Systematic review and narrative synthesis of surgeons' perception of postoperative outcomes and risk.

BACKGROUND: The accuracy with which surgeons can predict outcomes following surgery has not been explored in a systematic way. The aim of this review was to determine how accurately a surgeon's 'gut feeling' or perception of risk correlates with patient outcomes and available risk scoring systems. METHODS: A systematic review was undertaken in accordance with PRISMA guidelines. A narrative synthesis was performed in accordance with the Guidance on the Conduct of Narrative Synthesis In Systematic Reviews. Studies comparing surgeons' preoperative or postoperative assessment of patient outcomes were included. Studies that made comparisons with risk scoring tools were also included. Outcomes evaluated were postoperative mortality, general and operation-specific morbidity and long-term outcomes. RESULTS: Twenty-seven studies comprising 20 898 patients undergoing general, gastrointestinal, cardiothoracic, orthopaedic, vascular, urology, endocrine and neurosurgical operations were included. Surgeons consistently overpredicted mortality rates and were outperformed by existing risk scoring tools in six of seven studies comparing area under receiver operating characteristic (ROC) curves (AUC). Surgeons' prediction of general morbidity was good, and was equivalent to, or better than, pre-existing risk prediction models. Long-term outcomes were poorly predicted by surgeons, with AUC values ranging from 0·51 to 0·75. Four of five studies found postoperative risk estimates to be more accurate than those made before surgery. CONCLUSION: Surgeons consistently overestimate mortality risk and are outperformed by pre-existing tools; prediction of longer-term outcomes is also poor. Surgeons should consider the use of risk prediction tools when available to inform clinical decision-making.

ANTECEDENTES: La precisión con la cual los cirujanos pueden predecir los resultados de la cirugía no se ha estudiado de forma sistemática. El objetivo de esta revisión fue determinar con qué precisión la intuición de un cirujano o su percepción del riesgo se correlacionaba con los resultados del paciente y con los sistemas de puntuación del riesgo disponibles. MÉTODOS: Se efectuó una revisión sistemática siguiendo las directrices PRISMA. Se realizó una síntesis narrativa de acuerdo con la guía para la realización de síntesis narrativas en revisiones sistemáticas. Se incluyeron los estudios que comparaban las evaluaciones preoperatorias o postoperatorias de los cirujanos respecto a los resultados de los pacientes. También se incluyeron aquellos estudios en los que se hacían comparaciones con herramientas de puntuación de riesgo. Se evaluaron la mortalidad postoperatoria, la morbilidad global y la morbilidad específica de las intervenciones, y los resultados a largo plazo. RESULTADOS: Se incluyeron 27 estudios con 20.898 pacientes en los que se realizaron procedimientos de cirugía general, digestiva, cardiotorácica, ortopédica, vascular, urológica, endocrina y neurocirugía. Los cirujanos predijeron consistentemente mayores tasas de mortalidad, siendo superados en precisión por los sistemas de estimación del riesgo existentes en seis de los siete estudios que utilizaron el área bajo la curva (area under curve, AUC) operativa del receptor. La predicción de la morbilidad general por parte de los cirujanos fue buena y era equivalente, incluso mejor, que los modelos de predicción de riesgos preexistentes. La capacidad de los cirujanos para predecir los resultados a largo plazo fue pobre, con una AUC que oscilaba entre 0,51 y 0,75. Cuatro de cinco estudios encontraron que las estimaciones de riesgo postoperatorias fueron más precisas que las realizadas preoperatoriamente. CONCLUSIÓN: Los cirujanos sobrestiman consistentemente el riesgo de mortalidad, siendo superados en precisión por las herramientas preexistentes. La predicción de resultados a largo plazo también es muy pobre. Los cirujanos deberían considerar el uso de herramientas de predicción de riesgo cuando estén disponibles para informar en el proceso de decisión clínica.

Angiosome Specific Revascularisation: Does the Evidence Support It?

OBJECTIVE: To explain the angiosome concept and explore the practical application of the angiosome literature to a clinical scenario, in this case a tibial angioplasty for critical ischaemia. METHODS: Clinical vignette with explanation of the decisions made and subsequent clinical results based on the theory of the angiosome concept and the literature on angiosomal revascularisation; in this case the results of our group's recent update to a systematic review and meta-analysis. RESULTS: Endovascular combined or direct angiosomal revascularisation if superior to indirect revascularisation. This was borne out in the clinical scenario, where an indirect peroneal reperfusion of the AT angiosome resulted in major amputation. Open surgery is less dependent on the angiosome concept. The presence of adequate collateralisation into a foot arch seems to be the most important factor predicting success of indirect revascularisation. The evidence for both suffers from selection bias and many of the findings in the literature are wholly due to selection bias. CONCLUSION: The angiosome concept is useful during both open and endovascular tibial revascularisation. However, the runoff in the foot is critical to success and may not follow the 'classic' angiosome model in diabetes.

Inflammatory cell ratios predict major septic complications following rectal cancer surgery.

INTRODUCTION: The inflammatory response is known to have an important role in tumourigenesis and the response to treatment. Previous studies have demonstrated that inflammatory cell ratios such as the neutrophil-to-lymphocyte ratio (NLR) can predict survival and recurrence following surgery for various cancers. The objective of this study was to demonstrate if pre-operative NLR has a role in predicting post-operative septic complications in patients undergoing rectal cancer surgery. METHODOLOGY: Consecutive patients undergoing scheduled resection for rectal cancer in a tertiary centre from July 2007 to Dec 2015 were included. Data was gathered from a prospectively held database of rectal cancer. Normally distributed data were compared with paired t tests (mean ± standard error in the mean (SEM)), and proportions were compared with Fisher's exact test. A p value of < 0.05 was considered statistically significant. RESULTS: Three hundred fourteen patients were identified in this study. Sixty nine (22.0%) patients had a major septic complication following surgery for rectal cancer, which was associated with a poor survival outcome (p < 0.01) Both pre and post-operative NLR and PLR (platelet lymphocyte ratio) were associated with post-operative septic complications (both p < 0.01). A pre-operative NLR threshold level of 4 was chosen from ROC analysis, and this provided a relatively specific test to predict post-operative septic complications in these patients (specificity = 83.7%, negative predictive value (NPV) = 74.8%). DISCUSSION: In this study, the pre-operative NLR and PLR were both predictive of major post-operative septic complications. A pre-operative NLR of less than 4 was strongly negative predictor of post-operative complications in rectal cancer surgery. It can be regarded as a predictive and prognostic factor for these patients.

Role of glycogen synthase kinase following myocardial infarction and ischemia-reperfusion.

Glycogen synthase kinase-3 beta (GSK3ß) is principally is a glycogen synthase phosphorylating enzyme that is well known for its role in muscle metabolism. GSK3ß is a serine/threonine protein Kinase, which is responsible for several essential roles in mammalian cells. This enzyme is implicated in the pathophysiology of many conditions involved in homeostasis and cellular immigration. GSK3ß is involved in several pathways leading to neurodegenerative diseases such as Alzheimer's disease and Parkinson's disease. Increasing evidence has shown the potential importance of GSK3ß in ischemic heart disease and ischemia-reperfusion pathologies. Reperfusion injury may occur in tissues after prolonged ischemia following reperfusion. Reperfusion injury can be life threatening. Reperfusion injury occurs due to a change in ionic homeostasis, excess free radical production, mitochondrial damage and cell death. There are however clear, cardiac-protective signals; although the molecular pathophysiology is not clearly understood. In normal physiology, GSK3ß has a critical role in the cytoprotective pathway. However, it`s controversial role in ischemia and ischemia-reperfusion is a topic of current interest. In this review, we have opted to focus on GSK3ß interactions with mitochondria in ischemic heart disease and expand on the therapeutic interventions.