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Wu SC, Cheng CC, Yeh HC, Cheng HT, Wang YC, Tzeng CW, Hsu CH, Muo CH. High Volume Plasma Exchange Improves Survival Rates in Surgical Critically Ill Patients With Medical Jaundice and Hepatic Failure: A Comparative Study. World J Surg 2025; 49:364-373. [PMID: 39794861 DOI: 10.1002/wjs.12483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 11/21/2024] [Accepted: 12/29/2024] [Indexed: 01/13/2025]
Abstract
OBJECTIVES Acute liver failure poses a significant challenge in surgical critically ill patients. Treatments typically focus on physiological support and alleviation of hepatic insult. This study aims to evaluate the role of high-volume plasma exchange (HVPE) in surgical critically ill patients with medical jaundice and hepatic failure. METHOD A retrospective review was conducted on surgical critically ill patients with hepatic failure unresponsive to conventional therapy, excluding those with obstructive jaundice. HVPE was considered for patients with persistent hyperbilirubinemia (> 10 mg/dL) and coexisting conditions such as coagulopathy, hyperammonemia, more than Grade II hepato-encephalopathy, or exacerbated sepsis/septic shock status or multiple organ failure. Patients were categorized into standard medical treatment (SMT) and SMT + HVPE groups. Demographics and laboratory data were collected for analysis. RESULT A total of 117 patients were enrolled, with 79 in the SMT group and 38 in the SMT + HVPE group. There were no significant differences in laboratory data and MELD score upon admission. Before treatment, patients in the SMT + HVPE group exhibited higher levels of T-bil., D-bil., and sugar than the SMT group. After treatment, the SMT + HVPE group showed lower serum D-bil. and AST levels but higher levels of albumin and platelets compared to the SMT group. The SMT + HVPE group demonstrated significantly lower delta T-bil., delta D-bil., and higher delta platelet levels. The survival rate was 31.6% (12/38) in the SMT + HVPE group and 1.3% (1/79) in the SMT group. The in-hospital mortality rate in the SMT + HVPE group was lower than that in the SMT group, with a hazard ratio of 0.42 in the crude model and 0.34 (95% CI = 0.20-0.60 and p = 0.0002) in the adjusted model. CONCLUSION Our findings suggest that HVPE improves survival rates in surgical critically ill patients with medical jaundice and hepatic failure. However, due to its retrospective nature, further studies were warranted.
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Affiliation(s)
- Shih-Chi Wu
- School of Medicine, China Medical University, Taichung, Taiwan
- Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Chung Cheng
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Chieh Yeh
- Kidney Institute and Division of Nephrology, China Medical University Hospital, Taichung, Taiwan
| | - Han-Tsung Cheng
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Chun Wang
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Wei Tzeng
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Hao Hsu
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Hsin Muo
- Management Office for Health Data, China Medical University and Hospital, Taichung, Taiwan
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Basso C, Gennaro N, Dotto M, Ferroni E, Noale M, Avossa F, Schievano E, Aceto P, Tommasino C, Crucitti A, Incalzi RA, Volpato S, Petrini F, Carron M, Pace MC, Bettelli G, Chiumiento F, Corcione A, Montorsi M, Trabucchi M, Maggi S, Corti MC. Congestive heart failure and comorbidity as determinants of colorectal cancer perioperative outcomes. Updates Surg 2022; 74:609-617. [PMID: 34115323 PMCID: PMC8995267 DOI: 10.1007/s13304-021-01086-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/10/2021] [Indexed: 12/03/2022]
Abstract
There has been an increase in surgical interventions in frailer elderly with concomitant chronic diseases. The purpose of this paper was to evaluate the impact of aging and comorbidities on outcomes in patients who underwent surgery for the treatment of colorectal cancer (CRC) in Veneto Region (Northeastern Italy). This is a retrospective cohort study in patients ≥ 40 years who underwent elective or urgent CRC surgical resection between January 2013 and December 2015. Independent variables included: age, sex, and comorbidities. We analyzed variables associated with the surgical procedure, such as stoma creation, hospitalization during the year before the index surgery, the surgical approach used, the American Society of Anesthesiologists (ASA) score, and the Charlson Comorbidity Index score. Eight thousand four hundred and forty-seven patients with CRC underwent surgical resection. Patient age affected both pre- and post-resection LOS as well as the overall survival (OS); however, it did not affect the 30-day readmission and reoperation rates. Multivariate analysis showed that age represented a risk factor for longer preoperative and postoperative LOS as well as for 30-day and 365-day mortality, but it was not associated with an increased risk of 30-day reoperation and 30-day readmission. Chronic Heart Failure increased the 30-day mortality risk by four times, the preoperative LOS by 51%, and the postoperative LOS by 33%. Chronic renal failure was associated with a 74% higher 30-day readmission rate. Advanced age and comorbidities require a careful preoperative evaluation and appropriate perioperative management to improve surgical outcomes in older patients undergoing elective or urgent CRC resection.
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Affiliation(s)
- Cristina Basso
- Epidemiological Department (SER), Azienda Zero, Via Jacopo Avanzo 35, Veneto Region, 35132, Padua, Italy.
| | - Nicola Gennaro
- Epidemiological Department (SER), Azienda Zero, Via Jacopo Avanzo 35, Veneto Region, 35132, Padua, Italy
| | - Matilde Dotto
- Epidemiological Department (SER), Azienda Zero, Via Jacopo Avanzo 35, Veneto Region, 35132, Padua, Italy
| | - Eliana Ferroni
- Epidemiological Department (SER), Azienda Zero, Via Jacopo Avanzo 35, Veneto Region, 35132, Padua, Italy
| | - Marianna Noale
- National Research Council (CNR), Neuroscience Institute, Aging Branch, Padua, Italy
- Consorzio di Ricerca "Luigi Amaducci", Padua, Italy
| | - Francesco Avossa
- Epidemiological Department (SER), Azienda Zero, Via Jacopo Avanzo 35, Veneto Region, 35132, Padua, Italy
| | - Elena Schievano
- Epidemiological Department (SER), Azienda Zero, Via Jacopo Avanzo 35, Veneto Region, 35132, Padua, Italy
| | - Paola Aceto
- SIAARTI, Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Concezione Tommasino
- SIAARTI, Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care, Rome, Italy
- Department of Biomedical, Surgical and Odontoiatric Sciences, University of Milano, Anaesthesia and Intensive Care, Polo Universitario Ospedale San Paolo, Milan, Italy
| | - Antonio Crucitti
- SICG, Società Italiana di Chirurgia Geriatrica, Naples, Italy
- Cristo Re Hospital, Catholic University Rome, Rome, Italy
| | - Raffaele Antonelli Incalzi
- SIGG, Società Italiana di Geriatria e Gerontologia, Florence, Italy
- AIP, Società Italiana di Psicogeriatria, Brescia, Italy
- Cattedra di Medicina Interna e Geriatria, Università Campus Bio-Medico, Rome, Italy
| | - Stefano Volpato
- SIGG, Società Italiana di Geriatria e Gerontologia, Florence, Italy
- AIP, Società Italiana di Psicogeriatria, Brescia, Italy
- Dipartimento di Scienze Mediche, Università di Ferrara, Ferrara, Italy
| | - Flavia Petrini
- SIAARTI, Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care, Rome, Italy
- Perioperative Medicine, Pain Therapy, ICU and Emergency Department, Chieti-Pescara University, Pescara, Italy
| | - Michele Carron
- SIAARTI, Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care, Rome, Italy
- Department of Medicine, DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Padua, Italy
| | - Maria Caterina Pace
- Dipartimento di Scienze Biomediche, Chirurgiche ed Odontostomatologiche, Università di Milano, Milan, Italy
| | - Gabriella Bettelli
- SIAARTI, Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care, Rome, Italy
- University of San Marino, San Marino, San Marino
- Department of Anaestesia, Intensive Care, Day Surgery and Pain Therapy and Geriatric Surgery Area, IRCCS INRCA, Italian National Research Centres on Aging, Ancona, Italy
| | - Fernando Chiumiento
- SIAARTI, Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care, Rome, Italy
- Dipartimento Area Critica, ASL Salerno, Salerno, Italy
| | - Antonio Corcione
- Dipartimento di Area Critica UOC Anestesia e TIPO, AORN dei Colli-Monaldi, Naples, Italy
| | - Marco Montorsi
- SIC, Società Italiana di Chirurgia, Rome, Italy
- Humanitas University and Research Hospital IRCCS, Milan, Italy
| | | | - Stefania Maggi
- National Research Council (CNR), Neuroscience Institute, Aging Branch, Padua, Italy
- Consorzio di Ricerca "Luigi Amaducci", Padua, Italy
| | - Maria Chiara Corti
- Epidemiological Department (SER), Azienda Zero, Via Jacopo Avanzo 35, Veneto Region, 35132, Padua, Italy
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Sarcopenia estimation using psoas major enhances P-POSSUM mortality prediction in older patients undergoing emergency laparotomy: cross-sectional study. Eur J Trauma Emerg Surg 2021; 48:2003-2012. [PMID: 33884449 DOI: 10.1007/s00068-021-01669-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 04/07/2021] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Emergency laparotomy is a considerable component of a colorectal surgeon's workload and conveys substantial morbidity and mortality, particularly in older patients. Frailty is associated with poorer surgical outcomes. Frailty and sarcopenia assessment using Computed Tomography (CT) calculation of psoas major area predicts outcomes in elective and emergency surgery. Current risk predictors do not incorporate frailty metrics. We investigated whether sarcopenia measurement enhanced mortality prediction in over-65 s who underwent emergency laparotomy and emergency colorectal resection. METHODS An analysis of data collected prospectively during the National Emergency Laparotomy Audit (NELA) was conducted. Psoas major (PM) cross-sectional area was measured at the L3 level and a ratio of PM to L3 vertebral body area (PML3) was calculated. Outcome measures included inpatient, 30-day and 90-day mortality. Statistical analysis was conducted using Mann-Whitney, Chi-squared and receiver operating characteristics (ROC). Logistic regression was conducted using P-POSSUM variables with and without the addition of PML3. RESULTS Nine-hundred and forty-four over-65 s underwent emergency laparotomy from three United Kingdom hospitals were included. Median age was 76 years (IQR 70-82 years). Inpatient mortality was 21.9%, 30-day mortality was 16.3% and 90-day mortality was 20.7%. PML3 less than 0.39 for males and 0.31 for females indicated significantly worse outcomes (inpatient mortality 68% vs 5.6%, 30-day mortality 50.6% vs 4.0%,90-day mortality 64% vs 5.2%, p < 0.0001). PML3 was independently associated with mortality in multivariate analysis (p < 0.0001). Addition of PML3 to P-POSSUM variables improved area under the curve (AUC) on ROC analysis for inpatient mortality (P-POSSUM:0.78 vs P-POSSUM + PML3:0.917), 30-day mortality(P-POSSUM:0.802 vs P-POSSUM + PML3: 0.91) and 90-day mortality (P-POSSUM:0.79 vs P-POSSUM + PML3: 0.91). CONCLUSION PML3 is an accurate predictor of mortality in over-65 s undergoing emergency laparotomy. Addition of PML3 to POSSUM appears to improve mortality risk prediction.
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Portinari M, Bianchi L, De Troia A, Valpiani G, Spadaro S, Fogagnolo A, Acciarri P, Soliani G, Carcoforo P. Non-traumatic emergency abdominal surgery in nonagenarian patients: a retrospective study. Eur J Trauma Emerg Surg 2021; 48:1205-1216. [PMID: 33742224 DOI: 10.1007/s00068-021-01646-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/11/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The primary aim of this study was to evaluate the 30-day survival of nonagenarian patients who underwent non-traumatic emergency abdominal surgery. Other aims were: 90-day and 12-month survival rates, the postoperative complications rate, the impact of the emergency operation on postoperative functional status, the accuracy of the P-POSSUM in predicting 30-day postoperative mortality and changes in care services after surgery. METHODS This was a retrospective cohort study of nonagenarian patients who underwent non-traumatic emergency abdominal surgery between January 2010 and June 2017. Patients were divided in two groups according to the 30-day survival status to compare the distribution of patients' characteristics and postoperative outcomes. Overall survival was estimated using the Kaplan-Meier method. To assess the accuracy of P-POSSUM to predict 30-day mortality, a receiver operating characteristic curve and the Hosmer-Lemeshow goodness of fit test were used. RESULTS 85 nonagenarian patients were enrolled in this study; of these, 27 (31.8%) died within 30 days. The Kaplan-Meier curve showed a rapid decline in survival over the first 30 postoperative days, followed by a more gradual reduction during the rest of the first year. The majority of patients (92.6%) who died within 30 days experienced a medical complication, with a preponderance of respiratory failure (48.2%) and multiple organ failure (33.3%). In the surviving patients, the postoperative functional status had worsened, and 64.2% of patients did not return to their original housing situation or were institutionalized. The accuracy of P-POSSUM in predicting 30-day mortality in nonagenarian patients was poor. CONCLUSIONS This study may help doctors convey the postoperative risks of morbidity and mortality, and also to adequately inform relatives about the possible adverse discharge destination of surviving nonagenarian patients with a consequent increase in care needs.
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Affiliation(s)
- Mattia Portinari
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy. .,Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Università di Ferrara, Ferrara, Italia. .,Dipartimento Chirurgico, Azienda Ospedaliero-Universitaria, Arcispedale S. Anna di Ferrara, Via Aldo Moro, 8
- Stanza 2 34 39 (1C2), 44124, Ferrara, Cona, Italia.
| | - Lara Bianchi
- Department of Internal Medicine, University Hospital of Ferrara, Ferrara, Italy
| | - Alessandro De Troia
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy
| | - Giorgia Valpiani
- Research Innovation Quality and Accreditation Unit, University Hospital of Ferrara, Ferrara, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesiology and Intensive Care, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Alberto Fogagnolo
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesiology and Intensive Care, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Pierfilippo Acciarri
- Department of Surgery, Unit of Vascular Surgery, University Hospital of Ferrara, Ferrara, Italy
| | - Giorgio Soliani
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy
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Cao Y, Bass GA, Ahl R, Pourlotfi A, Geijer H, Montgomery S, Mohseni S. The statistical importance of P-POSSUM scores for predicting mortality after emergency laparotomy in geriatric patients. BMC Med Inform Decis Mak 2020; 20:86. [PMID: 32380980 PMCID: PMC7206787 DOI: 10.1186/s12911-020-1100-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 04/23/2020] [Indexed: 12/14/2022] Open
Abstract
Background Geriatric patients frequently undergo emergency general surgery and accrue a greater risk of postoperative complications and fatal outcomes than the general population. It is highly relevant to develop the most appropriate care measures and to guide patient-centered decision-making around end-of-life care. Portsmouth - Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) has been used to predict mortality in patients undergoing different types of surgery. In the present study, we aimed to evaluate the relative importance of the P-POSSUM score for predicting 90-day mortality in the elderly subjected to emergency laparotomy from statistical aspects. Methods One hundred and fifty-seven geriatric patients aged ≥65 years undergoing emergency laparotomy between January 1st, 2015 and December 31st, 2016 were included in the study. Mortality and 27 other patient characteristics were retrieved from the computerized records of Örebro University Hospital in Örebro, Sweden. Two supervised classification machine methods (logistic regression and random forest) were used to predict the 90-day mortality risk. Three scalers (Standard scaler, Robust scaler and Min-Max scaler) were used for variable engineering. The performance of the models was evaluated using accuracy, sensitivity, specificity and area under the receiver operating characteristic curve (AUC). Importance of the predictors were evaluated using permutation variable importance and Gini importance. Results The mean age of the included patients was 75.4 years (standard deviation =7.3 years) and the 90-day mortality rate was 29.3%. The most common indication for surgery was bowel obstruction occurring in 92 (58.6%) patients. Types of post-operative complications ranged between 7.0–36.9% with infection being the most common type. Both the logistic regression and random forest models showed satisfactory performance for predicting 90-day mortality risk in geriatric patients after emergency laparotomy, with AUCs of 0.88 and 0.93, respectively. Both models had an accuracy > 0.8 and a specificity ≥0.9. P-POSSUM had the greatest relative importance for predicting 90-day mortality in the logistic regression model and was the fifth important predictor in the random forest model. No notable change was found in sensitivity analysis using different variable engineering methods with P-POSSUM being among the five most accurate variables for mortality prediction. Conclusion P-POSSUM is important for predicting 90-day mortality after emergency laparotomy in geriatric patients. The logistic regression model and random forest model may have an accuracy of > 0.8 and an AUC around 0.9 for predicting 90-day mortality. Further validation of the variables’ importance and the models’ robustness is needed by use of larger dataset.
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Affiliation(s)
- Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, 70182, Örebro, Sweden.
| | - Gary A Bass
- Faculty of Medicine and Health, School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.,Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Rebecka Ahl
- Faculty of Medicine and Health, School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.,Department of General Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Arvid Pourlotfi
- Faculty of Medicine and Health, School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.,Department of General Surgery, Örebro University Hospital, Örebro, Sweden
| | - Håkan Geijer
- Department of Radiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, 70182, Örebro, Sweden.,Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, 17177, Stockholm, Sweden.,Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, UK
| | - Shahin Mohseni
- Faculty of Medicine and Health, School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.,Department of General Surgery, Örebro University Hospital, Örebro, Sweden
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Kim SY, Kim JH, Chin H, Jun KH. Prediction of postoperative mortality and morbidity in octogenarians with gastric cancer - Comparison of P-POSSUM, O-POSSUM, and E-POSSUM: A retrospective single-center cohort study. Int J Surg 2020; 77:64-68. [PMID: 32198101 DOI: 10.1016/j.ijsu.2020.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/24/2020] [Accepted: 03/15/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate various POSSUM scoring systems in predicting postoperative morbidity and mortality in elderly patients with gastric cancer. METHODS A total of 1262 patients with gastric cancer who underwent curative gastrectomy between January 2006 and December 2013 were retrospectively reviewed. The subjects were stratified by age into <80 years old and ≥80 years old. To assess the predictability and efficacy of various POSSUM scores (POSSUM, P-POSSUM, O-POSSUM, and E-POSSUM), the observed-to-expected (O:E) ratio and area under the receiver operating characteristic curve (AUC) were calculated and compared with actual postoperative morbidity and mortality. RESULTS Among the 1262 patients, 75 were elderly (≥80 years old). The observed mortality rates were 0.5% (n = 6) in the whole cohort, and 4.0% (n = 3) in elderly patients. The predicted mortalities of POSSUM, P-POSSUM, E-POSSUM, and O-POSSUM for elderly patients were 13.2%, 5.3%, 5.7%, and 21.8%, respectively (O:E ratio = 0.3, 0.75, 0.7, and 0.18, respectively). P-POSSUM and E-POSSUM showed superior discriminatory power compared to POSSUM and O-POSSUM. In terms of morbidity, E-POSSUM showed better predictive capabilities than POSSUM in elderly patients (O:E ratio = 0.56 and 0.74, respectively). CONCLUSIONS All POSSUM scoring systems tend to overestimate postoperative mortality and morbidity in gastric cancer patients. E-POSSUM and P-POSSUM provided a better prediction of mortality and morbidity after curative gastrectomy in elderly patients compared to other POSSUM scores.
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Affiliation(s)
- Shinn Young Kim
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji-Hyun Kim
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyungmin Chin
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyong-Hwa Jun
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Emergency General Surgery in Older Patients: Where Are We Now? CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00352-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Er S, Sevim Y, Özden S, Tikici D, Yıldız BD, Yüksel BC, Turan UF, Tez M. A novel simplified scoring system for predicting mortality in emergency colorectal surgery: prediction model development. SAO PAULO MED J 2019; 137:132-136. [PMID: 31314873 PMCID: PMC9721224 DOI: 10.1590/1516-3180.2018.0316240119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 08/06/2018] [Accepted: 01/24/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Despite advances in surgical approaches, emergency colorectal surgery has high mortality and morbidity. OBJECTIVE We aimed to create a simple and distinctive scoring system, for predicting mortality among patients undergoing emergency colorectal surgery. DESIGN AND SETTING Prediction model development study based on retrospective data-gathering. METHODS Patients who underwent emergency colorectal surgery between March 2014 and December 2016 at a single tertiary-level referral center were included in our study. Patient demographics, comorbidities, type of surgery, etiology and laboratory and radiological findings were collected retrospectively and analyzed. A new clinical score (named the Numune emergency colorectal resection score) was constructed from the last logistic regression model, in which one point was assigned for the presence of each predictive factor. RESULTS 138 patients underwent emergency colorectal surgery. These comprised 64 males (46.4%) and 74 females (53.6%), with a mean age of 64 years. Multivariate analysis revealed that blood urea nitrogen level > 65 mg/dl (odds ratio, OR: 8.03; 95% confidence interval, CI: 2.16-15.77), albumin level < 0.7 -mg/-dl (OR: 4.43; 95% CI: 1.96-14.39) and American Society of Anesthesiologists score ≥ 3 (OR: 3.47; 95% CI: 0.81-9.18) were associated with postoperative complications. The Numune score was graded from I to III. The risk of mortality was found to be 63.2% in the group with grade III, which accounted for 35.2% of the subjects. There were 37 postoperative deaths. CONCLUSIONS Surgeons need scoring systems, especially to predict postoperative mortality. We propose the Numune emergency colorectal resection score for emergency surgical procedures as a practical, usable and effective system for predicting postoperative morbidity.
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Affiliation(s)
- Sadettin Er
- MD. Attending Physician, Department of Surgery, Ankara Numune Eğitim ve Araştırma Hastanesi, Ankara, Turkey.
| | - Yusuf Sevim
- MD. Associate Professor, Department of Surgery, Ankara Numune Eğitim ve Araştırma Hastanesi, Ankara, Turkey.
| | - Sabri Özden
- MD. Attending Physician, Department of Surgery, Ankara Numune Eğitim ve Araştırma Hastanesi, Ankara, Turkey.
| | - Deniz Tikici
- MD. Attending Physician, Department of Surgery, Ankara Numune Eğitim ve Araştırma Hastanesi, Ankara, Turkey.
| | - Barış Doğu Yıldız
- MD. Associate Professor, Department of Surgery, Ankara Numune Eğitim ve Araştırma Hastanesi, Ankara, Turkey.
| | - Bülent Cavit Yüksel
- MD. Associate Professor, Department of Surgery, Ankara Numune Eğitim ve Araştırma Hastanesi, Ankara, Turkey.
| | - Umut Fırat Turan
- MD. Attending Physician, Department of Surgery, Ankara Numune Eğitim ve Araştırma Hastanesi, Ankara, Turkey.
| | - Mesut Tez
- MD. Associate Professor, Department of Surgery, Ankara Numune Eğitim ve Araştırma Hastanesi, Ankara, Turkey.
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A comparative study of risk of pneumonia and mortalities between nasogastric and jejunostomy feeding routes in surgical critically ill patients with perforated peptic ulcer. PLoS One 2019; 14:e0219258. [PMID: 31269088 PMCID: PMC6608947 DOI: 10.1371/journal.pone.0219258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 06/19/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Enteral nutrition (EN) is important in the management of critically illness. Yet, the best route (e.g. pre-pyloric or post-pyloric) for EN in critically ill patients remains to be investigated, especially in specific surgical patients group. In addition, EN could be associated with a higher risk of aspiration pneumonia. Therefore, we evaluate the effect of various EN routes in surgical critically ill perforated peptic ulcer (PPU) patients who underwent surgery and required mechanical ventilation. METHOD We collected data of surgical critically ill PPU patients admitted to intensive care unit. The patients were managed with appropriate care bundle and program. To reduce the impact of surgery types, we excluded those who had received other surgical procedures and included patients that only received simple closure. Patients were classified into nasogastric and jejunostomy feeding groups. The demographics, severity scores (e.g.: APACHE II, SOFA, and POSSUM), body mass index (BMI), comorbidities, ventilator days, use of proton pump inhibitors (PPIs), pneumonia occurrence, mortality and complications were collected for analysis. RESULTS A total of 136 critically ill PPU patients that received surgery and mechanical ventilation were enrolled. There were 53 patients in NG group and 83 patients in FJ group. There were no differences in demographics, severity scores, BMI, comorbidities, ventilator days, use of PPIs, pneumonia occurrence, mortalities and complications between groups. CONCLUSION Our study indicates that there are no differences in mortalities and pneumonia occurrence using nasogastric or feeding jejunostomy in surgical critically ill PPU patients underwent surgery. However, further studies are required.
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van Boxel GI, McLure S, Jones K, Jones G. Inter-operator variability in pPOSSUM scores: a note of caution. Br J Hosp Med (Lond) 2019; 80:343-347. [PMID: 31180764 DOI: 10.12968/hmed.2019.80.6.343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE Predicting perioperative morbidity and mortality can be achieved by several risk predicting algorithms. In the UK, the National Emergency Laparotomy Audit, mandated for all patients undergoing emergency laparotomy, uses pPOSSUM as its risk prediction tool. However, there is no literature reporting the inter-operator variability in calculating the score. Inter-rater variability was assessed based on 10 real general surgical cases that went on to have an emergency laparotomy. METHODS Forty clinicians, 10 each of registrars and consultants in anaesthetics and general surgery, were asked to calculate the pPOSSUM based on the clinical information typically available at the time of making the decision to proceed to emergency laparotomy for the same 10 National Emergency Laparotomy Audit cases. All participants were surveyed to assess their understanding and use of the pPOSSUM score. RESULTS More than 80% of respondents stated that they use pPOSSUM in daily clinical practice. There was variability in the calculated scores between the groups analysed. Two subgroups were evident: one in which the calculated mean pPOSSUM was similar between participants but did not reflect the true value, and the other which was accurate, but demonstrated high inter-rater variability. CONCLUSIONS This is the first study to investigate inter-operator variability in pPOSSUM scores. Previous reports on the validity of the tool fail to account for subjective variation. At a time where pPOSSUM has become a routine part of clinical practice, this variability needs to be accounted for and taken into consideration in the decision-making process.
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Affiliation(s)
- Gijsbert I van Boxel
- Surgical Registrar, Department of General Surgery, Royal Berkshire Hospital, Reading RG1 5AN
| | - Stewart McLure
- Core Trainee in Anaesthetics, Department of Anaesthetics, Royal Berkshire Hospital, Reading
| | - Keaton Jones
- Surgical Registrar, Department of General Surgery, Oxford University Hospitals Foundation Trust, Oxford
| | - Gregory Jones
- Consultant, Department of General Surgery, Royal Berkshire Hospital, Reading
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McGuckin DG, Mufti S, Turner DJ, Bond C, Moonesinghe SR. The association of peri-operative scores, including frailty, with outcomes after unscheduled surgery. Anaesthesia 2018; 73:819-824. [DOI: 10.1111/anae.14269] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2018] [Indexed: 12/15/2022]
Affiliation(s)
| | - S. Mufti
- Elderly Care; Homerton University Hospital NHS Foundation Trust; London UK
| | - D. J. Turner
- Stroke and Geriatric Medicine; University College Hospital; London UK
| | - C. Bond
- Medicine for the Elderly; University College Hospital; London UK
| | - S. R. Moonesinghe
- Surgical Outcomes Research Centre; UCL/UCKH; London UK
- Health Services Research Centre, National Institute of Academic Anaesthesia; Royal College of Anaesthetists; London UK
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Sudlow A, Tuffaha H, Stearns AT, Shaikh IA. Outcomes of surgery in patients aged ≥90 years in the general surgical setting. Ann R Coll Surg Engl 2018; 100:172-177. [PMID: 29364011 PMCID: PMC5930088 DOI: 10.1308/rcsann.2017.0203] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction An increasing proportion of the population is living into their nineties and beyond. These high risk patients are now presenting more frequently to both elective and emergency surgical services. There is limited research looking at outcomes of general surgical procedures in nonagenarians and centenarians to guide surgeons assessing these cases. Methods A retrospective analysis was conducted of all patients aged ≥90 years undergoing elective and emergency general surgical procedures at a tertiary care facility between 2009 and 2015. Vascular, breast and endocrine procedures were excluded. Patient demographics and characteristics were collated. Primary outcomes were 30-day and 90-day mortality rates. The impact of ASA (American Society of Anesthesiologists) grade, operation severity and emergency presentation was assessed using multivariate analysis. Results Overall, 161 patients (58 elective, 103 emergency) were identified for inclusion in the study. The mean patient age was 92.8 years (range: 90-106 years). The 90-day mortality rates were 5.2% and 19.4% for elective and emergency procedures respectively (p=0.013). The median survival was 29 and 19 months respectively (p=0.001). Emergency and major gastrointestinal operations were associated with a significant increase in mortality. Patients undergoing emergency major colonic or upper gastrointestinal surgery had a 90-day mortality rate of 53.8%. Conclusions The risk for patients aged over 90 years having an elective procedure differs significantly in the short term from those having emergency surgery. In selected cases, elective surgery carries an acceptable mortality risk. Emergency surgery is associated with a significantly increased risk of death, particularly after major gastrointestinal resections.
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Affiliation(s)
- A Sudlow
- Norfolk and Norwich University Hospitals NHS Foundation Trust, UK
| | - H Tuffaha
- Norfolk and Norwich University Hospitals NHS Foundation Trust, UK
| | - AT Stearns
- Norfolk and Norwich University Hospitals NHS Foundation Trust, UK
| | - IA Shaikh
- Norfolk and Norwich University Hospitals NHS Foundation Trust, UK
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Imaoka Y, Kuranishi F, Ogawa Y. Usefulness of Totally Implantable Central Venous Access Devices in Elderly Patients: A Retrospective Study. ANNALS OF NUTRITION AND METABOLISM 2018; 72:112-116. [PMID: 29353284 DOI: 10.1159/000486534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 12/28/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS The need for totally implantable central venous access devices (TICVADs) has increased with increased opportunities in the use of chemotherapy and parenteral nutrition. This study aimed to determine the outcomes of TICVAD implantation and use in patients aged ≥85 years. METHODS Between January 2010 and August 2016, 117 patients underwent TICVAD implantation and their records were retrospectively reviewed. RESULTS Participants were divided into 2 groups (plus-85 and sub-85 groups). Fifty-five patients (47.0%) had solid organ cancer alone; 35 patients (29.9%) had cerebrovascular or cranial nerve disease. The average follow-up period was 201 (2-1,620) days. Major complications were identified in 6 (14.6%) plus-85 patients and 11 (14.5%) sub-85 patients (p = 0.9813). Catheter-related infections developed in 3 plus-85 (7.3%) and 4 sub-85 patients (5.3%; p = 0.6549). There were no significant group differences in hematoma, pneumothorax, occlusion, and removal rates. In plus-85 patients examined just before surgery and a month after surgery, increased rates of serum albumin and Onodera's prognostic nutritional index were observed in 48% (14/39) and 41% (12/39), respectively. CONCLUSIONS The use of TICVADs in the plus-85 group resulted in effective outcomes. The results of this retrospective study support the wider use of TICVADs in patients aged ≥85 years.
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Affiliation(s)
- Yuki Imaoka
- Department of Surgery, Innoshima Ishikai Hospital, Hiroshima, Japan.,Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Fumito Kuranishi
- Department of Surgery, Innoshima Ishikai Hospital, Hiroshima, Japan
| | - Yoshiteru Ogawa
- Department of Surgery, Innoshima Ishikai Hospital, Hiroshima, Japan
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Zietlow K, McDonald SR, Sloane R, Browndyke J, Lagoo-Deenadayalan S, Heflin MT. Preoperative Cognitive Impairment As a Predictor of Postoperative Outcomes in a Collaborative Care Model. J Am Geriatr Soc 2018; 66:584-589. [PMID: 29332302 DOI: 10.1111/jgs.15261] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To compare postoperative outcomes of individuals with and without cognitive impairment enrolled in the Perioperative Optimization of Senior Health (POSH) program at Duke University, a comanagement model involving surgery, anesthesia, and geriatrics. DESIGN Retrospective analysis of individuals enrolled in a quality improvement program. SETTING Tertiary academic center. PARTICIPANTS Older adults undergoing surgery and referred to POSH (N = 157). MEASUREMENTS Cognitive impairment was defined as a score less than 25 out of 30 (adjusted for education) on the St. Louis University Mental Status (SLUMS) Examination. Median length of stay (LOS), mean number of postoperative complications, rates of postoperative delirium (POD, %), 30-day readmissions (%), and discharge to home (%) were compared using bivariate analysis. RESULTS Seventy percent of participants met criteria for cognitive impairment (mean SLUMS score 20.3 for those with cognitive impairment and 27.7 for those without). Participants with and without cognitive impairment did not significantly differ in demographic characteristics, number of medications (including anticholinergics and benzodiazepines), or burden of comorbidities. Participants with and without cognitive impairment had similar LOS (P = .99), cumulative number of complications (P = .70), and 30-day readmission (P = .20). POD was more common in those with cognitive impairment (31% vs 24%), but the difference was not significant (P = .34). Participants without cognitive impairment had higher rates of discharge to home (80.4% vs 65.1%, P = .05). CONCLUSION Older adults with and without cognitive impairment referred to the POSH program fared similarly on most postoperative outcomes. Individuals with cognitive impairment may benefit from perioperative geriatric comanagement. Questions remain regarding the validity of available measures of cognition in the preoperative period.
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Affiliation(s)
- Kahli Zietlow
- Division of Geriatrics, Department of Internal Medicine, Duke University Health Systems, Durham, North Carolina
| | - Shelley R McDonald
- Division of Geriatrics, Department of Internal Medicine, Duke University Health Systems, Durham, North Carolina
| | - Richard Sloane
- Center for Aging, Duke University Health Systems, Durham, North Carolina
| | - Jeffrey Browndyke
- Division of Geriatric Behavioral Health, Department of Psychiatry, Duke University Health Systems, Durham, North Carolina
| | | | - Mitchell T Heflin
- Division of Geriatrics, Department of Internal Medicine, Duke University Health Systems, Durham, North Carolina.,Center for Aging, Duke University Health Systems, Durham, North Carolina
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Shen Z, Lin Y, Ye Y, Jiang K, Xie Q, Gao Z, Wang S. The development and validation of a novel model for predicting surgical complications in colorectal cancer of elderly patients: Results from 1008 cases. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018; 44:490-495. [PMID: 29402555 DOI: 10.1016/j.ejso.2018.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 11/14/2017] [Accepted: 01/05/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To establish predicting models of surgical complications in elderly colorectal cancer patients. BACKGROUND Surgical complications are usually critical and lethal in the elderly patients. However, none of the current models are specifically designed to predict surgical complications in elderly colorectal cancer patients. METHODS Details of 1008 cases of elderly colorectal cancer patients (age ≥ 65) were collected retrospectively from January 1998 to December 2013. Seventy-six clinicopathological variables which might affect postoperative complications in elderly patients were recorded. Multivariate stepwise logistic regression analysis was used to develop the risk model equations. The performance of the developed model was evaluated by measures of calibration (Hosmer-Lemeshow test) and discrimination (the area under the receiver-operator characteristic curve, AUC). RESULTS The AUC of our established Surgical Complication Score for Elderly Colorectal Cancer patients (SCSECC) model was 0.743 (sensitivity, 82.1%; specificity, 78.3%). There was no significant discrepancy between observed and predicted incidence rates of surgical complications (AUC, 0.820; P = .812). The Surgical Site Infection Score for Elderly Colorectal Cancer patients (SSISECC) model showed significantly better prediction power compared to the National Nosocomial Infections Surveillance index (NNIS) (AUC, 0.732; P ˂ 0.001) and Efficacy of Nosocomial Infection Control index (SENIC) (AUC; 0.686; P˂0.001) models. CONCLUSIONS The SCSECC and SSISECC models show good prediction power for postoperative surgical complication morbidity and surgical site infection in elderly colorectal cancer patients.
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Affiliation(s)
- Zhanlong Shen
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China.
| | - Yuanpei Lin
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China
| | - Yingjiang Ye
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China.
| | - Kewei Jiang
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China
| | - Qiwei Xie
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China
| | - Zhidong Gao
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China
| | - Shan Wang
- Department of Gastroenterological Surgery, Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China
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Perioperative risk prediction in the era of enhanced recovery: a comparison of POSSUM, ACPGBI, and E-PASS scoring systems in major surgical procedures of the colorectal surgeon. Int J Colorectal Dis 2018; 33:1627-1634. [PMID: 30078107 PMCID: PMC6208691 DOI: 10.1007/s00384-018-3141-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE This study aims to determine whether traditional risk models can accurately predict morbidity and mortality in patients undergoing major surgery by colorectal surgeons within an enhanced recovery program. METHODS One thousand three hundred eighty patients undergoing surgery performed by colorectal surgeons in a single UK hospital (2008-2013) were included. Six risk models were evaluated: (1) Physiology and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM), (2) Portsmouth POSSUM (P-POSSUM), (3) ColoRectal (CR-POSSUM), (4) Elderly POSSUM (E-POSSUM), (5) the Association of Great Britain and Ireland (ACPGBI) score, and (6) modified Estimation of Physiologic Ability and Surgical Stress Score (E-PASS). Model accuracy was assessed by observed to expected (O:E) ratios and area under Receiver Operating Characteristic curve (AUC). RESULTS Eleven patients (0.8%) died and 143 patients (10.4%) had a major complication within 30 days of surgery. All models overpredicted mortality and had poor discrimination: POSSUM 8.5% (O:E 0.09, AUC 0.56), P-POSSUM 2.2% (O:E 0.37, AUC 0.56), CR-POSSUM 7.1% (O:E 0.11, AUC 0.61), and E-PASS 3.0% (O:E 0.27, AUC 0.46). ACPGBI overestimated mortality in patients undergoing surgery for cancer 4.4% (O:E = 0.28, AUC = 0.41). Predicted morbidity was also overestimated by POSSUM 32.7% (O:E = 0.32, AUC = 0.51). E-POSSUM overestimated mortality (3.25%, O:E 0.57 AUC = 0.54) and morbidity (37.4%, O:E 0.30 AUC = 0.53) in patients aged ≥ 70 years and over. CONCLUSION All models overestimated mortality and morbidity. New models are required to accurately predict the risk of adverse outcome in patients undergoing major abdominal surgery taking into account the reduced physiological and operative insult of laparoscopic surgery and enhanced recovery care.
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Abstract
Older adults undergoing elective surgical procedures suffer higher rates of morbidity and mortality than younger patients. A geriatric-focused preoperative evaluation can identify risk factors for complications and opportunities for health optimization and care coordination. Key components of a geriatric preoperative evaluation include (1) assessments of function, mobility, cognition, and mental health; (2) reviews of medical conditions and medications; and (3) discussion of risks, preferences, and goals of care. A geriatric-focused, team-based approach can improve surgical outcomes and patient experience.
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Affiliation(s)
- Julianna G Marwell
- Department of Medicine, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, USA
| | - Mitchell T Heflin
- Division of Geriatrics, Duke University School of Medicine, DUMC Box 3003, Durham, NC 27710, USA
| | - Shelley R McDonald
- Division of Geriatrics, Duke University School of Medicine, DUMC Box 3003, Durham, NC 27710, USA.
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Beisani M, Vallribera F, García A, Mora L, Biondo S, Lopez-Borao J, Farrés R, Gil J, Espin E. Subtotal colectomy versus left hemicolectomy for the elective treatment of splenic flexure colonic neoplasia. Am J Surg 2017; 216:251-254. [PMID: 28709626 DOI: 10.1016/j.amjsurg.2017.06.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 06/05/2017] [Accepted: 06/13/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Optimal elective surgical treatment for splenic flexure neoplasm (SFN) is unclear. Subtotal colectomy (STC) and left hemicolectomy (LHC) are the two more common strategies used. METHODS Observational multicentric study comparing postoperative morbidity, mortality and long-term survival on patients with SFN electively operated by STC versus LHC between 2003 and 2014. RESULTS After revision of the databases, 144 patients were included (STC group, n = 68; LHC group, n = 76). No differences were found on epidemiological and surgical data. A higher global morbidity (58%vs37%, p = 0.014), surgical morbidity (50%vs33%, p = 0.037), postoperative ileus (37%vs20%, p = 0.023) and harvested lymph nodes (26vs18, p = 0.0001) were found on the STC group. No significant differences in complications according to severity, reoperation rate, hospital stay, mortality, recurrence or long-term survival were found between groups. CONCLUSIONS A higher surgical morbidity was found on the STC group, mainly due to mild postoperative ileus. No differences on long-term oncological results were found.
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Affiliation(s)
- Marc Beisani
- Department of Surgery, Colorectal Unit, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain.
| | - Francesc Vallribera
- Department of Surgery, Colorectal Unit, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain.
| | - Albert García
- Department of Surgery, Corporació Sanitària Parc Taulí, Parc Taulí, 1, 08208, Sabadell, Barcelona, Spain.
| | - Laura Mora
- Department of Surgery, Corporació Sanitària Parc Taulí, Parc Taulí, 1, 08208, Sabadell, Barcelona, Spain.
| | - Sebastiano Biondo
- Department of Surgery, Colorectal Unit, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Jaime Lopez-Borao
- Department of Surgery, Colorectal Unit, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Ramon Farrés
- Department of Surgery, Hospital Universitari de Girona Ramon Trueta, Avinguda de França, s/n, 17007, Girona, Spain.
| | - Júlia Gil
- Department of Surgery, Hospital Universitari de Girona Ramon Trueta, Avinguda de França, s/n, 17007, Girona, Spain.
| | - Eloy Espin
- Department of Surgery, Colorectal Unit, Hospital Universitari Vall d'Hebron, Autonomous University of Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain.
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Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity and modified Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity for the mortality prediction among nonagenarians undergoing emergency surgery. J Surg Res 2017; 210:198-203. [PMID: 28457329 DOI: 10.1016/j.jss.2016.11.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/02/2016] [Accepted: 11/23/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND The aims of this study were to determine the outcomes of emergency abdominal surgery in patients aged ≥90 y and to analyze the role of Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and modified POSSUM in predicting their morbidity and mortality. MATERIALS AND METHODS Patients aged ≥90 y who underwent emergency abdominal surgery from January 2011 to December 2014 were enrolled in this study. RESULTS A total of 36 patients satisfied the inclusion criteria. The mortality and morbidity rates in the study group were 8.3% and 61.1%, respectively. Overall observed-to-expected morbidity ratio calculated by POSSUM and modified POSSUM were 0.83 (χ2 = 32.189, P = 0.6045) and 0.97 (χ2 = 33.915, P = 0.7398), respectively. Both models demonstrated a good fit for prediction of morbidity. Overall observed-to-expected mortality ratios calculated by POSSUM and modified POSSUM were 0.26 (χ2 = 12.217, P = 0.2013) and 0.20 (χ2 = 12.217, P = 0.0936), respectively. CONCLUSIONS Both POSSUM and modified POSSUM accurately predicted morbidity in the setting of emergency abdominal surgery in nonagenarians.
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20
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Armas-Bencomo A, Tamargo-Barbeito TO, Fuentes-Valdés E, Jiménez-Paneque RE. Severity of illness index for surgical departments in a Cuban hospital: a revalidation study. Medwave 2017; 17:e6880. [PMID: 28306707 DOI: 10.5867/medwave.2017.02.6880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 01/26/2016] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION In the context of the evaluation of hospital services, the incorporation of severity indices allows an essential control variable for performance comparisons in time and space through risk adjustment. The severity index for surgical services was developed in 1999 and validated as a general index for surgical services. Sixteen years later the hospital context is different in many ways and a revalidation was considered necessary to guarantee its current usefulness. OBJECTIVE To evaluate the validity and reliability of the surgical services severity index to warrant its reasonable use under current conditions. METHODS A descriptive study was carried out in the General Surgery service of the "Hermanos Ameijeiras" Clinical Surgical Hospital of Havana, Cuba during the second half of 2010. We reviewed the medical records of 511 patients discharged from this service. Items were the same as the original index as were their weighted values. Conceptual or construct validity, criterion validity and inter-rater reliability as well as internal consistency of the proposed index were evaluated. RESULTS Construct validity was expressed as a significant association between the value of the severity index for surgical services and discharge status. A significant association was also found, although weak, with length of hospital stay. Criterion validity was demonstrated through the correlations between the severity index for surgical services and other similar indices. Regarding criterion validity, the Horn index showed a correlation of 0.722 (95% CI: 0.677-0.761) with our index. With the POSSUM score, correlation was 0.454 (95% CI: 0.388-0.514) with mortality risk and 0.539 (95% CI: 0.462-0.607) with morbidity risk. Internal consistency yielded a standardized Cronbach's alpha of 0.8; inter-rater reliability resulted in a reliability coefficient of 0.98 for the quantitative index and a weighted global Kappa coefficient of 0.87 for the ordinal surgical index of severity for surgical services (IGQ). CONCLUSIONS The validity and reliability of the proposed index was satisfactory in all aspects evaluated. The surgical services severity index may be used in the original context and is easily adaptable to other contexts as well.
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Affiliation(s)
- Amadys Armas-Bencomo
- Departamento de Admisión, Archivo y Estadística, Centro de Investigaciones Médico Quirúrgico (CIMEQ), La Habana, Cuba. Address: Calle San Lázaro 701, Centro Habana, La Habana, Cuba.
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Abstract
As the number of older patients with cancer is increasing, oncology disciplines are faced with the challenge of managing patients with multiple chronic conditions who have difficulty maintaining independence, who may have cognitive impairment, and who also may be more vulnerable to adverse outcomes. National and international societies have recommended that all older patients with cancer undergo geriatric assessment (GA) to detect unaddressed problems and introduce interventions to augment functional status to possibly improve patient survival. Several predictive models have been developed, and evidence has shown correlation between information obtained through GA and treatment-related complications. Comprehensive geriatric evaluations and effective interventions on the basis of GA may prove to be challenging for the oncologist because of the lack of the necessary skills, time constraints, and/or limited available resources. In this article, we describe how the Geriatrics Service at Memorial Sloan Kettering Cancer Center approaches an older patient with colon cancer from presentation to the end of life, show the importance of GA at the various stages of cancer treatment, and how predictive models are used to tailor the treatment. The patient's needs and preferences are at the core of the decision-making process. Development of a plan of care should always include the patient's preferences, but it is particularly important in the older patient with cancer because a disease-centered approach may neglect noncancer considerations. We will elaborate on the added value of co-management between the oncologist and a geriatric nurse practitioner and on the feasibility of adapting elements of this model into busy oncology practices.
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Affiliation(s)
| | - Soo Jung Kim
- Memorial Sloan Kettering Cancer Center, New York, NY
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Abe T, Shirabe K, Harimoto N, Gion T, Nagaie T, Kajiyama K. Prediction of 30-day mortality after emergency surgery for colorectal perforation. Eur Surg 2017. [DOI: 10.1007/s10353-016-0460-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lee YH, Oh HK, Kim DW, Ihn MH, Kim JH, Son IT, Kang SI, Kim GI, Ahn S, Kang SB. Use of a Comprehensive Geriatric Assessment to Predict Short-Term Postoperative Outcome in Elderly Patients With Colorectal Cancer. Ann Coloproctol 2016; 32:161-169. [PMID: 27847786 PMCID: PMC5108662 DOI: 10.3393/ac.2016.32.5.161] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/07/2016] [Indexed: 11/21/2022] Open
Abstract
Purpose This study was conducted to identify the effectiveness of a preoperative comprehensive geriatric assessment (CGA) for predicting postoperative morbidity in elderly patients who underwent surgery for colorectal cancer. Methods Elderly patients (≥70 years old) who underwent surgery for colorectal cancer at a tertiary hospital in Korea were identified, and their cases were analyzed using data from a prospectively collected database to establish an association between major postsurgical complications and 'high-risk' patient as defined by the CGA. Results A total of 240 patients, with a mean age of 76.7 ± 5.2 years, were enrolled. Ninety-five patients (39.6%) were classified as "high-risk" and 99 patients (41.3%) as having postoperative complications. The univariate analysis indicated that risk factors for postoperative complications were age, American Society of Anesthesiologists physical status classification, serum hemoglobin, carcinoembryonic antigen, cancer stage, and "high-risk" status. The multivariable analyses indicated that "high-risk" status (odds ratio, 2.107; 95% confidence interval, 1.168–3.804; P = 0.013) and elevated preoperative carcinoembryonic antigen (odds ratio, 2.561; 95% confidence interval, 1.346–4.871, P = 0.004) were independently associated with postoperative complications. A multivariable analysis of the individual CGA domains indicated that high comorbidities and low activities of daily living were significantly related with postoperative complications. Conclusion A preoperative CGA indicating "high-risk" was associated with major postoperative complications in elderly patients who underwent surgery for colorectal cancer. Thus, using the CGA to identify elderly colorectal-cancer patients who should be given more care during postoperative management may be clinically beneficial.
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Affiliation(s)
- Yoon Hyun Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Myong Hoon Ihn
- Department of Surgery, Soonchunhyang University Gumi Hospital, Gumi, Korea
| | - Jee Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Il Tae Son
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung Il Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Gwang Il Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Soyeon Ahn
- Division of Statistics, Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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Manceau G, Hain E, Maggiori L, Mongin C, Prost À la Denise J, Panis Y. Is the benefit of laparoscopy maintained in elderly patients undergoing rectal cancer resection? An analysis of 446 consecutive patients. Surg Endosc 2016; 31:632-642. [PMID: 27317029 DOI: 10.1007/s00464-016-5009-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 05/27/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Several studies showed that age is significantly associated with impaired outcomes after open colorectal surgery. However, very few data exist on laparoscopic rectal cancer surgery in elderly patients. The aim of this study was to assess operative results of laparoscopic rectal cancer surgery according to age. METHODS From 2005 to 2014, 446 consecutive patients who underwent laparoscopic rectal cancer resection were identified from a prospective database. Five groups were defined: age <45 (n = 44), 45-54 (n = 80), 55-64 (n = 166), 65-74 (n = 95) and ≥75 years (n = 61). RESULTS Elderly patients presented significantly higher ASA score (p = 0.004), higher Charlson comorbidity index (p < 0.0001) and more frequent cardiovascular, pulmonary (p < 0.0001) and neurological (p = 0.03) comorbidities. Overall postoperative morbidity rate was similar between groups (34-35-37-43-43 %, p = 0.70). Medical morbidity slightly increased with age (14-9-14-19-26 %, p = 0.06), but there was no significant difference regarding clinical anastomotic leakage, surgical morbidity, major morbidity (Dindo ≥3), cardiopulmonary complications and length of hospital stay. In multivariate analysis, age was not an independent factor for postoperative morbidity, unlike ASA score ≥3 (p = 0.039), neoadjuvant radiotherapy/chemoradiotherapy (p = 0.034) and operative time ≥240 min (p = 0.013). CONCLUSIONS This study showed that laparoscopic rectal cancer resection might safely be performed irrespective of age.
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Affiliation(s)
- Gilles Manceau
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Denis Diderot University (Paris VII), 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Elisabeth Hain
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Denis Diderot University (Paris VII), 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Léon Maggiori
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Denis Diderot University (Paris VII), 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Cécile Mongin
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Denis Diderot University (Paris VII), 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Justine Prost À la Denise
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Denis Diderot University (Paris VII), 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Denis Diderot University (Paris VII), 100 Boulevard du Général Leclerc, 92110, Clichy, France.
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Wagner D, DeMarco MM, Amini N, Buttner S, Segev D, Gani F, Pawlik TM. Role of frailty and sarcopenia in predicting outcomes among patients undergoing gastrointestinal surgery. World J Gastrointest Surg 2016; 8:27-40. [PMID: 26843911 PMCID: PMC4724585 DOI: 10.4240/wjgs.v8.i1.27] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/19/2015] [Accepted: 10/20/2015] [Indexed: 02/06/2023] Open
Abstract
According to the United States census bureau 20% of Americans will be older than 65 years in 2030 and half of them will need an operation - equating to about 36 million older surgical patients. Older adults are prone to complications during gastrointestinal cancer treatment and therefore may need to undergo special pretreatment assessments that incorporate frailty and sarcopenia assessments. A focused, structured literature review on PubMed and Google Scholar was performed to identify primary research articles, review articles, as well as practice guidelines on frailty and sarcopenia among patients undergoing gastrointestinal surgery. The initial search identified 450 articles; after eliminating duplicates, reports that did not include surgical patients, case series, as well as case reports, 42 publications on the impact of frailty and/or sarcopenia on outcome of patients undergoing gastrointestinal surgery were included. Frailty is defined as a clinically recognizable state of increased vulnerability to physiologic stressors resulting from aging. Frailty is associated with a decline in physiologic reserve and function across multiple physiologic systems. Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength. Unlike cachexia, which is typically associated with weight loss due to chemotherapy or a general malignancy-related cachexia syndrome, sarcopenia relates to muscle mass rather than simply weight. As such, while weight reflects nutritional status, sarcopenia - the loss of muscle mass - is a more accurate and quantitative global marker of frailty. While chronologic age is an important element in assessing a patient's peri-operative risk, physiologic age is a more important determinant of outcomes. Geriatric assessment tools are important components of the pre-operative work-up and can help identify patients who suffer from frailty. Such data are important, as frailty and sarcopenia have repeatedly been demonstrated among the strongest predictors of both short- and long-term outcome following complicated surgical procedures such as esophageal, gastric, colorectal, and hepato-pancreatico-biliary resections.
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Stornes T, Wibe A, Endreseth BH. Complications and risk prediction in treatment of elderly patients with rectal cancer. Int J Colorectal Dis 2016; 31:87-93. [PMID: 26298183 DOI: 10.1007/s00384-015-2372-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The primary aim of this study was to characterise complications, identify predictors of postoperative morbidity and mortality and to evaluate existing risk prediction models in elderly rectal cancer patients. METHODS An observational single-centre study of 330 consecutive patients >75 years treated in 1994-2006. Analyses were performed by age group: 75-79 years, 80-85 years and >85 years. RESULTS Total observed in-hospital morbidity was 48.7 %. In multivariate analysis, age (OR 1.04, 95 % CI 1.01-1.08, p = 0.04), ASA grade ≥ 3 (p = 0.01), acute presentation (OR 1.67, 95 % CI 1.2-13.2, p = 0.02) and major surgery (APR OR 3.72, 95 % CI 1.37-10.15, p = 0.01, LAR OR 2.98, 95 % CI 1.14-7.79, p = 0.03, Hartmann OR 5.46, 95 % CI 1.60-19.28, p = 0.02) were independent risk factors for postoperative morbidity. The 30-day mortality was 6.3, 6.4 and 14.3 % (p = 0.146) in the three age groups, and the 100-day mortality was 8.7, 10.1 and 22.2 % (p = 0.03), respectively. ASA group 3 (OR 6.21, 95 % CI 4.39-27.69, p = 0.017), ASA group 4 (OR 32.6, 95 % CI 5.12-207.75, p < 0.001) and acute presentation (OR 6.48, 95 % CI 1.62-25.99, p = 0.008) increased the risk of 100-day mortality. The Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) observed/estimated (O/E) ratio for morbidity was 1.05. For 30-day mortality, the colorectal POSSUM (Cr-POSSUM) O/E ratio was 0.74, Surgical Risk Scale 0.61 and the Association of Coloproctology of Great Britain and Ireland (ACPGBI) mortality model 0.63, and for 100-day mortality, ratios were 1.12, 0.91 and 0.95, respectively. CONCLUSION In this series, age increased the risk of in-hospital morbidity and 100-day mortality. Cr-POSSUM, SRS and ACPGBI overestimated 30-day mortality but predicted 100-day mortality with a high degree of accuracy. POSSUM correctly predicted in-hospital morbidity.
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Affiliation(s)
- T Stornes
- Department of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, N-7006, Norway.
| | - A Wibe
- Department of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, N-7006, Norway.,Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - B H Endreseth
- Department of Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, N-7006, Norway.,Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Tomaszewski JJ, Kutikov A. Small renal mass management in the elderly and the calibration of risk. Urol Oncol 2015; 33:197-200. [DOI: 10.1016/j.urolonc.2015.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 03/02/2015] [Accepted: 05/02/2015] [Indexed: 01/20/2023]
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Jorgensen M, Young J, Dobbins T, Solomon M. A mortality risk prediction model for older adults with lymph node-positive colon cancer. Eur J Cancer Care (Engl) 2015; 24:179-88. [DOI: 10.1111/ecc.12288] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2014] [Indexed: 01/20/2023]
Affiliation(s)
- M.L. Jorgensen
- Cancer Epidemiology and Services Research (CESR); Sydney School of Public Health; Sydney Medical School; University of Sydney; Sydney NSW Australia
| | - J.M. Young
- Cancer Epidemiology and Services Research (CESR); Sydney School of Public Health; Sydney Medical School; University of Sydney; Sydney NSW Australia
- Surgical Outcomes Research Centre (SOuRCe); Sydney Local Health District and University of Sydney; Sydney NSW Australia
| | - T.A. Dobbins
- Cancer Epidemiology and Services Research (CESR); Sydney School of Public Health; Sydney Medical School; University of Sydney; Sydney NSW Australia
| | - M.J. Solomon
- Surgical Outcomes Research Centre (SOuRCe); Sydney Local Health District and University of Sydney; Sydney NSW Australia
- Discipline of Surgery; University of Sydney; Sydney NSW Australia
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van der Sluis FJ, Espin E, Vallribera F, de Bock GH, Hoekstra HJ, van Leeuwen BL, Engel AF. Predicting postoperative mortality after colorectal surgery: a novel clinical model. Colorectal Dis 2014; 16:631-9. [PMID: 24506067 DOI: 10.1111/codi.12580] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 12/15/2013] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to develop and externally validate a clinically, practical and discriminative prediction model designed to estimate in-hospital mortality of patients undergoing colorectal surgery. METHOD All consecutive patients who underwent elective or emergency colorectal surgery from 1990 to 2005, at the Zaandam Medical Centre, The Netherlands, were included in this study. Multivariate logistic regression analysis was performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) linking the explanatory variables to the outcome variable in-hospital mortality, and a simplified Identification of Risk in Colorectal Surgery (IRCS) score was constructed. The model was validated in a population of patients who underwent colorectal surgery from 2005 to 2011 in Barcelona, Spain. Predictive performance was estimated by calculating the area under the receiver operating characteristic curve. RESULTS The strongest predictors of in-hospital mortality were emergency surgery (OR = 6.7, 95% CI 4.7-9.5), tumour stage (OR = 3.2, 95% CI 2.8-4.6), age (OR = 13.1, 95% CI 6.6-26.0), pulmonary failure (OR = 4.9, 95% CI 3.3-7.1) and cardiac failure (OR = 3.7, 95% CI 2.6-5.3). These parameters were included in the prediction model and simplified scoring system. The IRCS model predicted in-hospital mortality and demonstrated a predictive performance of 0.83 (95% CI 0.79-0.87) in the validation population. In this population the predictive performance of the CR-POSSUM score was 0.76 (95% CI 0.71-0.81). CONCLUSIONS The results of this study have shown that the IRCS score is a good predictor of in-hospital mortality after colorectal surgery despite the relatively low number of model parameters.
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Affiliation(s)
- F J van der Sluis
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Korc-Grodzicki B, Downey RJ, Shahrokni A, Kingham TP, Patel SG, Audisio RA. Surgical considerations in older adults with cancer. J Clin Oncol 2014; 32:2647-53. [PMID: 25071124 DOI: 10.1200/jco.2014.55.0962] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The aging of the population is a real concern for surgical oncologists, who are increasingly being asked to treat patients who would not have been considered for surgery in the past. In many cases, decisions are made with relatively little evidence, most of which was derived from trials in which older age was a limiting factor for recruitment. METHODS This review focuses on risk assessment and perioperative management. It describes the relationship between age and outcomes for colon, lung, hepatobiliary, and head and neck cancer, which are predominantly diseases of the elderly and are a major cause of morbidity and mortality. RESULTS Effective surgery requires safe performance as well as reasonable postoperative life expectancy and maintenance of quality of life. Treatment decisions for potentially vulnerable elderly patients should take into account data obtained from the evaluation of geriatric syndromes, such as frailty, functional and cognitive limitations, malnutrition, comorbidities, and polypharmacy, as well as social support. Postoperative care should include prevention and treatment of complications seen more frequently in the elderly, including postoperative delirium, functional decline, and the need for institutionalization. CONCLUSION Surgery remains the best modality for treatment of solid tumors, and chronologic age alone should not be a determinant for treatment decisions. With adequate perioperative risk stratification, functional assessment, and oncologic prognostication, elderly patients with cancer can do as well in terms of morbidity and mortality as their younger counterparts. If surgery is determined to be the appropriate treatment modality, patients should not be denied this option because of their age.
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Affiliation(s)
- Beatriz Korc-Grodzicki
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom.
| | - Robert J Downey
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
| | - Armin Shahrokni
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
| | - T Peter Kingham
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
| | - Snehal G Patel
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
| | - Riccardo A Audisio
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
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Wu SC, Fu CY, Hsieh CH, Wang YC, Lo HC, Cheng HT, Tzeng CW. Early predictors for tissue healing deficit and leakage in geriatric critically ill patients receiving emergent abdominal surgery: a case control study. Int J Surg 2014; 12:315-9. [PMID: 24486934 DOI: 10.1016/j.ijsu.2014.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 11/26/2013] [Accepted: 01/21/2014] [Indexed: 01/29/2023]
Abstract
BACKGROUND As our world ages and the elderly population grows. Surgery on the aged critically ill tend to result in additional morbidity and mortality. We sought to determine early predicting factors that were associated with postoperative leakage and tissue healing deficiency after emergent abdominal surgery in geriatric critically ill patients. MATERIAL AND METHOD Retrospectively, geriatric critically ill patients received anticipated, single-stage emergent abdominal surgery via emergency room were enrolled. Patients who received only one definitive surgery during their hospital course were labeled as group A, patients received anticipated one-stage surgery and eventually with postoperative leakage and tissue healing deficiency were labeled as group B. The demographics and parameters were obtained for comparison. RESULT There were 45 patients in group A, and 34 patients in group B. The mean age is 77.4 ± 6.1 years in Group A and 76.9 ± 8.5 years in Group B, the mean APACHE score was 20.3 ± 7.5 vs. 21.6 ± 7.7. There were no significances in age, gender, comorbidities, and physiological scores. There were significances in the persistent post-operative use of vasopressors and hypoalbuminemia. The 30-day mortality rate was 0% in group A and 38.2% in group B. CONCLUSION Persistent post operative vasopressor use and hypoalbuminemia are associated with higher rate of morbidity and mortality after emergent abdominal surgery in geriatric critically ill patients. Early recognition is essential for proper management. Further studies are required for a better understanding in identifying risk factors.
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Affiliation(s)
- Shih-Chi Wu
- Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linko, Taiwan.
| | - Chi-Hsun Hsieh
- Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Yu-Chun Wang
- Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Hung-Chieh Lo
- Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Han-Tsung Cheng
- Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan.
| | - Chia-Wei Tzeng
- Trauma and Emergency Center, China Medical University Hospital, Taichung, Taiwan.
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Abstract
SummaryIncreasing numbers of older people are undergoing both emergency and elective surgery. However, they remain at increased risk of adverse outcome in comparison with younger patients. This may relate to the association of ageing with physiological deterioration, multi-morbidity and geriatric syndromes such as frailty, all of which are independent predictors of adverse post-operative outcome. Although there is an emerging evidence base for the identification and management of these predictors, this has not yet translated into routine clinical practice. Older patients undergoing surgery often receive sub-optimal care and surgical pathways are not well suited to complex older patients with multi-pathology. Evidence is emerging for alternative models of care that incorporate the evolving evidence base for optimal peri-operative management of the older surgical patient, including risk assessment and optimization. This article aims to provide a practical overview of the literature to all disciplines working in this field.
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Ying L, Bo B, Huo-Yan W, Hong Z. Evaluation of a Modified POSSUM Scoring System for Predicting the Morbidity in Patients Undergoing Lumbar Surgery. Indian J Surg 2013; 76:212-6. [PMID: 25177119 DOI: 10.1007/s12262-013-0840-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 01/16/2013] [Indexed: 10/27/2022] Open
Abstract
For most spine surgeons, operative intervention is common for the treatment of lumbar disc herniation, lumbar stenosis, lumbar fracture or lumbar spondylolisthesis. However, with the increase in lumbar surgery, the complication rate increases accordingly. Whereas the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system has been widely used to predict morbidity in various surgical fields, the application of this system in lumbar surgery has not been reported. From January 2008 to January 2010, we recruited 158 patients (85 males and 73 females) with operation for lumbar disc herniation, lumbar stenosis, lumbar fracture, or lumbar spondylolisthesis. All patients were analyzed to compare the morbidity by a modified POSSUM scoring system. According to the modified POSSUM, the expected morbidity was 51 cases (32.3 %), whereas the observed mortality was 42 cases (26.6 %). The overall observed-to-expected ratio was 0.82, and the chi-squared test indicated no statistically significant difference between the expected and observed morbidities (χ (2) = 1.23, P = 0.27), suggesting that the modified POSSUM can accurately estimate the outcome. The modified POSSUM scoring system we developed is a useful tool for predicting and evaluating morbidity in lumbar surgery. Further studies are required to investigate whether this scoring system can predict mortality.
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Affiliation(s)
- Li Ying
- Department of Orthopaedics, Guangdong Hospital of Integrated Traditional and Western Medicine, Foshan, Guangdong 528200 People's Republic of China
| | - Bai Bo
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou Medical College, Guangzhou, Guangdong 510120 People's Republic of China
| | - Wu Huo-Yan
- Department of Orthopaedics, Guangdong Hospital of Integrated Traditional and Western Medicine, Foshan, Guangdong 528200 People's Republic of China
| | - Zhuang Hong
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405 People's Republic of China
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Gray LD, Morris CG. Organisation and planning of anaesthesia for emergency surgery. Anaesthesia 2013; 68 Suppl 1:3-13. [PMID: 23210552 DOI: 10.1111/anae.12054] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Patients presenting for emergency surgery represent a category at high risk of complications, with substantial morbidity and mortality, whose management may be extremely challenging. In this first of two articles we consider the identification and evaluation of high risk emergency patients, the provision of critical care support, the management of sepsis, common postoperative complications and in-theatre death.
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Affiliation(s)
- L D Gray
- Department of Anaesthesia and Intensive Care Medicine, Queen's Medical Centre, Nottingham, UK
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Pelavski AD, Lacasta A, de Miguel M, Rochera MI, Roca M. Mortality and surgical risk assessment among the extreme old undergoing emergency surgery. Am J Surg 2013; 205:58-63. [DOI: 10.1016/j.amjsurg.2012.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 03/05/2012] [Accepted: 03/05/2012] [Indexed: 11/27/2022]
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Merad F, Baron G, Pasquet B, Hennet H, Kohlmann G, Warlin F, Desrousseaux B, Fingerhut A, Ravaud P, Hay JM. Prospective Evaluation of In-hospital Mortality with the P-POSSUM Scoring System in Patients Undergoing Major Digestive Surgery. World J Surg 2012; 36:2320-7. [DOI: 10.1007/s00268-012-1683-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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van Walraven C, Wong J, Bennett C, Forster AJ. The Procedural Index for Mortality Risk (PIMR): an index calculated using administrative data to quantify the independent influence of procedures on risk of hospital death. BMC Health Serv Res 2011; 11:258. [PMID: 21982489 PMCID: PMC3200180 DOI: 10.1186/1472-6963-11-258] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 10/07/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgeries and other procedures can influence the risk of death in hospital. All published scales that predict post-operative death risk require clinical data and cannot be measured using administrative data alone. This study derived and internally validated an index that can be calculated using administrative data to quantify the independent risk of hospital death after a procedure. METHODS For all patients admitted to a single academic centre between 2004 and 2009, we estimated the risk of all-cause death using the Kaiser Permanente Inpatient Risk Adjustment Methodology (KP-IRAM). We determined whether each patient underwent one of 503 commonly performed therapeutic procedures using Canadian Classification of Interventions codes and whether each procedure was emergent or elective. Multivariate logistic regression modeling was used to measure the association of each procedure-urgency combination with death in hospital independent of the KP-IRAM risk of death. The final model was modified into a scoring system to quantify the independent influence each procedure had on the risk of death in hospital. RESULTS 275 460 hospitalizations were included (137,730 derivation, 137,730 validation). In the derivation group, the median expected risk of death was 0.1% (IQR 0.01%-1.4%) with 4013 (2.9%) dying during the hospitalization. 56 distinct procedure-urgency combinations entered our final model resulting in a Procedural Index for Mortality Rating (PIMR) score values ranging from -7 to +11. In the validation group, the PIMR score significantly predicted the risk of death by itself (c-statistic 67.3%, 95% CI 66.6-68.0%) and when added to the KP-IRAM model (c-index improved significantly from 0.929 to 0.938). CONCLUSIONS We derived and internally validated an index that uses administrative data to quantify the independent association of a broad range of therapeutic procedures with risk of death in hospital. This scale will improve risk adjustment when administrative data are used for analyses.
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Affiliation(s)
- Carl van Walraven
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, K1Y 4E9, Canada.
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Yaghoubian A, Ge P, Tolan A, Saltmarsh G, Kaji AH, Neville AL, Bricker S, De Virgilio C. Renal Insufficiency Predicts Mortality in Geriatric Patients Undergoing Emergent General Surgery. Am Surg 2011. [DOI: 10.1177/000313481107701010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinical predictors of perioperative mortality in geriatric patients undergoing emergent general surgery have not been well described. The purpose of this study was to determine the incidence of postoperative morbidity and mortality in geriatric patients and factors associated with mortality. A retrospective review of patients 65 years of age or older undergoing emergent general surgery at a public teaching hospital was performed over a 7-year period. Data collected included demographics, comorbidities, laboratory studies, perioperative morbidities, and mortality. Descriptive statistics and predictors of morbidity and mortality are described. The mean age was 74 years. Indications for surgery included small bowel obstruction (24%), diverticulitis (20%), perforated viscous (16%), and large bowel obstruction (9%). The overall complication rate was 41 per cent with six cardiac complications (14%) and seven perioperative (16%) deaths. Mean admission serum creatinine was significantly higher in patients who died (3.6 vs 1.5 mg/dL, P = 0.004). Mortality for patients with an admission serum creatinine greater than 2.0 mg/dL was 42 per cent (5 of 12) compared with 3 per cent (2 of 32) for those 2.0 mg/dL or less (OR, 10.7; CI, 1.7 to 67; P = 0.01). Morbidity and mortality in geriatric patients undergoing emergency surgery remains high with the most significant predictor of mortality being the presence of renal insufficiency on admission.
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Affiliation(s)
| | - Phillip Ge
- Harbor-UCLA Medical Center, Torrance, California
| | - Amy Tolan
- Harbor-UCLA Medical Center, Torrance, California
| | | | - Amy H. Kaji
- Harbor-UCLA Medical Center, Torrance, California
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Risk factors for mortality in major digestive surgery in the elderly: a multicenter prospective study. Ann Surg 2011; 254:375-82. [PMID: 21772131 DOI: 10.1097/sla.0b013e318226a959] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To identify the mortality risk factors of elderly patients (≥65 years old) during major digestive surgery, as defined according to the complexity of the operation. BACKGROUND In the aging populations of developed countries, the incidence rate of major digestive surgery is currently on the rise and is associated with a high mortality rate. Consequently, validated indicators must be developed to improve elderly patients' surgical care and outcomes. METHODS We acquired data from a multicenter prospective cohort that included 3322 consecutive patients undergoing major digestive surgery across 47 different facilities. We assessed 27 pre-, intra-, and postoperative demographic and clinical variables. A multivariate analysis was used to identify the independent risk factors of mortality in elderly patients (n = 1796). Young patients were used as a control group, and the end-point was defined as 30-day postoperative mortality. RESULTS In the entire cohort, postoperative mortality increased significantly among patients aged 65-74 years, and an age ≥65 years was by itself an independent risk factor for mortality (odds ratio [OR], 2.21; 95% confidence interval [CI], 1.36-3.59; P = 0.001). The mortality rate among elderly patients was 10.6%. Six independent risk factors of mortality were characteristic of the elderly patients: age ≥85 years (OR, 2.62; 95% CI, 1.08-6.31; P = 0.032), emergency (OR, 3.42; 95% CI, 1.67-6.99; P = 0.001), anemia (OR, 1.80; 95% CI, 1.02-3.17; P = 0.041), white cell count > 10,000/mm³ (OR, 1.90; 95% CI, 1.08-3.35; P = 0.024), ASA class IV (OR, 9.86; 95% CI, 1.77-54.7; P = 0.009) and a palliative cancer operation (OR, 4.03; 95% CI, 1.99-8.19; P < 0.001). CONCLUSION Characterization of independent validated risk indicators for mortality in elderly patients undergoing major digestive surgery is essential and may lead to an efficient specific workup, which constitutes a necessary step to developing a dedicated score for elderly patients.
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Tan KY, Tan P, Tan L. A collaborative transdisciplinary "geriatric surgery service" ensures consistent successful outcomes in elderly colorectal surgery patients. World J Surg 2011; 35:1608-1614. [PMID: 21523500 DOI: 10.1007/s00268-011-1112-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND We hypothesized that a dedicated collaborative transdisciplinary Geriatric Surgery Service (GSS) will improve care for elderly colorectal surgery patients. METHODS Patients older than 75 years of age who underwent major colorectal surgery were included in this study. The Geriatric Surgery Service employed a transdisciplinary, collaborative model of care. There were frequent quality reviews and a patient-centered culture was ensured. Treatment protocols and checklists were instituted. Perioperative outcome data were collected prospectively between 2007 and 2009. These data were compared to those from similar patients not managed by the service. Success and failure of surgical treatment of the two groups were analyzed using CUSUM methodology. Failure was defined as mortality, prolonged hospital stay for any reason, including morbidity, and failure to regain preoperative function by 6 weeks. RESULTS Twenty-nine patients managed by the GSS were compared to 52 patients who underwent standard treatment. The median age of the patients managed by the GSS was higher but there was no difference in the ASA score and predicted morbidity scores based on the POSSUM model. The GSS achieved lower mortality and major complication rates. A large majority (84.6%) of the patients managed by the GSS returned to preoperative functional status by 6 weeks. The GSS was able to produce a trend of successively desired outcomes consistently leading to the CUSUM curve exhibiting a sustained downward slope. This was in contrast to patients not managed by the GSS. CONCLUSION The Geriatric Surgery Service, through its transdisciplinary, collaborative care processes, was able to achieve sustained superior outcomes compared to standard management.
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Affiliation(s)
- Kok-Yang Tan
- Department of Surgery, Alexandra Health, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore.
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Abstract
BACKGROUND Predicting major post-operative complications is an important task for which simple and reliable methods are lacking. A simple scoring system based on intraoperative heart rate, blood pressure and blood loss was recently developed to fill this gap. This system, the Surgical Apgar Score, shows promising results both in terms of validity and in terms of usefulness. The goal of this study was to study both these components in a Scandinavian setting. METHODS Pre-operative patient characteristics and intraoperative variables were recorded for 224 patients undergoing general and vascular surgery between 26 October and 17 December 2009. Major complications were evaluated during a 30-day follow-up. The relationship between Surgical Apgar Score and major complication was analysed using χ(2)-tests and the relative risk between different scoring patient groups was analysed. RESULTS The study showed a strong correlation between the Surgical Apgar Score and major complication (P<0.001). 61.5% of the lowest-scoring patients sustained a major complication compared with only 6.4% in the highest-scoring group. This is equivalent to a relative risk of 7.14 (95% CI: 2.88-17.5, P<0.001). CONCLUSIONS The Surgical Apgar Score is valid in a Scandinavian setting. We also note that there were no practical issues in collecting the score. Together with patient pre-operative risk, the score has great potential to guide clinicians when making post-operative decisions and give immediate feedback about the surgical procedure. The next step should be to educate surgical staff about the score.
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Affiliation(s)
- H Ohlsson
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Umeå, Sweden.
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