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Levenson G, Coutrot M, Voron T, Gronnier C, Cattan P, Hobeika C, D'Journo XB, Bergeat D, Glehen O, Mathonnet M, Piessen G, Goéré D. Root cause analysis of mortality after esophagectomy for cancer: a multicenter cohort study from the FREGAT database. Surgery 2024; 176:82-92. [PMID: 38641545 DOI: 10.1016/j.surg.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 01/17/2024] [Accepted: 03/10/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Esophagectomy is associated with significant mortality. A better understanding of the causes leading to death may help to reduce mortality. A root cause analysis of mortality after esophagectomy was performed. METHODS Root cause analysis was retrospectively applied by an independent expert panel of 4 upper gastrointestinal surgeons and 1 anesthesiologist-intensivist to patients included in the French national multicenter prospective cohort FREGAT between August 2014 and September 2019 who underwent an esophagectomy for cancer and died within 90 days of surgery. A cause-and-effect diagram was used to determine the root causes related to death. Death was classified as potentially preventable or non-preventable. RESULTS Among the 1,040 patients included in the FREGAT cohort, 70 (6.7%) patients (male: 81%, median age 68 [62-72] years) from 17 centers were included. Death was potentially preventable in 37 patients (53%). Root causes independently associated with preventable death were inappropriate indication (odds ratio 35.16 [2.50-494.39]; P = .008), patient characteristics (odds ratio 5.15 [1.19-22.35]; P = .029), unexpected intraoperative findings (odds ratio 18.99 [1.07-335.55]; P = .045), and delay in diagnosis of a complication (odds ratio 98.10 [6.24-1,541.04]; P = .001). Delay in treatment of a complication was found only in preventable deaths (28 [76%] vs 0; P < .001). National guidelines were less frequently followed (16 [43%] vs 22 [67%]; P = .050) in preventable deaths. The only independent risk factor of preventable death was center volume <26 esophagectomies per year (odds ratio 4.71 [1.55-14.33]; P = .006). CONCLUSIONS More than one-half of deaths after esophagectomy were potentially preventable. Better patient selection, early diagnosis, and adequate management of complications through centralization could reduce mortality.
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Affiliation(s)
- Guillaume Levenson
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Service de Chirurgie Viscérale, Cancérologique et Endocrinienne, Paris, France; Université Paris Cité, Paris, France.
| | - Maxime Coutrot
- Université Paris Cité, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Département d'anesthésie réanimation et centre de traitement des brûlés, Paris, France
| | - Thibault Voron
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Chirurgie Générale et Digestive, Paris, France; Sorbonne Université, Paris, France. https://www.twitter.com/ThibaultVORON
| | - Caroline Gronnier
- Unité de Chirurgie Œsogastrique et Endocrinienne, Service de Chirurgie Digestive et Endocrinienne, Centre Médico-Chirurgical Magellan, Centre Hospitalo-Universitaire de Bordeaux, Pessac, France; Faculté de Médecine, Université Bordeaux-Segalen, Bordeaux, France
| | - Pierre Cattan
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Service de Chirurgie Viscérale, Cancérologique et Endocrinienne, Paris, France; Université Paris Cité, Paris, France
| | - Christian Hobeika
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, Clichy, Paris-Cité University, Paris, France; UMR Inserm 1275 CAP Paris-Tech, Lariboisière Hospital, Paris, Paris-Cité University, Paris, France
| | - Xavier Benoît D'Journo
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Damien Bergeat
- Service de Chirurgie Hépatobiliaire et Digestive, Hôpital Pontchaillou, Centre Hospitalier Universitaire (CHU Rennes), Université de Rennes 1 Centre, Rennes, France
| | - Olivier Glehen
- Department of General Surgery and Surgical Oncology, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France; EMR 3738 Lyon Sud Charles Mérieux Faculty, Claude Bernard University Lyon 1, Oullins, France
| | - Muriel Mathonnet
- Service de Chirurgie Digestive, Endocrinienne et Générale, CHU de Limoges, Avenue Martin Luther King, Limoges Cedex, France
| | - Guillaume Piessen
- Centre Hospitalo-Universitaire Lille, Service de Chirurgie Digestive et Oncologique, Lille, France; University Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer, Heterogeneity Plasticity and Resistance to Therapies, Lille, France. https://www.twitter.com/PiessenG
| | - Diane Goéré
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Service de Chirurgie Viscérale, Cancérologique et Endocrinienne, Paris, France; Université Paris Cité, Paris, France
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Ebert MP, Fischbach W, Hollerbach S, Höppner J, Lorenz D, Stahl M, Stuschke M, Pech O, Vanhoefer U, Porschen R. S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:535-642. [PMID: 38599580 DOI: 10.1055/a-2239-9802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Matthias P Ebert
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universitätsmedizin, Universität Heidelberg, Mannheim
- DKFZ-Hector Krebsinstitut an der Universitätsmedizin Mannheim, Mannheim
- Molecular Medicine Partnership Unit, EMBL, Heidelberg
| | - Wolfgang Fischbach
- Deutsche Gesellschaft zur Bekämpfung der Krankheiten von Magen, Darm und Leber sowie von Störungen des Stoffwechsels und der Ernährung (Gastro-Liga) e. V., Giessen
| | | | - Jens Höppner
- Klinik für Allgemeine Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck
| | - Dietmar Lorenz
- Chirurgische Klinik I, Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Darmstadt, Darmstadt
| | - Michael Stahl
- Klinik für Internistische Onkologie und onkologische Palliativmedizin, Evang. Huyssensstiftung, Evang. Kliniken Essen-Mitte, Essen
| | - Martin Stuschke
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Essen, Essen
| | - Oliver Pech
- Klinik für Gastroenterologie und Interventionelle Endoskopie, Krankenhaus Barmherzige Brüder, Regensburg
| | - Udo Vanhoefer
- Klinik für Hämatologie und Onkologie, Katholisches Marienkrankenhaus, Hamburg
| | - Rainer Porschen
- Gastroenterologische Praxis am Kreiskrankenhaus Osterholz, Osterholz-Scharmbeck
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Perry R, Barbosa JP, Perry I, Barbosa J. Short-term outcomes of robot-assisted versus conventional minimally invasive esophagectomy for esophageal cancer: a systematic review and meta-analysis of 18,187 patients. J Robot Surg 2024; 18:125. [PMID: 38492067 PMCID: PMC10944433 DOI: 10.1007/s11701-024-01880-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/20/2024] [Indexed: 03/18/2024]
Abstract
The role of robotic surgery in the curative-intent treatment of esophageal cancer patients is yet to be defined. To compare short-term outcomes between conventional minimally invasive (cMIE) and robot-assisted minimally invasive esophagectomy (RAMIE) in esophageal cancer patients. PubMed, Web of Science and Cochrane Library were systematically searched. The included studies compared short-term outcomes between cMIE and RAMIE. Individual risk of bias was calculated using the MINORS and RoB2 scales. There were no statistically significant differences between RAMIE and cMIE regarding conversion to open procedure, mean number of harvested lymph nodes in the mediastinum, abdomen and along the right recurrent laryngeal nerve (RLN), 30- and 90-day mortality rates, chyle leakage, RLN palsy as well as cardiac and infectious complication rates. Estimated blood loss (MD - 71.78 mL, p < 0.00001), total number of harvested lymph nodes (MD 2.18 nodes, p < 0.0001) and along the left RLN (MD 0.73 nodes, p = 0.03), pulmonary complications (RR 0.70, p = 0.001) and length of hospital stay (MD - 3.03 days, p < 0.0001) are outcomes that favored RAMIE. A significantly shorter operating time (MD 29.01 min, p = 0.004) and a lower rate of anastomotic leakage (RR 1.23, p = 0.0005) were seen in cMIE. RAMIE has indicated to be a safe and feasible alternative to cMIE, with a tendency towards superiority in blood loss, lymph node yield, pulmonary complications and length of hospital stay. There was significant heterogeneity among studies for some of the outcomes measured. Further studies are necessary to confirm these results and overcome current limitations.
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Affiliation(s)
- Rui Perry
- Faculty of Medicine, University of Porto, Porto, Portugal.
| | - José Pedro Barbosa
- Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Stomatology, São João University Hospital Center, Porto, Portugal
| | - Isabel Perry
- Faculty of Medicine, University of Salamanca, Salamanca, Spain
| | - José Barbosa
- Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of General Surgery, São João University Hospital Center, Porto, Portugal
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Damen PJ, van Rossum PS, Chen Y, Abana CO, Liao Z, Hobbs BP, Mohan R, Blum-Murphy M, Hofstetter WL, Lin SH. Comparing 90-Day Postoperative Mortality After Neoadjuvant Proton-Based Versus Photon-Based Chemoradiotherapy for Esophageal Cancer. Int J Part Ther 2024; 11:100012. [PMID: 38757082 PMCID: PMC11095098 DOI: 10.1016/j.ijpt.2024.100012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/07/2024] [Accepted: 03/05/2024] [Indexed: 05/18/2024] Open
Abstract
Purpose Evidence suggests that proton-beam therapy (PBT) results in less toxicity and postoperative complications compared to photon-based radiotherapy in patients who receive chemoradiotherapy followed by esophagectomy for cancer. Ninety-day mortality (90DM) is an important measure of the postoperative (nononcologic) outcome as proxy of quality-of-care. We hypothesize that PBT could reduce 90DM compared to photon-based radiotherapy. Materials and Methods From a single-center retrospective database patients treated with chemoradiotherapy before esophagectomy for cancer were selected (1998-2022). Univariable logistic regression was used to study the association of radiotherapy modality with 90DM. Three separate methods were applied to adjust for confounding bias, including multivariable logistic regression, propensity score matching, and inverse probability of treatment weighting. Stratified analysis for the age threshold that maximized the difference in 90DM (ie, ≥67 vs <67 years) was performed. Results A total of 894 eligible patients were included and 90DM was 5/202 (2.5%) in the PBT versus 29/692 (4.2%) in the photon-based radiotherapy group (P = .262). After adjustment for age and tumor location, PBT versus photon-based radiotherapy was not significantly associated with 90DM (P = .491). The 90DM was not significantly different for PBT versus photon-based radiotherapy in the propensity score matching (P = .379) and inverse probability of treatment weighting cohort (P = .426). The stratified analysis revealed that in patients aged ≥67 years, PBT was associated with decreased 90DM (1.3% vs 8.8%; P = .026). Higher age significantly increased 90DM risk within the photon-based radiotherapy (8.8% vs 2.7%; P = .001), but not within the PBT group (1.3% vs 3.2%; P = .651). Conclusion No statistically significant difference was observed in postoperative 90DM after esophagectomy for cancer between PBT and photon-based neoadjuvant chemoradiotherapy. However, among older patients a signal was observed that PBT may reduce 90DM risk.
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Affiliation(s)
- Pim J.J. Damen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiotherapy, Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Peter S.N. van Rossum
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiation Oncology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Yiqing Chen
- Department of Biostatistics and Data Science, University of Texas Health Science Center, Houston, Texas, USA
| | - Chike O. Abana
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brian P. Hobbs
- Department of Population Health, The University of Austin Dell Medical School, Austin, Texas, USA
| | - Radhe Mohan
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mariela Blum-Murphy
- Department of Gastrointestinal Medical Oncology, The University of Texas. MD Anderson Cancer Center, Houston, Texas, USA
| | - Wayne L. Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Steven H. Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Kulasegaran S, Wang Y, Woodhouse B, MacCormick A, Srinivasa S, Koea J. Quality Performance Indicators for the Surgical Management of Oesophageal Cancer: A Systematic Literature Review. World J Surg 2023; 47:3262-3269. [PMID: 37865917 PMCID: PMC10694097 DOI: 10.1007/s00268-023-07216-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND The objective of this systematic review was to identify pre-existing quality performance indicators (QPIs) for the surgical management of oesophageal cancer (OC). These QPIs can be used to objectively measure and compare the performance of individual units and capture key elements of patient care to improve patient outcomes. METHODS A systematic literature search of PubMed, MEDLINE, Scopus and Embase was conducted. Articles reporting on the quality of healthcare in relation to oesophageal neoplasm or cancer and the surgical treatment of OC available until the 1st of March 2022 were included. RESULTS The final list of articles included retrospective reviews (n = 13), prospective reviews (n = 8), expert guidelines (n = 1) and consensus (n = 1). The final list of QPIs was categorized as process, outcome or structural measures. Process measures included multidisciplinary involvement, availability of multimodality diagnostic and treatment pathways and surgical metrics. Outcome measures included reoperation and readmission rates, the achievement of RO resection and length of hospital stay. Structural measures include multidisciplinary meetings. CONCLUSIONS This systematic review summarizes QPIs for the surgical treatment of OC. The data will serve as an introduction to establishing a quality initiative project for OC resections.
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Affiliation(s)
| | - Yijiao Wang
- Department of Surgery, North Shore Hospital, Auckland, New Zealand
| | - Braden Woodhouse
- Department of Oncology, The University of Auckland, Auckland, New Zealand
| | - Andrew MacCormick
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Sanket Srinivasa
- Department of Surgery, North Shore Hospital, Auckland, New Zealand
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Jonathan Koea
- Department of Surgery, North Shore Hospital, Auckland, New Zealand
- Department of Surgery, The University of Auckland, Auckland, New Zealand
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6
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Kouladouros K. Applications of endoscopic vacuum therapy in the upper gastrointestinal tract. World J Gastrointest Endosc 2023; 15:420-433. [PMID: 37397978 PMCID: PMC10308278 DOI: 10.4253/wjge.v15.i6.420] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/15/2023] [Accepted: 06/02/2023] [Indexed: 06/14/2023] Open
Abstract
Endoscopic vacuum therapy (EVT) is an increasingly popular treatment option for wall defects in the upper gastrointestinal tract. After its initial description for the treatment of anastomotic leaks after esophageal and gastric surgery, it was also implemented for a wide range of defects, including acute perforations, duodenal lesions, and postbariatric complications. Apart from the initially proposed handmade sponge inserted using the “piggyback” technique, further devices were used, such as the commercially available EsoSponge and VAC-Stent as well as open-pore film drainage. The reported pressure settings and intervals between the subsequent endoscopic procedures vary greatly, but all available evidence highlights the efficacy of EVT, with high success rates and low morbidity and mortality, so that in many centers it is considered to be a first-line treatment, especially for anastomotic leaks.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy, Surgical Clinic, Mannheim University Hospital, University of Heidelberg, Mannheim 68167, Baden-Wuerttemberg, Germany
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7
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S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:701-745. [PMID: 37285870 DOI: 10.1055/a-1771-7087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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8
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S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e209-e307. [PMID: 37285869 DOI: 10.1055/a-1771-6953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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9
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Ubels S, Matthée E, Verstegen M, Klarenbeek B, Bouwense S, van Berge Henegouwen MI, Daams F, Dekker JWT, van Det MJ, van Esser S, Griffiths EA, Haveman JW, Nieuwenhuijzen G, Siersema PD, Wijnhoven B, Hannink G, van Workum F, Rosman C, Heisterkamp J, Polat F, Schouten J, Singh P, Eshuis WJ, Kalff MC, Feenstra ML, van der Peet DL, Stam WT, Van Etten B, Poelmann F, Vuurberg N, Willem van den Berg J, Martijnse IS, Matthijsen RM, Luyer M, Curvers W, Nieuwenhuijzen T, Taselaar AE, Kouwenhoven EA, Lubbers M, Sosef M, Lecot F, Geraedts TC, van den Wildenberg F, Kelder W, Lubbers M, Baas PC, de Haas JW, Hartgrink HH, Bahadoer RR, van Sandick JW, Hartemink KJ, Veenhof X, Stockmann H, Gorgec B, Weeder P, Wiezer MJ, Genders CM, Belt E, Blomberg B, van Duijvendijk P, Claassen L, Reetz D, Steenvoorde P, Mastboom W, Klein Ganseij HJ, van Dalsen AD, Joldersma A, Zwakman M, Groenendijk RP, Montazeri M, Mercer S, Knight B, van Boxel G, McGregor RJ, Skipworth RJ, Frattini C, Bradley A, Nilsson M, Hayami M, Huang B, Bundred J, Evans R, Grimminger PP, van der Sluis PC, Eren U, Saunders J, Theophilidou E, Khanzada Z, Elliott JA, Ponten J, King S, Reynolds JV, Sgromo B, Akbari K, Shalaby S, Gutschow CA, Schmidt H, Vetter D, Moorthy K, Ibrahim MA, Christodoulidis G, Räsänen JV, Kauppi J, Söderström H, Koshy R, Manatakis DK, Korkolis DP, Balalis D, Rompu A, Alkhaffaf B, Alasmar M, Arebi M, Piessen G, Nuytens F, Degisors S, Ahmed A, Boddy A, Gandhi S, Fashina O, Van Daele E, Pattyn P, Robb WB, Arumugasamy M, Al Azzawi M, Whooley J, Colak E, Aybar E, Sari AC, Uyanik MS, Ciftci AB, Sayyed R, Ayub B, Murtaza G, Saeed A, Ramesh P, Charalabopoulos A, Liakakos T, Schizas D, Baili E, Kapelouzou A, Valmasoni M, Pierobon ES, Capovilla G, Merigliano S, Constantinoiu S, Birla R, Achim F, Rosianu CG, Hoara P, Castro RG, Salcedo AF, Negoi I, Negoita VM, Ciubotaru C, Stoica B, Hostiuc S, Colucci N, Mönig SP, Wassmer CH, Meyer J, Takeda FR, Aissar Sallum RA, Ribeiro U, Cecconello I, Toledo E, Trugeda MS, Fernández MJ, Gil C, Castanedo S, Isik A, Kurnaz E, Videira JF, Peyroteo M, Canotilho R, Weindelmayer J, Giacopuzzi S, De Pasqual CA, Bruna M, Mingol F, Vaque J, Pérez C, Phillips AW, Chmelo J, Brown J, Koshy R, Han LE, Gossage JA, Davies AR, Baker CR, Kelly M, Saad M, Bernardi D, Bonavina L, Asti E, Riva C, Scaramuzzo R, Elhadi M, Ahmed HA, Elhadi A, Elnagar FA, Msherghi AA, Wills V, Campbell C, Cerdeira MP, Whiting S, Merrett N, Das A, Apostolou C, Lorenzo A, Sousa F, Barbosa JA, Devezas V, Barbosa E, Fernandes C, Smith G, Li EY, Bhimani N, Chan P, Kotecha K, Hii MW, Ward SM, Johnson M, Read M, Chong L, Hollands MJ, Allaway M, Richardson A, Johnston E, Chen AZ, Kanhere H, Prasad S, McQuillan P, Surman T, Trochsler M, Schofield W, Ahmed SK, Reid JL, Harris MC, Gananadha S, Farrant J, Rodrigues N, Fergusson J, Hindmarsh A, Afzal Z, Safranek P, Sujendran V, Rooney S, Loureiro C, Fernández SL, Díez del Val I, Jaunoo S, Kennedy L, Hussain A, Theodorou D, Triantafyllou T, Theodoropoulos C, Palyvou T, Elhadi M, Ben Taher FA, Ekheel M, Msherghi AA. Practice variation in anastomotic leak after esophagectomy: Unravelling differences in failure to rescue. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:974-982. [PMID: 36732207 DOI: 10.1016/j.ejso.2023.01.010] [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: 09/29/2022] [Revised: 12/20/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Failure to rescue (FTR) is an important outcome measure after esophagectomy and reflects mortality after postoperative complications. Differences in FTR have been associated with hospital resection volume. However, insight into how centers manage complications and achieve their outcomes is lacking. Anastomotic leak (AL) is a main contributor to FTR. This study aimed to assess differences in FTR after AL between centers, and to identify factors that explain these differences. METHODS TENTACLE - Esophagus is a multicenter, retrospective cohort study, which included 1509 patients with AL after esophagectomy. Differences in FTR were assessed between low-volume (<20 resections), middle-volume (20-60 resections) and high-volume centers (≥60 resections). Mediation analysis was performed using logistic regression, including possible mediators for FTR: case-mix, hospital resources, leak severity and treatment. RESULTS FTR after AL was 11.7%. After adjustment for confounders, FTR was lower in high-volume vs. low-volume (OR 0.44, 95%CI 0.2-0.8), but not versus middle-volume centers (OR 0.67, 95%CI 0.5-1.0). After mediation analysis, differences in FTR were found to be explained by lower leak severity, lower secondary ICU readmission rate and higher availability of therapeutic modalities in high-volume centers. No statistically significant direct effect of hospital volume was found: high-volume vs. low-volume 0.86 (95%CI 0.4-1.7), high-volume vs. middle-volume OR 0.86 (95%CI 0.5-1.4). CONCLUSION Lower FTR in high-volume compared with low-volume centers was explained by lower leak severity, less secondary ICU readmissions and higher availability of therapeutic modalities. To reduce FTR after AL, future studies should investigate effective strategies to reduce leak severity and prevent secondary ICU readmission.
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Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Eric Matthée
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Marc J van Det
- Department of Surgery, ZGT Hospital Group, Almelo, the Netherlands
| | - Stijn van Esser
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | | | - Fatih Polat
- Canisius-Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Radboud University Medical Center, Nijmegen, the Netherlands
| | - Pritam Singh
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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Görgec B, Benedetti Cacciaguerra A, Pawlik TM, Aldrighetti LA, Alseidi AA, Cillo U, Kokudo N, Geller DA, Wakabayashi G, Asbun HJ, Besselink MG, Cherqui D, Cheung TT, Clavien PA, Conrad C, D’Hondt M, Dagher I, Dervenis C, Devar J, Dixon E, Edwin B, Efanov M, Ettore GM, Ferrero A, Fondevilla C, Fuks D, Giuliante F, Han HS, Honda G, Imventarza O, Kooby DA, Lodge P, Lopez-Ben S, Machado MA, Marques HP, O’Rourke N, Pekolj J, Pinna AD, Portolani N, Primrose J, Rotellar F, Ruzzenente A, Schadde E, Siriwardena AK, Smadi S, Soubrane O, Tanabe KK, Teh CS, Torzilli G, Van Gulik TM, Vivarelli M, Wigmore SJ, Abu Hilal M. An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS). Ann Surg 2023; 277:821-828. [PMID: 35946822 PMCID: PMC10082050 DOI: 10.1097/sla.0000000000005668] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To reach global expert consensus on the definition of TOLS in minimally invasive and open liver resection among renowned international expert liver surgeons using a modified Delphi method. BACKGROUND Textbook outcome is a novel composite measure combining the most desirable postoperative outcomes into one single measure and representing the ideal postoperative course. Despite a recently developed international definition of Textbook Outcome in Liver Surgery (TOLS), a standardized and expert consensus-based definition is lacking. METHODS This international, consensus-based, qualitative study used a Delphi process to achieve consensus on the definition of TOLS. The survey comprised 6 surgical domains with a total of 26 questions on individual surgical outcome variables. The process included 4 rounds of online questionnaires. Consensus was achieved when a threshold of at least 80% agreement was reached. The results from the Delphi rounds were used to establish an international definition of TOLS. RESULTS In total, 44 expert liver surgeons from 22 countries and all 3 major international hepato-pancreato-biliary associations completed round 1. Forty-two (96%), 41 (98%), and 41 (98%) of the experts participated in round 2, 3, and 4, respectively. The TOLS definition derived from the consensus process included the absence of intraoperative grade ≥2 incidents, postoperative bile leakage grade B/C, postoperative liver failure grade B/C, 90-day major postoperative complications, 90-day readmission due to surgery-related major complications, 90-day/in-hospital mortality, and the presence of R0 resection margin. CONCLUSIONS This is the first study providing an international expert consensus-based definition of TOLS for minimally invasive and open liver resections by the use of a formal Delphi consensus approach. TOLS may be useful in assessing patient-level hospital performance and carrying out international comparisons between centers with different clinical practices to further improve patient outcomes.
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Affiliation(s)
- Burak Görgec
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, AmsterdamUMC, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrea Benedetti Cacciaguerra
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Timothy M. Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | | | - Adnan A. Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Umberto Cillo
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy
| | - Norihiro Kokudo
- Department of Surgery, Hepatobiliary Pancreatic Surgery Division, National Center for Global Health and Medicine, Tokyo, Japan
| | - David A. Geller
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Go Wakabayashi
- Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan
| | - Horacio J. Asbun
- Hepato-Biliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL
| | - Marc G. Besselink
- Department of Surgery, AmsterdamUMC, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Daniel Cherqui
- Department of Hepatobiliary Surgery, Paul Brousse University Hospital, Villejuif, France
| | - Tan To Cheung
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Pierre-Alain Clavien
- Department of surgery and transplantation, University Hospital Zurich, Switzerland
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, MA
| | - Mathieu D’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart, France
| | - Christos Dervenis
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, Athens, Greece
| | - John Devar
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Hepato-Pancreatico-Biliary Unit, Department of General Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Bjørn Edwin
- Department of Hepato-Pancreato-Biliary Surgery and The Intervention Center, Oslo University Hospital Oslo, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia
| | - Giuseppe M. Ettore
- General Surgery and Transplantation Unit, San Camillo Hospital, Rome, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, Umberto I Mauriziano Hospital, Turin, Italy
| | | | - David Fuks
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - Felice Giuliante
- Chirurgia Epatobiliare, Università Cattolica del Sacro Cuore-IRCCS, Rome, Italy
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Goro Honda
- Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Oscar Imventarza
- Department of surgery, Hospital Argerich, Buenos Aires, Argentina
- Department of surgery, Hospital Garrahan, Buenos Aires, Argentina
| | - David A. Kooby
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA
| | - Peter Lodge
- HPB and Transplant Unit, St James’s University Hospital, Leeds, UK
| | - Santiago Lopez-Ben
- Department of General and Digestive Surgery, HPB Unit, Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain
| | | | - Hugo P. Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Nick O’Rourke
- Department of HPB Surgery, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Juan Pekolj
- Division of HPB Surgery and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Antonio D. Pinna
- Abdominal Transplant and HPB Center, Cleveland Clinic Florida, Weston, Florida
| | - Nazario Portolani
- Department of Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, Italy
| | - John Primrose
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Fernando Rotellar
- Department of General and Digestive Surgery, Clinica Universidad de Navarra, Pamplona, Spain
| | | | - Erik Schadde
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland
- Division of Transplant Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Ajith K. Siriwardena
- Hepatobiliary and Pancreatic Surgery Unit, Manchester University NHS FT, Manchester, UK
| | - Sameer Smadi
- Department of Surgery, King Hussein Medical Center, Amman, Jordan
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Kenneth K. Tanabe
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Catherine S.C. Teh
- Section of Hepatobiliary Pancreatic Surgery, Surgical Oncology, and Minimally Invasive Surgery, St Luke’s Medical Center, Quezon City, Philippines
| | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center, IRCCS, Humanitas University, Rozzano, Italy
| | - Thomas M. Van Gulik
- Department of Surgery, AmsterdamUMC, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Stephen J. Wigmore
- Department of Hepato-Pancreato-Biliary (HPB)/Transplant Surgery, The University of Edinburgh Clinical Surgery, Edinburgh, UK
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Wei MY. Multimorbidity, 30-Day Readmissions, and Postdischarge Mortality Among Medicare Beneficiaries Using a New ICD-Coded Multimorbidity-Weighted Index. J Gerontol A Biol Sci Med Sci 2023; 78:727-734. [PMID: 36480692 PMCID: PMC10061939 DOI: 10.1093/gerona/glac242] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Medically complex, disabled adults have high 30-day readmission rates. However, physical functioning is not routinely included in risk-adjustment models. We examined the association between multimorbidity with readmissions and mortality using a physical functioning weighted International Classification of Diseases (ICD)-coded multimorbidity-weighted index (MWI-ICD) representing 84 conditions. METHODS We included Medicare beneficiaries with ≥1 hospitalization 2000-2015 who participated in a Health and Retirement Study interview before admission. We computed MWI-ICD by summing physical functioning weighted conditions from Medicare claims. We examined 30-, 90-, and 365-day postdischarge mortality using multivariable logistic regression and length of stay through zero-inflated negative binomials. Models adjusted for age, sex, race/ethnicity, body mass index, smoking status, physical activity, education, net worth, and marital status/living arrangement. RESULTS The final sample of 10 737 participants had mean ± standard deviation (SD) age 75.9 ± 8.7 years, MWI-ICD 14.9 ± 9.0, and 20% had a 30-day readmission. Adults in the highest versus lowest quartile MWI-ICD had 92% increased odds of 30-day readmission (odds ratio [OR] = 1.92, 95% confidence interval [CI]: 1.65-2.22). A 1-point increase in MWI-ICD was associated with 24% increased odds of 30-day readmission (OR = 1.24, 95% CI: 1.18-1.31). A 1-point increase in MWI-ICD was associated with 32% increased odds of death within 365-day postdischarge (OR = 1.32, 95% CI: 1.25-1.40). Readmitted participants with the highest versus lowest quartile MWI-ICD had 37% increased number of expected hospitalized days (incidence rate ratio = 1.37, 95% CI: 1.17-1.59). CONCLUSION Among Medicare beneficiaries, multimorbidity using MWI-ICD is associated with an increased risk of readmissions, mortality, and longer length of stay. MWI-ICD appears to be a valid measure of multimorbidity that embeds physical functioning and presents an opportunity to incorporate functional status into claims-based risk-adjustment models.
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Affiliation(s)
- Melissa Y Wei
- Division of General Internal Medicine and Health Services Research, Department of Internal Medicine, David Geffen School of Medicine at University of California, Los Angeles, California, USA
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California,USA
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12
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Papaconstantinou D, Fournaridi AV, Tasioudi K, Lidoriki I, Michalinos A, Konstantoudakis G, Schizas D. Identifying the role of preoperative oral/dental health care in post-esophagectomy pulmonary complications: a systematic review and meta-analysis. Dis Esophagus 2023; 36:6695457. [PMID: 36097793 DOI: 10.1093/dote/doac062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/16/2022] [Indexed: 12/11/2022]
Abstract
Esophageal surgery has traditionally been associated with high morbidity rates. Despite the recent advances in the field of minimally invasive surgery and the introduction of enhanced recovery after surgery (ERAS) protocols, post-esophagectomy morbidity, especially that attributed to the respiratory system, remains a concern. In that respect, preoperative intensification of oral care or introduction of structured oral/dental hygiene regimens may lead to tangible postoperative benefits associated with reduced morbidity (respiratory or otherwise) and length of hospital stay. A systematic literature search of the Medline, Embase, Web of Knowledge and clinicaltrials.gov databases was undertaken for studies reporting use of preoperative oral/dental hygiene improvement regimens in patients scheduled to undergo esophagectomy for esophageal cancer. Meta-analysis was performed using a random-effects model. After screening 796 unique studies, seven were deemed eligible for inclusion in the meta-analysis. Pooled results indicated equivalent postoperative pneumonia rates in the oral pretreatment group and control groups (8.7 vs. 8.5%, respectively); however, the odds for developing pneumonia were reduced by 50% in the pretreatment group (odds ratio 0.5, 95% C.I. 0.37 to 0.69, P < 0.001). No statistically significant difference was detected in the anastomotic leak (odds ratio 0.93, 95% C.I. 0.38 to 2.24, P = 0.87) and length of stay outcomes (mean difference 0.63, 95% C.I. -3.22 to 4.47, P = 0.75). Oral/dental pretreatment reduces the odds for developing post-esophagectomy pneumonia. This finding should be cautiously interpreted given the significant limitations inherent in this meta-analysis. Further investigation via well-designed clinical trials is thus warranted before implementation in routine practice can be recommended.
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Affiliation(s)
- Dimitrios Papaconstantinou
- Third Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | | | - Konstantina Tasioudi
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Irene Lidoriki
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | | | | | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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13
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Fischer C, Alvarico SJ, Wildner B, Schindl M, Simon J. The relationship of hospital and surgeon volume indicators and post-operative outcomes in pancreatic surgery: a systematic literature review, meta-analysis and guidance for valid outcome assessment. HPB (Oxford) 2023; 25:387-399. [PMID: 36813680 DOI: 10.1016/j.hpb.2023.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Available evidence on the volume-outcome relationship after pancreatic surgery is limited due to the narrow focus of interventions, volume indicators and outcomes considered as well as due to methodological differences of the included studies. Therefore, we aim to evaluate the volume-outcome relationship following pancreatic surgery following strict study selection and quality criteria, to identify aspects of methodological variation and to define a set of key methodological indicators to consider when aiming for comparable and valid outcome assessment. METHODS Four electronic databases were searched to identify studies on the volume-outcome relationship in pancreatic surgery published between the years 2000-2018. Following a double-screening process, data extraction, quality appraisal, and subgroup analysis, results of included studies were stratified and pooled using random effects meta-analysis. RESULTS Consistent associations were found between high hospital volume and both postoperative mortality (OR 0.35, 95% CI: 0.29-0.44) and major complications (OR 0.87, 95% CI: 0.80-0.94). A significant decrease in the odds ratio was also found for high surgeon volume and postoperative mortality (OR 0.29, 95%CI: 0.22-0.37). DISCUSSION Our meta-analysis confirms a positive effect for both hospital and surgeon volume indicators for pancreatic surgery. Further harmonization (e.g. surgery types, volume cut-offs/definition, case-mix adjustment, reported outcomes) are recommended for future empirical studies.
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Affiliation(s)
- Claudia Fischer
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria.
| | - Stefanie J Alvarico
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - B Wildner
- University Library, Medical University of Vienna, Vienna, Austria
| | - Martin Schindl
- Department of Surgery, Comprehensive Cancer Center (CCC), Medical University and Pancreatic Cancer Unit, Vienna, Austria
| | - Judit Simon
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria; Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, United Kingdom; Ludwig Boltzmann Institute Applied Diagnostics, Vienna, Austria
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14
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Ubels S, Klarenbeek B, Verstegen M, Bouwense S, Griffiths EA, van Workum F, Rosman C, Hannink G. Predicting mortality in patients with anastomotic leak after esophagectomy: development of a prediction model using data from the TENTACLE-Esophagus study. Dis Esophagus 2022; 36:6862938. [PMID: 36461788 PMCID: PMC10150169 DOI: 10.1093/dote/doac081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/28/2022] [Accepted: 10/25/2022] [Indexed: 12/04/2022]
Abstract
Anastomotic leak (AL) is a common but severe complication after esophagectomy, and over 10% of patients with AL suffer mortality. Different prognostic factors in patients with AL are known, but a tool to predict mortality after AL is lacking. This study aimed to develop a prediction model for postoperative mortality in patients with AL after esophagectomy. TENTACLE-Esophagus is an international retrospective cohort study, which included 1509 patients with AL after esophagectomy. The primary outcome was 90-day postoperative mortality. Previously identified prognostic factors for mortality were selected as predictors: patient-related (e.g. comorbidity, performance status) and leak-related predictors (e.g. leucocyte count, overall gastric conduit condition). The prediction model was developed using multivariable logistic regression and validated internally using bootstrapping. Among the 1509 patients with AL, 90-day mortality was 11.7%. Sixteen predictors were included in the prediction model. The model showed good performance after internal validation: the c-index was 0.79 (95% confidence interval 0.75-0.83). Predictions for mortality by the internally validated model aligned well with observed 90-day mortality rates. The prediction model was incorporated in an online tool for individual use and can be found at: https://www.tentaclestudy.com/prediction-model. The developed prediction model combines patient-related and leak-related factors to accurately predict postoperative mortality in patients with AL after esophagectomy. The model is useful for clinicians during counselling of patients and their families and may aid identification of high-risk patients at diagnosis of AL. In the future, the tool may guide clinical decision-making; however, external validation of the tool is warranted.
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Affiliation(s)
- Sander Ubels
- Address correspondence to: Sander Ubels, Radboud university medical center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
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15
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Fielding-Singh V, Vanneman MW, Grogan T, Neelankavil JP, Winkelmayer WC, Chang TI, Liu VX, Lin E. Association Between Preoperative Hemodialysis Timing and Postoperative Mortality in Patients With End-stage Kidney Disease. JAMA 2022; 328:1837-1848. [PMID: 36326747 PMCID: PMC9634601 DOI: 10.1001/jama.2022.19626] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
Importance For patients with end-stage kidney disease treated with hemodialysis, the optimal timing of hemodialysis prior to elective surgical procedures is unknown. Objective To assess whether a longer interval between hemodialysis and subsequent surgery is associated with higher postoperative mortality in patients with end-stage kidney disease treated with hemodialysis. Design, Setting, and Participants Retrospective cohort study of 1 147 846 procedures among 346 828 Medicare beneficiaries with end-stage kidney disease treated with hemodialysis who underwent surgical procedures between January 1, 2011, and September 30, 2018. Follow-up ended on December 31, 2018. Exposures One-, two-, or three-day intervals between the most recent hemodialysis treatment and the surgical procedure. Hemodialysis on the day of the surgical procedure vs no hemodialysis on the day of the surgical procedure. Main Outcomes and Measures The primary outcome was 90-day postoperative mortality. The relationship between the dialysis-to-procedure interval and the primary outcome was modeled using a Cox proportional hazards model. Results Of the 1 147 846 surgical procedures among 346 828 patients (median age, 65 years [IQR, 56-73 years]; 495 126 procedures [43.1%] in female patients), 750 163 (65.4%) were performed when the last hemodialysis session occurred 1 day prior to surgery, 285 939 (24.9%) when the last hemodialysis session occurred 2 days prior to surgery, and 111 744 (9.7%) when the last hemodialysis session occurred 3 days prior to surgery. Hemodialysis was also performed on the day of surgery for 193 277 procedures (16.8%). Ninety-day postoperative mortality occurred after 34 944 procedures (3.0%). Longer intervals between the last hemodialysis session and surgery were significantly associated with higher risk of 90-day mortality in a dose-dependent manner (2 days vs 1 day: absolute risk, 4.7% vs 4.2%, absolute risk difference, 0.6% [95% CI, 0.4% to 0.8%], adjusted hazard ratio [HR], 1.14 [95% CI, 1.10 to 1.18]; 3 days vs 1 day: absolute risk, 5.2% vs 4.2%, absolute risk difference, 1.0% [95% CI, 0.8% to 1.2%], adjusted HR, 1.25 [95% CI, 1.19 to 1.31]; and 3 days vs 2 days: absolute risk, 5.2% vs 4.7%, absolute risk difference, 0.4% [95% CI, 0.2% to 0.6%], adjusted HR, 1.09 [95% CI, 1.04 to 1.13]). Undergoing hemodialysis on the same day as surgery was associated with a significantly lower hazard of mortality vs no same-day hemodialysis (absolute risk, 4.0% for same-day hemodialysis vs 4.5% for no same-day hemodialysis; absolute risk difference, -0.5% [95% CI, -0.7% to -0.3%]; adjusted HR, 0.88 [95% CI, 0.84-0.91]). In the analyses that evaluated the interaction between the hemodialysis-to-procedure interval and same-day hemodialysis, undergoing hemodialysis on the day of the procedure significantly attenuated the risk associated with a longer hemodialysis-to-procedure interval (P<.001 for interaction). Conclusions and Relevance Among Medicare beneficiaries with end-stage kidney disease, longer intervals between hemodialysis and surgery were significantly associated with higher risk of postoperative mortality, mainly among those who did not receive hemodialysis on the day of surgery. However, the magnitude of the absolute risk differences was small, and the findings are susceptible to residual confounding.
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Affiliation(s)
- Vikram Fielding-Singh
- Department of Anesthesiology, Perioperative, and Pain Medicine, School of Medicine, Stanford University, Stanford, California
| | - Matthew W. Vanneman
- Department of Anesthesiology, Perioperative, and Pain Medicine, School of Medicine, Stanford University, Stanford, California
| | - Tristan Grogan
- Department of Medicine, Statistics Core, David Geffen School of Medicine, University of California, Los Angeles
| | - Jacques P. Neelankavil
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health and Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Tara I. Chang
- Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | - Eugene Lin
- Division of Nephrology, Department of Medicine, University of Southern California, Los Angeles
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
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16
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Lacueva FJ, Escrig-Sos J, Marti-Obiol R, Zaragoza C, Mingol F, Oviedo M, Peris N, Civera J, Roig A. Short-term postoperative outcomes of gastric adenocarcinoma patients treated with curative intent in low-volume centers. World J Surg Oncol 2022; 20:344. [PMID: 36253780 PMCID: PMC9575241 DOI: 10.1186/s12957-022-02804-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quality standards in postoperative outcomes have not yet been defined for gastric cancer surgery. Also, the effect of centralization of gastric cancer surgery on the improvement of postoperative outcomes continues to be debated. Short-term postoperative outcomes in gastric carcinoma patients in centers with low-volume of annual gastrectomies were assessed. The effect of age on major postoperative morbidity and mortality was also analyzed. METHODS Patients with gastric or gastroesophageal junction Siewert III type carcinomas who underwent surgical treatment with curative intent between January 2013 and December 2016 were included. Data were obtained from the population-based surgical registry Esophagogastric Carcinoma Registry of the Comunitat Valenciana (RECEG-CV). The RECEG-CV gathers information on demographic characteristics and comorbidity, preoperative study and neoadjuvant treatment, surgical procedure, pathological study, postoperative outcomes, and follow-up. Seventeen hospitals belonging to the public network participated in this registry. RESULTS Data from 591 patients were analyzed. Postoperative major morbidity occurred in 154 (26.1%) patients. Overall 30-day or in-hospital mortality, and 90-day postoperative mortality rates were 8.6% and 10.1% respectively. Failure-to-rescue was 39% and it was significantly higher in patients aged 75 years or older in comparison with younger patients (55.3% vs 23.1% p < 0.001). In the multivariable analysis, age ≥ 75 years (p = 0.029), laparoscopic approach (p = 0.005), and total gastrectomy (p = 0.005) were associated with major postoperative morbidity. Age ≥ 75 years (p = 0.027), pulmonary complications (p = 0.001), cardiac complications (p = 0.001), leakage (p = 0.003), and hemorrhage (p = 0.013) were associated with postoperative mortality. CONCLUSIONS Centralization of gastric adenocarcinoma treatment in centers with higher annual caseload should be considered to improve the short-term postoperative outcomes in low-volume centers. Patients aged 75 or older had a significantly increased risk of major postoperative morbidity and mortality, and higher failure-to-rescue.
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Affiliation(s)
| | - Javier Escrig-Sos
- Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | | | | | - Fernando Mingol
- Hospital Universitario y Politécnico La Fe de Valencia, Valencia, Spain
| | - Miguel Oviedo
- Hospital General Universitario de Valencia, Valencia, Spain
| | - Nuria Peris
- Hospital Universitario Doctor Peset de Valencia, Valencia, Spain
| | - Joaquin Civera
- Hospital Universitario Arnau de Vilanova de Valencia, Valencia, Spain
| | - Amparo Roig
- Hospital Lluis Alcanyis de Xativa, Valencia, Spain
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17
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Hardt JL, Merkow RP, Reissfelder C, Rahbari NN. Quality assurance and quality control in surgical oncology. J Surg Oncol 2022; 126:1560-1572. [PMID: 35994027 DOI: 10.1002/jso.27074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/10/2022] [Indexed: 11/09/2022]
Abstract
Even though surgery has remained a key component within multi-disciplinary cancer care, the expectations have changed. Instead of serving as a modality to free a patient of a mass at all means and at the risk of high morbidity, modern cancer surgery is expected to provide adequate tumor clearance with lowest invasiveness. This review summarizes the evidence on quality assurance in surgical oncology and gives a comprehensive overview of quality improvement tools.
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Affiliation(s)
- Julia L Hardt
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nuh N Rahbari
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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18
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Ubels S, Verstegen M, Klarenbeek B, Bouwense S, van Berge Henegouwen M, Daams F, van Det MJ, Griffiths EA, Haveman JW, Heisterkamp J, Koshy R, Nieuwenhuijzen G, Polat F, Siersema PD, Singh P, Wijnhoven B, Hannink G, van Workum F, Rosman C, Matthée E, Slootmans CAM, Ultee G, Schouten J, Gisbertz SS, Eshuis WJ, Kalff MC, Feenstra ML, van der Peet DL, Stam WT, van Etten B, Poelmann F, Vuurberg N, van den Berg JW, Martijnse IS, Matthijsen RM, Luyer M, Curvers W, Nieuwenhuijzen T, Taselaar AE, Kouwenhoven EA, Lubbers M, Sosef M, Lecot F, Geraedts TCM, van Esser S, Dekker JWT, van den Wildenberg F, Kelder W, Lubbers M, Baas PC, de Haas JWA, Hartgrink HH, Bahadoer RR, van Sandick JW, Hartemink KJ, Veenhof X, Stockmann H, Gorgec B, Weeder P, Wiezer MJ, Genders CMS, Belt E, Blomberg B, van Duijvendijk P, Claassen L, Reetz D, Steenvoorde P, Mastboom W, Klein Ganseij HJ, van Dalsen AD, Joldersma A, Zwakman M, Groenendijk RPR, Montazeri M, Mercer S, Knight B, van Boxel G, McGregor RJ, Skipworth RJE, Frattini C, Bradley A, Nilsson M, Hayami M, Huang B, Bundred J, Evans R, Grimminger PP, van der Sluis PC, Eren U, Saunders J, Theophilidou E, Khanzada Z, Elliott JA, Ponten J, King S, Reynolds JV, Sgromo B, Akbari K, Shalaby S, Gutschow CA, Schmidt H, Vetter D, Moorthy K, Ibrahim MAH, Christodoulidis G, Räsänen JV, Kauppi J, Söderström H, Manatakis DK, Korkolis DP, Balalis D, Rompu A, Alkhaffaf B, Alasmar M, Arebi M, Piessen G, Nuytens F, Degisors S, Ahmed A, Boddy A, Gandhi S, Fashina O, Van Daele E, Pattyn P, Robb WB, Arumugasamy M, Al Azzawi M, Whooley J, Colak E, Aybar E, Sari AC, Uyanik MS, Ciftci AB, Sayyed R, Ayub B, Murtaza G, Saeed A, Ramesh P, Charalabopoulos A, Liakakos T, Schizas D, Baili E, Kapelouzou A, Valmasoni M, Pierobon ES, Capovilla G, Merigliano S, Silviu C, Rodica B, Florin A, Cristian Gelu R, Petre H, Guevara Castro R, Salcedo AF, Negoi I, Negoita VM, Ciubotaru C, Stoica B, Hostiuc S, Colucci N, Mönig SP, Wassmer CH, Meyer J, Takeda FR, Aissar Sallum RA, Ribeiro U, Cecconello I, Toledo E, Trugeda MS, Fernández MJ, Gil C, Castanedo S, Isik A, Kurnaz E, Videira JF, Peyroteo M, Canotilho R, Weindelmayer J, Giacopuzzi S, De Pasqual CA, Bruna M, Mingol F, Vaque J, Pérez C, Phillips AW, Chmelo J, Brown J, Han LE, Gossage JA, Davies AR, Baker CR, Kelly M, Saad M, Bernardi D, Bonavina L, Asti E, Riva C, Scaramuzzo R, Elhadi M, Abdelkarem Ahmed H, Elhadi A, Elnagar FA, Msherghi AAA, Wills V, Campbell C, Perez Cerdeira M, Whiting S, Merrett N, Das A, Apostolou C, Lorenzo A, Sousa F, Adelino Barbosa J, Devezas V, Barbosa E, Fernandes C, Smith G, Li EY, Bhimani N, Chan P, Kotecha K, Hii MW, Ward SM, Johnson M, Read M, Chong L, Hollands MJ, Allaway M, Richardson A, Johnston E, Chen AZL, Kanhere H, Prasad S, McQuillan P, Surman T, Trochsler MI, Schofield WA, Ahmed SK, Reid JL, Harris MC, Gananadha S, Farrant J, Rodrigues N, Fergusson J, Hindmarsh A, Afzal Z, Safranek P, Sujendran V, Rooney S, Loureiro C, Leturio Fernández S, Díez del Val I, Jaunoo S, Kennedy L, Hussain A, Theodorou D, Triantafyllou T, Theodoropoulos C, Palyvou T, Elhadi M, Abdullah Ben Taher F, Ekheel M, Msherghi AAA. Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score. Br J Surg 2022. [DOI: https://doi.org/10.1093/bjs/znac226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Background
Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.
Methods
This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.
Results
Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.
Conclusion
The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.
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Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre+ , Maastricht , the Netherlands
| | - Mark van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam , Amsterdam , the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam , Amsterdam , the Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT hospital group , Almelo , the Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham , Birmingham , UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK
| | - Jan W Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen , Groningen , the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital , Tilburg , the Netherlands
| | - Renol Koshy
- Department of Surgery, Newcastle upon Tyne Hospital NHS Trust , Newcastle upon Tyne , UK
- Department of Surgery, University Hospitals of Coventry and Warwickshire NHS Trust , Coventry , UK
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital , Nijmegen , the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Pritam Singh
- Department of Surgery, Nottingham University Hospitals NHS Trust , Nottingham , UK
- Department of Surgery, Regional Oesophago-Gastric Unit, Royal Surrey County Hospital , Guildford , UK
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Centre , Rotterdam , the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital , Nijmegen , the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
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19
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Ubels S, Verstegen M, Klarenbeek B, Bouwense S, van Berge Henegouwen M, Daams F, van Det MJ, Griffiths EA, Haveman JW, Heisterkamp J, Koshy R, Nieuwenhuijzen G, Polat F, Siersema PD, Singh P, Wijnhoven B, Hannink G, van Workum F, Rosman C. Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score. Br J Surg 2022; 109:864-871. [PMID: 35759409 PMCID: PMC10364775 DOI: 10.1093/bjs/znac226] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/02/2022] [Accepted: 05/31/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score. METHODS This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally. RESULTS Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification. CONCLUSION The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.
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Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Mark van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT hospital group, Almelo, the Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jan W Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Renol Koshy
- Department of Surgery, Newcastle upon Tyne Hospital NHS Trust, Newcastle upon Tyne, UK.,Department of Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pritam Singh
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Department of Surgery, Regional Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, UK
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands.,Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
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20
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Stundner O, Myles PS. The ‘long shadow’ of perioperative complications: association with increased risk of death up to 1 year after surgery. Br J Anaesth 2022; 129:471-473. [DOI: 10.1016/j.bja.2022.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/12/2022] [Indexed: 11/17/2022] Open
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21
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Grass JK, Küsters N, Kemper M, Tintrup J, Piecha F, Izbicki JR, Perez D, Melling N, Bockhorn M, Reeh M. Risk stratification of cirrhotic patients undergoing esophagectomy for esophageal cancer: A single-centre experience. PLoS One 2022; 17:e0265093. [PMID: 35263385 PMCID: PMC8906633 DOI: 10.1371/journal.pone.0265093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 02/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Concomitant liver cirrhosis is a crucial risk factor for major surgeries. However, only few data are available concerning cirrhotic patients requiring esophagectomy for malignant disease.
Methods
From a prospectively maintained database of esophageal cancer patients, who underwent curative esophagectomy between 01/2012 and 01/2016, patients with concomitant liver cirrhosis (liver-cirrhotic patients, LCP) were compared to non-liver-cirrhotic patients (NLCP).
Results
Of 170 patients, 14 cirrhotic patients with predominately low MELD scores (≤ 9, 64.3%) were identified. Perioperative outcome was significantly worse for LCP, as proofed by 30-day (57.1% vs. 7.7, p<0.001) and 90-day mortality (64.3% vs. 9.6%, p<0.001), anastomotic leakage rate (64.3 vs. 22.3%, p = 0.002) and sepsis (57.1 vs. 21.5%, p = 0.006). Even after adjustment for age, gender, comorbidities, and surgical approach, LCP revealed higher odds for 30-day and 90-day mortality compared to NLCP. Moreover, 5-year survival analysis showed a significantly poorer long-term outcome of LCP (p = 0.023). For risk stratification, none of the common cirrhosis scores proved prognostic impact, whereas components as Bilirubin (auROC 94.4%), INR (auROC = 90.0%), and preoperative ascites (p = 0.038) correlated significantly with the perioperative outcome.
Conclusion
Curative esophagectomy for cirrhotic patients is associated with a dismal prognosis and should be evaluated critically. While MELD and Child score failed to predict perioperative mortality, Bilirubin and INR proofed excellent prognostic capacity in this cohort.
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Affiliation(s)
- Julia K. Grass
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
| | - Natalie Küsters
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marius Kemper
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Tintrup
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Felix Piecha
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Jakob R. Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Perez
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of General and Visceral Surgery, University Medical Center Oldenburg, Oldenburg, Germany
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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22
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Kuppusamy MK, Low DE. Evaluation of International Contemporary Operative Outcomes and Management Trends Associated With Esophagectomy: A 4-Year Study of >6000 Patients Using ECCG Definitions and the Online Esodata Database. Ann Surg 2022; 275:515-525. [PMID: 33074888 DOI: 10.1097/sla.0000000000004309] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aims to verify the utility of international online datasets to benchmark and monitor treatment and outcomes in major oncologic procedures. BACKGROUND The Esophageal Complication Consensus Group (ECCG) has standardized the reporting of complications after esophagectomy within the web-based Esodata.org database. This study will utilize the Esodata dataset to update contemporary outcomes and to monitor trends in practice in an era of rapid technical change. METHODS This observational study, based on a prospectively developed specific database, updates esophagectomy outcomes collected between 2015 and 2018. Evolution in patient and operative demographics, treatment, complications, and quality outcome measures were compared between patients undergoing surgery in 2015 to 2016 and 2017 to 2018. RESULTS Between 2015 and 2018, 6022 esophagectomies from 39 centers were entered into Esodata. Most patients were male (78.3%) with median age 63. Patients having minimally invasive esophagectomy constituted 3177 (52.8%), a chest anastomosis 3838 (63.7%), neoadjuvant chemoradiotherapy 2834 (48.7%), and R0 resections 5441 (93.5%). For quality measures, 30- and 90-day mortality was 2.0% and 4.5%, readmissions 9.7%, transfusions 12%, escalation in care 22.1%, and discharge home 89.4%. Trends in quality measures between 2015 and 2016 (2407 patients) and 2017 and 2018 (3318 patients) demonstrated significant (P < 0.05) improvements in readmissions 11.1% to 8.5%, blood transfusions 14.3% to 10.2%, and escalation in care from 24.5% to 20% A significantly (P < 0.05) reduced incidence in pneumonia (15.3%-12.8%) and renal failure (1.0%-0.4%) was observed. Anastomotic leak rates increased from 11.7% to 13.1%, whereas leaks requiring surgery decreased 3.3% and 3.0%, respectively. CONCLUSIONS The Esodata database provides a valuable resource for assessing contemporary international outcomes. This study highlights an increased application of minimally invasive approaches, a high percentage of complications, improvements in pneumonia and key quality metrics, but with anastomotic leak rates still >10%.
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Affiliation(s)
- Madhan K Kuppusamy
- Agaplesion Markus Krankenhaus, Frankfurt, Germany
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Cambridge Oesophago-Gastric Centre, Addenbrookes Hospital, Cambridge, UK
- Claude Huriez University Hospital, Lille, France; Erasmus Medical Center, Rotterdam
- Netherlands; Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA
- Guy's & St Thomas' NHS Foundation Trust, London, UK
- Hirslanden Medical Center, Zürich, Switzerland; Hôpital Nord, Aix-Marseille Université, Marseille, France
- Hospital Universitario del Mar, Barcelona, Spain
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Katholieke Universiteit Leuven, Leuven, Belgium; Keio University, Tokyo, Japan
- Massachusetts General Hospital, Boston, MA
- MD Anderson Cancer Center, Houston, TX
- Memorial Sloan Kettering Cancer Center, New York City, NY
- National University Hospital, Singapore, Singapore
- Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Odense University Hospital, Odense, Denmark
- Oregon Health and Science University, Portland, OR
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
- Queen Elizabeth Hospital University of Birmingham, Birmingham, UK
- Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
- Royal Victoria Hospital, Belfast, Northern Ireland
- Sichuan Cancer Hospital & Institute, Chengdu, China
- St. James's Hospital Trinity College, Dublin, Ireland
- Tata Memorial Center, Mumbai, India
- The University of Chicago Medicine, Chicago, IL
- Toronto General Hospital, Toronto, Canada
- University Hospital of Cologne, Cologne, Germany
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University Medical Center, Utrecht, Netherlands
- University of Michigan Health System, Ann Arbor, MI
- University of São Paulo School of Medicine, São Paulo, Brazil
- University of Verona, Verona, Italy
- Virginia Mason Medical Center, Seattle, WA
- Vita-Salute San Raffaele University, Milan, Italy
| | - Donald E Low
- Agaplesion Markus Krankenhaus, Frankfurt, Germany
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Cambridge Oesophago-Gastric Centre, Addenbrookes Hospital, Cambridge, UK
- Claude Huriez University Hospital, Lille, France; Erasmus Medical Center, Rotterdam
- Netherlands; Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA
- Guy's & St Thomas' NHS Foundation Trust, London, UK
- Hirslanden Medical Center, Zürich, Switzerland; Hôpital Nord, Aix-Marseille Université, Marseille, France
- Hospital Universitario del Mar, Barcelona, Spain
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Katholieke Universiteit Leuven, Leuven, Belgium; Keio University, Tokyo, Japan
- Massachusetts General Hospital, Boston, MA
- MD Anderson Cancer Center, Houston, TX
- Memorial Sloan Kettering Cancer Center, New York City, NY
- National University Hospital, Singapore, Singapore
- Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Odense University Hospital, Odense, Denmark
- Oregon Health and Science University, Portland, OR
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
- Queen Elizabeth Hospital University of Birmingham, Birmingham, UK
- Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
- Royal Victoria Hospital, Belfast, Northern Ireland
- Sichuan Cancer Hospital & Institute, Chengdu, China
- St. James's Hospital Trinity College, Dublin, Ireland
- Tata Memorial Center, Mumbai, India
- The University of Chicago Medicine, Chicago, IL
- Toronto General Hospital, Toronto, Canada
- University Hospital of Cologne, Cologne, Germany
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University Medical Center, Utrecht, Netherlands
- University of Michigan Health System, Ann Arbor, MI
- University of São Paulo School of Medicine, São Paulo, Brazil
- University of Verona, Verona, Italy
- Virginia Mason Medical Center, Seattle, WA
- Vita-Salute San Raffaele University, Milan, Italy
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23
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Chaney MA, Il C. Outcome After Cardiac Surgery: The Devil Is in the Details. J Cardiothorac Vasc Anesth 2021; 36:91-92. [PMID: 34794878 DOI: 10.1053/j.jvca.2021.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 10/17/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago,.
| | - Chicago Il
- Department of Anesthesia and Critical Care, University of Chicago
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24
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Pather K, Ghannam AD, Hacker S, Guerrier C, Mobley EM, Esma R, Awad ZT. Reoperative Surgery After Minimally Invasive Ivor Lewis Esophagectomy. Surg Laparosc Endosc Percutan Tech 2021; 32:60-65. [PMID: 34516475 PMCID: PMC8814731 DOI: 10.1097/sle.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/17/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study is to identify factors influencing reoperations following minimally invasive Ivor Lewis esophagectomy and associated mortality and hospital costs. MATERIALS AND METHODS Between 2013 and 2018, 125 patients were retrospectively analyzed. Outcomes included reoperations, mortality, and hospital costs. Multivariable logistic regression analyses determined factors associated with reoperations. RESULTS In-hospital reoperations (n=10) were associated with in-hospital mortality (n=3, P<0.01), higher hospital costs (P<0.01), and longer hospital stay (P<0.01). Conversely, reoperations after discharge were not associated with mortality. By multivariable analysis, baseline cardiovascular (P=0.02) and chronic kidney disease (P=0.01) were associated with reoperations. However, anastomotic leaks were not associated with reoperations nor mortality. CONCLUSION The majority of reoperations occur within 30 days often during index hospitalization. Reoperations were associated with increased in-hospital mortality and hospital costs. Notably, anastomotic leaks did not influence reoperations nor mortality. Efforts to optimize patient baseline comorbidities should be emphasized to minimize reoperations following minimally invasive Ivor Lewis esophagectomy.
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Affiliation(s)
- Keouna Pather
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Alexander D. Ghannam
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Shoshana Hacker
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Christina Guerrier
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, FL
| | - Erin M. Mobley
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Rhemar Esma
- University of Florida Health, Jacksonville, FL
| | - Ziad T. Awad
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
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25
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D'Journo XB, Boulate D, Fourdrain A, Loundou A, van Berge Henegouwen MI, Gisbertz SS, O'Neill JR, Hoelscher A, Piessen G, van Lanschot J, Wijnhoven B, Jobe B, Davies A, Schneider PM, Pera M, Nilsson M, Nafteux P, Kitagawa Y, Morse CR, Hofstetter W, Molena D, So JBY, Immanuel A, Parsons SL, Larsen MH, Dolan JP, Wood SG, Maynard N, Smithers M, Puig S, Law S, Wong I, Kennedy A, KangNing W, Reynolds JV, Pramesh CS, Ferguson M, Darling G, Schröder W, Bludau M, Underwood T, van Hillegersberg R, Chang A, Cecconello I, Ribeiro U, de Manzoni G, Rosati R, Kuppusamy M, Thomas PA, Low DE. Risk Prediction Model of 90-Day Mortality After Esophagectomy for Cancer. JAMA Surg 2021; 156:836-845. [PMID: 34160587 PMCID: PMC8223144 DOI: 10.1001/jamasurg.2021.2376] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/13/2021] [Indexed: 02/06/2023]
Abstract
Importance Ninety-day mortality rates after esophagectomy are an indicator of the quality of surgical oncologic management. Accurate risk prediction based on large data sets may aid patients and surgeons in making informed decisions. Objective To develop and validate a risk prediction model of death within 90 days after esophagectomy for cancer using the International Esodata Study Group (IESG) database, the largest existing prospective, multicenter cohort reporting standardized postoperative outcomes. Design, Setting, and Participants In this diagnostic/prognostic study, we performed a retrospective analysis of patients from 39 institutions in 19 countries between January 1, 2015, and December 31, 2019. Patients with esophageal cancer were randomly assigned to development and validation cohorts. A scoring system that predicted death within 90 days based on logistic regression β coefficients was conducted. A final prognostic score was determined and categorized into homogeneous risk groups that predicted death within 90 days. Calibration and discrimination tests were assessed between cohorts. Exposures Esophageal resection for cancer of the esophagus and gastroesophageal junction. Main Outcomes and Measures All-cause postoperative 90-day mortality. Results A total of 8403 patients (mean [SD] age, 63.6 [9.0] years; 6641 [79.0%] male) were included. The 30-day mortality rate was 2.0% (n = 164), and the 90-day mortality rate was 4.2% (n = 353). Development (n = 4172) and validation (n = 4231) cohorts were randomly assigned. The multiple logistic regression model identified 10 weighted point variables factored into the prognostic score: age, sex, body mass index, performance status, myocardial infarction, connective tissue disease, peripheral vascular disease, liver disease, neoadjuvant treatment, and hospital volume. The prognostic scores were categorized into 5 risk groups: very low risk (score, ≥1; 90-day mortality, 1.8%), low risk (score, 0; 90-day mortality, 3.0%), medium risk (score, -1 to -2; 90-day mortality, 5.8%), high risk (score, -3 to -4: 90-day mortality, 8.9%), and very high risk (score, ≤-5; 90-day mortality, 18.2%). The model was supported by nonsignificance in the Hosmer-Lemeshow test. The discrimination (area under the receiver operating characteristic curve) was 0.68 (95% CI, 0.64-0.72) in the development cohort and 0.64 (95% CI, 0.60-0.69) in the validation cohort. Conclusions and Relevance In this study, on the basis of preoperative variables, the IESG risk prediction model allowed stratification of an individual patient's risk of death within 90 days after esophagectomy. These data suggest that this model can help in the decision-making process when esophageal cancer surgery is being considered and in informed consent.
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Affiliation(s)
- Xavier Benoit D'Journo
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - David Boulate
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Alex Fourdrain
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Anderson Loundou
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Mark I van Berge Henegouwen
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - J Robert O'Neill
- Department of Oesophago-Gastric Cancer Surgery, Cambridge Oesophago-Gastric Centre, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Arnulf Hoelscher
- Center for Esophageal Diseases, Elisabeth Hospital Essen, University Medicine Essen, Essen, Germany
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - Jan van Lanschot
- Department of Digestive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Bas Wijnhoven
- Department of Digestive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Blair Jobe
- Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Andrew Davies
- Department of Digestive Surgery, Guy's & St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Paul M Schneider
- Department of Digestive and Oncological Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - Manuel Pera
- Department of Digestive Surgery, Hospital Universitario del Mar, Barcelona, Spain
| | - Magnus Nilsson
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Philippe Nafteux
- Department of Digestive Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Yuko Kitagawa
- Department of Thoracic Surgery, Keio University, Tokyo, Japan
| | | | - Wayne Hofstetter
- Department of Thoracic Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Daniela Molena
- Department of Thoracic and Cardiovascular Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Jimmy Bok-Yan So
- Department of Thoracic Surgery, National University Hospital, Singapore, Singapore
| | - Arul Immanuel
- Department of Surgery, Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Simon L Parsons
- Department of Upper Gastrointestinal Surgery, Nottingham University Hospitals National Health Service Trust, Nottingham, United Kingdom
| | | | - James P Dolan
- Digestive Health Center, Oregon Health and Science University, Portland
| | - Stephanie G Wood
- Digestive Health Center, Oregon Health and Science University, Portland
| | - Nick Maynard
- Oesophagogastric Cancer Multidisciplinary Team, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Mark Smithers
- Department of Surgery, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
| | - Sonia Puig
- Department of Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham Foundation Trust, Birmingham, United Kingdom
| | - Simon Law
- Department of Gastrointestinal Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ian Wong
- Department of Gastrointestinal Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Andrew Kennedy
- Department of Gastrointestinal Surgery, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Wang KangNing
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Chengdu, China
| | - John V Reynolds
- Department of Surgery, St James's Hospital Trinity College, Dublin, Ireland
| | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Mark Ferguson
- Department of Thoracic Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Gail Darling
- Department of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Wolfgang Schröder
- Department of Digestive Surgery, University Hospital of Cologne, Cologne, Germany
| | - Marc Bludau
- Department of Digestive Surgery, University Hospital of Cologne, Cologne, Germany
| | - Tim Underwood
- Department of Gastrointestinal Surgery, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | | | - Andrew Chang
- Department of Thoracic Surgery, University of Michigan Health System, Ann Arbor
| | - Ivan Cecconello
- Department of Digestive Surgery, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Digestive Surgery, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Giovanni de Manzoni
- Department of Upper Gastrointestinal Surgery, University of Verona, Verona, Italy
| | - Riccardo Rosati
- Department of Upper Gastrointestinal Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | | | | | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
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Hirji S, McGurk S, Kiehm S, Ejiofor J, Ramirez-Del Val F, Kolkailah AA, Berry N, Sobieszczyk P, Pelletier M, Shah P, O'Gara P, Kaneko T. Utility of 90-Day Mortality vs 30-Day Mortality as a Quality Metric for Transcatheter and Surgical Aortic Valve Replacement Outcomes. JAMA Cardiol 2021; 5:156-165. [PMID: 31851293 DOI: 10.1001/jamacardio.2019.4657] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance Questions have recently arisen as to whether 30-day mortality is a reasonable metric for understanding institutional practice differences after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). Objective To examine the utility of 30-day vs 90-day mortality after TAVR and SAVR as a mortality quality metric. Design, Setting, and Participants This nationally representative, multicenter, cohort study analyzed data from Medicare beneficiaries undergoing TAVR and SAVR procedures from January 1, 2012, to December 31, 2015. Concomitant coronary artery bypass grafting and other heart valve or other major open-heart procedures were excluded. Hospitals that performed fewer than 50 TAVR or 70 SAVR procedures per year were excluded to ensure reliable estimates and to reduce the risks of inflated results because of small institutional sample sizes. Data were analyzed from October 2018 to August 2019. Exposures Hospitals were ranked into top- (10%), middle- (80%), and bottom-performing (10%) groups based on their 4-year mean 30-day mortality. Main Outcomes and Measures Changes in hospital performance rankings at 90 days and 1 year and correlation of 30- and 90-day mortality with 1-year mortality were examined. Results A total of 30 329 TAVR admissions at 184 hospitals and 26 021 SAVR admissions at 191 hospitals were evaluated. For TAVR, 40 hospitals (21.7%) changed performance rankings at 90 days: 13 (48.1%) in the top-performing group and 8 (29.6%) in the bottom-performing group. At 1 year, 56 hospitals (30.4%), which included 21 (77.8%) in the top-performing group and 12 (44.4%) in the bottom-performing group, changed rankings. Similar findings were observed for SAVR, with an overall 90-day conversion rate of 17.3% and a 1-year rate of 30.3%. These findings persisted after adjusting for the differences in patient risk profiles among the 3 groups. Capturing 90-day events was also more robustly informative regarding expected 1-year outcomes after both TAVR and SAVR, largely owing to the observed plateau in the instantaneous hazard observed beyond this point. Conclusions and Relevance The findings suggest that evaluation of hospital performance based on 30-day mortality may underestimate outcomes and therefore substantially misrepresent institutional performance after TAVR and SAVR compared with 90-day mortality, even after risk adjustment. Although 30-day mortality has been validated, 90-day mortality may be a more reliable outcome metric for measuring hospital performance and capturing procedure-related mortality.
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Affiliation(s)
- Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Spencer Kiehm
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julius Ejiofor
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fernando Ramirez-Del Val
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ahmed A Kolkailah
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Natalia Berry
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Piotr Sobieszczyk
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc Pelletier
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pinak Shah
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Patrick O'Gara
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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27
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Cheng Z, Johar A, Gottlieb-Vedi E, Nilsson M, Lagergren J, Lagergren P. Impact of co-morbidity on reoperation or death within 90 days of surgery for oesophageal cancer. BJS Open 2021; 5:6073399. [PMID: 33609378 PMCID: PMC7893455 DOI: 10.1093/bjsopen/zraa035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/08/2020] [Indexed: 11/15/2022] Open
Abstract
Background The impact of preoperative co-morbidity on postoperative outcomes in patients with oesophageal cancer is uncertain. A population-based and nationwide cohort study was conducted to assess the influence of preoperative co-morbidity on the risk of reoperation or mortality within 90 days of surgery for oesophageal cancer. Methods This study enrolled 98 per cent of patients who had oesophageal cancer surgery between 1987 and 2015 in Sweden. Modified Poisson regression models provided risk ratios (RRs) with 95 per cent confidence intervals (c.i.) to estimate associations between co-morbidity and risk of reoperation or death within 90 days of oesophagectomy. The RRs were adjusted for age, sex, educational level, pathological tumour stage, neoadjuvant therapy, annual hospital volume, tumour histology and calendar period of surgery. Results Among 2576 patients, 446 (17.3 per cent) underwent reoperation or died within 90 days of oesophagectomy. Patients with a Charlson Co-morbidity Index (CCI) score of 2 or more had an increased risk of reoperation or death compared with those with a CCI score of 0 (RR 1.78, 95 per cent c.i. 1.44 to 2.20), and the risk increased on average by 27 per cent for each point increase of the CCI (RR 1.27, 1.18 to 1.37). The RR was increased in patients with pulmonary disease (RR 1.66, 1.36 to 2.04), cardiac disease (RR 1.37, 1.08 to 1.73), diabetes (RR 1.50, 1.14 to 1.99) and cerebral disease (RR 1.40, 1.06 to 1.85). Conclusion Co-morbidity in general, and pulmonary disease, cardiac disease, diabetes and cerebral disease in particular, increased the risk of reoperation or death within 90 days of oesophageal cancer surgery. This highlights the value of tailored patient selection, preoperative preparation and postoperative care.
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Affiliation(s)
- Z Cheng
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Johar
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - E Gottlieb-Vedi
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Nilsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - J Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - P Lagergren
- Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Surgery and Cancer, Imperial College London, London, UK
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28
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Resio BJ, Gonsalves L, Canavan M, Mueller L, Phillips C, Sathe T, Swett K, Boffa DJ. Where the Other Half Dies: Analysis of Mortalities Occurring More Than 30 Days After Complex Cancer Surgery. Ann Surg Oncol 2020; 28:1278-1286. [PMID: 32885398 DOI: 10.1245/s10434-020-09080-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 07/15/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Nearly half of operative mortalities occur outside the traditionally studied 30-day period after surgery. To identify additional opportunities to improve surgical safety, the circumstances of deaths occurring 31-90 days after complex cancer surgery are analyzed. PATIENTS AND METHODS Patients aged ≥ 65 years who died within 90 days of complex cancer surgery for nonmetastatic cancer were analyzed in the Surveillance, Epidemiology, and End Results (SEER)-Medicare and the Connecticut Tumor Registry (CTR) databases. RESULTS Of the 36,114 patients undergoing complex cancer surgery from 2004 to 2013 in SEER-Medicare, 1367 (3.8%) died within 31-90 days ("late mortalities"). Seventy-eight percent of late mortalities were readmitted prior to death. The highest proportion of late mortalities occurred during a readmission (49%), and 11% were never discharged from their index admission. Cause of death (COD) was largely attributed to the malignancy itself (56%), which is unlikely to be the underlying cause. Of the noncancer COD, cardiac causes were most frequent (34%), followed by pulmonary causes (18%). Death was rarely attributed to thromboembolic disease (< 1%). The CTR provided location of death, which was most commonly in a hospital (65%) or nursing facility (20%); death at home was rare (6%). CONCLUSIONS The vast majority of patients dying between 31 and 90 days of surgery were admitted to a hospital or nursing facility at the time of their death after initially being discharged, and few patients died at home. Greater clarity in death documentation is needed to identify specific opportunities to rescue patients from fatal complications arising in the later postoperative period.
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Affiliation(s)
- Benjamin J Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Maureen Canavan
- Department of Internal Medicine, Cancer Outcomes and Public Policy and Effectiveness Research (COPPER), Yale School of Medicine, New Haven, CT, USA
| | | | | | | | | | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
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29
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Mulder FI, Hovenkamp A, van Laarhoven HWM, Büller HR, Kamphuisen PW, Hulshof MCCM, van Berge Henegouwen MI, Middeldorp S, van Es N. Thromboembolic and bleeding complications in patients with oesophageal cancer. Br J Surg 2020; 107:1324-1333. [PMID: 32424862 PMCID: PMC7497123 DOI: 10.1002/bjs.11665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/27/2020] [Accepted: 04/07/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND In patients who undergo curative treatment for oesophageal cancer, risk estimates of venous thromboembolism (VTE), arterial thromboembolism and bleeding are needed to guide decisions about thromboprophylaxis. METHODS This was a single-centre, retrospective cohort study of patients with stage I-III oesophageal cancer who received neoadjuvant chemoradiation followed by oesophagectomy. The outcomes VTE, arterial thromboembolism, major bleeding, clinically relevant non-major bleeding and mortality were analysed for four consecutive cancer treatment stages (from diagnosis to neoadjuvant chemoradiotherapy, during neoadjuvant treatment, 30-day postoperative period, and up to 6 months after postoperative period). RESULTS Some 511 patients were included. The 2-year survival rate was 67·3 (95 per cent c.i. 63·2 to 71·7) per cent. During the 2-year follow-up, 50 patients (9·8 per cent) developed VTE, 20 (3·9 per cent) arterial thromboembolism, 21 (4·1 per cent) major bleeding and 30 (5·9 per cent) clinically relevant non-major bleeding. The risk of these events was substantial at all treatment stages. Despite 30-day postoperative thromboprophylaxis, 17 patients (3·3 per cent) developed VTE after surgery. Patients with VTE had worse survival (time-varying hazard ratio 1·81, 95 per cent c.i. 1·25 to 2·64). Most bleeding events occurred around the time of medical intervention, and approximately one-half during concomitant use of prophylactic or therapeutic anticoagulation. CONCLUSION Patients with oesophageal cancer undergoing neoadjuvant chemoradiotherapy and surgery are at substantial risk of thromboembolic and bleeding events throughout all stages of treatment. Survival is worse in patients with thromboembolic events during follow-up.
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Affiliation(s)
- F. I. Mulder
- Department of Vascular MedicineAmsterdam Cardiovascular ScienceAmsterdamthe Netherlands
- Department of Internal Medicine, Tergooi HospitalsHilversumthe Netherlands
| | - A. Hovenkamp
- Department of Vascular MedicineAmsterdam Cardiovascular ScienceAmsterdamthe Netherlands
| | | | - H. R. Büller
- Department of Vascular MedicineAmsterdam Cardiovascular ScienceAmsterdamthe Netherlands
| | - P. W. Kamphuisen
- Department of Vascular MedicineAmsterdam Cardiovascular ScienceAmsterdamthe Netherlands
- Department of Internal Medicine, Tergooi HospitalsHilversumthe Netherlands
| | - M. C. C. M. Hulshof
- Department of Radiotherapy, Amsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | | | - S. Middeldorp
- Department of Vascular MedicineAmsterdam Cardiovascular ScienceAmsterdamthe Netherlands
| | - N. van Es
- Department of Vascular MedicineAmsterdam Cardiovascular ScienceAmsterdamthe Netherlands
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30
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Ng-Kamstra JS, Nepogodiev D, Lawani I, Bhangu A. Perioperative mortality as a meaningful indicator: Challenges and solutions for measurement, interpretation, and health system improvement. Anaesth Crit Care Pain Med 2020; 39:673-681. [PMID: 32745634 DOI: 10.1016/j.accpm.2019.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 12/20/2022]
Abstract
Expanding global access to safe surgical and anaesthesia care is crucial to meet the health targets of the Sustainable Development Goals (SDGs). As global surgical volume increases, improving safety throughout the patient care pathway is a public health priority. At present, an estimated 4.2 million individuals die within 30 days of surgery each year, and many of these deaths are preventable. Important considerations for the collection and reporting of perioperative mortality data have been identified in the literature, but consensus has not been established on the best methodology for the quantification of excess surgical mortality at a hospital or health system level. In this narrative review, we address challenges in the use of perioperative mortality rates (POMR) for improving patient safety. First, we discuss controversies in the use of POMR as a health system indicator and suggest advantages for using a "basket" of procedure-specific mortality rates as an adjunct to gross POMR. We offer then solutions to challenges in the collection and reporting of POMR data, and propose interventions for improving care in the preoperative, operative, and postoperative periods. Finally, we discuss how health systems leaders and frontline clinicians can integrate surgical safety into both national health plans and patient care pathways to drive a sustainable safety revolution in perioperative care.
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Affiliation(s)
- Joshua S Ng-Kamstra
- Department of Critical Care Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4, Canada.
| | - Dmitri Nepogodiev
- National Institute for Health Research Global Health Research Unit on Global Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Ismaïl Lawani
- Department of Surgery and Surgical Specialties, Faculty of Health Sciences, University of Abomey Calavi, Cotonou, Benin; Rediet Shimeles Workneh, MD, Department of Anaesthesiology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Aneel Bhangu
- National Institute for Health Research Global Health Research Unit on Global Surgery, University of Birmingham, Birmingham, United Kingdom
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Laparoscopic versus open hemihepatectomy: comprehensive comparison of complications and costs at 90 days using a propensity method. Updates Surg 2020; 72:1041-1051. [PMID: 32734578 PMCID: PMC7680740 DOI: 10.1007/s13304-020-00854-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Abstract
Laparoscopic hemihepatectomy (LHH) may offer advantages over open hemihepatectomy (OHH) in blood loss, recovery, and hospital stay. The aim of this study is to evaluate our recent experience performing hemihepatectomy and compare complications and costs up to 90 days following laparoscopic versus open procedures. Retrospective evaluation of patients undergoing hemihepatectomy at our center 01/2010–12/2018 was performed. Patient, tumor, and surgical characteristics; 90-day complications; and costs were analyzed. Inverse probability of treatment weighting (IPTW) was used to balance covariates. A total of 141 hemihepatectomies were included: 96 OHH and 45 LHH. While operative times were longer for LHH, blood loss and transfusions were less. At 90 days, there were similar rates of liver-specific and surgical complications but fewer medical complications following LHH. Medical complications that arose with greater frequency following OHH were primarily pulmonary complications and urinary and central venous catheter infections. Complications at 90 days were lower following LHH (Clavien–Dindo grade ≥ III OHH 23%, LHH 11%, p = 0.130; Comprehensive Complication Index OHH 20.0 ± 16.1, LHH 10.9 ± 14.2, p = 0.001). While operating costs were higher, costs for hospital stay and readmissions were lower with LHH. Patients undergoing LHH experience a significant reduction in postoperative medical complications and costs, resulting in 90-day cost equity compared with OHH.
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Rössler F, Keerl A, Bieri U, Slieker J, Nocito A. Natural Orifice Transluminal Endoscopic Surgery: Long-Term Experience with Hybrid Transvaginal Cholecystectomies. Surg Innov 2020; 27:594-601. [PMID: 32538319 DOI: 10.1177/1553350620932402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objective. To assess outcome and safety of 571 hybrid natural orifice transluminal endoscopic surgery (NOTES) cholecystectomies. Methods. We retrospectively analyzed all consecutive NOTES cholecystectomies performed at our center between June 2009 and January 2018. All procedures were performed using a hybrid transvaginal technique, including an umbilical small-size trocar. End points, calculated at discharge, 30 and up to 90 days postoperatively, included intra- and postoperative morbidity assessed by the validated Clavien-Dindo classification and the Comprehensive Complication Index (CCI). Special focus was held on outcome and necessity of pre- and postoperative gynecological examinations. Results. We performed 571 hybrid NOTES cholecystectomies within 9 years. The vast majority were elective, 9.6% were emergency cholecystectomies. 6.7% of patients developed at least one complication until discharge, most of them minor (≤grade II). 30- and 90-day complication rates were 10.7% and 11%, respectively. Mean CCI at discharge and postoperative days 30 and 90 was 1.45 (±6.4), 2.3 (±7.7), and 2.4 (±7.8), respectively. Major complications (≥grade IIIa) occurred in 1.6% of patients, and 4 patients required emergency reoperation. No mortality was observed. In 9.8%, an additional abdominal trocar was placed. All patients underwent routine gynecological examination, whereof only 5 were rejected for transvaginal access preoperatively. In no case transvaginal access was discontinued intraoperatively due to gynecological disease. Conclusion. Hybrid NOTES transvaginal cholecystectomy represents a safe and feasible alternative to standard laparoscopic cholecystectomy. Preoperative gynecological examination is no longer routinely necessary, as intraoperative assessment is adequate.
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Affiliation(s)
- Fabian Rössler
- Department for General, Visceral and Vascular Surgery, 30246Kantonsspital Baden, Switzerland
- Department of Surgery and Transplantation, 27243University Hospital Zurich, Switzerland
| | - Andreas Keerl
- Department for General, Visceral and Vascular Surgery, 30246Kantonsspital Baden, Switzerland
| | - Uwe Bieri
- Department for General, Visceral and Vascular Surgery, 30246Kantonsspital Baden, Switzerland
- Department of Urology, 27243University Hospital Zurich, Switzerland
| | - Juliette Slieker
- Department for General, Visceral and Vascular Surgery, 30246Kantonsspital Baden, Switzerland
| | - Antonio Nocito
- Department for General, Visceral and Vascular Surgery, 30246Kantonsspital Baden, Switzerland
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Brunaud L, Payet C, Polazzi S, Bihain F, Quilliot D, Lifante JC, Duclos A. Reoperation Incidence and Severity Within 6 Months After Bariatric Surgery: a Propensity-Matched Study from Nationwide Data. Obes Surg 2020; 30:3378-3386. [PMID: 32367174 DOI: 10.1007/s11695-020-04570-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Data about incidence and severity of reoperations up to 6 months after bariatric surgery are currently limited. The aim of this cohort study was to evaluate the incidence and severity of reoperations after initial bariatric surgical procedures and to compare this between the 3 most frequent current surgical procedures (sleeve, gastric bypass, gastric banding). STUDY DESIGN Nationwide observational cohort study using data from French Hospital Information System (2013-2015) to evaluate incidence and severity of reoperations within 6 months after bariatric surgery. Hazard ratios (HR) of longitudinal comparison between historical propensity-matched cohorts were estimated from a Fine and Gray's model using competing risk of death. RESULTS Cumulative reoperation rates increased from postoperative day-30 to day-180. Consequently, 31.1 to 90.0% of procedures would have been missed if the reoperation rate was based solely on a 30-day follow-up. Reoperation rate at 6 months was significantly higher after gastric bypass than after sleeve (HR 0.64; IC 95% [0.53-0.77]) and corresponded to moderate-risk reoperations (HR 0.65; IC 95% [0.53-0.78]). Reoperation rate at 6 months was significantly higher after gastric banding than after sleeve (HR 0.08; IC 95% [0.07-0.09]) and corresponded to moderate-risk reoperations (HR 0.08; IC 95% [0.07-0.10]). CONCLUSION Cumulative incidence of reoperations increased from 30 days to 6 months after sleeve, gastric bypass, or gastric banding and corresponded to moderate-risk surgical procedures. Consequently, 30-day reoperation rate should no longer be considered when evaluating complications and surgical performance after bariatric surgery.
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Affiliation(s)
- Laurent Brunaud
- Department of Gastrointestinal, Metabolic, and Surgical Oncology (DCVMC). Multidisciplinary unit of obesity surgery (UMCO), University of Lorraine, CHRU Nancy, Brabois Hospital, 11 allée du morvan, 54511, Vandoeuvre-les-Nancy, France. .,INSERM U1256, Nutrition, Genetics, Environmental Risks, Faculty of Medicine, University of Lorraine, Nancy, France.
| | - Cecile Payet
- Department of Medical Information Evaluation and Research, Lyon University Hospital, Lyon, France Health Services and Performance Research Lab (EA 7425 HESPER), Lyon 1 Claude Bernard University, Lyon, France
| | - Stephanie Polazzi
- Department of Medical Information Evaluation and Research, Lyon University Hospital, Lyon, France Health Services and Performance Research Lab (EA 7425 HESPER), Lyon 1 Claude Bernard University, Lyon, France
| | - Florence Bihain
- Department of Gastrointestinal, Metabolic, and Surgical Oncology (DCVMC). Multidisciplinary unit of obesity surgery (UMCO), University of Lorraine, CHRU Nancy, Brabois Hospital, 11 allée du morvan, 54511, Vandoeuvre-les-Nancy, France
| | - Didier Quilliot
- Department of Endocrinology, Diabetology and Nutrition, University of Lorraine, CHRU Nancy, Brabois Hospital, Nancy, France
| | | | - Antoine Duclos
- Department of Medical Information Evaluation and Research, Lyon University Hospital, Lyon, France Health Services and Performance Research Lab (EA 7425 HESPER), Lyon 1 Claude Bernard University, Lyon, France
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Jiang W, Verma V, Haque W, Moreno AC, Koshy M, Butler EB, Teh BS. Post-treatment mortality after definitive chemoradiotherapy versus resection for esophageal cancer. Dis Esophagus 2020; 33:5555765. [PMID: 31504359 DOI: 10.1093/dote/doz073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/14/2019] [Accepted: 07/03/2019] [Indexed: 12/11/2022]
Abstract
In efforts to better characterize incidence and predictors of 30- and 90-day mortality following operative versus nonoperative approaches for locally advanced esophageal cancer (EC), we conducted a novel investigation of a large, contemporary US database. The National Cancer Database was queried for newly-diagnosed T1-3N0-1 squamous cell or adenocarcinoma receiving surgical-based therapy (esophagectomy alone or preceded by chemotherapy and/or radiotherapy) versus definitive chemoradiotherapy (dCRT). Statistics included graphing cumulative incidences of mortality before and following propensity score matching (PSM), based on age-based intervals. Cox regression determined factors independently predictive of 30- and 90-day mortality. Of 15,585 patients, 9,278 (59.5%) received surgical-based therapy and 6,307 (40.5%) underwent dCRT. In the unadjusted population, despite nonsignificant differences at 30 days (3.3% dCRT, 3.6% surgical-based), the dCRT cohort experienced higher 90-day mortality (11.0% vs. 7.5%, P < 0.001). Following PSM, however, dCRT patients experienced significantly lower 30-day mortality (P < 0.001), with nonsignificant differences at 90 days (P = 0.092). Surgical-based management yielded similar (or better) mortality as dCRT in ≤70-year-old patients; however, dCRT was associated with reduced mortality in subjects > 70 years old. In addition to the intervention group, factors predictive for 30- and 90-day mortality included age, gender, insurance status, facility type, comorbidity index, tumor location, histology, and T/N classification. In summary, surgical-based therapy for EC is associated with higher 30-day mortality, which becomes statistically similar to dCRT by 90 days. Differences between surgery and dCRT were most pronounced in patients > 70 years of age. These data may better inform shared decision-making between multidisciplinary providers and patients.
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Affiliation(s)
- W Jiang
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA.,Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, Guangdong Province, China
| | - V Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - W Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - A C Moreno
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - M Koshy
- Department of Radiation Oncology, University of Chicago School of Medicine, Chicago, IL, USA
| | - E B Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - B S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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Kauppila JH, Santoni G, Tao W, Lynge E, Koivukangas V, Tryggvadóttir L, Ness-Jensen E, Romundstad P, Pukkala E, von Euler-Chelpin M, Lagergren J. Reintervention or mortality within 90 days of bariatric surgery: population-based cohort study. Br J Surg 2020; 107:1221-1230. [DOI: 10.1002/bjs.11533] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/11/2020] [Accepted: 01/15/2020] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Bariatric surgery carries a risk of severe postoperative complications, sometimes leading to reinterventions or even death. The incidence and risk factors for reintervention and death within 90 days after bariatric surgery are unclear, and were examined in this study.
Methods
This population-based cohort study included all patients who underwent bariatric surgery in one of the five Nordic countries between 1980 and 2012. Data on surgical and endoscopic procedures, diagnoses and mortality were retrieved from national high-quality and complete registries. Multivariable Cox regression analysis was used to calculate hazard ratios (HRs), adjusted for country, age, sex, co-morbidity, type of surgery and approach, year and hospital volume of bariatric surgery.
Results
Of 49 977 patients, 1111 (2·2 per cent) had a reintervention and 95 (0·2 per cent) died within 90 days of bariatric surgery. Risk factors for the composite outcome reintervention/mortality were older age (HR 1·65, 95 per cent c.i. 1·36 to 2·01, for age at least 50 years versus less than 30 years) and co-morbidity (HR 2·66, 1·53 to 4·62, for Charlson co-morbidity index score 2 or more versus 0). The risk of reintervention/mortality was decreased for vertical banded gastroplasty compared with gastric bypass (HR 0·37, 0·28 to 0·48) and more recent surgery (HR 0·51, 0·39 to 0·67, for procedures undertaken in 2010 or later versus before 2000). Sex, surgical approach (laparoscopic versus open) and hospital volume did not influence risk of reintervention/mortality, but laparoscopic surgery was associated with a lower risk of 90-day mortality (HR 0·29, 0·16 to 0·53).
Conclusion
Reintervention and death were uncommon events within 90 days of bariatric surgery even in this unselected nationwide cohort from five countries. Older patients with co-morbidities have an increased relative risk of these outcomes.
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Affiliation(s)
- J H Kauppila
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Surgery Research Unit, Medical Research Centre Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - G Santoni
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - W Tao
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - E Lynge
- Department of Public Health, University of Copenhagen, Denmark
| | - V Koivukangas
- Surgery Research Unit, Medical Research Centre Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - L Tryggvadóttir
- Icelandic Cancer Registry, Icelandic Cancer Society, Iceland
- Faculty of Medicine, Laeknagardur, University of Iceland, Reykjavik, Iceland
| | - E Ness-Jensen
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - P Romundstad
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - E Pukkala
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | | | - J Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- School of Cancer and Pharmaceutical Sciences, King's College London, and Guy's and St Thomas' NHS Foundation Trust, London, UK
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Gómez-Hernández MT, Novoa NM, Varela G, Jiménez MF. Quality Control in Anatomical Lung Resection. Major Postoperative Complications vs Failure to Rescue. Arch Bronconeumol 2020; 57:251-255. [PMID: 31982251 DOI: 10.1016/j.arbres.2019.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Failure to rescue (FTR) is defined by the number of deaths among patients experiencing major complications after surgery. In this report we analyze FTR and apply a cumulative sum control chart (CUSUM) methodology for monitoring performance in a large series of operated lung carcinoma patients. METHODS Prospectively stored records of cases undergoing anatomical lung resection in one center were reviewed. Postoperative adverse events were coded and included as a binary variable (major, or minor complications). The occurrence of 30-day mortality was also recorded. Patients dying after suffering major complications were considered as FTR. Risk-adjusted CUSUM graphs using EuroLung1 and 2 variables were constructed for major complications and FTR. Points of plateauing or trend inversion were checked to detect intentional or non-adverted changes in the process of care. RESULTS 2237 cases included. 9.1% cases suffered major complications. The number of cases considered as failures to rescuing was 46 (2.1% of the total series and 22.5% of cases having major complications). The predictive performance of EuroLung1 and 2 models was as follows: EuroLung1 (major morbidity) C-index 0.70 (95%CI: 0.66-0.73); EuroLung2 (applied to FTR) C-index 0.81 (95%CI: 0.750.87). CUSUM graphs depicted improvement in rescuing complicated patients after case 330 but no improvement in the rate of non-complicated cases until case 720. CONCLUSIONS FTR offers a complementary view to classical outcomes for quality assessment in Thoracic Surgery. Our study also shows how the analysis of FTR on time series can be applied to evaluate changes in team performance along time.
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Affiliation(s)
| | - Nuria M Novoa
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | - Gonzalo Varela
- Salamanca Institute of Biomedical Research (IBSAL), Spain.
| | - Marcelo F Jiménez
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
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Helminen O, Kauppila JH, Kytö V, Gunn J, Lagergren J, Sihvo E. Preoperative esophageal stenting and short-term outcomes of surgery for esophageal cancer in a population-based study from Finland and Sweden. Dis Esophagus 2019; 32:5373135. [PMID: 30855081 DOI: 10.1093/dote/doz005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/06/2018] [Accepted: 01/15/2019] [Indexed: 12/11/2022]
Abstract
Population-based studies examining whether preoperative esophageal stenting influences the short-term outcomes after esophagectomy for esophageal cancer are lacking. This nationwide cohort combining data from Finland and Sweden was conducted to cover this gap. Patients with locally advanced esophageal cancer (T ≥ 3 and/or N ≥ 1, M0) who underwent esophagectomy between 2007 and 2014 were identified from nationwide registries in Finland and Sweden. The study exposure was preoperative stenting. The primary outcomes were 30- and 90-day mortality. Secondary outcomes were length of hospital stay and 30- and 90-day readmission rates. Multivariable Cox and linear regression analyses provided hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, sex, comorbidity, tumor histology, year of surgery, and country. Of all 1029 participating patients who underwent surgery for locally advanced esophageal cancer, 127 (12.3%) had an esophageal stent inserted preoperatively. The absolute 30-day mortality rates were higher in stented patients (3.9%) than in those without a stent (1.6%), but the HR was not statistically significantly increased (HR 2.42; 95% CI 0.85-6.92). Similarly, the absolute 90-day mortality rates were increased after preoperative stenting (11.8%) compared to no stenting (7.0%), but again the HR was not statistically significantly increased (HR 1.68; 95% CI 0.95-2.98). Preoperative stenting did not influence length of hospital stay or readmission rates. The possibly increased short-term mortality after preoperative stenting in patients who undergo esophagectomy for esophageal cancer indicated in this study suggests a cautious approach to preoperative stenting until future research or meta-analyses provide a more definite answer.
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Affiliation(s)
- Olli Helminen
- Department of Surgery, Central Finland Central Hospital, Jyväskylä.,Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu
| | - Joonas H Kauppila
- Cancer and Translational Medicine Research Unit, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu.,Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ville Kytö
- Heart Center, Turku University Hospital, and Research Center of Applied and Preventive Cardiovascular Medicine
| | - Jarmo Gunn
- Heart Center, Turku University Hospital, Finland Department of Surgery, Faculty of Medicine, University of Turku, Turku, Finland
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,School of Cancer and Pharmaceutical Sciences, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Eero Sihvo
- Department of Surgery, Central Finland Central Hospital, Jyväskylä
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Preoperative Statin Use and 90-Day Mortality after Noncardiac Surgery: A Hospital Registry Study. Ann Surg 2019; 274:e515-e521. [PMID: 31850989 DOI: 10.1097/sla.0000000000003737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the association between preadmission statin use and 90-day mortality after planned elective noncardiac surgery in adult patients. SUMMARY BACKGROUND DATA Statin therapy is known to have pleiotropic effects, which improve the outcomes of various diseases. However, the effect of perioperative statin therapy on postoperative mortality remains controversial. METHODS This retrospective cohort study analyzed the medical records of adult patients who were admitted to a single tertiary academic hospital for elective noncardiac surgery between January 2012 and December 2018. The primary endpoint was 90-day mortality, which was defined as any mortality within 90 days after surgery. The secondary endpoint was overall survival. RESULTS After propensity score matching, a total of 33,514 patients (16,757 patients in each group) were included in the analysis. The logistic regression analysis of the propensity score-matched cohort indicated that the odds ratio (OR) of 90-day mortality in the statin group was 26% lower than that of the nonstatin group [OR: 0.74; 95% confidence interval (CI): 0.59 to 0.92; P = 0.009]. The sensitivity analysis indicated that the high-dose intensity statin group had a 61% lower 90-day mortality rate than the nonstatin group (OR: 0.39; 95% CI: 0.18-0.84; P = 0.016). The overall survival time was significantly longer in the statin group than in the nonstatin group after propensity score matching (P < 0.001 by log-rank test). CONCLUSIONS Preoperative statin use was associated with lower 90-day mortality and longer overall survival for adult patients who underwent elective noncardiac surgery. This association was more evident for high-intensity statin users.
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Oh TK, Do SH, Jeon YT, Kim J, Na HS, Hwang JW. Association of Preoperative Serum Chloride Levels With Mortality and Morbidity After Noncardiac Surgery: A Retrospective Cohort Study. Anesth Analg 2019; 129:1494-1501. [PMID: 31743168 DOI: 10.1213/ane.0000000000003958] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative hyperchloremia is known to be related to increases in mortality and morbidity after surgery. However, the relationship between preoperative hyperchloremia and hypochloremia and postoperative mortality and morbidity is not well established. Our aim was to evaluate the relationship between preoperative hyperchloremia or hypochloremia, as assessed using preoperative serum chloride tests, and 90-day mortality and morbidity after noncardiac surgery. METHODS In this retrospective cohort study, we reviewed the medical records of patients >20 years of age who underwent noncardiac surgery between January 2010 and December 2016. Patients were categorized into one of the following groups on the basis of the results of serum chloride testing performed within 1 month before surgery: normochloremia, 97-110 mmol·L; hyperchloremia, >110 mmol·L; and hypochloremia, <97 mmol·L. The primary end point of this study was the difference in postoperative 90-day mortality among the preoperative serum chloride groups. The secondary end point was the difference in postoperative acute kidney injury incidence among the preoperative serum chloride groups. RESULTS A total of 106,505 patients were included in the final analysis (2147 were allocated to the preoperative hypochloremia group and 617 to the hyperchloremia group). Multivariable Cox regression analysis revealed significantly increased 90-day mortality in the hypochloremia (hazard ratio, 1.46; 95% CI, 1.16-1.84; P = .001) and hyperchloremia (hazard ratio, 1.76; 95% CI, 1.13-2.73; P = .013) groups when compared with the normochloremia group. In addition, multivariable logistic regression analysis revealed a 1.83-fold increased odds of acute kidney injury in the preoperative hypochloremia group when compared with the normochloremia group (odds ratio, 1.83; 95% CI, 1.53-2.19; P < .001). CONCLUSIONS Preoperative hypochloremia and hyperchloremia were related to increased 90-day mortality after noncardiac surgery. In addition, preoperative hypochloremia was related to an increased risk for postoperative acute kidney injury.
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Affiliation(s)
- Tak Kyu Oh
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Sang-Hwan Do
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
| | - Young-Tae Jeon
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
| | - Jinhee Kim
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
| | - Hyo-Seok Na
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jung-Won Hwang
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
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40
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Mokdad AA, Yopp AC, Polanco PM, Mansour JC, Reznik SI, Heitjan DF, Choti MA, Minter RR, Wang SC, Porembka MR. Adjuvant Chemotherapy vs Postoperative Observation Following Preoperative Chemoradiotherapy and Resection in Gastroesophageal Cancer: A Propensity Score-Matched Analysis. JAMA Oncol 2019; 4:31-38. [PMID: 28975352 DOI: 10.1001/jamaoncol.2017.2805] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Distant recurrence following preoperative chemoradiotherapy and resection in patients with gastroesophageal adenocarcinoma is common. Adjuvant chemotherapy may improve survival. Objective To compare adjuvant chemotherapy with postoperative observation following preoperative chemoradiotherapy and resection in patients with gastroesophageal adenocarcinoma. Design, Setting, and Participants Propensity score-matched analysis using the National Cancer Database. We included adult patients who received a diagnosis between 2006 and 2013 of clinical stage T1N1-3M0 or T2-4N0-3M0 adenocarcinoma of the distal esophagus or gastric cardia who were treated with preoperative chemoradiotherapy and curative-intent resection. Patients receiving adjuvant chemotherapy were matched by propensity score to patients undergoing postoperative observation. Exposures Adjuvant chemotherapy and postoperative observation. Main Outcomes and Measures Overall survival. Results We identified 10 086 patients (8840 [88%] male; mean [SD] age, 61 [9.5] years), 9272 in the postoperative observation group and 814 in the adjuvant chemotherapy group. Patients receiving adjuvant chemotherapy were younger (18-54 years: 252 [31%] vs 1989 [21%]; P < .001) and were more likely to have advanced disease (ypT3/4: 458 [62%] vs 3531 [46%]; P < .001; ypN+: 572 [72%] vs 3428 [39%]; P < .001), as well as shorter postoperative inpatient stays (>2 weeks: 94 [13%] vs 1589 [20%]; P < .001). A total of 732 patients in the adjuvant chemotherapy group were matched by propensity score to 3660 patients in the postoperative observation group. Adjuvant chemotherapy was associated with improved overall survival compared with postoperative observation (median survival: 40 months; 95% CI, 36-46 months vs 34 months; 95% CI, 32-35 months; stratified log-rank P < .001; hazard ratio, 0.79; 95% CI, 0.72-0.88). Overall survival at 1, 3, and 5 years was 88%, 47%, and 34% in the observation group, and 94%, 54%, and 38% in the adjuvant chemotherapy group, respectively. Adjuvant chemotherapy was associated with a survival benefit compared with postoperative observation in most patient subgroups. Conclusions and Relevance For patients with locally advanced gastroesophageal adenocarcinoma treated with preoperative chemoradiotherapy and resection, adjuvant chemotherapy was associated with improved overall survival. Our findings have important implications for the postoperative treatment of this patient group for which few data are available.
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Affiliation(s)
- Ali A Mokdad
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Adam C Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Patricio M Polanco
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - John C Mansour
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Scott I Reznik
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Daniel F Heitjan
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas.,Department of Statistical Science, Southern Methodist University, Dallas, Texas
| | - Michael A Choti
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Rebecca R Minter
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Sam C Wang
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Matthew R Porembka
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas
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Li SS, Costantino CL, Mullen JT. Morbidity and Mortality of Total Gastrectomy: a Comprehensive Analysis of 90-Day Outcomes. J Gastrointest Surg 2019; 23:1340-1348. [PMID: 31062268 DOI: 10.1007/s11605-019-04228-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 04/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Total gastrectomy (TG) is a complex procedure that carries a high risk of morbidity and mortality and in which patients may experience post-operative sequelae well past the standard 30-day follow-up period. Large studies from high-volume centers with detailed 90-day follow-up data are needed to provide benchmarks for high-quality care for this complex procedure. METHODS Single-institution, retrospective review of a comprehensive gastric cancer database of 148 patients undergoing curative intent TG from 2000 to 2017. Clinicopathologic and treatment factors were analyzed for their impact on 90-day outcomes. RESULTS The median age of the cohort was 66 years, and 61% were male. Neoadjuvant chemotherapy and radiation therapy were delivered to 32% and 11% of patients, respectively. Open and laparoscopic TG were performed in 93% (n = 137) and 7% (n = 11) of patients, respectively. Extended lymphadenectomy, pancreatectomy, and splenectomy were performed in 37%, 4.7%, and 19% of patients, respectively. The 30- and 90-day mortality rates were 2.0% and 3.4%, respectively. At least one 90-day complication was experienced by 43.9% (n = 65) of patients, and 14% (n = 21) experienced a Clavien-Dindo grade 3 or 4 complication. Anastomotic leak occurred in 5.4% (n = 8) of patients, half of which required an invasive intervention. Median length of stay was 8 days. The readmission rate was 22%, and most readmissions were due to dehydration and/or nutritional compromise. CONCLUSIONS This study defines 30- and 90-day post-operative outcomes after total gastrectomy in a high-volume center. These outcomes data are critical to the improvement of the informed consent process and as benchmarks for future quality improvement initiatives.
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Affiliation(s)
- Selena S Li
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, YAW-7926, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Christina L Costantino
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, YAW-7926, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - John T Mullen
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, YAW-7926, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
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Sihvo E, Helminen O, Gunn J, Sipilä JO, Rautava P, Kytö V. Long-term outcomes following minimally invasive and open esophagectomy in Finland: A population-based study. Eur J Surg Oncol 2019; 45:1099-1104. [DOI: 10.1016/j.ejso.2018.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/18/2018] [Accepted: 12/06/2018] [Indexed: 01/04/2023] Open
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Hardt J, Buhr HJ, Klinger C, Benz S, Ludwig K, Kalff J, Post S. [Quality indicators for colon cancer surgery : Evidence-based development of a set of indicators for the outcome quality]. Chirurg 2019; 89:17-25. [PMID: 29189878 DOI: 10.1007/s00104-017-0559-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Quality assessment in surgery is gaining in importance. Although sporadic recommendations for quality indicators (QI) in oncological colon surgery can be found in the literature, these are usually not systematically derived from a solid evidence base. Moreover, reference ranges for QI are unknown. OBJECTIVE The aim of this initiative was the development of evidence-based QI for oncological colon resections by an expert panel invited by the German Society of General and Visceral Surgery (DGAV). Reference ranges from the literature and reference values from the Study, Documentation, and Quality Center (StuDoQ)|Colon Cancer Register were compared in order to deduce recommendations which are tailored to the German healthcare system. RESULTS Based on the most recent scientific evidence and agreed by expert consensus, five QI for oncological colon surgery were defined and evaluated according to the QUALIFY tool. Mortality, MTL30 (mortality, transfer to another acute care hospital, or length of stay ≥30 days), anastomotic leakage requiring reintervention, surgical site infections necessitating reopening of the wound and ≥12 lymph nodes in the specimen qualified as QI owing to their relevance, scientific nature, and practicability. Based on the results of the systematic literature search and the statistical analysis of the StuDoQ|Colon Cancer Register, preliminary reference values are proposed for each QI. CONCLUSION The presented set of QI seems appropriate for quality assessment of oncological colon surgery in the context of the German healthcare system. The validity of the QI and the reference values must be reviewed within the framework of their implementation. The StuDoQ|Colon Cancer Register provides a suitable infrastructure for collecting clinical data for quality assessment and risk adjustment.
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Affiliation(s)
- J Hardt
- Chirurgische Klinik, Universitätsmedizin Mannheim (UMM), Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - H-J Buhr
- Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland
| | - C Klinger
- Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV), Berlin, Deutschland
| | - S Benz
- Chirurgische Klinik, Klinikum Sindelfingen-Böblingen, Böblingen, Deutschland
| | - K Ludwig
- Chirurgische Klinik, Klinikum Südstadt Rostock, Rostock, Deutschland
| | - J Kalff
- Chirurgische Klinik, Universitätsklinikum Bonn (UKB), Bonn, Deutschland
| | - S Post
- Chirurgische Klinik, Universitätsmedizin Mannheim (UMM), Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
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Confirmation of the prognostic value of pretherapeutic tumor SUR and MTV in patients with esophageal squamous cell carcinoma. Eur J Nucl Med Mol Imaging 2019; 46:1485-1494. [PMID: 30949816 DOI: 10.1007/s00259-019-04307-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 03/04/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE The prognosis for patients with inoperable esophageal carcinoma is still poor and the reliability of individual therapy outcome prediction based on clinical parameters is not convincing. In a recent publication, we were able to show that PET can provide independent prognostic information in such a patient group and that the tumor-to-blood standard uptake ratio (SUR) can improve the prognostic value of tracer uptake values. The present investigation addresses the question of whether the distinctly improved prognostic value of SUR can be confirmed in a similar patient group that was examined and treated at a different site. METHODS 18F-FDG PET/CT was performed in 147 consecutive patients (115 male, 32 female, mean age: 62 years) with newly diagnosed esophageal squamous cell carcinoma prior to definitive radiochemotherapy. In the PET images, the metabolic active volume (MTV) of the primary tumor was delineated with an adaptive threshold method. For the resulting ROIs, SUVmax and total lesion glycolysis (TLG = MTV × SUVmean) were computed. The blood SUV was determined by manually delineating the aorta in the low-dose CT. SUR values were computed as ratio of tumor SUV and blood SUV. Univariate Cox regression and Kaplan-Meier analysis with respect to overall survival (OS), distant-metastases-free survival (DM), and locoregional control (LRC) was performed. Additionally, a multivariate Cox regression including clinically relevant parameters was performed. RESULTS Univariate Cox regression revealed MTV, TLG, and SURmax as significant prognostic factors for OS. MTV as well as TLG were significant prognostic factors for LRC while SURmax showed only a trend for significance. None of the PET parameters was prognostic for DM. In univariate analysis, SUVmax was not prognostic for any of the investigated clinical endpoints. In multivariate analysis (T-stage, N-stage, MTV, and SURmax), MTV was an independent prognostic factor for OS and showed a trend for significance for LRC. SURmax was not an independent predictor for OS or LRC. When including the PET parameters separately in multivariate analysis, MTV as well as SURmax were prognostic factors for OS indicating that SURmax is independent from the clinical parameters but not from MTV. In addition, MTV was an independent prognostic factor for LRC in this separate analysis. CONCLUSIONS Our study revealed a clearly improved prognostic value of tumor SUR compared to tumor SUV and confirms our previously published findings regarding OS. Furthermore, SUR delivers prognostic information beyond that provided by the clinical parameters alone, but does not add prognostic information beyond that provided by MTV in this patient group. Therefore, our results suggest that pretherapeutic MTV is the parameter of choice for PET-based risk stratification in the considered setting but further investigations are necessary to demonstrate that this suggestion is correct.
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Can We Increase the Resection Rate by Minimally Invasive Approach? Experience from 100 Minimally Invasive Esophagectomies. JOURNAL OF ONCOLOGY 2019; 2019:3809383. [PMID: 30915119 PMCID: PMC6409017 DOI: 10.1155/2019/3809383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/24/2019] [Accepted: 02/04/2019] [Indexed: 12/21/2022]
Abstract
Background Whether we can increase the resection rate of esophageal cancer by minimally invasive esophagectomy (MIE) is unknown. The aim was to report the number and results of MIE in high-risk patients considered unsuitable for open surgery and compare these results to other operated patients and to high-risk patients not undergoing surgery. Methods At Central Finland Central Hospital, between September 2012 and July 2018, the number of operated MIEs was 100. Of these, 10 patients were prospectively considered unfit for open approach. Nineteen additional high-risk patients with operable disease were ruled out of surgery. The short- and long-term outcomes of these 3 groups were compared. Results In patients eligible for any approach (n=90), MIE only (n=10), and no surgery (n=19), WHO performance status Grade 0 was observed in 66.7%, 20.0%, and 5.3%, respectively; stair climbing with ≥4 stairs was successfully completed in 77.8%, 50%, and 36.8%, respectively. Between any approach and MIE only groups, rate of major complications (Clavien-Dindo ≥3a) was 6.7% vs. 50.0% (p<0.001) without a difference in median hospital stay (9 vs. 10 days, p=0.542). Readmission rates were 4.4% vs. 30.0% (p=0.003). Survival rates were 100% vs. 80% (p<0.001) at 90-days, 91.5% vs. 66.7% (p=0.005) at 1-year, and 68.9% vs. 53.3% (p=0.024) at 3-years, respectively. In comparison between MIE only and no surgery groups, these survival rates from day of diagnosis were 80% vs. 100%, 68.6% vs. 67.1%, and 45.7% vs. 32.0% (p=0.290), respectively. Conclusions By operating patients unsuitable for open approach with MIE, the resection rate increased 11.1%. These high-risk patients had, however, higher early morbidity and reduced long-term survival compared to other operated patients. Though there seems to be long-term benefit of surgery compared to nonsurgical patients, we have to be cautious when offering surgery to those considered unfit for open surgery.
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Abstract
OBJECTIVES The use of mortality prediction scores in clinical trials in the PICU is essential for comparing patient groups. Because of the decline in PICU mortality over the last decades, leading to a shift toward later deaths, recent trials use 90-day mortality as primary outcome for estimating mortality and survival more accurately. This study assessed and compared the performance of two frequently used PICU mortality prediction scores for prediction of PICU and 90-day mortality. DESIGN This secondary analysis of the randomized controlled Early versus Late Parenteral Nutrition in the Pediatric Intensive Care Unit trial compared the discrimination (area under the receiver operating characteristic curve) and calibration of the Pediatric Index of Mortality 3 and the Pediatric Risk of Mortality III scores for prediction of PICU and 90-day mortality. SETTING Three participating PICUs within academic hospitals in Belgium, the Netherlands, and Canada. PATIENTS One-thousand four-hundred twenty-eight critically ill patients 0-17 years old. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Although Pediatric Index of Mortality 3 only includes information available at the time of PICU admission, thus before any intervention in the PICU, it showed good discrimination (area under the receiver operating characteristic curve, 0.894; 95% CI, 0.892-0.896) and good calibration (no deviation from the diagonal, p = 0.58) for PICU mortality. Pediatric Risk of Mortality III, which involves the worst values for the evaluated variables during the first 24 hours of PICU stay, was statistically more discriminant (area under the receiver operating characteristic curve, 0.920; 95% CI, 0.918-0.921; p = 0.04) but poor in calibration (significant deviation from the diagonal; p = 0.04). Pediatric Index of Mortality 3 and Pediatric Risk of Mortality III discriminated equally well between 90-day mortality and survival (area under the receiver operating characteristic curve, 0.867; 95% CI, 0.866-0.869 and area under the receiver operating characteristic curve, 0.882; 95% CI, 0.880-0.884, respectively, p = 0.77), but Pediatric Risk of Mortality III was not well calibrated (p = 0.04), unlike Pediatric Index of Mortality 3 (p = 0.34). CONCLUSIONS Pediatric Index of Mortality 3 performed better in calibration for predicting PICU and 90-day mortality than Pediatric Risk of Mortality III and is not influenced by intervention or PICU quality of care. Therefore, Pediatric Index of Mortality 3 seems a better choice for use in clinical trials with 90-day mortality as primary outcome.
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Toh Y, Yamamoto H, Miyata H, Gotoh M, Watanabe M, Matsubara H, Kakeji Y, Seto Y. Significance of the board-certified surgeon systems and clinical practice guideline adherence to surgical treatment of esophageal cancer in Japan: a questionnaire survey of departments registered in the National Clinical Database. Esophagus 2019; 16:362-370. [PMID: 30980202 PMCID: PMC6744385 DOI: 10.1007/s10388-019-00672-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 04/07/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND It remains unknown how much institutional medical structure and process of implementation of clinical practice guidelines for esophageal cancers can improve quality of surgical outcome in Japan. METHODS A web-based questionnaire survey was performed for departments registered in the National Clinical Database in Japan from October 2014 to January 2015. Quality indicators (QIs) including structure and process indicators (clinical practice guideline adherence) were evaluated on the risk-adjusted odds ratio for operative mortality (AOR) of the patients using registered cases in the database who underwent esophagectomy and reconstruction in 2013 and 2014. RESULTS Among 916 departments which registered at least one esophagectomy case during the study period, 454 departments (49.6%) responded to the questionnaire. Analyses of 6661 cases revealed that two structure QIs (certification of training hospitals by Japan Esophageal Society and presence of board-certified esophageal surgeons) were associated with significantly lower AOR (p < 0.001 and p = 0.005, respectively). One highly recommended process QI regarding preoperative chemotherapy had strong tendency to associate with lower AOR (p = 0.053). In two process QIs, the answer "performed at the doctor's discretion" showed a significant negative impact on prognosis, suggesting importance of institutional uniformity. CONCLUSIONS The medical institutional structure of board-certified training sites for esophageal surgeons and of participation of board-certified esophageal surgeons improves surgical outcome in Japan. Establishment of appropriate QIs and their uniform implementation would be crucial for future quality improvement of medical care in esophagectomy.
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Affiliation(s)
| | | | | | - Mitsukazu Gotoh
- The Japanese Society of Gastroenterological Surgery, 3-1-17 Axior Mita 6F, Minato-ku, Tokyo, 108-0073 Japan
| | | | | | - Yoshihiro Kakeji
- The Japanese Society of Gastroenterological Surgery, 3-1-17 Axior Mita 6F, Minato-ku, Tokyo, 108-0073 Japan
| | - Yasuyuki Seto
- The Japanese Society of Gastroenterological Surgery, 3-1-17 Axior Mita 6F, Minato-ku, Tokyo, 108-0073 Japan
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Berlth F, Bludau M, Plum PS, Herbold T, Christ H, Alakus H, Kleinert R, Bruns CJ, Hölscher AH, Chon SH. Self-Expanding Metal Stents Versus Endoscopic Vacuum Therapy in Anastomotic Leak Treatment After Oncologic Gastroesophageal Surgery. J Gastrointest Surg 2019; 23:67-75. [PMID: 30374816 DOI: 10.1007/s11605-018-4000-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 09/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anastomotic leak after gastroesophageal surgery is a life-threatening complication. Self-expanding metal stent (SEMS) implantation or endoscopic vacuum therapy (EVT) have been established as alternatives to reoperation. This study compares the outcome of both interventions for anastomotic leak clinical management. METHODS In this retrospective study, we identified all patients who received SEMS or EVT for anastomotic leaks after oncological gastroesophageal surgery between January 2007 and December 2016. Only patients with type II leaks according to the Esophagectomy Complications Consensus Group were included. Sealing rates, intervention-related complications, demographic characteristics, clinical history, leak characteristics, therapy duration, and in-hospital mortality were analyzed. RESULTS One hundred eleven patients who received SEMS (n = 76) or EVT (n = 35) were identified and categorized by primary and final treatment. The overall closure rate in the final treatment analysis was 85.7% for EVT and 72.4% for SEMS (p = 0.152). ICU stay ranged from 0 to 60 days (median 6 days) for EVT and from 0 to 295 days (median 9 days) for SEMS (p = 0.704). EVT patients were hospitalized for 19-119 days (median 39 days) and SEMS patients for 13-296 days (median 37 days; p = 0.812). Demographic factors, comorbidities, and surgical parameters did not correlate with treatment or treatment success. CONCLUSIONS SEMS and EVT show comparable results for anastomotic leak management after oncologic gastroesophageal surgery. No superior outcome could be found for either one of the two treatments options.
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Affiliation(s)
- Felix Berlth
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Marc Bludau
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Patrick Sven Plum
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Till Herbold
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen, Aachen, Germany
| | - Hildegard Christ
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany
| | - Hakan Alakus
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Robert Kleinert
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Christiane Josephine Bruns
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | | | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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Brunaud L, Polazzi S, Lifante JC, Pascal L, Nocca D, Duclos A. Health Care Institutions Volume Is Significantly Associated with Postoperative Outcomes in Bariatric Surgery. Obes Surg 2018; 28:923-931. [PMID: 29039053 DOI: 10.1007/s11695-017-2969-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE The volume of bariatric surgery has significantly increased over the past decade with concomitant postoperative outcomes improvement. The goal of this nationwide study was to estimate the volume-outcome relationship in bariatric surgery at the hospital level. MATERIALS AND METHODS A cross-sectional analysis of all patients who underwent bariatric surgery procedure in France from January 2011 to December 2014 was designed. Volume-outcome relationship was analyzed using generalized estimating equations. RESULTS We identified 184,332 inpatient stays for bariatric surgical procedures performed in 606 hospitals. Health care institutions performing more than 200 bariatric cases per year were significantly associated with shorter average length of stay (p < 0.001) and less frequent need for intensive or critical care unit (p = 0.003) during the index stay in comparison with lower volume institutions. Reoperations rate increased from 3.1% [95% CI, 2.8-3.3] (n = 5627) at 1 month to 4.9% [4.6-5.2] at 3 months and 8.2% [7.8-8.7] at 6 months. The risk of reoperation after gastric bypass was 1.37 times less frequent in higher volume institutions (≥ 200 inpatient stays per year, p = 0.003), while it was 1.26 times more frequent after gastric banding in higher volume institutions (p = 0.057) and was unaltered regarding sleeve gastrectomy (p = 0.819). CONCLUSION This study showed for the first time in bariatric surgery that reoperation rate after gastric bypass or sleeve significantly increased at 3 and 6 months postoperatively. Health care institutions performing more than 200 bariatric cases per year were significantly associated with improved postoperative outcomes and less frequent need for reoperation.
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Affiliation(s)
- Laurent Brunaud
- CHU Nancy - Hospital Brabois Adultes, Department of Digestive, Hepato-Biliary and Endocrine Surgery, and Multidisciplinary Unit for Obesity Surgery (UMCO), Université de Lorraine, 11 allée du morvan, 54511, Vandoeuvre-les-Nancy, France. .,Unité INSERM U954 « Nutrition - génétique et exposition aux risques environnementaux », Faculté de Médecine, Université de Lorraine, 54511, Vandoeuvre-les-Nancy, France.
| | - Stephanie Polazzi
- Hospices Civils de Lyon, Pôle Information Médicale Évaluation Recherche, Health Services and Performance Research Lab, Université Claude Bernard Lyon 1, 69003, Lyon, France
| | - Jean-Christophe Lifante
- Centre Hospitalier Lyon Sud, Service de Chirurgie Générale et Endocrinienne, Hospices Civils de Lyon, 69300, Pierre Bénite, France
| | - Lea Pascal
- Hospices Civils de Lyon, Pôle Information Médicale Évaluation Recherche, Health Services and Performance Research Lab, Université Claude Bernard Lyon 1, 69003, Lyon, France
| | - David Nocca
- CHRU Montpellier, Département de Chirurgie Digestive, Hôpital St Eloi, Université de Montpellier, 34000, Montpellier, France
| | - Antoine Duclos
- Hospices Civils de Lyon, Pôle Information Médicale Évaluation Recherche, Health Services and Performance Research Lab, Université Claude Bernard Lyon 1, 69003, Lyon, France
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Klevebro F, Garritano S, Scandavini CM, Shetye A, Coppola A, Kamiya S, Nilsson M, Lundell L, Rouvelas I. Surgical outcomes of oesophagectomy or gastrectomy due to cancer for patients ≥75 years of age: a single-centre cohort study. ANZ J Surg 2018; 89:228-233. [PMID: 30151854 DOI: 10.1111/ans.14761] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 05/30/2018] [Accepted: 06/04/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The increasing age of the population and prolonged life expectancy result in a widening of age limit criteria for a variety of surgical procedures. Oesophagectomy and total gastrectomy are complex operations associated with significant risks of post-operative complications. METHODS This is a single-centre cohort study of patients operated with curative intent due to oesophageal or gastric cancer. RESULTS From 2007 to 2017, 548 patients underwent surgery with curative intent, with 122 patients (22.3%) classified as elderly (≥75 years). There was no difference in total complication rates between the groups. The adjusted odds ratio for 90-day mortality after oesophageal resection in the elderly group was 3.65 (95% confidence interval (CI): 1.33-10.03) and after gastrectomy was 1.62 (95% CI: 0.55-4.79). The adjusted hazard ratio for 1-year mortality after oesophagectomy was 2.29 (95% CI: 1.25-4.19), and after gastrectomy the adjusted hazard ratio was 1.48 (95% CI: 0.75-2.92). In the event of a complication with Clavien-Dindo score IIIb or higher, there was a statistically significant increase of 90-day mortality to over 50% among elderly patients both after oesophagectomy and gastrectomy (50.0% versus 19.8%; P = 0.005 and 57.1% versus 17.4%; P = 0.012, respectively). CONCLUSION There is a statistically significant increase in 90-day mortality after oesophageal and gastric cancer surgery in elderly compared with younger patients. Post-operative complications with high Clavien-Dindo score in patients undergoing oesophagectomy or gastrectomy, with age ≥75 years, are a dramatic risk factor for post-operative death.
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Affiliation(s)
- Fredrik Klevebro
- Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Stefano Garritano
- Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden.,Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Chiara M Scandavini
- Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden.,Department of Emergency Surgery, Saint Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Alysha Shetye
- Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Alessandro Coppola
- Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden.,Department of General Surgery, A. Gemelli Hospital, Catholic University of Sacro Cuore, Rome, Italy
| | - Satoshi Kamiya
- Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Lars Lundell
- Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Cancer, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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