Preoperative frailty assessment in older patients with colorectal cancer: use of clinical and radiological tool.

PURPOSE: The Memorial Sloan Kattering Frailty Index (MSK-FI) and the Skeletal Muscle Index (SMI) have recently gained attention as markers of frailty and decreased physiologic reserve, and are promising as predictors of adverse postoperative outcomes in patients undergoing oncologic surgery. The objective of this study was to establish the prognostic accuracy of these indexes in a cohort of patients with colorectal cancer subjected to surgical intervention. METHODS: We performed an observational study including all patients older than 60 years, subjected to colorectal cancer surgery between January 2010 and May 2020, and stratified our cohort based on the presence of frailty, as defined by MSK-FI ≥ 3. Computed tomography was used to calculate SMI, using a standardized institutional protocol. A multivariable analysis was used to study the association between these novel indexes with adverse postoperative outcomes in our cohort. RESULTS: A total of 216 patients were included. Among these, 56 (26%) qualified as frail and 132 (62%) had a low SMI. On multivariable analysis (adjusted by patient and intraoperative characteristics), frailty was associated with increased risk of having a major postoperative complication (OR 29.78, 95%CI 10.36-85.71) and increased admission to the intensive care unit (OR 4.99, 95%CI 1.55-16.06), while both frailty and low SMI were associated with prolonged length of stay (OR 11.22, 95%CI 8.91-13.53 and OR 0.14, 95% CI 0.06-0.20, respectively). CONCLUSION: MSK-FI ≥ 3 and low SMI are associated with adverse postoperative outcomes in elderly patients undergoing colorectal cancer surgery. Implementing this practical tool in routine clinical practice, may help identify patients that would benefit from surgical prehabilitation and preoperative optimization to improve outcomes.

Deloyers procedure compared to ileorectal anastomosis as restoration techniques of bowel continuity after extended left colon resection.

BACKGROUND: Restoration of bowel continuity after left extended colectomy may be challenging because the remaining colon may not reach the rectal stump without tension to perform a safe anastomosis. Performing a total colectomy with ileorectal anastomosis (IRA) is an option, but the quality of life can be significantly impaired due to loose stools and an increase in bowel frequency. In contrast, the preservation of the right colon and ileocaecal valve in the Deloyers procedure (DP) might ensure a better stool consistency and bowel transit, and therefore a superior quality of life. MATERIALS AND METHODS: A transverse study comparing patients that underwent DP versus patients with an IRA was performed. Postoperative morbidity, mortality, functional outcomes, and quality of life were analysed between groups. Quality of life after the surgical procedure was assessed with the SF-36 V2® health survey. RESULTS: A total of 16 patients with DP and 32 with IRA were included. The groups had similar demographic characteristics concerning age, sex, body mass index, ASA classification, diagnosis and Charlson comorbidity index. The median follow-up was 55 months for DP and 99 months for IRA. Postoperative complications were similar in both groups. Patients in the DP group had fewer bowel movements (P = 0.01), tenesmus (P = 0.04) and use of loperamide (P = 0.03). DP patients achieved better scores in physical pain (P = 0.02) and general health (P < 0.01) than IRA patients. CONCLUSIONS: DP for intestinal continuity restoration after extended left colon resection is a safe and feasible alternative, possibly achieving better functional outcomes and quality-of-life compared to IRA.

The Frailty Based on the Memorial Sloan Kettering Frailty Index for Prediction of Surgical Outcome in Advance Epithelial Ovarian Cancer-Experience of a Single Center in Mexico.

Retrospective impact evaluation of frailty as measured by the Memorial Sloan Kettering Frailty Index (MSK-FI) on outcomes in older women surgically treated for advanced epithelial ovarian cancer (EOC). Women ≥ 60 years with stage IIIC/IV EOC who underwent primary debulking surgery (PDS) or interval debulking surgery (IDS) were included. Medical records were reviewed for patients' characteristics and outcomes. We retrospectively applied the MSK-FI which included 10 comorbidities and functional assessment that were extracted from medical records. The MSK-FI ranges from 0 to 11; a score of ≥ 3 was considered frail. Associations were assessed using logistic regression and Cox proportional hazards regression. We identified 79 patients treated with PDS (n = 36, 45.5%) or IDS (n = 43, 54.4%) with complete data. The prevalence of frailty based on MSK-FI was 25%. Almost half of the frail patients (47.3%) were admitted to the ICU compared to 16% of non-frail patients (p = 0.006). In univariable analysis, the MSK-FI was associated with postoperative complications [OR 1.57 (95% CI 1.04-2.37), p = 0.03] and ICU admission [OR 2.05 (95% CI 1.30-3.23), p = 0.002], but not with readmission rate [OR 1.29 (95% CI 0.65-2.59), p = 0.5], postoperative mortality [OR 1.02 (95% CI 0.51-2.00), p = 0.9], and hospital stay [ß 0.60 (95% CI - 1.19-2.41)]. In multivariable analysis, the frailty index was independently associated with postoperative complications [OR 1.54 (95% CI 1.02-2.34), p = 0.04] and ICU admissions [OR 1.97 (95% CI 1.23-3.16), p = 0.004]. Frailty, based on the Memorial Sloan Kettering Frailty Index, is associated with adverse postoperative outcomes in older women with advanced ovarian cancer, suggesting that MSK-FI can improve the predictive ability of current surgical assessment tools.

The Educational Quality of Laparoscopic Right Hemicolectomy Videos on YouTube.

Introduction. Surgical technique videos are an important part of surgical fellows' education. YouTube has been identified as the preferred source of educational videos among trainees. The aim of this article is to objectively evaluate the quality of the 50 most viewed videos on YouTube concerning right laparoscopic hemicolectomy using LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS). We hypothesized that the number of likes or views will not necessarily reciprocate with the educational content. Materials and methods. This observational study started with a YouTube search under the words "laparoscopic right hemicolectomy", "right colectomy", and "right hemicolectomy". The 50 most viewed videos with an English title were chosen. Video characteristics and LAP-VEGaS score were analyzed by four colorectal surgery fellows from a tertiary center in Mexico City. Results. Right hemicolectomy videos were reviewed; there was no correlation between the LAP-VEGaS score and the view ratio, the like ratio, or the video power index. The LAP-VEGaS score was significantly higher among videos uploaded by medical associations, journals, or commercial when compared with videos uploaded by doctors/physicians or academic associations. Conclusion. Educational quality in right laparoscopic hemicolectomy videos did not reciprocate with their educational quality, but it agrees significantly with the video uploading source. Low educational quality was identified among the videos underscoring the need to endorse peer-reviewed video channels.

Colonic lipomas an uncommon cause of intussusception in adult patients: report of three cases and literature review.

Colonic lipomas are infrequent, benign, non-epithelial, fatty neoplasms. Most of the colonic lipomas are asymptomatic, but around 25% of patients may develop symptoms. Nowadays, surgical resection of the involved segment is the treatment of choice. We report three cases of colonic intussusceptions caused by colonic lipomas in adult patients. The patients underwent surgical resection, and the diagnosis was confirmed by histopathological examination of the specimens.

Los lipomas colónicos son neoplasias benignas, adiposas, no epiteliales poco frecuentes. La mayoría de los lipomas de colon son asintomáticos, pero alrededor del 25% de los pacientes pueden desarrollar síntomas. En la actualidad, la resección quirúrgica del segmento afectado es el tratamiento de elección. Presentamos tres casos de intususcepción intestinal secundaria a lipomas colónicos en pacientes adultos. Los pacientes fueron sometidos a resección quirúrgica y el diagnóstico se confirmó mediante examen histopatológico.

Influence of Muscle Mass Area and Visceral Obesity on 30-day Mortality After Colorectal Surgery with Primary Anastomosis.

BACKGROUND: Muscle mass and visceral fat may be assessed at the level of the third lumbar vertebra (L3) in computed tomography (CT). Both variables have been related with adverse surgical outcomes. OBJECTIVE: The objective of the study was to study the association of skeletal muscle index (SMI) and visceral fat area (VFA) with 30-day mortality in colorectal surgery. METHODS: This is a retrospective cohort study conducted at a tertiary referral hospital in Mexico City. Patients who underwent colorectal surgery with primary anastomosis from January 2007 to December 2018 were included in the study. Their preoperative CT scans were analyzed with the NIH ImageJ software at the level of the third lumbar vertebra to determine their SMI (L3-SMI) and the VFA. Logistic regression analysis (adjusted by surgery anatomical location) was used to determine the association between these variables and surgical 30-day mortality. RESULTS: A total of 548 patients were included; 30-day mortality was 4.18% (23 patients). On univariable analysis, L3-SMI, low SMI, anastomosis leak, pre-operative albumin, estimated blood loss, age, steroid use, Charlson comorbidity index score >2, and type of surgery were associated with 30-day mortality. On multivariable analysis, low SMI remained an independent risk factor with an odds ratio of 4.74, 95% confidence interval 1.22-18.36 (p = 0.02). CONCLUSION: Low SMI was found to be an independent risk factor for 30-day mortality in patients submitted to colorectal surgery with a primary anastomosis, whether for benign or malignant diagnosis. VFA was not associated with 30-day mortality.

Frailty index as a predictive preoperative tool in the elder population undergoing major abdominal surgery: a prospective analysis of clinical utility.

PURPOSE: The geriatric population has increased considerably in the last decades. Such increases come along with new challenges for surgical practitioners, who now face a risen number of frail patients in need of major operations. The value of frailty indexes in this setting has been discussed recently. This study assessed the modified Rockwood frailty index (mRFI) as a predictive tool for postoperative complications in older adults subjected to major abdominal operations and correlated it with other scores widely utilized for this purpose. METHODS: We performed a prospective study utilizing the mRFI including all patients older than 65 years subjected to major abdominal surgery between May 2017 and May 2019 in a third-level academic center. A comparison between frail (mRFI >0.25) and non-frail patients (mRFI <0.25) was performed. We performed logistic regression to identify predictors of postoperative complications and 30-day mortality. We analyzed the correlation between mRFI and ACS-NSQIP, P-POSSUM, PMP, and Charlson score risk calculators. RESULTS: One hundred forty patients were included in our study, of whom 49 (35%) were identified as frail. Frail patients demonstrated significantly prolonged hospital stay (p<.0001), ICU admission rates (p=0.004), hospital readmissions (p=0.007), and higher mortality rates (p=0.02). Our univariate analysis associated frailty (mRFI>0.25), ASA >III, increased age, and BMI with postoperative complications. In our multivariate analysis, frailty remained an independent predictor for postoperative complications (OR 6.38, 95% CI [2.45-16.58], p<0.001). Frailty was also associated with length of stay (LOS) regardless of the type of surgery (OR 3.35, 95% CI [0.37-6.33], p= 0.03). mRFI>0.25 demonstrated a sensitivity (Se) of 70% and specificity (Sp) 67% with area under the curve (AUC) 0.75 for perioperative complications, Se 69% and Sp 70% with AUC 0.74 for ICU admissions, and Se 83% and Sp 68% with AUC 0.83 for mortality. CONCLUSION: Frail patients demonstrated significantly prolonged hospital stay, ICU admission rates, hospital readmissions, and higher mortality rates. mRFI is an independent predictor for perioperative complications with a Se of 70% and Sp 67% and AUC 0.75.

Sociodemographic factors related with emergency colorectal cancer surgery at a referral center in Mexico.

BACKGROUND: Diagnosis of colorectal cancer (CRC) after emergency presentation is associated with a worse prognosis. AIM: The aim of the study was to determine the sociodemographic factors related with emergency CRC surgery at our institution. METHODS: From January 2009 to December 2017, patients that underwent CRC surgery at our institution were included in the study. Univariate and multivariate logistic regression were used to determine the effect of the potential risk factors on the rate of emergency surgery. RESULTS: A total of 247 patients underwent CRC surgery at our institution. The rate of emergency surgery was 7.7%. On univariate analysis, patients without a family history of cancer (odds ratio [OR]: 4.95), living in a rural area (OR: 3.7), and late clinical cancer stage (OR: 5.06) were associated with emergent surgery. Mid-income status was a protective factor for emergency surgery (OR: 0.14, p = 0.003). On multivariate analysis, late clinical cancer stage (OR: 4.41, 95% CI 1.21-16.05, p = 0.024) and mid-income economic status (OR: 0.41, 95% CI 0.04-0.55, p = 0.004) were identified as independent risk factors for emergency surgery. CONCLUSION: Social, economic, and demographic factors were identified as predictors for emergent CRC surgery.

ANTECEDENTES: El diagnóstico de cáncer colorrectal (CCR) en el contexto de urgencia está asociado a un mal pronóstico. OBJETIVO: Determinar los factores sociodemográficos asociados a cirugía de urgencia en el CCR en nuestra institución. MÉTODO: De enero de 2009 a diciembre de 2017 se incluyeron los pacientes operados de CCR y se realizaron análisis univariado y multivariado para determinar los potenciales factores de riesgo. RESULTADOS: Se incluyeron en el estudio 247 pacientes operados de CCR. El 7.7% de las cirugías fueron de urgencia. En el análisis univariado, los pacientes sin antecedentes familiares de cáncer (odds ratio [OR]: 4.95), los habitantes de zonas rurales (OR: 3.7) y aquellos en etapas avanzadas del cáncer (OR: 5.06) se asociaron a cirugía de urgencia. Los pacientes con nivel socioeconómico medio tuvieron menos probabilidad de que su cirugía fuera de urgencia (OR: 0.14; p = 0.003). En el análisis multivariado, debutar con una etapa clínica avanzada (OR: 4.41; intervalo de confianza del 95% [IC95%]: 1.21-16.05; p = 0.024) y tener un nivel socioeconómico medio (OR: 0.41; IC95%: 0.04-0.55; p = 0.004) fueron factores independientes para cirugía de urgencia por CCR. CONCLUSIONES: Los factores sociales, económicos y demográficos se encontraron relacionados con la necesidad de cirugía de urgencia por CCR.

A systematic review and meta-analysis of diverting loop ileostomy versus total abdominal colectomy for the treatment of Clostridium difficile colitis.

BACKGROUND: Clostridium difficile is an increasingly common source of in-patient morbidity and mortality. We aim to assess the effects of diverting loop ileostomy (DLI) versus total abdominal colectomy (TAC) for Clostridium difficile colitis (CDC), in terms of mortality and morbidity. METHODS: Systematic literature search was performed using PubMed, Embase, Cochrane, and Web of Science databases for randomized and non-randomized studies comparing DLI and TAC for fulminant CDC. Meta-analysis was carried out for mortality and postoperative complications. RESULTS: Five non-randomized studies qualified for inclusion in the quantitative synthesis. In total, 3683 patients were allocated to DLI (n = 733) or TAC (n = 2950). The overall mortality was equivalent (OR 0.73; 95% CI 0.45-1.20; P = 0.22). Regarding secondary outcomes, the pooled analysis revealed the following equivalent rates of postoperative events: thromboembolism (OR 0.45; 95% CI 0.14-1.43; P = 0.18), acute renal failure (OR 1.71; 95% CI 0.91-3.23; P = 0.10), surgical site infection (OR 0.95; 95% CI 0.11-8.59; P = 0.97), pneumonia (OR 0.98; 95% CI 0.36-2.66; P = 0.97), urinary tract infection (OR 0.81; 95% CI 0.26-2.52; P = 0.72), and reoperation (OR 0.95; 95% CI 0.50-1.82; P = 0.78). The ostomy reversal rate was significantly higher in DLI (OR 12.55; 95% CI 3.31-47.55; P = 0.0002). CONCLUSIONS: The overall morbidity and mortality rates between DLI and TAC for the treatment of CDC seemed to be equivalent. Evidence from a randomized controlled trial is needed to clarify the timing and understand the impact of DLI for CDC.

Acute cholecystitis in neutropenic patients.

BACKGROUNDS/AIMS: The frequency of acute cholecystitis reported in neutropenic patients is between 0.4-1.65%. Clinical manifestations differ from general population as well as clinical approach, diagnosis and treatment. The aim of this work is to describe clinical characteristics, diagnostic approach, and outcomes of patients with hematological diseases that presented with neutropenia and fever associated with acute cholecystitis in a tertiary referral hospital. METHODS: We performed a retrospective analysis of patients with diagnosis of neutropenia and fever associated with acute cholecystitis in the period between January 2000 and January 2017. Quantitative variables were analyzed with mean and standard deviation, and qualitative variables with frequency and percentage. RESULTS: During the study period, 2007 patients presented with neutropenia and fever. Twelve of them (0.59%) had associated acute cholecystitis. The most common hematologic disease among these patients was lymphoblastic leukemia. Acute acalculous cholecystitis was diagnosed in 6 cases (50%). Eleven patients (91.6%) had a severe presentation and cholecystostomy was performed in 9 (75%) cases. The main cause of mortality was septic shock (33.3%). CONCLUSIONS: Treatment of acute cholecystitis in patients with neutropenia must be individualized. Cholecystostomy should be considered as a bridge therapy for an interval cholecystectomy.

The use of telemedicine in the preoperative management of pheochromocytoma saves resources.

BACKGROUND: Surgical management of pheochromocytomas involves appropriate pre-operative alpha blockade. This process often results in multiple clinic visits, substantial delay in resection, and use of limited resources. We sought to evaluate the benefit of patient participation and doctor-patient telecommunication in pre-operative alpha blockade. METHODS: A "study group" of patients, retrospectively collected, with pheochromocytoma requiring alpha-blockade therapy, during their initial clinic visit were educated on the use of a sphygmomanometer and the accurate detection of orthostatic blood pressure (BP). Subsequently, orthostatic evaluation and dose escalation were conducted through e-mail correspondence between the patient and the surgeon on a biweekly basis. This group of patients was compared with an historical "control group" consisting of 14 patients, whose preoperative treatment was titrated during clinic visits. RESULTS: The two groups were similar in terms of operation performed (laparoscopic versus open), estimated blood loss, tumor size, and post-operative length of stay. Active patient participation in pre-operative alpha blockade therapy resulted in significantly fewer preoperative visits (mean 1.52 vs. 3.20 visits; P=0.02) and a significantly shorter time from initiation of blockade to resection (33 vs. 82 days; P=0.03). CONCLUSIONS: Titration of alpha blockade therapy through patient and surgeon e-mail correspondence is efficacious and saves limited resources and time. This process eliminates unnecessary travel time and expenses for the patient. Due to the benefits of telemedicine for pheochromocytoma preoperative care, our method should be implemented in the routine surgical care of pheochromocytomas.