Postoperative complications in patients with rectal cancer are associated with delays in chemotherapy that lead to worse disease-free and overall survival

Enhanced recovery protocol improves postoperative outcomes and minimizes narcotic use following resection for colon and rectal cancer

Background

Enhanced recovery protocols are associated with improved recovery. However, data on outcomes following the implementation of an enhanced recovery protocol in colorectal cancer are limited. We set out to study the postoperative outcomes, opioid use patterns, and cost impact for patients undergoing colon or rectal resection for cancer.

Methods

A retrospective review of all elective colorectal cancer resections from January 2015 to June 2018 at a single institution was performed. Patient demographics, operative details, and postoperative outcomes were collected. Colon and rectal patients were studied separately, with comparison of patients before and after the implementation of an enhanced recovery protocol.

Results

One hundred ninety-two patients underwent elective colorectal resection for cancer. In January 2016, an enhanced recovery protocol was implemented for all elective resections - 71 patients (33 colon and 38 rectal) underwent surgery before implementation and 121 patients (56 colon and 65 rectal) underwent surgery after implementation of the enhanced recovery protocol. There were no differences with regard to age, gender, or body mass index before or after implementation (all P > .05). For both colon and rectal cancer patients, the enhanced recovery protocol reduced time to regular diet (both P < .05) and length of stay (colon: 3 vs 4 days; rectal: 4 vs 6 days; both P < .01). Enhanced recovery protocol patients also consumed fewer total narcotics (colon: 44 vs 184 morphine milligram equivalents, P < .01; rectal: 121 vs 393 morphine milligram equivalents, P < .01).

Conclusions

Enhanced recovery protocol use reduced length of stay and narcotic use with similar total costs and no difference in 30-day complications for both colon and rectal cancer resections.

Impacts of the surgical safety checklist on postoperative clinical outcomes in gastrointestinal tumor patients: A single-center cohort study

A 19-item surgical safety checklist (SSC) was published by the World Health Organization in 2008 and was proved to reduce postoperative complications. To date, however, the impacts of SSC implementation in China have not been evaluated clearly. The study was performed to evaluate the impacts of the SSC on postoperative clinical outcomes in gastrointestinal tumor patients.Between April 2007 and March 2013, 7209 patients with gastrointestinal tumor who underwent elective surgery at the Affiliated Hospital of Qingdao University were studied. Data on the clinical records and outcomes of 3238 consecutive surgeries prior to SSC implementation were retrospectively collected; data on another 3971 consecutive surgeries performed after SSC implementation were prospectively collected. The clinical outcomes (including mortality, morbidity, readmission, reoperation, unplanned intervention and postoperative hospital stay) within postoperative 30 days were compared between the two groups. Univariate and multivariate logistic regression analysis were performed to identify independent factors for postoperative complications.The rates of morbidity and in-hospital mortality before and after SSC implementation were 16.43% vs 14.33% (P = .018), 0.46% vs 0.18% (P = .028), respectively. Median of postoperative hospital stay in post-implementation group was shorter than that in pre-implementation group (8 vs 9 days, P < .001). Multivariable analysis demonstrated that the SSC was an independent factor influencing postoperative complications (odds ratio = 0.860; 95% CI, 0.750-0.988).Implementation of the SSC could improve the clinical outcomes in gastrointestinal tumor patients undergoing elective surgery in China.

Increased Levels of Genomic Instability and Mutations in Homologous Recombination Genes in Locally Advanced Rectal Carcinomas

Pre-operative 5-fluoracil-based chemoradiotherapy (nCRT) is the standard treatment for patients with locally advanced rectal cancer (LARC). Patients with pathological complete response (pCR–0% of tumor cells in the surgical specimen after nCRT) have better overall survival and lower risk of recurrence in comparison with incomplete responders (pIR). Predictive biomarkers to be used for new therapeutic strategies and capable of stratifying patients to avoid overtreatment are needed. We evaluated the genomic profiles of 33 pre-treatment LARC biopsies using SNP array and targeted-next generation sequencing (tNGS). Based on the large number of identified genomic alterations, we calculated the genomic instability index (GII) and three homologous recombination deficiency (HRD) scores, which have been reported as impaired DNA repair markers. We observed high GII in our LARC cases, which was confirmed in 165 rectal cancer cases from TCGA. Patients with pCR presented higher GII compared with pIR. Moreover, a negative correlation between GII and the fraction of tumor cells remaining after surgery was observed (ρ = –0.382, P = 0.02). High HRD scores were detected in 61% of LARC, of which 70% were incomplete responders. Using tNGS (105 cancer-related genes, 13 involved in HR and 5 in mismatch repair pathways), we identified 23% of cases with mutations in HR genes, mostly in pIR cases (86% of mutated cases). In agreement, the analysis of the TCGA dataset (N = 145) revealed 21% of tumors with mutations in HR genes. The HRD scores were shown to be predictive of better response to PARP-inhibitors and platinum-based chemotherapy in breast and ovarian cancer. Our results suggest that the same strategy could be applied in a set of LARC patients with HRD. In conclusion, we identified high genomic instability in LARC, which was related to alterations in the HR pathway, especially in pIR. These findings suggest that patients with impaired HRD would clinically benefit from PARP-inhibitors and platinum-based therapy.

The impact of improved functional capacity before surgery on postoperative complications: a study in colorectal cancer

Background: Poor functional capacity (FC) is an independent predictor of postoperative morbidity. However, there is still a lack of evidence as to whether enhancing FC before surgery has a protective effect on postoperative complications. The purpose of this study was to determine whether an improvement in preoperative FC impacted positively on surgical morbidity. Methods: This was a secondary analysis of a cohort of patients who underwent colorectal resection for cancer under Enhanced Recovery After Surgery care. FC was assessed with the 6-min walk test, which measures the distance walked in 6 min (6MWD), at 4 weeks before surgery and again the day before. The study population was classified into two groups depending on whether participants achieved a significant improvement in FC preoperatively (defined as a preoperative 6MWD change ≥19 meters) or not (6MWD change <19 meters). The primary outcome measure was 30-d postoperative complications, assessed with the Comprehensive Complication Index (CCI). The association between improved preoperative FC and severe postoperative complication was evaluated using multivariable logistic regression. Results: A total of 179 eligible adults were studied: 80 (44.7%) improved in 6MWD by ≥19 m preoperatively, and 99 (55.3%) did not. Subjects whose FC increased had lower CCI (0 [0-8.7] versus 8.7 [0-22.6], p = .022). Furthermore, they were less likely to have a severe complication (adjusted OR 0.28 (95% CI 0.11-0.74), p = .010), and to have an ED visit. Conclusion: Improved preoperative FC was independently associated with a lower risk of severe postoperative complications. Further investigation is required to establish a causative relationship conclusively.

Clinical and pathological outcomes of induction chemotherapy before neoadjuvant radiotherapy in locally-advanced rectal cancer

Background and Objectives

In North America, preoperative combination chemoradiation is the most commonly recommended and utilized approach to locally advanced rectal cancer. There is increasing interest in the use of induction chemotherapy (IC) before radiation and surgery in locally advanced rectal cancer. How widely IC is being used and whether it improves pathologic and oncologic outcomes is unknown.

Methods

We evaluated clinical stage 2 or 3 rectal cancer patients in the National Cancer Database between 2006 and 2015. We identified predictors of use of IC with multivariable logistic regression and compared survival between groups using Cox proportional hazards regression.

Results

Among 36 268 patients, IC use increased significantly over time from 5.5% in 2006 to 15.9% in 2015 (P < 0.001). Treatment at a hospital with a high IC rate was an independent predictor of receipt of IC. IC and traditional therapy yielded similar pathologic complete response rates (32.2% vs 30.5%, P = 0.2) and similar 5‐year survival (82.4% vs 81.4%, 0.71).

Conclusions

Use of IC for locally advanced rectal cancer has increased significantly. The choice of IC seems to be driven more by institutional and regional practice patterns than clinical characteristics and is not associated with improved pathologic or oncologic outcomes.

A Surgeon's Guide to Treating Older Patients with Colorectal Cancer

PURPOSE OF REVIEW

Review strategies to improve outcomes of colorectal cancer treatment in older patients.

RECENT FINDINGS

Older colorectal patients face many barriers to recovery during their initial inpatient stay following surgery and after leaving the hospital. In addition to the risk of inpatient morbidity and mortality, older patients are more likely to require post-acute care services, to face nutritional deficits, and to experience complications of chemoradiation.

SUMMARY

In order to improve outcomes for older patients with colorectal cancer, it is important for surgeons to recognize their unique needs and to develop plans to address them. The involvement of a multidisciplinary team with geriatric experience can guide planning for surgery, the immediate postoperative recovery, and long-term survivorship.

First, Do No Harm: Rethinking Routine Diversion in Sphincter-Preserving Rectal Cancer Resection

BACKGROUND

Although diverting stomas have reduced anastomotic leak rates after sphincter-preserving proctectomy in some series, the effectiveness of routine diversion among a broad population of rectal cancer patients remains controversial. We hypothesized that routine temporary diversion is not associated with decreased rates of leak or reintervention in cancer patients at large undergoing sphincter-sparing procedures.

STUDY DESIGN

The Florida State Inpatient Database (AHRQ, Healthcare Cost and Utilization Project) was queried for patients undergoing sphincter-preserving proctectomy for cancer (2005 to 2014). Matched cohorts defined by diversion status were created using propensity scores based on patient and hospital characteristics. Incidence of anastomotic leak, nonelective reintervention, and readmission were compared, and cumulative 90-day inpatient costs were calculated.

RESULTS

Of 8,620 eligible sphincter-sparing proctectomy patients, 1,992 matched pairs were analyzed. Leak rates did not significantly vary between groups (4.5% vs 4.3%; p = 0.76), but diversion was associated with significantly higher odds of nonelective reintervention (2.37; 95% CI 1.90 to 2.96) and readmission (1.55; 95% CI 1.33 to 1.81) compared with undiverted patients. Median costs were higher among those diverted (US$21,325 vs US$15,050; p < 0.01).

CONCLUSIONS

No association between diversion and anastomotic leak was found. However, temporary diversion was associated with increased incidence of nonelective reinterventions, readmissions, and higher costs. We therefore challenge the paradigm of routine diversion in rectal cancer operations. Additional study is needed to identify which patients would benefit most from diversion.

Total mesorectal excision with or without preoperative chemoradiotherapy for resectable mid/low rectal cancer: a long-term analysis of a prospective, single-center, randomized trial

BACKGROUND

The preliminary results of our phase II randomized trial reported comparable functional sphincter preservation rates and short-term survival outcomes between patients undergoing total mesorectal excision (TME) with or without preoperative concurrent chemoradiotherapy (CCRT). We now report the long-term results after a median follow-up of 71 months.

METHODS

Between March 23, 2008 and August 2, 2012, 192 patients with T3-T4 or node-positive, resectable, mid/low rectal adenocarcinoma were randomly assigned to receive TME with or without preoperative CCRT. The following endpoints were assessed: cumulative rates of local recurrence and distant metastasis, disease-free survival (DFS), and overall survival (OS).

RESULTS

The data of 184 eligible patients were analyzed: 94 patients in the TME group and 90 patients in the CCRT + TME group. In the whole cohort, the 5-year DFS and OS rates were 84.8% and 85.1%, respectively. The 5-year DFS rates were 85.2% in the CCRT + TME group and 84.3% in the TME group (P = 0.969), and the 5-year OS rates were 83.5% in the CCRT + TME group and 86.5% in the TME group (P = 0.719). The 5-year cumulative rates of local recurrence were 6.3% and 5.0% (P = 0.681), and the 5-year cumulative rates of distant metastasis were 15.0% and 15.7% (P = 0.881) in the CCRT + TME and TME groups, respectively. No significant improvements in 5-year DFS and OS were observed with CCRT by subgroup analyses.

CONCLUSIONS

Both treatment strategies yielded similar long-term outcomes. A selective policy towards preoperative CCRT is thus recommended for rectal cancer patients if high-quality TME surgery and enhanced chemotherapy can be performed. Trial registration ChiCTR-TRC-08000122. Registered 16 July 2008.

Efficacy and safety of consolidation chemotherapy during the resting period in patients with local advanced rectal cancer

It remains controversial as to whether a long interval between neoadjuvant chemoradiotherapy (NCRT) and surgery may provide clinical benefits for patients with local advanced rectal cancer (LARC). The addition of consolidation chemotherapy during the resting period was recently considered as a treatment option. The present study aimed to verify the efficacy and safety of consolidation chemotherapy during the resting period in patients with LARC. A total of 156 patients with local advanced stage T3-4N0-2 rectal cancer were enrolled between January 2010 and July 2016. Patients were divided into two groups, those who received consolidation chemotherapy prior to surgery (n=76) and the control group who did not (n=80). Multivariate logistic regression and the Kaplan-Meier method were used to explore the predictors of pathological complete response (pCR) and survival. The demographic and tumor characteristics were comparable between the two groups. The consolidation group yielded significantly higher pCR and near pCR rates compared with the control group (P=0.015). Patients in the consolidation group who also underwent standard adjuvant chemotherapy displayed improved 3-year disease-free survival (DFS) compared with the control group (P=0.036). Notably, the addition of consolidation chemotherapy between NCRT and surgery did not significantly increase the incidence of surgical complications and grade 3 or 4 toxicities when compared with the control group. Consolidation chemotherapy was associated with increased pCR/near pCR rates and improved 3-year DFS, and displayed a manageable safety profile. The present study provided primary evidence for the efficacy and safety of consolidation chemotherapy in LARC. Further prospective studies are warranted in the future to verify these results.

Cancer Tsunami: Emerging Trends, Economic Burden, and Perioperative Implications

PURPOSE OF REVIEW

This review discusses global trends in cancer mortality and survival, the socioeconomic drivers of those trends, and recent innovations in cancer surgery.

RECENT FINDINGS

Cancer is a leading cause of death worldwide. Cancer, previously a disease primarily of wealthy countries, is rapidly becoming a leading cause of death in low- and middle-income countries. Major economic forces driving global cancer trends include aging, frailty, and obesity. Alcohol consumption, poor diet, and lack of exercise also contribute to cancer types associated with modifiable causes. Surgery is responsible for 65% of cancer care globally, providing an opportunity for anesthesiologists to improve that care. Anesthesiologists can contribute to cancer remission through perioperative interventions that reduce risk of metastasis and speed return to intended oncologic therapy.

SUMMARY

Cancer surgery comprises a large proportion of anesthetic caseload. Good outcomes come from high volume cancer centers using a multidisciplinary approach.

Prognostic Factors of Salvage Esophagectomy for Residual or Recurrent Esophageal Squamous Cell Carcinoma After Definitive Chemoradiotherapy

BACKGROUND

The aim of this study was to confirm prognostic factors for salvage esophagectomy for remnant or recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy.

STUDY DESIGN

We retrospectively analyzed clinicopathological backgrounds of 50 patients who underwent salvage esophagectomy between April 2005 and January 2016. Salvage esophagectomy comprised 40 three-incision esophagectomies, two transhiatal esophagectomies and eight pharyngolaryngoesophagectomies. Independent prognostic factors for overall survival were assessed using Cox regression analysis of the factors.

RESULTS

Salvage esophagectomy remains a highly invasive surgery and correlated with a higher incidence of all morbidities of Clavien-Dindo classification (CDc) ≥II, severe morbidities of CDc ≥ IIIb, any pulmonary morbidities and chylorrhea, compared with those in patients without preoperative definitive chemoradiotherapy. Cox regression analysis suggested that R0 resection (hazard ratio [HR] 6.39; 95% confidence interval [CI] 2.03-9.68, P = 0.002), absence of severe complications (HR 4.97; 95% CI 1.70-14.81, P = 0.004) and early pStage (0-II) (HR 3.42; 95% CI 1.24-10.12, P = 0.018) were independent prognostic factors for salvage esophagectomy.

CONCLUSIONS

Salvage esophagectomy remains correlated with a high incidence of postoperative complications. Avoiding non-curative surgery and reducing the incidence of severe postoperative complications are important if patients are to receive prognostic benefit of this highly invasive surgery.

Impact of postoperative complications on long-term survival following surgery for T4 colorectal cancer

BACKGROUND

Postoperative complications (POCs) after the resection of locally advanced colorectal cancer (CRC) may influence adjuvant treatment timing, outcomes, and survival. This study aimed to evaluate the impact of POCs on long-term outcomes in patients surgically treated for T4 CRC.

METHODS

All consecutive patients who underwent the resection of T4 CRC at a single centre from 2004 to 2013 were retrospectively analysed from a prospectively maintained database. POCs were assessed using the Clavien-Dindo classification. Patients who developed POCs were compared with those who did not in terms of recurrence-free survival (RFS) and overall survival (OS).

RESULTS

The study population comprised 106 patients, including 79 (74.5%) with synchronous distant metastases. Overall, 46 patients (43%) developed at least one POC during the hospital stay, and of those patients, 9 (20%) had severe complications (Clavien-Dindo ≥ grade III). POCs were not associated with OS (65% with POCs vs. 69% without POCs; p = 0.72) or RFS (58% with POCs vs. 70% without POCs; p = 0.37). Similarly, POCs did not affect OS or RFS in patients who had synchronous metastases at diagnosis compared with those who did not.

CONCLUSIONS

POCs do not affect the oncological course of patients subjected to the resection of T4 CRC, even in cases of synchronous metastases.

Does the Surgical Apgar Score predict serious complications after elective major cancer surgery?

BACKGROUND

Major cancer surgery is associated with significant risks of perioperative morbidity and mortality, resulting in delayed adjuvant therapy, higher recurrence rates, and worse overall survival. Previous retrospective studies have used the Surgical Apgar Score (SAS) for perioperative risk assessment. This study prospectively evaluated the predictive value of SAS to predict serious complication (SC) after elective major cancer surgery.

METHODS

Demographic, comorbidity, procedure, and intraoperative data were collected prospectively for 405 patients undergoing elective major cancer surgery between 2014-17. The SAS was calculated immediately postoperative and outcome data were collected prospectively. Rates of SC according to SAS risk category were compared using Cochran-Armitage trend test. Receiver operating characteristic curves and area under the receiver operating characteristic curves were generated and 95% confidence intervals were calculated.

RESULTS

Eighty percent, 17.3%, and 2.7% of patients were low (SAS 7-10), intermediate (SAS 5-6), and high risk (SAS 0-4), respectively, for SC based on their SAS. Forty-six (11.4%) had an SC within 30 days; 3.7% returned to the operating room, 3.7% experienced a urinary tract infection, 3.2% experienced a respiratory complication, 2.7% experienced a wound complication, and 1.2% experienced a cardiac complication. Overall, 9.3%, 18.6%, and 27.3% of patients with SAS 7-10, 5-6, and 0-4 experienced an SC, respectively (P = 0.005). The overall discriminatory ability of the SAS was modest (area under the receiver operating characteristic curves 0.661; 95% confidence intervals, 0.582-0.740).

CONCLUSIONS

Although there was an overall association between SAS and higher risk of subsequent postoperative SC in our cohort, the ability of the SAS to accurately predict risk of postoperative SC at the patient level was limited.

The age-adjusted Charlson comorbidity index as a predictor of survival in surgically treated vulvar cancer patients

Objective

To evaluate the impact of age-adjusted Charlson comorbidity index (ACCI) in predicting disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS) among surgically treated patients with vulvar carcinoma. The secondary aim is to evaluate its impact as a predictor of the pattern of recurrence.

Methods

We retrospectively evaluated data of patients that underwent surgical treatment for vulvar cancer from 1998 to 2016. ACCI at the time of primary surgery was evaluated and patients were classified as low (ACCI 0–1), intermediate (ACCI 2–3), and high risk (>3). DFS, OS and CSS were analyzed using the Kaplan-Meir and the Cox proportional hazard models. Logistic regression model was used to assess predictors of distant and local recurrence.

Results

Seventy-eight patients were included in the study. Twelve were classified as low, 36 as intermediate, and 30 as high risk according to their ACCI. Using multivariate analysis, ACCI class was an independent predictor of worse DFS (hazard ratio [HR]=3.04; 95% confidence interval [CI]=1.54–5.99; p<0.001), OS (HR=5.25; 95% CI=1.63–16.89; p=0.005) and CSS (HR=3.79; 95% CI=1.13–12.78; p=0.03). Positive nodal status (odds ratio=8.46; 95% CI=2.13–33.58; p=0.002) was the only parameter correlated with distant recurrence at logistic regression.

Conclusion

ACCI could be a useful tool in predicting prognosis in surgically treated vulvar cancer patients. Prospective multicenter trials assessing the role of ACCI in vulvar cancer patients are warranted.

BACCHUS: A randomised non-comparative phase II study of neoadjuvant chemotherapy (NACT) in patients with locally advanced rectal cancer (LARC)

BACKGROUND

Chemoradiation (CRT) or short-course radiotherapy (SCRT) are standard treatments for locally advanced rectal cancer (LARC). We evaluated the efficacy/safety of two neoadjuvant chemotherapy (NACT) regimens as an alternative prior to total mesorectal excision (TME).

METHODS/DESIGN

This multi-centre, phase II trial in patients with magnetic resonance imaging (MRI) defined high-risk LARC (>cT3b, cN2+ or extramural venous invasion) randomised patients (1:1) to FOLFOX + Bevacizumab (Arm 1) or FOLFOXIRI + bevacizumab (Arm 2) every 14 days for 6 cycles prior to surgery. Patients were withdrawn if positron emission tomography (PET) standardised uptake value (SUV) after 3 cycles failed to decrease by >30% or increased compared to baseline. Primary endpoint was pathological complete response rate (pCR). Secondary endpoints included adverse events (AE) and toxicity. Neoadjuvant rectal (NAR) scores based on "T" and "N" downstaging were calculated.

FINDINGS

Twenty patients aged 18-75 years were randomised. The trial stopped early because of poor accrual. Seventeen patients completed all 6 cycles of NACT. One stopped due to myocardial infarction, 1 poor response on PET (both received CRT) and 1 committed suicide. 11 patients had G3 AE, 1 G4 AE (neutropenia), and 1 G5 (suicide). pCR (the primary endpoint) was 0/10 for Arm 1 and 2/10 for Arm 2 i.e. 2/20 (10%) overall. Median NAR score was 14·9 with 5 (28%), 7 (39%), and 6 (33%) having low, intermediate, or high scores. Surgical morbidity was acceptable (1/18 wound infection, no anastomotic leak/pelvic sepsis/fistulae). The 24-month progression-free survival rate was 75% (95% CI: 60%-85%).

INTERPRETATION

The primary endpoint (pCR rate) was not met. However, FOLFOXIRI and bevacizumab achieved promising pCR rates, low NAR scores and was well-tolerated. This regimen is suitable for testing as the novel arm against current standards of SCRT and/or CRT in a future trial.

Postoperative complications are associated with worse survival after laparoscopic surgery for non-metastatic colorectal cancer - interim analysis of 3-year overall survival

Introduction

Postoperative morbidity after colorectal resections for cancer remains a significant problem. Data on the influence of complications on survival after laparoscopic colorectal resection are still limited.

Aim

To analyze the impact of postoperative complications on long-term survival after radical laparoscopic resection for colorectal cancer.

Material and methods

Two hundred and sixty-five consecutive non-metastatic colorectal cancer patients undergoing laparoscopic colorectal resection for cancer were included in the analysis. The entire study group was divided into two subgroups based on the occurrence of postoperative complications. Group 1 included patients without postoperative morbidity and group 2 included patients with complications. The primary outcome was overall survival.

Results

Median follow-up was 45 (IQR: 34–55) months. Group 1 consisted of 187 (70.5%) patients and group 2 comprised 78 (29.5%) patients. Studied groups were comparable in terms of sex, age, body mass index, ASA class, cancer staging, localization of the tumor and operative time. Patients in group 1 had significantly better overall 3-year survival compared to those with complications (84.9% vs. 69.8%, p = 0.022). Kaplan-Meier curves showed significantly improved survival rates in patients without complications compared with complicated cases. The Cox proportional multivariate model showed that postoperative complications (HR = 2.83; 95% CI: 1.35–5.92; p = 0.0058) and AJCC III (HR = 3.17; 95% CI: 1.52–6.6; p = 0.0021) were independent predictors of worse survival after laparoscopic colorectal cancer surgery.

Conclusions

Our analysis of interim results after 3 years confirms that complications after laparoscopic colorectal cancer surgery have an impact on survival. For this reason, these patients should be carefully monitored after surgery aiming at early detection of recurrence.

Chemoradiation and Local Excision for T2N0 Rectal Cancer Offers Equivalent Overall Survival Compared to Standard Resection: a National Cancer Database Analysis

BACKGROUND

Local excision (LE) alone is associated with worse survival compared to radical surgery (RS) for T2 rectal cancer, but LE with additional chemoradiation (CRT) may improve outcomes. The objective of this study was to compare combined CRT and LE versus RS for T2 rectal cancer.

METHODS

The 2004-2014 National Cancer Database was queried for patients with T2N0M0 rectal cancer undergoing LE with neoadjuvant(NA-CRT + LE) or adjuvant(LE + Adj-CRT) CRT, or RS. The main outcome was 5-year overall survival (OS). Cox proportional hazards was used to determine the independent effect of treatment on OS.

RESULTS

A total of 4822 patients were included (4367 RS, 242 CRT + LE, 213 LE + Adj-CRT). Mean follow-up was 48.6 (SD28.5) months. There were no differences in patient characteristics, but more high-risk features in the LE + Adj-CRT group. There were no differences in 90-day mortality. Five-year OS was similar (RS 77.4% vs. CRT + LE 76.1% vs. LE + Adj-CRT 79.7%, p = 0.786). Older age, male gender, and higher Charlson score were independently associated with worse OS, whereas treatment type was not. If 90-day mortality was excluded, LE + Adj-CRT was independently associated with worse OS compared to RS.

CONCLUSIONS

CRT with LE for T2N0M0 rectal cancer was not associated with worse OS compared to RS, and may be a viable treatment modality.

Phase II study on early start of chemotherapy after excising primary colorectal cancer with distant metastases (Pearl Star 02)

Initiating chemotherapy usually requires a delay of more than 4 weeks after surgically resecting colorectal cancer. However, there is little evidence regarding the required delay interval. We have previously reported a pilot study to determine the safety and feasibility of early initiation of chemotherapy after resecting primary colorectal cancer with distant metastases. We aimed to determine the safety and efficacy of early initiation of chemotherapy after resecting colorectal cancer with distant metastases.

This phase II study (trial number UMIN000006310) was a prospective, single-arm trial. A total of 20 patients (men, 15 and women, 5) were enrolled. They underwent XELOX therapy (130 mg/m² oxaliplatin on day 1+1000 mg/m² capecitabine twice daily on days 1-4) on postoperative day 7 and XELOX+bevacizumab (7.5 mg/kg bevacizumab on day 1) after the second chemotherapy cycle.

Baseline characteristics included a median age of 64 (range, 43-72) years. Surgical procedures included right hemicolectomy in six patients, sigmoidectomy in three, anterior resection in five, and Hartmann procedure in six. All patients started chemotherapy on postoperative day 7. Median progression-free survival was 14.9 months; overall response rate was 80%. Disease control rate was 100%. Grade 3 or higher hemotoxicity and grade 3 or higher non-hematological toxicity was noted in 5.0% and 25.0% of patients, respectively. Postoperative complications were observed in two patients (superficial incisional surgical site infection and ileus).

Early initiation of chemotherapy after surgery is feasible. These findings suggest future changes of the start time of chemotherapy after surgery.

Trainee-associated outcomes in laparoscopic colectomy for cancer: propensity score analysis accounting for operative time, procedure complexity and patient comorbidity

BACKGROUND

Surgical trainee association with operative outcomes is controversial. Studies are conflicting, possibly due to insufficient control of confounding variables such as operative time, case complexity, and heterogeneous patient populations. As operative complications worsen long-term outcomes in oncologic patients, understanding effect of trainee involvement during laparoscopic colectomy for cancer is of utmost importance. Here, we hypothesized that resident involvement was associated with worsened 30-day mortality and 30-day overall morbidity in this patient population.

METHODS

Patients undergoing laparoscopic colectomy for oncologic diagnosis from 2005 to 2012 were assessed using the American College of Surgeons National Surgical Quality Improvement Program dataset. Propensity score matching accounted for demographics, comorbidities, case complexity, and operative time. Attending only cases were compared to junior, middle, chief resident, and fellow level cohorts to assess primary outcomes of 30-day mortality and 30-day overall morbidity.

RESULTS

A total of 13,211 patients met inclusion criteria, with 4075 (30.8%) cases lacking trainee involvement and 9136 (69.2%) involving a trainee. Following propensity matching, junior (PGY 1-2) and middle level (PGY 3-4) resident involvement was not associated with worsened outcomes. Chief (PGY 5) resident involvement was associated with worsened 30-day overall morbidity (15.5 vs. 18.6%, p = 0.01). Fellow (PGY > 5) involvement was associated with worsened 30-day overall morbidity (16.0 vs. 21.0%, p < 0.001), serious morbidity (9.3 vs. 13.5%, p < 0.001), minor morbidity (9.8 vs. 13.1%, p = 0.002), and surgical site infection (7.9 vs. 10.5%, p = 0.006). No differences were seen in 30-day mortality for any resident level.

CONCLUSION

Following propensity-matched analysis of cancer patients undergoing laparoscopic colectomy, chief residents, and fellows were associated with worsened operative outcomes compared to attending along cases, while junior and mid-level resident outcomes were no different. Further study is necessary to determine what effect the PGY surgical trainee level has on post-operative morbidity in cancer patients undergoing laparoscopic colectomy in the context of multiple collinear factors.

Morphologic change of the psoas muscle as a surrogate marker of sarcopenia and predictor of complications after colorectal cancer surgery

PURPOSE

Sarcopenia is reported to be associated with complications after surgery. However, there is no established optimal parameter to determine sarcopenia affecting surgical outcome. This study investigated whether morphologic change of the psoas muscle (MPM) reflects sarcopenia and could be a predictor of complications after colorectal cancer surgery.

METHODS

Colorectal cancer patients who underwent primary tumor resection with anastomosis between 2015 and 2016 were analyzed. MPM score was evaluated as the ratio of the short-to-long axis of the psoas muscle in CT images at the L3 vertebrae and classified into five MPM grades. Then, the impact of MPM grade on development of postoperative complications was investigated.

RESULTS

A total of 133 patients were studied. MPM score was significantly correlated to the sectional areas of the psoas muscle at the L3 vertebrae which was evaluated by manual tracing. 21.1% of the subjects were classified into severe MPM (defined as MPM grade 3-4). Overall and infectious complications were noted in 37 (27.8%) and 16 (12.0%) patients. Severe MPM (odds ratio [OR] 2.71, 95% confidence interval [CI] 1.09-6.73), longer operative time (OR 1.01, 95%CI 1.001-1.01), and open surgery (OR 2.73, 95%CI 1.17-6.35) were identified as independent risk factors of overall complications. Severe MPM (OR 4.26,95%CI 1.38-13.10) and open surgery (OR 3.42, 95%CI 1.11-10.48) were identified as independent factors associated with infectious complications.

CONCLUSIONS

MPM grade may be used as a simple and convenient marker of sarcopenia and to identify patients at increased risk of complications after colorectal cancer surgery.

Optimal fractionation of preoperative radiotherapy and timing to surgery for rectal cancer (Stockholm III): a multicentre, randomised, non-blinded, phase 3, non-inferiority trial

BACKGROUND

Radiotherapy reduces the risk of local recurrence in rectal cancer. However, the optimal radiotherapy fractionation and interval between radiotherapy and surgery is still under debate. We aimed to study recurrence in patients randomised between three different radiotherapy regimens with respect to fractionation and time to surgery.

METHODS

In this multicentre, randomised, non-blinded, phase 3, non-inferiority trial (Stockholm III), all patients with a biopsy-proven adenocarcinoma of the rectum, without signs of non-resectability or distant metastases, without severe cardiovascular comorbidity, and planned for an abdominal resection from 18 Swedish hospitals were eligible. Participants were randomly assigned with permuted blocks, stratified by participating centre, to receive either 5 × 5 Gy radiation dose with surgery within 1 week (short-course radiotherapy) or after 4-8 weeks (short-course radiotherapy with delay) or 25 × 2 Gy radiation dose with surgery after 4-8 weeks (long-course radiotherapy with delay). After a protocol amendment, randomisation could include all three treatments or just the two short-course radiotherapy treatments, per hospital preference. The primary endpoint was time to local recurrence calculated from the date of randomisation to the date of local recurrence. Comparisons between treatment groups were deemed non-inferior if the upper limit of a double-sided 90% CI for the hazard ratio (HR) did not exceed 1·7. Patients were analysed according to intention to treat for all endpoints. This study is registered with ClinicalTrials.gov, number NCT00904813.

FINDINGS

Between Oct 5, 1998, and Jan 31, 2013, 840 patients were recruited and randomised; 385 patients in the three-arm randomisation, of whom 129 patients were randomly assigned to short-course radiotherapy, 128 to short-course radiotherapy with delay, and 128 to long-course radiotherapy with delay, and 455 patients in the two-arm randomisation, of whom 228 were randomly assigned to short-course radiotherapy and 227 to short-course radiotherapy with delay. In patients with any local recurrence, median time from date of randomisation to local recurrence in the pooled short-course radiotherapy comparison was 33·4 months (range 18·2-62·2) in the short-course radiotherapy group and 19·3 months (8·5-39·5) in the short-course radiotherapy with delay group. Median time to local recurrence in the long-course radiotherapy with delay group was 33·3 months (range 17·8-114·3). Cumulative incidence of local recurrence in the whole trial was eight of 357 patients who received short-course radiotherapy, ten of 355 who received short-course radiotherapy with delay, and seven of 128 who received long-course radiotherapy (HR vs short-course radiotherapy: short-course radiotherapy with delay 1·44 [95% CI 0·41-5·11]; long-course radiotherapy with delay 2·24 [0·71-7·10]; p=0·48; both deemed non-inferior). Acute radiation-induced toxicity was recorded in one patient (<1%) of 357 after short-course radiotherapy, 23 (7%) of 355 after short-course radiotherapy with delay, and six (5%) of 128 patients after long-course radiotherapy with delay. Frequency of postoperative complications was similar between all arms when the three-arm randomisation was analysed (65 [50%] of 129 patients in the short-course radiotherapy group; 48 [38%] of 128 patients in the short-course radiotherapy with delay group; 50 [39%] of 128 patients in the long-course radiotherapy with delay group; odds ratio [OR] vs short-course radiotherapy: short-course radiotherapy with delay 0·59 [95% CI 0·36-0·97], long-course radiotherapy with delay 0·63 [0·38-1·04], p=0·075). However, in a pooled analysis of the two short-course radiotherapy regimens, the risk of postoperative complications was significantly lower after short-course radiotherapy with delay than after short-course radiotherapy (144 [53%] of 355 vs 188 [41%] of 357; OR 0·61 [95% CI 0·45-0·83] p=0·001).

INTERPRETATION

Delaying surgery after short-course radiotherapy gives similar oncological results compared with short-course radiotherapy with immediate surgery. Long-course radiotherapy with delay is similar to both short-course radiotherapy regimens, but prolongs the treatment time substantially. Although radiation-induced toxicity was seen after short-course radiotherapy with delay, postoperative complications were significantly reduced compared with short-course radiotherapy. Based on these findings, we suggest that short-course radiotherapy with delay to surgery is a useful alternative to conventional short-course radiotherapy with immediate surgery.

FUNDING

Swedish Research Council, Swedish Cancer Society, Stockholm Cancer Society, and the Regional Agreement on Medical Training and Clinical Research in Stockholm.

Effect of Pancreatic Fistula on Recurrence and Long-Term Prognosis of Periampullary Adenocarcinomas after Pancreaticoduodenectomy

Pancreatic fistula (PF) is common after pancreaticoduodenectomy (PD). Its effect on recurrence and survival is not known. Retrospective study of patients undergoing PD for periampullary adenocarcinomas (2000–2012). Standard statistical analyses were performed to determine the impact of PF on disease-free survival (DFS) and overall survival (OS). There were 634 PDs (pancreatic adenocarcinoma: 347, other periampullary adenocarcinomas: 287). Any-grade PF developed in 81/634 (13%). Perioperative mortality rate was 1.7 per cent (11/634), higher in patients with PF (10 vs 0.5%, P < 0.001). In multivariable analysis, PF significantly reduced DFS in pancreatic [hazard ratio (HR) = 1.6, 95% confidence-interval (CI): 1.1–2.6, P = 0.043] but not in other periampullary adenocarcinomas [HR = 1.3 (95% CI: 0.8–2.2), P = 0.45]. Positive lymph nodes, margins, and high-grade histology were associated with decreased DFS and OS. Adjuvant therapy was associated with improved OS in pancreatic [HR = 0.7 (95% CI: 0.5–0.9), P = 0.02] but not in other periampullary adenocarcinomas [HR = 1.14 (95% CI: 0.8–1.7), P = 0.49]. PF did not alter OS in either group. After PD, PF is associated with decreased DFS in pancreatic but not in other periampullary adenocarcinomas. This decrease DFS did not alter OS. Tumor grade, lymph nodes, and resection margin status are associated with DFS and OS.

Initiation of adjuvant chemotherapy within 8 weeks of elective colorectal resection improves overall survival regardless of reoperation

AIM

Reoperation after elective colorectal resection may delay the start of adjuvant chemotherapy (AC). The study investigated the dual impact of a reoperation and AC delay on overall survival (OS).

METHOD

The Hospital Episode Statistics database was analysed between 1997 and 2012. Patients were divided into colon and rectal cancer cohorts and data were analysed based on whether there was delay in receiving AC beyond 8 weeks and whether a patient suffered reoperation within 30 days. Multivariate regression analysis was undertaken to investigate the relationship between delay in giving AC and reoperation and their combined effect on OS.

RESULTS

Logistic regression showed reoperation, amongst other things, to be an independent predictor of AC delay, in both colon and rectal cancer (colon, odds ratio 2.31, P < 0.001; rectal, odds ratio 2.19, P < 0.001). There was no significant difference in OS between patients who had no AC delay but suffered a reoperation and patients who had no AC delay and no reoperation. Patients who had AC delay but no reoperation, however, had significantly worse OS compared to those who had no AC delay and no reoperation [colon, hazard ratio (HR) 1.16, P < 0.001; rectal, HR 1.17, P < 0.001]. Individuals who had both AC delay and a reoperation also had worse OS compared with patients who had neither (colon, HR 1.33, P = 0.037; rectal, HR 1.38, P < 0.001).

CONCLUSION

Delayed receipt of AC beyond 8 weeks after surgery is associated with significantly reduced OS regardless of reoperation status in both colon and rectal cancer patients.

Characterizing Short-Term Outcomes Following Surgery for Rectal Cancer: the Role of Race and Insurance Status

BACKGROUND

There is a paucity of data demonstrating the effect race and insurance status have on postoperative outcomes for patients with rectal cancer. We evaluated factors impacting short-term outcomes following rectal cancer surgery.

DESIGN

Patients who underwent surgery for rectal cancer using the University Health System Consortium database from 2011 to 2012 were studied. Univariate and multivariable analyses were used to identify patient related risk factors for 30-day outcomes after proctectomy: complication rate, 30-day readmission, ICU stay, and length of hospital stay (LOS).

RESULTS

A total of 9272 proctectomies were identified in this cohort. After adjustment for potential confounders, black patients were more likely to have 30-day readmissions (OR 1.51, 95 % CI 1.26-1.81), ICU stays (OR 1.25, 95 % CI 1.03-1.51), and longer LOS (+1.67 days, 95 % CI 1.21-2.13) when compared to whites. Compared to those with private insurance, patients with public or military insurance or who were self-pay had a higher likelihood of having postoperative complications.

CONCLUSIONS

In patients who undergo elective proctectomy for rectal cancer, non-white and non-privately insured status are associated with significantly worse short-term outcomes. Further studies are needed to determine the implications with respect to receipt of adjuvant therapy and survival.

Risk scores as useful predictors of perioperative complications in patients with rectal cancer who received radical surgery

BACKGROUND

Rectal cancer is associated with a higher rate of surgical complications. The ability to predict the risk of complications before treatment would facilitate the design of personalized treatment strategies optimally suited for each patient.

METHODS

We retrospectively studied 260 patients with rectal cancer who underwent radical surgery to examine the relations between complications and 5 types of risk scores.

RESULTS

Complications developed in 56 patients (21.5%). Nineteen patients had infectious complications, 16 had intestinal obstruction, and 12 had other complications. Twelve patients out of 187 patients who received low anterior resection had anastomotic leakage. Estimation of Physiologic Ability and Surgical Stress Comprehensive Risk Score (E-PASS CRS) and Neutrophil-to-lymphocyte Ratio (NLR) were significantly related to all complications, infectious complications, and anastomotic leakage. Surgical Apgar Score was significantly related to infectious complications. Prognostic Nutritional Index was significantly related to all complications and intestinal obstruction. Colorectal Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity was significantly related to all complications, and infectious complications. A multivariate analysis showed that body-mass index, E-PASS CRS, and NLR were independent risk factors for anastomotic leakage. In particular, NLR was the only score that could be evaluated before surgery.

CONCLUSIONS

Five types of risk scores were useful methods for evaluating the risks of complications in patients with rectal cancer. NLR is a score that can be evaluated before surgery and predicted the risk of anastomotic leakage, suggesting that it is useful for assessing the need for a diverting colostomy.

Impact of Surgical Complications Following Resection of Locally Advanced Rectal Adenocarcinoma on Adjuvant Chemotherapy Delivery and Survival Outcomes

BACKGROUND

Surgical complications after resection for locally advanced rectal cancer may influence adjuvant treatment outcomes and survival. Few studies have examined this effect.

OBJECTIVE

This study aimed to examine the impact of surgical complications on adjuvant therapy delivery and survival in patients with locally advanced rectal cancer treated with long-course chemoradiation followed by surgery.

DESIGN

This is a retrospective analysis of a prospectively collected multicenter colorectal cancer database.

SETTINGS

Data were collected from the Australian Comprehensive Cancer Outcomes and Research Database.

PATIENTS

All patients who completed neoadjuvant chemoradiotherapy followed by surgery for locally advanced rectal cancer between January 2003 and December 2014 were selected.

MAIN OUTCOME MEASURES

We examined the types and frequency of surgical complications and their impact on the delivery of adjuvant chemotherapy and survival.

RESULTS

Data were available for 517 patients, of whom 147 (28%) had a surgical complication. Patients with a surgical complication were less likely to commence adjuvant chemotherapy (33% vs 66%; p = 0.0005) and more likely to have adjuvant treatment commencing more than 8 weeks from surgery (71.8% vs 21.2%; p = 0.004). Wound-related complications (p = 0.001), return to operating theater (p = 0.004), and readmission within 30 days (p = 0.02) had the most significant negative impact on the delivery of adjuvant chemotherapy. Surgical complications were significantly more likely in males (31.6% vs 20.8%, p = 0.003) and laparoscopic converted cases (47.8% vs 21.8%, p = 0.03). For the entire patient population, adjuvant chemotherapy compared with surveillance was not associated with an improved recurrence-free survival (HR, 1.06; p = 0.83) but was associated with an improved overall survival (HR, 0.53; p = 0.04).

LIMITATIONS

This study was limited by its retrospective design.

CONCLUSION

Surgical complications in patients having surgery following neoadjuvant chemoradiotherapy for locally advanced rectal cancer were associated with significantly reduced uptake and delays to receiving adjuvant therapy. Surgical complications, however, were not associated with either significantly reduced recurrence-free or overall survival. Adjuvant chemotherapy delivery was associated with improved overall survival.

Timing of adjuvant chemotherapy in colorectal cancer

AIM

Delay in commencing adjuvant therapy for colorectal cancer seems to impair survival in some retrospective studies. This study was planned to evaluate its impact on survival.

METHODS

This was a retrospective study enrolling patients registered from 2000 to 2012 in two large cancer-dedicated institutions in Brazil. The primary outcome was overall survival according to early vs late chemotherapy initiation. The interval between the primary surgery and the start of adjuvant chemotherapy was calculated. Survival was estimated using the Kaplan-Meier method and the impact of multiple prognostic factors on survival by Cox regression analysis.

RESULTS

By the end of 2012, a total of 1963 Stage II and III colorectal patients were identified and 1318 patients received adjuvant chemotherapy, with 22% and 46% of those starting adjuvant chemotherapy within 6 weeks and 8 weeks of surgery. The median period of follow-up was 41 months. Patients starting chemotherapy within 6-8 weeks of surgery had longer overall survival compared with those who started after (6 weeks vs later, hazard ratio 0.76, 95% CI 0.57-0.99, P = 0.046; 8 weeks vs later, hazard ratio 0.74, 95% CI 0.59-0.93, P = 0.011). In the multivariate analysis, age, stage, histological grade, angiolymphatic invasion, emergency surgery and preoperative therapy were independent prognostic factors, but the interval between surgery and start of adjuvant therapy was not.

CONCLUSION

In this large retrospective study, the standard prognostic factors impacted on survival whereas the timing of adjuvant therapy did not. Patients with delayed adjuvant chemotherapy may have worse prognostic factors which could play a major role in their poor outcome.

Postoperative Complications: Looking Forward to a Safer Future

Colorectal surgery patients frequently suffer from postoperative complications. Patients with complications have been shown to be at higher risk for mortality, poor oncologic outcomes, additional complications, and worse quality of life. Complications are increasingly recognized as markers of quality of care with more use of risk-adjusted national surgical databases and increasing transparency in health care. Quality improvement work in colorectal surgery has identified methods to decrease complication rates and improve outcomes in this patient population. Future work will continue to identify best practices and standardized ways to measure quality of care.

Time to Initiation of Adjuvant Chemotherapy in Colon Cancer: Comparison of Open, Laparoscopic, and Robotic Surgery

BACKGROUND

The time to initiation of adjuvant chemotherapy (TIC) can be used as a recovery parameter after surgery. The effect of laparoscopic or robotic surgery on TIC has not been thoroughly studied. This study aimed to compare the impact of open, laparoscopic, and robot-assisted surgery on TIC after colon cancer surgery.

MATERIALS AND METHODS

Patients who underwent curative resection for stage II or III colon cancer between January 2007 and June 2013 and who received adjuvant chemotherapy from surgeons capable of performing open, laparoscopic, and robotic surgeries were included in this study. Patient demographics, clinicopathologic variables, and TIC were compared among the three groups. Univariate and multivariate analyses were performed to identify factors affecting TIC.

RESULTS

Of the 252 patients, 40, 161, and 51 patients underwent open, laparoscopic, and robotic colectomy, respectively. The postoperative complication rate was lower in the laparoscopic and robotic groups compared to the open group (P = .002). The length of hospital stay was shorter in the laparoscopic group compared with the open and robotic groups (P < .001). Multivariate analysis revealed that the operation method was the only factor affecting TIC, with laparoscopic and robotic surgery being favorable (regression coefficient -5.1, 95% confidence interval -7.6 to -2.6; P < .001). However, there was no difference in TIC between the laparoscopic and robotic group.

CONCLUSIONS

Laparoscopic and robotic surgeries were associated with shorter TIC. This study demonstrates another benefit of minimally invasive surgery with regard to early initiation of adjuvant chemotherapy.

Impact of anastomotic leakage on long-term oncologic outcome and its related factors in rectal cancer

Anastomotic leakage (AL) is a well-known cause of morbidity after low anterior resection (LAR) for rectal cancer, but its impact on oncologic outcome is not well understood. The aim of this study is to investigate the impact of AL on long-term oncologic outcome and to identify factors associated with AL that may affect prognosis after LAR for rectal cancer.A retrospective analysis of patients who underwent curative resection for rectal cancer without diverting stoma was performed. To investigate AL related factors that may be associated with oncologic outcome, Clavien-Dindo grades, prognostic nutritional indices (PNI) and inflammatory indices were included.One hundred and one patients out of a total of 1258 patients developed postoperative AL, giving an AL rate of 8.0%. Patients with AL showed poorer disease-free survival (DFS), than patients without AL (hazard ratio [HR] = 1.6; 95% confidence intervals [CI]: 1.1-2.5; P = 0.01). In patients who developed AL, age over 60 (HR = 2.2; 95% CI: 1.1-4.7; P = 0.033), advanced pathologic stage (HR = 2.4; 95% CI: 1.4-4.0; P = 0.001), suppressed neutrophil-proportion (≤80%) (HR = 2.6; 95% CI: 1.2-5.8; P = 0.019) and PNI <36 (HR = 3.5; 95% CI: 1.2-9.6; P = 0.018) were associated with poorer DFS.AL was associated with poorer DFS. In patients with AL, a suppressed neutrophil-proportion and decreased PNI below 36 were associated with tumor recurrence.

Postoperative wound infections after a proctectomy--Patient experiences

Poor perineal wound healing and infections after proctectomy surgery cause a significant proportion of physical and psychological morbidities, such as pain, leakage, and abscesses. In the long run, some of these symptoms will lead to extended periods of hospitalization. These kinds of postoperative complications are also associated with delays in possible chemotherapy treatment. The aim of this study was to describe patient experiences of perineal wound infections following proctectomy due to rectal cancer, and the importance of the communication with and the self-care support from the nurse for these patients. Five women and five men (61-87 years, median age 71 years) were included and interviewed. A qualitative content analysis of the interviews was carried out and the following main categories emerged: "Managing postoperative complications," "Being independent," "Feeling safe," and "Accepting the situation." A perineal wound infection after a proctectomy is devastating for the individual patient. The limitations and changes to the patients' lives turn into new daily routines, which force them to find new ways to live and to accept the situation. For many of them, the infections remained for several months and, sometimes, for years. The ability to lead an independent life is drastically reduced, but through continuity in care it is possible to create a feeling of safety. Information, communication, and self-care support are all important and valuable factors for recovery. Specialized care containing an action plan is therefore needed in clinical practice to reduce the number of perineal wound infections postoperatively and should be initiated when the patient is discharged from the ward and continue until recovery.

Fragmentation of Care after Surgical Discharge: Non-Index Readmission after Major Cancer Surgery

BACKGROUND

Despite national emphasis on care coordination, little is known about how fragmentation affects cancer surgery outcomes. Our study examines a specific form of fragmentation in post-discharge care-readmission to a hospital different from the location of the operation-and evaluates its causes and consequences among patients readmitted after major cancer surgery.

STUDY DESIGN

We used the State Inpatient Database of California (2004 to 2011) to identify patients who had major cancer surgery and their subsequent readmissions. Logistic models were used to examine correlates of non-index readmissions and to assess associations between location of readmission and outcomes, measured by in-hospital mortality and repeated readmission.

RESULTS

Of 9,233 readmissions within 30 days of discharge after major cancer surgery, 20.0% occurred in non-index hospitals. Non-index readmissions were associated with emergency readmission (odds ratio [OR] = 2.63; 95% CI, 2.26-3.06), rural residence (OR = 1.81; 95% CI, 1.61-2.04), and extensive procedures (eg hepatectomy vs proctectomy; OR = 2.77; CI, 2.08-3.70). Mortality was higher during non-index readmissions than index readmissions independent of patient, procedure, and hospital factors (OR = 1.31; 95% CI, 1.03-1.66), but was mitigated by adjusting for conditions present at readmission (OR = 1.24; 95% CI, 0.98-1.58). Non-index readmission predicted higher odds of repeated readmission within 60 days of discharge from the first readmission (OR = 1.16; 95% CI, 1.02-1.32), independent of all covariates.

CONCLUSIONS

Non-index readmissions constitute a substantial proportion of all readmissions after major cancer surgery. They are associated with more repeated readmissions and can be caused by severe surgical complications and increased travel burden. Overcoming disadvantages of non-index readmissions represents an opportunity to improve outcomes for patients having major cancer surgery.

The impact of adjuvant chemotherapy timing on overall survival following colorectal cancer resection

BACKGROUND

Several studies including two meta-analyses have showed that delay between surgery and adjuvant chemotherapy adversely impacts colorectal cancer survival. This study investigated this impact at a population level over a fifteen year period in England.

METHODS

The Hospital Episode Statistics database was analysed between 1997 and 2012. Colonic cancer and rectal cancer patients were collated and multivariate Cox regression analyses were undertaken to ascertain the relationship between chemotherapy delay and overall survival.

RESULTS

A total of 181 984 patients underwent resection without any reoperation (106 477 (58.5%) having colonic cancer and 75 507 (41.5%) having rectal cancer). In total, 30 836 (16.9%) received adjuvant chemotherapy. 9019 (49.3%), 4573 (25.0%), 2587 (14.1%), 1323 (7.2%) and 804 (4.4%) of 18 306 colonic cancer patients received within 8 weeks, 8-10 weeks, 10-12 weeks, 12-14 weeks and 14-16 weeks, respectively. Sequentially worse overall survival was observed: <8 weeks: Ref; 8-10 wks: Hazard Ratio (HR) 1.09; 10-12 wks: HR 1.13; 12-14 wks HR 1.32 and 14-16 wks: HR 1.32, p < 0.001. 5625 (44.9%), 3087 (24.6%), 1940 (15.5%), 1162 (9.3%) and 716 (5.7%) of 12 530 rectal cancer patients received within 8 weeks, 8-10 weeks, 10-12 weeks, 12-14 weeks and 14-16 weeks, respectively. Sequentially worse overall survival was observed: <8 weeks: Ref; 8-10 wks: HR 1.09; 10-12 wks: HR 1.22; 12-14 wks HR 1.23 and 14-16 wks: HR 1.31, p < 0.001.

CONCLUSION

Adjuvant chemotherapy delay adversely impacts colonic and rectal cancer survival. Efforts to prevent complications such as reoperation and to improve access to chemotherapy services, will improve survival in this patient cohort.

Timing of adjuvant chemotherapy and its relation to survival among patients with stage III colon cancer

BACKGROUND

Currently available data suggest that delaying the start of adjuvant chemotherapy in colon cancer patients has a detrimental effect on survival. We analysed which factors impact on the timing of adjuvant chemotherapy and evaluated the influence on overall survival (OS).

PATIENTS AND METHODS

Stage III colon cancer patients who underwent resection and received adjuvant chemotherapy between 2008 and 2013 were selected from the Netherlands Cancer Registry. Timing of adjuvant chemotherapy was subdivided into: ⩽ 4, 5-6, 7-8, 9-10, 11-12 and 13-16 weeks post-surgery. Multivariable regressions were performed to assess the influence of several factors on the probability of starting treatment within 8 weeks post-surgery and to evaluate the association of timing of adjuvant chemotherapy with 5-year OS.

RESULTS

6620 patients received adjuvant chemotherapy, 14% commenced after 8 weeks. Factors associated with starting treatment after 8 weeks were older age (Odds ratio (OR) 65-74 versus < 65 years 1.3 (95% confidence interval (CI): 1.14-1.58); OR ⩾ 75 versus < 65 years 1.6 (1.25-1.94)), emergency resection (OR 1.8 (1.41-2.32)), anastomotic leakage (OR 8.1 (6.14-10.62)), referral to another hospital for adjuvant chemotherapy (OR 1.9 (1.36-2.57)) and prolonged postoperative hospital admission (OR 4.7 (3.30-6.68)). Starting 5-8 weeks post-surgery showed no decrease in OS compared to initiation within 4 weeks (Hazard ratio (HR) 5-6 weeks 0.9 (0.79-1.11); HR 7-8 weeks 1.1 (0.91-1.30)). However, commencing beyond 8 weeks was associated with decreased OS compared to initiation within 8 weeks (HR 9-10 weeks 1.4 (1.21-1.68); HR 11-12 weeks 1.3 (1.06-1.59); HR 13-16 weeks 1.7 (1.23-2.23)).

CONCLUSION

Our data support initiating adjuvant chemotherapy in stage III colon cancer patients within 8 weeks post-surgery.

Improved survival with early adjuvant chemotherapy after colonic resection for stage III colonic cancer: A nationwide study

BACKGROUND AND OBJECTIVES

In stage III colonic cancer, time from surgery to start of adjuvant chemotherapy may influence survival. In this study, we evaluated the effect of timing of adjuvant therapy on survival.

METHODS

Database study from the Danish Colorectal Cancer Group's national database. Data on patients with stage III colonic cancer operated between January 1, 2005 and August 31, 2012 were retrieved. Perioperative variables, surgical modality, and time to adjuvant therapy (<4, 4-8, or >8 weeks) were evaluated and Cox regression was performed to identify factors influencing survival.

RESULTS

The final population included 1,827 patients scheduled for adjuvant chemotherapy. Adjuvant therapy started within 4 and 8 weeks improved survival when compared to start later than 8 weeks (HR [95%CI]: 1.7 [1.1-2.6]; P = 0.024 and 1.4 [1.07-1.8]; P = 0.013, respectively), whereas there was no significant difference in survival with start after 4 versus 8 weeks (1.2 [0.8-1.8]; P = 0.37).

CONCLUSIONS

Survival increased when adjuvant therapy was started within 8 weeks after surgery for stage III colonic cancer.

Best practice in the administration of analgesia in postoncological surgery

The rationale for using multimodal analgesia after any major surgery is achievement of adequate analgesia while avoiding the unwanted effects of large doses of any analgesic, in particular opioids. There are two reasons why we can hypothesize that multimodal analgesia might have a significant impact on cancer-related outcomes in the context of oncological orthopedic surgery. First, because multimodal analgesia is a key component of enhanced-recovery pathways and can accelerate return to intended oncological therapy. And second, because some of the analgesic used in multimodal analgesia (i.e., COX inhibitors, local analgesics and dexamethasone) can induce apoptosis in cancer cells and/or diminish the inflammatory response during surgery which itself can facilitate tumor growth.

Factors Implicated for Delay of Adjuvant Chemotherapy in Colorectal Cancer: A Meta-analysis of Observational Studies

BACKGROUND

The survival benefit of administering adjuvant chemotherapy (AC) in colorectal cancer is well established, as is the impact of its timing. Although various factors have been associated with treatment delay, their implications remain controversial. We determined clinicopathological factors associated with delay in transition to AC via systematic review and meta-analysis.

METHODS

Studies assessing factors for delay in initiating AC were identified from MEDLINE, EMBASE, and Cochrane Databases. Studies were included only if relevant clinicopathological factors were adequately described and appropriate comparative groups were balanced. For each study, the odds ratio (OR) and 95 % confidence interval (CI) were estimated, regarding response to early versus delayed AC initiation.

RESULTS

We identified 15 eligible studies involving 67,537 patients. Twelve studies were multicentre studies and three were single-center cohort studies. Meta-analysis demonstrated age >75 years [4 studies, OR = 1.44 (95 % CI 1.32-1.58)], marital status-single [3 studies, OR = 1.32 (95 % CI 1.20-1.44)], low socioeconomic status (SES) [7 studies, OR = 1.67 (95 % CI 1.32-2.12)], worse comorbidity status [5 studies, OR = 1.47 (95 % CI 1.14-1.90)], low tumour grade [7 studies, OR = 1.06 (95 % CI 1.02-1.11)], prolonged length of stay [3 studies, OR 2.37 (95 % CI 2.10-2.68)], and readmission [3 studies, OR = 3.23 (95 % CI 1.66-6.26)] were significant predictors of delayed initiation of AC. Laparoscopy compared to an open surgical approach was a significant predictor of earlier AC initiation [5 studies, OR = 0.70 (95 % CI 0.51-0.97)].

CONCLUSIONS

Laparoscopy is associated with earlier initiation of AC, encouraging its increased adoption. Social isolation and low SES merit consideration of approaches that counter the lack of social support and deprivation to improve cancer outcomes.

New developments in colorectal surgery

PURPOSE OF REVIEW

Surgical management of diseases of the colon and rectum continues to evolve. This review examines the recent publications that have led to or may lead to changes in practice in this field.

RECENT FINDINGS

We identified and reviewed the recent publications in the areas of colon, rectal, and anal cancers; inflammatory bowel disease; incontinence; diverticulitis; hemorrhoids; fistulas; and quality improvement initiatives.

SUMMARY

New technologies and novel questions have changed practice and will improve patient outcomes. Multiinstitutional studies, ideally randomized, continue to be essential to answer the questions that will lead to identification of best practices.

Time to adjuvant chemotherapy and survival outcomes among patients with stage 2 to 3 rectal cancer treated with preoperative chemoradiation

BACKGROUND

Previous studies have evaluated the impact of time to adjuvant chemotherapy (AC) on survival in early-stage colon cancer. However, the optimal time to adjuvant chemotherapy (TTAC) in rectal cancer remains unclear. The objective of this study was to identify an optimal TTAC and determine its prognostic effect in stage 2 to 3 rectal cancer.

METHODS

Patients with stage 2 to 3 rectal cancer treated with preoperative chemoradiation and postoperative AC between 1999 and 2008 were included. Predetermined time points of 4, 6, 8, and 12 weeks from date of surgery were analyzed. Cut-point analysis was then used to determine an optimal TTAC, and overall survival at the identified cut-point was evaluated.

RESULTS

A total of 328 eligible patients were identified with a median age of 61 years (range 22-85 years), 70% male, and 75% stage 3 disease. The median TTAC was 7.0 weeks. Initiation of AC at 6 weeks from date of surgery was associated with a significant survival benefit (hazard ratio 0.52, 95% confidence interval 0.31-0.90, P = .017), while no significant association was seen at 4, 8 or 12 weeks (P > .05). The cut-point analysis identified an optimal TTAC of 5.6 weeks association with improved survival compared to those with a TTAC greater than 5.6 weeks (hazard ratio 0.42, 95% confidence interval 0.22-0.82, P = .0087). This cut-point was also found to be a significant prognostic factor in multivariable analysis (P = .04) adjusted for Eastern Cooperative Oncology Group performance status, age, gender, stage, margin status, and grade.

CONCLUSIONS

This study suggests that initiation of AC within an earlier time frame is associated with improved overall survival.