Preoperative assessment of lymph nodal metastases with [68Ga]Ga-DOTATOC PET radiomics for improved surgical planning in well-differentiated pancreatic neuroendocrine tumours.

PURPOSE: Accurate identification of lymph node (LN) metastases is pivotal for surgical planning of pancreatic neuroendocrine tumours (PanNETs); however, current imaging techniques have sub-optimal diagnostic sensitivity. Aim of this study is to investigate whether [68Ga]Ga-DOTATOC PET radiomics might improve the identification of LN metastases in patients with non-functioning PanNET (NF-PanNET) referred to surgical intervention. METHODS: Seventy-two patients who performed preoperative [68Ga]Ga-DOTATOC PET between December 2017 and March 2022 for NF-PanNET. [68Ga]Ga-DOTATOC PET qualitative assessment of LN metastases was measured using diagnostic balanced accuracy (bACC), sensitivity (SN), specificity (SP), positive and negative predictive values (PPV, NPV). SUVmax, SUVmean, Somatostatin receptor density (SRD), total lesion SRD (TLSRD) and IBSI-compliant radiomic features (RFs) were obtained from the primary tumours. To predict LN involvement, these parameters were engineered, selected and used to train different machine learning models. Models were validated using tenfold repeated cross-validation and control models were developed. Models' bACC, SN, SP, PPV and NPV were collected and compared (Kruskal-Wallis, Mann-Whitney). RESULTS: LN metastases were detected in 29/72 patients at histology. [68Ga]Ga-DOTATOC PET qualitative examination of LN involvement provided bACC = 60%, SN = 24%, SP = 95%, PPV = 78% and NPV = 65%. The best-performing radiomic model provided a bACC = 70%, SN = 77%, SP = 61%, PPV = 60% and NPV = 83% (outperforming the control model, p < 0.05*). CONCLUSION: In this study, [68Ga]Ga-DOTATOC PET radiomics allowed to increase diagnostic sensitivity in detecting LN metastases from 24 to 77% in NF-PanNET patients candidate to surgery. Especially in case of micrometastatic involvement, this approach might assist clinicians in a better patients' stratification.

Utility of the LACE index to assess risk of mortality and readmission in patients with spinal infections.

Retrospective cohort study. To assess the utility of the LACE index for predicting death and readmission in patients with spinal infections (SI). SIs are severe conditions, and their incidence has increased in recent years. The LACE (Length of stay, Acuity of admission, Comorbidities, Emergency department visits) index quantifies the risk of mortality or unplanned readmission. It has not yet been validated for SIs. LACE indices were calculated for all adult patients who underwent surgery for spinal infection between 2012 and 2021. Data were collected from a single academic teaching hospital. Outcome measures included the LACE index, mortality, and readmission rate within 30 and 90 days. In total, 164 patients were analyzed. Mean age was 64.6 (± 15.1) years, 73 (45%) were female. Ten (6.1%) patients died within 30 days and 16 (9.8%) died within 90 days after discharge. Mean LACE indices were 13.4 (± 3.6) and 13.8 (± 3.0) for the deceased patients, compared to 11.0 (± 2.8) and 10.8 (± 2.8) for surviving patients (p = 0.01, p < 0.001), respectively. Thirty-seven (22.6%) patients were readmitted ≤ 30 days and 48 (29.3%) were readmitted ≤ 90 days. Readmitted patients had a significantly higher mean LACE index compared to non-readmitted patients (12.9 ± 2.1 vs. 10.6 ± 2.9, < 0.001 and 12.8 ± 2.3 vs. 10.4 ± 2.8, p < 0.001, respectively). ROC analysis for either death or readmission within 30 days estimated a cut-off LACE index of 12.0 points (area under the curve [AUC] 95% CI, 0.757 [0.681-0.833]) with a sensitivity of 70% and specificity of 69%. Patients with SI had high LACE indices that were associated with high mortality and readmission rates. The LACE index can be applied to this patient population to predict the risk of early death or unplanned readmission.

Preoperative Factors for Lymphovascular Invasion in Prostate Cancer: A Systematic Review and Meta-Analysis.

Lymphovascular invasion (LVI) is one of the most important prognostic factors in prostate cancer (PCa) and is correlated with worse survival rates, biochemical recurrence (BCR), and lymph node metastasis (LNM). The ability to predict LVI preoperatively in PCa may be useful for proposing variations in the diagnosis and management strategies. We performed a systematic review and meta-analysis to identify preoperative clinicopathological factors that correlate with LVI in final histopathological specimens in PCa patients. Systematic literature searches of PubMed, Embase, and Web of Science were performed up to 31 January 2023. A total of thirty-nine studies including 389,918 patients were included, most of which were retrospective and single-center. PSA level, clinical T stage, and biopsy Gleason score were significantly correlated with LVI in PCa specimens. Meta-analyses revealed that these factors were the strongest predictors of LVI in PCa patients. Prostate volume, BMI, and age were not significant predictors of LVI. A multitude of preoperative factors correlate with LVI in final histopathology. Meta-analyses confirmed correlation of LVI in final histopathology with higher preoperative PSA, clinical T stage, and biopsy Gleason score. This study implies advancements in risk stratification and enhanced clinical decision-making, and it underscores the importance of future research dedicated to validation and exploration of contemporary risk factors in PCa.

A retrospective analysis of the association of effort-independent cardiopulmonary exercise test variables with postoperative complications in patients who underwent elective colorectal surgery.

PURPOSE: This study aimed to investigate the association of effort-independent variables derived from the preoperative cardiopulmonary exercise test (CPET) with 30-day postoperative complications after elective colorectal surgery. METHODS: A multicenter (n=4) retrospective explorative study was performed using data of patients who completed a preoperative CPET and underwent elective colorectal surgery. The preoperative slope of the relation between minute ventilation and carbon dioxide production (VE/VCO2-slope) and the oxygen uptake efficiency slope (OUES), as well as 30-day postoperative complications, were assessed. Multivariable logistic regression analyses and receiver operating characteristic (ROC) curves were used to investigate the prognostic value of the relationship between these preoperative CPET-derived effort-independent variables and postoperative complications. RESULTS: Data from 102 patients (60.1% males) with a median age of 72.0 (interquartile range 67.8-77.4) years were analyzed. Forty-four patients (43.1%) had one or more postoperative complications (of which 52.3% general and 77.3% surgical complications). Merely 10 (9.8%) patients had a general complication only. In multivariate analysis adjusted for surgical approach (open versus minimally invasive surgery), the VE/VCO2-slope (odds ratio (OR) 1.08, confidence interval (CI) 1.02-1.16) and OUES (OR 0.94, CI 0.89-1.00) were statistically significant associated with the occurrence of 30-day postoperative complications. CONCLUSION: The effort-independent VE/VCO2-slope and OUES might be used to assist in future preoperative risk assessment and could especially be of added value in patients who are unable or unwilling to deliver a maximal cardiorespiratory effort. Future research should reveal the predictive value of these variables individually and/or in combination with other prognostic (CPET-derived) variables for postoperative complications. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT05331196.

Fitbit Data to Assess Functional Capacity in Patients Before Elective Surgery: Pilot Prospective Observational Study.

BACKGROUND: Preoperative assessment is crucial to prevent the risk of complications of surgical operations and is usually focused on functional capacity. The increasing availability of wearable devices (smartwatches, trackers, rings, etc) can provide less intrusive assessment methods, reduce costs, and improve accuracy. OBJECTIVE: The aim of this study was to present and evaluate the possibility of using commercial smartwatch data, such as those retrieved from the Fitbit Inspire 2 device, to assess functional capacity before elective surgery and correlate such data with the current gold standard measure, the 6-Minute Walk Test (6MWT) distance. METHODS: During the hospital visit, patients were evaluated in terms of functional capacity using the 6MWT. Patients were asked to wear the Fitbit Inspire 2 for 7 days (with flexibility of -2 to +2 days) after the hospital visit, before their surgical operation. Resting heart rate and daily steps data were retrieved directly from the smartwatch. Feature engineering techniques allowed the extraction of heart rate over steps (HROS) and a modified version of Non-Exercise Testing Cardiorespiratory Fitness. All measures were correlated with 6MWT. RESULTS: In total, 31 patients were enrolled in the study (n=22, 71% men; n=9, 29% women; mean age 76.06, SD 4.75 years). Data were collected between June 2021 and May 2022. The parameter that correlated best with the 6MWT was the Non-Exercise Testing Cardiorespiratory Fitness index (r=0.68; P<.001). The average resting heart rate over the whole acquisition period for each participant had r=-0.39 (P=.03), even if some patients did not wear the device at night. The correlation of the 6MWT distance with the HROS evaluated at 1% quantile was significant, with Pearson coefficient of -0.39 (P=.04). Fitbit step count had a fair correlation of 0.59 with 6MWT (P<.001). CONCLUSIONS: Our study is a promising starting point for the adoption of wearable technology in the evaluation of functional capacity of patients, which was strongly correlated with the gold standard. The study also identified limitations in the availability of metrics, variability of devices, accuracy and quality of data, and accessibility as crucial areas of focus for future studies.

Preoperative Assessment and Optimization of Cardiopulmonary Disease in Noncardiac Surgery.

More than 50 million surgical procedures are carried out every year in the United States with the estimated risk of major adverse cardiac events perioperatively between 1.4 and 3.9%. Given that the majority of surgeries are elective, this allows ample opportunity to identify patients at higher risk of perioperative adverse events and optimize them for surgery. Preexisting cardiopulmonary disease is a major risk factor for adverse events perioperatively and can lead to significant morbidity and mortality. It can predispose patients to perioperative myocardial ischemia and infarction, perioperative pulmonary complications, and perioperative stroke among other complications. This article details an approach to preoperative interview and examination, indications for preoperative testing, and strategies for optimization in patients with underlying cardiopulmonary disease. It also includes guidelines on optimal timing of elective surgery in certain clinical scenarios that can escalate perioperative risk. Through the use of thorough preoperative assessment, targeted preoperative testing, and multidisciplinary optimization of preexisting disease, perioperative risk can be decreased significantly and perioperative outcomes improved.

Aerobic fitness and muscle density play a vital role in postoperative complications in colorectal cancer surgery.

BACKGROUND AND OBJECTIVES: To assess the association of preoperative aerobic fitness and body composition variables with a patient's resilience to the development and impact of postoperative complications after elective colorectal cancer (CRC) surgery. METHODS: Preoperative aerobic fitness was assessed by steep ramp test performance. Preoperative body composition was assessed by muscle mass and density determined from preoperative computed tomography scan analysis at the L3-level. Complication development and severity was graded according to Clavien-Dindo. Complication impact was assessed by the time to recovery of physical functioning after complications. Multivariable logistic regression analyses adjusted for age, sex, comorbidities and tumour location was performed. RESULTS: Of 238 included patients, 96 (40.3%) developed postoperative complications. Better preoperative aerobic fitness decreased the likelihood to develop complications, independent of muscle mass (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.35-0.85) or muscle density (OR: 0.57, 95% CI: 0.36-0.89). A prolonged time to recovery following complications was associated with lower preoperative muscle density (OR: 4.14, 95% CI: 1.28-13.41), independent of aerobic fitness. CONCLUSIONS: Lower aerobic fitness increases the risk of complication development, while low muscle density seems associated with a prolonged recovery from complications. Aerobic fitness and muscle density could be valuable additives to preoperative risk assessment.

The association between preoperative body composition and aerobic fitness in patients scheduled for colorectal surgery.

AIM: Although cardiopulmonary exercise testing (CPET) is considered the gold standard, a preoperative abdominal CT scan might also provide information concerning preoperative aerobic fitness for risk assessment. This study aimed to investigate the association between preoperative CT-scan-derived body composition variables and preoperative CPET variables of aerobic fitness in colorectal surgery. METHOD: In this retrospective cohort study, CT images at level L3 were analysed for skeletal muscle mass, skeletal muscle radiation attenuation, visceral adipose tissue (VAT) mass and subcutaneous adipose tissue mass. Regression analyses were performed to investigate the relation between CT-scan-derived body composition variables, CPET-derived aerobic fitness and other preoperative patient-related variables. Logistic regression analysis was performed to predict a preoperative anaerobic threshold (AT) ≤ 11.1 ml/kg/min as cut-off for having a high risk for postoperative complications. RESULTS: Data from 78 patients (45 men; mean [SD] age 74.5 [6.4 years]) were analysed. A correlation coefficient of 0.55 was observed between absolute AT and skeletal muscle mass index. Absolute AT (R2 of 51.1%) was lower in patients with a lower skeletal muscle mass index, together with higher age, lower body mass and higher American Society of Anesthesiologists (ASA) score. Higher ASA score (odds ratio 5.64; P = 0.033) and higher VAT mass (odds ratio 1.02; P = 0.036) were associated with an increased risk of an AT ≤ 11.1 ml/kg/min. CONCLUSION: Body composition variables from the preoperative CT scan were moderately associated with preoperative CPET-derived aerobic fitness. Higher ASA score and higher VAT mass were associated with an increased risk of an AT ≤ 11.1 ml/kg/min.

Inter-observer agreement of preoperative cardiopulmonary exercise test interpretation in major abdominal surgery.

BACKGROUND: Accurate determination of cardiopulmonary exercise test (CPET) derived parameters is essential to allow for uniform preoperative risk assessment. The objective of this prospective observational study was to evaluate the inter-observer agreement of preoperative CPET-derived variables by comparing a self-preferred approach with a systematic guideline-based approach. METHODS: Twenty-six professionals from multiple centers across the Netherlands interpreted 12 preoperative CPETs of patients scheduled for hepatopancreatobiliary surgery. Outcome parameters of interest were oxygen uptake at the ventilatory anaerobic threshold (V̇O2VAT) and at peak exercise (V̇O2peak), the slope of the relationship between the minute ventilation and carbon dioxide production (V̇E/V̇CO2-slope), and the oxygen uptake efficiency slope (OUES). Inter-observer agreement of the self-preferred approach and the guideline-based approach was quantified by means of the intra-class correlation coefficient. RESULTS: Across the complete cohort, inter-observer agreement intraclass correlation coefficient (ICC) was 0.76 (95% confidence interval (CI) 0.57-0.93) for V̇O2VAT, 0.98 (95% CI 0.95-0.99) for V̇O2peak, and 0.86 (95% CI 0.75-0.95) for the V̇E/V̇CO2-slope when using the self-preferred approach. By using a systematic guideline-based approach, ICCs were 0.88 (95% CI 0.74-0.97) for V̇O2VAT, 0.99 (95% CI 0.99-1.00) for V̇O2peak, 0.97 (95% CI 0.94-0.99) for the V̇E/V̇CO2-slope, and 0.98 (95% CI 0.96-0.99) for the OUES. CONCLUSIONS: Inter-observer agreement of numerical values of CPET-derived parameters can be improved by using a systematic guideline-based approach. Effort-independent variables such as the V̇E/V̇CO2-slope and the OUES might be useful to further improve uniformity in preoperative risk assessment in addition to, or in case V̇O2VAT and V̇O2peak are not determinable.

Stress testing before abdominal aortic aneurysm repair does not lead to a reduction in perioperative cardiac events.

OBJECTIVE: Stress testing is often used before abdominal aortic aneurysm (AAA) repair. Whether stress testing leads to a reduction in cardiac events after AAA repair has remained unclear. Our objective was to study the national stress test usage rates and compare the perioperative outcomes between centers with high and low usage of stress testing. METHODS: We used the Vascular Quality Initiative to study patients who had undergone elective endovascular AAA repair (EVAR) or open AAA repair (OAR). We measured the usage rates of stress testing across centers and compared the Vascular Study Group of New England cardiac risk index (VSG-CRI) among patients who had and had not undergone preoperative stress testing. We determined the rate of major adverse cardiac events (MACE), a composite of perioperative myocardial infarction, stroke, heart failure exacerbation, and death across the centers. We compared the MACE and 1-year mortality between the centers in the highest quintile of stress test usage and the lowest quintile. RESULTS: We studied 43,396 EVAR patients and 8935 OAR patients across 324 centers. The median proportion of stress test usage across centers before EVAR was 35.9% and varied from 10.2% (5th percentile) to 73.7% (95th percentile), with similar variability for OAR (median, 57.9%; 5th percentile, 13.0%; 95th percentile, 86.0%). The mean VSG-CRI for the EVAR group with preoperative stress testing was 5.6 ± 2.1 compared with 5.4 ± 2.1 (P < .001) for the EVAR group without preoperative stress testing. The findings were similar for OAR, with a VSG-CRI of 5.1 ± 2.0 vs 4.8 ± 2.1 (P < .001) for those with and without preoperative stress testing, respectively. The rate of MACE was 1.8% after EVAR and 11.6% after OAR. The 1-year mortality was 4.6% for EVAR and 6.6% for OAR. The centers in the highest quintile of stress testing had a higher adjusted likelihood of MACE after both EVAR (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.37-2.30) and OAR (OR, 1.99; 95% CI, 1.53-2.59) but similar 1-year mortality (EVAR: OR, 1.18; 95% CI, 1.02-1.37; OAR: OR, 0.87; 95% CI, 0.65-1.17) compared with the centers in the lowest quintile. The VSG-CRI was not different between the high stress test centers (EVAR, 5.5 ± 2.1; OAR: 5.0 ± 2.0), and low stress test centers (EVAR, 5.5 ± 2.1; P = .403; OAR, 4.9 ± 2.0; P = .563). CONCLUSIONS: Stress test usage before AAA repair varied widely across Vascular Quality Initiative centers despite similar patient risk profiles. No reduction was observed in MACE or 1-year mortality among centers with high stress test usage. The value of routine stress testing before AAA repair should be reconsidered, and stress testing should be used more selectively, given these findings and the associated costs of widespread testing.

Implementation of frailty preoperative assessment to predict outcome in patients undergoing urological surgery: a systematic review and meta-analysis.

BACKGROUND: A common limit of the widely used risk scores for preoperative assessment is the lack of information about aspects linked to frailty that may affect outcome, especially in the setting of elderly patients undergoing urological surgery. Frailty has recently been introduced as an additional characteristic to be assessed for better identifying patients at risk of negative outcomes. OBJECTIVE: To examine the evidence for recent advances in preoperative assessment in patients undergoing urological surgery focussing on the detrimental effect of frailty on outcome, including major (mPCs) and total postoperative complications (tPCs), discharge to a facility, and mortality. The secondary aim was to establish which cut-off scores of the modified Frailty Index (mFI, 11 items) and/or simplified FI (sFI, five items) predicted PCs. METHODS: We searched PubMed, the Excerpta Medica database (EMBASE), Cochrane Library and clinicaltrial.gov from inception to 31 May 2020. Studies reporting relationships between the investigated outcomes and patients' frailty were included. We estimated odds ratios (ORs) through a random effect model by using Revman 5.4. RESULTS: Frailty, assessed by different tools, was associated with a significantly higher rate of 30-day (OR 1.73, 95% confidence interval [CI] 1.58-1.89) and 90-day (OR 2.09, 95% CI 1.14-3.82) mPCs and 30-day tPCs (OR 2.10, 95% CI 1.76-2.52). A mFI of ≥2 was associated with a higher rate of 30-day mPCs (OR 1.79, 95% CI 1.69-1.89) and greater 30-day mortality (OR 3.46, 95% CI 2.10-5.49). A pre-planned post hoc analysis also revealed that a sFI of ≥3 was predictive of mPCs (OR 3.30, 95% CI 2.12-5.12). CONCLUSIONS: Frailty assessment may help to predict PCs and mortality in patients undergoing major urological surgery. Either a mFi of ≥2 or sFI of ≥3 should be considered potential 'red flags' for preoperative risk assessment and decision-making. There is not enough evidence to confirm the necessity to perform frailty assessment in minor urological surgery.

Few and feasible preoperative variables can identify high-risk surgical patients: derivation and validation of the Ex-Care risk model.

BACKGROUND: The development of feasible preoperative risk tools is desirable, especially for low-middle income countries with limited resources and complex surgical settings. This study aimed to derive and validate a preoperative risk model (Ex-Care model) for postoperative mortality and compare its performance with current risk tools. METHODS: A multivariable logistic regression model predicting in-hospital mortality was developed using a large Brazilian surgical cohort. Patient and perioperative predictors were considered. Its performance was compared with the Charlson comorbidity index (CCI), Revised Cardiac Risk Index (RCRI), and the Surgical Outcome Risk Tool (SORT). RESULTS: The derivation cohort included 16 618 patients. In-hospital death occurred in 465 patients (2.8%). Age, with adjusted splines, degree of procedure (major vs non-major), ASA physical status, and urgency were entered in a final model. It showed high discrimination with an area under the receiver operating characteristic curve (AUROC) of 0.926 (95% confidence interval [CI], 0.91-0.93). It had superior accuracy to the RCRI (AUROC, 0.90 vs 0.76; P<0.01) and similar to the CCI (0.90 vs 0.82; P=0.06) and SORT models (0.90 vs 0.92; P=0.2) in the temporal validation cohort of 1173 patients. Calibration was adequate in both development (Hosmer-Lemeshow, 9.26; P=0.41) and temporal validation cohorts (Hosmer-Lemeshow 5.29; P=0.71). CONCLUSIONS: The Ex-Care risk model proved very efficient at identifying high-risk surgical patients. Although multicentre studies are needed, it should have particular value in low resource settings to better inform perioperative health policy and clinical decision-making.

Predicting acute kidney injury after cardiac surgery: much work still to be done.

Accurate preoperative risk prediction for perioperative complications such as acute kidney injury (AKI) may serve to better inform patients and families of risk before surgery, assist with resource requirement planning, and aid with cohort enrichment for enrolment into clinical trials. Where a specific risk factor is modifiable, it may offer a potential therapeutic target for risk reduction. The report by Wang and colleagues describes the modest incremental benefit of N-terminal pro brain natriuretic peptide levels when added to almost 20 other variables for the preoperative prediction of AKI after cardiac surgery. This is consistent with previous smaller studies, but there are important additional questions still to be answered before this biomarker might be used for this purpose in clinical practice.

A simplified (modified) Duke Activity Status Index (M-DASI) to characterise functional capacity: a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) study.

BACKGROUND: Accurate assessment of functional capacity, a predictor of postoperative morbidity and mortality, is essential to improving surgical planning and outcomes. We assessed if all 12 items of the Duke Activity Status Index (DASI) were equally important in reflecting exercise capacity. METHODS: In this secondary cross-sectional analysis of the international, multicentre Measurement of Exercise Tolerance before Surgery (METS) study, we assessed cardiopulmonary exercise testing and DASI data from 1455 participants. Multivariable regression analyses were used to revise the DASI model in predicting an anaerobic threshold (AT) >11 ml kg-1 min-1 and peak oxygen consumption (VO2 peak) >16 ml kg-1 min-1, cut-points that represent a reduced risk of postoperative complications. RESULTS: Five questions were identified to have dominance in predicting AT>11 ml kg-1 min-1 and VO2 peak>16 ml.kg-1min-1. These items were included in the M-DASI-5Q and retained utility in predicting AT>11 ml.kg-1.min-1 (area under the receiver-operating-characteristic [AUROC]-AT: M-DASI-5Q=0.67 vs original 12-question DASI=0.66) and VO2 peak (AUROC-VO2 peak: M-DASI-5Q 0.73 vs original 12-question DASI 0.71). Conversely, in a sensitivity analysis we removed one potentially sensitive question related to the ability to have sexual relations, and the ability of the remaining four questions (M-DASI-4Q) to predict an adequate functional threshold remained no worse than the original 12-question DASI model. Adding a dynamic component to the M-DASI-4Q by assessing the chronotropic response to exercise improved its ability to discriminate between those with VO2 peak>16 ml.kg-1.min-1 and VO2 peak<16 ml.kg-1.min-1. CONCLUSIONS: The M-DASI provides a simple screening tool for further preoperative evaluation, including with cardiopulmonary exercise testing, to guide perioperative management.

Association of six-minute walk test distance with postoperative complications in non-cardiac surgery: a secondary analysis of a multicentre prospective cohort study.

PURPOSE: The six-minute walk test (6MWT) is a simple and valid test for assessing cardiopulmonary fitness. Nevertheless, the relationship between preoperative 6MWT distance and postoperative complications is uncertain. We conducted a secondary analysis of the 6MWT nested cohort substudy of the Measurement of Exercise Tolerance before Surgery study to determine if 6MWT distance predicts postoperative complications or death. METHODS: This analysis included 545 adults (≥ 40 yr) who were at elevated cardiac risk and had elective inpatient non-cardiac surgery at 15 hospitals in Canada, Australia, and New Zealand. Each participant performed a preoperative 6MWT and was followed for 30 days after surgery. The primary outcome was moderate or severe in-hospital complications. The secondary outcome was 30-day death or myocardial injury. Multivariable logistic regression modelling was used to characterize the adjusted association of 6MWT distance with these outcomes. RESULTS: Seven participants (1%) terminated their 6MWT sessions early because of lower limb pain, dyspnea, or dizziness. Eighty-one (15%) participants experienced moderate or severe complications and 69 (13%) experienced 30-day myocardial injury or death. Decreased 6MWT distance was associated with increased odds of moderate or severe complications (adjusted odds ratio, 1.32 per 100 m decrease; 95% confidence interval, 1.01 to 1.73; P = 0.045). There was no association of 6MWT distance with myocardial injury or 30-day death (non-linear association; P = 0.49). CONCLUSION: Preoperative 6MWT distance had a modest association with moderate or severe complications after inpatient non-cardiac surgery. Further studies are needed to determine the optimal role of the 6MWT as an objective exercise test for informing preoperative risk stratification.

RéSUMé: OBJECTIF: Le test de marche de six minutes (6MWT) est un test simple et validé pour évaluer la santé cardiopulmonaire. Néanmoins, la relation entre la distance parcourue lors d'un 6MWT préopératoire et les complications postopératoires est inconnue. Nous avons effectué une analyse secondaire de la sous-étude de cohorte imbriquée du 6MWT dans l'étude de la Mesure de la tolérance à l'exercice avant chirurgie (Measurement of Exercise Tolerance before Surgery) afin de déterminer si la distance parcourue lors du 6MWT était prédictive de complications postopératoires ou de décès. MéTHODE: Cette analyse comprenait 545 adultes (≥ 40 ans) courant un risque cardiaque élevé et hospitalisés pour une chirurgie non cardiaque élective dans 15 hôpitaux au Canada, en Australie et en Nouvelle-Zélande. Chaque participant a exécuté un 6MWT préopératoire et a été suivi pendant 30 jours post chirurgie. Le critère d'évaluation principal touchait aux complications modérées ou graves à l'hôpital. Le critère secondaire était le décès à 30 jours ou une lésion myocardique. Un modèle de régression logistique multivariée a été employé pour caractériser l'association ajustée entre la distance parcourue lors du 6MWT et ces critères d'évaluation. RéSULTATS: Sept participants (1 %) n'ont pas terminé leurs séances de 6MWT en raison de douleurs aux membres inférieurs, de dyspnée ou de vertiges. Quatre-vingt-un (15 %) participants ont souffert de complications modérées ou graves et 69 (13 %) ont subi une lésion myocardique ou sont décédés à 30 jours. La diminution de la distance parcourue au 6MWT a été associée à une augmentation du risque de complications modérées ou graves (rapport de cotes ajusté, 1,32 par diminution de 100 m; intervalle de confiance 95 %, 1,01 à 1,73; P = 0,045). Aucune association n'a été observée entre la distance parcourue au 6MWT et la lésion myocardique ou le décès à 30 jours (association non linéaire; P = 0,49). CONCLUSION: La distance parcourue lors d'un 6MWT préopératoire a été modestement associée à des complications modérées ou graves après une chirurgie non cardiaque avec hospitalisation. D'autres études sont nécessaires pour déterminer le rôle optimal du 6MWT en tant que test d'exercice objectif pour informer la stratification préopératoire des risques.

Preoperative risk assessment for ambulatory sinonasal surgery.

OBJECTIVES: An increasing proportion of patients who are candidates for endoscopic sinus surgery can be treated as an outpatient. A preoperative risk assessment is needed to evaluate eligibility for day surgery. This study analyses the effectiveness of a risk assessment scoring system which examines medical, procedure-related, and socioeconomic factors. DESIGN: Prospective multicenter study. SETTING: Three center study including Klinik Hirslanden, Zurich, Switzerland, Luzerner Kantonsspital, Lucerne, Switzerland and HNO-Klinik München-Bogenhausen, Munich, Germany. PARTICIPANTS: Patients with endoscopic sinus procedures between January 1st, 2017 and December 31st, 2018. MAIN OUTCOME MEASURES: The "day surgery risk score" consisted of three subgroups with medical, procedure-related and socioeconomic risk factors were assessed to determine if these predicted the severity of postoperative complications. RESULTS: Three-hundred and one patients who underwent endoscopic sinus surgery were included. The score resulted in a median value of 5 [5, 5]. In the Receiver-Operating Curve (ROC-the true-positive rate against the false-positive rate), the Area Under the Curve (AUC) was 0.59 with 95% confidence interval from 0.49 to 0.69, indicating that the "day surgery risk score" may be no better at predicting the likelihood of a complication than a random classification model. CONCLUSIONS: The "day surgery risk score" is a straightforward risk assessment which combines medical, procedure-related, and socioeconomic factors. The score is easy to use but in trying to decide whether a patient is eligible for ambulatory endoscopic sinus surgery it did not predict whether a complication was more likely to occur.

Frailty and functional outcomes after open and endovascular procedures for patients with peripheral arterial disease: A systematic review.

BACKGROUND: Frailty has been associated with postoperative complications and mortality across surgical specialties, including vascular surgery. However, the influence of frailty on postoperative functional outcomes is unclear. We sought to determine the influence of frailty on functional outcomes after open or endovascular vascular procedures in patients with peripheral arterial disease. METHODS: This systematic review was conducted according to the PRISMA guidelines. Eligible articles were identified through database searches of Pubmed and EMBASE in April 2017. Studies reporting on frailty and functional outcomes after vascular interventions for peripheral artery disease (PAD) were included. Outcomes of interest were dependency in activities of daily living (ADL), dependent mobility, discharge destination, disability-free survival, and quality of life. Individual studies were assessed for quality and risk of bias using the Quality in Prognosis Studies tool. RESULTS: Eight studies met the eligibility criteria and were included. The risk of bias was low in two studies, intermediate in three studies, and high in three studies. Methods for frailty assessment were different for each study. Frailty was a predictor for discharge to a higher level of care, dependent mobility, and dependency in ADL after vascular procedures for PAD. Both frailty models and individual frailty characteristics seem to be associated with these adverse functional outcomes. CONCLUSIONS: Despite a limited amount of literature and an overall intermediate quality of the included studies, this systematic review shows an association between frailty and adverse functional outcomes after peripheral arterial procedures for PAD, including discharge to a care facility, dependent mobility, and a decline in ADL functioning.

Adverse cardiac events after vascular surgery are prevalent despite negative results of preoperative stress testing.

OBJECTIVE: Cardiac risk assessment is a critical component of vascular disease management before surgical intervention. The predictive risk reduction of a negative cardiac stress test result remains poorly defined. The objective of this study was to compare the incidence of postoperative cardiac events among patients with negative stress test results vs those who did not undergo testing. METHODS: We reviewed all patients who underwent elective open abdominal aortic aneurysm repair, suprainguinal bypass, endovascular aneurysm repair (EVAR), carotid endarterectomy (CEA), and infrainguinal bypass within the Vascular Study Group of New England from 2003 to 2017. We excluded patients with positive stress test results (n = 3312) and studied two mutually exclusive groups: elective surgery patients with a negative stress test result and elective surgery patients with no stress test (total n = 26,910). The primary outcome was a composite of in-hospital postoperative cardiac events (dysrhythmia, heart attack, heart failure) or death. RESULTS: A preoperative stress test was obtained in 66.3% of open repairs, 42.8% of suprainguinal bypasses, 37.1% of EVARs, 36.0% of CEAs, and 31.2% of infrainguinal bypasses. The proportion of patients receiving a preoperative stress test varied widely across centers, from 37.1% to 80.0%. The crude odds ratio of in-hospital postoperative cardiac event or death was 1.37 (95% confidence interval [CI], 1.07-1.76) for open repair and 1.52 (CI, 1.13-2.03) for suprainguinal bypass, indicating that patients with negative stress test results before these procedures were 37% and 52% more likely to suffer a postoperative event or die compared with patients selected to proceed directly to surgery without testing. Conversely, the crude odds ratio was 0.92 (CI, 0.66-1.29) for EVAR, 0.92 (CI, 0.70-1.21) for CEA, and 1.13 (CI, 0.90-1.40) for infrainguinal bypass, indicating that patients undergoing these procedures had a similar likelihood of sustaining an event whether they had a negative stress test result or proceeded directly to surgery without a stress test. CONCLUSIONS: The use of cardiac stress testing before vascular surgery varies widely throughout New England. Whereas patients are often appropriately selected to proceed directly to surgery, a negative preoperative stress test result should not assuage the concern for an adverse outcome as these patients retain a substantial likelihood of cardiac events, especially after large-magnitude procedures.

Sarcopenia assessed by the quantity and quality of skeletal muscle is a prognostic factor for patients undergoing cardiac surgery.

PURPOSE: Sarcopenia was assessed as a prognostic factor for patients undergoing cardiac surgery by evaluating the quantity and quality of skeletal muscle. METHODS: Sarcopenia was assessed by perioperative abdominal computed tomography using the total psoas muscle index (TPI) and intra-muscular adipose tissue content (IMAC). Patients were classified into high- (HT, n = 143) and low- (LT, n = 63) TPI groups and low- (LI, n = 122) and high- (HI, n = 84) IMAC groups. RESULTS: There were significantly more complications in the LT and HI groups than in the HT and LI groups. (HT 15.4% vs. LT 30.2%, P = 0.014) (LI 11.5% vs. HI 31.1%, P < 0.001). There were more respiratory complications in the LT group (HT 0% vs. LT 6.3%, P = 0.002) and more surgical site infections in the HI group than in the LI group (LI 0.8% vs. HI 7.1%, P = 0.014). A multivariable analysis showed that low TPI and high IMAC significantly predicted more major complications than other combinations (odds ratio [OR] 2.375; 95% confidence interval [CI] 1.152-5.783; P = 0.036, OR 3.973; 95% CI 1.737-9.088; P = 0.001). CONCLUSIONS: Sarcopenia is a risk factor for complications. The quantity and quality of muscle must be assessed to predict operative outcomes. CLINICAL TRIAL REGISTRATION NUMBER: UMIN000027077.

The Perth Surgical Wound Dehiscence Risk Assessment Tool (PSWDRAT): development and prospective validation in the clinical setting.

OBJECTIVE: The worldwide volume of surgery today is considerable and postoperative wound healing plays a significant part in facilitating a patient's recovery and rehabilitation. While contemporary surgical procedures are relatively safe, complications such as surgical wound dehiscence (SWD) or breakdown of the incision site may occur despite advances in surgical techniques, infection control practices and wound care. SWD impacts on patient mortality and morbidity and significantly contributes to prolonged hospital stay. Preoperative identification of patients at risk of SWD may be valuable in reducing the risk of postoperative wound complications. METHOD: A three-phase study was undertaken to determine risk factors associated with SWD, develop a preoperative patient risk assessment tool and to prospectively validate the tool in a clinical setting. Phases 1 and 2 were retrospective case control studies. Phase 1 determined variables associated with SWD and these informed the development of a risk assessment tool. Univariate analysis and multiple logistic regression were applied to identify predictors of surgical risk. Phase 2 used the receiver operator curve statistic to determine the predictive power of the tool. Phase 3 involved a prospective consecutive case series validation to test the inter-rater reliability and predictive power of the tool. RESULTS: In addition to those already identified in the literature, one independent risk predictor for SWD was identified: previous surgery in the same anatomical location (p<0.001, odds ratio [OR] 4). Multiple combined factors were integrated into the tool and included: age (p<0.019, OR 3), diabetes (p<0.624, OR 2), obesity (p<0.94, OR 1.4), smoking (p<0.387, OR 2), cardiovascular disease (p<0.381 OR 3) and peripheral arterial disease (p<0.501, OR 3). The predictive power of the tool yielded 71% in a combined data sample. CONCLUSION: Patients with previous surgery in the same anatomical location were four times more likely to incur a dehiscence. Identification of at-risk patients for complications postoperatively is integral to reducing SWD occurrence and improving health-related outcomes following surgery.