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Xu D, Zhao Q. Clinical significance of preoperative albumin and alkaline phosphatase in colorectal cancer: a systematic review and meta-analysis. Am J Transl Res 2024; 16:3449-3461. [PMID: 39262704 PMCID: PMC11384371 DOI: 10.62347/shbh6258] [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: 03/20/2024] [Accepted: 06/10/2024] [Indexed: 09/13/2024]
Abstract
OBJECTIVE To investigate the association between preoperative serum levels of albumin (ALB) and alkaline phosphatase (ALP) with postoperative outcome in colorectal cancer (CRC) patients. METHODS A thorough literature search was conducted across Embase, PubMed, and Cochrane Library databases, identifying 20 eligible studies encompassing 61,296 participants. Studies were primarily observational and case-control in nature, with some randomized controlled trials also included. The random effects model was utilized to synthesize the effect sizes, while study quality was appraised using the Newcastle-Ottawa Scale and the Cochrane Risk of Bias Assessment Tool. RESULTS Findings revealed that CRC patients with preoperative ALB levels below 3.5 g/dl were at an elevated risk for postoperative complications (OR = 2.56, 95% CI: 2.12-3.08), increased mortality (OR = 4.54, 95% CI: 2.02-10.20), and a poorer prognostic survival risk (HR = 2.09, 95% CI: 1.58-2.77). Additionally, elevated ALP levels were associated with a higher risk of poor overall survival (HR = 1.67, 95% CI: 1.44-1.94). However, publication bias was noted in some studies. CONCLUSION Preoperative hypoalbuminemia and elevated ALP levels are significantly linked to adverse postoperative events and reduced survival in CRC patients, suggesting their potential as prognostic biomarkers.
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Affiliation(s)
- Dafang Xu
- Department of General Surgery, The First People's Hospital of Huzhou Huzhou 313000, Zhejiang, China
| | - Qun Zhao
- Department of General Surgery, The First People's Hospital of Huzhou Huzhou 313000, Zhejiang, China
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Lv Q, Yuan Y, Qu SP, Diao YH, Hai ZX, Xiang Z, Peng D. Development and validation of a nomogram to predict the risk factors of major complications after radical rectal cancer surgery. Front Oncol 2024; 14:1380535. [PMID: 38577342 PMCID: PMC10991776 DOI: 10.3389/fonc.2024.1380535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/11/2024] [Indexed: 04/06/2024] Open
Abstract
Purpose The aim of this study was to establish a validated nomogram to predict risk factors for major post-operative complications in patients with rectal cancer (RC) by analyzing the factors contributing to major post-operative complications in RC patients. Methods We retrospectively collected baseline and surgical information on patients who underwent RC surgery between December 2012 and December 2022 at a single-center teaching hospital. The entire cohort was randomly divided into two subsets (60% of the data for development, 40% for validation). Independent risk factors for major post-operative complications were identified using multivariate logistic regression analyses, and predictive models were developed. Area under the curve (AUC) was calculated using receiver operating characteristic curve (ROC) to assess predictive probability, calibration curves were plotted to compare the predicted probability of the nomogram with the actual probability, and the clinical efficacy of the nomogram was assessed using decision curve analysis (DCA). Results Our study included 3151 patients who underwent radical surgery for RC, including 1892 in the development set and 1259 in the validation set. Forty (2.1%) patients in the development set and 26 (2.1%) patients in the validation set experienced major post-operative complications. Through multivariate logistic regression analysis, age (p<0.01, OR=1.044, 95% CI=1.016-1.074), pre-operative albumin (p<0.01, OR=0.913, 95% CI=0.866-0.964), and open surgery (p<0.01, OR=2.461, 95% CI=1.284-4.761) were identified as independent risk factors for major post-operative complications in RC, and a nomogram prediction model was established. The AUC of the ROC plot for the development set was 0.7161 (95% Cl=0.6397-0.7924), and the AUC of the ROC plot for the validation set was 0.7191 (95% CI=0.6182-0.8199). The predicted probabilities in the calibration curves were highly consistent with the actual probabilities, which indicated that the prediction model had good predictive ability. The DCA also confirmed the good clinical performance of the nomogram. Conclusion In this study, a validated nomogram containing three predictors was created to identify risk factors for major complications after radical RC surgery. Due to its accuracy and convenience, it could contribute to personalized management of patients in the perioperative period.
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Affiliation(s)
| | | | | | | | | | | | - Dong Peng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Song JH, Oh RK, Lee JE, Lee KH, Kim JY, Kim JS. Computed tomography-assessed presarcopenia and clinical outcomes after laparoscopic surgery for rectal cancer. Ann Coloproctol 2023; 39:513-520. [PMID: 38081790 PMCID: PMC10781607 DOI: 10.3393/ac.2023.00031.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/25/2023] [Accepted: 02/01/2023] [Indexed: 01/09/2024] Open
Abstract
PURPOSE Previous studies have reported that presarcopenia negatively affects rectal cancer treatment. However, most studies have analyzed patients including majority of open surgery, and the association between presarcopenia and clinical outcomes after laparoscopic rectal cancer surgery remains unclear. This study aimed to evaluate the impact of presarcopenia on the clinical and oncological outcomes after laparoscopic rectal cancer surgery. METHODS Three hundred and one patients undergoing laparoscopic rectal cancer surgery between December 2009 and May 2016 were enrolled. Body composition was assessed using computed tomography by measuring the muscle and fat areas at the third lumbar (L3) vertebra. The L3 skeletal muscle area was used to calculate the skeletal muscle index and evaluate presarcopenia. RESULTS Presarcopenia was more common in older ( ≥ 70 years, P = 0.008) or female patients (P = 0.045). Patients with presarcopenia had decreased skeletal muscle area (P < 0.001), lower hemoglobin level (P = 0.034), longer time to first flatus (P < 0.001), and more frequent surgical site infection (P = 0.001). However, survival rates were not significantly different between those with and without presarcopenia. CONCLUSION Computed tomography-assessed presarcopenia was associated with delayed functional recovery and increased surgical site infection, although it was not revealed as a prognostic factor for oncological outcomes.
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Affiliation(s)
- Ji Hyeong Song
- Department of Surgery, Chungnam National University Sejong Hospital, Sejong, Korea
| | - Rak Kyun Oh
- Department of Surgery, Asan Medical Center, Seoul, Korea
| | - Jeong Eun Lee
- Department of Radiology, Chungnam National University College of Medicine, Daejeon, Korea
| | - Kyung Ha Lee
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Ji Yeon Kim
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jin Soo Kim
- Department of Surgery, Chungnam National University Sejong Hospital, Sejong, Korea
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
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Bowcutt JT, Shibuya N, Jupiter DC. Preoperative Serum Albumin and Other Risk Factors Related to 30-Day Postoperative Complications in Total Ankle Arthroplasty. J Foot Ankle Surg 2023; 62:981-985. [PMID: 37549784 DOI: 10.1053/j.jfas.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/08/2023] [Accepted: 07/29/2023] [Indexed: 08/09/2023]
Abstract
This study investigates effects of preoperative albumin on 30-day total ankle arthroplasty (TAA) outcomes. Additionally, other preoperative risk factors are addressed, including American Anesthesia Society (ASA) class, functional status, chronic obstructive pulmonary disease (COPD), diabetes, smoking status, time of operation, and age. Outcomes assessed were readmission, return to operating room, surgical site infection, wound dehiscence, and total length of stay (TLOS). Data were extracted from the National Surgical Quality Improvement Program database. Bivariate comparisons were analyzed using correlation coefficients, t tests, or chi-squared tests; multivariate comparisons used linear or logistic regression. Our data showed no significant correlation between serum albumin and patients with readmission (odds ratio -0.14, P = 0.06), return to operating room (-0.07, P = 0.61), or surgical site infection (-0.08, P = 0.56). With bivariate analysis, functional status and COPD were significant for readmission (12.67, P < 0.001 and 7.83, P < 0.001, respectively) and dehiscence (30.52, P < 0.001 and 6.74, P = 0.05, respectively), while high ASA class (0.4, P = 0.01), increased age (0.1, P < 0.001), and longer time of operation (0.19, P < 0.001) were associated with longer TLOS. With multivariate analysis, functional status showed higher odds of readmission (7.42, P = 0.02) and dehiscence (20.47, P = 0.01), while COPD showed higher odds for readmission (6.65, P < 0.001) and longer TLOS (0.31, P = 0.05). High ASA class (0.42, P < 0.001) and female sex (0.32, P < 0.001) also had higher odds for longer TLOS. In summary, low albumin was not significant for readmission, return to operating room, or surgical site infection in TAA. COPD, functional status, high ASA class, longer time of operation, increased age, and female sex were all correlated with adverse outcomes in TAA.
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Affiliation(s)
- Jeffrey T Bowcutt
- John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, TX
| | - Naohiro Shibuya
- The University of Texas Rio Grande Valley, School of Podiatric Medicine, Edinburg, TX
| | - Daniel C Jupiter
- Department of Biostatistics and Data Science, The University of Texas Medical Branch, Galveston, TX; Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX.
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Wang K, Tang Y, Zhang F, Guo X, Gao L. Combined application of inflammation-related biomarkers to predict postoperative complications of rectal cancer patients: a retrospective study by machine learning analysis. Langenbecks Arch Surg 2023; 408:400. [PMID: 37831218 DOI: 10.1007/s00423-023-03127-5] [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] [Received: 07/10/2023] [Accepted: 09/29/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Postoperative complications in patients of rectal cancer pose challenges to postoperative recovery. Accurately predicting these complications is crucial for developing effective treatment plans for patients. METHODS In this retrospective study, 493 patients with rectal cancer who underwent radical resection between January 2020 and December 2021 were examined. We evaluated logistic regression, support vector machines, regression trees, and random forests to predict the incidence of postoperative complications in patients and evaluate the performance of the model. The results will be analyzed to make recommendations for reducing complications. RESULTS Among the four machine learning models, random forest demonstrated the highest results. The performance of this model was showed with an AUC of 0.880 (95% CI 0.807-0.949), an accuracy of 88.0% (95% CI 0.815-0.929), a sensitivity of 96.6%, and a specificity of 45.8%. Notably, factors such as inflammation related prognostic index, prognostic nutritional index, tumor location, and T stage were found to significantly increase the probability of postoperative complications. CONCLUSION Our study provided evidence that machine learning models can effectively evaluate early postoperative complications of the patients after surgery.
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Affiliation(s)
- Kunyue Wang
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, 215006, Jiangsu Province, China
| | - Youyuan Tang
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, 215006, Jiangsu Province, China
| | - Feng Zhang
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, 215006, Jiangsu Province, China
| | - Xingpo Guo
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, 215006, Jiangsu Province, China.
| | - Ling Gao
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, 215006, Jiangsu Province, China.
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Tangvoraphonkchai K, Manasirisuk W, Sawadpanich K, Suttichaimongkol T, Mairiang P. Lubiprostone plus polyethylene glycol electrolyte lavage solution (PEG-ELS) versus PEG-ELS for bowel preparation in chronic constipation: a randomized controlled trial. Sci Rep 2023; 13:16265. [PMID: 37759079 PMCID: PMC10533515 DOI: 10.1038/s41598-023-43598-6] [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] [Received: 03/24/2023] [Accepted: 09/26/2023] [Indexed: 09/29/2023] Open
Abstract
Colonoscopy is considered the standard procedure for early detection and prevention of colorectal cancer. Adequate bowel cleansing is an important determinant of the efficacy of colonoscopy screening. Currently, there is no standard method of bowel preparation for patients with chronic constipation. The aim was to access the rate of adequate bowel cleansing achieved using split-dose polyethylene glycol electrolyte lavage solution (PEG-ELS) plus lubiprostone in comparison with split-dose PEG-ELS alone. A single-centre, endoscopist-blinded, randomized controlled trial was conducted. Seventy-eight constipated patients aged 18-75 years who were indicated for colonoscopy in the gastroenterology unit of Srinagarind Hospital, Khon Kaen University, between February 2020 and February 2021 were randomly allocated to receive either split-dose PEG-ELS in combination with lubiprostone (N = 39) or split-dose PEG-ELS alone (N = 39) before colonoscopy. Adequate bowel cleansing was defined as an Ottawa bowel preparation score ≤ 7. The rate of adequate bowel cleansing was comparable between the PEG-ELS plus lubiprostone group and the PEG-ELS alone group (50% vs. 52.9%, p value = 0.81) with a relative risk of 1.13 (95% CI = 0.43-2.91). There were no significant differences in adenoma detection rate (41.2% vs. 35.3%, p value = 0.62), adverse events, acceptance, compliance, or patient satisfaction between the 2 groups. No additional benefit to successful bowel preparation was achieved by the combination of lubiprostone and PEG-ELS in chronic constipation patients undergoing colonoscopy.
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Affiliation(s)
- K Tangvoraphonkchai
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
- GI Endoscopy Srinagarind Center of Excellence, Srinagarind Hospital, Khon Kaen, Thailand.
- Srinagarind Hospital, KKU, Khon Kaen, Thailand.
| | - W Manasirisuk
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - K Sawadpanich
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - T Suttichaimongkol
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - P Mairiang
- GI Endoscopy Srinagarind Center of Excellence, Srinagarind Hospital, Khon Kaen, Thailand
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Intraoperative complication of radical cystectomy for muscle-invasive bladder cancer: does the surgical approach matter? A retrospective multicenter study using the EAUiaiC classification. World J Urol 2023; 41:1061-1067. [PMID: 36847814 DOI: 10.1007/s00345-023-04340-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/10/2023] [Indexed: 03/01/2023] Open
Abstract
PURPOSE Despite surgical and anesthetic progress, radical cystectomy for bladder cancer remains one of the most morbid surgeries in urology. The objective of our study was to describe intraoperative complications and to assess the impact of surgical approach on morbidity. METHODS We retrospectively reviewed medical records of patients treated by radical cystectomy for localized muscle invasive bladder cancer between 2015 and 2020, following the Martin et al. criteria for complications reports. All intraoperative adverse events were graded according to the EAUiaiC scores. Multivariate regression models were used to determine predicting factors of complications. RESULTS A total of 318 patients were included for analysis. Among them, 17 patients (5.4%) presented an intraoperative complication. No preoperative oncological or clinical factor was associated with the occurrence of an intraoperative complication. Surgical approach had no impact on morbidity. Both overall survival (HR 2.02; CI95% 0.87-4.68; p = 0.101) and recurrence-free survival (HR 1.856; CI95% 0.804-4.284; p = 0.147) were not associated with intraoperative complication. CONCLUSION Radical cystectomy remains a highly morbid surgery and surgical approach did not improve the complication rate. Perioperative morbidity has a significant impact on patient survival. The association between intraoperative and postoperative complications illustrates the cumulative effect of perioperative events that are associated with survival.
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Huang J, Xie L, Yang Y, Xie H, Liu C. Hypoalbuminemia within One Hour After Surgery as a Predictor of Post-Operative Urosepsis in Patients Undergoing Flexible Ureteroscopy Lithotripsy: A Retrospective Study. Surg Infect (Larchmt) 2023; 24:75-81. [PMID: 36579922 DOI: 10.1089/sur.2022.290] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Abstract Background: To investigate retrospectively whether changes in serum albumin levels within one hour of flexible ureteroscopy (fURS) lithotripsy can be used as a predictor of post-operative urosepsis. Patients and Methods: Eligible patients with unilateral upper urinary calculi who underwent fRUS lithotripsy performed by a single surgeon at our center were included in the analysis. The patients were divided into sepsis and non-sepsis groups. The change ratio of albumin and white blood cell (WBC) count was calculated by post-operative/pre-operative index*100%. Univariable and multivariable logistic regression analyses were used to assess whether there was a correlation between risk factors and post-operative urosepsis. The receiver operating characteristic (ROC) curve was used to analyze factors that showed significant differences in multivariable logistic regression analysis. Results: A total of 314 patients were included in the analysis, 20 of whom had post-operative urosepsis and five developed septic shock; no deaths occurred. Multivariable logistic regression analysis showed that urine culture results, WBC counts within one hour after surgery, post-operative albumin levels, and the degree of albumin changes after surgery were independent predictors of post-operative urosepsis. Receiver operating characteristic curve analysis showed that noteworthy hypoalbuminemia after surgery and positive pre-operative urine culture could help screen high-risk patients for post-operative urosepsis effectively. Conclusions: Hypoalbuminemia shortly after operation can be utilized as a predictor for early diagnosis of post-operative urosepsis in patients undergoing fURS lithotripsy.
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Affiliation(s)
- Junkai Huang
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Linguo Xie
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Yu Yang
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Haijie Xie
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Chunyu Liu
- Department of Urology, Tianjin Institute of Urology, The Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
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Xu F, Meng C, Yang Z, Li H, Gao J, Sun L, Zhang X, Wei Q, Wu G, Yao H, Zhang Z. Prognostic nutrition index predicts short-term surgical complications in patients with rectal cancer after laparoscopic surgery. Front Surg 2022; 9:1000108. [PMID: 36386497 PMCID: PMC9640637 DOI: 10.3389/fsurg.2022.1000108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/03/2022] [Indexed: 11/07/2022] Open
Abstract
Purpose Surgical complications following laparoscopic rectal cancer surgery remain a major clinical problem. The prognostic nutritional index (PNI) is reportedly associated with postoperative outcomes. We aimed to evaluate the correlation between PNI and short-term surgical complications in patients with rectal cancer after laparoscopic surgery. Methods The prospective clinical data of 225 patients with rectal cancer receiving laparoscopic surgery between January 2021 and April 2022 were retrospectively analyzed. The cut-off values and diagnostic accuracy of PNI preoperatively and on postoperative day (POD) 1 were determined using receiver operating characteristic (ROC) curves. Univariate and multivariate analyses were performed to identify clinical characteristics and risk factors for surgical complications. Results In total, 81 (36.0%) patients developed surgical complications. The optimal cut-off value for preoperative PNI was 40.15, and that for PNI on POD 1 was 35.28. The DeLong test found no statistically between–group difference in the area under the ROC curve (P = 0.598). Multivariate analysis identified that a preoperative PNI ≤40.15 [odds ratio (OR): 2.856, 95% confidence interval (CI): 1.287–6.341, P = 0.010] and PNI on POD 1 ≤35.28 (OR: 2.773, 95% CI: 1.533–5.016, P = 0.001) were independent risk factors for surgical complications. Patients with a preoperative PNI ≤40.15 or PNI on POD 1 ≤35.28 were more likely to have surgical complications after laparoscopic surgery for rectal cancer (61.1% vs. 31.2%, P = 0.001; 53.0% vs. 28.9%, P = 0.001). Conclusion Preoperative and POD 1 PNI were independent predictors of short-term surgical complications after laparoscopic surgery for rectal cancer.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Guocong Wu
- Correspondence: Guocong Wu Hongwei Yao Zhongtao Zhang
| | - Hongwei Yao
- Correspondence: Guocong Wu Hongwei Yao Zhongtao Zhang
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Kang B, Zhao ZQ, Liu XY, Cheng YX, Tao W, Wei ZQ, Peng D. Effect of hypoalbuminemia on short-term outcomes after colorectal cancer surgery: A propensity score matching analysis. Front Nutr 2022; 9:925086. [PMID: 36105581 PMCID: PMC9464913 DOI: 10.3389/fnut.2022.925086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/29/2022] [Indexed: 12/09/2022] Open
Abstract
Purpose The purpose of our study was to investigate the effect of pre-operative hypoalbuminemia on the short-term outcomes after primary colorectal cancer (CRC) surgery. Materials and methods The retrospective study enrolled CRC patients who underwent primary surgery from January 2011 to December 2021 in a single teaching hospital. The short-term outcomes were compared between the hypoalbuminemia group and the normal group using propensity score matching (PSM). Univariate and multivariate logistic regression analyses were used for analyzing independent predictors of overall complications and major complications. Results A total of 7,072 patients from a single center were enrolled in this study. There were 1,078 (15.2%) patients in the pre-operative hypoalbuminemia group and 5,994 (84.8%) patients in the normal pre-operative albumin group. After 1:1 PSM, there were 1,028 patients in the hypoalbuminemia group and 1,028 patients in the normal group. No significant differences were found in baseline information between the two groups after PSM. In terms of short-term outcomes, the hypoalbuminemia group had a longer operation time (p = 0.003), greater volume of blood loss (p = 0.036), longer hospital stays (p < 0.01), higher proportion of overall complications (p = 0.003), major complications (p = 0.016), higher incidence of pneumonia and abdominal infection (p = 0.001) than the normal group after PSM. Furthermore, hypoalbuminemia was an independent predictor for overall complications (p = 0.008) and major complications (p = 0.016). Conclusion Pre-operative hypoalbuminemia increased overall complications and major complications after primary CRC surgery. Furthermore, hypoalbuminemia was an independent predictor for overall complications and major complications.
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Affiliation(s)
- Bing Kang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Clinical Nutrition, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhi-Qiang Zhao
- Department of General Surgery, Qijiang Hospital of the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Yu Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu-Xi Cheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Tao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zheng-Qiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dong Peng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- *Correspondence: Dong Peng,
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Pausawasdi N, Tongpong P, Geeratragool T, Charatcharoenwitthaya P. An Assessment of Physicians’ Recommendations for Colorectal Cancer Screening and International Guidelines Awareness and Adherence: Results From a Thai National Survey. Front Med (Lausanne) 2022; 9:847361. [PMID: 35572969 PMCID: PMC9100397 DOI: 10.3389/fmed.2022.847361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 04/11/2022] [Indexed: 12/24/2022] Open
Abstract
Background Colorectal cancer (CRC) screening uptake is generally low in the Asia Pacific and physicians’ recommendations affect the screening participation. Objective The study aimed to assess Thai physicians’ recommendations for CRC screening, and the awareness of and adherence to international guidelines. Methods A survey containing questions assessing physicians’ demographic data, screening recommendations, and awareness of the international CRC screening guidelines assessed by clinical vignettes. Independent predictors of physicians’ recommendations for CRC screening were determined by logistic regression analysis. Results Five hundred and eighty-sixth of 1,286 (46%) physicians completed the survey, and 58% of them offered CRC screening. The majority of colorectal surgeons (91%) and gastroenterologists (86%) endorsed screening, whereas 35% of primary care physicians recommended screening. The patient’s age was the only factor influencing the physician’s decision to offer CRC screening (OR, 2.75: 95% CI, 1.61–4.67). Colonoscopy was the most recommended modality among specialists, whereas 60% of primary care physicians offered fecal occult blood tests (FOBTs). The guidelines awareness was noted in 81% of participants, with the highest rates among gastroenterologists and colorectal surgeons. Gastroenterologists were more likely to adhere to the guidelines than surgeons, but both recommended shorter interval surveillance colonoscopy than guidelines recommendations in cases of small hyperplastic rectosigmoid polyps. Conclusions Recommendations for CRC screening and awareness of guidelines vary among different specialties. A low proportion of primary care physicians recommended screening and colorectal surgeons and gastroenterologists recommended shorter intervals for surveillance of small hyperplastic polyp than suggested by guidelines.
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Affiliation(s)
- Nonthalee Pausawasdi
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- *Correspondence: Nonthalee Pausawasdi,
| | - Pongkamon Tongpong
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tanawat Geeratragool
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Siriraj GI Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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12
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Akula B, Doctor N. A Prospective Review of Preoperative Nutritional Status and Its Influence on the Outcome of Abdominal Surgery. Cureus 2021; 13:e19948. [PMID: 34868791 PMCID: PMC8627379 DOI: 10.7759/cureus.19948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 11/06/2022] Open
Abstract
Aim To assess the incidence of malnutrition in a surgical gastroenterology unit and analyze its impact on postoperative complication rates. Method Data were prospectively accrued from patients admitted for emergency or elective surgery to the gastrointestinal surgery unit at Jaslok Hospital between May 2013 and May 2014. The nutritional status was preoperatively assessed by using anthropometric parameters like body mass index (BMI), midarm circumference (MAC), and tissue skinfold thickness (TSFT). In addition, a subjective global assessment scale (SGA), serum albumin, and absolute lymphocyte count (ALC) were used. Patients with BMI <18.5, MAC <24 cm in males and <22 cm in females, and TSFT <10 mm were considered malnourished. Patients with serum albumin between 3 and 3.5 g/dl were considered mild, 2.4-2.9 g/dl was moderate, and <2.4 g/dl were severely malnourished. Patients with ALC between 1200 and 2000/cm were labelled mild, between 800 and 1199/cm were moderate, and <800/cm were severely malnourished. As per SGA, well-nourished had less than 5% weight loss or if more than 5%, with recent gain and improved appetite, mild/moderately malnourished had 5% to 10% weight loss with no gain, mild subcutaneous fat loss, and those severely malnourished had more than 10% weight loss, severe subcutaneous fat loss, and muscle wasting. Postoperative complications were graded as per the Clavien-Dindo classification. Patients with grades 1 and 2 complications were labelled as minor and the rest as major. Result Men in the age group of 40-60 years comprised the majority of the study population. The most frequent reason for admission was cholelithiasis. The overall incidence of malnutrition was 22.16%. Out of the 96 patients who had complications, 45 had minor and 41 had significant complications. Amongst the well-nourished, the incidence of complications was 26.62% of which the majority were minor complications. Severely malnourished patients had a high complication rate (63.38%); 32% out of the 63.38% developed significant complications. The majority of the patients suffering from severe malnutrition belonged to the sub-group with chronic pancreatitis and carcinoma of the pancreas. According to the chi-square analysis of the data, ALC, serum albumin, and SGA correlate with the postoperative complication rate with a p-value <0.05 as significant. On the contrary, BMI, MAC, and TSFT did not correlate with postoperative complications. Conclusion Preoperative malnutrition is common among patients undergoing abdominal surgeries in the urban private health care sector. Although there have been studies that have analyzed the incidence of malnutrition in patients undergoing oncological surgeries, there is limited literature on malnutrition among patients subjected to gastrointestinal surgeries. We conclude that simple bedside nutritional assessment tools like serum albumin, absolute lymphocyte count, and SGA can accurately identify malnourished patients preoperatively and are good predictors of postoperative complications. Hence, it is imperative to assess and attempt to improve the nutritional status of the patients preoperatively.
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Affiliation(s)
- Bharathi Akula
- Surgery, University Hospital of Leicester, Leicestershire, GBR
| | - Nilesh Doctor
- Gastrointestinal Surgery, Jaslok Hospital and Research Centre, Mumbai, IND
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Sugimoto A, Toyokawa T, Miki Y, Yoshii M, Tamura T, Sakurai K, Kubo N, Tanaka H, Lee S, Muguruma K, Yashiro M, Ohira M. Preoperative C-reactive protein to albumin ratio predicts anastomotic leakage after esophagectomy for thoracic esophageal cancer: a single-center retrospective cohort study. BMC Surg 2021; 21:348. [PMID: 34548054 PMCID: PMC8454123 DOI: 10.1186/s12893-021-01344-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/15/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Postoperative anastomotic leakage (AL) is associated with not only prolonged hospital stay and increased medical costs, but also poor prognosis in esophageal cancer. Several studies have addressed the utility of various inflammation-based and/or nutritional markers as predictors for postoperative complications. However, none have been documented as specific predictors for AL in esophageal cancer. We aimed to identify predictors of AL after esophagectomy for thoracic esophageal cancer, focusing on preoperative inflammation-based and/or nutritional markers. METHODS We retrospectively analyzed 295 patients who underwent radical esophagectomy for thoracic esophageal squamous cell carcinoma between June 2007 and July 2020. As inflammation-based and/or nutritional markers, Onodera prognostic nutritional index, C-reactive protein (CRP)-to-albumin ratio (CAR) and modified Glasgow prognostic score were investigated. Optimal cut-off values of inflammation-based and/or nutritional markers for AL were determined by receiver operating characteristic curves. Predictors for AL were analyzed by logistic regression modeling. RESULTS AL was observed in 34 patients (11.5%). In univariate analyses, preoperative body mass index (≥ 22.1 kg/m2), serum albumin level (≤ 3.8 g/dL), serum CRP level (≥ 0.06 mg/dL), CAR (≥ 0.0139), operation time (> 565 min) and blood loss (≥ 480 mL) were identified as predictors of AL. Multivariate analyses revealed higher preoperative CAR (≥ 0.0139) as an independent predictor of AL (p = 0.048, odds ratio = 3.02, 95% confidence interval 1.01-9.06). CONCLUSION Preoperative CAR may provide a useful predictor of AL after esophagectomy for thoracic esophageal squamous cell carcinoma.
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Affiliation(s)
- Atsushi Sugimoto
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Takahiro Toyokawa
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Yuichiro Miki
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Mami Yoshii
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Tatsuro Tamura
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Katsunobu Sakurai
- Department of Gastroenterological Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Naoshi Kubo
- Department of Gastroenterological Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Hiroaki Tanaka
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Shigeru Lee
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kazuya Muguruma
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masakazu Yashiro
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masaichi Ohira
- Department of Gastroenterological Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
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Toritani K, Kimura H, Fukuoka H, Watanabe J, Ishibe A, Kunisaki R, Endo I. Preoperative risk factors of incisional surgical site infection in severe or intractable ulcerative colitis. Surg Today 2021; 52:475-484. [PMID: 34387734 DOI: 10.1007/s00595-021-02354-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/22/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The present study explored preoperative risk factors (predictors) of incisional surgical site infection (I-SSI) in severe or intractable ulcerative colitis (UC). METHODS This was a retrospective study of 230 consecutive patients who underwent primary surgery for UC. Patients whose surgical indications were UC with cancer or dysplasia were excluded. SSI was defined as an infection according to the Centers for Disease Control and Prevention Guidelines. Preoperative variables were examined by univariate, receiver operating characteristic curve, and multivariate analyses. RESULTS We analyzed 208 patients in this study. In a multivariate logistic analysis, C-reactive protein (CRP) ≥ 1.7 mg/dl [odds ratio (OR) 5.35; 95% confidence interval (CI) 1.50-19.06; p = 0.01), albumin ≤ 2.4 g/dl (OR 5.77; 95% CI 1.41-23.57; p = 0.02), and preoperative blood transfusion (OR 3.21; 95% CI 1.04-9.96; p = 0.04) were predictors of I-SSI. Patients with all predictors had a more than 50% incidence of I-SSI, a higher incidence of all severe complications (13.6% vs. 3.2%; p = 0.02), and a longer postoperative hospital stay (19.5 vs. 17.0 days, p = 0.04) than the other patients. CONCLUSIONS CRP ≥ 1.7 mg/dl, albumin ≤ 2.4 g/dl, and transfusion are predictors of I-SSI in severe or intractable UC. Clinician should carefully evaluate the surgical options before these predictors appear.
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Affiliation(s)
- Kenichiro Toritani
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Hideaki Kimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan.
| | - Hironori Fukuoka
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Jun Watanabe
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Atsushi Ishibe
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, 4-57, Urafune-cho, Minami-ku, Yokohama, 232-0024, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Oh EH, Kim N, Hwang SW, Park SH, Yang DH, Ye BD, Myung SJ, Yang SK, Yu CS, Kim JC, Byeon JS. Comparison of long-term recurrence-free survival between primary surgery and endoscopic resection followed by secondary surgery in T1 colorectal cancer. Gastrointest Endosc 2021; 94:394-404. [PMID: 33617859 DOI: 10.1016/j.gie.2021.02.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/13/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS We aimed to investigate whether endoscopic resection of T1 colorectal cancer (CRC) before surgery (secondary surgery) unfavorably affects long-term recurrence-free survival (RFS) compared with surgery without prior endoscopic resection (primary surgery). METHODS We reviewed the medical records of patients who underwent radical surgery for T1 CRC with high-risk histologic features at a tertiary referral hospital in Korea between 2011 and 2016. The primary outcome was RFS. We performed 2 types of propensity score (PS) analyses to control for confounders. RESULTS Of 852 patients, 388 underwent primary surgery and 464 secondary surgery. During the median follow-up period of 57.0 months (range, 41.0-63.0), cancer recurred in 18 patients (2.1%). The 5-year RFS rates did not differ between the primary and secondary surgery groups (97.0 vs 98.5%, P = .194). Further analyses of RFS rates according to nodal stages and number of high-risk histologic features showed no difference between groups. Moreover, RFS rates were not different between the groups after PS matching. In multivariable Cox proportional regression analysis, baseline serum carcinoembryonic antigen level was an independent risk factor for cancer recurrence (hazard ratio, 1.464; 95% confidence interval, 1.242-1.725; P < .001) but prior endoscopic resection of T1 CRC was not (P = .201). Both PS analyses consistently showed no increase in cancer recurrence risk in the secondary surgery group. CONCLUSIONS Our data showed no additional cancer recurrence risk by endoscopic resection before surgery of T1 CRC with high-risk histologic features.
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Affiliation(s)
- Eun Hye Oh
- Department of Gastroenterology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Nayoung Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Ghani M, Kuruppu S, Pritchard M, Harris M, Weerakkody R, Stewart R, Perera G. Vascular surgery receipt and outcomes for people with serious mental illnesses: Retrospective cohort study using a large mental healthcare database in South London. J Psychosom Res 2021; 147:110511. [PMID: 34051514 DOI: 10.1016/j.jpsychores.2021.110511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Vascular surgery can be common among people with serious mental illness (SMI) given the high prevalence of cardiovascular disease. However, post-operative outcomes following vascular surgery have received little investigation, particularly in a subpopulation of SMI. METHODS We conducted a retrospective observational study using data from the South London and Maudsley NHS Foundation Trust (SLaM) via its Clinical Record Interactive Search (CRIS) platform and linkage with Hospital Episode Statistic (HES). Vascular surgery recipients were identified using OPCS version 4 codes. Length of stay (LOS) was modelled using Incidence Rate Ratios (IRRs), and 30-day emergency hospital readmissions using Odds Ratios (ORs) for people with SMI compared with the general population. RESULTS Vascular surgery was received by 152 patients with SMI diagnoses (schizophrenia, schizoaffective disorder, bipolar disorder) and 8821 catchment residents without any mental health conditions. People with active SMI symptoms more likely to be admitted to hospital via emergency route OR: 1.80 (95% CI: 1.06, 3.07) and more likely to stay longer in the hospital for vascular surgery IRR: 1.35 (1.01, 1.80) and more likely to be readmitted to hospital via emergency route within 30 days OR: 1.53 (1.02, 2.67). People with SMI who had major open vascular surgery and peripheral endovascular surgery more likely to have worse post-operative outcomes. CONCLUSION Our study highlights the risks faced by people with SMI following vascular surgery. These suggest tailored guidelines and policies are needed, based on the identification of pre-operative risk factors, allowing for focused post-vascular surgery care to minimise adverse outcomes.
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Affiliation(s)
- Marvey Ghani
- King's College London (Institute of Psychiatry, Psychology and Neuroscience), London, United Kingdom
| | - Sajini Kuruppu
- King's College London (Institute of Psychiatry, Psychology and Neuroscience), London, United Kingdom
| | - Megan Pritchard
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Matthew Harris
- King's College Hospital, Denmark Hill, London, United Kingdom
| | - Ruwan Weerakkody
- King's College London (Institute of Psychiatry, Psychology and Neuroscience), London, United Kingdom
| | - Robert Stewart
- King's College London (Institute of Psychiatry, Psychology and Neuroscience), London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Gayan Perera
- King's College London (Institute of Psychiatry, Psychology and Neuroscience), London, United Kingdom.
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Furbetta N, Comandatore A, Gianardi D, Palmeri M, Di Franco G, Guadagni S, Caprili G, Bianchini M, Fatucchi LM, Picchi M, Bastiani L, Biancofiore G, Di Candio G, Morelli L. Perioperative Nutritional Aspects in Total Pancreatectomy: A Comprehensive Review of the Literature. Nutrients 2021; 13:1765. [PMID: 34067286 PMCID: PMC8224756 DOI: 10.3390/nu13061765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 02/05/2023] Open
Abstract
Total pancreatectomy (TP) is a highly invasive procedure often performed in patients affected by anorexia, malabsorption, cachexia, and malnutrition, which are risk factors for bad surgical outcome and even may cause enhanced toxicity to chemo-radiotherapy. The role of nutritional therapies and the association between nutritional aspects and the outcome of patients who have undergone TP is described in some studies. The aim of this comprehensive review is to summarize the available recent evidence about the influence of nutritional factors in TP. Preoperative nutritional and metabolic assessment, but also intra-operative and post-operative nutritional therapies and their consequences, are analyzed in order to identify the aspects that can influence the outcome of patients undergoing TP. The results of this review show that preoperative nutritional status, sarcopenia, BMI and serum albumin are prognostic factors both in TP for pancreatic cancer to support chemotherapy, prevent recurrence and prolong survival, and in TP with islet auto-transplantation for chronic pancreatitis to improve postoperative glycemic control and obtain better outcomes. When it is possible, enteral nutrition is always preferable to parenteral nutrition, with the aim to prevent or reduce cachexia. Nowadays, the nutritional consequences of TP, including diabetes control, are improved and become more manageable.
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Affiliation(s)
- Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Annalisa Comandatore
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Giovanni Caprili
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Lorenzo Maria Fatucchi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Martina Picchi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Luca Bastiani
- Institute of Clinical Physiology, National Council of Research, 56124 Pisa, Italy;
| | | | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy; (N.F.); (A.C.); (D.G.); (M.P.); (G.D.F.); (S.G.); (G.C.); (M.B.); (L.M.F.); (M.P.); (G.D.C.)
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Larson DW, Abd El Aziz MA, Perry W, D'Angelo AL, Behm KT, Mathis KL, Grass F. Additional Value of Preoperative Albumin for Surgical Risk Stratification among Colorectal Cancer Patients. ANNALS OF NUTRITION AND METABOLISM 2021; 76:422-430. [PMID: 33721871 DOI: 10.1159/000514058] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/26/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND BMI ≤18.5 kg/m2 and preoperative weight loss may lead to inaccurate assessment of nutritional status, given the increasing prevalence of obesity. The aim of this study was to assess whether clinical evaluation of malnutrition based on these parameters is sufficient to predict complications after colorectal cancer surgery. MATERIALS AND METHODS The American College of Surgeons-National Quality Improvement Program database was queried from 2005 to 2018. Patients undergoing elective colorectal cancer surgery were divided into 4 groups: (1) albumin <3.1 g/dL within 21 days of surgery, (2) European Society for Clinical Nutrition and Metabolism (ESPEN) 2 clinical parameters for malnutrition (≥10% loss of weight/6 months plus [BMI <20 kg/m2 if age <70 years OR BMI <22 kg/m2 if age ≥70 years]), (3) both aforementioned criteria, and (4) none of aforementioned criteria. RESULTS Of 82,280 patients, 5,932 (7.2%) had hypoalbuminemia <3.1 g/dL, 764 (0.9%) fulfilled clinical ESPEN 2 parameters, and 338 (0.4%) met both criteria. After adjusting for baseline confounders, patients in the hypoalbuminemia group had a higher risk of overall complications (odds ratio [OR] 1.92, p < 0.05 vs. OR 1.18 in the ESPEN 2 group, p < 0.05), major complications (OR 1.98, p < 0.05 vs. OR 1.20, p < 0.05), surgical complications (OR 1.77, 95% p < 0.05 vs. OR 1.1, p > 0.05), medical complications (OR 1.73, p < 0.05 vs. OR 1.16, p > 0.05), surgical site infection (OR 1.32, p < 0.05 vs. OR 0.86, p > 0.05), and prolonged hospitalization (OR 1.79, p < 0.05 vs. OR 1.22, p < 0.05). Patients who met both criteria were at highest risk. CONCLUSIONS Preoperative measurement of serum albumin appears to be essential to identify patients at risk for complications after colorectal cancer surgery. Clinical evaluation through BMI and weight loss alone may underestimate surgery-associated risks in the USA.
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Affiliation(s)
- David W Larson
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed A Abd El Aziz
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - William Perry
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anne-Lise D'Angelo
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fabian Grass
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne, Lausanne, Switzerland,
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Baik H, Bae KB. Low albumin level and longer interval to closure increase the early complications after ileostomy closure. Asian J Surg 2021; 44:352-357. [DOI: 10.1016/j.asjsur.2020.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/17/2020] [Accepted: 09/01/2020] [Indexed: 01/26/2023] Open
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Solanki S, Chakinala RC, Haq KF, Singh J, Khan MA, Solanki D, Vyas MJ, Kichloo A, Mansuri U, Shah H, Patel A, Haq KS, Iqbal U, Nabors C, Khan HMA, Aronow WS. Paralytic ileus in the United States: A cross-sectional study from the national inpatient sample. SAGE Open Med 2020; 8:2050312120962636. [PMID: 33088567 PMCID: PMC7545785 DOI: 10.1177/2050312120962636] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction: Paralytic ileus is a common clinical condition leading to significant morbidity and mortality. Most studies to date have focused on postoperative ileus, a common but not exclusive cause of the condition. There are limited epidemiological data regarding the incidence and impact of paralytic ileus and its relationship to other clinical conditions. In this cross-sectional study, we analyzed national inpatient hospitalization trends, demographic variation, cost of care, length of stay, and mortality for paralytic ileus hospitalizations as a whole. Methods: The National Inpatient Sample database was used to identify all hospitalizations with the diagnosis of paralytic ileus (International Classification of Diseases, 9th Revision code 560.1) as primary or secondary diagnosis during the period from 2001 to 2011. Statistical analysis was performed using Cochran–Armitage trend test, Wilcoxon rank sum test, and Poisson regression. Results: In 2001, there were 362,561 hospitalizations with the diagnosis of paralytic ileus as compared to 470,110 in 2011 (p < 0.0001). The age group 65–79 years was most commonly affected by paralytic ileus throughout the study period. In-hospital all-cause mortality decreased from 6.03% in 2001 to 5.10% in 2011 (p < 0.0001). However, the average cost of care per hospitalization increased from US$19,739 in 2001 to US$26,198 in 2011 (adjusted for inflation, p < 0.0001). Conclusion: There was a significant rise in the number of hospitalizations of paralytic ileus with increased cost of care and reduced all-cause mortality.
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Affiliation(s)
- Shantanu Solanki
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | | | - Khwaja Fahad Haq
- Division of Gastroenterology, Henry Ford Hospital, Detroit, MI, USA
| | - Jagmeet Singh
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Muhammad Ali Khan
- Division of Gastroenterology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Manasee J Vyas
- Mahatma Gandhi Mission Institute of Health Sciences, Navi Mumbai, India
| | - Asim Kichloo
- Department of Medicine, Central Michigan University, Saginaw, MI, USA
| | - Uvesh Mansuri
- Department of Medicine, MedStar Health, Baltimore, MD, USA
| | | | | | - Khwaja Saad Haq
- Department of Medicine, Kingsbrook Jewish Medical Center, Brooklyn, NY, USA
| | - Umair Iqbal
- Department of Medicine, Geisinger Health, Danville, PA, USA
| | | | | | - Wilbert S Aronow
- Division of Cardiology, Westchester Medical Center, Valhalla, NY, USA
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21
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Issangya CE, Msuya D, Chilonga K, Herman A, Shao E, Shirima F, Naman E, Mkumbi H, Pyuza J, Mtui E, Sanga LA, Abdul S, Leyaro BJ, Chugulu S. Perioperative serum albumin as a predictor of adverse outcomes in abdominal surgery: prospective cohort hospital based study in Northern Tanzania. BMC Surg 2020; 20:155. [PMID: 32664910 PMCID: PMC7362485 DOI: 10.1186/s12893-020-00820-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 07/08/2020] [Indexed: 01/02/2023] Open
Abstract
Background Albumin is an important protein that transports hormones, fatty acids, and exogenous drugs; it also maintains plasma oncotic pressure. Albumin is considered a negative active phase protein because it decreases during injuries and sepsis. In spite of other factors predicting surgical outcomes, the effect of pre and postoperative serum albumin to surgical complications can be assessed by calculating the percentage decrease in albumin (delta albumin). This study aimed to explore perioperative serum albumin as a predictor of adverse outcomes in major abdominal surgeries. Methods All eligible adult participants from Kilimanjaro Christian Medical Centre Surgical Department were enrolled in a convenient manner. Data were collected using a study questionnaire. Full Blood Count (FBP), serum albumin levels preoperatively and on postoperative day 1 were measured in accordance with Laboratory Standard Operating Procedures (SOP). Data was entered and analyzed using STATA version 14. Association and extent of decrease in albumin levels as a predictor of surgical site infection (SSI), delayed wound healing and death within 30 days of surgery was determined using ordinal logistic regression models. In determining the diagnostic accuracy, a Non-parametric Receiver Operating Curve (ROC) model was used. We adjusted for ASA classification, which had a negative confounding effect on the predictive power of the percent drop in albumin to adverse outcomes. Results Sixty one participants were studied; the mean age was 51.6 (SD16.3), the majorities were males 40 (65.6%) and post-operative adverse outcomes were experienced by 28 (45.9%) participants. In preoperative serum albumin values, 40 (67.8%) had lower than 3.4 g/l while 51 (91%) had postoperative albumin values lower than 3.4 g/l. Only 15 (27.3%) had high delta albumin with the median percentage value of 14.77%. Delta albumin was an independent significant factor associated with adverse outcome (OR: 6.68; 95% CI: 1.59, 28.09); with a good predictive power and area under ROC curve (AUC) of 0.72 (95% CI 0.55 0.89). The best cutoff value was 11.61% with a sensitivity of 76.92% and specificity of 51.72%. Conclusion Early perioperative decreases in serum albumin levels may be a good, simple and cost effective tool to predict adverse outcomes in major abdominal surgeries.
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Affiliation(s)
- Christian Ephata Issangya
- Kilimanjaro Christian Medical University College, P.O Box 2240, Moshi, Tanzania. .,Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania.
| | - David Msuya
- Kilimanjaro Christian Medical University College, P.O Box 2240, Moshi, Tanzania.,Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
| | - Kondo Chilonga
- Kilimanjaro Christian Medical University College, P.O Box 2240, Moshi, Tanzania.,Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
| | - Ayesiga Herman
- Kilimanjaro Christian Medical University College, P.O Box 2240, Moshi, Tanzania.,Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
| | - Elichilia Shao
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
| | - Febronia Shirima
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
| | - Elifaraja Naman
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
| | - Henry Mkumbi
- Kilimanjaro Christian Medical University College, P.O Box 2240, Moshi, Tanzania
| | - Jeremia Pyuza
- Kilimanjaro Christian Medical University College, P.O Box 2240, Moshi, Tanzania.,Department of Medical Laboratory, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
| | - Emmanuel Mtui
- Kilimanjaro Christian Medical University College, P.O Box 2240, Moshi, Tanzania
| | - Leah Anku Sanga
- Kilimanjaro Christian Medical University College, P.O Box 2240, Moshi, Tanzania
| | - Seif Abdul
- Kilimanjaro Christian Medical University College, P.O Box 2240, Moshi, Tanzania
| | | | - Samuel Chugulu
- Kilimanjaro Christian Medical University College, P.O Box 2240, Moshi, Tanzania.,Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania
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22
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Fauzan MR, Dahlan CK, Taslim NA, Syam A. The effect of giving fish extract (Pujimin Plus) on intake of protein and hemoglobin hypoalbuminemic patients. ENFERMERIA CLINICA 2020. [DOI: 10.1016/j.enfcli.2020.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Jayanth KS, Maroju NK. Utility of nutritional indices in preoperative assessment of cancer patients. Clin Nutr ESPEN 2020; 37:141-147. [PMID: 32359736 DOI: 10.1016/j.clnesp.2020.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/15/2020] [Accepted: 03/05/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Malnutrition is an important but neglected predictor for outcomes and healthcare costs in cancer patients. A simple screening tool for detecting malnutrition may have clinical utility in their preoperative assessment. OBJECTIVES This study compared three validated indices, for their predictive ability for prolonged length of stay (LOS) and 30-day postsurgical complications in malignancies in a tertiary hospital in South India. METHODS 342 cancer patients admitted for elective surgery were stratified on their preoperative day using MUST - Malnutrition Universal Screening Tool, SGA - Subjective Global Assessment and NRI - Nutritional Risk Index. The postoperative LOS and 30-day morbidity as per Clavien-Dindo classification (CDC) were compared to calculate the predictive accuracy of the various nutritional indices. RESULTS In our study, 44% patients were classified as malnourished by SGA. SGA was found to have maximum correlation coefficient with LOS (σ = 0.410), followed by MUST (σ = 0.401) and NRI (σ = 0.36). On logistic regression, MUST, NRI and SGA were all found to be significant independent predictors of LOS and CDC class. Age, acute illness and comorbidities were found to have significant confounding effects. Sensitivity of MUST and SGA to predict prolonged LOS (>10 d) were. DISCUSSION Our study showed that surgical cancer population was at high risk for malnutrition. MUST and SGA were good risk-stratification tools with independent predictive ability for prolonged LOS and postoperative complications. Patients having higher MUST and SGA scores fared poorly postoperatively with significant prolongation of stay. MUST had 88% agreement with SGA, and took shorter time to administer in the in-patient setting. CONCLUSION Routine preoperative nutritional assessment is important in cancer patients. SGA and MUST were found to be reliable tools, with MUST being the simplest and quickest tool for preoperative nutritional assessment. Patients stratified to be at risk for malnutrition may benefit with nutritional therapy.
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Affiliation(s)
- Kalkunte Sriram Jayanth
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India.
| | - Nanda Kishore Maroju
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India.
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Lohsiriwat V, Chaisomboon N, Pattana-Arun J. Current Colorectal Cancer in Thailand. Ann Coloproctol 2020; 36:78-82. [PMID: 32054248 PMCID: PMC7299565 DOI: 10.3393/ac.2020.01.07] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 01/07/2020] [Indexed: 12/24/2022] Open
Abstract
This article aimed to summarize the current status of colorectal cancer (CRC) in Thailand. In brief, CRC is the third most common cancer and accounts for 11% of the cancer burden in Thailand. It is the only malignancy with an increased incidence in both sexes in Thailand. Over 10,000 new CRC cases occur annually, and about 40% are rectal cancer. Due to the lack of CRC screening and public awareness, nonmetastatic cancer accounts only for 60%–70% of overall cases. The demand for general or colorectal surgeons outmatches the supply at a ratio of 1 general surgeon to 35,000 individuals. There are about 70 board-certified colorectal surgeons serving Thailand’s population of nearly 70 million. As a result, >25% of cancer patients wait more than 1 month before surgery. Regarding training for colorectal surgery, there are 3 major institutes in Bangkok providing a 2-year fellowship program. Cadaveric workshops are an important part of training – especially in laparoscopy for CRC. Recently, a population-based CRC screening program was launched using a fecal immunochemical test. The Ministry of Public Health of Thailand has established additional platforms for laparoscopy to support the potential detection of early CRC following implementation of this nationwide screening program.
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Affiliation(s)
- Varut Lohsiriwat
- Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Jirawat Pattana-Arun
- Department of Surgery, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
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25
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Thirty-day Postoperative Complications After Surgery For Metastatic Long Bone Disease Are Associated With Higher Mortality at 1 Year. Clin Orthop Relat Res 2020; 478:306-318. [PMID: 31714410 PMCID: PMC7438145 DOI: 10.1097/corr.0000000000001036] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The benefits of surgical treatment of a metastasis of the extremities may be offset by drawbacks such as potential postoperative complications. For this group of patients, the primary goal of surgery is to improve quality of life in a palliative setting. A better comprehension of factors associated with complications and the impact of postoperative complications on mortality may prevent negative outcomes and help surgeons in surgical decision-making. QUESTIONS/PURPOSES (1) What is the risk of 30-day postoperative complications after surgical treatment of osseous metastatic disease of the extremities? (2) What predisposing factors are associated with a higher risk of 30-day complications? (3) Are minor and major 30-day complications associated with higher mortality at 1 year? METHODS Between 1999 and 2016, 1090 patients with osseous metastatic disease of the long bones treated surgically at our institution were retrospectively included in the study. Surgery included intramedullary nailing (58%), endoprosthetic reconstruction (22%), plate-screw fixation (14%), dynamic hip screw fixation (2%), and combined approaches (4%). Surgery was performed if patients were deemed healthy enough to proceed to surgery and wished to undergo surgery. All data were retrieved by manually reviewing patients' records. The overall frequency of complications, which were defined using the Clavien-Dindo classification system, was calculated. We did not include Grade I complications as postoperative complications and complications were divided into minor (Grade II) and major (Grades III-V) complications. A multivariate logistic regression analysis was used to identify factors associated with 30-day postoperative complications. A Cox regression analysis was used to assess the association between postoperative complications and overall survival. RESULTS Overall, 31% of the patients (333 of 1090) had a postoperative complication within 30 days. The following factors were independently associated with 30-day postoperative complications: rapidly growing primary tumors classified according to the modified Katagiri classification (odds ratio 1.6; 95% confidence interval, 1.1-2.2; p = 0.011), multiple bone metastases (OR 1.6; 95% CI, 1.1-2.3; p = 0.008), pathologic fracture (OR 1.5; 95% CI, 1.1-2.0; p = 0.010), lower-extremity location (OR 2.2; 95% CI, 1.6-3.2; p < 0.001), hypoalbuminemia (OR 1.7; 95% CI, 1.2-2.4; p = 0.002), hyponatremia (OR 1.5; 95% CI, 1.0-2.2; p = 0.044), and elevated white blood cell count (OR 1.6; 95% CI, 1.1-2.4; p = 0.007). Minor and major postoperative complications within 30 days after surgery were both associated with greater 1-year mortality (hazard ratio 1.6; 95% CI, 1.3-1.8; p < 0.001 and HR 3.4; 95% CI, 2.8-4.2, respectively; p < 0.001). CONCLUSION Patients with metastatic disease in the long bones are vulnerable to postoperative adverse events. When selecting patients for surgery, surgeons should carefully assess a patient's cancer status, and several preoperative laboratory values should be part of the standard work-up before surgery. Furthermore, 30-day postoperative complications decrease survival within 1 year after surgery. Therefore, patients at a high risk of having postoperative complications are less likely to profit from surgery and should be considered for nonoperative treatment or be monitored closely after surgery. LEVEL OF EVIDENCE Level III, therapeutic study.
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26
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Dunn D, Ciccarelli E, Moltzen N. Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy, Part
II
: Implementation. AORN J 2019; 110:606-625. [DOI: 10.1002/aorn.12865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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27
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Wang N, Desai A, Ge B, Li W, Jin X, Bai H, Yu K, Ye H. Prognostic value of hypoalbuminemia at diagnosis in de novo non-M3 acute myeloid leukemia. Leuk Lymphoma 2019; 61:641-649. [PMID: 31722601 DOI: 10.1080/10428194.2019.1686499] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The association between serum albumin level and clinical outcomes has been reported for several hematological malignancies. Our study aimed to identify the relationship between serum albumin level at the time of diagnosis and subsequent clinical outcomes in patients with newly diagnosed acute myeloid leukemias (AMLs) other than acute promyelocytic leukemias (APLs). A total of 243 patients with de novo non-M3 AML were enrolled in this study. Variables including gender, age, serum albumin, white blood cell (WBC) count, hemoglobin (Hb), platelet (PLT) count, blasts at peripheral blood (PB) and bone marrow (BM), immunophenotype and cytogenetics at diagnosis, BM response after one course of chemotherapy and hematopoietic stem cell transplantation (HSCT) treatment were studied. We found that normal albumin level (serum albumin >3.5 g/dL) was significantly associated with superior overall survival (HR = 0.375, p < .001) and leukemia-free survival (HR = 0.411, p < .001). These results demonstrate that albumin could serve as a simple, cheap, and objective prognostication factor in refinement of AML regimens.
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Affiliation(s)
- Na Wang
- Health Care Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Aakash Desai
- Department of Medicine, University of Connecticut, Farmington, CT, USA
| | - Bei Ge
- Department of Infection Control, The Affiliated Eye Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenya Li
- Wenzhou Medical University, Wenzhou, China
| | - Xianghong Jin
- Wenzhou Medical University, Wenzhou, China.,Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | | | - Kang Yu
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Haige Ye
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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28
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Feng Y, Liu L, Zhu Y. Systemic inflammation score in locally advanced rectal cancer patients following total mesorectal excision. Onco Targets Ther 2019; 12:6617-6622. [PMID: 31695404 PMCID: PMC6707432 DOI: 10.2147/ott.s213720] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 07/30/2019] [Indexed: 01/17/2023] Open
Abstract
Objective The objective of the study was to evaluate whether any association exists between systemic inflammation score (SIS) and adverse events (AEs) and survival of locally advanced rectal cancer patients treated with total mesorectal excision (TME) followed by adjuvant chemoradiotherapy. Patients and methods All of the 109 rectal cancer patients recruited between May 2008 and June 2015 were treated with TME followed by adjuvant chemoradiotherapy. The prognostic ability of SIS for overall survival (OS) was calculated by the receiver operating characteristic (ROC) curves. Results According to the classification of the SIS, 22 (20.2%), 59 (54.1%) and 28 (25.7%) patients were classified as a score of 2, 1 and 0, respectively. With an area under the curve (AUC) of 0.616, the SIS score of 1 was defined as the optimal cut-off value. Therefore, we divided the patients into the SIS-low group (SIS score of 1 or 0, n=87) and SIS-high group (SIS score of 2, n=22). Multivariate analysis indicated that SIS was associated with OS (HR 0.390, 95% CI 0.186–0.817, P=0.012). The 5-year OS rate in patients without adjuvant chemotherapy was lower than the patients with adjuvant chemotherapy (53.3% vs 75.8%, P=0.010). Multivariate analysis showed that adjuvant chemotherapy was associated with OS (HR 0.217, 95% CI 0.089–0.529, P=0.001). A marginal statistically significant difference was observed in terms of leukopenia during adjuvant chemoradiotherapy between the SIS-low group and the SIS-high group (P=0.05). Conclusion These results suggest that SIS might serve as an independent biomarker for predicting AEs and prognosis in locally advanced rectal cancer treated with TME followed by adjuvant chemoradiotherapy. Strengthening treatment may be administered to locally advanced rectal cancer with high SIS score obtained before adjuvant chemoradiotherapy. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/4HtmAq1WMAE
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Affiliation(s)
- Yanru Feng
- Department of Radiation Oncology, Zhejiang Key Laboratory of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, People's Republic of China
| | - Luying Liu
- Department of Radiation Oncology, Zhejiang Key Laboratory of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, People's Republic of China
| | - Yuan Zhu
- Department of Radiation Oncology, Zhejiang Key Laboratory of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, People's Republic of China
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29
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Campillo-Recio D, Videla-Ces M, Sales-Pérez M, Molina-Olivella G, Videla S. Inter-implant fractures: an unmet medical need-a preventive approach proposal. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 30:539-543. [PMID: 31641841 DOI: 10.1007/s00590-019-02581-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
Inter-implant fractures are associated with reduced quality of life and increased 1-year mortality. For that reason, we propose, instead of treating, a novel, preventative surgical approach that involves splinting the inter-implant femoral shaft interval. In patients with a previous femoral implant in whom a second surgery for new material implantation was necessary (including knee or hip arthroplasty, plate or femoral nailing), an overlapping technique using the minimally invasive plate osteosynthesis technique was performed during the second surgery. Nine patients were included, all females with median (range) age of 78 (55-88) years. No surgery-related complications or mortality occurred. Two patients suffered fractures from a casual fall postoperatively with no implant failure or hospital admission required. In conclusion, instead of treating such fractures after they occur, we propose an effective, safe and reproducible preventative surgical approach, not previously reported, which involves internal femoral splinting, a plate and the minimally invasive plate osteosynthesis technique.
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Affiliation(s)
- David Campillo-Recio
- Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral Sant Joan Despí, Barcelona, Spain. .,Orthopaedic and Trauma Surgery Department, Institut Català de Traumatologia i Medicina de l´Esport (ICATME), Hospital Universitari Quiron-Dexeus, Carrer Sabino de Arana, 5-19, 08028, Barcelona, Spain.
| | - Miquel Videla-Ces
- Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral Sant Joan Despí, Barcelona, Spain
| | - Miquel Sales-Pérez
- Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral Sant Joan Despí, Barcelona, Spain
| | - Guillem Molina-Olivella
- Orthopaedic and Trauma Surgery Department, Hospital Consorci Sanitari Integral Sant Joan Despí, Barcelona, Spain
| | - Sebastian Videla
- Clinical Research Support Unit, Clinical Pharmacology Department, Bellvitge Biomedical Research Institute, Hospital Universitario Bellvitge, Barcelona, Spain
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30
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Nakagawa K, Sho M, Akahori T, Nagai M, Nakamura K, Takagi T, Tanaka T, Nishiofuku H, Ohbayashi C, Kichikawa K, Ikeda N. Significance of the inflammation-based prognostic score in recurrent pancreatic cancer. Pancreatology 2019; 19:722-728. [PMID: 31153778 DOI: 10.1016/j.pan.2019.05.461] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/09/2019] [Accepted: 05/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although the prognosis of recurrent pancreatic cancer (RPC) is improving with the appearance of new anticancer drugs, prognostic indicators for RPC are still poorly understood. The aim of this study was to evaluate significance of the inflammation-based prognostic score, including modified Glasgow Prognostic Score (mGPS), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and Prognostic Nutritional Index (PNI), in patients with RPC. METHODS This study reviewed 263 patients of pancreatic ductal adenocarcinoma at our institution between 2006 and 2015. A receiver operating characteristics curve analysis was performed to determine the cut-off values. The prognostic significance of the inflammation-based prognostic scores were evaluated by a multivariate analysis. RESULTS 172 patients (65.4%) who had recurrence was included in this study. The optimal PNI for predicting 1-year survival after recurrence was 40 with higher area under receiver operating characteristics curve value (0.704) in comparison with other inflammation-based prognostic scores. A univariate and multivariate analysis revealed that liver metastasis (P < 0.001) and PNI < 40 (P < 0.001) were independently associated with the survival time after recurrence. When each of the two predictors was counted as one point and the points were calculated for all cases, a good stratified survival curve was obtained, showing the shorter survival in the higher points: median survival times of 2, 1, and 0 points were 4.3, 11.1, and 21.2 months, respectively (P < 0.001). CONCLUSIONS Inflammation-based prognostic scores, especially PNI is useful clinical biomarker for predicting the survival time after recurrence in patients with pancreatic adenocarcinoma.
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Affiliation(s)
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Japan.
| | | | - Minako Nagai
- Department of Surgery, Nara Medical University, Japan
| | - Kota Nakamura
- Department of Surgery, Nara Medical University, Japan
| | | | | | | | - Chiho Ohbayashi
- Department of Diagnostic Pathology, Nara Medical University, Japan
| | | | - Naoya Ikeda
- Department of Surgery, Nara Medical University, Japan
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31
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Hu WH, Eisenstein S, Parry L, Ramamoorthy S. Preoperative malnutrition with mild hypoalbuminemia associated with postoperative mortality and morbidity of colorectal cancer: a propensity score matching study. Nutr J 2019; 18:33. [PMID: 31253199 PMCID: PMC6598281 DOI: 10.1186/s12937-019-0458-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 06/11/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Malnutrition with hypoalbuminemia (albumin < 35 g/L) is an important factor in predicting risks associated with colorectal cancer surgery. However, there is limited data about the effects of mild hypoalbuminemia with small decreases in albumin on postoperative complications. METHODS This is a retrospective study using the multi-institutional, nationally validated database of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) to investigate mild hypoalbuminemia and its association with postoperative mortality and morbidity by using a propensity score matching method. RESULTS In a group of 30,676 colorectal cancer patients who received surgery, 5230 had mild hypoalbuminemia (< 35 and > =30 g/L) and 21,310 had normal albumin levels (> = 35 g/L). Significant differences were noted in 21 clinical characteristics between the two groups. After 1:2 propensity score matching postoperative mortality was significantly associated with mild hypoalbuminemia (OR = 1.74; p < 0.001). There were significant associations between mild hypoalbuminemia and 11 postoperative morbidities including deep vein thrombosis, pulmonary embolism, superficial and deep surgical site infection, pneumonia, septic shock, ventilator> 48 h, blood transfusion, return to operating room, stroke and re-intubation. Mild hypoalbuminemia was also associated with overall complication (B = 0.064, p < 0.001) and length of total hospital stay (B = 2.236, p < 0.001). CONCLUSIONS In colorectal cancer, this is the first propensity score matching study of malnutrition with mild hypoalbuminemia which demonstrates that a mild decrease in serum albumin contributes significantly to poor postoperative outcome.
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Affiliation(s)
- Wan-Hsiang Hu
- Department of Colorectal Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Surgery, University of California, San Diego Health System, La Jolla, San Diego, CA, USA.,Department of Surgery and Rebecca and John Moores Cancer Center, University of California San Diego, 3855 Health Sciences Drive, La Jolla, San Diego, CA, 92093, USA
| | - Samuel Eisenstein
- Department of Surgery, University of California, San Diego Health System, La Jolla, San Diego, CA, USA
| | - Lisa Parry
- Department of Surgery, University of California, San Diego Health System, La Jolla, San Diego, CA, USA
| | - Sonia Ramamoorthy
- Department of Surgery, University of California, San Diego Health System, La Jolla, San Diego, CA, USA. .,Department of Surgery and Rebecca and John Moores Cancer Center, University of California San Diego, 3855 Health Sciences Drive, La Jolla, San Diego, CA, 92093, USA.
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Phan K, Ranson W, White SJW, Cheung ZB, Kim J, Shin JI, Ukogu C, Lee NJ, Kothari P, Cho SK. Thirty-Day Perioperative Complications, Prolonged Length of Stay, and Readmission Following Elective Posterior Lumbar Fusion Associated With Poor Nutritional Status. Global Spine J 2019; 9:417-423. [PMID: 31218201 PMCID: PMC6562206 DOI: 10.1177/2192568218797089] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To determine the rates of early postoperative mortality and morbidity in adults with hypoalbuminemia undergoing elective posterior lumbar fusion (PLF). METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was examined from 2005 to 2012. Current Procedural Terminology (CPT) codes were used to query the database for adults (≥18 years) who underwent PLF and/or posterior/transforaminal lumbar interbody fusion (PLIF/TLIF). Patients were divided into those with normal albumin concentration (≥3.5g/dL) and those with hypoalbuminemia (<3.5 g/dL). Both univariate and multivariate analyses were performed. RESULTS A total of 2410 patients were included, of whom 2251 (93.4%) were normoalbuminemic and 159 (6.6%) were hypoalbuminemic. Patients with preoperative serum albumin levels <3.5 g/dL were older with a higher American Society of Anesthesiologists (ASA) score, and more comorbidities, including anemia, diabetes, dependent functional status, and preoperative history of chronic steroid therapy. Hypoalbuminemic patients had higher rates of any 30-day perioperative complication (P < .001), unplanned readmission (P = .019), and prolonged length of stay (LOS) >5 days (P < .001). However, hypoalbuminemia was not significantly associated with any specific perioperative complication. On multivariate analysis, preoperative hypoalbuminemia was found to be an independent predictor of prolonged LOS (OR 2.4, 95% CI 1.7-3.5; P < .001) and unplanned readmission (OR 2.7, 95% CI 1.1-6.3; P = .023). CONCLUSION Hypoalbuminemia was found to be an important predictor of patient outcomes in this population. This study suggests that clinicians should consider nutritional screening and optimization as part of the preoperative risk assessment algorithm. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kevin Phan
- Prince of Wales Hospital, Sydney, New South Wales, Australia,University of New South Wales, Sydney, New South Wales, Australia
| | - William Ranson
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Zoe B. Cheung
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun Kim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John I. Shin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chierika Ukogu
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nathan J. Lee
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parth Kothari
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery,
Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1188, New York, NY 10029,
USA.
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Okita Y, Araki T, Okugawa Y, Kondo S, Fujikawa H, Hiro J, Inoue M, Toiyama Y, Ohi M, Uchida K, Kusunoki M. The prognostic nutritional index for postoperative infectious complication in patients with ulcerative colitis undergoing proctectomy with ileal pouch-anal anastomosis following subtotal colectomy. JOURNAL OF THE ANUS RECTUM AND COLON 2019; 3:91-97. [PMID: 31559374 PMCID: PMC6752123 DOI: 10.23922/jarc.2018-032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 02/15/2019] [Indexed: 12/18/2022]
Abstract
Objectives: Restorative proctocolectomy and ileal pouch-anal anastomosis is frequently performed in patients with ulcerative colitis and factors suspected of increasing the risk of postoperative infectious complications. Using a three-stage approach may result in improvement in overall outcomes, because this leads to improvement in nutritional status and reduction of immunosuppressive doses. However, the influence of preoperative nutritional status on postoperative infectious complications after this procedure has not been examined. The aim of this study was to clarify the potential associations between nutritional status and postoperative infectious complications in patients with ulcerative colitis undergoing proctectomy with ileal pouch-anal anastomosis. Methods: The records of 110 patients who had undergone proctectomy with ileal pouch-anal anastomosis from January 2000 to March 2018 in Mie University and met the eligibility criteria were reviewed and possible associations between postoperative infectious complications and clinical factors were assessed. Results: Of the remaining 110 patients, 18 (16.4%) had developed postoperative infectious complications. Multivariate analysis revealed that operative bleeding ≥270 g and prognostic nutritional index <47 were significant predictors of postoperative infectious complications (P = 0.033, 0.0076, respectively). Various variables associated with immunosuppressives before ileal pouch-anal anastomosis were not associated with postoperative infectious complications. Conclusions: Our findings suggest that immunosuppressives have no association with postoperative infectious complications, whereas a poor prognostic nutritional index may be a significant predictor of postoperative infectious complications in patients with ulcerative colitis undergoing proctectomy with ileal pouch-anal anastomosis.
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Affiliation(s)
- Yoshiki Okita
- Departments of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Toshimitsu Araki
- Departments of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Yoshinaga Okugawa
- Departments of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Satoru Kondo
- Departments of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroyuki Fujikawa
- Departments of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Junichiro Hiro
- Departments of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Mikihiro Inoue
- Departments of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Yuji Toiyama
- Departments of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Masaki Ohi
- Departments of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Keiichi Uchida
- Departments of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Masato Kusunoki
- Departments of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
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Kee YK, Kim H, Jhee JH, Han SH, Yoo TH, Kang SW, Park JT. Incidence of and risk factors for delayed acute kidney injury in patients undergoing colorectal surgery. Am J Surg 2019; 218:907-912. [PMID: 31018901 DOI: 10.1016/j.amjsurg.2019.03.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/22/2019] [Accepted: 03/30/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The risk of delayed AKI (AKI development beyond the perioperative period) in patients undergoing colorectal surgery is greater than that in patients undergoing other major operations. However, the characteristics of and risk factors for delayed AKI are unclear. METHODS We investigated 683 patients who underwent colorectal surgery with intestinal resection at a single tertiary hospital. All patients were followed-up for a year postoperatively. The primary outcome was the development of AKI during follow-up. RESULTS AKI occurred in 177 (25.9%) during the first postoperative year. Patients who developed AKI were significantly older, showed a lower body mass index, and significantly lower preoperative hemoglobin and serum albumin levels. AKI occurred most commonly during the first 3 months postoperatively. However, AKI occurred persistently even after this initial period. Older age, lower preoperative serum albumin levels, and late ostomy closure were independently associated with a higher risk of delayed AKI. CONCLUSION AKI commonly occurs beyond the perioperative period. Careful risk stratification and modification of risk factors may prevent delayed AKI in patients undergoing colorectal cancer surgery.
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Affiliation(s)
- Youn Kyung Kee
- Department of Internal Medicine, College of Medicine, Hallym University Medical Center, Hankang Sacred Heart Hospital, Seoul, South Korea
| | - Hyoungnae Kim
- Department of Internal Medicine, College of Medicine, Soonchunhyang University, Seoul, South Korea
| | - Jong Hyun Jhee
- Department of Internal Medicine, College of Medicine, Inha University, Incheon, South Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, South Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, South Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, South Korea
| | - Jung Tak Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, South Korea.
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Park JS, Kim HM, Jeung HC, Kang SA. Association between early nutritional risk and overall survival in patients with advanced pancreatic cancer: A single-center retrospective study. Clin Nutr ESPEN 2019; 30:94-99. [PMID: 30904235 DOI: 10.1016/j.clnesp.2019.01.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 11/14/2018] [Accepted: 01/31/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS We investigated the predictors of overall survival (OS) among Korean patients with advanced pancreatic cancer (PC) according to their baseline nutritional status. METHODS We retrospectively reviewed the data of 412 inpatients with PC between January 2007 and February 2015 at the Department of Oncology of the Gangnam Severance Hospital, Korea. Data on demographic and clinical parameters were collected from electronic medical records, and OS was estimated using the Kaplan-Meier method. Stepwise Cox regression analysis was used to determine the factors associated with survival. Patients with a Nutritional Risk Screening (NRS) 2002 score <3 were classified as "no-risk; " those with a score of 3 were classified as "moderate-risk; " and those with a score of ≥4 were classified as "high-risk." RESULTS Following nutritional screening at baseline, 194 patients (47.1%, mean age 61.8 ± 9.9 years) were classified as the "no risk" group; 81 patients (19.7%, mean age 65.4 ± 10.8 years), as the "moderate risk" group; and 137 patients (33.3%, mean age 67.8 ± 12.0 years), as the "high risk" group. Predictors of survival were NRS 2002 score (hazard ratio [HR] = 1.238; 95% confidence interval [CI] = 1.143-1.341), percentage of lymphocytes (HR = 0.973; 95% CI = 0.962-0.984), C-reactive protein level (HR = 1.003; 95% CI = 1.001-1.006), carcinoembryonic antigen level (HR = 1.000; 95% CI = 1.000-1.000), and carbohydrate antigen 19-9 level (HR = 1.000; 95% CI = 1.000-1.000). Kaplan-Meier survival analysis showed significant differences in the median OS among the NRS 2002 groups: "no risk" group: 12.3 ± 0.4 months (95% CI: 11.47-13.13 months); "moderate risk" group: 6.5 ± 0.9 months (95% CI: 4.78-8.17 months); and "high risk" group: 5.5 ± 0.6 months (95% CI: 4.31-6.69 months). CONCLUSIONS A good baseline nutritional status was associated with OS among Korean patients with advanced PC. An improvement in the nutritional status of patients with advanced PC through baseline nutritional interventions is therefore necessary to prolong OS.
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Affiliation(s)
- Joung Soon Park
- Department of Clinical Nutrition, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hyung-Mi Kim
- Department of Clinical Nutrition, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hei-Cheul Jeung
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Soon Ah Kang
- Department of Converting Technology, Graduated of Venture, Hoseo University, Seoul, Republic of Korea.
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Paulino Pereira NR, Ogink PT, Groot OQ, Ferrone ML, Hornicek FJ, van Dijk CN, Bramer JAM, Schwab JH. Complications and reoperations after surgery for 647 patients with spine metastatic disease. Spine J 2019; 19:144-156. [PMID: 29864546 DOI: 10.1016/j.spinee.2018.05.037] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/29/2018] [Accepted: 05/24/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Postoperative morbidity may offset the potential benefits of surgical treatment for spine metastatic disease; hence, risk factors for postoperative complications and reoperations should be taken into considerations during surgical decision-making. In addition, it remains unknown whether complications and reoperations shorten these patients' survival. PURPOSE We aimed to describe and identify factors associated with having a complication within 30 days of index surgery as well as factors associated with having a subsequent reoperation. Furthermore, we assessed the effect of 30-day complications and reoperations on the patients' postoperative survival, as well as described neurologic changes after surgery. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE We included 647 patients 18 years and older who had surgery for metastatic disease in the spine between January 2002 and January 2014 in one of two affiliated tertiary care centers. OUTCOME MEASURES Our primary outcomes were complications within 30 days after surgery and reoperations until final follow-up or death. METHODS We used multivariate logistic regression to identify risk factors for 30-day complications and reoperations. We used the Cox regression analysis to assess the effect of postoperative complications and reoperations on survival. RESULTS From 647 included patients, 205 (32%) had a complication within 30 days. The following variables were independently associated with 30-day complications: lower albumin levels (odds ratio [OR]: 0.69, 95% confidence interval [CI]=0.49-0.96, p=.021), additional comorbidities (OR=1.42, 95% CI=1.00-2.01, p=.048), pathologic fracture (OR=1.41, 95% CI=0.97-2.05, p=.031), three or more spine levels operated upon (OR=1.64, 95% CI=1.02-2.64, p=.027), and combined surgical approach (OR=2.44, 95% CI=1.06-5.60, p=.036). One hundred and fifteen patients (18%) had at least one reoperation after the initial surgery; prior radiotherapy (OR=1.56, 95% CI=1.07-2.29, p=.021) to the spinal tumor was independently associated with reoperation. 30-day complications were associated with worse survival (hazard ratio [HR]=1.40, 95% CI=1.17-1.68, p<.001), and reoperation was not significantly associated with worse survival (HR=0.80, 95% CI=0.09-1.00, p=.054). Neurologic status worsened in 42 (6.7%), remained stable in 445 (71%), and improved in 140 (22%) patients after surgery. CONCLUSIONS Three or more spine levels operated upon and prior radiotherapy should prompt consideration of a preoperative plastic surgery consultation regarding soft tissue coverage. Furthermore, if time allows, aggressive nutritional supplementation should be considered for patient with low preoperative serum albumin levels. Surgeons should be aware of the increase in complications in patients presenting with pathologic fracture, undergoing a combined approach, and with any additional preoperative comorbidities. Importantly, 30-day complications were associated with worsened survival.
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Affiliation(s)
- Nuno Rui Paulino Pereira
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
| | - Paul T Ogink
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
| | - Olivier Q Groot
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Brigham and Women's Hospital-Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
| | | | - C N van Dijk
- Department of Orthopaedic Surgery, Academisch Medisch Centrum, Meibergdreef 9, Amsterdam, 1105 AZ, USA.
| | - J A M Bramer
- Department of Orthopaedic Surgery, Academisch Medisch Centrum, Meibergdreef 9, Amsterdam, 1105 AZ, USA.
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
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Iyer SP, Kareem Z. Fast-track Protocol versus Conventional Protocol on Patient Outcome: A Randomized Clinical Trial. Niger J Surg 2019; 25:36-41. [PMID: 31007510 PMCID: PMC6452765 DOI: 10.4103/njs.njs_34_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The aim of this study is to compare fast-track methodology with traditional methods of surgical care in achieving better patient outcome, and ensuring a timely discharge from the hospital, and also note the factors that are responsible for a delayed discharge from the hospital. MATERIALS AND METHODS One hundred patients undergoing elective surgeries were randomly allocated into fast-track and traditional protocol of perioperative care. Patients who underwent fast-track protocol (FTP) were started on early oral feeding and were encouraged for early discharge, while the others were made to follow the traditional method of recovery. The gastrointestinal functions, postoperative complications and hospital stay time were recorded. The results were tabulated and analyzed. RESULTS Early feeding was well tolerated by all the patients in the "fast track" group, while the patients in the control group had increased number of "nil by mouth" days, and this result was statistically significant. Ambulation was started earlier in the case group as compared to the controls, and the mean period of starting of ambulation was statistically significant, in the cases as compared to the controls. The patients in the case group had an earlier discharge from the hospital, as compared to the control group. The most common reason for a delay in discharge from the hospital, in either group, was seen to be inadequate pain relief postoperatively. CONCLUSION The FTP can significantly shorten the postoperative hospital stay after elective surgery, as compared to the traditional protocol.
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Affiliation(s)
- Sandhya P Iyer
- Department of General Surgery, Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India
| | - Zeeshan Kareem
- Department of General Surgery, Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India
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Daniel SK, Thornblade LW, Mann GN, Park JO, Pillarisetty VG. Standardization of perioperative care facilitates safe discharge by postoperative day five after pancreaticoduodenectomy. PLoS One 2018; 13:e0209608. [PMID: 30592736 PMCID: PMC6310358 DOI: 10.1371/journal.pone.0209608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/07/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Pancreaticoduodenectomy is a complex surgical procedure associated with high morbidity and prolonged length of stay. Enhanced recovery after surgery principles have reduced complications rate and length of stay for multiple types of operations. We hypothesized that implementation of a standardized perioperative care pathway would facilitate safe discharge by five days after pancreaticoduodenectomy. METHODS We performed a retrospective cohort study of patients undergoing pancreaticoduodenectomy 18 months prior to and 18 months following implementation of a perioperative care pathway at a quaternary center performing high volume pancreatic surgery. RESULTS A total of 145 patients underwent pancreaticoduodenectomy (mean age 63 ± 10 years, 52% female), 81 before and 64 following pathway implementation, and the groups were similar in terms of preoperative comorbidities. The percentage of patients discharged within 5 days of surgery increased from 36% to 64% following pathway implementation (p = 0.001), with no observed differences in post-operative serious adverse events (p = 0.34), pancreatic fistula grade B or C (p = 0.28 and p = 0.27 respectively), or delayed gastric emptying (p = 0.46). Multivariate regression analysis showed length of stay ≤5 days three times more likely after pathway implementation. Rates of readmission within 30 days (20% pre- vs. 22% post-pathway (p = 0.75)) and 90 days (27% pre- vs. 36% post-pathway (p = 0.27)) were unchanged after pathway implementation, and were no different between patients discharged before or after day 5 at both 30 days (19% ≤5 days vs. 23% ≥ 6 days (p = 0.68)) and 90 days (32% ≤5 days vs. 30% ≥ 6 days (p = 0.81)). CONCLUSIONS Standardizing perioperative care via enhanced recovery protocols for patients undergoing pancreaticoduodenectomy facilitates safe discharge by post-operative day five.
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Affiliation(s)
- Sara K. Daniel
- University of Washington Department of Surgery, Seattle, WA, United States of America
| | - Lucas W. Thornblade
- University of Washington Department of Surgery, Seattle, WA, United States of America
| | - Gary N. Mann
- University of Washington Department of Surgery, Seattle, WA, United States of America
| | - James O. Park
- University of Washington Department of Surgery, Seattle, WA, United States of America
| | - Venu G. Pillarisetty
- University of Washington Department of Surgery, Seattle, WA, United States of America
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Phan K, Kim JS, Xu J, Di Capua J, Lee NJ, Kothari P, Vig KS, Dowdell J, Cho SK. Nutritional Insufficiency as a Predictor for Adverse Outcomes in Adult Spinal Deformity Surgery. Global Spine J 2018; 8:164-171. [PMID: 29662747 PMCID: PMC5898673 DOI: 10.1177/2192568217708777] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data. OBJECTIVE The effect of malnutrition on outcomes after general surgery has been well reported in the literature. However, there is a paucity of data on the effect of malnutrition on postoperative complications during adult deformity surgery. The study attempts to explore and quantify the association between hypoalbuminemia and postoperative complications. METHODS A retrospective cohort analysis was performed on the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010 to 2014. Patients (≥18 years of age) from the NSQIP database undergoing adult deformity surgery were separated into cohorts based serum albumin (<3.5 or >3.5 g/dL). Chi-square and multivariate logistic regression models were used to identify independent risk factors. RESULTS A total of 2236 patients met the inclusion criteria for the study, of which 2044 (91.4%) patients were nutritionally sufficient while 192 (8.6%) patients were nutritionally insufficient. Multivariate logistic regressions revealed nutritional insufficiency as a risk factors for mortality (odds ratio [OR] = 15.67, 95% confidence interval [CI] = 6.01-40.84, P < .0001), length of stay ≥5 days (OR = 2.22, 95% CI = 1.61-3.06, P < .0001), any complications (OR = 1.82, 95% CI = 1.31-2.51, P < .0001), pulmonary complications (OR = 2.29, 95% CI = 1.29-4.06, P = .005), renal complications (OR = 2.71, 95% CI = 1.05-7.00, P = .039), and intra-/postoperative red blood cell transfusion (OR = 1.52, 95% CI = 1.08-2.12, P = .015). CONCLUSIONS This study demonstrates that preoperative hypoalbuminemia is a significant and independent risk factor for postoperative complications, 30-day mortality, and increased length of hospital in patients undergoing adult deformity surgery surgery. Nutritional status is a modifiable risk factor that can potentially improve surgical outcomes after adult deformity surgery.
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Affiliation(s)
- Kevin Phan
- University of New South Wales, Sydney, New South Wales, Australia
- Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Jun S. Kim
- Icahn School of Medicine at Mount Sinai, New York NY, USA
| | - Joshua Xu
- Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - John Di Capua
- Icahn School of Medicine at Mount Sinai, New York NY, USA
| | - Nathan J. Lee
- Icahn School of Medicine at Mount Sinai, New York NY, USA
| | - Parth Kothari
- Icahn School of Medicine at Mount Sinai, New York NY, USA
| | | | - James Dowdell
- Icahn School of Medicine at Mount Sinai, New York NY, USA
| | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York NY, USA
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Farasatinasab M, Amouzegar A, Safari S, Ghanbari B, Darkahian M, Emami S, Pakdaman N, Salili M. Albumin Utilization Evaluation in a Major Teaching Hospital in Iran: Recommendations for Guideline Development. J Res Pharm Pract 2018; 7:157-163. [PMID: 30211241 PMCID: PMC6121762 DOI: 10.4103/jrpp.jrpp_18_4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: Human albumin solution is an expensive colloidal preparation which is commonly used in clinical practice. Due to high cost of albumin, increased rate of the inappropriate use worldwide, and many other reasons, it is imperative to establish a practical protocol to use albumin products and limit its usage. The aim of this study was to identify albumin utilization patterns in a teaching hospital and to demonstrate the importance of the need to reconsider prescribing strategies for albumin administration. Methods: This retrospective cross-sectional study was performed between August 2016 and December 2016 at Firoozgar Hospital affiliated to Iran University of Medical Sciences, Tehran, Iran. All albumin prescriptions for adult patients during the study period were enrolled for appropriateness evaluation according to the latest evidence-based studies and guidelines. Findings: Among 320 albumin prescriptions, 168 (52.5%) were inappropriate according to the current evidence. The most common irrational causes for the albumin usage were hypoalbuminemia (23.4%), nutritional support (13.7%), neuroprotection in subarachnoid hemorrhage (3%), pretreatment for cancer surgery (2.8%), edema (1.6%), hepatic failure (1.6%), and paracentesis (3%). The total amount of albumin used for 320 patients was 52,050 g, from which 28,470 g was inappropriate resulting in $97,398 wastage. Conclusion: These findings, along with aforementioned guidelines, support the requirement for physicians' educational programs and proper strategies for appropriate prescriptions and could also be important in modifying the available guidelines concerning expensive drugs such as albumin.
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Affiliation(s)
- Maryam Farasatinasab
- Department of Clinical Pharmacy, Firoozgar Clinical Research Development Center, International Campus, Iran University of Medical Sciences, Tehran, Iran
| | - Atefeh Amouzegar
- Department of Nephrology, Firoozgar Clinical Research Development Center, Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Safari
- Department of Surgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Behrooz Ghanbari
- Gastrointestinal and Liver Disease Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Majid Darkahian
- Department of Cardiology, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Sepideh Emami
- Department of Cardiology, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Nashmin Pakdaman
- Firoozgar Clinical Research Development Center, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Salili
- Department of Pharmacy, Firoozgar Hospital, Hospital Pharmacy Management (Madad Iran Holding), Iran University of Medical Sciences, Tehran, Iran
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Kim S, McClave SA, Martindale RG, Miller KR, Hurt RT. Hypoalbuminemia and Clinical Outcomes: What is the Mechanism behind the Relationship? Am Surg 2017; 83:1220-1227. [PMID: 29183523 DOI: 10.1177/000313481708301123] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Albumin has a number of important physiologic functions, which include maintaining oncotic pressure, transporting various agents (fatty acids, bile acids, cholesterol, metal ions, and drugs), scavenging free oxygen radicals, acting as an antioxidant, and exerting an antiplatelet effect. Hypoalbuminemia in adults, defined by an intravascular albumin level of <3.5 g/dL, is associated with poor postoperative outcomes in patients undergoing surgical intervention. Although the relationship of hypoalbuminemia and poor surgical outcome has been known for many years, the pathophysiology behind the relationship is unclear. Three theoretical constructs might explain this relationship. First, albumin might serve as a nutritional marker, such that hypoalbuminemia represents poor nutritional status in patients who go on to experience poor postoperative outcomes. Second, albumin has its own pharmacologic characteristics as an antioxidant or transporter, and therefore, the lack of albumin might result in a deficiency of those functions, resulting in poor postoperative outcomes. Or third, albumin is known to be a negative acute phase protein, and as such hypoalbuminemia might represent an increased inflammatory status of the patient, potentially leading to poor outcomes. A thorough review of the literature reveals the fallacy of these arguments and fails to show a direct cause and effect between low albumin levels per se and adverse outcomes. Interventions designed solely to correct preoperative hypoalbuminemia, in particular intravenous albumin infusion, do little to change the patient's course of hospitalization. While surgeons may use albumin levels on admission for their prognostic value, they should avoid therapeutic strategies whose main endpoint is correction of this abnormality.
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Zhang C, Fan HW, Yi WW, Zheng ZQ. Hidden Blood Loss and Its Influential Factors After Laparoscopy-Assisted Gastrectomy for Gastric Cancer. J Laparoendosc Adv Surg Tech A 2017; 28:237-241. [PMID: 29064310 DOI: 10.1089/lap.2017.0468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Laparoscopy-assisted gastrectomy (LAG) is a minimally invasive procedure for the treatment of gastric cancer. It is generally thought that a minimally invasive technique results in less visible blood loss during the surgery. Nevertheless, a meaningful perioperative hidden blood loss (HBL) is often ignored. In this study, we investigated the amount of HBL and the influential factors after LAG for gastric cancer. METHODS A retrospectively analyzed clinical data of 62 consecutive patients who underwent laparoscopy-assisted total or distal gastrectomy at our center from May 2016 to May 2017. The HBL was calculated according to Gross's and Nadler's formula. The data of patient gender, age, height, weight, body mass index, preoperative and postoperative hematocrit, postoperative drainage, albumin loss, diabetes mellitus, and hypertension were analyzed by multivariate linear regression analysis. The type of surgical reconstruction was analyzed by one-way analysis of variance. The difference between the preoperative blood pressure and postoperative blood pressure was measured by paired sample t-test and boxplot. RESULTS The HBL was 322.2 ± 195.9 mL (64.3% ± 14.1% in total blood loss [TBL]), the TBL was 475.6 ± 222.8 mL, and the hemoglobin (HB) loss was 15.0 ± 8.7 (11.5% ± 6.1% of HB level loss). Multivariate linear regression analysis revealed that gender, hypertension, and albumin loss between preoperation and postoperation are influential factors of HBL in patients after LAG for gastric cancer. Compared to male patients, female patients are positively associated with HBL. CONCLUSION In our study, we found HBL is a significant segment of TBL and is much larger than what we considered previously in LAG for gastric cancer. Gender, hypertension, and albumin loss are significantly correlated with HBL. Therefore, paying attention to HBL is significant for promoting clinical treatment and ensuring patients' safety.
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Affiliation(s)
- Chao Zhang
- 1 Department of General Surgery, The Second Affiliated Hospital of Wenzhou Medical University , Wenzhou, China
| | - Heng-Wei Fan
- 2 Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University , Shanghai, China
| | - Wan-Wan Yi
- 3 Department of Nuclear, Shanghai Tenth People's Hospital, Tongji University , Shanghai, China
| | - Zhi-Qiang Zheng
- 1 Department of General Surgery, The Second Affiliated Hospital of Wenzhou Medical University , Wenzhou, China
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Perioperative use of nonsteroidal anti-inflammatory drugs and the risk of anastomotic failure in emergency general surgery. J Trauma Acute Care Surg 2017; 83:657-661. [PMID: 28930958 DOI: 10.1097/ta.0000000000001583] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used analgesic and anti-inflammatory adjuncts. Nonsteroidal anti-inflammatory drug administration may potentially increase the risk of postoperative gastrointestinal anastomotic failure (AF). We aim to determine if perioperative NSAID utilization influences gastrointestinal AF in emergency general surgery (EGS) patients undergoing gastrointestinal resection and anastomosis. METHODS Post hoc analysis of a multi-institutional prospectively collected database was performed. Anastomotic failure was defined as the occurrence of a dehiscence/leak, fistula, or abscess. Patients using NSAIDs were compared with those without. Summary, univariate, and multivariable analyses were performed. RESULTS Five hundred thirty-three patients met inclusion criteria with a mean (±SD) age of 60 ± 17.5 years, 53% men. Forty-six percent (n = 244) of the patients were using perioperative NSAIDs. Gastrointestinal AF rate between NSAID and no NSAID was 13.9% versus 10.7% (p = 0.26). No differences existed between groups with respect to perioperative steroid use (16.8% vs. 13.8%; p = 0.34) or mortality (7.39% vs. 6.92%, p = 0.84). Multivariable analysis demonstrated that perioperative corticosteroid (odds ratio, 2.28; 95% confidence interval, 1.04-4.81) use and the presence of a colocolonic or colorectal anastomoses were independently associated with AF. A subset analysis of the NSAIDs cohort demonstrated an increased AF rate in colocolonic or colorectal anastomosis compared with enteroenteric or enterocolonic anastomoses (30.0% vs. 13.0%; p = 0.03). CONCLUSION Perioperative NSAID utilization appears to be safe in EGS patients undergoing small-bowel resection and anastomosis. Nonsteroidal anti-inflammatory drug administration should be used cautiously in EGS patients with colon or rectal anastomoses. Future randomized trials should validate the effects of perioperative NSAIDs use on AF. LEVEL OF EVIDENCE Therapeutic study, level III.
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Hardt J, Pilz L, Magdeburg J, Kienle P, Post S, Magdeburg R. Preoperative hypoalbuminemia is an independent risk factor for increased high-grade morbidity after elective rectal cancer resection. Int J Colorectal Dis 2017; 32:1439-1446. [PMID: 28823064 DOI: 10.1007/s00384-017-2884-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE This study investigated the association of preoperative hypoalbuminemia and postoperative complications after elective resection for rectal cancer. METHODS From September 2009 to December 2014, all patients who underwent elective rectal resection for adenocarcinoma of the rectum were identified using a prospective colorectal cancer database. Hypoalbuminemia was defined as a serum albumin < 35 g/L. Characteristics and outcomes of hypoalbuminemic patients were compared to those of patients with normal albumin levels. Potential risk factors for postoperative major morbidity, defined as Clavien-Dindo ≥ grade 3, were analyzed by both univariate and multivariate analyses. RESULTS Three hundred seventy patients met the inclusion criteria. Hypoalbuminemic patients (67/370 (18%)) were significantly older and had more advanced tumor stages and more comorbidities (more ASA III, higher percentage of diabetics). Furthermore, they were more likely to undergo abdominoperineal resection instead of low anterior resection and less likely to be operated laparoscopically. On univariate analysis, a higher BMI, advanced tumor stages, diabetes, open procedures, pre- and postoperative hypoalbuminemia, a higher decrease in albumin (∆ preop-postop), and conversion were significantly associated with postoperative high-grade morbidity. On multivariate analysis, diabetes, advanced tumor stages, a higher decrease in the albumin level, as well as preoperative hypoalbuminemia turned out to be independent risk factors for postoperative high-grade morbidity. CONCLUSIONS Hypoalbuminemia is an independent risk factor for postoperative high-grade morbidity. As a low-cost and easy accessible test, serum albumin should be used as a prognostic tool to detect patients at risk for adverse outcomes after resection for rectal cancer.
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Affiliation(s)
- J Hardt
- Department of Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany
| | - L Pilz
- Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - J Magdeburg
- Department of Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany
| | - P Kienle
- Department of Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany.
| | - S Post
- Department of Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany
| | - R Magdeburg
- Department of Surgery, Medical Faculty Mannheim, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany
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Short and Long-Term Outcomes After Surgical Procedures Lasting for More Than Six Hours. Sci Rep 2017; 7:9221. [PMID: 28835620 PMCID: PMC5569056 DOI: 10.1038/s41598-017-09833-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/31/2017] [Indexed: 11/10/2022] Open
Abstract
Long-term all-cause mortality and dependency after complex surgical procedures have not been assessed in the framework of value-based medicine. The aim of this study was to investigate the postoperative and long-term outcomes after surgical procedures lasting for more than six hours. Retrospective cohort study of patients undergoing a first elective complex surgical procedure between 2004 and 2013. Heart and transplant surgery was excluded. Mortality and dependency from the healthcare system were selected as outcome variables. Gender, age, ASA, creatinine, albumin kinetics, complications, benign vs malignant underlying condition, number of drugs at discharge, and admission and length of stay in the ICU were recorded as predictive variables. Some 620 adult patients were included in the study. Postoperative, <1year and <5years cumulative mortality was 6.8%, 17.6% and 45%, respectively. Of patients discharged from hospital after surgery, 76% remained dependent on the healthcare system. In multivariate analysis for postoperative, <1year and <5years mortality, postoperative albumin concentration, ASA score and an ICU stay >7days, were the most significant independent predictive variables. Prolonged surgery carries a significant short and long-term mortality and disability. These data may contribute to more informed decisions taken concerning major surgery in the framework of value-based medicine.
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Bendersky V, Sun Z, Adam MA, Rushing C, Kim J, Youngwirth L, Turner M, Migaly J, Mantyh CR. Determining the Optimal Quantitative Threshold for Preoperative Albumin Level Before Elective Colorectal Surgery. J Gastrointest Surg 2017; 21:692-699. [PMID: 28138809 DOI: 10.1007/s11605-017-3370-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 01/12/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hypoalbuminemia is associated with adverse surgical outcomes. A minimum threshold and the impact of incrementally decreasing albumin remain undefined for colorectal surgery patients. STUDY DESIGN The 2011-2013 National Surgical Quality Improvement Program (NSQIP) dataset was queried for patients undergoing elective colorectal surgery. Multivariable regression analyses with restricted cubic splines (RCS) were used to examine the adjusted association between preoperative serum albumin level and the incidence of complications and to establish an optimal threshold. RCS allows for flexible evaluation in multivariable models without having to assume a specific relationship a priori. RESULTS Sixteen thousand one hundred forty-five patients met study criteria. RCS analysis demonstrated an inflection point at serum albumin level of 3.9 mg/dL. Patients with preoperative albumin <3.9 mg/dL vs. albumin ≥3.9 mg/dL had a higher likelihood of experiencing a major complication (odds ratio (OR) = 1.18, confidence interval (CI) 1.07-1.30, p = 0.0007) or any complications (OR 1.18, CI 1.08-1.29, p = 0.0002,) and had a lengthened hospital stay (p < 0.001). CONCLUSIONS This study objectively determines that a threshold preoperative serum albumin of ≥3.9 mg/dL is associated with improved outcomes in elective colorectal surgery patients. Each 0.5 mg/dL decrease in albumin was progressively associated with increased risk for complications. Identifying a minimum albumin threshold has implications in perioperative optimization of patients undergoing colorectal surgery.
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Affiliation(s)
| | - Zhifei Sun
- Department of Surgery, Duke University, Durham, NC, USA
| | | | - Christel Rushing
- Duke Department of Biostatics and Bioinformatics, Durham, NC, USA
| | - Jina Kim
- Department of Surgery, Duke University, Durham, NC, USA
| | | | - Megan Turner
- Department of Surgery, Duke University, Durham, NC, USA
| | - John Migaly
- Department of Surgery, Duke University, Durham, NC, USA
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Lee SH, Chung MJ, Kim B, Lee HS, Lee HJ, Heo JY, Kim YJ, Park JY, Bang S, Park SW, Song SY, Chung JB. The Significance of the Prognostic Nutritional Index for All Stages of Pancreatic Cancer. Nutr Cancer 2016; 69:512-519. [DOI: 10.1080/01635581.2016.1250921] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Sang Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Bun Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyun Jik Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ja Yoon Heo
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yeong Jin Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Si Young Song
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Bock Chung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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Meyer CP, Rios-Diaz AJ, Dalela D, Ravi P, Sood A, Hanske J, Chun FKH, Kibel AS, Lipsitz SR, Sun M, Trinh QD. The association of hypoalbuminemia with early perioperative outcomes - A comprehensive assessment across 16 major procedures. Am J Surg 2016; 214:871-883. [PMID: 29106849 DOI: 10.1016/j.amjsurg.2016.11.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 11/12/2016] [Accepted: 11/16/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND Poor nutritional status is thought to influence peri- and postoperative outcomes. We assessed the association of hypoalbuminemia, a surrogate for poor nutritional status, with perioperative outcomes in patients undergoing one of 16 major surgical procedures. METHODS Patients undergoing one of 16 major surgeries were identified using the ACS-NSQIP (2005-2011). Risk-adjusted logistic regression models examined the association of hypoalbuminemia on perioperative outcomes. RESULTS Overall, 204,819 complete cases were identified, of whom 25.4% underwent major cardiovascular, 19.0% orthopedic and 55.6% oncologic surgery. Patients with hypoalbuminemia had significantly higher rates of complications, reoperations, readmissions, prolonged length-of-stay and mortality (all p < 0.001). After adjustment, hypoalbuminemia was an independent predictor of overall complications in 12 of the procedures examined and 30-day mortality in 11 of the procedures. Individual perioperative complication profile varied widely among procedures. CONCLUSIONS Hypoalbuminemia exerts significant impact on perioperative outcomes. Its effect is procedure-specific and thus warrants targeted management strategies to improve surgical outcomes. In the absence of clear recommendations, our findings invite surgeons to assess preoperative albumin levels and to manage nutritional status accordingly.
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Affiliation(s)
- Christian P Meyer
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA; Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Arturo J Rios-Diaz
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA.
| | - Deepansh Dalela
- Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Blvd, Detroit, 48202, MI, USA
| | - Praful Ravi
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA
| | - Akshay Sood
- Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Blvd, Detroit, 48202, MI, USA
| | - Julian Hanske
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA
| | - Felix K H Chun
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Adam S Kibel
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA
| | - Maxine Sun
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA
| | - Quoc-Dien Trinh
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA
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Preoperative hypoalbuminemia is associated with worse outcomes in colon cancer patients. Clin Nutr 2016; 36:1333-1338. [PMID: 27612919 DOI: 10.1016/j.clnu.2016.08.023] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/05/2016] [Accepted: 08/23/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND & AIMS The National Veterans' Affairs Surgical Risk Study identified preoperative hypoalbuminemia as an independent risk factor for postoperative morbidity and mortality. Since that time, few studies have investigated the use of preoperative markers as tools to risk stratify colon cancer patients. The purpose of our study is to determine if there is an association between preoperative hypoalbuminemia and 30-day patient morbidity and mortality in colon cancer patients using the Targeted-Colectomy American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP). METHODS Stage I, II, and III elective colon resections with ileocolostomy or colocolostomy were identified within the ACS-NSQIP targeted colectomy database from 2012 through 2013. Hypoalbuminemia was defined as albumin <3.5 g/dL. Patients with hypoalbuminemia were compared to those with a normal albumin level in terms of 30-day morbidity and mortality. The albumin level at which point 30-day morbidity and mortality increased was identified. RESULTS A total of 5143 patients met inclusion criteria; 4397 (85.5%) patients had a normal albumin level while 746 (14.5%) had hypoalbuminemia. Preoperative hypoalbuminemia significantly increased the risk of 30-day mortality (p < 0.0001). The association of hypoalbuminemia with 30-day outcomes was more significant in patients who underwent open surgery and had an intra-abdominal anastomosis. The risk of an adverse event was observed to increase at an albumin level ≤3.1 g/dL. CONCLUSIONS Preoperative hypoalbuminemia is associated with an increased risk of early patient morbidity and mortality in patients undergoing surgery for colon cancer. Preoperative optimization of this patient population warrants further investigation in order to prevent delay from surgical intervention to adjuvant therapy.
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Yoo SH, Kook HY, Hong YJ, Kim JH, Ahn Y, Jeong MH. Influence of undernutrition at admission on clinical outcomes in patients with acute myocardial infarction. J Cardiol 2016; 69:555-560. [PMID: 27567176 DOI: 10.1016/j.jjcc.2016.05.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 05/04/2016] [Accepted: 05/20/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although the effect of overweight or obesity on clinical outcomes in patients with acute myocardial infarction (MI) has been reported, the effect of undernutrition is not as well understood. Therefore, we investigated whether acute MI patients frequently present with undernutrition, and whether this influences poor clinical outcomes. METHODS AND RESULTS Using the Korea Acute Myocardial Infarction Registry database, we screened initial data on acute MI patients admitted within 48h of symptom onset to a tertiary university hospital between November 1, 2011 and May 31, 2015. We then assessed nutritional status at admission, using the Geriatric Nutritional Risk Index (GNRI). Of a total of 2251 patients, there were 1585 (70.4%) men, and mean age was 65.0±12.8 years. Based on GNRI score, undernutrition at admission was present in 409 (18.2%) patients. Multiple logistic regression analysis found undernutrition to be an independent factor influencing post-MI complications [odds ratio (OR), 2.13; 95% confidence interval (CI), 1.61-2.84; p<0.001], after adjusting for age, sex, hypertension, diabetes, hyperlipidemia, previous stroke, smoking, diagnosis, number of involved vessel lesions, Killip class, atrial fibrillation, baseline blood pressure, hemoglobin, creatine kinase-MB, creatinine, performance of percutaneous coronary intervention, reperfusion time, recanalization, and use of antithrombotics. Undernutrition was also an important factor influencing in-hospital death (OR, 2.48; 95% CI, 1.55-3.95; p<0.001), after adjusting for all potential factors by univariate analysis. CONCLUSIONS Nutritional status is a significant prognostic factor in clinical outcomes after MI during hospitalization. Therefore, nutritional assessment and intervention, especially for undernourished MI patients, should be considered.
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Affiliation(s)
- Sung Hee Yoo
- College of Nursing, Chonnam National University, Gwangju, Republic of Korea
| | - Hyun Yi Kook
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Young Joon Hong
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Ju Han Kim
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Youngkeun Ahn
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Myung Ho Jeong
- Chonnam National University Hospital, Gwangju, Republic of Korea.
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