Visceral obesity, body mass index and risk of complications after colon cancer resection: A retrospective cohort study

[Anastomotic leaks in colorectal surgery]

A leakage of a colorectal anastomosis represents a severe complication in visceral surgery. An anastomotic insufficiency (AI) is a potentially life-threatening complication for patients that carries a high risk of subsequent complications and long-term stoma care. Numerous factors influence the risk of AI. Knowing and being able to estimate these factors are essential for successful treatment in colorectal surgery as they help determine the surgical strategy. The recognition of an AI can be challenging for practitioners due to the variability in the clinical presentation. If the presence of AI is suspected appropriate diagnostic measures must therefore be taken. If an AI has occurred a colorectal specialist should definitely be involved in the treatment as this can significantly reduce further complications and the rate of permanent stomas.

Body composition and peri- and postoperative complications in patients with gynaecological malignancies: A systematic review

BACKGROUND

In general abdominal surgery, the ratio of fat to muscle mass, or body composition measures, shows a stronger association with complications than body mass index. These studies include male and female patients. Women have a different body composition than men. Therefore, findings from general abdominal surgery cannot be extrapolated to women with cancer. The aim of this systematic review is to summarise the evidence on the association between body composition and peri- and postoperative complications in patients with gynaecological cancer.

METHODS

Pubmed, Embase and the Cochrane Central databases were searched in June 2023. Studies were eligible if they included patients undergoing surgery for gynaecological cancer and reported on the association between body composition (muscle or fat mass) and surgical complications. The quality of the studies was assessed using the Newcastle-Ottawa quality assessment scale. A best-evidence synthesis was used to summarise the level of evidence.

RESULTS

Fifteen studies were included that assessed muscle mass (n = 9) or fat mass (n = 6). We found strong evidence that there was no association between visceral fat and length of hospital stay. We found moderate evidence that a higher amount of good quality muscle was associated with a lower risk of postoperative complications. We found moderate evidence that there was no association between muscle or fat mass (i.e., muscle- or subcutaneous fat) and postoperative complications or fat mass and intraoperative complications. There was insufficient evidence for an association between visceral fat and intraoperative or postoperative complications, and for an association between muscle mass or -quality and length of hospital stay. There was high heterogeneity in the methods used to measure body composition, hampering meta-analyses.

CONCLUSION

The association between body composition, particularly adipose tissue and muscle quality, and complications suggests that these measures may be of interest in determining postoperative risk in women undergoing surgery for gynaecological cancer.

Association of computed tomography-derived body composition and complications after colorectal cancer surgery: A systematic review and meta-analysis

The prediction of the risk of developing complications after colorectal surgery for colorectal carcinoma remains imprecise. Body composition measurements on a computed tomography (CT) scan can potentially contribute to a better preoperative risk assessment. The aim of this systematic review is to evaluate the evidence for the use of body composition measurements on CT scans to predict short-term complications after colorectal cancer surgery. A literature search (in PubMed, Embase and Web of Science) was performed up to 1 August 2022. Two researchers independently screened the articles, extracted data and assessed the quality of the studies using the Quality in Prognosis Studies tool. The primary outcome measure was the occurrence of complications within 30 days after surgery. Meta-analysis was conducted using a random-effects model to synthesize a pooled odds ratio (OR). The study protocol was registered in PROSPERO (CRD42021281010). Forty-five articles with a total of 16 537 patients were included. In total, 26 body composition measures were investigated: 8 muscle-related measures, 11 adipose tissue measures, 4 combined muscle and adipose tissue measures, and 3 other measures. These were investigated as potential predictors for more than 50 differently defined postoperative complications. Meta-analysis was only possible for two measurements and showed that higher amounts of visceral fat increase the risk of developing overall complications (OR: 2.52 [1.58-4.00], P < 0.0001) and anastomotic leakage (OR: 1.76 [1.17-2.65], P = 0.006). A wide variety of body composition measurements on preoperative CT scans have been investigated as a predictive factor for postoperative complications. Visceral fat appeared to be associated with overall complications and anastomotic leakage; however, the association is weak, and its clinical relevance or applicability is questionable. The current evidence is limited by methodological heterogeneity and the risk of bias. To improve comparability of results across studies and improve decision-making, future studies should use standardized methods for measuring body composition on CT scans, outcome definitions and statistical analyses.

Unraveling the role of computed tomography derived body composition metrics on anastomotic leakages rates in rectal cancer surgery: A protocol for a systematic review and meta-analysis

INTRODUCTION

Anastomotic leakage is a major concern following total mesorectal excision for rectal cancer, affecting oncological outcomes, morbidity an treatment costs. Body composition has been suggested to influence anastomotic leakage rates. However, literature on how body composition impact anastomotic leakage rates is conflicting. This systematic review aims to evaluate the role of computed tomography derived body composition metrics on anastomotic leakage rates in rectal cancer patients.

METHODS

Databases PubMed/MEDLINE, Cochrane Library, web of science, and EMBASE, will be systematically searched for papers from January 2010 onwards. Study selection, data collection and quality assessment will be independently performed by three research fellows. Outcomes described in three or more studies will be included in the meta-analysis. The Q-test and I2 statistic will be used to assess statistical heterogeneity between studies. Publication bias will be examined by visual inspection of funnel plots and quantified by Egger's test. Sensitivity analyses will be conducted to examine the robustness of the meta-analysis. Reporting of the findings will be in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines.

CONCLUSIONS

This systematic review will synthesize the current evidence and will identify knowledge gaps. Results of the systematic review will aid health care professional in pre-operative decision making and will be distributed through a peer-reviewed publication and presentation of results at international meetings.

TRIAL REGISTRATION

PROSPERO protocol number: CRD42023471537.

Impact of visceral obesity on infectious complications after resection for colorectal cancer: a retrospective cohort study

OBJECTIVES

To explore the impact of visceral obesity (VO) measured by preoperative abdominal computed tomography (CT) on postoperative infectious complications for colorectal cancer (CRC) patients and establish a predictive model.

METHODS

Patients who underwent resection for colorectal cancer between January 2015 and January 2021 were enrolled in this study. All patients were measured for body mass index (BMI) and visceral fat area (VFA) preoperatively. Infectious complications were compared between the different groups according to BMI and VO categories. Univariate and multivariate logistic regression were used to analyze whether VO was an independent risk factor for postoperative infectious complications. According to the results of logistic regression, six machine learning approaches were used to establish predictive models and perform internal validation. The best-performing model was interpreted by the SHAPley Additive exPlanations value.

RESULTS

Approximately 64.81% of 520 patients had VO. VO was significantly connected with postoperative infectious complications (P < 0.001), coronary heart disease (P = 0.004), cerebral infarction (P = 0.001), hypertension (P < 0.001), diabetes (P < 0.001), and fatty liver (P < 0.001). The rates of wound infection (P = 0.048), abdominal or pelvic infection (P = 0.006), and pneumonia (P = 0.008) increased obviously in patients with VO. Compared to the low BMI group, a high BMI was found to be significantly associated with hypertension (P=0.007), fatty liver (P＜0.001), and a higher rate of postoperative infection (P=0.003). The results of logistic regression revealed that VO (OR = 2.01, 95% CI 1.17 ~ 3.48, P = 0.012), operation time ≥ 4 h (OR = 2.52, 95% CI 1.60 ~ 3.97, P < 0.001), smoking (OR = 2.04, 95% CI 1.16 ~ 3.59, P = 0.014), ostomy (OR = 1.65, 95% CI 1.04 ~ 2.61, P = 0.033), and chronic obstructive pulmonary disease (COPD) (OR = 2.23, 95% CI 1.09 ~ 4.57, P = 0.029) were independent risk factors. The light gradient boosting machine (LGBM) model displayed the largest area under the receiver operating characteristic curve (AUC) (0.74, 95% CI 0.68 ~ 0.81).

CONCLUSIONS

In this study, VO was superior to BMI in evaluating the influence of obesity on metabolic comorbidities and postoperative infectious complications in colorectal cancer patients.

Visceral obesity and anastomotic leakage rates in colorectal cancer: a systematic review and meta-analysis

Background

Numberous studies have heatedly discussed whether obesity is a risk factor for anastomotic leakage (AL) because of the increasing number of colorectal cancer (CRC) cases and high incidence of CRC in patients with obesity.

Objective

We aimed to explore the relationship between visceral obesity(VO) and AL after CRC surgery. The databases of Pubmed, Embase, and the Cochrane Library were searched for relevant data and articles published until November 1, 2022. We identified the difference in the incidence of AL after CRC surgery between patients with and without VO. The quality of included studies was evaluated using the Newcastle- Ottawa Scale, and odds ratio (OR) and 95% CI were used to assess the association between VO and AL.

Results

This meta-analysis included 7 studies with 2,136 patients. The OR of patients with VO versus those without VO was 2.15 (95%CIs = 1.46-3.15, test for heterogeneity: P = 0.29, I2 = 18%) based on the fixed-effect model in seven studies. Notably, the difference between the two groups was statistically significant (Z = 3.91 P < 0.0001). Patients with VO in the colon cancer group exhibited a higher incidence of AL (OR = 2.88, 95% CIs = 1.38-5.99, test for heterogeneity: P = 0.27, I2 = 20%) than those in the rectal cancer group (OR = 2.74, 95% CIs = 1.13-6.65, test for heterogeneity: P = 0.20, I2 = 38%). In the studies in the relevant literature, heterogeneity was low. Regarding patients with VO, four Asian studies reported increased morbidity due to AL (OR = 2.79, 95% CIs = 1.35-5.78, test for heterogeneity: P = 0.35, I2 = 9%) compared with three non-Asian studies.

Conclusions

Our findings confirmed the significant relationship between VO and AL. Thus, VO could be considered a reliable risk factor of surgery for colon cancer.

Anastomotic leak risk factors following colon cancer resection: a systematic review and meta-analysis

BACKGROUND

Despite improved surgical techniques, anastomotic leakage is still a serious complication that can occur after colon cancer resection, resulting in increased morbidity and mortality. The aim of this study was to evaluate the risk factors for anastomotic leakage after colon cancer surgery, provide a theoretical basis for reducing its occurrence, and guide the practice of clinicians.

METHODS

A systematic review of PubMed, Ovid, Web of Science and Cochrane Central Register of Controlled Trials databases was conducted by using a combination of subject terms and free words for online searches. The databases were searched from their inception to 31 March 2022, and all cross-sectional, cohort or case‒control studies examining the risk factors for the development of anastomotic fistula after surgery for colon cancer were identified.

RESULT

A total of 2133 articles were searched for this study, and 16 publications were ultimately included, all of which were cohort studies. A total of 115,462 subjects were included, and a total of 3959 cases of anastomotic leakage occurred postoperatively, with an incidence of 3.4%. The odds ratio (OR) and 95% confidence interval (CI) were used for evaluation. Male sex (OR = 1.37, 95% CI: 1.29-1.46, P < 0.00001), BMI (OR = 1.04, 95% CI: 1.00-1.08, P = 0.03), diabetes (OR = 2.80, 95% CI: 1.81-4.33, P < 0.00001), combined lung disease (OR = 1.28, 95% CI: 1.15-1.42, P < 0.00001), anaesthesia ASA score (OR = 1.35, 95% CI: 1.24-1.46, P < 0.00001), ASA class ≥ III (OR = 1.34, 95% CI: 1.22-1.47, P < 0.00001), emergency surgery (OR = 1.31, 95% CI: 1.11-1.55, P = 0.001), open surgery (OR = 1.94, 95% CI: 1.69-2.24, P < 0.00001) and type of surgical resection (OR = 1.34, 95% CI: 1.12-1.61, P = 0.002) are risk factors for anastomotic leakage after colon cancer surgery. There is still a lack of strong evidence on whether age (OR = 1.00, 95% CI: 0.99-1.01, P = 0.36) and cardiovascular disease (OR = 1.18, 95% CI: 0.94-1.47, P = 0.16) are factors influencing the occurrence of anastomotic leakage after colon cancer surgery.

CONCLUSIONS

Male sex, BMI, obesity, coexisting pulmonary disease, anaesthesia ASA score, emergency surgery, open surgery and type of resection were risk factors for anastomotic leakage after colon cancer surgery. The effect of age and cardiovascular disease on postoperative anastomotic leakage in patients with colon cancer needs further study.

Perirenal fat thickness as a risk factor for postoperative complications in elective colorectal cancer surgery

Visceral obesity is an important factor that increases the risk of complications after colorectal cancer surgery. As calculating visceral fat is difficult and time-consuming, more practical fat measurements that are not time-consuming have been introduced. This study aimed to investigate the effects of perirenal fat thickness on postoperative complications and prognosis in patients undergoing surgery for colorectal cancer. Perirenal fat thickness was measured from the dorsal aspect of the left kidney on preoperative computerized tomography of patients who underwent surgery for colorectal cancer. The effects of perirenal fat thickness on postoperative complications were investigated. Diagnostic test performance was examined using the Roc Curve test to determine the cutoff value for the perirenal fat thickness values according to the complication findings of the patients. The cutoff value of perirenal fat thickness was found to be above 25.1, according to the presence of complications in the patients. Those with a perirenal fat thickness greater than 25.1 mm were considered to have high perirenal fat thickness values, and those with a low perirenal fat thickness value were considered low. Multivariate analysis revealed that increased perirenal fat thickness is an independent risk factor for postoperative complications. We believe that perirenal fat thickness measurement, as an indicator of visceral fat volume, can be used to identify patients at high risk of developing complications after colorectal cancer surgery. This may change the disease management and affect the patient information process.

Prediction model of anastomotic leakage after anterior resection for rectal cancer-based on nomogram and multivariate analysis with 1995 patients

BACKGROUND

Postoperative anastomotic leakage for rectal cancer shows higher morbidity with grievous concomitant symptoms. Accurate assessment of the incidence of anastomotic leakage, multivariate analysis, and establishment of a scientific prediction model can be useful to dispose of its possible severe clinical consequences.

METHODS

This retrospective study collected 1995 consecutive patients who underwent anterior resection of rectal cancer with primary anastomosis at Northern Jiangsu People's Hospital between January 2016 and June 2022. Independent risk factors associated with anastomotic leakage were analyzed by univariate and multivariate logistic regression. The chosen independent risk factors were used to construct a nomogram risk prediction model whose availability was evaluated by using a bootstrapped-concordance index and calibration plots with R software.

RESULTS

A total of 1995 patients who underwent anterior resection for rectal cancer were included while 120 patients were diagnosed with anastomotic leakage, an incidence of 6.0%. Univariate analysis and its concomitant multivariate cox regression analysis indicated that independent risk factors associated with anastomotic leakage included male gender (odds ratio (OR) = 2.873), diabetes (OR = 2.480), neoadjuvant therapy (OR = 5.283), tumor's distance from the anus verge < 5 cm (OR = 5.824), tumor size ≥ 5 cm (OR = 4.888), and the blood lose > 50 mL (OR = 9.606).We established a nomogram prediction model with proper applicability (concordance index, 0.83) and the calibration curve to justify its predictive ability that the predicted occurrence probability keeps a high degree of consistency with the actual occurrence probability. Meanwhile, the area under the receiver operating characteristic (ROC) curve was 0.83.

CONCLUSIONS

The characteristics of patients and tumor surgery-related conditions can affect the incidence of anastomotic leakage. However, whether the surgical method will affect morbidity is still controversial. Our nomogram can be seen as an effective instrument to predict anastomotic leakage after anterior resection for rectal cancer precisely.

Sarcobesity, but not visceral fat, is an independent risk factor for complications after radical resection of colorectal cancer

Background

The influence of body composition on the outcome of colorectal cancer surgery is controversial. The aim of this study was to evaluate the effects of visceral obesity and sarcobesity on the incidence of total and surgical complications after radical resection of colorectal cancer.

Methods

We collected a total of 426 patients who underwent elective radical resection of colorectal cancer at Beijing Friendship Hospital, Capital Medical University from January 2017 to May 2018. According to the inclusion and exclusion criteria, 387 patients were finally included. A CT scan at the level of the L3-L4 intervertebral disk was selected to measure the values of visceral fat area and skeletal muscle area. Multivariate analysis was used to explore the independent risk/protective factors affecting postoperative complications.

Results

128 (33.1%) patients developed complications, and 44 (11.4%) patients developed major complications. Among them, 111 patients developed surgical complications and 21 developed medical complications. Visceral fat area (Z = -3.271, p = 0.001), total fat area (Z = -2.613, p = 0.009), visceral fat area to subcutaneous fat area ratio (V/S, Z = -2.633, p = 0.008), and sarcobesity index (Z = -2.282, p = 0.023) were significantly associated with total complications. Visceral fat area (Z = -2.119, p = 0.034) and V/S (Z = -2.010, p = 0.044) were significantly associated with total surgical complications. Sarcobesity index, smoking, stoma, blood loss, surgery time, and American Society of Anesthesiology (ASA) score were selected as risk factors for total postoperative complications according to LASSO regression. Multivariate logistic regression analysis suggested that sarcobesity index was an independent risk factor for postoperative total complications and surgical complications. Subgroup analysis suggested that albumin level was an independent protective factor for postoperative total complications in male patients. Smoking, operative time, and sarcobesity index were independent risk factors, and cholesterol was an independent protective factor for total postoperative complications in female patients.

Conclusion

Increased sarcobesity index is an independent risk factor for postoperative complications in patients with colorectal cancer, while visceral fat area is not. For female patients, smoking, operation time, and obesity index are independent risk factors for postoperative complications, while cholesterol is an independent protective factor. For male patients, serum albumin is an independent protective factor for postoperative complications.

Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going?

Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.

Propensity score matching comparisons of postoperative complications and morbidity between digestive tract reconstruction methods after gastrectomy in gastric cancer patients with visceral obesity

Background

Few studies have compared the prognosis of different reconstruction methods after gastrectomy for gastric cancer (GC) patients with obesity. The aim of the present study was to compare postoperative complications and overall survival (OS) between the following reconstruction methods: Billroth I (B-I), Billroth II (B-II), and Roux-en-Y (R-Y) after gastrectomy for GC patients with visceral obesity (VO).

Methods

We performed a double-institutional dataset study of 578 patients who underwent radical gastrectomy with B-I, B-II, and R-Y reconstructions between 2014 and 2016. VO was defined as a visceral fat area at the level of the umbilicus greater than 100 cm². Propensity score-matching analysis was performed to balance the significant variables. Postoperative complications and OS were compared between the techniques.

Results

VO was determined in 245 patients, of which 95, 36, and 114 underwent B-I, B-II, and R-Y reconstructions, respectively. B-II and R-Y were fused into the Non-B-I group due to the similar incidence of overall postoperative complications and OS. Therefore, 108 patients were enrolled after matching. The overall postoperative complications incidence and overall operative time in the B-I group were significantly lower than those in the non-B-I group. Further, multivariable analysis showed that B-I reconstruction was an independent protective factor for overall postoperative complications (odds ratio (OR) 0.366, P=0.017). However, no statistical difference in OS was found between the two groups (hazard ratio (HR) 0.644, P=0.216).

Conclusions

B-I reconstruction was associated with decreased overall postoperative complications, rather than OS, in GC patients with VO who underwent gastrectomy.

Associations of muscle and adipose tissue parameters with long-term outcomes in middle and low rectal cancer: a retrospective cohort study

OBJECTIVE

To investigate the role of preoperative body composition analysis for muscle and adipose tissue distribution on long-term oncological outcomes in patients with middle and low rectal cancer (RC) who received curative intent surgery.

METHODS

A total of 155 patients with middle and low rectal cancer who underwent curative intent surgery between January 2014 and December 2016 were included for the final analysis. Skeletal muscle area (SMA), skeletal muscle radiodensity (SMD), visceral fat area (VFA) and mesorectal fat area (MFA) were retrospectively measured using preoperative CT images. To standardize the area according to patient stature, SMA was divided by the square of the height (m²) and the skeletal muscle mass index (SMI, cm²/m²) was obtained. Each median values of the distribution in male and female served as cut-off point for SMI, SMD, VFA, and MFA, respectively. Univariate and multivariate analysis were performed to evaluate the association between body composition and long-term oncological outcomes. Overall survival (OS) measured in months from the day of primary surgery until death for any cause. Disease-free survival (DFS) was defined as the interval between surgery and tumor recurrence. The Kaplan-Meier method with log-rank testing was used to validate prognostic biomarkers. Intraclass correlation coefficient (ICC) was used to evaluate interobserver and intraobserver reproducibility for SMA, SMD, MFA,VFA.

RESULTS

During the follow-up period, 42 (27.1%) patients had tumor recurrence; 21 (13.5%) patients died. The sex-specific median value of SMI was 28.6 cm²/m² for females and 48.2 cm²/m² for males. The sex-specific median value of SMD was 34.7 HU for females and 37.4 HU for males. The sex-specific median value of VFA was 123.1 cm² for females and 123.2 cm² for males. The sex-specific median value of MFA was 13.8 cm² for females and 16.0 cm² for males. In the Cox regression multivariate analysis, SMI (P = 0.036), SMD (P = 0.022), and postoperative complications grades (P = 0.042) were significantly different between death group and non-death group; SMD (P = 0.011) and MFA (P = 0.022) were significantly different between recurrence group and non-recurrence group. VFA did not show any significant differences. By the Kaplan-Meier method with log-rank testing, DFS was significantly longer in patients with high-MFA (P = 0.028) and shorter in patients with low-SMD (P = 0.010), OS was significantly shorter in patients with low-SMI (P = 0.034) and low-SMD (P = 0.029).

CONCLUSIONS

Quantitative evaluation of skeletal muscle mass and adipose tissue distributions at initial diagnosis were important predictors for long-term oncologic outcomes in RC patients. SMD and SMI were independent factors for predicting OS in patients with middle and low rectal cancer who had radical surgery. SMD and MFA were independent factors for predicting DFS in patients with middle and low rectal cancer who had radical surgery.

Impact of metabolic syndrome on the short- and long-term outcomes for the elderly patients with gastric cancer after radical gastrectomy

BACKGROUND

Metabolic syndrome (MetS) and gastric cancer are age-related diseases, and their incidence rates have risen in past decades. However, few studies have examined the relationship between MetS and the prognosis of elderly patients who underwent radical gastrectomy, and the conclusions remain controversial.

METHODS

We conducted a prospective study of elderly patients who underwent radical gastrectomy for gastric cancer from August 2014 to February 2018. MetS was defined based on visceral fat area (VFA) instead of BMI or waist circumference. Receiver operating characteristic curve analysis was used to determine the cutoff values for VFA.

RESULTS

A total of 585 patients were included in this study. The optimal cutoff values for VFA were 96.1 cm² for men and 105.2 cm² for women, and 212 patients were diagnosed with MetS. The patients with MetS suffered significantly more postoperative complications than those without MetS (37.3% versus 21.4%, P < 0.001). The multivariable logistic regression analysis demonstrated that MetS (OR 2.923, P < 0.001), BMI < 18.5 kg/m² (OR 2.086, P = 0.045), cardiac tumor (OR 1.865, P = 0.013), and Nutritional Risk Screening 2002 scores ≥ 3 (OR 1.654, P = 0.015) were independent risk factors for postoperative complications. During a median follow-up period of 56.4 months, the MetS group and the non-MetS group had comparable overall survival and disease-specific survival.

CONCLUSIONS

MetS was an independent risk factor for complications of the elderly patients after radical gastrectomy, but had no influence on long-term survival.

Development and validation of a nomogram to predict anastomotic leakage in colorectal cancer based on CT body composition

Background

Anastomotic leakage (AL) is one of the most serious postoperative complications. This study aimed to investigate the predictive value of preoperative body composition for AL in patients with colorectal cancer (CRC).

Methods

We first reviewed data from 3,681 patients who underwent radical CRC resection 2013–2021 in our hospital, and 60 patients were diagnosed with AL after surgery. We designed a nested case-control study and two controls were randomly selected for each case according to the time and position of surgery. Body composition was measured at the level of the third lumbar vertebra based on computed tomography (CT) images. The risk factors of AL were analyzed by univariate and multivariate analysis. Nomogram was built using binary regression analysis and assessed for clinical usefulness, calibration, and discrimination.

Results

In the multivariate analysis, gender, blood glucose, nutrition risk screening (NRS), skeletal muscle area (SMA) and visceral fat area (VFA) were independent risk factors for developing anastomotic leakage after surgery. The prognostic model had an area under the receiver operating characteristic curve of 0.848 (95% CI, 0.781–0.914). The calibration curve showed good consistency between the predicted and observed outcomes. Decision curve analysis indicated that patients with colorectal cancer can benefit from the prediction model.

Conclusions

The nomogram that combined with gender, blood glucose, NRS, SMA, and VFA had good predictive accuracy and reliability to AL. It may be conveniently for clinicians to predict AL preoperatively and be useful for guiding treatment decisions.

Impact of preoperative body mass index and weight loss on morbidity and mortality following colorectal cancer-a retrospective cohort study

PURPOSE

Body weight and preoperative weight loss (WL) are controversially discussed as risk factors for postoperative morbidity and mortality in colorectal cancer surgery. The objective of this study is to determine whether body mass index (BMI) or WL is associated with a higher postoperative complication rate.

METHODS

In this retrospective cohort study, data analysis of 1241 consecutive patients undergoing colorectal cancer surgery in an 11-year period was performed. The main outcome measures were wound infections (WI), anastomotic leakages (AL), and in-house mortality.

RESULTS

A total of 697 (56%) patients with colon and 544 (44%) with rectum carcinoma underwent surgery. The rate of WI for each location increased with rising BMI. The threshold value was 28.8 kg/m2. Obese patients developed significantly more WI than normal-weight patients did following rectal resection (18.0% vs. 8.2%, p = 0.018). Patients with preoperative WL developed significantly more AL following colon resections than did patients without preoperative WL (6.2% vs. 2.5%, p = 0.046). In-house mortality was significantly higher in obese patients following colon resections than in overweight patients (4.3% vs. 0.4%, p = 0.012). Regression analysis with reference to postoperative in-house mortality revealed neither increased BMI nor WL as an independent risk factor.

CONCLUSIONS

Increased preoperative BMI is associated with a higher WI rate. AL rate after colon resection was significantly higher in patients showing preoperative WL. Preoperative BMI and WL are therefore risk factors for postoperative morbidity in this study. Nevertheless, this has to be further clarified by means of prospective studies. Trial registration DRKS00025359, 21.05.2021, retrospectively registered.

Impact of sarcopenia on surgical and oncologic outcomes of laparoscopic surgery for colorectal cancer

BACKGROUND

The study aimed to evaluate the impact of sarcopenia on short- and long-term outcomes for laparoscopic colorectal cancer surgery.

METHODS

Study participants were 209 patients who underwent laparoscopic surgery for any stage of colorectal cancer between 2016 and 2017. Skeletal muscle indices were calculated with preoperative computed tomography. Patients were divided into sarcopenic and non-sarcopenic groups based on index cut-off values and variables were compared.

RESULTS

The prevalence of sarcopenia was 41.1%. Sarcopenic patients experienced shorter operative times and a lower incidence of surgical site infections; however, the incidence of severe postoperative complications and readmission were increased for this group. Although the 3-year disease-free survival rate was not statistically different between groups, sarcopenic patients had a significantly worse 3-year overall survival rate compared with than the non-sarcopenic group.

CONCLUSION

Sarcopenia has both favorable and unfavorable effects on patients who underwent laparoscopic colorectal cancer surgery.

Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery

Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.

In-hospital economic burden of anastomotic leakage after colorectal anastomosis surgery: a real-world cost analysis in Italy

BACKGROUND

Anastomotic leakage (AL) is a severe complication of colorectal surgery. We aimed to quantify inpatient costs and key cost contributors associated with AL in a single Italian center.

RESEARCH DESIGN AND METHODS

Electronic records for adults who had undergone colorectal surgery with anastomosis (January 2015 - December 2016), were retrospectively reviewed. Patients with AL were identified using clinical signs and/or imaging findings and/or intraoperative findings. Available data included patient, clinical, and procedural characteristics, healthcare resource utilization, and inpatient costs. Multivariate models were used to adjust for potential confounders.

RESULTS

AL occurred in 12.3% of patients (N = 317). Mean adjusted inpatient cost was 108% higher (p < 0.001) for patients with AL versus no AL (€14,711; 95% CI: 12,113; 17,866 versus €7,089; 95% CI: 6,623; 7,587). Key cost contributors were ward stay, disposables, operating room, and hospital consultations. Mean losses (reimbursement minus costs) were €2,041/patient with AL. AL extended mean length of stay by 9 days and increased odds of reoperation and ICU stay (all p < 0.001).

CONCLUSIONS

Patients with AL place considerable economic and resource burden on healthcare systems and hospital reimbursement rates do not cover treatment costs. This study highlights an unmet need for novel techniques to reduce the burden of AL.

Obesity and anastomotic leak rates in colorectal cancer: a meta-analysis

PURPOSE

Anastomotic leak (AL) following colorectal cancer resection is associated with considerable morbidity and mortality with an impact on recurrence rates and survival. The impact of obesity on AL rates is debated. This meta-analysis aims to investigate the relationship between obesity and AL.

METHODS

A search was conducted of the PubMed/MEDLINE, and Web of Science databases and included studies were split into Western and Asian groups based on population-specific body mass index (BMI) ranges for obesity. A meta-analysis was performed to assess the impact of obesity on AL rate following colorectal cancer resection.

RESULTS

Two thousand three hundred and four articles were initially screened. Thirty-one studies totaling 32,953 patients were included. Patients with obesity had a statistically significant increase in AL rate in all Western and Asian study groups. However, this increase was only clinically significant in the rectal anastomotic subgroups-Western: 10.8% vs 8.4%, OR 1.57 (1.01-2.44) and Asian: 9.4% vs 7.4%, OR 1.58 (1.07-2.32).

CONCLUSIONS

The findings of this analysis confirm that obesity is a significant risk factor for anastomotic leak, particularly in rectal anastomoses. This effect is thought to be primarily mediated via technical difficulties of surgery although metabolic and immunological factors may also play a role. Obesity in patients undergoing restorative CRC resection should be discussed and considered as part of the pre-operative counselling.

The Relationship Between Visceral Obesity and Post-operative Complications: A Meta-analysis

BACKGROUND

Body composition can have important influence on surgical outcome. There is substantial literature examining sarcopenia, however much less in known about the impact of fat. Visceral fat area (VFA) is a reliable measures of fat distribution that can be quantified with CT scan. The aim of this study is to determine the impact of VFA to predict complications and mortality after emergent or elective surgery.

MATERIALS AND METHODS

A systematic review and meta-analysis was performed in accordance with the Preferred.

Influence of Postoperative Changes in Sarcopenia on Long-Term Survival in Non-Metastatic Colorectal Cancer Patients

Simple Summary

The number of colorectal cancer survivors is increasing due to improvements in oncologic outcomes. Therefore, the risks of metachronous cancer and second cancer are also increased, as well as recurrences. The influence of muscle mass measured as sarcopenia on long-term survival has been studied recently in colorectal cancer patients. Sarcopenia is a factor controllable by lifestyle modification and has gained interest more recently. This study showed an influence of changes in sarcopenia on long-term oncologic outcomes in colorectal cancer and suggests a basis for further investigation of body composition factors, including sarcopenia.

Abstract

The effect of perioperative sarcopenic changes on prognosis remains unclear. We conducted a retrospective cohort study with 2333 non-metastatic colorectal cancer patients treated between January 2009 and December 2012 at the Asan Medical Center. The body composition at diagnosis was measured via abdominopelvic computed tomography (CT) using Asan-J software. Patients underwent CT scans preoperatively, as well as at 6 months–1 year and 2–3 years postoperatively. The primary outcome was the association between perioperative sarcopenic changes and survival. According to sarcopenic criteria, 1155 (49.5%), 890 (38.2%), and 893 (38.3%) patients had sarcopenia preoperatively, 6 months–1 year, and 2–3 years postoperatively, respectively. The 5-year overall survival (OS) (95.8% vs. 92.1%, hazard ratio (HR) = 2.234, p < 0.001) and 5-year recurrence-free survival (RFS) (93.2% vs. 86.2%, HR = 2.251, p < 0.001) rates were significantly lower in patients with preoperative sarcopenia. Both OS and RFS were lower in patients with persistent sarcopenia 2–3 years postoperatively than in those who recovered (OS: 96.2% vs. 90.2%, p = 0.001; RFS: 91.1% vs. 83.9%, p = 0.002). In multivariate analysis, postoperative sarcopenia was confirmed as an independent factor associated with decreased OS and RFS. Pre- and postoperative sarcopenia and changes in the condition during surveillance were associated with oncological outcomes.

Laparoscopic gastrectomy reduces adverse postoperative outcomes and decreases morbidity for gastric cancer patients with visceral obesity: a propensity score-matched analysis

Background: Laparoscopic gastrectomy for gastric cancer shortens the recovery period without decreasing long-term survival. However, clinical evidence on whether laparoscopic radical gastrectomy reduces the surgical stress and improves the short- and long-term outcomes of obese patients with gastric cancer is lacking. We compared the short- and long-term outcomes of gastric cancer patients with visceral obesity (VO) who underwent laparoscopic gastrectomy (LG) or open gastrectomy (OG).

Methods: We prospectively collected data from 578 patients who underwent radical gastrectomy in two centers between January 2014 and December 2016. The visceral fat area (VFA) was measured on the umbilicus level, and VFA ≥100 cm² was defined as VO. The section bias was reduced by conducting a propensity score matching analysis. The short- and long-term outcomes were further compared between patients who underwent OG and those who underwent LG.

Results: Overall, 245 patients (42.61%) were classified as having VO, of whom 102 were included for further analysis after matching. There were no significant differences in clinical characteristics between the two groups in the matched cohort. The LG group had significantly fewer overall complications (P<0.001) and shorter postoperative hospital stays (P<0.001). Subgroup analysis of postoperative complications also showed that the incidence of surgical complications was lower in the LG group (P=0.002). Further survival analysis showed the LG group had significantly better long-term overall survival (P=0.017).

Conclusions: Compared with open radical gastrectomy, laparoscopy would reduce the rate of postoperative complications in patients with VO, as well as prolong their overall survival.

Visceral Fat and Anastomotic Leakage After Colon Cancer Resection

BACKGROUND

Visceral fat is considered a risk for postoperative complications in colon cancer surgery. However, the association with anastomotic leakage as the most worrisome complication is not clear mainly because of underpowered studies.

OBJECTIVE

The purpose of this study was to analyze the effect of visceral fat as a continuous variable on anastomotic leakage in a large cohort of colon cancer resections.

DESIGN

This was a retrospective, multicenter cohort study.

SETTINGS

This study used data of the Dutch Surgical Colorectal Audit of the years 2011 through 2014 from 8 Dutch teaching hospitals. Visceral fat was assessed on the routine preoperative abdominal CT scan.

PATIENTS

A total of 2370 patients underwent colon cancer resection with primary anastomosis. There were 2011 patients operated electively and 359 in an emergency setting.

MAIN OUTCOME MEASURES

The effect of visceral fat on anastomotic leakage after multivariable analysis was measured.

RESULTS

Visceral fat was associated with anastomotic leakage in the elective colon resection group (n = 2011) but not in emergency colon resections (n = 359). Significant confounding was found for type of resection, BMI, and sex. The association of male sex and BMI as previously reported risk factors for anastomotic leakage was explained by visceral fat.

LIMITATIONS

The study was limited by its retrospective character and missing clinical data of known risk factors for anastomotic leakage, like smoking history and certain medication.

CONCLUSIONS

The independent association of visceral fat with anastomotic leakage was confined to the elective colon cancer resection group. The previously reported associations of male sex and BMI with anastomotic leakage were explained by visceral fat. Visceral fat-associated comorbidities did not influence anastomotic leakage, suggesting that its effect on colon anastomotic healing is local rather than systemic. Future risk analysis for anastomotic leakage in colon cancer surgery should contain visceral fat values and consider subgroup differences. See Video Abstract at http://links.lww.com/DCR/B396.

ADIPOSIDAD VISCERAL Y FUGA ANASTOMTICA EN CASOS DE RESECCIN DE CNCER DE COLON

ANTECEDENTES:La acumulación de grasa visceral se considera como un factor de riesgo en caso de complicaciones postoperatorias de cirugía de cáncer de colon. Sin embargo, la asociación con la fuga anastomótica como la complicación más preocupante no está clara principalmente debido a los estudios de bajo impacto disponibles.OBJETIVO:Analizar el efecto de la adiposidad visceral como una variable contínua sobre la fuga anastomótica en una gran cohorte de resecciones de cáncer de colon.DISEÑO:Estudio de cohorte multicéntrico retrospectivo.AJUSTES:Se utilizaron los datos de la Auditoría Colorrectal Quirúrgica Holandesa entre los años 2011 y 2014 en 8 hospitales de enseñanza de los Paises bajos. La grasa visceral fué evaluada por medio de la tomografía computada abdominal preoperatoria de rutina.PACIENTES:Un total de 2370 pacientes fueron sometidos a resección de cáncer de colon con anastomosis primaria. 2011 pacientes fueron operados electivamente y 359 en situación de emergencia.PRINCIPALES MEDIDAS DE RESULTADO:El efecto de la adiposidad visceral en la fuga anastomótica después del análisis multivariable.RESULTADOS:La grasa visceral se asoció con la fuga anastomótica en el grupo de resección electiva de colon (n = 2011) pero no en las resecciones de emergencia (n = 359). Se encontraron factores de confusión significativos para el tipo de resección, el índice de masa corporal y el género. La adiposidad visceral explica la asociación del género masculino y el índice de masa corporal como factores de riesgo reportados previamente en los casos de fugas anastomóticas.LIMITACIONES:Carácter retrospectivo del estudio y la falta de datos clínicos de factores de riesgo conocidos para la fuga anastomótica, como los antecedentes de tabaquismo y el consumo de ciertos medicamentos.CONCLUSIONES:La asociación independiente de la adiposidad visceral con la fuga anastomótica se limitó al grupo de resección electiva por cáncer de colon. Las asociaciones previamente reportadas de género masculino e índice de masa corporal con fuga anastomótica se explicaron por la grasa visceral. Las comorbilidades asociadas a la grasa visceral no influyeron en la fuga anastomótica, lo que sugiere que la cicatrisación anastomótica obedece más a un factor local que a un factor sistémico. Un análisis de riesgos previsibles para fugas anastomóticas en casos de resección de cáncer de colon deben involucrar los valores de la adiposidad visceral y considerar las diferencias entre subgrupos. Consulte Video Resumen en http://links.lww.com/DCR/B396. (Traducción-Dr Xavier Delgadillo).

Three different computed tomography obesity indices, two standard methods, and one novel measurement, and their association with outcomes after colorectal cancer surgery

BACKGROUND

Obesity can be measured by different indices, either as body mass index (BMI) or by more intuitive radiological measurements, and obesity has been shown to have an impact on outcome after colorectal cancer (CRC) surgery.

PURPOSE

To investigate whether the thickness of the subcutaneous adipose tissue (SAT) in the abdominal wall can be used as a surrogate for the visceral fat area (VFA)-both measured on computed tomography (CT)-in prediction of short- and long-term outcomes after elective CRC surgery.

MATERIAL AND METHODS

Preoperative CT scans of all patients having elective CRC surgery (stages I-III), in two consecutive years at a single-center institution, were used to measure the SAT (mm) and VFA (cm²). BMI was calculated for each patient. The three different obesity indices were used in different analyses in order to predict postoperative complications and overall survival.

RESULTS

A BMI >30 kg/m² was an independent prognostic factor in postoperative complications (odds ratio 3.2, 95% confidence interval [CI] 1.43-7.03). SAT and VFA were not able to predict complications. Patients considered visceral obese according to a high VFA (>130 cm²) had poorer survival (hazard ratio 1.53, 95% CI 1.00-2.36) compared to non-obese patients, but in the adjusted model, VFA lost its predictive power. BMI and SAT were not able to predict mortality.

CONCLUSION

The novel measurement of the thickness of SAT in a preoperative setting before elective CRC surgery cannot predict either postoperative complications or overall survival; the other obesity indices had better predictive features.

Visceral obesity and muscle mass determined by CT scan and surgical outcome in patients with advanced ovarian cancer. A retrospective cohort study

OBJECTIVE

Visceral obesity (VO) is a risk factor for developing postoperative complications in patients undergoing abdominal oncological surgery. However, in ovarian cancer patients this influence of body composition on postoperative morbidity is not well established. The aim of this study is to assess the association between body composition and complications in patients with advanced ovarian cancer undergoing cytoreductive surgery.

METHODS

Patients with FIGO stage 3 or 4 ovarian cancer between 2006 and 2017 were included. Visceral fat area, total skeletal mass and total fat area were measured on a single slice on the level of L3-L4 of the preoperative CT-scan. VO was defined as visceral fat ≥100cm². The perioperative data were extracted retrospectively. A multivariate logistic regression analysis was performed to test the predictive value of multiple variables such as body composition, albumin levels and preoperative morbidity.

RESULTS

298 consecutive patients out of nine referring hospitals were included. VO patients were more likely to be hypertensive (38% vs 17% p < 0.001), and to have an ASA 3 score (21% vs 10% P = 0.012). Complications occurred more often in VO patients (43% vs 21% P < 0.001). Thrombotic events were found in 4.9% of VO patients versus 0.6% of the non-visceral obese patients (p = 0.019). VO(OR: 4.37, p < 0.001), hypertension (OR:1.9, p = 0.046) and duration of surgery (OR: 1.004, p = 0.017) were predictors of post-surgical complications. Muscle mass is not a predictor of complications.

CONCLUSION

Visceral obesity is associated with a higher occurrence of complications in patients with advanced ovarian cancer undergoing cytoreductive surgery.

Metabolic Syndrome, as Defined Based on Parameters Including Visceral Fat Area, Predicts Complications After Surgery for Rectal Cancer

BACKGROUND/OBJECTIVES

Metabolic syndrome (MetS) has become a major public health problem. However, few studies have examined the impact of MetS on the postoperative complications of colorectal cancer and the conclusions remain controversial. The present study aimed to investigate whether MetS, as defined based on visceral fat area (VFA) instead of BMI or waist circumference, would predict complications after surgery for rectal cancer.

SUBJECTS/METHODS

We conducted a retrospective study of patients who underwent surgery for rectal cancer at our department between January 2013 and August 2018. Univariate and multivariate analyses evaluating the risk factors for postoperative complications were performed. A receiver operating characteristic curve analysis was used to determine the gender-specific cut-off values for VFA.

RESULTS

A total of 381 patients were included in the study. The optimal cut-off values for VFA were 117.9 cm² for men and 76.9 cm² for women, and 153 patients were diagnosed as having MetS. The rate of postoperative complication was significantly higher in the MetS group than that in the non-MetS group (34.6% versus 15.8%, P < 0.001). The multivariate logistic regression analysis demonstrated that MetS (OR 3.712, P < 0.001), NRS 2002 scores ≥ 3 (OR 2.563, P = 0.001), and tumor located at the lower 1/3 (OR 3.290, P = 0.001) were independent risk factors for complications after surgery for rectal cancer.

CONCLUSION

Metabolic syndrome, as defined based on parameters including visceral fat area, was an independent risk factor for complications after surgery for rectal cancer.

Association of a Preoperative Leisure-Time Physical Activity With Short- and Long-term Outcomes of Patients Undergoing Curative Resection for Stage I to III Colorectal Cancer: A Propensity Score Matching Analysis

BACKGROUND

Physical activity might be directly or indirectly linked to the risk of colorectal cancer and the prognosis of patients with colorectal cancer.

OBJECTIVE

This study aimed to elucidate whether preoperative physical activity plays a role in reducing short-term postoperative complications and improving long-term survival of patients with colorectal cancer.

DESIGN

This was a retrospective analysis of prospectively collected data.

SETTINGS

This study was conducted at a department of colorectal surgery in a tertiary teaching hospital between January 1995 and December 2016.

PATIENTS

Patients who underwent curative resection for stage I to III primary colorectal cancer were enrolled. According to the preoperative leisure-time weekly metabolic equivalent of task values, patients were divided into 2 groups: the metabolic equivalent of task <12 group and the metabolic equivalent of task ≥12 group. A 1:1 propensity score matching was used to reduce imbalance and selection biases based on 6 covariates, namely, age, sex, BMI, tumor location, tumor stage, and adjuvant chemotherapy administration.

MAIN OUTCOME MEASURES

χ tests were used to analyze short-term postoperative complications. Kaplan-Meier analyses were used to evaluate disease-free survival and overall survival.

RESULTS

In the matched cohort patients, significant differences in overall postoperative complications and mortality were observed in favor of the metabolic equivalent of task ≥12 group, although there was no difference in any single item of postoperative morbidity. The results of the Kaplan-Meier analysis and log-rank test demonstrated a significant survival benefit in the metabolic equivalent of task ≥12 group compared with the metabolic equivalent of task <12 group both for disease-free and overall survival.

LIMITATIONS

This study is limited by its retrospective nature.

CONCLUSIONS

This single-institute study provides evidence of the association of preoperative leisure-time physical activity with short-term postoperative morbidity and mortality, as well as long-term survival. See Video Abstract at http://links.lww.com/DCR/B189. ASOCIACIÓN DE ACTIVIDAD FÍSICA DE TIEMPO LIBRE PREOPERATORIA CON RESULTADOS A CORTO Y LARGO PLAZO DE PACIENTES SOMETIDOS A RESECCIÓN CURATIVA POR CÁNCER COLORRECTAL EN ESTADIO I-III: UN ANÁLISIS DE COINCIDENCIA DE PUNTAJE DE PROPENSIÓN ANTECEDENTES: LA ACTIVIDAD FíSICA PUEDE ESTAR DIRECTA O INDIRECTAMENTE RELACIONADA CON EL RIESGO DE CÁNCER COLORRECTAL Y EL PRONÓSTICO DE LOS PACIENTES CON CÁNCER COLORRECTAL.: Este estudio tuvo como objetivo dilucidar si la actividad física preoperatoria desempeña un papel en la reducción de las complicaciones postoperatorias a corto plazo y en mejorar la supervivencia a largo plazo de los pacientes con cáncer colorrectal.Este fue un análisis retrospectivo de datos recolectados prospectivamente.Este estudio se realizó en un departamento de cirugía colorrectal en un hospital universitario terciario entre Enero de 1995 y Diciembre de 2016.Se incluyeron pacientes sometidos a resección curativa por cáncer colorrectal primario en estadio I-III. De acuerdo con el equivalente metabólico semanal en el tiempo libre de los valores de la tarea preoperatorio, los pacientes se dividieron en dos grupos: el equivalente metabólico del grupo de tarea <12 y el equivalente metabólico del grupo de tarea ≥ 12. Se utilizó una coincidencia de puntaje de propensión 1: 1 para reducir los desequilibrios y los sesgos de selección basados en seis covariables, principalmente, edad, sexo, índice de masa corporal, ubicación del tumor, estadio del tumor y administración de quimioterapia adyuvante.Las pruebas de Chi-cuadrado se utilizaron para analizar las complicaciones postoperatorias a corto plazo. Los análisis de Kaplan-Meier se utilizaron para evaluar la supervivencia libre de enfermedad y la supervivencia general.en los pacientes de la cohorte emparejada, se observaron diferencias significativas en las complicaciones postoperatorias generales y la mortalidad a favor del equivalente metabólico del grupo de tareas ≥ 12, aunque no hubo diferencias en ningún elemento único de morbilidad postoperatoria. Los resultados del análisis de Kaplan-Meier y la prueba de log-rank demostraron un beneficio de supervivencia significativo en el equivalente metabólico del grupo tarea ≥ 12 en comparación con el equivalente metabólico del grupo tarea <12 tanto para la supervivencia libre de enfermedad como para la supervivencia general.Este estudio está limitado por su naturaleza retrospectiva.Este estudio de instituto único proporciona evidencia de la asociación de la actividad física preoperatoria en el tiempo libre con la morbilidad y mortalidad postoperatorias a corto plazo, así como la supervivencia a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B189. (Traducción-Dr. Yesenia Rojas-Kahlil).

Which obesity-associated parameters can better reflect the risk of the occurrence of the anastomotic leakage?

Purpose: We investigated which obesity-associated parameters can better predict the risk of anastomotic leakage (AL) in rectal cancer patients that underwent anterior resection of the rectum.Method: Patients (n = 589) who underwent anterior resection of the rectum with a primary anastomosis were included in this study, including 44 patients with AL and 545 without AL. Univariate analysis was used to compare demographic characteristics and to select risk factors that were used in one-to-one propensity score matching (PSM). Obesity-associated parameters, including preoperative body mass index (BMI), visceral fat area (VFA), subcutaneous fat area (SFA), total fat area (TFA), VFA/TFA ratio, serum cholesterol, and triglycerides, were compared between the two groups after PSM.Results: Sex, neoadjuvant chemotherapy, operation time, and anastomosis level from the anal verge were risk factors for AL (p < .05). After the PSM, BMI, VFA, SFA, TFA, VFA/TFA, and serum cholesterol showed no significant difference between the two group (p > .05). However, the level of serum triglycerides was an independent risk factor for AL (p = .024, odds ratio = 2.95).Conclusions: Serum triglycerides have potential as a predictive indicator for AL, which may improve the treatment and outcomes of patients with AL.

Impact of adiposity on staging and prognosis of colorectal cancer

Abdominal visceral fat is a well-recognized a risk for colorectal cancer (CRC). In contrast to the risk for CRC, the impact of adiposity in disease staging and patient survival is less well-established. Our aim was to critically review the literature on the influence of adiposity assessed by different methods routinely used in clinical settings, on CRC staging and prognosis. In the 32 studies reviewed, overweight was initially identified as a survival advantage, an evidence that was later challenged by studies suggesting that body adiposity is likely to have a deleterious effect in CRC outcomes, particularly in males. Hence, whether obesity has a negative impact in CRC staging or prognosis remains controversial. In sum, addressing the impact of body fat in CRC biological behavior is still an unmet need. Understanding how adiposity influences CRC staging and prognosis could allow further patient risk stratification for devising targeted interventions and improve clinical outcomes.

Computed Tomography-Based Body Composition Is Not Consistently Associated with Outcome in Older Patients with Colorectal Cancer

Background

Current literature is inconsistent in the associations between computed tomography (CT)‐based body composition measures and adverse outcomes in older patients with colorectal cancer (CRC). Moreover, the associations with consecutive treatment modalities have not been studied. This study compared the associations of CT‐based body composition measures with surgery‐ and chemotherapy‐related complications and survival in older patients with CRC.

Materials and Methods

A retrospective single‐center cohort study was conducted in patients with CRC aged ≥65 years who underwent elective surgery between 2010 and 2014. Gender‐specific standardized scores of preoperative CT‐based skeletal muscle (SM), muscle density, intermuscular adipose tissue (IMAT), visceral adipose tissue (VAT), subcutaneous adipose tissue, IMAT percentage, SM/VAT, and body mass index (BMI) were tested for their associations with severe postoperative complications, prolonged length of stay (LOS), readmission, and dose‐limiting toxicity using logistic regression and 1‐year and long‐term survival (range 3.7–6.6 years) using Cox regression. Bonferroni correction was applied to account for multiple testing.

Results

The study population consisted of 378 patients with CRC with a median age of 73.4 (interquartile range 69.5–78.4) years. Severe postoperative complications occurred in 13.0%, and 39.4% of patients died during follow‐up. Dose‐limiting toxicity occurred in 77.4% of patients receiving chemotherapy (n = 53). SM, muscle density, VAT, SM/VAT, and BMI were associated with surgery‐related complications, and muscle density, IMAT, IMAT percentage, and SM/VAT were associated with long‐term survival. After Bonferroni correction, no CT‐based body composition measure was significantly associated with adverse outcomes. Higher BMI was associated with prolonged LOS.

Conclusion

The associations between CT‐based body composition measures and adverse outcomes of consecutive treatment modalities in older patients with CRC were not consistent or statistically significant.

Implications for Practice

Computed tomography (CT)‐based body composition, including muscle mass, muscle density, and intermuscular, visceral, and subcutaneous adipose tissue, showed inconsistent and nonsignificant associations with surgery‐related complications, dose‐limiting toxicity, and overall survival in older adults with colorectal cancer. This study underscores the need to verify whether CT‐based body composition measures are worth implementing in clinical practice.

Colorectal cancer is prevalent in older individuals. This article compares the associations of computed tomography‐based body composition measures with surgery‐ and chemotherapy‐related complications and survival in older patients with colorectal cancer.

Visceral obesity is a preoperative risk factor for postoperative ileus after surgery for colorectal cancer: Single-institution retrospective analysis

AIM

Visceral obesity (VO) reportedly has a stronger association with complications after colorectal surgery than does body mass index. Here, we retrospectively assessed VO as a risk factor for postoperative ileus (POI) after colorectal resection in patients with colorectal cancer.

METHODS

This study included 417 consecutive patients with colorectal cancer who underwent elective surgery at our institute from January 2010 to December 2012. Visceral fat area (VFA) was calculated by image analysis software. VO was defined as VFA ≥100 cm2. We assessed 49 factors, including VO, comorbidities, surgical procedure, and postoperative complications. Data were analyzed using a propensity score-matching strategy.

RESULTS

Postoperative ileus occurred in 18 patients (4.3%) from the entire cohort, and in 14 (5.5%) of the 256 matched patients. Multivariate analysis (n = 417 patients) showed that significant risk factors for POI included VO (OR 7.9, 95% confidence interval [CI] 1.9-32.1, P = .004), open surgery (OR 6.4, 95% CI 1.6-26.7, P = .010), and pelvic/intra-abdominal abscess (OR 11.0, 95% CI 1.1-110.2, P = .041). Propensity score matching showed two independent risk factors in the multivariate analysis: VO (OR 6.2, 95% CI 1.3-30.4, P = .025) and open surgery (OR 9.1, 95% CI 2.0-40.5, P = .004).

CONCLUSION

Visceral obesity may be an independent risk factor for POI in patients with colorectal cancer.

Impact of Body Composition on Surgical Outcome in Rectal Cancer Patients, a Retrospective Cohort Study

BACKGROUND

Obesity is becoming a bigger health problem every year. Current research shows that the obesity-related metabolic problems are strongly associated with visceral fat and not subcutaneous fat. Visceral obesity (VO) is associated with a worse postoperative outcome in multiple fields of abdominal surgery. On the other hand, muscle mass is related to better postoperative outcome. In rectal cancer patients, we studied the influence of visceral obesity and muscle mass on postoperative complications.

METHODS

The visceral fat area (VFA) and skeletal muscle area (SMA) were determined on preoperative CT scans in 406 patients. The preoperative comorbidity, per-operative outcome and postoperative complications were extracted retrospectively from the patient files. VO was defined as a VFA > 100 cm². Correlations between body composition, postoperative complications and LOS were studied.

RESULTS

In our study, 67% of the patients were classified as visceral obese. Mean body mass index (BMI) was higher in the VO group (26.6 ± 3.5 vs 23.5 ± 2.8; p < 0.001). Visceral obese patients had a higher prevalence of cardiac comorbidity (29% vs 13% p = 0.001), hypertension (36% vs 20% p = 0.002) and diabetes mellitus (16% vs 5% p = 0.002). In addition, VO patients had more operative blood loss (431 vs 310 mL; p = 0.008), longer operating time (166 vs 149 min p = 0.003) and more wound infections (14% vs 8% p = 0.048). Visceral obesity was associated with more complications (OR: 1.63 p = 0.043) and longer LOS (risk estimate: 1.18 p = 0.009).

CONCLUSION

VO patients more often had a history of cardiac disease, hypertension and diabetes mellitus. Visceral obesity correlated with a worse outcome after surgery for rectal cancer.

Visceral obesity and short-term outcomes after laparoscopic rectal cancer resection

BACKGROUND

Complications after rectal resection are frequent. Recently, methods to assess visceral obesity (VO) have become available as an alternative to measurement of body mass index (BMI). The aim of this study was to examine the association between visceral fat volume (VFV) and the short-term outcomes after laparoscopic low anterior resection (LLAR) in patients with rectal cancer.

METHODS

We studied a consecutive series of patients undergoing LLAR at Bispebjerg University Hospital from 01.01.2013 to 01.01.2016. Preoperative VFV was calculated from abdominal CT scans using an automatic segmentation tool. The primary outcome was anastomotic leakage (AL). Secondary outcomes included conversion to open surgery, number of lymph nodes harvested, the rates of 30-day complications as well as reoperations, and 1-year survival.

RESULTS

A total of 102 patients were included. VO was defined as a VFV above the 75 percentile. Thirteen (12.7%) patients developed AL, four (15.4%) of whom were in the VO group (p = 0.900). At least one postoperative complication developed in 38 (37.3%) patients, with no significant difference between the VO and non-VO patients after univariable analysis (42.3% vs. 35.4%, p = 0.702) or multivariable adjustment (OR 1.01, 95% CI 0.38-2.65, p = 0.984). VO was significantly associated with an increased incidence of conversion to open surgery (OR 4.30, 95% CI 1.29-14.86, p = 0.018). There was a significant difference in the number of harvested lymph nodes between the two groups (mean 23.5 vs. 29.1, p = 0.045).

CONCLUSIONS

In this study on patients undergoing laparoscopic rectal resection, VO was not associated with development of AL or other complications. However, we found that visceral obesity was associated with an increased risk of conversion to open surgery.

The effect of increased body mass index values on surgical outcomes after radical resection for low rectal cancer

PURPOSES

This study aimed to explore the effect of increased body mass index (BMI) values (overweight: BMI ≥ 25-30 kg/m²; obese: BMI ≥ 30 kg/m²) on surgical outcomes after radical resection for low rectal cancer (LRC).

METHODS

Patients with LRC who underwent radical surgery from January 2009 to December 2013 were included. The patients were divided into three groups according to their BMI values (control group: BMI < 25 kg/m²; overweight group: BMI 25 to < 30 kg/m²; obese group: BMI ≥ 30 kg/m²). The patients' clinicopathological characteristics and survival data were collected and analyzed.

RESULTS

A total of 792 patients were enrolled in this study finally (control, n = 624; overweight, n = 147; obese, n = 21). The baseline characteristics of the three groups were similar. We found that an increased BMI was associated with a longer operative time (P < 0.001) and length of postoperative hospital stay (P = 0.032). Patients with increased BMI values had a significantly higher incidence of postoperative complications, including pulmonary infection (P = 0.008), anastomotic leakage (P = 0.029), allergy (P = 0.017) and incisional hernia (P = 0.045). The limited data showed that the pathological outcomes of the three groups did not differ to a statistically significant extent. A multivariate analysis showed that increased BMI was not associated with poorer OS or DFS.

CONCLUSION

In LRC resection, an increased BMI was associated with a longer operative time, postoperative hospital stay, and an increased number of postoperative complications. However, it did not contribute to poorer pathological or survival outcomes.

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.

The association between body mass index and postoperative complications, 30-day mortality and long-term survival in Dutch patients with colorectal cancer

INTRODUCTION

This retrospective study aims to examine the association between body mass index (BMI) and serious postoperative complications, 30-day mortality and overall survival in colorectal cancer (CRC) patients.

MATERIALS AND METHODS

All CRC patients diagnosed between 2008 and 2013 in the south-eastern part of the Netherlands were included. Patients were categorized into four BMI groups: underweight (<18.5), normal weight (18.5 ≥ BMI<25), overweight (25 ≥ BMI<30), and obese (≥30).

RESULTS

A total of 7371 CRC patients were included (underweight 133 (1.8%); normal weight 2054 (41.4%); overweight 2955 (40.1%); obesity 1229 (16.7%)). Underweight patients were more likely to have postoperative complications (18.8% vs. 11.7%, adjusted OR 1.95, 95% CI 1.08-3.49) and had a worse 30-day mortality (9.8% vs. 3.3%, adjusted OR 4.37, 95% CI 2.03-9.42) compared to normal weight patients. After stratification for stage (stage I-III and stage IV), underweight was associated with a worse overall survival in both groups compared to normal weight (stage I-III: HR 2.06, 95%CI 1.51-2.80; stage IV: HR 1.65, 95% CI 1.11-2.45). Overweight was associated with an improved overall survival compared to normal weight in both stage groups. Only in stage IV patients obesity was associated with a significant better overall survival compared to stage IV normal weight patients.

CONCLUSION

Underweight CRC patients were more likely to have postoperative complications and a worse 30-day mortality compared to patients in other BMI categories. The underweight population also has a worse long-term survival while overweight CRC patients and obese stage IV CRC patients were associated with an improved survival compared to normal weight patients.

Quantitative assessment of mesorectal fat: new prognostic biomarker in patients with mid-to-lower rectal cancer

OBJECTIVES

To investigate the impact of mesorectal fat area (MFA) on oncologic outcomes in patients with mid-to-lower rectal cancer who received curative-intent surgery.

METHODS

Patients with mid-to-lower rectal cancer who underwent preoperative abdominopelvic computed tomography (CT) and curative-intent surgery in 2011 were divided into two groups by tumour recurrence (group A) or no recurrence (group B) during a 5-year follow-up. Visceral fat area (VFA) and MFA were measured on preoperative CT and cutoff values were calculated using the Youden index. Univariate and multivariate regression analyses including BMI, VFA, and MFA were performed to investigate meaningful prognostic biomarkers. The Kaplan-Meier method with log-rank testing was used to validate prognostic biomarkers.

RESULTS

Group A contained 42 patients and group B had 155 patients. Cutoff values were 25 kg/m² for BMI, 130 cm² for VFA, and 10 cm² for MFA using the Youden index. On multivariate Cox regression analysis, MFA (odds ratio [OR] = 0.426, p = 0.010), TNM stage (p = 0.027), and perioperative complication grade (p = 0.028) were significantly different between groups. BMI and VFA did not show significant differences. By the Kaplan-Meier method with log-rank testing, disease-free survival (DFS) was significantly longer in patients with MFA ≥10 cm² compared to patients with MFA <10 cm² (p = 0.021), with no significant difference in overall survival (OS).

CONCLUSIONS

MFA was an independent biomarker for predicting DFS in patients who underwent curative-intent surgery for mid-to-lower rectal cancer.

KEY POINTS

• Mesorectal fat area is associated with the prognosis of rectal cancer patients. • Mesorectal fat area can be calculated easily in pre-operative CT scan. • Predicting prognosis of the cancer patient before operation is important.

Impact of visceral fat on surgical complications and long-term survival of patients with gastric cancer after radical gastrectomy

BACKGROUND/OBJECTIVES

The aim of this study was to examine the impact of visceral fat on surgical complications and long-term survival for patients undergoing radical gastrectomy.

SUBJECTS/METHODS

From 2009 to 2013, 859 patients who underwent curative resection for gastric cancer were enrolled from a prospectively maintained database. Visceral fat area (VFA) was assessed by preoperative CT scans. Patients were divided into two groups by VFA. Perioperative variables and postoperative outcomes were compared between the high VFA group and low VFA group. Univariable and multivariable analysis were performed to investigate independent risk factors of postoperative complications and survival.

RESULTS

Some 859 patients were included in the study, 308 of whom were classified as high VFA. High VFA was correlated with advance age (P = 0.020), higher albumin levels (P = 0.001), hemoglobin levels (P < 0.05), ASA grade (P = 0.043) and Charlson Comorbidity Index (P = 0.004). Relative to patients with low VFA, those with high VFA had longer surgical durations (P = 0.004), higher rate of postoperative complications (P = 0.004), and longer hospital stays (P = 0.004). High VFA was identified as the only determinant for surgical complications by logistic regression analysis (OR, 2.236, 95% CI, 1.537-3.254; P < 0.001). Cox proportional hazards regression revealed no correlation between VFA and overall survival (OS) or disease-free survival (DFS).

CONCLUSIONS

Increased VFA independently predicts surgical complications in patients after gastrectomy. However, VFA is not a prognostic biomarker of OS or DFS in patients with gastric cancer.

A quantified risk-scoring system and rating model for postsurgical gastroparesis syndrome in gastric cancer patients

BACKGROUND AND OBJECTIVES

The study aimed to investigate the relationship between obesity and postsurgical gastroparesis syndrome (PGS), and to construct a scoring system and a risk model to identify patients at high risk.

METHODS

A total of 634 patients were retrospectively analyzed. Clinical characteristics were evaluated via receiver operating characteristic (ROC) curve analysis. Logistic analysis was performed to determine the independent predictive indicators of PGS. A scoring system consisting of these indicators and a risk-rating model were constructed and evaluated via ROC curve analysis.

RESULTS

Based on the ROC curves, the visceral fat area (VFA) cutoff value for PGS was 94.00. Logistic analysis showed that visceral obesity (VFA ≥ 94.00 cm² ), the reconstruction technique, and tumor size were independent prognostic factors for PGS. The scoring system could predict PGS reliably with a high area under the ROC curve ([AUC] = 0.769). A high-risk rating had a high AUC (AUC I = 0.56, AUC II = 0.65, and AUC III = 0.77), indicating that the risk-rating model could effectively screen patients at high risk of PGS.

CONCLUSIONS

Visceral obesity defined by VFA effectively predicted PGS. Our scoring system may be a reliable instrument for identifying patients most at risk of PGS.

Impact of visceral obesity and metabolic syndrome on the postoperative immune, inflammatory, and endocrine response following surgery for esophageal adenocarcinoma

Visceral obesity and metabolic syndrome (MetSyn) represent a constellation of inflammation, insulin resistance, and hyperglycemia and are established risk factors for gastrointestinal cancer. However, their impact on the immune and inflammatory response after major upper gastrointestinal oncologic surgery is unknown. In 125 consecutive patients who underwent esophagectomy, C-reactive protein (CRP) and CRP:albumin levels were recorded preoperatively and on days 1, 3, 7, and 14 postoperatively. In a subset of 30 patients, circulating levels of IL-6, IL-8, IL-10, IL-12p70, IFN-γ, TNF-α, TGF-β, and cortisol were measured. Incidences of postoperative complications were prospectively recorded. In the study cohort, 51% of patients were viscerally obese, 40.7% had MetSyn, and 33.6% were hyperglycemic. Viscerally obese and MetSyn-positive patients demonstrated greater postoperative CRP levels and CRP:albumin levels on day 7 and day 14 compared with nonobese and MetSyn-negative patients (P < 0.05). Higher postoperative circulating levels of cortisol were observed in the viscerally obese and hyperglycemic patients compared to nonobese and normoglycemic patients. No association was observed between visceral obesity, MetSyn or hyperglycemia, and postoperative cytokine profile. Viscerally obese patients had an increased overall incidence of postoperative complications compared to nonobese patients (67.2% vs. 47.5%, P = 0.031) on univariate but not multivariate analysis (P = 0.078) and visceral obesity was not associated with an increased incidence of specific complications. Visceral obesity, MetSyn, and hyperglycemia are prevalent in patients undergoing major upper gastrointestinal resection and are associated with an exaggerated acute-phase inflammatory response postoperatively. Further research is warranted to determine whether this association is directly causal.

BMI as a Predictor for Perioperative Outcome of Laparoscopic Colorectal Surgery: a Pooled Analysis of Comparative Studies

BACKGROUND

There has been a long-lasting controversy about whether higher BMI is associated with worse perioperative outcomes of laparoscopic colorectal surgery. Recently, a number of newly published investigations have made it possible to draw a quantitative conclusion.

OBJECTIVE

We conducted this comprehensive meta-analysis to clarify the exact effect that BMI imposes on perioperative outcome of laparoscopic colorectal surgery.

DATA SOURCES

We systematically searched MEDLINE, Embase, and Cochrane Library databases to identify all relevant studies.

STUDY SELECTION

Comparative studies in English that investigated perioperative outcome of laparoscopic colorectal surgery for patients with different BMIs were included. Quality of studies was evaluated by using the Newcastle-Ottawa Scale.

INTERVENTION

The risk factor of interest was BMI.

MAIN OUTCOME MEASURES

Effective sizes were pooled under a random-effects model to evaluate preoperative, intraoperative, and postoperative outcomes.

RESULTS

A total of 43 studies were included. We found that higher BMI was associated with significantly longer operative time (p < 0.001), greater blood loss (p = 0.01), and higher incidence of conversion to open surgery (p < 0.001). Moreover, BMI was a risk factor for overall complication rates (p < 0.001), especially for ileus (p = 0.02) and events of the urinary system (p = 0.03). Significant association was identified between higher BMI and risk of surgical site infection (p < 0.001) and anastomotic leakage (p = 0.02). Higher BMI might also led to a reduced number of harvest lymph nodes for patients with colorectal cancer (p = 0.02). The heterogeneity test identified no significant cross-study heterogeneity, and the results of cumulative meta-analysis, sensitivity analysis, and the publication bias test verified the reliability of our study.

LIMITATIONS

Most studies included were retrospectively designed.

CONCLUSIONS

Body mass index is a practical and valuable measurement for the prediction of the perioperative outcome of laparoscopic colorectal surgery. Higher BMI is associated with worse perioperative outcome. More accurate conclusions, with more precise cutoff values, can be achieved by future well-designed prospective investigations.

Quantitative Assessment of Visceral Obesity and Postoperative Colon Cancer Outcomes

BACKGROUND

Quantitative computed tomography (CT) assessment of visceral adiposity may be superior to body mass index (BMI) as a predictor of surgical morbidity. We sought to examine the association of CT measures of obesity and BMI with short-term postoperative outcomes in colon cancer patients.

METHODS

In this retrospective study, 110 patients treated with colectomy for stage I-III colon cancer were classified as obese or non-obese by preoperative CT-based measures of adiposity or BMI [obese: BMI ≥ 30 kg/m², visceral fat area (VFA) to subcutaneous fat area ratio (V/S) ≥0.4, and VFA > 100 cm²]. Postoperative morbidity and mortality rates were compared.

RESULTS

Obese patients, by V/S and VFA but not BMI, were more likely to be male and have preexisting hypertension and diabetes. The overall complication rate was 25.5%, and there were no mortalities. Obese patients by VFA (with a trend for V/S but not BMI) were more likely to develop postoperative complications as compared to patients classified as non-obese: VFA (30.5 vs.10.7%, p = 0.03), V/S (29.2 vs. 9.5%, p = 0.05), and BMI (32.4 vs. 21.9%, p = 0.23).

CONCLUSIONS

Elevated visceral obesity quantified by CT is associated with the presence of key metabolic comorbidities and increased postoperative morbidity and may be superior to BMI for risk stratification.

The impact of obesity on febrile urinary tract infection and renal scarring in children with vesicoureteral reflux

INTRODUCTION

It has become clear that obesity is associated with a variety of infectious diseases, including urinary tract infection (UTI) and renal scarring.

OBJECTIVE

The aim of this study was to evaluate the association between obesity and the degree of febrile UTI (fUTI) and renal scarring in children with vesicoureteral reflux (VUR), and to stratify the results into obesity subcategories.

STUDY DESIGN

A total of 186 patients were diagnosed with VUR between January 2002 and December 2008. This study retrospectively reviewed the medical records of 72 children with primary VUR who had recurrent fUTI (more than twice). Overweight or obese status of the patients aged <2 years was defined using weight-for-length (WFL) measurements. For 2-5 year old children, body mass index (BMI) percentile-for-age was used. They were divided into three groups as follows; standard (<85%), overweight (85-95%), and obese (≥95%). The following clinical variables were compared: age at diagnosis of primary VUR (months), sex, VUR grade, hydronephrosis grade, presence of renal scarring, surgical treatment, and degree of inflammation during fUTI.

RESULTS

In the overweight and obese groups, VUR was diagnosed at a young age (P = 0.05), the degree of renal scarring was more severe (P = 0.006), and serum white blood cell count, C-reactive protein, and erythrocyte sedimentation rate (ESR) levels were significantly higher (P < 0.001, P < 0.001, and P < 0.001, respectively). Abnormal focal dimercaptosuccinic acid (DMSA) defects were present in 25 of the 72 children (35%). Cortical defects occurred more frequently in children with obesity, and they were associated with a higher grade of reflux and serum ESR levels (P = 0.007, P = 0.042, and P = 0.021, respectively). Among these risk factors, high-grade VUR (OR = 9.93, 95% CI = 1.13-86.71), and being overweight and obese (OR = 5.26, 95% CI = 1.75-15.82) were associated with increased renal scarring. However, ESR was not associated with renal scarring (OR = 1.01, 95% CI = 0.95-1.07).

DISCUSSION

The relationships between obesity and UTI are controversial. Some studies have shown positive results; however, other studies have shown opposite results. The main limitations of this study were the retrospective data collection via electronic medical records, and the small number of subjects.

CONCLUSIONS

This study showed that obesity in patients with VUR has an effect on fUTI and renal scar formation. If the patients with VUR have obesity, close follow-up should be performed, and VUR patients should be started on a weight-loss program, which could reduce the number of patients with chronic kidney disease in the future.

Computed Tomography Morphometrics and Pulmonary Intolerance in Endometrial Cancer Robotic Surgery

STUDY OBJECTIVES

To identify morphometric characteristics of obese patients that best predict pulmonary intolerance to robotic pelvic surgery using a novel method for quantifying adipose distribution.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

Fifty-nine patients with endometrial cancer who underwent robotic hysterectomy and lymphadenectomy between April 2008 and May 2014 and also underwent perioperative computed tomography (CT) imaging within 1 year.

INTERVENTION

Visceral fat volume (VFV) and subcutaneous fat volume (SFV) were quantified through waist circumference measurements along with average volume estimation of slices taken at 3 levels: mid-waist, L2-L3, and L4-L5. Mean and maximum values were obtained for intraoperative physiological data.

MEASUREMENTS AND MAIN RESULTS

The patients' mean body mass index (BMI) was 34 (range, 20-59). Along with waist circumference, VFV and SFV quantified by CT at the mid-waist, L2-L3, and L4-L5 levels were all significant independent predictors for peak airway pressure (PAP; average and maximum) and plateau airway pressure (Pplat; average and maximum) on multivariate regression analysis after adjustment for age, ethnicity, diabetes, hypertension, pulmonary disease, smoking, obstructive sleep apnea, American Society of Anesthesiologists classification, and duration of anesthesia. Compared with the other CT parameters, L2-L3 VFV was the best predictor of average PAP (β = 0.398; p = .002), maximum PAP (β = 0.493; p < .001), average Pplat (β = 0.536; p < .001), and maximum Pplat (β = 0.573; p < .001).

CONCLUSION

These novel CT morphometric measurements represent valid predictors of pulmonary intolerance to robotic surgery in obese patients. Of the measures analyzed, VFV at L2-L3 best predicts pulmonary tolerance in obese patients.

Is obesity an advantage in patients with colorectal cancer?

Obesity/higher BMI appears to be important determinants in the development of colon cancer as well as in predicting outcomes in the adjuvant setting in these patients. These associations seem to be stronger for men and tend to be 'J-shaped', with worse outcomes in both lower and upper BMI categories than in the middle categories. How this factors in the metastatic setting is less clear. A recent pooled analysis of patients with metastatic colorectal cancer receiving bevacizumab in the first-line setting observed that patients with the lowest BMI had the lowest median overall survival. An incremental BMI increase of 5 kg/m(2) led to actually a decrease in the risk of death (hazard ratio, 0.911 [95% CI, 0.879-0.944]). The observed association does not necessarily mean that obesity is an advantage for patients with metastatic colorectal cancer. More likely, it is conceivable that, in patients with metastatic colorectal cancer with a lower BMI, the effects of cancer-related cachexia may be more deleterious than the potential adverse events related to a higher BMI. In patients already diagnosed with metastatic disease, studying how body weight affects tumor biology and treatment-related decisions are important considerations.

Single-port endoscopic mesocolic and mesorectal excision using an extraperitoneal approach

BACKGROUND

The extraperitoneal rectal dissection via a transanal approach facilitates the mesorectal dissection. The retroperitoneal approach for mesocolic excision may also offer some similar advantages. To complete the lymphadenectomy of extraperitoneal mesorectal resection, we developed an innovative approach for upper rectal and mesocolic excision via an exclusive retroperitoneal dissection using a single-port access at the site of the future stomy.

METHODS

This study was a prospective pilot study and was conducted between 2013 and 2015 at two oncologic centers. Five consecutive patients, with ano-rectal cancer requiring permanent stoma, underwent this procedure.

RESULTS

The bowel was never touched or mobilized to perform the lymphadenectomy, and no Trendelenburg was required. The median operative duration was 300 min (range 205-310). The quality of the surgical plane was classified as good (mesorectal) in the five patients. The median circumferential and distal margins were, respectively, 5 mm (range 1-20) and 20 mm (range 5-25). The median number of harvested lymph nodes was 11 (range 5-18). No laparotomy or multiport laparoscopy was required. There was no death. Two patients had perineal wound dehiscence (one minor and one major).

CONCLUSIONS

The mesocolic excision via a retroperitoneal approach is feasible, completes naturally the transanal mesorectal excision and may confer several advantages including no morbidity of small bowel manipulation or Trendelenburg position. Further studies are required to analyze this approach.

Visceral Obesity Predicts Fewer Lymph Node Metastases and Better Overall Survival in Colon Cancer

BACKGROUND

The relationship between visceral obesity and colon cancer outcome has not been well studied. The goal of this study was to determine the impact of visceral obesity on lymph node (LN) metastasis and overall survival (OS) in colon cancer.

MATERIALS AND METHODS

Metastatic LN ratio (MLR) was defined as the number of involved nodes by tumor divided by the total number of resected LNs. Visceral (VFA) and subcutaneous fat areas (SFA) were determined by measuring abdominal fat volume distribution via CT scan, and visceral obesity was defined as a VFA to total fat area ratio (V/T) > 0.29.

RESULTS

In a multivariate analysis among 186 patients, there were inverse associations between V/T and MLR (OR = 0.413, 95% CI = 0.216-0.789, P = 0.007). Furthermore, patients with visceral obesity tended to have significantly better OS than patients with non-visceral obesity.

CONCLUSIONS

Higher V/T ratios which indicate referring to visceral obesity was significantly associated with decreased MLR and better OS for CRC.