The long-term effects of postoperative complications

Scoping review: The terminology used to describe major abdominal surgical procedures

BACKGROUND

Major abdominal surgery (MAS) can have a profound impact on the patient but there is currently no consensus as to which surgical procedures constitute MAS. The main objective of this work is to ascertain the terminology used to describe MAS procedures and to apply these findings in order to propose a definition of MAS.

METHODS

The following databases were searched: Ovid MEDLINE (R) ALL, Embase Classic and Embase (via OvidSP), Global Health (via OvidSP), Health Management Information Consortium (via OvidSP), APA PsycInfo (via OvidSP), PubMed and Web of Science. Original research articles, published between 1980 and April 26, 2022 that contained a description of MAS procedure were included in this study. Article screening and data extraction was undertaken independently by 3 authors. Content analysis was performed to identify key terminology used to describe MAS.

RESULTS

Five thousand six hundred and sixty three articles were identified, of which 767 underwent full-text review and 312 were included in the scoping review. Content analysis resulted in 4 main categories: (1) pre-operative factors, (2) intraoperative factors, (3) operation-related factors, (4) post-operative factors. Operation-related factors was the predominant category (1137 references coded). The gastrointestinal resection made the vast majority of the references coded (591).

CONCLUSIONS

Based on these results, the term "major abdominal surgery" should be defined as an intra-peritoneal operation with no primary involvement of the thorax, involving either luminal resection and/or resection of a solid organ associated with the gastrointestinal tract. However, further work is required to verify this definition using real world data.

Understanding Outcomes After Major Surgery

The global volume of surgery is increasing. Adverse outcomes after surgery have resource implications and long-term impact on quality of life and consequently represent a significant and underappreciated public health issue. Standardization of outcome reporting is essential for evidence synthesis, risk stratification, perioperative care planning, and to inform shared decision-making. The association between short- and long-term outcomes, which persists when corrected for base-line risk, has significant implications for patients and providers and warrants further investigation. Candidate mechanisms include sustained inflammation and reduced physician activity, which may, in the future, be mitigated by targeted interventions.

Performance and usability of pre-operative prediction models for 30-day peri-operative mortality risk: a systematic review

Estimating pre-operative mortality risk may inform clinical decision-making for peri-operative care. However, pre-operative mortality risk prediction models are rarely implemented in routine clinical practice. High predictive accuracy and clinical usability are essential for acceptance and clinical implementation. In this systematic review, we identified and appraised prediction models for 30-day postoperative mortality in non-cardiac surgical cohorts. PubMed and Embase were searched up to December 2022 for studies investigating pre-operative prediction models for 30-day mortality. We assessed predictive performance in terms of discrimination and calibration. Risk of bias was evaluated using a tool to assess the risk of bias and applicability of prediction model studies. To further inform potential adoption, we also assessed clinical usability for selected models. In all, 15 studies evaluating 10 prediction models were included. Discrimination ranged from a c-statistic of 0.82 (MySurgeryRisk) to 0.96 (extreme gradient boosting machine learning model). Calibration was reported in only six studies. Model performance was highest for the surgical outcome risk tool (SORT) and its external validations. Clinical usability was highest for the surgical risk pre-operative assessment system. The SORT and risk quantification index also scored high on clinical usability. We found unclear or high risk of bias in the development of all models. The SORT showed the best combination of predictive performance and clinical usability and has been externally validated in several heterogeneous cohorts. To improve clinical uptake, full integration of reliable models with sufficient face validity within the electronic health record is imperative.

Association Between Postoperative Complications and Long-term Survival After Non-cardiac Surgery Among Veterans

OBJECTIVE

To evaluate the relationship between postoperative complications and long-term survival.

SUMMARY AND BACKGROUND

Postoperative complications remain a significant driver of healthcare costs and are associated with increased perioperative mortality, yet the extent to which they are associated with long-term survival is unclear.

METHODS

National cohort study of Veterans who underwent non-cardiac surgery using data from the Veterans Affairs Surgical Quality Improvement Program (2011-2016). Patients were classified as having undergone outpatient, low-risk inpatient, or high-risk inpatient surgery. Patients were categorized based on number and type of complications. The association between the number of complications (or the specific type of complication) and risk of death was evaluated using multivariable Cox regression with robust standard errors using a 90-day survival landmark.

RESULTS

Among 699,002 patients, complication rates were 3.0%, 6.1%, and 18.3% for outpatient, low-risk inpatient, and high-risk inpatient surgery, respectively. There was a dose-response relationship between an increasing number of complications and overall risk of death in all operative settings [outpatient surgery: no complications (ref); one-hazard ratio (HR) 1.30 (1.23 - 1.38); multiple-HR 1.61 (1.46 - 1.78); low-risk inpatient surgery: one-HR 1.34 (1.26 - 1.41); multiple-HR 1.69 (1.55 - 1.85); high-risk inpatient surgery: one-HR 1.14 (1.10 - 1.18); multiple-HR 1.42 (1.36 - 1.48)]. All complication types were associated with risk of death in at least 1 operative setting, and pulmonary complications, sepsis, and clostridium difficile colitis were associated with higher risk of death across all settings. Conclusions: Postoperative complications have an adverse impact on patients' long-term survival beyond the immediate postoperative period. Although most research and quality improvement initiatives primarily focus on the perioperative impact of complications, these data suggest they also have important longer-term implications that merit further investigation.

Development, implementation and evaluation of high-quality virtual preoperative anaesthetic assessment during COVID-19 and beyond: a quality improvement report

BACKGROUND

Preoperative risk factor identification and optimisation are widely accepted as the gold standard of care for elective surgery and are essential for reducing morbidity and mortality. COVID-19 public health restrictions required a careful balance between ensuring best medical practices and maintaining safety by minimising patient face-to-face attendance in the hospital. Based on the successful implementation of telemedicine (TM) in other medical specialties and its feasibility in the preoperative context, this study aimed to develop, implement and evaluate a high-quality virtual preoperative anaesthetic assessment process.

METHODS

The three-step model for improvement was used. The specific, measurable, actionable, relevant, time aim (step 1) and measures for improvement (step 2) were defined at the onset of the project. The plan-do-study-act tool was used for the structured implementation of improvement interventions (step 3) in three phases. Data relating to virtual and in-person referrals, assessments, did-not-attend (DNA) rate, consultation time, day of surgery delays and cancellations, and service-user and provider experience surveys were recorded prospectively.

RESULTS

A total of 2805 patients were assessed in the preoperative anaesthetic assessment clinic between July 2020 and March 2021. The mean rate of virtual preoperative assessments was 50% (SD ±10) (1390/2805). 0.1% (30/2805) were inappropriately referred on the alternative pathway. The DNA rate was 0.4% (8/1398) and 3% (43/1458) for virtual and in-person pathways, respectively. The mean consultation times for virtual and in-person attendance were 19 (SD ±7) and 31 (SD ±13) min, respectively. There were five same-day surgery cancellations and one delay due to medical reasons. When asked about their experience with the virtual assessment, both service users and providers reported high satisfaction, minimal technical difficulties and shared concerns about limited opportunities for physical examination.

CONCLUSION

This is one of the first implementational studies to comprehensively outline the feasibility of TM in preoperative anaesthetic assessment during COVID-19.

Change in healthcare utilisation after surgical treatment: observational study of routinely collected patient data from primary and secondary care

BACKGROUND

Most patients fully recover after surgery. However, high-risk patients may experience an increased burden of medical disease.

METHODS

We performed a prospectively planned analysis of linked routine primary and secondary care data describing adult patients undergoing non-obstetric surgery at four hospitals in East London between January 2012 and January 2017. We categorised patients by 90-day mortality risk using logistic regression modelling. We calculated healthcare contact days per patient year during the 2 yr before and after surgery, and express change using rate ratios (RaR) with 95% confidence intervals.

RESULTS

We included 70 021 patients, aged (mean [standard deviation, sd]) 49.8 (19) yr, with 1238 deaths within 2 yr after surgery (1.8%). Most procedures were elective (51 693, 74.0%), and 20 441 patients (29.1%) were in the most deprived national quintile for social deprivation. Elective patients had 12.7 healthcare contact days per patient year before surgery, increasing to 15.5 days in the 2 yr after surgery (RaR, 1.22 [1.21-1.22]), and those at high-risk of 90-day mortality (11% of population accounting for 80% of all deaths) had the largest increase (37.0 days per patient year before vs 60.8 days after surgery; RaR, 1.64 [1.63-1.65]). Emergency patients had greater increases in healthcare burden (13.8 days per patient year before vs 24.8 days after surgery; RaR, 1.8 [1.8-1.8]), particularly in high-risk patients (28% of patients accounting for 80% of all deaths by day 90), with 21.6 days per patient year before vs 49.2 days after surgery; RaR, 2.28 [2.26-2.29].

DISCUSSION

High-risk patients who survive the immediate perioperative period experience large and persistent increases in healthcare utilisation in the years after surgery. The full implications of this require further study.

The Perioperative Quality Improvement Programme (PQIP patient study): protocol for a UK multicentre, prospective cohort study to measure quality of care and outcomes after major surgery

Introduction

Major surgery accounts for a substantial proportion of health service activity, due not only to the primary procedure, but the longer-term health implications of poor short-term outcome. Data from small studies or from outside the UK indicate that rates of complications and failure to rescue vary between hospitals, as does compliance with best practice processes. Within the UK, there is currently no system for monitoring postoperative complications (other than short-term mortality) in major non-cardiac surgery. Further, there is variation between national audit programmes, in the emphasis placed on quality assurance versus quality improvement, and therefore the principles of measurement and reporting which are used to design such programmes.

Methods and analysis

The PQIP patient study is a multi-centre prospective cohort study which recruits patients undergoing major surgery. Patient provide informed consent and contribute baseline and outcome data from their perspective using a suite of patient-reported outcome tools. Research and clinical staff complete data on patient risk factors and outcomes in-hospital, including two measures of complications. Longer-term outcome data are collected through patient feedback and linkage to national administrative datasets (mortality and readmissions). As well as providing a uniquely granular dataset for research, PQIP provides feedback to participating sites on their compliance with evidence-based processes and their patients’ outcomes, with the aim of supporting local quality improvement.

Ethics and dissemination

Ethical approval has been granted by the Health Research Authority in the UK. Dissemination of interim findings (non-inferential) will form a part of the improvement methodology and will be provided to participating centres at regular intervals, including near-real time feedback of key process measures. Inferential analyses will be published in the peer-reviewed literature, supported by a comprehensive multi-modal communications strategy including to patients, policy makers and academic audiences as well as clinicians.

The burden of perioperative hypertension/hypotension: A systematic review

Study objective

Our goal is to review the outcomes of acute hypertensive/hypotensive episodes from articles published in the past 10 years that assessed the short- and long-term impact of acute hypertensive/hypotensive episodes in the perioperative setting.

Methods

We conducted a systematic peer review based upon PROSPERO and Cochrane Handbook protocols. The following study characteristics were collected: study type, author, year, population, sample size, their definition of acute hypertension, hypotension or other measures, and outcomes (probabilities, odds ratio, hazard ratio, and relative risk) and the p-values; and they were classified according to the type of surgery (cardiac and non-cardiac).

Results

A total of 3,680 articles were identified, and 66 articles fulfilled the criteria for data extraction. For the perioperative setting, the number of articles varies by outcome: 20 mortality, 16 renal outcomes, 6 stroke, 7 delirium and 34 other outcomes. Hypotension was reported to be associated with mortality (OR 1.02–20.826) as well as changes from the patient’s baseline blood pressure (BP) (OR 1.02–1.36); hypotension also had a role in the development of acute kidney injury (AKI) (OR 1.03–14.11). Postsurgical delirium was found in relation with BP lability (OR 1.018–1.038) and intra- and postsurgical hypotension (OR 1.05–1.22), and hypertension (OR 1.44–2.34). Increased OR (37.67) of intracranial hemorrhage was associated to postsurgical systolic BP >130 mmHg. There was a wide range of additional diverse outcomes related to hypo-, hypertension and BP lability.

Conclusions

The perioperative management of BP influences short- and long-term effects of surgical procedures in cardiac and non-cardiac interventions; these findings support the burden of BP fluctuations in this setting.

Perioperative Outcome in Dogs Undergoing Emergency Abdominal Surgery: A Retrospective Study on 82 Cases (2018-2020)

Emergency abdominal surgery carries high morbidity and mortality rates in human medicine; however, there is less evidence characterising the outcome of these surgeries as a single group in dogs. The aim of the study was to characterise the clinical course, associated complications and outcome of dogs undergoing emergency abdominal surgery. A retrospective study was conducted. Dogs undergoing emergency laparotomy were included in the study. Logistic regression analysis was performed to identify variables correlated with death and complications. Eighty-two dogs were included in the study. The most common reason for surgery was a gastrointestinal foreign body. Overall, the 15-day mortality rate was 20.7% (17/82). The median (range) length of hospitalisation was 3 (0.5-15) days. Of the 82 patients, 24 (29.3%) developed major complications and 66 (80.5%) developed minor complications. Perioperative factors significantly associated with death included tachycardia (p < 0.001), hypothermia (p < 0.001), lactate acidosis (p < 0.001), shock index > 1 (p < 0.001), leukopenia (p < 0.001) and thrombocytopenia (p < 0.001) at admission, as well as intraoperative hypotension (p < 0.001) and perioperative use of blood products (p < 0.001). The results of this study suggest that mortality and morbidity rates after emergency abdominal surgery in dogs are high.

The Effects of Hyperbaric Oxygenation on Oxidative Stress, Inflammation and Angiogenesis

Hyperbaric oxygen therapy (HBOT) is commonly used as treatment in several diseases, such as non-healing chronic wounds, late radiation injuries and carbon monoxide poisoning. Ongoing research into HBOT has shown that preconditioning for surgery is a potential new treatment application, which may reduce complication rates and hospital stay. In this review, the effect of HBOT on oxidative stress, inflammation and angiogenesis is investigated to better understand the potential mechanisms underlying preconditioning for surgery using HBOT. A systematic search was conducted to retrieve studies measuring markers of oxidative stress, inflammation, or angiogenesis in humans. Analysis of the included studies showed that HBOT-induced oxidative stress reduces the concentrations of pro-inflammatory acute phase proteins, interleukins and cytokines and increases growth factors and other pro-angiogenesis cytokines. Several articles only noted this surge after the first HBOT session or for a short duration after each session. The anti-inflammatory status following HBOT may be mediated by hyperoxia interfering with NF-κB and IκBα. Further research into the effect of HBOT on inflammation and angiogenesis is needed to determine the implications of these findings for clinical practice.

Impact of Postoperative Complications on Long-Term Survival After Resection of Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

Controversy exists over the relationship between postoperative complications (POCs) and long-term survival for hepatocellular carcinoma (HCC) after hepatectomy. This study aimed to evaluate the impact of POCs on overall survival (OS) and disease-free survival (DFS) for HCC after liver resection.

PATIENTS AND METHODS

The PubMed, EMBASE, and Cochrane Library databases were used to search for eligible studies published through 18 April 2020, and studies comparing the long-term outcomes between HCC patients with and without POCs after hepatectomy were included. A random-effects model was used to calculate the pooled hazard ratio (HR) with a 95% confidence interval (CI). Subgroup analysis and meta-regression were performed to assess the potential influence of study-, patient-, and tumor-related factors on the relationship between POCs and oncologic outcomes and to adjust their effect. This study was registered at the International Prospective Register of Systematic Reviews (CRD42019136109).

RESULTS

Thirty-seven studies, including 14,096 patients, were deemed eligible and included in this study. Compared with those without POCs, patients who developed POCs had a significant reduction in OS (HR 1.39, 95% CI 1.28-1.50, P < 0.001; prediction interval 1.04-1.85) and tended to have worse DFS (HR 1.25, 95% CI 1.16-1.35, P < 0.001; prediction interval 0.98-1.60). Contour-enhanced funnel plots suggested a risk of publication bias. Subgroup analysis and meta-regression showed that POCs remained a threat to OS and DFS regardless of the influence of clinicopathological factors.

CONCLUSION

This study demonstrated that POCs had an adverse impact on OS and DFS in HCC patients after liver resection.

Association of Postoperative Infection With Risk of Long-term Infection and Mortality

Importance

Surgical site infection has been shown to decrease survival in veterans by up to 42%. The association of 30-day postoperative infections with long-term infections in the overall surgical population remains unknown.

Objective

To determine whether exposure to 30-day postoperative infection is associated with increased incidence of infection and mortality during postoperative days 31 to 365.

Design, Setting, and Participants

In this retrospective observational cohort study, veterans undergoing major surgery through the Veterans Health Administration from January 2008 to December 2015 were included. Stabilized inverse probability of treatment weighting was used to balance baseline characteristics of the control and exposure groups. Cox proportional hazards regression was used to estimate hazard ratios of long-term infection and mortality. Data were analyzed from September 2018 to May 2019.

Exposures

Any 30-day postoperative infection (exposure group) vs no 30-day infection (control group).

Main Outcomes and Measures

Number of days between index surgery and the occurrence of death or the patient's first infection during postoperative days 31 to 365. Patients who died before having a long-term infection were censored for the infection outcome.

Results

Of the 659 486 included patients, 604 534 (91.7%) were male, and the mean (SD) age was 59.7 (13.6) years. Among these patients, 23 815 (3.6%) had a 30-day infection, 43 796 (6.6%) had a long-term infection, and 24 810 (3.8%) died during follow-up. The most frequent 30-day infections were surgical site infection (9574 [40.2%]), urinary tract infection (6545 [27.5%]), pneumonia (3515 [14.8%]), and bloodstream infection (1906 [8.0%]). Long-term infection types included urinary tract infection (21 420 [48.7%]), skin and soft tissue infection (14 348 [32.6%]), bloodstream infection (3862 [8.8%]), and pneumonia (2543 [5.8%]). Patients in the exposure group had a higher observed incidence of long-term infection (5187 of 23 815 [21.8%]) and mortality (3067 of 23 815 [12.9%]) compared with those without 30-day infection (38 789 of 635 671 [6.1%] and 21 743 of 635 671 [3.4%], respectively). The estimated hazard ratio for long-term infection was 3.17 (95% CI, 3.05-3.28) and for mortality was 1.89 (95% CI, 1.79-1.99).

Conclusions and Relevance

At any given point during the follow-up period, patients with 30-day postoperative infection had a 3.2-fold higher risk of 1-year infection and a 1.9-fold higher risk of mortality compared with those who had no 30-day infection. Cost-benefit calculations for surgical infection prevention programs should include the increased risk and costs of long-term infection and death. Preventive efforts in the first 30 days postoperatively may improve long-term patient outcomes.

Effect of abdominal binder after laparoscopic cholecystectomy on enhanced recovery: a randomized controlled trialcontrolled trial

Purpose

The purpose of this randomized controlled trial was to compare the effects of abdominal binder after laparoscopic cholecystectomy.

Methods

From August to December 2020, 66 patients who were set to undergo cholecystectomy were selected for a prospective trial at Kangbuk Samsung Hospital, Seoul, Republic of Korea, and their clinical characteristics and postoperative surgical outcomes were evaluated. Among 66 patients, 33 patients belong to the abdominal binder group and the other 33 patients belong to the control group.

Results

The average hospital stay was 2.46 ± 1.29 days, and was not significantly different between the two groups. The average postoperative pain score (visual analogue scale, 0–10) 12, 24, and 48 hours after surgery were not significantly different. However, the degree of comfort score was significantly higher for the control group patients (2.56 vs. 3.33, p < 0.001). Time to the first ambulation, walking ability, return of bowel function, time to full diet resumption, and the numbers of analgesics and antiemetics administered were not significantly different between the two groups.

Conclusion

No postoperative recovery benefit and no reduction in hospital stay was found in patients who used an abdominal binder while undergoing laparoscopic cholecystectomy. Statistically, between the group that used the binder and the one that did not, no significant differences in surgical outcome nor postoperative outcome were observed. The only exception was that the degree of comfort score was significantly higher in the control group. Therefore, in terms of patient benefit and convenience, wearing an abdominal binder after laparoscopic cholecystectomy is not recommended.

Developing and validating subjective and objective risk-assessment measures for predicting mortality after major surgery: An international prospective cohort study

BACKGROUND

Preoperative risk prediction is important for guiding clinical decision-making and resource allocation. Clinicians frequently rely solely on their own clinical judgement for risk prediction rather than objective measures. We aimed to compare the accuracy of freely available objective surgical risk tools with subjective clinical assessment in predicting 30-day mortality.

METHODS AND FINDINGS

We conducted a prospective observational study in 274 hospitals in the United Kingdom (UK), Australia, and New Zealand. For 1 week in 2017, prospective risk, surgical, and outcome data were collected on all adults aged 18 years and over undergoing surgery requiring at least a 1-night stay in hospital. Recruitment bias was avoided through an ethical waiver to patient consent; a mixture of rural, urban, district, and university hospitals participated. We compared subjective assessment with 3 previously published, open-access objective risk tools for predicting 30-day mortality: the Portsmouth-Physiology and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Surgical Risk Scale (SRS), and Surgical Outcome Risk Tool (SORT). We then developed a logistic regression model combining subjective assessment and the best objective tool and compared its performance to each constituent method alone. We included 22,631 patients in the study: 52.8% were female, median age was 62 years (interquartile range [IQR] 46 to 73 years), median postoperative length of stay was 3 days (IQR 1 to 6), and inpatient 30-day mortality was 1.4%. Clinicians used subjective assessment alone in 88.7% of cases. All methods overpredicted risk, but visual inspection of plots showed the SORT to have the best calibration. The SORT demonstrated the best discrimination of the objective tools (SORT Area Under Receiver Operating Characteristic curve [AUROC] = 0.90, 95% confidence interval [CI]: 0.88-0.92; P-POSSUM = 0.89, 95% CI 0.88-0.91; SRS = 0.85, 95% CI 0.82-0.87). Subjective assessment demonstrated good discrimination (AUROC = 0.89, 95% CI: 0.86-0.91) that was not different from the SORT (p = 0.309). Combining subjective assessment and the SORT improved discrimination (bootstrap optimism-corrected AUROC = 0.92, 95% CI: 0.90-0.94) and demonstrated continuous Net Reclassification Improvement (NRI = 0.13, 95% CI: 0.06-0.20, p < 0.001) compared with subjective assessment alone. Decision-curve analysis (DCA) confirmed the superiority of the SORT over other previously published models, and the SORT-clinical judgement model again performed best overall. Our study is limited by the low mortality rate, by the lack of blinding in the 'subjective' risk assessments, and because we only compared the performance of clinical risk scores as opposed to other prediction tools such as exercise testing or frailty assessment.

CONCLUSIONS

In this study, we observed that the combination of subjective assessment with a parsimonious risk model improved perioperative risk estimation. This may be of value in helping clinicians allocate finite resources such as critical care and to support patient involvement in clinical decision-making.

The value of the "Surgical Risk Preoperative Assessment System" (SURPAS) in preoperative consultation for elective surgery: a pilot study

Background

Risk assessment is essential to informed decision making in surgery. Preoperative use of the Surgical Risk Preoperative Assessment System (SURPAS) providing individualized risk assessment, may enhance informed consent. We assessed patient and provider perceptions of SURPAS as a risk assessment tool.

Methods

A convergent mixed-methods study assessed SURPAS’s trial implementation, concurrently collecting quantitative and qualitative data, separately analyzing it, and integrating the results. Patients and providers were surveyed and interviewed on their opinion of how SURPAS impacted the preoperative encounter. Relationships between patient risk and patient and provider assessment of SURPAS were examined.

Results

A total of 197 patients were provided their SURPAS postoperative risk estimates in nine surgeon’s clinics. Of the total patients, 98.8% reported they understood their surgical risks very or quite well after exposure to SURPAS; 92.7% reported SURPAS was very helpful or helpful. Providers shared that 83.4% of the time they reported SURPAS was very or somewhat helpful; 44.7% of the time the providers reported it changed their interaction with the patient and this change was beneficial 94.3% of the time. As patient risk increased, providers reported that SURPAS was increasingly helpful (p < 0.0001).

Conclusions

Patients and providers reported the use of SURPAS helpful and informative during the preoperative risk assessment of patients, thus improving the surgical decision making process. Patients thought that SURPAS was helpful regardless of their risk level, whereas providers thought that SURPAS was more helpful in higher risk patients.

Risk factors and long-term impact of urologic complications during radical hysterectomy for cervical cancer in China, 2004-2016

OBJECTIVE

The primary objective was to describe the incidence and risk factors of urologic complications during radical hysterectomy for cervical cancer. The secondary objective was to investigate the impact of urologic complications on long-term survival.

METHODS

Patients who underwent radical hysterectomy for cervical cancer from 2004 to 2016 were identified in the MSCCCC (Major Surgical Complications of Cervical Cancer in China) database. Data on demographic characteristics, clinical characteristics, hospital characteristics and urologic complications were collected. Multivariable logistic regression was used to assess the risk factors of urologic complications and Cox proportional hazards models were performed to identify prognostic factors.

RESULTS

A total of 21,026 patients undergoing radical hysterectomy for cervical cancer were identified. The incidence of any urologic complications was 1.54%: 83 (0.39%) ureteral injuries, 17 (0.08%) bladder injuries, 1 (0.005%) ureteral injury combined with bladder injury, and 223 (1.05%) genitourinary fistulas. In a multivariable analysis, surgery at a women and children's hospital (OR = 2.26, 95% CI 1.47-3.48), surgery at a facility in a first-tier city (OR = 2.08, 95% CI 1.24-3.48), and laparoscopic surgery (OR = 4.68, 95% CI 3.44-6.36) were associated with a higher risk of urologic complications. Cox proportional hazards models revealed that the occurrence of urologic complications was a significant predictor of 2-year overall survival (OR = 1.78, 95% CI = 1.09-2.92), but was not a predictor of 5-year overall survival (OR = 1.27, 95% CI = 0.83-1.94).

CONCLUSION

The incidence of urologic complications during radical hysterectomy is low. The risk of urologic complications may be higher for patients who are treated at a women and children's hospital, are treated in first-tier city hospitals, and receive laparoscopic surgery. Urologic complications have an impact on short-term survival, but not on long-term survival.

Mixed-methods evaluation of the Perioperative Medicine Service for High-Risk Patients Implementation Pilot (POMSHIP): a study protocol

INTRODUCTION

Perioperative complications have a lasting effect on health-related quality of life and long-term survival. The Royal College of Anaesthetists has proposed the development of perioperative medicine (POM) services as an intervention aimed at improving postoperative outcome, by providing better coordinated care for high-risk patients. The Perioperative Medicine Service for High-risk Patients Implementation Pilot was developed to determine if a specialist POM service is able to reduce postoperative morbidity, failure to rescue, mortality and cost associated with hospital admission. The service involves individualised objective risk assessment, admission to a postoperative critical care unit and follow-up on the surgical ward by the POM team. This paper introduces the service and how it will be evaluated.

METHODS AND ANALYSIS OF THE EVALUATION

A mixed-methods evaluation is exploring the impact of the service. Clinical effectiveness of the service is being analysed using a 'before and after' comparison of the primary outcome (the PostOperative Morbidity Score). Secondary outcomes will include length of stay, validated surveys to explore quality of life (EQ-5D) and quality of recovery (Quality of Recovery-15 Score). The impact on costs is being analysed using 'before and after' data from the Patient-Level Information and Costing System and the National Schedule of Reference Costs. The perceptions and experiences of staff and patients with the service, and how it is being implemented, are being explored by a qualitative process evaluation.

ETHICS AND DISSEMINATION

The study was classified as a service evaluation. Participant information sheets and consent forms have been developed for the interviews and approvals required for the use of the validated surveys were obtained. The findings of the evaluation are being used formatively, to make changes in the service throughout implementation. The findings will also be used to inform the potential roll-out of the service to other sites.

New outcome measures in perioperative care

Improvements in outcome measurement are needed to produce quality improvement in perioperative care. However, problems with the collection and use of outcome data persist in research and clinical practice. This is being addressed by several national programmes and initiatives to standardize and integrate outcome measurement. The use of different outcome measures is changing and there has been a transition towards patient-focused measures. Traditional measures of quality in perioperative care include mortality, morbidity and resource utilization measures. Patient-focused measures include patient-reported outcome measures and measures of patient experience. Each of these has advantages and disadvantages in different situations. The routine collection, analysis and dissemination of data relating to perioperative outcome is beneficial to patients, clinicians, hospitals, commissioners, regulators and researchers.

Perioperative Complications are Associated With Adverse Long-Term Prognosis and Affect the Cause of Death After General Surgery

BACKGROUND

It is unclear how mortality and causes of death vary between patients and surgical procedures and how occurrence of postoperative complications is associated with prognosis. This study describes long-term mortality rates and causes of death in a general surgical population. Furthermore, we explore the effect of postoperative complications on mortality.

METHODS

A single-centre analysis of postoperative complications, with mortality as primary endpoint, was conducted in 4479 patients undergoing surgery. We applied univariate and multivariable regression models to analyse the effect of risk factors, including surgical risk and postoperative complications, on mortality. Causes of death were also explored.

RESULTS

75 patients (1.7 %) died within 30 days after surgery and 730 patients (16.3 %) died during a median follow-up of 6.3 years (IQR 5.8-6.8). Significant differences in long-term mortality were observed with worst outcome for patients undergoing high-risk vascular surgery (HR 1.5; 95 % CI 1.2-1.9). When looking at causes of death, high-risk surgery was associated with a twofold higher risk of cardiovascular death (HR 1.9; 95 % CI 1.2-3.1), whereas the intermediate-risk group had a higher risk of dying from cancer-related causes (HR 1.5; 95 % CI 1.1-2.0). Occurrence of complications-particularly of cardiovascular nature- was associated with worse survival (HR 1.9; 95 % CI 1.3-2.7).

CONCLUSION

High-risk vascular surgery and occurrence of postoperative complications are important predictors of late mortality. Further focus on these groups of patients can contribute to reduced morbidity. Improvement in quality of care should be aimed at preventing postoperative complications and thus a better outcome in a general surgical population.

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on measurement to maintain and improve quality of enhanced recovery pathways for elective colorectal surgery

BACKGROUND

This article sets out a framework for measurement of quality of care relevant to enhanced recovery pathways (ERPs) in elective colorectal surgery. The proposed framework is based on established measurement systems and/or theories, and provides an overview of the different approaches for improving clinical monitoring, and enhancing quality improvement or research in varied settings with different levels of available resources.

METHODS

Using a structure-process-outcome framework, we make recommendations for three hierarchical tiers of data collection.

DISCUSSION

Core, Quality Improvement, and Best Practice datasets are proposed. The suggested datasets incorporate patient data to describe case-mix, process measures to describe delivery of enhanced recovery and clinical outcomes. The fundamental importance of routine collection of data for the initiation, maintenance, and enhancement of enhanced recovery pathways is emphasized.

Different survival outcomes after curative R0-resection for Eastern Asian and European gastric cancer: Results from a propensity score matched analysis comparing a Korean and a German specialized center

Several retrospective analyses on patients who underwent gastric cancer (GC) surgery revealed different survival outcomes between Eastern (Korean, Japanese) and Western (USA, Europe) countries due to potential ethnical and biological differences. This study investigates treatment outcomes between specialized institution for GC in Korea and Germany.The prospectively documented databases of the Gastric Cancer Center of the National Cancer Center, Korea (NCCK) and the Department of Surgery of the Technische Universitaet Muenchen (TUM), Germany were screened for patients who underwent primary surgical resection for GC between 2002 and 2008. Baseline characteristics were compared using χ testing, and 2 cohorts were matched using a propensity score matching (PSM) method. Patients' survival was estimated using Kaplan-Meier method, and multivariable Cox proportional hazard model was used for comparison.Three thousand seven hundred ninety-five patients were included in the final analysis, 3542 from Korea and 253 from Germany. Baseline characteristics revealed statistically significant differences for age, tumor location, pT stage, grading, lymphatic vessel infiltration (LVI), comorbidities, number of dissected lymph nodes (LN), postoperative complications, lymph-node ratio stage, and application of adjuvant chemotherapy. After PSM, 171 patients in TUM were matched to NCCK patients, and baseline characteristics for both cohorts were well balanced. Patients in Korea had significantly longer survival than those in Germany both before and after PSM. When the analysis was performed for each UICC stage separately, same trend was found over all UICC stages before PSM. However, significant difference in survival was observed only for UICC I after PSM.This analysis demonstrates different survival outcomes after surgical treatment of GC on different continents in specialized centers after balancing of baseline characteristics by PSM.

Long-Term Survival After Complications Following Major Abdominal Surgery

INTRODUCTION

Postoperative complications have been associated with decreased long-term survival in cardiac, orthopedic, and vascular surgery. For major abdominal surgery research, conflicting evidence is reported in smaller studies. The aim of this study was to assess the effect of complications on long-term survival in major abdominal surgery.

MATERIAL AND METHODS

An observational cohort study was conducted of 861 consecutive patients that underwent major abdominal surgery between January 2009 and March 2014, with prospective assessment of the survival status. The effect of postoperative complications on survival was assessed.

RESULTS

Postoperative complications were associated with decreased survival, even after applying correction for 30-day mortality (p < 0.001). Stratified Cox regression analysis depicted postoperative complications to be an important predictor for survival in upper gastrointestinal and female hepatopancreaticobiliary patients. Correction was applied for age, gender, BMI, ASA classification, radicality, and positive lymph node status.

CONCLUSION

These results further indicate the importance of prevention and early diagnosis and treatment of complications. Etiological factors are believed to be both sustained levels of inflammatory markers, as well as attenuated immune response in malignancy with subsequent cancer cell seeding. Future research should aim to prevent and early diagnose postoperative complications to prevent morbidity and mortality not only in the early postoperative phase, but also in the long term.

Survival after postoperative morbidity: a longitudinal observational cohort study

Background

Previous studies have suggested that there may be long-term harm associated with postoperative complications. Uncertainty exists however, because of the need for risk adjustment and inconsistent definitions of postoperative morbidity.

Methods

We did a longitudinal observational cohort study of patients undergoing major surgery. Case-mix adjustment was applied and morbidity was recorded using a validated outcome measure. Cox proportional hazards modelling using time-dependent covariates was used to measure the independent relationship between prolonged postoperative morbidity and longer term survival.

Results

Data were analysed for 1362 patients. The median length of stay was 9 days and the median follow-up time was 6.5 yr. Independent of perioperative risk, postoperative neurological morbidity (prevalence 2.9%) was associated with a relative hazard for long-term mortality of 2.00 [P=0.001; 95% confidence interval (CI) 1.32–3.04]. Prolonged postoperative morbidity (prevalence 15.6%) conferred a relative hazard for death in the first 12 months after surgery of 3.51 (P<0.001; 95% CI 2.28–5.42) and for the next 2 yr of 2.44 (P<0.001; 95% CI 1.62–3.65), returning to baseline thereafter.

Conclusions

Prolonged morbidity after surgery is associated with a risk of premature death for a longer duration than perhaps is commonly thought; however, this risk falls with time. We suggest that prolonged postoperative morbidity measured in this way may be a valid indicator of the quality of surgical healthcare. Our findings reinforce the importance of research and quality improvement initiatives aimed at reducing the duration and severity of postoperative complications.