Safe discharge for patients admitted for lower gastrointestinal bleeding (LGITB): derivation and validation of a novel scoring system.

AIM: Bleeding from the lower gastrointestinal tract (LGITB) is a common clinical presentation. Recent guidelines have recommended for incorporation of clinical risk assessment tools in the management for LGITB. We derived and validated a novel clinical scoring system to predict safe discharge after LGITB admission, and compared it to other published scoring systems in current literature. METHODS: A retrospective cohort of 798 patients with LGITB from August 2018 to March 2021 was included in the derivation cohort. Multivariate binary logistic regression was performed to identify significant clinical variables predictive of safe discharge. A clinical scoring system was developed based on the results, and validated on a prospective cohort of 312 consecutive patients with LGITB from April 2021 to March 2022. The performance of the novel scoring system was compared to other LGITB clinical risk assessment scores via area under the receiver operating characteristics curve (AUROC) analysis. RESULTS: Variables predictive of safe discharge included the following; absence of previous LGITB admission, absence of ischemic heart disease, absence of blood on digital rectal examination, absence of dizziness or syncope at presentation and the systolic blood pressure and haemoglobin levels at presentation. The novel score had an AUROC of 0.907. A cut-off point of 4 provided a sensitivity of 41.9%, specificity of 97.5%, positive predictive value of 96.4% and negative predictive value of 51.5% for prediction of safe discharge. The score performs comparably to the Oakland score. CONCLUSION: The novel LGITB clinical risk score has good predictive performance for safe discharge in patients admitted for LGITB.

Clinical outcomes and cost comparison of laparoscopic versus open surgery in elderly colorectal cancer patients over 80 years.

PURPOSE: The growth of Singapore's geriatric population, coupled with the rise in colorectal cancer (CRC), has increased the number of colorectal surgeries performed on elderly patients. This study aimed to compare the clinical outcomes and costs of laparoscopic versus open elective colorectal resections in elderly CRC patients over 80 years. METHODS: A retrospective cohort study using data from the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) identified patients over 80 years undergoing elective colectomy and proctectomy between 2018 and 2021. Patient demographics, length of stay (LOS), 30-day postoperative complications, and mortality rates were analysed. Cost data in Singapore dollars were obtained from the finance database. Univariate and multivariate regression models were used to determine cost drivers. The 5-year overall survival (OS) for the entire octogenarian CRC cohort with and without postoperative complications was estimated using the Kaplan-Meier curves. RESULTS: Of the 192 octogenarian CRC patients undergoing elective colorectal surgery between 2018 and 2021, 114 underwent laparoscopic resection (59.4%), while 78 underwent open surgery (40.6%). The proportion of proctectomy cases was similar between laparoscopic and open groups (24.6% vs. 23.1%, P = 0.949). Baseline characteristics, including Charlson Comorbidity Index, albumin level, and tumour staging, were comparable between both groups. Median operative duration was 52.5 min longer in the laparoscopic group (232.5 vs. 180.0 min, P < 0.001). Both groups had no significant differences in postoperative complications and 30-day and 1-year mortality rates. Median LOS was 6 days in the laparoscopic group compared to 9 days in the open group (P < 0.001). The mean total cost was 11.7% lower in the laparoscopic group (S$25,583.44 vs. S$28,970.85, P = 0.012). Proctectomy (P = 0.024), postoperative pneumonia (P < 0.001) and urinary tract infection (P < 0.001), and prolonged LOS > 6 days (P < 0.001) were factors contributing to increased costs in the entire cohort. The 5-year OS of octogenarians with minor or major postoperative complications was significantly lower than those without complications (P < 0.001). CONCLUSION: Laparoscopic resection is associated with significantly reduced overall hospitalization costs and decreased LOS compared to open resection among octogenarian CRC patients, with comparable postoperative outcomes and 30-day and 1-year mortality rates. The extended operative time and higher consumables costs from laparoscopic resection were mitigated by the decrease in other inpatient hospitalization costs, including ward accommodation, daily treatment fees, investigation costs, and rehabilitation expenditures. Comprehensive perioperative care and optimised surgical approach to mitigate the impact of postoperative complications can improve survival in elderly patients undergoing CRC resection.

A Novel Derivation Predicting Survival After Primary Tumor Resection in Stage IV Colorectal Cancer: Validation of a Prognostic Scoring Model and an Online Calculator to Provide Individualized Survival Estimation.

BACKGROUND: A prognostic scoring model has been devised previously to predict survival following primary tumor resection in patients with metastatic colorectal cancer and unresectable metastases. This has yet to be validated. OBJECTIVE: The main objectives of this study are to validate the proposed prognostic scoring model and create an interactive online calculator to estimate an individual's survival after primary tumor resection. DESIGN: Clinical data and survival outcomes of patients were extracted from a prospectively maintained database. Patients were categorized into good, moderate, or poor survivor groups based on the previously proposed scoring algorithm. Discrimination was assessed and recalibration was performed, with the recalibrated model implemented as an interactive Web application to provide individualized survival probability. SETTINGS: This study was conducted at a tertiary referral center. PATIENTS: The study included 324 consecutive patients with metastatic colorectal carcinoma and unresectable metastases who underwent primary tumor resection between January 2008 and December 2013. MAIN OUTCOME MEASURES: The primary outcome measured was overall survival. RESULTS: Three hundred twenty-four patients were included in the study. Median survival in the good, moderate, and poor prognostic groups was 56.8, 25.7, and 19.9 months (log rank test, p = 0.003). The κ statistic was 0.638 and RD was 0.101. Significant differences in survival were found between the moderate and good prognostic groups (HR, 2.79; 95% CI, 1.51-5.15; p = 0.001) and between poor and good prognostic groups (HR, 4.12; 95% CI, 1.98-8.55; p < 0.001). The model was implemented as an interactive online calculator to provide individualized survival estimation after primary tumor resection (http://bit.ly/Stage4PrognosticScore). LIMITATIONS: Selection bias and single-center data preclude the generalizability of the proposed model. Information regarding the severity or likelihood of developing symptoms from the primary tumor were also not accounted for in the prognostic scoring model proposed. CONCLUSIONS: The prognostic scoring model provides good prognostic stratification of survival after primary tumor resection and may be a useful tool to predict survival after primary tumor resection. See Video Abstract at http://links.lww.com/DCR/A330.