E-PASS score as a useful predictor of postoperative complications and mortality after colorectal surgery in elderly patients

Patient-reported performance status and postoperative complications in elective colorectal cancer surgery

PURPOSE

The purpose of this study was to evaluate the concordance between patient-reported performance status (prPS) and surgeon-reported performance status (srPS), and to assess the correlation between srPS and prPS and postoperative complications following elective colorectal cancer surgery. Not all patients are deemed suitable for undergoing a surgical procedure. We aimed to assess whether prPS can aid the surgeons' decision-making prior to surgery.

METHODS

In this retrospective study, 524 patients undergoing colorectal cancer surgery were included. prPS were collected via questionnaires, while 30-day postoperative complications were obtained from the Danish Colorectal Cancer Group (DCCG) database. To evaluate the agreement between prPS and srPS, linearly weighted kappa statistics were applied. Rank-biserial correlation analysis was used to calculate the correlation between prPS and srPS with postoperative complications.

RESULTS

In total, there was an approximate 71% concordance between the assessments. Around 17% of the patients rated themselves with a higher PS status than the surgeons, while 13% of the patients rated themselves with a lower PS. Overall postoperative complications, minor surgical complications, and medical complications were all significantly correlated to both srPS and prPS, while only srPS was correlated with major surgical complications. Neither srPS nor prPS were correlated with overall surgical complications (major and minor collapsed).

CONCLUSION

The agreement between prPS and srPS is poor and in nearly one-third of the cases, disagreement occurs. Overall, both prPS and srPS were correlated to postoperative complications, with srPS demonstrated a slightly higher correlation.

Estimation of Physiologic Ability and Surgical Stress scoring system for predicting complications following abdominal surgery: A meta-analysis spanning 2004 to 2022

BACKGROUND

Postoperative complications remain a paramount concern for surgeons and healthcare practitioners.

AIM

To present a comprehensive analysis of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system's efficacy in predicting postoperative complications following abdominal surgery.

METHODS

A systematic search of published studies was conducted, yielding 17 studies with pertinent data. Parameters such as preoperative risk score (PRS), surgical stress score (SSS), comprehensive risk score (CRS), postoperative complications, postoperative mortality, and other clinical data were collected for meta-analysis. Forest plots were employed for continuous and binary variables, with χ2 tests assessing heterogeneity (P value).

RESULTS

Patients experiencing complications after abdominal surgery exhibited significantly higher E-PASS scores compared to those without complications [mean difference and 95% confidence interval (CI) of PRS: 0.10 (0.05-0.15); SSS: 0.04 (0.001-0.08); CRS: 0.19 (0.07-0.31)]. Following the exclusion of low-quality studies, results remained valid with no discernible heterogeneity. Subgroup analysis indicated that variations in sample size and age may contribute to heterogeneity in CRS analysis. Binary variable meta-analysis demonstrated a correlation between high CRS and increased postoperative complication rates [odds ratio (OR) (95%CI): 3.01 (1.83-4.95)], with a significant association observed between high CRS and postoperative mortality [OR (95%CI): 15.49 (3.75-64.01)].

CONCLUSION

In summary, postoperative complications in abdominal surgery, as assessed by the E-PASS scoring system, are consistently linked to elevated PRS, SSS, and CRS scores. High CRS scores emerge as risk factors for heightened morbidity and mortality. This study establishes the accuracy of the E-PASS scoring system in predicting postoperative morbidity and mortality in abdominal surgery, underscoring its potential for widespread adoption in effective risk assessment.

Five-year follow-up mortality prognostic index for colorectal patients

PURPOSE

To identify 5-year survival prognostic variables in patients with colorectal cancer (CRC) and to propose a survival prognostic score that also takes into account changes over time in the patient's health-related quality of life (HRQoL) status.

METHODS

Prospective observational cohort study of CRC patients. We collected data from their diagnosis, intervention, and at 1, 2, 3, and 5 years following the index intervention, also collecting HRQoL data using the EuroQol-5D-5L (EQ-5D-5L), European Organization for Research and Treatment of Cancer's Quality of Life Questionnaire-Core 30 (EORTC-QLQ-C30), and Hospital Anxiety and Depression Scale (HADS) questionnaires. Multivariate Cox proportional models were used.

RESULTS

We found predictors of mortality over the 5-year follow-up to be being older; being male; having a higher TNM stage; having a higher lymph node ratio; having a result of CRC surgery classified as R1 or R2; invasion of neighboring organs; having a higher score on the Charlson comorbidity index; having an ASA IV; and having worse scores, worse quality of life, on the EORTC and EQ-5D questionnaires, as compared to those with higher scores in each of those questionnaires respectively.

CONCLUSIONS

These results allow preventive and controlling measures to be established on long-term follow-up of these patients, based on a few easily measurable variables.

IMPLICATIONS FOR CANCER SURVIVORS

Patients with colorectal cancer should be monitored more closely depending on the severity of their disease and comorbidities as well as the perceived health-related quality of life, and preventive measures should be established to prevent adverse outcomes and therefore to ensure that better treatment is received.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02488161.

Total Risk Points Predict Short- and Long-term Outcomes Following Colorectal Cancer Resection in Older Patients

BACKGROUND/AIM

Estimation of physiological ability and surgical stress (E-PASS) is reported to be useful as a predictor of postoperative complications and poor long-term survival after colorectal cancer. The total risk points (TRP) system is a simplified scoring system of E-PASS, and this study evaluated the utility of TRP in colorectal cancer resection in older patients.

PATIENTS AND METHODS

The clinicopathological data of 237 patients who underwent curative resection for colorectal cancer from 2015 to 2020 were analyzed retrospectively. The data were compared between a high TRP group (≥1,000, n=38) and a low TRP group (<1,000, n=199). We also conducted an analysis to determine risk factors of postoperative complications and poor long-term survival.

RESULTS

TRP showed statistically significant correlations with the comprehensive risk score (CRS) of E-PASS (R=0.999, p<0.001). The high TRP group experienced postoperative complications (Clavien-Dindo grade ≥2) more frequently (42.1% vs. 11.1%, p<0.001). Multivariate analysis showed that high TRP [odds ratio (OR)=5.214; 95% confidence interval (95%CI)=2.338-11.629; p<0.001] and age ≥80 (OR=2.760; 95%CI=1.308-5.826; p=0.008) were independent predictors of postoperative complications. Overall survival (OS) was poor in the high TRP group (5-year OS, 61.2% vs. 82.6%, p<0.001) compared with the low TRP group, and in the low prognostic nutritional index (<45) group (5-year OS, 70.9% vs. 86.3%, p=0.013) compared with the high prognostic nutritional index (≥45) group. Multivariate analysis showed that high TRP [hazard ratio (HR)=3.202; 95%CI=1.324-7,745; p=0.010] was an independent prognostic factor for poor OS.

CONCLUSION

Patients aged ≥80 years should be closely monitored regarding postoperative complications. Reducing TRP to less than 1,000 is important to reduce postoperative complications and improve OS.

Which Frailty Evaluation Method Can Better Improve the Predictive Ability of the SASA for Postoperative Complications of Patients Undergoing Elective Abdominal Surgery?

Purpose

To determine which frailty method can better improve the predictive ability of the Surgical Apgar Score combined with American Society of Anesthesiologists physical status classification (SASA).

Patients and Methods

A prospective cohort study was conducted. A total of 194 elderly patients undergoing elective abdominal surgery were included. Preoperative frailty using FRAIL questionnaire, frailty index (FI), Clinical Frailty Scale (CFS) and SASA scores was assessed. Primary outcome was in-hospital Clavien-Dindo ≥grade II complications. Multiple logistic regression was used to examine the association between frailty and complications. Receiver operating characteristic curves were used to explore the predictive ability of frailty.

Results

According to the FRAIL, FI and CFS criteria, the prevalence of frailty in the study population was 43.8%, 32.5%, and 36.6%, respectively. After adjusting for all covariates, frailty was significantly associated with postoperative complications in hospital by FRAIL [odds ratio: 5.11, 95% CI: 1.41–18.44, P = 0.013], by FI [OR: 4.25, 95% CI: 1.21–14.90, P = 0.024] and by CFS [OR: 5.10, 95% CI: 1.52–17.17, P = 0.008]. The area under the curve (AUC) for SASA was 0.768 (95% CI: 0.702–0.826). Addition of frailty assessment (FRAIL, FI and CFS) increased the AUC to 0.787 (95% CI: 0.722–0.842), 0.798 (95% CI: 0.734–0.852), and 0.815 (95% CI: 0.753–0.867), respectively. Compared to SASA, only addition of CFS had a significant difference (P = 0.0478).

Conclusion

Frailty is an effective predictor of postoperative complications in elderly Chinese patients undergoing elective abdominal surgery. Frailty assessment of CFS can better improve the predictive ability of SASA.

Targets for Intervention? Preoperative Predictors of Postoperative Ileus After Colorectal Surgery in an Enhanced Recovery Protocol

BACKGROUND

Postoperative ileus occurs in up to 30% of colorectal surgery patients and is associated with increased length of stay, costs, and morbidity. While Enhanced Recovery Protocols seek to accelerate postoperative recovery, data on modifiable preoperative factors associated with postoperative ileus in this setting are limited. We aimed to identify preoperative predictors of postoperative ileus following colorectal surgery in Enhanced Recovery Protocols, to determine new intervention targets.

METHODS

We performed a retrospective single-center cohort study of patients ≥ 18 years old who underwent colorectal surgery via Enhanced Recovery Protocols (7/2015-7/2017). Postoperative ileus was defined as nasogastric tube insertion postoperatively or nil-per-os by postoperative day 4. Preoperative risk factors including comorbidities and medication use were identified using multivariable stepwise logistic regression.

RESULTS

Of 530 patients, 14.9% developed postoperative ileus. On univariate analysis of perioperative and postoperative factors, postoperative ileus patients had increased psychiatric illness, antidepressant and antipsychotic use, American Society of Anesthesiologists classification, ileostomy creation, postoperative opioid use, complications, surgery duration, and length of stay (p < 0.05). Multivariable logistic regression model for preoperative factors identified psychiatric illness, preoperative antipsychotic use, and American Society of Anesthesiologists classification ≥ 3 as significant predictors of postoperative ileus (p < 0.05).

DISCUSSION

Postoperative ileus remains a common complication following colorectal surgery under Enhanced Recovery Protocols. Patients with pre-existing psychiatric comorbidities and preoperative antipsychotic use may be a previously overlooked cohort at increased risk for postoperative ileus. Additional research and preoperative interventions within Enhanced Recovery Protocols to reduce postoperative ileus for this higher-risk population are needed.

Usefulness of scoring systems in outcome prediction for older cancer patients undergoing abdominal surgery

BACKGROUND

Several postoperative outcome scoring systems have been developed and validated, combining both pre- and intraoperative factors. Among others are the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), the Estimation of Physiologic Ability and Stress (E-PASS) and the Surgical Apgar Score combined with the American Society of Anesthesiologists physical status classification (SASA). The aim of this study was to compare the above scoring systems in the prediction of 30-day postoperative outcome in older patients with cancer undergoing abdominal surgery.

METHODS

Consecutive patients ≥70 years were prospectively enrolled. Pre- and intraoperative variables were used to calculate the scores, the ROC and perform logistic regression analysis.

RESULTS

The study sample comprised 201 patients with a median age of 77 (range 70-93) years. The most common surgical procedure was for colorectal (75%), followed by gastric (10.4%) pancreas (7.0%), gall bladder (3.5%), small bowel (2.5%), and other (1.5%) types of cancer. All scores were independent predictors of 30-day postoperative mortality. In case of 30-day morbidity only SASA turned to be significant. The ROC curves were highly valid and area under the curve showed fair to good discriminatory ability (0.60-0.77) for 30-day postoperative mortality and fair (AUC 0.6) in case of SASA for the 30-day postoperative.

CONCLUSION

The SASA, E-PASS, and P-POSSUM were confirmed to be predictive of 30-day postoperative mortality in older patients undergoing abdominal elective cancer surgery. Only SASA demonstrated as independent factor predicting postoperative 30-day major morbidity.

Relationship between markers of malnutrition and clinical outcomes in older adults with cancer: systematic review, narrative synthesis and meta-analysis

Malnutrition predicts poorer clinical outcomes for people with cancer. Older adults with cancer are a complex, growing population at high risk of weight-losing conditions. A number of malnutrition screening tools exist, however the best screening tool for this group is unknown. The aim was to systematically review the published evidence regarding markers and measures of nutritional status in older adults with cancer (age ≥ 70). A systematic search was performed in Ovid Medline, EMBASE, Web of Science, CINAHL, British Nursing Database and Cochrane CENTRAL; search terms related to malnutrition, cancer, older adults. Titles, abstracts and papers were screened and quality-appraised. Data evaluating ability of markers of nutritional status to predict patient outcomes were subjected to meta-analysis or narrative synthesis. Forty-two studies, describing 15 markers were included. Meta-analysis found decreased food intake was associated with mortality (OR 2.15 [2.03-4.20] p = < 0.00001) in univariate analysis. Prognostic Nutritional Index (PNI) was associated with overall survival (HR 1.89 [1.03-3.48] p = 0.04). PNI markers (albumin, total lymphocyte count) could be seen as markers of inflammation rather than nutrition. There a suggested relationship between very low body mass index (BMI) (<18 kg/m2) and clinical outcomes. No tool was identified as appropriate to screen for malnutrition, as distinct from inflammatory causes of weight-loss. Risk of cancer-cachexia and sarcopenia in older adults with cancer limits the tools analysed. Measures of food intake predicted mortality and should be included in clinical enquiry. A screening tool that distinguishes between malnutrition, cachexia and sarcopenia in older adults with cancer is needed.

E-PASS Scoring System May Be Useful for Prediction of Postoperative Complications in Super Elderly Colorectal Cancer Surgery Patients

Objectives:

Japan is facing an aging society. Elderly individuals are generally more prone to comorbidities and have weaker immune defenses, with ominous prognostic implications if postoperative complications arise. The aim of this study was to explore scoring systems for predicting postoperative morbidity risk in super elderly patients (≥85 years old) after colorectal surgery for cancer.

Methods:

A population of elderly patients (n = 145) surgically treated for primary colorectal cancer within our department between April 2007 and December 2018 was examined retrospectively, assessing the capacities of various indices, such as Estimation of Physiologic Ability and Surgical Stress (E-PASS), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), prognostic nutritional index (PNI), and modified Glasgow Prognostic Score (mGPS), to predict postoperative complications.

Results:

NLR, PLR, and mGPS did not differ significantly in the presence or absence of complications, whereas PNI tended to be lower if complications developed. The E-PASS system showed no group-wise differences in preoperative risk score (PRS), but the surgical stress score (SSS) and the comprehensive risk score (CRS; a composite of PRS and SSS) was significantly higher in patients with complications. Based on the cutoff value calculated from the Receiver operating curve (ROC) for the E-PASS CRS (−0.0580), patients were stratified into low-scoring and high-scoring (HSG) groups. Although not significantly different, the overall survival in the HSG tended to be lower by comparison.

Conclusions:

The E-PASS scoring system may be a useful predictor of postoperative complications in super elderly patients requiring colorectal cancer surgery.

Does Preoperative Comprehensive Geriatric Assessment and Frailty Predict Postoperative Complications?

BACKGROUND

The influence of preoperative comprehensive geriatric assessment and frailty on postoperative morbidity, mortality, delirium were examined.

METHODS

A total of 108 patients were evaluated. The Katz Index of Independence in Activities of Daily Living (ADL), the Lawton Brody Instrumental Activities of Daily Living Scale (IADL), the Mini-Nutrition Assessment test (MNA), the Mini-Mental State Examination (MMSE), Yesavage Geriatric Depression Scale (GDS) were performed. Fried Criteria were used to assess physical frailty. We used the Physiological and Operative Severity Scores for the Enumeration of Mortality and Morbidity score (POSSUM), the American Society of Anesthesiologists Score (ASA), and the Charlson Comorbidity Index (CCI) to determine the risk of postoperative morbidity and mortality. Assessment Test for Delirium (4AT) was applied for detection of delirium.

RESULTS

The median age was 71 years (min-max: 65-84). IADL (p = 0.032), MNA (p = 0.01), MMSE scores (p = 0.026) were found to be significantly lower in patients with morbidity. POSSUM physiology score (p = 0.005), operative score (p = 0.015) and CCI (p = 0.029) were significantly higher in the patients with morbidity. Patients developed morbidity were found to be more frail (p < 0.001). The patients with delirium were found to have lower IADL (p = 0.049) and MMSE scores (p = 0.004), higher POSSUM physiology score (p = 0.005) and all of them were frail. It was found that frailty (OR = 23.695 95% CI: 6.912-81.231 p < 0.001), POSSUM operative score (OR:1.118 95% CI: 1.021-1.224 p = 0.016) and preoperative systolic blood pressure (OR:0.937%95 CI: 0.879-0.999 p = 0.048) were independently related factors for postoperative morbidity.

CONCLUSION

In our study, CGA and frailty in preoperative period were found to be indicators for postoperative morbidity and delirium.

Treatment option of endoscopic stent insertion or gastrojejunostomy for gastric outlet obstruction due to gastric cancer: a propensity score-matched analysis

BACKGROUND

There are currently two treatment options for gastric outlet obstruction (GOO) due to gastric cancer, endoscopic stenting and surgical gastrojejunostomy. However, their therapeutic effects have not yet been established. Therefore, the present study was undertaken to examine these effects.

METHODS

The Japanese Gastric Cancer Association invited its delegates to participate in a retrospective multicenter cohort study on patients with GOO due to gastric cancer who underwent stent therapy or gastrojejunostomy in 2015.

RESULTS

We obtained data from 85 patients undergoing stent therapy and 94 undergoing gastrojejunostomy from 42 hospitals. Baseline data revealed that stent patients had lower food intake, poorer performance status, and worse prognostic indices than gastrojejunostomy patients. Postoperative food intake and survival times were worse in stent patients than in gastrojejunostomy patients. We performed propensity score matching to select pairs of patients with similar baseline characteristics in the two treatment groups. After matching, the frequency of postoperative complications was significantly less in stent patients (3%, 1/33) than in gastrojejunostomy patients (21%, 7/34; p = 0.03). A low residue or full diet was achieved by 97% of stent patients (32/33) and 97% of gastrojejunostomy patients (33/34) (p = 0.98). Median survival times were 7.8 months in stent patients and 4.0 months in gastrojejunostomy patients (p = 0.38).

CONCLUSIONS

Propensity score matching demonstrated that endoscopic stent placement resulted in less postoperative morbidity than and a similar food intake and equivalent survival times to gastrojejunostomy. These results suggest the utility of stent therapy.

Frailty and postoperative complications in older Chinese adults undergoing major thoracic and abdominal surgery

Purpose: To determine the association between frailty and postoperative complications in elderly Chinese patients and to determine whether addition of frailty assessment improves the predictive ability of the American Society of Anesthesiologists (ASA) score, Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM), and Estimation of Physiologic Ability and Surgical Stress (E-PASS) score.

Patients and methods: A prospective cohort study was conducted in a tertiary hospital. Elderly patients undergoing major thoracic or abdominal surgery were included. Frailty phenotype and ASA, POSSUM, and E-PASS scores were assessed. Demographic, preoperative, and surgical variables were extracted from medical records. Primary outcome measure was in-hospital Clavien-Dindo ≥ grade II complications. Multiple logistic regression was used to examine the association between frailty and complications. Receiver operating characteristic curves were used to explore the predictive ability of frailty.

Results: Prevalence of frailty was 26.12%. Significant differences were observed between the frail and non-frail groups with respect to age, Activities of Daily Living, Charlson Comorbidity Index, respiratory function, presence of malignancy, serum albumin, prealbumin, and hemoglobin levels (P<0.05). ASA, POSSUM, and E-PASS scores were higher in the frail group. After adjusting for all covariates, frailty was significantly associated with postoperative complications in hospital [odds ratio: 16.59, 95% CI: 4.56–60.40, P<0.001]. The area under the curve (AUC) for frailty was 0.762 (95% CI: 0.703–0.814). The AUC for ASA, POSSUM, and E-PASS for prediction of complications was 0.751 (95% CI: 0.692–0.804), 0.762 (95% CI: 0.704–0.814), and 0.824 (95% CI: 0.771–0.870), respectively. Addition of frailty assessment increased the AUC to 0.858 (95% CI: 0.808–0.899), 0.842 (95% CI: 0.790–0.885), and 0.854 (95% CI: 0.803–0.896), respectively.

Conclusion: Frailty is an effective predictor of postoperative complications in elderly Chinese patients undergoing major thoracic and abdominal surgery. Frailty assessment can improve the predictive ability of current surgical risk assessment tools. Frailty phenotype should be considered perioperatively. Frailty assessment could also expand the scope for nurses to evaluate patients for safety management.

Prolonged Postoperative Ileus Significantly Increases the Cost of Inpatient Stay for Patients Undergoing Elective Colorectal Surgery: Results of a Multivariate Analysis of Prospective Data at a Single Institution

BACKGROUND

Prolonged postoperative ileus is a common major complication after abdominal surgery. Retrospective data suggest that ileus doubles the cost of inpatient stay. However, current economic impact data are based on retrospective studies that rely on clinical coding to diagnose ileus.

OBJECTIVE

The aim of this study was to determine the economic burden of ileus for patients undergoing elective colorectal surgery.

DESIGN

Economic data were audited from a prospective database of patients who underwent surgery at Auckland City Hospital between September 2012 and June 2014.

SETTINGS

Auckland City Hospital is a large tertiary referral center, using an enhanced recovery after surgery protocol.

PATIENTS

Patients were prospectively diagnosed with prolonged postoperative ileus using a standardized definition.

MAIN OUTCOME MEASURES

The cost of inpatient stay was analyzed with regard to patient demographics and operative and postoperative factors. A multivariate analysis was performed to determine the cost of ileus when accounting for other significant covariates.

RESULTS

Economic data were attained from 325 patients, and 88 patients (27%) developed ileus. The median inpatient cost (New Zealand dollars) for patients with prolonged ileus, including complication rates and length of stay, was $27,981 (interquartile range= $20,198 to $42,174) compared with $16,317 (interquartile range = $10,620 to $23,722) for other patients, a 71% increase in cost (p < 0.005). Ileus increased all associated healthcare costs, including medical/nursing care, radiology, medication, laboratory costs, and allied health (p < 0.05). Multivariate analysis showed that ileus remained a significant financial burden (p < 0.005) when considering rates of major complications and length of stay.

LIMITATIONS

This is a single-institution study, which may impact the generalizability of our results.

CONCLUSIONS

Prolonged ileus causes a substantial financial burden on the healthcare system, in addition to greater complication rates and length of stay in these patients. This is the first study to assess the financial impact of prolonged ileus, diagnosed prospectively using a standardized definition. See Video Abstract at http://links.lww.com/DCR/A825.

Review of risk assessment tools to predict morbidity and mortality in elderly surgical patients

BACKGROUND

Informed surgical consent requires accurate estimation of risks and benefits. Multiple risk assessment tools are available; however, most are not widely used or are specific to certain interventions. Assessing surgical risk is especially challenging in elderly patients because of their range of comorbidities, level of frailty, or severity of illness and a number of available surgical interventions.

DATA SOURCES

We searched MEDLINE from January 2014 to July 2017 for studies that used risk assessment tools in studies on elderly surgical patients. We then sought the original articles describing each assessment tool and subsequent validation studies.

CONCLUSIONS

We identified risk assessment tools that can improve surgical risk assessment in elderly surgical patients. The majority of the identified tools are not commonly used for pre-operative risk assessment. NSQIP-PMP, mFI and SURPAS are promising tools. Age is commonly used to predict risk, but frailty may be a more appropriate measure.

Assessment of postoperative complications using E-PASS and APACHE II in patients undergoing oral and maxillofacial surgery

Background

The prediction of postoperative complications is important for oral and maxillofacial surgeons. We herein aimed to evaluate the efficacy of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) and Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II scoring systems to predict postoperative complications in patients undergoing oral and maxillofacial surgery.

Methods

Thirty patients (22 males, 8 females; mean age: 65.1 ± 12.9 years) who underwent major oral surgeries and stayed in the intensive care unit for postoperative management were enrolled in this study. Postoperative complications were discriminated according to the necessity of the therapeutic intervention by the Medical Department, i.e. according to the Clavien–Dingo classification. E-PASS and APACHE II scores as well as laboratory test values were compared between patients with/without postoperative complications.

Results

Postoperative complications were developed in seven patients. The comprehensive risk score (CRS: 1.13 ± 0.24) and APACHE II score (13.0 ± 2.58) were significantly higher in patients with postoperative complications than in those without ones (p < 0.01, p < 0.05, respectively). The CRS showed an appropriate discriminatory power for predicting postoperative complications (area under the curve: 0.814). Furthermore, a correlation was detected between APACHE II scores and postoperative data until C-reactive protein levels decreased to < 1.0 mg/L (r = 0.43, p < 0.05).

Conclusion

The E-PASS and APACHE II scoring systems were both shown to be useful to predict postoperative complications after oral and maxillofacial surgery.

Frailty and emergency surgery in the elderly: protocol of a prospective, multicenter study in Italy for evaluating perioperative outcome (The FRAILESEL Study)

Improvements in living conditions and progress in medical management have resulted in better quality of life and longer life expectancy. Therefore, the number of older people undergoing surgery is increasing. Frailty is often described as a syndrome in aged patients where there is augmented vulnerability due to progressive loss of functional reserves. Studies suggest that frailty predisposes elderly to worsening outcome after surgery. Since emergency surgery is associated with higher mortality rates, it is paramount to have an accurate stratification of surgical risk in such patients. The aim of our study is to characterize the clinicopathological findings, management, and short-term outcome of elderly patients undergoing emergency surgery. The secondary objectives are to evaluate the presence and influence of frailty and analyze the prognostic role of existing risk-scores. The final FRAILESEL protocol was approved by the Ethical Committee of "Sapienza" University of Rome, Italy. The FRAILESEL study is a nationwide, Italian, multicenter, observational study conducted through a resident-led model. Patients over 65 years of age who require emergency surgical procedures will be included in this study. The primary outcome measures are 30-day postoperative mortality and morbidity rates. The Clavien-Dindo classification system is used to categorize complications. The secondary outcome measures include length of hospital stay, length of stay in intensive care unit, and predictive value for morbidity and mortality of several frailty and surgical risk-scores. The results of the FRAILESEL study will be disseminated through national and international conference presentations and peer-reviewed journals. The study is also registered at ClinicalTrials.gov (ClinicalTrials.gov identifier: NCT02825082).

Postoperative complications in individuals aged 70 and over undergoing elective surgery for colorectal cancer

AIM

This study aims to describe the nature, incidence, severity and outcomes of in-hospital postoperative complications (POCs) in older patients undergoing elective surgery for colorectal cancer.

METHOD

Patients ≥ 70 years old were identified from a prospectively collected database (2009-2015) focusing on the implementation of geriatric screening and assessment in patients with cancer. Medical and surgical POCs were retrieved retrospectively from the medical records, and the severity of the POCs was graded by the Clavien-Dindo (CD) grading system. The following outcomes were analysed comparing patients with and without CD ≥ 2 and CD ≥ 3 POCs: length of stay (LOS), transfer to the intensive care unit, 30-day readmission rates, 30-day and 1-year mortality.

RESULTS

In the 190 patients included, medical POCs (40.5%) were more frequent than surgical POCs (17.9%), and 37.9% experienced CD ≥ 2 POCs. The most common medical POCs were infections (26.8%), transient confusion or altered mental function (12.1%), cardiac arrhythmia (4.7%), and ileus/gastroparesis/prolonged recovery of transit (4.7%). The most common surgical POCs were surgical site infections (12.1%), wound dehiscence/bleeding (4.7%), anastomotic leak (3.7%) and surgical site bleeding (3.7%). The reoperation rate was 7.9%. CD ≥ 2 POCs led to 11 intensive care unit admissions and increased median postoperative LOS by 114% (P < 0.0001 for both), but did not significantly alter 30-day readmission and 30-day and 1-year mortality rates. CD ≥ 3 POCs increased LOS by 162% (P < 0.0001) and showed an increased 1-year mortality (P = 0.07).

CONCLUSION

This study shows that in-hospital medical and surgical complications after surgery for colorectal cancer in patients ≥ 70 years old are frequent and that complications lead to less favourable outcomes.

Estimation of physiologic ability and surgical stress (E-PASS) scoring system could provide preoperative advice on whether to undergo laparoscopic surgery for colorectal cancer patients with a high physiological risk

Laparoscopic colorectal surgery had been widely used for colorectal cancer patient and showed a favorable outcome on the postoperative morbidity rate. We attempted to evaluate physiological status of patients by mean of Estimation of physiologic ability and surgical stress (E-PASS) system and to analyze the difference variation of postoperative morbidity rate of open and laparoscopic colorectal cancer surgery in patients with different physiological status.In total 550 colorectal cancer patients who underwent surgery treatment were included. E-PASS and some conventional scoring systems were reviewed to examine their mortality prediction ability. The preoperative risk score (PRS) in the E-PASS system was used to evaluate the physiological status of patients. The difference of postoperative morbidity rate between open and laparoscopic colorectal cancer surgeries was analyzed respectively in patients with different physiological status.E-PASS had better prediction ability than other conventional scoring systems in colorectal cancer surgeries. Postoperative morbidities were developed in 143 patients. The parameters in the E-PASS system had positive correlations with postoperative morbidity. The overall postoperative morbidity rate of laparoscopic surgeries was lower than open surgeries (19.61% and 28.46%), but the postoperative morbidity rate of laparoscopic surgeries increased more significantly than in open surgery as PRS increased. When PRS was more than 0.7, the postoperative morbidity rate of laparoscopic surgeries would exceed the postoperative morbidity rate of open surgeries.The E-PASS system was capable to evaluate the physiological and surgical risk of colorectal cancer surgery. PRS could assist preoperative decision-making on the surgical method. Colorectal cancer patients who were assessed with a low physiological risk by PRS would be safe to undergo laparoscopic surgery. On the contrary, surgeons should make decisions prudently on the operation method for patient with a high physiological risk.

Does postoperative morbidity worsen the oncological outcome after radical surgery for gastrointestinal cancers? A systematic review of the literature

PURPOSE

The impact of postoperative complications on survival after radical surgery for esophageal, gastric, and colorectal cancers remains controversial. We conducted a systematic review of recent publications to examine the effect of postoperative complications on oncological outcome.

METHODS

A literature search of PubMed/MEDLINE was performed using the keywords "esophageal cancer," "gastric cancer," and "colorectal cancer," obtaining 27 reports published online up until the end of April 2016. Articles focusing on (i) postoperative morbidity and oncological outcome; and (ii) body mass index (BMI), postoperative morbidity, and oncological outcome, were selected. Univariate and multivariate analyses (Cox proportional hazards model) were performed.

RESULTS

Patients with postoperative complications had significantly poorer long-term survival than those without complications. Complications were associated with impaired oncological outcomes. The hazard ratios for overall survival were 1.67 (95% confidence interval [CI], 1.31-2.12), 1.59 (95% CI, 1.13-2.24), and 1.55 (95% CI, 1.28-1.87) in esophageal, gastric, and colorectal cancers, respectively. High BMI was associated with postoperative morbidity rate but not with poor oncological outcome. Low BMI was significantly associated with inferior oncological outcome.

CONCLUSIONS

Complications after radical surgery for esophageal, gastric, and colorectal cancers are associated with patient prognosis. Avoiding such complications might improve the outcomes.

Risk scores as useful predictors of perioperative complications in patients with rectal cancer who received radical surgery

BACKGROUND

Rectal cancer is associated with a higher rate of surgical complications. The ability to predict the risk of complications before treatment would facilitate the design of personalized treatment strategies optimally suited for each patient.

METHODS

We retrospectively studied 260 patients with rectal cancer who underwent radical surgery to examine the relations between complications and 5 types of risk scores.

RESULTS

Complications developed in 56 patients (21.5%). Nineteen patients had infectious complications, 16 had intestinal obstruction, and 12 had other complications. Twelve patients out of 187 patients who received low anterior resection had anastomotic leakage. Estimation of Physiologic Ability and Surgical Stress Comprehensive Risk Score (E-PASS CRS) and Neutrophil-to-lymphocyte Ratio (NLR) were significantly related to all complications, infectious complications, and anastomotic leakage. Surgical Apgar Score was significantly related to infectious complications. Prognostic Nutritional Index was significantly related to all complications and intestinal obstruction. Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity was significantly related to all complications, and infectious complications. A multivariate analysis showed that body-mass index, E-PASS CRS, and NLR were independent risk factors for anastomotic leakage. In particular, NLR was the only score that could be evaluated before surgery.

CONCLUSIONS

Five types of risk scores were useful methods for evaluating the risks of complications in patients with rectal cancer. NLR is a score that can be evaluated before surgery and predicted the risk of anastomotic leakage, suggesting that it is useful for assessing the need for a diverting colostomy.