Prognostic value of neutrophil-to-lymphocyte ratio at diagnosis in colorectal cancer: propensity score analysis.

INTRODUCTION: baseline neutrophil-to-lymphocyte ratio (NLR) at the time of colorectal cancer (CRC) diagnosis has been proposed as a predictor of long-term survival. The aim of this study was to analyze its usefulness in a homogeneous population with control of the main confounding factors. METHODOLOGY: observational study of 836 patients who underwent surgery for CRC. Patients were divided into two groups: NLR ≤ 3.3 vs NLR > 3.3. To control for confounders, they were matched one-to-one by propensity analysis. A final cohort of 526 patients was included in the study. RESULTS: the two groups were mismatched in terms of age, comorbidity, tumor stage, rectal location, and neoadjuvant therapy. Once matching was performed, baseline NLR was statistically significantly associated with long-term survival (p < 0.001) and behaved as an independent prognostic factor for survival (p = 0.001; HR: 1.99; 95 % CI: 1.32-3.00) when adjusted in a Cox regression model using age (p < 0.001; HR: 1.04; 95 % CI: 1.02-1.06) and the Charlson Comorbidity Index (p < 0.001; HR: 1.40; 95 % CI: 1.27-1.55). Neoadjuvant therapy lost its statistical significance (p = 0.137; HR: 1.59; 95 % CI: 0.86-2.93). CONCLUSIONS: a high baseline NLR (> 3.3) in patients with colorectal cancer at diagnosis represents a poor prognostic factor in terms of survival. Its use in routine practice could intensify therapeutic strategies and follow-up in these patients.

Hypercoagulability status, operative mortality, and long-term survival in patients operated on for mesenteric venous thrombosis.

OBJECTIVE: Mesenteric venous thrombosis (MVT) is a rare cause of acute surgical abdomen, with high mortality. The aim of this study was to analyze long-term outcomes and possible factors influencing its prognosis. METHODS: All patients who underwent urgent surgery for MVT from 1990 to 2020 in our center were reviewed. Epidemiological, clinical, and surgical data; postoperative outcomes; origin of thrombosis; and long-term survival were analyzed. Patients were divided into two groups: primary MVT (hypercoagulability disorders or idiopathic MVT) and secondary MVT (underlying disease). RESULTS: Fifty-five patients, 36 (65.5%) men and 19 (34.5%) women, mean age 66.7 years (standard deviation: ±18.0 years), underwent surgery for MVT. Arterial hypertension (63.6%) was the most prevalent comorbidity. Regarding the possible origin of MVT, 41 (74.5%) patients had primary MVT and 14 (25.5%) patients had secondary MVT. From these, 11 (20%) patients had hypercoagulable states, 7 (12.7%) had neoplasia, 4 (7.3%) had abdominal infection, 3 (5.5%) had liver cirrhosis, 1 (1.8%) patient had recurrent pulmonary thromboembolism, and 1 (1.8%) had deep venous thrombosis. Computed tomography was diagnostic of MVT in 87.9% of the cases. Intestinal resection was performed in 45 patients due to ischemia. Only 6 patients (10.9%) had no complication, 17 patients (30.9%) presented minor complications, and 32 patients (58.2%) presented severe complications according to the Clavien-Dindo classification. Operative mortality was 23.6%. In univariate analysis, comorbidity measured by the Charlson index (P = .019) and massive ischemia (P = .002) were related to operative mortality. The probability of being alive at 1, 3, and 5 years was 66.4%, 57.9%, and 51.0%, respectively. In univariate analysis of survival, age (P < .001), comorbidity (P < .001), and type of MVT (P = .003) were associated with a good prognosis. Age (P = .002; hazard ratio: 1.05, 95% confidence interval: 1.02-1.09) and comorbidity (P = .019; hazard ratio: 1.28, 95% confidence interval: 1.04-1.57) behaved as independent prognostic factors for survival. CONCLUSIONS: Surgical MVT continues to show high lethality. Age and comorbidity according to the Charlson index correlate well with mortality risk. Primary MVT tends to have a better prognosis than secondary MVT.

Utility of a new prognostic score based on the Comprehensive Complication Index (CCI®) in patients operated on for colorectal cancer (S-CRC-PC score).

BACKGROUND: Postoperative complications after colorectal cancer surgery have been associated with poor long-term prognosis. The aim of the present study was to investigate the prognostic impact of postoperative complications after colorectal cancer surgery assessed by the Comprehensive Complication Index (CCI®) and designing a new prognostic score based on this index. METHODS: This observational longitudinal study included a series of 604 patients who underwent colorectal surgery for cancer. Demographic data, comorbidity measured by Charlson Index, tumor characteristics, surgical data and postoperative complications were recorded as predictors. Univariate and multivariate analysis were performed and long-term survival was the output variable. Based on Hazard Ratios obtained on multivariate analysis, a new score, S-CRC-PC, was created for predicting long-term survival. RESULTS: Two-hundred and twelve (35.1%) patients developed some postoperative complication. The mean CCI was 11.6 (±19.19). Mild complications (CCI <26.2) were detected in 95 (15.7%) patients. Moderate complications (CCI 26.2-42.2) were detected in 64 (10.6%) patients. Severe complications (CCI >42.3) were detected in 53 patients (8.8%) patients. Mortality rate was 1.7%. In multivariate analysis, age (p < 0.001), Charlson score (p = 0.014), CCI (p < 0.001), and TNM stage (p < 0.001) were statistically significantly in relation to long-term survival rate. S-CRC-PC score was statistically associated with survival rate (HR: 1.34-95% CI: 1.27-1.41). Patients with S-CRC-PC values from 0 to 8 points (low risk), 8.1-16 points (medium risk), and scores above 16 points (high risk) had a cumulative survival rate at five-years of 98%, 83%, and 31% respectively. CONCLUSIONS: Postoperative complications after colorectal cancer surgery assessed by CCI are an independent prognostic factor of survival rate. The S-CRC-PC score may be helpful in predicting long-term cancer outcomes.

Comparative study of postoperative complications after open and laparoscopic surgery of the perforated peptic ulcer: Advantages of the laparoscopic approach.

BACKGROUND: Despite the acceptance of the laparoscopic approach for the treatment of perforated peptic ulcers, its definitive implantation is still a matter of discussion. We performed a comparative study between the open and laparoscopic approach focused on postoperative surgical complications. METHODS: Retrospective observational study in which patients operated on for perforated peptic ulcus in our center between 2001 and 2017 were analyzed. Only those in whom suture and/or omentoplasty had been performed were selected, either for open or laparoscopic approach. Demographic, clinical, and intraoperative variables, complications, mortality and length of stay were collected. Both groups, open and laparoscopic surgery patients, were compared. RESULTS: The final study sample was 250 patients, 190 (76%) men and 60 (24%) women, mean age 54 years (SD ± 16.7). In 129 cases (52%), the surgical approach was open, and in 121 (48%) it was laparoscopic. Grades III-V complications of the Clavien-Dindo Classification occurred in 23 cases (9%). Operative mortality was 1.2% (3 patients). Laparoscopically operated patients had significantly fewer complications (p = 0.001) and shorter hospital stay (p < 0.001). In multivariate analysis, laparoscopic approach (p = 0.025; OR:0.45-95%CI: 0.22-0.91), age (p = 0.003; OR:1.03-95%CI: 1.01-1.06), and Boey score (p = 0.024 - OR:1.71 - CI95%: 1.07-2.72), were independent prognostic factors for postoperative surgical complications. CONCLUSION: Laparoscopic surgery should be considered the first-choice approach for patients with perforated peptic ulcer. It is significantly associated with fewer postoperative complications and a shorter hospital stay than the open approach.

Mixed adenoneuroendocrine carcinoma of the colon - a complex and unique clinical duality.

In relation to the article "A case of mixed adenoneuroendocrine tumor of the colon", we would like to contribute a new case of this exceptional and biphasic clinical entity - the MANEC (mixed adenoneuroendocrine carcinoma). These tumors represent a mix of pathological components, are highly aggressive, and affect the gastrointestinal and pancreatobiliary tract. They are characterized by the dual presence of glandular and neuroendocrine epithelial elements, where each component represents at least 30 % of the tumor.

Impact of frailty on 5-year survival in patients older than 70 years undergoing colorectal surgery for cancer.

BACKGROUND: Frailty has been shown to be a good predictor of post-operative complications and death in patients undergoing gastrointestinal surgery. The aim of this study was to analyze the differences between frail and non-frail patients undergoing colorectal cancer surgery, as well as the impact of frailty on long-term survival in these patients. METHODS: A cohort of 149 patients aged 70 years and older who underwent elective surgery for colorectal cancer was followed-up for at least 5 years. The sample was divided into two groups: frail and non-frail patients. The Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) was used to detect frailty. The two groups were compared with regard to demographic data, comorbidities, functional and cognitive statuses, surgical risk, surgical variables, tumor extent, and post-operative outcomes, which were mortality at 30 days, 90 days, and 1 year after the procedure. Univariate and multivariate analyses were also performed to determine which of the predictive variables were related to 5-year survival. RESULTS: Out of the 149 patients, 96 (64.4%) were men and 53 (35.6%) were women, with a median age of 75 years (IQR 72-80). According to the CSHA-CFS scale, 59 (39.6%) patients were frail, and 90 (60.4%) patients were not frail. Frail patients were significantly older and had more impaired cognitive status, worse functional status, more comorbidities, more operative mortality, and more serious complications than non-frail patients. Comorbidities, as measured by the Charlson Comorbidity Index (p = 0.001); the Lawton-Brody Index (p = 0.011); failure to perform an anastomosis (p = 0.024); nodal involvement (p = 0.005); distant metastases (p < 0.001); high TNM stage (p = 0.004); and anastomosis dehiscence (p = 0.013) were significant univariate predictors of a poor prognosis on univariate analysis. Multivariate analysis of long-term survival, with adjustment for age, frailty, comorbidities and TNM stage, showed that comorbidities (p = 0.002; HR 1.30; 95% CI 1.10-1.54) and TNM stage (p = 0.014; HR 2.06; 95% CI 1.16-3.67) were the only independent risk factors for survival at 5 years. CONCLUSIONS: Frailty is associated with poor short-term post-operative outcomes, but it does not seem to affect long-term survival in older patients with colorectal cancer. Instead, comorbidities and tumor stage are good predictors of long-term survival.

Colorectal cancer surgery in selected nonagenarians is relatively safe and it is associated with a good long-term survival: an observational study.

BACKGROUND: Advanced age is a risk factor for colorectal cancer, and very elderly patients often need to be surgically treated. This study aimed to analyze the outcomes of a cohort of nonagenarian patients operated on for colorectal cancer. METHODS: Observational study conducted on a cohort of 40 nonagenarian patients, who were treated surgically for colorectal cancer between 2000 and 2018 in our institution. Clinical data, ASA score, Charlson Comorbidity Index, Surgical Mortality Probability Model, tumor characteristics, and nature and technical features of the surgical procedure, were recorded. The Comprehensive Complication Index (CCI) and survival time after the procedure were recorded as outcome variables. Univariate and multivariate analyses were performed in order to define risk factors for postoperative complications and long-term survival. RESULTS: Out of the 40 patients, 13 (32.5%) were men, 27 (67.5%) women, and mean age 91.6 years (SD ± 1.5). In 24 patients (60%), surgery was elective, and in 16 patients (40%), surgery was emergent. Curative surgery with intestinal resection was performed in 34 patients (85%). In 22 patients (55%), intestinal continuity was restored by performing an anastomosis. The median CCI was 22.6 (IRQ 0.0-42.6). Operative mortality was 10% (4 patients). Cumulative survival at 1, 3, and 5 years was 70%, 47%, and 29%, respectively. In multivariate analysis, only the need for transfusion remained as an independent prognostic factor for complications (p = 0.021) and TNM tumor stage as a significant predictor of survival (HR 3.0, CI95% 1.3-7.2). CONCLUSIONS: Colorectal cancer surgery is relatively safe in selected nonagenarian patients and may achieve long-term survival.

Usefulness of pre- and intraoperative risk scores in nonagenarian surgical patients.

PURPOSE: Preoperative assessment at extreme ages would identify patients at a high risk of developing postoperative complications. The objective of this study was to compare the usefulness of different risk scales in a series of nonagenarian surgical patients. METHODS: A total of 244 surgical nonagenarians, 148 women (60.7%), median age 91 years (IQR: 90-93), were analysed. The following scales were evaluated: preoperative status (ASA-PS, Charlson Comorbidity Index, Lee Index, Reiss Index, and surgical mortality probability model-S-MPM); intraoperative status (Surgical Apgar Score and SASA score), and, as output variables, surgical outcomes (morbidity measured by the Comprehensive Complication Index-CCI, and death). Univariate analysis and receiver operating characteristic curves (ROC) were performed. Area under ROC curves (AUROC) were evaluated to define the best predictors of poor outcomes. RESULTS: Operative mortality was 27.0%, and 73.4% presented some type of postoperative complication. Operative mortality was associated with the ASA-PS score (p < 0.001), Reiss Index (p < 0.001), Lee Index (p = 0.010), S-MPM (p < 0.001), Surgical Apgar Score (p < 0.001), SASA score (p < 0.001), and emergency surgery (p < 0.001). Postoperative complications were related to the ASA-PS score (p = 0.001), Reiss Index (p < 0.001), Lee Index (p < 0.001), S-MPM (p < 0.001), Surgical Apgar Score (p < 0.001) and SASA score (p < 0.001). The best predictors of operative mortality and complications were the SASA and Surgical Apgar Score (AUROCs > 0.88). CONCLUSION: As in the general population, the Surgical Apgar Score and SASA score are the best predictors of operative mortality and morbidity in nonagenarian patients. These risk scales should be considered in the perioperative management of these patients.

Metastatic choriocarcinoma in the proximal jejunum, an exceptional cause of massive upper gastrointestinal bleeding.

We present the clinical case of a 34-year-old woman with a history of stage IV choriocarcinoma, after her diagnostic debut two years ago, a hysterectomy and resection of the right single pulmonary nodule with anatomopathological confirmation of both as uterine choriocarcinoma and pulmonary nodule compatible with metastatic choriocarcinoma, subsequently the patient received chemotherapy treatment with stability of her disease until now.

Surgical Outcomes in Acute Mesenteric Ischemia: Has Anything Changed Over the Years?

BACKGROUND: Despite increases in knowledge and advances in the management of acute mesenteric ischemia syndrome (AMI), there have been no significant improvements in mortality in recent years. The objective of this study was to assess the changes in clinical characteristics and surgical outcomes in patients who underwent AMI over time. METHODS: A total of 323 consecutive patients who underwent acute mesenteric ischemia at our institution between 1990 and 2015 were examined. The occurrence of significant changes over this 25-year period in demographic data, comorbidity, clinical characteristics, laboratory results, operative findings, etiology of the AMI, and operative mortality were evaluated. The evolution mortality rates for the studied period were analyzed using the additive logistic regression, and the significant effect was determined using the Akaike Information Criterion (AIC). RESULTS: A significant increasing linear trend was observed in recent years in Charlson score values (p = 0.008), antiplatelet drug intake (p < 0.001), use of CT scan (p < 0.001), arterial thrombosis (p < 0.001), and intestinal resection (p = 0.047), while a decreasing linear trend was observed in digoxin intake (p < 0.001), angiography use (p = 0.004), and embolia (p < 0.001). The rest of the parameters did not present changes over time. Regarding the evolution of the adjusted surgical mortality, a significant decrease according the AIC criterion was observed. CONCLUSIONS: In recent years, the characteristics of patients with AMI requiring surgery have changed. Changes in operative mortality have also been detected, showing a tendency toward a progressive and significant decrease.

The Comprehensive Complication Index is Related to Frailty in Elderly Surgical Patients.

BACKGROUND: Frailty has been proposed as an independent risk factor for predicting postsurgical outcomes in elderly surgical patients. The Comprehensive Complication Index (CCI) seems to be the most widely used grading of individual complications in many surgical fields. The objective of this study was to evaluate the association of frailty, measured by Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS), with the CCI in the elderly surgical patient. MATERIAL AND METHODS: A prospective cross-sectional study was carried out in 256 patients aged ≥70 y who underwent major gastrointestinal surgery. Sociodemographic characteristics, baseline disease, CSHA-CFS, and medical/surgical complication using the Comprehensive Comorbidity Index were evaluated. We hypothesized that frailty measured by CSHA-CFS and the CCI are associated. RESULTS: Of 256 patients, 154 (60%) were men and 102 (40%) were women, with mean age of 76.1 y (SD ± 5.1). One-hundred and eighty-five patients (74%) underwent surgery for a malignant cause, and 97 patients (38%) had some degree of frailty. Mean CCI was 16.1 (SD ± 23.0). Postoperative mortality was 3%. Pondering the scale CCI 0-100, frailty correlated well with postoperative complications (P = 0.035). For patients who developed at least 1 complication, for each unit that the CSHA-CFS was raised, the CCI increased by 5.2 points (P = 0.002). The multivariate analysis showed that the CSHA-CFS was the only independent prognostic factor associated with postoperative CCI in this series. CONCLUSIONS: Frailty determined by CSHA-CFS is closely associated with the CCI, being a good predictor of postoperative complications in the elderly patient operated on by a major gastrointestinal procedure.

Emergency surgery and American Society of Anesthesiologists physical status score are the most influential risk factors of death in nonagenarian surgical patients.

AIM: The number of nonagenarians undergoing surgery has increased considerably in recent decades as a result of population aging. Greater knowledge of the most influential factors affecting perioperative morbidity and mortality would improve the quality of care and provision of health resources for these patients. The objective of the present study was to analyze the perioperative mortality, and its most determinant factors, among nonagenarian patients who underwent a surgical procedure in the Department of General and Digestive Surgery. METHODS: A retrospective descriptive study was carried out in a cohort of 159 consecutive non-selected surgical nonagenarian patients. Clinical data, type of operation, perioperative hemodynamic instability, the need for blood transfusion and medical/surgical complications were evaluated as predictor variables. The outcome variable was operative mortality. RESULTS: The mean age was 91.8 years (SD ± 2.0); there were 60 men (37.7%) and 99 (62.3%) women. Perioperative mortality was 28.93% (46 patients). The variables age (P = 0.025), American Society of Anesthesiologists physical status score (P < 0.001), neoplastic pathology (P = 0.025), intestinal surgery (P = 0.001), emergent surgery (P ≤ 0.001), perioperative blood transfusion (P = 0.003), postoperative medical complications (P < 0.001) and surgical complications (P = 0.022) showed a statistically significant correlation with mortality. American Society of Anesthesiologists physical status score (P = 0.007), emergent surgery (P < 0.032) and perioperative blood transfusion (P = 0.047) were identified as independent predictors of mortality. CONCLUSIONS: Surgery should not be denied to nonagenarian patients based only on their age. Emergency surgery and American Society of Anesthesiologists physical status classification are the most significant factors when deciding whether to intervene. Geriatr Gerontol Int 2019; 19: 293-298.

Major ambulatory surgery for the treatment of breast cancer: Factors conditioning conversion to conventional hospitalization. / Cirugía mayor ambulatoria del cáncer de mama: factores relacionados con la conversión a hospitalización convencional.

INTRODUCTION: The main step in curative treatment for breast cancer is surgery. Its use in an ambulatory setting can contribute towards more efficient healthcare, providing additional benefits for patients. In this study, we analyze the results obtained with this treatment method and identify factors related with conversion to hospitalization. METHODS: Results were analyzed from the 206 surgeries performed for breast cancer in 2016, using three different methods: day surgery, overnight ambulatory (23h) and conventional hospitalization. The ambulatory success and conversion rates were calculated for the global sample and stratified, distinguishing between conservative surgery, mastectomy and axillary surgery. A univariate analysis was performed to identify the factors involved in conversion. RESULTS: For the global sample, the ambulatory surgery rate was 61.2%, 16.5% conversions and a success rate of 83.4%. For conservative surgery, ambulatory, success and conversion rates were 78.8%, 88.6 and 11.4%, respectively. For mastectomies, the ambulatory rate was 28.6%, with 62.9% success and 37.1% conversions. The 11 axillary surgeries were performed as day surgeries. Factors associated with conversion were mastectomy vs. vs. conservative surgery and the appearance of postoperative complications. CONCLUSIONS: Ambulatory surgery for the surgical treatment of breast cancer should be standard care. Optimized results require adequate patient selection and the performance of surgical technique that needs to be as careful and as conservative as possible.

Intraoperative radiotherapy with the Intrabeam® device for the treatment of resectable pancreatic adenocarcinoma. / Radioterapia intraoperatoria con Intrabeam® para el tratamiento del adenocarcinoma de páncreas resecable.

INTRODUCTION: The application of intraoperative radiation therapy to the tumor bed after resection of pancreatic cancer has been shown to be beneficial in the local control of the disease. The objective of this study was to evaluate the preliminary outcomes after the application of a single intraoperative dose to the tumor bed with a new intraoperative radiotherapy device (Intrabeam®) in terms of viability, safety and short-term results. METHODS: We studied 5 patients who underwent pancreaticoduodenectomy for resectable pancreatic cancer in which a radiotherapy boost (5Gy) was intraoperatively applied to the tumoral bed using the portable Intrabeam® device, a low-energy point-source X-ray. Postoperative complications, hospital stay and mortality, recurrences and short-term survival were analyzed. RESULTS: Mean patient age was 68 years. All patients had a T3-stage tumor and one of them N1. In 3 patients, R0 resection was performed, while R1 resection was conducted in 2. Perioperative mortality was 0%. The only complications included delayed gastric emptying and postoperative hemorrhage. There were no pancreatic fistulas. During follow-up (mean: 11.2 months), there was a relapse in the patient who had undergone R1 resection. CONCLUSIONS: The application of radiotherapy with the Intrabeam® device in selected patients has not resulted in increased perioperative morbidity or mortality; therefore, this is a safe procedure for the treatment of resectable cancer.

Obesity Surgery Score (OSS) for Prioritization in the Bariatric Surgery Waiting List: a Need of Public Health Systems and a Literature Review.

BACKGROUND: In the last decades, we have experienced an increase in the prevalence of obesity in western countries with a higher demand for bariatric surgery and consequently prolonged waiting times. Currently, in many public hospitals, the only criterion that establishes priority for bariatric surgery is waiting time regardless of obesity severity. METHODS: We propose a new, simple, and homogeneous clinical prioritization system, the Obesity Surgery Score (OSS), which takes into account simultaneously and equitably the time on surgical waiting list and the obesity severity based on three variables: body mass index, obesity-related comorbidities, and functional limitations. We have reviewed the current literature related to obesity clinical staging systems, and we have carried out an analysis of our patients in waiting list and divided their characteristics according to their degree of severity (A, B, or C) in the OSS. Patients with OSS grade C have a higher mean BMI, greater severity in comorbidities, and greater socio-labor impact. The current surgery waiting time of our series is of 26 months. Currently, 27 patients (51.9%) with OSS grade B and 15 patients (51.7%) with OSS grade C have been on our waiting list for more than 1 year. CONCLUSION: Since the obesity severity, the waiting time and its clinical consequences are associated with an increase in morbidity and mortality, it is important to apply a structured prioritization system for bariatric surgery waiting list. This allows prioritization of patients at greater risk, improves patient prognosis, and optimizes costs and available health resources.

Intrathoracic leak after an Ivor Lewis procedure for an esophageal neoplasm treated with a stent.

A 75-year-old male who underwent an Ivor Lewis esophagectomy due to a distal adenocarcinoma had a leak at the gastroplasty on the 5th day after surgery, which required two surgeries and a primary suture. He was transferred to our hospital due to a poor outcome and endoscopy revealed a 2.5cm gap perianastomotically on the gastroplasty wall, for which a stent was placed. Due to hemodynamic impairment, a thoracotomy procedure was performed, which revealed stent protrusion into the cavity. The patient underwent an esophagogastric anastomosis resection, cervical esophagostomy and gastrostomy. Sepsis was resolved postoperatively and the patient had a protracted stay in the PACU due to poor respiratory dynamics following a prolonged intubation.