Major Cancer Surgery Research Articles

Prevalence of preoperative anxiety and depression in patients undergoing major oncologic surgeries: An analytical cross-sectional study

Background: Depression and anxiety experienced before major cancer surgeries have been associated with postoperative morbidity and mortality. Objectives: This study aimed to estimate the prevalence of preoperative anxiety and depression in patients undergoing major oncosurgeries. Materials and Methods: This was a cross-sectional analytical study conducted between June 2021 and June 2022 at Malabar Cancer Center in Thalassery, Kerala, in South India. We enrolled patients aged 18–65 years undergoing major oncosurgeries with American Society of Anesthesiologists (ASA) Physical Status Grades I and II. Patients were administered a questionnaire (in the local language, Malayalam) by the anesthesiologist on their first preoperative visit after the preanesthetic checkup. The questionnaire was in two parts: part 1 consisted of the demographic data, and part 2 comprised the Patient Health Questionnaire-4 (PHQ-4) and the Amsterdam Preoperative Anxiety and Information Scale (APAIS). On the PHQ-4, a score of ≥3 for the first two questions was the cutoff for anxiety, and a score of ≥3 for the last two questions was the cutoff for depression. APAIS is a six-item questionnaire; a score of ≥11 on the anxiety scale was considered positive for anxiety, and a score of >5 was considered to indicate the need for more information. Results: We enrolled 200 patients; 136 (68%) were women, and the median age overall was 52 (interquartile range [IQR], 42–60). Patients enrolled were planned for surgeries for head-and-neck cancers (n = 55, 27.5%), laparotomies or therapeutic laparoscopies (n = 70, 35%), breast cancers (n = 67, 33.5%), and bone and soft tissue surgeries (n = 8, 4%). Anxiety was noted in 49 (24.5%) patients by PHQ-4 and 23 (11.5%) patients by APAIS; depression was detected in 31 (15.5%). The presence of depression significantly contributed to anxiety. Patients who screened positive for depression had 79.6 times higher odds of screening positive for anxiety, as compared to those who screened negative for depression. Conclusion: Almost one in four patients undergoing major oncosurgeries experience preoperative anxiety, and one in six have depression. Patients have a substantial requirement for information concerning anesthesia and surgical procedures, which, if unmet, contributes to anxiety and/or depression. Preoperative counseling and providing more information to patients could reduce anxiety or depression. Other causative personal, familial, social, or economic factors should also be assessed and managed (Clinical Trials Registry of India number: CTRI/2021/07/034568).

Postoperative pulmonary complication as an emerging complication in major head and neck cancer surgery: A retrospective study.

Postoperative pulmonary complications (PPCs) are one of the most significant complications following head and neck cancer surgery (HNCS). Patients requiring tracheostomy, free tissue transfer reconstruction, and postoperative ventilation in an intensive care unit (ICU) may have a high incidence of PPCs. This study aimed to identify the most likely situations for developing PPCs in HNCS. A retrospective analysis of 40 patients who had undergone HNCS has been conducted. We individually traced each patient for 7 days postoperatively and collected data on various parameters. The incidence of PPCs after HNCS is more with free flap reconstruction. Patient-related risk factors with PPCs were advanced age, smoking, body mass index (BMI) >25, and bilateral or unilateral neck dissection. Postoperative ICU stay was significantly related to an increased incidence of PPCs. In terms of specific surgical sites, both the maxilla and mandible also showed significant relationship with PPCs. Tracheostomy was also considered a related factor in developing PPCs. To reduce PPCs in HNCS, patients with one or more of these risk factors should be subjected to exaggerated postoperative pulmonary care.

Risk of venous thromboembolism and bleeding after major surgery for ovarian cancer: standard in-hospital versus extended duration of thromboprophylaxis

BackgroundVenous thromboembolism (VTE) is a frequent complication in patients with ovarian cancer after major surgery. Based on limited data, international guidelines recommend extended thromboprophylaxis for up to 28 days. ObjectivesTo assess the incidence of VTE and bleeding within 30 days following major surgery in patients with ovarian cancer and to evaluate the association between VTE and thromboprophylaxis duration. MethodsThis was a single-center, retrospective, “before-after” cohort study in patients with ovarian cancer undergoing major surgery. Before July 2019, the local protocol mandated a standard course of thromboprophylaxis during hospital stay only. From July 2019 onward, patients received extended thromboprophylaxis for 28 days. The cumulative incidences of VTE and major bleeding within 30 days after surgery were estimated using the Kaplan-Meier method, with 95% confidence intervals (CIs). Cox regression analysis was performed to evaluate the association between thromboprophylaxis duration and VTE incidence. ResultsBetween January 2018 and December 2020, 250 women were included, of which 118 (47.2%) received extended and 132 (52.8%) standard thromboprophylaxis. During follow-up, 12 patients developed VTE (cumulative incidence, 4.8%; 95% CI, 2.1–7.4) and 2 major bleeding (cumulative incidence 0.8%; 95% CI, 0.0–1.9). Compared with standard thromboprophylaxis, VTE incidence was numerically lower with extended duration of thromboprophylaxis (5/118 [4.2%] vs 7/132 [5.3%]) but not significantly different (hazard ratio, 0.80; 95% CI, 0.25–2.52). The risk of major bleeding was similar in both groups (1/118 [0.8%] vs 1/132 [0.8%]; hazard ratio, 1.12; 95% CI, 0.07–17.89). ConclusionsThe cumulative VTE incidence in patients with ovarian cancer following major surgery was considerable. Extended thromboprophylaxis was safe and associated with a numerically lower risk of VTE but not significantly different.

Malnutrition universal screening tool predicts postoperative complications following major head and neck cancer surgery.

Head and neck cancer patients are at risk for malnutrition, which can impact postoperative outcomes. This study evaluates the Malnutrition Universal Screening Tool (MUST) to predict outcomes in major head and neck surgeries. A retrospective chart review included 275 major surgical procedures performed on 242 patients over the age of 18 years between May 2015 and May 2020. The majority of patients had a MUST score of zero (68.7%). Just under 17% scored 2 or greater indicating malnourishment. Having a MUST score of 2 or higher was associated with occurrence of a postoperative complication (p < 0.001). Patients with alcohol use disorder or depression were 5.2 (CI: 2.0-13.7, p=0.001) and 2.75 (CI 1.1-7.0; p=0.033) times more likely to develop a postoperative complication, respectively. Malnutrition and comorbidities were associated with complications in our surgical cohort. MUST is a novel tool to identify patients who may benefit from nutritional interventions.

Comparison between ultrasound-guided multi-injection intertransverse process and thoracic paravertebral blocks for major breast cancer surgery: a randomized non-inferiority trial

BackgroundThis study investigated whether a novel multi-injection intertransverse process block could provide non-inferior analgesia and recovery quality following major breast cancer surgery compared with the multi-injection thoracic paravertebral block.MethodsEighty-eight females...

Risk Assessment of Postoperative Pneumonia in Cancer Patients Using a Common Data Model.

The incidence of postoperative pneumonia (POP) in patients with cancer is high, but its incidence following major cancer surgeries is unclear. Therefore, we investigated the incidence and risk factors of POP after surgery in patients with the five most common cancers in Korea using a common data model (CDM). Patients aged &gt;19 years who underwent gastric, colon, liver, lung, or breast cancer surgery between January 2011 and December 2020 were included, excluding patients who underwent chemotherapy or radiotherapy. Pneumonia was defined as a pneumonia diagnosis code in patients hospitalized postoperatively. Gastric, colon, lung, breast, and liver cancers were noted in 4004 (47.4%), 622 (7.4%), 2022 (24%), 958 (11.3%), and 839 (9.9%) of 8445 patients, respectively. The cumulative POP incidence was 3.1% (n = 262), with the highest incidence in lung cancer (n = 91, 4.5%), followed by gastric (n = 133, 3.3%), colon (n = 19, 3.1%), liver (n = 14, 1.7%), and breast (n = 5, 0.5%) cancers. In multivariable analysis, older age, male sex, history of chronic pulmonary disease, mood disorder, and cerebrovascular disease were POP predictors. The cumulative POP incidence in the five cancers using the CDM was approximately 3%. Older age, male sex, chronic pulmonary disease, mood disorder, and cerebrovascular disease were POP risk factors in patients with cancer.

91. The effect of preoperative alcohol detoxification admission on postoperative delirium for major head & neck cancer surgery

Postoperative delirium (POD) remains a challenging complication following major head and neck cancer (HNC) surgery and is associated with poorer functional recovery and prolonged hospital stay. Excess alcohol consumption is a risk factor for developing POD. An inpatient intervention for alcohol/drug detoxification was introduced in our unit to address this. Here we assess the effect of preoperative alcohol detoxification on POD for major HNC surgery.

The association between vital signs abnormalities during postanaesthesia care unit stay and deterioration in the general ward following major abdominal cancer surgery assessed by continuous wireless monitoring

Objective: Vital signs abnormalities in the post-anaesthesia care unit (PACU) may identify patients at risk of severe postoperative complications in the general ward, but are sparsely investigated by continuous monitoring. We aimed to assess if the severity of vital signs abnormalities in the PACU was correlated to the duration of severe vital signs abnormalities and serious adverse events (SAEs) in the general ward. Design: Prospective cohort study. Primary exposure was PACU vital signs abnormalities assessed by a standardised PACU recovery score. Participants: Adult patients, aged ≥ 60 years, who underwent major abdominal cancer surgery. Main outcome measures: The duration of severe vital signs abnormalities were assessed by continuous wireless vital signs monitoring and, secondly, by any SAE within the first 96 hours in the general ward. Results: One-hundred patients were included, and 92 patients with a median of 91 hours (interquartile range, 71-95 hours) of vital signs recording were analysed. The maximum vital signs abnormalities in the PACU were not significantly correlated to overall vital signs abnormalities in the general ward (R = 0.13; P = 0.22). Severe circulatory abnormalities in the overall PACU stay and at discharge were significantly correlated to the duration of circulatory vital signs abnormalities on the ward (R = 0.32 [P = 0.00021] and R = 0.26 [P = 0.014], respectively). Seventeen patients (18%) experienced SAEs, without significant association to the PACU stay (area under the receiver operating characteristic [AUROC], 0.59; 95% CI, 0.46-0.73). Conclusion: Vital signs abnormalities in the PACU did not show a tendency towards predicting overall severe vital signs abnormalities or SAEs during the first days in the general ward. Circulatory abnormalities in the PACU showed a tendency towards predicting circulatory complications in the ward.

In this Issue of CCR

Point of View: A four-step model to aid teaching, clinical assessment and communication of circulatory disorders amongst junior clinicians Editorial: Midodrine – why don't you just work better? Review: Midodrine Use in Critically Ill Patients – A Narrative Review Original Articles: Study protocol and statistical analysis plan for the 20% Human Albumin Solution Fluid Bolus Administration Therapy in Patients after Cardiac Surgery-II (HAS FLAIR-II) trial Early sedation in traumatic brain injury: a multicentre international observational study The association between vital signs abnormalities during post-anaesthesia care unit stay and deterioration in the general ward following major abdominal cancer surgery assessed by continuous wireless monitoring Mortality associated with Acute Respiratory Distress Syndrome 2009-2019: A systematic review and meta-analysis The prevalence of post extubation dysphagia in critically ill adults: An Australian data linkage study ANTIPORT: adaptation of a transfusion prediction score to an Australian cardiac surgery population

Mobile Postoperative Symptom Intervention Tool and Biometric Monitoring After Radical Cystectomy: Pilot Study Evaluating Feasibility, Usability, and Potential Utility.

Mobile health technology and integration of patient-reported outcome measures into clinical interventions have the potential to transform patient care. Though patient-reported outcome measure management has been shown to improve outcomes in ambulatory care settings, few studies have examined remote patient-reported outcome measure assessment after major cancer surgery. A multiphased feasibility and usability study was designed. A mobile app-based postoperative symptom intervention tool was developed and evaluated by a focus group of bladder cancer patients and caregivers. Patients were prospectively accrued prior to cystectomy and asked to complete the daily mobile postoperative symptom intervention tool and wear biometric monitoring devices for 30 days post discharge. Retention, postoperative symptom intervention tool completion, and usability were assessed. Exploratory analysis of daily symptoms and patient-generated health information correlated signals with postsurgical complications and hospital readmission. Fifteen patients with a median age of 72 years completed 78% of daily surveys over the 30-day recovery period. Average time to complete the postoperative symptom intervention tool was 152 seconds. All patients agreed that the daily survey was easy to use, and most reported it would be a better way to communicate with the care team about symptoms than calling the clinic. Frequency and severity of patient-reported symptoms appeared to cluster prior to or at the time of complication or unplanned health care encounters on visual-analogue mapping. Using smartphone and wearable technology to capture patient-reported symptoms and biometric data is feasible and rated as highly usable by bladder cancer patients after cystectomy. Symptom scores may signal developing complications and help clinicians identify postsurgical patients who may benefit from intervention.

Thickness of Biceps and Quadriceps Femoris Muscle Measured Using Point-of-Care Ultrasound as a Representation of Total Skeletal Muscle Mass.

Generalized loss of muscle mass is associated with increased morbidity and mortality in patients with cancer. The gold standard to measure muscle mass is by using computed tomography (CT). However, the aim of this prospective observational cohort study was to determine whether point-of-care ultrasound (POCUS) could be an easy-to-use, bedside measurement alternative to evaluate muscle status. Patients scheduled for major abdominal cancer surgery with a recent preoperative CT scan available were included. POCUS was used to measure the muscle thickness of mm. biceps brachii, mm. recti femoris, and mm. vasti intermedius 1 day prior to surgery. The total skeletal muscle index (SMI) was derived from patients' abdominal CT scan at the third lumbar level. Muscle force of the upper and lower extremities was measured using a handheld dynamometer. A total of 165 patients were included (55% male; 65 ± 12 years). All POCUS measurements of muscle thickness had a statistically significant correlation with CT-derived SMI (r ≥ 0.48; p &lt; 0.001). The strongest correlation between POCUS muscle measurements and SMI was observed when all POCUS muscle groups were added together (r = 0.73; p &lt; 0.001). Muscle strength had a stronger correlation with POCUS-measured muscle thickness than with CT-derived SMI. To conclude, this study indicated a strong correlation between combined muscle thickness measurements performed by POCUS- and CT-derived SMI and measurements of muscle strength. These results suggest that handheld ultrasound is a valid tool for the assessment of skeletal muscle status.

End-tidal carbon dioxide in the early phase of cardiopulmonary exercise testing prior to major colorectal cancer surgery associates with postoperative outcome.

Cardiopulmonary exercise testing (CPET) objectively informs preoperative risk stratification prior to major surgery. CPET facilities are resource intensive and therefore more cost-effective triage methods are desirable for scalability. We tested two dynamic CPET parameters (end-tidal CO<inf>2</inf> (P<inf>et</inf>CO<inf>2</inf>) and heart rate (HR)) to early phase exercise and resting diffusion capacity (DLCO) as potential point of care assessments that could be used outside of formal CPET testing facilities. We conducted a retrospective cohort study including 84 patients who underwent CPET prior to elective major abdominal cancer surgery. Data were analyzed for P<inf>et</inf>CO<inf>2</inf> and HR in response to early phase (2 minutes) exercise as well as resting DLCO against postoperative complications and two-year survival. Complications were classified according to Clavien-Dindo classification into less severe and severe (CD>IIIb) grades. Optimal cut points for predicting outcomes were determined using the Youden Index of receiver operating characteristic (ROC) curves. Multivariate regression modeling including both logistic and Cox proportional-hazards model adjusted to age and comorbidity burden was used to analyse the association between the selected parameters and postoperative outcomes. P<inf>et</inf>CO<inf>2</inf>, in response to two minutes of loaded exercise was higher in survivors than in non-survivors (median (IQR) 40.0 (4.2) mmHg vs. 34.5 (5.2) mmHg, P<0.001). There was no association between chronotropic response and postoperative outcome. The optimal cut point for predicting postoperative complications and survival was 38 mmHg and 37.1 mmHg for P<inf>et</inf>CO<inf>2</inf>, respectively. Low P<inf>et</inf>CO<inf>2</inf> was associated with considerably lower odds of survival (OR 0.12; 95% CI 0.03, 0.47; P=0.003) and additionally increased odds of severe postoperative complications (OR 6.77; 95% CI 1.45, 38.4; P=0.019). Reduced age-predicted DLCO% <80% was associated with increased mortality (HR 5.27; 95% CI 1.09, 25.5; P=0.039). Assessment of DLCO at rest and dynamic assessment of P<inf>et</inf>CO<inf>2</inf> during the early phase of exercise may potentially be developed as inexpensive point-of-care triage tools to scale objective preoperative risk assessment.

Effect of Combined Epidural Morphine and Midazolam on Postoperative Pain in Patients Undergoing Major Abdominal Cancer Surgery.

The objective was to compare analgesic effect of combined epidural morphine-midazolam with either drug alone on postoperative pain in patients undergoing major abdominal cancer surgery. Eighty-four patients were allocated in prospective randomized double-blind study to receive epidural analgesia. Patients received 5mg morphine in morphine (Mor) group, 5mg midazolam in midazolam (Mid) group, 5mg morphine + 5mg midazolam in morphine-midazolam (MM) group, 0.25% bupivacaine was added to injected solution with same volume in all groups. All groups were compared with time of first analgesic request, total analgesic consumption, number of epidural doses, postoperative Visual Analog Scale score, and adverse events. Time of first analgesic request was 4 to 8 hours in Mid versus 12 to 23 and 14 to 24 hours in Mor and MM groups, respectively, with significant difference between Mid versus Mor ( P <0.001), Mid versus MM ( P <0.001), and Mor versus MM groups ( P <0.031). Analgesic consumption was more in Mid than Mor and MM groups, with significant difference between Mid versus Mor ( P <0.008), Mid versus MM ( P <0.001), with no significant difference between Mor and MM groups ( P <0.6). The number of epidural doses in Mid was 1 to 3 versus 1 to 3, and 1 to 2 in Mor and MM groups, respectively, with significant difference between Mid versus Mor ( P <0.025), Mid versus MM ( P <0.004), with no significant difference between Mor and MM groups ( P =1.0). Addition of midazolam to epidural morphine prolonged time of first analgesic request and decreased total analgesic consumption.

Hybrid GA-SVM Approach for Postoperative Life Expectancy Prediction in Lung Cancer Patients

Medical outcomes must be tracked in order to enhance quality initiatives, healthcare management, and mass education. Thoracic surgery data have been acquired for those who underwent major lung surgery for primary lung cancer, a field in which there has been little research and few reliable recommendations have been made for lung cancer patients. Early detection of lung cancer benefits therapy choices and increases the odds of a patient surviving a lung cancer infection. Using a Hybrid Genetic and Support Vector Machine (GA-SVM) methodology, this study proposes a method for identifying lung cancer patients. To estimate postoperative life expectancy, ensemble machine-learning techniques were applied. The article also presents a strategy for estimating a patient’s life expectancy following thoracic surgery after the detection of cancer. To perform the prediction, hybrid machine-learning methods were applied. In ensemble machine-learning algorithms, attribute ranking and selection are critical components of robust health outcome prediction. To enhance the efficacy of algorithms in health data analysis, we propose three attribute ranking and selection procedures. Compared to other machine-learning techniques, GA-SVM achieves an accuracy of 85% and a higher F1 score of 0.92. The proposed algorithm was compared with two recent state-of-the-art techniques and its performance level was ranked superior to those of its counterparts.

Impact of age and comorbidities on short- and long-term outcomes of patients undergoing surgery for colorectal cancer

As the world population is progressively ageing, more and more elderly patients will require cancer surgery. Although curative surgery is the treatment of choice for resectable colorectal cancer (CRC), it is still debated whether elderly frail patients should undergo major cancer surgery due to the increased risk of postoperative and long-term mortality. The aim of this retrospective study was to evaluate the impact of age and comorbidities on postoperative mortality/morbidity and long-term outcomes, looking for potential age-related survival differences. A total of 1,482 patients operated for CRC at our institution between January 2005 and October 2020 were analysed. The independent effect of age and comorbidities on postoperative complications was assessed by a logistic model, while the effect on overall survival (OS) and cancer-related survival (CRS) was estimated by a Cox regression model. The median age in the cohort was 67.8 years. Postoperative mortality was very low in the whole cohort (0.8%) and contained even in older age groups (3.2% in patients aged 80-84 years, 4% in the 85-90-year age group). The cumulative incidence of postoperative complications was doubled in patients with comorbidities (32.8% vs. 15.1%, p = 0.002). With regard to OS, as expected, it exponentially decreased with advancing age. Conversely, differences in CRS were less pronounced between age groups and absent in patients with stage 0-I CRC. Analysis of all causes and cancer-related mortality revealed a peak within 2 years from surgery, suggesting a prolonged impact of surgery. In patients aged 75 years and above, all-cause mortality showed a steep increase 1 year after surgery, while cancer-related mortality plateaued at about 4 years after surgery. On multivariable analysis, OS, but not CRS, was significantly influenced by age. Although acceptable results of surgery in elderly patients, OS is strongly dependent on age: older people die more from competing causes than cancer-related treatments compared to younger age classes. The preoperative identification of risk factors for low OS may help the selection of those elderly patients who would benefit from curative CRC surgery.

The Marsden Morbidity Index: the derivation and validation of a simple risk index scoring system using cardiopulmonary exercise testing variables to predict morbidity in high-risk patients having major cancer surgery

BackgroundMorbidity and mortality risk prediction tools are increasingly being used as part of preoperative assessment of patients presenting for major abdominal surgery. Cardiopulmonary exercise testing (CPET) can predict which patients undergoing major abdominal surgery are at risk of complications. The primary objective of this study was to identify preoperative variables including those derived from CPET, which were associated with inpatient morbidity in high-risk patients following major abdominal cancer surgery. The secondary objective was to use these variables to derive and validate a morbidity risk prediction tool.MethodsWe conducted a retrospective cohort analysis of consecutive adult patients who had CPET as part of their preoperative work-up for major abdominal cancer surgery. Morbidity was a composite outcome, defined by the Clavien-Dindo score and/or the postoperative morbidity survey (POMS) score which was assessed on postoperative day 7. A risk prediction tool was devised using variables from the first analysis which was then applied prospectively to a matched cohort of patients.ResultsA total of 1398 patients were included in the first phase of the analysis between June 2010 and May 2017. Of these, 540 patients (38.6%) experienced postoperative morbidity. CPET variables deemed significant (p < 0.01) were anaerobic threshold (AT), maximal oxygen consumption at maximal exercise capacity (VO2 max), and ventilatory equivalent for carbon dioxide at anaerobic threshold (AT VE/VCO2). In addition to the CPET findings and the type of surgery the patient underwent, eight preoperative variables that were associated with postoperative morbidity were identified. These include age, WHO category, body mass index (BMI), prior transient ischaemic attack (TIA) or stroke, chronic renal impairment, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and cancer stage. Both sets of variables were then combined to produce a validated morbidity risk prediction scoring tool called the Marsden Morbidity Index. In the second phase of the analysis, this tool was applied prospectively to 424 patients between June 2017 and December 2018. With an area under the curve (AUC) of 0.79, this new model had a sensitivity of 74.2%, specificity of 78.1%, a positive predictive value (PPV) of 79.7%, and a negative predictive value of (NPV) of 79%.ConclusionOur study showed that of the CPET variables, AT, VO2 max, and AT VE/VCO2 were shown to be associated with postoperative surgical morbidity following major abdominal oncological surgery. When combined with a number of preoperative comorbidities commonly associated with increased risk of postoperative morbidity, we created a useful institutional scoring system for predicting which patients will experience adverse events. However, this system needs further validation in other centres performing oncological surgery.

Perioperative blood transfusion in major abdominal cancer surgery: a multi-centre service evaluation and national survey.

Anaemia is associated with complications and death after surgery. Perioperative red-cell transfusion triggers are not well defined in patients having oncological surgery, or with cardiovascular disease. We carried out a prospective multicentre cohort study and a clinician survey of UK transfusion practice in adult patients undergoing surgery for abdominal malignancy. The primary outcome was red cell transfusion. Secondary outcomes were transfusion trigger haemoglobin, incidence of complications, length of hospital stay, and acute hospital mortality. In this prospective cohort study, data were collected on 412 patients undergoing surgery for intrabdominal malignancy in 14 NHS hospitals. Twenty-two (5.2%) patients received preoperative, 42 (10.2%) intraoperative, and 52 (12.2%) postoperative red blood cell transfusion. The mean postoperative transfusion trigger was 75.3 g L-1, and the mean number of units of red blood cells transfused was 1.5 (standard deviation, 1.1). Seventeen (4.0%) patients had a documented postoperative troponin elevation. Five (1.2%) patients died within 30 days of surgery. In the survey, 117 clinicians submitted complete responses, of whom 62 (53%) indicated that a transfusion threshold of 70 g L-1 was appropriate: however, this decreased to six (5.1%) if there was evidence of recent cardiac ischaemia. There were 100 (86%) respondents who indicated equipoise for a trial of restrictive vs liberal transfusion, decreasing to 56% if there was coexisting cardiovascular disease. Many patients having oncological surgery receive red cell transfusion, the majority being given postoperatively. Restrictive transfusion practice is generally followed; however, variability exists especially in cardiovascular disease. Equipoise exists for a study of transfusion thresholds in this group.

Predictive value of the G8 and the IADL-modified G8 screening tools for postoperative delirium following major urological cancer surgery

IntroductionThe purpose of this study was to evaluate whether the Geriatric-8 (G8) and the instrumental activities of daily living (IADL)-modified G8 are associated with the occurrence of postoperative delirium after major urological cancer surgery. Materials and MethodsWe retrospectively analyzed a total of 415 consecutive patients who underwent major urologic cancer surgery and were screened preoperatively using the G8 and the IADL-modified G8 at our institution between January 2020 and July 2021. For both the G8 and the IADL-modified G8, a cut-off value of 14 was used. All patients underwent perioperative management according to the Enhanced Recovery After Surgery protocol formulated at our institution. Delirium was diagnosed using the Confusion Assessment Method. The relationship between these screening tests and clinical variables was examined. Predictive accuracy was evaluated by the area under the receiver operating characteristic curve (AUC). To determine the risk factors for the occurrence of postoperative delirium, univariate and multivariate analyses were performed. ResultsOf the 415 patients, 160 (39%) were assigned to the low G8 (score ≤ 14) group and 166 (40%) to the low IADL-modified G8 (score ≤ 14) group. The median age of the patients was 72 years. Postoperative delirium occurred in 31 patients (7%). The AUC values for predicting postoperative delirium were 0.69 for the G8 and 0.71 for the IADL-modified G8. Multivariate analysis for the G8 showed that G8 ≤ 14 (odds ratio [OR] = 2.6; 95% confidence interval [CI] = 1.2–6.0; P = 0.02), preoperative use of benzodiazepine (OR = 3.8; 95% CI = 1.6–8.6; P = 0.002), and operative time ≥ 237 min (OR = 3.3; 95% CI = 1.5–7.1; P = 0.003) were independent risk factors for postoperative delirium. Similarly, for the IADL-modified G8, IADL-modified G8 ≤ 14 (OR = 2.6; 95% CI = 1.1–5.8; P = 0.02), preoperative use of benzodiazepine (OR = 3.9; 95% CI = 1.7–8.8; P = 0.001), and operative time ≥ 237 min (OR = 3.3; 95% CI = 1.5–7.2; P = 0.003) were independent risk factors for postoperative delirium. DiscussionThe G8 and the IADL-modified G8 screening may allow for better identification of patients at risk of postoperative delirium.

Prehabilitation in high-risk patients scheduled for major abdominal cancer surgery: a feasibility study

BackgroundPatients presenting for major surgery with low cardiorespiratory fitness (deconditioning) and other modifiable risk factors are at increased risk of postoperative complications. This study investigated the feasibility of delivering prehabilitation in high-risk patients scheduled for major abdominal cancer surgery.MethodsEligible patients in this single-center cohort study included patients with poor fitness (objectively assessed by cardiopulmonary exercise testing, CPET) scheduled for elective major abdominal cancer surgery. Patients were recruited to participate in a prehabilitation program that spanned up to 6 weeks pre-operatively and comprised aerobic and resistance exercise training, breathing exercise, and nutritional support. The primary outcome assessed pre-specified feasibility targets: recruitment >70%, retention >85%, and intervention adherence >70%. Secondary outcomes were assessed for improved pre-operative functional status and health-related quality of life and for postoperative complications.ResultsEighty-two (34%) out of 238 patients screened between April 2018 and December 2019 were eligible for recruitment. Fifty (61%) patients (52% males) with a median age of 71 (IQR, 63–77) years participated in the study. Baseline oxygen consumption the at anaerobic threshold and at peak exercise (mean±SD: 9.8±1.8 and 14.0±2.9 mL/kg/min, respectively) confirmed the deconditioned state of the study cohort. The retention rate within the prehabilitation program was 84%, with 42 participants returning for repeat CPET testing. While >60% of participants preferred to do home-based prehabilitation, adherence to the intervention was low—with only 12 (28%) and 15 (35%) of patients having self-reported compliance >70% with their exercise prescriptions.ConclusionOur prehabilitation program in high-risk cancer surgery patients did not achieve pre-specified targets for recruitment, retention, and self-reported program adherence. These findings underpin the importance of implementation research and strategies for the prehabilitation programs in major surgery.Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12620000073909) retrospectively registered.

TH8.5 VTE Pharmacological Prophylaxis in Oesophagogastric Cancer Resection Patients: A Triple Cycle Closed Loop Audit Against NICE Guidance NG89

Abstract Aims NICE NG89 Guidance introduced in 2018 recommends 28 days extended VTE pharmacological prophylaxis in patients who have major abdominal surgery for cancer. In 2018, our oesophagogastric unit protocols prescribed only inpatient VTE prophylaxis. Through the interventions of clinician education and modified unit protocols we improved our unit's compliance with NICE NG89. Methods We conducted a three cycle hybrid audit. 50 patients who underwent either oesophagectomy or gastrectomy were randomly chosen from 2017–19 (Cycle 1), 2019–21 (Cycle 2) and 2021–22 (Cycle 3). The first cycle intervention was the requirement for 14 days postoperative VTE pharmacological prophylaxis. The second cycle intervention increased this requirement to 28 days. All cycles additionally had interventions of clinician education. Results Against the NICE NG89 recommendation for 28 days postoperative pharmacological prophylaxis, our audit showed 14% compliance in Cycle 1, 26% in Cycle 2 and 91% in Cycle 3. The median duration of VTE prophylaxis prescription (combined inpatient and outpatient) was 7 days in Cycle 1, 23 days in Cycle 2 and 28 days in Cycle 3. The correct dose by weight for VTE prophylaxis was prescribed in 89% of cases in Cycle 1 and 100% of cases in Cycle 2 and 3. Whilst small numbers preclude statistical analysis, there were 2 bleeding events and 1 VTE event in both Cycles 1 and 2 but none in Cycle 3. Conclusions Our unit made a stepwise improvement against the NICE NG89 recommendation for extended VTE prophylaxis in cancer resections. Furthermore, clinician education improved correct weight based dosage.