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Merga ZC, Lee JS, Gong CS. Outcomes of Gastrectomy for Gastric Cancer in Patients Aged >80 Years: A Systematic Literature Review and Meta-Analysis. J Gastric Cancer 2023; 23:428-450. [PMID: 37553130 PMCID: PMC10412976 DOI: 10.5230/jgc.2023.23.e23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 08/10/2023] Open
Abstract
This meta-analysis examined the surgical management of older patients (>80 years) with gastric cancer, who were often excluded from randomized controlled trials. We analyzed 23 retrospective cohort studies involving 18,372 patients and found that older patients had a higher in-hospital mortality rate (relative risk [RR], 3.23; 95% confidence interval [CI], 1.46-7.17; P<0.01) and more post-operative complications (RR, 1.36; 95% CI, 1.19-1.56; P<0.01) than did younger patients. However, the surgical complications were similar between the two groups. Older patients were more likely to undergo less extensive lymph node dissection and longer hospital stays. Although older patients had statistically significant post-operative medical complications, they were not deprived of surgery for gastric cancer. The comorbidities and potential risks of post-operative complications should be carefully evaluated in older patients, highlighting the importance of careful patient selection. Overall, this meta-analysis provides recommendations for the surgical management of older patients with gastric cancer. Careful patient selection and evaluation of comorbidities should be performed to minimize the risk of post-operative complications in older patients, while recognizing that they should not be deprived of surgery for gastric cancer.
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Affiliation(s)
| | - Ji Sung Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chung-Sik Gong
- Division of Gastrointestinal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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2
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Mathoulin S, Minto G, Taylor G, Erasmus P. The impact of universal cardiopulmonary exercise testing on perioperative pathways and short-term patient outcomes following elective pancreatic surgery: A retrospective cohort study. J Intensive Care Soc 2022; 23:407-413. [PMID: 36751357 PMCID: PMC9679911 DOI: 10.1177/17511437211022128] [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: 11/16/2022] Open
Abstract
Background The utility of Cardiopulmonary Exercise Testing (CPET) to identify higher risk surgical patients remains controversial. There is limited research investigating the value of preoperative CPET to plan perioperative pathways for patients undergoing major pancreatic surgery. Methods Retrospective cohort study, comprising two groups before and after a change in referral policy for High Risk preoperative anaesthetic clinic with CPET. Period 1 discretionary referral and Period 2: universal referral. The primary aim was to investigate the impact of this policy change on critical care use (planned vs unplanned) on the day of surgery and on delayed critical care admission. Secondary end points included a comparison of the total number of critical care bed days, days in hospital, complication rates and mortality data between the two cohorts. Results 177 patients were included; 114 in Period 1 and 63 in Period 2. There was a reduction in unplanned day of surgery postoperative admissions to critical care (28.1% vs. 11.1%, p = 0.008). Seven (6.1%) of patients in Period 1 and 1 (1.6%) patient in Period 2 had delayed admission, though no p value was calculated due to the small numbers involved. Complication rates were similar in each group. The median critical care bed days was 1 (range 0-21) days in Period 1 and 1 (0-13) days in Period 2. Conclusions A universal referral policy for preoperative CPET demonstrated a decrease in unplanned day of surgery critical care admissions and a trend towards reducing delayed (>24 h postop) critical care admission which could be investigated in a larger study. No measurable impact was seen on clinical outcomes.
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Affiliation(s)
- Sophie Mathoulin
- Department of Anaesthesia, Derriford Hospital, Plymouth,
UK,Sophie Mathoulin, Department of
Anaesthesia, Derriford Hospital, Plymouth, UK.
| | - Gary Minto
- Department of Anaesthesia, Derriford Hospital, Plymouth,
UK
| | - Gordon Taylor
- Department of Medical Statistics, University of Exeter, Exeter,
UK
| | - Paul Erasmus
- Department of Anaesthesia, Derriford Hospital, Plymouth,
UK
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3
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Argillander TE, Heil TC, Melis RJF, van Duijvendijk P, Klaase JM, van Munster BC. Preoperative physical performance as predictor of postoperative outcomes in patients aged 65 and older scheduled for major abdominal cancer surgery: A systematic review. Eur J Surg Oncol 2021; 48:570-581. [PMID: 34629224 DOI: 10.1016/j.ejso.2021.09.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/02/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Abdominal cancer surgery is associated with considerable morbidity in older patients. Assessment of preoperative physical status is therefore essential. The aim of this review was to describe and compare the objective physical tests that are currently used in abdominal cancer surgery in the older patient population with regard to postoperative outcomes. METHODS Medline, Embase, CINAHL and Web of Science were searched until 31 December 2020. Non-interventional cohort studies were eligible if they included patients ≥65 years undergoing abdominal cancer surgery, reported results on objective preoperative physical assessment such as Cardiopulmonary Exercise Testing (CPET), field walk tests or muscle strength, and on postoperative outcomes. RESULTS 23 publications were included (10 CPET, 13 non-CPET including Timed Up & Go, grip strength, 6-minute walking test (6MWT) and incremental shuttle walk test (ISWT)). Meta-analysis was precluded due to heterogeneity between study cohorts, different cut-off points, and inconsistent reporting of outcomes. In CPET studies, ventilatory anaerobic threshold and minute ventilation/carbon dioxide production gradient were associated with adverse outcomes. ISWT and 6MWT predicted outcomes in two studies. Tests addressing muscle strength and function were of limited value. No study compared different physical tests. DISCUSSION CPET has the ability to predict adverse postoperative outcomes, but it is time-consuming and requires expert assessment. ISWT or 6MWT might be a feasible alternative to estimate aerobic capacity. Muscle strength and function tests currently have limited value in risk prediction. Future research should compare the predictive value of different physical instruments with regard to postoperative outcomes in older surgical patients.
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Affiliation(s)
- T E Argillander
- Department of Surgery, Gelre Hospitals, Apeldoorn, the Netherlands; Department of Geriatric Medicine, Gelre Hospitals, Apeldoorn, the Netherlands; University Center for Geriatric Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - T C Heil
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - R J F Melis
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - J M Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - B C van Munster
- University Center for Geriatric Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Steffens D, Ismail H, Denehy L, Beckenkamp PR, Solomon M, Koh C, Bartyn J, Pillinger N. Preoperative Cardiopulmonary Exercise Test Associated with Postoperative Outcomes in Patients Undergoing Cancer Surgery: A Systematic Review and Meta-Analyses. Ann Surg Oncol 2021; 28:7120-7146. [PMID: 34101066 PMCID: PMC8186024 DOI: 10.1245/s10434-021-10251-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/17/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUNDS There is mixed evidence on the value of preoperative cardiorespiratory exercise test (CPET) to predict postoperative outcomes in patients undergoing a cancer surgical procedure. The purpose of this review was to investigate the association between preoperative CPET variables and postoperative complications, length of hospital stay, and quality of life in patients undergoing cancer surgery. METHODS A search was conducted on MEDLINE, Embase, AMED, and Web of science from inception to April 2020. Cohort studies investigating the association between preoperative CPET variables, including peak oxygen uptake (peak VO2), anaerobic threshold (AT), or ventilatory equivalent for carbon dioxide (VE/VCO2), and postoperative outcomes (complications, length of stay, and quality of life) were included. Risk of bias was assessed using the QUIPS tool. A random-effect model meta-analysis was performed whenever possible. RESULTS Fifty-two unique studies, including 10,030 patients were included. Overall, most studies were rated as having low risk of bias. Higher preoperative peak VO2 was associated with absence of postoperative complications (mean difference [MD]: 2.28; 95% confidence interval [CI]: 1.26-3.29) and no pulmonary complication (MD: 1.47; 95% CI: 0.49-2.45). Preoperative AT and VE/VCO2 also demonstrated some positive trends. None of the included studies reported a negative trend. CONCLUSIONS This systematic review and meta-analysis demonstrated a significant association between superior preoperative CPET values, especially peak VO2, and better postoperative outcomes. The assessment of preoperative functional capacity in patients undergoing cancer surgery has the potential to facilitate treatment decision making.
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Affiliation(s)
- Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia. .,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, Australia.
| | - Hilmy Ismail
- School of Health Sciences, The University of Melbourne, Melbourne, Australia.,Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Linda Denehy
- School of Health Sciences, The University of Melbourne, Melbourne, Australia.,Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Paula R Beckenkamp
- Faculty of Health Sciences, Discipline of Physiotherapy, Musculoskeletal Health, The University of Sydney, Sydney, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, Australia
| | - Jenna Bartyn
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia
| | - Neil Pillinger
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, Australia
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5
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Hubbard TJE, Pringle H, Bethune R, McDermott FD. Survival outcomes of elderly patients referred to the lower gastrointestinal 2-week wait service. Colorectal Dis 2021; 23:1434-1443. [PMID: 33742557 DOI: 10.1111/codi.15620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/25/2021] [Accepted: 02/28/2021] [Indexed: 02/08/2023]
Abstract
AIM The benefit to elderly patients (≥80 years old) of referral to the resource-intensive lower gastrointestinal 2-week wait (LGI-2WW) pathway is unknown. The aim of this study was to investigate the survival outcome of elderly patients referred to a LGI-2WW service. METHOD This study comprised a retrospective analysis of a prospectively gathered database of patients referred to a single-centre LGI-2WW service and conformed to STROBE guidelines. The primary outcome was all-cause mortality. Statistical analysis was performed with the chi-square test and Kaplan-Meier survival curves compared with the generalized log-rank test. RESULTS A total of 10 155 patients referred to the LGI-2WW service between 1 January 2015 and 31 December 2018 were analysed; median follow-up was 37.0 months (range 0-66 months). Six hundred and ninety one cancers were diagnosed (6.8% detection rate); 551 (80%) of these were lower GI cancers (LGICas) [517 (75%) colorectal; 34 (5%) anal]. Forty per cent of LGICas were diagnosed via the LGI-2WW service. Patients aged ≥80 years with LGICa were more likely to be treated with palliative intent [age <80 years, 92/360 (26%) vs. age ≥80 years, 105/191 (55%); p < 0.001]. LGICa patients aged <85 years had a survival difference between those treated with curative intent (LGICa-Cur) or palliative intent (LGICa-Pal) (median survival for patients aged 80-84 years: LGICa-Cur 57 months vs. LGICa-Pal 15 months; p < 0.001). Patients aged ≥85 years did not have any survival difference by treatment intent (median survival for patients aged 85-89 years: LGICa-Cur 31 months vs. LGICa-Pal 16 months; p = 0.062; median survival for patients aged ≥90 years: LGICa-Cur 14 months vs. LGICa-Pal 16 months; p = 0.703). CONCLUSION Patients with LGICa aged ≥85 years have similar survival whether treated with curative or palliative intent. This can inform management discussions with patients and LGI-2WW referral pathway prioritization approaches.
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Affiliation(s)
- Thomas J E Hubbard
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.,Colorectal Department, Royal Devon and Exeter Hospital, Exeter, UK
| | - Heather Pringle
- Colorectal Department, Royal Devon and Exeter Hospital, Exeter, UK
| | - Robert Bethune
- Colorectal Department, Royal Devon and Exeter Hospital, Exeter, UK
| | - Frank D McDermott
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.,Colorectal Department, Royal Devon and Exeter Hospital, Exeter, UK
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Stubbs DJ, Grimes LA, Ercole A. Performance of cardiopulmonary exercise testing for the prediction of post-operative complications in non cardiopulmonary surgery: A systematic review. PLoS One 2020; 15:e0226480. [PMID: 32012165 PMCID: PMC6996804 DOI: 10.1371/journal.pone.0226480] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/24/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Cardiopulmonary exercise testing (CPET) is widely used within the United Kingdom for preoperative risk stratification. Despite this, CPET's performance in predicting adverse events has not been systematically evaluated within the framework of classifier performance. METHODS After prospective registration on PROSPERO (CRD42018095508) we systematically identified studies where CPET was used to aid in the prognostication of mortality, cardiorespiratory complications, and unplanned intensive care unit (ICU) admission in individuals undergoing non-cardiopulmonary surgery. For all included studies we extracted or calculated measures of predictive performance whilst identifying and critiquing predictive models encompassing CPET derived variables. RESULTS We identified 36 studies for qualitative review, from 27 of which measures of classifier performance could be calculated. We found studies to be highly heterogeneous in methodology and quality with high potential for bias and confounding. We found seven studies that presented risk prediction models for outcomes of interest. Of these, only four studies outlined a clear process of model development; assessment of discrimination and calibration were performed in only two and only one study undertook internal validation. No scores were externally validated. Systematically identified and calculated measures of test performance for CPET demonstrated mixed performance. Data was most complete for anaerobic threshold (AT) based predictions: calculated sensitivities ranged from 20-100% when used for predicting risk of mortality with high negative predictive values (96-100%). In contrast, positive predictive value (PPV) was poor (2.9-42.1%). PPV appeared to be generally higher for cardiorespiratory complications, with similar sensitivities. Similar patterns were seen for the association of Peak VO2 (sensitivity 85.7-100%, PPV 2.7-5.9%) and VE/VCO2 (Sensitivity 27.8%-100%, PPV 3.4-7.1%) with mortality. CONCLUSIONS In general CPET's 'rule-out' capability appears better than its ability to 'rule-in' complications. Poor PPV may reflect the frequency of complications in studied populations. Our calculated estimates of classifier performance suggest the need for a balanced interpretation of the pros and cons of CPET guided pre-operative risk stratification.
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Affiliation(s)
- Daniel J. Stubbs
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
| | - Lisa A. Grimes
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
| | - Ari Ercole
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, Cambridge, United Kingdom
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7
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Iida H, Shimizu T, Maehira H, Kitamura N, Mori H, Miyake T, Kaida S, Tani M. A pilot study: The association between physical activity level using by accelerometer and postoperative complications after hepatic resection. Exp Ther Med 2018; 16:4893-4899. [PMID: 30542445 DOI: 10.3892/etm.2018.6816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/17/2018] [Indexed: 11/05/2022] Open
Abstract
Recently, accelerometers measuring physical activity level have been available to the public. In the present study, it was examined whether the accelerometer could evaluate postoperative outcomes for 12 patients subjected to hepatic resection from August-November 2016. The association was evaluated between the changing pattern of activity level until the postoperative day (POD) 7 and the occurrence of postoperative complications. The median age of patients was 79 years (range, 58-85). Postoperative complications were identified in 6 patients. The activity level in patients with complications was low from POD 1 and was significantly lower than patients without complications following POD 6. The changing pattern of activity level with all included patients could be divided into the following 3 types: Increase type, bell curve type and flat type. Patients without complications exhibited an accelerated increase of postoperative activity level, categorized as increase type. Bell curve type and flat type demonstrated delay of recovery in postoperative activity levels, and were suggested to be associated with the occurrence of postoperative complications. These findings may provide rationale for larger sample studies to evaluate whether physical activity level measured via accelerometer may be a surrogate marker for postoperative complications.
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Affiliation(s)
- Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Tomoharu Shimizu
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Naomi Kitamura
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Toru Miyake
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Sachiko Kaida
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
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Systematic Review and Meta-analysis of Objective Assessment of Physical Fitness in Patients Undergoing Colorectal Cancer Surgery. Dis Colon Rectum 2018; 61:400-409. [PMID: 29377872 DOI: 10.1097/dcr.0000000000001017] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gas exchange-derived variables obtained from cardiopulmonary exercise testing allow objective assessment of functional capacity and hence physiological reserve to withstand the stressors of major surgery. Field walk tests provide an alternate means for objective assessment of functional capacity that may be cheaper and have greater acceptability, in particular, in elderly patients. OBJECTIVE This systematic review evaluated the predictive value of cardiopulmonary exercise testing and field walk tests in surgical outcomes after colorectal surgery. DATA SOURCE A systematic search was undertaken using Medline, PubMed, Embase, CINAHL, and PEDro. STUDY SELECTION Adult patients who had cardiopulmonary exercise testing and/or field walk test before colorectal surgery were included. MAIN OUTCOME MEASURE The primary outcomes measured were hospital length of stay and postoperative morbidity and mortality. RESULTS A total of 7 studies with a cohort of 1418 patients who underwent colorectal surgery were identified for inclusion in a qualitative analysis. Both pooled oxygen consumption at anaerobic threshold (range, 10.1-11.1 mL·kg·min) and peak oxygen consumption (range, 16.7-18.6 mL·kg·min) were predictive of complications (OR for anaerobic threshold, 0.76; 95% CI, 0.66-0.85, p<0.0001; OR for peak oxygen consumption, 0.76; 95% CI, 0.67-0.85, p<0.0001). Patients had significant increased risk of developing postoperative complications if their anaerobic threshold was below this cut point (p<0.001). However, it was not predictive of anastomotic leak (p = 0.644). Shorter distance (<250 m) walked in incremental shuttle walk test, lower anaerobic threshold, and lower peak oxygen consumption were associated with prolonged hospital length of stay, which was closely related to the development of complications. CONCLUSIONS Variables derived from cardiopulmonary exercise testing are predictive of postoperative complications and hospital length of stay. Currently, there are insufficient data to support the predictive role of the field walk test in colorectal surgery.
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Sothisrihari SR, Wright C, Hammond T. Should preoperative optimization of colorectal cancer patients supersede the demands of the 62-day pathway? Colorectal Dis 2017; 19:617-620. [PMID: 28493352 DOI: 10.1111/codi.13713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 03/24/2017] [Indexed: 02/08/2023]
Affiliation(s)
| | - C Wright
- Department of Anaesthetics, Broomfield Hospital, Chelmsford, UK
| | - T Hammond
- Department of Colorectal Surgery, Broomfield Hospital, Chelmsford, UK
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Sellars HE, Keogh K, Thakral N, Bethune R. Response to 'Morbidity after laparoscopic and open rectal cancer surgery: a comparative analysis of morbidity in octogenarians and younger patients'. Colorectal Dis 2016; 18:1016. [PMID: 27401193 DOI: 10.1111/codi.13455] [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: 05/13/2016] [Accepted: 05/24/2016] [Indexed: 02/08/2023]
Affiliation(s)
- H E Sellars
- Colorectal Department, Royal Devon and Exeter Hospital, Exeter, UK.
| | - K Keogh
- Colorectal Department, Royal Devon and Exeter Hospital, Exeter, UK
| | - N Thakral
- Colorectal Department, Royal Devon and Exeter Hospital, Exeter, UK
| | - R Bethune
- Colorectal Department, Royal Devon and Exeter Hospital, Exeter, UK
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11
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Smart N. Risk Stratification for the elderly - a pressing issue. Colorectal Dis 2016; 18:437. [PMID: 27138710 DOI: 10.1111/codi.13324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Neil Smart
- Royal Devon & Exeter Hospital, Exeter, UK
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