The impact of complications on prolonged length of hospital stay after resection in colorectal cancer: A retrospective study of Taiwanese patients

Prediction of Length of Stay After Colorectal Surgery Using Intraoperative Risk Factors

Objective

The primary objective of this study was to develop a length of stay (LOS) prediction model.

Background

Predicting the LOS is crucial for patient care, planning, managing expectations, and optimizing hospital resources. Prolonged LOS after colorectal surgery is largely influenced by complications, and an accurate prediction model could significantly benefit patient outcomes and healthcare efficiency.

Methods

This study included patients who underwent colorectal surgery in 14 different hospitals between January 2016 and December 2020. Two distinct random forest models were developed: one solely based on preoperative variables (preoperative prediction model [PP model]) and the other incorporating both preoperative and intraoperative variables (intraoperative prediction model [IP model]). Both models underwent validation using 10-fold cross-validation. The discriminative power of the model was assessed using the area under the curve (AUC), and calibration was evaluated using a calibration curve. The 2 developed models were compared using DeLong test.

Results

A total of 2140 patients were included in the analysis. After internal validation, the PP model achieved an AUC of 0.75 (95% confidence interval [CI]: 0.73-0.77), and the IP model achieved an AUC of 0.84 (95% CI: 0.82-0.85). The difference in discrimination between the 2 models was statistically significant (DeLong test, P < 0.001). Both models exhibited good calibration.

Conclusions

Incorporating intraoperative parameters enhances the accuracy of the predictive model for LOS after colorectal surgery. Improving LOS prediction can assist in managing the increasing number of patients and optimizing the allocation of healthcare resources.

B7-1 and PlGF-1 are two possible new biomarkers to identify fracture-associated trauma patients at higher risk of developing complications: a cohort study

BACKGROUND

Around 10% of fractures lead to complications. With increasing fracture incidences in recent years, this poses a serious burden on the healthcare system, with increasing costs for treatment. In the present study, we aimed to identify potential 'new' blood markers to predict the development of post-surgical complications in trauma patients following a fracture.

METHODS

A total of 292 trauma patients with a complete three-month follow-up were included in this cohort study. Blood samples were obtained from 244 of these patients. Two complication groups were distinguished based on the Clavien-Dindo (CD) classification: CD grade I and CD grade III groups were compared to the controls (CD 0). The Mann-Whitney U test was used to compare the complication groups to the control group.

RESULTS

Analysis of the patients' data revealed that risk factors are dependent on sex. Both, males and females who developed a CD III complication showed elevated blood levels of B7-1 (p = 0.015 and p = 0.018, respectively) and PlGF-1 (p = 0.009 and p = 0.031, respectively), with B7-1 demonstrating greater sensitivity (B7-1: 0.706 (male) and 0.692 (female), PlGF-1: 0.647 (male) and 0.615 (female)). Further analysis of the questionnaires and medical data revealed the importance of additional risk factors. For males (CD 0: 133; CD I: 12; CD III: 18 patients) alcohol consumption was significantly increased for CD I and CD III compared to control with p = 0.009 and p = 0.007, respectively. For females (CD 0: 107; CD I: 10; CD III: 12 patients) a significantly increased average BMI [kg/m2] from 25.5 to 29.7 with CD III was observed, as well as an elevation from one to three comorbidities (p = 0.003).

CONCLUSIONS

These two potential new blood markers hold promise for predicting complication development in trauma patients. Nevertheless, further studies are necessary to evaluate the diagnostic utility of B7-1 and PlGF-1 in predicting complications in trauma patients and consider sex differences before their possible use as routine clinical screening tools.

Social Determinants of Health Impact Complications Following Free-Flap Reconstruction for Head and Neck Cancer

OBJECTIVE

Head and neck cancers (HNCs) have increased in prevalence and often require free-flap reconstruction (FFR) after tumor ablation. Postoperative complications following FFR can be high, occurring in as many as 48% and 71% of cases. HNC patients also have many disparities in Social Determinants of Health (SDOH), but the potential impact of SDOH disparities on postoperative complications following FFR has not been formally assessed.

STUDY DESIGN

Retrospective cohort review.

SETTING

Academic Tertiary Care Institution in Northeast United States.

METHODS

Patients that underwent head and neck FFR between January 2018 and December 2021 were analyzed to determine associations between quartiles of the national Area Deprivation Index (ADI), a proxy for SDOH disparity, and various medical and surgical postoperative complications. Associations were assessed using χ2 analysis.

RESULTS

Two hundred four patients were included in the study, and 61 patients had 97 complications. Significant associations between higher national ADI quartile and incidence of several postoperative complications were identified, including any surgical complication (P = .0419), wound dehiscence (P = .0494), myocardial infarction (MI) (P = .0215), and sepsis (P = .0464).

CONCLUSION

There are significant associations between SDOH disparities and postoperative surgical complications, wound dehiscence, MI, and sepsis following head and neck FFR. Addressing SDOH disparities in HNC is pivotal to enhance postoperative outcomes and promote holistic patient care.

Call for Action to Target Interhospital Variation in Cardiovascular Mortality, Readmissions, and Length-of-Stay: Results of a National Population Analysis

BACKGROUND

Excessive interhospital variation threatens healthcare quality. Data on variation in patient outcomes across the whole cardiovascular spectrum are lacking. We aimed to examine interhospital variability for 28 cardiovascular All Patient Refined-Diagnosis-related Groups (APR-DRGs).

METHODS

We studied 103,299 cardiovascular admissions in 99 (98%) Belgian acute-care hospitals between 2012 and 2018. Using generalized linear mixed models, we estimated hospital-specific and APR-DRG-specific risk-standardized rates for in-hospital mortality, 30-day readmissions, and length-of-stay above the APR-DRG-specific 90th percentile. Interhospital variation was assessed based on estimated variance components and time trends between the 2012-2014 and 2016-2018 periods were examined.

RESULTS

There was strong evidence of interhospital variation, with statistically significant variation across the 3 outcomes for 5 APR-DRGs after accounting for patient and hospital factors: percutaneous cardiovascular procedures with acute myocardial infarction, heart failure, hypertension, angina pectoris, and arrhythmia. Medical diagnoses, with in particular hypertension, heart failure, angina pectoris, and cardiac arrest, showed strongest variability, with hypertension displaying the largest median odds ratio for mortality (2.51). Overall, hospitals performing at the upper-quartile level should achieve improvements to the median level, and an annual 633 deaths, 322 readmissions, and 1578 extended hospital stays could potentially be avoided.

CONCLUSIONS

Analysis of interhospital variation highlights important outcome differences that are not explained by known patient or hospital characteristics. Targeting variation is therefore a promising strategy to improve cardiovascular care. Considering their treatment in multidisciplinary teams, policy makers, and managers should prioritize heart failure, hypertension, cardiac arrest, and angina pectoris improvements by targeting guideline implementation outside the cardiology department.

Operative duration as independent predictor of increased postoperative healthcare utilization

PURPOSE

Few studies have examined the risk factors for postoperative healthcare resource utilization (HRU) among minimally invasive partial nephrectomy (MIPN), minimally invasive prostatectomy (MIP), and cystectomy (Cx). The aim of this study is to assess if operative duration (OD) is a predictor of HRU in this population.

METHODS

The ACS-NSQIP database was filtered for MIPN, MIP, and Cx. Patient characteristics and intraoperative variables were examined. HRU was defined as prolonged length of stay (LOS), unplanned readmission within 30 days, and discharge to continued care facility. Multivariate regression analysis was used to identify independent predictors of HRU.

RESULTS

18,904 MIPN, 50,807 MIP, and 12,451 Cx were included. For MIPN, HRU was seen in 13.9% of cases < 1.75 h, increasing to 36.2% in OD > 4.5 h (p < 0.001). For MIP, HRU was seen in 10.6% of OD < 2 h, increasing to 32.2% for OD > 4.9 h (p < 0.001). For Cx, 57% of those with OD > 8.5 h required HRU compared to 42.1% for OD < 3.3 h (p < 0.001). On multivariate analyses, OD was an independent predictor for increased HRU for all procedures regardless of patient characteristics or comorbidities. For MIPN, OD > 4.5 h had 3.5-fold increased use of HRU (p < 0.001). For MIP, OD > 5 h had 3.7-fold increased use of HRU (p < 0.001). For Cx, OD > 8.5 h demonstrated a twofold increased use of HRU (p < 0.001).

CONCLUSIONS

OD during MIPN, MIP, and Cx is an independent predictor of increased HRU irrespective of patient comorbidities. Patients with OD > 4.5 h for MIPN, > 5 h for MIP, and > 8.5 h for Cx have 3.5-fold, 3.7-fold, and twofold increased risk of HRU, respectively.

Evaluation of Factors That Contribute to Intraoperative and Postoperative Complications Following Colorectal Cancer Surgeries at King Abdulaziz University Hospital, Jeddah, Saudi Arabia

BACKGROUND

Colorectal cancer (CRC) is a major contributor to cancer-related mortality and morbidity due to its high prevalence. Surgery remains the curative option. Colorectal cancer patients come to our institute at an advanced stage due to the lack of adequate national screening programs in developing countries. This carries a particularly high risk of morbidity and mortality. In this study, we aim to provide an overview of the complications of colorectal cancer surgery and to describe the preoperative and intraoperative factors associated with it.

METHODS

This retrospective record review was done at King Abdulaziz University Hospital (KAUH), a tertiary center in Jeddah, Saudi Arabia. It included all patients aged 18 and older who have undergone colorectal cancer surgeries from January 2017 until August 2022.

RESULTS

In our sample of 195 patients, 52.3% of the patients were males. The mean age of our sample was 59.32 ± 13.21. We found that 19 (9.7%) patients had an intraoperative complication (IOC). The most frequent IOC was bleeding reported in seven patients (3.6%), followed by intestinal injury in three (1.2%), bladder injury in three (1.2%), and ureter injury in three (1.2%). Regarding preoperative lab tests, patients who had low blood albumin levels (P = 0.004) and high preoperative white blood cell count (WBC; P = 0.015) were more likely to experience IOC. There was a statistically significant relationship between the patient's ASA score and IOC (P = 0.011). Postoperative complications (POC) occurred in 58 patients (29.7%). The most frequent POC was surgical site infection (SSI; 16.4%), followed by urinary tract infections (UTI) (6.7%) and prolonged postoperative ileus (5.6%). Patients who initially presented with vomiting (P = 0.015), had free air on a preoperative abdominal computed tomography (CT) scan (P = 0.028), required intraoperative blood transfusions (P = 0.033), were diagnosed with transverse colon tumors (P = 0.045), and required longer hospital stays (P = 0.011) were found to have a higher rate of POC.

CONCLUSION

The incidence of colorectal cancer is increasing, and surgery is a successful treatment option. However, complications from surgery may result in morbidities and prolonged hospital stays. The risk of IOC is increased by preoperative variables such as high WBC levels, low albumin, and ASA scores. Patients with initial obstruction signs, free air on CT scans, intraoperative blood transfusions, transverse colon tumors, and longer hospital stays have a higher rate of POC. Patient monitoring and the provision of standardized clinical tools enhance general survival and quality of life.

The effects of curcumin on the biological behavior of colorectal cancer cells through the JAK/STAT3 and RAS/MAPK/NF-κB pathways

The purpose of this work was to investigate the effects of curcumin on the biological behavior of colorectal cancer cells through the JAK/STAT3 and RAS/MAPK/NF-κB pathways. Human colorectal cancer HCT116 cells were cultured and divided into a control group and low, medium and high-dose curcumin groups (n =5). HCT116 colorectal cancer cells became long-growing cells after incubation and culture at 37°C. The control group was treated with 15μL phosphate-buffered saline, and the low-dose, medium-dose and high-dose curcumin groups were treated with 20, 40 and 80μmol/L curcumin, respectively. All groups were treated with rel-evant drug intervention, digested and centrifuged for 48h, washed twice with a PBS solution, centrifuged at 1000 rpm for 3 min, and the cells precipitated. The prolif-eration, apoptosis and growth cycle of cells in each group were observed, and the ex-pressions of the JAK/STAT3 and RAS/MAPK/NF-κB pathways and related proteins in each group were studied. Compared with the curcumin low-dose and medium-dose groups, the proliferation ability of the curcumin high-dose group was significantly decreased (P<0.05). When the low-dose and medium-dose curcumin groups were compared with the high-dose curcumin group, the apoptosis ability was significantly increased (P<0.05). When the low-dose and medium-dose curcumin groups were compared, the growth ratio of the G0/G1 phase in the high-dose curcumin group was significantly increased, and the percentage of the S phase was significantly de-creased (P<0.05). Compared with the curcumin low-dose and medium-dose groups, the expression of JAK-STAT3 and RAS/MAPK/NF-κB pathway in the curcumin high-dose group was significantly decreased (P<0.05). The protein expressions of STAT3, RAS, P-P38 and P65 in the curcumin high-dose group were significantly lower than those in the curcumin low-dose and medium-dose groups (P<0.05). Curcumin can inhibit the expression of JAK/STAT3 and RAS/MAPK/NF-κB pathways, block the growth cycle, and inhibit the proliferation and induce apoptosis of colorectal cancer cells, providing a new idea for the clinical treatment of colorectal cancer.

Significance of information obtained during transanal drainage tube placement after anterior resection of colorectal cancer

Introduction

It has recently been reported that the placement of a transanal drainage tube after rectal cancer surgery reduces the rate of anastomotic leakage. However, transanal drainage tube cannot completely prevent anastomotic leakage and the management of transanal drainage tube needs to devise. We investigated the information obtained during transanal drainage tube placement and evaluated the relationship between these factors and anastomotic leakage.

Patients and methods

Fifty-one patients who underwent anterior resection of rectal cancer was retrospectively reviewed. transanal drainage tube was placed for more than 5 days after surgery. The daily fecal volume from transanal drainage tube was measured on postoperative day 1–5, and the defecation during transanal drainage tube placement was investigated.

Results

Anastomotic leakage during transanal drainage tube placement occurred in 4 patients. The anastomotic leakage rate during transanal drainage tube placement in patients whose maximum daily fecal volume or total fecal volume from the transanal drainage tube during postoperative days 1–5 was large was significantly higher than that in patients whose fecal volume was small. The anastomotic leakage rate of the patients with intentional defecation during transanal drainage tube placement was significantly higher than that of the patients without intentional defecation during transanal drainage tube placement. The maximum daily fecal volume and the total fecal volume from the transanal drainage tube during postoperative days 1–5 in patients who experienced intentional defecation during transanal drainage tube placement was significantly higher than that of patients without intentional defecation during transanal drainage tube placement.

Conclusion

A large fecal volume from transanal drainage tube after anterior rectal resection or intentional defecation in patients with transanal drainage tube placement were suggested to be risk factors for anastomotic leakage.

Transversus abdominis plane block for laparoscopic colorectal surgery: A meta-analysis of randomised controlled trials

BACKGROUND

The effectiveness of transversus abdominis plane block (TAP) on pain management after laparoscopic colorectal surgery (CRS) remains unclear since the only relevant meta-analysis on this topic did not separate laparoscopic CRS from open CRS. The aim of the study was to compare the analgesic efficacy and safety of TAP with non-TAP in patients undergoing laparoscopic CRS.

METHODS

Four databases were searched for randomized controlled trials (RCTs) on this topic using relevant keywords. Two authors independently completed evidence selection, data extraction, and critical appraisal. Available data were pooled in the random-effects model, and point estimates with 95% confidence interval (CI) were reported for postoperative pain at rest and on coughing, opioid consumption, length of hospital stay, and adverse events.

RESULTS

A total of 14 RCTs (n = 1216) contributed to the present synthesis. Pooled result showed that patients in the TAP group had lower pain at rest than those in the non-TAP group at postoperative 2-h (mean difference [MD] = -1.42; P < 0.05), 4-h (MD = -0.97; P < 0.05), 12-h (MD = -0.75; P < 0.05), and 24-h (MD = -0.61; P < 0.05). Patients in the TAP group also had lower postoperative pain on coughing than those in the non-TAP group on the first day (MD = -1.02; P < 0.05). Moreover, TAP had lesser postoperative opioid consumption than non-TAP (standardized mean difference, -0.26; P < 0.05; I-square = 20%), and there were non-significant differences in hospital stay and adverse event between the two groups.

CONCLUSION

Intraoperative TAP is a safe and feasible pain management for laparoscopic CRS, particularly it is recommended when patient-controlled analgesia is not delivered. Therefore, laparoscopic TAP block might be a favorable administered strategy.

Data analytics and artificial intelligence in predicting length of stay, readmission, and mortality: a population-based study of surgical management of colorectal cancer

Data analytics and artificial intelligence (AI) have been used to predict patient outcomes after colorectal cancer surgery. A prospectively maintained colorectal cancer database was used, covering 4336 patients who underwent colorectal cancer surgery between 2003 and 2019. The 47 patient parameters included demographics, peri- and post-operative outcomes, surgical approaches, complications, and mortality. Data analytics were used to compare the importance of each variable and AI prediction models were built for length of stay (LOS), readmission, and mortality. Accuracies of at least 80% have been achieved. The significant predictors of LOS were age, ASA grade, operative time, presence or absence of a stoma, robotic or laparoscopic approach to surgery, and complications. The model with support vector regression (SVR) algorithms predicted the LOS with an accuracy of 83% and mean absolute error (MAE) of 9.69 days. The significant predictors of readmission were age, laparoscopic procedure, stoma performed, preoperative nodal (N) stage, operation time, operation mode, previous surgery type, LOS, and the specific procedure. A BI-LSTM model predicted readmission with 87.5% accuracy, 84% sensitivity, and 90% specificity. The significant predictors of mortality were age, ASA grade, BMI, the formation of a stoma, preoperative TNM staging, neoadjuvant chemotherapy, curative resection, and LOS. Classification predictive modelling predicted three different colorectal cancer mortality measures (overall mortality, and 31- and 91-days mortality) with 80-96% accuracy, 84-93% sensitivity, and 75-100% specificity. A model using all variables performed only slightly better than one that used just the most significant ones.

Preoperative physical activity and functional performance levels are predictors of acute postoperative outcomes in a private South African colorectal cancer cohort

BACKGROUND

For patients with colorectal cancer, surgical resection of the primary tumour remains the best treatment option. Surgery for colorectal cancer is being performed on patients who would previously not have been considered as suitable candidates. It remains to be seen which factors influence hospital length of stay (LOS) and the development of acute postoperative complications in South African patients.

OBJECTIVES

The objectives of our study were to determine the modifiable factors that influence patients' development of postoperative complications and hospital LOS and, to identify the types of postoperative complications that develop.

METHOD

A retrospective review and secondary analysis of information in an existing database of patients with colorectal cancer were conducted. Regression analysis statistics were used to determine the predictors of postoperative outcomes. The level of significance at which testing was performed was set at 5% (p ≤ 0.05).

RESULTS

Data of 125 patients were included. Surgical site infections and postoperative paralytic ileus were the most frequently reported postoperative complications. Preoperative vigorous-intensity physical activity (p = 0.048, β = -0.000) and functional performance status (p = 0.05, β = 0.926) significantly predicted hospital LOS and the incidence of postoperative complications, respectively.

CONCLUSION

Preoperative physical activity and functional performance levels are predictors of acute postoperative outcomes in a private South African cohort of patients with colorectal cancer. Future research which includes other modifiable factors is required to make informed suggestions for changes in clinical practice.

CLINICAL IMPLICATIONS

Patients requiring surgery for colorectal cancer should be screened for signs of physical deconditioning and referred for physiotherapy intervention before elective surgery to optimise their recovery.

A simple prediction score for prolonged length of stay following elective colorectal cancer surgery

BACKGROUND

Current enhanced recovery after surgery (ERAS) protocols are designed for all patients without tailored programmes for at-risk groups. A risk score to determine elective colorectal cancer patients at risk for prolonged length of stay (LOS) would help to identify this group for preoperative intervention.

METHODS

Multivariate analysis of demographic and preoperative variables was performed to identify independent risk factors for prolonged LOS, defined as 7 days or more. A stepwise variable selection approach using logistic regression was then used to build a risk prediction model.

RESULTS

Among 172 patients in our population, 41.9% of patients had prolonged LOS. Five variables were included in our risk prediction model. These were age ≥ 65 years (OR 13.9 5.09-38.0; p < 0.0001), neoadjuvant therapy (OR 7.60 2.51-23.0; p < 0.0001), open approach (OR 3.96 1.68-15.9); p = 0.008), history of smoking (OR 5.18 1.68-15.9; p = 0.004) and white blood cell (WBC) count (OR 0.83/unit 0.69-0.99; p = 0.040). These variables were combined to produce a score, for which the area under the receiving operator curve was 0.82 (95% CI 0.76-0.88), and Hosmer-Lemeshow test showed a χ² statistic of 9.14 and p = 0.519. Using 0.9 as a cut-off, the score has sensitivity of 81.9% and specificity of 65.0%.

CONCLUSION

A simple, clinical score can be used to predict for prolonged LOS based on preoperative variables, allowing for intervention before surgery. Age, neoadjuvant therapy, smoking status, open approach and WBC count are independent risk factors for prolonged length of stay following elective colorectal cancer surgery. A risk score comprising the above independent variables was developed with area under the receiving operator curve of 0.82 (95% CI 0.76-0.88), and a Hosmer-Lemeshow test showing a χ2 statistic of 9.14 and p = 0.519.

The Intersection of Age and Tumor Biology with Postoperative Outcomes in Patients After Cytoreductive Surgery and HIPEC

BACKGROUND

Patient age is a significant factor in preoperative selection for major abdominal surgery. The association of age, tumor biology, and postoperative outcomes in patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains ill-defined.

METHODS

Retrospective analysis was performed for patients who underwent a CCR0/1 CRS/HIPEC from the US HIPEC Collaborative Database (2000-2017). Age was categorized into < 65 or ≥ 65 years. Primary outcome was postoperative major complications. Secondary outcomes were non-home discharge (NHD) and readmission. Analysis was stratified by disease histology: non-invasive (appendiceal LAMN/HAMN), and invasive (appendiceal/colorectal adenocarcinoma).

RESULTS

Of 1090 patients identified, 22% were ≥ 65 (n = 240), 59% were female (n = 646), 25% had non-invasive (n = 276) and 51% had invasive (n = 555) histology. Median PCI was 13 (IQR 7-20). Patients ≥ 65 had a higher rate of major complications (37 vs 26%, p = 0.02), NHD (12 vs 5%, p < 0.01), and readmission (28 vs 22%, p = 0.05), compared to those < 65. For non-invasive histology, age ≥ 65 was not associated with major complications or NHD on multivariable analysis. For invasive histology, when accounting for PCI and CCR, age ≥ 65 was associated with major complications (OR 2.04, 95% CI 1.16-3.59, p = 0.01). When accounting for major complications, age ≥ 65 was associated with NHD (OR 2.54, 95% CI 1.08-5.98, p = 0.03). Age ≥ 65 was not predictive of readmission for any histology when accounting for major complications.

CONCLUSIONS

Age ≥ 65 years is an independent predictor for postoperative major complications and non-home discharge for invasive histology, but not non-invasive histology. These data inform preoperative counseling, risk stratification, and early discharge planning.

Impact of a Dual-Ring Wound Protector on Outcome After Elective Surgery for Colorectal Cancer

BACKGROUND

The impact of dual-ring wound protectors (DRWPs) on the long-term outcomes of patients with colorectal cancer (CRC) undergoing elective surgery remains unclear. The aim of this cohort study was to compare short- and long-term outcomes after CRC resection with or without use of a DRWP.

METHODS

This study enrolled 625 patients with stage I-III CRC undergoing curative resection and divided them into DRWP (n = 348) and control (n = 277) groups. Primary endpoints were postoperative short- and long-term complications. Secondary endpoints were oncological outcomes including wound recurrence, disease-free survival, and overall survival.

RESULTS

Rates of postoperative complications (P = 0.004) and laparotomy wound infection (LWI) (P < 0.001) were markedly lower in the DRWP group. Operation quality, as per the number of lymph nodes harvested and rate of R0 resection, did not differ between the groups (all P > 0.05). The DRWP group exhibited significantly lower rates of incisional hernia occurrence (5.3% versus 9.5%, P = 0.045) compared with the control group. Multivariable analyses demonstrated an increased risk of LWI with no wound protector in colorectal surgery (odds ratio, 3.778; P = 0.001), and patients who developed LWI after surgery were more than 4 times more likely to develop an incisional hernia during outpatient follow-up (odds ratio, 4.333; P = 0.001). One patient in the control group (0.36%) had isolated wound recurrence at 12 mo postoperatively.

CONCLUSIONS

Fewer postoperative and late complications, comparable oncological safety, and similar long-term clinical outcomes confirmed the benefits of DRWP use for patients with CRC undergoing elective surgery. Therefore, the use of DRWP may be considered in curative CRC resection.

Clinical Factors Associated with Longer Hospital Stay Following Ovarian Cancer Surgery

Background: Ovarian cancer (OC) is the leading cause of death from gynecologic malignancy and is treated with a combination of cytoreductive surgery and platinum-based chemotherapy. Extended length of stay (LOS) after surgery can affect patient morbidity, overall costs, and hospital resource utilization. The primary objective of this study was to identify factors contributing to prolonged LOS for women undergoing surgery for ovarian cancer. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify women from 2012-2016 who underwent hysterectomy for ovarian, fallopian tube and peritoneal cancer. The primary outcome was LOS >50th percentile. Preoperative and intraoperative variables were examined to determine which were associated with prolonged LOS. Results: From 2012-2016, 1771 women underwent elective abdominal surgery for OC and were entered in the ACS-NSQIP database. The mean and median LOS was 4.6 and 4.0 days (IQR 0-38), respectively. On multivariate analysis, factors associated with prolonged LOS included: American Society of Anesthesiologists (ASA) Classification III (aOR 1.71, 95% CI 1.38-2.13) or IV (aOR 1.88, 95% CI 1.44-2.46), presence of ascites (aOR 1.88, 95% CI 1.44-2.46), older age (aOR 1.23, 95% CI 1.13-1.35), platelet count >400,000/mm3 (aOR 1.74, 95% CI 1.29-2.35), preoperative blood transfusion (aOR 11.00, 95% CI 1.28-94.77), disseminated cancer (aOR 1.28, 95% CI 1.03-1.60), increased length of operation (121-180 min, aOR 1.47, 95% CI 1.13-1.91; >180 min, aOR 2.78, 95% CI 2.13-3.64), and postoperative blood transfusion within 72 h of incision (aOR 2.04, 95% CI 1.59-2.62) (p < 0.05 for all). Conclusions: Longer length of hospital stay following surgery for OC is associated with many patient, disease, and treatment-related factors. The extent of surgery, as evidenced by perioperative blood transfusion and length of surgical procedure, is a factor that can potentially be modified to shorten LOS, improve patient outcomes, and reduce hospital costs.

Short- and long-term outcomes of laparoscopic-assisted surgery, mini-laparotomy and conventional laparotomy in patients with Stage I-III colorectal cancer

Background:

Three operative techniques have been used for colorectal cancer (CRC) resection: Conventional laparotomy (CL) and the mini-invasive techniques (MITs)– laparoscopic-assisted surgery (LAS) and mini-laparotomy (ML). The aim of the study was to compare the short- and long-term outcomes of patients undergoing the three surgical approaches for Stage I–III CRC resection.

Patients and Methods:

This study enrolled 688 patients with Stage I–III CRC undergoing curative resection. The primary endpoints were perioperative quality and outcomes. The secondary endpoints were oncological outcomes including disease-free survival (DFS), overall survival (OS) and local recurrence (LR).

Results:

Patients undergoing LAS had significantly less blood loss (P < 0.001), earlier first flatus (P = 0.002) and earlier resumption of normal diet (P = 0.025). Although post-operative complication rates were remarkably higher in patients undergoing CL than in those undergoing MITs (P = 0.002), no difference was observed in the post-operative mortality rate (P = 0.099) or 60-day re-intervention rate (P = 0.062). The quality of operation as assessed by the number of lymph nodes harvested and rates of R0 resection did not differ among the groups (all P > 0.05). During a median follow-up of 5.42 years, no significant difference was observed among the treatment groups in the rates of 3-year late morbidity, 3-year LR, 5-year LR, 5-year OS or 5-year DFS (all P > 0.05).

Conclusions:

Patients undergoing CL had higher post-operative morbidities. Moreover, the study findings confirm the favourable short-term and comparable long-term outcomes of LAS and ML for curative CRC resection. Therefore, both MITs may be feasible and safe alternatives to CL for Stage I-III CRC resection.

Mortality, readmission and length of stay have different relationships using hospital-level versus patient-level data: an example of the ecological fallacy affecting hospital performance indicators

BACKGROUND

Ecological fallacy refers to an erroneous inference about individuals on the basis of findings for the group to which those individuals belong. Suppose analysis of a large database shows that hospitals with a high proportion of long length of stay (LOS) patients also have higher than average in-hospital mortality. This may prompt efforts to reduce mortality among patients with long LOS. But patients with long LOS may not be the ones at higher risk of death. It may be that hospitals with higher mortality (regardless of LOS) also have more long LOS patients-either because of quality problems on both counts or because of unaccounted differences in case mix. To provide more insight how the ecological fallacy influences the evaluation of hospital performance indicators, we assessed whether hospital-level associations between in-hospital mortality, readmission and long LOS reflect patient-level associations.

METHODS

Patient admissions from the Dutch National Medical Registration (2007-2012) for specific diseases (stroke, colorectal carcinoma, heart failure, acute myocardial infarction and hip/knee replacements in patients with osteoarthritis) were analysed, as well as all admissions. Logistic regression analysis was used to assess patient-level associations. Pearson correlation coefficients were used to quantify hospital-level associations.

RESULTS

Overall, we observed 2.2% in-hospital mortality, 8.1% readmissions and a mean LOS of 5.9 days among 8 478 884 admissions in 95 hospitals. Of the 10 disease-specific associations tested, 2 were reversed at hospital-level, 3 were consistent and 5 were only significant at either hospital-level or patient-level. A reversed association was found for stroke: patients with long LOS had 58% lower in-hospital mortality (OR 0.42 (95% CI 0.40 to 0.44)), whereas the hospital-level association was reversed (r=0.30, p<0.01). Similar negative patient-level associations were found for each hospital, but LOS varied across hospitals, thereby resulting in a positive hospital-level association. A similar effect was found for long LOS and readmission in patients with heart failure.

CONCLUSIONS

Hospital-level associations did not reflect the same patient-level associations in 7 of 10 associations, and were even reversed in 2 associations. Ecological fallacy thus potentially influences interpretation of hospital performance when patient-level associations are not taken into account.