Operative Mortality Prediction for Primary Rectal Cancer: Age Matters

Analysis of the factors influencing moderate to poor performance status in patients with cancer after chemotherapy: a cross-sectional study comparing three models

There are no models for assessing the factors that determine moderate to poor performance status in patients with cancer after chemotherapy. This study investigated the influencing factors and identified the best model for predicting moderate-poor performance status. A convenience sampling method was used. Demographic and clinical data and evaluation results for fatigue, pain, quality of life and Eastern Cooperative Oncology Group status were collected three days after the end of chemotherapy. Decision tree, random forest and logistic regression models were constructed. Ninety-four subjects in the case group had moderate to poor performance status, and 365 subjects in the control group had no or mild activity disorders. The random forest model was the most accurate model. Physical function, total protein, general quality of life within one week before chemotherapy, hemoglobin, pain symptoms and globulin were the main factors. Total protein and hemoglobin levels reflect nutritional status, and globulin levels are an index of liver function. Therefore, physical function, nutritional status, general quality of life and pain symptoms within one week before chemotherapy and liver function can be used to predict moderate-poor performance status. Nurses should pay more attention to patients with poor physical function, poor nutritional status, lower quality of life and pain symptoms after chemotherapy.

A nomogram and risk classification system forecasting the cancer-specific survival of lymph- node- positive rectal cancer patient after radical proctectomy

Background

The aim of the study was to develop and validate a nomogram for predicting cancer-specific survival (CSS) in lymph- node- positive rectal cancer patients after radical proctectomy.

Methods

In this study, we analyzed data collected from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015. In addition, in a 7:3 randomized design, all patients were split into two groups (development and validation cohorts). CSS predictors were selected via univariate and multivariate Cox regressions. The nomogram was constructed by analyzing univariate and multivariate predictors. The effectiveness of this nomogram was evaluated by concordance index (C-index), calibration plots, and receiver operating characteristic (ROC) curve. Based on the total score of each patient in the development cohort in the nomogram, a risk stratification system was developed. In order to analyze the survival outcomes among different risk groups, Kaplan-Meier method was used.

Results

We selected 4,310 lymph- node- positive rectal cancer patients after radical proctectomy, including a development cohort (70%, 3,017) and a validation cohort (30%, 1,293). The nomogram correlation C-index for the development cohort and the validation cohort was 0.702 (95% CI, 0.687-0.717) and 0.690 (95% CI, 0.665-0.715), respectively. The calibration curves for 3- and 5-year CSS showed great concordance. The 3- and 5-year areas under the curve (AUC) of ROC curves in the development cohort were 0.758 and 0.740, respectively, and 0.735 and 0.730 in the validation cohort, respectively. Following the establishment of the nomogram, we also established a risk stratification system. According to their nomogram total points, patients were divided into three risk groups. There were significant differences between the low-, intermediate-, and high-risk groups (p< 0.05).

Conclusions

As a result of our research, we developed a highly discriminatory and accurate nomogram and associated risk classification system to predict CSS in lymph-node- positive rectal cancer patients after radical proctectomy. This model can help predict the prognosis of patients with lymph- node- positive rectal cancer.

Clinical Safety and Effectiveness of Robotic-Assisted Surgery in Patients with Rectal Cancer: Real-World Experience over 8 Years of Multiple Institutions with High-Volume Robotic-Assisted Surgery

Simple Summary

The aim of this retrospective observational study was to evaluate perioperative and short-term oncological outcomes of robotic-assisted rectal surgery (RRS) in hospitals with a high-volume of robotic-assisted surgeries. This study enrolled patients with rectal adenocarcinoma undergoing RRS from three high-volume institutions from December 2011 to June 2020. Compared with other studies, our results revealed the equivalent or superior perioperative and short-term oncological outcomes. Hence, RRS is an effective, safe, and feasible technique for patients with rectal cancers in high-volume hospitals.

Abstract

The perioperative and short-term oncological outcomes of robotic-assisted rectal surgery (RRS) are unclear. This retrospective observational study enrolled patients with rectal adenocarcinoma undergoing RRS from three high-volume institutions in Taiwan. Of the 605 enrolled patients, 301 (49.75%), 176 (29.09%), and 116 (19.17%) had lower, middle, and upper rectal cancers, respectively. Low anterior resection (377, 62.31%) was the most frequent surgical procedure. Intraoperative blood transfusion was performed in 10 patients (2%). The surgery was converted to an open one for one patient (0.2%), and ten (1.7%) patients underwent reoperation. The overall complication rate was 14.5%, including 3% from anastomosis leakage. No deaths occurred during surgery and within 30 days postoperatively. The positive rates of distal resection margin and circumferential resection margin were observed in 21 (3.5%) and 30 (5.0%) patients, respectively. The 5-year overall and disease-free survival rates for patients with stage I–III rectal cancer were 91.1% and 86.3%, respectively. This is the first multi-institutional study in Taiwan with 605 patients from three high-volume hospitals. The overall surgical and oncological outcomes were equivalent or superior to those estimated in other studies. Hence, RRS is an effective and safe technique for rectal resection in high-volume hospitals.

Short-Term Outcomes for Restorative and Non-Restorative Proctocolectomy in Older Adults

BACKGROUND

Curative surgery for ulcerative colitis can be subdivided into restorative (with pouch and anastomosis) and non-restorative operations. Restorative surgery in older adults is controversial, due to concerns about surgical risk and long-term functional outcome. The goal of this study is to compare 30-day outcomes for restorative and non-restorative surgery in older adults with ulcerative colitis.

METHODS

Data were obtained from the American College of Surgeons National Surgical Quality Initiative Program from 2012-2018. Patients were included if they were >65 years old and had ulcerative colitis. Restorative and non-restorative surgeries were defined with procedure codes. Patient characteristics and adverse surgical outcomes were compared between restorative and non-restorative surgeries utilizing chi-square tests and Fisher's exact tests. Multivariate logistic regression models were constructed to evaluate the association of restorative versus non-restorative surgery with adverse surgical outcomes while adjusting for potential confounders.

RESULTS

Of 392 total patients, 95 had restorative and 297 had non-restorative surgery. Patients undergoing restorative surgery, compared to non-restorative surgery, were significantly younger (P<0.01), had lower incidences of steroid usage (P<0.001) and higher rates of readmission (P = 0.02). There were no differences in post-operative complications between the groups in both unadjusted analyses and covariate-adjusted regression analysis (P > 0.05).

CONCLUSION

In carefully selected older patients with ulcerative colitis, restorative surgery is associated with increased readmission, but otherwise similar rates of morbidity or mortality compared to non-restorative surgery. Data regarding postoperative functional outcome and quality of life are also needed to help select the most appropriate curative option for older adults.

Surgical outcomes following colorectal cancer resections in patients aged 80 years and over: results from the Australia and New Zealand Binational Colorectal Cancer Audit

AIM

The primary aim was to compare the 30-day morbidity and mortality in patients aged ≥80 years undergoing surgery for colorectal cancer with those aged <80 years. The secondary aim was to identify independent outcome predictors.

METHOD

This was a retrospective study of patients undergoing surgery for colorectal cancer between January 2007 and February 2018. Patients were divided into those <80 years and those ≥80 years at the time of surgery. Data had been collected prospectively by the Australasian Binational Colorectal Cancer Audit and included patient demographics, site and stage of tumour, comorbidity, operative details, American Society of Anesthesiologists score (ASA), pathological staging, 30-day mortality and morbidity (medical and surgical). Univariate and multivariate analyses were used to identify predictors of 30-day morbidity and mortality.

RESULTS

During the study period, 4600 out of 20 463 (22.5%) patients were ≥80 years. They had a greater 30-day mortality after both colonic (97/2975 [3.3%] vs. 66/7010 [0.9%], P < 0.001) and rectal resections (50/1625 [3.1%] vs. 36/9006 [0.4%], P < 0.001) compared with younger patients. They also had an increased length of stay (colon cancer, 9 vs. 7 days; rectal cancer, 10 vs. 8 days; P < 0.001) and medical complications (colon cancer, 23.5% vs. 12.7%; rectal cancer, 25.2% vs. 11.2%; P < 0.001). Surgical complications were equivalent. Age ≥80 years was not an independent predictor of 30-day morbidity or mortality. Patients ≥80 years who were ASA 2/3 and had rectal cancer seemed to fare worse in terms of 30-day mortality (ASA 2, 22%, 95% CI 9%-36%, P < 0.001; ASA 3, 11%, 95% CI 4%-19%, P< 0.001).

CONCLUSIONS

Postoperative morbidity and mortality are significantly greater in patients ≥80 years undergoing colorectal cancer surgery. Any recommendation for surgery in this age group should take into account patient comorbidity and not be based on age alone.

ERAS pathway in colorectal surgery: structured implementation program and high adherence for improved outcomes

Although there is clear evidence that an Enhanced Recovery After Surgery (ERAS) program in colorectal surgery leads to significantly reduced morbidity rates and length of hospital stay (LOS), it is still unclear what modalities and levels of implementation of the program are necessary to achieve these results. The purpose of this study is to analyze the methods and results of the first year of structured implementation of a colorectal ERAS program in two surgical units of the Azienda Sanitaria Unica Regionale (ASUR) Marche in Italy. A two-center observational study on a prospectively maintained database was performed on 196 consecutive colorectal resections (excluding emergencies and American Society of Anesthesiologists class > III cases) over a 1-year period. More than 50 variables including adherence to the individual items of the ERAS program were considered. Primary outcomes were overall morbidity, major morbidity, mortality and anastomotic leakage rates; secondary outcomes were LOS, re-admission and re-operation. The results were evaluated by univariate and multivariate analyses through logistic regression. After a median follow-up of 39.5 days, we recorded complications in 72 patients (overall morbidity 36.7%), major complications in 14 patients (major morbidity 7.1%), 6 deaths (mortality 3.1%), anastomotic dehiscence in 9 cases (4.9%), mean overall LOS of 6.6 days, 10 readmissions (5.1%) and 13 reoperations (6.7%). The mean adherence rate to the items of the ERAS program was 85.4%, showing a significant dose-effect curve for overall and major morbidity rates, anastomotic leakage rates and LOS. The implementation methods of a colorectal ERAS program in this study led to a high adherence (> 80%) to the program items. High adherence had significant effects also on major morbidity and anastomotic leakage rates.

Risk factors for adverse events after elective colorectal surgery: beware of blood transfusions

Purpose of the present study is to analyze risk factors for adverse events after elective colorectal resection. A wide range of adverse events after elective colorectal surgery was reported, anastomotic leakage (AL) and related morbidity and mortality being the most feared ones. Clear definition of risk factors is crucial to limit the related mortality. Prospective, 1-year multicenter enrollment of 1546 elective colorectal resections with anastomosis. Endpoints were anastomotic leakage (AL), overall morbidity, major morbidity and mortality rates (ClinicalTrials.gov; Identifier: NCT03560180). AL rate was 4.92%. Overall morbidity, major morbidity and mortality rates were 30.20%, 9.76% and 1.29%, respectively. Intra- and/or postoperative blood transfusion(s) was the only variable independently influencing all the endpoints: Odds ratios (OR) were 8.15 for AL, 19.33 for overall morbidity, 10.17 for major morbidity and 3.70 for mortality); overall morbidity rates were also independently influenced by American Society of Anesthesiologists class III vs I-II and extra- vs intra-corporeal anastomosis (OR 1.57 and 1.49, respectively); major morbidity rates were also independently influenced by female vs male gender and by the length of the procedure (OR 0.60 and 1.004, respectively); mortality rates were also independently influenced by increasing age (OR 1.16). This study clearly identifies intra- and/or postoperative blood transfusion(s) as an independent risk factor for all adverse events after elective colorectal surgery.