Preoperative Risk Estimation Research Articles

2024 Update of The Society of Thoracic Surgeons Short-term Esophagectomy Risk Model: More Inclusive and Improved Calibration

BackgroundThe Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD) previously reported short-term risk models for esophagectomy for esophageal cancer. We sought to update existing models using more inclusive contemporary cohorts, with consideration of additional risk factors based on clinical evidence. MethodsThe study population consisted of adult patients in the STS-GTSD who underwent esophagectomy for esophageal cancer between January 2015 and December 2022. Separate esophagectomy risk models were derived for 3 primary end points: operative mortality, major morbidity, and composite morbidity or mortality. Logistic regression with backward selection was used, with predictors retained in models if P < .10. All derived models were validated using 9-fold cross-validation. Model discrimination and calibration were assessed for the overall cohort and specified subgroups. ResultsA total of 18,503 patients from 254 centers underwent esophagectomy for esophageal cancer. Operative mortality, morbidity, and composite morbidity or mortality rates were 3.4%, 30.5%, and 30.9%, respectively. Novel predictors of short-term outcomes in the updated models included body surface area and insurance payor type. Overall discrimination was similar or superior to previous STS-GTSD models for operative mortality (C statistic = 0.72) and for composite morbidity or mortality (C statistic = 0.62), Model discrimination was comparable across procedure- and demographic-specific subcohorts. Model calibration was excellent in all patient subgroups. ConclusionsThe newly derived esophagectomy risk models showed similar or superior performance compared with previous models, with broader applicability and clinical face validity. These models provide robust preoperative risk estimation and can be used for shared decision making, assessment of provider performance, and quality improvement.

An MRI-based grading system for preoperative risk estimation of positive surgical margin after radical prostatectomy

ObjectiveTo construct a simplified grading system based on MRI features to predict positive surgical margin (PSM) after radical prostatectomy (RP).MethodsPatients who had undergone prostate MRI followed by RP between January 2017 and January 2021 were retrospectively enrolled as the derivation group, and those between February 2021 and November 2022 were enrolled as the validation group. One radiologist evaluated tumor-related MRI features, including the capsule contact length (CCL) of lesions, frank extraprostatic extension (EPE), apex abutting, etc. Binary logistic regression and decision tree analysis were used to select risk features for PSM. The area under the curve (AUC), sensitivity, and specificity of different systems were calculated. The interreader agreement of the scoring systems was evaluated using the kappa statistic.ResultsThere were 29.8% (42/141) and 36.4% (32/88) of patients who had PSM in the derivation and validation cohorts, respectively. The first grading system was proposed (mrPSM1) using two imaging features, namely, CCL ≥ 20 mm and apex abutting, and then updated by adding frank EPE (mrPSM2). In the derivation group, the AUC was 0.705 for mrPSM1 and 0.713 for mrPSM2. In the validation group, our grading systems showed comparable AUC with Park et al.’s model (0.672–0.686 vs. 0.646, p > 0.05) and significantly higher specificity (0.732–0.750 vs. 0.411, p < 0.001). The kappa value was 0.764 for mrPSM1 and 0.776 for mrPSM2. Decision curve analysis showed a higher net benefit for mrPSM2.ConclusionThe proposed grading systems based on MRI could benefit the risk stratification of PSM and are easily interpretable.Critical relevance statementThe proposed mrPSM grading systems for preoperative prediction of surgical margin status after radical prostatectomy are simplified compared to a previous model and show high specificity for identifying the risk of positive surgical margin, which might benefit the management of prostate cancer.Key points• CCL ≥ 20 mm, apex abutting, and EPE were important MRI features for PSM.• Our proposed MRI-based grading systems showed the possibility to predict PSM with high specificity.• The MRI-based grading systems might facilitate a structured risk evaluation of PSM.Graphical

Análisis de los datos del Registro Español de Cirugía Cardiaca (RECC) 2021-2022

IntroductionSince February 8, 2021, the Spanish Society of Cardiovascular and Endovascular Surgery got under way the Spanish Registry of Cardiac Surgery (RECC), which is available for the different units of cardiovascular surgeons in our country. It is a tool that allows collect patient-level data of patients undergoing cardiac, vascular or endovascular surgery. After two years of development, we have carried out an analysis of the quality of the information obtained in order to acquire an overview of its content. MethodsThe information has been analyzed anonymously at patient, hospital and province level. For risk-adjusted mortality estimation, the EuroSCORE II preoperative risk estimation scale was used. ResultsA total of 7087 interventions have been included. Six thousand two hundred and sixty-seven were major cardiac surgeries: 53.9% valvular, 25.2% coronary artery bypass grafting, and 14.9% aortic procedures. The overall mortality was 5.0% and the risk-adjusted mortality rate was 0.88. The EuroSCORE II calibration in the overall sample was good in the lowest-risk patients, although it overestimated mortality in high-risk patients. ConclusionsRECC is a nationally defined clinical database in the field of cardiovascular surgery. RECC allows a patient-level data analysis in order to perform an accurate analysis of the volumen of activity, risk adjustment and results. Locally, it could be used as a tool to improve the quality of care and development of corrective programs.

Cardiac Evaluation of Patients with Diabetes Mellitus Before Noncardiac Surgery

Up to 40% of patients undergoing elective surgeries have underlying diabetes mellitus (DM), and therefore an elevated risk of perioperative adverse cardiovascular outcomes. Preoperative cardiovascular risk assessment and therapeutic optimization are warranted in all patients with DM. This is an updated review on preoperative evaluation of cardiac risk in patients with DM undergoing surgery and strategies to minimize the risk. This article summarizes the current evidence and recommendations for cardiac evaluation in DM before noncardiac surgery. Preoperative risk estimation includes risk stratification of the proposed surgery and estimating the risk in the patient using available risk calculators such as the Revised Cardiac Risk Index and assessment of the functional status of the patient in terms of metabolic equivalents of tasks. Preoperative cardiac investigations such as electrocardiogram, echocardiography, stress testing, or cardiac biomarkers should be done in high-risk surgeries, and in certain subsets of patients undergoing low- or intermediate-risk surgeries. Additional testing and preoperative optimization are warranted in patients with heart failure and reduced or preserved ejection fraction, those with cardiac autonomic neuropathy, hypertension with or without end-organ damage, and patients undergoing transplant surgery, all of which are discussed in the current review.

Additional Prognostic Value of Tissue Doppler Evaluation in Patients with Aortic Stenosis and Left-Ventricular Systolic Dysfunction Undergoing Aortic Valve Replacement.

Background and Objectives: Patients with surgical aortic stenosis (AS) show impaired diastolic filling, which is a risk factor for early and late mortality after aortic valve replacement (AVR). There is a paucity of information concerning the impact of restrictive diastolic filling and the evolution of diastolic dysfunction in the early and medium terms post-AVR. We aimed to determine the prognostic value of the presence of a restrictive left-ventricular (LV) diastolic filling pattern (LVDFP) and dilated left atrium (LA) in patients with AS and LV systolic dysfunction (LVEF < 40%) who underwent AVR, and to define the independent predictors for immediate and long-term prognosis and their value for preoperative risk estimation. Materials and Methods: The study was prospective and included 197 patients with surgical AS and LVEF <40% who underwent AVR. Preoperative echocardiographic examinations were repeated at day 10, at 1, 3 and 6 months, and at 1 and 2 years after surgery, with evaluation of LVEF, diastolic function and LA dimension index (mm/m2). Depending on LV systolic performance, patients were classified as Group A (LVEF: 30–40%) or Group B (LVEF < 30%). Results: The main echographic independent parameters for early and late postoperative death were: restrictive LVDFP, significant pulmonary hypertension, LV end-systolic diameter (LVESD) >55 mm and the presence of second-degree mitral regurgitation. Restrictive LVDFP and LA dimension >30 mm/m2 were independent predictors for fatal outcome (p = 0.0017). Conclusions: Assessment of diastolic function and LA dimension are reliable parameters in predicting fatal outcome and hospitalization for heart failure, having an independent and incremental prognostic value in patients with surgical AS. Complete evaluation of LVDFP with all the echographic measurements (including TDI) should routinely be part of the preoperative assessment of patients with LV systolic dysfunction undergoing AVR.

Kidney Disease: Improving Global Outcomes Classification of Chronic Kidney Disease and Short-Term Outcomes of Patients Undergoing Liver Resection.

The impact of chronic kidney disease (CKD) on surgery is still not well defined. We sought to characterize the association of preoperative CKD with 30-day mortality after hepatic resection. Patients included in the American College of Surgeons (ACS) NSQIP who underwent hepatectomy between 2014 and 2018 were identified. Kidney function was stratified according to the "Kidney Disease: Improving Global Outcomes" (KDIGO) Classification: G1, normal/high function (estimated glomerular-filtration-rate ≥ 90 ml/min/1.73m2); G2-3, mild/moderate CKD (89-30 ml/min/1.73m2); G4-5, severe CKD (≤ 29 ml/min/1.73m2). Overall, 18,321 patients were included. Older patients (ie more than 70 years old) and those with serious medical comorbidities (ie American Society of Anesthesiologists [ASA] class 3) had an increased incidence of severe CKD (both p < 0.001). Patients with G2-3 and G4-5 CKD were more likely to have a prolonged length of stay and to experience postoperative complications (both p < 0.001). Adjusted odds of 30-day mortality increased with the worsening CKD (p = 0.03). The degree of CKD was able to stratify patients within the NSQIP risk calculator. Among patients who underwent major hepatectomy for primary cancer, the rate of 30-day mortality was 2-fold higher with G2-3 and G4-5 CKD vs normal kidney function (p = 0.03). The degree of CKD was related to the risk of complications and 30-day mortality after hepatectomy. CKD classification should be strongly considered in the preoperative risk estimation of these patients.

Prediction of mortality in isolated tricuspid surgery.

Isolated tricuspid surgery is a rarely performed procedure considered at high risk for mortality. Preoperative risk estimation is still a s missing process and currently used risk score system are not validated for this procedures. To discuss the external validation of the EuroSCORE II and STS-TVS score in the setting of isolated tricuspid valve surgery. The stratification of the patient profile and risk estimation are still lacking in isolated tricuspid surgery. MELD Score, EuroSCORE II and STS-TVS score may help in the preoperative evaluation. Recently a dedicated score called TRI-SCORE has been introduced. We believe that the combination of these scores may determine a range of expected mortality rate and it could be an interesting approach to define the preoperative risk-profile of a patient planned for isolated tricuspid disease. Conclusion Further studies are needed to define the optimal risk stratification of patient affected by isolated tricuspid disease.

Long‐Term Survival and Risk of Institutionalization in Onco‐Geriatric Surgical Patients: Long‐Term Results of the PREOP Study

OBJECTIVESTo evaluate long‐term survival and institutionalization in onco‐geriatric surgical patients, and to analyze the association between these outcomes and a preoperative risk score.DESIGNProspective cohort study with long‐term follow‐up.SETTINGInternational and multicenter locations.PARTICIPANTSPatients aged 70 years or older undergoing elective surgery for a malignant solid tumor at five centers (n = 229).MEASUREMENTSWe assessed long‐term survival and institutionalization using the Preoperative Risk Estimation for Onco‐geriatric Patients (PREOP) score, developed to predict the 30‐day risk of major complications. The PREOP score collected data about sex, type of surgery, and the American Society for Anesthesiologists classification, as well as the Timed Up & Go test and the Nutritional Risk Screening results. An overall score higher than 8 was considered abnormal.RESULTSWe included 149 women and 80 men (median age = 76 y; interquartile range = 8). Survival at 1, 2, and 5 years postoperatively was 84%, 77%, and 56%, respectively. Moreover, survival at 1 year was worse for patients with a PREOP risk score higher than 8 (70%) compared with 8 or lower (91%). Of those alive at 1 year, 43 (26%) were institutionalized, and by 2 years, almost half of the entire cohort (46%) were institutionalized or had died. A PREOP risk score higher than 8 was associated with increased mortality (hazard ratio = 2.6; 95% confidence interval [CI] = 1.7‐4.0), irrespective of stage and age, but not with being institutionalized (odds ratios = 1 y, 1.6 [95% CI = .7‐3.8]; 2 y, 2.2 [95% CI = .9‐5.5]).CONCLUSIONA high PREOP score is associated with mortality but not with remaining independent. Despite acceptable survival rates, physical function may deteriorate after surgery. It is imperative to discuss treatment goals and expectations preoperatively to determine if they are feasible. Using the PREOP risk score can provide an objective measure on which to base decisions. J Am Geriatr Soc 68:1235–1241, 2020.

Laparoscopic Liver Resection Difficulty Score—a Validation Study

Objective(s)The technical complexity of laparoscopic liver resection (LLR) poses unique challenges distinct from open surgery. An objective scoring system was developed that preoperatively quantifies the difficulty of LRR to help guide surgeon decision-making regarding the feasibility and safety of minimally invasive approaches. The aim of this multiinstitutional study was to externally validate this scoring system. MethodsPatients who underwent LLR at two institutions were reviewed. LLR difficulty score (LDS) was calculated based on patient, tumor, and anatomic characteristics by two independent, blinded hepatobiliary surgeons. Surrogates of case complexity (e.g., conversion rate, operative time) were used for validation of this index. ResultsFrom 2006 to 2016, 444 LLR were scored as low (n = 94), intermediate (n = 98), and high difficulty (n = 152) with respective conversion rates of 5.3%, 15.7%, and 25%. Cases of higher LDS correlated with larger mean blood loss (203 ml vs. 331 ml vs. 635 ml). Mean operative and Pringle maneuver used were associated with increasing LDS (155 min vs. 202 min vs. 315 min and 14.4% vs. 29.7% vs. 45.1% respectively). These operative surrogates of difficulty correlated significantly with the LDS (all p < 0.0001). ConclusionsThis comprehensive external validation of the LDS is robust and applicable in diverse patient populations. This LDS serves as a useful objective predictor of technical difficulty for LLR to help surgeons in selecting patients according to their individual operative experience and is valuable for preoperative risk estimation and stratification in randomized trials.

PS01.177: ERAS HYBRID IVOR LEWIS ESOPHAGECTOMY

Abstract Background We introduced a multiprofessional fast track programme in esophagectomy in order to increase surgical safety and to reduce the perioperative burden to the patient. Methods Consecutive patients scheduled for oncological Hybrid Ivor Lewis (HIL) procedure were included. An adapted ERAS protocol beginning from the process of preoperative risk estimation involving internists, oncologists, physiotherapists, psychologists, dietricians, surgeons and anesthesiologists to make patients fit for surgery. In locally advanced tumor stages neoadjuvant treatment was adopted according to interdisciplinary consensus. Perioperative measures were undertaken to enhance recovery and to reduce morbidity by an adopted ERAS protocol. Parameters regarding surgical safety, oncological quality of surgery, duration of hospital stay, unplanned readmissions and survival were recorded. Results Since 2014 94 patients underwent esophageal resection. Among them 80 had an Ivor Lewis procedure, 69 patients (female, 16; mean age, 66a) underwent HIL for cancer. The majority received neoadjuvant treatment before HIL (chemotherapy, 47; radiochemotherapy, 10). R-0 rate was 92,8%, mean number of examined lymphnodes was 33,5. Major morbidity (Clavien-Dindo III-V) occurred in 13,04%, anastomotic leaks in 7,2%, 8 (11,6%) patients underwent redo surgery. 6 (8,7%) patients needed prolonged mechanical ventilation. Hospital, 30d- and 90d-mortality was 2.9, 2.9 and 4,3%, respectively. Median hospital stay was 12 days (8–57) in all patients and 26 days (14–57) in patients with major morbidity. Unplanned readmission occurred in 7,2%. Overall, ERAS protocol was fulfilled in 66,7% of cases. Estimated 2-year overall survival is 82%. Conclusion Adopting an ERAS protocol with dedicated interprofessional perioperative care operative safety compares favourably with other reports. Performing the abdominal part endoscopically does not impair surrogate parameters of oncological quality. However, length of hospital stay seems to be optimizable. Disclosure All authors have declared no conflicts of interest.

Optimising preoperative risk stratification tools for prostate cancer using mpMRI

PurposeTo improve preoperative risk stratification for prostate cancer (PCa) by incorporating multiparametric MRI (mpMRI) features into risk stratification tools for PCa, CAPRA and D’Amico.Methods807 consecutive patients operated on by robot-assisted radical prostatectomy at our institution during the period 2010–2015 were followed to identify biochemical recurrence (BCR). 591 patients were eligible for final analysis. We employed stepwise backward likelihood methodology and penalised Cox cross-validation to identify the most significant predictors of BCR including mpMRI features. mpMRI features were then integrated into image-adjusted (IA) risk prediction models and the two risk prediction tools were then evaluated both with and without image adjustment using receiver operating characteristics, survival and decision curve analyses.Results37 patients suffered BCR. Apparent diffusion coefficient (ADC) and radiological extraprostatic extension (rEPE) from mpMRI were both significant predictors of BCR. Both IA prediction models reallocated more than 20% of intermediate-risk patients to the low-risk group, reducing their estimated cumulative BCR risk from approximately 5% to 1.1%. Both IA models showed improved prognostic performance with a better separation of the survival curves.ConclusionIntegrating ADC and rEPE from mpMRI of the prostate into risk stratification tools improves preoperative risk estimation for BCR.Key points• MRI-derived features, ADC and EPE, improve risk stratification of biochemical recurrence.• Using mpMRI to stratify prostate cancer patients improves the differentiation between risk groups.• Using preoperative mpMRI will help urologists in selecting the most appropriate treatment.

Aspectos perioperatorios: riesgo quirúrgico y fragilidad, condicionamiento isquémico remoto, umbral transfusional, postoperatorio inmediato y vías de corta estancia

An exquisite perioperative management, besides an adequate surgical technique, is mandatory to obtain good outcomes in coronary artery bypass grafting surgery (CABG).So, all the steps related to the surgical procedure should be optimized, from the beginning of the process, when surgical candidates are selected for CABG, to the recommendations and medications prescribed at Hospital discharge. There are several steps that can be modified to improve the early and late surgical results.In this review we will deal with some of this factors, such as preoperative risk estimation taking into account the frailty of the patient, ischemic preconditioning, blood transfusions, intensive care unit management and fast track protocols.

A Cluster-Based Method for the Preoperative Identification of Lumbar Degenerative Patients having Higher Risk for Poor Global Outcome

Introduction Surgery for lumbar disc degeneration has been shown to yield poor results in 10 to 45% of the patients. Evidence-based clinical tools for preoperative risk estimation would be very important to identify the “at-risk” patients. Several factors referring on the patients' symptoms, psychosocial issues, and medical history were previously published as significant individual risk factors on outcome, but there is low number of reports on integrative models with advanced statistics. The aim of this study was to identify significant outcome predictors and clinically different subgroups in patients surgically treated because of lumbar degenerative disc disease. Patients and Methods A total of 750 consecutive patients indicated for one- or two-level lumbar decompression/microdiscectomy or fusion surgery (TLIF) were recruited into the study. Patients with previous lumbar surgery or nondisc degeneration-related phenotype were not included into the analysis. Patients completed a questionnaire booklet containing the Oswestry disability index (ODI), visual analogue scales on low back (LBP), and leg pain (LP), Zung depression scale (ZDS), and the Modified Somatic Perception Questionnaire (MSPQ) before the surgery and 2 years after the surgery. Five-point Likert scale on self-reported outcome of the surgery was classified into two categories (“good” and “poor” outcome) and effect of preoperative parameters on that was determined applying uni- and multivariate logistic regression models. Two-step agglomerative cluster analysis was used to determine the best fit cluster structure of the cohort entering the significant outcome predictors into the model. Multivariate analysis of variance (MANOVA) and Fischer test were used to analyze the clinical clusters and their canonical discriminant functions. Chi-square tests were applied to investigate the clinical outcome in the different clusters. Results Four different preoperative parameters; number of spinal levels treated, severity of low back pain, duration of pain, and distress (calculated from ZDS and MSPQ scores) were proved to be significant predictors on surgical outcome in the final multivariate regression model ( p &lt; 0.001). The four parameters identified four different subgroups in patients with good cluster quality. Clinical outcome was significantly different in the four preoperative patient-clusters (poor outcome in 5.1, 12.4, 20.9, and 25.6% of subjects, chi-square = 29.3, df = 3, p &lt; 0.001). Conclusion Preoperative parameters of the patients with lumbar disc degeneration have got significant influence on the midterm surgical outcome. Outcome predictors determine different patient clusters with different risk for poor outcome. Advanced statistical approaches are advised to use in the future for patient stratification and risk estimation.

Prostate-specific antigen density as a parameter for the prediction of positive lymph nodes at radical prostatectomy.

Objective:The aim was to determine the prognostic ability of Partin's tables for a patient collective undergoing radical prostatectomy (RP) and to evaluate the association of prostate-specific antigen (PSA) density (PSAD) and postoperative lymph node status.Methods:From 1999 to 2006, 393 consecutive patients underwent RP at our Urology department. Patients with Gleason scores < 6, clinical stages >T2c or neoadjuvant hormonal therapy were excluded. Preoperative PSA, biopsy results, digital rectal examination, and prostate size at transrectal ultrasound were recorded. Risk stratification according to the Partin scoring system was performed. Postoperative results were compared with preoperative risk estimation. Univariate and multivariate statistical analysis about prediction of postoperative lymph node status was performed.Results:Lymph node invasion (LNI) was found in 36 patients (9.16%). Kendall's rank correlation analysis revealed a significant association between the number of removed LN and LNI (P = 0.016). Patients with LNI had a significantly higher preoperative PSA and PSAD. Preoperative Gleason score was a significant predictor of LNI. The Partin tables' prediction of organ confined stages, extraprostatic extension, and seminal vesicle invasion was in line with the pathological findings in our collective. PSAD was a significant predictor of LNI in univariate and multivariate analysis.Conclusion:The most widely used nomogram is of high value in therapy decision-making, although it remains an auxiliary means. Considering the performance of lymph node dissection, surgeons should be aware of the specifics of the applied nomogram. PSAD appears as a useful adjunctive parameter for preoperative prostate risk estimation and warrants further evaluation.

Comparison of different scoring systems in patients undergoing colorectal cancer surgery for predicting mortality and morbidity

Preoperative risk estimation evaluating mortality and morbidity might help surgical decision. The aim of this study was to compare the sensitivities of physiologic and operative severity score for the enumeration of mortality and morbidity (POSSUM), portsmouth-POSSUM (P-POSSUM), colorectal-POSSUM (CR-POSSUM), the Association of Coloproctology of Great Britain and Ireland colorectal cancer model (ACPGBI CRC) and revised ACPGBI CRC scoring systems that are used for evaluating mortality and morbidity in colorectal surgery performed in third-level healthcare centers. A retrospective analysis has been performed on 335 consecutive patients undergoing colorectal cancer surgery between 2002 and 2012. Mortality and morbidity risks of 335 patients who underwent colorectal cancer were evaluated using these scoring systems and the results were compared with actual mortality and morbidity within postoperative 30-day that extend the duration of hospital stay. The receiver operating characteristic (ROC) curves were designed to identify the score values. Results of POSSUM and P-POSSUM systems showed statistical differences compared with those of CR-POSSUM, ACPGBI CRC and revised ACPGBI CRC systems (P < 0.05). P-POSSUM was found to be the best scoring system for predicting mortality risk, although all scoring systems seem to be appropriate for this parameter. On the other hand POSSUM, which can predict morbidity, was found to have moderate differentiation ability due to the magnitude of the area under the ROC curve. Despite altering patient demographics and surgical conditions, POSSUM seems to lead as the best scoring system for predicting mortality and morbidity among others including those most-recently proposed.

Herzinsuffizienz – Intensivmedizinisches Management nach Implantation eines mechanischen Linksherzunterstützungssystems

Left ventricular assist devices (LVAD) have become an important option for the treatment of patients with advanced heart failure. Unfortunately, patients undergoing LVAD-implantation still experience considerable perioperative morbidity and mortality. Right ventricular failure, bleeding, infections and device-associated problems represent the major postoperative complications. The present overview summarizes current strategies for preoperative risk estimation and for the prevention and treatment of frequently occurring perioperative complications.

Size and volume of metastatic and non-metastatic lymph nodes in pelvis and lower abdomen in patients with carcinoma of the bladder undergoing radical cystectomy

This study aimed to evaluate the usability of size and volume of lymph nodes (LNs) in the pelvis and lower abdomen to predict metastatic disease in patients with carcinoma of the urinary bladder. LNs retrieved from 177 patients undergoing radical cystectomy and extended LN dissection were prospectively registered with number, location, presence of metastatic disease, longitudinal length, transverse diameter and a calculated LN volume. A mean of 21.2 LNs was removed from each patient. Thirty-eight patients (21.5%) had positive LNs. The total LN volume per patient was independent of the number of LNs removed, whereas mean volume per LN was inversely proportional to the number of LNs removed in node-negative patients, suggesting a physiological variation in the number of pelvic LNs. Positive LNs were generally larger than negative LNs. This difference was more pronounced using the transverse diameter than using longitudinal length. Calculated higher volume of an LN was also associated with an increased risk of metastases. However, no optimal cut-off values predicting metastatic disease based on LN size were found owing to low sensitivity and low predictive value at the tested cut-off values. The size difference comparing positive and negative LNs was therefore not clinically applicable as an overall preoperative risk estimation of metastatic disease. A fixed volume of lymphatic tissue rather than a fixed number of LNs seems to be present in node-negative patients. Size of LNs remains a poor predictor of metastatic disease in bladder cancer.

Preoperative risk estimation for onco-geriatric patients (PREOP) – preoperative assessment of elderly surgical patients

XXI Annual Meeting of The Italian Society of Geriatric Surgery Francesco Sciannameo, Giammario Giustozzi and Beatrice Sensi Publication of this supplement was made possible with support from the Fondazione Cassa di Risparmio di Terni e Narni Meeting abstracts – A single PDF containing all abstracts in this Supplement is available here . http://www.biomedcentral.com/content/pdf/1471-2318-9-S1info.pdf

Discordance between predicted postoperative forced expiratory volumes in one second (ppoFEV1) calculated before and after resection of bronchogenic carcinoma

The aim of this study is to evaluate the concordance between predicted postoperative forced expiratory volumes in 1s (ppoFEV1) calculated on the basis of data known before surgery with ppoFEV1 calculated after completing surgical procedure. We have prospectively studied 66 consecutive patients (55 cases scheduled for lobectomy and 11 for pneumonectomy) operated on for bronchial carcinoma. According to location, 33 tumours were classified as central and 33 as peripheral. In all cases, ppoFEV1 was calculated twice: first (ppoFEV1-A) according to the scheduled surgical procedure; second (ppoFEV1-B) according to the procedure eventually performed. At operation, 43 lobectomies (65.2%) and 23 pneumonectomies (34.8%) were performed. Differences between ppoFEV1 A and B were found in 18 cases (12 central tumours). In three of them (4.5% of 66 cases), ppoFEV1-B was under 40%. Pearson coefficient was 0.85 (P<0.001) for the whole series of cases; 0.83 (P<0.001) for central and 0.87 (P<0.001) for peripheral tumours. On multiple regression analysis, R2 was 0.76 and ppoFEV1-A had the highest influence on the dependent variable. We have found that: (1) there is no perfect correlation between ppoFEV1 calculated with data known before and after surgery; (2) discrepancies are most important in centrally located tumours and (3) in 4.5% of cases, discrepancies could have influenced the preoperative risk estimation.

Prognostic relevance of three histological grading methods in breast cancer

Histological grading is an important parameter for the risk assessment in patients with breast cancer. However, up to now differing grading methods are used which have not been compared with respect to their prognostic significance. In the present study the prognostic significance of three different methods of histological grading (Elston, Contesso, Helpap) was determined in a sample of 292 patients. Furthermore, results obtained in needle biopsies were compared with those obtained in surgical resection specimens in 31 cases. The mitotic counts and the Contesso method were performed on two microscopes with different field areas (0.238 mm2 and 0.345 mm2). Univariate and multivariate analysis revealed that all three histological grading methods had a high prognostic value concerning overall survival (OS) and disease-free survival (DFS). Using univariate and multivariate analysis the Elston method performed best to determine OS and DFS (p<0.0001 and p<0.001). The field area of the microscope had a minor influence on the mitotic count and on the results of the Contesso method. The histological grading was reliable in needle biopsies: the best agreement to grading obtained in the definitive surgical specimen was achieved with the Elston method (kappa statistic 0.727). As a conclusion, we could show that determination of the histological grade is an important prognostic factor in breast cancer with the Elston method giving the best results. Also, we could demonstrate that histological grading in needle biopsies is reliable enough to allow a preoperative risk estimation.