Perioperative use of statins in elective colectomy

Correlations between preoperative statin treatment with short- and long-term survival following colorectal cancer surgery: a propensity score-matched national cohort study

INTRODUCTION

The pleiotropic effects of statins have attracted considerable attention in oncological treatment. Several preclinical and epidemiological studies have highlighted their potential anti-tumor properties in patients with colorectal cancer, although results have been conflicting. This study aimed to examine the association between statin exposure before colorectal cancer surgery with long and short-term survival outcomes.

METHODS

This retrospective propensity score-adjusted study was conducted on a Danish cohort of patients who underwent elective curative-intended surgery for stage I-III colorectal cancer in 2008-2020, using four national patient databases. The primary and secondary outcomes were overall, 90-day, and disease-free survival. Propensity scores were calculated using all available data to match patients with and without statin exposure in a 1:1 ratio.

RESULTS

Following propensity score matching, 7120 patients were included in the primary analysis. The median follow-up time was 5 years. A Cox proportional hazards model showed no statistically significant difference in overall survival between patients with or without statin exposure 365 days before surgery (HR 0.93, 95% CI 0.85-1.02) and no association with 90-day survival (OR 0.91, 95% CI 0.76-1.10). However, a subgroup analysis examining a 90-day exposure before surgery found a statistically significant association with increased overall survival (HR 0.85, 95% CI 0.77-0.93).

CONCLUSION

Although a subgroup of patients with a preoperative exposure time of 90 days showed statistically significant better overall survival, we found no statistically significant association between statin exposure 1 year before colorectal cancer surgery and overall survival.

Statin Therapy Is Associated With Decreased 90-Day Postoperative Mortality After Colon Cancer Surgery

BACKGROUND

There have been conflicting reports regarding a protective effect of statin therapy after colon cancer surgery.

OBJECTIVE

This study aimed to evaluate the association between statin therapy and the postoperative mortality following elective colon cancer surgery.

DESIGN

This population-based cohort study is a retrospective analysis of prospectively collected data from the Swedish Colorectal Cancer Register.

SETTINGS

Patient inclusion was achieved through a nationwide register.

PATIENTS

All adult patients undergoing elective surgery for colon cancer between January 2007 and September 2016 were included in the study. Patients who had received and collected a prescription for statins pre- and postoperatively were allocated to the statin-positive cohort.

MAIN OUTCOME MEASURES

The primary and secondary outcomes of interest were 90-day all-cause mortality and 90-day cause-specific mortality.

RESULTS

A total of 22,337 patients underwent elective surgery for colon cancer during the study period, of whom 6,494 (29%) were classified as statin users. Statin users displayed a significant survival benefit despite being older, having a higher comorbidity burden, and being less fit for surgery. Multivariate analysis illustrated significant reductions in the incidence risk for 90-day all-cause mortality (Incidence Rate Ratio = 0.12, p < 0.001) as well as 90-day cause-specific deaths due to sepsis, due to multiorgan failure, or resulting from a cardiovascular and respiratory origin.

LIMITATIONS

The limitations of this study include its observational retrospective design, restricting the ability to perform standardized follow-up of statin therapy. Confounding from other uncontrolled variables cannot be excluded.

CONCLUSIONS

Statin users had a significant postoperative benefit regarding short-term mortality following elective colon cancer surgery in the current study; however, further research is needed to ascertain whether this relationship is causal. See Video Abstract at http://links.lww.com/DCR/B738.

LA TERAPIA CON ESTATINAS SE ASOCIA CON UNA DISMINUCIN DE LA MORTALIDAD POSOPERATORIA A LOS DAS DESPUS DE LA CIRUGA DE CNCER DE COLON

ANTECEDENTES:Ha habido informes contradictorios con respecto al efecto protector de la terapia con estatinas después de la cirugía de cáncer de colon.OBJETIVO:Este estudio tuvo como objetivo evaluar la asociación entre la terapia con estatinas y la mortalidad postoperatoria después de la cirugía electiva por cáncer de colon.DISEÑO:Este estudio de cohorte poblacional es un análisis retrospectivo de datos recopilados prospectivamente del Registro Sueco de Cáncer Colorrectal.AJUSTES:La inclusión de pacientes se logró mediante la inclusión a través de un registro a nivel nacional.PACIENTES:Se incluyeron en el estudio todos los pacientes adultos sometidos a cirugía electiva por cáncer de colon en el período de enero de 2007 y septiembre de 2016. Los pacientes que habían recibido y recogido una receta de estatinas antes y después de la operación fueron asignados a la cohorte positiva de estatinas.PRINCIPALES MEDIDAS DE DESENLACES:Los desenlaces primarios y secundarios de interés fueron la mortalidad por cualquier causa a los 90 días y la mortalidad por causas específicas a los 90 días.RESULTADOS:Un total de 22.337 pacientes se sometieron a cirugía electiva por cáncer de colon durante el período de estudio, de los cuales 6.494 (29%) se clasificaron como usuarios de estatinas. Los usuarios de estatinas mostraron un beneficio significativo en la supervivencia a pesar de ser mayores, de tener una mayor carga de comorbilidad y de estar menos acondicionado para la cirugía. El análisis multivariado ilustró reducciones significativas en el riesgo de incidencia de mortalidad por cualquier causa a 90 días (índice de tasa de incidencia = 0,12, p < 0,001), así como muertes específicas ena 90 días debidas a sepsis, falla multiorgánica o dea enfermedades de origen cardiovascular y respiratorio.LIMITACIONES:Las limitaciones de este estudio incluyen su diseño observacional retrospectivo, que restringe la capacidad de realizar un seguimiento estandarizado de la terapia con estatinas. No se puede excluir confusión a partir de otras variables no controladas.CONCLUSIONES:Los usuarios de estatinas tuvieron un beneficio posoperatorio significativo con respecto a la mortalidad a corto plazo después de cirugía electiva por cáncer de colon en el estudio actual, sin embargo, se necesita más investigación para confirmar si eexiste una relación es causal. Consulte Video Resumen en http://links.lww.com/DCR/B738.

Statin therapy and its association with long-term survival after colon cancer surgery

BACKGROUND

The current study aims to address the clinical equipoise regarding the association of ongoing statin therapy at time of surgery with long-term postoperative mortality rates after elective, curative, surgical resections of colon cancer by analyzing data from a large validated national register.

METHODS

All adults with stage I to III colon cancer who underwent elective surgery with curative intent between January 2007 and October 2016 were retrieved from the Swedish Colorectal Cancer Register, a prospectively collected national register. Patients were identified as having ongoing statin therapy if they filled a prescription within 12 months pre- and postoperatively. Study outcomes included 5-year all-cause and cancer-specific postoperative mortality. To reduce the impact of confounding from covariates owing to nonrandomization, the inverse probability of treatment weighting method was used. Subsequently, Cox proportional hazards models were fitted to the weighted cohorts.

RESULTS

In total, 19,118 patients underwent elective surgery for colon cancer in the specified period, of whom 31% (5,896) had ongoing statin therapy. Despite being older, having a higher preoperative risk, and having more comorbidities, patients with statin therapy had a higher postoperative survival. After inverse probability of treatment weighting, patients with statin therapy displayed a significantly lower mortality risk up to 5 years after surgery for both all-cause (hazard ratio 0.68, 95% confidence interval 0.63-0.74, P < .001) and cancer-specific mortality (hazard ratio 0.76, 95% confidence interval 0.66-0.89, P < .001).

CONCLUSION

The results of this study indicate that statin therapy is associated with a sustained reduction in all-cause and cancer-specific mortality up to 5 years after elective colon cancer surgery. The findings warrant validation in future prospective clinical trials.

Statin Use and Long-Term Mortality after Rectal Cancer Surgery

BACKGROUND

The current study aimed to assess the association between regular statin therapy and postoperative long-term all-cause and cancer-specific mortality following curative surgery for rectal cancer. The hypothesis was that statin exposure would be associated with better survival.

METHODS

Patients with stage I-III rectal cancer undergoing surgical resection with curative intent were extracted from the nationwide, prospectively collected, Swedish Colorectal Cancer Register (SCRCR) for the period from January 2007 and October 2016. Patients were defined as having ongoing statin therapy if they had filled a statin prescription within 12 months before and after surgery. Cox proportional hazards models were employed to investigate the association between statin use and postoperative five-year all-cause and cancer-specific mortality.

RESULTS

The cohort consisted of 10,743 patients who underwent a surgical resection with curative intent for rectal cancer. Twenty-six percent (n = 2797) were classified as having ongoing statin therapy. Statin users had a considerably decreased risk of all-cause (adjusted hazard ratio (HR) 0.66, 95% confidence interval (CI): 0.60-0.73, p < 0.001) and cancer-specific (adjusted HR 0.60, 95% CI: 0.47-0.75, p < 0.001) mortality up to five years following surgery.

CONCLUSIONS

Statin use was associated with a lower risk of both all-cause and rectal cancer-specific mortality following curative surgical resections for rectal cancer. The findings should be confirmed in future prospective clinical trials.

Statin therapy and postoperative short-term mortality after rectal cancer surgery

AIM

This study aimed to assess the correlation between regular statin therapy and postoperative mortality following surgical resection for rectal cancer.

METHOD

This retrospective cohort study included all adult patients undergoing abdominal rectal cancer surgery in Sweden between January 2007 and September 2016. Data were gathered from the Swedish Colorectal Cancer Registry, a large population-based prospectively collected registry. Statin users were defined as patients with one or more collected prescriptions of a statin within 12 months before the date of surgery. The statin-positive and statin-negative cohorts were matched by propensity scores based on baseline demographics.

RESULTS

A total of 11 966 patients underwent surgical resection for rectal cancer, of whom 3019 (25%) were identified as statin users. After applying propensity score matching (1:1), 3017 pairs were available for comparison. In the matched groups, statin users demonstrated reduced 90-day all-cause mortality (0.7% vs. 5.5%, p < 0.001) and also showed significantly reduced cause-specific mortality due to cardiovascular and respiratory events, as well as sepsis and multiorgan failure. The significant postoperative survival benefit of statin users was seen despite a higher rate of cardiovascular comorbidity.

CONCLUSION

Preoperative statin therapy displays a strong association with reduced postoperative mortality following surgical resection for rectal cancer. The results from the current study warrant further investigation to determine whether a causal relationship exists.

Statin therapy does not influence the outcome of patients undergoing surgery for pancreatic cancer

BACKGROUND

Recently, statins have been associated with improved survival in certain cancers. The aim of this study was to evaluate the impact of statins on the outcome of patients undergoing surgery for pancreatic cancer. In addition, the effect of statins on the histopathological characteristics of the disease was assessed.

METHODS

A retrospective review of the prospectively maintained hepato-pancreatico-biliary database was performed and patients with pancreatic cancer who underwent surgery between January 2014 and December 2017 were included. Statistical analysis was performed to assess the impact of statins on histopathological characteristics and survival outcome.

RESULTS

A total of 151 patients were included, of whom 71 underwent pancreatic resections and 80 underwent trial dissection and bypass procedures. In the operated group, 20 patients were on statin therapy preoperatively. With respect to disease-free survival, tumour size (P = 0.023) and lymphatic invasion (P = 0.015) were significant variables on univariate analysis. Gender (P = 0.022), adjuvant chemotherapy (P < 0.001), lymphatic invasion (P = 0.021) and tumour size (P = 0.041) were significant variables on univariate analysis with respect to overall survival. Multivariate analysis identified adjuvant chemotherapy as the only independent predictor of overall survival (P < 0.001). No correlations between the use of statins and the histopathological characteristics were identified.

CONCLUSION

Adjuvant chemotherapy is an independent predictor of overall survival in patients undergoing surgery for pancreatic cancer. Statin therapy does not influence survival outcomes and histopathological characteristics following surgery for pancreatic cancer.

Statin use is not associated with improved 30-day survival in patients undergoing surgery for colorectal cancer

PURPOSE

Besides the lipid-lowering properties, statins are thought to have anti-inflammatory effects and it has been shown that statins directly attenuate the inflammatory stress response after surgical trauma. The aim of the study was to examine the association between preoperative statin use and 30-day mortality as well as postoperative complications after curative-intended surgery for colorectal cancer.

METHODS

The study was a Danish nationwide register-based observational study. A total of 29,352 patients undergoing surgery for colorectal cancer between January 1, 2003, and December 31, 2012, were included in the study. At the time of surgery, 5961 were registered as statin users. The outcomes were 30-day mortality and risk of postoperative complications.

RESULTS

The adjusted hazard ratio of 30-day mortality was 0.91 (95 CI 0.80-1.04, P = 0.16) among statin users compared with the non-statin group. There was no difference between the two groups regarding the risk of infectious complications (sepsis, anastomotic leakage, pneumonia) (odds ratio 0.95, 95% CI 0.86-1.05, P = 0.31). For other postoperative complications (cardiovascular events, stroke, renal failure, respiratory insufficiency, and thromboembolic events), there was no significant difference between the two groups (odds ratio 0.89, 95% CI 0.78-1.01, P = 0.06).

CONCLUSION

The study did not show an improved 30-day survival after surgery for colorectal cancer in patients treated with statins in the year preceding surgery. No overall association with the risk of postoperative complications was shown.

Systematic review of the role of biomarkers in diagnosing anastomotic leakage following colorectal surgery

BACKGROUND

Anastomotic leakage (AL) following colorectal surgery can be difficult to diagnose owing to varying clinical presentations. This systematic review aimed to assess biomarkers as potential diagnostic tests for preclinical detection of AL.

METHODS

A comprehensive literature review was conducted according to PRISMA guidelines. All published studies evaluating biomarkers, both systemic and peritoneal, in the context of AL following colorectal surgery were included. Studies were sought in three electronic databases (MEDLINE, PubMed and Embase) from January 1990 to June 2016.

RESULTS

Thirty-six studies evaluated 51 different biomarkers in the context of AL after colorectal surgery. Biomarkers included markers of ischaemia and inflammation, and microbiological markers, and were measured in both peritoneal drain fluid and the systemic circulation. The most commonly evaluated peritoneal drain fluid biomarkers were interleukin (IL) 6, IL-10 and tumour necrosis factor. Significantly raised drain levels in the early postoperative period were reported to be associated with the development of AL. C-reactive protein, procalcitonin and leucocytes were the most commonly evaluated systemic biomarkers with significant negative and positive predictive values. Associated area under the curve values ranged from 0·508 to 0·960.

CONCLUSION

Peritoneal drain fluid and systemic biomarkers are poor predictors of AL after colorectal surgery. Combinations of these biomarkers showed improvement in predictive accuracy.

Perioperative Simvastatin Therapy in Major Colorectal Surgery: A Prospective, Double-Blind Randomized Controlled Trial

BACKGROUND

Statins have numerous potential benefits relevant to abdominal surgery, and their use has been associated with a reduction in the systemic inflammatory response syndrome, wound infection, and anastomotic leak after colorectal surgery. However, this clinical evidence is limited to retrospective studies. The aim of this study was to prospectively investigate whether perioperative statin therapy can decrease the incidence of complications after major colorectal surgery.

STUDY DESIGN

A prospective, double-blind, parallel-group, randomized controlled trial was conducted at 3 tertiary hospitals in New Zealand, between October 2011 and August 2013. Adult patients undergoing elective colorectal resection for any indication or reversal of Hartmann's procedure were randomized with a 1:1 patient allocation ratio to receive either 40 mg oral simvastatin or placebo once daily for 3 to 7 days preoperatively until 14 days postoperatively. The primary outcome was the overall incidence of complications for 30 days postoperatively. Secondary outcomes included the systemic and peritoneal cytokine response (interleukin [IL]-1α, IL-1β, IL-6, IL-8, IL-10, tumor necrosis factor [TNF]α) on postoperative day 1.

RESULTS

There were 132 patients included in the study (65 simvastatin, 67 placebo). There were no significant differences between the 2 groups at baseline with regard to patient, operation, and disease characteristics. There were no significant differences between the 2 groups in the incidence, grade, and type of postoperative complications (simvastatin: 44 [68%] vs placebo: 50 [75%], odds ratio 0.71 [95% CI 0.33 to 1.52], p = 0.444). Plasma concentrations of IL-6, IL-8, and TNFα, and peritoneal concentrations of IL-6 and IL-8, were significantly lower in the simvastatin group postoperatively.

CONCLUSIONS

Perioperative simvastatin therapy in major colorectal surgery attenuates the early proinflammatory response to surgery, but there were no differences in postoperative complications.

Diabetes and risk of anastomotic leakage after gastrointestinal surgery

BACKGROUND

Anastomotic leakage (AL) is one of the most common and lethal complications in gastrointestinal surgery. However, the relationship between AL risk and diabetes mellitus (DM) remains ambiguous. This meta-analysis was to evaluate the association between DM and AL risk in patients after gastrointestinal resection.

METHODS

Odds ratios (OR) estimate with their corresponding 95% confidence intervals (CIs) were combined and weighted to produce pooled OR using the fixed-effects model. Relative risks were calculated in subgroup analysis of prospective studies. We calculated publication bias by Begg rank correlation test and Egger linear regression test.

RESULTS

DM was significantly and independently associated with an increased risk of AL morbidity in colorectal patients, 1.661 times in total patients (95% CIs = 1.266-2.178), 1.995 times in a subgroup of case-control studies, 1.581 times in cohort investigations, 1.688 times in retrospective trials, and 1.562 times in prospective designs. After adjusting for the factor of obesity and/or body mass index in the subgroup analyses of colorectal surgery, DM patients without obesity experienced a significantly increased risk of AL (OR = 1.572, 95% CIs = 1.112-2.222). Furthermore, when obesity had not been adjusted, DM patients endured a dramatical increase of AL incidence (OR = 1.812, 95% CIs = 1.171-2.804). Perforation incidence after gastric resection showed borderline association with DM (OR = 2.170, 95% CIs = 0.956-4.926).

CONCLUSIONS

The present meta-analysis provides strong evidence for the first time that DM is significantly and independently associated with an increased risk of AL mortality in colorectal surgery.

Perioperative statin therapy is not associated with reduced risk of anastomotic leakage after colorectal resection

BACKGROUND

Anastomotic leakage is a serious complication of colorectal surgery. Several studies have demonstrated the beneficial pleiotropic effects of statins, and preliminary studies have suggested that perioperative statin treatment may be associated with reduced risk of anastomotic leakage.

OBJECTIVE

We aimed to investigate whether perioperative statin therapy was associated with a reduced anastomotic leakage rate after colorectal resections with primary anastomosis.

DESIGN

The study was based on prospectively collected data from the Danish Colorectal Cancer Group and electronically registered medical records holding information on perioperative statin therapy.

SETTINGS

Data were collected from the 6 major surgical centers responsible for all elective colorectal cancer surgery in the eastern part of Denmark.

PATIENTS

We collected data on 2766 patients with electronically registered medical records who underwent resection of the colon or rectum with primary anastomosis from 2006 to 2009.

MAIN OUTCOME MEASURE

The primary outcome measured was anastomotic leakage requiring surgical intervention.

RESULTS

Five hundred eighteen patients (19%) were treated with statins perioperatively. Four hundred ninety-six patients received statins both before and after surgery. Fifty-two patients (10.5%) received high-dose statin therapy. Possible risk factors for anastomotic leakage were identified via univariate regression analyses. In subsequent multivariate analysis, perioperative statin therapy was not associated with reduced anastomotic leakage rate (OR (95% CI) 1.31 (0.84-2.05), p = 0.23). We identified intraoperative blood transfusion, rectal resection (versus colonic), male sex, and tobacco usage as risk factors for anastomotic leakage in the multivariate analysis.

LIMITATIONS

This study is limited by its observational design and missing data on comorbidities and BMI.

CONCLUSION

Perioperative statin therapy was not significantly associated with reduced anastomotic leakage rate after colorectal resection with primary anastomosis.