Effect of Age and Comorbidities on Short- and Long-Term Results in Patients Undergoing Laparoscopic Curative Resection for Rectal Cancer

Association of high-risk comorbidity with overall survival among patients with gastric cancer and its sex-specific differences in China: a retrospective observational cohort study

BACKGROUND

Concomitant diseases often occur in cancer patients and are important in decision-making regarding treatments. However, information regarding the prognostic relevance of comorbidities for mortality risk is still limited among Chinese gastric cancer (GC) patients. This study aimed to investigate the association between comorbidities and 3-year mortality risk.

METHODS

This retrospective study enrolled 376 GC patients undergoing radical gastrectomy at the Affiliated Zhongshan Hospital of Dalian University from January 2011 to December 2019. Demographic and clinicopathological information and treatment outcomes were collected. Patients were divided into low-, moderate- and high-risk comorbidity groups based on their Charlson Comorbidity Index (CCI) and age-adjusted CCI (ACCI) scores. Kaplan-Meier survival and Cox regression analyses were used to examine 3-year overall survival (OS) and mortality risk for each group.

RESULTS

The median follow-up time was 43.5 months, and 40.2% (151/376) of GC patients had died at the last follow-up. There were significant differences in OS rates between ACCI-based comorbidity groups (76.56; 64.51; 54.55%, log-rank P = 0.011) but not between CCI-based comorbidity groups (log-rank P = 0.16). The high-risk comorbidity group based on the ACCI remained a significant prognostic factor for 3-year OS in multivariate analysis, with an increased mortality risk (hazard ratio [HR], 1.99; 95% CI, 1.15-3.44). Subgroup analysis revealed that this pattern only held for male GC patients but not for female patients.

CONCLUSION

The present study suggested that high-risk comorbidities were significantly associated with a higher mortality risk, particularly in Chinese male GC patients. Moreover, the ACCI score was an independent prognostic factor of long-term mortality.

The psoas muscle density as a predictor of postoperative complications in elderly patients undergoing rectal cancer resection

Background

Muscle depletion that impairs normal physiological function in elderly patients leads to poor prognosis. This study aimed to evaluate the association between total abdominal muscle area (TAMA), total psoas area (TPA), psoas muscle density (PMD), and short-term postoperative complications in elderly patients with rectal cancer.

Methods

All elderly patients underwent rectal cancer resection with perioperative abdominal computed tomography (CT). Complications were assessed according to the Clavien-Dindo classification. Severe complications were defined as grade III-V following the Clavien-Dindo classification. Univariate and multivariate analyses were performed to evaluate risk factors of short-term severe postoperative complications.

Results

The cohort consisted of 191 patients with a mean age of 73.60 ± 8.81 years. Among them, 138 (72.25%) patients had Clavien-Dindo 0- II, 53 (27.75%) patients had severe postoperative complications (Clavien-Dindo III-V), and 1(0.52%) patient died within 30 days of surgery. PMD was significantly higher in the Clavien-Dindo 0-II cohort compared to the Clavien-Dindo III-V cohort (p=0.004). Nevertheless, TAMA and TPA failed to exhibit significant differences. Moreover, the multivariate regression analysis implied that advanced age [OR 1.07 95%CI (1.02-1.13) p=0.013], male [OR 5.03 95%CI (1.76-14.41) p=0.003], high charlson comorbidity index (CCI) score [OR 3.60 95%CI (1.44-9.00) p=0.006], and low PMD [OR 0.94 95%CI (0.88-0.99) p=0.04] were independent risk factors of Clavien-Dindo III-V.

Conclusion

Preoperative assessment of the PMD on CT can be a simple and practical method for identifying elderly patients with rectal cancer at risk for severe postoperative complications.

A Diagnostic Nomogram for Predicting the Risk of Anastomotic Leakage in Elderly Patients With Rectal Cancer: A Single-center Retrospective Cohort Study

BACKGROUND

Laparoscopic resection for rectal cancer has been gaining popularity over the past 2 decades. Whether elderly patients had more benefits from laparoscopy-assisted anterior resection (LAR) need further investigation when comparing with open anterior resection (OAR).

OBJECTIVES

This study aimed to evaluate the clinical outcomes and prognosis of LAR in elderly patients (65 y and above) with rectal cancer and investigate the factors associated with the anastomotic leakage (AL). Besides, the study sought to create a nomogram for precise prediction of AL after anterior resection for rectal cancer.

MATERIALS AND METHODS

A total of 343 rectal cancer patients over 65 years old who underwent LAR or OAR at a single center between January 2013 to January 2021 were retrospectively reviewed. Univariate analysis was conducted to explore potential risk factors for AL, and a nomogram for AL was created based on the multivariate logistic regression model.

RESULTS

A total of 343 patients were included in this study, 271 patients in LAR group and 72 patients in OAR group. Most of the variables were comparable between the 2 groups. The mean operative time was longer in the LAR group than that in the OAR group (191.66±58.33 vs. 156.85±53.88 min, P<0.0001). The LAR group exhibited a significantly lower intraoperative blood loss than the OAR group (85.17±50.03 vs. 131.67±79.10 mL; P<0.0001). Moreover, laparoscopic surgery resulted in shorter postoperative hospital stay, lower rates of diverting stoma and receiving sphincter sparing surgery in comparison with open surgery. The overall rates of complications were 25.1% and 40.3% in the LAR and OAR groups (P=0.011), respectively. And the reoperation rates in the OAR group (0%) was lower than in the LAR group (1.5%), but the difference did not reach statistical significance (P=0.300). Sex, location of tumor, diverting stoma and combined organ resection were identified as independent risk factors for AL based on multivariate analysis. Such factors were selected to develop a nomogram. After a median follow-up of 37.0 months, our study showed no significant difference in overall survival or disease free survival between the 2 groups for treatment of rectal cancer.

CONCLUSIONS

This study suggests that LAR is an alternative minimally invasive surgical procedure in patients above 65 years with better short-term outcomes and acceptable long-term outcomes compared with OAR. In addition, our nomogram has satisfactory accuracy and clinical utility may benefit for clinical decision-making.

Predictive Value of the Age-Adjusted Charlson Comorbidity Index for Outcomes After Hepatic Resection of Hepatocellular Carcinoma

BACKGROUND

This study aimed to evaluate the impact of the age-adjusted Charlson comorbidity index (ACCI) on outcomes after hepatic resection for hepatocellular carcinoma (HCC).

METHODS

We assessed 763 patients who underwent hepatic resection for HCC. The ACCI scores were categorized as follows: ACCI ≤ 5, ACCI = 6, and ACCI ≥ 7.

RESULTS

A multivariate analysis showed that the odds ratios for postoperative complications in ACCI = 6 and ACCI ≥ 7 groups, with reference to ACCI ≤ 5 group, were 0.71 (p = 0.41) and 4.15 (p < 0.001), respectively. The hazard ratios for overall survival of ACCI = 6 and ACCI ≥ 7 groups, with reference to ACCI ≤ 5 group, were 1.52 (p = 0.023) and 2.45 (p < 0.001), respectively. The distribution of deaths due to HCC-related, liver-related, and other causes was 68.2%, 11.8%, and 20% in ACCI ≤ 5 group, 47.2%, 13.9%, and 38.9% in ACCI = 6 group, and 27.3%, 9.1%, and 63.6% in ACCI ≥ 7 group (p = 0.053; ACCI ≤ 5 vs. = 6, p = 0.19; ACCI = 6 vs. ≥ 7, p < 0.001; ACCI ≤ 5 vs. ≥ 7). In terms of the treatment for HCC recurrence in ACCI ≤ 5, ACCI = 6, and ACCI ≥ 7 groups, adaptation rate of surgical resection was 20.1%, 7.3%, and 11.1% and the rate of palliative therapy was 4.3%, 12.2%, and 22.2%, respectively.

CONCLUSIONS

The ACCI predicted the short-term and long-term outcomes after hepatic resection of HCC. These findings will help physicians establish a treatment strategy for HCC patients with comorbidities.

Neoadjuvant chemoradiotherapy or radiotherapy in patients aged 75 years or older with locally advanced rectal cancer

Background: To evaluate the efficacy and treatment related morbidity of neoadjuvant chemoradiotherapy or radiotherapy in elderly patients (aged 75 years or older) with locally advanced rectal cancer (LARC).

Methods: We reviewed clinical records of elderly patients with LARC treated with neoadjuvant chemoradiotherapy or radiotherapy between January 2008 and June 2017 at our institute. A dose of 45-50Gy in 25 fractions was delivered to pelvis. The primary tumor received a dose of 55Gy concomitantly for patients receiving intensity modulated radiotherapy (IMRT). The concurrent chemotherapy included capecitabine alone and capecitabine plus oxaliplatin (Xelox). Surgery was performed for suitable patients at least 6 weeks after neoadjuvant treatment. Overall survival (OS), disease specific survival (DSS), disease free survival (DFS) and local control (LC) were calculated with Kaplan-Meier method.

Results: A total of 85 patients were enrolled in this study, the median age was 80 years old (range: 75-90 years). After neoadjuvant treatment, surgery was performed in 56 patients (65.9%). Downstaging rate was 85.7% (48/56) with T downstaging in 35 patients (62.5%) and N downstaging in 36 patients (64.3%). Twelve patients (21.4%) obtained pathological complete response (pCR). The incidence of grade 3 or greater acute hematological, gastrointestinal and genitourinary toxicities were 10.7%, 5.2% and 1.8%, respectively. Seven patients (12.5%) experienced postoperative complications. The median follow-up duration was 35.7 months (range: 4.3-100.3 months), The 3-year and 5-year OS, DSS, DFS, LC were 68.9% and 47.2%, 75.8% and 60.4%, 68.2% and 56.1%, 83.9% and 78.3%, respectively.

Conclusion: In patients aged 75 years or older with LARC, neoadjuvant chemoradiotherapy followed by surgery was well tolerated with promising survival outcomes, which should be strongly suggested if medically suitable.

Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida

BACKGROUND

Patients with diverticulitis have a 20% risk of requiring urgent/emergent treatment. Since morbidity and mortality rates differ between elective and urgent/emergent care, understanding associated disparities is critical. We compared factors associated with treatment setting for diverticulitis and evaluated disparities regarding access to Minimally Invasive Surgery (MIS) and development of complications.

METHODS

The Florida Inpatient Discharge Dataset was queried for patients diagnosed with diverticulitis. Three multivariate models were utilized: 1) elective vs urgent/emergent surgery, 2) MIS vs open and 3) presence of complications.

RESULTS

The analysis included 12,654 patients. Factors associated with increased odds of urgent/emergent care included being uninsured or covered by Medicaid, African American, obese, or more comorbid. MIS was associated with reduced odds of complications. Patients treated by high-volume or colorectal surgeons had increased odds of receiving MIS.

CONCLUSIONS

Patients were more likely to receive MIS if they were treated by a colorectal surgeon, or a high-volume surgeon (colorectal, or general surgeon). Additionally, patients that were older, had increased comorbidities, or did not have health insurance were less likely to receive MIS.