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de la Plaza Llamas R, Soto García P, Sun W, Gemio Del Rey IA, Díaz Candelas DA, Gorini L, Al Shwely Abduljabar F, Latorre Fragua RA. Comparison and combination of three data sources from patient medical records to determine optimal quantification of postoperative morbidity according to the Clavien Dindo Classification and the Comprehensive Complication Index. A prospective study. Cir Esp 2024:S2173-5077(24)00112-1. [PMID: 38705257 DOI: 10.1016/j.cireng.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/19/2024] [Indexed: 05/07/2024]
Abstract
INTRODUCTION It is currently unknown which data sources from the clinical history, or combination thereof, should be evaluated to achieve the most complete calculation of postoperative complications (PC). The objectives of this study were: to analyze the morbidity and mortality of 200 consecutive patients undergoing major surgery, to determine which data sources or combination collect the maximum morbidity, and to determine the accuracy of the morbidity reflected in the discharge report. METHODS Observational and prospective cohort study. The sum of all PC found in the combined review of medical notes, nursing notes, and a specific form was considered the gold standard. PC were classified according to the Clavien Dindo Classification and the Comprehensive Complication Index (CCI). RESULTS The percentage of patients who presented PC according to the gold standard, medical notes, nursing notes and form were: 43.5%, 37.5%, 35% and 18.7% respectively. The combination of sources improved CCI agreement by 8%-40% in the overall series and 39.1-89.7 % in patients with PC. The correct recording of PC was inversely proportional to the complexity of the surgery, and the combination of sources increased the degree of agreement with the gold standard by 35 %-67.5% in operations of greater complexity. The CDC and CCI of the discharge report coincided with the gold-standard values in patients with PC by 46.8% and 18.2%, respectively. CONCLUSIONS The combination of data sources, particularly medical and nursing notes, considerably increases the quantification of PC in general, most notably in complex interventions.
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Affiliation(s)
- Roberto de la Plaza Llamas
- Departamento de Cirugía, Ciencias Médicas y Sociales, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Spain; Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Spain.
| | - Paula Soto García
- Departamento de Cirugía, Ciencias Médicas y Sociales, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Spain.
| | - Wenzhong Sun
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Spain.
| | - Ignacio Antonio Gemio Del Rey
- Departamento de Cirugía, Ciencias Médicas y Sociales, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Spain; Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Spain.
| | | | - Ludovica Gorini
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Spain.
| | - Farah Al Shwely Abduljabar
- Departamento de Cirugía, Ciencias Médicas y Sociales, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Spain; Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Spain.
| | - Raquel Aránzazu Latorre Fragua
- Departamento de Cirugía, Ciencias Médicas y Sociales, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, Spain; Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Spain.
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Hsiung PY, Shih PY, Wu YL, Chen HT, Hsu HH, Lin MW, Cheng YJ, Wu CY. Effects of nonintubated thoracoscopic surgery on postoperative neurocognitive function: a randomized controlled trial. Eur J Cardiothorac Surg 2024; 65:ezad434. [PMID: 38175778 DOI: 10.1093/ejcts/ezad434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/11/2023] [Accepted: 12/28/2023] [Indexed: 01/06/2024] Open
Abstract
OBJECTIVES Postoperative neurocognitive disorder following thoracoscopic surgery with general anaesthesia may be linked to reduced intraoperative cerebral oxygenation and perioperative inflammation, which can potentially be exacerbated by mechanical ventilation. However, nonintubated thoracoscopic surgery, which utilizes regional anaesthesia and maintains spontaneous breathing, provides a unique model for studying the potential benefits of avoiding mechanical ventilation. This approach allows investigation into the impact on perioperative neurocognitive profiles, inflammatory responses and intraoperative cerebral oxygen levels. METHODS In total, 110 patients undergoing thoracoscopic surgery were randomly equally assigned to the intubated group and the nonintubated group. Regional cerebral oxygenation was monitored during surgery. Serum neuroinflammatory biomarkers, including interleukin-6 and glial fibrillary acidic protein, were measured at baseline (before surgery) and 24 h after surgery. Postoperative complication severity was compared using the Comprehensive Complication Index. The primary outcome was perioperative changes in neurocognitive test score, which was assessed at baseline, 24 h and 6 months after surgery. RESULTS Patients in the nonintubated group had higher neurocognitive test scores at 24 h (69.9 ± 10.5 vs 65.3 ± 11.8; P = 0.03) and 6 months (70.6 ± 6.7 vs 65.4 ± 8.1; P < 0.01) after surgery and significantly higher regional cerebral oxygenation over time during one-lung ventilation (P = 0.03). Patients in the intubated group revealed a significantly higher postoperative serum interleukin-6 level (group by time interaction, P = 0.04) and a trend towards a significantly higher serum glial fibrillary acidic protein level (group by time interaction, P = 0.11). Furthermore, patients in the nonintubated group had a significantly lower Comprehensive Complication Index (9.0 ± 8.2 vs 6.1 ± 7.1; P < 0.05). CONCLUSIONS Nonintubated thoracoscopic surgery was associated with improved postoperative neurocognitive recovery, more stable intraoperative cerebral oxygenation, ameliorated perioperative inflammation and attenuated postoperative complication severity.
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Affiliation(s)
- Ping-Yan Hsiung
- Department of Anesthesiology, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Po-Yuan Shih
- Department of Anesthesiology, National Taiwan University Hospital, Taipei City, Taiwan
| | - Yi-Luen Wu
- Department of Anesthesiology, National Taiwan University Hospital, Taipei City, Taiwan
| | - Hsin-Ting Chen
- Department of Anesthesiology, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
| | - Hsao-Hsun Hsu
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University, Taipei City, Taiwan
| | - Mong-Wei Lin
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University, Taipei City, Taiwan
| | - Ya-Jung Cheng
- Department of Anesthesiology, National Taiwan University Hospital, Taipei City, Taiwan
| | - Chun-Yu Wu
- Department of Anesthesiology, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
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Horio Y, Uchino M, Igeta M, Nagano K, Kusunoki K, Kuwahara R, Sato T, Shinzaki S, Ikeuchi H. The Comprehensive Complication Index in Ulcerative Colitis: A Comparison with the Clavien-Dindo Classification. Inflamm Intest Dis 2024; 9:85-95. [PMID: 38590798 PMCID: PMC11001287 DOI: 10.1159/000538180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 03/01/2024] [Indexed: 04/10/2024] Open
Abstract
Introduction The comprehensive complication index (CCI), which weights all postoperative complications according to severity and integrates them into a single formula, has been reported as a new evaluation system. We aimed to compare the CCI with the Clavien-Dindo Classification (CDC) to patients with ulcerative colitis (UC). Methods Patients who underwent initial surgery for UC from April 2012 to March 2020 were included. The patients were classified into a length of stay (LOS) >30 days group or an LOS ≤30 days group. We performed a multivariate analysis of risk factors for LOS >30 days in the model with the factors identified in the univariate analysis plus the CCI (the CCI model) and plus CDC (the CDC model). An ROC curve was used to test the difference in the area under the curve (AUC) between the CCI model and the CDC model. Results The median LOS was 21 days (IQR: 16-29 days), and the rate of LOS >30 days was 119/588 (20.2%). In the CCI model, age at the time of surgery (odds ratio [OR] = 1.24, 95% confidence interval [CI] 1.07-1.45, p = 0.01), ASA score ≥3 (OR = 1.94, 95% CI:1.00-3.76, p = 0.04), and CCI (OR = 1.07, 95% CI: 1.05-1.09; p < 0.01) were identified as independent risk factors for LOS >30 days. The AUC value of the CCI model (0.86) was significantly better in relation to LOS >30 days than that of the CDC model (0.82) (p = 0.02). Conclusion The CCI was a better measure of LOS than was the CDC and was found to be a useful indicator in UC.
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Affiliation(s)
- Yuki Horio
- Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Motoi Uchino
- Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Masataka Igeta
- Department of Biostatistics, Hyogo Medical University, Nishinomiya, Japan
| | - Kentaro Nagano
- Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Kurando Kusunoki
- Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Ryuichi Kuwahara
- Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Toshiyuki Sato
- Department of Gastroenterology, Hyogo Medical University, Nishinomiya, Japan
| | - Shinichiro Shinzaki
- Department of Gastroenterology, Hyogo Medical University, Nishinomiya, Japan
| | - Hiroki Ikeuchi
- Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Japan
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Incarbone N, De Carlis R, Centonze L, Bernasconi DP, Valsecchi MG, Lauterio A, De Carlis L. The impact of postoperative complications on oncological outcomes of liver transplantation for hepatocellular carcinoma: A competing risk analysis. Dig Liver Dis 2023; 55:1690-1698. [PMID: 37316362 DOI: 10.1016/j.dld.2023.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To investigate the influence of postoperative complications on tumor-related (TRD), disease-free survival (DFS) and overall survival (OS) in patients undergoing liver transplant (LT) for hepatocellular carcinoma (HCC). METHODS We retrospectively evaluated 425 LTs for HCC from 2010 to 2019. Postoperative complications were classified according to Comprehensive Complication Index (CCI) and the posttransplant risk of TRD assessed through Metroticket 2.0 calculator. The population was stratified into high-risk and low-risk cohorts based on the predicted TRD risk of 80%. In a second step, we re-evaluated TRD, DFS and OS of both cohorts according to a further stratification based on 47.3 points of CCI cut-off. RESULTS In the low-risk cohort, we observed a significantly better DFS (84% vs. 46%, p<0.001), TRD (3% vs. 26%, p<0.001) and OS (89% vs. 62%, p<0.001) in the group with CCI < 47.3. In the high-risk cohort, patients with CCI < 47.3 had significantly better DFS (50% vs. 23%, p = 0.003) and OS (68% vs. 42%, p = 0.02) and a comparable TRD (22% vs. 31%, p = 0.142). CONCLUSIONS A complicated postoperative course negatively influenced long-term survival. This poorer oncological outcome associated with in-hospital postoperative complications suggests that every effort should be made to improve the early posttransplant course in HCC patients, including a careful donor-to recipient match and use of new perfusion technologies.
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Affiliation(s)
- Niccolò Incarbone
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; PhD Course in Clinical and Experimental Sciences, University of Padua, Padua, Italy
| | - Leonardo Centonze
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.
| | - Davide Paolo Bernasconi
- Bicocca Bioinformatics Biostatistics and Bioimaging Center - B4, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Maria Grazia Valsecchi
- Bicocca Bioinformatics Biostatistics and Bioimaging Center - B4, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Andrea Lauterio
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
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Triemstra L, de Jongh C, Tedone F, Brosens LAA, Luyer MDP, Stoot JHMB, Lagarde SM, van Hillegersberg R, Ruurda JP. The Comprehensive Complication Index versus Clavien-Dindo grading after laparoscopic and open D2-gastrectomy in the multicenter randomized LOGICA-trial. Eur J Surg Oncol 2023; 49:107095. [PMID: 37913608 DOI: 10.1016/j.ejso.2023.107095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 09/22/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Complications can be classified using the most-severe Clavien-Dindo-Classification (CDC) per patient or the total complication burden per patient expressed in the Comprehensive Complication Index (CCI). This study determined the additional value of CCI to CDC in examining the impact of complications after gastric cancer surgery. METHODS The CCI and CDC were determined in the multicenter randomized LOGICA-trial comparing laparoscopic versus open D2-gastrectomy for cancer (cT1-4aN0-3M0). Differences in median CCI between laparoscopic and open gastrectomy were compared for overall postoperative complications and cardiovascular, gastrointestinal, infectious, pulmonary, and other complications. CCI and CDC were correlated to hospitalization, ICU-stay and reoperations using Spearman's rho-test and compared with standard Fisher's z-transformation. RESULTS Between 2015 and 2018, 211 patients underwent laparoscopic (n = 106) or open (n = 105) D2-gastrectomy, and 157 (74%) received neoadjuvant chemotherapy. Median CCI was comparable between laparoscopic versus open gastrectomy regarding overall complications (CCI 0 [IQR 0-23.5] versus 0 [IQR 0-22.6]; p = 0.755) and subgroups of complications (p > 0.05). Both CCI and CDC showed moderate positive correlations for hospitalization (rs = 0.646 versus rs = 0.628; p = 0.001, difference clinically irrelevant), and reoperations (rs = 0.590 versus rs = 0.599; p = 0.070), and weak correlations for ICU-stay (rs = 0.446 versus rs = 0.440; p = 0.189). CONCLUSIONS The CCI is a composite scoring system based on the CDC and reflects a subjective interpretation of complication burden from the perspectives of both physicians and patients, following abdominal surgery other than gastrectomy. Implementing CCI showed no clinically relevant benefit and caused additional workload compared to CDC for assessing complication burden. Therefore, using the CCI alongside the CDC after gastric cancer surgery is not recommended.
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Affiliation(s)
- Lianne Triemstra
- University Medical Center (UMC) Utrecht, Department of Surgery, Utrecht, the Netherlands
| | - Cas de Jongh
- University Medical Center (UMC) Utrecht, Department of Surgery, Utrecht, the Netherlands
| | - Fabrizio Tedone
- University Medical Center (UMC) Utrecht, Department of Surgery, Utrecht, the Netherlands
| | | | - Misha D P Luyer
- Catharina Hospital Eindhoven, Department of Surgery, Eindhoven, the Netherlands
| | - Jan H M B Stoot
- Zuyderland Medical Center, Department of Surgery, Sittard, the Netherlands
| | | | | | - Jelle P Ruurda
- University Medical Center (UMC) Utrecht, Department of Surgery, Utrecht, the Netherlands.
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Ida S, Morita Y, Matsumoto A, Muraki R, Kitajima R, Furuhashi S, Takeda M, Kikuchi H, Hiramatsu Y, Takeuchi H. Prediction of postoperative complications after hepatectomy with dynamic monitoring of central venous oxygen saturation. BMC Surg 2023; 23:343. [PMID: 37957615 PMCID: PMC10644466 DOI: 10.1186/s12893-023-02238-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The usefulness of static monitoring using central venous pressure has been reported for anesthetic management in hepatectomy. It is unclear whether intra-hepatectomy dynamic monitoring can predict the postoperative course. We aimed to investigate the association between intraoperative dynamic monitoring and post-hepatectomy complications. Furthermore, we propose a novel anesthetic management strategy to reduce postoperative complication. METHODS From 2018 to 2021, 93 patients underwent hepatectomy at our hospital. Fifty-three patients who underwent dynamic monitoring during hepatectomy were enrolled. Flo Trac system was used for dynamic monitoring. The baseline central venous oxygen saturation (ScvO2) was defined as the average ScvO2 for 30 min after anesthesia induction. ScvO2 fluctuation (ΔScvO2) was defined as the difference between the baseline and minimum ScvO2. Postoperative complications were evaluated using the comprehensive complication index (CCI). RESULTS Patients with ΔScvO2 ≥ 10% had significantly higher CCI scores (0 vs. 20.9: p = 0.043). In univariate analysis, patients with higher CCI scores demonstrated significantly higher preoperative C-reactive protein-to-lymphocyte ratio (7.51 vs. 24.49: p = 0.039), intraoperative bleeding (105 vs. 581 ml: p = 0.008), number of patients with major hepatectomy (4/45 vs. 3/8: p = 0.028), and number of patients with ΔScvO2 ≥ 10% (11/45 vs. 6/8; p = 0.010). Multivariate logistic regression analysis revealed that ΔScvO2 ≥ 10% (odds ratio: 9.53, p = 0.016) was the only independent predictor of elevated CCI. CONCLUSIONS Central venous oxygen saturation fluctuation during hepatectomy is a predictor of postoperative complications. Anesthetic management based on intraoperative dynamic monitoring and minimizing the change in ScvO2 is a potential strategy for decreasing the risk of post-hepatectomy complications.
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Affiliation(s)
- Shinya Ida
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Yoshifumi Morita
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan.
- Division of Surgical Care, Morimachi, Hamamatsu University School of Medicine, Hamamatsu, Japan.
| | - Akio Matsumoto
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Ryuta Muraki
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Ryo Kitajima
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Satoru Furuhashi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Makoto Takeda
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Hirotoshi Kikuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
| | - Yoshihiro Hiramatsu
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
- Department of Perioperative Functioning Care and Support, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, 431-3192, Japan
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Broadbent A, Rahman S, Grace B, Walker R, Noble F, Kelly J, Byrne J, Underwood T. The effect of surgical complications on long-term prognosis following oesophagectomy. Eur J Surg Oncol 2023; 49:106930. [PMID: 37258358 DOI: 10.1016/j.ejso.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 04/26/2023] [Accepted: 05/04/2023] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Complications are frequent after oesophagectomy, and there is evidence these adversely impact long-term prognosis. However, the effect of multiple complications, and the absolute magnitude of effect on survival is unclear. This study aimed to examine these effects in a single high-volume UK unit. METHODS Patients undergoing oesophagectomy for cancer and who survived to 90 days post-oesophagectomy were analysed. Complications were graded according to the Clavien-Dindo (CD) classification and the Comprehensive Complication Index (CCI). The effect and magnitude of effect of complications on survival were assessed using multivariable cox regression and the risk-adjusted population attributable fraction. RESULTS In total, 380 patients were included. Complications occurred in 251 (66.1%). Suffering ≥3 complications (HR 1.89, 95%CI 1.13-3.16, p = 0.015) or an unplanned escalation in care (HR 2.22, 95%CI 1.43-3.45, p < 0.001) significantly reduced survival whereas pulmonary complications and anastomotic leak did not. Patients with a CCI>30 had worse overall survival (HR 1.91, 95%CI 1.32-2.76, p < 0.001) and CCI>30 due to multiple minor complications gave a worse prognosis compared to CCI>30 due to major complications (HR 2.44, 95%CI 1.14-5.20, p = 0.022). An estimated 9.1% (95%CI 3.4-14.4%) of deaths at 5 years were attributable to a CCI>30. CONCLUSION Long-term survival following oesophagectomy for cancer is significantly affected by complications and the cumulative effect of multiple complications. Interestingly, multiple minor complications had a worse effect on survival than major complications. The absolute magnitude of effect is substantial: minimising all types of postoperative complications could have significant benefit to overall outcomes.
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Affiliation(s)
- A Broadbent
- Upper Gastrointestinal Surgery Department, University Hospitals Southampton, UK; Cancer Sciences Unit, Faculty of Medicine, University of Southampton, UK
| | - S Rahman
- Upper Gastrointestinal Surgery Department, University Hospitals Southampton, UK; Cancer Sciences Unit, Faculty of Medicine, University of Southampton, UK
| | - B Grace
- Upper Gastrointestinal Surgery Department, University Hospitals Southampton, UK; Cancer Sciences Unit, Faculty of Medicine, University of Southampton, UK
| | - R Walker
- Upper Gastrointestinal Surgery Department, University Hospitals Southampton, UK; Cancer Sciences Unit, Faculty of Medicine, University of Southampton, UK
| | - F Noble
- Upper Gastrointestinal Surgery Department, University Hospitals Southampton, UK
| | - J Kelly
- Upper Gastrointestinal Surgery Department, University Hospitals Southampton, UK
| | - J Byrne
- Upper Gastrointestinal Surgery Department, University Hospitals Southampton, UK
| | - T Underwood
- Upper Gastrointestinal Surgery Department, University Hospitals Southampton, UK; Cancer Sciences Unit, Faculty of Medicine, University of Southampton, UK.
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Cai Z, Yang Y, Han Y, Fu X, Mao L, Qiu Y. Clinical Validation of the Comprehensive Complication Index in a Pancreaticoduodenectomy Cohort. Eur Surg Res 2023; 64:334-341. [PMID: 37068477 DOI: 10.1159/000530634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 04/06/2023] [Indexed: 04/19/2023]
Abstract
INTRODUCTION Although the Clavien-Dindo classification (CDC) is the most widely utilized method for quantifying surgical complications, it fails to properly capture all events. To address this, the comprehensive complication index (CCI) was introduced. The purpose of this study was to compare the CCI and CDC as predictors of postoperative length of stay (PLOS) and total hospitalization costs in patients undergoing pancreaticoduodenectomy (PD). METHODS Data were collected from February 2018 to February 2021. Complications were graded on the CDC scale and the CCI was calculated for each patient. The correlations between CDC and CCI with PLOS and hospitalization costs were compared. Linear analyses were performed to identify factors associated with PLOS and costs. RESULTS 291 patients were enrolled with an average age of 61.2 years. 286 of them developed postoperative complications at CDC grade 1 (17.8%), 2 (59.9%), 3a (13.4%), 3b (4.5%), 4 (2.1%), and 5 (0.6%). Median CCI of the study cohort was 30.8. Spearman's correlation analysis showed the CDC and CCI were significantly correlated with PLOS and hospitalization costs, but the CCI showed a stronger correlation with PLOS (+0.552 day of stay for each additional CCI point; CCI: ρ = 0.663 vs. CDC: ρ = 0.581; p = 0.036). There were no significant differences in the correlations between total hospitalization costs and the CDC or CCI (CCI: ρ = 0.566 vs. CDC: ρ = 0.565; p = 0.78). CONCLUSION CCI is an accurate tool for quantifying morbidities after PD and shows a stronger correlation with PLOS compared with the CDC.
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Affiliation(s)
- Zhenghua Cai
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Medical School of Nanjing University, Nanjing, China
| | - Yifei Yang
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Medical School of Nanjing University, Nanjing, China
| | - Yuqing Han
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Medical School of Nanjing University, Nanjing, China
| | - Xu Fu
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Liang Mao
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yudong Qiu
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Buia A, Oguz S, Lehn A, Herrmann E, Hanisch E. Effect of 2D vs. 3D laparoscopy on postoperative complications and operation time in a propensity-score-matched real-world data analysis. Asian J Surg 2023; 46:508-513. [PMID: 35753916 DOI: 10.1016/j.asjsur.2022.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/03/2022] [Accepted: 06/01/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Postoperative complication rates using 3D visualization are rarely reported. The primary aim of our study is to detect a possible advantage of using 3D on postoperative complication rates in a real-world setting. METHOD With a sample size calculation for a medium effect size difference that 3D reduces significantly postoperative complications, data of 287 patients with 3D visualization and 832 with 2D procedure were screened. The groups underwent an exact propensity score-matching to be comparable. Comprehensive complication index (CCI) for every procedure was calculated and Operation Time was determined. RESULTS Including 1078 patients in the study, 213 exact propensity score-matched pairs could finally be established. Concerning overall CCI (3D: 5.70 ± 13.63 vs. 2D: 3.37 ± 9.89; p = 0.076) and operation time (3D: 103.98 ± 93.26 min vs. 2D: 88.60 ±6 9.32 min; p = 0.2569) there was no significant difference between the groups. CONCLUSION Our study shows no advantage of 3D over 2D laparoscopy regarding postoperative complications in a real-world setting, the second endpoint operation time, too, was not influenced by 3D overall.
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Affiliation(s)
- Alexander Buia
- Department of General-, Visceral- and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-University Frankfurt, Langen, Germany.
| | - Sibel Oguz
- Department of General-, Visceral- and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-University Frankfurt, Langen, Germany
| | - Annette Lehn
- Institute of Biostatistics and Mathematical Modelling, Department of Medicine, Goethe-University Frankfurt, Frankfurt, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Department of Medicine, Goethe-University Frankfurt, Frankfurt, Germany
| | - Ernst Hanisch
- Department of General-, Visceral- and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-University Frankfurt, Langen, Germany
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Kudo T, Oshikiri T, Goto H, Harada H, Urakawa N, Hasegawa H, Kanaji S, Yamashita K, Matsuda T, Kakeji Y. Comprehensive complication index as a prognostic factor in minimally invasive esophagectomy for esophageal squamous cell carcinoma. Esophagus 2022; 19:410-416. [PMID: 35220510 DOI: 10.1007/s10388-022-00911-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/15/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Postoperative complications affect long-term prognosis in patients with esophageal squamous cell carcinoma (ESCC). Although a comprehensive estimator can predict long-term prognosis, the Clavien-Dindo classification system, a widely used approach to evaluate complications, assesses each complication individually. We aimed to clarify the utility of the comprehensive complication index (CCI) on predicting the overall survival (OS) of patients with ESCC following minimally invasive esophagectomy (MIE). METHODS This was a retrospective study of patients undergoing MIE for ESCC in the prone position between January 2011 and December 2018. Multivariate analyses using the Cox proportional hazards model were performed to determine independent risk factors for OS. RESULTS The study cohort included 229 patients who were categorized into patients with CCI values of ≥ 33.7 (CCI high) and < 33.7 (CCI low) by receiver-operating characteristic (ROC) curve analysis. There were no significant differences between the two groups according to clinicopathological factors, such as sex, age, tumor location, tumor depth, lymph node metastasis, and neoadjuvant chemotherapy. The intraoperative transfusion rate in the CCI high group was significantly higher than in the CCI low group. The 5 year OS rate was significantly lower in the CCI high group than in the CCI low group (49.5% vs. 65.7%, p = 0.030). By multivariate analyses, age, tumor depth, lymph node metastasis, and the CCI were independent predictors of OS. CONCLUSIONS Comprehensive assessment of postoperative complications using the CCI was useful in predicting OS of patients undergoing MIE for the ESCC.
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Affiliation(s)
- Takuya Kudo
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Taro Oshikiri
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Hironobu Goto
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hitoshi Harada
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Naoki Urakawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hiroshi Hasegawa
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Shingo Kanaji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kimihiro Yamashita
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Takeru Matsuda
- Division of Minimally Invasive Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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11
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朱 易, 王 飞, 赵 怡, 朱 涛. [Research Updates: Standardized Reporting and Evaluation Instruments for Postoperative Complications]. Sichuan Da Xue Xue Bao Yi Xue Ban 2022; 53:342-348. [PMID: 35332740 PMCID: PMC10409346 DOI: 10.12182/20220360506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Indexed: 06/14/2023]
Abstract
Postoperative complications are important indicators for evaluating surgical outcomes, and mortality and the incidence of various specific complications are often used to measure the efficacy of surgical and perioperative management strategies. With the progress of medical technology, there has been a dramatic decline in mortality and the incidence of complications. As a result, reporting and evaluation in the traditional methods no longer meets the actual needs of the world. There has arisen an urgent need for an instrument of standardized reporting and evaluation. The instrument should be aligned with the actual circumstances and should represent the patient's overall burden of postoperative complications. We herein reviewed the latest research findings on Clavien-Dindo Classification (CDC) system and comprehensive complication index (CCI), two instruments of standardized reporting and evaluation of postoperative complications, and discussed the space for improvement and prospects of application of CDC and CCI.
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Affiliation(s)
- 易豪 朱
- 四川大学华西医院 麻醉科 (成都 610041)Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 飞 王
- 四川大学华西医院 麻醉科 (成都 610041)Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
- 电子科技大学 四川省医学科学院·四川省人民医院 麻醉科 (成都 610041)Department of Anesthesiology, Sichuan Academy of Medical Science and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu 610041, China
| | - 怡 赵
- 四川大学华西医院 麻醉科 (成都 610041)Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 涛 朱
- 四川大学华西医院 麻醉科 (成都 610041)Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
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12
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Jin HY, Hong I, Bae JH, Lee CS, Han SR, Lee YS, Lee IK. Predictive factors of high comprehensive complication index in colorectal cancer patients using Enhanced Recovery After Surgery protocol: role as a safety net in early discharge. Ann Surg Treat Res 2021; 101:340-349. [PMID: 34934761 PMCID: PMC8651989 DOI: 10.4174/astr.2021.101.6.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/01/2021] [Accepted: 09/24/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose This study was performed to evaluate complications using comprehensive complication index (CCI) in colorectal cancer patients with implementation of the Enhanced Recovery After Surgery (ERAS) protocol, and to investigate the predictive factors associated with high morbidity rates. It can be used as a safety net in determining the timing of discharge. Methods A total of 335 consecutive patients who underwent elective colorectal cancer surgery between January 2017 and December 2017 at a single tertiary center were enrolled. Postoperative complications were defined as occurring within 30 days after surgery. The predictive factor analysis for the high CCI group was also performed. Results In total, 116 patients experienced postoperative complications. Wound-related complications and postoperative ileus were the most common. The mean CCI for overall colorectal cancer surgery was 9.1 ± 16.7. Patients featuring low CCI (<26.2) were 297 (88.7%) and high CCI were 38 (11.3%). In multivariable analysis, obstructive colorectal cancer (odds ratio, 3.278; 95% confidence interval, 1.217–8.829; P = 0.019) and CRP value on postoperative day (POD) 3–4 (odds ratio, 1.152; 95% confidence interval, 1.036–1.280; P < 0.010) were significant predictors for high CCI. Conclusion The clinical usefulness of CCI in colorectal cancer patients with the ERAS protocol was verified, and it can be used for surgical quality control. More cautious care is needed and the timing of discharge should be carefully determined for patients with obstructive colorectal cancer or POD 3–4 CRP of ≥6.47 mg/dL.
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Affiliation(s)
- Hyeong Yong Jin
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Injae Hong
- Division of Colorectal Surgery, Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Hoon Bae
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul Seung Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Rim Han
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoon Suk Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Kyu Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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13
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Nickel F, Probst P, Studier-Fischer A, Nienhüser H, Pauly J, Kowalewski KF, Weiterer S, Knebel P, Diener MK, Weigand MA, Büchler MW, Schmidt T, Müller-Stich BP. Minimally Invasive Versus open AbdominoThoracic Esophagectomy for esophageal carcinoma (MIVATE) - study protocol for a randomized controlled trial DRKS00016773. Trials 2021; 22:41. [PMID: 33430937 PMCID: PMC7798277 DOI: 10.1186/s13063-020-04966-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 12/11/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The only curative treatment for most esophageal cancers is radical esophagectomy. Minimally invasive esophagectomy (MIE) aims to reduce postoperative morbidity, but is not yet widely established. Linear stapled anastomosis is a promising technique for MIE because it is quite feasible even without robotic assistance. The aim of the present study is to compare total MIE with linear stapled anastomosis to open esophagectomy (OE) with circular stapled anastomosis with special regard to postoperative morbidity in an expertise-based randomized controlled trial (RCT). METHODS/DESIGN This superiority RCT compares MIE with linear stapled anastomosis (intervention) to OE with circular stapled anastomosis (control) for Ivor-Lewis esophagectomy. It was initiated in February 2019, and recruitment is expected to last for 3 years. For inclusion, patients must be 18 years of age or more with a resectable primary malignancy in the distal esophagus. Participants with tumor localizations above the azygos vein, metastasis, or infiltration into adjacent tissue will be excluded. In an expertise-based approach, the allocated treatment will only be carried out by the single most experienced surgeon of the surgical center for each respective technique. The sample size was calculated with 20 participants per group for the primary endpoint postoperative morbidity according to comprehensive complication index (CCI) within 30 postoperative days. Secondary endpoints include anastomotic insufficiency, pulmonary complications, other intra- and postoperative outcome parameters such as estimated blood loss, operative time, length of stay, short-term oncologic endpoints, adherence to a standardized fast-track protocol, postoperative pain, and postoperative recovery (QoR-15). Quality of life (SF-36, CAT EORTC QLQ-C30, CAT EORTC QLQ-OES18) and oncological outcomes are evaluated with 60 months follow-up. DISCUSSION MIVATE is the first RCT to compare OE with circular stapled anastomosis to total MIE with linear stapled anastomosis exclusively for intrathoracic anastomosis. The expertise-based approach limits bias due to heterogeneity of surgical expertise. The use of a dedicated fast-track protocol in both OE and MIE will shed light on the role of the access strategy alone in this setting. The findings of this study will serve to define which approach has the best perioperative outcome for patients requiring esophagectomy. TRIAL REGISTRATION German Clinical Trials Register DRKS00016773 . Registered on 18 February 2019.
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Affiliation(s)
- Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Alexander Studier-Fischer
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Henrik Nienhüser
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Jana Pauly
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Karl-Friedrich Kowalewski
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Sebastian Weiterer
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Philipp Knebel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
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14
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Grüne B, Kowalewksi KF, Waldbillig F, von Hardenberg J, Rassweiler-Seyfried MC, Kriegmair MC, Herrmann J. The Comprehensive Complication Index (CCI) for improved reporting of complications in endourological stone treatment. Urolithiasis 2021; 49:269-279. [PMID: 33388823 DOI: 10.1007/s00240-020-01234-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 11/21/2020] [Indexed: 12/23/2022]
Abstract
The Clavien-Dindo Classification (CDC) lacks a combined score of multiple complications in one patient. The comprehensive complication index (CCI) circumvents this problem making it a valuable instrument to optimize quality control. We aimed to introduce and validate CCI in the treatment of urolithiasis. 60 day postoperative complications of 327 consecutive patients undergoing percutaneous nephrolitholapaxy (PNL) and ureterorenoscopy (URS) between 2017 and 2019 were retrospectively assessed and graded according to CDC. CCI was calculated for each patient. Overall morbidity scores of CCI and CDC were compared. Correlation analyses between the two scores and length of hospital stay (LOS) were performed. A multivariate analysis was performed to identify predictive factors for complications. Sample size calculation for an imaginary clinical trial was compared between CCI and CDC. A significant difference in overall morbidity between CCI and CDC was revealed for PNL (p < 0.001) and URS (p = 0.001). There was no statistically significant difference in comparing correlations between cumulative CCI and LOS versus non-cumulative CDC and LOS for both cohorts. Operating time > 90 min, maximum stone size, positive preoperative urine culture and PNL type (p < 0.001) were predictive factors for postoperative complications in PNL, while urine culture (p = 0.02) was for URS. Sample size calculation based on CCI resulted in a significant reduction of required patients for PNL (- 48%) and URS (- 84%) compared to CDC. CCI could successfully be validated in endourological stone treatment with the advantage of assessing complications in their entirety compared to CDC. CCI can significantly reduce the required sample size in future clinical trials.
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Affiliation(s)
- Britta Grüne
- Department of Urology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Karl-Friedrich Kowalewksi
- Department of Urology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Frank Waldbillig
- Department of Urology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Jost von Hardenberg
- Department of Urology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Marie-Claire Rassweiler-Seyfried
- Department of Urology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Maximilian C Kriegmair
- Department of Urology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Jonas Herrmann
- Department of Urology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Haas M, Huber T, Pickl C, van Rhijn BWG, Gužvić M, Gierth M, Breyer J, Burger M, Mayr R. The comprehensive complication index is associated with a significant increase in complication severity between 30 and 90 days after radical cystectomy for bladder cancer. Eur J Surg Oncol 2020; 47:1163-1171. [PMID: 33046281 DOI: 10.1016/j.ejso.2020.09.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/27/2020] [Accepted: 09/29/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the true cumulative morbidity after RC by implementing the Comprehensive Complication Index (CCI) over a 90-day period, since recent evidence suggests underreporting of the cumulative morbidity after radical cystectomy (RC) with inconsistent complication rates when reported with conventional reporting systems. PATIENTS AND METHODS Medical records of 433 patients with bladder cancer who underwent RC were retrospectively reviewed over a 90-day period. Clinical variables were assessed and complications were graded by the Clavien-Dindo Classification (CDC). The resulting 30- and 90-day CCI-scores were calculated and compared for each patient. Multivariable regression models for developing at least one severe (≥CDC IIIb) complication were designed. RESULTS Overall, 848 complications were recorded in 371 patients (85.7%). Severe complications occurred in 130 patients (30%) and the cumulative morbidity corresponded to the level of a severe complication in 159 patients (36.7%), meaning an upgrade in 6.7% of patients compared to the CDC. The 90-day CCI (24.2 (median, IQR 20.9-39.7)) was higher than the 30-day CCI (22.6 (median, IQR 8.7-39.7)), (p < 0.001). Comorbidity indices (ASA, ACE 27), BMI, and incontinent urinary diversions were independent risk factors for suffering a severe complication within 90 days post-surgery. CONCLUSION The cumulative morbidity (CCI) after RC seems to be higher than previously reported with CDC, especially over a 90-day period. The CCI is an appropriate assessment-tool with an upgrade in morbidity in a significant proportion of patients when compared to the CDC. BMI, several comorbidity indices, and incontinent urinary diversions are independent risk factors for suffering a severe complication after RC.
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Affiliation(s)
- Maximilian Haas
- Department of Urology, Caritas St. Josef Hospital, University of Regensburg, Landshuterstr. 65, 93053, Regensburg, Germany.
| | - Toni Huber
- Department of Urology, Caritas St. Josef Hospital, University of Regensburg, Landshuterstr. 65, 93053, Regensburg, Germany
| | - Christoph Pickl
- Department of Urology, Caritas St. Josef Hospital, University of Regensburg, Landshuterstr. 65, 93053, Regensburg, Germany
| | - Bas W G van Rhijn
- Department of Urology, Caritas St. Josef Hospital, University of Regensburg, Landshuterstr. 65, 93053, Regensburg, Germany; Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands
| | - Miodrag Gužvić
- Experimental Medicine and Therapy Research, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Michael Gierth
- Department of Urology, Caritas St. Josef Hospital, University of Regensburg, Landshuterstr. 65, 93053, Regensburg, Germany
| | - Johannes Breyer
- Department of Urology, Caritas St. Josef Hospital, University of Regensburg, Landshuterstr. 65, 93053, Regensburg, Germany
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Hospital, University of Regensburg, Landshuterstr. 65, 93053, Regensburg, Germany
| | - Roman Mayr
- Department of Urology, Caritas St. Josef Hospital, University of Regensburg, Landshuterstr. 65, 93053, Regensburg, Germany
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Hébert M, Cartier R, Dagenais F, Langlois Y, Coutu M, Noiseux N, El-Hamamsy I, Stevens LM. Standardizing Postoperative Complications-Validating the Clavien-Dindo Complications Classification in Cardiac Surgery. Semin Thorac Cardiovasc Surg 2020; 33:443-451. [PMID: 32979483 DOI: 10.1053/j.semtcvs.2020.09.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 09/19/2020] [Indexed: 11/11/2022]
Abstract
Cardiac surgery lacks a method for quantifying postoperative morbidities. The Clavien-Dindo Complications Classification (CDCC) and the Comprehensive Complication Index (CCI) were successfully implemented as outcome reporting methods in other surgical specialties. This study aims to validate these complication scales in cardiac surgery. Between 2010 and 2019, we prospectively collected data on 41,218 adult patients (73% men, mean age 67 ± 11 years) undergoing cardiac surgery at 6 university hospitals. Complications were graded using the CDCC based on the complication's treatment invasiveness with adaptations for common treatments in cardiac surgery. CCI were calculated, representing multiple complications on a scale of 0 (no complication) to 100 (death). Associations with predictors of poor outcome were assessed using mixed-effects models accounting for center as a random effect. CDCC grade was 0 in 23.0%, I in 11.4%, II in 35.3%, IIIa in 6.4%, IIIb in 2.6%, IVa in 16.1%, IVb in 2.1%, and V in 3.1%. Median CCI was 23 (9, 40). A change from lowest to highest observed CDCC grade was associated with an increase in the Society of Thoracic Surgeons mortality score from 1.1% to 4.7%, surgery duration from 177 to 233 minutes, and hospital stay from 5.2 to 17 days (all P < 0.0001). The CCI also increased with greater procedure complexity (P < 0.0001). Increase in CDCC/CCI is associated with greater comorbidities, surgery durations, lengths of stay, and procedure complexity, accurately reflecting the nuances of the adult cardiac surgery postoperative course. These have great potential for uniform outcome reporting and quality improvement initiatives.
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Affiliation(s)
- Mélanie Hébert
- Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Raymond Cartier
- Faculty of Medicine, Université de Montréal, Montreal, Canada; Division of Cardiac Surgery, Montreal Heart Institute, Montreal, Canada
| | - François Dagenais
- Division of Cardiac Surgery, Quebec Heart and Lung Institute, Québec, Canada
| | - Yves Langlois
- Division of Cardiac Surgery, Jewish General Hospital, Montreal, Canada
| | - Marianne Coutu
- Division of Cardiac Surgery, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Nicolas Noiseux
- Faculty of Medicine, Université de Montréal, Montreal, Canada; Division of Cardiac Surgery, Centre Hospitalier Universitaire de l'Université de Montréal, Montreal, Canada
| | - Ismail El-Hamamsy
- Faculty of Medicine, Université de Montréal, Montreal, Canada; Division of Cardiac Surgery, Montreal Heart Institute, Montreal, Canada; Division of Cardiac Surgery, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Louis-Mathieu Stevens
- Faculty of Medicine, Université de Montréal, Montreal, Canada; Division of Cardiac Surgery, Centre Hospitalier Universitaire de l'Université de Montréal, Montreal, Canada.
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Castanedo S, Toledo E, Fernández-Santiago R, Castillo F, Echeverri J, Rodríguez-Sanjuán JC. Influence of postoperative complications on long-term survival in liver transplant patients. World J Gastrointest Surg 2020; 12:336-345. [PMID: 32903918 PMCID: PMC7448209 DOI: 10.4240/wjgs.v12.i8.336] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/12/2020] [Accepted: 08/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver transplant (LT) is a complex procedure with frequent postoperative complications. In other surgical procedures such as gastrectomy, esophagectomy or resection of liver metastases, these complications are associated with poorer long-term survival. It is possible this happens in LT but there are not enough data to establish this relationship.
AIM To analyze the possible influence of postoperative complications on long-term survival and the ability of the comprehensive complication index (CCI) to predict this.
METHODS Retrospective study in a tertiary-level university hospital. The 164 participants were all patients who received a LT from January 2012 to July 2019. The follow-up was done in the hospital until the end of the study or death. Comorbidity and risk after transplantation were calculated using the Charlson and balance of risk (BAR) scores, respectively. Postoperative complications were graded according to the Clavien-Dindo classification and the CCI. To assess the CCI cut-off value with greater prognostic accuracy a receiver operating characteristic (ROC) curve was built, with calculation of the area under the curve (AUC). Overall survival was estimated according to the Kaplan-Meier test and log-rank test. Groups were compared by the Mann-Whitney test. For the multivariable analysis the Cox regression was used.
RESULTS The mean follow-up time of the cohort was 37.76 (SD = 24.5) mo. A ROC curve of CCI with 5-year survival was built. The AUC was 0.826 (0.730-0.922), P < 0.001. The cut-off was calculated by means of the Youden index with a result of 35.95. The sensitivity was 84.6% and the specificity 61.3%. Survival curves for comparison of patients with CCI score < 36 vs ≥ 36 were calculated. The estimated 5-year survival was 57.65 and 43.95 months, respectively (log-rank < 0.001). This suggests that patients with more severe complications exhibit worse long-term survival. Other cut-off values were analysed. Comparison between patients with CCI < 33.5 vs > 33.5 (33.5 = median CCI value) showed estimated 5-year survival was 57.4 and 45.71 months, respectively (log-rank < 0.0001). Dividing patients according to the mode CCI value (20.9) showed an estimated 5-year survival of 60 mo for a CCI below 20.9 vs 57 mo for a CCI above 20.9 (log-rank = 0.147). The univariate analysis did not show any association between individual complications and long-term survival. A multivariate analysis was carried out to analyse the possible influence of CCI, Charlson comorbidity index, BAR and hepatocellular carcinoma on survival. Only the CCI score showed significant influence on long-term survival.
CONCLUSION A complicated postoperative period – well-defined by means of the CCI score – can influence not only short-term survival, but also long-term survival.
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Affiliation(s)
- Sonia Castanedo
- Department of General Surgery, University Hospital Marqués de Valdecilla, University of Cantabria, Santander 39008, Spain
| | - Enrique Toledo
- Department of General Surgery, University Hospital Marqués de Valdecilla, University of Cantabria, Santander 39008, Spain
| | - Roberto Fernández-Santiago
- Department of General Surgery, University Hospital Marqués de Valdecilla, University of Cantabria, Santander 39008, Spain
| | - Federico Castillo
- Department of General Surgery, University Hospital Marqués de Valdecilla, University of Cantabria, Santander 39008, Spain
| | - Juan Echeverri
- Department of General Surgery, University Hospital Marqués de Valdecilla, University of Cantabria, Santander 39008, Spain
| | - Juan Carlos Rodríguez-Sanjuán
- Department of General Surgery, University Hospital Marqués de Valdecilla, University of Cantabria, Santander 39008, Spain
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Brorson F, Thorarinsson A, Kölby L, Elander A, Hansson E. Early complications in delayed breast reconstruction: A prospective, randomized study comparing different reconstructive methods in radiated and non-radiated patients. Eur J Surg Oncol 2020; 46:2208-2217. [PMID: 32807615 DOI: 10.1016/j.ejso.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/25/2020] [Accepted: 07/08/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND There is little high-quality scientific evidence identifying the best and safest methods for delayed breast reconstruction, with most previous studies retrospective in nature. The primary aim was to compare early complication rates for two different breast-reconstructive methods in radiated and non-radiated patients, using a validated scale. The secondary aim was to identify predictors for complications. MATERIALS AND METHODS This study represents a clinical, randomized, prospective trial (ClinicalTrials.Gov identifier: NCT03963427), where the patients were divided into two study arms: non-radiated and radiated. In the non-radiated arm, patients were randomized to a one-stage lateral thoracodorsal flap with an implant or two-stage expander reconstruction. In the radiated arm, patients were randomized to a latissimus dorsi reconstruction combined with an implant or deep inferior epigastric artery perforator (DIEP) reconstruction. All adverse events were classified according to Clavien-Dindo and summarization of overall morbidity was performed by calculating the Comprehensive Complication Index score. The study was conducted from 2008 to 2020. RESULTS The complication frequencies were similar for the two surgical methods within each arm. In the non-radiated arm, risk factors for any complication were any comorbidities, and in the radiated arm, factors were a high body mass index and a contralateral operation. CONCLUSIONS The usage of the Clavien-Dindo scale in reconstructive surgery is feasible, but further validation is needed. In non-radiated patients, the frequencies of short-term complications were similar for lateral thoracodorsal flap and expander reconstruction, whereas in radiated patients, they were similar for DIEP and latissimus dorsi. The complication profile of the methods varied.
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Affiliation(s)
- Fredrik Brorson
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Andri Thorarinsson
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Kölby
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Elander
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Emma Hansson
- Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden.
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19
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Kowalewski KF, Müller D, Mühlbauer J, Hendrie JD, Worst TS, Wessels F, Walach MT, von Hardenberg J, Nuhn P, Honeck P, Michel MS, Kriegmair MC. The comprehensive complication index (CCI): proposal of a new reporting standard for complications in major urological surgery. World J Urol 2020; 39:1631-1639. [PMID: 32813094 PMCID: PMC8166677 DOI: 10.1007/s00345-020-03356-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/07/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The comprehensive complication index (CCI) is a new tool for reporting the cumulative burden of postoperative complications on a continuous scale. This study validates the CCI for urological surgery and its benefits over the Clavien-Dindo-Classification (Clavien). MATERIAL AND METHODS Data from a prospectively maintained data base of all consecutive patients at a university care-center was analyzed. Complications after radical cystectomy (RC), radical prostatectomy (RP), and partial nephrectomy (PN) were classified using the CCI and Clavien system. Differences in complications between the CCI and the Clavien were assessed and correlation analyses performed. Sample size calculations for hypothetical clinical trials were compared between CCI and Clavien to evaluate whether the CCI would reduce the number of required patients in a clinical trial. RESULTS 682 patients (172 RC, 297 RP, 213 PN) were analyzed. Overall, 9.4-46.6% of patients had > 1 complication cumulatively assessed with the CCI resulting in an upgrading in the Clavien classification for 2.4-32.4% of patients. Therefore, scores between the systems differed for RC: CCI (mean ± standard deviation) 26.3 ± 20.8 vs. Clavien 20.4 ± 16.7, p < 0.001; PN: CCI 8.4 ± 14.7 vs. Clavien 7.0 ± 11.8, p < 0.001 and RP: CCI 5.8 ± 11.7 vs. Clavien 5.3 ± 10.6, p = 0.102. The CCI was more accurate in predicting LOS after RC than Clavien (p < 0.001). Sample size calculations based in the CCI (for future hypothetical trials) resulted in a reduction of required patients for all procedures (- 25% RC, - 74% PN, - 80% RP). CONCLUSION The CCI is more accurate to assess surgical complications and reduces required sample sizes that will facilitate the conduction of clinical trials.
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Affiliation(s)
- K F Kowalewski
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - D Müller
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - J Mühlbauer
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - J D Hendrie
- Department of Internal Medicine, Prisma Health, 701 Grove Road, Greenville, SC, 29605, USA
| | - T S Worst
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - F Wessels
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - M T Walach
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - J von Hardenberg
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - P Nuhn
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - P Honeck
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - M S Michel
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - M C Kriegmair
- Department of Urology and Urological Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Riquelme F, Muñoz C, Ausania F, Hessheimer AJ, Torres F, Calatayud D, Sandomenico R, García Pérez R, Ferrer J, Fuster J, García-Valdecasas JC, Fondevila C. Laparoscopic versus open hemihepatectomy: comprehensive comparison of complications and costs at 90 days using a propensity method. Updates Surg 2020; 72:1041-51. [PMID: 32734578 DOI: 10.1007/s13304-020-00854-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Abstract
Laparoscopic hemihepatectomy (LHH) may offer advantages over open hemihepatectomy (OHH) in blood loss, recovery, and hospital stay. The aim of this study is to evaluate our recent experience performing hemihepatectomy and compare complications and costs up to 90 days following laparoscopic versus open procedures. Retrospective evaluation of patients undergoing hemihepatectomy at our center 01/2010–12/2018 was performed. Patient, tumor, and surgical characteristics; 90-day complications; and costs were analyzed. Inverse probability of treatment weighting (IPTW) was used to balance covariates. A total of 141 hemihepatectomies were included: 96 OHH and 45 LHH. While operative times were longer for LHH, blood loss and transfusions were less. At 90 days, there were similar rates of liver-specific and surgical complications but fewer medical complications following LHH. Medical complications that arose with greater frequency following OHH were primarily pulmonary complications and urinary and central venous catheter infections. Complications at 90 days were lower following LHH (Clavien–Dindo grade ≥ III OHH 23%, LHH 11%, p = 0.130; Comprehensive Complication Index OHH 20.0 ± 16.1, LHH 10.9 ± 14.2, p = 0.001). While operating costs were higher, costs for hospital stay and readmissions were lower with LHH. Patients undergoing LHH experience a significant reduction in postoperative medical complications and costs, resulting in 90-day cost equity compared with OHH.
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21
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De la Plaza Llamas R, Ramia JM. Cost of postoperative complications: How to avoid calculation errors. World J Gastroenterol 2020; 26:2682-2690. [PMID: 32550746 PMCID: PMC7284181 DOI: 10.3748/wjg.v26.i21.2682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/27/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023] Open
Abstract
Postoperative complications (PC) are a basic health outcome, but no surgery service in the world records and/or audits the PC associated with all the surgical procedures it performs. Most studies that have assessed the cost of PC suffer from poor quality and a lack of transparency and consistency. The payment system in place often rewards the volume of services provided rather than the quality of patients’ clinical outcomes. Without a thorough registration of PC, the economic costs involved cannot be determined. An accurate, reliable appraisal would help identify areas for investment in order to reduce the incidence of PC, improve surgical results, and bring down the economic costs. This article describes how to quantify and classify PC using the Clavien-Dindo classification and the comprehensive complication index, discusses the perspectives from which economic evaluations are performed and the minimum postoperative follow-up established, and makes various recommendations. The availability of accurate and impartially audited data on PC will help reduce their incidence and bring down costs. Patients, the health authorities, and society as a whole are sure to benefit.
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Affiliation(s)
- Roberto De la Plaza Llamas
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
| | - José M Ramia
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
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22
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Mora López L, Pallisera Llovera A, Serra-Aracil X, Serra Pla S, Lucas Guerrero V, Rebasa P, Tremps Domínguez C, Pujol Caballé G, Martínez Castela R, Subirana Giménez L, Martínez Cabañero J, Del Pino Zurita C, Agudo Arcos C, Carol Boeris FG, Navarro Soto S. A single-center prospective observational study on the effect of trimodal prehabilitation in colorectal surgery. Cir Esp 2020; 98:605-611. [PMID: 32430159 DOI: 10.1016/j.ciresp.2020.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION A trimodal prehabilitation protocol was designed with the aim to evaluate whether it contributes to reducing postoperative morbidity, to evaluate the effect of prehabilitation on overall hospital stay, and to analyze the evolution of functional capacity before and after surgery. METHODS A single-center observational study of patients with colorectal cancer who underwent surgery with curative intent after a trimodal prehabilitation protocol. We collected data for postoperative morbidity according to the Comprehensive Complication Index and hospital stay, which were compared with a historical matrix. Functional capacity data were also collected before and after the application of the prehabilitation protocol. RESULTS Compared to the historical population, the overall Comprehensive Complication Index was reduced from 13.2 to 11.5, which was statistically significant. Analyzed by morbidity type, all decreased in percentage, although without achieving significance (surgical site infection from 11.7% to 8.4%, nosocomial infection 15.8 to 10% and medical morbidity 8.6% to 4.2%). The overall hospital stay went from 6 to 4 days, and the decrease in the percentage of patients who prepared at home was statistically significant in both cases. CONCLUSIONS Trimodal prehabilitation can contribute to lowering the postoperative morbidity and overall hospital stay of patients undergoing colorectal cancer surgery.
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Affiliation(s)
- L Mora López
- Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España.
| | - A Pallisera Llovera
- Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - X Serra-Aracil
- Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - S Serra Pla
- Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - V Lucas Guerrero
- Unidad de Coloproctología, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - P Rebasa
- Unidad de Esofagogastroesofágica, Servicio de Cirugía, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - C Tremps Domínguez
- Servicio de Anestesia y Reanimación, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - G Pujol Caballé
- Servicio de Anestesia y Reanimación, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - R Martínez Castela
- Servicio de Anestesia y Reanimación, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - L Subirana Giménez
- Servicio de Anestesia y Reanimación, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - J Martínez Cabañero
- Servicio de Anestesia y Reanimación, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - C Del Pino Zurita
- Enfermería Grupo Rehabilitación, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - C Agudo Arcos
- Enfermería Grupo Rehabilitación, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - F G Carol Boeris
- Servicio de Anestesia y Reanimación, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
| | - S Navarro Soto
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Parc Tauli, Sabadell, Barcelona, España
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Linecker M, Botea F, Aristotele Raptis D, Nicolaescu D, Limani P, Alikhanov R, Kim P, Wirsching A, Kron P, Schneider MA, Tschuor C, Kambakamba P, Oberkofler C, De Oliveira ML, Bonvini J, Efanov M, Graf R, Petrowsky H, Khatkov I, Clavien PA, Popescu I. Perioperative omega-3 fatty acids fail to confer protection in liver surgery: Results of a multicentric, double-blind, randomized controlled trial. J Hepatol 2020; 72:498-505. [PMID: 31626819 DOI: 10.1016/j.jhep.2019.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS In a variety of animal models, omega-3 polyunsaturated fatty acids (Ω3-FAs) conferred strong protective effects, alleviating hepatic ischemia/reperfusion injury and steatosis, as well as enhancing regeneration after major tissue loss. Given these benefits along with its safety profile, we hypothesized that perioperative administration of Ω3-FAs in patients undergoing liver surgery may ameliorate the postoperative course. The aim of this study was to investigate the perioperative use of Ω3-FAs to reduce postoperative complications after liver surgery. METHODS Between July 2013 and July 2018, we carried out a multicentric, double-blind, randomized, placebo-controlled trial designed to test whether 2 single intravenous infusions of Omegaven® (Ω3-FAs) vs. placebo may decrease morbidity. The primary endpoints were postoperative complications by severity (Clavien-Dindo classification) integrated within the comprehensive complication index (CCI). RESULTS A total of 261 patients (132 in the Omegaven and 129 in the placebo groups) from 3 centers were included in the trial. Most cases (87%, n = 227) underwent open liver surgery and 56% (n = 105) were major resections (≥3 segments). In an intention-to-treat analysis including the dropout cases, the mortality rate was 4% and 2% in the Omegaven and placebo groups (odds ratio0.40;95% CI 0.04-2.51; p = 0.447), respectively. Any complications and major complications (Clavien-Dindo ≥ 3b) occurred in 46% vs. 43% (p = 0.709) and 12% vs. 10% (p = 0.69) in the Omegaven and placebo groups, respectively. The mean CCI was 17 (±23) vs.14 (±20) (p = 0.417). An analysis excluding the dropouts provided similar results. CONCLUSIONS The routine perioperative use of 2 single doses of intravenous Ω3-FAs (100 ml Omegaven) cannot be recommended in patients undergoing liver surgery (Grade A recommendation). LAY SUMMARY Despite strong evidence of omega-3 fatty acids having liver-directed, anti-inflammatory and pro-regenerative action in various rodent models, 2 single omega-3 fatty acid infusions given to patients before and during liver surgery failed to reduce complications. Because single omega-3 fatty acid infusions failed to confer liver protection in this trial, they cannot currently be recommended. TRIAL REGISTRATION ClinicalTrial.gov: ID: NCT01884948; Institution Ethical Board Approval: KEK-ZH-Nr. 2010-0038; Swissmedic Notification: 2012DR3215.
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Affiliation(s)
- Michael Linecker
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Florin Botea
- Center of General Surgery and Liver Transplantation, Fundeni Institute Bucharest, Romania
| | - Dimitri Aristotele Raptis
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland; Department of HPB- and Liver Transplantation Surgery, University College London, Royal Free Hospitals, London, UK
| | - Diana Nicolaescu
- Center of General Surgery and Liver Transplantation, Fundeni Institute Bucharest, Romania
| | - Përparim Limani
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Ruslan Alikhanov
- Department of Liver and Pancreatic Surgery, Moscow Clinical Scientific Center, Russia
| | - Pavel Kim
- Department of Liver and Pancreatic Surgery, Moscow Clinical Scientific Center, Russia
| | - Andrea Wirsching
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Philipp Kron
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland; Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK
| | - Marcel A Schneider
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Christoph Tschuor
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Patryk Kambakamba
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Christian Oberkofler
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | | | - John Bonvini
- Department of Anesthesiology, University Hospital Zurich, Switzerland
| | - Michail Efanov
- Department of Liver and Pancreatic Surgery, Moscow Clinical Scientific Center, Russia
| | - Rolf Graf
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Igor Khatkov
- Department of Liver and Pancreatic Surgery, Moscow Clinical Scientific Center, Russia
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland.
| | - Irinel Popescu
- Center of General Surgery and Liver Transplantation, Fundeni Institute Bucharest, Romania
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Ray S, Mehta NN, Mangla V, Lalwani S, Mehrotra S, Chugh P, Yadav A, Nundy S. A Comparison Between the Comprehensive Complication Index and the Clavien-Dindo Grading as a Measure of Postoperative Outcome in Patients Undergoing Gastrointestinal Surgery-A Prospective Study. J Surg Res 2019; 244:417-424. [PMID: 31326707 DOI: 10.1016/j.jss.2019.06.093] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/07/2019] [Accepted: 06/21/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND The Clavien-Dindo (CD) grading system reports the most severe of all the postoperative complications. The comprehensive complication index (CCI) sums up all the complications in postoperative period. We compared the CCI and CD to assess which of the two was a better measure of postoperative outcomes. MATERIALS AND METHODS Between June 2015 and December 2016, we recorded the complications using CD grading and CCI in 1000 consecutive patients in our gastrointestinal and hepatopancreaticobiliary surgery unit. The outcome variables studied were postoperative length of hospital stay (LOS), postoperative intensive care unit (ICU) stay, and time to normal activity. The results were expressed as strength of correlation and predictive accuracy of the outcome variables. RESULTS There were 600 males and 400 female patients, with a mean age of 50.3 y. A total of 788 (78.8%) elective and 212(21.2%) emergency procedures were performed. The overall 90-day/in-hospital mortality was 7.9%. Both CD and CCI showed a good correlation with LOS (r = 0.58; P = 0.001, r = 0.57; P = 0.001), ICU stay (r = 0.62; P = 0.002, r = 0.62; P = 0.001), and time to normal activity (r = 0.48; P = 0.01; r = 0.49; P = 0.01). The accuracy of CCI to predict the LOS (area under the curve [AUC] = 0.89; P < 0.001), ICU stay (AUC = 0.85; P < 0.001), and time to normal activity (AUC = 0.76; P < 0.001) was comparable to that of CD (AUC = 0.90; P < 0.001, AUC = 0.87; P < 0.001, AUC = 0.77; P < 0.001). CONCLUSIONS Both CD and CCI were equally accurate in measuring the postoperative outcomes and in their ability to predict the same in patients undergoing gastrointestinal and hepatopancreaticobiliary surgeries. Considering the relative ease of determination of CD, it remains a more commonly used measure for assessing the severity of complications and outcomes compared to CCI.
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Affiliation(s)
- Samrat Ray
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India.
| | - Naimish N Mehta
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Vivek Mangla
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Shailendra Lalwani
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Siddharth Mehrotra
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Parul Chugh
- Department of Biostatistics and Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Amitabh Yadav
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
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Shimizu S, Saito H, Kono Y, Murakami Y, Shishido Y, Miyatani K, Matsunaga T, Fukumoto Y, Fujiwara Y. The prognostic significance of the comprehensive complication index in patients with gastric cancer. Surg Today 2019; 49:913-20. [PMID: 31147763 DOI: 10.1007/s00595-019-01828-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/06/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Postoperative complications worsen the prognosis of gastric cancer patients. The Clavien-Dindo classification is used to evaluate postoperative complications. The prognostic significance of the comprehensive complication index (CCI), a new tool for evaluating postoperative complications, remains unclear. METHODS This study included 452 gastric adenocarcinoma patients who underwent curative surgery. RESULTS The CCI values were significantly higher in older patients ( ≥ 70 years; P < 0.0001), male patients (P < 0.0001), those with lymphatic invasion (P = 0.039), and those with vascular invasion (P = 0.037). The five-year overall survival (OS) and disease-specific survival (DSS) rates were significantly higher in patients without postoperative complications and those with Clavien-Dindo grade 1 complications in comparison to those with Clavien-Dindo grade 2-4 complications (80.4% vs. 66.2%, P = 0.0011; 89.7% vs. 82.3%; P = 0.045, respectively). Among patients with Clavien-Dindo grade 2-4 complications, the 5-year OS and DSS rates in the CCIHigh group ( ≥ 32.15) were significantly lower than those in the CCILow group ( < 32.15; 47.5% vs. 74.9%, P = 0.0086; 63.1% vs. 90.0%, P = 0.0003). A multivariate analysis identified the CCI as an independent prognostic indicator in patients with Clavien-Dindo grade 2-4 complications. CONCLUSIONS The CCI was closely associated with the prognosis of patients with Clavien-Dindo grade 2-4 complications and may be a prognostic indicator.
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van Rooijen S, Carli F, Dalton S, Thomas G, Bojesen R, Le Guen M, Barizien N, Awasthi R, Minnella E, Beijer S, Martínez-Palli G, van Lieshout R, Gögenur I, Feo C, Johansen C, Scheede-Bergdahl C, Roumen R, Schep G, Slooter G. Multimodal prehabilitation in colorectal cancer patients to improve functional capacity and reduce postoperative complications: the first international randomized controlled trial for multimodal prehabilitation. BMC Cancer 2019; 19:98. [PMID: 30670009 PMCID: PMC6341758 DOI: 10.1186/s12885-018-5232-6] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 12/19/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the second most prevalent type of cancer in the world. Surgery is the only curative option. However, postoperative complications occur in up to 50% of patients and are associated with higher morbidity and mortality rates, lower health related quality of life (HRQoL) and increased expenditure in health care. The number and severity of complications are closely related to preoperative functional capacity, nutritional state, psychological state, and smoking behavior. Traditional approaches have targeted the postoperative period for rehabilitation and lifestyle changes. However, recent evidence shows that the preoperative period might be the optimal moment for intervention. This study will determine the impact of multimodal prehabilitation on patients' functional capacity and postoperative complications. METHODS/DESIGN This international multicenter, prospective, randomized controlled trial will include 714 patients undergoing colorectal surgery for cancer. Patients will be allocated to the intervention group, which will receive 4 weeks of prehabilitation (group 1, prehab), or the control group, which will receive no prehabilitation (group 2, no prehab). Both groups will receive perioperative care in accordance with the enhanced recovery after surgery (ERAS) guidelines. The primary outcomes for measurement will be functional capacity (as assessed using the six-minute walk test (6MWT)) and postoperative status determined with the Comprehensive Complication Index (CCI). Secondary outcomes will include HRQoL, length of hospital stay (LOS) and a cost-effectiveness analysis. DISCUSSION Multimodal prehabilitation is expected to enhance patients' functional capacity and to reduce postoperative complications. It may therefore result in increased survival and improved HRQoL. This is the first international multicenter study investigating multimodal prehabilitation for patients undergoing colorectal surgery for cancer. TRIAL REGISTRATION Trial Registry: NTR5947 - date of registration: 1 August 2016.
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Affiliation(s)
- Stefanus van Rooijen
- Department of Surgical Oncology, Máxima Medical Center, Veldhoven, the Netherlands
| | - Francesco Carli
- Department of Anesthesiology, the Montréal General Hospital, McGill University, Montréal, Canada
| | - Susanne Dalton
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Gwendolyn Thomas
- Department of Surgical Oncology, Máxima Medical Center, Veldhoven, the Netherlands
| | - Rasmus Bojesen
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Morgan Le Guen
- Department of Anesthesiology, Foch Hôpital, Paris, France
| | | | - Rashami Awasthi
- Department of Anesthesiology, the Montréal General Hospital, McGill University, Montréal, Canada
| | - Enrico Minnella
- Department of Anesthesiology, the Montréal General Hospital, McGill University, Montréal, Canada
| | - Sandra Beijer
- Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| | - Graciela Martínez-Palli
- Department of Anesthesiology, Hospital Clinic de Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Ismayil Gögenur
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Carlo Feo
- Department of Surgery, S. Anna University Hospital, Ferrara, Italy
| | - Christoffer Johansen
- Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Oncology, Finsen Center, Rigshospitalet, Copenhagen, Denmark
| | - Celena Scheede-Bergdahl
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Køge, Denmark
- Department of Kinesiology and Physical Education, McGill University, Montréal, Canada
| | - Rudi Roumen
- Department of Surgical Oncology, Máxima Medical Center, Veldhoven, the Netherlands
| | - Goof Schep
- Department of Sports Medicine, Máxima Medical Center, Veldhoven, the Netherlands
| | - Gerrit Slooter
- Department of Surgical Oncology, Máxima Medical Center, Veldhoven, the Netherlands
- Department of Surgery, Máxima Medical Center, P.O. Box 7777, Veldhoven, the Netherlands
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Zhu F, Feng D, Zhang T, Gu L, Zhu W, Guo Z, Li Y, Gong J, Li N, Li J. Toward a More Sensitive Endpoint for Assessing Postoperative Complications in Patients with Inflammatory Bowel Disease: a Comparison Between Comprehensive Complication Index (CCI) and Clavien-Dindo Classification (CDC). J Gastrointest Surg 2018; 22:1593-1602. [PMID: 29766444 DOI: 10.1007/s11605-018-3786-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/13/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The comprehensive complication index (CCI) is a novel approach to evaluate complications. However, application of the CCI in inflammatory bowel disease (IBD) population is scarce and the difference between the CCI and the Clavien-Dindo classification (CDC) remains unknown. The aim of this study was to compare the CCI to the conventional CDC by applying the CCI among the IBD patients. METHODS The data of 426 IBD patients who underwent surgery between September 1, 2015 and August 31, 2017 were collected. Univariate and multivariate analyses were conducted to identify risk factors for postoperative complications. The efficacy of CCI and CDC was compared using correlation analysis and logistic regression. Cumulative sum control (CUSUM) models were applied to monitor the CCI continuously. RESULTS Totally, 297 complications occurred in 144 (33.8%) patients. The rate of severe complications (CDC grade ≥ III) was 12.9% and the mean CCI was 9.8 ± 15.5. Preoperative glucocorticoids usage and previous abdominal surgery were related to higher CCI value (p = 0.002, p = 0.006, respectively) but not related to higher incidence of severe complications (CDC grade ≥ III) (p = 0.117, p = 0.177, respectively). In patients with multiple complications, the CCI demonstrated a stronger correlation with hospital stay (ρ = 0.604, p < 0.001) than CDC (ρ = 0.508, p < 0.001). Higher CCI value (p < 0.001, OR 1.161, 95% CI 1.093-1.234) and the CDC grade (p < 0.001, OR 3.811, 95% CI 2.283-6.362) were risk factors for prolonged LOS. In the CUSUM-CCI model of IBD surgery, a gradual decrease was observed over time. CONCLUSIONS The CCI and the CDC are both risk factors for prolonged postoperative LOS after surgery for IBD patients. The CCI is more strongly correlated with postoperative LOS than is the conventional CDC. The CUSUM-CCI model is effective in monitoring surgical quality.
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Affiliation(s)
- Feng Zhu
- Department of General Surgery, Jinling Hospital, Nanjing Medical University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Dengyu Feng
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Tenghui Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Lili Gu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Nanjing Medical University, East Zhongshan Road, 305, Nanjing, 210002, China. .,Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China.
| | - Ning Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, East Zhongshan Road, 305, Nanjing, 210002, China
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Panwar R, Mohapatra V, Raichurkar K, Sahni P. Development and validation of a new score for measuring post-operative complications. Langenbecks Arch Surg 2018; 403:1021-1027. [PMID: 30094627 DOI: 10.1007/s00423-018-1701-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 08/05/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE Assigning a numerical value to post-operative morbidity may improve its usefulness as an outcome measure. The recently developed Comprehensive Complication Index (CCI) is a step forward in this process but assigns an inappropriately high score to a combination of complications. METHODS We developed a new score called the complication severity score (CSS) using a mathematical process and compared it with the CCI using a questionnaire-based survey of 49 experienced gastrointestinal and hepato-pancreatico-biliary surgeons. The CSS was modified based on the results of this survey and was correlated with other patient-centered outcomes in a prospective cohort of consecutive patients undergoing elective surgery. RESULTS Of the nine sets of scenarios, experienced surgeons' opinion matched with CSS in 6, CSS as well as CCI in 1, and neither CSS nor CCI in 2 scenarios. Of the total 441 responses, 281 matched with CSS while 143 matched with CCI (p = 0.0001, odds ratio: 3.7; 95% CI: 2.8 to 4.8). The modified CSS significantly correlated with the post-operative length of stay (r = 0.76; 95% CI: 0.68 to 0.82; p < 0.001), the length of ICU stay (r = 0.61; 95% CI: 0.50 to 0.70; p < 0.001) and with the difference between pre-operative and post-operative quality of life scores in the physical (r = 0.29; 95% CI: 0.14 to 0.42; p < 0.001) and social (r = 0.29; 95% CI: 0.14 to 0.43; p < 0.001) domains. CONCLUSIONS The CSS more often matched the opinion of experienced senior surgeons compared to CCI. The modified CSS significantly correlated with other patient-centered outcomes.
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Affiliation(s)
- Rajesh Panwar
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, Room No. 1007, Academic Block, Ansari Nagar, New Delhi, Delhi, 110029, India.
| | - Vedavyas Mohapatra
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, Room No. 1007, Academic Block, Ansari Nagar, New Delhi, Delhi, 110029, India
| | - Karthik Raichurkar
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, Room No. 1007, Academic Block, Ansari Nagar, New Delhi, Delhi, 110029, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, Room No. 1007, Academic Block, Ansari Nagar, New Delhi, Delhi, 110029, India
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Gfroerer S, Theilen TM, Fiegel HC, Rolle U. Laparoscopic versus open surgery for the repair of congenital duodenal obstructions in infants and children. Surg Endosc 2018; 32:3909-17. [PMID: 29484555 DOI: 10.1007/s00464-018-6130-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 02/23/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Laparoscopic repair of congenital duodenal obstruction (LCDO) was described more than 15 years ago. However, studies comparing outcomes of LCDO with open repair (OCDO) are rare. Standardized assessments of complications using the Clavien-Dindo classification (CDC) and the comprehensive complication index (CCI) are not available. METHODS All patients undergoing OCDO or LCDO between 2004 and 2017 were identified from the institutional database by retrospective analysis. Postoperative outcomes were assessed, including all complications using the CDC and the CCI. RESULTS Forty-seven consecutive patients were identified; 27 patients underwent LCDO and 20 patients had OCDO. Both groups did not differ regarding demographics, associated congenital anomalies, intraoperative pathologic findings, and operative procedures. LCDO was associated with a longer operative time [mean (SD), 202 (89) vs. 112 (41) min, P < 0.0001], shorter time to initiation of feeds [median (range), 1 (0-4) vs. 3 (1-12) days, P = 0.0027], and shorter time to full feeds [mean (SD), 8.2 (4.1) vs. 12.2 (6.4) days, P = 0.0243] compared to OCDO. Shorter length of postoperative hospital stay in LCDO group was achieved for patients without cardiac anomalies [mean (SD), 9.4 (3.1) days in LCDO group vs. 17.2 (9.4) days in OCDO, P = 0.0396] and patients without other anomalies [median (range), 12 (3-38) days in LCDO group vs. 21 (7-31) days in OCDO, P = 0.0460]. LCDO was associated with a lower CCI [median (range) 0 (0-39.7) vs. 4.3 (0-100), P = 0.0270]. CONCLUSIONS Despite a longer operative time for LCDO, a number of advantages of LCDO over OCDO were recognized comparing both approaches in the repair of congenital duodenal obstruction. Such advantages include a lower morbidity, reduced time to initiation and completion of full enteral feeds, and shorter length of postoperative hospitalization for patients without concomitant cardiac anomalies and for patients without other anomalies when operated laparoscopic. In view of the present results, LCDO, performed in selected patients, appears to represent a viable alternative to OCDO.
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Serrano PE, Gafni A, Parpia S, Ruo L, Simunovic M, Meyers BM, Reiter H, Wei A, Gallinger S, Karanicolas P, Hallet J, Devaud N, Levine M. Simultaneous resection of colorectal cancer with synchronous liver metastases (RESECT), a pilot study. Int J Surg Protoc 2018; 8:1-6. [PMID: 31851740 PMCID: PMC6913566 DOI: 10.1016/j.isjp.2018.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/10/2018] [Accepted: 01/14/2018] [Indexed: 12/11/2022] Open
Abstract
Traditionally, synchronous colorectal cancer and CRLM are resected separately. Many institutions have begun performing these procedures simultaneously. Minimal data support simultaneous resection including major liver resection. Complications will be investigated following simultaneous resection. This protocol will be implemented in 5 high-volume tertiary care centres worldwide.
Introduction The “traditional approach” to resect synchronous colorectal cancer with liver metastases (CRLM) is to perform staged resections. Many institutions perform simultaneous resection. Disadvantages to the simultaneous approach include longer operating room times, which may increase major postoperative complication rates. Data supporting simultaneous resection are limited to retrospective studies that are subject to selection bias. Therefore, we have proposed a single-arm prospective cohort pilot study to evaluate the postoperative complications following simultaneous resection of synchronous CRLM. Methods and analysis This single-arm study will be performed in five high-volume hepatobiliary centres to prospectively evaluate the following objectives: (1) To determine the 90-day postoperative complication rate of patients diagnosed with synchronous CRLM undergoing a simultaneous colorectal and liver resection, including major liver resections; (2) To determine the postoperative mortality rate at 90 days following index surgery; (3) To determine change in global health-related Quality of Life (QoL) following simultaneous resection at three months compared to baseline; and (4) To build a costing model for simultaneous resection, We will also evaluate the feasibility of performing combined resection in these patients by evaluating the number of eligible patients enrolled in the study and determining the reasons eligible patients were not enrolled. This protocol has been registered with ClinicalTrials.gov (NCT02954913). Ethics and dissemination This study has been provincially approved by the central research ethics board. Study results will inform the design a randomized controlled trial by providing information about the comprehensive complication index in this patient population used to calculate the sample size for the trial.
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Affiliation(s)
- Pablo E. Serrano
- Department of Surgery, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
- Corresponding author at: Juravinski Hospital & Cancer Centre, 711 Concession St, B3 - Rm. 161, Hamilton, ON L8V 1C3, Canada.
| | - Amiram Gafni
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Sameer Parpia
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
| | - Leyo Ruo
- Department of Surgery, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Marko Simunovic
- Department of Surgery, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Brandon M. Meyers
- Department of Oncology, Division of Medical Oncology, McMaster University, Canada
| | - Harold Reiter
- Department of Oncology, Division of Radiation Oncology, McMaster University, Canada
| | - Alice Wei
- Department of General Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada
| | - Steven Gallinger
- Department of General Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada
- Department of General Surgery, Mount Sinai Hospital, University of Toronto, Canada
| | - Paul Karanicolas
- Department of Surgery Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Julie Hallet
- Department of Surgery Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | | | - Mark Levine
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Ontario Clinical Oncology Group, Hamilton, Ontario, Canada
- Department of Oncology, Division of Medical Oncology, McMaster University, Canada
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van den Berg EH, Douwes RM, de Meijer VE, Schreuder TCMA, Blokzijl H. Liver transplantation for NASH cirrhosis is not performed at the expense of major post-operative morbidity. Dig Liver Dis 2018; 50:68-75. [PMID: 28935188 DOI: 10.1016/j.dld.2017.08.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 07/23/2017] [Accepted: 08/03/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH) is an emerging indication for liver transplantation (LT) and coexists with multiple comorbidities. Obese and cirrhotic patients experience more perioperative complications. Limited data exist about short-term complications after LT for NASH cirrhosis. AIM Investigate short-term complications in patients transplanted for NASH cirrhosis. METHODS Single center retrospective cohort study including patients >18years who underwent LT between 2009-2015. Exclusion criteria were LT for acute liver failure and non-cirrhotic disease. Post-operative complications and severity within 90-days were classified using the Clavien-Dindo classification of surgical complications and comprehensive complication index (CCI). P<0.05 was significant. RESULTS Out of 169 eligible patients, 34 patients (20.1%) were transplanted for NASH cirrhosis. These patients were significantly older (59.2 vs. 54.8 years, P=0.01), more obese (61.8% vs. 8.1%, P<0.01), had more diabetes mellitus (73.5% vs. 20%, P<0.01), metabolic syndrome (83.3% vs. 37.8%, P<0.01) and cardiovascular disease (29.4% vs. 11.1%, P<0.01). More grade 1 complications (OR 1.64, 95%CI 1.03-2.63, P=0.04) and more grade 2 urogenital infections (OR 3.4, 95%CI 1.1-10.6, P=0.03) were found. Major complications, CCI, 90-day mortality and graft survival were similar. CONCLUSION Despite significantly increased comorbidities in patients transplanted for NASH cirrhosis, major morbidity, mortality and graft survival after 90days were comparable to patients transplanted for other indications.
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Affiliation(s)
- Eline H van den Berg
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Rianne M Douwes
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Vincent E de Meijer
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Tim C M A Schreuder
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Slankamenac K, Slankamenac M, Schlegel A, Nocito A, Rickenbacher A, Clavien PA, Turina M. Impact of postoperative complications on readmission and long-term survival in patients following surgery for colorectal cancer. Int J Colorectal Dis 2017; 32:805-11. [PMID: 28411352 DOI: 10.1007/s00384-017-2811-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE It is well known that specific postoperative complications such as stroke influence readmissions and overall survival (OS) after surgery for colorectal cancer (CRC). Whether overall hospital morbidity is associated with increased risk of readmission and poorer long-term survival is unknown. New tools are available to accurately quantify overall morbidity, such as the comprehensive complication index (CCI). The aim is to evaluate the impact of complications on readmission and overall survival (OS) in patients operated for colorectal cancer. METHODS Postoperative complications of patients undergoing surgery for CRC were assessed over a 5-year period using the Clavien-Dindo classification, and overall morbidity was assessed by using the CCI. Individual scores were analyzed regarding their association with readmission and OS by using the multivariate logistic and Cox proportional-hazards regression analysis, respectively. RESULTS Two hundred eighty-four patients were operated for CRC, of which 22 (8%) were readmitted. One hundred five patients (37%) developed at least one postoperative complication during the hospital stay. While single complications or the use of severe complication only (grade ≥IIIb) was not associated with readmission, overall morbidity (CCI) predicted readmission (OR 1.02 (95% CI 1.0-1.04), p = 0.044). Similarly, morbidity assessed by the CCI had a significant negative predictive value on OS, e.g., patients with a CCI of 20 were 22% more likely to die within a 5-year follow-up, when compared to patients with a CCI of 10 (p = 0.022). CONCLUSIONS Overall combined morbidity as assessed by the CCI leads to more frequent readmission, and is associated with poorer long-term survival after surgery for CRC.
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Tahiri M, Sikder T, Maimon G, Teasdale D, Hamadani F, Sourial N, Feldman LS, Guralnick J, Fraser SA, Demyttenaere S, Bergman S. The impact of postoperative complications on the recovery of elderly surgical patients. Surg Endosc 2015; 30:1762-70. [PMID: 26194260 DOI: 10.1007/s00464-015-4440-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/13/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND While the negative impact of postoperative complications on hospital costs, survival, and cancer recurrence is well known, few studies have quantified the impact of postoperative complications on patient-centered outcomes such as functional status. The objective of this study was to estimate the impact of postoperative complications on recovery of functional status after elective abdominal surgery in elderly patients. METHODS Elderly patients (70 years and older) undergoing elective abdominal surgery, with a planned length of stay >1 day, were prospectively enrolled between July 2012 and December 2014. The primary outcome was time to recovery to the preoperative functional status measured by the short physical performance battery (SPPB) preoperatively and at 1 week, 1, 3, and 6 months after surgery. The comprehensive complication index was calculated to grade the severity and number of postoperative complications. A Weibull survival model with interval censoring was performed, controlling for age, sex, body mass index (BMI), comorbidities (Charlson comorbidity index-CCI), frailty, presence of cancer, nutritional status, wound class, preoperative functional status, and surgical approach. RESULTS Hundred and forty-nine patients (79 men and 70 women) were included in the analysis. Mean age was 77.7 ± 4.9 years, mean BMI was 27.2 ± 5.5 kg/m(2), and the median CCI was 3 (IQR 2-6). The mean preoperative SPPB score was 9.62 ± 2.33. A total of 52 patients (34.9 %) experienced one or more postoperative complications, including four mortalities, and a total of 72 complications. The mean comprehensive complication index score for these patients was 25.7 ± 23.8. In the presence of all other variables included in the model, a higher comprehensive complication index score was found to significantly decrease the hazard of recovery (HR 0.96, CI 0.94-0.98, p value = 0.0004) and hence increase the time to recovery. CONCLUSION Following elective abdominal surgery, elderly patients who experience a greater number and more severe postoperative complications take longer to return to their preoperative functional status.
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Affiliation(s)
- Mehdi Tahiri
- Division of General Surgery, Department of Surgery, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada.,Lady Davis Institute for Medical Research, Montreal, Canada
| | - Tarifin Sikder
- Lady Davis Institute for Medical Research, Montreal, Canada.,St-Mary's Hospital Center, McGill University, Montreal, Canada
| | - Geva Maimon
- Lady Davis Institute for Medical Research, Montreal, Canada
| | - Debby Teasdale
- Lady Davis Institute for Medical Research, Montreal, Canada
| | - Fadi Hamadani
- Division of General Surgery, Department of Surgery, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Nadia Sourial
- Lady Davis Institute for Medical Research, Montreal, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Center for Minimally Invasive Surgery, McGill University, Montreal, Canada
| | - Jack Guralnick
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shanon A Fraser
- Division of General Surgery, Department of Surgery, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
| | | | - Simon Bergman
- Division of General Surgery, Department of Surgery, Jewish General Hospital, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada. .,Lady Davis Institute for Medical Research, Montreal, Canada.
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