Postoperative Decline Research Articles

P01.14.B Visuospatial selective attention deficit after resection of right hemisphere gliomas: a multivariate lesion symptom mapping and diffusion tractography study

Abstract Background The ability to select relevant information to current behavioural goals despite concomitant distractors (i.e. selective attention) is crucial for daily life. Despite the implication of fronto-parietal network in sustaining visuospatial selective attention has been considered crucial, the role of subcortical structures is still unclear. Aim of this study was to evaluate the impact of neurosurgical removal of right gliomas on visuospatial selective attention performances. Material and Methods The visuospatial selective attention domain was assessed pre- and postoperatively (1 month follow-up) in 73 patients operated for right hemisphere gliomas. Support-vector-regression lesion-symptom mapping and disconnectome analysis (Lesion Quantification Toolkit, HCP 1065 data) were used to evaluate the relationship between the resection cavities and the postoperative performance on a standardized selective attention test. To test and refine the atlas-based results, in a subset of 17 patients with preoperative diffusion tractography, the postoperative outcome was correlated with the percentage of disconnection for different white matter tracts. Results Results showed that resection of a cluster enclosing the SMA-complex and the surrounding white matter was significantly associated with a decline in visuospatial selective attention performances (p<.05). Disconnectome analysis at population level revealed that the deficit was significantly correlated with the resection of superior cortico-striatal fibres, superior thalamic radiations, corticopontine projections, callosal connections and fibres of the frontal aslant tract. Within all the cortico-subcortical terminations of these tracts, disconnection of streamlines of the SMA-complex was the most associated with selective attention deficits. Tractography in single patients confirmed the population level results and suggested that ventro-lateral resections in case of inferior frontal or insular tumours significantly disconnecting the frontal aslant tract but sparing superior projection fibres were not associated with any postoperative disturbances. Conclusion Results show converging evidence to support a critical role for the SMA/preSMA and its projections in maintaining efficiency of attentive control. The present results reveal the importance of a fronto-medial descending connectivity in mediating the voluntary control of visuospatial selective attention. From a surgical standpoint, to avoid postoperative deficits, it seems crucial to preserve SMA projection pathways, while the disconnection of the frontal aslant tract is feasible without any postoperative decline.

P01.10.B The relation between executive functioning and MEG multilayer network centrality in glioma patients

Abstract Background Many patients with glioma suffer from deficits in executive functioning (EF), regardless of tumor location and size. While some patients experience improving EF after tumor resection, others deteriorate over time. This variability in cognitive trajectories is still poorly understood, but neuroscientific approaches that view the brain as a network may bear correlative and predictive value in this respect. Particularly integrative network connectivity of the fronto-parietal network are crucial for EF, but studies so far have only investigated isolated neural frequency bands of interest. Here, we synergize fronto-parietal network connectivity across frequency bands and test its explanatory power for EF at diagnosis and 1 year after tumor resection. Material and Methods Patients with diffuse glioma (n=37) underwent neuropsychological assessments, including three tests for EF, and resting-state magnetoencephalography (MEG) at both time points. Patients’ EF performance was standardized to z-scores using validated norm scores, adjusting for age, sex and education. MEG was source-reconstructed using patients’ MRI in combination with a beamformer approach and time series were filtered into six classical frequency bands. Band-specific functional connectivity between 78 cortical regions was estimated, after which an interconnected multilayer, multi-frequency network was created per patient. Multilayer centrality was then calculated as a measure of integrative network connectivity per region, and averaged over all fronto-parietal network regions to yield a single value reflecting integrative, multi-frequency network connectivity per patient at each time point. Results At diagnosis, eight patients had z-scores <-1.5, indicating clinically relevant cognitive deficits. Preoperatively, poorer performance on the Concept Shifting Task was associated with lower multilayer centrality (p=.017), while improving performance on this task from diagnosis to 1 year after resection was associated with an increase in multilayer centrality (p=.022). Multilayer centrality at diagnosis did not significantly predict EF at follow-up. Conclusion Our results establish a significant relationship between poorer and decreasing EF with lower and decreasing multilayer, multi-frequency integrative connectivity of the fronto-parietal network in glioma patients. Studies with larger and more homogeneous samples may further explore the relevance of this multilayer approach in understanding and particularly predicting postoperative decline in EF in these patients, as our sample was characterized by large heterogeneity in cognitively relevant patient and tumor characteristics.

OS06.7.A Underlying mechanisms of verbal fluency in glioma patients: language or executive functioning?

Abstract Background Glioma patients often suffer from cognitive deficits, such as in language and executive functioning (EF). A sensitive test to identify these deficits is verbal fluency (VF). In VF, participants are asked to generate as many unique words within a given semantic category (category fluency - CF) or starting with a given letter (letter fluency - LF) within one minute. While both language and EF play a role in VF, the relative contribution of both domains remains unclear. We aim to retrospectively investigate performance on VF and, for the first time, on Non-Verbal Fluency (NVF), requiring to connect 5 points in different patterns within three minutes. Additionally, we aim to explore the influence of language and EF on VF performance in glioma patients. Materials and Methods 69 adults with gliomas in eloquent areas underwent a comprehensive neuropsychological test-battery at 1-2 months before surgery (T1) and 3 (T2) and 12 months (T3) after surgery. The protocol consisted of VF (CF: animals, professions, LF: D-A-T/K-O-M), language tests (Repetition (Akense Afasie Test), Token Test, Boston Naming Test) and EF tests (Five Point Test, Trail Making Test, Stroop Colour-Word Test, Wisconsin Modified Card Sorting Task). VF and NVF performance were compared 1) to healthy population using one sample t-tests/Wilcoxon rank-tests (all patients), and 2) between T1, T2, and T3 with paired sample t-tests/Wilcoxon rank-tests (31 patients). Linear regression analyses were conducted to investigate the predictive value of language and EF on VF for all patients. Results Preoperatively, patients were impaired on all VF tasks. Especially CF profession performance was more prone to deterioration after surgery at T2 and T3. In contrast, NVF was intact and even improved after surgery (T1-T3, T2-T3). NVF (p = .032, EF) was a predictor for CF animals while the Token Test (p = .023, language) was a predictor for CF professions. Both NVF (p = .032, EF) and the Token Test (p = .004, language) were predictors for LF. Conclusion First, glioma patients were preoperatively impaired in VF but were preserved in NVF, as is in line with the literature. Secondly, CF professions appeared to be particularly sensitive to detect long-term postoperative decline. Thirdly, the main result of this study is that both language and EF mechanisms appeared to be responsible for VF performance in glioma patients. These findings are useful for interpreting VF impairment in glioma patients and for therapeutic interventions, suggesting a combination of language and EF training materials.

The weight loss grading system as a predictor of cancer cachexia in oesophageal cancer survivors

BackgroundOesophageal cancer survivorship is afflicted by cancer cachexia related weight loss and nutrition impact symptoms. Identifying the factors which predict cancer cachexia specifically is warranted in order to identify those at risk and render the right kind of support. We aimed to assess if preoperative and postoperative body mass index (BMI) adjusted weight loss grading system (WLGS) is predictive of cancer cachexia at one year after surgery for oesophageal cancer.MethodsData were used from a prospective nationwide cohort study on patients operated on for oesophageal cancer in Sweden between 2013 and 2018 included at one year after surgery. The study exposure is BMI adjusted weight loss graded into one of five distinct weight loss grades (grades 0–4), defined in accordance with the WLGS by combining BMI and percentage weight loss, assessed at two clinical time points: preoperative and at 6 months post-surgery for oesophageal cancer. The study outcome is subjective measures of cancer cachexia one year after surgery, assessed using the cancer-cachexia specific questionnaire EORTC QLQ-CAX24. Multivariable linear regression models calculated mean score differences (MD) with 95% confidence intervals (CI) adjusted for predefined confounders. Statistical significance at p < 0.05 together with a clinically relevant difference of 10-points in mean scores was considered as a significant difference.ResultsAmong a total of 232 patients, the highest grade of preoperative WLGS 4 was associated with significantly worse physical decline than lower grades of WLGS 1 (MD -10, 95% CI: −20 to −1) and WLGS 2 (MD −11, 95% CI: −20 to −2). Those with preoperative WLGS 2, 3 and 4 reported lower scores on the adequacy of information on weight loss provided to them than those with preoperative WLGS 0. Those with the highest postoperative WLGS 4 had greater eating and weight loss worry than WLGS 2 (MD −17, 95% CI: −32 to −3) and WLGS 3 (MD −11, 95% CI: −21 to −2) and worse physical decline than WLGS 0 (MD −14, 95% CI: −25 to −2).ConclusionsHigher grades of both preoperative and postoperative WLGS are predictive of cancer cachexia related physical decline one year after surgery for oesophageal cancer. Additionally, preoperative and postoperative WLGS were also predictive of inadequate information concerning weight loss and more worry regarding eating and weight loss, respectively. The WLGS may be an effective risk prediction tool for postoperative cachexia related physical decline in patients undergoing treatment for oesophageal cancer emphasizing its usability in the clinical setting.

Longer Daily Duration of Supervised Rehabilitation after Laparoscopic Surgery for Colorectal Cancer Improves Activities of Daily Living

ObjectiveTo evaluate the effect of a supervised rehabilitation programme with longer hours per day on activities of daily living after laparoscopic surgery for colorectal cancer.DesignThis study represents retrospective observational use of nationwide administrative data.PatientsEligible patients (n = 8,633) were first diagnosed with colorectal cancer between 1 April 2017 and 31 March 2018, underwent laparoscopic-assisted colorectal resection, and began rehabilitation within 3 days of surgery.MethodsPatients underwent a long (40 min or more) or short (less than 40 min) supervised rehabilitation programme, defined as rehabilitation under physiotherapist and occupational therapist supervision. The main outcome measure was improvement in activities of daily living from postoperative day 0 to day 14 using Nursing Need Degree.ResultsPatients who underwent longer daily supervised rehabilitation (n = 7,173) showed greater improvements in activities of daily living at 14 days after laparoscopic surgery than patients who underwent shorter daily supervised rehabilitation (n = 1,460) (odds ratio (95% confidence interval; 95% confidence interval): 1.42 (1.22–1.64), p < 0.001). The rate of postoperative complications did not differ between groups.ConclusionLonger daily supervised rehabilitation for colorectal cancer improves activities of daily living after laparoscopic surgery.LAY ABSTRACTPost-operative rehabilitation is performed for muscle weakness, decreased range of motion of joints, and pain caused by surgery, in order to promote recovery and help patients with activities of daily living after surgery. Supervised rehabilitation provides the patient with a programme based on their postoperative condition and background. Laparoscopic surgery for colorectal cancer, the focus of this study, is minimally invasive and results in less postoperative decline than other surgeries. The aim of this study was to evaluate the effect of a supervised rehabilitation programme with longer daily duration on the ability of patients (n = 8,633) to perform activities of daily living after laparoscopic surgery for colorectal cancer. The results show that engaging in daily supervised rehabilitation for longer duration (40 min or more) after laparoscopic surgery for colorectal cancer improves activities of daily living.

One-year neuropsychological outcome after temporal lobe epilepsy surgery in large Czech sample: Search for factors contributing to memory decline.

Background: Assessment of cognitive functions is an integral part of the evaluation the efficacy of temporal resections. We studied postoperative neuropsychological changes and factors contributing to worse memory outcomes in patients who experienced a significant decline using reliable change indices.Methods: We prospectively studied 110 patients in whom we indicated anteromesial temporal resection (AMTR) and 46 patients who underwent selective amygdalohippocampectomy (SAHE). We administrated Wechsler Adult Intelligence Scale-Revised, Wechsler Memory Scale-Revised, and the Verbal Fluency Test before and 1 year after the operation.Results: At a group level, we did not observe any statistically significant changes in global, verbal, and visual MQ in either the AMTR or the SAHE group. At an individual level, we found a mean decrease of verbal MQ after left-sided AMTR by −4.43 points (P = 0.01). We detected no significant differences between the left and right side of surgery in the SAHE group. In patients with significant postoperative memory decline, we found either pre-existing extrahippocampal deficits/postoperative complications or incomplete hippocampal resection or a combination of these factors.Conclusion: In addition to the side of surgery, structural integrity and functional adequacy of resected hippocampus and volume of resected tissue and preoperative extrahippocampal lesions/postoperative complications also contribute to postoperative memory decline after temporal lobe epilepsy surgery.

Preoperative Phase Angle as a Risk Indicator in Cardiac Surgery-A Prospective Observational Study.

Background: The phase angle (PhA) can be used for prognostic assessments in critically ill patients. This study describes the perioperative course of PhA and associated risk indicators in a cohort of elective cardiac surgical patients. Methods: The PhA was measured in 168 patients once daily until postoperative day (POD) seven. Patients were split into two groups depending on their median preoperative PhA and analyzed for several clinical outcomes; logistic regression models were used. Results: The PhA decreased from preoperative (6.1° ± 1.9°) to a nadir on POD 2 (3.5° ± 2.5°, mean difference −2.6° (95% CI, −3.0°; −2.1°; p < 0.0001)). Patients with lower preoperative PhA were older (71.0 ± 9.1 vs. 60.9 ± 12.0 years; p < 0.0001) and frailer (3.1 ± 1.3 vs. 2.3 ± 1.1; p < 0.0001), needed more fluids (8388 ± 3168 vs. 7417 ± 2459 mL, p = 0.0287), and stayed longer in the ICU (3.7 ± 4.5 vs. 2.6 ± 3.8 days, p = 0.0182). Preoperative PhA was independently influenced by frailty (OR 0.77; 95% CI 0.61; 0.98; p = 0.0344) and cardiac function (OR 1.85; 95%CI 1.07; 3.19; p = 0.028), whereas the postoperative PhA decline was independently influenced by higher fluid balances (OR 0.86; 95% CI 0.75; 0.99; p = 0.0371) and longer cardiopulmonary bypass times (OR 0.99; 95% CI 0.98; 0.99; p = 0.0344). Conclusion: Perioperative PhA measurement is an easy-to-use bedside method that may critically influence risk evaluation for the outcome of cardiac surgery patients.

Raised initial total white cell count and lower post-operative decline of C reactive protein increases the risk of secondary surgery in septic arthritis of the native knee.

Septic arthritis is an orthopaedic emergency with high morbidity and mortality. The aim of this study is to determine the risk factors associated with secondary surgery for septic arthritis of the native knee joint. This is a retrospective study reviewing all patients who underwent surgery for septic arthritis of the knee from 2012 to 2019 in a single institution. A total of 117 patients were recruited. Patients were divided into 2 groups: Group I (79/117, 67.5%) underwent one surgery and Group II (38/117, 32.5%) underwent more than one surgery. Patients with a raised initial total white (TW) cell count of > 20 × 109/L had a significantly higher risk of secondary surgery. (Adjusted hazard ratio 2.42, p < 0.05) A decline of CRP level of less than 20% within 24h from initial operation was also a risk for secondary surgery. (Adjusted hazard ratio 0.34, p < 0.01) Patients in group II also had significantly higher post-operative median TW cell count and neutrophil count. There was no significant difference in the offending microbe, surgical approach, and duration of operation from initial presentation between the groups. Patients with septic arthritis of the native knee joint who present with raised initial total white cell count of > 20 × 109/L and decline of CRP level of less than 20% within 24h from initial operation are at higher risk of secondary operation. In these patients, more aggressive treatment strategies and appropriate counselling on the risks of repeated surgery are recommended. Level IV.

Developing Predictor Models of Postoperative Verbal Fluency After Deep Brain Stimulation Using Preoperative Neuropsychological Assessment.

Deep brain stimulation (DBS) for Parkinson disease provides significant improvement of motor symptoms but can also produce neurocognitive side effects. A decline in verbal fluency (VF) is among the most frequently reported side effects. Preoperative factors that could predict VF decline have yet to be identified. To develop predictive models of DBS postoperative VF decline using a machine learning approach. We used a prospective database of patients who underwent neuropsychological and VF assessment before both subthalamic nucleus (n = 47, bilateral = 44) and globus pallidus interna (n = 43, bilateral = 39) DBS. We used a neurobehavioral rating profile as features for modeling postoperative VF. We constructed separate models for action, semantic, and letter VF. We used a leave-one-out scheme to test the accuracy of the predictive models using median absolute error and correlation with actual postoperative scores. The predictive models were able to predict the 3 types of VF with high accuracy ranging from a median absolute error of 0.92 to 1.36. Across all three models, higher preoperative fluency, digit span, education, and Mini-Mental State Examination were predictive of higher postoperative fluency scores. By contrast, higher frontal system deficits, age, Questionnaire for Impulsive-Compulsive Disorders in Parkinson's disease scored by the patient, disease duration, and Behavioral Inhibition/Behavioral Activation Scale scores were predictive of lower postoperative fluency scores. Postoperative VF can be accurately predicted using preoperative neurobehavioral rating scores above and beyond preoperative VF score and relies on performance over different aspects of executive function.

Recent Update on Serum Alkaline and Acid Phosphatases in Pre- and Postoperative Breast Cancer Patients

Background: Breast carcinoma in females is an ever-growing malaise with significant mortality and morbidity. In resource-poor settings, the need for a cost-effective and reliable diagnostic tool is of utmost importance.&#x0D; Methods: In the present study, 54 histopathologically proven breast cancer patients were investigated for their pre- and postoperative serum ALP and ACP levels.&#x0D; Results: A total of 34 cases (belonging to the age interval of 40–60 years) exhibited a significant drop in serum ALP level after surgery (P = 0.002). Although the serum ACP also showed a postoperative decline, it was not as significant as that of serum ALP.&#x0D; Conclusion: The role of serum ALP and ACP in the diagnosis, prognosis, and monitoring/surveillance of breast carcinoma cannot be underestimated particularly in third-world countries lacking in medical infrastructure or resource-poor settings.

Impact of perioperative blood transfusions on postoperative renal function and survival after resection of colorectal liver metastases

Background and aimsRecent studies focusing on thoracic surgery suggest postoperative kidney injury depending on the amount of perioperative blood transfusions. Data investigating similar effects after resection of colorectal liver metastases (CRLM) are not available. Aim of this study was therefore to evaluate the influence of perioperative blood transfusions on postoperative renal function and survival after resection of CRLM.MethodsSeven hundred twenty-seven cases of liver resection for CRLM were retrospectively analyzed. Renal function was measured via estimated glomerular filtration rate (eGFR) and a postoperative decline of ≥ 10% was considered substantial. Potential influences on postoperative kidney function were assessed using univariable and multivariable logistic regression analyses. Cox-regression analyses were performed to estimate the impact on overall survival (OS).ResultsPreoperative impaired kidney function (p = 0.001, OR 2.477) and transfusion of > 2 units of packed red blood cells (PRBC) (p = 0.046; OR 1.638) were independently associated with an increased risk for ≥ 10% loss of renal function. Neither a pre-existing renal impairment, nor the additional loss of renal function were associated with reduced survival. Chemotherapies in the context of primary colorectal cancer treatment (p = 0.002), age > 70 years at liver resection (p = 0.005), number (p = 0.001), and size of metastases > 50 mm (p = 0.018), duration of resection > 120 min (p = 0.006) and transfusions of > 2 units of PRBC (p = 0.039) showed a negative independent influence on OS.ConclusionThe results demonstrate a negative impact of perioperative blood transfusions on the postoperative renal function and OS. Hence, efforts to reduce blood transfusions should be intensified.

Naming-related spectral responses predict neuropsychological outcome after epilepsy surgery.

This prospective study determined the use of intracranially recorded spectral responses during naming tasks in predicting neuropsychological performance following epilepsy surgery. We recruited 65 patients with drug-resistant focal epilepsy who underwent preoperative neuropsychological assessment and intracranial EEG recording. The Clinical Evaluation of Language Fundamentals evaluated the baseline and postoperative language function. During extra-operative intracranial EEG recording, we assigned patients to undergo auditory and picture naming tasks. Time-frequency analysis determined the spatiotemporal characteristics of naming-related amplitude modulations, including high gamma augmentation at 70-110 Hz. We surgically removed the presumed epileptogenic zone based on the intracranial EEG and MRI abnormalities while maximally preserving the eloquent areas defined by electrical stimulation mapping. The multivariate regression model incorporating auditory naming-related high gamma augmentation predicted the postoperative changes in Core Language Score with r2 of 0.37 and in Expressive Language Index with r2 of 0.32. Independently of the effects of epilepsy and neuroimaging profiles, higher high gamma augmentation at the resected language-dominant hemispheric area predicted a more severe postoperative decline in Core Language Score and Expressive Language Index. Conversely, the model incorporating picture naming-related high gamma augmentation predicted the change in Receptive Language Index with an r2 of 0.50. Higher high gamma augmentation independently predicted a more severe postoperative decline in Receptive Language Index. Ancillary regression analysis indicated that naming-related low gamma augmentation and alpha/beta attenuation likewise independently predicted a more severe Core Language Score decline. The machine learning-based prediction model suggested that naming-related high gamma augmentation, among all spectral responses used as predictors, most strongly contributed to the improved prediction of patients showing a >5-point Core Language Score decline (reflecting the lower 25th percentile among patients). We generated the model-based atlas visualizing sites, which, if resected, would lead to such a language decline. With a 5-fold cross-validation procedure, the auditory naming-based model predicted patients who had such a postoperative language decline with an accuracy of 0.80. The model indicated that virtual resection of an electrical stimulation mapping-defined language site would have increased the relative risk of the Core Language Score decline by 5.28 (95% confidence interval: 3.47-8.02). Especially, that of an electrical stimulation mapping-defined receptive language site would have maximized it to 15.90 (95% confidence interval: 9.59-26.33). In summary, naming-related spectral responses predict neuropsychological outcomes after epilepsy surgery. We have provided our prediction model as an open-source material, which will indicate the postoperative language function of future patients and facilitate external validation at tertiary epilepsy centres.

Evaluation of the safety of anterior capsule staining with trypan blue under air: a retrospective analysis.

To evaluate the safety of using 0.03% trypan blue under air for anterior capsule staining in cataract surgery. The current study involved a retrospective analysis of the medical records of 86 patients with vitreous hemorrhage, who underwent pars plana vitrectomy and cataract surgery. The patients were classified into two groups. The trypan blue group (n=45) comprised patients who underwent anterior capsule staining with 0.03% trypan blue under an air bubble. The control group (n=41) comprised of patients who underwent intracameral illuminator-assisted capsulorhexis. The status of endothelial cell density (ECD) in both the groups was analyzed. The trypan blue group displayed significant decline in ECD at 1mo (7.91% loss, P<0.001) and 3mo (9.65% loss, P<0.001) after the surgery, whereas no significant changes were observed in the control group. Moreover, the number of patients who did not display a postoperative decline in ECD was significantly higher in the control group (43.9%; 18 patients) than in the trypan blue group (17.1%; 7 patients, P=0.004). Anterior capsule staining with trypan blue under the air bubble would not be as safe as the intracameral illuminator. The ECD loss might be attributed to the air bubble rather than to the deleterious effects of 0.03% trypan blue. Further studies are required to clarify this.

Clustering of indicators of the cognitive status in cardiac surgery patients to assess the risk of postoperative decline

The aim of the study. To determine the informational value of psychometric indicators used for the integral assessment of cognitive status in cardiac patients, and to find those that would help differentiate the individual sensibility to postoperative cognitive dysfunction (POCD).Materials and methods. The clustering methods were analyzed the extended psychometric testing data in 256 cardiac surgery patients. The psychometric testing carried out 3–5 days before and on days 7–10 after surgery using the psychophysiological complex program “Status PF”.Results. The cluster analysis revealed that the most informative tests for a screening risk assessment of POCD are the testing the speed of response to visual stimuli with feedback of changes in the stimuli exposition according to the individual reaction time and the testing short-term memory (memorized words). While the analysis of postoperative psychometric indicators, the patients in a modified clustering group were characterized by a deterioration of verbal memory and a decrease of the time reaction to visual stimuli whereas that its observed acceleration in the general “stable” group.Conclusion. The clustering methods enabled the identification of cardiac surgery patients in the preoperative stage who had less cognitive reserve for recovery after surgery. The changes in the relationship of complex visual and motor response, attention, and memory indicators, which depended on the belonging to the identified clusters, suggest that the preoperative period is characterized by the dedifferentiation of cognitive functions indicating a cognitive deficit.

RNA-sequencing Reveals a Gene Expression Signature in Skeletal Muscle of a Mouse Model of Age-associated Postoperative Functional Decline.

This study aimed to characterize the effects of laparotomy on postoperative physical function and skeletal muscle gene expression in male C57BL/6N mice at 3, 20, and 24 months of age to investigate late-life vulnerability and resiliency to acute surgical stress. Pre and postoperative physical functioning was assessed by forelimb grip strength on postoperative day (POD) 1 and 3 and motor coordination on POD 2 and 4. Laparotomy-induced an age-associated postoperative decline in forelimb grip strength that was the greatest in the oldest mice. While motor coordination declined with increasing age at baseline, it was unaffected by laparotomy. Baseline physical function as stratified by motor coordination performance (low functioning vs high functioning) in 24-month-old mice did not differentially affect postlaparotomy reduction in grip strength. RNA sequencing of soleus muscles showed that laparotomy-induced age-associated differential gene expression and canonical pathway activation with the greatest effects in the youngest mice. Examples of such age-associated, metabolically important pathways that were only activated in the youngest mice after laparotomy included oxidative phosphorylation and NRF2-mediated oxidative stress response. Analysis of lipid mediators in serum and gastrocnemius muscle showed alterations in profiles during aging and confirmed an association between such changes and functional status in gastrocnemius muscle. These findings demonstrate a mouse model of laparotomy which recapitulated some features of postoperative skeletal muscle decline in older adults, and identified age-associated, laparotomy-induced molecular signatures in skeletal muscles. Future research can build upon this model to study molecular mechanisms of late-life vulnerability and resiliency to acute surgical stress.

Postoperative decline in ambulatory function after lower extremity bypass is associated with higher short- and long-term mortality

ObjectiveAlthough the importance of preexisting functional and ambulatory status among patients undergoing lower extremity bypass (LEB) has been increasingly recognized, a paucity of reported data is available on the significance of a postoperative decline in ambulatory status after LEB surgery. The purpose of the present analysis was to determine the effects of a new decline in ambulatory status after LEB surgery on the postoperative short- and long-term outcomes. MethodsThe Vascular Quality Initiative infrainguinal bypass dataset was queried from 2003 to 2021 for patients with peripheral arterial disease (PAD) who had undergone LEB. Information on ambulatory status at admission and discharge from the hospital was recorded. Patients with a decline in ambulatory status at discharge from the hospital were included in group I, and those who had maintained their ambulatory status at discharge were included in group II. The primary outcomes were mortality, amputation, and a composite outcome of mortality or amputation at 30 days and 1 year postoperatively. The secondary outcomes were major adverse cardiovascular events, myocardial infarction, congestive heart failure, stroke, dysrhythmia, pneumonia, and the need for prolonged ventilation. ResultsA total of 40,478 patients were included in the present study, of whom 16,032 (39.6%) were included in group I and 24,446 (60.4%) were included in group II. The patients in group I were more often aged >70 years, women, African American, transferred from another hospital or rehabilitation facility, prior or current smokers, or had an American Society of Anesthesiologists classification of III or IV compared with those with unchanged ambulatory status (P < .05 for all). Patients with a decline in ambulatory status had had a greater incidence of mortality at 30 days (2.4% vs 0.6%; P < .001) and 1 year (9.7% vs 7%; P < .001) postoperatively. Patients with a decline in ambulatory status had had a greater occurrence of major adverse cardiovascular events, myocardial infarction, stroke, dysrhythmia, and the need for prolonged ventilation. The following factors were associated with a decline in postoperative ambulatory status: older age (70-79 years: adjusted odds ratio [aOR], 1.20; 95% confidence interval [CI], 1.07-1.34; P = .001; and ≥80 years: aOR, 1.18; 95% CI, 1.05-1.35; P = .007), female sex (aOR, 1.06; 95% CI, 1.00-1.11; P = .019), African-American race (aOR, 1.15; 95% CI, 1.07-1.21; P < .001), transfer from another hospital or rehabilitation unit (aOR, 1.30; 95% CI, 1.18-1.41; P < .001), and a history of diabetes mellitus (aOR, 1.12; 95% CI, 1.06-1.17; P = .004). The magnitude of decline in ambulatory function was associated with worse primary outcomes. Patients whose ambulatory function had declined from ambulatory to bedridden after LEB surgery had had the highest mortality (aOR, 21 at 30 days and 15 at 1 year). ConclusionsA new decline in ambulatory function at discharge from the hospital after LEB surgery was associated with increased short- and long-term mortality and the composite outcome of mortality or amputation. It was also associated with reduced amputation-free survival at 30 days and 1 year postoperatively.

Challenges in Geriatric Oncology-A Surgeon's Perspective.

As our global population ages, we will see more cancer diagnoses in older adults. Surgery is an important treatment modality for solid tumours, forming the majority of all cancers. However, the management of older adults with cancer can be more complex compared to their younger counterparts. This narrative review will outline the current challenges facing older adults with cancer and potential solutions. The challenges facing older adults with cancer are complex and include lack of high-level clinical trials targeting older adults and selection of the right patient for surgery. This may be standard surgical treatment, minimally invasive surgery or alternative therapies (no surgery) which can be local or systemic. The next challenge is to identify the individual patient’s vulnerabilities to allow them to be maximally optimised for treatment. Prehabilitation has been shown to be of benefit in some cancer settings but uniform guidance across all surgical specialties is required. Greater awareness of geriatric conditions amongst surgical oncologists and integration of geriatric assessment into a surgical clinic are potential solutions. Enhanced recovery programmes tailored to older adults could reduce postoperative functional decline. Ultimately, the greatest challenge an older adult with cancer may face is the mindset of their treating clinicians—a shared care approach between surgical oncologists and geriatricians is required.

Association Between Microstructural Asymmetry of Temporal Lobe White Matter and Memory Decline After Anterior Temporal Lobectomy.

Risk for memory decline is a substantial concern in patients with temporal lobe epilepsy (TLE) undergoing anterior temporal lobectomy (ATL). Although prior studies have identified associations between memory and integrity of white matter (WM) networks within the medial temporal lobe (MTL) preoperatively, we contribute a study examining whether microstructural asymmetry of deep and superficial WM networks within the MTL predicts postoperative memory decline. Patients with drug-resistant TLE were recruited from 2 epilepsy centers in a prospective longitudinal study. All patients completed preoperative T1 and diffusion-weighted MRI (DWI) as well as preoperative and postoperative neuropsychological testing. Preoperative fractional anisotropy (FA) of the WM directly beneath the neocortex (i.e., superficial WM [SWM]) and of deep WM tracts associated with memory were calculated. Asymmetry was calculated for hippocampal volume and FA of each WM tract or region and examined in linear and logistic regressions with preoperative to postoperative memory change as the primary outcome. Data were analyzed from 42 patients with TLE (19 left TLE [LTLE], 23 right TLE [RTLE]) who underwent ATL. Leftward FA asymmetry of the entorhinal SWM was associated with decline on prose and associative recall in LTLE, whereas leftward FA asymmetry of the uncinate fasciculus (UNC) was associated with decline on prose recall only. After controlling for preoperative memory score and hippocampal volume, leftward FA asymmetry of the entorhinal SWM uniquely contributed to decline in both prose and associative recall (β = -0.46; SE 0.14 and β = -0.68; SE 0.22, respectively) and leftward FA asymmetry of the UNC uniquely contributed to decline in prose recall (β = -0.31; SE 0.14). A model combining asymmetry of hippocampal volume and entorhinal FA correctly classified memory outcomes in 79% of patients with LTLE for prose (area under the curve [AUC] 0.89; sensitivity 82%; specificity 75%) and 81% of patients for associative (AUC 0.79; sensitivity 83%; specificity 80%) recall. Entorhinal SWM asymmetry was the strongest predictor in both models. Preoperative asymmetry of deep WM and SWM integrity within the MTL is a strong predictor of postoperative memory decline in TLE, suggesting that surgical decision-making may benefit from considering each patient's WM network adequacy and reserve in addition to hippocampal integrity. This study provides Class II evidence that preoperative asymmetry of deep WM and SWM integrity within the MTL is a predictor of postoperative memory decline.

Cognitive outcomes following pediatric epilepsy surgery

ObjectivesTo characterize outcomes following pediatric epilepsy surgery across a broad range of cognitive domains using empirical methods (i.e., reliable change indices: RCIs), compare these outcomes with those based on traditional methods (i.e., standard deviation: SD), and identify factors associated with postoperative cognitive declines and/or improvements. MethodsThis retrospective cohort study included 186 children who underwent surgical resection for treatment of pharmacoresistant epilepsy and who completed pre- and postoperative neuropsychological assessments. Postoperative testing occurred approximately 6.5 months after surgery and included measures of intelligence, attention/working memory, processing speed, language, executive functioning, visuospatial skills, memory, and academic achievement. Change scores for each patient were classified as decline, no change, or improvement using epilepsy-specific RCIs. Chi-square goodness of fit tests were used to compare the distribution of outcomes as classified with RCIs to those obtained using a traditional one SD cutoff. Multinomial regression analyses were conducted to identify factors associated with cognitive decline and/or improvement. ResultsWhile 18% of children demonstrated no postoperative declines or improvements in any cognitive domain, the majority demonstrated relatively focal changes (declines and/or improvements in 1–2 cognitive domains). Rates of postoperative decline and improvement across individual cognitive domains were variable and ranged from 4‐35% and 2–31%, respectively. Compared to RCIs, SD methodology often overestimated postoperative improvements and varied with respect to declines. Factors associated with RCI decline or improvement included preoperative performance, age at surgery, surgery site, and postoperative seizures. SignificanceResults suggest substantial variability in individual cognitive outcomes approximately 6.5 months following pediatric epilepsy surgery. The differences in change distributions obtained using epilepsy-specific RCIs versus SDs highlight the need for studies using empiric methodology to study postoperative cognitive change. Variables associated with postoperative cognitive change may be used to develop multivariable prediction models in future studies to aid clinical decision-making and patient counseling.

Effect of neoadjuvant chemotherapy combined with intraperitoneal chemotherapy after interval tumor cell reduction on the prognosis of advanced epithelial ovarian cancer

Objectives: To investigate the effect of neoadjuvant chemotherapy combined with intraperitoneal chemotherapy after interval tumor cell reduction on the prognosis of advanced epithelial ovarian cancer. Methods: A retrospective study was performed among 210 patients with advanced ovarian cancer who were treated with neoadjuvant chemotherapy from May 1, 2007 to December 1, 2015. 121 patients with NACT-IDS (Neoadjuvant chemotherapy followed by interval debulking surgery) were enrolled. The patients were divided into observation group (NACT-IDS + IP group, n = 28) and control group (NACT-IDS + IV group, n = 93) depending on whether intraperitoneal chemotherapy was used after interval debulking surgery. The effects of intraperitoneal chemotherapy after NACT-IDS on PFS (progression-free survival) and OS (overall survival) were analyzed and the influencing factors were explored through multivariate analysis. The competitive model was used to analyze the effect of intraperitoneal chemotherapy after NACT-IDS on tumor recurrence. Toxicities associated with adjuvant chemotherapy were also analyzed between two groups. The effect of neoadjuvant chemotherapy cycles on prognosis and the correlation between postoperative CA125 decline and recurrence were evaluated. Results: Intraperitonal chemotherapy and R0 (no gross residual) were independent factors for PFS, with HRs of 0.560 (95% CI, 0.342–0.918, p = 0.022) and 0.578 (95% CI, 0.377–0.887, p = 0.012). There was no independent factor associated with OS. Significant difference in PFS was detected among the R0 + IP group, R0 + IV group, non-R0 + IP group and non-R0 + IV group. In patients with R0 tumor reduction, IP patients showed significantly better PFS, bonferronei adjusted p = 0.036. In patients without R0 tumor reduction, no significant difference was detected between IP and IV group, bonferronei adjusted p = 0.28. There were no significant differences of grade 3–4 toxicities, abdominal pain, treatment delays, dose reductions, and treatment modifications in NACT-IDS + IP group and NACT-IDS + IV group. Neoadjuvant chemotherapy cycles (≤3 and &gt;3) were not the influencing factors of PFS or OS and did not affect platinum-sensitive relapse or platinum-resistant relapse. The decrease in postoperative CA125 was not related to platinum-sensitive recurrence or platinum-resistant recurrence. Conclusions: Neoadjuvant chemotherapy combined with intraperitoneal chemotherapy after interval debulking surgery could improve the PFS of patients with advanced epithelial ovarian cancer compared to intravenous chemotherapy without significant differences in toxicity.