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Journal of Neurorestoratology  2019, Vol. 7 Issue (3): 143-152    doi: 10.26599/JNR.2019.9040015
Research Article     
Impact of preoperative Karnofsky Performance Scale (KPS) and American Society of Anesthesiologists (ASA) scores on perioperative complications in patients with recurrent glioma undergoing repeated operation
Zhong Deng1,2(),Hai Yu1,2(),Ning Wang1,Wahap Alafate1,2(),Jia Wang1(),Tuo Wang1(),Changwang Du1,(✉)(),Maode Wang1,(✉)()
1 Department of Neurosurgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi, China
2 School of Medicine, Xi'an Jiaotong University, Xi'an 710061, Shaanxi, China
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Abstract  Objective:

The objective of this study was to document the impact of the preoperative Karnofsky Performance Scale (KPS) and American Society of Anesthesiologists (ASA) scores on perioperative complications in patients with recurrent glioma who underwent tumor resection via craniotomy.

Methods:

A total of 96 patients were retrospectively reviewed. Based on KPS and ASA scores, patients were categorized into high KPS (> 70) or low KPS (≤ 70) and high ASA (3~4) or low ASA (1~2) groups. Differences in intraoperative risk factors and perioperative complications among the groups were analyzed. Multivariate analysis was performed to identify risk factors for perioperative complications.

Results:

The most frequent perioperative complications were cerebrospinal fluid leakage (31.8%) and intracranial infection (27.0%); 30-day mortality was 5.2%. The incidence rates of severe complications, central nervous system complications, and total complications were comparable in the low and high KPS groups and in the low and high ASA groups (all p > 0.05). Multivariate analysis showed that low KPS and high ASA scores were not the independent risk factors for perioperative complications.

Conclusion:

Low KPS and high ASA scores are not associated with increased postoperative complications in patients with recurrent glioma who undergo tumor resection via craniotomy.



Key wordscomplications      repeated craniotomy      glioma      Karnofsky Performance Scale (KPS) score      American Society of Anesthesiologists (ASA) score     
Received: 17 July 2019      Published: 18 September 2019
Corresponding Authors: Changwang Du,Maode Wang     E-mail: dz8981201@126.com;smart5216@163.com;alafate513@163.com;jiawang_xjtu@163.com;943133953@qq.com;duchang1981@163.com;maodewang@163.com
About author: Zhong Deng, MD, Department of Neurosurgery, Center of Brain Science, the First Affiliated Hospital of Xi’an Jiaotong University, China. He specializes in brain tumor minimally invasive craniotomy, experimental tumor biology, and immune therapy in glioblastoma (GBM). Email: dz8981201@126.com.|Hai Yu, Department of Neurosurgery, Center of Brain Science, the First Affiliated Hospital of Xi’an Jiaotong University, China. He specializes in brain tumor minimally invasive craniotomy and tumor heterogeneity in GBM. Email: smart5216@163.com.|Ning Wang, MD, Department of Neurosurgery, the First Affiliated Hospital of Xi’an Jiaotong University, China. He specializes in minimally invasive craniotomy for brain tumors, hypertensive hemorrhage, and spinal disease. Email: 8115411@qq.com.|Wahap Alafate, MD, Department of Neurosurgery, Center of Brain Science, the First Affiliated Hospital of Xi’an Jiaotong University, China. He specializes in chemotherapy and radiation therapy resistance in GBM. Email: alafate513@163.com.|Jia Wang, MD, Department of Neurosurgery, Center of Brain Science, the First Affiliated Hospital of Xi’an Jiaotong University, China. He specializes in minimally invasive craniotomy for brain tumors and hypertensive hemorrhage and experimental chemotherapy and radiation therapy resistance in GBM. Email: jiawang_xjtu@163.com.|Tuo Wang, MD, Department of Neurosurgery, the First Affiliated Hospital of Xi’an Jiaotong University, China. He specializes in minimally invasive craniotomy for skull base diseases, including meningioma, craniopharyngioma, and medulloblastoma. Email: 943133953@qq.com.|Changwang Du, MD, Department of Neurosurgery, the First Affiliated Hospital of Xi’an Jiaotong University, China. He specializes in minimally invasive surgical treatment for brain tumors, hypertensive hemorrhage, Parkinson’s disease, and epilepsy, among others, and in experimental brain tumor biology and three-dimensional imaging. Email: duchang1981@163.com.|Maode Wang, MD, Department of Neurosurgery, Center of Brain Science, the First Affiliated Hospital of Xi’an Jiaotong University, China. He specializes in minimally invasive surgical treatment for brain tumors, hypertensive hemorrhage, Parkinson’s disease and other functional diseases and in experimental tumor biology, heterogeneity, chemotherapy and radiation therapy resistance, and immune therapy. Email: maodewang@163.com.
Cite this article:

Zhong Deng,Hai Yu,Ning Wang,Wahap Alafate,Jia Wang,Tuo Wang,Changwang Du,Maode Wang. Impact of preoperative Karnofsky Performance Scale (KPS) and American Society of Anesthesiologists (ASA) scores on perioperative complications in patients with recurrent glioma undergoing repeated operation. Journal of Neurorestoratology, 2019, 7: 143-152.

URL:

http://jnr.tsinghuajournals.com/10.26599/JNR.2019.9040015     OR     http://jnr.tsinghuajournals.com/Y2019/V7/I3/143

ComplicationsIncidence, n (%)
Extent of resection
GTR79 (82.3)
STR14 (14.5)
PR3 (3.1)
Death within 30 days5 (5.2)
Re-operation1 (1.0)
Hemorrhage4 (4.2)
Severe edema3 (3.1)
Hydrocephalus1 (1.0)
Neurological deficit19 (19.8)
Intracranial infection26 (27.0)
Seizure13 (13.5)
Systemic infection10 (10.4)
Pulmonary infection9 (9.7)
Urinary infection1 (1.0)
Venous thrombosis0 (0)
CSF leak21 (31.8)
Porencephalia3 (3.1)
Severe complication7 (7.3)
CNS complication54 (56.3)
Systemic complication10 (10.4)
Total complication60 (62.5)
Table 1Types of complications in 96 patients.
VariableKPS ≤ 70(n = 11)KPS > 70(n = 85)p value
Sex (male), n (%)4 (36.4)49 (57.6)0.182
Age (years)45 ± 1545 ± 100.032
Body mass index (kg/m2)21.3 ± 2.723.6 ± 3.10.897
Tumor stroke < 0.001
Hemorrhagic stroke, n (%)6 (54.5)2 (2.4)
Ischemic stroke, n (%)0 (0)4 (4.7)
Hypertension, n (%)2 (18.2)7 (8.2)0.287
Diabetes Mellitus, n (%)0 (0)2 (2.4)0.607
Cardiovascular Disease, n (%)0 (0)2 (2.4)0.607
Chronic Lung Disease, n (%)0 (0)1 (1.2)0.718
Smoking, n (%)1 (9.1)12 (14.1)0.647
Drinking, n (%)2 (18.2)9 (10.6)0.457
White blood cells (109/L)8.7 ± 4.16.2 ± 2.90.019
Platelet count (109/L)162 ± 52162 ± 450.570
Hemoglobin (g/L)13.0 ± 17.4138.1 ± 17.70.695
PT (s)12.7 ± 0.812.5 ± 1.00.516
APTT (s)31.8 ± 5.533.3 ± 4.80.679
Albumin (g/L)43.1 ± 5.941.0 ± 3.30.023
PNI43.1 ± 5.941.0 ± 3.30.023
Tumor Size (cm)5.5 ± 0.94.9 ± 1.60.352
Tumor Location, n (%) 0.686
Frontal3 (27.3)35 (41.2)
Temporal3 (27.3)14 (16.5)
Parietal0 (0)6 (7.1)
Occipital0 (0)2 (2.4)
Thalamus5 (45.5)23 (27.1)
Multiple location0 (0)2 (2.4)
Infratentorial0 (0)3 (3.5)
Tumor Grade, n (%) 0.760
WHO I0 (0)5 (5.9)
WHO Ⅱ6 (54.5)35 (41.2)
WHO Ⅲ4 (36.4)35 (41.2)
WHO Ⅳ1 (9.1)10 (11.8)
Table 2Clinical and pathological characteristics stratified by KPS in 96 patients received repeated surgery.
VariableASA = 1~2(n = 52)ASA = 3~4 (n = 44)p value
Sex (male), n (%)33 (63.5)20 (45.5)0.077
Age (years)46 ± 844 ± 120.020
Body mass index (kg/m2)23.3 ± 2.923.3 ± 3.50.451
Tumor stroke 0.019
Hemorrhagic stroke, n (%)1 (1.9)7 (15.9)
Ischemic stroke, n (%)1 (1.9)3 (6.8)
Hypertension, n (%)4 (7.7)5 (11.4)0.539
Diabetes Mellitus, n (%)1 (1.9)1 (2.3)0.905
Cardiovascular Disease, n (%)1 (1.9)1 (2.3)0.905
Chronic Lung Disease, n (%)0 (0)1 (2.3)0.274
Smoking, n (%)6 (11.5)7 (15.9)0.533
Drinking, n (%)3 (5.8)8 (18.2)0.057
White blood cells (109/L)5.8 ± 1.97.3 ± 4.00.002
Platelet count (109/L)157 ± 44170 ± 480.798
Hemoglobin (g/L)138 ± 15138 ± 210.106
PT (s)12.6 ± 1.012.4 ± 0.90.906
APTT (s)32.1 ± 3.734.4 ± 5.70.027
Albumin (g/L)40.4 ± 3.142.3 ± 4.10.280
PNI40.4 ± 3.142.3± 4.10.281
Tumor Size (cm)5.0 ± 1.55.0 ± 1.50.735
Tumor Location, n (%) 0.935
Frontal22 (42.3)16 (36.4)
Temporal8 (15.4)9 (20.5)
Parietal4 (7.7)2 (4.5)
Occipital1 (1.9)1 (2.3)
Thalamus15 (28.8)13 (29.5)
Multiple location1 (1.9)1 (2.3)
Infratentorial1 (1.9)2 (4.5)
Tumor Grade, n (%) 0.422
WHO Ⅰ4 (7.7)1 (2.3)
WHO Ⅱ23 (44.2)18 (40.9)
WHO Ⅲ18 (34.6)21 (47.7)
WHO Ⅳ7 (13.5)4 (9.1)
Table 3Clinical and pathological characteristics stratified by ASA score in 96 patients received repeated surgery.
ComplicationsKPS ≤ 70(n = 11)KPS > 70(n = 85)p value
Emergency surgery4 (36.4)4 (4.7)< 0.001
Operation Duration (h)3.6 ± 1.04.6 ± 1.90.143
Blood-loss (mL)639 ± 326567 ± 4480.590
Extent of resection, n (%) 0.779
GTR9 (81.8)70 (82.4)
STR2 (18.2)12 (14.1)
PR0 (0)3 (3.5)
NICU duration(days)2 ± 14 ± 70.313
Death within 30 days0 (0)5 (5.9)0.409
Re-operation, n (%)0 (0)1 (1.2)0.718
Hemorrhage, n (%)0 (0)4 (4.7)0.462
Severe edema, n (%)0 (0)3 (3.5)0.527
Hydrocephalus, n (%)0 (0)1 (1.2)0.718
Neurological deficit, n (%)3 (27.3)16 (18.8)0.508
Intracranial infection, n (%)4 (36.4)22 (25.9)0.462
Seizure, n (%)2 (18.2)11 (12.9)0.633
Systemic infection, n (%) 0.936
Pulmonary infection, n (%)1 (9.1)8 (9.4)
Urinary infection, n (%)0 (0)1 (1.2)
Venous thrombosis, n (%)0 (0)0 (0)
CSF leak, n (%)1(9.1)20 (23.5)0.276
Porencephalia, n (%)0 (0)3 (3.1)0.527
Severe complication, n (%)0 (0)7 (8.2)0.323
CNS complication, n (%)5 (45.5)49 (57.6)0.443
Systemic complication, n (%)1 (9.1)9 (10.6)0.878
Total complication, n (%)5 (45.5)55 (64.7)0.215
Table 4Comparison of complications in patients received repeated surgery classified by KPS.
ComplicationsASA = 1~2(n = 52)ASA = 3~4(n = 44)p value
Emergency surgery1 (1.9)7 (15.9)0.013
Operation Duration (h)4.7 ± 1.84.4 ± 20.824
Blood-loss (mL)545 ± 458611 ± 4090.990
Extent of resection, n (%) 0.041
GTR47 (90.4)32 (72.7)
STR5 (9.6)9 (20.5)
PR0 (0)3 (6.8)
NICU duration(days)4 ± 84 ± 60.829
Death within 30 days2 (3.8)3 (6.8)0.514
Re-operation, n (%)0 (0)1 (2.3)0.274
Hemorrhage, n (%)1 (1.9)3 (6.8)0.232
Severe edema, n (%)1 (1.9)2 (4.5)0.462
Hydrocephalus, n (%)0 (0)1 (2.3)0.274
Neurological deficit, n (%)9 (17.3)10 (22.7)0.507
Intracranial infection, n (%)15 (28.8)11 (25.0)0.673
Seizure, n (%)6 (11.5)7 (15.9)0.533
Systemic infection, n (%) 0.445
Pulmonary infection, n (%)4 (7.7)5 (11.4)
Urinary infection, n (%)0 (0)1 (2.3)
Venous thrombosis, n (%)0 (0)0 (0)
CSF leak, n (%)11 (21.2)10 (22.7)0.853
Porencephalia, n (%)0 (0)3 (6.8)0.056
Severe complication, n (%)2 (3.8)5 (11.4)0.158
CNS complication, n (%)29 (55.8)25 (56.8)0.918
Systemic complication, n (%)4 (7.7)6 (13.6)0.342
Total complication, n (%)32 (61.5)28 (63.6)0.832
Table 5Comparison of complications between ASA score 1~2 and 3~4.
VariableSevere complicationsCNS complicationsTotal complications
Univariate analysis HR (95% CI)p valueUnivariate analysis HR (95% CI)p valueUnivariate analysis HR (95% CI)p value
Sex (Male)0.482 (0.043~5.331)0.5512.630 (0.948~7.292)0.0632.540 (0.851~7.584)0.095
Age (≥ 65) 0.9980.671 (0.041~10.852)0.7780.790 (0.047~13.288)0.870
KPS (< 70) 0.9981.878 (0.353~10.006)0.460 0.217
ASA score (ASA 3~4)0.221 (0.023~2.137)0.1921.112 (0.416~2.972)0.8331.112 (0.393~3.148)0.842
BMI0.858 (0.576~1.279)0.4521.057 (0.891~1.255)0.5220.996 (0.836~1.186)0.965
PNI1.159 (0.853~1.575)0.3461.088 (0.957~1.238)0.1971.175 (1.021~1.353)0.025
Hypertension (Yes) 0.9990.236 (0.029~1.899)0.1750.200 (0.022~1.854)0.157
Diabetes (Yes) 0.999 0.999 0.999
Smoking (Yes)0.541 (0.035~8.305)0.6601.686 (0.394~7.224)0.4811.540 (0.351~6.753)0.567
Tumor size (≥ 5cm)0.153 (0.015~1.532)0.1100.484 (0.176~1.331)0.1600.453 (0.154~1.338)0.152
Location (Supratentorial)14.073 (0.650~332.616)0.0911.525 (0.110~21.228)0.754 0.999
Tumor stoke (Yes) 0.9983.020 (0.277~32.984)0.3653.848 (0.313~47.242)0.292
Emergency (Yes) 0.9980.848 (0.051~14.099)0.9091.033 (0.053~20.033)0.983
Table 6Multivariable analysis for severe complications, CNS complications and total complications after repeated surgery.
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