Improvement In Postoperative Mortality Research Articles

Outcomes of clinical decision support systems in real-world perioperative care: A systematic review and meta-analysis.

Although clinical decision support systems (CDSS) have been developed to enhance the quality and efficiency of surgeries, little is known regarding the practical effects in real-world perioperative care. To systematically review and meta-analyze the current impact of CDSS on various aspects of perioperative care, providing evidence support for future research on CDSS development and clinical implementation. This systematic review and meta-analysis followed the Cochrane Handbook and PRISMA statement guidelines, searching databases up to February 2, 2024, including MEDLINE, PubMed, Embase, Cochrane, and Web of Science. It included studies on the effectiveness of CDSS in assisting perioperative decision-making, involving anaesthesiologists, doctors, or surgical patients, and reporting at least one outcome such as complications, mortality, length of stay, compliance, or cost. Forty studies met inclusion criteria, analyzing outcomes from 408,357 participants, predominantly in developed countries. Most perioperative CDSS use was associated with improved guideline adherence, decreased medication errors, and some improvements in patient safety measures such as reduced postoperative nausea and vomiting and myocardial injury. However, reported results varied widely, and no significant improvement in postoperative mortality was observed. The preliminary findings of this review offer an overview of the potential use of CDSS in real-world perioperative situations to enhance patient and anaesthesiologist outcomes, but further researches with broader outcome dimensions, involving more stakeholders, and with longer follow-up periods are warranted for the critical evaluation of CDSS and then in better facilitate clinical adoption.

1657 Resected Gastric Adenocarcinomas at a Single Institution: Outcomes and Trends over 17 Years.

Outside of clinical trials, real-world data of advanced gastric cancers (AGCs) managed with perioperative or adjuvant chemotherapy with a backbone of D2 lymphadenectomy is limited. Curative resections for gastric adenocarcinoma between January 2003 and January 2020 at the Tata Memorial Centre were analyzed, comparing three time periods marking major increments in annual gastric resections (GRs). 1657 radical gastric resections were performed with a morbidity and mortality rate of 34.9% and 1.4%, respectively. Over three consecutive periods, the number of annual GRs increased from 56/year to 97/year to 156/year (P < 0.001) with a significant escalation in surgical magnitude and complexity. Improvement in surgical quality indicators (median lymph node yield from 15 to 25, P < 0.001 and margin negativity from 8.2 to 5.5%, P = 0.002) was observed with no corresponding increase in severe complications (6.9%) or mortality (1.4%). The proportion of distal and signet ring cancers was found to decrease over time, with an increase in proximal cancers and younger age at presentation. Overall, 90% of GRs were for AGCs with a median overall survival (OS) of 4.4 years (± 6 months), and 5-year OS rate of 47.6% (± 1.9%). Change in pattern of tumor characteristics was observed. Aggressive treatment options for AGC were employed progressively with excellent survival. With increase in volumes, improvements in surgical quality indicators, and a relative improvement in postoperative mortality was observed. These results provide a roadmap for developing dedicated gastric cancer centers.

Dynamic volume-outcome association for esophagectomies: Do current volume thresholds still apply?

BackgroundIt is unknown if the current minimum case volume recommendation of 20 cases per year per hospital is applicable to contemporary practice. MethodsPatients undergoing esophageal resection between 2005 and 2015 were identified in the National Cancer Database. High, medium, and low-volume hospital strata were defined by quartiles. Adjusted odds ratios and adjusted 30-day mortality between low-, medium-, and high-volume hospitals were calculated using logistic regression analyses and trended over time. ResultsOnly 1.1% of hospitals had ≥20 annual cases. The unadjusted 30-day mortality for esophagectomy was 3.8% overall. Unadjusted and adjusted 30-day mortality trended down for all three strata between 2005 and 2015, with disproportionate decreases for low-volume and medium-volume versus high-volume hospitals. By 2015, adjusted 30-day mortality was similar in medium- and high-volume hospitals (odds ratio 1.35, 95% confidence interval 0.96–1.91). For hospitals with 20 or more annual cases the adjusted 30-day mortality was 2.7% overall. To achieve this same 30-day mortality the minimum volume threshold had lowered to 7 annual cases by 2015. ConclusionOnly 1.1% of hospitals meet current volume recommendations for esophagectomy. Differential improvements in postoperative mortality at low- and medium- versus high-volume hospitals have led to 7 cases in 2015 achieving the same adjusted 30-day mortality as 20 cases in the overall cohort. Lowering volume thresholds for esophagectomy in contemporary practice would potentially increase the proportion of hospitals able to meet volume standards and increase access to quality care without sacrificing quality.

Association of persistent poverty and U.S. News and World Report hospital rankings among patients undergoing major surgery

BackgroundWe sought to determine the association of persistent poverty on patient outcomes relative to US News World Report (USNWR) rankings among individuals undergoing common major surgical procedures. MethodsMedicare beneficiaries who underwent AAA repair, CABG, colectomy, or lung resection were identified. Multivariable logistic regression was used to evaluate the relationship between care at USNWR hospitals, county-level duration of poverty (never-high poverty (NHP); intermittent high poverty (IHP): persistent-poverty (PP)) and 30-day mortality. ResultsAmong 916,164 beneficiaries, individuals residing in PP neighborhoods who received surgical care at ranked hospitals had lower risk-adjusted 30-day mortality (5.89% vs 8.89%; p ​< ​0.001). On multivariable analysis, 30-day mortality was lower at ranked hospitals across all poverty categories with greatest decrease among patients from PP regions (NHP: OR-0.91, 95%CI0.87–0.95; IHP: OR-0.78, 95%CI0.69–0.88; PP: OR-0.69, 95%CI0.57–0.83; p ​< ​0.001). ConclusionReceipt of surgical care at top-ranked hospitals was associated with improvement in postoperative mortality, especially among patients residing in persistent poverty..

The physiological and clinical importance of cardiorespiratory fitness in people with abdominal aortic aneurysm.

New Findings What is the topic of this review? This review focuses on the physiological impact of abdominal aortic aneurysm (AAA) on cardiorespiratory fitness and the negative consequences of low fitness on clinical outcomes in AAA. We also discuss the efficacy of exercise training for improving cardiorespiratory fitness in AAA. What advances does it highlight? We demonstrate the negative impact of low fitness on disease progression and clinical outcomes in AAA. We highlight potential mechanistic determinants of low fitness in AAA and present evidence that exercise training can be an effective treatment strategy for improving cardiorespiratory fitness, postoperative mortality and disease progression. An abdominal aortic aneurysm (AAA) is an abnormal enlargement of the aorta, below the level of the renal arteries, where the aorta diameter increases by >50%. As an aneurysm increases in size, there is a progressive increase in the risk of rupture, which ranges from 25 to 40% for aneurysms >5.5 cm in diameter. People with AAA are also at a heightened risk of cardiovascular events and associated mortality. Cardiorespiratory fitness is impaired in people with AAA and is associated with poor (postoperative) clinical outcomes, including increased length of hospital stay and postoperative mortality after open surgical or endovascular AAA repair. Although cardiorespiratory fitness is a well‐recognized prognostic marker of cardiovascular health and mortality, it is not assessed routinely, nor is it included in current clinical practice guidelines for the management of people with AAA. In this review, we discuss the physiological impact of AAA on cardiorespiratory fitness, in addition to the consequences of low cardiorespiratory fitness on clinical outcomes in people with AAA. Finally, we summarize current evidence for the effect of exercise training interventions on cardiorespiratory fitness in people with AAA, including the associated improvements in postoperative mortality, AAA growth and cardiovascular risk. Based on this review, we propose that cardiorespiratory fitness should be considered as part of the routine risk assessment and monitoring of people with AAA and that targeting improvements in cardiorespiratory fitness with exercise training might represent a viable adjunct treatment strategy for reducing postoperative mortality and disease progression.

High Volume Center for Distal Pancreatectomy

Introduction: The association between high procedural volume and improved outcomes is generally accepted for most high risk,low volume procedures,such as pancreatic or esophageal surgery,which supports the beneficial effects of the concentration of these procedures in high-volume centers.Several cutoffs have been reported to define a high-volume center for pancreatic surgery; however,the definition of high-volume center for distal pancreatectomy still needs to be determined.The purpose of this study was to evaluate the association between hospital-procedure-volume and patient mortality for patients undergoing distal pancreatectomy using a large database to determine an evidence-based threshold of hospital-volume associated with improvement in postoperative mortality. Methods: Patients who underwent distal pancreatectomy were identified using the National Cancer Database (2004-2015). Logistic regression analysis and restricted cubic spline regression analysis was performed to determine the linear and non-linear association between mean hospital-volume and mean 90-day mortality. Results: 13307 patients underwent distal pancreatectomy at 1081 unique hospitals. 30 and 90-day mortality of the study population were 1.77% (n=236) and 4.07%(n=542), respectively.Baseline characteristics and mean annual mortality of individual hospitals were determined. A logistic regression analysis was performed,which demonstrated that institutional volume is significantly associated with decreased 90-day mortality.The maximum improvement in 90-day mortality was seen if the annual hospital volume was greater than 6 (p< 0.0001, OR=2.057(1.697-2.493)).The non-linear association demonstrated continued improvement in 90-day mortality with an increase in average hospital-volume (Fig1). Conclusion: This data suggests that hospital-volume has a direct impact on 90-day mortality after distal pancreatectomy.Based on our results, we recommend defining a high volume center as hospitals performing seven or more distal pancreatectomy cases/year.

In-Hospital Postoperative Mortality Rates for Selected Procedures in Tanzania\u2019s Lake Zone

BackgroundPostoperative mortality rate is one of six surgical indicators identified by the Lancet Commission on Global Surgery for monitoring access to high-quality surgical care. The primary aim of this study was to measure the postoperative mortality rate in Tanzania’s Lake Zone to provide a baseline for surgical strengthening efforts. The secondary aim was to measure the effect of Safe Surgery 2020, a multi-component intervention to improve surgical quality, on postoperative mortality after 10 months.MethodsWe prospectively collected data on postoperative mortality from 20 health centers, district hospitals, and regional hospitals in Tanzania’s Lake Zone over two time periods: pre-intervention (February to April 2018) and post-intervention (March to May 2019). We analyzed postoperative mortality rates by procedure type. We used logistic regression to determine the impact of Safe Surgery 2020 on postoperative mortality.ResultsThe overall average in-hospital non-obstetric postoperative mortality rate for all surgery procedures was 2.62%. The postoperative mortality rates for laparotomy were 3.92% and for cesarean delivery was 0.24%. Logistic regression demonstrated no difference in the postoperative mortality rate after the Safe Surgery 2020 intervention.ConclusionsOur results inform national surgical planning in Tanzania by providing a sub-national baseline estimate of postoperative mortality rates for multiple surgical procedures and serve as a basis from which to measure the impact of future surgical quality interventions. Our study showed no improvement in postoperative mortality after implementation of Safe Surgery 2020, possibly due to low power to detect change.

The improvement in post-operative mortality following pancreaticoduodenectomy between 2006 and 2016 is associated with an improvement in the ability to rescue patients after major morbidity, not in the rate of major morbidity

BackgroundThe postoperative mortality rate of pancreaticoduodenectomy is decreasing over time. It is unknown whether this is related to reduction in incidence of major morbidity or failure to rescue. We aimed to make this determination. MethodsACS-NSQIP was retrospectively reviewed from 2006 to 2016. Comparisons were assessed with Spearman's rank-order correlation test, chi-square test with linear-by-linear association, and multivariable hierarchical logistic regression. ResultsMortality decreased significantly from 2.9% to 1.5% (p < 0.001). This decrease was independent of preoperative variables on multivariable analysis (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.55–5.21, p < 0.001). In contrast, no change in incidence of major morbidity was seen on univariable (26.8% to 25.9%, p = 1.00) or multivariable analysis (OR 1.22, 95% CI 1.03–1.45, p = 0.060). Failure to rescue was observed to decrease on univariable (9.8% to 4.1%, p < 0.001) and multivariable analysis (OR 3.65, 95% CI 2.07–6.76, p < 0.001). ConclusionThere has been a sizeable reduction in the mortality rate after pancreaticoduodenectomy from 2006 to 2016. This predominantly results from a reduction in failure to rescue rate rather than a decrease in incidence of major morbidity.

The effect of trimodal prehabilitation on the physical and psychological health of patients undergoing colorectal surgery: a randomised clinical trial.

Prehabilitation aims to increase the endurance capacity of patients who are awaiting major surgery. However, there are no studies investigating the implementation of this demanding and expensive intervention in low-income countries. This study aimed to assess the impact of a 4-week trimodal prehabilitation program on the physical and psychological health of patients waiting for colorectal surgery compared with a control group managed according to enhanced recovery after surgery principles supplemented by nutritional care. This study was a single-centre, randomised controlled trial. The primary outcome measures for the physical aspects were 6-minute walking distance (6MWD) and incentive spirometry, whereas the psychological elements were measured using the 36-item short form survey questionnaire and the hospital anxiety and depression score. In total, data from 149 patients were analysed (77 in the prehabilitation group and 72 in the control group). At the time of surgery, patients in the prehabilitation group had improved 6MWD and incentive spirometry compared with the control group (median (IQR [range]) percentage improvement 131% (112-173 [68-376]) vs. 107% (99-120 [63-163]); p<0.001 and 113% (100-125 [75-200]) vs. 100% (100-112 [86-167]); p<0.001 respectively). Patients in the prehabilitation group also had reduced anxiety scores compared with the control group (mean (SD) anxiety score (4 (3) vs. 5 (3) respectively; p=0.032). However, these effects did not translate into improvements in postoperative mortality and morbidity, or a reduction in duration of hospital stay. Trimodal (physical, emotional and nutritional) prehabilitation is able to improve functional status as well as some parameters of emotional and physical well-being of patients waiting for colorectal surgery.

Contemporary Improvements in Postoperative Mortality After Major Cancer Surgery are Associated with Weakening of the Volume-Outcome Association.

Regionalization of complex visceral surgery across the United States has followed identification of a volume-outcome association. However, improvements in postoperative mortality overall during the last decade may have weakened the strength of this association. The National Cancer Database was used to identify patients undergoing colon, esophageal, liver, and pancreatic surgery from 2003 to 2011. Hospitals were divided into low-volume (< 33rd %tile), medium-volume (34-66th %tile), and high-volume (> 67th %tile) groups. Annual cancer-specific adjusted observed versus expected (O/E) ratios for 30- and 90-day mortality for each volume strata were calculated and plotted over time. In the year 2003, the O/E ratios decreased from low- to medium- to high-volume hospitals for all cancer surgeries for both 30- and 90-day mortality, indicating a strong volume-outcome relationship. For all volume strata, the O/E ratios trended downward from 2003 to 2011 for both 30- and 90-day mortality for all cancer surgeries. This trend was more pronounced for low- and medium-volume than for high-volume hospitals. Consequently, by 2011 the confidence intervals of the O/E ratios for the low-volume groups, and particularly for the medium-volume groups, overlapped those for the high-volume groups for most of the cancer surgeries studied. The volume-outcome association for major cancer surgery is dynamic and has attenuated over time primarily due to improvements in postoperative mortality at low- and medium-volume hospitals.

Improvement in postoperative mortality in elective gastrectomy for gastric cancer: Analysis of predictive factors in 1066 patients from a single centre

BackgroundGastrectomy represents the main treatment for gastric adenocarcinoma. This procedure is associated with substantial morbidity and mortality. The aim of this study was to evaluate the postoperative mortality changes across the study period and to identify predictive factors of 30-day mortality after elective gastrectomy for gastric cancer. MethodsThis was a retrospective cohort study of a prospective database from a single centre. Patients treated with an elective gastrectomy from 1996 to 2014 for gastric adenocarcinoma were included. We compared postoperative mortality between four time periods: 1996–2000, 2001–2005, 2006–2010, and 2011–2014. Univariate and multivariate analyses were applied to identify predictors of 30-day postoperative mortality. ResultsWe included 1066 patients (median age 65 years; 67% male). The 30-day mortality rate was 4.7%. Mortality decreased across the four time periods; from 6.5% to 1.8% (P = 0.022). In the univariate analysis, age, ASA score, albumin <3.5, multivisceral resection, splenectomy, intrathoracic esophagojejunal anastomosis, R status, and T status were significantly associated with postoperative mortality. In the multivariate analysis, ASA class 3 (OR 10.06; CI 1.97–51.3; P = 0.005) and multivisceral resection (OR 1.6; CI 1.09–2.36; P = 0.016) were associated with higher postoperative 30-day mortality; surgery between 2011 and 2014 was associated with lower postoperative 30-day mortality (OR 0.55; CI 0.33–0.15; P = 0.030). ConclusionThere was a decrease in postoperative 30-day mortality during this 18-year period at our institution. We have identified ASA score and multivisceral resection as predictors of 30-day mortality for elective gastrectomy for cancer.

Survival after Resection of Pancreatic Adenocarcinoma: Results from a Single Institution over Three Decades

Randomized trials have demonstrated a benefit associated with adjuvant therapy for pancreatic cancer, and retrospective studies have demonstrated improvements in postoperative mortality. The purpose of this study was to evaluate whether these improvements could be identified in a cohort of patients who underwent resection for pancreatic cancer at a single institution over three decades. Short- (30days), intermediate- (1year), and long-term survival were compared between decades. Long-term survival focused on patients who survived at least 1year to minimize the effects of perioperative mortality and patient selection. Between 1983 and 2009, 1147 pancreatic resections were performed for ductal adenocarcinoma, including 123 resections in the 1980s, 399 in the 1990s, and 625 in the 2000s. The 30-day mortality rates were 4.9%, 1.5% (P=0.03 vs. 1980s), and 1.3% (P=0.007 vs. 1980s). The 1-year mortality rates were 42%, 31% (P<0.001 vs. 1980s), and 24% (P<0.001 vs. 1980s and 1990s). In the group of patients who survived 1year, the overall survivals were 23.2months, 25.6months (P=0.6 vs. 1980s), and 24.5months (P=0.2 vs. 1980s). In a multivariate analysis adjusted for pathologic features, the decade of resection was not a significant predictor of long-term survival (hazard ratio=1.1, P=0.3). Patients who underwent resection for pancreatic cancer between 2000 and 2009 experienced improved operative mortality and 1-year survival compared to those who underwent resection in the 1980s, while the long-term survival was similar over all three decades. These results underscore the need for early detection strategies and more effective adjuvant therapies for patients with pancreatic cancer.

Risk factors for 30-day mortality after resection of lung cancer and prediction of their magnitude

Background:There is considerable variability in reported postoperative mortality and risk factors for mortality after surgery for lung cancer. Population-based data provide unbiased estimates and may aid in treatment selection.Methods:All patients...

Clinicopathologic characteristics of esophagectomy for esophageal carcinoma in elderly patients

To evaluate the risk of esophagectomy for carcinoma of the esophagus in the elderly (70 years or more) compared with younger patients (< 70 years) and to determine whether the short-term outcomes of esophagectomy in the elderly have improved in recent years. Preoperative risks, postoperative morbidity and mortality in 60 elderly patients (> or = 70 years) with esophagectomy for carcinoma of the esophagus were compared with the findings in 1782 younger patients (< 70 years) with esophagectomy between January 1990 and December 2004. Changes in perioperative outcome and short-time survival in elderly patients between 1990 to 1997 and 1998 to 2004 were separately analyzed. Preoperatively, there were significantly more patients with hypertension, pulmonary dysfunction, cardiac disease, and diabetes mellitus in the elderly patients as compared with the younger patients. No significant difference was found regarding the operation time, blood loss, organs in reconstruction and anastomotic site between the two groups, but elderly patients were more often to receive blood transfusion than younger patients. Significantly more transhiatal and fewer transthoracic esophagectomies were performed in the elderly patients as compared with the younger patients. Resection was considered curative in 71.66% (43/60) elderly and 64.92% (1157/1782) younger patients, which was not statistically significant (P>0.05). There were no significant differences in the prevalence of surgical complications between the two groups. Postoperative cardiopulmonary medical complications were encountered more frequently in elderly patients. The hospital mortality rate was 3.3% (2/60) for elderly patients and 1.1% (19/1 782) for younger patients without a significant difference. When the study period was divided into a former (1990 to 1997) and a recent (1997 to 2004) period, operation time, blood loss, and percentage of patients receiving blood transfusion of the elderly patients significantly improved from the former period to the recent period. The hospital mortality rate of the elderly patients dropped from the former period (5.9%) to the recent period (2.3%), but it was not statistically significant. Preoperative medical risk factors and postoperative cardiopulmonary complications after esophagectomy are more common in the elderly, but operative mortality is comparable to that of younger patients. These encouraging results and improvements in postoperative mortality and morbidity of the elderly patients in recent period are attributed to better surgical techniques and more intensive perioperative care in the elderly.

Recent advances in the surgical treatment of pancreatic cancer.

Pancreatic cancer remains the fourth commonest cause of cancer related death in the western world[1]. The prognosis remains dismal due partly to late presentation, with associated low resectability rates, and the aggressive biological nature of these tumors. The median survival time from diagnosis in unresectable tumors remains only 4-6 mo. For those patients amenable to surgical resection over the last 20 years have seen marked improvements in postoperative mortality and morbidity, especially in specialist pancreatic centres[2,3]. Despite these changes long-term survival remains low, with a total 5-year survival rate remaining less than 5%. Patients with ampullary cancer have a better 5-year survival of 40%-60%. Resection, however, remains the only chance of long term survival with adjuvant therapies providing disappointing results. Operability remains low due to the local and distant extent of the disease. Assessment of this extent has been greatly advanced by modern radiological techniques.