Skip to main content

Advertisement

SpringerLink
Log in

Prognostic value of the Duke Activity Status Index (DASI) in patients undergoing colorectal surgery

  • Original Scientific Report
  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Background

Complications are common after colorectal surgery and remain a target for quality improvement. Lower preoperative physical functioning is associated with poor postoperative outcomes, but assessment often relies on subjective judgment or resource-intensive tests. Recent literature suggests that self-reported functional capacity, measured using the Duke Activity Status Index (DASI), is a strong predictor of postoperative outcomes. This study aimed to estimate the extent to which DASI predicts 30-day complications after colorectal surgery.

Methods

In this observational study, 100 patients undergoing colorectal resection [median age 63, 57% men, 81% laparoscopic, 37% rectal surgery] responded to DASI two weeks preoperatively. Complications were classified according to Clavien–Dindo and quantified using the comprehensive complication index (CCI). Our primary analysis targeted the relationship between preoperative DASI and odds of complications. Secondary analyses focused on 30-day severe complications, CCI, readmissions, and length of stay (LOS). We also explored the predictive ability of DASI with scores dichotomized based on a previously validated threshold (≤ 34).

Results

Mean preoperative DASI was 48 ± 12. Forty-six patients (46%) experienced 30-day complications (8% severe, CCI 9.6 ± 15). Lower DASI scores were associated with higher odds of complications (OR 1.08, 95%CI 1.03–1.14; p = 0.001). Preoperative DASI was also an independent predictor of severe complications, CCI, and readmissions. The predictive ability was supported when scores were dichotomized at ≤ 34.

Conclusion

DASI is a significant predictor of postoperative complications after colorectal surgery. This questionnaire can be easily implemented in clinical practice to identify patients with low preoperative functional capacity and target interventions to those at higher risk.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Archer S, Pinto A, Vuik S et al (2019) Surgery, complications, and quality of life: a longitudinal cohort study exploring the role of psychosocial factors. Ann Surg 270:95–101. https://doi.org/10.1097/SLA.0000000000002745

    Article  PubMed  Google Scholar 

  2. Brown SR, Mathew R, Keding A et al (2014) The impact of postoperative complications on long-term quality of life after curative colorectal cancer surgery. Ann Surg 259:916–923. https://doi.org/10.1097/SLA.0000000000000407

    Article  PubMed  Google Scholar 

  3. Khuri SF, Henderson WG, DePalma RG et al (2015) Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 242:326–343

    Article  Google Scholar 

  4. Birkmeyer JD, Gust C, Dimick JB et al (2012) Hospital quality and the cost of inpatient surgery in the United States. Ann Surg 255:1–5. https://doi.org/10.1097/SLA.0b013e3182402c17

    Article  PubMed  Google Scholar 

  5. Vonlanthen R, Slankamenac K, Breitenstein S et al (2011) The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients. Ann Surg 254:907–913. https://doi.org/10.1097/SLA.0b013e31821d4a43

    Article  PubMed  Google Scholar 

  6. Schilling PL, Dimick JB, Birkmeyer JD (2008) Prioritizing quality improvement in general surgery. J Am Coll Surg 207:698–704. https://doi.org/10.1016/j.jamcollsurg.2008.06.138

    Article  PubMed  Google Scholar 

  7. Scarborough JE, Schumacher J, Kent KC et al (2017) Associations of specific postoperative complications with outcomes after elective colon resection: a procedure-targeted approach toward surgical quality improvement. JAMA Surg 152:e164681

    Article  PubMed  Google Scholar 

  8. Marres CCM, van de Ven AWH, Verbeek PCM et al (2016) The effect of a postoperative quality improvement program on outcomes in colorectal surgery in a community hospital. Int J Colorectal Dis 31:1603–1609. https://doi.org/10.1007/s00384-016-2619-1

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Biccard BM (2005) Relationship between the inability to climb two flights of stairs and outcome after major non-cardiac surgery: implications for the pre-operative assessment of functional capacity. Anaesthesia 60:588–593. https://doi.org/10.1111/j.1365-2044.2005.04181.x

    Article  CAS  PubMed  Google Scholar 

  10. Fleisher LA, Fleischmann KE, Auerbach AD et al (2014) 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American college of cardiology/American heart association task force on practice guidelines. Circulation 130:2215–2245. https://doi.org/10.1161/CIR.0000000000000105

    Article  PubMed  Google Scholar 

  11. Kristensen SD, Knuuti J, Saraste A et al (2014) 2014 ESC/ESA guidelines on non-cardiac surgery: cardiovascular assessment and management: the joint task force on non-cardiac surgery: cardiovascular assessment and management of the European society of cardiology (ESC) and the European society of anaesthesiology (ESA). Eur Heart J 35:2383–2431

    Article  PubMed  Google Scholar 

  12. Melon CC, Eshtiaghi P, Luksun WJ et al (2014) Validated questionnaire vs physicians’ judgment to estimate preoperative exercise capacity. JAMA Intern Med 174:1507–1508

    Article  PubMed  Google Scholar 

  13. Stokes JW, Wanderer JP, McEvoy MD (2016) Significant discrepancies exist between clinician assessment and patient self-assessment of functional capacity by validated scoring tools during preoperative evaluation. Perioper Med (Lond) 5:18

    Article  Google Scholar 

  14. Wijeysundera DN, Pearse RM, Shulman MA et al (2018) Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet 391:2631–2640

    Article  PubMed  Google Scholar 

  15. Richardson K, Levett DZH, Jack S et al (2017) Fit for surgery? Perspectives on preoperative exercise testing and training. Br J Anaesth 119:i34–i43

    Article  CAS  PubMed  Google Scholar 

  16. Levett DZH, Jack S, Swart M et al (2018) Perioperative cardiopulmonary exercise testing (CPET): consensus clinical guidelines on indications, organization, conduct, and physiological interpretation. Br J Anaesth 120:484–500. https://doi.org/10.1016/j.bja.2017.10.020

    Article  CAS  PubMed  Google Scholar 

  17. Sinclair RCF, Batterham AM, Davies S et al (2012) Validity of the 6 min walk test in prediction of the anaerobic threshold before major non-cardiac surgery. Br J Anaesth 108:30–35. https://doi.org/10.1093/bja/aer322

    Article  CAS  PubMed  Google Scholar 

  18. Lee L, Schwartzman K, Carli F et al (2013) The association of the distance walked in 6 min with pre-operative peak oxygen consumption and complications 1 month after colorectal resection. Anaesthesia 68:811–816. https://doi.org/10.1111/anae.12329

    Article  CAS  PubMed  Google Scholar 

  19. ATS committee on proficiency standards for clinical pulmonary function laboratories, (2002) ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 166:111–117. https://doi.org/10.1164/ajrccm.166.1.at1102

    Article  Google Scholar 

  20. American Thoracic Society; American College of Chest Physicians (2003) ATS/ACCP statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med 167:211–277. https://doi.org/10.1164/rccm.167.2.211

    Article  Google Scholar 

  21. Hlatky MA, Boineau RE, Higginbotham MB et al (1989) A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol 64:651–654. https://doi.org/10.1016/0002-9149(89)90496-7

    Article  CAS  PubMed  Google Scholar 

  22. Hanley C, Wijeysundera DN, Duminda N (2021) Perioperative risk assessment - focus on functional capacity. Curr Opin Anaesthesiol 34(3):309–316. https://doi.org/10.1097/ACO.0000000000000988

    Article  PubMed  Google Scholar 

  23. Wijeysundera DN, Beattie WS, Hillis GS et al (2020) Integration of the duke activity status index into preoperative risk evaluation: a multicentre prospective cohort study. Br J Anaesth 124:261–270. https://doi.org/10.1016/j.bja.2019.11.025

    Article  PubMed  Google Scholar 

  24. Shulman MA, Cuthbertson BH, Wijeysundera DN et al (2019) Using the 6-minute walk test to predict disability-free survival after major surgery. Br J Anaesth 122:111–119. https://doi.org/10.1016/j.bja.2018.08.016

    Article  CAS  PubMed  Google Scholar 

  25. Fiore JF Jr, Castelino T, Pecorelli N et al (2017) Ensuring early mobilization within an enhanced recovery program for colorectal surgery: a randomized controlled trial. Ann Surg 266:223–231. https://doi.org/10.1097/SLA.0000000000002114

    Article  PubMed  Google Scholar 

  26. Lee L, Mata J, Ghitulescu GA et al (2015) Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg 262:1026–1033. https://doi.org/10.1097/SLA.0000000000001019

    Article  PubMed  Google Scholar 

  27. Gustafsson UO, Scott MJ, Schwenk W et al (2013) Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS(®)) society recommendations. World J Surg 37:259–284. https://doi.org/10.1007/s00268-012-1772-0

    Article  CAS  PubMed  Google Scholar 

  28. Lassen K, Soop M, Nygren J et al (2009) Consensus review of optimal perioperative care in colorectal surgery: enhanced recovery after surgery (ERAS) group recommendations. Arch Surg 144:961–969. https://doi.org/10.1001/archsurg.2009.170

    Article  PubMed  Google Scholar 

  29. Von Elm E, Altman DG, Egger M et al (2007) The Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 147(8):573–577. https://doi.org/10.7326/0003-4819-147-8-200710160-00010

    Article  Google Scholar 

  30. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae

    Article  PubMed  PubMed Central  Google Scholar 

  31. Slankamenac K, Graf R, Barkun J et al (2013) The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 258:1–7. https://doi.org/10.1097/SLA.0b013e318296c732

    Article  PubMed  Google Scholar 

  32. Hendry PO, Hausel J, Nygren J et al (2009) Determinants of outcome after colorectal resection within an enhanced recovery programme. Br J Surg 96:197–205. https://doi.org/10.1002/bjs.6445

    Article  CAS  PubMed  Google Scholar 

  33. Kirchhoff P, Clavien PA, Hahnloser D (2010) Complications in colorectal surgery: risk factors and preventive strategies. Patient Saf Surg 4:5. https://doi.org/10.1186/1754-9493-4-5

    Article  PubMed  PubMed Central  Google Scholar 

  34. Lee CHA, Kong JC, Ismail H et al (2018) Systematic review and meta-analysis of objective assessment of physical fitness in patients undergoing colorectal cancer surgery. Dis Colon Rectum 61(3):400–409. https://doi.org/10.1097/DCR.0000000000001017

    Article  PubMed  Google Scholar 

  35. Clavien PA, Vetter D, Staiger RD et al (2017) The comprehensive complication index (CCI®): added value and clinical perspectives 3 years “down the line.” Ann Surg 265:1045–1050. https://doi.org/10.1097/SLA.0000000000002132

    Article  PubMed  Google Scholar 

  36. Banugo P, Amoako D (2017) Prehabilitation. BJA. Education 17:401–405

    Google Scholar 

  37. Fry BT, Hallway A, Englesbe MJ (2018) Moving toward every patient training for surgery. JAMA Surg 153:1089. https://doi.org/10.1001/jamasurg.2018.1658

    Article  PubMed  Google Scholar 

  38. Wynter-Blyth V, Moorthy K (2017) Prehabilitation: preparing patients for surgery. BMJ 358:j3702

    Article  PubMed  Google Scholar 

  39. Carli F, Bousquet-Dion G, Awasthi R et al (2020) Effect of multimodal prehabilitation vs postoperative rehabilitation on 30-day postoperative complications for frail patients undergoing resection of colorectal cancer: a randomized clinical trial. JAMA Surg 155:233–242. https://doi.org/10.1001/jamasurg.2019.5474

    Article  PubMed  PubMed Central  Google Scholar 

  40. Hijazi Y, Gondal U, Aziz O (2017) A systematic review of prehabilitation programs in abdominal cancer surgery. Int J Surg 39:156–162. https://doi.org/10.1016/j.ijsu.2017.01.111

    Article  PubMed  Google Scholar 

  41. Thomas G, Tahir MR, Bongers BC et al (2019) Prehabilitation before major intra-abdominal cancer surgery: a systematic review of randomised controlled trials. Eur J Anaesthesiol 36:933–945. https://doi.org/10.1097/EJA.0000000000001030

    Article  PubMed  PubMed Central  Google Scholar 

  42. Riedel B, Li MHG, Lee CHA et al (2021) A simplified (modified) duke activity status index (M-DASI) to characterise functional capacity: a secondary analysis of the measurement of exercise tolerance before surgery (METS) study. Br J Anaesth 126:181–190. https://doi.org/10.1016/j.bja.2020.06.016

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank Tanya Castelino (Department of Surgery, McGill University), Petru Niculiseanu (Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University), Julia Munden (Department of Anesthesia, McGill University), Meagan Barrett-Bernstein (Department of Anesthesia, McGill University), Enrico M. Minnella (Department of Anesthesia, McGill University), and Berson Augustin (Department of Anesthesia, McGill University) for their assistance with patient recruitment and follow-up. We also acknowledge Pepa Kaneva (Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University) for her administrative and technical support during the study.

Funding

This study was supported by a MITACS Elevate Postdoctoral Fellowship (Ref. IT02887). The funder had no role in the design, data collection and analysis, preparation or decision to publish the manuscript. Dr. Fiore Jr. reported receiving research funding from Merck and receiving honorarium as a research consultant to Shionogi. Dr. Feldman reported receiving research funding from Merck and Johnson & Johnson and an educational grant from Medtronic. Dr. Lee reported receiving research funding from Johnson & Johnson. No other authors reported relevant disclosures.

Author information

Authors and Affiliations

  1. Division of Experimental Surgery, McGill University, Montreal, QC, Canada

    Charbel El-Kefraoui, Fateme Rajabiyazdi, Lawrence Lee, Liane S. Feldman & Julio F. Fiore Jr.

  2. Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada

    Charbel El-Kefraoui, Fateme Rajabiyazdi, Lawrence Lee, Liane S. Feldman & Julio F. Fiore Jr.

  3. Pancreas Translational & Clinical Research Center, San Raffaele Hospital, Milan, Italy

    Nicolò Pecorelli

  4. Department of Anesthesia, McGill University, Montreal, QC, Canada

    Franco Carli

  5. Department of Surgery, McGill University, Montreal, QC, Canada

    Lawrence Lee, Liane S. Feldman & Julio F. Fiore Jr.

  6. Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada

    Lawrence Lee, Liane S. Feldman & Julio F. Fiore Jr.

Authors
  1. Charbel El-Kefraoui
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Fateme Rajabiyazdi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nicolò Pecorelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Franco Carli
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Lawrence Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Liane S. Feldman
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Julio F. Fiore Jr.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Julio F. Fiore Jr..

Ethics declarations

Ethical approval

The institutional review board approved the original study (MUHC Research Ethics Board ref. 13–329-SDR).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 89 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

El-Kefraoui, C., Rajabiyazdi, F., Pecorelli, N. et al. Prognostic value of the Duke Activity Status Index (DASI) in patients undergoing colorectal surgery. World J Surg 45, 3677–3685 (2021). https://doi.org/10.1007/s00268-021-06256-4

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-021-06256-4

Search

Navigation