Surgical complications are associated with omission of chemotherapy for stage III colorectal cancer

Diagnostic Performance of MRI and FDG PET/CT for Preoperative Locoregional Staging of Colon Cancer: Systematic Review and Meta-Analysis

Background: CT is the standard-of-care test for colon cancer (CC) preoperative locoregional staging, but has limited diagnostic performance. More accurate preoperative staging would guide selection among expanding patient-tailored treatment options. Objective: To evaluate the diagnostic performance of MRI for T and N staging and of FDG PET/CT for N staging in CC locoregional staging through systematic review. Evidence Acquisition: PubMed, Embase, and Cochrane Library were searched through December 31, 2023 for studies reporting diagnostic performance of MRI or FDG PET/CT for primary (nonrectal) CC before resection without neoadjuvant therapy using histopathology as reference. Study quality was assessed using the QUADAS-2 tool. Publication bias was assessed with Deeks' funnel plot. Primary outcomes were estimated pooled predictive values, stratified by T and N categories for MRI and N categories for PET/CT. Secondary outcomes were pooled sensitivity and specificity. Evidence Synthesis: The systematic review included 11 MRI studies (686 patients) and five PET/CT studies (408 patients). Thirteen studies had at least one risk of bias or concern of applicability. Deeks' funnel plot asymmetry indicated possible publication bias in MRI studies for differentiation of T3cd-4 from T1-3ab disease and N- from N+ disease. For MRI, for discriminating T1-2 from T3-4 disease, PPV was 64.8% (95% CI [52.9-75.5%]), and NPV was 88.9% (95% CI [82.7-93.7%]); for discriminating T1-3ab from T3cd-4 disease, PPV was 83.4% (95% CI [75.0-90.3%]), and NPV was 74.6% (95% CI [58.2-86.7%]); for discriminating T1-3 from T4 disease, PPV was 94.0% (95% CI [89.4-97.3%]), and NPV was 39.9% (95% CI [24.9-56.6%]); for discriminating N- from N+ disease, PPV was 74.9% (95% CI [69.3-80.0%]), and NPV was 53.9% (95% CI [45.3-62.0%]). For PET/CT, for discriminating N- from N+ disease, PPV was 76.4% (95% CI [67.9-85.1%]), and NPV was 68.2% (95% CI [56.8-78.6%]). Across outcomes, MRI and PET/CT exhibited pooled sensitivity of 55.1-81.4% and pooled specificity of 70.3-88.1%. Conclusion: MRI had strongest predictive performance for T1-2 and T4 disease. MRI and PET/CT had otherwise limited predictive values, sensitivity, and specificity for evaluated outcomes related T and N staging. Clinical Impact: MRI and FDG PET/CT had overall limited utility for preoperative locoregional staging in colon cancer.

Measurement that matters: A systematic review and modified Delphi of multidisciplinary colorectal cancer quality indicators

AIM

To develop a priority set of quality indicators (QIs) for use by colorectal cancer (CRC) multidisciplinary teams (MDTs).

METHODS

The review search strategy was executed in four databases from 2009-August 2019. Two reviewers screened abstracts/manuscripts. Candidate QIs and characteristics were extracted using a tailored abstraction tool and assessed for scientific soundness. To prioritize candidate indicators, a modified Delphi consensus process was conducted. Consensus was sought over two rounds; (1) multidisciplinary expert workshops to identify relevance to Australian CRC MDTs, and (2) an online survey to prioritize QIs by clinical importance.

RESULTS

A total of 93 unique QIs were extracted from 118 studies and categorized into domains of care within the CRC patient pathway. Approximately half the QIs involved more than one discipline (52.7%). One-third of QIs related to surgery of primary CRC (31.2%). QIs on supportive care (6%) and neoadjuvant therapy (6%) were limited. In the Delphi Round 1, workshop participants (n = 12) assessed 93 QIs and produced consensus on retaining 49 QIs including six new QIs. In Round 2, survey participants (n = 44) rated QIs and prioritized a final 26 QIs across all domains of care and disciplines with a concordance level > 80%. Participants represented all MDT disciplines, predominantly surgical (32%), radiation (23%) and medical (20%) oncology, and nursing (18%), across six Australian states, with an even spread of experience level.

CONCLUSION

This study identified a large number of existing CRC QIs and prioritized the most clinically relevant QIs for use by Australian MDTs to measure and monitor their performance.

Nationwide practice in CT-based preoperative staging of colon cancer and concordance with definitive pathology

INTRODUCTION

In an era of exploring patient-tailored treatment options for colon cancer, preoperative staging is increasingly important. This study aimed to evaluate completeness and reliability of CT-based preoperative locoregional colon cancer staging in Dutch hospitals.

MATERIALS AND METHODS

Patients who underwent elective oncological resection of colon cancer without neoadjuvant treatment in 77 Dutch hospitals were evaluated between 2011 and 2021. Completeness of T-stage was calculated for individual hospitals and stratified based on a 60% cut-off. Concordance between routine CT-based preoperative locoregional staging (cTN) and definitive pathological staging (pTN) was examined.

RESULTS

A total of 59,558 patients were included with an average completeness of 43.4% and 53.4% for T and N-stage, respectively. Completeness of T-stage improved from 4.9% in 2011-2014 to 74.4% in 2019-2021. Median completeness for individual hospitals was 53.9% (IQR 27.3-80.5%) and were not significantly different between low and high-volume hospitals. Sensitivity and specificity for T3-4 tumours were relatively low: 75.1% and 76.0%, respectively. cT1-2 tumours were frequently understaged based on a low negative predictive value of 56.8%. Distinction of cT4 and cN2 disease had a high specificity (>95%), but a very low sensitivity (<50%). Positive predictive values of <60% indicated that cT4 and cN1-2 were often overstaged. Completeness and time period did not influence reliability of staging.

CONCLUSION

Completeness of locoregional staging of colon cancer improved during recent years and varied between hospitals independently from case volume. Discriminating cT1-2 from cT3-4 tumours resulted in substantial understaging and overstaging, additionally cT4 and cN1-2 were overstaged in >40% of cases.

Evaluation of the ACS-NSQIP Surgical Risk Calculator in Patients with Hepatic Metastases from Colorectal Cancer Undergoing Liver Resection

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator (ACS-NSQIP SRC) has been designed to predict morbidity and mortality and help stratify surgical patients. This study evaluates the performance of the SRC for patients undergoing surgery for colorectal liver metastases (CRLM).

METHODS

SRC was retrospectively computed for patients undergoing liver or simultaneous colon and liver surgery for colorectal cancer (CRC) in two high tertiary referral centres from 2011 to 2020. C-statistics and Brier score were calculated as a mean of discrimination and calibration respectively, for both group and for every level of surgeon adjustment score (SAS) for liver resections in case of simultaneous liver-colon surgery. An AUC ≥ 0.7 shows acceptable discrimination; a Brier score next to 0 means the prediction tool has good calibration.

RESULTS

Four hundred ten patients were included, 153 underwent simultaneous resection, and 257 underwent liver-only resections. For simultaneous surgery, the ACS-NSQIP SRC showed good calibration and discrimination only for cardiac complication (AUC = 0.720, 0.740, and 0.702 for liver resection unadjusted, SAS-2, and SAS-3 respectively; 0.714 for colon resection; and Brier score = 0.04 in every case). For liver-only surgery, it only showed good calibration for cardiac complications (Brier score = 0.03). The SRC underestimated the incidence of overall complications, pneumonia, cardiac complications, and the length of hospital stay.

CONCLUSIONS

ACS-NSQIP SRC showed good predicting capabilities only for 1 out of 5 evaluated outcomes; therefore, it is not a reliable tool for patients undergoing liver surgery for CRLM, both in the simultaneous and staged resections.

Biosynthetic Mesh Reconstruction after Abdominoperineal Resection for Low Rectal Cancer: Cross Relation of Surgical Healing and Oncological Outcomes: A Multicentric Observational Study

BACKGROUND

Local wound complications are among the most relevant sequelae after an abdominoperineal resection (APR) for low rectal cancer. One of the proposed techniques to improve the postoperative recovery and to accelerate the initiation of adjuvant chemotherapy is the mesh reinforcement of the perineal wound. The aim of the current study is to compare the surgical and oncological outcomes after APR performed with a biosynthetic mesh reconstruction versus the conventional procedure.

METHODS

From 2015 to 2020, in two tertiary centres, the surgical outcomes, the wound events (i.e., surgical site infections, wound dehiscence and the complete healing time) and the oncological outcomes (i.e., time length to start adjuvant chemo-radiotherapy, an over 8-week delay in chemotherapy and the recurrence rate) were retrospectively analysed in patients undergoing APR reinforced with biosynthetic mesh (Group A) and conventional APR (Group B). Results Sixty-one patients were treated with APR (25 in Group A and 36 in Group B). Patients in Group A presented lower time for: healing (16 versus 24 days, p = 0.015), inferior perineal wound dehiscence rates (one versus nine cases, p = 0.033), an earlier adjuvant therapy start (26 versus 70 days, p = 0.003) and a lower recurrence rate (16.6% vs. 33.3%, p = 0.152).

CONCLUSIONS

In our series, the use of a biosynthetic mesh for the neo-perineum reconstruction after a Miles' procedure has resulted in safe, reproducible results affected by limited complications, guarantying a rapid start of the adjuvant therapy with clear benefits in oncological outcomes. Further randomized clinical trials with long-term follow-up are needed to validate these results.

Comparison of short-term surgical outcomes and long-term survival between emergency and elective surgery for colorectal cancer: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to summarize relevant data from previous reports and perform a meta-analysis to compare short-term surgical outcomes and long-term oncological outcomes between emergency and elective surgery for colorectal cancer (CRC).

METHODS

A systematic literature search was performed using PubMed and Embase databases, and relevant data were extracted. Postoperative morbidity, hospital mortality within 30 days, postoperative recovery, overall survival (OS), and relapse-free survival (RFS) were compared using a fixed or random-effect model.

RESULTS

A total of 28 studies involving 353,686 participants were enrolled for this systematic review and meta-analysis, and 23.5% (83,054/353,686) of CRC patients underwent emergency surgery. The incidence of emergency presentations in CRC patients ranged from 2.7 to 38.8%. The lymph node yield of emergency surgery was comparable to that of elective surgery (WMD:0.70, 95%CI: - 0.74,2.14, P = 0.340; I² = 80.6%). Emergency surgery had a higher risk of postoperative complications (OR:1.83, 95%CI:1.62-2.07, P < 0.001; I² = 10.6%) and hospital mortality within 30 days (OR:4.62, 95%CI:4.18-5.10, P < 0.001; I² = 42.9%) than elective surgery for CRC. In terms of long-term oncological outcomes, emergency surgery was significantly associated with poorer RFS (HR: 1.51, 95%CI:1.24-1.83, P < 0.001; I² = 58.9%) and OS(HR:1.60, 95%CI: 1.47-1.73, P < 0.001; I² = 63.4%) of CRC patients. In addition, the subgroup analysis for colon cancer patients revealed a pooled HR of 1.73 for OS (95%CI:1.52-1.96, P < 0.001), without the evidence of significant heterogeneity (I² = 21.2%).

CONCLUSION

Emergency surgery for CRC had an adverse impact on short-term surgical outcomes and long-term survival. A focus on early screening programs and health education was warranted to reduce emergency presentations of CRC patients.

Functional and cognitive outcomes after suprapubic catheter placement in nursing home residents: A national cohort study

BACKGROUND

Long-term functional and cognitive outcomes in nursing home residents after procedures are poorly understood. Our objective was to evaluate these outcomes after suprapubic tube (SPT) placement.

METHODS

We performed a retrospective, cohort study in the nursing home setting. Participants were long-term nursing home residents who underwent SPT placement from 2014 to 2016 in the United States. SPT placements were identified in Medicare Inpatient, Outpatient, and Carrier files using International Classification of Diseases and Current Procedural Terminology codes. Residents were identified through the Minimum Data Set (MDS) 3.0 for Nursing Home Residents. MDS Activities of Daily Living (MDS-ADL) and Brief Interview for Mental Status (BIMS) scores were used to assess function and cognition, respectively. Outcomes of interest were worsening MDS-ADL and BIMS scores at 1 year postoperatively, 30-day postoperative complications, and 1-year mortality. Functional and cognitive trajectories were modeled to 1 year postoperatively using mixed-effect spline models.

RESULTS

From 2014 to 2016, 9647 residents with a mean age of 80.9 (SD 8.1) years underwent SPT placement. At 1 year postoperatively, 37.6% of residents died, while of survivors, 33.7% had worsening MDS-ADL and 36.2% worsened BIMS. Residents had steeper postoperative rates of functional decline compared to relatively stable preoperative trends that never recovered to baseline status. However, robustly characterizing an association between SPT placement and functional decline would require a propensity score matched cohort without SPT placement. Decline in cognitive status was not clearly associated with SPT placement, suggesting either the natural course of a vulnerable population or limitations of BIMS scores.

CONCLUSIONS

Outcomes important to older adults, such as functional ability and cognitive status, do not show improvement after SPT placement. These findings emphasize that this "minor" procedure should be considered with caution in this population and primarily for palliation.

The Effect of Complications on Oncological Outcomes of Colorectal Cancer Patients After Primary Surgery: A Propensity Score Matching Analysis

Purpose

The purpose of this study is to explore the oncologic outcomes of complications on colorectal cancer (CRC) patients who underwent primary surgery using a propensity score matching (PSM) analysis.

Methods

A retrospective study was conducted from Jan 2011 to Jan 2020 in a clinical center. The overall survival (OS) and disease-free survival (DFS) were compared among the no complications group, the major complications group and the minor complications group.

Results

A total of 4250 CRC patients who underwent radical primary surgery were included in the current study. Among them, 927 (21.8%) patients suffered complications. After 1:1 ratio PSM, there were 98 patients in the major complications group and in the minor complications group, and 911 patients in the overall complications group and in the no complications group. There was no significant difference in terms of baseline information after PSM (p>0.05). Complications were independent predictors of OS (p=0.000, HR=1.693, 95% CI=1.476-1.941) and DFS (p=0.000, HR=1.555, 95% CI=1.367-1.768). In terms of specific tumor stage, the no complications group had better OS on all stages (p=0.006) and stage III (p=0.003) CRC than the complications group after PSM. Furthermore, the no complications group had better DFS on all stages (p=0.005) and stage III (p=0.021) CRC than the complications group after PSM. However, there was no significant difference between the minor complications group and the major complications group in different tumor stages (p>0.05).

Conclusion

Complications were associated with poor prognosis of CRC and surgeons should be cautious of the adverse events.

Frailty Is Associated with an Increased Risk of Complications and Need for Repeat Procedures after Sling Surgery in Older Adults

PURPOSE

Sling surgery is the gold standard treatment for stress urinary incontinence in women. While data support the use of sling surgery in younger and middle-aged women, outcomes in older, frail women are largely unknown.

MATERIALS AND METHODS

Data were examined for all Medicare beneficiaries ≥65 years old who underwent sling surgery with or without concomitant prolapse repair from 2014 to 2016. Beneficiaries were stratified using the Claims-Based Frailty Index (CFI) into 4 categories: not frail (CFI <0.15), prefrail (0.15 ≤CFI <0.25), mildly frail (0.25 ≤CFI <0.35) and moderately to severely frail (CFI ≥0.35). Outcomes included rates and relative risk of 30-day complications, 1-year mortality and repeat procedures for persistent incontinence or obstructed voiding at 1 year.

RESULTS

A total of 54,112 women underwent sling surgery during the study period, 5.2% of whom were mildly to moderately to severely frail. Compared to the not frail group, moderately to severely frail beneficiaries demonstrated an increased adjusted relative risk (aRR) of 30-day complications (56.5%; aRR 2.5, 95% CI: 2.2-2.9) and 1-year mortality (10.5%; aRR 6.7, 95% CI: 4.0-11.2). Additionally, there were higher rates of repeat procedures in mildly to severely frail beneficiaries (6.6%; aRR 1.4, 95% CI: 1.2-1.6) compared to beneficiaries who were not frail.

CONCLUSIONS

As frailty increased, there was an increased relative risk of 30-day complications, 1-year mortality and need for repeat procedures for persistent incontinence or obstructed voiding at 1 year. While there were fewer sling surgeries in performed frail women, the observed increase in complication rates was significant. Frailty should be strongly considered before pursuing sling surgery in older women.

Association of preoperative smoking with complications following major gastrointestinal surgery

BACKGROUND

Understanding modifiable surgical risk factors is essential for preoperative optimization. We evaluated the association between smoking and complications following major gastrointestinal surgery.

METHODS

Patients who underwent elective colorectal, pancreatic, gastric, or hepatic procedures were identified in the 2017 ACS NSQIP dataset. The primary outcome was 30-day death or serious morbidity (DSM). Secondary outcomes included pulmonary complications, wound complications, and readmission. Multivariable logistic regression was used to evaluate the association between smoking and these outcomes.

RESULTS

A total of 46,921 patients were identified, of whom 7,671 (16.3%) were smokers. Smoking was associated with DSM (23.2% vs. 20.4%, OR 1.15 [1.08-1.23]), wound complications (13.0% vs. 10.4%, OR 1.24 [1.14-1.34]), pulmonary complications (4.9% vs 2.9%, OR 1.93 [1.70-2.20]), and unplanned readmission (12.6% vs. 11%, OR 1.14 [95% CI 1.06-1.23]).

CONCLUSIONS

Smoking is associated with complications following major gastrointestinal surgery. Patients who smoke should be counseled prior to surgery regarding risks.

eSyM: An Electronic Health Record-Integrated Patient-Reported Outcomes-Based Cancer Symptom Management Program Used by Six Diverse Health Systems

PURPOSE

Collecting patient-reported outcomes (PROs) can improve symptom control and quality of life, enhance doctor-patient communication, and reduce acute care needs for patients with cancer. Digital solutions facilitate PRO collection, but without robust electronic health record (EHR) integration, effective deployment can be hampered by low patient and clinician engagement and high development and deployment costs. The important components of digital PRO platforms have been defined, but procedures for implementing integrated solutions are not readily available.

METHODS

As part of the NCI's IMPACT consortium, six health care systems partnered with Epic to develop an EHR-integrated, PRO-based electronic symptom management program (eSyM) to optimize postoperative recovery and well-being during chemotherapy. The agile development process incorporated user-centered design principles that required engagement from patients, clinicians, and health care systems. Whenever possible, the system used validated content from the public domain and took advantage of existing EHR capabilities to automate processes.

RESULTS

eSyM includes symptom surveys on the basis of the PRO-Common Terminology Criteria for Adverse Events (PRO-CTCAE) plus two global wellness questions; reminders and symptom self-management tip sheets for patients; alerts and symptom reports for clinicians; and population management dashboards. EHR dependencies include a secure Health Insurance Portability and Accountability Act-compliant patient portal; diagnosis, procedure and chemotherapy treatment plan data; registries that identify and track target populations; and the ability to create reminders, alerts, reports, dashboards, and charting shortcuts.

CONCLUSION

eSyM incorporates validated content and leverages existing EHR capabilities. Build challenges include the innate technical limitations of the EHR, the constrained availability of site technical resources, and sites' heterogenous EHR configurations and policies. Integration of PRO-based symptom management programs into the EHR could help overcome adoption barriers, consolidate clinical workflows, and foster scalability and sustainability. We intend to make eSyM available to all Epic users.

Postoperative Complications Predict Long-term Outcome After Curative Resection for Perforated Colorectal Cancer

BACKGROUND/AIM

Perforation and postoperative complications have a negative effect on long-term outcomes in patients with colorectal cancer (CRC). The aim of this study was to evaluate the clinical factors with special reference to postoperative complications predicting the long-term outcome in those for whom curative resection for perforated CRC was performed.

PATIENTS AND METHODS

Patients who underwent curative resection for perforated CRC at stage II or III from April 2003 to March 2020 were included. Clinical factors were retrospectively analyzed.

RESULTS

Forty-four patients met the selection criteria. The 30-day mortality rate was 4.5% and the complication rate was 47.7%. Excluding 30-day mortality, five-year recurrence-free survival (RFS) and overall survival (OS) were 62.3% and 73.6%, respectively. Multivariate analysis showed that postoperative complications (p=0.005) and pT4 pathological factor (p=0.009) were independent prognostic factors for RFS. Only postoperative complications (p=0.023) were an independent prognostic factor for OS.

CONCLUSION

Postoperative complications were significantly associated with RFS and OS, and pT4 was associated with RFS. The prevention and management of postoperative adverse events may be important for perforated CRC.

Visceral-to-Subcutaneous Fat Ratio Is a Potential Predictor of Postoperative Complications in Colorectal Cancer

Background

Colorectal cancer (CRC) is one of the most common malignant tumors. Surgery is the primary treatment for CRC. Recent studies have shown that visceral-to-subcutaneous fat ratio (VSR) may be a potential indicator of risk. The aim of the present study was to determine whether VSR is a suitable predictor of the impact of postoperative complications in CRC.

Material/Methods

Clinical data from 129 patients were analyzed retrospectively. All patients underwent laparoscopic surgery for CRC. Preoperative imaging was used to quantify VSR. The primary outcome was 30-day postoperative complications. Multivariate logistic regression was used to determine the association between obesity indexes and postoperative complications.

Results

There were 129 patients who underwent primary resections of colorectal cancer. At 30 days after surgery, postoperative complications had occurred in 33 (25.6%) patients. VSR was significantly associated with postoperative complications in multivariate analysis (P=0.032, OR 6.103, 95% CI 1.173–31.748). In ROC analysis, VSR was a potential predictor of complications (AUC 0.650). A cutoff value of VSR ≥0.707 was associated with 60% sensitivity and 29% specificity for postoperative complications. Patients with VSR ≥0.707 had 41.7% risk of morbidity, whereas those with <0.707 had 16.0% risk (P=0.001).

Conclusions

Our study shows that VSR is superior to VFA for prediction of the risk of complications following CRC laparoscopic surgery. We have also identified the optimal cutoff values for the use of VSR for this purpose. Measurement of VSR and identifying patients with increased risk of postoperative complications facilitate making perioperative decisions.

Impact of postoperative complications after primary tumor resection on survival in patients with incurable stage IV colorectal cancer: A multicenter retrospective cohort study

AIMS

Primary tumor resection for patients with incurable stage IV colorectal cancer can prevent tumor-related complications but may cause postoperative complications. Postoperative complications delay the administration of chemotherapy and can lead to the spread of malignancy. However, the impact of postoperative complications after primary tumor resection on survival in patients with incurable stage IV colorectal cancer remains unclear. Therefore, this study aimed to investigate how postoperative complications after primary tumor resection affect survival in this patient group.

METHODS

We reviewed data on 966 patients with stage IV colorectal cancer who underwent palliative primary tumor resection between January 2006 and December 2007. We examined the association between major complications (National Cancer Institute Common Terminology Criteria for Adverse Events v3.0 grade 3 or more) and overall survival using Cox proportional hazard model and explored risk factors associated with major complications using multivariable logistic regression analysis.

RESULTS

Ninety-three patients (9.6%) had major complications. The 2-year overall survival rate was 32.7% in the group with major complications and 50.3% in the group with no major complications. Patients with major complications had a significantly poorer prognosis than those without major complications (hazard ratio: 1.62; 95% confidence interval: 1.21-2.18; P < .01). Male, rectal tumor, and open surgery were identified to be risk factors for major complications.

CONCLUSIONS

Postoperative complications after primary tumor resection was associated with decreased long-term survival in patients with incurable stage IV colorectal cancer.

Postoperative morbidity following pancreatic cancer surgery is significantly associated with worse overall patient survival; systematic review and meta-analysis

BACKROUND

The influence of postoperative morbidity on survival after potentially curative resection for pancreatic ductal adenocarcinoma (PDAC) remains unclear.

METHODS

Medline, Web of Science and Cochrane Library were searched for studies reporting survival in patients with and without complications, defined according to the Clavien-Dindo classification, after primary, potentially curative resection for pancreatic cancer followed by adjuvant treatment. Meta-analysis was performed using a random-effects model.

RESULTS

Fourteen retrospective cohort studies comprising a total of 7.604 patients with an overall complication rate of 40.8% (n = 3.103 patients) were included. Median overall survival for the entire patient cohort ranged from 15.5 to 24 months. Overall survival in patients with severe postoperative complications ranged from 7.1 to 37.1 months and was significantly worse compared to the overall survival in patients without severe complications ranging from 16.5 to 38.2 months. Postoperative complication rates ranged from 24.3% to 64%, severe (Clavien-Dindo ≥ III) complication rates from 4.2% to 31%. Results sufficient for meta-analysis were reported by ten studies, representing 6.028 patients. Meta-analysis showed reduced overall survival following any complication (summary adjusted HR 1.47; 95% CI 1.23-1.76, p < 0.0001). Hazard of death was 1.5 times higher in patients experiencing severe postoperative complications than in patients without severe complications (summary adjusted HR 1.45; 95% CI 1.13-1.85, p = 0.003).

CONCLUSIONS

Postoperative complications after potentially curative resection of PDAC are significantly associated with worse overall patient survival.

Comparative outcomes for older adults undergoing surgery for bladder and bowel dysfunction

BACKGROUND/OBJECTIVES

To compare surgical outcomes between vulnerable nursing home (NH) residents and matched community-dwelling older adults undergoing surgery for bladder and bowel dysfunction.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 55,389 NH residents and propensity matched (based on procedure, age, sex, race, comorbidity, and year) community-dwelling older adults undergoing surgery for bladder and bowel dysfunction [female pelvic surgery, transurethral resection of the prostate, suprapubic tube placement, hemorrhoid surgery, rectal prolapse surgery]. Individuals were identified using Medicare claims and the Minimum Data Set (MDS) for NH residents between 2014 and 2016.

MEASUREMENTS

Thirty-day complications, 1-year mortality, and weighted changes in healthcare resource utilization (hospital admissions, emergency room visits, office visits) in the year before and after surgery.

RESULTS

NH residents demonstrated statistically significant increased risk of 30-day complications [60.1% v. 47.2%; RR 1.3 (95% CI 1.3-1.3)] and 1-year mortality [28.9% vs. 21.3%; RR 1.4 (95% CI 1.3-1.4)], compared to community-dwelling older adults. NH residents also demonstrated decreased healthcare resource utilization, compared to community-dwelling older adults, changing from 3.9 to 1.9 (vs.1.1 to 1.0) hospital admissions, 11 to 10.1 (vs. 9 to 9.7) office visits, and 3.4 to 2.2 (vs. 1.9 to 1.9) emergency room visits from the year before to after surgery.

CONCLUSION

Despite matching on several important clinical characteristics, NH residents demonstrated increased rates of 30-day complications and 1-year mortality after surgery for bowel and bladder dysfunction, while demonstrating decreased healthcare resource utilization. These mixed findings suggest that outcomes may be more varied among vulnerable older adults and warrant further investigation.

The Role of Neoadjuvant Chemotherapy in Locally Advanced Colon Cancer

Neoadjuvant systemic therapy has many potential advantages over up-front surgery, including tumor downstaging, early treatment of micrometastatic disease, and providing an in vivo test of tumor biology. Due to these advantages, neoadjuvant therapy is becoming the standard of care for an increasing number of tumor types. Currently, colon cancer patients are still routinely treated with up-front surgery, and neoadjuvant systemic therapy is not yet standard. Limitations to widespread use of neoadjuvant therapy have included inaccurate radiological staging, concerns about tumor progression while undergoing preoperative treatment rendering a patient incurable, and a lack of randomized data demonstrating benefit. However, there is great interest in neoadjuvant chemotherapy, and a number of trials are under way. Early follow up of the first phase III trial of neoadjuvant chemotherapy for colon cancer demonstrated tumor downstaging and suggested an improvement in disease-free survival with neoadjuvant chemotherapy, and it is hoped that this will translate into longer-term overall survival benefit. Clinicians should closely watch this developing field, consider the option of neoadjuvant chemotherapy for colon cancer patients, and actively seek out opportunities for their patients to participate in ongoing clinical trials to further inform this field in future.

Association of Patient Experience With Guideline-Concordant Colon Cancer Treatment in the Elderly

PURPOSE

The association between patient-reported experience of care and care quality is not well described. The purpose of this study was to assess the relationship between the patient-reported experience and receipt of guideline-concordant colon cancer (CC) treatment.

METHODS

Medicare beneficiaries with resected stage I-III CC (2003-2013) were identified in the linked SEER Consumer Assessment of Healthcare Providers and Systems data set. Patient-reported scores were compared by receipt of guideline concordant care (GCC) (resection of ≥ 12 lymph nodes [stage I-III] and adjuvant chemotherapy [stage III]). Linear mixed-effects regression was performed to compare adjusted mean patient experience scores by GCC.

RESULTS

Of the 1,010 identified patients, 58.4% of stage I (n = 192/329) and 73.4% of stage II (n = 298/406) patients underwent resection of ≥ 12 LN. Among stage III patients, 76.0% (n = 209/275) underwent resection of ≥ 12 lymph node and 52.4% (n = 144/275) received adjuvant chemotherapy. By multivariable analysis, patient-reported scores of healthcare quality, physicians, physician communication, getting needed care, and getting care quickly were similar among patients who received GCC compared with those who did not. However, mean scores of overall healthcare quality (91.3 v 82.4, P = .0004) and getting needed care (92.8 v 86.8, P = .047) were higher among stage III patients who received GCC compared with those who did not.

CONCLUSION

Patient-reported scores of healthcare quality and ability to get needed care are associated with GCC among elderly patients with stage III CC. Further investigation is needed to determine whether patient-reported experience correlates with other clinical measures of quality of CC care.

Comparative Outcomes for Pelvic Organ Prolapse Surgery among Nursing Home Residents and Matched Community Dwelling Older Adults

PURPOSE

We compared short and long-term outcomes between nursing home residents and matched community dwelling older adults undergoing surgery for pelvic organ prolapse.

MATERIALS AND METHODS

This retrospective cohort study evaluates women 65 years old or older undergoing different types of pelvic organ prolapse repairs (anterior/posterior, apical and colpocleisis) between 2007 and 2012 using Medicare claims and the Minimum Data Set for Nursing Home Residents. Long-stay nursing home residents were identified and propensity score matched (1:2) to community dwelling older individuals based on procedure type, age, race and Charlson score. Generalized estimating equation models were created to determine the relative risk of hospital length of stay 3 or more days, 30-day complications and 1-year mortality between the 2 groups. Kaplan-Meier curves were created comparing 1-year mortality between groups.

RESULTS

There were 799 nursing home residents and 1,598 matched community dwelling older adults who underwent pelvic organ prolapse surgery and were included in our analyses. Nursing home residents demonstrated statistically significant increased risk for hospital length of stay 3 or more days (38.9% vs 18.6%, adjusted RR 2.1, 95% CI 1.8-2.4), 30-day complications (15.1% vs 3.8%, aRR 3.9, 95% CI 2.9-5.3) and 1-year mortality (11.1% vs 3.2%, aRR 3.5, 95% CI 2.5-4.8) compared to community dwelling older adults. Kaplan-Meier curves illustrated similar survival findings at 1 year (11.1%, 95% CI 9.0-13.3 vs 3.2%, 95% CI 2.3-4.1, p <0.0001).

CONCLUSIONS

Despite matching on several characteristics, nursing home residents demonstrated worse short and long-term outcomes compared to community dwelling older adults, suggesting other key vulnerabilities exist that contribute additional surgical risk in this population.

Neoadjuvant chemotherapy in locally advanced colon cancer: a systematic review

BACKGROUND

Preoperative or neoadjuvant chemotherapy (NAC) has emerged as a novel alternative to treat locally advanced colon cancer (LACC), as in other gastrointestinal malignancies. However, evidence of its efficacy and safety has not yet been gathered in the literature. The aim of the present study was to perform an extensive review of the scientific evidence for NAC in patients with LACC.

METHODS

PubMed, EMBASE, MEDLINE and Cochrane Library were searched for a systematic review of the literature from 2010 to 2019. Six eligible studies were included, with a total of 27,937 patients, 1232 of them (4.4%) treated with NAC. There were only one randomized controlled trial, three phase II non-randomized single arm studies and two retrospective studies.

RESULTS

The baseline computed tomography scan showed that most of patients had a T3 tumor. The completion rate of the planned neoadjuvant treatment ranged from 52.5 to 93.8%. Between 97.2 and 100% of patients had the scheduled surgery. The median tumor volume reduction after NAC ranged from 62.5 to 63.7%. The anastomotic leak rate in the NAC group ranged from 0 to 7%, with no cases of postoperative mortality. There was major pathological tumor regression in 4-34.7% of cases. Between 84 and 100% of NAC patients had R0-surgery. Survival after NAC seems to be encouraging although significant improvement has only been proven in T4b tumours.

CONCLUSIONS

According to our systematic review, the NAC may be a safe and effective emerging therapeutic alternative for treating LACC. This approach, which is still being tested, increases the reliance on accurate radiological staging.

A pathological complete response after neoadjuvant triplet chemotherapy for locally advanced transverse colon cancer

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Perioperative chemotherapy could improve oncological outcome for colon cancer.

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The effectiveness of triplet chemotherapy as neoadjuvant setting is still unknown.

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A pathological complete response after neoadjuvant triplet chemotherapy was described.

Introduction

Perioperative chemotherapy could improve oncological outcomes for patients with advanced colon cancer. However, the effectiveness of triplet chemotherapy in the neoadjuvant setting is still unknown.

Presentation of case

A 61-year-old man was referred to our hospital due to abdominal distention. Abdominal computed tomography showed a huge, 18-cm mass in the right upper abdomen. Biopsy showed well-differentiated adenocarcinoma. Locally advanced transverse colon cancer T4b N2a M0 Stage IIIC was diagnosed. Considering the extensive invasion to surrounding organs and difficulties in achieving margin-negative surgery, an emergency ileostomy was performed first. Then, neoadjuvant chemotherapy (NAC) consisting of a combination of 5-fluorouracil (5-FU), oxaliplatin, irinotecan, and leucovorin (FOLFOXIRI) was planned, followed by primary tumor resection. After 6 courses of treatment, the primary tumor shrank remarkably. Finally, laparoscopic radical extended right hemi-colectomy was performed. There were no residual tumor cells in resected specimens, including the primary tumor and surrounding lymph nodes. The pathological diagnosis was complete response.

Conclusion

A case of pathological complete response after neoadjuvant treatment followed by radical resection was reported. Further research is needed to confirm the appropriate indications for neoadjuvant FOLFOXIRI therapy for patients with LACC.

Nutritional risk screening score is associated with omission of adjuvant chemotherapy for stage III colon cancer

BACKGROUND

This study aimed to evaluate the association between nutritional risk screening (NRS) score and administration of adjuvant chemotherapy for stage III colon cancer.

METHODS

A total of 404 patients with stage III colon cancer who underwent curative resection between January 2012 and December 2015 were included. Patients with a preoperative high nutritional risk score (NRS ≥4) were compared with those with an NRS <4. Predictive factors for omission of adjuvant chemotherapy, and prognostic factors for overall survival (OS) were analyzed.

RESULTS

Eighty (19.8%) patients had a high nutritional risk (NRS ≥4). An NRS score ≥4 was associated with higher risk of omission of adjuvant chemotherapy (26.3% vs. 13.6%, p = 0.006), which was significant after adjusting for covariables (odds ratio = 1.862, p = 0.047). Multivariable survival analysis showed that omission of adjuvant chemotherapy was an independent poor prognostic factor for OS (hazard ratio = 4.060, p < 0.001).

CONCLUSIONS

An NRS score ≥4 was associated with omission of adjuvant chemotherapy in stage III colon cancer, which resulted in poor OS.

Usefulness of Inflammation-Based Prognostic Scores for Predicting the Risk of Complications After Radical Resection of Colorectal Carcinoma

Purpose

We aimed to investigate the value of inflammation-based prognostic scores for predicting early complications after radical surgery for colorectal carcinoma.

Methods

We retrospectively analyzed data of 154 patients who underwent elective resection of colorectal carcinoma between January 2017 and December 2018 at Beijing Friendship Hospital. Univariate, multivariate, and receiver operating characteristic curve analyses were conducted. As inflammation indices, we evaluated the preoperative modified Glasgow Prognostic Score (GPS), as well as the C-reactive protein/albumin ratio (CAR), postoperative GPS, and C-reactive protein levels on postoperative day 3 (POD3).

Results

Within 30 days postoperatively, complications occurred in 80 patients (51.9%). And high levels of preoperative mGPS (P=0.002), preoperative CAR (P=0.019), POD3 CAR (P<0.001) and POD3 poGPS (P<0.001) can significantly affect postoperative complications after surgery for colorectal cancer, with CRP on POD3 (odds ratio, 1.015; 95% confidence interval, 1.006–1.024; P=0.001) as independent risk factors. Among all inflammation-based indicators, POD3 CAR had the highest area under the curve (0.711) and positive predictive value (83.2%). Higher CAR (≥2.6) on POD3 was associated with a higher rate of complications (92.9% vs 36.6%, P<0.001), especially of infectious nature (54.8% vs 16.1%, P<0.001).

Conclusion

CAR≥2.6 on POD3 reflects sustained systemic inflammation and represents a useful predictor of complications after surgery for colorectal carcinoma, facilitating early detection, timely intervention, and enhanced recovery.

The Impact of Delays to Definitive Surgical Care on Survival in Colorectal Cancer Patients

INTRODUCTION

Treatment delay may have detrimental effects on cancer outcomes. The impact of longer delays on colorectal cancer outcomes remains poorly described. The objective of this study was to determine the effect of delays to curative-intent surgical resection on survival in colorectal cancer patients.

METHODS

All adult patients undergoing elective resection of primary non-metastatic colorectal adenocarcinoma from January 2009 to December 2014 were reviewed. Treatment delays were defined as the time from tissue diagnosis to definitive surgery, categorized as < 4, 4 to < 8, and ≥ 8 weeks. Primary outcomes were 5-year disease-free (DFS) and overall survival (OS). Statistical analysis included Kaplan-Meier curves and Cox regression models.

RESULTS

A total of 408 patients were included (83.2% colon;15.8% rectal) with a mean follow-up of 58.4 months (SD29.9). Fourteen percent (14.0%) of patients underwent resection < 4 weeks, 40.0% 4 to < 8 weeks, and 46.1% ≥ 8 weeks. More rectal cancer patients had treatment delay ≥ 8 weeks compared with colonic tumors (69.8% vs. 41.4%, p < 0.001). Cumulative 5-year DFS and OS were similar between groups (p = 0.558; p = 0.572). After adjusting for confounders, surgical delays were not independently associated with DFS and OS.

CONCLUSIONS

Treatment delays > 4 weeks were not associated with worse oncologic outcomes. Delaying surgery to optimize patients can safely be considered without compromising survival.

Implementation of an Enhanced Recovery Protocol Is Associated With On-Time Initiation of Adjuvant Chemotherapy in Colorectal Cancer

BACKGROUND

Delayed initiation of adjuvant chemotherapy negatively impacts long-term survival in patients with colorectal cancer. Colorectal enhanced recovery protocols result in decreased complications and length of stay; however, the impact of enhanced recovery on the timing of adjuvant chemotherapy remains unknown.

OBJECTIVE

This study aimed to identify factors associated with on-time delivery of adjuvant chemotherapy after colorectal cancer surgery, hypothesizing that implementation of an enhanced recovery protocol would result in more patients receiving on-time chemotherapy.

DESIGN

This was a retrospective cohort study comparing the rate of on-time adjuvant chemotherapy delivery after colorectal cancer resection before and after implementation of an enhanced recovery protocol.

SETTINGS

The study was conducted at a large academic medical center.

PATIENTS

All of the patients who underwent nonemergent colorectal cancer resections for curative intent from January 2010 to June 2017, excluding patients who had no indication for adjuvant chemotherapy, had received preoperative systemic chemotherapy, or did not have medical oncology records available were included.

MAIN OUTCOME MEASURES

Patients before and enhanced recovery were compared, with the rate of on-time adjuvant chemotherapy delivery as the primary outcome. Adjuvant chemotherapy delivery was considered on time if initiated ≤8 weeks postoperatively, and treatment was considered delayed or omitted if initiated >8 weeks postoperatively (delayed) or never received (omitted). Multivariable logistic regression identified predictors of on-time chemotherapy delivery.

RESULTS

A total of 363 patients met inclusion criteria, with 189 patients (52.1%) undergoing surgery after enhanced recovery implementation. Groups differed in laparoscopic approach and median procedure duration, both of which were higher after enhanced recovery. Significantly more patients received on-time chemotherapy after enhanced recovery implementation (p = 0.007). Enhanced recovery was an independent predictor of on-time adjuvant chemotherapy (p = 0.014).

LIMITATIONS

The study was limited by its retrospective and nonrandomized before-and-after design.

CONCLUSIONS

Enhanced recovery was associated with receiving on-time adjuvant chemotherapy. As prompt initiation of adjuvant chemotherapy improves survival in colorectal cancer, future investigation of long-term oncologic outcomes is necessary to evaluate the potential impact of enhanced recovery on survival. See Video Abstract at http://links.lww.com/DCR/B21. LA IMPLEMENTACIÓN DE UN PROTOCOLO DE RECUPERACIÓN ACELERADA SE ASOCIA CON EL INICIO A TIEMPO DE QUIMIOTERAPIA ADYUVANTE EN CÁNCER COLORRECTAL:: El inicio tardío de la quimioterapia adyuvante afecta negativamente la supervivencia a largo plazo en pacientes con cáncer colorrectal. Los protocolos de recuperación acelerada colorrectales dan lugar a una disminución de las complicaciones y la duración de estancia hospitalaria; sin embargo, el impacto de la recuperación acelerada en el momento de inicio de quimioterapia adyuvante sigue siendo desconocido.Este estudio tuvo como objetivo identificar los factores asociados con la administración a tiempo de la quimioterapia adyuvante después de la cirugía de cáncer colorrectal, con la hipótesis de que la implementación de un protocolo de recuperación acelerada daría lugar a que más pacientes reciban quimioterapia a tiempo.Estudio de cohorte retrospectivo que compara la tasa de administración de quimioterapia adyuvante a tiempo después de la resección del cáncer colorrectal antes y después de la implementación de un protocolo de recuperación acelerada.Centro médico académico grande.Todos los pacientes que se sometieron a resecciones de cáncer colorrectal no emergentes con intención curativa desde enero de 2010 hasta junio de 2017, excluyendo a los pacientes que no tenían indicación de quimioterapia adyuvante, que recibieron quimioterapia sistémica preoperatoria o no tenían registros médicos de oncología disponibles.Los pacientes se compararon antes y después de la implementación de la recuperación acelerada, con la tasa de administración de quimioterapia adyuvante a tiempo como el resultado primario. La administración de quimioterapia adyuvante se consideró a tiempo si se inició ≤8 semanas después de la operación, y el tratamiento se consideró retrasado / omitido si se inició> 8 semanas después de la operación (retrasado) o nunca fue recibido (omitido). La regresión logística multivariable identificó predictores de administración de quimioterapia a tiempo.363 pacientes cumplieron con los criterios de inclusión, con 189 (52.1%) pacientes sometidos a cirugía después de la implementación de recuperación acelerada. Los grupos difirieron en el abordaje laparoscópico y la duración media del procedimiento; ambos factores fueron mayores después de la recuperación acelerada. Significativamente más pacientes recibieron quimioterapia a tiempo después de la implementación de recuperación acelerada (p = 0.007). La recuperación acelerada fue un factor predictivo independiente de quimioterapia adyuvante a tiempo (p = 0.014).Diseño retrospectivo, tipo ¨antes y después¨ no aleatorizado.La recuperación acelerada se asoció con la recepción de quimioterapia adyuvante a tiempo. Debido a que el inicio rápido de la quimioterapia adyuvante mejora la supervivencia en el cáncer colorrectal, en el futuro será necesario investigar los resultados oncológicos a largo plazo para evaluar el impacto potencial de la recuperación acelerada en la supervivencia. Vea el Resumen en Video en http://links.lww.com/DCR/B21.

Outcomes of Hysterectomy Performed by Very Low-Volume Surgeons

OBJECTIVE

To perform a population-based analysis to first examine the changes in surgeon and hospital procedural volume for hysterectomy over time and then to explore the association between very low surgeon procedural volume and outcomes.

METHODS

All women who underwent hysterectomy in New York State from 2000 to 2014 were examined. Surgeons were classified based on the average annual procedural volume as very low-volume surgeons if they performed one procedure per year. We used multivariable models to examine the association between very low-volume surgeon status and morbidity, mortality, transfusion, length of stay, and cost.

RESULTS

Among 434,125 women who underwent hysterectomy, very low-volume surgeons accounted for 3,197 (41.0%) of the surgeons performing the procedures and operated on 4,488 (1.0%) of the patients. The overall complication rates were 32.0% for patients treated by very low-volume surgeons compared with 9.9% for those treated by other surgeons (P<.001) (adjusted relative risk 1.97, 95% CI 1.86-2.09). Specifically, the rates of intraoperative (11.3% vs 3.1%), surgical site (15.1% vs 4.1%) and medical complications (19.5% vs 4.8%), and transfusion (38.5% vs 11.8%) were higher for very low-volume compared with higher volume surgeons (P<.001 for all). Patients treated by very low-volume surgeons were also more likely to have a prolonged length of stay (62.0% vs 22.0%) and excessive hospital charges (59.8% vs 24.6%) compared with higher volume surgeons (P<.001 for both). Mortality rate was 2.5% for very low-volume surgeons compared with 0.2% for higher volume surgeons (P<.001) (adjusted relative risk 2.89, 95% CI 2.32-3.61).

CONCLUSION

A substantial number of surgeons performing hysterectomy are very low-volume surgeons. Performance of hysterectomy by very low-volume surgeons is associated with increased morbidity, mortality, and resource utilization.

Quality of life from a randomized trial of laparoscopic or open liver resection for colorectal liver metastases

Background

Most treatments for cancer cause a decline in patients' health-related quality of life (HRQoL). Limiting this decline is a universal goal for healthcare providers. Using minimally invasive instead of open surgical techniques might be one way to achieve this. The aim of this study was to compare postoperative HRQoL after open and laparoscopic liver resection.

Methods

This was a predefined substudy of an RCT comparing open with laparoscopic liver resection. Patients with colorectal liver metastases were assigned randomly to open or laparoscopic parenchyma-sparing liver resection. HRQoL was assessed with the Short Form 36 questionnaire at baseline, and 1 and 4 months after surgery.

Results

A total of 280 patients were randomized, of whom 273 underwent surgery (129 laparoscopic, 144 open); 682 questionnaires (83.3 per cent) were available for analysis. One month after surgery, patients in the laparoscopic surgery group reported reduced scores in two HRQoL domains (physical functioning and role physical), whereas those in the open surgery group reported reduced scores in five domains (physical functioning, role physical, bodily pain, vitality and social functioning). Four months after surgery, HRQoL scores in the laparoscopic group had returned to preoperative levels, whereas patients in the open group reported reduced scores for two domains (role physical and general health). The between-group difference was statistically significant in favour of laparoscopy for four domains after 1 month (role physical, bodily pain, vitality and social functioning) and for one domain after 4 months (role physical).

Conclusion

Patients assigned to laparoscopic liver surgery reported better postoperative HRQoL than those assigned to open liver surgery. For role limitations caused by physical health problems, patients in the laparoscopic group reported better scores up to 4 months after surgery. Registration number: NCT01516710 (http://www.clinicaltrials.gov).

The impact of postoperative morbidity on survival in patients with metastatic colon and rectal cancer

INTRODUCTION

Avoiding postoperative morbidity is essential in patients with advanced cancer. To further improve treatment in stage IV colorectal cancer, knowledge about risk factors which effect short- and long-term outcomes is important.

METHODS

All stage IV colon and rectal cancer who underwent elective surgery between 2004 and 2015 were included (n = 345). We compared resectable colon and rectal patients, and unresectable colon and rectal cancer patients.

RESULTS

Median follow-up duration was 22.2 (unresectable) and 56.7 months (resectable) with no difference in tumor location. Colon cancer patients were more often considered unresectable (P < .001). Rectal procedures were correlated with a higher morbidity rate and a longer surgical duration (P < .001). In the resectable cohort, obese patients, open procedures and prolonged surgery were independently associated with postoperative complications. Considering the palliative group, neoadjuvant treatment and age were correlated with worse outcomes. Morbidity was not associated with long-term outcomes in the resectable cohort. However, unresectable patients who developed respiratory (hazard ratio [HR]: 7.53) or cardiac (HR: 3.75) complications and patients with an American Society of Anesthesiologists-score III to IV (HR: 1.51) had an impaired survival.

CONCLUSION

Our results emphasize the need for an adequate preoperative assessment to identify patients at risk for postoperative complications and impaired 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.

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.

Postoperative complications increase the risk of long-term chronic kidney disease after nephron-sparing surgery in patients with renal cancer and normal preoperative renal function

OBJECTIVES

To investigate whether postoperative complications affect long-term functional outcomes of renal patients treated with nephron-sparing surgery (NSS).

MATERIALS AND METHODS

We performed an observational study, enrolling 596 patients with preoperative normal renal function treated with NSS for clinical T1abN0M0 renal masses. Cox regression models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for chronic kidney disease (CKD) including as covariates age, comorbidity (scored according to the Charlson comorbidity index), hypertension, tumour size, preoperative estimated glomerular filtration rate (eGFR), eGFR < 60 mL/min/1.73 m² at discharge, and ischaemia time.

RESULTS

A total of 137 patients (23%) developed postoperative complications. At a median (interquartile range) follow-up of 53 (26-91) months, CKD risk was 19% for patients with postoperative complications and 11% for those without complications. Patients experiencing postoperative complications (HR 1.90, 95% CI 1.26-2.86) were at increased risk of developing CKD during the follow-up at multivariable analysis, after accounting for confounders.

CONCLUSIONS

Our data outline how postoperative complications might have a detrimental impact on postoperative renal function in patients submitted to NSS. Improper patient selection, increasing the risk of postoperative complications, could limit the benefit in terms of renal function brought by NSS.

Incidence of extramural venous invasion in colorectal carcinoma as determined at the invasive tumor front and its prognostic impact

Extramural venous invasion (EMVI) is prognostic for colorectal cancer; however, veins are only detected partially by normal perpendicular preparation. Therefore, reported findings are conflicting and standardization is required. A total of 239 resection specimens were examined by tangential preparation of the extramural veins at the invasive tumor front. Average follow-up was 39 months. The relationship of EMVI to metachronous hematogenic metastasis (MHM) was evaluated. With this method, a high prevalence of EMVI beginning in stage II is apparent. In stage I, 66% of patients with EMVI developed MHM; in stage II, 25%; and in stage III, 49%. In stage III, the number of tumor-invaded veins is crucial. In the absence of detection of EMVI, MHM occurred in 1 of 29 patients in stage II and in 2 of 13 patients in early stage III. By tangential sectioning at the invasive tumor front, we found a high incidence of EMVI beginning in stage II, which increases with tumor stage. Especially in stages II and III, the correct determination of absent EMVI has a high negative predictive value for MHM. In stage I, EMVI defines a patient group with increased risk for MHM. The quantification of EMVI is an important issue for standardization.

Perirenal fat surface area as a risk factor for perioperative difficulties and 30-day postoperative complications in elective colon cancer surgery

AIM

Visceral obesity is associated with perioperative and postoperative complications in colorectal surgery. We aimed to investigate the association between the perirenal fat surface area (PRF) and postoperative complications.

METHOD

Data on 610 patients undergoing curative, elective colon cancer resection between 2006 and 2016 at Stockholm South General Hospital were retrieved from a local quality register. We assessed perioperative and postoperative outcomes using a multinomial regression model adjusted for age, sex, American Society of Anesthesiologists classification and surgical approach (open/laparoscopy) in relation to PRF.

RESULTS

PRF could be measured in 605 patients; the median area was 24 cm² . Patients with PRF ≥ 40 cm² had longer operation time (median 223 vs 184 min), more intra-operative bleeding (250 vs 125 ml), reoperations (11% vs 6%), surgical complications (27% vs 13%) and nonsurgical infectious complications (16% vs 9%) than patients with PRF < 40 cm² , but there were no differences in the need for intensive care or duration of hospital stay. The multivariate analyses revealed an increased risk of any complication [OR 1.68 (95% CI 1.1-2.6)], which was even more pronounced for moderate complications [Clavien-Dindo II, OR 2.14 (CI 1.2-2.4]; Clavien-Dindo III, OR 2.35 (CI 1.0-5.5)] in patients with PRF ≥ 40 vs < 40 cm² . The absolute risk of complications was similar in men and women with PRF ≥ 40 cm² .

CONCLUSION

PRF, an easily measured indirect marker of visceral obesity, was associated with overall and moderate complications in men and women and could serve as a useful tool in the assessment of preoperative risk.

Visceral fat area, not body mass index, predicts postoperative 30-day morbidity in patients undergoing colon resection for cancer

PURPOSE

Colectomy for cancer in obese patients is technically challenging and may be associated with worse outcomes. Whether visceral obesity, as measured on computed tomography, is a better predictor of complication than body mass index (BMI) or determines long-term oncologic outcomes has not been well characterized. This study examines the association between derived anthropometrics and postoperative complication and long-term oncologic outcomes.

METHODS

Retrospective review of patients undergoing elective colectomy for cancer at a single tertiary-care center from 2010 to 2016. Adipose tissue distribution measurements, including visceral fat area (VFA), were determined from preoperative imaging. The primary outcome was 30-day postoperative complication; secondary outcomes included overall and disease-free survival. Multivariable logistic regression was performed to determine association between obesity metrics and outcome.

RESULTS

Two hundred and sixty-four patients underwent 266 primary resections of colon cancer. Twenty-eight patients (10.5%) developed major morbidity (Clavien-Dindo grade ≥ III). VFA but not BMI was significantly associated with morbidity in multivariate analysis (p = 0.004, odds ratio 1.99, 95% confidence interval 1.25-3.19). No other imaging-derived anthropometric was associated with increased morbidity. In receiver operating characteristic analysis, VFA was predictive of major morbidity (area under curve 0.660). A cutoff value of VFA ≥ 191 cm² was associated with 50% sensitivity and 76% specificity for predicting major morbidity. Patients with VFA ≥ 191cm² had 19.4% risk of morbidity, whereas those with < 191 cm² had 7.2% risk (relative risk ratio 2.69, unadjusted p = 0.004). Neither VFA nor BMI was associated with overall or disease-free survival.

CONCLUSION

VFA but not BMI predicts morbidity following elective surgery for colon cancer.

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.

Laparoscopic liver resection for colorectal liver metastasis patients allows patients to start adjuvant chemotherapy without delay: a propensity score analysis

BACKGROUND

Although adjuvant chemotherapy (AC) is widely used after liver resection (LR) for colorectal liver metastasis (CRLM), surgical invasiveness may lead to delay in starting AC, which is preferably started within 8 weeks postoperative. We investigated whether laparoscopic liver resection (LLR) for CRLM facilitates AC start without delay.

METHODS

Between November 2014 and December 2016, 117 consecutive CRLM patients underwent LR followed by AC. LLR and OLR were performed in 30 and 87 patients, respectively. After propensity score matching on clinical characteristics, oncologic features, and type of resection, the time interval between liver resection and AC start was compared between LLR (n = 22) and OLR (n = 44) groups.

RESULTS

After propensity score matching, major LR was performed in 8/22 (36%) and 15/44 (34%) cases of LLR and OLR groups, respectively (P = 1.0). Clinical-pathological characteristic and intraoperative findings were comparable between two groups. There was no significant difference in postoperative complications between the two groups. The time interval between liver resection and AC start was significantly shorter in LLR than in OLR group (43 ± 10 versus 55 ± 18 days, P = 0.012). While 15/44 (34%) patients started AC after 8 weeks postoperative in OLR group, all patients in LLR group started AC within 8 weeks.

CONCLUSIONS

LLR for CRLM is associated with quicker return to AC when compared to OLR. The delivery of AC without delay allows CRLM patients to optimize the oncologic treatment sequence.

MicroRNAs and their role for T stage determination and lymph node metastasis in early colon carcinoma

Worldwide, colon cancer is among the most common cancer entities. Understanding the molecular background is the key to enable accurate stage determination, which is crucial to assess optimal therapy options. The search for preoperative biomarkers is ongoing. In recent years, several studies have proposed a diagnostic and prognostic role for miRNAs in cancer. Aim of this study was to evaluate miRNA expression patterns correlating with tumor stage, especially lymph node metastasis, in primary colon carcinoma tissue. Screening was accomplished using GeneChip^® miRNA v3.0 arrays (Thermo Fisher Scientific, Waltham, MA, USA) and validated via TaqMan^® qPCR assays (Thermo Fisher Scientific, Waltham, MA, USA) to investigate miRNA expressions in 168 FFPE and 83 fresh frozen colon carcinoma samples. Regarding lymph node status, analyses displayed no significantly differential miRNA expression. Interestingly, divergent expression of miR-18a-5p, miR-20a-5p, miR-21-5p, miR-152-3p and miR-1973 was detected in stage pT1. Although miRNAs might not represent reliable biomarkers regarding lymph node metastasis status, they could support risk assessment in stage T1 tumors.

Hospital Variability in Use of Adjuvant Chemotherapy for Patients with Stage 2 and 3 Colon Cancer

BACKGROUND

Following oncologic resection, adjuvant chemotherapy is associated with decreased recurrence and improved survival in stage 3 colon cancer. However, there is controversy regarding its use in stage 2 colon cancer with high-risk features (tumor depth T4, poorly differentiated, positive margin, and/or inadequate lymph node retrieval). Consensus guidelines recommend no adjuvant chemotherapy in the absence of these high-risk features (low-risk stage 2).

OBJECTIVE

This study aimed to examine hospital characteristics associated with poor risk-adjusted, stage-specific guideline compliance for the use of adjuvant chemotherapy in stage 3 and low-risk stage 2 colon cancer.

DESIGN

This was a retrospective study. Stepwise logistic regression was used to identify patient and hospital factors associated with administration of adjuvant chemotherapy. Hierarchical regression models were used to calculate risk- and reliability-adjusted rates of chemotherapy use and observed-to-expected ratios in each hospital's stage 2 low-risk and stage 3 patients.

SETTINGS

Data were retrieved from the National Cancer Database.

PATIENTS

Patients selected were adults treated with oncologic resection for stage 2 to 3 colon cancer between 2004 and 2010.

MAIN OUTCOME MEASURES

The primary outcome measured was receipt of adjuvant chemotherapy.

RESULTS

A total of 167,345 patients were identified at 1395 hospitals. The mean overall risk-adjusted adjuvant chemotherapy rate was 65.3% for stage 3 and 15.2% for low-risk stage 2. Analysis of low outlier hospitals for stage 3 colon cancer, where adjuvant chemotherapy was underutilized, demonstrated that 62.8% were low-volume centers and 51.4% were community centers. Of high outlier hospitals for stage 2 low-risk disease, where adjuvant chemotherapy was overutilized, 87.2% were low-volume hospitals and 67.2% were community centers.

LIMITATIONS

Selection bias and the inability to compare specific chemotherapy regimens were limitations of this study.

CONCLUSIONS

Following oncologic resection, administration of adjuvant chemotherapy for low-risk stage 2 and stage 3 disease varies substantially among hospitals in the United States. Outlier hospitals were most likely to be low-volume community centers.

Postoperative mortality and morbidity in older patients undergoing emergency right hemicolectomy for colon cancer

INTRODUCTION

Even with the advances in surgical technique and perioperative care, morbidity and mortality after colorectal cancer surgery remain considerable, and patients (pt) who present as an emergency have an even higher mortality and morbidity rate.

METHODS

A total of 35 pt with caecum or ascending colon cancer between January 2007 and June 2015, three departments in Italy and in Poland, were included in the study. The intention of surgery in all cases was curative resection with ileo-colic anastomosis. Comparative statistical analysis was performed.

RESULTS

Acute bowel obstruction was the major complication of CRC that led to an emergency hemicolectomy. Postoperative mortality and morbidity rates were in total 12.5 and 28.1%, respectively. All the deaths happened in Poland. Of the pt, 42.8% had morbidity in Poland and 16.6% in Italy. Out of the pt, 25% presenting with perforation: 25% died, 25% had wound dehiscence, 12.5% had pulmonary oedema, and 12.5% had an intra-abdominal abscess. The mean age of the pt with complications in Poland and in Italy was 79.3 and 72.0 years, respectively.

CONCLUSION

We observed that particularly lethal combination is older age, perforation with peritonitis and advanced stage of the cancer.

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.