The impact of frailty on clinical outcomes in colorectal cancer surgery: a systematic literature review.

BACKGROUND: The majority of colorectal cancer is diagnosed in people aged >65 years, yet the elderly are less likely to undergo curative surgery. Chronological age is poorly correlated with post-operative outcomes and is not an acceptable measure of risk. Conversely, frailty is a strong predictor of poor post-operative outcomes and presents an opportunity for optimisation. This systematic review aims to assess the evidence between frailty and outcomes in patients of all ages undergoing colorectal cancer resections and to compare the predictive value of frailty status to that of age alone. METHODS: The review was registered on Prospero, CRD42019150542. PubMed was searched for articles reporting outcomes for frail patients undergoing elective or emergency colorectal cancer resection up until August 2019. All studies reporting outcomes in frail patients were deemed eligible for inclusion and assessed according to the PRISMA guidelines. RESULTS: Of the 143 identified studies, 17 were eligible for inclusion. Study type, frailty assessments and outcomes measured were highly variable. 'Frailty' was associated with significantly higher rates of post-operative complications (7/7 studies), post-operative mortality (5/7 studies), readmission (3/4 studies) and length of stay (3/3 studies). Seven of 11 studies reported no association between age and adverse outcomes. CONCLUSION: Frailty is a predictor of poor clinical outcomes in patients undergoing surgery for colorectal cancer. Standardisation of frailty assessment and outcome measure is needed. Accurate risk stratification of patients will allow us to make informed treatment decisions, identify patients who may benefit from preoperative intervention and tailor post-operative care.

Pre-designed consent forms for total hip replacement, total knee replacement, and caesarean section: A national observational study of current English practice.

BACKGROUND: Pre-designed procedure-specific consent forms (PCFs) have potential advantages over handwritten forms for improving the consent process and disclosing material risks, as necessitated by the 2015 'Montgomery' ruling. We aimed to assess the use and quality of English NHS Trust PCFs for total hip replacement (THR), total knee replacement (TKR), and caesarean section (CS). METHODS: All 233 English NHS Trusts were sent a Freedom of Information request seeking PCFs for these operations. Listed risks, and whether their incidence was quoted, were compared against those listed in published PCFs from the British Orthopaedic Association (BOA) and the Royal College of Obstetricians and Gynaecologists (RCOG). RESULTS: 203/233 (87.1%) Trusts responded, contributing 17 THR PCFs, 15 TKR PCFs, and 33 CS PCFs. Overall, the type of risks listed for each operation was highly variable. 5.9% of THR PCFs contained all 18 BOA-quoted risks. No TKR PCF contained all 19 BOA-quoted risks. 24.2% of CS PCFs contained all 17 RCOG-quoted risks. For each operation, few PCFs listed incidences for quoted-risks. CONCLUSIONS: Very few Trusts use PCFs for these common operations. When PCFs are used, the reporting of risks and their likelihood is variable and insufficient. BOA- and RCOG-approved PCFs are high quality and influential on Trust-PCF design but still omit important risks. We fear PCFs analysed here do not sufficiently improve the consent process compared to handwritten forms. PCFs have potential to improve the quality of consent, however they need greater uptake and to be of greater quality.

Outcomes Following Primary Realignment Versus Suprapubic Cystostomy with Delayed Urethroplasty for Pelvic Fracture-Associated Posterior Urethral Injury: A Systematic Review with Meta-Analysis.

OBJECTIVE: Pelvic fracture can be complicated by posterior urethral injury (PUI) in up to 25% of cases. PUI can produce considerable morbidity, including urethral stricture, erectile dysfunction (ED), and urinary incontinence. Optimal management of PUI is unclear, however, the current gold standard is placement of a suprapubic cystostomy with delayed urethroplasty (SCDU) performed several months later. Another option is early primary realignment (PR) with urethral catheter, performed either open or endoscopically. Through a systematic review and meta-analysis, we aimed to compare PR and SCDU regarding stricture, ED, and urinary incontinence rates. In light of advancing endoscopic techniques, we also aimed to compare early endoscopic realignment (EER) alone with SCDU. METHODS: PubMed, Medline, and Embase were searched for eligible studies comparing PR, including EER, and suprapubic cystostomy plus delayed urethroplasty from database inception until July 17th, 2018. We also reviewed reference lists from relevant articles. Study quality assessment was conducted using a modified Newcastle-Ottawa (mNOS) scale (maximum score 9). RESULTS: From 461 identified articles, 13 studies encompassing 414 PR and 308 SCDU patients met our eligibility criteria. Twelve studies were retrospective non-randomized case studies, with 1 prospective randomized case study. Included studies were of moderately low quality (mNOS mean score: 6.0 ± 0.6). Meta-analysis demonstrated that PR and SCDU had similar stricture rates [odds ratio (OR): 2.14; 95% confidence interval (CI): 0.67-6.85; p = 0.20], similar rates of ED (OR: 1.06; 95% CI: 0.62-1.81; p = 0.84), and similar rates of urinary incontinence (OR: 0.94; 95% CI: 0.49-1.79; p = 0.86). Six studies compared EER alone (229 patients) versus SCDU (195 patients). Meta-analysis demonstrated that these modalities also had similar stricture rates (OR: 4.14; 95% CI: 0.76-22.45; p = 0.10), similar rates of ED (OR: 0.79; 95% CI: 0.41-1.54; p = 0.49), and similar rates of urinary incontinence (OR: 1.10; 95% CI: 0.48-2.53; p = 0.82). CONCLUSION: For PUI patients, neither PR nor EER produces superior outcomes compared to SCDU regarding stricture, ED, and urinary incontinence rates. The quality of studies in the literature, however, is very poor, with the majority of studies being non-randomized retrospective case studies with potentially high bias. Additional high-quality research, particularly prospective studies and randomized controlled trials, are needed to strengthen the evidence base.

Publication Fate of Abstracts Presented at Four British Surgical Meetings: An 11-Year Follow-Up.

BACKGROUND: The gold standard for research is publication within a peer-reviewed journal. There is a discrepancy between the number of abstracts presented at scientific meetings and the number published as full articles. We identified publication rates for the 2012 meetings of four British surgical societies. These were the Association of Surgeons of Great Britain & Ireland (ASGBI), the Vascular Society of Great Britain and Ireland, the British Transplantation Society (BTS), and the Association of Coloproctology of Great Britain and Ireland (ACPGBI). We also compared publication rates with these societies' 2001 meetings and identified univariate factors associated with publication. MATERIALS AND METHODS: PubMed was searched to identify publications stemming from meeting abstracts. We extracted abstract characteristics to identify factors associated with publication and also characteristics of subsequent publications to enable comparison. RESULTS: Publication rates were 24.1% (ASGBI), 24.6% (BTS), 21.7% (ACPGBI), and 39.4% (Vascular Society of Great Britain and Ireland). Rates for ASGBI, BTS, and ACPGBI meetings were significantly lower compared to 2001 meetings (P = 0.001-0.026). Mean time to publication was 12.1-22.0 mo. Mean 5-y impact factor differed significantly between meetings (P = 0.001), with the BTS meeting having the highest mean 5-y impact factor (4.658). Factors associated with publication included being an oral presentation (ASGBI P = 0.001), multi-institution study (ASGBI P = 0.003), or randomized-controlled trial (BTS P = 0.049). CONCLUSIONS: Reduced publication rates may represent increased acceptance of low-quality abstracts at meetings or a more competitive journal submission process. Further data are required to strengthen conclusions. Nonetheless, authors and meeting organizers should push for higher quality abstracts to promote future peer-reviewed journal publication.