Intraoperative blood pressure changes as a risk factor for anastomotic leakage in colorectal surgery.

PURPOSE: Anastomotic leakage is a serious complication after colorectal surgery. Pre- and intraoperative factors may contribute to failure of colorectal anastomosis. In this study we have tried to determine risk factors for anastomotic leakage, with special emphasis on intraoperative blood pressure changes. METHODS: During a 24-month period, patients receiving a colorectal anastomosis were prospectively evaluated. For each patient preoperative characteristics, intraoperative adverse events and surgical outcome data were collected. Blood pressure changes were calculated as a relative decrease (>25% and >40%) from preoperative baseline values. RESULTS: During the study period, 285 patients underwent colorectal surgery with an anastomosis. Fifteen patients developed an anastomotic leakage (5.3%). All patients who developed a leakage had a left-sided procedure (P < 0.001). When blood loss was more than 250 mL (P = 0.003) or an intraoperative adverse event occurred (P = 0.050), the risk for developing an anastomotic leakage was significantly increased. A preoperative high diastolic blood pressure of ≥90 mmHg (P = 0.008) and severe intraoperative hypotension [>40% decrease in diastolic blood pressure (P = 0.049)] were identified as univariate risk factors for anastomotic leakage. CONCLUSIONS: The development of an anastomotic leakage after colorectal surgery is related to surgical, patient and anaesthetic risk factors. A high preoperative diastolic blood pressure and profound intraoperative hypotension combined with complex surgery, marked by a blood loss of ≥250 mL and the occurrence of intraoperative adverse events, is associated with an increased risk of developing anastomotic leakage.

Computerized model for preoperative risk assessment.

BACKGROUND: In order to improve the consistency of anaesthetic risk scoring, we have developed an automated method for the calculation of ASA (cASA) scores using decision logic programming. We investigated whether ASA scoring by anaesthetic caregivers could be matched or closely approximated by a cASA. METHODS: We used a web-based preoperative assessment system to present a structured questionnaire comprising 22 questions. These were designed to score and identify conditions that are known, from the literature and expert opinion, to be risk factors. The answers from 14,349 cases were processed using decision logic to provide a variety of risk scores including a computed overall anaesthetic risk (cASA), which was then compared with the ASA score estimated by anaesthesia caregivers (eASA). RESULTS: We found a close agreement between the two measures in almost all cases. In 159 cases (1.1%), there was an underestimation of cASA, in comparison with the eASA, which appeared to be a result predominantly of incorrect or incomplete answers, or an overestimation of the ASA score by the human classifier (43%). CONCLUSION: We showed that ASA scores estimated by a heterogeneous group of anaesthesia caregivers (anaesthetists, anaesthesia trainees, and physician assistants) could be mimicked by the cASA computed by our preoperative assessment system.

Distinction between hereditary and sporadic breast cancer on the basis of clinicopathological data.

BACKGROUND: About 5% of all breast cancer cases are attributable to germline mutations in BRCA1 or BRCA2 genes. BRCA mutations in suspected carriers, however, may be missed, which hampers genetic counselling. MATERIALS AND METHODS: Different clinicopathological features were compared between 22 breast cancers from carriers of proved BRCA1 mutations and 604 cancers from sporadic controls. In addition, 5 BRCA2-related breast cancers and 66 breast cancers of untested patients at intermediate risk and 19 breast cancers of untested patients at high risk of hereditary disease on the basis of family history were evaluated. RESULTS: A "probably sporadic" class (age >or=54 years and epidermal growth factor receptor (EGFR) negative; 68% of cases) with a 0% chance of BRCA1-related breast cancer containing 79% of the sporadic cases was yielded by using a decision tree with age, Ki67 and EGFR. A 75% chance of BRCA1-related breast cancer was shown by the "probably BRCA1-related" class (age <54 years and Ki67 >or=25%; 8% of cases) with 82% of the BRCA1-related cases but only 1.4% of the sporadic cases. Most cases at intermediate or high risk of hereditary disease on the basis of family history could be classified with high probability as either probably BRCA1 related or probably sporadic. CONCLUSION: Breast carcinomas can be classified with a high level of certainty as sporadic or related to BRCA1 germline mutations by using a decision tree with age, Ki67 and EGFR. This can be clinically useful in mutation analysis in families with a borderline risk of hereditary disease.