Major Cancer Surgery Research Articles

Maintained ERAS compliance and outcomes after major colorectal cancer surgery in a designated cold site hospital during the SARS-CoV-2 pandemic

Maintained ERAS compliance and outcomes after major colorectal cancer surgery in a designated cold site hospital during the SARS-CoV-2 pandemic

Chronic heart failure in patients undergoing major head and neck surgery: A hospital-based study

ObjectiveTo investigate the effects of chronic heart failure on various post-operative outcomes in head and neck cancer patients undergoing major cancer surgery. Study designFor this retrospective cohort study of patients undergoing major head and neck cancer surgery, a sample of 10,002 patients between 2017 and 2019 were identified through the Nationwide Inpatient Sample. SettingPatients were selected as undergoing major head and neck cancer surgery, defined as laryngectomy, pharyngectomy, glossectomy, neck dissection, mandibulectomy, and maxillectomy, then separated based on pre-surgical diagnosis of chronic heart failure. MethodsThe effects of pre-operative chronic heart failure on post-surgical outcomes in these patients were investigated by univariable and multivariable logistic regression using ICD-10 codes and SPSS. ResultsA diagnosis of chronic heart failure was observed in 265 patients (2.6 %). Patients with chronic heart failure had more preexisting comorbidities when compared to patients without chronic heart failure (mean ± SD; 4 ± 1 vs. 2 ± 1). Multivariable logistic regression showed that chronic heart failure patients had significantly greater odds of dying during hospitalization (OR 2.86, 95 % CI 1.38–5.91) and experiencing non-routine discharge from admission (OR 1.89, 95 % CI 1.41–2.54) after undergoing major head and neck cancer surgery. ConclusionChronic heart failure is associated with greater length of stay and hospital charges among head and neck cancer patients undergoing major head and neck cancer surgeries. Chronic heart failure patients have significantly greater rates of unfavorable post-operative outcomes, including death during hospitalization and non-routine discharge from admission.

In-Hospital Venous Thromboembolism and Pulmonary Embolism After Major Urologic Cancer Surgery

BackgroundThis study aimed to test for temporal trends of in-hospital venous thromboembolism (VTE) and pulmonary embolism (PE) after major urologic cancer surgery (MUCS).MethodsIn the Nationwide Inpatient Sample (NIS) database (2010–2019), this study identified non-metastatic radical cystectomy (RC), radical prostatectomy (RP), radical nephrectomy (RN), and partial nephrectomy (PN) patients. Temporal trends of VTE and PE and multivariable logistic regression analyses (MLR) addressing VTE or PE, and mortality with VTE or PE were performed.ResultsOf 196,915 patients, 1180 (1.0%) exhibited VTE and 583 (0.3%) exhibited PE. The VTE rates increased from 0.6 to 0.7% (estimated annual percentage change [EAPC] + 4.0%; p = 0.01). Conversely, the PE rates decreased from 0.4 to 0.2% (EAPC − 4.5%; p = 0.01). No difference was observed in mortality with VTE (EAPC − 2.1%; p = 0.7) or with PE (EAPC − 1.2%; p = 0.8). In MLR relative to RP, RC (odds ratio [OR] 5.1), RN (OR 4.5), and PN (OR 3.6) were associated with higher VTE risk (all p < 0.001). Similarly in MLR relative to RP, RC (OR 4.6), RN (OR 3.3), and PN (OR 3.9) were associated with higher PE risk (all p < 0.001). In MLR, the risk of mortality was higher when VTE or PE was present in RC (VTE: OR 3.7, PE: OR 4.8; both p < 0.001) and RN (VTE: OR 5.2, PE: OR 8.3; both p < 0.001).ConclusionsRC, RN, and PN predisposes to a higher VTE and PE rates than RP. Moreover, among RC and RN patients with either VTE or PE, mortality is substantially higher than among their VTE or PE-free counterparts.

Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm

Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume. To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes. This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]). After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1. Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses. A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups. In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.

584 Extended VTE Prophylaxis in Patients Undergoing Oesophagogastric Cancer Surgery

Abstract Aim Venous thromboembolism (VTE) is a life-threatening complication in cancer patients undergoing surgery. NICE recommends VTE-prophylaxis to 28days for patients undergoing major abdominal cancer surgery. The efficacy of in-hospital VTE-prophylaxis is well-documented, but the optimal duration of postoperative VTE-prophylaxis remains controversial. Patients undergoing oesophagogastric cancer surgery have a higher risk of VTE due to suboptimal oral intake, dehydration, need for adjuvant and neoadjuvant chemotherapy. Hence in 2014, extended VTE-prophylaxis to 28days from hospital discharge (HD) was adopted as a departmental policy. This study aims to evaluate its effectiveness, prescribing compliance and safety. Method This is a 10-year retrospective study from July 2012-2022. All patients who underwent cardio-oesophagectomy or gastrectomy for oesophagogastric cancers were included. Patients who died during the index admission, benign oesophagogastric surgery including excision of GIST, and central line associated VTE were excluded. The primary outcome is prescribing compliance with 28-day VTE prophylaxis from HD. The secondary outcome includes the incidence of VTE and bleeding complications requiring hospital readmission within 28days from HD. Results 582 patients were included in our study. Since 2014, 423/490patients (86.3%) have been discharged with 28days VTE-prophylaxis from HD compared to pre-2014 (13/92patients,14.1%). There was a statistically significant difference in improving prescribing compliance following the introduction of this policy (p&amp;lt;0.05). No patient was readmitted due to bleeding complications. Only 1 patient (1/582,0.17%) developed VTE within 28days from HD. Conclusions We recommend extending VTE-prophylaxis for 28days from hospital discharge for all patients undergoing oesophagogastric cancer surgery. This improves prescribing compliance, reduces the incidence of post-discharge VTE and is safe.

542 Prolonged VTE Prophylaxis Post Abdominal Cancer Surgery: Is It Necessary?

Abstract Aim NICE guidance currently recommends extending venous thromboembolism (VTE) prophylaxis to 28 days for patients who have undergone major cancer surgery in the abdomen. Literature highlights controversy around the efficacy of prolonged treatment preventing deep vein thrombosis (DVT) and pulmonary embolism (PE) and potential areas for improvement. Method Retrospective study of urology and colorectal cancer patients undergoing surgery between October 2020 and September 2022. Electronic patient notes were used to determine adherence to guideline and prevalence of PE and/or DVT in post-operative patients. Comparison was made between both cohorts. Results Patient cohort n = 802, colorectal n = 345 and urology n = 457. Average age 66.6±10.4. M:F ratio = 543:258. Colorectal cohort 20.9%(n = 71) received extended prophylaxis, 79.1%(n = 269) did not, of which 19.7%(n = 53) prophylaxis was contraindicated. 5 excluded as died or an inpatient. Urology cohort 53.4%(n = 244) received extended prophylaxis, 46.6%(n = 213) did not, of which 28.2%(n = 60) prophylaxis was contraindicated. Overall, 39.5%(n = 315) received extended prophylaxis vs 60.5%(n = 482) did not. n = 4 developed PE/DVT. Of which, n = 1 on extended prophylaxis and n = 3 not, Chi-squared 0.35, P value = 0.55. Conclusions Very few patients developed symptomatic PE and/or DVT despite a significant proportion of patients not receiving extended prophylaxis. No significant difference in symptomatic PE or DVT in patients with extended prophylaxis vs patients without. Prolonged administration of low molecular weight heparin as anticoagulation has repercussions such as cost and patients’ ability to self-administer which may subsequently require community support or a longer hospital stay. Therefore, a more targeted approach to extended VTE should be explored.

A Content Framework of a Novel Patient-Reported Outcome Measure for Detecting Early Adverse Events After Major Abdominal Surgery.

Systematic health monitoring with patient-reported outcome instruments may predict post-discharge complications after major surgery. The objective of this study was to conceptualize a novel patient-reported outcome instrument for detecting early adverse events within two weeks of discharge after major emergency abdominal surgery and colorectal cancer surgery. This study was conducted in two phases. (1) An exhaustive health concept pool was generated using systematic content analysis of existing patient-reported outcome measures (N = 31) and semi-structured interviews of readmitted patients (N = 49) and health professionals (N = 10). Concepts were categorized into three major domains: 'Symptoms,' 'functional status,' and 'general health perception.' We calculated the frequency of each health concept as the proportion of patients, who experienced the respective concept prior to readmission. (2) Colorectal cancer surgeons (N = 13) and emergency general surgeons (N = 12) rated the relevance of each health concept (1 = irrelevant, 5 = very relevant) in the context of detecting post-discharge adverse events. We selected concepts with either a high mean relevance score (≥ 4) or a combination of moderate mean relevance score and high patient-reported frequency (≥ 3 and ≥ 20% or ≥ 2.5 and ≥ 50%, respectively). Content analysis of existing items with additions from patients and experts resulted in 58 health concepts, of which the majority were distinct symptoms (N = 40). The selection procedure resulted in 29 patient-reported health concepts relevant for detecting adverse events after discharge. The outlined framework provides content validity for future patient-reported outcome instruments detecting adverse events in the early post-discharge period after major emergency abdominal surgery and colorectal cancer surgery.

FTP3.13 Patients undergoing major abdominal cancer surgery should receive 28 days of VTE prophylaxis: a single-centre audit of patients treated surgically for colorectal cancer

Abstract Aims The incidence of venous thromboembolism (VTE) following major abdominal cancer surgery is reduced by extended post-operative VTE prophylaxis using low molecular weight heparin, without an associated increase in bleeding risk. The National Institute for Health and Care Excellence (NICE) issued guidance in 2018, recommending 28 days of post-operative VTE prophylaxis for these patients. We audited local compliance for patients undergoing major surgery for colorectal cancer. Methods Clinical records of patients with colorectal cancer were retrieved from a local registry. 104 patients treated surgically between 01/08/2021–24/01/2023 were included in the first audit cycle. Retrospective analysis investigated the nature of operations (elective or emergency) and whether extended VTE prophylaxis was prescribed. Records were examined for documented plans for prophylaxis post-discharge. Data was presented locally and strategies to increase compliance were implemented. Second cycle data is being collected prospectively from 25/01/2023 until the presentation date. Results Of the included patients, 89% underwent elective operations and 11% required emergency surgery. Our first cycle demonstrated 84% compliance with guidance across all patients (88% for elective and 55% for emergency procedures, respectively). An explicitly documented plan for extended prophylaxis was observed for 82% of recipients and 12% of those who did not receive it. Conclusions Compliance to guidance was particularly high for electively treated patients. This should not differ between elective and emergency cases. Documenting post-discharge anticoagulation plans may act as a simple quality improvement measure. We plan to re-audit and present second cycle results following implementation of interventions, including education, posters, and improving electronic discharge processes.

Effect of Clindamycin compared with Ampicillin-Sulbactam as prophylactic antibiotics for wound infections following major surgery for head and neck cancer: A meta-analysis.

A meta-analysis examination was implemented to review the effect of Clindamycin compared with Ampicillin-Sulbactam as prophylactic antibiotics (PAs) management for surgical site wound infections (SSWIs) following major surgery (MS) for head and neck cancer (H&NC). A comprehensive literature examination till May 2023 was done and 1296 interrelated examinations were reviewed. The six elected examinations, enclosed 4293 personals with MS for H&NC were in the utilized examinations' starting point, 1722 of them were utilizing Clindamycin, and 2571 were utilizing Ampicillin-Sulbactam. Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the consequence of Clindamycin compared with Ampicillin-Sulbactam as PAs management for SSWIs following MS for H&NC by the dichotomous approach and a fixed or random model. Clindamycin had significantly higher SSWI compared with Ampicillin-Sulbactam (OR, 2.65; 95% CI, 1.40-5.02, p = 0.003) in personals with MS for H&NC. Clindamycin had significantly higher SSWI compared with Ampicillin-Sulbactam in personals with MS for H&NC. However, caution needs to be taken when interacting with its values because there was a low sample size of some of the chosen examinations and a low number of examinations found for the comparisons in the meta-analysis.

The significance of SARC-F scores in predicting postoperative outcomes of older adults undergoing elective major surgery for urologic cancer

Recently, the strength, assistance with walking, rise from a chair, climb stairs, and falls (SARC-F) questionnaire has been developed to screen patients with signs of sarcopenia. However, its clinical benefit remains uncertain in elderly patients undergoing elective major surgeries. This study aimed to explore the role of the SARC-F questionnaire as a screening tool for patients who plan to undergo elective major surgery for urologic cancer and to also evaluate correlations of SARC-F scores with established indicators of sarcopenia. This retrospective observational study enrolled 815 patients over 40 years of age undergoing elective major surgery for urologic cancer and who were screened with the SARC-F questionnaire, preoperatively. The primary endpoint was an association between SARC-F scores and postoperative ambulation failure. Here we define postoperative ambulation failure as a condition where a patient is unable to walk independently within 2 days after surgery and required physical rehabilitation or was transferred to other hospitals in a bedridden state. The secondary endpoint was an association between SARC-F scores and overall survival (OS). Psoas muscle density (PMD) and psoas muscle index (PMI) were calculated from abdominal computed tomography images, and their correlations with SARC-F scores grouped by sex. Of the 815 patients, 738 (91%) were male and the median age was 72 years. Although SARC-F scores weakly correlated with PMD in males and moderately correlated in females (ρ=-0.222 and ρ=-0.474, respectively), their correlation with PMI was negligible (ρ=-0.179 and ρ=-0.084, respectively). SARC-F scores successfully discriminate postoperative ambulation failure in both males and females with the respective area under the receiver operating characteristic curve of 0.856 and 0.813. Multivariate analysis also showed that SARC-F scores greater than 4 are an independent risk factor of postoperative ambulation failure along with older age, lower PMD, and poor performance status. SARC-F scores greater than 4 were significantly associated with a shorter OS in the whole cohort (P<0.001) and a subgroup of patients undergoing radical cystectomy (P=0.03; median follow-up of 515 days). The SARC-F questionnaire might be applicable to identify elderly patients at a higher risk of unfavourable outcomes after major urologic cancer surgery. A randomised controlled trial is necessary to confirm this finding.

Outcomes of Patients Undergoing Major Surgery for Cancer with COVID-19 in the Postoperative Period.

The aim of our study was to report about the clinical outcomes of patients who underwent major surgery for cancer and developed COVID-19 in the postoperative period. A retrospective and observational study was done in the Surgical Oncology Division of a tertiary care cancer hospital in North-East India. The study period was from 1st April 2020 to 31st December 2021. Patients with a confirmed diagnosis of cancer who underwent a major surgery and developed COVID-19 in the postoperative period, within the same hospital stay were included in the study. Data was obtained from a prospectively maintained database and case records. Descriptive statistics were used to state the results in median values, range and percentages. A total of 22 patients developed COVID-19 in the postoperative period during the study period out of a total of 1402 patients operated during that time period (1.57%). The have been followed up for a median period of 16months (range 2 to 18months). The median age at presentation was 50years (range 25 to 74years). The incidence of co-morbidities was 27.3%. The median duration of ICU stay was 3days (range 0 to 9days) and median duration of hospital stay was 22days (range 9 to 55days).. The postoperative mortality rate was 18.2%. COVID-19 in the postoperative period in patients undergoing major abdominal and thoracic surgeries for cancer caused high postoperative mortality and prolonged hospital stay.

Role of intraoperative processes of care during major upper gastrointestinal oncological resection in postoperative outcomes: a scoping review protocol

IntroductionOptimal delivery and organisation of care is critical for surgical outcomes and healthcare systems efficiency. Anaesthesia volumes have been recently associated with improved postoperative recovery outcomes; however, the mechanism is...

Major surgery for HBP cancer: Experience in Fatmawati Central Hospital, Jakarta

Major surgery for HBP cancer: Experience in Fatmawati Central Hospital, Jakarta

Long-term survival in older patients given propofol or sevoflurane anaesthesia for major cancer surgery: follow-up of a multicentre randomised trial

BackgroundExperimental evidence indicates that i.v. anaesthesia might reduce cancer recurrence compared with volatile anaesthesia, but clinical information is observational only. We therefore tested the primary hypothesis that propofol-based anaesthesia improves survival over 3 or more years after potentially curative major cancer surgery. MethodsThis was a long-term follow-up of a multicentre randomised trial in 14 tertiary hospitals in China. We enrolled 1228 patients aged 65–90 yr who were scheduled for major cancer surgery. They were randomised to either propofol-based i.v. anaesthesia or to sevoflurane-based inhalational anaesthesia. The primary endpoint was overall survival after surgery. Secondary endpoints included recurrence-free and event-free survival. ResultsAmongst subjects randomised, 1195 (mean age 72 yr; 773 [65%] male) were included in the modified intention-to-treat analysis. At the end of follow-up (median 43 months), there were 188 deaths amongst 598 patients (31%) assigned to propofol-based anaesthesia compared with 175 deaths amongst 597 patients (29%) assigned to sevoflurane-based anaesthesia; adjusted hazard ratio 1.02; 95% confidence interval (CI): 0.83–1.26; P=0.834. Recurrence-free survival was 223/598 (37%) in patients given propofol anaesthesia vs 206/597 (35%) given sevoflurane anaesthesia; adjusted hazard ratio 1.07; 95% CI: 0.89–1.30; P=0.465. Event-free survival was 294/598 (49%) in patients given propofol anaesthesia vs 274/597 (46%) given sevoflurane anaesthesia; adjusted hazard ratio 1.09; 95% CI 0.93 to 1.29; P=0.298. ConclusionsLong-term survival after major cancer surgery was similar with i.v. and volatile anaesthesia. Propofol-based iv. anaesthesia should not be used for cancer surgery with the expectation that it will improve overall or cancer-specific survival. Clinical trial registrationsChiCTR-IPR-15006209; NCT02660411.

Delirium in older patients given propofol or sevoflurane anaesthesia for major cancer surgery: a multicentre randomised trial

BackgroundDelirium is a common and disturbing postoperative complication that might be ameliorated by propofol-based anaesthesia. We therefore tested the primary hypothesis that there is less delirium after propofol-based than after sevoflurane-based anaesthesia within 7 days of major cancer surgery. MethodsThis multicentre randomised trial was conducted in 14 tertiary care hospitals in China. Patients aged 65–90 yr undergoing major cancer surgery were randomised to either propofol-based anaesthesia or to sevoflurane-based anaesthesia. The primary endpoint was the incidence of delirium within 7 postoperative days. ResultsA total of 1228 subjects were enrolled and randomised, with 1195 subjects included in the modified intention-to-treat analysis (mean age 71 yr; 422 [35%] women); one subject died before delirium assessment. Delirium occurred in 8.4% (50/597) of subjects given propofol-based anaesthesia vs 12.4% (74/597) of subjects given sevoflurane-based anaesthesia (relative risk 0.68 [95% confidence interval {CI}: 0.48–0.95]; P=0.023; adjusted relative risk 0.59 [95% CI: 0.39–0.90]; P=0.014). Delirium reduction mainly occurred on the first day after surgery, with a prevalence of 5.4% (32/597) with propofol anaesthesia vs 10.7% (64/597) with sevoflurane anaesthesia (relative risk 0.50 [95% CI: 0.33–0.75]; P=0.001). Secondary endpoints, including ICU admission, postoperative duration of hospitalisation, major complications within 30 days, cognitive function at 30 days and 3 yr, and safety outcomes, did not differ significantly between groups. ConclusionsDelirium was a third less common after propofol than sevoflurane anaesthesia in older patients having major cancer surgery. Clinicians might therefore reasonably select propofol-based anaesthesia in patients at high risk of postoperative delirium. Clinical trial registrationChinese Clinical Trial Registry (ChiCTR-IPR-15006209) and ClinicalTrials.gov (NCT02662257).

Association between early mobilisation after abdominal cancer surgery and postoperative complications

IntroductionPostoperative complications and readmission to hospital after major cancer surgery are common. Early mobilisation in hospital is thought to reduce complications, and patients are recommended to mobilise for at least 2 h on the day of surgery, and thereafter at least 6 h per day. Evidence for early mobilisation is limited and therefore also how early mobilisation may influence the development of postoperative complications. The aim of this study was to evaluate the association between early mobilisation after abdominal cancer surgery and readmission to hospital due to postoperative complications. Material and methodsAdult patients who had abdominal cancer surgery due to ovarian, colorectal, or urinary bladder cancer between January 2017 and May 2018 were included in the study. Exposure was set to the mean number of steps taken over the first three postoperative days, measured with an activity monitor. Primary outcome was readmission to hospital within 30 days after discharge, and secondary outcome was severity of complications. Data were obtained from medical records. Logistic regression was used to investigate the association between exposure and outcomes. ResultsOf 133 patients included in the study, 25 were readmitted to the hospital within 30 days after discharge. The analysis showed no association between early mobilisation and readmission or severity of complications. ConclusionEarly mobilisation does not seem to increase the odds of readmission, nor the severity of complications. This study contributes to the limited research on the association between early mobilisation and postoperative complications after abdominal cancer surgery.

Surgical care and outcomes in older patients with cancer through implementation of a pre-surgical toolkit (OPTI-Surg): Interim results of a phase III cluster randomized trial (Alliance A231601CD).

1541 Background: Frailty is common in older adults undergoing major cancer surgery. Mounting evidence indicates multimodal interventions to optimize patient functional status by addressing vulnerabilities associated with frailty before surgery result in decreased complications and enhanced functional recovery. This study tested the effectiveness of OPTI-Surg, a surgical prehabilitation toolkit for improving surgical care and outcomes in older patients undergoing major cancer surgery. Here, we report results from the planned futility interim analysis (IA). Methods: Thoracic (T), gastrointestinal (GI), and urologic (GU) oncological surgery practices affiliated with NCI’s Community Oncology Research Program were randomized 1:1:1, stratified by practice type, to usual care (control), OPTI-Surg toolkit, or OPTI-Surg with an implementation coach. The toolkit was implemented at the practice level. It consisted of the 12-item Edmonton Frail Scale and guided recommendations for interventions directed at identified vulnerabilities. Eligible patients were adults ≥70 years old undergoing curative intent surgery for lung, gastrointestinal, or urologic cancers. Primary outcome was 8-week post-operative function (weekly caloric expenditure) derived from the validated Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire. A linear mixed model was used to compare usual care to the 2 OPTI-Surg arms combined, controlling for baseline function. Results: From July 2019 to October 2021, 225 patients, 50% of the total accrual goal, were enrolled from 29 practices, triggering the IA. Study was suspended to new patient accrual March to June 2020 due to the COVID-19 pandemic. There were no differences in demographics by arm (mean age 76.2 years; 46.4% women; 79.6% white; 20.4% lung resection, 69.8% major GI surgery, 9.8% total cystectomy). Of the 225 patients, 140 (47 Usual Care, 93 OPTI-Surg) were evaluable for the IA. There was no significant difference in post-operative function between OPTI-Surg and usual care (mean decrease of 0.59 kCal/week for OPTI-Surg patients and 0.19 kCal/week for usual care patients, p = 0.762, intraclass correlation = 0.033). Based on the futility analysis, the DSMB recommended closure of recruitment on September 16, 2022. Conclusions: Implementation of the OPTI-Surg toolkit did not significantly improve functional outcomes 8 weeks after surgery for patients aged 70 and older undergoing major cancer surgery compared to usual care. Future analysis of implementation and ethnographic data may identify reasons why significant differences between the intervention and usual care arms were not observed, potentially including disruptions due to the COVID-19 pandemic. Clinical trial information: NCT03857620 .

C35 A RARE CASE OF NON–BACTERIAL THROMBOTIC ENDOCARDITIS IN YOUNG WOMAN AFFECTED BY ADVANCED UTERINE CANCER

Abstract A 37–year–old woman affected by uterine HPV–related adenocarcinoma complicated by paraneoplastic pulmonary thromboembolism, came to the emergency department for recurrent episodes of dysarthria and blurred vision with spontaneous resolution. Home medications: Enoxaparin 5000 UI b.i.d, levofloxacin 500 mg/die, deltacortene 25 mg/die and omeprazole 20 mg/die. Blood analysis: normocytic anemia (Hb 9 gr/dl),elevated D–dimer (22.5 mcg/ml) and elevated C–reactive protein (18.3 mg/dl). Procalcitonin and blood cultures resulted negative. Brain CT scan: ischemic brain lesions of embolic nature in the right precentral gyrus and in the left post central gyrus. EKG: sinus rhythm, T–wave inversion in inferior leads. In the suspect of cardioembolic stroke a transthoracic (TTE) and subsequent transesophageal (TOE) echocardiography was performed: TTE: isoechoic oval–shaped thickening of the aortic valve cusp tips, producing aortic regurgitation with double jet regurgitation. TOE: evidence of multiple isoechoic masses involving all the aortic cusps, without perivalvular aortic extension, producing significant aortic regurgitation due to coaptation– gap (Figure 1). The diagnosis of non–bacterial thrombotic endocarditis (NBTE) was made up. Although the standard medical therapy (anticoagulation and chemotherapy) was promptly started, it wasn’t effective with progression of the disease leading to surgical indications of valve intervention. The patient underwent aortic valve replacement with bioprosthesis avoiding mechanical prosthesis, despite the young age, in anticipation of major surgery for the uterine cancer. Surgical specimen turned negative for microorganism growth confirming the diagnosis of marantic endocarditis. No further episodes of ischemic stroke appeared after the replacement of the valve and the patient had no neurological sequelae. NBTE is a rare condition of non–infective endocarditis characterized by the formation of aggregates of platelets and fibrin that affects usually undamaged heart valves in the absence of bacteremia and mostly occurs in patients with a predisposing state like hypercoagulability. Surgical indications of valve intervention are not well encoded but in most cases they follow the raccomandations for infective endocarditis. Our experience highlights the need of a prompt intervention in order to reduce the damage of systemic embolization and preserve patient’s hemodynamics with a strict checking of disease progression.

Deviations in continuously monitored electrodermal activity before severe clinical complications: a clinical prospective observational explorative cohort study

Monitoring of high-risk patients in hospital wards is crucial in identifying and preventing clinical deterioration. Sympathetic nervous system activity measured continuously and non-invasively by Electrodermal activity (EDA) may relate to complications, but the clinical use remains untested. The aim of this study was to explore associations between deviations of EDA and subsequent serious adverse events (SAE). Patients admitted to general wards after major abdominal cancer surgery or with acute exacerbation of chronic obstructive pulmonary disease were continuously EDA-monitored for up to 5 days. We used time-perspectives consisting of 1, 3, 6, and 12 h of data prior to first SAE or from start of monitoring. We constructed 648 different EDA-derived features to assess EDA. The primary outcome was any SAE and secondary outcomes were respiratory, infectious, and cardiovascular SAEs. Associations were evaluated using logistic regressions with adjustment for relevant confounders. We included 714 patients and found a total of 192 statistically significant associations between EDA-derived features and clinical outcomes. 79% of these associations were EDA-derived features of absolute and relative increases in EDA and 14% were EDA-derived features with normalized EDA above a threshold. The highest F1-scores for primary outcome with the four time-perspectives were 20.7–32.8%, with precision ranging 34.9–38.6%, recall 14.7–29.4%, and specificity 83.1–91.4%. We identified statistically significant associations between specific deviations of EDA and subsequent SAE, and patterns of EDA may be developed to be considered indicators of upcoming clinical deterioration in high-risk patients.

Insignificant influence of the intertransverse process block for major breast cancer surgery: a randomized, blinded, placebo-controlled, clinical trial

IntroductionThe intertransverse process (ITP) block mimics the thoracic paravertebral block and allegedly ameliorates hemithoracic postoperative pain. However, concerning major reconstructive breast cancer surgery the modality has never been tested against...