Recovery (OSCAR) program and controls who received standard of care. Main outcome measures were postoperative complications and hospital charges, 30-day readmission rate, length of stay (LOS), and transfer to intensive care during hospitalization. Multivariable linear regression was used to model total charge and multivariable logistic regression to model complications, adjusted for multiple variables (e.g., age, sex, race, body mass index, Charlson Comorbidity Index [CCI], American Society of Anesthesiologists score, surgery duration). RESULTS All 187 patients in the OSCAR and control groups had a similar mean CCI score of 2.7 (p = 0.95). Compared to the control group, OSCAR recipients experienced less postoperative delirium (17% vs. 8%; p = 0.05), cardiac arrhythmia (12% vs. 3%; p = 0.03), and clinical worsening requiring transfer to intensive care (20% vs. 6%; p < 0.005). OSCAR group patients had a shorter mean LOS among high-risk patients (CCI ≥3) (-1.8 days; p = 0.09) and those ≥80 years old (-2.3 days; p = 0.07) compared to the control group. Mean total hospital charge was $10,297 less per patient in the OSCAR group (p = 0.01), with $17,832 less per patient with CCI ≥3 (p = 0.01), than the control group. CONCLUSIONS A co-management care approach after colorectal surgery in older patients improves outcomes and decreases costs, with the most benefit going to the oldest patients and those with higher comorbidity scores.
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Affiliation(s)
- Sevdenur Cizginer
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA.,Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Eian G Prohl
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Ferhat Yildiz
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA
| | - Richard N Jones
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Steven Schechter
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA
| | - Robert Patterson
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA
| | - Adam Klipfel
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA
| | | | - Lori A Daiello
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nadia Mujahid
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Iva Neupane
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - William G Cioffi
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA
| | - Maria Ducharme
- Department of Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Matthew D Vrees
- Department of Surgery, The Miriam Hospital, Providence, Rhode Island, USA
| | - Lynn McNicoll
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Gómez Sánchez J, Forneiro Pérez R, Zurita Saavedra M, de Castro Monedero P, González Puga C, Garde Lecumberri C, Mirón Pozo B. Oncologic colorectal surgical site infection: oral or not oral antibiotic preparation, that is the question. Int J Colorectal Dis 2022; 37:373-379. [PMID: 34854980 DOI: 10.1007/s00384-021-04074-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgical wound infection is the most frequent postoperative complication in abdominal surgery, especially at the colorectal level. The aim of this study is analysing the results of mechanical colon preparation combined with oral antibiotic versus mechanical colon preparation without antibiotic therapy in patients with colorectal cancer undergoing elective surgery. METHODS This retrospective cohort study had been developed from November 2017 to February 2020. We have included a total of 281 consecutive patients undergoing elective colon and rectal oncological surgeries by the same surgical group using laparoscopic and open approaches. Transanal minimally invasive surgery (TAMIS) and transanal total mesorectal excision (TaTME) approaches were excluded. Exposed patients undergoing colon and rectal cancer surgery received mechanical bowel preparation and oral antibiotics with three doses of neomycin 1 g and erythromycin 500 mg the day before surgery. RESULTS The primary outcome was reduction in surgical wound infection rates before and after starting the oral antibiotic therapy from 17 to 6% (p < 0.05). As a secondary analysis, we evaluated the anastomotic dehiscence rate, corresponding with a decrease from 12 to 3% (p < 0.05). CONCLUSION Mechanical bowel preparation combined with oral antibiotic therapy is still not unanimously carried out in all the medical hospitals. In this report, we show that mechanical bowel preparation in combination with oral antibiotic reduces the risk of surgical wound infection and anastomotic leakage in patients undergoing colon and rectal cancer surgery.
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Affiliation(s)
- Javier Gómez Sánchez
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Rocio Forneiro Pérez
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Marisol Zurita Saavedra
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Paola de Castro Monedero
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Cristina González Puga
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Carlos Garde Lecumberri
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
| | - Benito Mirón Pozo
- Department of Colorectal Surgery, Hospital Universitario Clínico San Cecilio, Avd. de la Investigación s/n, 18016, Granada, Spain
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Portale G, Cipollari C, Pedon S, Benacchio L, Fiscon V. A novel and simple technique to close the enterotomy after intracorporeal anastomosis in laparoscopic right hemicolectomy. Updates Surg 2021; 73:1435-1442. [PMID: 33840070 DOI: 10.1007/s13304-021-01025-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 11/09/2020] [Indexed: 11/28/2022]
Abstract
We developed a new technique to reduce the length of the enteric defect to be closed during intracorporeal anastomosis in laparoscopic right hemicolectomy (LRH), also avoiding the need to suture the first part of the anastomosis in a deep space with an acute angle. From January 2017, after the ileo-colic anastomosis was completed, an additional stapler cartridge was applied starting at the colonic rim and including the small bowel part of the anastomosis. The isoperistaltic fashion of the ileo-colonic anastomosis was maintained. The remaining defect left to be closed was 2-3 cm. We compared the results of the novel technique with those of the 'standard' closure (full-length enterotomy). In the last 30 months, this technique was successfully used in 32 patients (Group A), compared with 33 patients (2012-2016) operated with 'standard' closure (Group B). Age, BMI and post-operative stage distribution were similar. The mean operative time was 175.2 min (± 36.7) in Group A and 165.9 min (± 42.5) in Group B (p = ns), with 53.1% and 27.3% of associated procedures (cholecystectomy, ovariectomy, etc.), respectively (p < 0.05). Overall morbidity rate was 28.1% and 30.3% (Group A vs Group B, p = ns), with no anastomotic bleeding/leak in either group. This technique, which simplifies the closure of the enteric defect after LRH with intracorporeal anastomosis is safe, reproducible and easy to learn. It might help more surgeons to perform a fully laparoscopic procedure in right hemicolectomy, offering the advantages of intracorporeal anastomosis to their patients.
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Affiliation(s)
- Giuseppe Portale
- Department of General Surgery, Azienda Euganea ULSS 6, Via Casa di Ricovero, 40, 35013, Cittadella, Padova, Italy.
| | - Chiara Cipollari
- Department of General Surgery, Azienda Euganea ULSS 6, Via Casa di Ricovero, 40, 35013, Cittadella, Padova, Italy
| | - Sabrina Pedon
- Department of General Surgery, Azienda Euganea ULSS 6, Via Casa di Ricovero, 40, 35013, Cittadella, Padova, Italy
| | - Luca Benacchio
- Department of Epidemiology, Azienda Euganea ULSS 6, Padua, Italy
| | - Valentino Fiscon
- Department of General Surgery, Azienda Euganea ULSS 6, Via Casa di Ricovero, 40, 35013, Cittadella, Padova, Italy
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Teixeira Farinha H, Martin D, Ramó A, Hübner M, Demartines N, Hahnloser D. Proposition of a simple binary grading of estimated blood loss during colon surgery. Int J Colorectal Dis 2021; 36:2111-2117. [PMID: 33864102 PMCID: PMC8426219 DOI: 10.1007/s00384-021-03925-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Intraoperative estimated blood loss (EBL) is often reported in nearly all surgical papers; however, there is no consensus regarding its measurement. The aim of this study was to determine whether EBL (ml) is as reliable and reproducible in predicting complications as a simple binary grading of EBL. METHODS All consecutive patients undergoing colectomies between January 2015 and December 2018 were included. EBL was assessed prospectively by the surgeon and anaesthesiologist in ml and with a binary scale: bleeding "as usual" versus "more than usual" by the surgeon. Differences between pre- and post-operative haemoglobin levels (ΔHb g/dl) were correlated to EBL. Blood loss impact on 30-day postoperative morbidity was analysed. RESULTS A total of 270 patients were included, with a mean age of 65 years (SD 17). Mean EBL documented by surgeons correlated to EBL by anaesthesiologists (79.5 ml, SD 99 vs. 84.5 ml, SD 118, ϱ = 0.926, p < 0.001). Surgeons and anaesthesiologists' EBL correlated also with ΔHb (ϱ = - 0.273, p = 0.01 and ϱ = - 0.344, p = 0.01, respectively). Patient with surgeon EBL ≥ 250 ml or graded as "more than usual" bleeding had significantly more severe complications (8% vs. 20%, p = 0.02 and 8% vs. 27%, p = 0.001, respectively). CONCLUSION Anaesthesiologist and surgeon's EBL correlated with ΔHb. Simple grading of blood loss as "usual" and "more than usual" predicted severe complications and higher mortality rates. This simple binary grading of blood loss in colon surgery could be an alternative to the estimation of blood loss in ml as it is easy to apply but needs to be validated externally.
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Affiliation(s)
- Hugo Teixeira Farinha
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - David Martin
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Audrey Ramó
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Grass F, Storlie CB, Mathis KL, Bergquist JR, Asai S, Boughey JC, Habermann EB, Etzioni DA, Cima RR. Challenges of Modeling Outcomes for Surgical Infections: A Word of Caution. Surg Infect (Larchmt) 2020; 22:523-531. [PMID: 33085571 DOI: 10.1089/sur.2020.208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: We developed a novel analytic tool for colorectal deep organ/space surgical site infections (C-OSI) prediction utilizing both institutional and extra-institutional American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data. Methods: Elective colorectal resections (2006-2014) were included. The primary end point was C-OSI rate. A Bayesian-Probit regression model with multiple imputation (BPMI) via Dirichlet process handled missing data. The baseline model for comparison was a multivariable logistic regression model (generalized linear model; GLM) with indicator parameters for missing data and stepwise variable selection. Out-of-sample performance was evaluated with receiver operating characteristic (ROC) analysis of 10-fold cross-validated samples. Results: Among 2,376 resections, C-OSI rate was 4.6% (n = 108). The BPMI model identified (n = 57; 56% sensitivity) of these patients, when set at a threshold leading to 80% specificity (approximately a 20% false alarm rate). The BPMI model produced an area under the curve (AUC) = 0.78 via 10-fold cross- validation demonstrating high predictive accuracy. In contrast, the traditional GLM approach produced an AUC = 0.71 and a corresponding sensitivity of 0.47 at 80% specificity, both of which were statstically significant differences. In addition, when the model was built utilizing extra-institutional data via inclusion of all (non-Mayo Clinic) patients in ACS-NSQIP, C-OSI prediction was less accurate with AUC = 0.74 and sensitivity of 0.47 (i.e., a 19% relative performance decrease) when applied to patients at our institution. Conclusions: Although the statistical methodology associated with the BPMI model provides advantages over conventional handling of missing data, the tool should be built with data specific to the individual institution to optimize performance.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John R Bergquist
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Shusaku Asai
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Judy C Boughey
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David A Etzioni
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Scottsdale, Arizona, USA
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Portale G, Pedon S, Benacchio L, Cipollari C, Fiscon V. Two-dimensional (2-D) vs. three-dimensional (3-D) laparoscopic right hemicolectomy with intracorporeal anastomosis for colon cancer: comparison of short-term results. Surg Endosc 2020; 35:5279-5286. [PMID: 32940793 DOI: 10.1007/s00464-020-07977-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 09/09/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND There are few reports comparing safety and efficacy of 2-D and 3-D video technology in laparoscopic right hemicolectomy. The aim of the study was to assess the short-term results of laparoscopic right hemicolectomy (LHR) with intracorporeal anastomosis with 2-D/3-D video in patients with right colon cancer. METHODS Data from 239 patients undergoing LRH for cancer in a 14-year period (June 2005-January 2020) were prospectively collected. Surgical procedures were performed by two expert laparoscopic surgeons. RESULTS One hundred and fourteen patients were included in the study: 55 (48.2%) operated with 2-D and 59 (51.8%) with 3-D video. Tumor site and postoperative stage distribution were similar. Mean operative time was comparable in the two groups (159.0 ± 48.8 min vs. 17.06 ± 36.0 min, p = ns, group 2-D and 3-D, respectively). Group 3-D patients had a similar percentage of associated procedures (44.1% vs. 29.1%, p = ns). Intraoperative complications were nil in both groups, while postoperative complications were similar (30.9% 2-D vs 25.4% 3-D, p = ns). The mean number of lymph nodes retrieved was similar in group 3-D (26.0 ± 14.6 vs. 22.9 ± 9.3, p = ns) and the length of stay was comparable in 3-D and 2-D patients (8.4 ± 2.6 vs. 9.1 ± 3.3 days, respectively, p = ns). CONCLUSIONS Laparoscopic 3-D vision is as equally effective as 2-D vision in LRH with intracorporeal anastomosis, with a similar proportion of associated procedures and number of lymph nodes retrieved in the same operative time. Further prospective larger randomized studies are necessary to verify if LRH with 3-D video can reduce postoperative complications, compared to 2-D video.
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Affiliation(s)
- Giuseppe Portale
- Department of General Surgery, Azienda Euganea ULSS 6, Via Casa di Ricovero, 40, 35013, Cittadella, Italy.
| | - Sabrina Pedon
- Department of General Surgery, Azienda Euganea ULSS 6, Via Casa di Ricovero, 40, 35013, Cittadella, Italy
| | - Luca Benacchio
- Department of Epidemiology, Azienda Euganea ULSS 6, Padua, Italy
| | - Chiara Cipollari
- Department of General Surgery, Azienda Euganea ULSS 6, Via Casa di Ricovero, 40, 35013, Cittadella, Italy
| | - Valentino Fiscon
- Department of General Surgery, Azienda Euganea ULSS 6, Via Casa di Ricovero, 40, 35013, Cittadella, Italy
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12
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Management Considerations for the Surgical Treatment of Colorectal Cancer During the Global Covid-19 Pandemic. Ann Surg 2020; 272:e98-e105. [PMID: 32675510 PMCID: PMC7373490 DOI: 10.1097/sla.0000000000004029] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective: The COVID-19 pandemic requires to conscientiously weigh “timely surgical intervention” for colorectal cancer against efforts to conserve hospital resources and protect patients and health care providers. Summary Background Data: Professional societies provided ad-hoc guidance at the outset of the COVID-19 pandemic on deferral of surgical and perioperative interventions, but these lack specific parameters to determine the optimal timing of surgery. Methods: Using the GRADE system, published evidence was analyzed to generate weighted statements for stage, site, acuity of presentation, and hospital setting to specify when surgery should be pursued, the time and duration of oncologically acceptable delays, and when to utilize nonsurgical modalities to bridge the waiting period. Results: Colorectal cancer surgeries—prioritized as emergency, urgent with imminent emergency or oncologically urgent, or elective—were matched against the phases of the pandemic. Surgery in COVID-19-positive patients must be avoided. Emergent and imminent emergent cases should mostly proceed unless resources are exhausted. Standard practices allow for postponement of elective cases and deferral to nonsurgical modalities of stage II/III rectal and metastatic colorectal cancer. Oncologically urgent cases may be delayed for 6(–12) weeks without jeopardizing oncological outcomes. Outside established principles, administration of nonsurgical modalities is not justified and increases the vulnerability of patients. Conclusions: The COVID-19 pandemic has stressed already limited health care resources and forced rationing, triage, and prioritization of care in general, specifically of surgical interventions. Established guidelines allow for modifications of optimal timing and type of surgery for colorectal cancer during an unrelated pandemic.
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Maselli R, Galtieri PA, Di Leo M, Ferrara EC, Anderloni A, Carrara S, Vanni E, Mangiavillano B, Genco A, Al Awadhi S, Fuccio L, Hassan C, Repici A. Cost analysis and outcome of endoscopic submucosal dissection for colorectal lesions in an outpatient setting. Dig Liver Dis 2019; 51:391-396. [PMID: 30385079 DOI: 10.1016/j.dld.2018.09.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 09/23/2018] [Accepted: 09/25/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD), a minimally invasive treatment for early gastrointestinal (GI) cancer, is considered challenging and risky in the colorectum. As such, most patients undergoing ESD are hospitalized due to the perceived increased risk of adverse events. The aim of this study was to compare the costs, safety and efficacy of colorectal-ESD in an outpatient vs inpatient setting in a tertiary level center. METHODS This is a retrospective study on consecutive patients admitted for colorectal-ESD. Patients were divided into outpatients (Group-A, same-day discharge), and inpatients (Group-B, admitted for at least one night). Data on overall costs, outcomes and adverse events were assessed for each group. RESULTS A total of 136 patients were considered. Fourteen were excluded because ESD was not performed due to intraprocedural suspicion of invasive cancer. Eighty-three patients were treated as outpatients (Group-A, 68%) and 39 (Group-B, 32%) were hospitalized. R0-rate was 90.4% in Group-A and 89.7% in Group-B(P = 0.98). One perforation occurred in Group-A (1.2%) and 2 in Group-B(5.1%, P = 0.2). Mean Length of stay (LOS) was 1 day for outpatients and 3.3 days for inpatients. Management of Group-A as outpatients produced a cost savings of 941€ on average per patient. CONCLUSIONS Outpatient colorectal-ESD is a feasible, cost-effective strategy to manage superficial colorectal tumors with outcomes comparable to inpatient colorectal-ESD. By using proper selection criteria, outpatient ESD could be considered the first-line approach for most patients.
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Affiliation(s)
- Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy.
| | - Piera Alessia Galtieri
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Milena Di Leo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy; Humanitas University, Department of Biomedical Science, Milan, Italy
| | - Elisa Chiara Ferrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Elena Vanni
- Humanitas Clinical and Research Center, Business Operating Officer, Milan, Italy
| | - Benedetto Mangiavillano
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy
| | - Alfredo Genco
- Department of Surgical Sciences, Umberto I° General Hospital, Sapienza University, Rome, Italy
| | - Sameer Al Awadhi
- Gastroenterology Division, Rashid Hospital, Dubai Health Autority, Dubai, UAE
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Cesare Hassan
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy; Nuovo Regina Margherita Hospital, Rome, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Milan, Italy; Humanitas University, Department of Biomedical Science, Milan, Italy
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Portale G, Valdegamberi A, Cavallin F, Frigo F, Fiscon V. Effect of Age and Comorbidities on Short- and Long-Term Results in Patients Undergoing Laparoscopic Curative Resection for Rectal Cancer. J Laparoendosc Adv Surg Tech A 2019; 29:353-359. [DOI: 10.1089/lap.2018.0340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Giuseppe Portale
- Department of General Surgery, ULSS 6 Euganea, Cittadella, Italy
| | | | | | - Flavio Frigo
- Department of General Surgery, ULSS 6 Euganea, Cittadella, Italy
| | - Valentino Fiscon
- Department of General Surgery, ULSS 6 Euganea, Cittadella, Italy
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15
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Orive M, Aguirre U, Gonzalez N, Lázaro S, Redondo M, Bare M, Anula R, Briones E, Escobar A, Sarasqueta C, Garcia-Gutierrez S, Quintana JM. Risk factors affecting hospital stay among patients undergoing colon cancer surgery: a prospective cohort study. Support Care Cancer 2019; 27:4133-4144. [PMID: 30793242 DOI: 10.1007/s00520-019-04683-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 09/26/2018] [Indexed: 02/03/2023]
Abstract
PURPOSE To identify and validate risk factors that contribute to prolonged length of hospital stay (LOS) in patients undergoing resection for colorectal cancer. METHODS This prospective cohort study included 1955 patients admitted to 22 hospitals for primary resection of colorectal cancer. Multivariate analyses were used to identify and validate risk factors, randomizing patients into a derivation and a validation cohort. Multiple correspondence and cluster analysis were performed to identify clinical subtypes based on LOS. RESULTS The strongest independent predictors of prolonged LOS were postoperative reintervention, surgical site infection, open surgery, and distant metastasis. The multiple correspondence and cluster analysis provided three groups of patients in relation to prolonged LOS: patients with the longest LOS included the highest percentage of patients with open surgery, distant metastasis, deep surgical site infections, emergency admissions, additional diagnostic factors, and highly contaminated surgical sites. Patients with prolonged LOS (> 14 days) were more likely to develop adverse outcomes within 30 days after discharge. CONCLUSIONS Patients undergoing resection of colorectal cancer cluster into different groups based on LOS of the index admission. Those with prolonged LOS were more likely to develop adverse outcomes within 30 days after discharge. Some of the strongest independent predictors of prolonged LOS, such as surgical infections or open surgery, could be modified to reduce LOS and, in turn, other adverse outcomes. TRIAL REGISTRATION NCT02488161.
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Affiliation(s)
- Miren Orive
- Research Unit, Hospital Galdakao-Usansolo, B° Labeaga s/n, 48960, Galdakao, Biscay, Spain.
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain.
| | - Urko Aguirre
- Research Unit, Hospital Galdakao-Usansolo, B° Labeaga s/n, 48960, Galdakao, Biscay, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
| | - Nerea Gonzalez
- Research Unit, Hospital Galdakao-Usansolo, B° Labeaga s/n, 48960, Galdakao, Biscay, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
| | - Santiago Lázaro
- General Surgery Service, Galdakao-Usansolo Hospital, Galdakao, Bizkaia, Spain
| | - Maximino Redondo
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
- Research Unit, Hospital Costa del Sol, Málaga, Spain
| | - Marisa Bare
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
- Clinical Epidemiology Unit, Corporacio Parc Tauli, Barcelona, Spain
| | - Rocío Anula
- Colorectal Unit, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Antonio Escobar
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
- Research Unit, Basurto University Hospital, Basurto, Bilbao, Bizkaia, Spain
| | - Cristina Sarasqueta
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
- Research Unit, Donostia University Hospital, Donostia-San Sebastian, Gipuzkoa, Spain
| | - Susana Garcia-Gutierrez
- Research Unit, Hospital Galdakao-Usansolo, B° Labeaga s/n, 48960, Galdakao, Biscay, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
| | - José M Quintana
- Research Unit, Hospital Galdakao-Usansolo, B° Labeaga s/n, 48960, Galdakao, Biscay, Spain
- Health Services Research on Chronic Patients Network (REDISSEC), Barakaldo, Spain
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16
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Laparoscopic Curative Resection for Rectal Cancer: A Cohort Study on Long-term Outcome. Surg Laparosc Endosc Percutan Tech 2018; 28:318-323. [DOI: 10.1097/sle.0000000000000565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Chakedis J, Spolverato G, Beal EW, Woelfel I, Bagante F, Merath K, Sun SH, Chafitz A, Galo J, Dillhoff M, Cloyd J, Pawlik TM. Pre-operative Sarcopenia Identifies Patients at Risk for Poor Survival After Resection of Biliary Tract Cancers. J Gastrointest Surg 2018; 22:1697-1708. [PMID: 29855867 DOI: 10.1007/s11605-018-3802-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 04/26/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Biliary tract cancers (BTC) are aggressive malignancies that require complex surgical procedures. Patients with BTC can present with skeletal muscle depletion, yet the effects of muscle wasting (sarcopenia) on outcomes have not been well studied. The objective of the current study was to define the impact of sarcopenia on survival among patients undergoing resection of BTC. METHODS Patients who underwent exploration for BTC who had a pre-operative CT scan available for review were identified. Body composition variables including total and psoas muscle area (cm2), muscle density (Hounsfield units), visceral fat area, subcutaneous fat area, and waist-to-hip ratio were analyzed at the level of L3. Outcomes were assessed according to the presence or absence of sarcopenia defined using sex- and BMI-specific threshold values for Psoas Muscle Index (PMI, cm2/m2). RESULTS Among 117 patients with BTC, 78 (67%) underwent curative-intent resection and 39 (33%) were explored but did not undergo resection due to metastatic/locally advanced disease. Tumor type included distal cholangiocarcinoma (n = 18, 15.4%), hilar cholangiocarcinoma (n = 27, 23.1%), gallbladder carcinoma (n = 52, 44.4%), and intrahepatic cholangiocarcinoma (n = 20, 17.1%). Median patient age was 65.6 years and 43.6% were male. Mean patient BMI was 26.1 kg/m2 among men and 27.5 kg/m2 among women. Overall, 41 (35.0%) patients had sarcopenia. Sarcopenia was associated with an increased risk of death among patients who underwent resection (HR 3.52, 95%CI 1.60-7.78, p = 0.002), which was comparable to patients with unresectable metastatic disease. Other factors such as low serum albumin (HR 3.17, 95% CI 1.30-7.74, p = 0.011) and low psoas density (HR 2.96, 95% CI 1.21-7.21, p = 0.017) were also associated with increased risk of death. Survival was stratified based on sarcopenia, psoas density, and serum albumin. The presence of each variable was associated with an incremental increased risk of death (0 variables ref.; 1 variable HR 3.8, 95% CI 1.0-14, p = 0.043; 2 variables HR 13.1, 95% CI 3.0-57.7, p = 0.001; 3 variables HR 14.6, 95% CI 2.5-87.1, p = 0.003). Patients who had no adverse prognostic factors had a 3-year OS of 67% versus no survival among patients with all 3 factors. CONCLUSIONS Sarcopenia was common among patients undergoing resection of BTC, occurring in 1 of every 3 patients. Sarcopenia was associated with poor survival after resection, particularly among patients who experienced a recurrence. Body composition metrics such as sarcopenia and low psoas muscle density in addition to low albumin level were able to stratify patients into different prognostic categories.
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Affiliation(s)
- Jeffery Chakedis
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Gaya Spolverato
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Eliza W Beal
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Ingrid Woelfel
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Steven H Sun
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Aaron Chafitz
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Jason Galo
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, 43210, USA.
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Portale G, Cavallin F, Valdegamberi A, Frigo F, Fiscon V. Platelet-to-Lymphocyte Ratio and Neutrophil-to-Lymphocyte Ratio Are Not Prognostic Biomarkers in Rectal Cancer Patients with Curative Resection. J Gastrointest Surg 2018; 22:1611-1618. [PMID: 29687424 DOI: 10.1007/s11605-018-3781-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/09/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Actual predictors of survival and recurrence for rectal cancer patients undergoing curative resection mostly come from pathological data of surgical specimen. Recently, novel blood biomarkers have been proposed as useful tools in cancer patient management, but few and conflicting data have been reported in rectal cancer. We evaluated the prognostic relevance of preoperative platelet-to-lymphocyte (P/L) ratio and neutrophil-to-lymphocyte (N/L) ratio on survival and recurrence in patients undergoing laparoscopic curative resection for rectal cancer. METHODS All consecutive patients who referred for primary rectal disease to the Department of General Surgery in Cittadella (Italy) from June 2005 to September 2015 were retrospectively evaluated. Patients with metastatic disease at surgery were excluded. P/L and N/L ratios were calculated. For patients undergoing neoadjuvant chemo-radiotherapy, pre-treatment data were considered. Follow-up data were updated at December 2016. RESULTS One hundred fifty-two patients were included in the study, 49 (32%) received neoadjuvant chemo-radiotherapy. Both P/L and N/L ratios showed poor discriminative performance on 5-year OS and DFS. Time-dependent ROC curves showed no improvements in discriminative performance of P/L and N/L ratios when considering different time endpoints. Multivariable analysis identified CEA-rather than P/L or N/L ratios-as independent predictor of OS and DFS, adjusting for age, tumor stage, and postoperative morbidity. CONCLUSION Neither P/L nor N/L ratios were associated with survival after rectal cancer surgery. Further studies on large series might provide insights on the role of these inexpensive blood biomarkers in rectal cancer.
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Affiliation(s)
- Giuseppe Portale
- Department of General Surgery, Azienda ULSS 6, Cittadella, Via Casa di Ricovero, 40, 35013, Cittadella, Padova, Italy.
| | | | - Alessandro Valdegamberi
- Department of General Surgery, Azienda ULSS 6, Cittadella, Via Casa di Ricovero, 40, 35013, Cittadella, Padova, Italy
| | - Flavio Frigo
- Department of General Surgery, Azienda ULSS 6, Cittadella, Via Casa di Ricovero, 40, 35013, Cittadella, Padova, Italy
| | - Valentino Fiscon
- Department of General Surgery, Azienda ULSS 6, Cittadella, Via Casa di Ricovero, 40, 35013, Cittadella, Padova, Italy
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Predictors of one and two years' mortality in patients with colon cancer: A prospective cohort study. PLoS One 2018; 13:e0199894. [PMID: 29953553 PMCID: PMC6023168 DOI: 10.1371/journal.pone.0199894] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 06/15/2018] [Indexed: 12/12/2022] Open
Abstract
Background Tools to aid in the prognosis assessment of colon cancer patients in terms of risk of mortality are needed. Goals of this study are to develop and validate clinical prediction rules for 1- and 2-year mortality in these patients. Methods This is a prospective cohort study of patients diagnosed with colon cancer who underwent surgery at 22 hospitals. The main outcomes were mortality at 1 and 2 years after surgery. Background, clinical parameters, and diagnostic tests findings were evaluated as possible predictors. Multivariable multilevel logistic regression and survival models were used in the analyses to create the clinical prediction rules. Models developed in the derivation sample were validated in another sample of the study. Results American Society of Anesthesiologists Physical Status Classification System (ASA), Charlson comorbidity index (> = 4), age (>75 years), residual tumor (R2), TNM stage IV and log of lymph nodes ratio (> = -0.53) were predictors of 1-year mortality (C-index (95% CI): 0.865 (0.792–0.938)). Adjuvant chemotherapy was an additional predictor. Again ASA, Charlson Index (> = 4), age (>75 years), log of lymph nodes ratio (> = -0.53), TNM, and residual tumor were predictors of 2-year mortality (C-index:0.821 (0.766–0.876). Chemotherapy was also an additional predictor. Conclusions These clinical prediction rules show very good predictive abilities of one and two years survival and provide clinicians and patients with an easy and quick-to-use decision tool for use in the clinical decision process while the patient is still in the index admission.
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Blair BM, Lehman EB, Jafri SM, Kaag MG, Raman JD. Predicted versus observed 30-day perioperative outcomes using the ACS NSQIP surgical risk calculator in patients undergoing partial nephrectomy for renal cell carcinoma. Int Urol Nephrol 2018; 50:1249-1256. [DOI: 10.1007/s11255-018-1898-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 05/18/2018] [Indexed: 12/30/2022]
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Duraes LC, Stocchi L, Dietz D, Kalady MF, Kessler H, Schroeder D, Remzi FH. The Disproportionate Effect of Perioperative Complications on Mortality within 1 Year After Colorectal Cancer Resection in Octogenarians. Ann Surg Oncol 2016; 23:4293-4301. [DOI: 10.1245/s10434-016-5445-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Mortality after emergency surgery continues to rise after discharge in the elderly: Predictors of 1-year mortality. J Trauma Acute Care Surg 2015; 79:349-58. [PMID: 26307865 DOI: 10.1097/ta.0000000000000773] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND It is known that emergency surgery in the elderly is associated with high short-term mortality, but longer-term outcomes are not well described. We hypothesized that 30-day mortality may underestimate the true operative mortality experienced in this cohort. The purposes of this study were to characterize postoperative mortality rates extending to 1 year and to identify preoperative predictors of 1 year mortality after emergency abdominal surgery. METHODS We retrospectively reviewed the records of all patients older than 70 years who underwent emergency abdominal surgery at a major teaching hospital between 2006 and 2011. Demographics, preoperative physiology, prehospital status, body mass index, laboratory values, Charlson scores, comorbid conditions, American Society of Anesthesiologists classification, and operative details were recorded. The primary end point was 1-year mortality. Complementary log-log binary regression was used to determine independent predictors of death. Model discrimination was evaluated using the c statistic. RESULTS A total of 390 patients met our inclusion criteria. The mean age was 79 years, and 56% were women. Postoperative mortality was 16.2% at 30 days and 32.5% at 1 year, reflecting a doubling of mortality over 11 months. Independent preoperative predictors of 1-year mortality were Charlson score of 4 or higher (hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.38-2.34), American Society of Anesthesiologists class of 4 or higher (HR, 1.66; 95% CI, 1.22-2.21), albumin less than 3.5 (HR, 1.71; 95% CI, 1.31-2.28), and body mass index lower than 18.5 (HR, 3.36; 95% CI, 1.48-6.86). The c statistic was 0.81. CONCLUSION The 1-year mortality after emergency surgery in the elderly is significantly higher than that at 30 days. We identified a constellation of preoperative clinical markers that were highly predictive of this poor late outcome. The presence of these findings in the emergency setting should prompt preoperative discussion about treatment goals and encourage surgeons to set realistic expectations about outcomes with the patient and family. Future studies will develop a clinical scoring tool that can be applied at the bedside to provide more effective counseling for this high-risk population. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III; therapeutic study, level IV.
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The current status of emergent laparoscopic colectomy: a population-based study of clinical and financial outcomes. Surg Endosc 2015; 30:3321-6. [PMID: 26490770 DOI: 10.1007/s00464-015-4605-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 09/28/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Population-based studies evaluating laparoscopic colectomy and outcomes compared with open surgery have concentrated on elective resections. As such, data assessing non-elective laparoscopic colectomies are limited. Our goal was to evaluate the current usage and outcomes of laparoscopic in the urgent and emergent setting in the USA. METHODS A national inpatient database was reviewed from 2008 to 2011 for right, left, and sigmoid colectomies in the non-elective setting. Cases were stratified by approach into open or laparoscopic groups. Demographics, perioperative clinical variables, and financial outcomes were compared across each group. RESULTS A total of 22,719 non-elective colectomies were analyzed. The vast majority (95.8 %) was open. Most cases were performed in an urban setting at non-teaching hospitals by general surgeons. Colorectal surgeons were significantly more likely to perform a case laparoscopic than general surgeons (p < 0.001). Demographics were similar between open and laparoscopic groups; however, the disease distribution by approach varied, with significantly more severe cases in the open colectomy arm (p < 0.001). Cases performed laparoscopically had significantly better mortality and complication rates. Laparoscopic cases also had significantly improved outcomes, including shorter length of stay and hospital costs (all p < 0.001). CONCLUSIONS Our analysis revealed less than 5 % of urgent and emergent colectomies in the USA are performed laparoscopically. Colorectal surgeons were more likely to approach a case laparoscopically than general surgeons. Outcomes following laparoscopic colectomy in this setting resulted in reduced length of stay, lower complication rates, and lower costs. Increased adoption of laparoscopy in the non-elective setting should be considered.
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Impact Total Psoas Volume on Short- and Long-Term Outcomes in Patients Undergoing Curative Resection for Pancreatic Adenocarcinoma: a New Tool to Assess Sarcopenia. J Gastrointest Surg 2015; 19:1593-602. [PMID: 25925237 PMCID: PMC4844366 DOI: 10.1007/s11605-015-2835-y] [Citation(s) in RCA: 182] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 04/20/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND While sarcopenia is typically defined using total psoas area (TPA), characterizing sarcopenia using only a single axial cross-sectional image may be inadequate. We sought to evaluate total psoas volume (TPV) as a new tool to define sarcopenia and compare patient outcomes relative to TPA and TPV. METHOD Sarcopenia was assessed in 763 patients who underwent pancreatectomy for pancreatic adenocarcinoma between 1996 and 2014. It was defined as the TPA and TPV in the lowest sex-specific quartile. The impact of sarcopenia defined by TPA and TPV on overall morbidity and mortality was assessed using multivariable analysis. RESULT Median TPA and TPV were both lower in women versus men (both P < 0.001). TPA identified 192 (25.1%) patients as sarcopenic, while TPV identified 152 patients (19.9%). Three hundred sixty-nine (48.4%) patients experienced a postoperative complication. While TPA-sarcopenia was not associated with higher risk of postoperative complications (OR 1.06; P = 0.72), sarcopenia defined by TPV was associated with morbidity (OR 1.79; P = 0.002). On multivariable analysis, TPV-sarcopenia remained independently associated with an increased risk of postoperative complications (OR 1.69; P = 0.006), as well as long-term survival (HR 1.46; P = 0.006). CONCLUSION The use of TPV to define sarcopenia was associated with both short- and long-term outcomes following resection of pancreatic cancer. Assessment of the entire volume of the psoas muscle (TPV) may be a better means to define sarcopenia rather than a single axial image.
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Cologne KG, Keller DS, Liwanag L, Devaraj B, Senagore AJ. Use of the American College of Surgeons NSQIP Surgical Risk Calculator for Laparoscopic Colectomy: How Good Is It and How Can We Improve It? J Am Coll Surg 2015; 220:281-6. [DOI: 10.1016/j.jamcollsurg.2014.12.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 12/08/2014] [Accepted: 12/08/2014] [Indexed: 02/04/2023]
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Gomes A, Rocha R, Marinho R, Sousa M, Pignatelli N, Carneiro C, Nunes V. Colorectal surgical mortality and morbidity in elderly patients: comparison of POSSUM, P-POSSUM, CR-POSSUM, and CR-BHOM. Int J Colorectal Dis 2015; 30:173-9. [PMID: 25430595 DOI: 10.1007/s00384-014-2071-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aims to compare the predictive value of POSSUM, P-POSSUM, CR-POSSUM and CR-BHOM in colorectal surgical mortality and morbidity in patients over 80 years old. METHODS This is a retrospective observational longitudinal study. A total of 991 patients who underwent major colorectal surgery between 2008 and 2012 in a secondary hospital in Portugal were screened, and 204 who were over 80 years old were included. Subgroup analysis was performed for malignant/benign disease and emergent/elective surgery. The main outcome measure was 30-day postoperative mortality and morbidity with Clavien-Dindo classification ≥ 2. RESULTS Of the 204 patients included in this study, 155 had malignant disease, and 65 underwent emergent procedures. Overall average age was 84.3 ± 3.9 years (range 80-100). Overall surgical mortality and morbidity were 18.6% (n = 38) and 52.4% (n = 87), respectively. Expected mortality followed the order P-POSSUM<CR-POSSUM<CR-BHOM (p < 0.001), and expected morbidity followed the order POSSUM<CR-BHOM (p < 0.001) in all groups. All scores were higher in the emergent surgery group compared with elective surgery (p < 0.05). All scores had sensitivity below 60%. Physiology scores were higher among patients with surgical mortality (p < 0.05), with no differences in operative scores. CONCLUSIONS In our population, CR-POSSUM was the best predictor of surgical mortality. POSSUM and P-POSSUM underestimated surgical mortality and morbidity, and CR-BHOM overestimated surgical mortality, being however the best predictor of morbidity. Nevertheless, none of the scores showed sufficient discriminatory power to have clinical application value. Moreover, our results suggest that, in elderly patients, it is the patient's health status and not the type of surgery that is mainly responsible for the surgical outcome.
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Affiliation(s)
- António Gomes
- B Surgery Department, Hospital Prof. Doutor Fernando Fonseca, Estrada IC-19, 2720-276, Amadora, Portugal,
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Hodgson R, An V, Stupart DA, Guest GD, Watters DAK. Who gets Hartmann's reversed in a regional centre? Surgeon 2015; 14:184-9. [PMID: 25630375 DOI: 10.1016/j.surge.2014.11.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 11/09/2014] [Accepted: 11/13/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Many patients who undergo a Hartmann's procedure do not have their stoma reversed. We analysed parameters and co-morbidity scales to assess their accuracy in predicting likelihood of undergoing reversal. MATERIAL AND METHODS Retrospective analysis of 165 patients from a prospective colorectal database who were discharged home following a Hartmann's procedure at Barwon Health (Geelong, Australia), a regional centre, between 2002 and 2010. Parameters measured included age, sex, time to reversal, ICU admission and pathology results were recorded. Patients' ASA, POSSUM and Elixhauser co-morbidity scales were retrospectively analysed. RESULTS Reversal of Hartmann's was performed in 74/165 (45%) patients after a median of 294 days (range 70-902). Age (mean 58.5 vs 72.9 years, p < 0.001), ICU stay (34/74 vs 66/91, p < 0.001), ASA (p < 0.002), Elixhauser co-morbidity count (mean 1.14 vs 1.92, p < 0.002) and a malignant diagnosis (9/74 vs 31/91, p < 0.002) were all associated with a decreased reversal rate on univariate analysis. Age was the only parameter found to be significant on multivariate analysis. The complication rate was 23/74, with 7/74 noted to have major complications (Clavian-Dindo III-IV). Reasons for not reversing patients included age and co-morbidities, patient refusal, and malignant disease progression. CONCLUSIONS More than half the patients undergoing a Hartmann's procedure did not proceed to a closure of their stoma. Age was the only parameter significant in predicting those patients undergoing reversal.
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Affiliation(s)
- R Hodgson
- Department of Surgery, Barwon Health, Geelong, Australia; Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Australia.
| | - V An
- Department of Surgery, Barwon Health, Geelong, Australia
| | - D A Stupart
- Department of Surgery, Barwon Health, Geelong, Australia
| | - G D Guest
- Department of Surgery, Barwon Health, Geelong, Australia
| | - D A K Watters
- Department of Surgery, Barwon Health, Geelong, Australia
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Abe H, Mafune KI, Minamimura K, Hirata T. Validation of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) score for maintenance hemodialysis patients undergoing elective abdominal surgery. Dig Surg 2014; 31:269-75. [PMID: 25322745 DOI: 10.1159/000365293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 06/15/2014] [Indexed: 12/10/2022]
Abstract
AIMS This study assessed the validity of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) score in maintenance hemodialysis patients undergoing elective abdominal surgery. METHODS We retrospectively reviewed the medical records of 73 hemodialysis patients who underwent elective gastrointestinal surgery. The main outcomes analyzed were the E-PASS score and postoperative course, which were defined by mortality and morbidity. The discriminative capability of the E-PASS score was evaluated using receiver operating characteristic (ROC) curve analysis. RESULTS The overall mortality rate observed was 2.7% (2 patients) and the morbidity rate was 36.9%. There were no significant differences in the comprehensive risk score, preoperative score or surgical stress score for patients with or without complications (p = 0.556, 0.639 and 0.168, respectively). Subsequent ROC curve analysis demonstrated poor predictive accuracy for morbidity. When the results in our study population were compared with those in Haga's study population, our population exhibited a highly significant rightward shift (p < 0.001). CONCLUSION The E-PASS score was a poor predictor of complications because maintenance hemodialysis patients already have relatively high risk factors. This scoring system should not be applied in such a special group with high risk factors.
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Affiliation(s)
- Hayato Abe
- Division of Gastrointestinal Surgery, Mitsui Memorial Hospital, Tokyo, Japan
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Ahlenstiel G, Hourigan LF, Brown G, Zanati S, Williams SJ, Singh R, Moss A, Sonson R, Bourke MJ. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc 2014; 80:668-676. [PMID: 24916925 DOI: 10.1016/j.gie.2014.04.015] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 04/02/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND EMR of advanced mucosal neoplasia (AMN) (ie, sessile or laterally spreading lesions of ≥20 mm) of the colon has become an increasingly popular alternative to surgical resection. However, data regarding safety and mortality of EMR in comparison to surgery are limited. OBJECTIVE To compare actual endoscopic with predicted surgical mortality. DESIGN Prospective, observational, multicenter cohort study. SETTING Academic, high-volume, tertiary-care referral center. PATIENTS Consecutive patients referred for EMR. INTERVENTION EMR MAIN OUTCOME MEASUREMENTS To predict hypothetical surgical mortality, the Association of Coloproctology of Great Britain and Ireland score, composed of physiological and surgical components, was calculated for each patient. Predicted surgical mortality was then compared with actual outcomes of EMR. The results were validated by an unselected subcohort by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity. RESULTS Among 1050 patients with AMN treated by EMR, including patients with a predicted mortality rate of greater than 5% (13.8% of cohort), no deaths occurred within 30 days after the procedure. The predicted surgical mortality rate was 3.3% with the Association of Coloproctology of Great Britain and Ireland score (P < .0001). This suggests a significant advantage of EMR over surgery. The results were validated by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity in 390 patients predicting a surgical mortality rate of 3.2% (P = .0003). LIMITATIONS Nonrandomized study. CONCLUSION In this large multicenter study of EMR for colonic AMN, the predicted surgical mortality rate was significantly higher than the actual endoscopic mortality rate. Given that endoscopic therapy is less morbid and less expensive than surgery and can be performed as an outpatient treatment, it should be considered as the first line of treatment for most patients with these lesions.
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Affiliation(s)
- Golo Ahlenstiel
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Department of Gastroenterology and Hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Gregor Brown
- Department of Gastroenterology and Hepatology, The Alfred Melbourne, Victoria, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Victoria, Australia
| | - Simon Zanati
- Department of Gastroenterology and Hepatology, The Alfred Melbourne, Victoria, Australia; Department of Gastroenterology and Hepatology, Western Hospital, Melbourne, Victoria, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Rajvinder Singh
- Department of Gastroenterology and Hepatology, Western Hospital, Melbourne, Victoria, Australia; Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Alan Moss
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, Western Hospital, Melbourne, Victoria, Australia
| | - Rebecca Sonson
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
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Postoperative 30-day mortality in patients undergoing surgery for colorectal cancer: development of a prognostic model using administrative claims data. Cancer Causes Control 2014; 25:1503-12. [PMID: 25104569 DOI: 10.1007/s10552-014-0451-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 07/22/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To develop a prognostic model to predict 30-day mortality following colorectal cancer (CRC) surgery using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked data and to assess whether race/ethnicity, neighborhood, and hospital characteristics influence model performance. METHODS We included patients aged 66 years and older from the linked 2000-2005 SEER-Medicare database. Outcome included 30-day mortality, both in-hospital and following discharge. Potential prognostic factors included tumor, treatment, sociodemographic, hospital, and neighborhood characteristics (census-tract-poverty rate). We performed a multilevel logistic regression analysis to account for nesting of CRC patients within hospitals. Model performance was assessed using the area under the receiver operating characteristic curve (AUC) for discrimination and the Hosmer-Lemeshow goodness-of-fit test for calibration. RESULTS In a model that included all prognostic factors, important predictors of 30-day mortality included age at diagnosis, cancer stage, and mode of presentation. Race/ethnicity, census-tract-poverty rate, and hospital characteristics were independently associated with 30-day mortality, but they did not influence model performance. Our SEER-Medicare model achieved moderate discrimination (AUC = 0.76), despite suboptimal calibration. CONCLUSIONS We developed a prognostic model that included tumor, treatment, sociodemographic, hospital, and neighborhood predictors. Race/ethnicity, neighborhood, and hospital characteristics did not improve model performance compared with previously developed models.
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Osman KA, Ryan D, Afshar S, Mohamed ZK, Garg D, Gill T. Transanal Endoscopic Microsurgery (TEM) for Rectal Cancer: University Hospital of North Tees Experience. Indian J Surg 2014; 77:930-5. [PMID: 27011485 DOI: 10.1007/s12262-014-1067-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 03/27/2014] [Indexed: 01/08/2023] Open
Abstract
Transanal endoscopic microsurgery (TEM) is a minimally invasive technique that is increasingly being used to treat early rectal cancer (T1/T2). We studied the outcomes of TEM for rectal cancer at our institution looking at the indication, recurrence rate, need for further radical surgery, 30-day and 12-month mortality and complication rate. We performed a retrospective analysis of prospectively collected data of cases between 2008 and 2012: 110 TEM procedures were performed during this period: 40 were confirmed rectal cancers and 70 were benign. We analysed the data for the 40 patients with confirmed rectal cancer. Thirty (75 %) of the subjects were male with a mean age of 71 ± 10 years (range 49-90 years) and 19 (48 %) patients were ASA 3 and 4. Nineteen (48 %) of cancers were pT1, eighteen (45 %) were pT2, two (5 %) were pT3 and one was yPT0. Mean specimen size was 66 ± 20 mm (range 33-120 mm) with a mean polyp size of 41 ± 24 mm (range 18-110 mm). The mean cancer size was 24 ± 13 mm (range 2-50 mm). Average distance from the anal verge was 70 ± 37 mm (range 10-150 mm), and the mean operating time was 72 ± 22 min (range 40-120 min), with an average blood loss of 28 ± 15 ml (range 10-50ml). Median hospital stay was 2 ± 1 days (range 1-7 days). Complete excision (R0) was achieved in 37 (93 %) patients. Minor post-operative complications included urinary retention in two and pyrexia in three patients. There were no 30-day or 12-month mortalities. Mean follow-up was 13 ± 11 months, range (3-40 months) Local recurrence occurred in two (5 %) patients, both underwent redo TEM. Twelve (30 %) patients underwent laparoscopic radical resections (seven AR and five APER) post-TEM. Post-operative histology confirmed pT0N0 in 7/12 patients. Three were lymph node-positive (T0N1), one was pT3N1 and the fifth was pT3N2. TEM is associated with quicker recovery, shorter hospital stay and fewer complications than radical surgery. It is a good alternative to radical surgery in early rectal cancer, especially for high-risk patients. Recurrent tumours can be treated with redo TEM.
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Affiliation(s)
- Khalid A Osman
- Department of Colorectal Surgery, University Hospital of North Tees, Hardwick Road, Stockton on Tees, TS19 8PE UK
| | - Daniel Ryan
- Department of Colorectal Surgery, University Hospital of North Tees, Hardwick Road, Stockton on Tees, TS19 8PE UK
| | - Sorena Afshar
- Department of Colorectal Surgery, University Hospital of North Tees, Hardwick Road, Stockton on Tees, TS19 8PE UK
| | - Zakir K Mohamed
- Department of Colorectal Surgery, University Hospital of North Tees, Hardwick Road, Stockton on Tees, TS19 8PE UK
| | - Dharmendra Garg
- Department of Colorectal Surgery, University Hospital of North Tees, Hardwick Road, Stockton on Tees, TS19 8PE UK
| | - Talvinder Gill
- Department of Colorectal Surgery, University Hospital of North Tees, Hardwick Road, Stockton on Tees, TS19 8PE UK
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Hershman MJ, Mohammad H, Hussain A, Ahmed A. Local excision of rectal tumours by minimally invasive transanal surgery. Br J Hosp Med (Lond) 2013; 74:387-90. [PMID: 24159640 DOI: 10.12968/hmed.2013.74.7.387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Michael J Hershman
- Department of Colorectal Surgery, Mid Staffordshire NHS Foundation Trust, Stafford ST16 3SA.
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Young JA, Waugh L, McPhillips G, Steele RJC, Thompson AM. Use of the high dependency unit, increased consultant involvement and reduction in adverse events in patients who die after colorectal cancer surgery. Colorectal Dis 2013; 15:824-9. [PMID: 23375051 DOI: 10.1111/codi.12161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 11/11/2012] [Indexed: 01/01/2023]
Abstract
AIM We prospectively audited adverse events for surgical patients with colorectal cancer who died under surgical care to test the hypothesis that increased critical care and consultant input could be associated with a reduction in adverse events. METHOD Patients with a diagnosis of colorectal cancer who died under surgical care in Scotland from 1996 to 2005 underwent peer review audit using established methodologies through the Scottish Audit of Surgical Mortality. RESULTS In the 10-year study period, 3029 patients with colorectal cancer, mean age 76 (13-105) years, died under surgical care, of whom 80% had presented as an emergency admission. Operative intervention was performed in 1557 (51%) patients of whom 1030 (34%) patients had a resection of the cancer. The annual number of patients dying after a cancer resection decreased significantly (P = 0.009). Significant decreases in adverse events were noted over time with a 67% fall in adverse events relating to critical care (P = 0.009), a 37% fall for surgical care (P = 0.04) and a significant increase in consultant anaesthetist and consultant surgeon input, but there was a 9% increase in delay as an adverse event (P = 0.006). The documented anastomotic leakage rate in patients who died increased from 8% in 1996 to 19% in 2005 (P = 0.016). CONCLUSION The number of patients dying with colorectal cancer after surgery has decreased in recent years. Adverse events in these patients have significantly reduced over a decade with increased consultant involvement although there is the potential for further improvement.
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Affiliation(s)
- J A Young
- Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee, UK.
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Jang WM, Park JH, Park JH, Oh JH, Kim Y. Improving the performance of risk-adjusted mortality modeling for colorectal cancer surgery by combining claims data and clinical data. J Prev Med Public Health 2013; 46:74-81. [PMID: 23573371 PMCID: PMC3615382 DOI: 10.3961/jpmph.2013.46.2.74] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 02/19/2013] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES The objective of this study was to evaluate the performance of risk-adjusted mortality models for colorectal cancer surgery. METHODS We investigated patients (n=652) who had undergone colorectal cancer surgery (colectomy, colectomy of the rectum and sigmoid colon, total colectomy, total proctectomy) at five teaching hospitals during 2008. Mortality was defined as 30-day or in-hospital surgical mortality. Risk-adjusted mortality models were constructed using claims data (basic model) with the addition of TNM staging (TNM model), physiological data (physiological model), surgical data (surgical model), or all clinical data (composite model). Multiple logistic regression analysis was performed to develop the risk-adjustment models. To compare the performance of the models, both c-statistics using Hanley-McNeil pair-wise testing and the ratio of the observed to the expected mortality within quartiles of mortality risk were evaluated to assess the abilities of discrimination and calibration. RESULTS The physiological model (c=0.92), surgical model (c=0.92), and composite model (c=0.93) displayed a similar improvement in discrimination, whereas the TNM model (c=0.87) displayed little improvement over the basic model (c=0.86). The discriminatory power of the models did not differ by the Hanley-McNeil test (p>0.05). Within each quartile of mortality, the composite and surgical models displayed an expected mortality ratio close to 1. CONCLUSIONS The addition of clinical data to claims data efficiently enhances the performance of the risk-adjusted postoperative mortality models in colorectal cancer surgery. We recommended that the performance of models should be evaluated through both discrimination and calibration.
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Affiliation(s)
| | - Jae-Hyun Park
- Department of Social and Preventive Medicine, Sungkyunkwan University, Suwon, Korea
| | - Jong-Hyock Park
- Division of Cancer Policy and Management, National Cancer Control Research Institute, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Yoon Kim
- Institute of Health Policy and Management, Medical Research Center, Seoul National University, Seoul, Korea
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
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Pelavski AD, Lacasta A, de Miguel M, Rochera MI, Roca M. Mortality and surgical risk assessment among the extreme old undergoing emergency surgery. Am J Surg 2013; 205:58-63. [DOI: 10.1016/j.amjsurg.2012.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 03/05/2012] [Accepted: 03/05/2012] [Indexed: 11/27/2022]
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Kolfschoten NE, Wouters MWJM, Gooiker GA, Eddes EH, Kievit J, Tollenaar RAEM, Marang-van de Mheen PJ. Nonelective colon cancer resections in elderly patients: results from the dutch surgical colorectal audit. Dig Surg 2012; 29:412-9. [PMID: 23235489 DOI: 10.1159/000345614] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 11/05/2012] [Indexed: 12/10/2022]
Abstract
AIMS The aim of the study was to assess which factors contribute to postoperative mortality, especially in elderly patients who undergo emergency colon cancer resections, using a nationwide population-based database. METHODS 6,161 patients (1,172 nonelective) who underwent a colon cancer resection in 2010 in the Netherlands were included. Risk factors for postoperative mortality were investigated using a multivariate logistic regression model for different age groups, elective and nonelective patients separately. RESULTS For both elective and nonelective patients, mortality risk increased with increasing age. For nonelective elderly patients (80+ years), each additional risk factor increased the mortality risk. For a nonelective patient of 80+ years with an American Society of Anesthesiologists score of III+ and a left hemicolectomy or extended resection, postoperative mortality rate was 41% compared with 7% in patients without additional risk factors. CONCLUSIONS For elderly patients with two or more additional risk factors, a nonelective resection should be considered a high-risk procedure with a mortality risk of up to 41%. The results of this study could be used to adequately inform patient and family and should have consequences for composing an operative team.
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Affiliation(s)
- N E Kolfschoten
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Klima DA, Brintzenhoff RA, Agee N, Walters A, Heniford BT, Mostafa G. A Review of Factors that Affect Mortality Following Colectomy. J Surg Res 2012; 174:192-9. [DOI: 10.1016/j.jss.2011.09.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2011] [Revised: 08/10/2011] [Accepted: 09/07/2011] [Indexed: 12/20/2022]
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Roxburgh CSD, Richards CH, Moug SJ, Foulis AK, McMillan DC, Horgan PG. Determinants of short- and long-term outcome in patients undergoing simultaneous resection of colorectal cancer and synchronous colorectal liver metastases. Int J Colorectal Dis 2012; 27:363-9. [PMID: 22086199 DOI: 10.1007/s00384-011-1339-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2011] [Indexed: 02/04/2023]
Abstract
PURPOSE The optimal surgical strategy for patients presenting with colorectal liver metastases has yet to be determined. Short- and long-term outcomes must be considered if simultaneous resection of primary and liver metastases is to gain acceptance. We examine the prognostic value of patient and tumour characteristics in predicting short- and long-term outcomes following simultaneous resection for synchronous disease. METHODS Forty-six patients undergoing simultaneous resection between April 2002 and June 2010 in a single institution were included. Patient characteristics included preoperative ASA grade and POSSUM. Tumour characteristics included TNM stage, Petersen Index and the Clinical Risk Score. RESULTS There were no postoperative deaths. The most common complications were atrial fibrillation (seven patients) and pneumonia (seven patients). Mean hospital stay with an uncomplicated postoperative recovery was 11 days versus 17 days with complicated recovery. Age (p = 0.015), ASA grade (p = 0.010) and POSSUM score (p = 0.032) were associated with postoperative complications. No pathological characteristics of the primary or secondary tumours related to surgical morbidity. Median follow-up was 37 months (5-87) during which 24 patients died, 23 from cancer. Twenty-seven had disease recurrence. N stage of the primary (p = 0.035), high-risk Petersen Index of the primary (p = 0.010) and Clinical Risk Score ≥ 3 (p = 0.005) were associated with poorer recurrence-free and cancer-specific survival. CONCLUSIONS Post operative morbidity was determined by patient factors rather than operative or tumour characteristics. In addition to the Clinical Risk Score, pathological characteristics of the primary are important determinants of long-term outcome following simultaneous resection for synchronous disease.
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Affiliation(s)
- C S D Roxburgh
- University Department of Surgery, University of Glasgow, Royal Infirmary, Glasgow, G31 2ER, UK.
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Abstract
AIM The review aimed to offer a contemporary perspective of the quality of current colorectal surgery. METHOD A literature search was undertaken to identify relevant indicators. Citations were included if they related to quality in colorectal surgery. The search terms used included the Medical Subject Heading terms and Boolean characters: 'colon' OR 'colorectal', OR 'rectal' OR 'rectum' AND 'Quality Indicators', OR 'Quality Assurance', OR 'Quality of healthcare', OR 'Reference Standards', OR 'Quality' plus a variable floating term. A two-person independent review was undertaken from resulting citations and their consequent reference lists. The search was limited to citations from 2000 to 2010 in humans and to the English language. RESULTS Metrics identified as potential quality indicators in colorectal surgery are discussed according to the structure, process and outcome framework. CONCLUSION A clear appreciation of the scope of individual metrics for quality appraisal purposes is necessary if they are to be used meaningfully for performance benchmarking.
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Affiliation(s)
- A M Almoudaris
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
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Predictive value of POSSUM and ACPGBI scoring in mortality and morbidity of colorectal resection: a case-control study. J Gastrointest Surg 2011; 15:294-303. [PMID: 20936370 PMCID: PMC3035786 DOI: 10.1007/s11605-010-1354-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 09/17/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Preoperative risk prediction to assess mortality and morbidity may be helpful to surgical decision making. The aim of this study was to compare mortality and morbidity of colorectal resections performed in a tertiary referral center with mortality and morbidity as predicted with physiological and operative score for enumeration of mortality and morbidity (POSSUM), Portsmouth POSSUM (P-POSSUM), and colorectal POSSUM (CR-POSSUM). The second aim of this study was to analyze the accuracy of different POSSUM scores in surgery performed for malignancy, inflammatory bowel diseases, and diverticulitis. POSSUM scoring was also evaluated in colorectal resection in acute vs. elective setting. In procedures performed for malignancy, the Association of Coloproctology of Great Britain and Ireland (ACPGBI) score was assessed in the same way for comparison. METHODS POSSUM, P-POSSUM, and CR-POSSUM predictor equations for mortality were applied in a retrospective case-control study to 734 patients who had undergone colorectal resection. The total group was assessed first. Second, the predictive value of outcome after surgery was assessed for malignancy (n = 386), inflammatory bowel diseases (n = 113), diverticulitis (n = 91), and other indications, e.g., trauma, endometriosis, volvulus, or ischemia (n = 144). Third, all subgroups were assessed in relation to the setting in which surgery was performed: acute or elective. In patients with malignancy, the ACPGBI score was calculated as well. In all groups, receiver operating characteristic (ROC) curves were constructed. RESULTS POSSUM, P-POSSUM, and CR-POSSUM have a significant predictive value for outcome after colorectal surgery. Within the total population as well as in all four subgroups, there is no difference in the area under the curve between the POSSUM, P-POSSUM, and CR-POSSUM scores. In the subgroup analysis, smallest areas under the ROC curve are seen in operations performed for malignancy, which is significantly worse than for diverticulitis and in operations performed for other indications. For elective procedures, P-POSSUM and CR-POSSUM predict outcome significantly worse in patients operated for carcinoma than in patients with diverticulitis. In acute surgical interventions, CR-POSSUM predicts mortality better in diverticulitis than in patients operated for other indications. The ACPGBI score has a larger area under the curve than any of the POSSUM scores. Morbidity as predicted by POSSUM is most accurate in procedures for diverticulitis and worst when the indication is malignancy. CONCLUSION The POSSUM scores predict outcome significantly better than can be expected by chance alone. Regarding the indication for surgery, each POSSUM score predicts outcome in patients operated for diverticulitis or other indications more accurately than for malignancy. The ACPGBI score is found to be superior to the various POSSUM scores in patients who have (elective) resection of colorectal malignancy.
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Richards CH, Leitch FE, Horgan PG, McMillan DC. A systematic review of POSSUM and its related models as predictors of post-operative mortality and morbidity in patients undergoing surgery for colorectal cancer. J Gastrointest Surg 2010; 14:1511-20. [PMID: 20824372 DOI: 10.1007/s11605-010-1333-5] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 08/12/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model and its Portsmouth (P-POSSUM) and colorectal (CR-POSSUM) modifications are used extensively to predict and audit post-operative mortality and morbidity. This aim of this systematic review was to assess the predictive value of the POSSUM models in colorectal cancer surgery. METHODS Major electronic databases, including Medline, Embase, Cochrane Library and Pubmed were searched for original studies published between 1991 and 2010. Two independent reviewers assessed each study against inclusion and exclusion criteria. All data was specific to colorectal cancer surgery. Predictive value was assessed by calculating observed to expected (O/E) ratios. RESULTS Nineteen studies were included in final review. The mortality analysis included ten studies (4,799 patients) on POSSUM, 17 studies (6,576 patients) on P-POSSUM and 14 studies (5,230 patients) on CR-POSSUM. Weighted O/E ratios for mortality were 0.31 (CI 0.31-0.32) for POSSUM, 0.90 (CI 0.88-0.92) for P-POSSUM and 0.64 (CI 0.63-0.65) for CR-POSSUM. The morbidity analysis included four studies (768 patients) on POSSUM with a weighted O/E ratio of 0.96 (CI 0.94-0.98). CONCLUSIONS P-POSSUM was the most accurate model for predicting post-operative mortality after colorectal cancer surgery. The original POSSUM model was accurate in predicting post-operative complications.
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Affiliation(s)
- Colin Hewitt Richards
- University Department of Surgery, Faculty of Medicine-University of Glasgow, Royal Infirmary, Glasgow G4 0SF, UK.
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Saxena A, Yan TD, Morris DL. A critical evaluation of risk factors for complications after cytoreductive surgery and perioperative intraperitoneal chemotherapy for colorectal peritoneal carcinomatosis. World J Surg 2010; 34:70-8. [PMID: 19760317 DOI: 10.1007/s00268-009-0206-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with colorectal peritoneal carcinomatosis (CRPC). This treatment modality is associated with relatively high rates of perioperative morbidity and mortality. This study evaluated the clinical and treatment-related risk factors for perioperative morbidity and mortality in patients with CRPC who underwent CRS and PIC. METHODS Sixty-three consecutive patients who underwent CRS and PIC for CRPC were evaluated. Adverse events were rated from grades I to V with increasing severity. Clinical and treatment-related risk factors for grades III and IV/V morbidity were determined. RESULTS There were no perioperative deaths (0%). The grades III and IV morbidity rates were 14 and 17%, respectively. A peritoneal cancer index >12 (p = 0.019), transfusion >4 units (p = 0.028), number of peritonectomy procedures >3 (p = 0.013), left upper quadrant peritonectomy procedure (p < 0.001), and number of primary colonic anastomosis >1 (p = 0.004) were associated with grade IV morbidity on univariate analysis. Only left upper quadrant procedure was associated with grade IV morbidity on multivariate analysis (p = 0.002). Only number of primary colonic anastomosis >1 (p = 0.037) was associated with grade III morbidity on univariate analysis. This also was associated with grade III morbidity on multivariate analysis (p = 0.028). CONCLUSIONS CRS and PIC has an acceptable risk of perioperative morbidity in carefully selected patients with CRPC. Patients who require extensive surgery have the highest risk for a severe adverse event. Preoperative evaluation of patients is essential to improve perioperative outcome.
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Affiliation(s)
- Akshat Saxena
- Department of Surgery, St George Hospital, University of New South Wales, Sydney, Australia.
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Saxena A, Yan TD, Chua TC, Morris DL. Critical assessment of risk factors for complications after cytoreductive surgery and perioperative intraperitoneal chemotherapy for pseudomyxoma peritonei. Ann Surg Oncol 2009; 17:1291-301. [PMID: 20039212 DOI: 10.1245/s10434-009-0875-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with pseudomyxoma peritonei (PMP). However, this aggressive treatment modality has been consistently associated with variable rates of perioperative mortality between 0% and 18% and morbidity between 30% and 70%. This study evaluates the clinical and treatment-related risk factors for perioperative morbidity and mortality in PMP patients who underwent CRS and PIC. MATERIALS AND METHODS A total of 145 consecutive CRS and PIC procedures for PMP performed between January 1996 and March 2009 were evaluated. The association of 12 clinical and 20 treatment-related risk factors with grades III and IV/V morbidity were assessed by univariable and multivariable analysis. RESULTS The mortality (grade V) rate was 3%. The morbidity rates of grades III and IV were 23% and 22%, respectively. Eight factors were associated with grade IV/V morbidity on univariable analysis: peritoneal cancer index >or=21 (P = .034), ASA score >or=3 (P = .003), operation duration >or=10 h (P < .001), left upper quadrant peritonectomy procedure (P = .037), colonic resection (P = .012), ostomy (P = .005), ileostomy (P = .012), and transfusion >or=6 units (p = 0.011). Multivariable analysis showed 2 significant risk factors for grade IV/V morbidity: ASA >or= 3 (P = .006) and an operation length >or=10 h (P < .001). CONCLUSIONS CRS and PIC has an acceptable rate of perioperative mortality and morbidity in selected patients with PMP. Patients with bulky disease who undergo a long operation are at a particularly high risk of a severe adverse event.
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Affiliation(s)
- Akshat Saxena
- Department of Surgery, St George Hospital, University of New South Wales, Sydney, Australia.
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External validation of Cleveland Clinic Foundation colorectal cancer model in a University Clinic in terms of predicting operative mortality. Tech Coloproctol 2009; 14:9-12. [DOI: 10.1007/s10151-009-0546-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Accepted: 11/03/2009] [Indexed: 10/20/2022]
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Pereira LCM, Oliveira KM, L'Abbate GL, Sugai R, Ferreira JA, da Motta LA. Outcome of fully awake craniotomy for lesions near the eloquent cortex: analysis of a prospective surgical series of 79 supratentorial primary brain tumors with long follow-up. Acta Neurochir (Wien) 2009; 151:1215-30. [PMID: 19730779 DOI: 10.1007/s00701-009-0363-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2008] [Accepted: 03/26/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite possible advantages, few surgical series report specifically on awake craniotomy for intrinsic brain tumors in eloquent brain areas. OBJECTIVES Primary: To evaluate the safety and efficacy of fully awake craniotomy (FAC) for the resection of primary supratentorial brain tumors (PSBT) near or in eloquent brain areas (EBA) in a developing country. Secondary: To evaluate the impact of previous surgical history and different treatment modalities on outcome. PATIENTS AND METHODS From 1998 to 2007, 79 consecutive FACs for resection PSBT near or in EBA, performed by a single surgeon, were prospectively followed. Two groups were defined based on time period and surgical team: group A operated on from March 1998 to July 2004 without a multidisciplinary team and group B operated on from August 2004 to October 2007 in a multidisciplinary setting. For both time periods, two groups were defined: group I had no previous history of craniotomy, while group II had undergone a previous craniotomy for a PSBT. Forty-six patients were operated on in group A, 46 in group B, 49 in group I and 30 in group II. Psychological assessment and selection were obligatory. The preferred anesthetic procedure was an intravenous high-dose opioid infusion (Fentanil 50 microg, bolus infusion until a minimum dose of 10 microg/kg). Generous scalp and periosteous infiltrations were performed. Functional cortical mapping was performed in every case. Continuous somato-sensory evoked potentials (SSEPs) and phase reversal localization were available in 48 cases. Standard microsurgical techniques were performed and monitored by continuous clinical evaluation. RESULTS Clinical data showed differences in time since clinical onset (p < 0.001), slowness of thought (p = 0.02) and memory deficits (p < 0.001) between study periods and also time since recent seizure onset for groups I and II (p = 0.001). Mean tumor volume was 51.2 +/- 48.7 cm3 and was not different among the four groups. The mean extent of tumor reduction was 90.0 +/- 12.7% and was similar for the whole series. A trend toward a larger incidence of glioblastoma multiforme occurred in group B (p = 0.05) and I (p = 0.04). Recovery of previous motor deficits was observed in 75.0% of patients, while motor worsening in 8.9% of cases. Recovery of semantic language deficits, control of refractory seizures and motor worsening were statistically more frequent in group B (p = 0.01). Satisfaction with the procedure was reported by 89.9% of patients, which was similar for all groups. Clinical complications were minimal, and surgical mortality was 1.3%. CONCLUSIONS These data suggest that FAC is safe and effective for the resection of PSBT in EBA as the main technique, and in a multidisciplinary context is associated with greater clinical and physiological monitoring. The previous history of craniotomy for PSBT did not seem to influence the outcome.
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Mortality rate prediction by Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM), Portsmouth POSSUM and Colorectal POSSUM and the development of new scoring systems in Chinese colorectal cancer patients. Am J Surg 2009; 198:31-8. [DOI: 10.1016/j.amjsurg.2008.06.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2008] [Revised: 06/24/2008] [Accepted: 06/24/2008] [Indexed: 11/24/2022]
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Cohen ME, Bilimoria KY, Ko CY, Hall BL. Development of an American College of Surgeons National Surgery Quality Improvement Program: Morbidity and Mortality Risk Calculator for Colorectal Surgery. J Am Coll Surg 2009; 208:1009-16. [DOI: 10.1016/j.jamcollsurg.2009.01.043] [Citation(s) in RCA: 260] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Revised: 01/27/2009] [Accepted: 01/28/2009] [Indexed: 10/20/2022]
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Validation of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) Score in Liver Surgery. World J Surg 2009; 33:1259-65. [DOI: 10.1007/s00268-009-9989-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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