Systematic review and narrative synthesis of surgeons’ perception of postoperative outcomes and risk

Background The accuracy with which surgeons can predict outcomes following surgery has not been explored in a systematic way. The aim of this review was to determine how accurately a surgeon's ‘gut feeling’ or perception of risk correlates with patient outcomes and available risk scoring systems. Methods A systematic review was undertaken in accordance with PRISMA guidelines. A narrative synthesis was performed in accordance with the Guidance on the Conduct of Narrative Synthesis In Systematic Reviews. Studies comparing surgeons' preoperative or postoperative assessment of patient outcomes were included. Studies that made comparisons with risk scoring tools were also included. Outcomes evaluated were postoperative mortality, general and operation‐specific morbidity and long‐term outcomes. Results Twenty‐seven studies comprising 20 898 patients undergoing general, gastrointestinal, cardiothoracic, orthopaedic, vascular, urology, endocrine and neurosurgical operations were included. Surgeons consistently overpredicted mortality rates and were outperformed by existing risk scoring tools in six of seven studies comparing area under receiver operating characteristic (ROC) curves (AUC). Surgeons' prediction of general morbidity was good, and was equivalent to, or better than, pre‐existing risk prediction models. Long‐term outcomes were poorly predicted by surgeons, with AUC values ranging from 0·51 to 0·75. Four of five studies found postoperative risk estimates to be more accurate than those made before surgery. Conclusion Surgeons consistently overestimate mortality risk and are outperformed by pre‐existing tools; prediction of longer‐term outcomes is also poor. Surgeons should consider the use of risk prediction tools when available to inform clinical decision‐making. Introduction Surgical procedures all carry associated risks. It is therefore important that surgeons are able to make accurate predictions of potential benefit and risk, including immediate mortality and morbidity, as well as long‐term outcomes, to enable balanced decision‐making and fully informed consent. Risks can also be estimated after surgery, based on additional perioperative and intraoperative data, which allows contemporary prediction of outcome. There are numerous risk prediction models that enable the surgeon to quantify risk based on measurable parameters1-5. However, there are inherent limitations in using a generalized risk prediction model, which may not include clinical data pertinent to the individual case in question, leading to variability in model accuracy6-10. As a result, risk prediction tools are generally used in tandem with the surgeon's ‘gut feeling’ of overall risk and anticipated outcome (‘clinical gestalt’). Several disparate factors influence surgeons' perception of outcome: patient factors, such as their perceived fitness, their pathology and planned procedure; setting factors, such as the experience of other members of staff; and surgeon factors, such as clinical knowledge, operative skill, previous significant surgical complications, and inclinations and attitudes11-13. Anticipating surgical risk is subject to multiple biases, which make it challenging. These include the natural tendency toward anecdotal recall and the availability heuristic (the likelihood of making a decision based on how easily the topic or examples come to mind)14, 15. Some studies16-18 support the accuracy and reproducibility of surgeons' predictions, whereas others19-22 demonstrate less favourable results. The complexity of synthesizing risk perceptions is significant and incompletely understood23, 24. The accuracy of surgeons' prediction has not been explored previously in a systematic manner. The aim of this review was thus to determine, from the available evidence, whether a surgeon's gut feeling or perception of risk correlates with postoperative outcomes, and to compare this prediction with currently available risk scoring systems, where available. Methods This systematic review was undertaken in accordance with the PRISMA guidelines25, 26. MEDLINE (via PubMed), Embase, the Cochrane Library Database, and the Cochrane Collaboration Central Register of Controlled Clinical Trials were searched with no date or language restrictions, with the last search date on 9 July 2018. The search term used was (‘Surgeons’[Mesh] OR ‘General Surgery/manpower*’ [MeSH]) AND (‘perception’ OR ‘intuition’ OR ‘predict*’ OR ‘decision making’ [mesh]). There was no restriction on publication type. This search was complemented by an exhaustive review of the bibliography of key articles, and also by using the Related Articles function in PubMed of included papers. Results were restricted to human research published in English. Inclusion and exclusion criteria All studies of patients undergoing surgery in which a preoperative or postoperative surgeon assessment (or proxy assessment) of a postoperative outcome was performed were included. This included articles that reported general risk (such as mortality) or a surgery‐specific risk (for example anastomotic leakage). Studies that made comparisons with established risk scoring tools were also included. Papers or abstracts in English, or non‐English papers with an English abstract, were included. Papers describing the risk assessment of ‘theoretical’ cases, or patient vignettes in a situation distant from clinical practice (such as a conference), were excluded, as were studies in which surgeons' assessment of risk was compared with an established risk scoring tool, without data on actual patient outcome. Data extraction and assessment of study quality Three authors independently extracted data and assessed the methodological quality of the studies, with all data extraction independently checked by the senior author. The following baseline data were extracted from each study: first author, year of publication, data collection period, geographical location, study design and type (single or multiple centres, number of surgeons involved in risk estimation, whether consecutive patients were enrolled), surgical specialty, whether other risk scoring systems were used for comparison and, if so, whether the assessor was blinded to this result. Data extracted regarding the assessment of risk included: risk outcome assessed; timing of risk estimation (preoperative or postoperative); type of risk assessment by surgeons (qualitative, quantitative, continuous scale such as a visual analogue scale (VAS), or composite score); absolute value of risk event predicted by surgeon and by scoring system; absolute value of risk occurrence rate; summary data on outcome reported, including area under the curve (AUC) of receiver operating characteristic (ROC) curves, observed : expected (O : E) or predicted : observed (P : O) ratios, or any other summary data. When data were available, AUCs were extracted with their 95 per cent confidence intervals. AUCs greater than 0·9 were considered as indicating high performance, 0·7–0·9 as moderate performance, 0·5–0·7 as low performance, and less than 0·5 as indicating risk assessment no better than chance alone27, 28. Risk predictions made by pre‐existing tools, such as the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (POSSUM)1, Portsmouth‐POSSUM (P‐POSSUM)4 or Continuous Improvement in Cardiac Surgery Program (CICSP)5, were compared with outcome when given. Internal prediction models, where authors would derive significant predictive co‐variables from their data set and assess the accuracy of these co‐variables within the same data set, were not evaluated as they lacked validity. Study quality was assessed using the Newcastle–Ottawa (NO) score29, 30. The NO score assigns points based on: the quality of patient selection (maximum 4 points); comparability of the cohort (maximum 2 points); and outcome assessment (maximum 3 points). Studies that scored 6 points or more were considered to be of higher quality. Outcome measures The following outcome measures were defined a priori and refined during data extraction: postoperative mortality (usually defined as 30 days after surgery); postoperative general morbidity (usually defined as 30 days after surgery); postoperative procedure‐specific morbidity; and long‐term outcome (typically operation‐specific). Further comparative analyses of outcomes included comparison of preoperative and postoperative predictions, and of predictions made by consultants and surgical trainees. Narrative synthesis Given the marked heterogeneity in study design, patient population included, method of assessing risk and outcomes assessed, meta‐analysis was deemed not appropriate. A narrative synthesis was therefore performed according to the Guidance on the Conduct of Narrative Synthesis In Systematic Reviews31. Three authors systematically summarized each article using bullet points to document key aspects of each study, focusing particularly on methods used and results obtained. The validity and certainty of the results were noted (whether appropriate statistical comparisons were used and, if so, their effect size and significance). The senior author identified and grouped common themes, divided larger themes into subthemes, tabulated a combined summary of the paper, and synthesized a common rubric for each theme. Consolidated reviewers' comments can be found in Table S1 (supporting information). Results A total of 584 articles were identified from the literature search, of which 48 were retrieved for evaluation. Papers were excluded on the basis of being duplicates (1) and being irrelevant based on the title (497) and abstract (38) (Fig. 1). Twenty‐seven studies16-24, 32-49 comprising 20 898 patients met the inclusion criteria and were included in the narrative synthesis (Appendix S1, supporting information)

Expression of hepatocyte growth factor-like protein in human wound tissue and its biological functionality in human keratinocytes

Hepatocyte growth factor-like protein (HGFl) and its receptor, Recepteur d'Origine Nantais (RON), have been implicated in the development of wound chronicity. HGFl and RON expression was detected in acute wound tissue, chronic wound tissue and in normal skin using quantitative polymerase chain reaction (Q-PCR). HGFl and RON expression was also assessed in chronic healing and chronic non-healing wound tissues using Q-PCR and immunohistochemical staining. Expression was similarly detected in the HaCaT immortalized human keratinocyte cell line using reverse transcription polymerase chain reaction (RT-PCR). rhHGFl was used to assess the impact of this molecule on HaCaT cell functionality using in vitro growth assays and electric cell-substrate impendence sensing (ECIS) migration assays. HGFl and RON transcript expression were significantly increased in acute wound tissue compared to chronic wound tissue and were also elevated, though non-significantly, in comparison to normal skin. Minimal expression was seen in both healing and non-healing chronic wounds. Treatment of HaCaT cells with rhHGFl had no effect on growth rates but did enhance cell migration. This effect was abolished by the addition of a phospholipase C gamma (PLCγ) small molecule inhibitor. The increased expression of HGFl and RON in acute, healing wounds and the pro-migratory effect of HGFl in an in vitro human keratinocyte model, may indicate a role for HGFl in active wound healing

Angiosome specific revascularisation: does the evidence support it?

Objective To explain the angiosome concept and explore the practical application of the angiosome literature to a clinical scenario, in this case a tibial angioplasty for critical ischaemia. Methods Clinical vignette with explanation of the decisions made and subsequent clinical results based on the theory of the angiosome concept and the literature on angiosomal revascularisation; in this case the results of our group’s recent update to a systematic review and meta-analysis. Results Endovascular combined or direct angiosomal revascularisation if superior to indirect revascularisation. This was borne out in the clinical scenario, where an indirect peroneal reperfusion of the AT angiosome resulted in major amputation. Open surgery is less dependent on the angiosome concept. The presence of adequate collateralisation into a foot arch seems to be the most important factor predicting success of indirect revascularisation. The evidence for both suffers from selection bias and many of the findings in the literature are wholly due to selection bias. Conclusion The angiosome concept is useful during both open and endovascular tibial revascularisation. However, the runoff in the foot is critical to success and may not follow the ‘classic’ angiosome model in diabetes

Single versus dual antiplatelet therapy following peripheral arterial endovascular intervention for chronic limb threatening ischaemia:retrospective cohort study

ObjectivesAntiplatelet therapy following peripheral arterial endovascular intervention lacks high quality evidence to guide practice. The aim of this study was to assess the effect of three months of dual antiplatelet therapy on amputation-free survival following peripheral arterial endovascular intervention in patients with chronic limb threatening ischemia.MethodsA retrospective review of symptomatic patients undergoing primary peripheral arterial endovascular intervention over a seven-year period was performed. The primary outcome measure was amputation-free survival. A sample size calculation based on previous cohort studies suggested that 629 limbs would be required to show a difference between single and dual therapy. Kaplan-Meier estimates and multivariate logistic regression analysis of recorded baseline characteristics was performed to determine predictors of amputation-free survival. Dual antiplatelet therapy was routinely given for 3 months.Results754 limbs were treated with primary angioplasty and/or stenting over a 7-year period, 508 of these for chronic limb threatening ischemia. There was no difference in unadjusted amputation-free survival between patients with chronic limb threatening ischaemia taking single vs. dual antiplatelet therapy (69% vs. 74% respectively Log rank Chi2 = 0.1, p = .72). After adjusting for confounders, at 1 year there was also no significant difference in amputation-free survival between patients taking single vs. dual antiplatelet therapy [OR 0.8, 95% CI 0.5-1.2, p = .3]. There was no difference in rates of major bleeding between single and dual antiplatelet therapy.ConclusionsThere was no clear evidence of reduced amputation-free survival in patients with chronic limb threatening ischemia undergoing peripheral arterial endovascular intervention being treated with dual antiplatelet therapy for 3 months. This is at odds with other retrospective case series and highlights the limitations in basing clinical practice on such data. There is a need for an adequately powered, independent randomised trial to definitively answer the question

Development of core outcome sets for people undergoing major lower limb amputation for complications of peripheral vascular disease

Objective Every year, thousands of patients with peripheral vascular disease undergo major lower limb amputation. Despite this, evidence for optimal management is weak. Core outcome sets capture consensus on the most important outcomes for a patient group to improve the consistency and quality of research. The aim was to define short and medium term core outcome sets for studies involving patients undergoing major lower limb amputation. Methods A systematic review of the literature and focus groups involving patients, carers, and healthcare professionals were used to derive a list of potential outcomes. Findings informed a three round online Delphi consensus process, where outcomes were rated for both short and medium term studies. The results of the Delphi process were discussed at a face to face consensus meeting, and recommendations were made for each core outcome set. Results A systematic review revealed 45 themes to cazrry forward to the consensus survey. These were supplemented by a further five from focus groups. The consensus survey received responses from 123 participants in round one, and 91 individuals completed all three rounds. In the final round, nine outcomes were rated as “core” for short term studies and a further nine for medium term studies. Wound infection and healing were rated as “core” for both short and medium term studies. Outcomes related to mortality, quality of life, communication, and additional healthcare needs were also rated as “core” for short term studies. In medium term studies, outcomes related to quality of life, mobility, and social integration/independence were rated as “core”. The face to face stakeholder meeting ratified inclusion of all outcomes from the Delphi and suggested that deterioration of the other leg and psychological morbidity should also be reported for both short and medium term studies. Conclusion Consensus was established on 11 core outcomes for short and medium term studies. It is recommended that all future studies involving patients undergoing major lower limb amputation should report these outcomes

Psoriasin promotes invasion, aggregation and survival of pancreatic cancer cells; association with disease progression

Psoriasin (S100A7) is an 11-kDa small calcium binding protein initially isolated from psoriatic skin lesions. It belongs to the S100 family of proteins which play an important role in a range of cell functions including proliferation, differentiation, migration and apoptosis. Aberrant Psoriasin expression has been implicated in a range of cancers and is often associated with poor prognosis. This study examined the role of Psoriasin on pancreatic cancer cell functions and the implication in progression of the disease. Expression of Psoriasin was determined in a cohort of pancreatic tissues comprised of 126 pancreatic tumours and 114 adjacent non-tumour pancreatic tissues. Knockdown and overexpression of Psoriasin in pancreatic cancer cells was performed using specifically constructed plasmids, which either had anti-Psoriasin ribozyme transgene or the full length human Psoriasin coding sequence. Psoriasin knockdown and overexpression was verified using conventional RT-PCR and qPCR. The effect of manipulating Psoriasin expression on pancreatic cancer cell functions was assessed using several in vitro cell function assays. Local invasive pancreatic cancers extended beyond the pancreas expressed higher levels of Psoriasin transcripts compared with the cancers confined to the pancreas. Primary tumours with distant metastases exhibited a reduced expression of Psoriasin. Psoriasin overexpression cell lines exhibited significantly increased growth and migration compared to control cells. In addition, Psoriasin overexpression resulted in increased pancreatic cancer cell invasion which was associated with upregulation of matrix metalloproteinase-2 (MMP-2) and MMP-9. Overexpression of Psoriasin also promoted aggregation and survival of pancreatic cancer cells when they lost anchorage. Taken together, higher expression of Psoriasin was associated with local invasion in pancreatic cancers. Psoriasin expression is associated with pancreatic cancer cell growth, migration, cell-matrix adhesion, and invasion via regulation of MMPs. As such, the proposed implications of Psoriasin in invasion, disease progression and as a potential therapeutic target warrant further investigation

Sensitivity of the wound edge gene signature "WD14" in responding to clinical change: a longitudinal cohort study

Introduction: WounD14 (WD14) gene signature is a recently developed tool derived from genetic interrogation of wound edge biopsies of chronic venous leg ulcers to identify heard-to-heal wounds and enable clinicians to target aggressive therapies to promote wound healing. This study aimed to evaluate if changes in wound clinical healing status were detected by the WD14 gene signature over time as this is currently poorly understood. Material and methods: WD14 was developed through gene screening and subsequent validation in 3 patient cohorts involving 85 consecutive patients with chronic venous leg ulcers referred to a tertiary wound healing unit. Patients underwent a wound edge biopsy to interrogate for a “healing” or “non-healing” genotype. A smaller cohort (18%) underwent a second biopsy, which comprised this pilot cohort reported herein. Twelve weeks following biopsy, wounds were clinically assessed for healing status based on reduction in size and compared to WD14 genotype. Results: Sequential biopsies and WD14 scores were derived from 16 patients. WD14 signature predicted wound healing status among this cohort at either visit (32 wound edge biopsies) with a positive predictive value (PPV) of 85.2% (95% CI 74.1%-92.0%) and negative predictive value (NPV) of 80.0% (95% CI 34.2%-96.9%). A total of 6 wounds underwent altered clinical status between the 2 visits. In this cohort, WD14 has a PPV of 66.7% (95% CI 47.3%-81.7%) and NPV of 100%. Conclusion: Although the WD14 gene signature did change with wound healing status, larger studies are required to precisely clarify its role and ability to prognosticate wounds of differing clinical status over time