In major surgery, the implementation of multidisciplinary, multimodal and individualized strategies, collectively termed Patient Blood Management, aims to identify modifiable risks and optimise ...patients’ own physiology with the ultimate goal of improving outcomes. Among the various strategies utilized in Patient Blood Management, timely detection and management of preoperative anaemia is most important, as it is in itself a risk factor for worse clinical outcome, but also one of the strongest predisposing factors for perioperative allogeneic blood transfusion, which in turn increases postoperative morbidity, mortality and costs. However, preoperative anaemia is still frequently ignored, with indiscriminate allogeneic blood transfusion used as a ‘quick fix’. Consistent with reported evidence from other medical specialties, this imprudent practice continues to be endorsed by non-evidence based misconceptions, which constitute serious barriers for a wider implementation of preoperative haemoglobin optimisation. We have reviewed a number of these misconceptions, which we unanimously consider should be promptly abandoned by health care providers and replaced by evidence-based strategies such as detection, diagnosis and proper treatment of preoperative anaemia. We believe that this approach to preoperative anaemia management may be a viable, cost-effective strategy that is beneficial both for patients, with improved clinical outcomes, and for health systems, with more efficient use of finite health care resources.
To accurately calculate the risk for postoperative complications and death after surgery in the preoperative period using machine-learning modeling of clinical data.
Postoperative complications cause ...a 2-fold increase in the 30-day mortality and cost, and are associated with long-term consequences. The ability to precisely forecast the risk for major complications before surgery is limited.
In a single-center cohort of 51,457 surgical patients undergoing major inpatient surgery, we have developed and validated an automated analytics framework for a preoperative risk algorithm (MySurgeryRisk) that uses existing clinical data in electronic health records to forecast patient-level probabilistic risk scores for 8 major postoperative complications (acute kidney injury, sepsis, venous thromboembolism, intensive care unit admission >48 hours, mechanical ventilation >48 hours, wound, neurologic, and cardiovascular complications) and death up to 24 months after surgery. We used the area under the receiver characteristic curve (AUC) and predictiveness curves to evaluate model performance.
MySurgeryRisk calculates probabilistic risk scores for 8 postoperative complications with AUC values ranging between 0.82 and 0.94 99% confidence intervals (CIs) 0.81-0.94. The model predicts the risk for death at 1, 3, 6, 12, and 24 months with AUC values ranging between 0.77 and 0.83 (99% CI 0.76-0.85).
We constructed an automated predictive analytics framework for machine-learning algorithm with high discriminatory ability for assessing the risk of surgical complications and death using readily available preoperative electronic health records data. The feasibility of this novel algorithm implemented in real time clinical workflow requires further testing.
The aim of the study was to evaluate sarcopenia as a predictor of postoperative risk of major and total complications after surgery for gastrointestinal cancer.
Sarcopenia is associated with poor ...survival in gastrointestinal cancer patients, but the role of sarcopenia as prognostic tool in surgical oncology has not been established, and no consensus exists regarding assessment and management of sarcopenic patients.
We performed a systematic search for citations in EMBASE, Web of Science, and PubMed from 2004 to January 31, 2017. Random effects meta-analyses were used to estimate the pooled risk ratio for postoperative complications by Clavien-Dindo grade (total complications: grade ≥2; major complications: grade ≥3) in patients with sarcopenia versus patients without sarcopenia. Stratified analyses were performed by sarcopenia criteria, cutoff level, assessment methods, study quality, cancer diagnosis, and "Enhanced Recovery After Surgery" care.
Twenty-nine studies (n = 7176) were included with sarcopenia prevalence ranging between 12% and 78%. Preoperative incidence of sarcopenia was associated with increased risk of major complications (risk ratio 1.40; 95% confidence interval, 1.20-1.64; P < 0.001; I = 52%) and total complications (risk ratio 1.35; 95% confidence interval, 1.12-1.61; P = 0.001; I = 60%). Moderate heterogeneity was found for both meta-analyses. Subgroup analyses showed that sarcopenia remained a consistent risk factor across stratification by sarcopenia criteria, assessment methods, study quality, and diagnoses.
Sarcopenia was associated with an increased risk of complications after gastrointestinal tumor resection, but lack of methodological consensus hampers the interpretation and clinical utilization of these findings. Combining assessment of muscle mass with measures of physical function may increase the prognostic value and accuracy in preoperative risk stratification.
Background
Numerous published studies have explored associations between anaemia and adverse outcomes after surgery. However, there are no evidence syntheses describing the impact of preoperative ...anaemia on postoperative outcomes.
Methods
A systematic review and meta‐analysis of observational studies exploring associations between preoperative anaemia and postoperative outcomes was performed. Studies investigating trauma, burns, transplant, paediatric and obstetric populations were excluded. The primary outcome was 30‐day or in‐hospital mortality. Secondary outcomes were acute kidney injury, stroke and myocardial infarction. Predefined analyses were performed for the cardiac and non‐cardiac surgery subgroups. A post hoc analysis was undertaken to evaluate the relationship between anaemia and infection. Data are presented as odds ratios (ORs) with 95 per cent c.i.
Results
From 8973 records, 24 eligible studies including 949 445 patients were identified. Some 371 594 patients (39·1 per cent) were anaemic. Anaemia was associated with increased mortality (OR 2·90, 2·30 to 3·68; I2 = 97 per cent; P < 0·001), acute kidney injury (OR 3·75, 2·95 to 4·76; I2 = 60 per cent; P < 0·001) and infection (OR 1·93, 1·17 to 3·18; I2 = 99 per cent; P = 0·01). Among cardiac surgical patients, anaemia was associated with stroke (OR 1·28, 1·06 to 1·55; I2 = 0 per cent; P = 0·009) but not myocardial infarction (OR 1·11, 0·68 to 1·82; I2 = 13 per cent; P = 0·67). Anaemia was associated with an increased incidence of red cell transfusion (OR 5·04, 4·12 to 6·17; I2 = 96 per cent; P < 0·001). Similar findings were observed in the cardiac and non‐cardiac subgroups.
Conclusion
Preoperative anaemia is associated with poor outcomes after surgery, although heterogeneity between studies was significant. It remains unclear whether anaemia is an independent risk factor for poor outcome or simply a marker of underlying chronic disease. However, red cell transfusion is much more frequent amongst anaemic patients.
Associated with poor outcome
Research supports use of prehabilitation to optimize physical status before and after colorectal cancer resection, but its effect on postoperative complications remains unclear. Frail patients are a ...target for prehabilitation interventions owing to increased risk for poor postoperative outcomes.
To assess the extent to which a prehabilitation program affects 30-day postoperative complications in frail patients undergoing colorectal cancer resection compared with postoperative rehabilitation.
This single-blind, parallel-arm, superiority randomized clinical trial recruited patients undergoing colorectal cancer resection from September 7, 2015, through June 19, 2019. Patients were followed up for 4 weeks before surgery and 4 weeks after surgery at 2 university-affiliated tertiary hospitals. A total of 418 patients 65 years or older were assessed for eligibility. Of these, 298 patients were excluded (not frail n = 290, unable to exercise n = 3, and planned neoadjuvant treatment n = 5), and 120 frail patients (Fried Frailty Index,≥2) were randomized. Ten patients were excluded after randomization because they refused surgery (n = 3), died before surgery (n = 3), had no cancer (n = 1), had surgery without bowel resection (n = 1), or were switched to palliative care (n = 2). Hence, 110 patients were included in the intention-to-treat analysis (55 in the prehabilitation Prehab and 55 in the rehabilitation Rehab groups). Data were analyzed from July 25 through August 21, 2019.
Multimodal program involving exercise, nutritional, and psychological interventions initiated before (Prehab group) or after (Rehab group) surgery. All patients were treated within a standardized enhanced recovery pathway.
The primary outcome included the Comprehensive Complications Index measured at 30 days after surgery. Secondary outcomes were 30-day overall and severe complications, primary and total length of hospital stay, 30-day emergency department visits and hospital readmissions, recovery of walking capacity, and patient-reported outcome measures.
Of 110 patients randomized, mean (SD) age was 78 (7) years; 52 (47.3%) were men and 58 (52.7%) were women; 31 (28.2%) had rectal cancer; and 87 (79.1%) underwent minimally invasive surgery. There was no between-group difference in the primary outcome measure, 30-day Comprehensive Complications Index (adjusted mean difference, -3.2; 95% CI, -11.8 to 5.3; P = .45). Secondary outcome measures were also not different between groups.
In frail patients undergoing colorectal cancer resection (predominantly minimally invasive) within an enhanced recovery pathway, a multimodal prehabilitation program did not affect postoperative outcomes. Alternative strategies should be considered to optimize treatment of frail patients preoperatively.
ClinicalTrials.gov identifier: NCT02502760.
Use of next-generation sequencing of RNA and machine learning algorithms can classify the risk of malignancy in cytologically indeterminate thyroid nodules to limit unnecessary diagnostic surgery.
To ...measure the performance of a genomic sequencing classifier for cytologically indeterminate thyroid nodules.
A blinded validation study was conducted on a set of cytologically indeterminate thyroid nodules collected by fine-needle aspiration biopsy between June 2009 and December 2010 from 49 academic and community centers in the United States. All patients underwent surgery without genomic information and were assigned a histopathology diagnosis by an expert panel blinded to all genomic information. There were 210 potentially eligible thyroid biopsy samples with Bethesda III or IV indeterminate cytopathology that constituted a cohort previously used to validate the gene expression classifier. Of these, 191 samples (91.0%) had adequate residual RNA for validation of the genomic sequencing classifier. Algorithm development and independent validation occurred between August 2016 and May 2017.
Thyroid nodule surgical histopathology diagnosis by an expert panel blinded to all genomic data.
The primary end point was measurement of genomic sequencing classifier sensitivity, specificity, and negative and positive predictive values in biopsies from Bethesda III and IV nodules. The secondary end point was measurement of classifier performance in biopsies from Bethesda II, V, and VI nodules.
Of the 183 included patients, 142 (77.6%) were women, and the mean (range) age was 51.7 (22.0-85.0) years. The genomic sequencing classifier had a sensitivity of 91% (95% CI, 79-98) and a specificity of 68% (95% CI, 60-76). At 24% cancer prevalence, the negative predictive value was 96% (95% CI, 90-99) and the positive predictive value was 47% (95% CI, 36-58).
The genomic sequencing classifier demonstrates high sensitivity and accuracy for identifying benign nodules. Its 36% increase in specificity compared with the gene expression classifier potentially increases the number of patients with benign nodules who can safely avoid unnecessary diagnostic surgery.
Preoperative fasting is a major cause of perioperative discomfort in paediatric anaesthesia and leads to postoperative insulin resistance, thus potentially enhancing the inflammatory response to ...surgery. Addressing these problems by preoperative carbohydrate intake has not been a well-defined approach in children.
We randomised 120 children scheduled for gastroscopy under general anaesthesia to either a control group of standard preoperative fasting or a study group receiving a carbohydrate beverage (PreOp™; Nutricia, Erlangen, Germany). Their stomach contents were aspirated endoscopically, and the volume and pH measured. Perioperative discomfort was evaluated using, among other parameters, an observational pain scale in ≤4-yr-olds and a VAS in >4-yr-olds. The investigators doing the endoscopies and outcome evaluations were blinded to the study group allocation.
Compared with fasting, carbohydrate loading was associated with significantly less gastric content (P=0.01), fewer patients experiencing postoperative nausea (P=0.028), with no significant difference in postoperative vomiting. High preoperative VAS scores (>5) were recorded for only one child in the carbohydrate group vs five children in the fasting group. Bowel cleansing for simultaneous colonoscopies (n=61) made no difference to any of the intergroup findings.
Preoperative carbohydrates can reduce nausea and gastric content, the latter being a surrogate parameter for the risk and severity of gastric aspiration into the lungs during anaesthesia. Our study adds knowledge for preoperative fasting guidelines in paediatric anaesthesia.
DRKS00005020.
Accurate identification of axillary lymph node (ALN) involvement in patients with early-stage breast cancer is important for determining appropriate axillary treatment options and therefore avoiding ...unnecessary axillary surgery and complications. Here, we report deep learning radiomics (DLR) of conventional ultrasound and shear wave elastography of breast cancer for predicting ALN status preoperatively in patients with early-stage breast cancer. Clinical parameter combined DLR yields the best diagnostic performance in predicting ALN status between disease-free axilla and any axillary metastasis with areas under the receiver operating characteristic curve (AUC) of 0.902 (95% confidence interval CI: 0.843, 0.961) in the test cohort. This clinical parameter combined DLR can also discriminate between low and heavy metastatic burden of axillary disease with AUC of 0.905 (95% CI: 0.814, 0.996) in the test cohort. Our study offers a noninvasive imaging biomarker to predict the metastatic extent of ALN for patients with early-stage breast cancer.
The goal of this project was to first address barriers to implementation of the Risk Analysis Index (RAI) within a large, multi-hospital, integrated healthcare delivery system, and to subsequently ...demonstrate its utility for identifying at-risk surgical patients.
Prior studies demonstrate the validity of the RAI for evaluating preoperative frailty, but they have not demonstrated the feasibility of its implementation within routine clinical practice.
Implementation of the RAI as a frailty screening instrument began as a quality improvement initiative at the University of Pittsburgh Medical Center in July 2016. RAI scores were collected within a REDCap survey instrument integrated into the outpatient electronic health record and then linked to information from additional clinical datasets. NSQIP-eligible procedures were queried within 90 days following the RAI, and the association between RAI and postoperative mortality was evaluated using logistic regression and Cox proportional hazards models. Secondary outcomes such as inpatient length of stay and readmissions were also assessed.
RAI assessments were completed on 36,261 unique patients presenting to surgical clinics across five hospitals from July 1 to December 31, 2016, and 8,172 of these underwent NSQIP-eligible surgical procedures. The mean RAI score was 23.6 (SD 11.2), the overall 30-day and 180-day mortality after surgery was 0.7% and 2.6%, respectively, and the median time required to collect the RAI was 33 IQR 23-53 seconds. Overall clinic compliance with the recommendation for RAI assessment increased from 58% in the first month of the study period to 84% in the sixth and final month. RAI score was significantly associated with risk of death (HR=1.099 95% C.I.: 1.091 - 1.106, p < 0.001). At an RAI cutoff of ≥37, the positive predictive values for 30- and 90-day readmission were 14.8% and 26.2%, respectively, and negative predictive values were 91.6% and 86.4%, respectively.
The RAI frailty screening tool can be efficiently implemented within multi-specialty, multi-hospital healthcare systems. In the context of our findings and given the value of the RAI in predicting adverse postoperative outcomes, health systems should consider implementing frailty screening within surgical clinics.
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