Laparoscopic Surgery for Elderly Colorectal Cancer Patients With High American Society of Anesthesiologists Scores.

BACKGROUND/AIM: To evaluate the safety of colorectomy in elderly colorectal cancer patients with high American Society of Anesthesiologists (ASA) scores compared to those with low scores. PATIENTS AND METHODS: Two hundred patients with stage I-IV colorectal cancer aged ≥80 years were retrospectively analyzed. Short- and long-term outcomes were compared between 136 patients with ASA scores ≤2 (low ASA group) and 64 patients with scores ≥3 (high ASA group). RESULTS: The incidence of postoperative complications, duration of postoperative hospital stay, and 5-year overall and cancer-specific survival rates did not differ significantly between the groups. Laparoscopic surgery was significantly associated with a lower incidence of postoperative complications than open surgery in the high ASA score group (p=0.041), whereas no difference was observed in the low ASA score group (p=0.639). In the high ASA group, open surgery (p=0.024) and higher body mass index (p=0.040) were independent risk factors for postoperative complications. CONCLUSION: Colorectal cancer resection can be safely performed in elderly patients with high ASA scores. Moreover, laparoscopic surgery may have a stronger contribution to the reduction of postoperative complications in elderly patients with colorectal cancer with high ASA scores than in those with low ASA scores.

Two surgical pathways for isolated hip fractures: A comparative study.

BACKGROUND: Hip fractures (HF) are common among the aging population, and surgery within 48 h is recommended. Patients can be hospitalized for surgery through different pathways, either trauma or medicine admitting services. AIM: To compare management and outcomes among patients admitted through the trauma pathway (TP) vs medical pathway (MP). METHODS: This Institutional Review Board-approved retrospective study included 2094 patients with proximal femur fractures (AO/Orthopedic Trauma Association Type 31) who underwent surgery at a level 1 trauma center between 2016-2021. There were 69 patients admitted through the TP and 2025 admitted through the MP. To ensure comparability between groups, 66 of the 2025 MP patients were propensity matched to 66 TP patients by age, sex, HF type, HF surgery, and American Society of Anesthesiology score. The statistical analyses included multivariable analysis, group characteristics, and bivariate correlation comparisons with the χ² test and t-test. RESULTS: After propensity matching, the mean age in both groups was 75-years-old, 62% of both groups were females, the main HF type was intertrochanteric (TP 52% vs MP 62%), open reduction internal fixation was the most common surgery (TP 68% vs MP 71%), and the mean American Society of Anesthesiology score was 2.8 for TP and 2.7 for MP. The majority of patients in TP and MP (71% vs 74%) were geriatric (≥ 65-years-old). Falls were the main mechanism of injury in both groups (77% vs 97%, P = 0.001). There were no significant differences in pre-surgery anticoagulation use (49% vs 41%), admission day of the week, or insurance status. The incidence of comorbidities was equal (94% for both) with cardiac comorbidities being dominant in both groups (71% vs 73%). The number of preoperative consultations was similar for TP and MP, with the most common consultation being cardiology in both (44% and 36%). HF displacement occurred more among TP patients (76% vs 39%, P = 0.000). Time to surgery was not statistically different (23 h in both), but length of surgery was significantly longer for TP (59 min vs 41 min, P = 0.000). Intensive care unit and hospital length of stay were not statistically different (5 d vs 8 d and 6 d for both). There were no statistical differences in discharge disposition and mortality (3% vs 0%). CONCLUSION: There were no differences in outcomes of surgeries between admission through TP vs MP. The focus should be on the patient's health condition and on prompt surgical intervention.

A Comparative Study between Peptic Ulcer Perforation Score, Mannheim Peritonitis Index, ASA Score, and Jabalpur Score in Predicting the Mortality in Perforated Peptic Ulcers.

Introduction Peptic ulcer disease continues to be a major public health in most developing countries despite the advances in medical management. The incidence of perforations remains high and has the highest mortality rate of any complication of ulcer disease. Risk stratification of cases will lead to better preoperative management and efficient utilization of intensive care unit resources. The purpose of the present study is to compare different existing scoring systems and identify the most accurate predictor of mortality in perforated peptic ulcer (PPU) cases. Materials and Methods This is an observational study conducted in Karnataka Institute of Medical Sciences, Hubli, India. All cases of PPU disease admitted from December 2017 to August 2019 who were treated surgically were included in the study. Demographic data were collected and peptic ulcer perforation (PULP) score, Mannheim peritonitis index (MPI), American Society of Anesthesiologists (ASA) score, and Jabalpur score (JS) were calculated for individual patient and compared. The patient was followed up during the postoperative period. Observation A total of 45 patients were included in the study with a mean age of 42.5 years. Most of the patients presented with 24 hours of the onset of symptoms. Nonsteroidal anti-inflammatory drug use was noted in 8.9% patients, and steroid use was present in 2.2% patients. Of the 45 patients, 7 deaths were reported. Between the various scoring systems, the MPI and JS were better predictors of mortality with a p -value of <0.001 and 0.007, respectively. In contrast, the PULP and ASA scores had p -value not statistically significant. However, the PULP score was a better predictor of postoperative complication with a p -value of 0.047. Conclusion Of the four scoring systems validated, the MPI and JS were better predictors of mortality in the given population. PULP score is a better predictor of postoperative complications in the present study.

Prediction of intensive care unit admission (>24h) after surgery in elective noncardiac surgical patients using machine learning algorithms.

Background: To develop a highly discriminative machine learning model for the prediction of intensive care unit admission (>24h) using the easily available preoperative information from electronic health records. An accurate prediction model for ICU admission after surgery is of great importance for surgical risk assessment and appropriate utilization of ICU resources. Method: Data were collected retrospectively from a large hospital, comprising 135,442 adult patients who underwent surgery except for cardiac surgery between 1 January 2014, and 31 July 2018 in China. Multiple existing predictive machine learning algorithms were explored to construct the prediction model, including logistic regression, random forest, adaptive boosting, and gradient boosting machine. Four secondary analyses were conducted to improve the interpretability of the results. Results: A total of 2702 (2.0%) patients were admitted to the intensive care unit postoperatively. The gradient boosting machine model attained the highest area under the receiver operating characteristic curve of 0.90. The machine learning models predicted intensive care unit admission better than the American Society of Anesthesiologists Physical Status (area under the receiver operating characteristic curve: 0.68). The gradient boosting machine recognized several features as highly significant predictors for postoperatively intensive care unit admission. By applying subgroup analysis and secondary analysis, we found that patients with operations on the digestive, respiratory, and vascular systems had higher probabilities for intensive care unit admission. Conclusion: Compared with conventional American Society of Anesthesiologists Physical Status and logistic regression model, the gradient boosting machine could improve the performance in the prediction of intensive care unit admission. Machine learning models could be used to improve the discrimination and identify the need for intensive care unit admission after surgery in elective noncardiac surgical patients, which could help manage the surgical risk.

Asymmetric dimethylarginine predicts perioperative cardiovascular complications in patients undergoing medium-to-high risk non-cardiac surgery.

OBJECTIVES: Perioperative cardiovascular events remain an important factor that affects surgery outcome. We assessed if asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthesis, predicts perioperative risk, and if pre-operative supplementation with L-arginine/L-citrulline improves the plasma L-arginine/ADMA ratio. METHODS: In this prospective study, planned thoracic and/or abdominal surgery patients were randomized to receive L-arginine/L-citrulline (5 g/day) or placebo 1 to 5 days before surgery. We measured perioperative plasma ADMA and L-arginine levels. The primary outcome was a 30-day combined cardiovascular endpoint. RESULTS: Among 269 patients, 23 (8.6%) experienced a major adverse cardiovascular event. ADMA and C-reactive protein were significantly associated with the incidence of cardiovascular complications in the multivariable-adjusted analysis. The L-arginine plasma concentration was significantly higher on the day of surgery with L-arginine/L-citrulline supplementation compared with placebo. In patients with high pre-operative ADMA, there was a non-significant trend towards reduced incidence of the primary endpoint with L-arginine/L-citrulline supplementation (six vs. nine events). CONCLUSIONS: ADMA is a predictor of major adverse cardiovascular complications in the perioperative period for patients who are undergoing major abdominal and/or thoracic surgery. Supplementation with L-arginine/L-citrulline increased the L-arginine plasma concentration, enhanced the L-arginine/ADMA ratio, and induced a trend towards fewer perioperative events.

American Society of Anesthesiologists Score is Not Predictive of Complication Incidence After Minimally Invasive Posterior Lumbar Spine Procedures.

BACKGROUND: Complications occurring after spinal procedures are associated with recurrent symptomatology, new-onset symptomatology, and increased health care costs. The American Society of Anesthesiologists (ASA) score is a commonly cited risk factor for complication incidence. Few investigations have been performed analyzing the relationship between ASA score and complication rate following spinal minimally invasive surgery (MIS) decompressions or fusions. Therefore, the purpose of this study is to determine whether an association exists between preoperative ASA score and the incidence of postoperative complications among patients undergoing MIS posterior lumbar decompression or fusion. METHODS: A surgical registry of patients undergoing single-level MIS posterior lumbar decompressions or fusions between 2007 and 2016 was retrospectively reviewed. Patients were stratified by preoperative ASA score (≤2, >2). The ASA score was tested for an association with preoperative demographic, comorbidity, and perioperative characteristics using the Student t test or χ2 analysis. Multivariate Poisson regression with robust error variance was used to test for an association between ASA score and the incidence of complications up to 6 months postoperatively. RESULTS: A total of 772 patients were analyzed. Of those, 86.7% had an ASA score ≤2, whereas 13.3% had an ASA score >2. An ASA score >2 was associated with older age (P < .001), higher comorbidity burden (P < .001), and higher rates of obesity (P < .001). An ASA score >2 was also associated with significantly longer operative time (P = .001) and longer length of hospital stay (P < .001). Upon multivariate analysis, ASA score category was not associated with the incidence of any complication (P = .248), medical complications (P = .227), or surgical complications (P = .816). CONCLUSIONS: The ASA score was not a predictive factor for complication incidence up to 6 months postoperatively. Thus, a higher ASA score should not preclude patients from being surgical candidates for MIS posterior lumbar decompressions or fusions. Further investigation is required to identify other predictive factors for complication incidence after minimally invasive spine surgery. LEVEL OF EVIDENCE: 3.

Infections after shoulder arthroplasty are correlated with higher anesthetic risk score: a case-control study in Brazil

ABSTRACT Purposes: Shoulder arthroplasty (SA) has been performed by many years for the treatment of several conditions, including osteoarthritis and proximal humeral fractures following trauma. Surgical site infection (SSI) following Shoulder arthroplasty remains a challenge, contributing to increased morbidity and costs. Identification of risk factors may help implementing adequate strategies to prevent infection. We aimed to identify pre- and intra-operative risk factors associated with deep infections after Shoulder arthroplasty. Methods: An unmatched case-control study was conducted to describe the prevalence, clinical and microbiological findings, and to evaluate patient and surgical risk factors for prosthetic shoulder infection (PSI), among 158 patients who underwent SA due to any reason, at a tertiary public university institution. Risk factors for PSI was assessed by uni- and multivariate analyses using multiple logistic regression. Results: 168 SA from 158 patients were analyzed, with an overall infection rate of 9.5% (16/168 cases). Subjects undergoing SA with American Society of Anesthesiologists (ASA) grade III or higher (odds ratio [OR] = 5.30, 95% confidence interval [CI] = 1.58-17.79, p < 0.013) and presenting local hematoma after surgery (odds ratio [OR] = 7.10, 95% confidence interval [CI] = 1.09-46.09, p = 0.04) had higher risk for PSI on univariate analysis. However, only ASA score grade III or higher remained significant on multivariate analysis (OR = 4.74, 95% CI = 1.33-16.92, p = 0.016). Gram-positive cocci and Gram-negative bacilli were equally isolated in 50% of cases; however, the most commonly detected bacterium was Pseudomonas aeruginosa (18.7%). Conclusion: This study provides evidence suggesting that patient-related known factors such as higher ASA score predisposes to shoulder arthroplasty-associated infection. Furthermore, unusual pathogens associated with PSI were identified.

Infections after shoulder arthroplasty are correlated with higher anesthetic risk score: a case-control study in Brazil.

PURPOSES: Shoulder arthroplasty (SA) has been performed by many years for the treatment of several conditions, including osteoarthritis and proximal humeral fractures following trauma. Surgical site infection (SSI) following Shoulder arthroplasty remains a challenge, contributing to increased morbidity and costs. Identification of risk factors may help implementing adequate strategies to prevent infection. We aimed to identify pre- and intra-operative risk factors associated with deep infections after Shoulder arthroplasty. METHODS: An unmatched case-control study was conducted to describe the prevalence, clinical and microbiological findings, and to evaluate patient and surgical risk factors for prosthetic shoulder infection (PSI), among 158 patients who underwent SA due to any reason, at a tertiary public university institution. Risk factors for PSI was assessed by uni- and multivariate analyses using multiple logistic regression. RESULTS: 168 SA from 158 patients were analyzed, with an overall infection rate of 9.5% (16/168 cases). Subjects undergoing SA with American Society of Anesthesiologists (ASA) grade III or higher (odds ratio [OR]=5.30, 95% confidence interval [CI]=1.58-17.79, p<0.013) and presenting local hematoma after surgery (odds ratio [OR]=7.10, 95% confidence interval [CI]=1.09-46.09, p=0.04) had higher risk for PSI on univariate analysis. However, only ASA score grade III or higher remained significant on multivariate analysis (OR=4.74, 95% CI=1.33-16.92, p=0.016). Gram-positive cocci and Gram-negative bacilli were equally isolated in 50% of cases; however, the most commonly detected bacterium was Pseudomonas aeruginosa (18.7%). CONCLUSION: This study provides evidence suggesting that patient-related known factors such as higher ASA score predisposes to shoulder arthroplasty-associated infection. Furthermore, unusual pathogens associated with PSI were identified.