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Pergialiotis V, Papalios T, Haidopoulos D, Papapanagiotou A, Vlachos A, Rodolakis A, Thomakos N. Pre-Operative Neutrophil-to-Lymphocyte Ratio as a Predictor of Post-Operative Infectious Morbidity in Gynecologic Oncology Patients. Surg Infect (Larchmt) 2023; 24:390-396. [PMID: 37040268 DOI: 10.1089/sur.2022.381] [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] [Indexed: 04/12/2023] Open
Abstract
Background: Neutrophil-to-lymphocyte ratio (NLR) has been described as a predictor of progression-free and overall survival, and in the field of peri-operative care it seems to be a factor that can help discriminate patients at risk of developing post-operative complications. In the present study we sought to determine whether NLR is useful as a biomarker in predictive models that aim to identify patients with gynecologic cancer undergoing surgery at risk of developing post-operative infectious morbidity. Patients and Methods: We designed a prospective cohort study that enrolled 208 patients with gynecologic cancer. Post-operative infectious morbidity was evaluated based on a 30-day follow-up interval from the procedure. Results: Forty-three patients (20.5%) developed post-operative infectious morbidity. Using an optimal cutoff value of 1.7 for the pre-operative NLR we observed that the sensitivity of the biomarker was 76.7% and the specificity 73.3% with a produced area under the curve of 0.760 (95% confidence interval [CI], 0.680-0.839). Univariable logistic regression indicated that NLR is a predictor of post-operative morbidity. Cox regression analysis revealed that NLR was the only factor that was associated with the timing of infectious morbidity (hazard ratio [HR], 1.339; 95% CI, 1.180-1.519; p < 0.001). Using random forest analysis and decision trees we achieved a diagnostic accuracy of the predictive model that exceeded 90%. Conclusions: Neutrophil-to-lymphocyte ratio may be a factor that could potentially help evaluate the risk of post-operative morbidity in patients with gynecologic cancer.
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Affiliation(s)
- Vasilios Pergialiotis
- First Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, "Alexandra" General Hospital, Athens, Greece
| | - Theodoros Papalios
- First Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, "Alexandra" General Hospital, Athens, Greece
| | - Dimitrios Haidopoulos
- First Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, "Alexandra" General Hospital, Athens, Greece
| | - Angeliki Papapanagiotou
- Department of Biological Chemistry, Medical School, National and Kapodistrial University of Athens, Athens, Greece
| | - Athanasios Vlachos
- First Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, "Alexandra" General Hospital, Athens, Greece
| | - Alexandros Rodolakis
- First Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, "Alexandra" General Hospital, Athens, Greece
| | - Nikolaos Thomakos
- First Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, "Alexandra" General Hospital, Athens, Greece
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Correa-Paris A, Gorraiz Ochoa V, Hernandez Gutiérrez A, Gilabert Estellés J, Díaz-Feijoo B, Gil-Moreno A. Simple radiologic assessment of visceral obesity and prediction of surgical morbidity in endometrial cancer patients undergoing laparoscopic aortic lymphadenectomy: A reliability and accuracy study. J Obstet Gynaecol Res 2023; 49:988-997. [PMID: 36593218 DOI: 10.1111/jog.15528] [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: 08/05/2022] [Accepted: 12/05/2022] [Indexed: 01/04/2023]
Abstract
AIM To evaluate the reliability of sagittal abdominal diameter (SAD)-a surrogate of visceral obesity-in magnetic resonance imaging, and its accuracy to predict the surgical morbidity of aortic lymphadenectomy. METHODS We conducted a multicenter reliability (phase 1) and accuracy (phase 2) cohort study in three Spanish referral hospitals. We retrospectively analyzed data from the STELLA-2 randomized controlled trial that included high-risk endometrial cancer patients undergoing minimally invasive surgical staging. Patients were classified into subgroups: conventional versus robotic-assisted laparoscopy, and transperitoneal versus extraperitoneal technique. In the first phase, we measured the agreement of three SAD measurements (at the umbilicus, renal vein, and inferior mesenteric artery) and selected the most reliable one. In phase 2, we evaluated the diagnostic accuracy of SAD to predict surgical morbidity. Surgical morbidity was the main outcome measure, it was defined by a core outcome set including variables related to blood loss, operative time, surgical complications, and para-aortic lymphadenectomy difficulty. RESULTS In phase 1, all measurements showed good inter-rater and intra-rater agreement. Umbilical SAD (u-SAD) was the most reliable one. In phase 2, we included 136 patients. u-SAD had a good diagnostic accuracy to predict surgical morbidity in patients undergoing transperitoneal laparoscopic lymphadenectomy (0.73 in ROC curve). It performed better than body mass index and other anthropometric measurements. We calculated a cut-off point of 246 mm (sensitivity: 0.56, specificity: 0.80). CONCLUSIONS u-SAD is a simple, reliable, and potentially useful measurement to predict surgical morbidity in endometrial cancer patients undergoing minimally invasive surgical staging, especially when facing transperitoneal aortic lymphadenectomy.
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Affiliation(s)
- Alejandro Correa-Paris
- Obstetrics and Gynecology Department, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Verónica Gorraiz Ochoa
- Obstetrics and Gynecology Department, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Juan Gilabert Estellés
- Obstetrics and Gynecology Department, Hospital General de Valencia, Valencia, Spain.,University of Valencia, Valencia, Spain
| | - Berta Díaz-Feijoo
- Obstetrics and Gynecology Department, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Gil-Moreno
- Obstetrics and Gynecology Department, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Biomedical Research Group in Gynecology, Vall d'Hebron Institut de Recerca, Barcelona, Spain
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Narasimhulu DM, Fagotti A, Scambia G, Weaver AL, McGree M, Quagliozzi L, Langstraat C, Kumar A, Cliby W. Validation of a risk-based algorithm to reduce poor operative outcomes after complex surgery for ovarian cancer. Int J Gynecol Cancer 2023; 33:83-88. [PMID: 36517075 PMCID: PMC9972179 DOI: 10.1136/ijgc-2022-003799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE We developed an algorithm that identifies patients at high risk of morbidity/mortality after cytoreductive surgery for advanced ovarian cancer. We have previously shown that the Mayo triage algorithm reduces operative mortality internally, followed by validation using an external low complexity national dataset. However, validation in a higher complexity surgical setting is required before widespread acceptance of this approach, and this was the goal of our study. METHODS We included patients who underwent debulking surgery (including primary or interval debulking surgery) for stage IIIC/IV ovarian cancer between October 2011 and November 2019 (SCORPION trial patients until May 2016 and non-trial patients thereafter) at Fondazione Policlinico A Gemelli, Italy. Using the algorithm, we classified patients as either high-risk or triage-appropriate and compared 30-day grade 3+ complications and 90-day mortality using a χ2 test or Fisher's exact test. RESULTS A total of 625 patients were included. The mean age was 58.7±11.4 years, 73.6% (n=460) were stage IIIC, and 63.0% (n=394) underwent primary debulking surgery. Surgical complexity was intermediate or high in 82.6% (n=516) of patients (95.7% (n=377) for primary surgery and 60.2% (n=139) for interval surgery), and 20.3% (n=127) were classified as high-risk. When compared with triage-appropriate patients, high-risk patients had (1) a threefold higher rate of 90-day mortality (6.3% vs 2.0%, p=0.02); (2) a higher likelihood of 90-day mortality following a grade 3+ complication (25.9% vs 10.0%, p=0.05); and (3) comparable rates of grade 3+ complications (21.3% vs 16.1%, p=0.17). CONCLUSION The evidence-based triage algorithm identifies patients at high risk of morbidity/mortality after cytoreductive surgery. Triage high-risk patients are poor candidates for surgery when complex surgery is required. This algorithm has been validated in heterogeneous settings (internal, national, and international) and degree of surgical complexity. Risk-based decision making should be standard of care when planning surgery for patients with advanced ovarian cancer, whether primary or interval surgery.
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Affiliation(s)
- Deepa Maheswari Narasimhulu
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anna Fagotti
- Department of Gynecological Oncology, Catholic University of the Sacred Heart, Milano, Lombardia, Italy
- Department for Women's and Children's Health and Public Health, Gynecologic Oncology Unit, Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
| | - Giovanni Scambia
- Department of Gynecological Oncology, Catholic University of the Sacred Heart, Milano, Lombardia, Italy
- Department for Women's and Children's Health and Public Health, Gynecologic Oncology Unit, Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
| | - Amy L Weaver
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michaela McGree
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Lorena Quagliozzi
- Department for Women's and Children's Health and Public Health, Gynecologic Oncology Unit, Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
| | - Carrie Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - William Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Levin SR, de Geus SWL, Noel NL, Paasche-Orlow MK, Farber A, Siracuse JJ. Vascular repairs in gynecologic operations are uncommon but predict major morbidity and mortality. J Vasc Surg 2020; 72:1059-1066.e2. [PMID: 32035777 DOI: 10.1016/j.jvs.2019.11.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/10/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Gynecologic surgery has potential for adjunct vascular interventions, given the proximity of major intra-abdominal and pelvic blood vessels. Our goal was to determine contemporary incidence, associations, and outcomes of vascular repairs in gynecologic operations. METHODS The American College of Surgeons National Surgical Quality Improvement Program database (2005-2017) was queried for patients undergoing elective gynecologic operations. Vascular repairs were performed concurrently or during reoperation. Univariable and multivariable analyses evaluated associations with vascular repairs and 30-day morbidity. RESULTS A total of 201,224 gynecologic operations were identified: hysterectomy (88.3%), myomectomy (5.9%), adnexal surgery (3.5%), vulvovaginectomy/other (1.1%), nonadnexal tumor or cyst excision (0.5%), ectopic pregnancy treatment (0.4%), and pelvic lymphadenectomy (0.3%). There were 187 vascular repairs in 176 (0.09%) patients. Repairs were typically concurrent (89.8%) and most commonly included open abdominal blood vessel repair (51.8%), major abdominal artery ligation (25%), vena cava reconstruction/ligation (6%), common iliac vein ligation (4.2%), and aorta/great vessel repair (4.2%). A minority were performed endovascularly (1.7%). Patients undergoing vascular repairs were older (56 vs 46 years), were more likely to have an open vs minimally invasive/vaginal operation (71.6% vs 28.4%), and were more likely to have a hysterectomy (85.2%; P < .001 for all). In multivariable analysis, vascular repairs were observed more often with hysterectomy (odds ratio [OR]; 7.63, 95% confidence interval [CI], 2.28-25.55; P = .001) and open vs minimally invasive/vaginal operations (OR, 5.24; 95% CI, 2.64-10.42; P < .001). Vascular repairs were also more common for patients with malignant disease (OR, 2.84; 95% CI, 1.78-4.53; P < .001), patients assigned to American Society of Anesthesiologists class 3 or class 4 (OR, 1.85; CI, 1.36-2.53; P = .002), and patients without obesity (OR, 1.45; 95% CI, 1.08-1.96; P = .014). Vascular repairs independently predicted major morbidity and mortality (OR, 7.26; 95% CI, 5.26-10.03; P < .001) after adjustment for open operative approach, American Society of Anesthesiologists class 3 or class 4, and hysterectomy. CONCLUSIONS Whereas vascular repairs during gynecologic operations are rare, they are associated with morbidity and mortality. These findings provide an evidence base for risk assessment and informed consent.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Susanna W L de Geus
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Nyia L Noel
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Michael K Paasche-Orlow
- Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
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Long D, Lihn A, Friedrich S, Scheffenbichler F, Safavi K, Burns S, Schneider J, Grabitz S, Houle T, Eikermann M. Association between intraoperative opioid administration and 30-day readmission: a pre-specified analysis of registry data from a healthcare network in New England. Br J Anaesth 2018; 120:1090-1102. [DOI: 10.1016/j.bja.2017.12.044] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 12/06/2017] [Accepted: 01/25/2018] [Indexed: 11/17/2022] Open
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