The Impact of the Surgical Apgar Score On Oncological Outcomes in Patients With Colorectal Cancer: A Single-Center Retrospective Cohort Study

Abstract Background: The surgical Apgar score (SAS) predicts postoperative complications (POCs) following gastrointestinal cancer surgery. Recently, the SAS was reported to be a predictor of not only POCs but also the prognosis. However, the impact of the SAS on oncological outcomes in patients with colorectal cancer (CRC) has not been fully examined. The present study therefore explored the oncological significance of the SAS in patients with CRC.Methods: We retrospectively analyzed 639 patients who underwent radical surgery for CRC. The SAS was calculated based on three intraoperative parameters: estimated blood loss, lowest mean arterial pressure and lowest heart rate. The optimal cut-off value of the SAS was determined by receiver operating characteristic curves. All patients were classified into 2 groups based on the SAS (≤6 and >6). The association of the SAS with the recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS) was analyzed.Results: Univariate analyses revealed that a lower SAS (≤6) was significantly associated with a worse RFS, OS and CSS. A multivariate analysis revealed that age ≥75 years old, Charlson comorbidity index ≥1, ASA-Physical Status ≥3, SAS ≤6, histologically undifferentiated tumor type and an advanced pStage were independent factors for the OS, and an SAS ≤6 and advanced pStage were independent factors for the CSS.Conclusions: A lower SAS (≤6) was an independent prognostic factor for not only the OS but also the CSS in patients with CRC, suggesting that the SAS might be a useful biomarker predicting oncological outcomes in patients with CRC.

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Predictive value of Surgical Apgar Score for long-term outcome in patients with gastric cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.4_suppl.178 ◽

2017 ◽

Vol 35 (4_suppl) ◽

pp. 178-178

Author(s):

Masanori Tokunaga ◽

Tomoyuki Irino ◽

Rie Makuuchi ◽

Yutaka Tanizawa ◽

Etsuro Bando ◽

...

Keyword(s):

Gastric Cancer ◽

Apgar Score ◽

Cancer Center ◽

Curative Gastrectomy ◽

Term Survival ◽

Long Term Outcome ◽

Estimated Blood Loss ◽

The Impact ◽

Surgical Apgar Score

178 Background: Recently, a simple and easy complication prediction system, the surgical Apgar score (SAS) calculated according to three intraoperative parameters (estimated blood loss, lowest mean arterial pressure, and lowest heart rate), has been proposed for general surgery. We previously reported on the predictive power of SAS for severe complications after gastrectomy. However, the impact of SAS on long-term survival is still unclear. The aim of the present study was to clarify the relationship between SAS and survival outcome in patients with gastric cancer undergoing curative gastrectomy. Methods: This study included 302 patients who underwent curative gastrectomy at the Shizuoka Cancer Center in 2010. Clinical data, including intraoperative parameters, were collected retrospectively. When the SAS score was ≤ 6, patients were classified into an L-SAS group (n = 82), otherwise, they were classified into an H-SAS group (n = 220). Clinicopathological characteristics and survival outcomes were compared between the groups. Results: There was no difference in demographic data including sex and age between the groups. Total gastrectomy was more frequently performed in the L-SAS group (43%) than in the H-SAS group (21%; P < 0.001). The L-SAS group included patients with higher pT and pN stage. Five-year overall survival rate was worse in the L-SAS group (65.4%) than in the H-SAS group (82.7%; P < 0.001). Multivariate analysis, which included age, sex, histology, pT, pN, type of surgery and SAS as covariates, identified lower SAS (HR, 1.71, 95% C.I., 1.04-2.80) as well as age (HR, 1.62, 95% C.I., 1.10-2.40) and pN (HR, 2.05, 95% C.I., 1.19-3.52) as independent prognostic factors. Conclusions: The SAS was found to be a predictive factor for survival. Intraoperative bleeding and vital signs may affect survival of patients, and therefore warrant special attention from surgeons and anesthesiologists.

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The Surgical Apgar Score Predicts Postoperative Complications in Elderly Patients After Surgery for Colorectal Cancer

The American Surgeon ◽

10.1177/00031348211038576 ◽

2021 ◽

pp. 000313482110385

Author(s):

Atsushi Sugimoto ◽

Tatsunari Fukuoka ◽

Hisashi Nagahara ◽

Masatsune Shiutani ◽

Yasuhito Iseki ◽

...

Keyword(s):

Colorectal Cancer ◽

Rectal Cancer ◽

Postoperative Complications ◽

Elderly Patients ◽

Apgar Score ◽

Assessment Tool ◽

Univariate Analysis ◽

Operation Time ◽

Estimated Blood Loss ◽

Surgical Apgar Score

Objective The surgical Apgar score (SAS) has been validated as a risk assessment tool for postoperative complications. However, the utility of the SAS in elderly patients with colorectal cancer remains unclear. In this study, we evaluated the utility of the SAS for predicting the severe complications in elderly patients with colorectal cancer. Methods We retrospectively analyzed 295 patients underwent radical surgery for colorectal cancer in elderly patients ≥75 years old. The SAS was calculated based on 3 intraoperative parameters: estimated blood loss (EBL), lowest mean arterial pressure, and lowest heart rate. Severe complications were defined as Clavien-Dindo classification grade ≥ IIIa. We divided all patients into 2 groups according to with or without severe complications. The optimal cut-off value of SAS for severe complications has been determined by receiver operator characteristic curve. Predictors for severe complications were analyzed by logistic regression modeling. Results Severe complications were observed in 57 patients (19.3%). Male, rectal cancer, operation time (>240 minutes), EBL (≥120 mL), and a low SAS (≤6) were significantly associated with severe complications in univariate analysis. A multivariate analysis revealed that male, rectal cancer, and a low SAS (≤6) were independent predictors for severe complications. Conclusions A low SAS (≤6) was associated with severe complications after colorectal cancer surgery in elderly patients. The SAS is a valuable predictor for severe complications in elderly patients with colorectal cancer.

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Impact of relapse site on oncological outcomes after radical nephroureterectomy for upper urinary tract urothelial carcinoma.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.2_suppl.426 ◽

2016 ◽

Vol 34 (2_suppl) ◽

pp. 426-426

Author(s):

Shinichi Yamashita ◽

Akihiro Ito ◽

Koji Mitsuzuka ◽

Yoshihide Kawasaki ◽

Ichiro Shintaku ◽

...

Keyword(s):

Urinary Tract ◽

Local Recurrence ◽

Lymph Nodes ◽

Multivariate Analyses ◽

Survival Rates ◽

Upper Urinary Tract ◽

Radical Nephroureterectomy ◽

Cancer Specific Survival ◽

Oncological Outcomes ◽

The Impact

426 Background: Most upper urinary tract urothelial carcinomas (UTUC) are invasive and advanced with a poor prognosis. Patients often relapse after treatment with radical nephroureterectomy (RNU). However, little is known about an association between sites of recurrence after RNU and oncological outcomes. The present study retrospectively evaluated the impact of a first recurrence site on survival. Methods: A total of 650 patients with UTUC treated by RNU at 12 institutions that participated in the Tohoku Urological Evidence-Based Medicine Study Group between 2000 and 2011 were initially enrolled. Patients who experienced relapse other than intravesical recurrence after RNU were included in this study. Those who had metastasis at the time of UTUC diagnosis or missing data regarding the time and location of relapse were excluded. Finally, 173 patients were eligible to participate in this study. Survival rates were analyzed using Kaplan-Meier curves and the log-rank test, and factors predicting survival were assessed using multivariate analyses. Results: The median follow-up after relapse was nine months. The cancer-specific survival rates at one and two years after relapse were 49% and 22%, respectively. Cancer in 59 (34%), 32 (18%), 23 (13%), and 94 (53%) patients recurred in the lung, liver, bone and lymph nodes, and 23 (13%) had local recurrence. The one-year cancer-specific survival rates were 44%, 27%, 22% and 52% among patients with metastasis of the lungs, liver, bone and lymph nodes respectively, and 41% among those with local recurrence. The survival rate was worse among 48 patients with metastasis at multiple sites, than in those with metastasis at a single site. Fourteen (8%) patients with a single lymph, lung or local recurrence survived for over three years after a first relapse. Multivariate analyses selected the liver, bone and local recurrence as critical factors for cancer-specific survival. Conclusions: Liver or bone metastasis was a negative prognostic factor for UTUC with relapse after RNU. Information about recurrence sites might be helpful for patient counseling.

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Expansion of the Surgical Apgar Score across All Surgical Subspecialties as a Means to Predict Postoperative Mortality

Anesthesiology ◽

10.1097/aln.0b013e318219d734 ◽

2011 ◽

Vol 114 (6) ◽

pp. 1305-1312 ◽

Cited By ~ 47

Author(s):

Paul Q. Reynolds ◽

Neal W. Sanders ◽

Jonathan S. Schildcrout ◽

Nathaniel D. Mercaldo ◽

Paul J. St. Jacques

Keyword(s):

Apgar Score ◽

Scoring System ◽

Postoperative Mortality ◽

Predictive Ability ◽

Apgar Scores ◽

Logistic Regression Models ◽

Risk Of Death ◽

Estimated Blood Loss ◽

Increased Risk ◽

Surgical Apgar Score

Background A surgical scoring system, akin to the obstetrician's Apgar score, has been developed to assess postoperative risk. To date, evaluation of this scoring system has been limited to general and vascular services. The authors attempt to externally validate and expand the Surgical Apgar Score across a wide breadth of surgical subspecialties. Methods Intraoperative data for 123,864 procedures including all surgical subspecialties were collected and associated with Surgical Apgar Scores (created by the summation of point values associated with the lowest mean arterial pressure, lowest heart rate, and estimated blood loss). Patients' death records were matched to the corresponding score, and logistic regression models were created in which mortality within 7, 30, and 90 days was regressed on the Apgar score. Results Lower Surgical Apgar Scores were associated with an increased risk of death. The magnitude of this association varied by subspecialty. Some subspecialties exhibited higher odds ratios, suggesting that the score is not as useful for them. For most of the subspecialties the association between the Apgar score and mortality decreased as the time since surgery increased, suggesting that predictive ability ceases to be helpful over time. After adjusting for the patient's American Society of Anesthesiologists classification, Apgar scores remained associated with death among most of the subspecialties. Conclusion A previously published methodology for calculating risk among general and vascular surgical patients can be applied across many surgical services to provide an objective means of predicting and communicating patient outcomes in surgery as well as planning potential interventions.

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Survival among colorectal cancer patients with a history of previous cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e16146 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e16146-e16146

Author(s):

Sandi Pruitt ◽

David E. Gerber ◽

Hong Zhu ◽

Daniel Heitjan ◽

Bhumika Maddineni ◽

...

Keyword(s):

Colorectal Cancer ◽

Overall Survival ◽

Cox Regression ◽

Population Based ◽

Competing Risk ◽

Cancer Specific Survival ◽

Risk Of Death ◽

Number Of Patients ◽

Significant Difference ◽

The Impact

e16146 Background: A growing number of patients with colorectal cancer (CRC) have survived a previous cancer. Although little is known about their prognosis, this population is frequently excluded from clinical trials. We examined the impact of previous cancer on overall and cancer-specific survival in a population-based cohort of patients diagnosed with incident CRC. Methods: We identified patients aged ≥66 years and diagnosed with CRC between 2005-2015 in linked SEER-Medicare data. For patients with and without previous cancer, we estimated overall survival using Cox regression and cause-specific survival using competing risk regression, separately by CRC stage, while adjusting for numerous covariates and competing risk of death from previous cancer, other causes, or the incident CRC. Results: Of 112,769 CRC patients diagnosed with incident CRC, 15,935 (14.1%) had a previous cancer – most commonly prostate (32.9%) or breast (19.4%) cancer, with many 7505 (47.1%) diagnosed ≤5 years of CRC. For all CRC stages except IV in which there was no significant difference in survival, patients with previous cancer had modestly worse overall survival (hazard ratios from fully adjusted models range from 1.11-1.28 across stages; see Table). This survival disadvantage was driven by deaths due to previous cancer and other causes. Notably, most patients with previous cancer had improved CRC-specific survival. Conclusions: CRC patients who have survived a previous cancer have generally worse overall survival but superior CRC-specific survival. This evidence should be considered concurrently with concerns about trial generalizability, low accrual, and heterogeneity of participants when determining exclusion criteria. [Table: see text]

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Risk Assessment of Pancreatic Surgery by Surgical Apgar Score and Body Mass Index

International Surgery ◽

10.9738/intsurg-d-14-00294.1 ◽

2016 ◽

Vol 101 (5-6) ◽

pp. 263-269 ◽

Cited By ~ 1

Author(s):

Toru Aoyama ◽

Yusuke Katayama ◽

Masaaki Murakawa ◽

Koichiro Yamaoku ◽

Amane Kanazawa ◽

...

Keyword(s):

Risk Factors ◽

Pancreatic Cancer ◽

Body Mass Index ◽

Body Mass ◽

Apgar Score ◽

Pancreatic Surgery ◽

Significant Risk ◽

Cancer Center ◽

Estimated Blood Loss ◽

Surgical Apgar Score

Postoperative morbidity is high after pancreatic surgery. Recently, a simple and easy-to-use surgical complication prediction system, the surgical Apgar score (SAS), calculated using 3 intraoperative parameters (estimated blood loss, lowest mean arterial pressure, and lowest heart rate) has been proposed for general surgery. In this study, we evaluated the predictability of the SAS for severe complications after pancreatic surgery for pancreatic cancer. We investigated 189 patients who underwent pancreatic surgery at Kanagawa Cancer Center between 2005 and 2014. Clinicopathologic data, including the intraoperative parameters, were collected retrospectively. In this study, the patients with postoperative morbidities classified as Clavien-Dindo grade 2 or higher were classified as having severe complications. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for morbidity. Postoperative complications were identified in 73 patients, and the overall morbidity rate was 38.6%. The results of both univariate and multivariate analyses of various factors for overall operative morbidity showed that an SAS of 0 to 4 points and a body mass index ≥25 kg/m2 were significant independent risk factors for overall morbidity (P = 0.046 and P = 0.013). The SAS and body mass index were significant risk factors for surgical complications after pancreatic surgery for pancreatic cancer.

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Colon Cancer Survival Is Associated With Decreasing Ratio of Metastatic to Examined Lymph Nodes

Journal of Clinical Oncology ◽

10.1200/jco.2005.02.8852 ◽

2005 ◽

Vol 23 (34) ◽

pp. 8706-8712 ◽

Cited By ~ 333

Author(s):

Adam C. Berger ◽

Elin R. Sigurdson ◽

Thomas LeVoyer ◽

Alexandra Hanlon ◽

Robert J. Mayer ◽

...

Keyword(s):

Colorectal Cancer ◽

Colon Cancer ◽

Cancer Survival ◽

Regional Lymph Node ◽

Disease Free Survival ◽

Tumor Stage ◽

The United States ◽

Cancer Specific Survival ◽

End Points ◽

The Impact

Purpose Colorectal cancer is the second leading cause of cancer deaths in the United States, with poor survival predicted by regional lymph node (LN) metastasis. The impact of LN ratio (LNR) on survival is unknown in this disease. Patients and Methods We analyzed data from Intergroup trial 0089 of adjuvant chemotherapy for stage II and III patients with colon cancer, in which all patients received fluorouracil-based therapy. Survival was similar for all arms of the study, allowing us to evaluate all patients together. End points included overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS). Multivariate analyses were performed on all patients and on groups according to LNR quartiles (LNR: < 0.05, 0.05 to 0.19, 0.2 to 0.39, and 0.4 to 1.0). Covariates included in the models were age, sex, tumor stage, grade, histology, number of positive LNs, number of LNs removed, and LNR. Results The median age was 63.7 years, and the median number of LNs removed was 11. In the multivariate analysis, LNR was a significant factor for OS, DFS, and CSS in patients with 10 to 15 LN and more than 15 LN removed but not for patients with less than 10 LN removed. Using quartiles, LNR maintained its significance for all three end points when patients were grouped by node status. Conclusion After curative resection for colorectal cancer, the LNR is an important prognostic factor and should be used in stratification schemes for future clinical trials investigating adjuvant treatments.

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Preoperative Surgical Risk Predictions Are Not Meaningfully Improved by Including the Surgical Apgar Score

Anesthesiology ◽

10.1097/aln.0000000000000858 ◽

2015 ◽

Vol 123 (5) ◽

pp. 1059-1066 ◽

Cited By ~ 8

Author(s):

Maxim A. Terekhov ◽

Jesse M. Ehrenfeld ◽

Jonathan P. Wanderer

Keyword(s):

Risk Stratification ◽

Apgar Score ◽

Information Criteria ◽

Brier Score ◽

Clinical Parameters ◽

Preoperative Risk ◽

Surgical Risk ◽

Estimated Blood Loss ◽

Surgical Apgar Score ◽

Relative Quality

Abstract Background Estimating surgical risk is critical for perioperative decision making and risk stratification. Current risk-adjustment measures do not integrate dynamic clinical parameters along with baseline patient characteristics, which may allow a more accurate prediction of surgical risk. The goal of this study was to determine whether the preoperative Risk Quantification Index (RQI) and Present-On-Admission Risk (POARisk) models would be improved by including the intraoperative Surgical Apgar Score (SAS). Methods The authors identified adult patients admitted after noncardiac surgery. The RQI and POARisk were calculated using published methodologies, and model performance was compared with and without the SAS. Relative quality was measured using Akaike and Bayesian information criteria. Calibration was compared by the Brier score. Discrimination was compared by the area under the receiver operating curves (AUROCs) using a bootstrapping procedure for bias correction. Results SAS alone was a statistically significant predictor of both 30-day mortality and in-hospital mortality (P < 0.0001). The RQI had excellent discrimination with an AUROC of 0.8433, which increased to 0.8529 with the addition of the SAS. The POARisk had excellent discrimination with an AUROC of 0.8608, which increased to 0.8645 by including the SAS. Similarly, overall performance and relative quality increased. Conclusions While AUROC values increased, the RQI and POARisk preoperative risk models were not meaningfully improved by adding intraoperative risk using the SAS. In addition to the estimated blood loss, lowest heart rate, and lowest mean arterial pressure, other dynamic clinical parameters from the patient’s intraoperative course may need to be combined with procedural risk estimate models to improve risk stratification.

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