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Pouncey AL, Loría-Rebolledo LE, Sharples L, Bicknell C, Ryan M, Powell J. Impact of patient sex on selection for abdominal aortic aneurysm repair: a discrete choice experiment. BMJ Open 2025; 15:e091661. [PMID: 40010836 PMCID: PMC11865737 DOI: 10.1136/bmjopen-2024-091661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 01/29/2025] [Indexed: 02/28/2025] Open
Abstract
OBJECTIVES Women with an abdominal aortic aneurysm (AAA) are less likely to receive elective repair than men. This study explored the effect of patient sex and other attributes on vascular surgeons' decision-making for infrarenal AAA repair. DESIGN Discrete choice experiment. SETTING Simulated environment using case scenarios with varying patient attributes. PARTICIPANTS Vascular surgeons. INTERVENTIONS Surgical decision-making. MAIN OUTCOME MEASURES AAA repair versus no repair and endovascular versus open repair. RESULTS 182 surgeons completed 2987 scenarios. When all other attributes were equal, a woman was more likely to be offered an AAA repair (marginal rate of substitution (MRS) 3.86 (95% CI 2.93, 4.79)), while very high anaesthetic risk (MRS -4.33 (95% CI -5.63, -3.03)) and hostile anatomy (MRS -3.28 (95% CI -4.55, -2.01)) were deterrents. Increasing age did not adversely affect the likelihood of offering repair to men but decreased the likelihood for women, which negated women's selection advantage from the age of 83 years. Women were also more likely to be offered endovascular repair (MRS 2.57 (95% CI 1.30, 3.84)). CONCLUSIONS Patient sex alone did not account for real-world disparity observed in selection for surgery. Rather, being a woman was associated with a higher likelihood of being offered AAA repair but also a higher likelihood of being offered less invasive endovascular repair. Increased age decreased the likelihood of surgical selection for women but not men. Preference for less invasive repair, combined with inferior rates of anatomical suitability, and the comparably older age of women at the time of AAA repair selection may account for lower rates of repair for women observed.
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Affiliation(s)
| | | | - Linda Sharples
- Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Mandy Ryan
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Pang TS, Cao LP. Estimation of Physiologic Ability and Surgical Stress scoring system for predicting complications following abdominal surgery: A meta-analysis spanning 2004 to 2022. World J Gastrointest Surg 2024; 16:215-227. [PMID: 38328319 PMCID: PMC10845291 DOI: 10.4240/wjgs.v16.i1.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/24/2023] [Accepted: 12/19/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Postoperative complications remain a paramount concern for surgeons and healthcare practitioners. AIM To present a comprehensive analysis of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system's efficacy in predicting postoperative complications following abdominal surgery. METHODS A systematic search of published studies was conducted, yielding 17 studies with pertinent data. Parameters such as preoperative risk score (PRS), surgical stress score (SSS), comprehensive risk score (CRS), postoperative complications, postoperative mortality, and other clinical data were collected for meta-analysis. Forest plots were employed for continuous and binary variables, with χ2 tests assessing heterogeneity (P value). RESULTS Patients experiencing complications after abdominal surgery exhibited significantly higher E-PASS scores compared to those without complications [mean difference and 95% confidence interval (CI) of PRS: 0.10 (0.05-0.15); SSS: 0.04 (0.001-0.08); CRS: 0.19 (0.07-0.31)]. Following the exclusion of low-quality studies, results remained valid with no discernible heterogeneity. Subgroup analysis indicated that variations in sample size and age may contribute to heterogeneity in CRS analysis. Binary variable meta-analysis demonstrated a correlation between high CRS and increased postoperative complication rates [odds ratio (OR) (95%CI): 3.01 (1.83-4.95)], with a significant association observed between high CRS and postoperative mortality [OR (95%CI): 15.49 (3.75-64.01)]. CONCLUSION In summary, postoperative complications in abdominal surgery, as assessed by the E-PASS scoring system, are consistently linked to elevated PRS, SSS, and CRS scores. High CRS scores emerge as risk factors for heightened morbidity and mortality. This study establishes the accuracy of the E-PASS scoring system in predicting postoperative morbidity and mortality in abdominal surgery, underscoring its potential for widespread adoption in effective risk assessment.
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Affiliation(s)
- Tian-Shu Pang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
| | - Li-Ping Cao
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, Zhejiang Province, China
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Abstract
PURPOSE OF REVIEW Preoperative risk assessment and perioperative factors may help identify patients at increased risk of postoperative complications and allow postoperative management strategies that improve patient outcomes. This review summarizes historical and more recent scoring systems for predicting patients with increased morbidity and mortality in the postoperative period. RECENT FINDINGS Most prediction scores predict postoperative mortality with, at best, moderate accuracy. Scores that incorporate surgery-specific and intraoperative covariates may improve the accuracy of traditional scores. Traditional risk factors including increased ASA physical status score, emergent surgery, intraoperative blood loss and hemodynamic instability are consistently associated with increased mortality using most scoring systems. SUMMARY Preoperative clinical risk indices and risk calculators estimate surgical risk with moderate accuracy. Surgery-specific risk calculators are helpful in identifying patients at increased risk of 30-day mortality. Particular attention should be paid to intraoperative hemodynamic instability, blood loss, extent of surgical excision and volume of resection.
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Ishihata K, Kakihana Y, Yoshimura T, Murakami J, Toyodome S, Hijioka H, Nozoe E, Nakamura N. Assessment of postoperative complications using E-PASS and APACHE II in patients undergoing oral and maxillofacial surgery. Patient Saf Surg 2018; 12:3. [PMID: 29632558 PMCID: PMC5885352 DOI: 10.1186/s13037-018-0152-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 02/22/2018] [Indexed: 11/25/2022] Open
Abstract
Background The prediction of postoperative complications is important for oral and maxillofacial surgeons. We herein aimed to evaluate the efficacy of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) and Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II scoring systems to predict postoperative complications in patients undergoing oral and maxillofacial surgery. Methods Thirty patients (22 males, 8 females; mean age: 65.1 ± 12.9 years) who underwent major oral surgeries and stayed in the intensive care unit for postoperative management were enrolled in this study. Postoperative complications were discriminated according to the necessity of the therapeutic intervention by the Medical Department, i.e. according to the Clavien–Dingo classification. E-PASS and APACHE II scores as well as laboratory test values were compared between patients with/without postoperative complications. Results Postoperative complications were developed in seven patients. The comprehensive risk score (CRS: 1.13 ± 0.24) and APACHE II score (13.0 ± 2.58) were significantly higher in patients with postoperative complications than in those without ones (p < 0.01, p < 0.05, respectively). The CRS showed an appropriate discriminatory power for predicting postoperative complications (area under the curve: 0.814). Furthermore, a correlation was detected between APACHE II scores and postoperative data until C-reactive protein levels decreased to < 1.0 mg/L (r = 0.43, p < 0.05). Conclusion The E-PASS and APACHE II scoring systems were both shown to be useful to predict postoperative complications after oral and maxillofacial surgery.
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Affiliation(s)
- Kiyohide Ishihata
- 1Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Yasuyuki Kakihana
- 2Department of Emergency and Intensive Care Medicine, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
| | - Takuya Yoshimura
- 1Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Juri Murakami
- 1Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Soichiro Toyodome
- 1Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Hiroshi Hijioka
- 1Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Etsuro Nozoe
- 1Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Norifumi Nakamura
- 1Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544 Japan
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Chun DH, Kim DY, Choi SK, Shin DA, Ha Y, Kim KN, Yoon DH, Yi S. Feasibility of a Modified E-PASS and POSSUM System for Postoperative Risk Assessment in Patients with Spinal Disease. World Neurosurg 2017; 112:e95-e102. [PMID: 29277590 DOI: 10.1016/j.wneu.2017.12.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This retrospective case control study aimed to evaluate the feasibility of using Estimation of Physiological Ability and Surgical Stress (E-PASS) and Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) systems in patients undergoing spinal surgical procedures. Degenerative spine disease has increased in incidence in aging societies, as has the number of older adult patients undergoing spinal surgery. Many older adults are at a high surgical risk because of comorbidity and poor general health. METHODS We retrospectively reviewed 217 patients who had undergone spinal surgery at a single tertiary care. We investigated complications within 1 month after surgery. Criteria for both skin incision in E-PASS and operation magnitude in the POSSUM system were modified to fit spine surgery. We calculated the E-PASS and POSSUM scores for enrolled patients, and investigated the relationship between postoperative complications and both surgical risk scoring systems. To reinforce the predictive ability of the E-PASS system, we adjusted equations and developed modified E-PASS systems. RESULTS The overall complication rate for spinal surgery was 22.6%. Forty-nine patients experienced 58 postoperative complications. Nineteen major complications, including hematoma, deep infection, pleural effusion, progression of weakness, pulmonary edema, esophageal injury, myocardial infarction, pneumonia, reoperation, renal failure, sepsis, and death, occurred in 17 patients. The area under the receiver operating characteristic curve (AUC) for predicted postoperative complications after spine surgery was 0.588 for E-PASS and 0.721 for POSSUM. For predicted major postoperative complications, the AUC increased to 0.619 for E-PASS and 0.842 for POSSUM. The AUC of the E-PASS system increased from 0.588 to 0.694 with the Modified E-PASS equation. CONCLUSIONS The POSSUM system may be more useful than the E-PASS system for estimating postoperative surgical risk in patients undergoing spine surgery. The preoperative risk scores of E-PASS and POSSUM can be useful for predicting postoperative major complications. To enhance the predictability of the scoring systems, using of modified equations based on spine surgery-specific factors may help ensure surgical outcomes and patient safety.
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Affiliation(s)
- Dong Hyun Chun
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Do Young Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Kyu Choi
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ah Shin
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ha
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Keung Nyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Do Heum Yoon
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Yi
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.
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Estimation of V-POSSUM and E-PASS Scores in Prediction of Acute Kidney Injury in Patients after Elective Open Abdominal Aortic Aneurysm Surgery. Ann Vasc Surg 2017; 42:189-197. [PMID: 28359795 DOI: 10.1016/j.avsg.2017.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 02/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND V-POSSUM and E-PASS scoring systems are usually used to predict morbidity and early mortality in surgical patients. We conducted this study to assess the validity of the V-POSSUM and E-PASS scores in predicting risk of acute kidney injury (AKI) development in patients undergoing elective open abdominal aortic aneurysm (AAA) repair. METHODS We studied a consecutive series of 171 patients with AAA, qualified for elective open infrarenal repair. Patients underwent a thorough examination, and the physiological and surgical stress components of the V-POSSUM and E-PASS scores were calculated. The classification of patients in terms of postoperative AKI was performed in accordance with KDIGO criteria. RESULTS AKI was recognized in 62 patients. In these patients, we found significantly higher physiological and surgical stress components of V-POSSUM and E-PASS scores in relation to patients without AKI. ROC analysis showed that the E-PASS score with a cutoff point ≥0.796 and the V-POSSUM score (morbidity) with a cutoff point ≥77.2% with sensitivity of 75.8% and 74.2%, respectively, and with specificity of 83.5% for both, identified patients with postoperative AKI. CONCLUSIONS V-POSSUM and E-PASS scores have similar good properties in predicting postoperative AKI in patients undergoing elective open AAA repair.
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Menezes FH, Ferrarezi B, Souza MAD, Cosme SL, Molinari GJDP. Results of Open and Endovascular Abdominal Aortic Aneurysm Repair According to the E-PASS Score. Braz J Cardiovasc Surg 2016; 31:22-30. [PMID: 27074271 PMCID: PMC5062688 DOI: 10.5935/1678-9741.20160006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 01/19/2016] [Indexed: 12/18/2022] Open
Abstract
Introduction: Endovascular repair (EVAR) of abdominal aortic aneurysm has become the
standard of care due to a lower 30-day mortality, a lower morbidity, shorter
hospital stay and a quicker recovery. The role of open repair (OR) and to
whom this type of operation should be offered is subject to discussion. Objective: To present a single center experience on the repair of abdominal aortic
aneurysm, comparing the results of open and endovascular repairs. Methods: Retrospective cross-sectional observational study including 286 patients
submitted to OR and 91 patients submitted to EVAR. The mean follow-up for
the OR group was 66 months and for the EVAR group was 39 months. Results: The overall mortality was 11.89% for OR and 7.69% for EVAR
(P=0.263), EVAR presented a death relative risk of
0.647. It was also found a lower intraoperative bleeding for EVAR
(OR=1417.48±1180.42 mL versus
EVAR=597.80±488.81 mL, P<0.0002) and a shorter
operative time for endovascular repair (OR=4.40±1.08 hours
versus EVAR=3.58±1.26 hours,
P<0.003). The postoperative complications presented no
statistical difference between groups (OR=29.03% versus
EVAR=25.27%, P=0.35). Conclusion: EVAR presents a better short term outcome than OR in all classes of
physiologic risk. In order to train future vascular surgeons on OR, only
young and healthy patients, who carry a very low risk of adverse events,
should be selected, aiming at the long term durability of the procedure.
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Affiliation(s)
| | - Bárbara Ferrarezi
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | | | - Susyanne Lavor Cosme
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Estimation of Physiologic Ability and Surgical Stress (E-PASS) versus modified E-PASS for prediction of postoperative complications in elderly patients who undergo gastrectomy for gastric cancer. Int J Clin Oncol 2016; 22:80-87. [DOI: 10.1007/s10147-016-1028-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 07/28/2016] [Indexed: 11/26/2022]
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Law Y, Chan YC, Cheung GC, Ting ACW, Cheng SWK. Outcome and risk factor analysis of patients who underwent open infrarenal aortic aneurysm repair. Asian J Surg 2016; 39:164-71. [DOI: 10.1016/j.asjsur.2015.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 02/26/2015] [Accepted: 03/02/2015] [Indexed: 12/20/2022] Open
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Value of E-PASS models for predicting postoperative morbidity and mortality in resection of perihilar cholangiocarcinoma and gallbladder carcinoma. HPB (Oxford) 2016; 18:271-8. [PMID: 27017167 PMCID: PMC4814599 DOI: 10.1016/j.hpb.2015.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 09/22/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND It has previously been reported that a general risk model, Estimation of Physiologic Ability and Surgical Stress (E-PASS), and its modified version, mE-PASS, had a high predictive power for postoperative mortality and morbidity in a variety of gastrointestinal surgeries. This study evaluated their utilities in proximal biliary carcinoma resection. METHODS E-PASS variables were collected in patients undergoing resection of perihilar cholangiocarcinoma and gallbladder carcinoma in Japanese referral hospitals. RESULTS Analysis of 125 patients with gallbladder cancer and 97 patients with perihilar cholangiocarcinoma (n = 222). Fifty-six patients (25%) underwent liver resection with either hemihepatectomy or extended hemihepatectomy. The E-PASS models showed a high discrimination power to predict in-hospital mortality; areas under the receiver operating characteristic curve (95% confidence intervals) were 0.85 (0.76-0.94) for E-PASS and 0.82 (0.73-0.91) for mE-PASS. The predicted mortality rates correlated with the severity of postoperative complications (Spearman's rank correlation coefficient: ρ = 0.51, P < 0.001 for E-PASS; ρ = 0.47, P < 0.001 for mE-PASS). CONCLUSIONS The E-PASS models examined herein may accurately predict postoperative morbidity and mortality in proximal biliary carcinoma resection. These models will be useful for surgical decision-making, informed consent, and risk adjustments in surgical audits.
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Evaluation of the utility of the Estimation of Physiologic Ability and Surgical Stress score for predicting post-operative morbidity after orthopaedic surgery. INTERNATIONAL ORTHOPAEDICS 2015; 39:2167-72. [DOI: 10.1007/s00264-015-2993-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 09/08/2015] [Indexed: 12/15/2022]
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Abe H, Mafune KI, Minamimura K, Hirata T. Validation of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) score for maintenance hemodialysis patients undergoing elective abdominal surgery. Dig Surg 2014; 31:269-75. [PMID: 25322745 DOI: 10.1159/000365293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 06/15/2014] [Indexed: 12/10/2022]
Abstract
AIMS This study assessed the validity of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) score in maintenance hemodialysis patients undergoing elective abdominal surgery. METHODS We retrospectively reviewed the medical records of 73 hemodialysis patients who underwent elective gastrointestinal surgery. The main outcomes analyzed were the E-PASS score and postoperative course, which were defined by mortality and morbidity. The discriminative capability of the E-PASS score was evaluated using receiver operating characteristic (ROC) curve analysis. RESULTS The overall mortality rate observed was 2.7% (2 patients) and the morbidity rate was 36.9%. There were no significant differences in the comprehensive risk score, preoperative score or surgical stress score for patients with or without complications (p = 0.556, 0.639 and 0.168, respectively). Subsequent ROC curve analysis demonstrated poor predictive accuracy for morbidity. When the results in our study population were compared with those in Haga's study population, our population exhibited a highly significant rightward shift (p < 0.001). CONCLUSION The E-PASS score was a poor predictor of complications because maintenance hemodialysis patients already have relatively high risk factors. This scoring system should not be applied in such a special group with high risk factors.
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Affiliation(s)
- Hayato Abe
- Division of Gastrointestinal Surgery, Mitsui Memorial Hospital, Tokyo, Japan
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Hirose J, Taniwaki T, Fujimoto T, Okada T, Nakamura T, Okamoto N, Usuku K, Mizuta H. Predictive value of E-PASS and POSSUM systems for postoperative risk assessment of spinal surgery. J Neurosurg Spine 2014; 20:75-82. [DOI: 10.3171/2013.9.spine12671] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Object
The Estimation of Physiological Ability and Surgical Stress (E-PASS) and Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) systems are surgical risk scoring systems that take into account both the patient's preoperative condition and intraoperative variables. While they predict postoperative morbidity and mortality rates for several types of surgery, spinal surgeries are currently not included. The authors assessed the usefulness of E-PASS and POSSUM algorithms and compared the predictive ability of both systems in patients with spinal disorders considered for surgery.
Methods
The E-PASS system includes a preoperative risk score, a surgical stress score, and a comprehensive risk score that is determined by both the preoperative risk score and surgical stress score. The POSSUM system is composed of a physiological score and an operative severity score; its total score is based on both the physiological score and operative severity score. The authors calculated the E-PASS and POSSUM scores for 601 consecutive patients who had undergone spinal surgery and investigated the relationship between the individual scores of both systems and the incidence of postoperative complications. They also assessed the correctness of the predicted morbidity rate of both systems.
Results
Postoperative complications developed in 64 patients (10.6%); there were no in-hospital deaths. All EPASS scores (p ≤ 0.001) and the operative severity score and total score of the POSSUM (p < 0.03) were significantly higher in patients with postoperative complications than in those without postoperative complications. The morbidity rates correlated linearly and significantly with all E-PASS scores (p ≤ 0.001); their coefficients (preoperative risk score, ρ = 0.179; surgical stress score, ρ = 0.131; and comprehensive risk score, ρ = 0.198) were higher than those for the POSSUM scores (physiological score, ρ = 0.059; operative severity score, ρ = 0.111; and total score, ρ = 0.091). The area under the receiver operating characteristic curve for the predicted morbidity rate was 0.668 for the E-PASS and 0.588 for the POSSUM system.
Conclusions
As E-PASS predicted morbidity more correctly than POSSUM, it is useful for estimating the postoperative risk of patients considered for spinal surgery.
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Affiliation(s)
- Jun Hirose
- 1Departments of Orthopaedic Surgery and
- 2Medical Information Science and Administration Planning, Kumamoto University Hospital, Kumamoto, Japan
| | | | | | | | | | | | - Koichiro Usuku
- 2Medical Information Science and Administration Planning, Kumamoto University Hospital, Kumamoto, Japan
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Abstract
STUDY DESIGN A single-center retrospective cohort study. OBJECTIVE To evaluate the ability of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) system to predict postoperative risk in patients scheduled for spinal surgery. SUMMARY OF BACKGROUND DATA The E-PASS system is a surgical audit to predict postoperative morbidity and mortality in general surgery. It is currently not applied in patients with spinal disorders. METHODS The E-PASS system is comprised of a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS). The latter reflects both the PRS and SSS. We calculated the E-PASS scores for 275 consecutive patients who underwent spinal surgery and evaluated the relationship between the incidence of postoperative complications and each score of the E-PASS system and their ability to predict postoperative morbidity. RESULTS Postoperative complications developed in 31 patients (11.3%). All E-PASS scores were significantly higher in patients with postoperative complications and they were linearly correlated with the overall incidence of postoperative complications. In particular, PRS was correlated with complications at nonsurgical sites and SSS with surgical site complications. The area under the receiver operating characteristic curve (AUC) for PRS and SSS was higher in patients with complications at nonsurgical and surgical sites, respectively. The AUC for CRS exhibited good predictive power for both types of complication. CONCLUSIONS The E-PASS system correctly predicted morbidity. The predictive ability of CRS was good for overall morbidity. The E-PASS system is useful for the accurate prediction of the risk for in-hospital morbidity in individual patients scheduled for spinal surgery.
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Development and validation of the Calculation of post-Operative Risk in Emergency Surgery (CORES) model. Surg Today 2013; 44:1443-56. [PMID: 23996132 DOI: 10.1007/s00595-013-0707-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 07/19/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE This study was undertaken to establish a model to predict the post-operative mortality for emergency surgeries. METHODS A regression model was constructed to predict in-hospital mortality using data from a cohort of 479 cases of emergency surgery performed in a Japanese referral hospital. The discrimination power of the current model termed the Calculation of post-Operative Risk in Emergency Surgery (CORES), and Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) were validated using the area under the receiver operating characteristic curve (AUC) in another cohort of 494 cases in the same hospital (validation subset). We further evaluated the accuracy of the CORES in a cohort of 1,471 cases in six hospitals (multicenter subset). RESULTS CORES requires only five preoperative variables, while the P-POSSUM requires 20 variables. In the validation subset, the CORES model had a similar discrimination power as the P-POSSUM for detecting in-hospital mortality (AUC, 95 % CI for CORES: 0.86, 0.80-0.93; for P-POSSUM: 0.88, 0.82-0.93). The predicted mortality rates of the CORES model significantly correlated with the severity of the post-operative complications. The subsequent multicenter study also demonstrated that the CORES model exhibited a high AUC value (0.85: 0.81-0.89) and a significant correlation with the post-operative morbidity. CONCLUSIONS This model for emergency surgery, the CORES, demonstrated a similar discriminatory power to the P-POSSUM in predicting post-operative mortality. However, the CORES model has a substantial advantage over the P-POSSUM in that it utilizes far fewer variables.
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Vandy FC, Campbell D, Eliassen A, Rectenwald J, Eliason JL, Criado E, Escobar G, Upchurch GR. Specialized vascular floors after open aortic surgery: cost containment while preserving quality outcomes. Ann Vasc Surg 2013; 27:45-52. [PMID: 23257073 DOI: 10.1016/j.avsg.2012.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 09/01/2012] [Accepted: 09/07/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Postoperative care of open abdominal aortic surgery (OAAS) traditionally involves the intensive care unit (ICU). We hypothesized that in patients without an indication for postoperative ICU admission, admission to a specialized vascular floor unit (hemodynamic monitoring, 2:1 nursing) offers cost savings to both payer and institution without compromising care. METHODS The electronic medical record was used to collect perioperative data for patients who underwent OAAS between July 2007 and July 2011. The university's cost accounting system provided information on revenue, total margin, and professional billing. Patients with ICU indications (spinal drain, Swan-Ganz monitoring, vasopressors, intubation, or blood product resuscitation) were excluded. Comparative cost and outcome analysis was performed on vascular ward and ICU admissions using the Fisher's exact test for dichotomous categorical variables and the Student's t-test for continuous variables. Long-term survival comparison was calculated using Kaplan-Meier survival estimates. RESULTS One hundred thirty of 215 patients were included for analysis (85 excluded, 51 floor, 79 ICU). Perioperative data amongst the floor and ICU cohorts were similar. Day of operation professional billing fees were comparable (ICU $13,365 vs. floor $12,626; P = 0.18); however, postoperative professional fees were significantly higher in the ICU cohort (ICU $3,258 vs. floor $2,101; P = 0.001) primarily because of intensivist billing. The hospital generated an average of 8.7% more revenue from the ICU cohort (ICU $37,770 vs. floor $34,756; P = 0.023). This was offset by greater expenses in the ICU cohort (ICU $30,756 vs. floor $25,144; P = 0.02), yielding a hospital profit margin of 107.5% favoring floor admission (ICU $2,858 vs. floor $5,931; P = 0.19). Duration of stay was similar (ICU 8.0 days vs. floor 7.8 days; P = 0.86). Kaplan-Meier survival analysis was not significantly different between cohorts (ICU 10.1%, median follow-up, 1,070 days vs. floor 0%, median follow-up, 405 days; P = 0.13). CONCLUSIONS Postoperative admission to the ICU is not always necessary after OAAS. Specialized vascular floors offer a financial savings to both payer and institution, which allows for simultaneous cost containment while preserving quality outcomes.
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Affiliation(s)
- Frank C Vandy
- University of Michigan Cardiovascular Center, Ann Arbor, MI, USA
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Griffin KJ, Fleming SJ, Bailey MA, Czoski-Murray C, Baxter PD. Target setting for elective infra-renal AAA surgery: A single mortality figure? Surgeon 2013; 11:191-8. [PMID: 23290747 DOI: 10.1016/j.surge.2012.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 12/03/2012] [Accepted: 12/07/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES One of the key standards set by the UK NAAASP is that centres performing elective abdominal aortic aneurysm (AAA) repair have a mortality rate of <6%. In light of this, and the current aim to reduce elective AAA repair mortality to 3.5% by 2013, we sought to investigate the statistical validity of such targets. METHODS The National Vascular Database (NVD) was interrogated and the degree of AAA missing data and its geographical variation is described. Utilising published data from 2006 to 2008 a funnel plot was used to illustrate NHS Trust level data for current estimates of mortality rate. A binomial distribution model was applied to calculate variation in observed mortality rates in relation to number of patients treated, based on a "true" mortality rate of 3.5%. Funnel plots were constructed using simulated data-sets for units performing 10, 30, 50, 100 or 150 procedures annually with control-limits calculated using a cumulative probability distribution. Finally the effect of case-mix on mortality was modelled and shown graphically. RESULTS The NVD AAA data set shows a range of data missingness across variables (median 22%, IQR 10-64%). High levels of missingness typically coincide with non-required, non-preferred variables however this is subject to geographical variation. Funnel plots of simulated data demonstrate that smaller units have greater variability in 3-year mortality (range 0.0-10.0%) than the largest units performing 150 procedures annually (1.3-5.6%). Around 20% of NVD variables are described as "preferred", these typically relate to clinical measurements and patient medications and would inform any risk model of mortality. Data missingness amongst these variables ranges from 5 to 50%. CONCLUSIONS There are many problems with the use of a single mortality figure to assess performance. These include the natural statistical variability and the means by which "case-mix" is taken into consideration. This article calls for further research into mortality target setting and suggests strategies which may help provide solutions nationally and facilitate international comparison.
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Affiliation(s)
- Kathryn J Griffin
- Leeds Vascular Institute, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK.
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Bryce G, Payne C, Gibson S, Kingsmore D, Byrne D, Delles C. Risk Stratification Scores in Elective Open Abdominal Aortic Aneurysm Repair: Are They Suitable for Preoperative Decision Making? Eur J Vasc Endovasc Surg 2012; 44:55-61. [DOI: 10.1016/j.ejvs.2012.03.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Accepted: 03/26/2012] [Indexed: 10/28/2022]
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Haga Y, Ikejiri K, Takeuchi H, Ikenaga M, Wada Y. Value of general surgical risk models for predicting postoperative liver failure and mortality following liver surgery. J Surg Oncol 2012; 106:898-904. [PMID: 22605669 DOI: 10.1002/jso.23160] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Accepted: 04/25/2012] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND OBJECTIVES This study evaluated the ability of general surgical models to predict postoperative morbidity and mortality in liver surgery. METHODS The postoperative course and mortality rates predicted by general surgical models were investigated in 960 patients who underwent hepatectomy or ablation therapy for primary or metastatic liver carcinoma. RESULTS The area under the receiver operative characteristic curve (95% confidence intervals) for detecting postoperative liver failure was 0.89 (0.84-0.94), 0.85 (0.78-0.92), and 0.78 (0.72-0.85) for the estimation of physiologic ability and surgical stress (E-PASS) model, the modified E-PASS (mE-PASS) model, and the Portsmouth Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) model, respectively, and those for detecting in-hospital mortality were 0.85 (0.76-0.93), 0.85 (0.78-0.92), and 0.79 (0.71-0.87), respectively. Nevertheless, all of the models overpredicted the overall mortality rate (by 2.3-fold for E-PASS, 2.3-fold for mE-PASS, and 2.9-fold for P-POSSUM). CONCLUSIONS The general surgical risk models demonstrated high discriminatory power for predicting postoperative outcomes in liver surgery, but overpredicted the overall mortality rate by more than twofold. Therefore, these models should be refined to make them more suitable for predicting liver surgery outcomes.
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Affiliation(s)
- Yoshio Haga
- Institute for Clinical Research, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan.
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Evaluation of modified Estimation of Physiologic Ability and Surgical Stress in gastric carcinoma surgery. Gastric Cancer 2012; 15:7-14. [PMID: 21538017 DOI: 10.1007/s10120-011-0052-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 03/17/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND We recently modified our prediction scoring system "Estimation of Physiologic Ability and Surgical Stress" and have designated the current version mE-PASS. This scoring system has been designed to obtain predicted postoperative mortality rates before surgery and this study was performed to assess its usefulness in elective surgery for gastric carcinoma. METHODS We investigated seven variables for mE-PASS and evaluated the postoperative course in 3,449 patients who underwent elective surgery for gastric carcinoma in Japan between August 20, 1987 and April 9, 2007, in order to quantify the predicted in-hospital mortality rates (R). The calibration and discrimination power of R were assessed using the Hosmer-Lemeshow test and the area under the receiver operating characteristic curve (AUC), respectively. The ratios of observed-to-estimated mortality rates (OE ratios) were quantified as a measure of quality. RESULTS The overall postoperative morbidity and mortality rates were 19.0 and 2.0%, respectively. R demonstrated good power in calibration (χ(2) value, 12.5; df 8; P = 0.89) as well as discrimination (AUC, 95% confidence intervals: 0.80, 0.75-0.85). The OE ratios between hospitals ranged from 0.44 to 1.8. Overall, the OE ratios seemed to improve with time (OE ratio, 95% confidence intervals: 1.3, 0.73-2.4 for the early period between 1987 and 2000; 1.0, 0.59-1.7 for the middle period between 2001 and 2004; and 0.65, 0.36-1.2 for the late period between 2005 and 2007). CONCLUSION Based on these findings, mE-PASS might be useful for medical decision-making and for assessing the quality of care in elective surgery for gastric carcinoma.
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Abstract
BACKGROUND Anastomotic leak (AL) is a dangerous postoperative complication in gastrointestinal surgery. The present study focuses on whether our prediction scoring system, "Estimation of Physiologic Ability and Surgical Stress" (E-PASS), could predict occurrence of AL and its prognosis in various kinds of gastrointestinal surgical procedures. METHODS We prospectively investigated parameters of E-PASS, absence or presence of AL, and in-hospital mortality in 6,005 patients who underwent elective digestive surgery with alimentary tract reconstruction in 45 acute care hospitals in Japan between 1 April 2002 and 31 March 2007. RESULTS Incidences of AL were 19.6% for esophagectomy via right thoracotomy and laparotomy, 11.7% for pancreaticoduodenectomy, 7.4% for low anterior resection, 4.0% for total gastrectomy, 1.8% for open distal gastrectomy, 1.3% for open colectomy, for an overall incidence of 4.1%. The incidence in each procedure significantly correlated with median value of surgical stress score of the E-PASS (R = 0.78, n = 11, p = 0.0048). The incidences of AL increased when Total Risk Points (TRP) of the E-PASS increased; 1.1% at the TRP range of <500, 2.8% at 500 to <1,000, 4.8% at 1,000 to <1,500, and 13.6% at ≥ 1,500 (p < 0.0001). In patients who suffered from AL, an in-hospital mortality rate at TRP < 1,000 was significantly lower than that at TRP of ≥ 1,000 (1.1 vs. 15.9%; p = 0.00019). CONCLUSIONS The E-PASS, requiring only nine variables, may be useful in predicting AL and its prognosis.
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Estimation of physiologic ability and surgical stress score does not predict immediate outcome after pancreatic surgery. Pancreas 2011; 40:723-9. [PMID: 21654545 DOI: 10.1097/mpa.0b013e318212c02c] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The Estimation of Physiologic Ability and Surgical Stress score was designed to predict postoperative morbidity and mortality in general surgery. Our study aims to evaluate its use and accuracy in estimating postoperative outcome after elective pancreatic surgery. METHODS Between 2002 and 2007, approximately 304 patients requiring pancreatic resection at our institution were recorded prospectively and evaluated retrospectively. The patients' preoperative risk score, surgical stress score (SSS), and comprehensive risk score (CRS) were calculated and compared with the severity of postoperative morbidity, where mortality was regarded as the most severe postoperative complication. RESULTS Observed and predicted mortality rates were 2.9% and 2.0%, respectively. Mean CRS was higher in patients who died than in patients that survived, but this difference was not statistically significant (P = 0.20). Preoperative risk score, SSS, and CRS did not differ between patients with and without complications (preoperative risk score: P = 0.32; SSS: P = 0.22; CRS: P = 0.13). Estimation of Physiologic Ability and Surgical Stress particularly underpredicted morbidity in patients with a CRS between 0.0 and less than 0.5. CONCLUSIONS The Estimation of Physiologic Ability and Surgical Stress scoring system is an ineffective predictor of complications after pancreatic resection. Further refinements to the score calculation are warranted to provide accurate prediction of immediate surgical outcome after pancreatic surgery.
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Evaluation of estimation of physiologic ability and surgical stress to predict in-hospital mortality in cardiac surgery. J Anesth 2011; 25:481-91. [PMID: 21560027 DOI: 10.1007/s00540-011-1162-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 04/22/2011] [Indexed: 12/14/2022]
Abstract
PURPOSE Prediction of postoperative risk in cardiac surgery is important for cardiac surgeons and anesthesiologists. We generated a prediction rule for elective digestive surgery, designated as Estimation of Physiologic Ability and Surgical Stress (E-PASS). This study was undertaken to evaluate the accuracy of E-PASS in predicting postoperative risk in cardiac surgery. METHODS We retrospectively collected data from patients who underwent elective cardiac surgery at a low-volume center (N = 291) and at a high-volume center (N = 784). Data were collected based on the variables required by E-PASS, the European system for cardiac operative risk evaluation (EuroSCORE), and the Ontario Province Risk Score (OPRS). Calibration and discrimination were assessed by the Hosmer-Lemeshow test and the area under the receiver operating characteristic curve (AUC), respectively. The ratio of observed-to-estimated in-hospital mortality rates (OE ratio) was defined as a measure of quality. RESULTS In-hospital mortality rates were 7.6% at the low-volume center and 1.3% at the high-volume center, accounting for an overall mortality rate of 3.0%. AUC values to detect in-hospital mortality were 0.88 for E-PASS, 0.77 for EuroSCORE, and 0.71 for OPRS. Hosmer-Lemeshow analysis showed a good calibration in all models (P = 0.81 for E-PASS, P = 0.49 for EuroSCORE, and P = 0.94 for OPRS). OE ratios for the low-volume center were 0.83 for E-PASS, 0.70 for EuroSCORE, and 0.83 for OPRS, whereas those for the high-volume center were 0.26 for E-PASS, 0.14 for EuroSCORE, and 0.27 for OPRS. CONCLUSIONS E-PASS may accurately predict postoperative risk in cardiac surgery. Because the variables are different between cardiac-specific models and E-PASS, patients' risks can be double-checked by cardiac surgeons using cardiac-specific models and by anesthesiologists using E-PASS.
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Menezes FH, Gomes de Souza VM. Physiologic component of the estimation of physiologic ability and surgical stress scoring system as a predictor of immediate outcome after elective open abdominal aortic aneurysm repair. Ann Vasc Surg 2011; 25:485-95. [PMID: 21549917 DOI: 10.1016/j.avsg.2010.12.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 10/27/2010] [Accepted: 12/09/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Previous studies have shown a good predictive power of the risk scoring method, Estimation of Physiologic Ability and Surgical Stress, in predicting mortality after open elective aortic aneurysm repair. The aim of the present study was to evaluate the physiologic component of this method to assess mortality risk in a different geographic population from previously published reports. METHODS Operative, morbidity and mortality data were collected retrospectively from charts of patients submitted to elective open repair of an abdominal aortic aneurysm over an 8-year period. There were 214 patients, the median age was 70 (range: 48-91) years; 179 (83.6%) patients were men. The Preoperative Physiologic Risk Score (PRS), Surgical Stress Score, and Comprehensive Risk Score (CRS) values were categorized and compared with morbidity and mortality rates. RESULTS There were 27 deaths (12.6%), and 81 (37.9%) patients experienced a postoperative complication that required medical intervention. There was a significant statistical difference for the values of PRS and CRS for patients who survived (0.53/0.63, respectively) and for those who died (0.88/1.02, respectively), p < 0.0001 for both values. There is a strong correlation between PRS and CRS values and development of complications (p < 0.0001). Surgical Stress Score did not correlate as strongly to development of complications (p = 0.0028). For PRS, the area under the receiver-operator characteristic curve was 0.844 (95% confidence interval: 0.747-0.941) for mortality and 0.725 (95% confidence interval: 0.650-0.799) for morbidity. For CRS, the area under the curve was 0.812 (95% confidence interval: 0.734-0.891) for mortality and 0.719 (95% confidence interval: 0.645-0.792) for morbidity. There was also a significant positive correlation between length of hospital stay and PRS and CRS scores (p < 0.0001). In this study, it was found that renal impairment has a significant positive correlation with mortality (p = 0.0008), with an odds ratio of 4.3. In a multivariate regression analysis, renal impairment failed to increase the accuracy of the model when associated with the other parameters considered in PRS. CONCLUSION This study corroborates with the previous findings that the Estimation of Physiologic Ability and Surgical Stress model seems to be a promising method of predicting death and postoperative complications in patients undergoing open abdominal aortic aneurysm repair.
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Affiliation(s)
- Fábio Hüsemann Menezes
- Division of Vascular Surgery, Department of Surgery, University of Campinas, Campinas, SP Brazil.
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Grant SW, Grayson AD, Purkayastha D, Wilson SD, McCollum C, participants in the Vascular Governance North West Programme. Logistic risk model for mortality following elective abdominal aortic aneurysm repair. Br J Surg 2011; 98:652-8. [PMID: 21412997 DOI: 10.1002/bjs.7463] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Collaborators] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim was to develop a multivariable risk prediction model for 30-day mortality following elective abdominal aortic aneurysm (AAA) repair. METHODS Data collected prospectively on 2765 consecutive patients undergoing elective open and endovascular AAA repair from September 1999 to October 2009 in the North West of England were split randomly into development (1936 patients) and validation (829) data sets. Logistic regression analysis was undertaken to identify risk factors for 30-day mortality. RESULTS Ninety-eight deaths (5·1 per cent) were recorded in the development data set. Variables associated with 30-day mortality included: increasing age (P = 0·005), female sex (P = 0·002), diabetes (P = 0·029), raised serum creatinine level (P = 0·006), respiratory disease (P = 0·031), antiplatelet medication (P < 0·001) and open surgery (P = 0·002). The area under the receiver operating characteristic (ROC) curve for predicted probability of 30-day mortality in the development and validation data sets was 0·73 and 0·70 respectively. Observed versus expected 30-day mortality was 3·2 versus 2·0 per cent (P = 0·272) in low-risk, 6·1 versus 5·1 per cent (P = 0·671) in medium-risk and 11·1 versus 10·7 per cent (P = 0·879) in high-risk patients. CONCLUSION This multivariable model for predicting 30-day mortality following elective AAA repair can be used clinically to calculate patient-specific risk and is useful for case-mix adjustment. The model predicted well across all risk groups in the validation data set.
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Affiliation(s)
- S W Grant
- University of Manchester, Manchester Academic Health Science Centre, University Hospital of South Manchester, Academic Surgery Unit, Education and Research Centre, Manchester, UK
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Collaborators
A Woodyer, C Pratap, L Wlowczyk, S Hardy, R Salaman, G Ferguson, M Onwudike, H Al-Khaffaf, A Rahi, J Mosley, M Jameel, J Abraham, P Wilson, M Bukhari, J Calvey, M Tomlinson, T Oshodi, M Hadfield, N Hulton, G Thomson, P Moody, T Nicholas, P Wake, D Olojugba, M Greaney, A Blair, R Chandrasekar, C Chan, A Chaudhuri, J Joseph, F Torella, O Klimach, M Hanafy, J V Smyth, F Serracino-Inglott, G Williams, M Madan, W Tait, C McCollum, M Baguneid, M Welch, D Jones, F Mason, U Kirkpatrick, L de Cossart, P Edwards, S Dimitri,
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Abstract
OBJECTIVE This study was undertaken to evaluate a modified form of Estimation of Physiologic Ability and Surgical Stress (E-PASS) for surgical audit comparing with other existing models. BACKGROUND Although several scoring systems have been devised for surgical audit, no nation-wide survey has been performed yet. METHODS We modified our previous E-PASS surgical audit system by computing the weights of 41 procedures, using data from 4925 patients who underwent elective digestive surgery, designated it as mE-PASS. Subsequently, a prospective cohort study was conducted in 43 national hospitals in Japan from April 1, 2005, to April 8, 2007. Variables for the E-PASS and American Society of Anesthesiologists (ASA) status-based model were collected for 5272 surgically treated patients. Of the 5272 patients, we also collected data for the Portsmouth modification of Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in 3128 patients. The area under the receiver operative characteristic curve (AUC) was used to evaluate discrimination performance to detect in-hospital mortality. The ratio of observed to estimated in-hospital mortality rates (OE ratio) was defined as a measure of quality. RESULTS The numbers of variables required were 10 for E-PASS, 7 for mE-PASS, 20 for P-POSSUM, and 4 for the ASA status-based model. The AUC (95% confidence interval) values were 0.86 (0.79-0.93) for E-PASS, 0.86 (0.79-0.92) for mE-PASS, 0.81 (0.75-0.88) for P-POSSUM, and 0.73 (0.63-0.83) for the ASA status-based model. The OE ratios for mE-PASS among large-volume hospitals significantly correlated with those for E-PASS (R = 0.93, N = 9, P = 0.00026), P-POSSUM (R = 0.96, N = 6, P = 0.0021), and ASA status-based model (R = 0.83, N = 9, P = 0.0051). CONCLUSION Because of its features of easy use, accuracy, and generalizability, mE-PASS is a candidate for a nation-wide survey.
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Moll FL, Powell JT, Fraedrich G, Verzini F, Haulon S, Waltham M, van Herwaarden JA, Holt PJE, van Keulen JW, Rantner B, Schlösser FJV, Setacci F, Ricco JB. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011; 41 Suppl 1:S1-S58. [PMID: 21215940 DOI: 10.1016/j.ejvs.2010.09.011] [Citation(s) in RCA: 1033] [Impact Index Per Article: 73.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Accepted: 09/12/2010] [Indexed: 12/11/2022]
Affiliation(s)
- F L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, The Netherlands.
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Walker TG, Kalva SP, Yeddula K, Wicky S, Kundu S, Drescher P, d'Othee BJ, Rose SC, Cardella JF. Clinical Practice Guidelines for Endovascular Abdominal Aortic Aneurysm Repair: Written by the Standards of Practice Committee for the Society of Interventional Radiology and Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association. J Vasc Interv Radiol 2010; 21:1632-55. [DOI: 10.1016/j.jvir.2010.07.008] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 05/24/2010] [Accepted: 07/11/2010] [Indexed: 12/17/2022] Open
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Hashimoto D, Takamori H, Sakamoto Y, Tanaka H, Hirota M, Baba H. Can the physiologic ability and surgical stress (E-PASS) scoring system predict operative morbidity after distal pancreatectomy? Surg Today 2010; 40:632-7. [DOI: 10.1007/s00595-009-4112-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 07/15/2009] [Indexed: 02/01/2023]
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Ryan D, McGreal G. Why routine intensive care unit admission after elective open infrarenal Abdominal Aortic Aneurysm repair is no longer an evidence based practice. Surgeon 2010; 8:297-302. [PMID: 20950766 DOI: 10.1016/j.surge.2010.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Accepted: 05/08/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Elective open infrarenal Abdominal Aortic Aneurysm (AAA) repair is major surgery performed on high-risk patients. Routine ICU admission postoperatively is the current accepted standard of care. Few of these patients actually require a level of care that cannot be provided just as effectively in a surgical high dependency unit (HDU). Our aim was to determine, 'can high risk patients that will require ICU admission postoperatively be reliably identified preoperatively?'. METHODS A retrospective analysis of all elective open infrarenal AAA repairs in our institution over a 3-year period was performed. The Estimation of Physiological Ability and Surgical Stress (E-PASS) model was used as our risk stratification tool for predicting post-operative morbidity. Renal function was also considered as a predictor of outcome, independent of the E-PASS. RESULTS 80% (n = 16) were admitted to ICU. Only 30% (n = 6) of the total study population necessitated intensive care. There were 9 complications in 7 patients in our study. The E-PASS comprehensive risk score (CRS)/Surgical stress score (SSS) were found to be significantly associated with the presence of a complication (p = 0.009)/(p = 0.032) respectively. Serum creatinine (p = 0.013) was similarly significantly associated with the presence of a complication. CONCLUSIONS The E-PASS model possessing increasing external validity is an effective risk stratification tool in safely deciding the appropriate level of post-operative care for elective infrarenal AAA repairs.
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Affiliation(s)
- David Ryan
- Department of Vascular Surgery, Mercy University Hospital, Cork, Ireland.
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Muehling B, Schelzig H, Steffen P, Meierhenrich R, Sunder-Plassmann L, Orend KH. A prospective randomized trial comparing traditional and fast-track patient care in elective open infrarenal aneurysm repair. World J Surg 2010; 33:577-85. [PMID: 19137363 DOI: 10.1007/s00268-008-9892-2] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Fast-track recovery programs have led to reduced patient morbidity and mortality after major surgery. In terms of elective open infrarenal aneurysm repair, no evidence is available about such programs. To address this issue, we have conducted a randomized prospective pilot study. METHODS The study involved prospective randomization of 101 patients with the indication for elective open aneurysm repair in a traditional and a fast-track treatment arm. The basic fast-track elements were no bowel preparation, reduced preoperative fasting, patient-controlled epidural analgesia (PCEA), enhanced postoperative feeding, and postoperative mobilization. Morbidity and mortality, need for postoperative mechanical ventilation, length of stay (LOS) in the intensive care unit (ICU) and total length of postoperative hospital stay were analyzed in terms of an intention to treat. RESULTS Demographic data for the two groups were similar. In the fast-track group the need for postoperative ventilation was significantly lower (6.1% versus 32%; p = 0.002), the median LOS on ICU did not significantly differ (20 h versus 32 h; p = 0.183), full enteral feeding was achieved significantly earlier (5 versus 7 days; p < 0.0001), and the rate of postoperative medical complications-gastrointestinal, cardiac, pulmonary, renal, and infective-was significantly lower (16% versus 36%; p = 0.039). The postoperative hospital stay was significantly shorter in the fast-track group (10 days versus 11 days; p = 0.016); the mortality rate in both groups was 0%. CONCLUSIONS An optimized patient care program in open infrarenal aortic aneurysm repair shows favorable results concerning need for postoperative assisted mechanical ventilation, time to full enteral feeding, and incidence of medical complications. Further ranomized multicentric trials are necessary to justify broad implementation (clinical trials. gov identifier NCT 00615888).
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Affiliation(s)
- Bernd Muehling
- Department of Thoracic and Vascular Surgery, University of Ulm, Steinhövelstrasse 9, 89075 Ulm, Germany.
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Hattori H, Kamiya J, Shimada H, Akiyama H, Yasui A, Kuroiwa K, Oda K, Ando M, Kawamura T, Harada A, Kitagawa Y, Fukata S. Assessment of the risk of postoperative delirium in elderly patients using E-PASS and the NEECHAM Confusion Scale. Int J Geriatr Psychiatry 2009; 24:1304-10. [PMID: 19319925 DOI: 10.1002/gps.2262] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The incidences of surgery-field disorders such as femur neck fracture and colorectal cancer in elderly persons have increased with the rapid aging of society. In such patients, postoperative delirium is also frequent. Patients should be generally assessed from the aspect of both physical and mental conditions in order to predict a high-delirium risk group. If so, delirium may be prevented more efficiently. In this study, we investigated whether the early detection of postoperative delirium in elderly patients is possible using a simple, useful behavior-assessing scale, the NEECHAM Confusion Scale, and a method for comprehensively evaluating elderly persons' stress related to surgery, E-PASS. METHODS The subjects were 160 patients aged more than 75 years who underwent surgery. Among them, three patients had vascular surgery-field disorders, 67 had orthopedic-field disorders, and 90 had digestive surgery-field disorders. To comprehensively evaluate surgery-related stress, E-PASS was employed. In addition, we assessed recognition, activities of daily living (ADL), and the quality of life (QOL). For delirium diagnosis and severity assessment, we used the NEECHAM Confusion Scale. The cut-off value of the NEECHAM score was established as 20 points, and patients showing values less than this after surgery were regarded as having postoperative delirium. Evaluation was performed until 10 days after surgery. RESULTS Postoperative delirium was noted in 54.7% of the subjects. There was a decrease in the NEECHAM score between the first and fourth postoperative days, but it gradually increased thereafter. Both uni- and multivariate analyses showed that postoperative delirium was associated with an advanced age (more than 80 years), low preoperative NEECHAM and MMSE scores, the preoperative QOL, and E-PASS. In groups showing an MMSE score of less than 25 or a preoperative NEECHAM score of less than 27, the incidence of postoperative delirium was 76%. CONCLUSION The results suggest that E-PASS and the NEECHAM score facilitate assessment of the risk of postoperative delirium in elderly patients, contributing to early prevention/treatment.
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Affiliation(s)
- Hideyuki Hattori
- Department of Psychiatry, National Center for Geriatrics and Gerontology, 36-3 Gengo, Morioka-machi, Obu City, Aichi Prefecture, Japan.
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Hashimoto D, Takamori H, Sakamoto Y, Ikuta Y, Nakahara O, Furuhashi S, Tanaka H, Watanabe M, Beppu T, Hirota M, Baba H. Is an estimation of physiologic ability and surgical stress able to predict operative morbidity after pancreaticoduodenectomy? JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:132-8. [PMID: 19430714 DOI: 10.1007/s00534-009-0116-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Accepted: 03/05/2009] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mortality rates after pancreaticoduodenectomy (PD) are below 4% in high volume centers, although morbidity rates still remain high. Therefore, it is important to clarify a predictor associated with operative morbidity after PD. The estimation of physiologic ability and surgical stress (E-PASS) score has been developed for comparative audit in general surgical patients. OBJECTIVE To evaluate whether E-PASS scoring system could predict the occurrence of complications after PD. METHODS We performed retrospective analysis of 69 patients (42.0% pancreatic cancer, 31.9% bile duct cancer, and others) who underwent PD using the E-PASS as a predictor of morbidity. Correlations between the incidence rates of postoperative complications and the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of the E-PASS scoring system were evaluated. RESULTS Of the 69 patients 30 (43.5%) experienced a total of 54 postoperative complications. All E-PASS scores, especially PRS and CRS were significantly higher in the patients with postoperative complications than in the patients without complication. The complication rate gradually increased as the PRS, SSS and CRS score increased. Under receiver operating characteristic analysis, if a cut-off point of CRS was 0.75, sensitivity and specificity for the prediction of operative morbidity after PD was 80.0 and 79.5%, respectively. Neoadjuvant chemotherapy and intraoperative radiation therapy (IORT) did not influenced on operative morbidity after PD. CONCLUSION E-PASS scoring system is useful to evaluate for morbidity after PD. Neoadjuvant chemotherapy and IORT could be adapted without significant extra risk for surgical complication.
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Affiliation(s)
- Daisuke Hashimoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, Kumamoto 860-8556, Japan
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Validation of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) Score in Liver Surgery. World J Surg 2009; 33:1259-65. [DOI: 10.1007/s00268-009-9989-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ouriel K. The PIVOTAL study: a randomized comparison of endovascular repair versus surveillance in patients with smaller abdominal aortic aneurysms. J Vasc Surg 2009; 49:266-9. [PMID: 19174266 DOI: 10.1016/j.jvs.2008.11.048] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 11/11/2008] [Accepted: 11/11/2008] [Indexed: 12/25/2022]
Abstract
The diameter of an abdominal aortic aneurysm (AAA) is the single most important factor in deciding whether to repair an aneurysm or to monitor it conservatively. Open surgical repair does not appear to be beneficial until the diameter of the aneurysm is >5.5 cm. Prospective clinical trials, however, confirmed a lower risk of operative mortality after endovascular aneurysm repair (EVAR) than after open surgical repair. Further, retrospective analyses of EVAR databases suggested that EVAR outcome is directly related to aneurysm size and is better for smaller aneurysms than for larger aneurysms. Noting similar results with open surgical management vs surveillance in patients with smaller AAA, lower morbidity rates with EVAR vs open repair, and the favorable results with EVAR in smaller aneurysms, a clinical trial testing the hypothesis that EVAR is beneficial in patients with small AAA appeared warranted. To answer this question, the 70-site Positive Impact of endoVascular Options for Treating Aneurysm earLy (PIVOTAL) was begun. PIVOTAL has an enrollment goal of up to 1025 patients with a 4- to 5-cm AAA, randomly assigning patients to EVAR or surveillance. The primary end points of PIVOTAL are aneurysm rupture and AAA-related death at up to 36 months after randomization. When complete, the results of PIVOTAL should provide objective evidence to guide the use of EVAR for small AAAs.
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Patterson BO, Holt PJE, Hinchliffe R, Loftus IM, Thompson MM. Predicting risk in elective abdominal aortic aneurysm repair: a systematic review of current evidence. Eur J Vasc Endovasc Surg 2008; 36:637-45. [PMID: 18922709 DOI: 10.1016/j.ejvs.2008.08.016] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Accepted: 08/27/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine and compare existing pre-operative risk prediction methods for elective abdominal aortic aneurysm (AAA) repair. DESIGN Systematic review. METHODS Medline, EMBASE and the Cochrane library were searched for articles that related to risk prediction models used for elective AAA repair. RESULTS 680 abstracts were reviewed and after exclusions 28 articles encompassing 10 risk models were identified. The most frequently studied of these were the Glasgow Aneurysm Score (GAS), the Physiological and Operative Severity Score for enUmeration of Mortality (POSSUM) predictor equation and the Vascular Biochemistry and Haematology Outcome Model (VBHOM). All models had strengths and weaknesses and some had unique features which were identified and discussed. CONCLUSION The GAS appeared to be the most useful and consistently validated score at present for open repair. Other systems were either not validated fully or were not consistently accurate. Some had significant drawbacks which appeared to severely limit their clinical application. Recent work has shown that no scores consistently predicted the risk associated with endovascular aneurysm repair (EVAR). Pre-operative risk stratification is a vital component of modern surgical practice, and we propose the need for a comprehensive new risk scoring method for AAA repair incorporating anatomical and physiological data.
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Affiliation(s)
- B O Patterson
- St George's Vascular Institute, St James Wing, St George's Hospital, London SW17 0QT, UK
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Prospective randomized controlled trial to evaluate “fast-track” elective open infrarenal aneurysm repair. Langenbecks Arch Surg 2008; 393:281-7. [DOI: 10.1007/s00423-008-0284-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 01/17/2008] [Indexed: 12/01/2022]
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Tang TY, Walsh SR, Fanshawe TR, Seppi V, Sadat U, Hayes PD, Varty K, Gaunt ME, Boyle JR. Comparison of risk-scoring methods in predicting the immediate outcome after elective open abdominal aortic aneurysm surgery. Eur J Vasc Endovasc Surg 2007; 34:505-13. [PMID: 17869138 DOI: 10.1016/j.ejvs.2007.07.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2007] [Accepted: 07/22/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND & OBJECTIVES The aim of this study was to apply three simple risk - scoring systems to prospectively collected data on all elective open Abdominal Aortic Aneurysm (AAA) operations in the Cambridge Academic Vascular Unit over a 6 - year period (January 1998 to January 2004), to compare their predictive values and to evaluate their validity with respect to prediction of mortality and post-operative complications. METHODS 204 patients underwent elective open infra-renal AAA repair. Data were prospectively collected and risk assessment scores were calculated for mortality and morbidity according to the Glasgow Aneurysm Score (GAS), VBHOM (Vascular Biochemistry and Haematology Outcome Models) and Estimation of Physiologic Ability and Surgical Stress (E-PASS). RESULTS The mortality rate was 6.3% (13/204) and 59% (121/204) experienced a post-operative complication (30-day outcome). For GAS, VBHOM and E-PASS the receiver operating characteristics (ROC) curve analysis for prediction of in-hospital mortality showed area under the curve (AUC) of 0.84 (95% confidence interval [CI], 0.76 to 0.92; p<0.0001), 0.82 (95% CI, 0.68 to 0.95; p=0.0001) and 0.92 (95% CI, 0.87 to 0.97; p<0.0001) respectively. There were also significant correlations between post-operative complications and length of hospital stay and each of the three scores, but the correlation was substantially higher in the case of E-PASS. CONCLUSIONS All three scoring systems accurately predicted the risk of mortality and morbidity in patients undergoing elective open AAA repair. Among these, E-PASS seemed to be the most accurate predictor in this patient population.
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Affiliation(s)
- T Y Tang
- Cambridge Vascular Unit, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
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