Modified frailty index (mFI): is it a predictor for early postoperative complications in arthroplasty surgery?

OBJECTIVE: It has been demonstrated that the modified frailty index (mFI) is a powerful and effective tool in the prediction of perioperative risk in many surgical fields. In many previous studies, mFI has been found to be successful in prediction of perioperative adverse effects. The aim of this study was to determine whether the mFI can be a predictor for early postoperative complications in arthroplasty surgery. PATIENTS AND METHODS: 145 patients aged 45-85 undergoing primary or revision total knee and hip arthroplasty were included in this prospective study. mFI was calculated in all patients, and patients included in the current study were grouped as "Frail" (n=42) and "Nonfrail" (n=103) patients according to modified frailty index values. Postoperative complications (myocardial infarction, cardiac arrest, pulmonary embolism, septic shock, postoperative dialysis requirement, cerebrovascular event, reintubation, prolonged mechanical ventilation, surgical wound complications), duration of hospitalization, requirement for intensive care unit (ICU) admission and rehospitalization and 30-day mortality were recorded and the correlation between mFI and these parameters were evaluated. RESULTS: The mean age was 67.58±9.35 years, and 72.4% of the patients were female. The percentage of frail patients in the current study was 28.9%. The percentage of ASA-1, ASA-2, and ASA-3 patients was 17.2%, 57.2%, and 25.5%, respectively. The rate of ICU admission, MI, septic shock, postoperative dialysis requirement, prolonged MV requirement, hospital readmission, and 30-day mortality were 45.2%, 14.3%, 16.7%, 16.7%, 14.3%, 11.9%, and 16.7%, respectively in the frail group and were 7.8%, 1%, 1.9%, 2.9, 1.9% and 3.9%, respectively in the nonfrail group. Advanced age, male gender, high ASA score and prolonged duration of surgery were found to be predictive factors for postoperative complications. Advanced age, high ASA score and prolonged duration of surgery were found to be predictive factors for ICU admission. Advanced age, male gender and high ASA score were found to be strong predictors of 30-day mortality. CONCLUSIONS: mFI was found to be a strong predictor for postoperative complications and mortality. It is an easy, reliable, and simple method to evaluate frailty during the preoperative period. CLINICAL TRIAL REGISTRATION NUMBER: NCT05424575.

Effects of aqueous soybean, mistletoe and red clover extracts on activities of adenosine deaminase and xanthine oxidase enzyme.

Soybean (Glycine max), mistletoe (Viscum album) and red clover (Trifolium pratence) have been argued to have anti-cancer effects. In the present study it was aimed to investigate possible effects of these plant extracts on the activities of DNA turn-over enzymes, namely adenosine deaminase (ADA) and xanthine oxidase (XO) in cancerous and non-cancerous gastric and colon tissues. For this aim, 6 cancerous and 6 non-cancerous adjacent human gastric tissues, and 7 cancerous and 7 non-cancerous adjacent colon tissues were obtained by surgical operations. Our results suggest that aqueous soybean, mistletoe and red clover extracts may exhibit anti-tumoral activity by depleting hypoxanthine concentration in the cancer cells through XO activation, which may lead to lowered salvage pathway activity necessary for the cancer cells to proliferate in the cancerous colon tissue. Some foods like soybean, mistletoe and red clover may provide nutritional support to medical cancer therapy through inhibiting and/or activating key enzymes in cancer metabolism (Tab. 4, Ref. 33).

Survival after curative resection for stage IE and IIE primary gastric lymphoma.

BACKGROUND/AIMS: There is considerable controversy regarding the optimal treatment of patients with primary gastric lymphomas. However, surgery still plays an important role in the management of stage IE and IIE gastric lymphomas. We aimed at assessing survival of primary gastric lymphoma cases with stage IE or IIE that were surgically treated at the Surgical Oncology Department. METHODOLOGY: Thirty-seven patients with stage IE and IIE primary gastric lymphoma who were surgically treated and had complete follow-up from January 1990 to September 1998 were reviewed retrospectively. Patients' age, gender, tumor location, tumor grade, histologic type, depth of tumor invasion, regional lymph node status, tumor stage, type of gastrectomy (total/subtotal), combined resection, extensive lymphadenectomy, adjuvant chemotherapy were used as the clinicopathologic variables. RESULTS: Five-year survival rates for stage IE and stage IIE disease were 75% and 37%, respectively. The overall 5-year survival rate of the patients was 57%. Univariate analysis demonstrated that age, tumor stage, and type of gastrectomy were associated with prognosis, but only type of gastrectomy (subtotal gastrectomy) and tumor stage were found to be independent prognostic factors (P < 0.05). CONCLUSIONS: To obtain prolonged survival we recommend radical resection with extensive lymphadenectomy for malignant lymphoma stages IE and IIE. Patients with small distal lymphomas of the stomach can be treated with subtotal gastric resection.

Activities of adenosine deaminase and 5'-nucleotidase in cancerous and noncancerous human colorectal tissues.

In order to characterize human colorectal cancer, much attention has been paid to enzyme studies. However, little is known about the correlation between the levels of key enzymes of purine nucleotide pathway and some clinical and biological indicators of tumor invasiveness and aggressiveness. Adenosine deaminase (ADA) and 5'-nucleotidase (5'-NT) were measured in cancerous and cancer-free adjacent large bowel tissues from 38 patients with colorectal carcinoma. We have analyzed the relationship between the enzyme levels and some clinical and pathological parameters. The enzymes' activities were markedly higher in primary tumors than in corresponding normal mucosae. The ADA level in tumor tissue was significantly correlated with lymph node metastasis, histologic type, tumor location, and patient's age, whereas the 5'-NT level showed a significant correlation with tumor grade and tumor location. ADA activity in tumor tissues was significantly higher in patients whose clinical course remained stable than in those with recurrent diseases. The purine metabolism and salvage pathway activity of purine nucleotides are accelerated in the cancerous human colorectal tissue. Although our findings suggest that these enzymes' activities are most likely related to the same histomorphological architecture of the tumor, the authors believe that long-term follow-up studies are needed to evaluate the prognostic value of purine enzymes for colorectal cancer.

Isolated limb perfusion with cisplatin and doxorubicin for locally advanced soft tissue sarcoma of an extremity.

AIMS: To identify independent adverse clinico-pathological factors for disease-free and overall survival in patients undergoing isolated limb perfusion (ILP) with cisplatin and doxorubicin for locally advanced soft tissue sarcoma (STS) of an extremity. METHODS: A retrospective analysis was carried out, using a univariate method and a multivariate analysis, to look at the patient, tumour and treatment associated with prognostic factors in 37 patients with locally advanced STSs of the limbs who underwent ILP with cisplatin and doxorubicin. Patient's age, gender, presenting status, tumour location, tumour grade, tumour stage according to TNM classification, tumour size and radiotherapy (RT) were analysed. Survival curves were calculated according to the Kaplan-Meier method. A Cox proportional hazard model was used to indicate which factors related to overall survival and the recurrence-free interval after ILP. RESULTS: No major systemic toxicity was seen. Regional toxicity was limited. Limb salvage was achieved in 94.6% of the patients. The estimated 5-year overall and disease-free survival rates were 62% and 54%, respectively. It was found that tumour stage, tumour grade, presenting status, RT and tumour size were associated with cumulative overall survival when the Kaplan-Meier method was applied (P<0.05). By Cox proportional hazards model, only tumour grade (P=0. 0254) was found to have significant influence on overall survival; however, tumour stage (P=0.0157) and RT (P=0.0014) were related to disease-free survival. CONCLUSIONS: ILP and delayed excision followed by RT achieves good limb salvage rates and may improve survival.

Retroperitoneal soft tissue sarcoma: effect of hyperthermic total abdominal perfusion.

AIMS AND BACKGROUND: Soft tissue sarcomas (STS) of the retroperitoneum are rare tumors. Surgery remains the principal modality of therapy in the management of primary and recurrent retroperitoneal STS. However, little is known about the effect of regional chemotherapy using hyperthermic total abdominal perfusion (HTAP). We analyzed independent prognostic variables in 33 patients with STS in the retroperitoneum admitted from November 1990 through December 1996. METHODS AND STUDY DESIGN: Data regarding patients' age, gender, tumor size, histological tumor type, tumor location, type of operation (primary or secondary surgery), extent of surgical management (marginal or extended), use of HTAP, tumor grade, and tumor stage according to the TNM classification were examined by univariate and multivariate analyses. RESULTS: All 33 patients underwent complete resections (marginal or extended). Eleven of them received locoregional chemotherapy by HTAP. The overall cumulative 5-year survival rates in patients with stage IIA and advanced disease were 82% and 22%, respectively (log-rank test, P<0.01). Using Cox's proportional hazard model, tumor stage, use of HTAP and type of operation were found to have significant influence on overall survival (P<0.05). CONCLUSIONS: Our results showed that complete resection along with HTAP chemotherapy may improve survival in patients with retroperitoneal STS. These phase II data could be used to support the initiation of a phase III trial to test HTAP in patients submitted to complete resection of retroperitoneal STS.

Serum concentrations of vascular endothelial growth factor and nitrite as an estimate of in vivo nitric oxide in patients with gastric cancer.

The importance of tumour angiogenesis in the process of tumour growth and progression in solid tumours has been widely accepted. Among many angiogenic factors, vascular endothelial growth factor (VEGF) has been shown to play a major role in the development and dissemination of the malignant tumours. Nitric oxide (NO) production was also observed in solid tumour tissues. NO has been reported to play an important role for the mitogenic effect of VEGF in the angiogenic process. However, little is known about the correlation between VEGF and NO in circulating levels. Therefore, we investigated serum VEGF and NO concentrations in human gastric cancers as well as healthy individuals, and examined the influence of tumour stage on circulating level of VEGF. The study consisted of 11 healthy individuals and 37 patients with primary gastric cancer who did not receive any prior therapy. Patients were categorized into four groups according to TNM classification. The level of VEGF165 in preoperative sera of gastric cancer patients and healthy donors was assayed using the quantitative sandwich enzyme immunoassay technique. NO concentration was estimated indirectly from serum nitrite. The ANOVA test showed a significant difference in serum VEGF165 concentrations between tumour stages (P < 0.001). A striking relationship was found between serum NO levels and tumour stage (P < 0.001). A significant difference was also seen between healthy individuals and patients with stage 1 disease. The present study suggested that large tumour burden was associated with significantly increased levels of VEGF165 and NO.

Primary hydatid cyst of the neck.

Hydatid cysts in the cervicofacial region are rare. We present an unusual case of a hydatid cyst found in the nape of a 66-year-old Turkish woman. There was no pulmonary or hepatic involvement. Excision of the cystic mass as definitive therapy was performed. The location of the lesion, diagnostic tests available and therapeutic approach are discussed and the literature reviewed.

Total thyroidectomy for differentiated thyroid carcinoma: primary and secondary operations.

AIMS: There is considerable controversy concerning the most appropriate surgical treatment of patients with differentiated thyroid carcinoma (DTC). Although some authors have advocated subtotal thyroidectomy because of the decreased surgical morbidity and the lack of improved survival with a more extensive procedure, total thyroidectomy has been defended by others as a treatment of choice with lower morbidity. METHODS: We reviewed 106 consecutive patients who had been treated with total thyroidectomy for DTC to determine the complication rate. Forty-seven patients had primary operations and 59 had reoperations with completion of total thyroidectomy. RESULTS: Residual tumour in the remnant thyroid tissue was found in 53.8% of patients who underwent prophylactic completion thyroidectomy. Permanent hypoparathyroidism was present in one (0.9%) patient and accidental transient unilateral recurrent laryngeal nerve injury occurred in 2.8% of the entire series. No patient had permanent bilateral recurrent nerve palsy. Furthermore, the risk of complication was not significantly different when comparing primary total thyroidectomy or completion surgery. CONCLUSIONS: We recommend total thyroidectomy as a safe treatment for DTC with a low rate of morbidity.

Treatment of non-resectable pelvic malignancies by isolated pelvic perfusion. A preliminary study.

Management of non-resectable pelvic tumours by intra-arterial local chemotherapy was shown to be beneficial but systemic toxicity limits its use. To overcome this problem isolated pelvic perfusion (IPP) was introduced as an alternative. This study summarizes our preliminary experience with IPP in the treatment of 18 non-resectable pelvic tumours [recurrent rectal adenocarcinoma (six), soft tissue sarcoma (STS) (five), bone tumour (three), epidermoid carcinoma (two), prostatic adenocarcinoma (one), malignant melanoma (one)]. Results of IPP were regarded as complete remission (CR), partial remission (PR), stable disease (SD) and disease progression (DP) according to the changes in three parameters including; scoring in pain, tumour marker and tumour size measurements. Complete and partial remission were established in five (27%) and seven (39%) patients respectively indicating a benefit ratio of 66%. Objective pain relief was encountered in 53% of the cases. All patients with STS had undergone further surgical treatment after IPP with successful curative resections in four. No residual tumour was found at the laparotomy of the fifth patient. Presenting symptom of the prostatic adenocarcinoma patient was symptomatic hypoglycaemia which resolved completely after IPP. To our knowledge, this represents the first case reported in the English literature in whom tumour related hypoglycaemia was successfully managed by IPP. In conclusion; management of non-resectable pelvic tumours by IPP seems to offer serious palliation and increase in the quality of life without any systemic toxicity. Our preliminary experience suggests even resectability may be achieved in a number of patients especially in those with STS.

Value of high-resolution intraoperative ultrasonography in the determination of limits of horizontal tumor spread during surgery for gastric malignancy.

Determination of the resection margins during surgery for gastric malignancy is a subject of controversy because accurate detection of horizontal limits of tumor spread is difficult by current methods. In this study, we investigated the value of intraoperative-ultrasonography (IUS) in the detection of proximal and distal limits of horizontal tumor spread (HTS) in 19 gastric adenocarcinoma (Group I) and five gastric lymphoma (Group II) patients. After sonographic and clinical limits of HTS were marked, resections were carried out 2 cm away from the IUS limits, and biopsies from IUS limits and resection margins were obtained. Then, the gap between IUS and clinical limits were recorded and compared with results of pathology. In both groups, the distance from clinical to IUS limits ranged from 0 cm to 3 cm and IUS limits were never inside the clinical limits. In Group I, results of sonographic proximal limit detection were satisfactory in all patients excluding recurrent cases (n:2) and a patient with early gastric cancer. Sonographic accuracy of distal limit detection was 68%. In Group I, only one resection margin (distal) was found to be infiltrated with cancer. In Group II, the success rate of IUS-guided HTS detection was 40%. IUS seems to be a valuable method for determining the extent of HTS during operation for gastric adenocarcinomas, especially so for the most problematic proximal limits. In recurrent cancers and lymphomas, however, results of IUS may be frequently misleading. IUS can be advocated as a routine procedure to determine the tumor limits and thus the resection margins during surgery for primary gastric adenocarcinomas.