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Postoperative complications of colorectal surgery are one of the most important reasons affecting patients' postoperative health and also an important factor increasing the burden of medical care. It can give policymakers a basis to the optimization of medical resources by clarifying the health economic burden of different postoperative complications through health economic evalua-tion. Through a detailed search of domestic and foreign literatures, the authors summarize and analyze the increased medical costs and prolonged hospital stays associated with postoperative anastomotic leak, surgical site infection, and postoperative ileus. Furthermore, the authors identify shortcomings in existing clinical studies of different mediacal centers for colorectal postoperative complications, in order to better guide future clinical researches related to colorectal postoperative complications.
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Registration of postoperative complications for surgical oncology including gastrointestinal cancer has received increasing attention with persistent researches on gastrointes-tinal tumor in China. The popularization of standardized gastric surgery and introduction of new technologies and concepts, including minimally invasive surgery, enhanced recovery after surgery, and neoadjuvant therapy, have promoted the conduction of clinical studies, e.g. the Chinese Laparoscopic Gastrointestinal Surgery Study Group series studies, on their safety, and further standardized the diagnosis and registration of postoperative complications as short-term study endpoints. Since then, for diagnosis and registration of complications in gastrointestinal surgery in China, the basis has evolved from clinical experience to clinical research. Since 2015, platforms such as China Gastrointestinal Cancer Surgical Union have been established to further promote the recording of real-world clinical data in more centers across the whole country. In recent years, the expert consensus on the diagnosis and registration of complications has been published sub-sequently and the prospective multicenter real-world complication registration study has been carried out. All of these efforts will facilitate medical centers especially the primary medical centers into the era of standardized diagnosis and registration of complications on a real-world basis.The authors review the standardized diagnosis and registration of surgical complications for gastrointes-tinal cancer in China, aiming to provide references to standardization of clinical practice of gastro-intestinal surgery.
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The digestive tract reconstruction after laparoscopic total gastrectomy has always been a hotspot but a difficult subject as well in gastric cancer surgery. The clinical technical characteristics and advantages of different digestive tract reconstruction methods by using linear stapler, circular stapler or hand-sewn anastomosis in laparoscopic surgery have formed consensuses. However, there is still insufficient clinical evidence for the safety evaluation of different digestive tract reconstruction methods. Combined with current clinical research progress and their clinical practice, the authors summarize and investigate the status and methods of safety evaluation of common digestive tract reconstruction after laparoscopic total gastrectomy.
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Since the outbreak of Corona Virus Disease 2019 occurred in December 2019, the reduction of population mobility has curbed the spread of the epidemic to some extent but also prolonged the waiting time for the treatment of patients with gastric cancer. Based on fully understanding the different staging characteristics of gastric cancer, clinical departments should develop reasonable out-of-hospital management strategies. On one hand, reasonable communication channels should be established to allow patients to receive adequate guidance out of the hospital. On the other hand, shared decisions with patients should be made to adjust treatment strategies, and education on viral prevention should be implemented to minimize the impact of the epidemic on tumor treatment.
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Since the China Gastrointestinal Cancer Surgery Union was established, it has continuously collected the annual reports of 95 gastrointestinal surgery centers nationwide from 2014 to 2017, and collected data on more than 130 000 cases of gastric cancer. This article combines the experience of associated databases at home and abroad to analyze the construction of the China Gastrointestinal Cancer Surgery Union Database, and explore the role of multi-center cooperation and big data analysis in the promotion of gastrointestinal surgery. For a complete database to successfully achieve its ultimate goal, it needs clear goals, continuous funding, a qualified management team, consensus on data content, a high completion rate, and the support and cooperation of an advanced processing system. As a high-quality database with clear construction goals and database project construction based on the goals, while promoting the level of clinical diagnosis and treatment, it is also widely used in risk prediction model development, audit supervision, epidemiological research, health service research, and clinical hypothesis testing, etc. How to build a high-quality database to give a full promotion in clinical diagnosis and treatment is a huge challenge. Although the construction of medical databases in China has just started, we believe that with the further improvement in understanding, management and analysis capabilities for surgical databases, more databases including the China Gastrointestinal Cancer Surgery Union Database will make greater contributions in promoting the development of diagnosis and treatment of gastrointestinal cancer in China and the world.
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Objective@#To summarize the characteristics of abdominal-pelvic unplanned reoperation (URO) in a cancer hospital.@*Methods@#Retrospectively descriptive cohort research was adopted. The classification of diseases was based on ICD-10, and surgical classification was based on ICD-9-CM-3. Medical record summary database from 2008 to 2018 in Beijing Cancer Hospital was collected, and all URO information of abdominal-pelvic surgery was retrieve. The time of URO, disease type, surgery type and cause were statistically analyzed. Distribution of main disease incidence and constituent ratio, and the application of major surgery and surgery type composition ratio were analyzed as well.@*Results@#From 2008 to 2018, a total of 46854 cases underwent abdominal-pelvic surgery (including gastrointestinal, hepatic-biliary-pancreatic, gynecological, urological, or esophageal cancer surgery) and 713 patients received URO (1.52%), including 486 males and 227 females (2.14:1.00) with a mean age of (58.1±12.2) years. A total of 246 patients (34.50%) had comorbidity, and with comorbidity: without comorbidity was 1.13:1.00. The hospital stay was (44.5±43.0) days, and the total cost was (178000±112000) yuan. There were 22 deaths (3.09%). The median interval between URO and the first operation was 8 (0 to 131) days. The highest rate of URO was 2.45% (89/3629) in 2012, while the lowest was 0.95% (53/5596) in 2015. The top 3 major cancer types of URO included colorectal cancer (222 cases, 31.14%), gastric cancer (166 cases, 23.28%) and esophageal cancer (45 cases, 6.31%). The cancer types with the highest URO rate included pancreatic cancer (3.97%, 30/756), gastric cancer (1.81%, 166/9171) and colorectal cancer (1.80%, 222/12333). The top 3 surgical procedures resulting in URO were rectal resection (109 cases, 15.29%), total gastrectomy (79 cases, 11.08%), and total pancreatectomy (64 cases, 8.98%). Focusing on 497 URO cases from 2012 to 2018, 465 cases (93.56%) followed relatively difficult grade III and IV surgery, while only 32 cases (6.44%) followed grade I and II surgery. The top 5 main causes of URO were bleeding (225 cases, 31.56%), anastomotic leak (225 cases, 31.56%), infection (89 cases, 12.48%), intestinal obstruction (53 cases, 7.43%), and wound dehiscence (35 cases, 4.91%), adding up to a total of 87.94% of all URO.@*Conclusion@#This study summarizes the epidemiology of abdominal - pelvic URO in our cancer institution, providing the solid baseline for future investigation of URO and the subsequent formulation of corresponding prevention and intervention measures.
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The postoperative complications in patients with gastric or colorectal cancer has been common but seriously affecting patients' recovery and even their life safety.According to the database of China Gastrointestinal Cancer Surgery Union,abdominal infectious complications are the main causes of secondary surgery and postoperative death,which deserve clinical attention.However,the incidence rate of postoperative abdominal infection varies widely from center to center.Due to the lack of nationwide data,it is unable to determine the incidence of abdominal infectious complications reasonably and formulate the corresponding strategies of evidence-based diagnosis and treatment.Therefore,this multi-center prospective cohort study,i.e.prediction of abdominal complication after gastroenterological surgery (PACAGE),aims to investigate the incidence,classification and outcomes of postoperative abdominal infection in patients with gastric or colorectal cancer,to implement the standardization of the complication registration,and to provide necessary data for improving surgical safety,preventing abdominal infection and decreasing the rate of postoperative complications in the future.
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Objective@#To explore the feasibility of assessing complications registration through medical information.@*Methods@#A descriptive case series study was performed to retrospectively collect medical information and complication registration information of gastric cancer patients at Department of Gastrointestinal Cancer Center Ward I, Peking University Cancer Hospital from November 1, 2016 to March 1, 2017 (the first period), and from November 1, 2018 to March 1, 2019 (the second period). Case inclusion criteria: (1) adenocarcinoma confirmed by gastroscopy and biopsy; (2) patients undergoing open surgery or laparoscopic radical gastrectomy; (3) complete postoperative medical information and complication information. Patients who were directly transferred to ICU after surgery and underwent emergency surgery were excluded. Because difference of the complication registration procedure at our department existed before and after 2018, so the above two periods were selected to be used for analysis on enrolled patients. The prescription information during hospitalization, including nursing, medication, laboratory examination, transference, surgical advice, etc. were compared with the current Standard Operating Procedure (SOP, including preoperative routine examinations, inspection, perioperative preventive antibiotic use, postoperative observational tests, inspection, routine nutritional support, prophylactic anticoagulation, and prophylactic inhibition of pancreatic enzymes, etc.) for gastric cancer at our department. Medical order beyond SOP was defined as medical order variation. Postoperative complication was diagnosed using the Clavien-Dindo classification criteria, which was divided into I, II, IIIa, IIIb, IVa, IVb, and V. Medical order variation and complication registration information were compared between the two periods, including consistence between medical order variation and complication registration, missing report, underestimation or overestimation of medical order variation, and registration rate of medical order variation [registration rate = (total number of patients–number of missing report patients)/total number of patients], severe complications (Clavien-Dindo classification ≥ III), medical order variation deviating from SOP and the corresponding inferred grading of complication. The data was organized using Microsoft Office Excel 2010.@*Results@#A total of 177 gastric cancer patients were included in the analysis. The first period group and the second period group comprised 89 and 88 cases, respectively. The registrated complication rate was 23.6% (21/89) and 36.4% (32/88), and the incidence of severe complication was 2.2% (2/89) and 4.5% (4/88) in the first and the second period, respectively. The complication rate inferred from medical order variation was 74.2% (66/89) and 78.4% (69/88), and the incidence of severe complication was 7.9% (7/89) and 4.5% (4/88) in the first and second period, respectively. In the first and second period, the proportions of medical order variation in accordance with registered complication were 36.0% and 45.5% respectively; the proportion of underestimation, overestimation and missing report were 5.6% and 4.5%, 4.5% and 4.5%, 53.9% and 45.5%, respectively; the registration rate of medical order variation was 46.1% and 54.5%; the number of case with grade I complications inferred from medical order variation was 34 (38.2%) and 25 (28.4%), respectively; and the number of grade II was 12 (13.5%) and 15 cases (17.0%), respectively. The reason of the missing report of medical order variation corresponding to grade I complication was mainly the single use of analgesic drugs outside SOP, accounting for 76.5% (26/34) and 64.0% (16/25) in the first and second period respectively, and that corresponding to grade II complication was mainly the use of non-prophylactic antibiotics, accounting for 9/12 cases and 5/15 cases, respectively.@*Conclusions@#Medical information can evaluate the morbidity of complication feasibly and effectively. Attention should be paid to routine registration to avoid specific missing report.
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Objective To explore the feasibility of early predicting intra-abdominopelvic infectious complications by closer observation of abdominal drainage.Methods Prospectively collected and evaluated the first-three-postoperative-day drainage samples of 207 up-to-standard patients underwent gastrointestinal surgery between April and September 2017 in Peking University Cancer Hospital.Among them,159 males (76.8％) and 48 females (23.2％) were included,the average age was (59.9 ± 10.6) years and the average body mass index was (23.7 ± 3.2) kg/m2.Characteristics of the samples were daily recorded and later on matched with the clinical outcomes,including complications recorded and graded according to the Clavien-Dindo classification.The measurement data with normal distribution were presented as mean and standard deviation,the enumeration data were recorded in the form of quantity and percentage,using the x2 test and Fisher accurate test.Results One hundred and ninty-nine patients (96.1％) were recorded as normal in the drainage samples,while the other 8 cases (3.9％) as abnormal (including pungent odor,purulent color etc.).There were 53 patients (25.6％) were diagnosed with postoperative complications.Among the patients with normal samples,the complication rate was 22.6％,while the eight abnormal ones were all diagnosed with postoperative complications (complication rate:100.00％,P =O.000 012).Notably,among those 8 cases,complications were diagnosed much later than 3 days after surgery in 7 (87.5％) patients.In 1 (12.5％) case,the drainage abnormality was the only abnormal signs and there was no complications detected during the postoperative period of hospitalization.The intra-abdominal infectious complication occurred within 30 days after discharge and the patient re-admitted two times.Conclusions Early change of basic characteristics of postoperative drainage is a promising candidate for detection of postoperative complications with strong specificity.Clinical practice should be further regulated to ensure in-time recording and following interventions of those signs.
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<p><b>OBJECTIVE</b>To compare the short-term safety and costs between laparoscopic assisted or totally laparoscopic uncut Roux-en-Y and Billroth II((BII() + Braun reconstruction after radical gastrectomy of distal gastric cancer.</p><p><b>METHODS</b>Clinical data from our prospective database of radical gastrectomy were systematically analyzed. The patients who underwent laparoscopic gastrectomy with uncut Roux-en-Y or BII(+ Braun reconstruction between March 1st, 2015 and June 30th, 2017 were screened out for further analysis. Both the reconstructions were completed by linear staplers. Uncut Roux-en-Y reconstruction was performed with a 45 mm no-knife linear stapler (ATS45NK) on the afferent loop below the gastrojejunostomy. Continuous variables were compared using independent samples t test or Mann-Whitney U. The frequencies of categorical variables were compared using Chi-squared or Fisher exact test.</p><p><b>RESULTS</b>Eighty-one patients were in uncut Roux-en-Y group and 58 patients were in BII(+Braun group. There were no significant differences between uncut Roux-en-Y group and BII(+Braun group in median age (56.0 years vs. 56.5 years, P=0.757), gender (male/female, 52/29 vs. 46/12, P=0.054), history of abdominal surgery (yes/no, 10/71 vs. 4/54, P=0.293), neoadjuvant chemotherapy (yes/no, 21/60 vs. 11/47, P=0.336), BMI (thin/normal/overweight/obesity, 2/49/26/3 vs. 3/39/14/2, P=0.591), NRS 2002 score (1/2/3/4, 58/15/5/3 vs. 47/5/3/3, P=0.403), pathological stage (0/I(/II(/III(, 3/41/20/17 vs. 1/28/13/16, P=0.755), median tumor diameter in long axis (2.5 cm vs. 3.0 cm, P=0.278), median tumor diameter in short axis (2.0 cm vs. 2.0 cm, P=0.126) and some other clinical and pathological characteristics. There were no significant differences between uncut Roux-en-Y group and BII(+Braun group in morbidity of postoperative complication more severe than grade I([12.3% (10/81) vs. 17.2% (10/58), P=0.417], morbidity of anastomotic complication [1.2%(1/81) vs. 0, P=1.000] or hospitalization costs [(94000±14000) yuan vs.(95000±16000) yuan, P=0.895]. The median first time to liquid diet (57.1 hours vs. 70.8 hours, P=0.017) and median postoperative hospital stay (9 days vs. 11 days, P=0.003) of the patients in uncut Roux-en-Y group were shorter than those in BII(+Braun group.</p><p><b>CONCLUSION</b>Laparoscopic assisted or totally laparoscopic uncut Roux-en-Y reconstruction after radical gastrectomy of distal gastric cancer is safe and feasible with better recovery than BII(+Braun reconstruction.</p>
Subject(s)
Female , Humans , Male , Middle Aged , Anastomosis, Roux-en-Y , Databases, Factual , Gastrectomy , Gastroenterostomy , Laparoscopy , Methods , Prospective Studies , Stomach Neoplasms , General Surgery , Treatment OutcomeABSTRACT
Postoperative complications of gastrointestinal surgery have become an important indicator for evaluating surgical safety in the process of the domestic and foreign clinical research and practice.The clinical economics evaluation of the complications provides an important reference in the clinical decision-making process,in addition to the mechanism investigation.It reveals that higher cost-effectiveness can be obtained through optimizing complication diagnosis and registration process from a national macroscopic level,while it also uncovers the targets of the yet-to-be improved clinical decision making process in the microscopic analysis.Through clinical economics evaluation,the necessity and feasibility of interventions targeting the complications can be better understood the clinical practice,which would eventually optimize clinical strategies and proper use of the limited health resources.
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Anastomotic leakage is one of the most serious complications of colorectal surgery. Despite progress in available surgical techniques, the morbidity associated with anastomotic leakage remains high. In this review, we summarize the current clinical status of this complication, the problems it causes, and relevant research achievements. To date, a lack of consensus regarding the diagnosis of anastomotic leakage has resulted in varying rates of diagnosis across countries and regions worldwide. Accurately predicting the occurrence of anastomotic leakage using the established risk factors and preoperative scoring systems remains difficult. Many of the described preventive measures, including defunctioning stoma creation, positive air leak testing, and use of effective tissue adhesives, remain controversial; more evidence-based medical information is urgently needed. Delayed diagnoses of anastomotic leakage also remain common in clinical practice. To prevent catastrophic outcomes, such as reoperations or deaths, early diagnosis is critically important. Parameters local to the area of the anastomosis may facilitate early detection of leakage, but their effectiveness is subject to clinical validation. Lastly, the pathological etiology of anastomotic leakage remains to be determined, and its elucidation may inspire innovative interventions that solve this critical surgical complication.
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Complications significantly postpone postoperative recovery and increase mortality after gastric cancer surgery. However, varied complication rates have been reported in the literature as well as in our annual report of China Gastrointestinal Oncological Surgery League. It appears that there have been some misunderstandings regarding the diagnosis and interventions as well as the etiology of major complications. We should be aware of the fact that reaching worldwide consensus for the diagnostic criteria is a difficult task in most complications, which disabled the possibility of data comparison among different studies in most cases. Disagreements among the Chinese and western surgeons in the complication diagnosis should also be acknowledged when interpreting data from both ends. The western colleagues appreciate more latent manifestations of the complications, which eventually lead to earlier and more aggressive examinations and interventions. We, together with all Chinese centers, need to acknowledge the differences, ensure the integrity of our reported data while proposing respective countermeasures. Although the complication registration may continue to differ among centers, we can register complications with the intervention details so that the reported complications can be classified with the same standard (i.e. Clavien-Dindo scoring system). We should also encourage multi-center collaborations and trials, which facilitate the standardization of complication diagnosis and registration. Recognizing the difficulty and long-course nature of reaching national or even international consensus, we continue aiming at the ultimate goal with our best effort.
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Humans , China , Consensus , Data Collection , Reference Standards , Diagnostic Techniques and Procedures , Reference Standards , Digestive System Surgical Procedures , Postoperative Complications , Classification , Epidemiology , Registries , Reference Standards , Stomach Neoplasms , General SurgeryABSTRACT
Postoperative complications are important outcome measurements for surgical quality and safety control. However, the complication registration has always been problematic due to the lack of definition consensus and the other practical difficulties. This narrative review summarizes the data registry system for single institutional registry, national data registry, international multi-center trial registries in the western world, aiming to share the experience of complication classification and data registration. We interviewed Dr. Koh from Royal Prince Alfred Hospital in Australia for single institutional experience, Dr. van der Wielen and Dr. Desideriofor, from two international multi-center trial(STOMACH) and registry (IMIGASTRIC) respectively, and Prof. Dr. Wijnhoven from the Dutch Upper GI Audit(DUCA). The major questions include which complications are obligated to report in the respective registry, what are the definitions of those complications, who perform the registration, and how are the complications evaluated or classified. Four telephone conferences were initiated to discuss the above-mentioned topics. The DUCA and IMGASTRIC provided the definition of the major complications. The consent definition provided by DUCA was based on the LOW classification which came out after a four-year discussion and consensus meeting among international experts in the according field. However, none of the four registries asked for an obligatory standardization of the diagnostic criteria among the participating centers or surgeons. Instead, all the registries required a detailed recording of the diagnostic strategy and classification of the complications with the Clavien-Dindo scoring system. Most data were registered by surgeons or data managers during or immediately after the hospitalization. The investigators or an independent third party conducted the auditing of the data quality. Standardization of complication diagnosis among different centers is a difficult task, consuming much effort and time. On top of that, standardization of the complication registration is of critical and practical importance. We encourage all centers to register complications with the diagnostic criteria and following intervention. Based on this, the Clavien-Dindo classification can be properly justified, which has been widely accepted by most centers and should be routinely used as the standard evaluation system for postoperative complications in gastric tumor surgery.
Subject(s)
Humans , Australia , Epidemiology , Data Collection , Reference Standards , Diagnostic Techniques and Procedures , Reference Standards , Digestive System Surgical Procedures , Health Care Surveys , Netherlands , Epidemiology , Postoperative Complications , Classification , Diagnosis , Epidemiology , Registries , Reference Standards , Risk Assessment , Methods , Reference Standards , Stomach Neoplasms , General SurgeryABSTRACT
<p><b>OBJECTIVE</b>To analyze the change in postoperative complication rate after gastric cancer surgery registered in the Peking University Cancer Hospital in recent 11 years and the learning curve of complication registration, and to investigate how to improve the complication registration and evaluation in gastric cancer surgery.</p><p><b>METHODS</b>Patients who underwent open or laparoscopic gastric cancer surgery between April 14, 2005 and February 15, 2016 in our institution were included in the study, and those without essential clinical and administrative data were excluded. Data were biennially collected, and linear regression was performed to investigate the changes of the following parameters, including overall complication rate, severe complication proportion (proportion of complications with Clavien-Dindo score ≥III(a in the total registered complications), re-operation rate and the major complication rate.</p><p><b>RESULTS</b>A total of 5 666 patients were included in the analysis, with 4 111 males (72.56%) and 1 555 females (27.44%). The average age was (58.87±11.50) years and average BMI was(23.15±3.30) kg/m. There were 305 patients included in the 2005-2006 interval, 810 patients in 2007-2008, 957 patients in 2009-2010, 1 163 patients in 2011-2012, 1 421 patients in 2013-2014, and 1 010 patients in 2015-2016, respectively. The overall re-operation rate was 2.34%(133/5 666), postoperative mortality was 0.41%(23/5 666), registered complication rate was 19.66%(1 114/5 666), severe complication proportion was 32.28%(338/1 047), and the proportion of complication missing the Clavien-Dindo score was 6.01%(67/1 114). The linear regression showed the re-operation rate (r=0.13, P=0.801) and postoperative mortality (r=0.58, P=0.231) remained low (< 4% and < 1% respectively) since 2005, and showed no statistical significance. The registered complication rate showed evident increase from 3.93%(12/305) to 29.13%(414/1 421) between 2005 and 2014 (r=0.92, P=0.010), and slight decrease to 22.77%(230/1 010) in 2015-2016. The severe complication proportion significantly decreased from 6/9 in 2005-2006 to 22.73%(50/220) in 2015-2016 (r=0.90, P=0.014). The proportion of complication missing the Clavien-Dindo score significantly decreased from 25.00%(3/12) in 2005-2006 to 4.35%(10/230) in 2015-2016(r=0.82, P=0.044). The most common complications were infection (9.12%, 517 cases), effusions (6.26%, 355 patients), gastrointestinal motility disorder (4.45%, 252 cases), anastomotic leakage (3.19%, 181 cases) and bleeding (2.31%, 131 cases). The registered rates of these complications all increased since 2005, and the rates of leakage and effusions decreased since 2012 while the others decreased after 2014.</p><p><b>CONCLUSIONS</b>According to the data from our institution in the recent 11 years, a learning curve exists in our institution for complication registration in gastric cancer surgery. The administrative data appears to be more reliable than registered complication data in quality and safety evaluation during the learning period. A detailed classification with the Clavien-Dindo score aids to the use of complication data for the quality and safety measurement.</p>