Abstract The impact of multimodal prehabilitation on postoperative complications in upper abdominal surgeries is understudied. This review analyzes randomized trials on multimodal prehabilitation ...with patient and hospital outcomes. MEDLINE, Embase, CINAHL, and Cochrane CENTRAL were searched for trials on prehabilitation before elective (non-emergency) abdominal surgery. Two reviewers independently screened studies, extracted data, and assessed study quality. Primary outcomes of interest were postoperative pulmonary complications (PPCs) and all-cause complications; secondary outcomes included hospital and intensive care length of stay. A meta-analysis with random-effect models was performed, and heterogeneity was evaluated with I-square and Cochran’s Q test. Dichotomous variables were reported in log-odds ratio and continuous variables were presented as mean difference. Ten studies (total 1503 patients) were included. Odds of developing complications after prehabilitation were significantly lower compared to various control groups (− 0.38 − 0.75– − 0.004, P = 0.048). Five studies described PPCs, and participants with prehabilitation had decreased odds of PPC (− 0.96 − 1.38– − 0.54, P < 0.001). Prehabilitation did not significantly reduce length of stay, unless exercise was implemented; with exercise, hospital stay decreased significantly (− 0.91 − 1.67– − 0.14, P = 0.02). Multimodal prehabilitation may decrease complications in upper abdominal surgery, but not necessarily length of stay; research should address heterogeneity in the literature.
Introduction
Preoperative coagulation screening for patients without bleeding disorders remains controversial. The combinatorial risk of INR, aPTT, and platelet count (PLT) abnormalities leading to ...bleeding requiring transfusion is not known in these patients. We examined the association between abnormal coagulation profile and the risk of transfusion following common elective surgery in patients without bleeding disorders.
Study Design and Methods
We utilized the National Surgical Quality Improvement Program (NSQIP) database from 2004 to 2018 to identify patients without a history of bleeding disorders undergoing common 23 major elective procedures across 10 specialties. Multivariable logistic regression was used to assess the association between coagulation profile and bleeding requiring packed red blood cell transfusion intra−/post‐operatively.
Results
Of the 672,075 patients meeting inclusion criteria, 53.7% presented with normal coagulation profile preoperatively. Overall, 12.2% (n = 82,368) received transfusion. In the setting of normal aPTT/PLT, both Equivocal INR of 1.1–1.5 (aOR 1.41, 95% CI 1.38–1.44) and Abnormal INR of >1.5 (aOR 1.81, 95% CI 1.71–1.93) were significantly associated with an increased risk of transfusion. Equivocal (60–70) and Abnormal (>70) aPTT with normal INR/PLT did not demonstrate a comparable risk of transfusion. We observed a synergistic effect of combinatorial lab abnormalities on the risk of transfusion when both Abnormal INR/aPTT and Low PLT of <100,000 were present (aOR 5.18, 95% CI 3.04–8.84), compared to the effect of Abnormal INR/aPTT and normal/elevated PLT (aOR 1.90, 95% CI 1.48–2.45).
Discussion
The preoperative presence of abnormal findings in INR or PLT was significantly associated with the risk of bleeding requiring transfusion during intraoperative and postoperative periods.
See editorial on page 2155–2157, in this issue
Trauma-related injury is the leading cause of non-obstetric maternal death. The gravid uterus is at risk for injury, particularly during motor vehicle accidents. Resuscitative endovascular balloon ...occlusion of the aorta (REBOA) is a means of controlling pelvic hemorrhage in the setting of trauma. We report the use of REBOA in a hemodynamically unstable, multiply-injured young woman with viable intrauterine pregnancy.
Age and comorbidity are independently associated with worse outcomes for pancreatic adenocarcinoma (PDAC). However, the effect of combined age and comorbidity on PDAC outcomes has rarely been ...studied. This study assessed the impact of age and comorbidity (CACI) and surgical center volume on PDAC 90-day and overall survival (OS).
This retrospective cohort study used the National Cancer Database from 2004 to 2016 to evaluate resected stage I/II PDAC patients. The predictor variable, CACI, combined the Charlson/Deyo comorbidity score with additional points for each decade lived ≥50 years. The outcomes were 90-day mortality and OS.
The cohort included 29,571 patients. Ninety-day mortality ranged from 2 % for CACI 0 to 13 % for CACI 6+ patients. There was a negligible difference (1 %) in 90-day mortality between high- and low-volume hospitals for CACI 0–2 patients; however, there was greater difference for CACI 3–5 (5 % vs. 9 %) and CACI 6+ (8 % vs. 15 %). The overall survival for CACI 0–2, 3–5, and 6+ cohorts was 24.1, 19.8, and 16.2 months, respectively. Adjusted overall survival showed a 2.7 and 3.1 month survival benefit for care at high-volume vs. low-volume hospitals for CACI 0–2 and 3–5, respectively. However, there was no OS volume benefit for CACI 6+ patients.
Combined age and comorbidity are associated with short- and long-term survival for resected PDAC patients. A protective effect of higher-volume care was more impactful for 90-day mortality for patients with a CACI above 3. A centralization policy based on volume may have greater benefit for older, sicker patients.
Combined comorbidity and age are strongly associated with 90-day mortality and overall survival for resected pancreatic cancer patients. When assessing the impact of age and comorbidity on resected pancreatic adenocarcinoma outcomes, 90-day mortality was 7 % higher (8 % vs. 15 %) for older, sicker patients treated at high-volume vs. low-volume centers but only 1 % (3 % vs. 4 %) for younger, healthier patients.
Abstract
Background
Patients undergoing hepatopancreatobiliary (HPB) surgery, such patients with pancreatic, periampullary, and liver cancer, are at high risk for malnutrition. Malnutrition increases ...surgical complications and reduces overall survival. Despite its severity, there are limited interventions addressing malnutrition after HPB surgery. The aim of this pilot trial was to examine feasibility, acceptability, usability, and preliminary efficacy of a remote nutrition monitoring intervention after HPB surgery.
Methods
Participants received tailored nutritional counseling before and after surgery at 2 and 4 weeks after hospital discharge. Participants also recorded nutritional intake daily for 30 days, and these data were reviewed remotely by registered dietitians before nutritional counseling visits. Descriptive statistics were used to describe study outcomes.
Results
All 26 patients approached to participate consented to the trial before HPB surgery. Seven were excluded after consent for failing to meet eligibility criteria (e.g., did not receive surgery). Nineteen participants (52.6% female, median age
=
65 years) remained eligible for remote monitoring post-surgery. Nineteen used the mobile app food diary, 79% of participants recorded food intake for greater than 80% of study days, 95% met with the dietitian for all visits, and 89% were highly satisfied with the intervention. Among participants with complete data, the average percent caloric goal obtained was 82.4% (IQR: 21.7).
Conclusions
This intervention was feasible and acceptable to patients undergoing HPB surgery. Preliminary efficacy data showed most participants were able to meet calorie intake goals. Future studies should examine intervention efficacy in a larger, randomized controlled trial.
Trial registration
Clinicaltrials.gov. Registered 16 September 2019,
https://clinicaltrials.gov/ct2/show/NCT04091165
.
We aimed to investigate the clinical utility of circulating tumor cell DNA (ctDNA) and exosome DNA (exoDNA) in pancreatic cancer.
We collected liquid biopsy samples from 194 patients undergoing ...treatment for localized or metastatic pancreatic adenocarcinoma from April 7, 2015, through October 13, 2017 (425 blood samples collected before baseline and during therapy). Additional liquid biopsy samples were collected from 37 disease control individuals. Droplet digital polymerase chain reaction was used to determine KRAS mutant allele fraction (MAF) from ctDNA and exoDNA purified from plasma. For the longitudinal analysis, we analyzed exoDNA and ctDNA in 123 serial blood samples from 34 patients. We performed analysis including Cox regression, Fisher exact test, and Bayesian inference to associate KRAS MAFs in exoDNA and ctDNA with prognostic and predictive outcomes.
In the 34 patients with potentially resectable tumors, an increase in exoDNA level after neoadjuvant therapy was significantly associated with disease progression (P = .003), whereas ctDNA did not show correlations with outcomes. Concordance rates of KRAS mutations present in surgically resected tissue and detected in liquid biopsy samples were greater than 95%. On univariate analysis, patients with metastases and detectable ctDNA at baseline status had significantly shorter times of progression-free survival (PFS) (hazard ratio HR for death, 1.8; 95% CI, 1.1–3.0; P = .019), and overall survival (OS) (HR, 2.8; 95% CI, 1.4–5.7; P = .0045) compared with patients without detectable ctDNA. On multivariate analysis, MAFs ≥5% in exoDNA were a significant predictor of PFS (HR, 2.28; 95% CI, 1.18–4.40; P = .014) and OS (HR, 3.46; 95% CI, 1.40–8.50; P = .007). A multianalyte approach showed detection of both ctDNA and exoDNA MAFs ≥5% at baseline status to be a significant predictor of OS (HR, 7.73, 95% CI, 2.61–22.91, P = .00002) on multivariate analysis. In the longitudinal analysis, an MAF peak above 1% in exoDNA was significantly associated with radiologic progression (P = .0003).
In a prospective cohort of pancreatic cancer patients, we show how longitudinal monitoring using liquid biopsy samples through exoDNA and ctDNA provides both predictive and prognostic information relevant to therapeutic stratification.
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We hypothesized that first-generation cephalosporins (G1CEP) provide adequate antimicrobial coverage for pancreaticoduodenectomy (PD) when no biliary stent is present but might be inferior to ...second-generation cephalosporins or broad-spectrum antibiotics (G2CEP/BS) in decreasing surgical-site infection (SSI) rates when a biliary stent is present.
The National Surgical Quality Improvement Program 2014-2019 was used to select patients who underwent elective open PD. We divided the population into no-stent versus stent groups based on the status of biliary drainage and then divided each group into G1CEP versus G2CEP/BS subgroups based on the choice of perioperative antibiotics. We matched the subgroups per a propensity score match and analyzed postoperative outcomes.
Six thousand two hundred forty five cases of 39,779 were selected; 2821 in the no-stent (45.2%) versus 3424 (54.8%) in the stent group. G1CEP were the antibiotics of choice in 2653 (42.5%) versus G2CEP/BS in 3592 (57.5%) cases. In the no-stent group, we matched 1129 patients between G1CEP and G2CEP/BS. There was no difference in SSI-specific complications (20.3% versus 21.0%; P = 0.677), general infectious complications (25.7% versus 26.9%; P = 0.503), PD-specific complications, overall morbidity, length of stay, or mortality. In the stent group, we matched 1244 pairs. G2CEP/BS had fewer SSI-specific complications (19.9% versus 26.6%; P < 0.001), collections requiring drainage (9.6% versus 12.9%; P = 0.011), and general infectious complications (28.5% versus 34.1%; P = 0.002) but no difference in overall morbidity, mortality, length of stay, and readmission rates.
G2CEP/BS are associated with reduced rates of SSI-specific and infectious complications in stented patients undergoing open elective PD. In patients without prior biliary drainage, G1CEP seems to provide adequate antimicrobial coverage.
We aimed to examine the psychosocial well-being in the pancreas cancer patient-caregiver dyad, and determine patient and caregiver characteristics that predict caregiver distress. This was a ...cross-sectional, observational study. Demographics and caregiving characteristics were gathered from patients and caregivers. Caregivers completed validated instruments investigating anxiety, depression, perceived stress and caregiver burden. Over a period of eleven months, 128 patient-caregiver dyads were enrolled. Patient and caregiver distress scores were not associated with patient clinical disease burden. Patient distress was a significant predictor of concurrent caregiver distress, anxiety, depression, and perceived burden. Younger caregivers were also associated with higher caregiver anxiety and perceived burden. Additionally, number of caregiving activities and caregiver overall health status were predictors of concurrent caregiver depression and perceived stress. Certain pancreatic cancer patient and caregiver variables may negatively impact the well-being of caregivers. Future efforts should focus on development and implementation of comprehensive caregiver support programs for those at risk for psychosocial distress.
•The morbidity and mortality associated with multivisceral resection (MVR) at the time of radical nephrectomy (RN) remains poorly described and quantified at the population level.•Patients undergoing ...RN+MVR were at greater risk of requiring reoperation, transfusion, and readmission, and experiencing increased rate of infections and longer hospital stays.•There was no significant difference in mortality rates between RN alone and RN+MVR.
Locally advanced renal cell carcinoma (RCC) can rarely invade into adjacent abdominal viscera without clinical evidence of distant metastases. The role of multivisceral resection (MVR) of involved adjacent organs at the time of radical nephrectomy (RN) remains poorly described and quantified. Using a national database, we aimed to evaluate the association between RN+MVR and 30-day postoperative complications.
We conducted a retrospective cohort study of adult patients undergoing RN for RCC with and without MVR between 2005 and 2020 using the ACS-NSQIP database. The primary outcome was a composite of any of the following 30-day major postoperative complications: mortality, reoperation, cardiac event, and neurologic event. Secondary outcomes included individual components of the composite primary outcome, as well as infectious and venous thromboembolic complications, unplanned intubation and ventilation, transfusion, readmission, and prolonged length of stay (LOS). Groups were balanced using propensity score matching. Likelihood of complications was assessed by conditional logistic regression adjusted for unbalanced total operation time. Postoperative complications were compared by Fisher's exact test among subtypes of resection.
A total of 12,417 patients were identified: 12,193 (98.2%) undergoing RN alone and 224 (1.8%) undergoing RN+MVR. Patients undergoing RN+MVR were more likely to experience major complications (odds ratio OR 2.46; 95% confidence interval CI 1.28–4.74). However, there was no significant association between RN+MVR and postoperative mortality (OR 2.49; 95% CI 0.89–7.01). RN+MVR was associated with higher rates of reoperation (OR 7.85; 95% CI 2.38–25.8), sepsis (OR 5.45; 95% CI 1.83–16.2), surgical site infection (OR 4.41; 95% CI 2.14–9.07), blood transfusion (OR 2.24; 95% CI 1.55–3.22), readmission (OR 1.78; 95% CI 1.11–2.84), infectious complications (OR 2.62; 95% CI 1.62–4.24), and longer hospital stay (5 days IQR 3–8 vs. 4 days IQR 3–7; OR 2.31 95% CI 2.13–3.03). There was no heterogeneity in the association between subtype of MVR and major complication rate.
Undergoing RN+MVR is associated with an increased risk of 30-day postoperative morbidity, including infectious complications, reoperation, blood transfusion, prolonged LOS, and readmission.
Hepatocellular carcinoma (HCC) patients with cirrhosis are high-risk for invasive procedures. Identification of those at risk may prevent complications and allow more informed decision-making. The ...aspartate aminotransferase (AST) to platelet ratio index (APRI) is a measure of cirrhosis that we hypothesize predicts survival and may estimate HCC mortality.
Institutional retrospective study of all HCC patients. Demographics and labs bilirubin, international normalized ratio (INR), creatinine, AST and platelets were recorded at the date-of-diagnosis to calculate APRI and the Model for End-Stage Liver Disease score (MELD). Poor survival was defined as death within 30-days from diagnosis. Models were created to determine predictors of death within 30-days and overall survival.
A total of 829 patients comprised this study and <30-day death was observed in 111 patients (17%). Mean APRI and MELD scores were higher in the <30-day death group. APRI odds ratio (OR) 1.45, 95% confidence interval (CI): 1.07-1.96 and MELD (OR 1.21, 95% CI: 1.14-1.28) were predictive of <30-day death. Stratified by stage, APRI hazard ratio (HR) 1.12, 95% CI: 1.01-1.24 and MELD (HR 1.07, 95% CI: 1.05-1.09) were associated with overall survival. Inclusion of APRI and MELD components in the Cox regression resulted in the best fit (c-index =0.67).
The APRI is an innovative marker of cirrhosis and survival for HCC patients. APRI provides additional prognostic information regarding the severity of cirrhosis and external validation is needed to determine clinical utility.
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