Postoperative complications and mortality in older patients having non-cardiac surgery at three Melbourne teaching hospitals

Ultrasonography guided erector spinae block in spinal surgery for pain management with enhanced recovery: A comparative study

Background

Improved and efficient management of pain can certainly aid enhanced recovery after spinal surgery. Our aim is to evaluate the effect of ESPB in thoracic and lumbar surgeries where we have evaluated VAS for pain, cumulative analgesics consumptions, length of hospital stay and post-operative complications.

Methods

A cross-sectional comparative study done in HAMS among the erector spinae block group and control group. The analysis of different variable was done according to standard statistical analysis. For quantitative data, univariate and multivariate analysis was performed to determine statistically significant differences using student's t-test for continuous variables.

Results

60 patients were analyzed, 30 got spinae block and 30 in control group.The mean pain score for spinae block group were 1.90 ± 0.712 and 3.27 ± 1.230 for control group (p < 0.001). Cumulative mean analgesic consumption values for spinae block vs. control groups were 0.030 ± 0.042 mg vs. 0.091 ± 0.891 mg (p = 0.001) for fentanyl; 1.06E4 ± 2833.300 mg vs. 1.53E4 ± 2848.349 mg (p < 0.001) for paracetamol; 213 ± 64.656 mg vs. 494 ± 58.816 mg (p < 0.001) for ketorol; 5440.00 ± 2060.064 mg vs. 8667.50 ± 2275.006 mg (p < 0.001) for ibuprofen and 121.67 ± 31.303 mg vs. 185.00 ± 51.108 mg (p < 0.001) for tramadol.

Conclusions

The ESPB technique shows early discharge from hospital and lower cumulative analgesics consumption which indicates enhanced recovery after spine surgery than control group. Improvement of pain using VAS shows immediate post-operative period recovery in those who receives spinae block.

The longitudinal impact of division-wide implementation of an enhanced recovery after thoracic surgery programme

OBJECTIVES

Data regarding enhanced recovery after thoracic surgery (ERATS) are sparse and inconsistent. This study aims to evaluate the effects of implementing an enhanced ERATS programme on postoperative outcomes, patient experience and quality of life (QOL).

METHODS

We conducted a prospective, longitudinal study evaluating 9 months before (pre-ERATS) and 9 months after (post-ERATS) a 3-month implementation of an ERATS programme in a single academic tertiary care centre. All patients undergoing major thoracic surgeries were included. The primary outcomes included length of stay (LOS), adverse events (AEs), 6-min walk test scores at 4 weeks, 30-day emergency room visits (without admission) and 30-day readmissions. The process-of-care outcomes included time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and removal of urinary catheter. Perioperative anaesthesia-related outcomes were examined as well as patient experience and QOL scores.

RESULTS

The pre-ERATS group (n = 352 patients) and post-ERATS group (n = 352) demonstrated no differences in demographics. Post-ERATS patients had improved LOS (4.7 vs 6.2 days, P < 0.02), 6-min walk test scores (402 vs 371 m, P < 0.05) and 30-day emergency room visits (13.7% vs 21.6%, P = 0.03) with no differences in AEs and 30-day readmissions. Patients experienced shorter mean time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and urinary catheter removal. There were no differences in postoperative analgesia administration, patient satisfaction and QOL scores.

CONCLUSIONS

ERATS implementation was associated with improved LOS, expedited feeding, ambulation and chest tube removal, without increasing AEs or readmissions, while maintaining a high level of patient satisfaction and QOL.

A critical decision point: Short- and long-term outcomes of older surgical patients admitted to a Queensland intensive care unit

OBJECTIVES

Critical care admission is a pivotal juncture for older patients undergoing surgery. We aimed to identify the in-hospital and postdischarge outcomes of older postsurgical patients (≥65 years) admitted to the intensive care unit (ICU).

METHODS

We collected clinical, morbidity and survival data on all patients aged ≥65 years postsurgically admitted to a tertiary metropolitan ICU between 2014 and 2019.

RESULTS

Within this older cohort (n = 370), the oldest patients (≥85 years) had the highest 1-year mortality (RR: 4.00; P < 0.001). Major surgery (RR: 5.67; P < 0.001), emergency surgery (RR: 2.89; P < 0.001) and APACHE III score ≥50 (RR: 2.63; P < 0.001) were associated with reduced 1-year survival.

CONCLUSION

APACHE III score and surgery subtype are strong predictors of post-ICU mortality and may be useful to preoperatively stratify whether surgery and subsequent ICU admission are in patients' best interests. These data may also inform prospective discussions regarding end-of-life care and advanced care planning.

Thromboelastography in elective total hip arthroplasty

BACKGROUND

Hypercoagulability plays an important role in predisposing patients to venous thromboembolism (VTE) after total hip arthroplasty (THA). We used thromboelastography (TEG) to examine the coagulation status of patients undergoing THA.

AIM

To examine coagulation as measured by TEG in patients undergoing THA who received standard VTE chemoprophylaxis with enoxaparin.

METHODS

After ethical approval, we performed a retrospective analysis of data collected in patients undergoing primary elective THA. We analyzed TEG data on samples performed before skin incision, intraoperatively and for 5 d postoperatively. Conventional coagulation tests were performed preoperatively and on postoperative day 5.

RESULTS

Twenty patients undergoing general anesthesia and 32 patients undergoing spinal anesthesia (SA) were included. TEG demonstrated a progressively hypercoagulable state postoperatively, characterized by elevated maximum amplitude. TEG also demonstrated transient intraoperative hypercoagulability in patients receiving SA. In contrast, conventional coagulation tests were normal in all patients, pre- and postoperatively, except for an increase in plasma fibrinogen day 5 postoperatively.

CONCLUSION

Despite VTE prophylaxis, patients following total hip replacement remain in a hypercoagulable state as measured by both TEG and conventional tests. This group may benefit from more optimal anticoagulation and/or additional perioperative hemostatic monitoring, via TEG or otherwise.

The Impact on 30-Day Mortality From a Brief Focused Ultrasound-Guided Management Protocol Immediately Before Emergency Noncardiac Surgery in Critically Ill Patients: A Multicenter Randomized Controlled Trial

OBJECTIVE

To determine whether brief ultrasound-guided treatment of hemodynamic shock and respiratory failure immediately before emergency noncardiac surgery reduced 30-day mortality.

DESIGN

Parallel, nonblinded, randomized trial with 1:1 allocation to control and intervention groups.

SETTING

Twenty-eight major hospitals within China.

PARTICIPANTS

Six-hundred sixty patients ≥14 years of age, scheduled for emergency noncardiac surgery with evidence of shock (heart rate >120 beat/min, systolic blood pressure< 90 mmHg or requiring inotrope infusion), or respiratory failure (Pulse Oxygen Saturation <92%, respiratory rate >20 beat/min, or requiring mechanical ventilation).

INTERVENTIONS

A brief (<15 minutes) focused ultrasound of ventricular filling and function, lung, and peritoneal spaces, with predefined treatment recommendation based on the ultrasound was performed before surgery or standard care.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was 30-day mortality. Secondary outcomes included changes in medical or surgical diagnosis and management due to ultrasound, intensive care unit, and hospital stay and cost, and Short Form-8 quality-of-life scores. Although there were frequent changes in diagnosis (82%) and management (49%) after the ultrasound, mortality at 30 days was not different between groups (50 [15.7%] v 53 [16.3%]; odds ratio 1.05, 0.69-1.6, p = 0.826). There were no differences in the secondary outcomes of the days spent in the hospital (mean 13.8 days, 95% confidence interval [CI] 12.1-15.6 v 14.4 d, 11.8-17.1, p = 0.718) or intensive care unit (mean 9.3 days, 95% CI 7.7-11.0 v 8.7 d, 7.2-10.2, p = 0.562), hospital cost (USD$14.5K, 12.2-16.7 v 13.7, 11.5-15.9, p = 0.611) or Short Form-8 scores at one year (mean 80.9, 95% CI 78.4-83.3 v 79.7, 76.9-82.5, p = 0.54) between participants allocated to the ultrasound and control groups.

CONCLUSIONS

In critically ill patients with hemodynamic shock or respiratory failure, a focused ultrasound-guided management did not reduce 30-day mortality but led to frequent changes in diagnosis and patient management.

Spinal Surgery in Patients Aged 80 Years and Older: Risk Stratification Using the Modified Frailty Index

STUDY DESIGN

This was an ambispective clinical quality registry study.

OBJECTIVE

To evaluate utility of 11-variable modified Frailty Index (mFI) in predicting postoperative outcomes among patients ≥80 years undergoing spinal surgery.

METHODS

Consecutive patients ≥80 years who underwent spinal surgery between January 1, 2013, and June 30, 2018, were included. Primary outcome measure was rate of major complication. Secondary outcome measures were (1) overall complication rate, (2) surgical site infection, and (3) 6-month mortality.

RESULTS

A total of 121 operations were performed. Demographic metrics were (1) age (mean ± SD) = 83.1 ± 2.8 years and (2) mFI (mean ± SD) = 2.1 ± 1.4 variables. As mFI increased from 0 to ≥4 variables, risk of major complication increased from 18.2% to 40.0% (P = .014); overall complication increased from 45.5% to 70.0% (P = .032); surgical site infection increased from 0.0% to 25.0% (P = .007). There were no significant changes in risk of 6-month mortality across mFIs (P = .115). Multivariate analysis showed that a higher mFI score of ≥3 variables was associated with a significantly higher risk of (1) major complication (P = .025); (2) overall complication (P = .015); (3) surgical site infection (P = .007); and (4) mortality (P = .044).

CONCLUSIONS

mFI scores of ≥3/11 variables were associated with a higher risk of postoperative morbidity in patients aged ≥80 years undergoing spinal surgery. The mFI-associated risk stratification provides a valuable adjunct in surgical decision making for this rapidly growing subpopulation of patients.

Endoscopic Mucosal Resection for Colonic Mucosal Neoplasia and Evaluation of Long-Term Recurrence: A Single-Center Experience of 500 Cases

OBJECTIVES

Endoscopic mucosal resection (EMR) is an alternative to surgery for the treatment of large laterally spreading lesions. Residual or recurrent adenoma is a major limitation. This study aimed to quantify early and late recurrences and to assess its associated risk factors.

METHODS

The study was a single-center, multiendoscopist, longitudinal study conducted between January 1, 2013 and April 26, 2017. A total of 480 patients with 500 polyps who underwent an endoscopic resection were included. Surveillance colonoscopy (SC) was performed at 4 to 6 months (SC1) and 16 to 18 months (SC2).

RESULTS

At SC1, early recurrence was noted in 77 of 354 (21.8%) lesions; 76 (98.7%) were treated endoscopically. The remaining 277 of 354 (78.2%) lesions had no recurrence at SC1; only 41 lesions (15%) were followed up at SC2. Recurrence at SC2 was found in 4 lesions (9.8%), all of which were treated endoscopically. Lesion size >40 mm was associated with recurrence. Recurrence at both SC1 and SC2 was successfully treated endoscopically in 78 of 81 lesions (96.3%).

CONCLUSIONS

EMR is an effective, minimally invasive technique for the treatment of large laterally spreading lesions. Although recurrence is a concern, its risk is low (21.8% on SC1 and 9.8% on SC2) and was managed endoscopically in 96.3% cases on follow-up endoscopy.

Predictors of 30-Day Mortality Among Dutch Patients Undergoing Colorectal Cancer Surgery, 2011-2016

IMPORTANCE

Quality improvement programs for colorectal cancer surgery have been introduced with benchmarking based on quality indicators, such as mortality. Detailed (pre)operative characteristics may offer relevant information for proper case-mix correction.

OBJECTIVE

To investigate the added value of machine learning to predict quality indicators for colorectal cancer surgery and identify previously unrecognized predictors of 30-day mortality based on a large, nationwide colorectal cancer registry that collected extensive data on comorbidities.

DESIGN, SETTING, AND PARTICIPANTS

All patients who underwent resection for primary colorectal cancer registered in the Dutch ColoRectal Audit between January 1, 2011, and December 31, 2016, were included. Multiple machine learning models (multivariable logistic regression, elastic net regression, support vector machine, random forest, and gradient boosting) were made to predict quality indicators. Model performance was compared with conventionally used scores. Risk factors were identified by logistic regression analyses and Shapley additive explanations (ie, SHAP values). Statistical analysis was performed between March 1 and September 30, 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome of this cohort study was 30-day mortality. Prediction models were trained on a training set by performing 5-fold cross-validation, and outcomes were measured by the area under the receiver operating characteristic curve on the test set. Machine learning was further used to identify risk factors, measured by odds ratios and SHAP values.

RESULTS

This cohort study included 62 501 records, most patients were male (35 116 [56.2%]), were aged 61 to 80 years (41 560 [66.5%]), and had an American Society of Anesthesiology score of II (35 679 [57.1%]). A 30-day mortality rate of 2.7% (n = 1693) was found. The area under the curve of the best machine learning model for 30-day mortality (0.82; 95% CI, 0.79-0.85) was significantly higher than the American Society of Anesthesiology score (0.74; 95% CI, 0.71-0.77; P < .001), Charlson Comorbidity Index (0.66; 95% CI, 0.63-0.70; P < .001), and preoperative score to predict postoperative mortality (0.73; 95% CI, 0.70-0.77; P < .001). Hypertension, myocardial infarction, chronic obstructive pulmonary disease, and asthma were comorbidities with a high risk for increased mortality. Machine learning identified specific risk factors for a complicated course, intensive care unit admission, prolonged hospital stay, and readmission. Laparoscopic surgery was associated with a decreased risk for all adverse outcomes.

CONCLUSIONS AND RELEVANCE

This study found that machine learning methods outperformed conventional scores to predict 30-day mortality after colorectal cancer surgery, identified specific patient groups at risk for adverse outcomes, and provided directions to optimize benchmarking in clinical audits.

The risk of postoperative deterioration of non-cardiac surgery patients with ICU referral status who are admitted to the regular ward: a retrospective observational cohort study

Background

Higher-risk surgical patients may not be admitted to the intensive care unit due to stable immediate post-operative status on review. The outcomes of this cohort are not well described. Our aim was to examine the subsequent inpatient course of intensive care unit -referred but not admitted surgical patients.

Methods

All patients aged ≥18 years who were referred but not admitted for post-operative management in a tertiary metropolitan intensive care unit following non-cardiac surgery between 1/7/2017 and 30/6/2018 were eligible for inclusion in this retrospective observational cohort study. Primary outcome was Medical Emergency Team activation. Secondary outcomes included unplanned intensive care unit admission; length of stay; and 30-day mortality. Risk of serious complications and predicted length of stay were calculated using the National Surgical Quality Improvement Program scoring tool.

Results

Fifteen of 60 patients (25%) had a MET-call following surgery, eight (13%) patients required unplanned intensive care unit admission, with median (IQR) time to Medical Emergency Team call 9 (6–13) hours. No patients died within 30-days. There was no significant difference between mean National Surgical Quality Improvement Program predicted and actual length of stay; after adjustment, National Surgical Quality Improvement Program predicted risk of serious complications was associated with unplanned intensive care unit admission (OR [95% CI] = 1.08 [1.00–1.16], p = 0.04), although not Medical Emergency Team calls.

Conclusions

Post-operative deterioration occurs frequently, and early, in a cohort of high-risk surgical patients initially assessed as being safe for ward care. Changes to current triage models for post-operative intensive care unit admission may reduce the impact of complications in this high-risk group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13037-021-00283-9.

The Effect of Organ System Surgery on Intensive Care Unit Mortality in a Cohort of Critically Ill Surgical Patients

BACKGROUND

The critical illness burden in the United States is growing with an aging population obtaining surgical intervention despite age-related comorbidities. The effect of organ system surgical intervention on intensive care units (ICUs) mortality is unknown.

METHODS

We performed an 8-year retrospective analysis of surgical ICU patients. Poisson regression analysis was performed assessing the relative risk of in-hospital mortality based on surgical intervention.

RESULTS

Of 468 000 ICU patients included, 97 968 (20.9%) were surgical admissions and 97 859 (99.9%) had complete outcomes data. Nonsurvivors were older (68.8 ± 15.4 vs. 62.7 ± 15.8 years, P < .001) with higher Acute Physiology, Age, Chronic Health Evaluation (APACHE) III Scores (81.4 ± 33.6 vs. 46.7 ± 20.1, P < .001. Patients with gastrointestinal (GI) (n = 1,558, 7.8%), musculoskeletal (n = 277, 5.5%), and neurological (n = 884, 4.6%) system operations had the highest mortality. Upon Poisson regression model, patients undergoing emergent operative interventions on the neurologic system (RR 1.86, 95% CI 1.67-2.07, P < .001) had increased relative risk of mortality when compared to emergent operative interventions on the cardiovascular system after controlling for pertinent covariates. Elective operative interventions on the respiratory (RR 2.39, 95% CI 2.03-2.80, P < .001), GI (RR 2.34, 95% CI 2.10-2.61, P < .001), and skin and soft tissue (RR 2.26, 95% CI 1.77-2.89, P < .001) systems had increased risk of mortality when compared to elective cardiovascular system surgery after controlling for pertinent covariates.

CONCLUSION

We found significant differences in the risk of mortality based on organ system of operative intervention. The prognostication of critically ill patients undergoing surgical intervention is currently not accounted for in prognostic scoring systems.

Pancreaticoduodenectomy can be indicated for elderly patients: risk prediction using the estimation of physiologic ability and surgical stress (E-PASS) system

BACKGROUND

Pancreaticobiliary malignant diseases are primarily treated by surgical resection. However, the surgical indications for elderly patients, especially for pancreaticoduodenectomy (PD), must be carefully considered due to patient compliance. Whether PD can contribute to better prognoses in elderly patients remains unclear. Therefore, we aimed to evaluate the complications, compliance, and survival of elderly and non-elderly patients who underwent PD in our department.

METHODS

We retrospectively analyzed 282 patients who underwent PD from 2000 to 2017 and divided them into non-elderly (aged ≤ 79 years, n = 238) and elderly (aged ≥ 80 years, n = 44) groups. The estimation of physiologic ability and surgical stress (E-PASS) system was used to evaluate morbidity and mortality using preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS).

RESULTS

Preoperative risk score was higher in the elderly group than in the non-elderly group, although SSS and CRS were similar. No significant differences were detected in the occurrence of postoperative complications. In the elderly group, CRS was higher in patients with complications than in those without. Long-term outcomes evaluated by overall and disease-specific survival were not significantly different.

CONCLUSIONS

In the elderly patients, E-PASS especially CRS can predict the occurrence of complications. The safety and prognoses of elderly patients after PD are comparable with those of non-elderly patients.

Common clinical thresholds of intraoperative hypotension and 30-day mortality following surgery: A retrospective cohort study

BACKGROUND

A wide range of thresholds define intraoperative hypotension and can be used to guide intraoperative blood pressure management. Many clinicians use the systolic blood pressure (SBP) <80 mmHg, the mean arterial pressure (MAP) <60 mmHg and the SBP percent drop from baseline (ΔSBP) >20% as alarming limits that should not be exceeded. Whether these common thresholds are valid limits that can inform clinicians on a possible increased risk of post-operative complications, particularly 30-day mortality, is currently unclear.

METHODS

We performed a retrospective registry-based cohort study between January 2015 and July 2016 using departmental hospital databases and the National Death Registry. Uni- and multivariate analyses were performed to assess the association between each of these three thresholds and 30-day post-operative mortality. Six specific markers of hypotension were used.

RESULTS

Of 11 304 patients, 86 (0.76%) died within 30 days following surgery. All intraoperative hypotension markers for SBP < 80 mmHg and MAP < 60 mmHg were significantly associated with 30-day mortality (P < .005). Markers of ΔSBP > 20% were not significant. After adjustment for age, gender, American Society of Anesthesiologists (ASA) score, emergency status and risk related to the type of surgery, both SBP < 80 mmHg and MAP < 60 mmHg (the per cent area under the threshold marker) showed the strongest associations with 30-day mortality, with odds ratios (ORs) of 3.02 (95% confidence interval (CI) 1.81-5.07) and 3.77 (95% CI 2.25-6.31) respectively.

CONCLUSIONS

Commonly accepted thresholds of intraoperative hypotension, such as an SBP of 80 mmHg and an MAP of 60 mmHg, are valid alarming limits that are significantly and independently associated with 30-day mortality.

Postoperative mortality in New Zealand following general anaesthetic: demographic patterns and temporal trends

OBJECTIVES

In this manuscript, we describe broad trends in postoperative mortality in New Zealand (a country with universal healthcare) for acute and elective/waiting list procedures conducted between 2005 and 2017.

DESIGN, PARTICIPANTS AND SETTING

We use high-quality national-level hospitalisation data to compare the risk of postoperative mortality between demographic subgroups after adjusting for key patient-level confounders and mediators. We also present temporal trends and consider how rates in postoperative death following acute and elective/waiting list procedures have changed over this time period.

RESULTS AND CONCLUSION

A total of 1 836 683 unique patients accounted for 3 117 374 admissions in which a procedure was performed under general anaesthetic over the study period. We observed an overall 30-day mortality rate of 0.5 per 100 procedures and a 90-day mortality rate of 0.9 per 100. For acute procedures, we observed a 30-day mortality rate of 1.6 per 100, compared with 0.2 per 100 for elective/waiting list procedures. In terms of procedure specialty, respiratory and cardiovascular procedures had the highest rate of 30-day mortality (age-standardised rate, acute procedures: 3-6 per 100; elective/waiting list: 0.7-1 per 100). As in other contexts, we observed that the likelihood of postoperative death was not proportionally distributed within our population: older patients, Māori patients, those living in areas with higher deprivation and those with comorbidity were at increased risk of postoperative death, even after adjusting for all available factors that might explain differences between these groups. Increasing procedure risk (measured using the Johns Hopkins Surgical Risk Classification System) was also associated with an increased risk of postoperative death. Encouragingly, it appears that risk of postoperative mortality has declined over the past decade, possibly reflecting improvements in perioperative quality of care; however, this decline did not occur equally across procedure specialties.

Dynamic functional clot formation in patients undergoing endoscopic mucosal resection

Background and Aim

Electric burns can induce fibrinolytic activity. Endoscopic mucosal resection (EMR) is a minimally invasive technique utilizing electrocautery for resection of dysplastic lesions from the gastrointestinal tract. EMR's main complication is clinically significant postendoscopic bleeding. Currently, no studies have investigated the impact of electrocautery during EMR on the coagulation cascade by viscoelastic hemostatic assay.

Methods

Thrombelastometry was performed and plasminogen levels were measured on blood samples taken prior to EMR, within an hour following the procedure and 2 days post‐EMR. Data were natural log‐transformed and analyzed using repeated‐measure analysis of covariance (ANCOVA) accounting for age, sex, body mass index (BMI) and site of EMR.

Results

Plasminogen levels decreased post‐EMR (P = 0.001) and then increased 2 days post‐EMR (P < 0.018). FIBTEM A10 and Maximum Clot Firmness, and EXTEM maximum lysis decreased an hour following EMR (P < 0.05 for all). These three measurements then increased 2 days post‐EMR (P < 0.01 for all). There were no significant differences in thrombelastometry or plasminogen measures according to sex, age, BMI, or site of EMR. One patient experienced clinically significant postendoscopic bleeding at one‐week post‐EMR, with substantially decreased FIBTEM A10 and Maximum Clot Firmness at 2 days post‐EMR.

Conclusions

Decreased post‐EMR plasminogen corresponds with reduced clot firmness and enhanced lysis affecting clot quality, strength, and stability. While further investigation in a larger sample is required to confirm the overall risk of clinically significant postendoscopic bleeding and mechanisms for plasminogen activation; this study highlights the potential utility of thrombelastometry in assessing fibrinolytic activity during EMR.

Colon mucosal neoplasia referred for endoscopic mucosal resection: Recurrence of adenomas and prediction of submucosal invasion

BACKGROUND

Endoscopic mucosal resection (EMR) is an effective and minimally invasive alternative to surgery for large polyps and laterally spreading lesions. Gross morphology and surface characteristics may help predict submucosal invasion of the lesion (SMIL) during endoscopic evaluation. This is one of the largest single-center studies reporting endoscopic mucosal resection for larger (≥ 20 mm) colorectal lesions in the United States.

AIM

To determine the recurrence rate of adenomas and endoscopic features that may predict submucosal invasion of colonic mucosal neoplasia.

METHODS

This is a retrospective cohort study of all the patients referred for endoscopic mucosal resection for lesions ≥ 20 mm, spanning a period from January 2013 to February 2017. The main outcome measure was identifying features that may predict submucosal invasion of mucosal lesions and predict recurrence of adenomas on follow-up surveillance colonoscopy performed at 4-6 mo.

RESULTS

A total of 480 patients with 500 lesions were included in the study. The median age was 68 (Inter quantile range: 14) with 52% males. The most common lesion location was ascending colon (161; 32%). Paris classification 0-IIa (Flat elevation of mucosa - 316; 63.2%); Kudo Pit Pattern IIIs (192; 38%) and Granular surface morphology (260; 52%) were most prevalent. Submucosal invasion was present in 23 (4.6%) out of 500 lesions. The independent risk factors for SMIL were Kudo Pit Pattern IIIL + IV and V (Odds ratio: 4.5; P value < 0.004) and Paris classification 0-IIc (Odds ratio: 18.2; P value < 0.01). Out of 500, 354 post-endoscopic mucosal resection scars were examined at surveillance colonoscopy. Recurrence was noted in 21.8% (77 cases).

CONCLUSION

There was overall low prevalence of SMIL in our study. Kudo pit pattern (IIIL + IV and V) and Paris classification 0-IIc were the only factors identified as an independent risk factor for submucosal invasion. The independent risk factor for recurrence was adenoma size (> 40 mm). Almost all recurrences (98.8%) were treated endoscopically.

Cap-fitted endoscopic mucosal resection of ≥ 20 mm colon flat lesions followed by argon plasma coagulation results in a low adenoma recurrence rate

Background and study aims  Endoscopic mucosal resection (EMR) is increasingly used for the treatment of large colonic polyps (≥ 20 mm). A drawback of EMR is local adenoma recurrence. Therefore, we studied the impact of argon plasma coagulation (APC) of the EMR edge on local adenoma recurrence. Patients and methods  This was a retrospective study of patients with laterally spreading tumors (LST) ≥ 20 mm, who underwent EMR from January 2009 to August 2018 and follow-up endoscopic assessment. A cap-fitted endoscope was used to assess completeness of resection by systematically inspecting the EMR defect for any macroscopic disease. This was followed by forced APC of the resection edge followed by clip closure of the defect. Surveillance colonoscopy was performed at 6 months after resection to detect recurrence. Results  Two hundred forty-six patients met the inclusion criteria. Most were female (53 %) and white (80 %), with a Median age of 64 years. Median polyp size was 35 mm (interquartile range, 30-45 mm). Most polyps were located in the right colon (77 %) and were removed by piecemeal EMR (70 %). Eleven patients (5 %) had residual tumor at the resection site. Conclusions  We observed low adenoma recurrence after argon plasma coagulation of the EMR edge with a cap fitted colonoscope in patients with LST ≥ 20 mm of the colon, which requires further validation in a randomized controlled study.

Utilisation of Adjuvant Chemotherapy and 5-Year Survival Analysis of Prospectively Recorded Cohort Data for Older Adults Versus Younger Adults with Resected Primary Colon Cancer

PURPOSE

Colon cancer is predominantly a disease of older adults. Studies determining the influence of age on outcomes of colon cancer have conflicting results. We aim to determine the long-term outcomes and utilisation of adjuvant chemotherapy of older adults compared with younger adults who had had a resection of a primary colon cancer.

METHODS

Consecutive patients who had resection of a primary colon cancer between January 1, 2000 and December 31, 2010 were identified from a prospective database and stratified into three age groups: ≤ 69 years, 70 to 79 years, and ≥ 80 years. Age-related differences in patients, cancer, and treatment characteristics were determined by chi-square tests. Five-year overall survival and cancer-specific survival were determined by Kaplan-Meier method and by multivariable Cox regression analysis to adjust for potential confounding factors.

RESULTS

Of 1135 included patients, 469 (41%) patients were aged ≤ 69 years, 382 (34%) were 70-79 years, and 284 (25%) were ≥ 80 years. Increasing age group predicted more comorbidity (p < 0.001), cardiac comorbidity (p < 0.001), right-sided cancers (p < 0.001), and less adjuvant chemotherapy (stage III only; p < 0.001). Increasing age group was associated with worse overall survival by stage (p < 0.001) but not cancer-specific survival by stage (p = 0.83). Adjuvant chemotherapy in patients with stage III colon cancer independently predicted improved overall survival (p < 0.001) and cancer-specific survival (p = 0.01).

CONCLUSIONS

Compared with younger adults, older adults with colon cancer had worse survival outcomes and received less adjuvant chemotherapy.

Improvement of perioperative care of the elderly patient (PeriAge): protocol of a controlled interventional feasibility study

INTRODUCTION

Geriatric patients have a pronounced risk to suffer from postoperative complications. While effective risk-specific perioperative measures have been studied in controlled experimental settings, they are rarely found in routine healthcare. This study aims (1) to implement a multicomponent preoperative and intraoperative intervention, and investigate its feasibility, and (2) exploratorily assess the effectiveness of the intervention in routine healthcare.

METHODS AND ANALYSIS

Feasibility and exploratory effectiveness of the intervention will be investigated in a monocentric, prospective, non-randomised, controlled trial. The intervention includes systematic information for patients and family about measures to prevent postoperative complications; preoperative screening for frailty, malnutrition, strength and mobility with nutrient supplementation and physical exercise (prehabilitation) as needed. Further components focus on potentially inadequate medication, patient blood-management and carbohydrate loading prior to surgery, retainment of orientation aids in the operating room and a geriatric anaesthesia concept. Data will successively be collected from control, implementation and intervention groups. Patients aged 65+ with impending surgery will be included. A sample size of 240, n=80 per group, is planned. Assessments will take place at inclusion and 2, 30 and 180 days after surgery. Mixed-methods analyses will be performed. Exploratory effectiveness will be assessed using mixed segmented regressions. The primary endpoint is functional status. Secondary endpoints include cognitive performance, health-related quality of life, length of inpatient stay and occurrence of postoperative complications. Feasibility will be assessed through semi-structured interviews with staff and patients and quantitative analyses of the data quality, focussing on practicability, acceptance, adoption and fidelity to protocol.

ETHICS AND DISSEMINATION

The study will be carried out in accordance with the Helsinki Declaration and to principles of good scientific practice. The Ethics Committee of the Medical Association Hamburg, Germany, approved the protocol (study ID: PV5596). Results will be disseminated in scientific journals and healthcare conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT03325413.

Morbidity and Mortality After Surgery for Nonmalignant Colorectal Polyps: A 10-Year Nationwide Analysis

OBJECTIVES

Rates of surgery for nonmalignant colorectal polyps are increasing in the United States despite evidence that most polyps can be managed endoscopically. We aimed to determine nationally representative estimates and to identify predictors of in-hospital mortality and morbidity after surgery for nonmalignant colorectal polyps.

METHODS

Data were analyzed from the National Inpatient Sample for 2005-2014. All discharges for adult patients undergoing surgery for nonmalignant colorectal polyps were identified. Rates of in-hospital mortality and postoperative wound, infectious, urinary, pulmonary, gastrointestinal, or cardiovascular adverse events were calculated. Multivariable logistic regression using survey-weighted data was used to evaluate covariables associated with postoperative mortality and morbidity.

RESULTS

An estimated 262,843 surgeries for nonmalignant colorectal polyps were analyzed. In-hospital mortality was 0.8% [95% confidence interval: 0.7%-0.9%] and morbidity was 25.3% [95% confidence interval: 24.2%-26.4%]. Postoperative mortality was associated with open surgical technique (vs laparoscopic), older age, black race (vs non-Hispanic white), Medicaid use, and burden of comorbidities. Female sex and private insurance were associated with lower risk. Patients developing a postoperative adverse event had a 106% increase in mean hospital length of stay (10.3 vs 5.0 days; P < 0.0001) and 91% increase in mean hospitalization cost ($77,015.24 vs $40,258.30; P < 0.0001).

DISCUSSION

Surgery for nonmalignant colorectal polyps is associated with almost 1% mortality and common morbidity. These findings should inform risk vs benefit discussions for clinicians and patients, and although confounding by patient selection cannot be excluded, the risks associated with surgery support consideration of endoscopic resection as a potentially less invasive therapeutic option.

Anesthetic Errors During Procedures in the United States

OBJECTIVES

The purpose of this study was to identify the incidence of anesthetic errors per discharges in the United States within these errors, the incidence of death. A secondary aim was to identify any association between the mortality and patient comorbidities.

METHODS

A retrospective analysis of the hospitals in the United States using the Nationwide Inpatient Sample (NIS) database during 2007-2014 was performed. The study population consisted of patients who were recorded as inpatient discharges who experienced complications as a result of incorrect anesthetic administration resulting from either an overdose or inappropriate medication administration in the United States.

RESULTS

Between 2007 and 2014, a total of 17,116 anesthetic errors were reported. There was a substantial decrease in the total number of these errors over time, from 2483 in 2007 to 1391 in 2014 (44% decrease). There were 131 reported deaths in this cohort (0.77% mortality rate), with 61 mortalities in teaching hospitals (0.86% mortality rate) and 57 in nonteaching hospitals (0.73% mortality rate). During the study period, deaths decreased from 21 in 2007 (0.85% mortality rate) to 11 in 2014 (0.79% mortality rate), corresponding with a 7.1% decrease in the mortality rate. Comorbidities associated with a significant increase in mortality from anesthetic substances included fluid and electrolyte disorders (odds ratio 8.82, 95% confidence interval 5.24-14.83, P < 0.001) and coagulopathies (odds ratio 5.26, 95% confidence interval 2.53-10.93, P < 0.001).

CONCLUSIONS

Our study showed that although the incidence of anesthetic errors is small, they do still exist in our hospitals. Certain comorbidities appear to predispose patients to increased risk. The subsets of patients who appear to be at the greatest risk include those with preexisting electrolyte and fluid disorders and coagulopathies.

Nurses' role in recognising and responding to clinical deterioration in surgical patients

AIM AND OBJECTIVES

To explore nurse' role in recognising and responding to deteriorating post-operative patients.

BACKGROUND

Clinical deterioration is a significant problem in acute care settings. Nurses play a vital role in post-operative patient monitoring; however, there is limited understanding of the nurses' role in recognising and responding to clinical deterioration in surgical patients.

METHODS

This qualitative exploratory study was conducted at a metropolitan teaching hospital in Melbourne, Australia. Data were collected through focus groups from 1 September to 31 October 2014. Four focus groups of 2-5 surgical nurses (n = 14) were conducted to explore the nurses' perception of their role in managing deterioration over the first 72 hr postoperatively. Qualitative data were recorded, transcribed and key themes identified.

RESULTS

Nurses demonstrated a high level of awareness of their role in recognising and responding to early signs of deterioration. The themes that arose from the focus group interviews were "struggling with blood pressure," and "we know our patient is sick." The nurses were confident about the clinical indicators of deterioration and the appropriate channels to use to escalate care. Using track and trigger observation charts enabled nurses to identify deteriorating patients prior to the patient fulfilling rapid response system escalation criteria.

CONCLUSIONS

These findings highlight the importance of a collective team approach to preventing, recognising and responding to clinical deterioration across the whole patient journey. Initiatives to ensure accurate written and verbal communication between medical and nursing staff warrants further assessment.

RELEVANCE TO CLINICAL PRACTICE

Nurses working in acute surgical wards are highly engaged in the process of recognising and responding to clinical deterioration in post-operative patients. Many nurses reported being able to anticipate deterioration occurring but are required by current organisational frameworks to escalate care to rapid response systems. How nurses anticipate and manage deterioration prior to the patient fulfilling rapid response system criteria warrants further investigation.

Evaluating quality standards' adherence in surgical care: a case study from Pakistan

Objective

To explore the extent of adherence to surgical quality standards and areas of improvement.

Design

Multi-method case study was done. Assessment of observed/actual and self-reported adherence to quality standards in surgical care was done on WHO's safe-surgery checklist. Client satisfaction through exit interviews assessed of all operated during 1 month. Semi-structured interviews of key informants were conducted to identify areas of improvements in surgical care in this hospital.

Setting

Conducted in a tertiary care teaching hospital in Lahore, Pakistan.

Participants

Out of all 154 patients during 1 month were admitted with indications for surgery and 35.71% patients gave consent and participated in the study.

Outcome measure

Actual and reported adherence data were categorized in excellent, good, satisfactory and poor adherence to standards. For in-depth interviews, themes were identified from textual data.

Results

Overall activities in surgical department were performed well, patients were satisfied and hospital surgical mortality rate was zero but infection control measures needs attention and these practices were found poor with high re-operation and re-admissionrate (P-value < 0.001). Adherence to standards of surgical quality was inadequate in pre-operative, operative and post-op steps as assessed on the checklist but actual adherence was different from reported adherence by surgical care providers.

Conclusion

This case study shows a complete picture of surgical care quality in a hospital of Pakistan. Discrepancy between perceived/reported adherence and actual practice was found. Patients' satisfaction is not a reliable outcome measure of surgical care quality.

Post-operative outcomes in older patients: a single-centre observational study

BACKGROUND

Improved life-expectancies have seen increased rates of older patients undergoing surgery worldwide. These patients are at increased risk of post-operative complications. Australian evidence is limited regarding the association between age and post-operative outcomes, especially rapid response calls (RRCs) as indicators of adverse outcomes. The aim was to compare the post-operative outcomes of older patients (≥80 years) to younger patients. Specifically, 30-day in-hospital mortality; unplanned intensive care unit (ICU) admission; and RRC activation within 72 h post-operatively.

METHODS

Single-centre retrospective observational study conducted over 12 months in a metropolitan Australian hospital. All adult patients (≥16 years) undergoing surgical procedures were included, excluding cardiac and obstetric/gynaecological surgeries. Patient co-morbidities were quantified using Charlson co-morbidity index (CCI) and American Society of Anesthesiologists physical status classification.

RESULTS

Seven thousand four hundred and seventy-nine patients met inclusion criteria, 14.5% (n = 1086) aged ≥80 years. Most procedures (65%) were elective; and general surgical procedures were most common (24.2%). Compared to younger patients, older patients had significantly higher 30-day mortality (2.3% versus 0.2%; P < 0.001), increased post-operative RRC rates (7.3% versus 1.2%; P < 0.001), and unplanned ICU admissions (3.2% versus 1.6%; P < 0.001). Increasing age was associated with increased risk of post-operative RRC, unplanned ICU admission, and in-hospital mortality (all P < 0.01), with associations remaining significant after controlling for surgery type and CCI.

CONCLUSION

Older patients are at increased risk of adverse post-operative outcomes, including post-operative RRC, unplanned ICU admission, and mortality, especially if they underwent emergency procedures. This has implications for preoperative risk stratification and post-operative management. Incidence of post-operative RRCs may be an important indicator of post-operative care.

Low medical morbidity and mortality after acute courses of electroconvulsive therapy in a population-based sample

BACKGROUND

To determine event rates for specific medical events and mortality among individuals receiving electroconvulsive therapy (ECT).

METHOD

Population-based cohort study using health administrative data of acute ECT treatments delivered in Ontario, Canada, from 2003 to 2011. We measured the following medical event rates, per 10 000 ECT treatments, up to 7 and 30 days post-treatment: stroke, seizure, acute myocardial infarction, arrhythmia, pneumonia, pulmonary embolus, deep vein thrombosis, gastrointestinal bleeding, falls, hip fracture, and mortality.

RESULTS

A total of 135 831 ECT treatments were delivered to 8810 unique patients. Overall medical event rates were 9.1 and 16.8 per 10 000 ECT treatments respectively. The most common medical events were falls (2.7 and 5.5 per 10 000 ECT treatments) and pneumonia (1.8 and 3.8 per 10 000 ECT treatments). Fewer than six deaths occurred on the day of an ECT treatment. This corresponded to a mortality rate of less than 0.4 per 10 000 treatments. Deaths within 7 and 30 days of an ECT treatment, excluding deaths due to external causes (e.g., accidental and intentional causes of death), were 1.0 and 2.4 per 10 000 ECT treatments respectively.

CONCLUSION

Morbidity and mortality events after ECT treatments were relatively low, supporting ECT as a low-risk medical procedure.

Dexmedetomidine Infusion for Routine Dental Management of an ASA IV Patient: A Case Report

Anesthetic management of elderly patients requires numerous physiological considerations. With aging, degenerative changes occur in the structure and functional capacity of tissues and organs. Typically, these patients experience clinical effects with lower doses of medication. Important considerations for the geriatric populations following anesthesia include increased time to recovery and avoidance of functional decline. A case is reported in which an 83-year-old Caucasian female with a complex medical history presented for routine dental treatment under intravenous sedation via dexmedetomidine infusion.

Factors influencing receipt of adjuvant chemotherapy after surgery for pancreatic cancer: a two-center retrospective cohort study

OBJECTIVE

The addition of adjuvant chemotherapy after surgical resection has improved survival rates for patients with pancreatic ductal adenocarcinoma (PDAC). However, outside clinical trials, many operated patients still do not receive adjuvant chemotherapy due to clinical and tumor-related factors. The aim of this study was to investigate factors that may influence the receipt of adjuvant chemotherapy and the effect on long-term survival.

MATERIALS AND METHODS

Patients undergoing macroscopically curative resection for PDAC at the University Hospitals in Lund and Linköping, Sweden, between 1 January 2007 and 31 December 2015, were retrospectively reviewed. Clinical and pathological data were compared between adjuvant and non-adjuvant chemotherapy groups and factors affecting chemotherapy receipt were analyzed by multiple logistic regression. Multivariable Cox regression analysis was performed to select predictive variables for survival.

RESULTS

A total of 233 patients were analyzed. Adjuvant chemotherapy was administered to 167 patients (71.7%). The likelihood of receiving adjuvant chemotherapy decreased with age, OR 0.91, 95% CI 0.86-0.95, p < .001. Moreover, patients with severe postoperative complications (Clavien-Dindo grade ≥ III) were less likely to receive adjuvant chemotherapy, OR 0.31, 95% CI 0.14-0.71, p = .005. The presence of lymph node metastases on histopathological reporting was associated with increased likelihood of initiating adjuvant chemotherapy, OR 2.19, 95% CI 1.09-4.40, p = .028. Adjuvant chemotherapy was an independent factor for prolonged survival on multivariable Cox regression analysis, HR 0.45 (95% CI 0.31-0.65), p < .001.

CONCLUSIONS

Age, postoperative complications and the presence of lymph node metastases affect the likelihood of receiving adjuvant chemotherapy after PDAC surgery.

Safety of endoscopic mucosal resection (EMR) of large non-pedunculated colorectal adenomas in the elderly

BACKGROUND

Endoscopic mucosal resection (EMR) has been proven to be safe and effective for the treatment of colorectal adenomas. However, data are limited on the safety of this technique for large polyps and in elderly patients. Aims of our study were to examine the bleeding and perforation rates in patients with large non-pedunculated adenomas (≥20mm) and to evaluate the influence of size (≥40mm) and age (≥75 years) on the complication rates.

METHODS

In this multicenter retrospective study, patients who underwent EMR of non-pedunculated adenomas ≥20mm between January 2012 and March 2016 were included. The demographics of the patients, the use of antithrombotic drugs, size of the polyps, type of resection, pathology report, occurrence of post-polypectomy bleeding, and perforation- and recurrence rate were collected.

RESULTS

In 343 patients, 412 adenomas were removed. Eighty patients (23.3%) were ≥75 years of age, 138 polyps (33.5%) were ≥40mm. Bleeding complications were observed in 28 cases (6.8%) and were found significantly more frequent in adenomas ≥40mm, independent of the use of antithrombotic therapy. Five perforations (1.2%) were described, not related to the size of the polyp. There was no significant difference in complication rates between patients <75 years and patients ≥75 years. Bleeding complications rates were significantly higher in patients receiving double antithrombotic therapy.

CONCLUSION

EMR is safe in elderly patients. EMR of adenomas of ≥40mm was associated with more bleeding complications. Future studies should address how the bleeding rates can be reduced in these patients, especially in those who use double antithrombotic treatment.

Post-operative serious adverse events in a mixed surgical population - a retrospective register study

BACKGROUND

The number of surgical procedures is increasing, and knowledge of surgical risk factors, post-operative mortality and serious adverse events (SAE) is essential. The aim with our study was to determine the risk of a composite outcome of post-operative: death; myocardial infarction; pulmonary embolism; stroke; gastrointestinal bleeding; dialysis or reoperation.

METHODS

Data of surgical procedures in the period from January 1, 2012 to June 30, 2012 were retrieved from the Danish Anaesthesia Database (DAD). Follow-up of all patients undergoing hip or knee replacement, abdominal or gynaecological surgery was conducted retrieving data from The Danish Civil Registration System and the National Patient Register. Total observation time was from January 1, 2012 to June 6, 2013.

RESULTS

A total7449 adult patients were included in the final analysis. The risk of the composite outcome during a follow-up until 342 days after inclusion of the last patient was estimated to 8.3%, 95% Confidence Intervals (CI) (7.8-9.0), with a median observation time of 437 days (IQR 387-485, range 0-522). The risk of the composite outcome within 90- and 180-day follow-up of each patient was 4.8% (4.4-5.3) and 5.9% (5.4-6.5), respectively. Mortality within longest follow-up as well as 90 and 180 days post-operatively was 3.6% (3.1-4.0), 1.7% (1.4-2.0), and 2.2% (1.9-2.6), respectively.

CONCLUSION

We found a risk of one or more events in the composite outcome within 342 days after inclusion of the last patients of 8.3% (7.8-9.0). The results are applicable in estimations of adequate sample sizes in future clinical trials investigating effects of interventions on SAEs.

Outcome and risk of recurrence for endoscopic resection of colonic superficial neoplastic lesions over 2 cm in diameter

BACKGROUND

Large colorectal superficial neoplastic lesions are challenging to remove. This study aimed to assess the outcomes of routine endoscopic resection of large (≥2 cm and <3 cm) and giant (≥3 cm) lesions.

METHODS

From 4587 endoscopic resections, 265 (5.7%) large and giant lesions were removed in 249 patients. We retrospectively analyzed 125 patients (141 endoscopic mucosal resection, 73 large and 68 giant lesions) with a follow-up of 6-12 months. Rate of en bloc and piecemeal resection, recurrence and risk factors were analyzed.

RESULTS

En bloc was performed in 92 cases (65.2%) and piecemeal resection in 49 (34.8%). A complete endoscopic resection was achieved in 139 cases (98.5%) with radical resection in 84/139 cases (60.4%). Argon plasma coagulation was applied in 18/141 lesions (12.8%). A recurrence occurred in 16/139 lesions (11.5%). The risk of recurrence at one year was significantly higher for giant than large lesions (p=0.03). The recurrence risk was higher in treated than in non-argon plasma coagulation treated lesions (p=0.01).

CONCLUSIONS

endoscopic mucosal resection is a safe and effective routine treatment for large superficial neoplastic lesions. The risk factors for recurrence include giant size, non-protruding morphology, piecemeal technique and argon plasma coagulation.

Design and implementation of an enhanced recovery program in thoracic surgery

Despite significant improvements in perioperative care, major surgery is still associated with major complications. Enhanced recovery after surgery was introduced by the National Health Service in the UK with the aim of improving patient outcomes and reducing length of stay in hospital. The degree of applicability differs between surgical specialties, and in thoracic surgery it has not been developed until recently. We have therefore reviewed recent literature specific to thoracic surgery, and will discuss key elements of the design, implementation and monitoring of an enhanced recovery (ER) program based on our recent experience. The program is divided into several high impact intervention measures that involve the preoperative, intraoperative and postoperative periods. Physical activity promotion and educational programs that provide information about the surgery and the surgical pathway are an essential part of the preoperative strategies. During surgery, an optimal pain control strategy, antibiotic prophylaxis and protective ventilation are important. Minimally invasive surgery and well-planned postoperative care including early drain removal and planned discharge are also important. Overall, we have shown that ER in thoracic surgery can facilitate early discharge from hospital and possibly reduce postoperative complications. Further studies are required to understand the extent of ER benefits when applied to thoracic surgery, and to test individual components in a prospective manner.

The effects on coagulation of the reinfusion of unprocessed residual blood from the cardiopulmonary bypass

Background

Autologous blood transfusion is a common technique in cardiac surgery to directly re-infuse residual blood from the cardiopulmonary bypass (CPB) circuit to the patient. The objective of this study was to evaluate the effects of reinfusion of unprocessed residual pump blood on the coagulation system after separation from the CPB circuit and reversal of systemic heparin with protamine.

Measurements and main results

After ethics approval, 40 participants undergoing cardiac surgery were recruited in a prospective single center cohort study. Changes in coagulation were assessed with standard plasma based laboratory assays and thromboelastography. After the reinfusion of unprocessed residual pump blood there were decreases in the mean aPTT (effect size 6 s; SD: 6.05; p < 0.0001) and thrombin time (effect size 4.08 s; SD: 9.7; p = 0.01). There were no significant changes in PT, INR and D-dimer. Post reinfusion there were increases in fibrinogen, hemoglobin and platelet counts. There were improvements in the R-time (effect size 9.1 s; SD: 16.9; p = 0.0023), K-time (effect size 1.5 s; SD: 3.6 s; p = 0.0017), alpha angle (6.9°; SD: 15.8; p = 0.012), and maximum amplitude (3.0 mm; SD: 5.6, p = 0.002) on thromboelastography.

Conclusion

The reinfusion of unprocessed residual CPB blood resulted in no deleterious effects on the coagulation system measured by both the common laboratory plasma based measurements of coagulation and thromboelastography.

Liver Metastasis from Colorectal Cancer in the Elderly: Is Surgery Justified?

BACKGROUND

The elderly population with liver metastasis from colorectal cancer has been increasing. As the potentially curative treatment, the role of liver resection in the elderly remains undetermined.

AIMS

This study provides a meta-analysis on the outcome of liver resection of colorectal liver metastasis in patients aged over 70.

METHODS

PubMed, Embase, Ovid, Web of Science, and Cochrane databases from the years 2000 to 2015 were searched for eligible studies. Data on perioperative mortality, postoperative complications, and survival were collected.

RESULTS

Twelve retrospective studies with a total of 11,285 patients (2498 elderly patients and 8787 younger patients) were identified. The elderly (>70 years old) were associated with a similar overall complication rate (30.5 vs. 28.0%; OR 1.08; 95% CI 0.91-1.28; p = 0.39) and a higher 30-day mortality (OR 1.92; 95% CI 1.12-3.31; p = 0.02) after liver resection of colorectal liver metastasis (CRLM). The overall survival showed a significant difference in favor of the younger patients (HR 0.76; 95% CI 0.65-0.89; p = 0.0007). However, with regard to disease-free survival, there was no significant difference between elderly and younger patients (HR 0.93; 95% CI 0.82-1.06; p = 0.30).

CONCLUSION

Liver resection of CRLM is relatively safe in carefully selected elderly patients. Liver resection should be offered to selected elderly patients with CRLM.

Anesthetic Considerations for Common Procedures in Geriatric Patients: Hip Fracture, Emergency General Surgery, and Transcatheter Aortic Valve Replacement

The elderly population is growing. Geriatric patients undergo a large proportion of surgical procedures and have increased complications, morbidity, and mortality, which may be associated with increased intensive care unit time, length of stay, hospital readmission, and cost. Identification of optimal anesthetic care for these patients, leading to decreased complications and contributing to best possible outcomes, will have great value. This article reviews the anesthetic considerations for intraoperative care of geriatric patients and focus on 3 procedures (hip fractures, emergency abdominal surgery, and transcatheter aortic valve replacement). An approach to evaluation and management of the elderly surgical patient is described.

Surgical care for the aged: a retrospective cross-sectional study of a national surgical mortality audit

OBJECTIVES

It is assumed that increased age signifies increased surgical care. Few surgical studies describe the differences in care provided to older patients compared with younger patients. We aimed to examine the relationships between increasing age, preoperative factors and markers of postoperative care in adults who died in-hospital after surgery in Australia.

DESIGN

This retrospective cross-sectional study extracted data from a national surgical mortality audit--an independent, peer-reviewed process.

SETTING

From January 2009 to December 2012, 111 public and 61 private Australian hospitals notified the audit of in-hospital deaths after general anaesthetic surgery or if the patient was admitted under a surgeon.

PARTICIPANTS

Notified deaths totalled 19,723. We excluded deaths if patients were brain dead, younger than 17 years or never had an operation (n=11,376). From this baseline population, we divided 11,201 deaths into three patient age groups: youngest (17-64 years), medium (65-79 years) and oldest (≥80 years).

OUTCOME MEASURES

Univariable and multivariable logistic regression analyses determined the relationships between increasing age and the measured preoperative factors and postoperative variables.

RESULTS

The baseline population's median age was 78 years (IQR 66-85), 43.7% (4892/11,201) were 80 years or older and 83.4% (9319/11,173) had emergency admissions. The oldest group had increased trauma and emergency admissions than the medium and youngest age groups. Seven of the eight measured markers of postoperative care demonstrate strong and significant relationships with increasing age. The oldest group compared with the medium group had decreased rates of: unplanned returns to theatre (11.2% (526/4709) vs 20.2% (726/3586)), unplanned intensive care admissions (16.3% (545/3350) vs 24.0% (601/2504)) and treatment in intensive care units (59.7% (2689/4507) vs 76.7% (2754/3590)).

CONCLUSIONS

The oldest patients received lower levels of care than the medium and youngest age groups.

Colorectal preOperative Surgical Score (CrOSS) for mortality in major colorectal surgery

BACKGROUND

Colorectal surgery carries a significant mortality risk, with reported rates of 1-6% for elective surgery and up to 22% in the emergency setting. Both clinicians and patients will benefit from being able to predict the likelihood of death before surgery. Recently, we have described and validated two risk stratification models for colorectal surgery, the Barwon Health 2012 and Association Française de Chirurgie models. However, these models are not suitable for assessment at patient's bedside. The purpose of this study is to develop a simplified preoperative model capable of predicting mortality following colorectal surgery.

METHODS

The new model is termed Colorectal preOperative Surgical Score (CrOSS). The development and internal validation of CrOSS was performed using a prospectively maintained colorectal database. External validation was performed using retrospective data. Univariate and multivariate analyses were performed in model development. Calibration and discrimination were used for model validation.

RESULTS

There were 474 and 389 consecutive colorectal surgeries at Geelong Hospital and Western Hospital. Overall mortality rates were 5.16% and 1.03%, respectively. Significant predictors for mortality were as follows: age ≥70, urgent operation, albumin ≤30 g/L and congestive heart failure (receiver operating characteristic (ROC) = 0.870, calibration P-value = 0.937). The predicted risk of mortality was stratified according to the risk profile of 0.39-66.51%. When validated externally, CrOSS predicted mortality accurately (ROC = 0.847, calibration P-value = 0.199).

CONCLUSIONS

A robust and simple preoperative model has been created to risk-stratify patients for colorectal surgery. This was successfully validated at another tertiary hospital.

Endoscopic and surgical treatment of malignant colorectal polyps: a population-based comparative study

BACKGROUND

Long-term population-based data comparing endoscopic therapy (ET) and surgery for management of malignant colorectal polyps (MCPs) are limited.

OBJECTIVE

To compare colorectal cancer (CRC)-specific survival with ET and surgery.

DESIGN AND SETTING

Population-based study.

PATIENTS

Patients with stage 0 and stage 1 MCPs were identified from the Surveillance Epidemiology and End Results (SEER) database (1998-2009). Demographic characteristics, tumor size, location, treatment modality, and survival were compared. Propensity-score matching and Cox proportional hazards regression models were used to evaluate the association between treatment and CRC-specific survival.

INTERVENTIONS

ET and surgery.

MAIN OUTCOME MEASUREMENTS

Mid-term (2.5 years) and long-term (5 years) CRC-free survival rates and independent predictors of CRC-specific mortality.

RESULTS

Of 10,403 patients with MCPs, 2688 (26%) underwent ET and 7715 (74%) underwent surgery. Patients undergoing ET were more likely to be older white men with stage 0 disease. Surgical patients had more right-sided lesions, larger MCPs, and stage 1 disease. There was no difference in the 2.5-year and 5-year CRC-free survival rates between the 2 groups in stage 0 disease. Surgical resection led to higher 2.5-year (97.8% vs 93.2%; P < .001) and 5-year (96.6% vs 89.8%; P < .001) CRC-free survival in stage 1 disease. These results were confirmed by propensity-score matching. ET was a significant predictor for CRC-specific mortality in stage 1 disease (hazard ratio 2.40; 95% confidence interval, 1.75-3.29; P < .001).

LIMITATIONS

Comorbidity index not available, selection bias.

CONCLUSIONS

ET and surgery had comparable mid- and long-term CRC-free survival rates in stage 0 disease. Surgical resection is the recommended treatment modality for MCPs with submucosal invasion.

Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study

OBJECTIVE

Wide-field endoscopic mucosal resection (WF-EMR) is an alternative to surgery for treatment of advanced colonic mucosal neoplasia up to 120 mm in size, but has been criticised for its potentially high recurrence rates. We aimed to quantify recurrence at 4 months (early) and 16 months (late) following successful WF-EMR and identify its risk factors and clinical significance.

DESIGN

Ongoing multicentre, prospective, intention-to-treat analysis of sessile or laterally spreading colonic lesions ≥20 mm in size referred for WF-EMR to seven academic endoscopy units. Surveillance colonoscopy (SC) was performed 4 months (SC1) and 16 months (SC2) after WF-EMR, with photographic documentation and biopsy of the scar.

RESULTS

1134 consecutive patients were enrolled when 1000 successful EMRs were achieved, of whom 799 have undergone SC1. 670 were normal. Early recurrent/residual adenoma was present in 128 (16.0%, 95% CI 13.6% to 18.7%). One case was unknown. The recurrent/residual adenoma was diminutive in 71.7% of cases. On multivariable analysis, risk factors were lesion size >40 mm, use of argon plasma coagulation and intraprocedural bleeding. Of 670 with normal SC1, 426 have undergone SC2, with late recurrence present in 17 cases (4.0%, 95% CI 2.4% to 6.2%). Overall, recurrent/residual adenoma was successfully treated endoscopically in 135 of 145 cases (93.1%, 95% CI 88.1% to 96.4%). If the initial EMR was deemed successful and did not contain submucosal invasion requiring surgery, 98.1% (95% CI 96.6% to 99.0%) were adenoma-free and had avoided surgery at 16 months following EMR.

CONCLUSIONS

Following colonic WF-EMR, early recurrent/residual adenoma occurs in 16%, and is usually unifocal and diminutive. Risk factors were identified. Late recurrence occurs in 4%. Overall, recurrence was managed endoscopically in 93% of cases. Recurrence is not a significant clinical problem following WF-EMR, as with strict colonoscopic surveillance, it can be managed endoscopically with high success rates.

TRIAL REGISTRATION NUMBER

NCT01368289.

Geographic variation of failure-to-rescue in public acute hospitals in New South Wales, Australia

Despite the wide acceptance of Failure-to-Rescue (FTR) as a patient safety indicator (defined as the deaths among surgical patients with treatable complications), no study has explored the geographic variation of FTR in a large health jurisdiction. Our study aimed to explore the spatiotemporal variations of FTR rates across New South Wales (NSW), Australia. We conducted a population-based study using all admitted surgical patients in public acute hospitals during 2002-2009 in NSW, Australia. We developed a spatiotemporal Poisson model using Integrated Nested Laplace Approximation (INLA) methods in a Bayesian framework to obtain area-specific adjusted relative risk. Local Government Area (LGA) was chosen as the areal unit. LGA-aggregated covariates included age, gender, socio-economic and remoteness index scores, distance between patient residential postcode and the treating hospital, and a quadratic time trend. We studied 4,285,494 elective surgical admissions in 82 acute public hospitals over eight years in NSW. Around 14% of patients who developed at least one of the six FTR-related complications (58,590) died during hospitalization. Of 153 LGAs, patients who lived in 31 LGAs, accommodating 48% of NSW patients at risk, were exposed to an excessive adjusted FTR risk (10% to 50%) compared to the state-average. They were mostly located in state's centre and western Sydney. Thirty LGAs with a lower adjusted FTR risk (10% to 30%), accommodating 8% of patients at risk, were mostly found in the southern parts of NSW and Sydney east and south. There were significant spatiotemporal variations of FTR rates across NSW over an eight-year span. Areas identified with significantly high and low FTR risks provide potential opportunities for policy-makers, clinicians and researchers to learn from the success or failure of adopting the best care for surgical patients and build a self-learning organisation and health system.

Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon

BACKGROUND

EMR of advanced mucosal neoplasia (AMN) (ie, sessile or laterally spreading lesions of ≥20 mm) of the colon has become an increasingly popular alternative to surgical resection. However, data regarding safety and mortality of EMR in comparison to surgery are limited.

OBJECTIVE

To compare actual endoscopic with predicted surgical mortality.

DESIGN

Prospective, observational, multicenter cohort study.

SETTING

Academic, high-volume, tertiary-care referral center.

PATIENTS

Consecutive patients referred for EMR.

INTERVENTION EMR MAIN OUTCOME MEASUREMENTS

To predict hypothetical surgical mortality, the Association of Coloproctology of Great Britain and Ireland score, composed of physiological and surgical components, was calculated for each patient. Predicted surgical mortality was then compared with actual outcomes of EMR. The results were validated by an unselected subcohort by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity.

RESULTS

Among 1050 patients with AMN treated by EMR, including patients with a predicted mortality rate of greater than 5% (13.8% of cohort), no deaths occurred within 30 days after the procedure. The predicted surgical mortality rate was 3.3% with the Association of Coloproctology of Great Britain and Ireland score (P < .0001). This suggests a significant advantage of EMR over surgery. The results were validated by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity in 390 patients predicting a surgical mortality rate of 3.2% (P = .0003).

LIMITATIONS

Nonrandomized study.

CONCLUSION

In this large multicenter study of EMR for colonic AMN, the predicted surgical mortality rate was significantly higher than the actual endoscopic mortality rate. Given that endoscopic therapy is less morbid and less expensive than surgery and can be performed as an outpatient treatment, it should be considered as the first line of treatment for most patients with these lesions.

Colonic endoscopic mucosal resection of large polyps: Is it safe in the very elderly?

BACKGROUND

Outcomes on colon endoscopic mucosal resection in the very elderly patient population are unknown.

AIMS

Aims of this study were to evaluate the outcomes and safety of colon endoscopic mucosal resection in this target population.

METHODS

Observational, retrospective study of patients ≥ 80 years of age that underwent colon endoscopic mucosal resection ≥ 2 cm. Demographics, American Society of Anesthesiologists classification, procedural data, and surgical treatment data were collected.

RESULTS

One-hundred-and-thirty-one colon endoscopic mucosal resections were performed on 99 patients ≥ 80 years of age with a mean age of 84. The majority of American Society of Anesthesiologists class was II. Mean lesion size was 3.3 cm (range, 2-12.5 cm), more procedures were performed in the right colon and adenoma/tubulovillous adenoma was the most common pathology. En bloc resection was performed on 26.7% of polyps (N=35). Eight procedure-related adverse events (8/131, 6.1%) occurred. No anaesthesia related adverse events or deaths occurred. Six patients required a colonic operation, and overall, 94% of the patient cohort evaded a colon operation.

CONCLUSIONS

Colon endoscopic mucosal resection in very elderly patients can be performed at experienced endoscopy centres with a low rate of complications and offers these patients a non-surgical option of management of colorectal lesions.

The impact of fluid intervention on complications and length of hospital stay after pancreaticoduodenectomy (Whipple's procedure)

BACKGROUND

There is limited information on the impact on perioperative fluid intervention on complications and length of hospital stay following pancreaticoduodenectomy. Therefore, we conducted a detailed analysis of fluid intervention in patients undergoing pancreaticoduodenectomy at a university teaching hospital to test the hypothesis that a restrictive intravenous fluid regime and/or a neutral or negative cumulative fluid balance, would impact on perioperative complications and length of hospital stay.

METHODS

We retrospectively obtained demographic, operative details, detailed fluid prescription, complications and outcomes data for 150 consecutive patients undergoing pancreaticoduodenectomy in a university teaching hospital. Prognostic predictors for length of hospital stay and complications were determined.

RESULTS

One hundred and fifty consecutive patients undergoing pancreaticoduodenectomy were evaluated between 2006 and 2012. The majority of patients were, middle-aged, overweight and ASA class III. Postoperative complications were frequent and occurred in 86 patients (57%). The majority of complications were graded as Clavien-Dindo Class 2 and 3. Postoperative pancreatic fistula occurred in 13 patients (9%), and delayed gastric emptying occurred in 25 patients (17%). Other postoperative surgical complications included sepsis (22%), bile leak (4%), and postoperative bleeding (2%). Serious medical complications included pulmonary edema (6%), myocardial infarction (8%), cardiac arrhythmias (13%), respiratory failure (8%), and renal failure (7%). Patients with complications received a higher median volume of intravenous therapy and had higher cumulative positive fluid balances. Postoperative length of stay was significantly longer in patients with complications (median 25 days vs. 10 days; p < 0.001). After adjustment for covariates, a fluid balance of less than 1 litre on postoperative day 1 and surgeon caseloads were associated with the development of complications.

CONCLUSIONS

In the context of pancreaticoduodenectomy, restrictive perioperative fluid intervention and negative cumulative fluid balance were associated with fewer complications and shorter length of hospital stay. These findings provide good opportunities to evaluate strategies aimed at improving perioperative care.

Postoperative complications in Australia and New Zealand (the REASON study)

Perioperative medicine is difficult to define, and thus, its progress may be hindered until internationally accepted definitions can be established within the field. The immediate agenda for perioperative physicians should be to agree upon such definitions in order to facilitate advancements in research, audits and outcome measurements. The REASON study, looking at institutions throughout New Zealand and Australia, confirmed that postoperative complications and mortality are important areas for multicentre trials.