Age-adjusted charlson comorbidity index score as predictor of prolonged postoperative ileus in patients with colorectal cancer who underwent surgical resection

Factors associated with gastrointestinal dysmotility in critically ill patients

Critical illness may disrupt nutritional, protective, immune, and endocrine functions of the gastrointestinal tract, leading to a state of gastrointestinal dysmotility. We aimed to identify factors associated with the occurrence of gastrointestinal dysmotility in critically ill patients. A cross-sectional retrospective study was conducted, using patient files as a source of data. The study included 185 critically ill patients treated in the intensive care unit of the University Clinical Center, Kragujevac, Serbia, from January 1, 2016, to January 1, 2022. Significant risk factors associated with some form of gastrointestinal dysmotility were acute kidney injury (with paralytic ileus, nausea, vomiting, and constipation), recent abdominal surgery (with ileus, nausea, vomiting, and constipation), mechanical ventilation (with ileus, and nausea), age (with ileus and constipation), and use of certain medication such as opioids (with ileus, gastro-esophageal reflux, nausea, vomiting, and constipation), antidepressants (with ileus, nausea, and vomiting), and antidiabetics (with ileus). On the other hand, Charlson comorbidity index had divergent effects, depending on the form of gastrointestinal dysmotility: it increased the risk of gastro-esophageal reflux but protected against ileus, nausea, and vomiting. In clonclusion, recognition of factors associated with gastrointestinal dysmotility should initiate preventative measures and, thus, accelerate the recovery of critically ill.

Depression and anxiety in cancer patient enrolled in clinical trials with serious adverse events

OBJECTIVE

Drug-induced side effects, particularly serious adverse events (SAEs), often affect cancer patients enrolled in clinical trials. However, little is known about anxiety and depression in cancer patients who experienced SAEs. This study evaluated the prevalence of anxiety and depression in cancer patients enrolled in clinical trials who experienced SAEs and explored the risk factors.

METHODS

A multi-center, cross-sectional survey was conducted in hospitals affiliated with the University of Science and Technology of China from December 2021 to November 2022. A total of 112 cancer patients who experienced SAEs while enrolled in clinical trials, and who completed the informed consent process and study questionnaires, were included in the final analysis.

RESULTS

The rate of moderate-severe depression in cancer patients was 38.4% and that of moderate-severe anxiety was 13.4%. Among the patients who had moderate-severe anxiety, 93.3% had concurrent moderate-severe depression. Lower cognitive function and lower global quality of life were risk factors for depression in cancer patients who experienced SAEs. Pain, low emotional function, low global quality of life, and a high Impact of Events Scale score were risk factors for anxiety.

CONCLUSIONS

Cancer patients enrolled in a clinical trial who experienced SAEs tended to be anxious and depressed, particularly the latter. These results indicate the need to evaluate anxiety and depression, and mental health treatment among cancer patients with SAEs in clinical trials.

Association of high-risk comorbidity with overall survival among patients with gastric cancer and its sex-specific differences in China: a retrospective observational cohort study

BACKGROUND

Concomitant diseases often occur in cancer patients and are important in decision-making regarding treatments. However, information regarding the prognostic relevance of comorbidities for mortality risk is still limited among Chinese gastric cancer (GC) patients. This study aimed to investigate the association between comorbidities and 3-year mortality risk.

METHODS

This retrospective study enrolled 376 GC patients undergoing radical gastrectomy at the Affiliated Zhongshan Hospital of Dalian University from January 2011 to December 2019. Demographic and clinicopathological information and treatment outcomes were collected. Patients were divided into low-, moderate- and high-risk comorbidity groups based on their Charlson Comorbidity Index (CCI) and age-adjusted CCI (ACCI) scores. Kaplan-Meier survival and Cox regression analyses were used to examine 3-year overall survival (OS) and mortality risk for each group.

RESULTS

The median follow-up time was 43.5 months, and 40.2% (151/376) of GC patients had died at the last follow-up. There were significant differences in OS rates between ACCI-based comorbidity groups (76.56; 64.51; 54.55%, log-rank P = 0.011) but not between CCI-based comorbidity groups (log-rank P = 0.16). The high-risk comorbidity group based on the ACCI remained a significant prognostic factor for 3-year OS in multivariate analysis, with an increased mortality risk (hazard ratio [HR], 1.99; 95% CI, 1.15-3.44). Subgroup analysis revealed that this pattern only held for male GC patients but not for female patients.

CONCLUSION

The present study suggested that high-risk comorbidities were significantly associated with a higher mortality risk, particularly in Chinese male GC patients. Moreover, the ACCI score was an independent prognostic factor of long-term mortality.

Predictors of readmission in a medical department of a tertiary university hospital in the Philippines

BACKGROUND

Identifying factors that increase the risk for hospital readmission helps in determining potential targets for quality improvement efforts. The main objective of this study was to examine factors that predict increased risk of hospital readmission within 30 days of hospital discharge of patients under the General Medicine service of a tertiary government hospital in Manila, Philippines.

METHODS

We performed a retrospective cohort study which included service patients 19 years old and above readmitted within 30 days following discharge. A total of 324 hospital readmissions within 30 days of discharge from January 1 to December 31, 2019 were reviewed. We estimated the rate of 30-day readmission and identified factors associated with preventable readmissions using multivariable logistic regression.

RESULTS

Of the 4,010 hospitalizations under General Medicine service in 2019, 602 (18%) were readmissions within 30 days of discharge, majority of which were related to the index admission (90%) and unplanned (68%). Predictors of preventable readmission were emergency readmission (OR 3.37, 95% CI 1.72 to 6.60), having five to ten medications at discharge (OR 1.78, 95% CI 1.10 to 2.87), and presence of nosocomial infection (OR 1.86, 95% CI 1.09 to 3.17). The most frequent reason for readmission among preventable ones is health-care related infection (42.9%).

CONCLUSIONS

We identified factors which increased the likelihood of preventable readmissions such as type of readmission, number of medications per day, and presence of nosocomial infections. We propose that these issues be addressed to improve healthcare delivery and reduce readmission-related expenditures. Further studies should be pursued to identify impactful evidence-based practices.

Risk Factors for Postoperative Paralytic Ileus in Advanced-age Patients after Laparoscopic Colorectal Surgery: A Retrospective Study of 124 Consecutive Patients

Objectives

Postoperative paralytic ileus (POI) is one of the most common and troublesome complications following colorectal surgery. However, to date, the risk factors for POI remain unclear. This study aimed to identify the risk factors for POI following laparoscopic colorectal surgery in advanced-age patients.

Methods

The clinical data of 124 patients aged ≥75 years who underwent curative colorectal surgery from January 2018 to December 2020 were retrospectively reviewed. The relationship between POI and clinicopathological data including sarcopenia and visceral fat obesity was then assessed. Sarcopenia was defined as a low skeletal muscle mass index; visceral obesity, visceral fat with an area ≥100 cm² on computed tomography at the level of the third lumbar vertebra; and sarcobesity, sarcopenia with visceral obesity.

Results

The rate of POI was 9% (12/124 patients), and all the affected patients improved with conservative treatment. In the univariate and multivariate analyses, sarcopenia and sarcobesity were significant predictive factors for POI.

Conclusions

Sarcopenia and sarcobesity may be risk factors for POI in patients aged ≥75 years after laparoscopic colorectal surgery.

The effects of nurse driven mobility intervention (NDMI) on activities of daily living, mobility, fear of falling, and balance performance in hospitalized older patients: A pilot study

A decrease in mobilization during hospitalization leads to a decline in physical function for older patients, and nurses play a critical role in mobility promotion. The purpose of this pilot study was to examine the feasibility of Nurse Driven Mobility Intervention (NDMI) in improving activities of daily living, mobility, fear of falling, balance performance, and maladaptive fall risk appraisal using a one-group pretest-posttest design. NDMI incorporates a multidisciplinary care team, early assessment, timely and frequent mobilization, and constant encouragement. A post-intervention interview was also conducted to explore the barriers and facilitators for mobilization during hospitalization. The result shows a significant improvement in balance performance.

Adjuvant chemotherapy and survival outcomes in rectal cancer patients with good response (ypT0-2N0) after neoadjuvant chemoradiotherapy and surgery: A retrospective nationwide analysis

Background

For rectal cancer, it remains unclear how to incorporate tumor response to neoadjuvant chemoradiotherapy (nCRT) when deciding whether to give adjuvant chemotherapy. In this study, we aim to determinate the survival benefit of adjuvant chemotherapy for rectal cancer patients with good response (ypT0-2N0) after nCRT and surgery.

Methods

The study cohort included 720 rectal cancer patients who had good response (ypT0-2N0) after nCRT and surgery, who did or did not receive adjuvant chemotherapy between January 2007 and December 2017, from the Taiwan Cancer Registry and National Health Insurance Research database. The Kaplan-Meier method, log-rank tests, and Cox regression analysis were performed to investigate the effect of adjuvant chemotherapy on 5-year overall survival (OS) and disease-free survival (DFS).

Results

Of 720 patients, 368 (51.1%) received adjuvant chemotherapy and 352 (48.9%) did not. Patients who received adjuvant chemotherapy were more likely to be female, younger (≤ 65), with advanced clinical T (3-4)/N (1-2) classification and ypT2 classification. No significant difference in 5-year OS (p=0.681) or DFS (p=0.942) were observed by receipt of adjuvant chemotherapy or not. Multivariable analysis revealed adjuvant chemotherapy was not associated with better OS (adjusted hazard ratio [aHR], 1.03; 95% Confidence Interval [CI], 0.88-1.21) or DFS (aHR, 1.05; 95% CI, 0.89-1.24). Stratified analysis for OS and DFS found no significant protective effect in the use of adjuvant chemotherapy, even for those with advanced clinical T or N classification.

Conclusion

Adjuvant chemotherapy may be omitted in rectal cancer patients with good response (ypT0-2N0) after nCRT and surgery.

Optimal Lymph Node Yield for Survival Prediction in Rectal Cancer Patients After Neoadjuvant Therapy

Purpose

A lymph node (LN) yield ≥12 is required to for accurate determination of nodal status for colorectal cancer but cannot always be achieved after neoadjuvant therapy. This study aims to determine the difference in LN yield from rectal cancer patients treated with and without neoadjuvant therapy and the effects of specific LN yields on survival.

Patients and Methods

The study cohort included a total of 4344 rectal cancer patients treated between January 2007 and December 2015, 2260 (52.03%) of whom received neoadjuvant therapy. Data were retrieved from the Taiwan nationwide cancer registry database. The minimum acceptable LN yield below 12 was investigated using the maximum area under the ROC curve.

Results

The median LN yield was 12 (8-17) for patients who received neoadjuvant therapy and 17 (13-24) for those who did not. The recommended LN yield ≥12 was achieved in 82.73% of patients without and 57.96% of those with neoadjuvant therapy (p < 0.0001). Patients with LN yield ≥12 had a higher OS probability than did those with LN <12 (OR, 1.33; 95% CI, 1.06-1.66; p = 0.0124). However, the predictive accuracy for survival was greater for LN yield ≥10 (AUC, 0.7767) than cut-offs of 12, 8, or 6, especially in patients with pathologically-negative nodes (AUC, 0.7660).

Conclusion

Neoadjuvant therapy significantly reduces the LN yield in subsequent surgery. A lower yield (LN ≥ 10) may be adequate for nodal evaluation in rectal cancer patients after neoadjuvant therapy.

Impact of obesity on short-term outcomes of laparoscopic colorectal surgery for Japanese patients with colorectal cancer: A multicenter study

INTRODUCTION

The impact of obesity on short-term outcomes after laparoscopic colorectal surgery (LAC) in Asian patients is unclear. The purpose of the present multicenter study was to evaluate the safety and feasibility of LAC in obese Japanese patients.

METHODS

We retrospectively reviewed 1705 patients who underwent LAC between April 2016 and February 2019. Patients were classified according to body mass index (BMI): non-obese (BMI < 25 kg/m² , n = 1335), obese I (BMI 25-29.9 kg/m² , n = 313), and obese II (BMI ≥30 kg/m² , n = 57). Clinical characteristics and surgical outcomes were compared among the three groups.

RESULTS

The proportion of patients with comorbidities (non-obese, 58.1%; obese I, 69.6%; obese II, 75.4%; P < .001) and median operation time (non-obese, 224 minutes; obese I, 235 minutes; obese II, 258 minutes; P = .004) increased significantly as BMI increased. The conversion rate was similar among the groups (P = .715). Infectious complications were significantly high in obese II patients (non-obese, 10.4%; obese I, 8.3%; obese II, 28.1%; P < .001). Multivariate analysis revealed that in obese II patients, BMI was an independent predictive factor of infectious postoperative complications (odds ratio 2.648; 95% confidence interval, 1.421-4.934; P = .002).

CONCLUSION

LAC has an increased risk of postoperative infectious complications in obese II patients, despite improvements in surgical technique. Management of obese II colorectal cancer patients requires meticulous perioperative management.

Men and Those With a History of Smoking Are Associated With the Development of Postoperative Ileus Following Elective Colorectal Cancer Resection at a Private Academic Hospital in Johannesburg, South Africa: A Retrospective Cohort Study

Introduction: A scarcity of local published data on colorectal cancer (CRC) postoperative complications, including postoperative ileus (POI), exists. POI is a temporary gastrointestinal (GI) state of absent or reduced gastric motility shown to increase patient morbidity, prolong length-of-stay (LOS), and intensify the healthcare resource burden. The pathogenesis of POI involves a neurogenic and inflammatory phase plus a pharmacological component. Aim and Objectives: This study aimed to determine centre-specific preoperative risk factors associated with the development of ileus post elective therapeutic CRC resection. The objectives were to determine whether patient demographics; functional status; comorbidities; GI history; pharmacotherapy (including neoadjuvant chemotherapy); and lastly neoadjuvant radiation and chemoradiation were associated with the development of POI. Method: Patients who underwent CRC resection between January 2016 and May 2019 were retrospectively identified from an existing database. Urgent-or non-therapeutic surgeries; surgeries with the complication anastomotic leak or GI obstruction; patients under 18 at the time of surgery or surgeries preceded by preoperative parenteral nutrition were excluded. A comparison was done of the incidence of exposure in the study cohort to investigated variables as potential risk factors for the complication POI. Results: A total of 155 patient cases were included, and 56 (36%) of them developed POI. Univariate comparison of patients who developed POI with demographic characteristics of patients who did not suggested that women were at lower risk to develop POI compared to men (p = 0,013; RR 0,56; 95% CI 0,36-0,89). Functional status suggested that all previous smokers were at a higher risk to develop POI compared to lifetime non-smokers (p = 0,0069; RR 1,78; 95% CI 1,17-2,70). Multivariable comparison of ≤ 5 qualifying parameters showed no significance. Conclusion: The high local incidence of POI in this patient population shows that intervention is required to reduce the POI rate and improve postoperative outcomes. This study suggests that for men and all patients with a history of smoking both, CRC resection preoperative recommendations with the intention to prevent POI should include instructions initiating the activation of preventive strategies like the Enhanced Recovery After Surgery (ERAS) programme. More studies are needed to adequately determine local perioperative risk factors for POI.

The Clinical Impact of the Age-adjusted Charlson Comorbidity Index on Esophageal Cancer Patients Who Receive Curative Treatment

BACKGROUND/AIM

We investigated the impact of the age-adjusted Charlson comorbidity index (ACCI) on esophageal cancer survival and recurrence after curative treatment.

PATIENTS AND METHODS

This study included 122 patients who underwent curative surgery followed by adjuvant chemotherapy for esophageal cancer between 2005 and 2017. The risk factors for the overall survival (OS) and recurrence-free survival (RFS) were identified.

RESULTS

An ACCI of 5 was regarded as the optimal critical point of classification considering the survival rates. The OS rates at 3 and 5 years after surgery were 64.2% and 54.4% in the low-ACCI group, respectively, and 42.3% and 29.2% in high-ACCI group, respectively (p=0.035). The RFS rates at 3 and 5 years after surgery were 50.2% and 43.6% in the low-ACCI group, respectively, and 28.5% and 21.3% in high-ACCI group, respectively (p=0.021). A multivariate analysis demonstrated that ACCI was a significant independent risk factor for both the OS and RFS.

CONCLUSION

ACCI is a risk factor for survival in patients who undergo curative treatment for esophageal cancer. An effective plan for the perioperative care and surgical strategy should be developed according to ACCI.

Factors associated with length of stay and death in tube-fed patients: A cross-sectional multicentre study

OBJECTIVES

To analyse the factors associated with length of stay (LOS) and death in nasogastric/nasoenteric tube (NG/NET)-fed patients.

DESIGN

A cross-sectional multicentre study.

METHOD

Data collection took place from October 2017-April 2019, and the sample consisted of 365 participants from seven Brazilian hospitals. Demographic, clinical and therapeutic data were collected from the patients' medical records. Data analysis was performed using bivariate and multivariate tests, considering a significance level of p<.05.

RESULTS

Most patients were male, older adults, with high risk of death and highly dependent on nursing care. The LOS was associated with age, patient care complexity and length of NG/NET use. Death was associated with patient age. In the multivariate analysis, patients highly dependent on nursing care, and intensive and semi-intensive care had a greater chance of dying when compared with patients receiving minimal care. Screening for factors affecting LOS and death is important to plan effective nursing care.

Risk Factors for Prolonged Postoperative Ileus in Colorectal Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Prolonged postoperative ileus (PPOI) represents a frequent complication following colorectal surgery, affecting approximately 10-15% of these patients. The objective of this study was to evaluate the perioperative risk factors for PPOI development in colorectal surgery.

METHODS

The present systematic review and meta-analysis was conducted in accordance with the PRISMA Statement. PubMed, EMBASE, SciELO, and LILACS databases were searched, without language or time restrictions, from inception until December 2018. The keywords used were: Ileus, colon, colorectal, sigmoid, rectal, postoperative, postoperatory, surgery, risk, factors. The Newcastle-Ottawa scale and the Jadad scale were used for bias assessment, while the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used for quality assessment of evidence on outcome levels.

RESULTS

Of the 64 studies included, 42 were evaluated in the meta-analysis, comprising 29,736 patients (51.84% males; mean age 62 years), of whom 2844 (9.56%) developed PPOI. Significant risk factors for PPOI development were: male sex (OR 1.43; 95% CI 1.25-1.63), age (MD 3.17; 95% CI 1.63-4.71), cardiac comorbidities (OR 1.54; 95% CI 1.19-2.00), previous abdominal surgery (OR 1.44; 95% CI 1.19, 1.75), laparotomy (OR 2.47; 95% CI 1.77-3.44), and ostomy creation (OR 1.44; 95% CI 1.04-1.98). Included studies evidenced a moderate heterogeneity. The quality of evidence was regarded as very low-moderate according to the GRADE approach.

CONCLUSIONS

Multiple factors, including demographic characteristics, past medical history, and surgical approach, may increase the risk of developing PPOI in colorectal surgery patients. The awareness of these will allow a more accurate assessment of PPOI risk in order to take measures to decrease its impact on this population.

The association between preoperative fatigue and instrumental activities in daily living with complications and length of hospital stay in patients undergoing colorectal surgery

BACKGROUND

The incidence of colorectal cancer (CRC) is highest among the elderly. An important treatment modality is surgery. After surgery, due to poor functional recovery, some elderly have an increased risk for complications and prolonged length of hospital stay (LOS). Preoperative elevated levels of fatigue and impaired functioning in instrumental activities of daily living (iADL) might be associated with these outcomes, and may, therefore, be helpful to recognize patients with elevated risk for complications or prolonged LOS, who should undergo more thorough functional assessment.

AIMS

This exploratory study aims to assess whether physical fatigue, reduced activity and/or iADL, assessed preoperatively, are associated with postoperative complications and prolonged LOS, in elderly patients undergoing surgery for CRC.

METHODS

We performed an exploratory prospective study in older (≥ 65 years) patients (n = 57) who were scheduled to undergo elective surgery for colorectal cancer. Fatigue and iADL functioning were assessed with questionnaires. Multivariable regression analyses were used to examine the relationship of fatigue and iADL with complications and LOS.

RESULTS

IADL was not associated with complications or LOS. Fatigue was not associated with complications. Patients with higher fatigue had increased LOS in the univariable analyses but not in the multivariable analyses after adjustment for nutritional status and neoadjuvant treatment.

DISCUSSION

We found that fatigue was associated with increased LOS in the univariable analysis. The results from the multivariable analysis and path analysis indicate, however, that this is likely not a causal relationship; the observed relationship between physical fatigue and LOS appears to be confounded by nutritional status and by having received neoadjuvant treatment.

CONCLUSIONS

Although fatigue is a predictor for increased LOS, assessment of fatigue and iADL has no additional value for identifying elderly at risk for poor functional outcome after CRC surgery.

A systematic review and meta-analysis of baseline risk factors for the development of postoperative ileus in patients undergoing gastrointestinal surgery

INTRODUCTION

Postoperative ileus occurs frequently following abdominal surgery. Identification of groups at high risk of developing ileus before surgery may allow targeted interventions. This review aimed to identify baseline risk factors for ileus.

METHODS

A systematic review was conducted with reference to PRISMA and MOOSE guidelines. It was registered on PROSPERO (CRD42017068697). Searches of MEDLINE, EMBASE and CENTRAL were undertaken. Studies reporting baseline risk factors for the development of postoperative ileus based on cohort or trial data and published in English were eligible for inclusion. Dual screening of abstracts and full texts was undertaken. Independent dual extraction was performed. Bias assessment was undertaken using the quality in prognostic studies tool. Meta-analysis using a random effects model was undertaken where two or more studies assessed the same variable.

FINDINGS

Searches identified 2,430 papers, of which 28 were included in qualitative analysis and 12 in quantitative analysis. Definitions and incidence of ileus varied between studies. No consistent significant effect was found for association between prior abdominal surgery, age, body mass index, medical comorbidities or smoking status. Male sex was associated with ileus on meta-analysis (odds ratio 1.12, 95% confidence interval 1.02-1.23), although this may reflect unmeasured factors. The literature shows inconsistent effects of baseline factors on the development of postoperative ileus. A large cohort study using consistent definitions of ileus and factors should be undertaken.

Cementless versus Cemented Fixation in Total Knee Arthroplasty: Usage, Costs, and Complications during the Inpatient Period

Cemented fixation has been the gold standard in total knee arthroplasty (TKA). However, with younger and more active patients requiring TKA, cementless (press-fit) fixation has sparked renewed interest. Therefore, we investigated differences in (1) patient demographics, (2) inpatient costs, (3) short-term complications, and (4) discharge disposition between patients who underwent TKA with cemented and cementless fixation. The National Inpatient Sample database was queried for TKA patients with cement or cementless fixation between October 1 and December 31, 2015. Primary outcomes of interest included complications, length of stay (LOS), discharge disposition, and inpatient costs. Student's t-test and chi-square analysis were used to assess continuous and categorical data, respectively. Multivariable analysis evaluated the effects of fixation type on the continuous and categorical dependent variables. Patients who received cementless fixation were more often younger (63.5 vs. 65.9 years), male (47.4 vs. 40.3%), Black (10.7 vs. 7.7%), from the Northeast census region (29.1 vs. 17.1%), and under private insurance (49.2 vs. 40.3%; p < 0.001 for all). Cementless fixation involved higher inpatient hospital costs (US$17,357 vs. US$16,888) and charges (US$67,366 vs. US$64,190; p < 0.001 for both), lower mean LOS (2.63 vs. 2.71 days; p < 0.001), and higher odds of being discharged to home (odds ratio = 1.99; p = 0.002). This study revisited the outcomes of TKA with cementless fixation and demonstrated higher inpatient charges and costs, shorter mean LOS, and higher odds of being discharged home. Future studies should investigate patient outcomes and complications past the inpatient period, evaluate long-term survivorship and failure rates, and implement a prospective study design.

Impact of the Age-adjusted Charlson comorbidity index on the short- and long-term outcomes of patients undergoing curative gastrectomy for gastric cancer

Background: The aim of this study was to determine whether or not the short- and long-term outcomes were affected by the age-adjusted Charlson comorbidity index (ACCI) in patients who underwent curative resection for gastric cancer.

Methods: The patients were retrospectively selected from among the medical records of consecutive patients who underwent curative gastrectomy with nodal dissection for gastric cancer at Yokohama City University and Kanagawa Cancer Center from January 2000 to August 2015.

Results: A total of 2254 patients were eligible for inclusion in the present study. One thousand six hundred fifty-six patients had an ACCI of <6 points (ACCI low group), while 598 had a score of ≥6 points (ACCI high group). The median age (p<0.001) and American Society of Anesthesiologists physical status (ASA-PS) score (p<0.001) of the ACCI high group were higher in comparison to the ACCI low group. The incidence of surgical complications in the ACCI high group was significantly higher than that in the ACCI low group (12.0% vs. 7.2%, p<0.001). Univariate and multivariate analyses demonstrated that an ACCI high classification was a significant risk factor for postoperative complications. In addition, the 5-year OS rates of the ACCI low and ACCI high groups were 85.4% and 74.1%, respectively. The difference was statistically significant (p<0.001). The univariate and multivariate analyses demonstrated that an ACCI high classification was a significant prognostic factor for OS.

Conclusions: Our results support that a high ACCI value is an independent risk factor for the short- and long-term outcomes of patients with gastric cancer. To improve the survival of patients with gastric cancer, it is necessary to carefully plan the perioperative care and the surgical strategy according to the ACCI.

Prevalence, Reasons, and Predisposing Factors Associated with 30-day Hospital Readmissions in Poland

There is a growing interest in quality issues associated with hospital care, with readmissions (rehospitalizations) being one of the main areas of interest. Retrospective data from a 914-bed university hospital in Bydgoszcz, Poland, was used to identify 30-day readmissions in 2015. We developed a catalogue of reasons for rehospitalization and differentiated between planned and unplanned readmissions, as well as those related and unrelated to index (initial) hospitalization. Multilevel logistic regression was used to determine factors associated with readmission risk. A total of 12.5% of patients were readmitted within 30 days of being discharged. The highest readmission rates were identified in pediatric, transplantation, and urology patients. The highest share of readmissions was due to the specific nature of a disease and its routine treatment practice. Almost two-thirds of readmission cases were classified as unplanned and related to the index hospitalization. The following characteristics were associated with a higher risk of rehospitalization: female gender, residing >35 km from the hospital, longer than average and very short stays at index admission, higher comorbidity score, and admission to a high-volume hospital sector. Due to the importance of quality issues in health policy, the topic should be further pursued to identify evidence-based practices that would improve hospitals’ performance.

Cost of benign versus oncologic colon resection among fee-for-service Medicare enrollees

BACKGROUND AND OBJECTIVES

Reimbursement for colonic pathology by the Centers for Medicare and Medicaid Services (CMS) are grouped in the Medicare Severity-Diagnosis Related Groups (MS-DRG). With limited available data, we sought to compare the relative impact of malignant vs benign colonic pathology on reimbursement under the MS-DRG system.

METHODS

We used 5% national Medicare data from 2011 to 2014. Patients were classified as having benign disease or malignancy. Descriptive statistics and multivariate regression analysis were used to evaluate the surgical approach and health resource utilization.

RESULTS

Of 10 928 patients, most were Non-Hispanic White women. The majority underwent open colectomy in both cohorts (P < .001). Colectomy for benign disease was associated with higher total charges (P < .001) and a longer length of stay (P = .0002). Despite higher charges, payments were not significantly different between the cohorts (P = .434). Both inpatient mortality and discharge to a rehab facility were higher in the oncologic group (P < .001).

CONCLUSION

Payment methodology for colectomy under the CMS MS-DRG system does not appear to accurately reflect the episode cost of care. The data suggest that inpatient costs are not fully compensated. A transition to value-based payments with expanded episode duration will require a better understanding of unique costs before adoption.

Treatment of Rectal Cancer in Older Adults

PURPOSE OF REVIEW

Rectal cancer is predominantly a disease of older adults but current guidelines do not incorporate the associated specific challenges leading to wide variation in the delivery of cancer care to this subset of population. Here, we will review the current data available regarding the management of rectal cancer in older adults.

RECENT FINDINGS

The greatest challenge arises in the management of stage II/III disease as it involves tri-modality treatment that can be harder to tolerate by frail older patients. Response to neoadjuvant treatment is being used as a new marker to tailor further therapy and possibly avoid surgery. Oxaliplatin can be omitted from the adjuvant treatment without compromising outcomes. Physicians should perform geriatric assessment utilizing many validated tools available to help predict treatment tolerability and outcomes in older adults that can help personalize subsequent management. Most older adults can undergo standard therapy for stages I, II, or III rectal cancer with curative intent. Increasing evidence suggests that patients with a clinical complete response to neoadjuvant treatment may be observed closely with the possibility of avoiding surgery. Studies are evaluating alternate systemic treatments for advanced metastatic disease with the hope of maintaining quality of life without compromising cancer outcomes.

Incidence and predictors of prolonged postoperative ileus after colorectal surgery in the context of an enhanced recovery pathway

BACKGROUND

Prolonged postoperative ileus (PPOI) is common after colorectal surgery but has not been widely studied in the context of enhanced recovery pathways (ERPs) that include interventions aimed to accelerate gastrointestinal recovery. The aim of this study is to estimate the incidence and predictors of PPOI in the context of an ERP for colorectal surgery.

METHODS

We analyzed data from an institutional colorectal surgery ERP registry. Incidence of PPOI was estimated according to a definition adapted from Vather (intolerance of solid food and absence of flatus or bowel movement for ≥ 4 days) and compared to other definitions in the literature. Potential risk factors for PPOI were identified from previous studies, and their predictive ability was evaluated using Bayesian model averaging (BMA). Results are presented as posterior effect probability (PEP). Evidence of association was categorized as: no evidence (PEP < 50%), weak evidence (50-75%), positive evidence (75-95%), strong evidence (95-99%), and very strong evidence (> 99%).

RESULTS

There were 323 patients analyzed (mean age 63.5 years, 51% males, 74% laparoscopic, 33% rectal resection). The incidence of PPOI was 19% according to the primary definition, but varied between 11 and 59% when using other definitions. On BMA analysis, intraoperative blood loss (PEP 99%; very strong evidence), administration of any intravenous opioids in the first 48 h (PEP 94%; strong evidence), postoperative epidural analgesia (PEP 56%; weak evidence), and non-compliance with intra-operative fluid management protocols (3 ml/kg/h for laparoscopic and 5 ml/kg/h for open; PEP 55%, weak evidence) were predictors of PPOI.

CONCLUSIONS

The incidence of PPOI after colorectal surgery is high even within an established ERP and varied considerably by diagnostic criteria, highlighting the need for a consensus definition. The use of intravenous opioids is a modifiable strong predictor of PPOI within an ERP, while the role of epidural analgesia and intraoperative fluid management should be further evaluated.

Temporal order of cancers and mental disorders in an adult population

BACKGROUND

Population-based examination of comorbidity is an emerging field of study.

AIMS

The purpose of the present population level study is to expand our understanding of how cancer and mental illness are temporally associated.

METHOD

A sample of 83 648 056 physician billing records for 664 838 (56% female) unique individuals over the age of 18 was stratified on ages 19-49 years and 50+ years, with temporal order of mental disorder and cancer forming the basis of comparison.

RESULTS

Mental disorders preceded cancers for both genders within each age strata. The full range of cancers and mental disorders preceding or following each pivot ICD class are described in terms of frequency of diagnosis and duration in days, with specific examples illustrated.

CONCLUSIONS

The temporal comorbidity between specific cancers and mental disorders may be useful in screening or clinical planning and may represent indicators of disease mechanism that warrant further screening or investigation.

DECLARATION OF INTEREST

None.

Preoperative evaluation of the elderly surgical patient and anesthesia challenges in the XXI century

Universally recognized goals of preoperative anesthesia assessment are the evaluation of patient's health status to define the entity of the surgical risk, and the anticipation of possible complications while optimizing and planning preventive strategies. Data obtained by Comprehensive Geriatric Assessment (CGA) and frailty evaluation are of extreme usefulness in surgical risk evaluation in older patients and in the decision about surgery. It is from the team-based discussion of such results that the most appropriate treatment can be individuated, surgery invasiveness and duration critically analyzed and if needed modified, and the best perioperative strategy carefully tailored. These data should thus be used as reference points not only in preoperative assessment but also in planning the perioperative course, from pre-habilitation to adequate intraoperative management to complications prevention and care continuity after discharge. It is from such a far-seeing approach that issues emerged from preoperative evaluation can really contribute to decision-making about surgery in the elderly.

A retrospective analysis on the relationship between intraoperative hypothermia and postoperative ileus after laparoscopic colorectal surgery

Postoperative ileus (POI) is an important factor prolonging the length of hospital stay following colorectal surgery. We retrospectively explored whether there is a clinically relevant association between intraoperative hypothermia and POI in patients who underwent laparoscopic colorectal surgery for malignancy within the setting of an enhanced recovery after surgery (ERAS) program between April 2016 and January 2017 at our institution. In total, 637 patients were analyzed, of whom 122 (19.2%) developed clinically and radiologically diagnosed POI. Overall, 530 (83.2%) patients experienced intraoperative hypothermia. Although the mean lowest core temperature was lower in patients with POI than those without POI (35.3 ± 0.5°C vs. 35.5 ± 0.5°C, P = 0.004), the independence of intraoperative hypothermia was not confirmed based on multivariate logistic regression analysis. In addition to three variables (high age-adjusted Charlson comorbidity index score, long duration of surgery, high maximum pain score during the first 3 days postoperatively), cumulative dose of rescue opioids used during the first 3 days postoperatively was identified as an independent risk factor of POI (odds ratio = 1.027 for each 1-morphine equivalent [mg] increase, 95% confidence interval = 1.014–1.040, P <0.001). Patients with hypothermia showed significant delays in both progression to a soft diet and discharge from hospital. In conclusion, intraoperative hypothermia was not independently associated with POI within an ERAS pathway, in which items other than thermal measures might offset its negative impact on POI. However, as it was associated with delayed discharge from the hospital, intraoperative maintenance of normothermia is still needed.

CHA2DS2-VASc score as predictor of ischemic stroke in patients undergoing coronary artery bypass grafting and percutaneous coronary intervention

Ischemic stroke following coronary revascularization procedures remains one of the most potentially devastating complications. CHA₂DS₂-VASc score has been widely used for stroke risk stratification in AF patients. The aim of this nationwide study was to examine the association between the CHA₂DS₂-VASc score and ischemic stroke following coronary revascularization procedures. We identified patients undergoing coronary revascularization procedures, coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), using the electronic Hospitalization Summary Reports. Logistic regression models were applied to evaluate the association of CHA₂DS₂-VASc score with the risk of post-procedural ischemic stroke. We identified 54,714 patients undergoing CABG and 263,063 patients undergoing PCI from 2013 to 2015. The CHA₂DS₂-VASc score had a positive graded association with the risk of post-procedural ischemic stroke in both CABG and PCI (P for trend <0.001). The adjusted risk of post-procedural ischemic stroke increased by an estimated 122.4% (odds ratio [OR], 2.22; 95% confidence interval [CI], 2.11–2.35) and 34.7% (OR, 1.35; 95% CI, 1.31–1.39) for each additional 1 point in the CHA₂DS₂-VASc score in CABG and PCI, respectively. In conclusion, these findings suggested that CHA₂DS₂-VASc score was an independent predictor of the development of post-procedural ischemic stroke in patients undergoing CABG and PCI.