Factors associated with not undergoing surgery for locally advanced rectal cancers: An NCDB propensity-matched analysis

BACKGROUND

The traditional treatment paradigm for patients with locally advanced rectal cancers has been neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. This study aimed to assess surgery trends for locally advanced rectal cancers, factors associated with forgoing surgery, and overall survival outcomes.

METHODS

Adults with locally advanced rectal cancers were retrospectively analyzed using the National Cancer Database (2004-2019). Propensity score matching was performed. Factors associated with not undergoing surgery were identified using multivariable logistic regression. Kaplan-Meier and log-rank tests were used for 5-year overall survival analysis, stratified by stage and treatment type.

RESULTS

A total of 72,653 patients were identified, with 64,396 (88.64%) patients undergoing neoadjuvant + surgery ± adjuvant therapy, 579 (0.80%) chemotherapy only, 916 (1.26%) radiation only, and 6,762 (9.31%) chemoradiation only. The proportion of patients who underwent surgery declined over the study period (95.61% in 2006 to 92.29% in 2019, P trend < .001), whereas the proportion of patients who refused surgery increased (1.45%-4.48%, P trend < .001). Factors associated with not undergoing surgery for locally advanced rectal cancers included older age, Black race (odds ratio 1.47, 95% CI 1.35-1.60, P < .001), higher Charlson-Deyo score (score ≥3: 1.79, 1.58-2.04, P < .001), stage II cancer (1.22, 1.17-1.28, P < .001), lower median household income, and non-private insurance. Neoadjuvant + surgery ± adjuvant therapy was associated with the best 5-year overall survival, regardless of stage, in unmatched and matched cohorts.

CONCLUSION

Despite surgery remaining an integral component in the management of locally advanced rectal cancers, there is a concerning decline in guideline-concordant surgical care for rectal cancer in the United States, with evidence of persistent socioeconomic disparities. Providers should seek to understand patient perspectives/barriers and guide them toward surgery if appropriate candidates. Continued standardization, implementation, and evaluation of rectal cancer care through national accreditation programs are necessary to ensure that all patients receive optimal treatment.

Association of Preoperative Functional Performance With Outcomes After Surgical Treatment of Head and Neck Cancer: A Clinical Severity Staging System

Importance

Patients with head and neck cancers have comorbidities and other constitutional symptoms known to be associated with adverse postoperative outcomes, but the role of functional performance is not well studied.

Objective

To explore the addition of functional performance to other clinical factors for association with 3 patient outcomes: 30-day unplanned readmission (UR), 90-day medical complications, and overall survival (OS).

Design, Setting, and Participants

This retrospective cohort study was conducted in a single tertiary care center with patients surgically treated for squamous cell cancer of the lip, oral cavity, pharynx, or larynx from January 2012 to December 2016. All analysis took place between January 2018 and November 2018. Data from 2 registries were analyzed, supplemented with medical record review. Logistic regression analysis was used to explore association of preoperative functional performance with outcomes. Conjunctive consolidation was used to create a useful clinical severity staging system, which included functional performance (estimated from metabolic equivalent [MET] score: <4, light-intensity activities; ≥4 at least moderate-intensity activities); overall comorbidity severity; preoperative weight loss; and TNM tumor staging. Logistic regression was used to assess the prognostic accuracy of the clinical severity staging system for 30-day UR and 90-day complications, and Cox proportional hazard regression for OS.

Exposures

All patients underwent surgical treatment for head and neck cancer.

Main Outcomes and Measures

The primary outcomes were 30-day UR and 90-day complications; the secondary outcome was OS.

Results

For the 657 patients included, the mean (SD) age was 62.0 (11.3) years; 73% were men (n = 477), and 88% were white (n = 580). A total of 75 (11%) had a 30-day UR; 204 (31%) developed a 90-day complication; and 127 (19%) patients died during the observation period. Individually, poor functional performance (<4 METs), high comorbidity burden, preoperative weight loss, and advanced TNM stage were associated with all 3 outcomes; the increased risk for each outcome ranged from 1.5 to 3.0 times the reference range. Using these 4 variables in combination, the 4-category clinical severity staging system demonstrated a strong association between severity stage and all 3 adverse outcomes: 30-day UR (C statistic, 0.63), 90-day complications (C statistic, 0.63), and OS (C statistic, 0.68).

Conclusions and Relevance

Poor preoperative functional performance, high comorbidity burden, preoperative weight loss, and advanced tumor stage were all associated with worse patient outcomes after head and neck cancer surgery. The model incorporating all 4 of these factors developed in this study may facilitate patient-centered risk assessment and patient-physician shared preoperative decision making.

Associations Between Complement Components and Vitamin D and the Physical Activities of Daily Living Among a Longevous Population in Hainan, China

Background: Vitamin D and complement components shared some common pathophysiological pathways in the musculoskeletal system, circulation, and metabolism, which were linked to physical function. It is hypothesized that serum complement components may interact with vitamin D in respect of the physical activities of daily living (PADLs). Objective: To investigate if serum complement components 3 (C3), complement components 4 (C4), and 25-hydroxyvitamin D [25(OH)D] associate with PADLs, and to examine whether the association between 25(OH)D levels and PADLs varies at different complement component levels among Chinese centenarians. Methods: This study was conducted in a group of population-based centenarians. PADLs were evaluated using the Barthel Index. Multiple regressions were used to analyze the associations among 25(OH)D, complements C3 and C4, and PADLs. Results: Among 943 participants, 672 (71.3%) had physical dependence (PD). After adjusting for potential confounders, serum 25(OH)D and C3 levels were positively correlated with PADLs, while C4 levels were negatively correlated with PADLs (Ps < 0.05). Serum 25(OH)D levels significantly interacted with both C3 (P for interaction = 0.033) and C4 (P for interaction = 0.006) levels on PADLs. At lower complement component levels, the multivariate odds ratios (ORs) of the upper tertile of vitamin D for PD were 0.32 (95% CI: 0.18-0.55) in the C3 group and 0.29 (95% CI: 0.16-0.50) in the C4 group. At higher complement component levels, the ORs in the C3 and C4 groups were not statistically significant. Conclusions: In a group of population-based Chinese centenarians, we observed that serum complement C3 and 25(OH)D levels were positively associated with PADLs, while C4 was negatively associated with PADLs. The associations between 25(OH)D levels and PADLs were more pronounced in groups with lower serum complement component levels.

Association of Anemia with Activities of Daily Living in Chinese Female Centenarian

OBJECTIVES

Although anemia and activities of daily living (ADL) disability in female elderly are common conditions and are more likely to occur as people age, little is known about the association of anemia with ADL in female centenarians. The objective of this study was to examine the relationship between anemia and ADL disability in Chinese female centenarians.

DESIGN, SETTING AND PARTICIPANTS

We conducted a population-based cross-sectional study of a sample of 822 Chinese female centenarians from 2014 to 2016.

MEASUREMENTS

Blood analysis, home interview, and physical examination were performed following standard procedures. ADL disability was defined as a Barthel Index total score≤60.

RESULTS

The prevalence of anemia and ADL disability were 66.8% and 29.7% respectively in Chinese female centenarians. Multiple logistic regression analyses revealed that inflammation (OR = 2.280, 95% CI, 1.524-3.410), underweight (OR = 1.653, 95% CI, 1.186-2.303), anemia (OR = 1.775, 95% CI, 1.250-2.521), and living with family (OR = 0.518, 95% CI, 0.302-0.888) were significant factors related to ADL disability. Centenarians with severe anemia had an approximately fourfold greater likelihood of ADL disability than those without anemia (OR =3.747; 95% CI 1.525-9.206). An apparent dose-response relationship was found between anemia and ADL disability.

CONCLUSION

These findings may provide some insights into targeted intervention for maintaining ADL independence in female centenarians, especially encouraging the interventions of anemia to improve ADL.

Who is a high-risk surgical patient?

PURPOSE OF REVIEW

Timely identification of high-risk surgical candidates facilitate surgical decision-making and allows appropriate tailoring of perioperative management strategies. This review aims to summarize the recent advances in perioperative risk stratification.

RECENT FINDINGS

Use of indices which include various combinations of preoperative and postoperative variables remain the most commonly used risk-stratification strategy. Incorporation of biomarkers (troponin and natriuretic peptides), comprehensive objective assessment of functional capacity, and frailty into the current framework enhance perioperative risk estimation. Intraoperative hemodynamic parameters can provide further signals towards identifying patients at risk of adverse postoperative outcomes. Implementation of machine-learning algorithms is showing promising results in real-time forecasting of perioperative outcomes.

SUMMARY

Perioperative risk estimation is multidimensional including validated indices, biomarkers, functional capacity estimation, and intraoperative hemodynamics. Identification and implementation of targeted strategies which mitigate predicted risk remains a greater challenge.

Is Norton Score a useful tool for identifying high-risk patients prior to emergency surgery?

BACKGROUND

Emergency surgery in elderly patients is associated with high mortality rates. Various scoring systems may be valuable in predicting mortality and morbidity rates. It has been suggested that the Norton Score (NS) could be used to quantify frailty. We hypothesized that NS could be a useful tool for identifying high-risk patients before emergency/urgent surgeries.

METHODS

A retrospective study was conducted in the Department of Surgery at Kaplan Medical Center, Rehovot, Israel.

INCLUSION CRITERIA

age ≥50 years, American Society of Anesthesiologists (ASA) physical status score ≥3 and urgent/emergency laparotomy. A total of 400 patients were identified, and 150 (37.5%) matched the inclusion criteria.

RESULTS

A total of 150 patients with ASA scores of 3-5 and who underwent emergent/urgent laparotomy from 1 January 2011 through 31 January 2013 were included. Mean age was 77 ± 9.7 years. The mortality rate at 1 month was 44% (66 patients) and at 1 year was 54.7% (82 patients). A higher ASA score was significantly associated with mortality (P < 0.001). Survivors had lower frailty scores and presented significantly higher preoperative NS (Modified Frailty Index 2.45 versus 3.06, P < 0.05; NS 16.09 versus 12.94, P < 0.01). Preoperative NS was the most significant variable that predicted poor patient prognosis (odds ratio 0.84; 95% confidence interval 0.73-0.96). For ASA 3 and ASA 4, the grade of daily personal independence in activities showed a positive correlation with survival (P < 0.001).

CONCLUSION

NS can be a very useful and quick tool to evaluate surgical risk in emergency surgery. Our study supports the use of NS in the perioperative evaluation prior to emergency surgery.

Prevalence of functional dependence in Chinese centenarians and its relationship with serum vitamin D status

Background

Functional dependence (FD) and vitamin D deficiency are common conditions in older adults. However, little is known about the relationship between FD and serum vitamin D status in centenarians. The current study was designed to evaluate the prevalence of FD and examine its relationship with serum vitamin D status among centenarians in China.

Subjects and methods

A cross-sectional study of a large sample of Chinese centenarians including 180 men and 822 women was conducted from June 2014 to December 2016. Home interviews, physical examinations, and blood analyses were performed in 958 centenarians following standard procedures. FD was evaluated using the Barthel index of activities of daily living (ADL). Serum 25-hydroxyvitamin D (25OHD) concentrations were measured as a marker of vitamin D status.

Results

The prevalence of centenarians with FD was 71.2%. Vitamin D deficiency, lack of tea consumption, lack of outdoor activities, visual impairment, and fracture were predictors of FD. Centenarians in the lowest quartile of serum 25OHD concentration had an approximately threefold greater likelihood of FD than those in the highest quartile in multiple logistic regression models (OR =2.88; 95% CI 1.75–4.73; P<0.001). The multivariable OR with a 1 ng/mL decrease in serum 25OHD concentration was 1.06 (95% CI 1.04–1.08; P<0.001) for FD.

Conclusion

Serum 25OHD levels have important associations with FD in Chinese centenarians. Future research could focus on the value of intervening in the case of low serum 25OHD levels through vitamin D supplementation and improving ADL in the older population.

In-hospital mortality does not increase in patients aged over 85 years after hip fracture surgery. A retrospective observational study in a Japanese tertiary hospital

Introduction

Hip fracture is a common and serious orthopedic injury among the geriatric population, necessitating surgical treatment. We tested whether age is a significant risk factor for in-hospital mortality after surgery in this retrospective cohort study and, further, analyzed causes and pattern of death in those patients.

Methods

We queried the electronic hospital records of in-patients aged over 75 years who had undergone hip fracture surgery from the start of 2010 to the end of August 2016 in our hospital, a tertiary hospital on the main island of Japan. The extracted data included patient ID, age, gender, location of fracture, ASA-PS scores, types of anesthesia, durations of anesthesia and surgery, days of hospital stay after surgery, and outcomes at hospital discharge including in-hospital death. The extracted data were divided into two groups based on the patient’s age at the time of surgery: the aged group (age of < 85) and the advanced age group (age of ≥ 85 years), and we compared patient characteristics and management variables and discharge disposition between the two groups.

Results

Eight hundred four patient records were extracted (360 in the aged and 444 in the advanced age groups). Although a smaller proportion of patients in the advanced age group could be discharged home, all-cause in-hospital mortality was also similar between the two groups (1.9 and 1.6%, aged and advanced age groups, respectively). Six patients died from advanced cancer, and five patients died of pneumonia resulting from aspiration.

Conclusions

The results of this study suggest that age is not a clinically significant risk factor for in-hospital mortality. The possibility decreasing in-hospital mortality exists in identifying patients at risk of aspiration and preventing it.

Functional status as a predictor of outcomes in open and endovascular abdominal aortic aneurysm repair

BACKGROUND

Functional status is a simple and rapidly assessable metric that may be used as a predictor for surgical outcomes. This study examined the association of functional status with short-term mortality after abdominal aortic aneurysm (AAA) repair in octogenarians to characterize the utility of functional status as a means of preoperative risk assessment.

METHODS

All patients who underwent endovascular and open AAA repair from 2002 to 2010 within the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database were identified. Functional status, defined as an ordinal scale from 1 to 3 (1, independent; 2, partially dependent; 3, totally dependent), was examined using multivariate regression models with 30-day mortality as the primary outcome. For the purpose of analysis, this 3-point scale was converted into a binomial scale of function, with "normal" including 1 (completely independent) and "abnormal" including 2 or 3 (partially to totally dependent).

RESULTS

We identified 9030 patients who underwent AAA repair (46.6% open and 53.4% endovascular). Mortality at 30 days was 2.8% for the entire cohort (4.2% open, 1.7% endovascular; P < .001). There were 1340 patients aged ≥80 years, of which 67.3% underwent endovascular AAA repair. Among all age groups, functional status was a significant predictor of 30-day mortality (<80 years, P < .001; ≥80 years, P < .001). The ≥80 cohort with abnormal function status also demonstrated increased operative mortality (P = .002), length of stay (P = .001), and incidence of pulmonary complications (P = .025) compared with the cohort with normal functional status. Multivariate logistic regression demonstrated that within the ≥80-year-old cohort, only functional status remained a significant predictor of mortality (P < .001). In addition, the strength of the association between functional status and mortality was greater in the older cohort than in the younger one (Cox regression hazard ratio: 3.13 vs 2.18).

CONCLUSIONS

Functional status is a simple and rapidly applicable predictor of mortality within AAA patients and may be a useful tool to help preoperatively risk-stratify elderly patients presenting with AAA in need of repair. Further studies are needed to understand how best to apply these data to the clinical setting to guide preoperative decision making.

Is Extended Lymphadenectomy Needed for Elderly Patients With Gastric Adenocarcinoma?

BACKGROUND

Extensive surgery is associated with greater mortality for elderly patients. For gastric adenocarcinoma (GA), it is unclear whether the benefit of an extended lymphadenectomy in this population outweighs the associated risks. This study aimed to determine the impact of lymphadenectomy on postoperative outcomes and survival for the elderly.

OBJECTIVE

To determine the impact of lymphadenectomy on postoperative outcomes and survival for elderly.

METHODS

From a cohort of 19 centers, patients who underwent resection of GA with curative intent between 1997 and 2010 were included in this study. Lymphadenectomy was defined according to the total number of lymph nodes in the surgical specimen (limited, <15; intermediate, 15-25; extended, >25). Postoperative outcomes and survival were compared between elderly (≥75 years) and younger patients and regarding the extent of lymphadenectomy for the elderly.

RESULTS

Of 1348 patients, 386 were elderly. The elderly presented with a higher American Society of Anesthesiologist (ASA) score (ASA 3-4: 45 vs. 16.5 %; p < 0.001) as well as greater postoperative morbidity (45 vs. 37 %; p = 0.009) and mortality (8 vs. 2.5 %; p < 0.001) despite less aggressive treatment including less neoadjuvant chemotherapy (5 vs. 20 %; p < 0.001) and adjuvant chemotherapy (7 vs. 44 %; p < 0.001), fewer total gastrectomies (41.5 vs. 60 %; p < 0.001), and less extended lymphadenectomy (38 vs. 48.5 %; p < 0.001). Among the elderly patients, limited lymphadenectomy (n = 116), intermediate lymphadenectomy (n = 125), and extended lymphadenectomy (n = 145) were comparable with respect to tumor stage, perioperative treatment, morbidity, and mortality. For the elderly patients, overall survival (OS) was 30.8 months, and disease-specific survival (DSS) was 63.9 months. The extent of the lymphadenectomy did not have an impact on OS or DSS for the elderly patients.

CONCLUSION

The expected benefit in terms of long-term survival did not justify an extended lymphadenectomy for elderly patients.

Postoperative Functional Outcomes in Older Adults

As the world's aging population grows, the surgical population is increasingly made up of older adults. Due to changes in physiologic function and increasing comorbidity burden, older adults are at increased risk of morbidity, mortality, and functional decline after surgery. In addition, decision to undergo surgery for the older adult may be based on the postoperative functional outcome rather than survival. Although few studies have evaluated an older adult's function as a postoperative outcome, surgeons are becoming increasingly aware of the importance of maintaining or regaining function in an older patient. Interventions to improve postoperative functional outcomes are being developed and show promising results. This review discusses existing literature on postoperative functional outcomes in older adults and recently developed interventions.

Patient-specific Immune States before Surgery Are Strong Correlates of Surgical Recovery

BACKGROUND

Recovery after surgery is highly variable. Risk-stratifying patients based on their predicted recovery profile will afford individualized perioperative management strategies. Recently, application of mass cytometry in patients undergoing hip arthroplasty revealed strong immune correlates of surgical recovery in blood samples collected shortly after surgery. However, the ability to interrogate a patient's immune state before surgery and predict recovery is highly desirable in perioperative medicine.

METHODS

To evaluate a patient's presurgical immune state, cell-type-specific intracellular signaling responses to ex vivo ligands (lipopolysaccharide, interleukin [IL]-6, IL-10, and IL-2/granulocyte macrophage colony-stimulating factor) were quantified by mass cytometry in presurgical blood samples. Selected ligands modulate signaling processes perturbed by surgery. Twenty-three cell surface and 11 intracellular markers were used for the phenotypic and functional characterization of major immune cell subsets. Evoked immune responses were regressed against patient-centered outcomes, contributing to protracted recovery including functional impairment, postoperative pain, and fatigue.

RESULTS

Evoked signaling responses varied significantly and defined patient-specific presurgical immune states. Eighteen signaling responses correlated significantly with surgical recovery parameters (|R| = 0.37 to 0.70; false discovery rate < 0.01). Signaling responses downstream of the toll-like receptor 4 in cluster of differentiation (CD) 14 monocytes were particularly strong correlates, accounting for 50% of observed variance. Immune correlates identified in presurgical blood samples mirrored correlates identified in postsurgical blood samples.

CONCLUSIONS

Convergent findings in pre- and postsurgical analyses provide validation of reported immune correlates and suggest a critical role of the toll-like receptor 4 signaling pathway in monocytes for the clinical recovery process. The comprehensive assessment of patients' preoperative immune state is promising for predicting important recovery parameters and may lead to clinical tests using standard flow cytometry.

Anesthesia for the elderly outpatient

PURPOSE OF REVIEW

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly patients will assume increased importance.

RECENT FINDINGS

Increasing evidence supports the expanded use of ambulatory surgery for managing elderly patients undergoing elective surgery procedures.

SUMMARY

This review article describes the demographics of ambulatory surgery in the elderly population. This review article describes the effects of aging on the responses of geriatric patients to anesthetic and analgesic drugs used during ambulatory surgery. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative side-effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. Finally, we discuss the future challenges related to the continued expansion of ambulatory surgery practice in this growing segment of our surgical population. The role of anesthesiologists as perioperative physicians is of critical importance for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. Providing high-quality, evidence-based anesthetic and analgesic care for elderly patients undergoing elective operations on an ambulatory basis will assume greater importance in the future.

Blood biomarkers and functional disability among extremely longevous individuals: a population-based study

BACKGROUND

Several blood biomarkers have been linked to functional disability, a health problem in general populations. However, there are limited data for evaluating the potential association of biomarkers with functional disability in an extremely longevous (95+) population.

METHODS

We used data from 420 extremely longevous individuals from the Rugao longevity cohort, a population-based association study conducted in Rugao, a longevity town in China. Functional disability was assessed by the Katz Index of Independence in activities of daily living. Blood biomarkers, including serum lipid, lipoprotein cholesterol, serum albumin, and lymphocyte count, were correlated with activities of daily living.

RESULTS

Among extremely longevous women, following the degree of functional disability, serum albumin and lymphocyte count decreased significantly (all p for trend < .001). In a univariate model, serum albumin (β = -0.279, p < .001), lymphocyte count (β = -0.187, p < .001), and neutrophil count (β = 0.140, p = .012) were found to be significantly associated with activities of daily living in women. After adjustment for other covariates, the significance remained. Notably, multivariate regression analysis revealed independent effects of all the three biomarkers on activities of daily living (β = -0.242, -0.185, and 0.143, all p < .05). We did not observe any association in men.

CONCLUSIONS

We found significant associations between serum albumin, lymphocyte count, and neutrophil count and physical disability even after adjustment for potential confounders in extremely longevous women, which call for further study. The findings provide preliminary but crucial clues for future studies specifically aimed at exploring the longitudinal relationships of interest before proceeding with interventions.