Background
The extent of surgery (ES) during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) is a well-known risk factor for major postoperative morbidity. ...Interestingly, the reliability of surgeons to predict the ES prior to CRS + HIPEC is unknown.
Methods
In this prospective, observational cohort study, five surgeons predicted the ES prior to surgery in all consecutive patients with peritoneal metastases (PM) who were scheduled for CRS + HIPEC between March 2018 and May 2019. After the preoperative work-up for CRS + HIPEC was completed, all surgeons independently predicted, for each individual patient, the resection or preservation of 22 different anatomical structures and the presence of a stoma post-HIPEC according to a standardized ES form. The actual ES during CRS + HIPEC was extracted from the surgical procedure report and compared with the predicted ES. Overall and individual positive (PPV) and negative predictive values (NPV) for each anatomical structure were calculated.
Results
One hundred and thirty-one ES forms were collected from 32 patients who successfully underwent CRS + HIPEC. The number of resections was predicted correctly 24 times (18.3%), overestimated 57 times (43.5%), and underestimated 50 times (38.2%). Overall PPVs for the different anatomical structures ranged between 33.3 and 87.8%. Overall, NPVs ranged between 54.9 and 100%, and an NPV > 90% was observed for 12 anatomical structures.
Conclusions
Experienced surgeons seem to be able to better predict the anatomical structures that remain in situ after CRS + HIPEC, rather than predict the resections that were necessary to achieve a complete cytoreduction.
Abstract
STUDY QUESTION
What affects women's treatment preferences in the management of an incomplete evacuation of the uterus after misoprostol treatment for a first-trimester miscarriage?
SUMMARY ...ANSWER
Women's treatment preferences in the management of an incomplete evacuation of the uterus after misoprostol treatment for miscarriage are most strongly influenced by ‘the risk of a reduced fertility’ followed by ‘the probability of success’.
WHAT IS KNOWN ALREADY
Available treatment options in miscarriage are surgical, medical or expectant management. Treatment with misoprostol leads to an incomplete evacuation of the uterus and additional surgical treatment in 20–50% of women. To our knowledge, women's preferences for subsequent treatment of an incomplete evacuation of the uterus after misoprostol treatment for miscarriage have not been studied yet.
STUDY DESIGN, SIZE, DURATION
Between April 2014 and January 2015, we conducted a prospective nationwide multicentre discrete-choice experiment (DCE). DCEs have become the most frequently applied approach for studying patient preferences in health care. In our DCE, which considerers five attributes, a target sample size was calculated including 20 patients per attribute for the main analysis. We intended to include 25% more patients, i.e. a total of 125 thus enabling us to assess heterogeneity of treatment choices.
PARTICIPANTS/MATERIALS, SETTING, METHODS
All women visiting the outpatient clinic with first-trimester miscarriage or incomplete miscarriage were invited to participate in the study. Women under 18 years of age, women who were unable to understand the Dutch questionnaire or women who already had received a treatment for the current miscarriage were excluded. Women's preferences were assessed using a DCE. A literature review, expert opinions and interviews with women from the general population were used to define relevant treatment characteristics. Five attributes were selected: (i) certainty about the duration of convalescence; (ii) number of days of bleeding after treatment; (iii) probability of success (empty uterus after treatment); (iv) risk of reduced fertility and (v) risk of complications requiring more time or readmission to hospital. Fourteen scenarios using these attributes were selected in the DCE. Each of these scenarios presented two treatment options, while treatment characteristics varied between the 14 scenarios. For each scenario, respondents were asked to choose the preferred treatment option. The importance of each attribute was analysed, and preference heterogeneity was investigated through latent-class analysis.
MAIN RESULTS AND THE ROLE OF CHANCE
One hundred and eighty-six women were included of whom 128 completed the DCE (69% response rate). The two attributes with the greatest effect on their preference were, probability of success and risk of reduced fertility. The latent-class analysis revealed two subgroups of patients with different preference patterns. Forty per cent of women were more influenced by treatment success and 59% were more influenced by risk.
LIMITATIONS, REASONS FOR CAUTION
Most women were highly educated and were of Dutch origin, which limits the generalizability of our findings. Women with lower education levels, other cultural backgrounds and/or different previous experiences may differ from our findings.
WIDER IMPLICATIONS OF THE FINDINGS
Patients preferences should be addressed when counselling patients with an incomplete miscarriage after misoprostol treatment.
STUDY FUNDING/COMPETING INTEREST(S)
This study was embedded in the MisoREST trial, and funded by ZonMw, a Dutch organization for Health Research and Development, project number 80-82310-97-12066. There were no conflicts of interests.
TRIAL REGISTRATION NUMBER
Dutch Trial Register NTR3310, http://www.trialregister.nl
TRIAL REGISTRATION DATE
27 February 2012.
DATE OF FIRST PATIENT'S ENROLMENT
12 June 2012.
Skeletal muscle loss is often observed in intensive care patients. However, little is known about postoperative muscle loss, its associated risk factors, and its long-term consequences. The aim of ...this prospective observational study is to identify the incidence of and risk factors for surgery-related muscle loss (SRML) after major abdominal surgery, and to study the impact of SRML on fatigue and survival.
Patients undergoing major abdominal cancer surgery were included in the MUSCLE POWER STUDY. Muscle thickness was measured by ultrasound in three muscles bilaterally (biceps brachii, rectus femoris, and vastus intermedius). SRML was defined as a decline of 10 per cent or more in diameter in at least one arm and leg muscle within 1 week postoperatively. Postoperative physical activity and nutritional intake were assessed using motility devices and nutritional diaries. Fatigue was measured with questionnaires and 1-year survival was assessed with Cox regression analysis.
A total of 173 patients (55 per cent male; mean (s.d.) age 64.3 (11.9) years) were included, 68 of whom patients (39 per cent) showed SRML. Preoperative weight loss and postoperative nutritional intake were statistically significantly associated with SRML in multivariable logistic regression analysis (P < 0.050). The combination of insufficient postoperative physical activity and nutritional intake had an odds ratio of 4.00 (95 per cent c.i. 1.03 to 15.47) of developing SRML (P = 0.045). No association with fatigue was observed. SRML was associated with decreased 1-year survival (hazard ratio 4.54, 95 per cent c.i. 1.42 to 14.58; P = 0.011).
SRML occurred in 39 per cent of patients after major abdominal cancer surgery, and was associated with a decreased 1-year survival.
Patients with peritoneal carcinomatosis (PC) from colorectal origin may undergo cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) as a curative approach. One major ...prognostic factor that affects survival is completeness of cytoreduction. Molecular Fluorescence Guided Surgery (MFGS) is a novel intraoperative imaging technique that may improve tumor identification in the future, potentially preventing over‐ and under‐treatment in these patients. This narrative review outlines a chronological overview of MFGS development in patients with PC of colorectal origin.
Enhanced recovery after surgery protocols emphasize the importance of early postoperative mobilization. However, literature quantifying actual physical activity after major abdominal cancer surgery ...is scarce and inconclusive.
A single-center prospective cohort study was conducted at the University Medical Center Groningen from 2019 to 2021. Patients’ postoperative physical activity was measured using an accelerometer, with the primary aim of assessing daily physical activity. Secondary aims were identifying patient-related factors associated with low physical activity and studying the consequences of low physical activity in terms of complication rate and length of hospital stay.
143 patients included (48 % male; mean age 65 years), 38.5 %, 24.5 %, 19.6 %, and 14 % underwent pancreatic, hepatic, colorectal, or cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, respectively. Median daily step count was low; from median 71 steps on the first to 918 steps on the seventh postoperative day. An association between physical activity and age (OR 3.597, p = 0.013), preoperative weight loss ≥10 % (OR 4.984, p = 0.004), Eastern Cooperative Oncology Group performance status ≥2 (OR 4.016, p = 0.001), midline laparotomy (OR 2.851, p = 0.025), and operation duration (OR 1.003, p = 0.044) was found. An association was observed between physical activity and the occurrence of complications (OR 3.197, p = 0.039) and prolonged hospital stay (β 4.068, p = 0.013).
Postoperative physical activity is low in patients undergoing major abdominal cancer surgery and is linked to postoperative outcomes. Although physical activity should be encouraged in all patients, patient-specific risk factors were identified that can aid early recognition of patients at risk of low physical activity.
It has been a standard practice to perform mechanical bowel preparation (MBP) prior to colorectal surgery to reduce the risk of colorectal anastomotic leakages (CAL). The latest Cochrane systematic ...review suggests there is no benefit for MBP in terms of decreasing CAL, but new studies have been published. The aim of this systematic review and meta-analysis is to update current evidence for the effectiveness of preoperative MBP on CAL in patients undergoing colorectal surgery. Consequently, PubMed, MEDLINE, Embase, CENTRAL and CINAHL were searched from 2010 to March 2017 for randomised controlled trials (RCT) that compared the effects of MBP in colorectal surgery on anastomotic leakages. The outcome CAL was expressed in odds ratios and analysed with a fixed-effects analysis in a meta-analysis. Quality assessment was performed by the cochrane risk of bias tool and grades of recommendation, assessment, development and evaluation (GRADE) methodology. Eight studies (1065 patients) were included. The pooled odds ratio showed no significant difference of MBP in colorectal surgery on CAL (odds ratio (OR) = 1.15, 95% CI = 0.68–1.94). According to GRADE methodology, the quality of the evidence was low. To conclude, MBP for colorectal surgery does not lower the risk of CAL. These results should, however, be interpreted with caution due to the small sample sizes and poor quality. Moreover, the usefulness of MBP in rectal surgery is not clear due to the lack of stratification in many studies. Future research should focus on high-quality, adequately powered RCTs in elective rectal surgery to determine the possible effects of MBP.
The peritoneal cancer index (PCI) calculated during exploratory laparotomy is a strong prognostic factor for overall survival (OS) in patients with colorectal peritoneal metastases (PM) who undergo ...cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). Progression of the PCI between diagnostic laparoscopy (DLS) and potential CRS + HIPEC (ΔPCI) might be a more dynamic prognostic factor for OS after CRS + HIPEC.
Between 2012 and 2018, all colorectal PM patients who underwent an exploratory laparotomy for potential CRS + HIPEC after DLS were retrospectively identified from a prospectively maintained database. Patients were divided into stable disease (ΔPCI 0–3), mild progression (ΔPCI 4–9), or severe progression (ΔPCI ≥10). Kaplan–Meier analysis and a multivariate Cox regression were performed.
Eighty-four patients (ΔPCI 0–3, n = 35; ΔPCI 4–9, n = 34; and ΔPCI ≥10, n = 15) were analysed. Median OS after CRS + HIPEC was significantly decreased in patients with a ΔPCI of 4–9 (35.1 95% CI 25.5–44.6) or ΔPCI ≥10 (24.1 95% CI 11.7–36.5) compared to patients with a ΔPCI of 0–3 (47.9 95% CI 40.0–55.7, p = 0.004). In multivariate regression analysis, ΔPCI remained an independent risk factor for OS: ΔPCI 4–9 HR 3.1 (95% CI 1.4–7.2, p = 0.007) and ΔPCI ≥10 HR 4.4 (95% CI 1.5–13.1, p = 0.007).
A high ΔPCI is an independent dynamic prognostic factor for OS and might reflect a more aggressive tumour biology in patients with colorectal PM. HIPEC surgeons should be aware of a high-ΔPCI-associated diminished prognosis and should reconsider CRS + HIPEC when confronted with a ΔPCI ≥10.
Abstract
Background
The aim of this study was to evaluate the impact of all minor and major complications on treatment-related healthcare costs in patients who undergo cytoreductive surgery (CRS) ...with hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of colorectal peritoneal metastases (PMs).
Method
Patients with histologically proven colorectal PMs who underwent CRS + HIPEC from March 2006 to October 2019 in a tertiary referral centre were retrospectively identified from a prospectively maintained database. Patients were divided into six subgroups according to the severity of the complications, which were scored using the comprehensive complication index (CCI) (CCI 0–9.9, CCI 10–19.9, CCI 20–29.9, CCI 30–39.9, CCI 40–49.9, and CCI 50 or higher). Treatment-related healthcare costs up to 1 year after CRS + HIPEC were obtained from the financial department. Differences in costs and survival outcomes were compared using the chi-squared test and Kruskal–Wallis H test.
Results
A total of 142 patients were included (CCI 0–9.9, 53 patients; CCI 10–19.9, 0 patients; CCI 20–29.9, 45 patients; CCI 30–39.9, 14 patients; CCI 40–49, 9 patients; and CCI 50 or higher, 21 patients). Median (interquartile range) treatment-related healthcare costs increased significantly and exponentially for the CCI 30–39, CCI 40–49, and CCI 50 or higher groups (€48 993 (€44 262–€84 805); €57 167 (€43 047–€67 591); and €82 219 (€55 487–€145 314) respectively) compared with those for the CCI 0–9.9 and CCI 20–29.9 groups (€33 856 (€24 433–€40 779) and €40 621 (€31 501–€58 761) respectively, P < 0.010).
Conclusion
Treatment-related healthcare costs increase exponentially as more complications develop among patients who undergo CRS + HIPEC for the treatment of colorectal PMs. Anastomotic leakages after CRS + HIPEC lead to an increase of 295 per cent of treatment-related healthcare costs.
The aim of this study was to compare hand grip strength (HGS) and manual dexterity of academic, subspecialized surgeons.
A single-center cross-sectional study was performed among 61 surgeons. HGS was ...analysed with a hand dynamometer and manual dexterity was extensively analysed with a Purdue Pegboard Test. Correlations between HGS and manual dexterity and specific characteristics of the surgeons were analysed using Pearson's correlation coefficient (r).
HGS and manual dexterity were comparable between surgeons from different specialities. HGS was positively correlated with male gender (r = 0.59, p < 0.001) and hand glove size (r = 0.61, p < 0.001), whereas manual dexterity was negatively correlated with male gender (r = −0.35, p = 0.006), age (r = −0.39, = 0.002), and hand glove size (r = −0.46, p < 0.001).
Surgical subspecialization was not correlated with HGS or manual dexterity. Male surgeons have greater HGS, whereas female surgeons have better manual dexterity. Manual dexterity is also correlated with age, showing better scores for younger surgeons.
•Hand grip strength (HGS) and manual dexterity are crucial surgical skills.•HGS and manual dexterity do not differ between surgeons of different specialities.•Male surgeons have greater HGS, whereas female surgeons have better manual dexterity.•Manual dexterity is correlated with age, showing better scores for younger surgeons.
Background: Surgery-related muscle loss (SRML) occurs in at least one out of three cancer patients within one week after major surgery. Though, this important phenomenon has hardly been investigated.
...Methods: The MUSCLE POWER is a prospective, observational cohort study that investigates the presence, impact, and predictors for clinically relevant SRML in 178 cancer patients after major abdominal surgery using ultrasound measurements, squeeze and force measurements, and QoL questionnaires. Primary endpoint is the proportion of patients with clinically relevant SRML defined as ≥5% muscle loss within one week after surgery, measured by the cross-sectional area (CSA) of three different muscles: m. biceps brachii, m. rectus femoris, and m. vastus intermedius. Possible correlation with QoL and fatigue up to six months after surgery will be investigated. Daily physical activity during hospital stay will be monitored by a motility tracker, and protein intake will be monitored by a dietician. Possible predictors for clinically relevant SRML—consisting of age ≥65 years, preoperative diabetes, preoperative sarcopenia, major postoperative complications (Clavien-Dindo ≥III), insufficient physical activity, and insufficient postoperative protein intake—will be investigated with a multivariable logistic regression analyses with a backward stepwise approach. Variables with a p<0.05 will be retrained in the final multivariable model.
Discussion: The MUSCLE POWER investigates the presence and impact of clinically relevant SRML in cancer patients after major abdominal surgery. Crucial information regarding possible predictors for clinically relevant SRML can be used in future intervention studies to prevent postoperative muscle loss and subsequently improve postoperative outcome and QoL.
Trial Registration: Medical Ethics Committee of the University Medical Center Groningen, the Netherlands (METc2018/361, version 3.0, January 21, 2019), and Netherlands Trial Register (NTR, NTR NL7505, version 1.0, February 7, 2019).
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