Predictors of major complications after elective abdominal surgery in cancer patients

Impact of Exergames on the Rehabilitation of Cancer Patients Undergoing Major Abdominal Surgery: A Randomized Controlled Trial

BACKGROUND

Exergames can be an appealing strategy that is integrated into post-abdominal surgery rehabilitation.

OBJECTIVE

The aim of this study was to assess the effectiveness of exergame rehabilitation in improving independence in activities of daily living (ADLs) and patient balance after abdominal cancer surgery.

METHODS

A randomized control-group study was carried out in an oncological hospital in Portugal. Seventy postoperative patients were included, and data collection took place between January 2023 and May 2023. The patients were randomly assigned to either an exergame rehabilitation program (n = 35) or a traditional rehabilitation program (n = 35). The assessed outcomes were the Barthel and Berg scales, and data collection occurred at 3 different time points: admission, 48 hours postoperatively, and on the seventh day after surgery.

RESULTS

At the third assessment, a statistically significant difference was observed between the 2 groups for both indicators, ADLs and balance.

CONCLUSIONS

There was an improvement in ADLs and balance in the exergames group. By the seventh day after surgery, the intervention group showed improvement in balance and ADLs compared with the control group.

IMPLICATIONS FOR PRACTICE

The use of exergames can be a solution to the challenges of traditional rehabilitation methods after abdominal surgery for cancer for postoperative patients. This is the first study carried out in this specific population.

The feasibility of an exercise intervention after robotic-assisted radical cystectomy for urinary bladder cancer, prior to the CanMoRe trial

BACKGROUND

Complications after radical cystectomy for urinary bladder cancer are common. Physical activity after surgery is thought to reduce complications. However, patients with urinary bladder cancer have low levels of physical activity, and interventions supporting physical exercise are needed. This study aimed to evaluate the feasibility of a physical exercise intervention in primary health care. One of the aims of the larger clinical trial will be to reduce complications.

METHODS

Patients with urinary bladder cancer and who were scheduled for a robotic-assisted radical cystectomy were recruited from Karolinska University Hospital, between February and May 2019. The patients had to be mobile, understand Swedish, and live in Stockholm. The exercise programme was conducted at one primary health care setting over 12 weeks. The exercise programme included supervised aerobic and strengthening exercises, which were performed twice a week, as well as daily walks. Feasibility was measured with process feasibility, including eligibility criteria, adherence, and acceptability, and scientific feasibility, including the ability of outcomes to indicate change, safety, and progression in the exercise programme.

RESULTS

Ten patients with a median age of 70 years (min 53-max 86) were included. Adherence to all parts of the intervention was not feasible because of patients' postoperative complications, resulting in dropouts. For the patients who took part in the exercise programme, adherence and acceptability for the exercise period were feasible, but the 6-min walk test was not feasible at discharge from the hospital. Physiotherapists in the primary health care setting perceived the process as feasible. Moreover, the ability of outcomes to indicate change and progression in the exercise programme was feasible, meanwhile no adverse events were registered.

CONCLUSIONS

The exercise intervention was feasible for the patients that took part in the exercise programme, with respect to safety and progression through the exercise programme. Furthermore, this study suggests that some improvements needed to be implemented in the process, prior to the upcoming randomised controlled trial.

Novel Textbook Outcomes following emergency laparotomy: Delphi exercise

BACKGROUND

Textbook outcomes are composite outcome measures that reflect the ideal overall experience for patients. There are many of these in the elective surgery literature but no textbook outcomes have been proposed for patients following emergency laparotomy. The aim was to achieve international consensus amongst experts and patients for the best Textbook Outcomes for non-trauma and trauma emergency laparotomy.

METHODS

A modified Delphi exercise was undertaken with three planned rounds to achieve consensus regarding the best Textbook Outcomes based on the category, number and importance (Likert scale of 1-5) of individual outcome measures. There were separate questions for non-trauma and trauma. A patient engagement exercise was undertaken after round 2 to inform the final round.

RESULTS

A total of 337 participants from 53 countries participated in all three rounds of the exercise. The final Textbook Outcomes were divided into 'early' and 'longer-term'. For non-trauma patients the proposed early Textbook Outcome was 'Discharged from hospital without serious postoperative complications (Clavien-Dindo ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation or death). For trauma patients it was 'Discharged from hospital without unexpected transfusion after haemostasis, and no serious postoperative complications (adapted Clavien-Dindo for trauma ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation on or death)'. The longer-term Textbook Outcome for both non-trauma and trauma was 'Achieved the early Textbook Outcome, and restoration of baseline quality of life at 1 year'.

CONCLUSION

Early and longer-term Textbook Outcomes have been agreed by an international consensus of experts for non-trauma and trauma emergency laparotomy. These now require clinical validation with patient data.

Enhancing recovery in older patients undergoing abdominal surgery: Examining the effect of a preoperative preparation program using a quasi-experimental design

Background

Older adult patients often experience delayed postoperative recovery due to a lack of self-efficacy in engaging in physical activities during early rehabilitation. Concurrently, family caregivers play a crucial role in caring for older adults. However, the extent of family involvement in improving self-efficacy and facilitating recovery following major abdominal surgeries in older adults remains largely unexplored.

Objective

This study aimed to examine the effect of a preoperative preparation program on the recovery of older patients undergoing major abdominal surgeries.

Methods

A quasi-experimental study with a two-group, pretest-posttest design was conducted. The participants included 60 older adult patients undergoing abdominal surgeries at Thammasat University Hospital, Thailand, between September 2019 and March 2020. Participants were selected by purposive sampling with the inclusion criteria and were assigned to the experimental (n = 30) or the control (n = 30) groups using matched pair according to the type of operation. The control group received standard care, while the intervention group underwent a two-week preoperative preparation program developed based on self-efficacy theory and family support. Data were collected using validated tools. Recovery was assessed at one week and two weeks after surgery. Descriptive statistics, as well as dependent and independent t-tests, were used for data analysis.

Results

The results revealed that the intervention group had significantly higher mean recovery scores than the control group at one week (M = 56.93, SD = 16.42; M = 44.60, SD = 16.30, t = -2.92, df = 58, p <0.01) and two weeks after surgery (M = 66.64, SD = 8.63; M = 61.68, SD = 7.86, t = -2.33, df = 58, p <0.05) when comparing between the two groups.

Conclusion

The preoperative preparation program effectively enhanced recovery one week and two weeks after surgery. The study findings can be valuable for nurses in implementing the preoperative preparation program to facilitate recovery among older adult patients undergoing abdominal surgeries.

Major open abdominal surgery is associated with increased levels of endothelial damage and interleukin-6

OBJECTIVE

To examine changes in biomarkers of endothelial glycocalyx shedding, endothelial damage, and surgical stress following major open abdominal surgery and the correlation to postoperative morbidity.

INTRODUCTION

Major abdominal surgery is associated with high levels of postoperative morbidity. Two possible reasons are the surgical stress response and the impairment of the glycocalyx and endothelial cells. Further, the degree of these responses may correlate with postoperative morbidity and complications.

METHODS

A secondary data analysis of prospectively collected data from two cohorts of patients undergoing open liver surgery, gastrectomy, esophagectomy, or Whipple procedure (n = 112). Hemodynamics and blood samples were collected at predefined timestamps and analyzed for biomarkers of glycocalyx shedding (Syndecan-1), endothelial activation (sVEGFR1), endothelial damage (sThrombomodulin (sTM)), and surgical stress (IL6).

RESULTS

Major abdominal surgery led to increased levels of IL6 (0 to 85 pg/mL), Syndecan-1 (17.2 to 46.4 ng/mL), and sVEGFR1 (382.8 to 526.5 pg/mL), peaking at the end of the surgery. In contrast, sTM, did not increase during surgery, but increased significantly following surgery (5.9 to 6.9 ng/mL), peaking at 18 h following the end of surgery. Patients characterized with high postoperative morbidity had higher levels of IL6 (132 vs. 78 pg/mL, p = 0.007) and sVEGFR1 (563.1 vs. 509.4 pg/mL, p = 0.045) at the end of the surgery, and of sTM (8.2 vs. 6.4 ng/mL, p = 0.038) 18 h following surgery.

CONCLUSION

Major abdominal surgery leads to significantly increased levels of biomarkers of endothelial glycocalyx shedding, endothelial damage, and surgical stress, with the highest levels seen in patients developing high postoperative morbidity.

Machine Learning for Postoperative Continuous Recovery Scores of Oncology Patients in Perioperative Care with Data from Wearables

Assessing post-operative recovery is a significant component of perioperative care, since this assessment might facilitate detecting complications and determining an appropriate discharge date. However, recovery is difficult to assess and challenging to predict, as no universally accepted definition exists. Current solutions often contain a high level of subjectivity, measure recovery only at one moment in time, and only investigate recovery until the discharge moment. For these reasons, this research aims to create a model that predicts continuous recovery scores in perioperative care in the hospital and at home for objective decision making. This regression model utilized vital signs and activity metrics measured using wearable sensors and the XGBoost algorithm for training. The proposed model described continuous recovery profiles, obtained a high predictive performance, and provided outcomes that are interpretable due to the low number of features in the final model. Moreover, activity features, the circadian rhythm of the heart, and heart rate recovery showed the highest feature importance in the recovery model. Patients could be identified with fast and slow recovery trajectories by comparing patient-specific predicted profiles to the average fast- and slow-recovering populations. This identification may facilitate determining appropriate discharge dates, detecting complications, preventing readmission, and planning physical therapy. Hence, the model can provide an automatic and objective decision support tool.

Pulmonary function and complication prevention: A randomized controlled trial on lung expansion modalities of older adults undergoing upper abdominal surgery

Postoperative pulmonary complications (PPCs) are a major catastrophic consequence of upper abdominal surgery, resulting in morbidity and mortality. Therefore, the study aims to assess the effect of lung expansion modalities (LEMs) on older adults' pulmonary function and the incidence of pulmonary complications. The study randomly allocated 80 older adults (40 cases and 40 controls). Pulmonary function testing revealed a significant improvement in the study group's forced expiratory volume in one second, sixth second, and oxygen saturation on the fifth postoperative day (POD) compared to the first day [55.23%, 38.41%, and 2.87%; P0.001]. The reported PPCs incidence of the intervention group was less than the control group (15% and 30% on the third POD; 15% and 37.5% on the fifth POD). In conclusion, LEMs provide practical enhancement for the postoperative care of older adults by reducing PPCs by restoring measured pulmonary volumes.

Intraoperative crystalloid-colloid infusion ratio associated with the development of early surgical complications after ileal pouch-anal anastomosis in ulcerative colitis: a multicenter long-term follow-up study

BACKGROUND

Intraoperative intravenous fluid administration proves to be associated with surgical patients' postoperative outcomes. Few studies reported the relationship between intraoperative crystalloid-colloid infusion ratio and early surgical complications after ileal pouch-anal anastomosis (IPAA) in ulcerative colitis (UC).

METHODS

Data on patients with underwent IPAA from January 2008 to March 2022 at our three inflammatory bowel disease (IBD) surgery centers were retrospectively collected. Intraoperative anesthetic data were recorded and later evaluated by our team anesthesiologist.

RESULTS

A total of 140 eligible patients with a median follow-up time of 6.0 years [interquartile range (IQR): 2.0-8.0] were enrolled. Among all enrolled patients, 34 (24.3%) developed early surgical complications after IPAA. Greater blood loss and lower crystalloid-colloid infusion ratio were observed in patients with early surgical complications. Crystalloid-colloid infusion ratio < 2 and blood loss ≥ 200 ml had the most significant area under the receiver-operating characteristic curve (AUC) of 0.664 and 0.674 in predicting early surgical complications. Crystalloid-colloid infusion ratio < 2 [odds ratio (OR), 2.571; 95% confidence intervals (CI), 1.067-6.195, p = 0.035] and blood loss ≥ 200 ml (OR, 3.165; 95% CI, 1.288-7.777, p = 0.012) were independent risk factors for the development of early post-IPAA complications.

CONCLUSION

Intraoperative crystalloid-colloid infusion ratio < 2 and blood loss volume over 200 ml during IPAA contribute to the occurrence of early surgical complications. Early attentions and necessary interventions are warranted to avoid these risk factors during the IPAA surgery in order to prevent the development of early surgical complications.

Driving pressure-guided ventilation improves homogeneity in lung gas distribution for gynecological laparoscopy: a randomized controlled trial

To investigate whether driving pressure-guided ventilation could contribute to a more homogeneous distribution in the lung for gynecological laparoscopy. Chinese patients were randomized, after pneumoperitoneum, to receive either positive end expiratory pressure (PEEP) of 5 cm H₂O (control group), or individualized PEEP producing the lowest driving pressure (titration group). Ventilation homogeneity is quantified as the global inhomogeneity (GI) index based on electrical impedance tomography, with a lower index implying more homogeneous ventilation. The perioperative arterial oxygenation index and respiratory system mechanics were also recorded. Blood samples were collected for lung injury biomarkers including interleukin-10, neutrophil elastase, and Clara Cell protein-16. A total of 48 patients were included for analysis. We observed a significant increase in the GI index immediately after tracheal extubation compared to preinduction in the control group (p = 0.040) but not in the titration group (p = 0.279). Furthermore, the GI index was obviously lower in the titration group than in the control group [0.390 (0.066) vs 0.460 (0.074), p = 0.0012]. The oxygenation index and respiratory compliance were significantly higher in the titration group than in the control group. No significant differences in biomarkers or hemodynamics were detected between the two groups. Driving pressure-guided PEEP led to more homogeneous ventilation, as well as improved gas exchange and respiratory compliance for patients undergoing gynecological laparoscopy.Trial Registration: ClinicalTrials.gov NCT04374162; first registration on 05/05/2020.

Iron deficiency screening is a key issue in chronic inflammatory diseases: A call to action

Iron deficiency is frequent in patients with chronic inflammatory conditions (e.g., chronic heart failure, chronic kidney disease, cancers, and bowel inflammatory diseases). Indeed, high concentrations of inflammatory cytokines increase hepcidin concentrations that lead to the sequestration of iron in cells of the reticuloendothelial system (functional iron deficiency). Iron parameters are often assessed only in the context of anemia, but iron deficiency, even without anemia, is present in about half of patients with inflammatory conditions. Iron deficiency worsens underlying chronic diseases and is an independent factor of morbidity and mortality. In daily practice, the most effective biomarkers of iron status are serum ferritin, which reflects iron storage, and transferrin saturation, which reflects the transport of iron. Serum ferritin is increased in an inflammatory context, and there is still no consensus on the threshold to be used in chronic inflammatory conditions. Nevertheless, recent recommendations of international guidelines agreed to define iron deficiency by serum ferritin &lt;100 µg/L and/or transferrin saturation &lt;20%. Iron parameters remain, however, insufficiently assessed in patients with chronic inflammatory conditions. Indeed, clinical symptoms of iron deficiency, such as fatigue, are not specific and often confused with those of the primary disease. Iron repletion, preferably by the intravenous route to bypass tissue sequestration, improves clinical signs and quality of life. Because of the negative impact of iron deficiency on chronic inflammatory diseases and the efficacy of intravenous iron repletion, screening of iron parameters should be part of the routine examination of all patients with chronic inflammatory diseases.

Complications and Their Association with Mortality Following Emergency Gastrointestinal Surgery-an Observational Study

PURPOSE

Emergency gastrointestinal surgery is followed by a high risk of major complications and death. This study aimed to investigate which complications showed the strongest association with death following emergency surgery for gastrointestinal obstruction or perforation.

METHODS

We retrospectively included adults who had undergone emergency gastrointestinal surgery for radiologically verified obstruction or perforation at three Danish hospitals between 2014 and 2015. The exposure variables comprised 16 predefined Clavien-Dindo-graded complications. Cox regression with delayed entry was used to analyze the association of these complications with 90-day mortality. We adjusted for hospital, age, American Society of Anesthesiologists classification, pre-operative Sepsis-2 score, cardiac comorbidity, renal comorbidity, hypertension, active cancer, bowel obstruction or perforation, and the surgical procedure. Subgroup analyses were done for patients with gastrointestinal obstruction or perforation.

RESULTS

Of the 349 included patients, 281 (80.5%) experienced at least one complication. The risk of death was 20.6% (14) for patients with no complications and varied between 21 and 57% for patients with complications. Renal impairment (hazard ratio (HR): 6.8 (95%CI: 3.7-12.4)), arterial thromboembolic events (HR 4.8 (2.3-9.9)), and atrial fibrillation (HR 4.4 (2.8-6.8)) showed the strongest association with 90-day mortality. Atrial fibrillation was the only complication significantly associated with death in patients with gastrointestinal obstruction as well as perforation.

CONCLUSION

This study of patients undergoing emergency gastrointestinal surgery revealed that renal impairment, arterial thromboembolic events, and atrial fibrillation had the strongest association with death. Atrial fibrillation may serve as an in-situ marker of patients needing escalation of care.

The role of postoperative neutrophil-to-lymphocyte ratio as a predictor of postoperative major complications following total gastrectomy for gastric cancer

Purpose

This study was performed to investigate the role of the perioperative neutrophil-to-lymphocyte ratio (NLR) as an early predictor of major postoperative complications after total gastrectomy for gastric cancer.

Methods

This single-center, retrospective study reviewed consecutive patients with gastric cancer who underwent total gastrectomy at a single institution from March 2009 to March 2021. The postoperative complications were graded according to the Clavien-Dindo classification. We analyzed the patient demographics and surgical outcomes according to the grade of postoperative complications in the major complications group (≥grade III) and the no major complications group (<grade III and no complication). Laboratory tests were performed preoperatively and on postoperative days (POD) 2 and 5 to determine the NLR.

Results

Out of 212 patients (mean age, 64.1 years; 152 male [71.7%]), 63 (29.7%) underwent minimally invasive surgery. Twenty-five (11.8%) were in the major complications group and 187 (88.2%) were in the no major complications group. There was a significant difference in the NLR on POD 2 (16.54 vs. 8.83, P = 0.033) between the 2 groups. According to the receiver operating characteristic curve for the NLR on POD 2, the cutoff was calculated to be 9.6. In multivariate analysis, an NLR on POD 2 of ≥9.6 and an American Society of Anesthesiologists physical status classification of ≥III were statistically significant predictors of major postoperative complications.

Conclusion

Determination of the NLR on POD 2 is a simple and useful method for the early prediction of major complications after total gastrectomy for gastric cancer.

Impact on blood loss and transfusion rates following administration of tranexamic acid in major oncological abdominal and pelvic surgery: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Major bleeding and receiving blood products in cancer surgery are associated with increased postoperative complications and worse outcomes. Tranexamic acid (TXA) reduces blood loss and improves outcomes in various surgical specialities. We performed a systematic review and meta-analysis to investigate TXA use on blood loss in elective abdominal and pelvic cancer surgery.

METHODS

A literature search was performed for studies comparing intravenous TXA versus placebo/no TXA in patients undergoing major elective abdominal or pelvic cancer surgery.

RESULTS

Twelve articles met the inclusion criteria, consisting of 723 patients who received TXA and 659 controls. Patients receiving TXA were less likely to receive a red blood cell (RBC) transfusion (p < 0.001, OR 0.4 95% CI [0.25, 0.63]) and experienced less blood loss (p < 0.001, MD -197.8 ml, 95% CI [-275.69, -119.84]). The TXA group experienced a smaller reduction in haemoglobin (p = 0.001, MD -0.45 mmol/L, 95% CI [-0.73, -0.18]). There was no difference in venous thromboembolism (VTE) rates (p = 0.95, OR 0.98, 95% CI [0.46, 2.08]).

CONCLUSIONS

TXA use reduced blood loss and RBC transfusion requirements perioperatively, with no significant increased risk of VTE. However, further studies are required to assess its benefit for cancer surgery in some sub-specialities.

OUP accepted manuscript

Background

Wearable devices have been proposed as a novel method for monitoring patients after surgery to track recovery, identify complications early, and improve surgical safety. Previous studies have used a heterogeneous range of devices, methods, and analyses. This review aimed to examine current methods and wearable devices used for monitoring after abdominal surgery and identify knowledge gaps requiring further investigation.

Methods

A scoping review was conducted given the heterogeneous nature of the evidence. MEDLINE, EMBASE, and Scopus databases were systematically searched. Studies of wearable devices for monitoring of adult patients within 30 days after abdominal surgery were eligible for inclusion.

Results

A total of 78 articles from 65 study cohorts, with 5153 patients were included. Thirty-one different wearable devices were used to measure vital signs, physiological measurements, or physical activity. The duration of postoperative wearable device use ranged from 15 h to 3 months after surgery. Studies mostly focused on physical activity metrics (71.8 per cent). Continuous vital sign measurement and physical activity tracking both showed promise for detecting postoperative complications earlier than usual care, but conclusions were limited by poor device precision, adherence, occurrence of false alarms, data transmission problems, and retrospective data analysis. Devices were generally well accepted by patients, with high levels of acceptance, comfort, and safety.

Conclusion

Wearable technology has not yet realized its potential to improve postoperative monitoring. Further work is needed to overcome technical limitations, improve precision, and reduce false alarms. Prospective assessment of efficacy, using an intention-to-treat approach should be the focus of further studies.

Risk Factors and Patient Outcomes Associated With Immediate Post-operative Anasarca Following Major Abdominal Surgeries: A Prospective Observational Study From 2019 to 2021

Introduction: Anasarca is well-known and refers to generalized edema caused by underlying clinical conditions and unknown risk factors in the patient. However, it is a relatively unexplored postoperative symptom following major abdominal surgeries. It is associated with poor patient outcomes in terms of delayed recovery and associated severe complications. Pedal edema is an early sign of post-operative anasarca, which progresses into an unfavorable clinical condition due to generalized edema followed by multiple organ dysfunction. 

Aim: This study aimed to assess risk factors and complications associated with postoperative anasarca among patients undergoing major abdominal surgery.

Methods and material: The prospective observational study included 241 patients undergoing major abdominal surgeries from July 2019 to February 2021 in a tertiary care health centre in Rajasthan, India. Risk factors like age, nutritional parameters, addictions like smoking, alcohol intake, opium intake, leukocytosis, and Charlson Comorbidity Index were assessed. Postoperative complications were graded by the Clavien-Dindo grading system. Mean, standard deviation, percentages, Pearson’s Chi-square test and Student’s t-test were used to analyze the data. 

Results: The incidence of anasarca was found to be 29.87%. Nutritional risk screening (NRS) 2002 score, albumin, age > 60 years and raised leukocyte counts were found to significantly correlate (p-value <0.05) with the development of anasarca postoperatively. Postoperative complications, according to Clavien-Dindo grading, were 16.67% in grade I (p value=0.002), 13.89% in grade II (p-value =0.199), 1.39% in grade III (p value=0.049), 20.83% in grade IV (p value<0.001), and 41.67% in grade V (p value<0.001).

Conclusion: Higher NRS 2002 score, low albumin levels, age > 60 years and raised leukocyte counts are significantly correlated with the development of postoperative anasarca. Postoperative anasarca is found to be a significant predictor of poor prognosis of patients undergoing major abdominal surgery. 

Perioperative Morbidity and Complications in Patients With an Established Ileostomy Undergoing Major Abdominal Surgery: A Retrospective Study

Background: Recently formed ileostomies may produce an average of 1,200 ml of watery stool per day, while an established ileostomy output varies between 600-800 ml per day. The reported incidence of renal impartment in patients with ileostomy is 8-20%, which could be caused by dehydration (up to 50%) or high output stoma (up to 40%). There is a lack of evidence if an ileostomy could influence perioperative fluid management and/or surgical outcomes. Methods: Subjects aged ≥18 years old with an established ileostomy scheduled to undergo an elective non-ileostomy-related major abdominal surgery under general anesthesia lasting more than 2 h and requiring hospitalization were included in the study. The primary outcome was to assess the incidence of perioperative complications within 30 days after surgery. Results: A total of 552 potential subjects who underwent non-ileostomy-related abdominal surgery were screened, but only 12 were included in the statistical analysis. In our study cohort, 66.7% of the subjects were men and the median age was 56 years old (interquartile range [IQR] 48-59). The median time from the creation of ileostomy to the qualifying surgery was 17.7 months (IQR: 8.3, 32.6). The most prevalent comorbidities in the study group were psychiatric disorders (58.3%), hypertension (50%), and cardiovascular disease (41.7%). The most predominant surgical approach was open (8 [67%]). The median surgical and anesthesia length was 3.4 h (IQR: 2.5, 5.7) and 4 h (IQR: 3, 6.5), respectively. The median post-anesthesia care unit (PACU) stay was 2 h (IQR:0.9, 3.1), while the median length of hospital stay (LOS) was 5.6 days (IQR: 4.1, 10.6). The overall incidence of postoperative complications was 50% (n = 6). Two subjects (16.7%) had a moderate surgical wound infection, and two subjects (16.7%) experienced a mild surgical wound infection. In addition, one subject (7.6%) developed a major postoperative complication with atrial fibrillation in conjunction with moderate hemorrhage. Conclusions: Our findings suggest that the presence of a well-established ileostomy might not represent a relevant risk factor for significant perioperative complications related to fluid management or hospital readmission. However, the presence of peristomal skin complications could trigger a higher incidence of surgical wound infections.

Postoperative aggressive diuresis prevents postoperative tissue edema and complications in patients undergoing distal pancreatectomy

PURPOSE

Intraoperative fluid restriction is reported to be associated with reduced postoperative tissue edema and decreased incidence of postoperative pancreatic fistula (POPF) in pancreatic surgery. However, there is limited information regarding the postoperative approach to prevent postoperative tissue edema and reduce POPF.

METHODS

Patients undergoing distal pancreatectomy from 2013 to 2018 in our institute were retrospectively enrolled (n = 128). The patients were classified into the two groups: an early diuresis group (ED group: patients administered diuretic agents on postoperative day 2 or earlier between 2016 and 2018, n = 69) and a conventional diuresis group (CD group: patients administered diuretic agents on postoperative day 3 or later between 2013 and 2015, n = 59). Postoperative tissue edema assessed by CT imaging and the incidence of clinically relevant POPF (CR-PF; grade B or C) were compared.

RESULTS

Postoperative tissue edema was significantly reduced in the ED group (p < 0.0001). The incidence of CR-PF was lower in the ED group (19% vs. 32%, p = 0.082), especially in patients with postoperative diuresis on POD 1 (12%, p = 0.044).

CONCLUSION

Early and aggressive postoperative diuresis potentially reduced postoperative visceral tissue edema. This postoperative approach to prevent tissue edema may reduce the incidence of CR-PF in pancreatic surgery.

Objectively measured preoperative physical activity is associated with time to functional recovery after hepato-pancreato-biliary cancer surgery: a pilot study

BACKGROUND

Surgical resection is currently the cornerstone of hepato-pancreato-biliary (HPB) cancer treatment. A low preoperative aerobic fitness level has been identified as a modifiable risk factor associated with complications after major abdominal surgery. A person's aerobic fitness is influenced by performing moderate to vigorous physical activity (MVPA). This study aims to determine the activity monitor measured levels of MVPA performed among patients on the waiting list for HPB cancer surgery and their association with postoperative outcomes.

METHODS

A prospective, observational multi-center cohort pilot study was conducted. Patients enlisted for resection surgery on suspicion of HPB (pre)malignancy were enrolled. Performed MVPA was measured by an Actigraph wGT3X-BT. Additionally, aerobic fitness was measured via the Incremental Shuttle Walk Test, and (post)operative variables were collected from the electronic patient files. The association between MVPA and the pre- and postoperative variables was determined by univariate and multivariable (logistic) robust regression.

RESULTS

A total of 38 participants, median age 66.0 (IQR 58.25-74.75) years, were enrolled. The median daily MVPA was 10.7 (IQR 6.9-18.0) min; only 8 participants met the Dutch MVPA guidelines. Participant's age and aerobic fitness were associated with MVPA by multivariable statistical analysis. Time to functional recovery was 8 (IQR 5-12) days and was associated with MVPA and type of surgery (major/minor) in multivariable analysis.

CONCLUSION

Seventy-six percent of patients enlisted for resection of HPB (pre)malignancy performed insufficient MVPA. A higher level of MVPA was associated with a shorter time to functional recovery.

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.

Low- versus High-Chloride Content Intravenous Solutions for Perioperative Patients: A Systematic Review and Meta-Analysis

Background

Studies have shown complications of normal saline infusion because of its high-chloride content. Therefore, in the present study, we aimed to explore whether the use of low- versus high-chloride solutions benefited the unselected and specifically perioperative patients and was associated with different outcomes.

Methods

Studies on the use of low- versus high-chloride content intravenous solutions for perioperative patients, published up to July 15, 2019, were systematically reviewed, and primary and secondary outcomes were quantitatively summarized.

Results

A total of 14 eligible randomized controlled trials with 943 perioperative patients were included. Five studies reported all-cause mortality, and eight studies provided detailed data on renal replacement therapy (RRT). The pooled result suggested no statistically significant difference in the effect of low- versus high-chloride solutions on all-cause mortality (risk ratio (RR) = 1.39; 95%confidence interval (CI) = 0.23–8.26) and RRT (RR = 1.05; 95%CI = 0.63–1.76). The pooled results on acute kidney injury (AKI) and the use of allogenic blood transfusion (P > 0.05) were similar.

Conclusion

Among specific perioperative patients, the use of low- versus high-chloride content intravenous solutions did not reduce the all-cause mortality, risk of severe AKI, or rate of RRT use. Further large randomized clinical trials are needed to confirm or refute this finding.

Challenges of Modeling Outcomes for Surgical Infections: A Word of Caution

Background: We developed a novel analytic tool for colorectal deep organ/space surgical site infections (C-OSI) prediction utilizing both institutional and extra-institutional American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data. Methods: Elective colorectal resections (2006-2014) were included. The primary end point was C-OSI rate. A Bayesian-Probit regression model with multiple imputation (BPMI) via Dirichlet process handled missing data. The baseline model for comparison was a multivariable logistic regression model (generalized linear model; GLM) with indicator parameters for missing data and stepwise variable selection. Out-of-sample performance was evaluated with receiver operating characteristic (ROC) analysis of 10-fold cross-validated samples. Results: Among 2,376 resections, C-OSI rate was 4.6% (n = 108). The BPMI model identified (n = 57; 56% sensitivity) of these patients, when set at a threshold leading to 80% specificity (approximately a 20% false alarm rate). The BPMI model produced an area under the curve (AUC) = 0.78 via 10-fold cross- validation demonstrating high predictive accuracy. In contrast, the traditional GLM approach produced an AUC = 0.71 and a corresponding sensitivity of 0.47 at 80% specificity, both of which were statstically significant differences. In addition, when the model was built utilizing extra-institutional data via inclusion of all (non-Mayo Clinic) patients in ACS-NSQIP, C-OSI prediction was less accurate with AUC = 0.74 and sensitivity of 0.47 (i.e., a 19% relative performance decrease) when applied to patients at our institution. Conclusions: Although the statistical methodology associated with the BPMI model provides advantages over conventional handling of missing data, the tool should be built with data specific to the individual institution to optimize performance.

The value of preoperative spirometry testing for predicting postoperative risk in upper abdominal and thoracic surgery assessed using big-data analysis

Background

Spirometry is used to evaluate postoperative outcomes in thoracic surgery. However, the clinical utility of spirometry for predicting postoperative complications has not been determined. We used big-data analysis to examine the relationship between pulmonary function tests and postoperative complications.

Methods

We retrospectively analysed clinical data from 31,827 patients who underwent spirometry within the 3 months prior to their surgery between January 2000 and December 2014 at a single tertiary referral hospital. The data were extracted in de-identified form via the automated clinical research information system. Surgical procedures included thoracic and upper abdominal surgery.

Results

Multivariable logistic regression analysis showed that type of surgery, older age (>65 years), low albumin and smoking were associated with postoperative infections [95% confidence interval (CI) of the odds ratio (OR) 1.27–1.60 (>65 years); 1.52–1.96 (low albumin); 1.40–1.98 (current smoker)]. Notably, lower forced vital capacity (FVC) was an independent risk factor for postoperative infection, prolonged intensive care unit stay, and in-hospital death, regardless of airflow limitation [OR 95% CI: 1.31–1.69 (FVC 50–80%); 2.02–4.24 (FVC <50%)]. Lower forced expiratory volume in 1 sec (FEV₁) was also an independent risk factor for postoperative infection [OR 95% CI: 1.61–2.26 (FEV₁ 50–80%); 2.27–4.21 (FEV₁ <50%)]. Airflow limitation assessed by FEV₁ was negatively correlated with postoperative infection in multivariable analysis (OR 95% CI: 0.51–0.88).

Conclusions

Lower preoperative FVC could be used to predict postoperative infection and complications in thoracic and upper abdominal surgery regardless of airflow limitation.

Effects of intraoperative positive end-expiratory pressure optimization on respiratory mechanics and the inflammatory response: a randomized controlled trial

Applying lung protective mechanical ventilation (LPV) during general anaesthesia even in patients with non-injured lungs is recommended. However, the effects of an individual PEEP-optimisation on respiratory mechanics, oxygenation and their potential correlation with the inflammatory response and postoperative complications have not been evaluated have not been compared to standard LPV in patients undergoing major abdominal surgery. Thirty-nine patients undergoing open radical cystectomy were enrolled in this study. In the study group (SG) optimal PEEP was determined by a decremental titration procedure and defined as the PEEP value resulting the highest static pulmonary compliance. In the control group (CG) PEEP was set to 6 cmH2O. Primary endpoints were intraoperative respiratory mechanics and gas exchange parameters. Secondary outcomes were perioperative procalcitonin kinetics and postoperative pulmonary complications. Optimal PEEP levels (median = 10, range: 8–14 cmH2O), PaO2/FiO2 (451.24 ± 121.78 mmHg vs. 404.15 ± 115.87 mmHg, P = 0.005) and static pulmonary compliance (52.54 ± 13.59 ml cmH2O-1 vs. 45.22 ± 9.13 ml cmH2O-1, P < 0.0001) were significantly higher, while driving pressure (8.26 ± 1.74 cmH2O vs. 9.73 ± 4.02 cmH2O, P < 0.0001) was significantly lower in the SG as compared to the CG. No significant intergroup differences were found in procalcitonin kinetics (P = 0.076). Composite outcome results indicated a non-significant reduction of postoperative complications in the SG. Intraoperative PEEP-optimization resulted in significant improvement in gas exchange and pulmonary mechanics as compared to standard LPV. Whether these have any effect on short and long term outcomes require further investigations. Trial registration: Clinicaltrials.gov, identifier: NCT02931409.

Epidemiology and outcome of high-surgical-risk patients admitted to an intensive care unit in Brazil

Objective

To define the epidemiological profile and the main determinants of morbidity and mortality in noncardiac high surgical risk patients in Brazil.

Methods

This was a prospective, observational and multicenter study. All noncardiac surgical patients admitted to intensive care units, i.e., those considered high risk, within a 1-month period were evaluated and monitored daily for a maximum of 7 days in the intensive care unit to determine complications. The 28-day postoperative, intensive care unit and hospital mortality rates were evaluated.

Results

Twenty-nine intensive care units participated in the study. Surgeries were performed in 25,500 patients, of whom 904 (3.5%) were high-risk (95% confidence interval - 95%CI 3.3% - 3.8%) and were included in the study. Of the participating patients, 48.3% were from private intensive care units, and 51.7% were from public intensive care units. The length of stay in the intensive care unit was 2.0 (1.0 - 4.0) days, and the length of hospital stay was 9.5 (5.4 - 18.6) days. The complication rate was 29.9% (95%CI 26.4 - 33.7), and the 28-day postoperative mortality rate was 9.6% (95%CI 7.4 - 12.1). The independent risk factors for complications were the Simplified Acute Physiology Score 3 (SAPS 3; odds ratio - OR = 1.02; 95%CI 1.01 - 1.03) and Sequential Organ Failure Assessment Score (SOFA) on admission to the intensive care unit (OR = 1.17; 95%CI 1.09 - 1.25), surgical time (OR = 1.001, 95%CI 1.000 - 1.002) and emergency surgeries (OR = 1.93, 95%CI, 1.10 - 3.38). In addition, there were associations with 28-day mortality (OR = 1.032; 95%CI 1.011 - 1.052), SAPS 3 (OR = 1.041; 95%CI 1.107 - 1.279), SOFA (OR = 1.175, 95%CI 1.069 - 1.292) and emergency surgeries (OR = 2.509; 95%CI 1.040 - 6.051).

Conclusion

Higher prognostic scores, elderly patients, longer surgical times and emergency surgeries were strongly associated with higher 28-day mortality and more complications during the intensive care unit stay.

Trans-arterial chemoembolization + radiofrequency ablation versus surgical resection in hepatocellular carcinoma - A meta-analysis

BACKGROUND

Hepatocellular Carcinoma (HCC) remains the third most common cause of cancer death worldwide, with countries in Asia being affected the most. The mainstay of curative therapy for early HCC is radiofrequency ablation (RFA) or surgery; either surgical resection (SR) or liver transplantation. Latest evidence however suggests that combination of TACE+ RFA may provide outcomes comparable to SR.

AIM

To compare oncologic outcomes and safety profile of TACE + RFA to SR alone in HCC.

MATERIALS AND METHODS

A systematic review was conducted through Pubmed, EMBASE and Cochrane Library for literature published before April 2019. Outcomes measured were disease-free survival(DFS), overall survival(OS) and major complications. DFS was further divided into local tumour progression(LTP), intrahepatic distant recurrence(IDR) and distant metastasis(DM).

RESULTS

Eight retrospective studies and one randomized controlled trial, involving 1892 patients met eligibility criteria and were included. Unadjusted pooled analysis demonstrated no significant difference in 1-year, 3-year and 5-year OS and 1-year DFS between TACE+RFA and SR. SR had superior 3-year DFS (OR 0.78, 95% CI 0.62-0.98, p = 0.03) and 5-year DFS (OR 0.74, 95% CI 0.58-0.95, p = 0.02) compared to TACE+RFA. When analysing only the propensity matched data, the difference in 3-year DFS and 5-year DFS was not significant. TACE+RFA had a higher LTP rate (OR 2.48, 95% CI 1.05-5.86, p = 0.04) compared to SR but IDR and DM rates were not significant.

DISCUSSION AND CONCLUSION

TACE+RFA offer comparable oncologic outcomes in patients with HCC as compared with SR and with added benefit of lower morbidity.