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 the study was to analyse its usefulness in a homogeneous population with control of the main confounding factors. METHODOLOGY: Observational study of 836 patients operated on for CRC who 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 sample of 526 patients remained for study. RESULTS: The two groups were mismatched in terms of age, comorbidity, tumour 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: 1,996; 95% CI: 1.32-3.00) when adjusted in a Cox regression model using age (p < 0,001; HR: 1,04; IC95%: 1,02-1,06) and the Charlson Comorbidity Index (p < 0,001; HR: 1,40; IC95%: 1,27-1,55). Neoadjuvant therapy lost its statistical significance (p = 0,137; HR: 1,59; IC95%: 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.

Resultados del Registro Nacional de Politraumatismos español ¿Dónde estamos y a dónde nos dirigimos? / Results of the Spanish National Polytrauma Registry. Where are we and where are we heading?

Introducción: En 2017 se emprendió el Registro Nacional de Politraumatismos (RNP) a nivel estatal español, cuya finalidad residía en mejorar la calidad de la atención al paciente politraumatizado grave y evaluar el uso de recursos y estrategias de tratamiento. El objetivo de este trabajo es presentar los datos recogidos en el RNP hasta la actualidad. Métodos: Estudio observacional retrospectivo a partir de los datos recogidos prospectivamente en el RNP. Se incluyen pacientes mayores de 14 años, con ISS≥15 o mecanismo de trauma penetrante, atendidos en 17 hospitales de tercer nivel de España. Resultados: Del 1/1/17 al 1/1/22 se han registrado un total de 2.069 pacientes politraumatizados. El 76,4% son varones; edad media: 45 años; ISS medio: 22,8 y mortalidad: 10,2%. El mecanismo de lesión más frecuente es el cerrado (80%) con mayor incidencia de accidentes de moto (23%). Un 12% de los pacientes sufren un traumatismo penetrante, por arma blanca en el 84%. Un 16% de los pacientes ingresa hemodinámicamente inestable en el hospital. Activando el protocolo de transfusión masiva en el 14% de los pacientes e interviniendo quirúrgicamente a un 53%. La estancia hospitalaria mediana es de 11 días. Precisando ingreso en la UCI un 73,4% (estancia media: 5 días). Conclusiones: Los pacientes politraumatizados registrados en el RNP son mayoritariamente varones de mediana edad, que sufren traumatismos cerrados y presentan una elevada incidencia de lesiones torácicas. La detección y el tratamiento dirigido de este tipo de lesiones probablemente permitirá mejorar la calidad asistencial del politraumatizado en nuestro medio. (AU)

Introduction: In 2017 the Spanish National Polytrauma Registry (SNPR) was initiated in Spain, its goal was to improve the quality of severe trauma management and evaluate the use of resources and treatment strategies. The objective of this study is to present the information obtained with the SNPR since it was initiated. Methods: Observational study with prospective data collection from the SNPR. Trauma patients included are older than 14 yeas, with ISS ≥ 15 or penetrating mechanism. In total 17 hospitals from Spain have participated. Results: From 1/1/17 to 1/1/22, 2069 trauma patients were registered. The majority were men (76.4%); mean age: 45 years; mean ISS: 22.8 and mortality: 10.2%. The most common mechanism of injury was blunt trauma (80%), being motorbike accident the most frequent (23%). Penetrating trauma is presented in 12% of patients, being stab wound the most common (84%). Sixteen percent of patients are hemodynamically unstable on hospital arrival. Massive transfusion protocol is activated in 14% of patients and 53% are operated. Median hospital stay is 11 days. There is a 73.4% of patients who need intensive care unit (ICU) admission, with a median ICU stay of 5 days. Conclusions: Trauma patients registered in the SNPR are predominantly middle-aged males who experience blunt trauma with a high incidence of thoracic injuries. Early and addressed detection of these kind of injuries would probably improve trauma quality of care in our environment. (AU)

Efficacy and Safety of Intraoperative Hyperthermic Intraperitoneal Chemotherapy for Locally Advanced Colon Cancer: A Phase 3 Randomized Clinical Trial.

Importance: Peritoneal metastasis in patients with locally advanced colon cancer (T4 stage) is estimated to recur at a rate of approximately 25% at 3 years from surgical resection and is associated with poor prognosis. There is controversy regarding the clinical benefit of prophylactic hyperthermic intraperitoneal chemotherapy (HIPEC) in these patients. Objective: To assess the efficacy and safety of intraoperative HIPEC in patients with locally advanced colon cancer. Design, Setting, and Participants: This open-label, phase 3 randomized clinical trial was conducted in 17 Spanish centers from November 15, 2015, to March 9, 2021. Enrolled patients were aged 18 to 75 years with locally advanced primary colon cancer diagnosed preoperatively (cT4N02M0). Interventions: Patients were randomly assigned 1:1 to receive cytoreduction plus HIPEC with mitomycin C (30 mg/m2 over 60 minutes; investigational group) or cytoreduction alone (comparator group), both followed by systemic adjuvant chemotherapy. Randomization of the intention-to-treat population was done via a web-based system, with stratification by treatment center and sex. Main Outcomes and Measures: The primary outcome was 3-year locoregional control (LC) rate, defined as the proportion of patients without peritoneal disease recurrence analyzed by intention to treat. Secondary end points were disease-free survival, overall survival, morbidity, and rate of toxic effects. Results: A total of 184 patients were recruited and randomized (investigational group, n = 89; comparator group, n = 95). The mean (SD) age was 61.5 (9.2) years, and 111 (60.3%) were male. Median duration of follow-up was 36 months (IQR, 27-36 months). Demographic and clinical characteristics were similar between groups. The 3-year LC rate was higher in the investigational group (97.6%) than in the comparator group (87.6%) (log-rank P = .03; hazard ratio [HR], 0.21; 95% CI, 0.05-0.95). No differences were observed in disease-free survival (investigational, 81.2%; comparator, 78.0%; log-rank P = .22; HR, 0.71; 95% CI, 0.41-1.22) or overall survival (investigational, 91.7%; comparator, 92.9%; log-rank P = .68; HR, 0.79; 95% CI, 0.26-2.37). The definitive subgroup with pT4 disease showed a pronounced benefit in 3-year LC rate after investigational treatment (investigational: 98.3%; comparator: 82.1%; log-rank P = .003; HR, 0.09; 95% CI, 0.01-0.70). No differences in morbidity or toxic effects between groups were observed. Conclusions and Relevance: In this randomized clinical trial, the addition of HIPEC to complete surgical resection for locally advanced colon cancer improved the 3-year LC rate compared with surgery alone. This approach should be considered for patients with locally advanced colorectal cancer. Trial Registration: ClinicalTrials.gov Identifier: NCT02614534.

Results of the Spanish National Polytrauma Registry. Where are we and where are we heading?

INTRODUCTION: In 2017, the Spanish National Polytrauma Registry (SNPR) was initiated in Spain with the goal to improve the quality of severe trauma management and evaluate the use of resources and treatment strategies. The objective of this study is to present the data obtained with the SNPR since its inception. METHODS: We conducted an observational study with prospective data collection from the SNPR. The trauma patients included were over 14 years of age, with ISS ≥ 15 or penetrating mechanism of injury, from a total of 17 tertiary hospitals in Spain. RESULTS: From 1/1/17 to 1/1/22, 2069 trauma patients were registered. The majority were men (76.4%), with a mean age of 45 years, mean ISS 22.8, and mortality 10.2%. The most common mechanism of injury was blunt trauma (80%), the most frequent being motorcycle accident (23%). Penetrating trauma was presented in 12% of patients, stab wounds being the most common (84%). On hospital arrival, 16% of patients were hemodynamically unstable. The massive transfusion protocol was activated in 14% of patients, and 53% underwent surgery. Median hospital stay was 11 days, while 73.4% of patients required intensive care unit (ICU) admission, with a median ICU stay of 5 days. CONCLUSIONS: Trauma patients registered in the SNPR are predominantly middle-aged males who experience blunt trauma with a high incidence of thoracic injuries. Early addressed detection and treatment of these kind of injuries would probably improve the quality of trauma care in our environment.

Gastric ischemia secondary to intestinal occlusion due to gallstone ileus.

Gallstone ileus is a rare complication of cholecystoduodenal fistula. Gastric ischemia due to intestinal obstruction is an extremely rare event that, if not diagnosed in time, can have a fatal outcome. We present the case of a patient with intestinal occlusion due to a gallstone obstructing the middle jejunum in which gastric ischemia was diagnosed intraoperatively due to the distension caused by the intestinal obstruction.

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.

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.

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.

Primer tratamiento PIPAC en un hospital público español. Una novedosa técnica para el tratamiento de la carcinomatosis / First PIPAC treatment in a Spanish public hospital: A novel technique for the treatment of carcinomatosis

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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.

Hemorragia digestiva grave secundaria a tumor yeyunal gigante del estroma gastrointestinal / Severe bleeding caused by giant gastrointestinal stromal tumor of the jejunum

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Gastroduodenectomía total con preservación pancreática para el tratamiento del síndrome de Gardner con poliposis gastroduodenal y degeneración maligna / Total gastroduodenectomy with pancreatic preservation for the treatment of Gardner's syndrome with gastroduodenal polyposis and malignant transformation

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