Low Preoperative Risk Research Articles

Successful Implementation of Enhanced Recovery After Surgery (ERAS) in Paediatric Cardiac Surgery in Australia

Fast-track or enhanced recovery after surgery (ERAS) is a care pathway for surgical patients based on a multidisciplinary team approach aimed at optimising recovery without increasing risk with protocols based on scientific evidence, which is monitored continuously to ensure compliance and improvement. These protocols have been shown to reduce the duration of postoperative mechanical ventilation and intensive care unit (ICU) length of stay (LOS) following paediatric cardiac surgery. We present the first structured implementation of ERAS in paediatric cardiac surgery in Australia. All patients enrolled in the ERAS pathway between October 2019 and July 2023 were identified. Demographic and perioperative data were collected retrospectively from hospital records for patients operated before June 2021 and prospectively from June 2021. A control group (non-ERAS) was identified using propensity matching from patients who underwent similar procedures and were not enrolled in the ERAS pathway (prior to October 2019). Patients were matched for age, weight, and comprehensive Aristotle score. Outcomes of interest were duration of postoperative mechanical ventilation, ICU LOS, readmission to the ICU, hospital LOS, cardiac reintervention rate, postoperative complication rate, and number of 30-day readmissions. Of 1,084 patients who underwent cardiac surgery during the study period (October 2019-July 2023), 121 patients (11.2%) followed the ERAS pathway. The median age at the time of surgery was 4.8 years (interquartile range [IQR] 2.8-8.8 years). The most common procedure was the closure of atrial septal defect (n=58, 47.9%). The median cardiopulmonary bypass and cross-clamp times were 40 min (IQR 28-53.5 minutes) and 24.5 min (IQR 13-34 minutes) respectively. The majority were extubated in the operating theatre (n=108, 89.3%). The median ICU and hospital LOS were 4.5 hrs (IQR 4.1-5.6 hours) and 4 days (IQR 4-5 days) respectively. None of the patients required readmission to the ICU within 24 hrs of discharge from the ICU. Three (3) patients (2.5%) required reintervention. When compared with the non-ERAS group, the duration of postoperative mechanical ventilation, ICU and hospital LOS were significantly lower in the ERAS group. There was no significant difference in the ICU readmission rate, reintervention rate, complication rate, and number of 30-day readmissions between both groups. ERAS after paediatric cardiac surgery is feasible and safe in select patients with low preoperative risk. This pathway reduces the duration of postoperative mechanical ventilation, ICU and hospital LOS without increasing risks, enabling the optimisation of resources.

Effect of in-hospital delay on acute appendicitis severity: does time really matter?

Appendicitis is one of the most common abdominal emergencies. Evidence is controversial in determining if the in-hospital time delay to surgery can worsen the clinical presentation of appendicitis. This study aimed to clarify if in-hospital surgical delay significantly affected the proportion of complicated appendicitis in a large prospective cohort of patients treated with appendectomy for acute appendicitis. Patients were grouped into low, medium, and high preoperative risk for acute appendicitis based on the Alvarado scoring system. Appendicitis was defined as complicated in cases of perforation, abscess, or diffuse peritonitis. The primary outcome was correlation of in-hospital delay with the proportion of complicated appendicitis. The study includes 804 patients: 278 (30.4%) had complicated appendicitis and median time delay to surgery in low-, medium-, and high-risk group was 23.15h (13.51-31.48), 18.47h (10.44-29.42), and 13.04 (8.13-24.10)h, respectively. In-hospital delay was not associated with the severity of appendicitis or with the presence of postoperative complications. It appears reasonably safe to delay appendicectomy for acute appendicitis up to 24h from hospital admission. Duration of symptoms was a predictor of complicated appendicitis and morbidity. Timing for appendicectomy in acute appendicitis should be calculated from symptoms onset rather than hospital presentation.

Feasibility of Postoperative Day One or Day Two Discharge After Robotic Cardiac Surgery

IntroductionThe robotic platform reduces the invasiveness of cardiac surgical procedures, thus facilitating earlier discharge in select patients. We sought to evaluate the characteristics, perioperative management, and early outcomes of patients who underwent postoperative day 1 or 2 (POD1-2) discharge after robotic cardiac surgery at our institution. MethodsRetrospective review of 169 patients who underwent robotic cardiac surgery at our facility between 2019 and 2021 identified 57 patients discharged early on POD1 (n = 19) or POD2 (n = 38) and 112 patients who underwent standard discharge (POD3 or later). Relevant data were extracted and compared. ResultsIn the early discharge group, median patient age was 62 [IQR: 55, 66] (IQR = interquartile range) years, and 70.2% (40/57) were male. Median Society of Thoracic Surgeons predictive risk of mortality score was 0.36 [IQR: 0.25, 0.56] %. The most common procedures performed were mitral valve repair [66.6%, (38/57)], atrial mass resection [10.5% (6/57)], and coronary artery bypass grafting [10.5% (6/57)]. The only significant differences between the POD1 and POD2 groups were shorter operative time, higher rate of in-operating room extubation, and shorter ICU length of stay in the POD1 group. Lower in-hospital morbidity and comparable 30-day mortality and readmission rates were observed between the early and standard discharge groups. ConclusionsPOD1-2 discharge after various robotic cardiac operations afforded lower morbidity and similar 30-day readmission and mortality rates compared to discharge on POD3 or later. Our findings support the feasibility of POD1-2 discharge after robotic cardiac surgery for patients with low preoperative risk, an uncomplicated postoperative course, and appropriate postoperative management protocols.

Midterm results of endovascular versus open surgical repair for infrarenal abdominal aortic aneurysms in low surgical risk patients

ObjectiveThe objective of this study was to analyze midterm outcomes of endovascular repair (EVAR) versus open repair (OR) for treatment of infrarenal abdominal aortic aneurysms (AAAs) in low surgical risk patients. MethodsElective patients with AAAs undergoing treatment from 2003 to 2017 in a single, tertiary-care institution were evaluated. All patients with a low preoperative risk of complications and perioperative mortality (Medicare Aneurysm Scoring System <3) were included, and rates of perioperative and long-term mortality, adverse events, and reintervention were evaluated for EVAR and OR. A propensity score-matched cohort, leveling age, risk factors, and comorbidities was additionally performed. ResultsA total of 227 patients were included (EVAR 59.9% and OR 40.1%) and followed for a mean of 80 ± 48 months. Patients undergoing EVAR were older (66.6 ± 5 vs. 64.1 ± 6 years; P <.001), had a higher body mass index (29.6 ± 4 vs 28.1 ± 3 kg/m2; P = .005), a higher prevalence of chronic obstructive pulmonary disease (27.3% vs 9.9%; P = .001), and lower prevalence of dyslipidaemia (46.3% vs 65.9%; P = .004). Patients undergoing OR had a higher rate of major adverse events (19.7% vs 2.6%; P = .001) and 30-day reinterventions (8.8% vs. 1.5%; P = .016), with 30-day mortality being 0% in both groups. The propensity-score matched cohort included 76 matched pairs (1:1), with differences in hospital stay and major complications remaining significant, without affecting mortality. At 5-year follow-up, there were no significant differences in the reintervention rate (EVAR 18.5% vs OR 17.6%; P = .67) or survival (EVAR 85% vs OR 91%; P = .195). ConclusionsIn low surgical risk patients with AAAs, EVAR may offer comparable midterm results to OR, with a lower rate of major adverse events and a shorter in-hospital stay. With the current OR-first paradigm in low-risk patients, several factors should be taken into account for decision-making (anatomic suitability, risk of sexual dysfunction, risk of type 2 endoleaks, and need for follow-up).

Contemporary short-term outcomes of surgery for aortic stenosis: transcatheter vs. surgical aortic valve replacement

ObjectivesThis study aimed to compare the short-term outcomes of transcatheter and surgical aortic valve replacements (TAVR and SAVR) in high-, intermediate-, and low-preoperative risk patients.MethodsA total of 454 patients who underwent TAVR or SAVR were included. Patients were categorized into high-, intermediate-, and low-risk according to the Society of Thoracic Surgery-Predicted Risk of Mortality score and clinical outcomes were compared between TAVR and SAVR groups.ResultsTAVR was less invasive, with less bleeding and transfusion (p < 0.001), less frequent new-onset atrial fibrillation (p < 0.001), and shorter intensive care unit stay (p < 0.001). Furthermore, transcatheter valves performed better than surgical valves, with lower peak velocity (p = 0.003) and pressure gradient (p < 0.001) and higher effective orifice area index (p < 0.001). The clinical outcomes of TAVR were comparable to or even superior to those of SAVR in high- and intermediate-risk patients. In low-risk patients, the 1- and 2-year mortality rates were 6.3% and 12.1%, respectively, in the TAVR group and 0% and 0.9%, respectively, in the SAVR group (p < 0.001). Mild or greater paravalvular leakage was a risk factor for mortality (hazard ratio 35.78; p < 0.001).ConclusionsTAVR was superior to SAVR in the sense of less invasiveness and valvular function. However, the indication of TAVR in low-risk patients should be carefully discussed, because paravalvular leakage was a risk factor for short-term mortality.

Accuracy of the surgical risk preoperative assessment system universal risk calculator in predicting risk for patients undergoing selected operations in 9 specialty areas

BackgroundThe universal Surgical Risk Preoperative Assessment System (SURPAS) prediction models for postoperative adverse outcomes have good accuracy for estimating risk in broad surgical populations and for surgical specialties. The accuracy in individual operations has not yet been assessed. The objective of this study was to evaluate the Surgical Risk Preoperative Assessment System in predicting adverse outcomes for selected individual operations. MethodsThe SURPAS models were applied to the top 2 most frequent common procedural terminology codes in 9 surgical specialties and 5 additional common general surgical operations in the 2009 to 2018 database of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Goodness of fit statistics were estimated, including c-indices for discrimination, Hosmer-Lemeshow graphs and P values for calibration, overall observed versus expected event rates, and Brier scores. ResultsThe total sample size was 2,020,172, which represented 29% of the 6.9 million operations in the ACS NSQIP database. Average c-indices across 12 outcomes were acceptable (≥0.70) for 13 (56.5%) of the 23 operations. Overall observed-to-expected rates were similar for mortality and overall morbidity across the 23 operations. Hosmer-Lemeshow graphs over quintiles of risk comparing observed-to-expected rates of mortality and overall morbidity were similar for 52% and 70% of operations, respectively. Model performance was better in less complex operations and those done in patients with lower preoperative risk. ConclusionSURPAS displayed accuracy in estimating postoperative adverse events for some of the 23 operations studied, but not all. In the procedures where SURPAS was not accurate, developing disease or operation-specific risk models might be appropriate.

Prise en charge chirurgicale des cancers gynécologiques en période de pandémie COVID-19 – Recommandations du Groupe FRANCOGYN pour le CNGOF

IntroductionRecommendations for the management of patients with gynecological cancer during the COVID-19 pandemic period. Material and methodRecommendations based on the consensus conference model. ResultsIn the case of a COVID-19 positive patient, surgical management should be postponed for at least 15 days. For cervical cancer, the place of surgery must be re-evaluated in relation to radiotherapy and Radio-Chemotherapy-Concomitant and the value of lymph node staging surgeries must be reviewed on a case-by-case basis. For advanced ovarian cancers, neo-adjuvant chemotherapy should be favored even if primary cytoreduction surgery could be envisaged. It is lawful not to offer hyperthermic intraperitoneal chemotherapy during a COVID-19 pandemic. In the case of patients who must undergo interval surgery, it is possible to continue the chemotherapy and to offer surgery after 6 cycles of chemotherapy. For early stage endometrial cancer, in case of low and intermediate preoperative ESMO risk, hysterectomy with bilateral annexectomy associated with a sentinel lymph node procedure should be favored. It is possible to consider postponing surgery for 1 to 2 months in low-risk endometrial cancers (FIGO Ia stage on MRI and grade 1-2 endometrioid cancer on endometrial biopsy). For high ESMO risk, it ispossible to favor the MSKCC algorithm (combining PET-CT and sentinel lymph node biopsy) in order to omit pelvic and lumbar-aortic lymphadenectomies. ConclusionDuring COVID-19 pandemic, patients suffering from cancer should not lose life chance, while limiting the risks associated with the virus.

Preoperative Cardiovascular Risk Assessment Prior Non Cardiac Surgery: A Case Series of Patients Undergoing Urological Surgery in Ngaoundere, Cameroon

Background and objective: Preoperative cardiovascular risk control is critical to reducing the frequency of perioperative cardiovascular events and improving the survival and quality of life of surgical patients. This study aimed at assessing preoperative cardiovascular of patients undergoing urological surgery in Ngaoundere, Cameroon. Methodology: A cross-sectional study was carried at the urological surgery department of the Ngaoundere Islamic Clinic. Participants’ sociodemographic, clinical and biological data were collected and analyzed using Sphinx V5 software. Results: A total of 58 patients were included in the study. Their mean age was 61.33 ± 16.16 years. The most represented age group was the one over 70 years (34.50%). In total, 50 (86.20%) patients had low risk surgical procedures and 20 (34.5%) patients had poor functional capacity. Lee score was calculated for all patients with low functional capacity. Of these patients, 17 (85%) had a low risk of cardiovascular events. Conclusion: The present study reveals a low preoperative cardiovascular risk in urological surgery in Ngaoundere, Cameroon; however, this observation does not exclude the need of systematic evaluation of preoperative cardiovascular risk for better prevention of postoperative complications, in surgical setting in our context.

Development and validation of a real-time mortality risk calculator before, during and after hepatectomy: an analysis of the ACS NSQIP database

BackgroundAlthough most conventional risk prediction models have been based on preoperative information, intra- and post-operative events may be more relevant to mortality after surgery. We sought to develop a mortality risk calculator based on real time characteristics associated with hepatectomy. MethodsPatients who underwent hepatectomy between 2014 and 2017 were identified in the ACS-NSQIP dataset. Three prediction models (pre-, intra-, post-operative) were developed and validated using perioperative data. ResultsAmong 14,720 patients, 197 (1.3%) experienced 30-day mortality. The predictive ability of the real-time mortality risk calculator was very good based on only preoperative factors (AUC; training cohort: 0.813, validation cohort: 0.731). Incorporating intra-operative variables into the model increased the AUC (training: 0.838, validation: 0.777), while the post-operative model achieved an AUC of 0.922 in the training and 0.885 in the validation cohorts, respectively. While patients with low preoperative risk had only very small fluctuations in the estimated 30-day mortality risk during the intraoperative (Δ0.4%) and postoperative (Δ0.6%) phases, patients who were already deemed high risk preoperatively had additional increased mortality risk based on factors that occurred in the intraoperative (Δ5.4%) and postoperative (Δ9.3%) periods. ConclusionA real-time mortality risk calculator may better help clinicians identify patients at risk of death at the different stages of the surgical episode.

Balancing intubation time with postoperative risk in cardiac surgery patients - a retrospective cohort analysis.

IntroductionIntubation time in patients undergoing cardiac surgery may be associated with increased mortality and morbidity. Premature extubation can have serious adverse physiological consequences. The aim of this study was to determine the influence of intubation time on morbidity and mortality in patients undergoing cardiac surgery.MethodsWe performed a retrospective analysis of data on 1,904 patients undergoing isolated coronary artery bypass grafting (CABG) and stratified them by duration of intubation time after surgery – 0–6, 6–9, 9–12, 12–24 and over 24 hours. Postoperative complications risk analysis was performed using multivariate logistic regression analysis for patients extubated ≤12 and >12 hours.ResultsIntubation percentages in each time cohort were as follows: 0–6 hours – 7.8%, 6–9 hours – 17.3%, 9–12 hours – 26.8%, 12–24 hours – 44.4% and >24 hours – 3.7%. Patients extubated ≤12 hours after CABG were younger, mostly males, more often smokers, with lower preoperative risk. They had lower 30-day mortality (2.02% vs 4.59%, P=0.002), shorter hospital stay (7.68±4.49 vs 9.65±12.63 days, P<0.001) and shorter intensive care unit stay (2.39 vs 3.30 days, P<0.001). Multivariate analysis showed that intubation exceeding 12 hours after CABG increases the risk of postoperative delirium (OR 1.548, 95% CI 1.161–2.064, P=0.003) and risk of postoperative hemofiltration (OR 1.302, 95% CI 1.023–1.657, P=0.032).ConclusionResults indicate that risk of postoperative complications does not increase until intubation time exceeds 12 hours. Shorter intubation time is seen in younger, men and smokers. Intubation time >12 hours is a risk factor for postoperative delirium and hemofiltration after cardiac surgery.

Cardiac Events after Noncardiac Surgery in Patients Undergoing Preoperative Dobutamine Stress Echocardiography: Findings From the Mayo Poce-DSE Investigators

BackgroundCurrent guidelines support the use of dobutamine stress echocardiography (DSE) prior to noncardiac surgery in higher-risk patients who are unable to perform at least 4 metabolic equivalents of physical activity. We evaluated postoperative outcomes of patients in different operative risk categories after preoperative DSE. MethodsWe collected data from the medical record on 4494 patients from January 1, 2006 to December 31, 2011 who had DSE up to 90 days prior to a noncardiac surgery. Patients were divided into low, intermediate, and high preoperative surgery-specific risk. Baseline demographic data and risk factors were abstracted from the medical record, as were postoperative cardiac events including myocardial infarction, cardiac arrest, and mortality within 30 days after surgery. ResultsThere were 103 cardiac outcomes (2.3%), which included myocardial infarction (n = 57, 1.3%), resuscitated cardiac arrest (n = 26, 0.6%), and all-cause mortality (n = 40, 0.9%). Cardiac event rates were 0.0% (95% confidence interval [CI], 0.0%-3.9%) in the low-surgical-risk group, 2.1% (95% CI, 1.6%-2.5%) in the intermediate-surgical-risk group, and 3.4% (95% CI, 2.0%-4.4%) in the high-risk group. Thirty-day postoperative mortality rates were 0%, 0.9%, and 0.8% for the low-risk, intermediate-risk, and high-risk surgical groups, respectively, and were not statistically different. ConclusionsThese findings demonstrate low cardiac event rates in patients who underwent a DSE prior to noncardiac surgery. The previously accepted construct of low-, intermediate-, and high-risk surgeries based on postoperative events of <1%, 1%-5%, and >5% overestimates the actual risk in contemporary settings.

Predictors of biochemical recurrence of prostate cancer

Aim. To study the role of postoperative parameters in predicting the probability of development of biochemical recurrence in patients with prostate cancer with low pre-operative risk of its progression. Methods. 95 patients who underwent radical prostatectomy, were included in the study, the average age being 59.5±0.7 (44-76) years. The average levels of total and free prostate-specific antigen were 5.8±0.2 (1.71-9.9) and 1.03±0.07 (0.2-3.6) ng/ml respectively. Biochemical recurrence was defined as the level of prostate-specific antigen higher than 0.2 ng/ml after radical prostatectomy. Results. 8 (8.4%) patients during the follow-up period were diagnosed with biochemical recurrence. The average period to biochemical recurrence development was 45.8±6.7 (24-84) months. Pathomorphological examination revealed presence of tumor cells at surgical margin in 18 (18.9%) cases. Biochemical recurrence was diagnosed in 5 out of 77 (6.5%) patients with negative surgical margins and in 3 out of 18 (1.7%) patients with positive surgical margins. In our study, no correlation between the state of surgical margin and biochemical recurrence development was revealed (χ2=1.958; р=0.162). In the study group postoperative Gleason score was not prognostically significant as well (р=0.294). The average tumor volume in resected material was 11.8±1.0% (1-55%) of prostate volume (мм3). Extraprostatic extension was diagnosed in 10 (10.5%) cases. Results of univariate dispersion analysis of postoperative parameters revealed prognostic significance of tumor volume in removed specimen (р=0.007) and extracapsular extension (р=0.027). Conclusion. In our study we determined that tumor volume and extracapsular extention are independent risk factors for biochemical recurrence in prostate cancer patients with low pre-operative risk of disease progression.

Results of surgical treatment of colorectal cancer in nonagenarian patients

PurposeThe objective of the present study was to compare the results of surgical treatment of nonagenarian patients having colorectal cancer with patients younger than 90 years. MethodsA total of 622 patients who underwent curative surgery were included in the present study. The database of the surgical service, in the period from 2007 to 2013, was used to obtain the sample. This is a descriptive, retrospective study that compared the profiles of 17 nonagenarian patients (Group I) with 605 patients younger than 90 years (Group II). The groups were compared regarding surgical complications, length of hospital stay, type of surgery performed and ASA classification. ResultsThe mean age between the groups was 92.2 years and 61.2 years. The mean length of hospital stay in Groups I and II was 17.3 days and 8.75 days, respectively. The surgery performed most frequently was the right colectomy, in both groups. The most common postoperative complication was sepsis (11.8%) among the nonagenarians, and paralytic ileus (4.5%) among those younger than 90 years. Laparoscopic surgery was performed on 5 out of a total of 17 patients evaluated in Group I. Among the three mortalities registered in this latter group, two were classified as ASA III and only one as ASA I. ConclusionThe results indicate that colorectal surgery may be performed in this group, with acceptable morbidity and mortality rates, in patients with low preoperative risk (ASA I/II).

Preoperative Risk Factors for Suicide in Candidates for Weight Loss Surgery

Suicide risk factors were examined in surgical weight loss (SWL) candidates and compared with weight management (WM) patients in an attempt to better understand the increased risk for suicide after bariatric surgery. Participants included 145 SWL and 103 WM patients. Body–mass index, thwarted belongingness, perceived burdensomeness, acquired capability, suicidal ideation, prior suicide attempts, and lifetime history of abuse were assessed. Perceived burdensomeness, thwarted belongingness, prior suicide attempts, lifetime physical abuse, and suicidal ideation were lower in SWL patients. SWL patients may demonstrate lower preoperative risk for suicide due to socially desirable responding or a sense of hope regarding their upcoming surgery. Additionally, the unique physical and psychological aspects of undergoing bariatric surgery may be associated with postoperative increases in suicidality.

Routine Cysticotomy and Flushing of the Cystic Duct in Patients with Low Risk of Common Duct Stones: Can It Be Beneficial?

Background Gallstone disease affects 15–20% of the general population and up to 20% of these patients present common bile duct stones. Aim This observational study reports our experience on routine cysticotomy and flushing of the cystic duct in patients with low risk of common duct stones. Materials and Methods We analyzed 731 patients who underwent laparoscopic cholecystectomy between September 2013 and September 2015. Results Patients were preoperatively stratified on the clinical risk; those presenting with low preoperative risk of common bile duct stones were referred to undergo laparoscopic cholecystectomy and routine cysticotomy with bile duct flushing. Patients presenting thick bile sludge, solid debrides, and/or increased tension of bile outflow underwent unplanned cholangiography. No intraoperative complications or conversion to open technique occurred. Average follow-up time was 22,8 months (range 12 to 37). Rate of retained ductal stones accounted for 0,3%. Conclusions Routine cysticotomy and bile flushing in our experience is a valid, simple, and not time consuming manoeuvre that can help decompressing and flushing CBD. Moreover, it is a valid tool for extending selective IOC approach in a focused manner. Further evaluations have to be conducted to evaluate risks and effectiveness of this manoeuvre.

Cardiac assessment prior to non-cardiac surgery.

Increasingly, patients undergoing non-cardiac surgery are older and have more comorbidities yet preoperative cardiac assessment appears haphazard and unsystematic. We hypothesised that patients at high cardiac risk were not receiving adequate cardiac assessment, and patients with low-cardiac risk were being over-investigated. To compare in a representative sample of patients undergoing non-cardiac surgery the use of cardiac investigations in patients at high and low preoperative cardiac risk. We examined cardiac assessment patterns prior to elective non-cardiac surgery in a representative sample of patients. Cardiac risk was calculated using the Revised Cardiac Risk Index. Of 671 patients, 589 (88%) were low risk and 82 (12%) were high risk. We found that nearly 14% of low-risk and 45% of high-risk patients had investigations for coronary ischaemia prior to surgery. Vascular surgery had the highest rate of investigation (38%) and thoracic patients the lowest rate (14%). Whilst 78% of high-risk patients had coronary disease, only 46% were on beta-blockers, 49% on aspirin and 77% on statins. For current smokers (17.3% of cohort, n = 98), 60% were advised to quit pre-op. Practice patterns varied across surgical sub-types with low-risk patients tending to be over-investigated and high-risk patients under-investigated. A more systemised approach to this large group of patients could improve clinical outcomes, and more judicious use of investigations could lower healthcare costs and increase efficiency in managing this cohort.

Clinical significance of prospectively assigned Gleason tertiary pattern 4 in contemporary Gleason score 3+3=6 prostate cancer.

To determine the oncologic impact of prospectively assigned tertiary pattern 4 in contemporary Gleason score (GS) 3 + 3 = 6 radical prostatectomy (RP) specimens. Oncologic outcomes were retrospectively reviewed for 720 consecutive patients from a single National Comprehensive Cancer Network (NCCN) center with at least 6 months follow-up after RP for GS3 + 3 = 6 (GS6, N = 222), GS6 with tertiary pattern 4 (GS6t4, N = 62), or GS3 + 4 = 7 (N = 436) prostate cancer, as prospectively graded since 2006 using the 2005 International Society of Urologic Pathologists criteria. Preoperative NCCN risk category, RP pathology, progression-free survival (PFS) and metastasis-free survival (MFS) were compared among the GS6, GS6t4, and GS3 + 4 = 7 groups using χ(2) , Kaplan-Meier, and log-rank analyses. The incidence of low NCCN preoperative risk classification for GS6t4 patients (63%) was less than that for GS6 patients (77%) while greater than that for GS3 + 4 = 7 patients (30%, P < 0.001). GS6t4 patients had RP pathologic features which were intermediate in risk between that of GS6 and GS3 + 4 = 7 based on extraprostatic extension (27% vs. 6% vs. 31%, respectively, P < 0.001) and mean percentage of prostate gland involvement (13% vs. 10% vs. 16%, respectively, P < 0.001). With a mean overall follow-up of 42 months, PFS for GS6t4 patients (5-year 85%) was intermediate between that of GS6 (5-year 93%) and GS3 + 4 = 7 (5-year 76%) patients (P < 0.001). The 5-year MFS rate was 100% for GS6 and GS6t4 patients compared to 97% for GS3 + 4 = 7 patients (P = 0.07). This study provides the longest follow-up to date for RP patients with prospectively assigned GS6t4 and supports a risk for adverse RP pathology and postoperative disease progression that is intermediate between GS6 and GS3 + 4 = 7. Whether a tertiary pattern 4 in GS6 disease increases the risk of metastasis is uncertain and requires longer term study. Given favorable oncologic outcomes, less stringent postoperative surveillance for both GS6 and GS6t4 patients may be warranted.

'Red blood transfusion in patients undergoing cardiac surgery'.

The use of allogeneic red blood cells (RBC) is commonplace in cardiac surgery, with reported transfusion rates ranging from 5 to 90 %. [1–4] Despite advantages, RBC transfusion is associated with well-described adverse outcomes. [1–4] Transfusion of RBCs is not only associated with an increased perioperative mortality and morbidity, however; it also results in a longer ICU stay, total hospital stay and increased costs. [2] Even the long-term results are influenced by perioperative RBC transfusions. Koch et al. found a significantly reduced 6-month and late survival in patients undergoing an isolated CABG with transfusion of RBCs. [1] Not only the question of RBC transfusion, but also the number of units of transfused RBCs and the method and duration of storage of RBCs is important. [3, 4] It is no surprise that several studies focus on blood conservation methods and a more judicious use of RBCs, with as prerequisite the identification of preoperative variables associated with an increased need for transfusion. [3, 4] Female gender, impaired left ventricular function, low preoperative haemoglobin, risk and complexity of the operation are the most identified variables with an increased risk for RBC transfusion [3, 4] However, even with the routine use of current blood conservation methods, a proportion of patients undergoing cardiac surgery continue to receive RBC transfusion and are hence exposed to its associated risk [1–4]. There is, therefore, an ongoing need to study further blood conservation methods. In their recent study, [5] Haanschoten et al. focus on reducing the immediate availability of RBCs in cardiac surgery. Since March 2010, the No Elective Red Cells (NERC) program is being used. The only change for their current study is that RBCs are now not directly available in the operating theatre and, when needed, the local blood bank can deliver the cross-matched RBCs within 20 min. So, the aim of this new strategy is to reduce the number of units of RBCs returned to the laboratory and certainly the numbers of those units that can no longer be used because of a reduced quality of the RBCs. This is of course an interesting point in the whole discussion of blood conservation, mostly evaluated only on the percentage of patients without RBC transfusion and /or the number of units transfused. The authors show that in a selected group of patients it is safe to perform cardiac surgery with the immediate availability of RBCs in the operating theatre. [5] Eighty-one percent of the patients did not receive any RBCs and the predictors for the need of blood transfusion are confirming the results of previous studies. [3, 4] However, some interesting points are not discussed in this study. Since the start of the NERC program, what was the percentage of RBCs returned to the blood bank and what was the percentage of units that could no longer be used because of reduced quality? It is emphasised that in all patients who need a blood transfusion, blood was available within 20 min after ordering it. However, was this really so? What was the time between ordering and delivering the blood in the operating theatre? What happens in cases of catastrophic bleeding problems, always possible even in the most simple cardiac procedure? These questions are essential before general conclusions can be made about safety and the effectiveness of this new strategy, no immediate availability of red blood cells, in the NERC program.

Red blood transfusion in patients undergoing cardiac surgery.

The use of allogeneic red blood cells (RBC) is commonplace in cardiac surgery, with reported transfusion rates ranging from 5 to 90 %. [1–4] Despite advantages, RBC transfusion is associated with well-described adverse outcomes. [1–4] Transfusion of RBCs is not only associated with an increased perioperative mortality and morbidity, however; it also results in a longer ICU stay, total hospital stay and increased costs. [2] Even the long-term results are influenced by perioperative RBC transfusions. Koch et al. found a significantly reduced 6-month and late survival in patients undergoing an isolated CABG with transfusion of RBCs. [1] Not only the question of RBC transfusion, but also the number of units of transfused RBCs and the method and duration of storage of RBCs is important. [3, 4] It is no surprise that several studies focus on blood conservation methods and a more judicious use of RBCs, with as prerequisite the identification of preoperative variables associated with an increased need for transfusion. [3, 4] Female gender, impaired left ventricular function, low preoperative haemoglobin, risk and complexity of the operation are the most identified variables with an increased risk for RBC transfusion [3, 4] However, even with the routine use of current blood conservation methods, a proportion of patients undergoing cardiac surgery continue to receive RBC transfusion and are hence exposed to its associated risk [1–4]. There is, therefore, an ongoing need to study further blood conservation methods. In their recent study, [5] Haanschoten et al. focus on reducing the immediate availability of RBCs in cardiac surgery. Since March 2010, the No Elective Red Cells (NERC) program is being used. The only change for their current study is that RBCs are now not directly available in the operating theatre and, when needed, the local blood bank can deliver the cross-matched RBCs within 20 min. So, the aim of this new strategy is to reduce the number of units of RBCs returned to the laboratory and certainly the numbers of those units that can no longer be used because of a reduced quality of the RBCs. This is of course an interesting point in the whole discussion of blood conservation, mostly evaluated only on the percentage of patients without RBC transfusion and /or the number of units transfused. The authors show that in a selected group of patients it is safe to perform cardiac surgery with the immediate availability of RBCs in the operating theatre. [5] Eighty-one percent of the patients did not receive any RBCs and the predictors for the need of blood transfusion are confirming the results of previous studies. [3, 4] However, some interesting points are not discussed in this study. Since the start of the NERC program, what was the percentage of RBCs returned to the blood bank and what was the percentage of units that could no longer be used because of reduced quality? It is emphasised that in all patients who need a blood transfusion, blood was available within 20 min after ordering it. However, was this really so? What was the time between ordering and delivering the blood in the operating theatre? What happens in cases of catastrophic bleeding problems, always possible even in the most simple cardiac procedure? These questions are essential before general conclusions can be made about safety and the effectiveness of this new strategy, no immediate availability of red blood cells, in the NERC program.

Postoperative radiotherapy in prostate cancer: Analysis of prognostic factors in a series of 282 patients

AimTo assess the outcomes of patients treated with postoperative RT in relation to the possible prognostic factors. BackgroundPostoperative radiotherapy (RT) has been proved to reduce the risk of biochemical recurrence in high-risk prostate cancer patients. Baseline prostate specific antigen (PSA), pathological Gleason score (GS), positive surgical margins, nodal status and seminal vesicle invasion are independent predictors of biochemical relapse. Materials and methodsThe clinical records of 282 patients who underwent postoperative RT were retrospectively reviewed. The prognostic value of postoperative PSA, preoperative risk class, nodal status, pathological GS, margins status, and administration of hormonal therapy (HT) was analyzed. ResultsPostoperative RT was delivered with a median dose to the prostatic fossa of 66Gy (range 50–72) in 1.8–2Gy/fraction. Median follow-up was 23.1 months (range 6–119). Five-year actuarial biochemical disease-free survival (bDFS) and overall survival rates were 76% and 95%, respectively. Higher bDFS was found for patients with postoperative PSA <0.02ng/ml (p=0.03), low preoperative risk class (p=0.01), pN0 (p=0.003), GS 4–6 (p=0.0006), no androgen deprivation therapy (p=0.02), and irrespective of surgical margin status (p=0.10). Multivariate analysis showed that postoperative PSA and Gleason score had a significant impact on bDFS (p=0.039 and p=0.05, respectively). ConclusionsPostoperative RT with a dose of 66Gy offers an acceptable toxicity and an optimal disease control after radical prostatectomy in patients with different risk features. A postoperative PSA >0.02ng/ml could be considered as a prognostic factor and a tool to select patients at risk for progression.