Surgical Apgar score (SAS) predicts perioperative morbidity, mortality, and length of stay in patients undergoing esophagectomy at a high-volume center

Surgical Apgar scores predict complications after emergency general surgery laparotomy

BACKGROUND

The Surgical Apgar Score (SAS) is a 10-point validated score comprised of three intraoperative variables (blood loss, lowest heart rate, and lowest mean arterial pressure). Lower scores are worse and predict major postoperative complications. The SAS has not been applied in emergency general surgery (EGS) but may help guide postoperative disposition. We hypothesize that SAS can predict complications in EGS patients undergoing a laparotomy.

METHODS

We performed a retrospective review of adult patients at a single, quaternary care center who underwent an exploratory laparotomy for EGS conditions within 6 hours of surgical consultation from 2015 to 2019. Patients were grouped by whether they experienced a postoperative complication (systemic, surgical, and/or death). Multivariable regression was performed to predict complications, accounting for SAS and other statistically significant variables between groups. Using this model, predicted probabilities of a complication were generated for each SAS.

RESULTS

The cohort comprised 482 patients: 32.8% (n = 158) experienced a complication, while 67.2% (n = 324) did not. Patients with complications were older, frailer, more often male, had worse SAS (6 vs. 7, p < 0.0001) and American Society of Anesthesiologists scores, and higher rates of perforated hollow viscus ( p = 0.0003) and open abdomens ( p < 0.0001). On multivariable regression, an increasing SAS independently predicted less complications (adjusted odds ratio, 0.85; 95% confidence interval, 0.75-0.96; p = 0.009). An SAS ≤4 was associated with a 49.2% predicted chance of complications, greater rates of septic shock (9.7% vs. 3%, p = 0.01), respiratory failure (20.5% vs. 10.8%, p = 0.02), and death (24.1% vs. 7.5%, p < 0.0001). An SAS ≤ 4 did not correlate with surgical complications ( p = 0.1).

CONCLUSION

The SAS accurately predicts postoperative complications in EGS patients undergoing urgent laparotomy, with an SAS ≤ 4 identifying patients at risk for septic shock, respiratory failure, and mortality. This tool can aid in rapidly determining postoperative disposition and resource allocation.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Ability to predict surgical outcomes by surgical Apgar score: a systematic review

BACKGROUND

The Surgical Apgar score (SAS) is a straightforward and unbiased measure to assess the probability of experiencing complications after surgery. It is calculated upon completion of the surgical procedure and provides valuable predictive information. The SAS evaluates three specific factors during surgery: the estimated amount of blood loss (EBL), the lowest recorded mean arterial pressure (MAP), and the lowest heart rate (LHR) observed. Considering these factors, the SAS offers insights into the probability of encountering postoperative complications.

METHODS

Three authors independently searched the Medline, PubMed, Web of Science, Scopus, and Embase databases until June 2022. This search was conducted without any language or timeframe restrictions, and it aimed to cover relevant literature on the subject. The inclusion criteria were the correlation between SAS and any modified/adjusted SAS (m SAS, (Modified SAS). eSAS, M eSAS, and SASA), and complications before, during, and after surgeries. Nevertheless, the study excluded letters to the editor, reviews, and case reports. Additionally, the researchers employed Begg and Egger's regression model to evaluate publication bias.

RESULTS

In this systematic study, a total of 78 studies \were examined. The findings exposed that SAS was effective in anticipating short-term complications and served as factor for a long-term prognostic following multiple surgeries. While the SAS has been validated across various surgical subspecialties, based on the available evidence, the algorithm's modifications may be necessary to enhance its predictive accuracy within each specific subspecialty.

CONCLUSIONS

The SAS enables surgeons and anesthesiologists to recognize patients at a higher risk for certain complications or adverse events. By either modifying the SAS (Modified SAS) or combining it with ASA criteria, healthcare professionals can enhance their ability to identify patients who require continuous observation and follow-up as they go through the postoperative period. This approach would improve the accuracy of identifying individuals at risk and ensure appropriate measures to provide necessary care and support.

Relationship between 30 Days Mortality and Incidence of Intraoperative Cardiac Arrest According to the Timing of ECMO

Background: Recently, the use of extracorporeal membrane oxygenation (ECMO) in noncardiac surgery, such as thoracic surgery, has increased. However, there have been no studies on the mortality and incidence of intraoperative cardiac arrest with or without ECMO during thoracic surgery. Methods: Between January 2011 and October 2018, 63 patients received ECMO support during thoracic surgery. All patients who applied ECMO from starting at any time before surgery to the day of surgery were included. Patients were divided into the emergency ECMO group and the non-emergency ECMO group according to the timing of ECMO. We compared the factors related to 30 day mortality using Cox regression analysis. Results: The emergency ECMO and non-emergency ECMO groups comprised 27 and 36 patients, respectively. On the operation day, cardiopulmonary resuscitation (CPR) was a very important result, and only occurred in the emergency ECMO group (n = 20, 74.1% vs. 0%, p < 0.001). The most common cause of ECMO indication was the CPR in the emergency ECMO group and respiratory failure in the non-emergency ECMO group. There were significant differences in 30 day mortality between the emergency ECMO group and the non-emergency ECMO group (n = 12, 44.4% vs. n = 3, 8.3%, p = 0.001). The Kaplan–Meier analysis curve for 30 day mortality showed that the emergency ECMO group had a significantly higher rate of 30 day mortality than the non-emergency ECMO group (X² = 14.7, p < 0.001). Conclusions: A lower incidence of intraoperative cardiac arrest occurred in the non-emergency ECMO group than in the emergency ECMO group. Moreover, 30 day mortality was associated with emergency ECMO.

Clinical Impact of the Prognostic Nutritional Index as a Predictor of Outcomes in Patients with Stage II/III Gastric Cancer: A Retrospective Cohort Study

BACKGROUND

The Japanese Gastric Cancer Treatment Guidelines recommend S-1 and S-1 plus docetaxel as postoperative chemotherapy for pathological stage II and III gastric cancer (GC). There is currently no strategy for using chemotherapy to treat high-risk recurrent pathological stage II/III. Previous studies reported that the several nutritional, immunological, and inflammatory markers examined the association with clinical outcomes after surgery for GC.

METHODS

Ninety patients with GC (stage II, n = 48; stage III, n = 42) for whom gastrectomy was performed at our institution between November 2009 and September 2018 were examined. Nutritional, immunological, and inflammatory markers were calculated from blood samples within 1 week before surgery.

RESULTS

The prognostic nutritional index (PNI) status correlated with the pathological stage and disease recurrence after surgery (p = 0.015 and p < 0.0001, respectively). Thirty-three patients had disease recurrence after gastrectomy (stage II, n = 11; stage III, n = 22). The PNI was significantly lower in the recurrent group than in the non-recurrent group (p = 0.0003). The PNI correlated with overall survival and recurrence-free survival after gastrectomy (p = 0.0021 and p = 0.0001, respectively). A multivariate analysis identified the PNI as an independent prognostic factor (p = 0.006).

CONCLUSION

The PNI may be useful for predicting the outcomes of patients with pathological stage II/III GC and may contribute to the selection of an appropriate adjuvant chemotherapy regimen.

An esophagectomy Surgical Apgar Score (eSAS)-based nomogram for predicting major morbidity in patients with esophageal carcinoma

Background

Performing an esophagectomy for a malignancy presents an operation with an elevated risk of complications. The esophagectomy Surgical Apgar Score (eSAS) has been confirmed to be a strong predictor of major postoperative morbidity. The purpose of this study was to construct and establish an eSAS-based nomogram for predicting major morbidity after esophagectomy for esophageal carcinoma.

Methods

A total of 194 patients underwent radical esophagectomy for the malignant disease was analyzed by internal validation, and the clinical value was calculated on external validation (n=135). The 30-day major morbidity was recorded as the outcome. Univariable and multivariable logistic regression analysis analyzed the preoperative and intraoperative variables. An eSAS-based nomogram was constructed to predict the risk of major postoperative morbidity. The verification curves for the performance were drawn.

Results

Major morbidity occurred in 34.04% (n=66) of cases. Based on the final regression analysis, we proved that the eSAS had a highly linear association with major morbidity after esophagectomy. We further constructed a nomogram integrating the eSAS and clinical predictors [body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and diabetes mellitus] to predict the probability of major postoperative morbidity. The performance of the eSAS-based nomogram was assessed and proven to be clinically useful by internal and external validation.

Conclusions

We constructed an eSAS-based nomogram that can effectively predict the risk of major morbidity after esophagectomy in patients with esophageal carcinoma. With a highly exact and exceedingly simple model, clinicians could more precisely ease the individual perioperative management for decreasing the postoperative complication.

Predictive value of intraoperative factors for complications after oesophagectomy

OBJECTIVES

Oesophagectomy for malignancy is a highly complex and difficult procedure associated with considerable postoperative complications. In this study, we aimed to identify the ability of an intraoperative factor (IPFs)-based classifier to predict complications after oesophagectomy.

METHODS

This retrospective review included 251 patients who underwent radical oesophagectomy from October 2015 to December 2017. Using the least absolute shrinkage and selection operator regression model, we extracted IPFs that were associated with postoperative morbidity and then built a classifier. Preoperative variables and the IPF-based classifier were analysed using univariable and multivariable logistic regression analysis. A nomogram to predict the risk of postoperative morbidity was constructed and validated using bootstrap resampling.

RESULTS

Following the least absolute shrinkage and selection operator regression analysis, we discovered that those 4 IPF (surgical approach, lowest heart rate, lowest mean arterial blood pressure and estimated blood loss) were associated with postoperative morbidity. After stratification into low-and high-risk groups with the IPF-based classifier, the differences in 30-day morbidity (7.2% vs 70.1%, P < 0.001, respectively) and mortality (0% vs 4.7%, P = 0.029, respectively) were found to be statistically significant. The multivariable analysis demonstrated that the IPF-based classifier was an independent risk factor for predicting postoperative morbidity for patients with oesophageal cancer. The performance of the nomogram was evaluated and proven to be clinically useful.

CONCLUSIONS

We demonstrated that an IPF-based nomogram could reliably predict the risk of postoperative morbidity. It has the potential to facilitate the individual perioperative management of patients with oesophageal cancer.

A low surgical Apgar score is a predictor of anastomotic leakage after transthoracic esophagectomy, but not a prognostic factor

BACKGROUND

The surgical Apgar score (SAS) has been a useful predictor of postoperative complications in several types of cancer. However, there are few reports about the correlation of SAS and esophageal cancer. This study aimed to examine the utility of SAS as a predictor of major complications, particularly anastomotic leakage, in patients who underwent transthoracic esophagectomy, and investigate the correlation between SAS and patient prognosis.

METHODS

This is a single-center, retrospective observational study. A total of 190 patients who underwent esophagectomy for esophageal cancer in 2012-2016 were reviewed to find the correlation between SAS and postoperative complications (Clavien-Dindo classification III or higher). SAS was calculated based on intraoperative estimated blood loss, lowest mean arterial pressure, and lowest heart rate. Major complications included anastomotic leakage, respiratory, cardiac, recurrent nerve palsy, chylothorax, and other complications. We also reviewed how SAS was correlated with 3 year overall survival (OS) and recurrence-free survival (RFS). A high SAS was defined as ≥ 6, and a low SAS as < 6.

RESULTS

On univariate analysis, SAS showed a statistical significance in all major complications and anastomotic leakage. On multiple logistic regression analysis, a low SAS was detected as a risk factor of the major complications and anastomotic leakage, with a significant difference. Moreover, we conducted survival analysis with SAS; however, we could not detect that a low SAS had a negative impact on OS and RFS.

CONCLUSIONS

A low SAS can be a predictor of postoperative complications, especially anastomotic leakage. However, SAS was not correlated with OS or RFS.

Is surgical Apgar score an effective assessment tool for the prediction of postoperative complications in patients undergoing oesophagectomy?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether the surgical Apgar score (SAS) was an effective assessment tool for the prediction of postoperative complications in patients undergoing oesophagectomy. In total, 7 papers were identified using the reported search, of which 6 cohort studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Five of 6 cohort studies demonstrated that a low SAS was significantly associated with more postoperative complications in patients undergoing oesophagectomy. The rates of major individual complications in patients with a lower SAS were commonly higher than those in patients with a higher SAS. Two cohort studies further reported that a low SAS was significantly associated with the prolonged length of stay. The cut-off value of the SAS that had the discriminative power for patients who were considered at high morbidity risk, however, was not defined but was more likely to be 6 or less. Current available evidence suggests that the SAS system may serve as an effective assessment tool for the prediction of morbidity risk after oesophagectomy.

Prediction of perioperative complications after robotic-assisted radical hysterectomy for cervical cancer using the modified surgical Apgar score

BACKGROUND

Although there has been marked development in surgical techniques, there is no easy and fast method of predicting complications in minimally invasive surgeries. We evaluated whether the modified surgical Apgar score (MSAS) could predict perioperative complications in patients undergoing robotic-assisted radical hysterectomy.

METHODS

All patients with cervical cancer undergoing robotic-assisted radical hysterectomy at our institution between January 2011 and May 2017 were included. Their clinical characteristics were retrieved from their medical records. The surgical Apgar score (SAS) was calculated from the estimated blood loss, lowest mean arterial pressure, and lowest heart rate during surgery. We modified the SAS considering the lesser blood loss typical of robotic surgeries. Perioperative complications were defined using a previous study and the Clavien-Dindo classification and subdivided into intraoperative and postoperative complications. We analyzed the association of perioperative complications with low MSAS.

RESULTS

A total of 138 patients were divided into 2 groups: with (n = 53) and without (n = 85) complications. According to the Clavien-Dindo classification, 49 perioperative complications were classified under Grade I (73.1%); 13, under Grade II (19.4%); and 5, under Grade III (7.5%); 0, under both Grade IV and Grade V. Perioperative complications were significantly associated with surgical time (p = 0.026). The MSAS had a correlation with perioperative complications (p = 0.047). The low MSAS (MSAS, ≤6; n = 52) group had significantly more complications [40 (76.9%), p = 0.01]. Intraoperative complications were more correlated with a low MSAS than were postoperative complications [1 (1.2%) vs. 21 (40.4%); p < 0.001, 13 (15.1%) vs. 25 (48.1%); p = 0.29, respectively]. We also analyzed the risk-stratified MSAS in 3 subgroups: low (MSAS, 7-10), moderate (MSAS 5-6), and high risks (MSAS, 0-4). The prevalence of intraoperative complications significantly increased as the MSAS decreased p = 0.01).

CONCLUSIONS

This study was consistent the concept that the intuitive and simple MSAS might be more useful in predicting intraoperative complications than in predicting postoperative complications in minimally invasive surgeries, such as robotic-assisted radical hysterectomy for cervical cancer.