Evaluation of the patients with colorectal cancer undergoing emergent curative surgery

Patient Factors Affecting Inpatient Mortality Following Colorectal Cancer Resection

BACKGROUND

Our objective is to identify factors for inpatient death in patients undergoing resection for colorectal cancer (CRC).

STUDY DESIGN

Unmatched 1:3 case-control study of surgically resected CRC at a tertiary care institution between 2004 and 2018. Variables for multivariate analysis were selected using tetrachoric correlation followed by a least absolute shrinkage and selection operator (LASSO) penalized regression model.

RESULTS

A total of 140 patients were included (N = 35 patients who died inpatient, N = 105 patients who did not die). Patients who died were older, had higher Charlson Comorbidity Index (CCI), higher rates of preoperative anemia, hypoalbuminemia, emergency surgeries, blood transfusion, postoperative vasopressor requirement, anastomotic leak, and postoperative ICU admission than patients who underwent surgical resection without inpatient mortality. Anemia (aOR = 8.62, 1.44-91.58), emergency admission (aOR = 5.71, 1.46-24.36), and ICU admission (aOR 45.51, 8.31-448.4) significantly predicted inpatient mortality when controlled for CCI and hypoalbuminemia.

CONCLUSIONS

Surprisingly, it appears that pre-existing anemia and perioperative factors are more important in predicting inpatient mortality of patients undergoing CRC surgery than baseline comorbidity or nutritional status.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Mortality of patients with metastatic colorectal cancer who received elective or emergent operation after exposure to bevacizumab: A nationwide database study

INTRODUCTION

Treatment guidelines for colorectal cancer (CRC) indicate that surgical intervention within 4 weeks or 8 weeks after bevacizumab therapy might increase the risk of postoperative complications and mortality, especially in patients who received emergent operation. Therefore, we aimed to assess the association between different surgical timings, emergent or elective surgery, and the risk of postoperative mortality.

MATERIALS AND METHODS

Using the Taiwan National Health Insurance Database and Taiwan Cancer Registry, we identified patients with metastatic colorectal cancer (mCRC) who underwent surgery within 1 year of receiving bevacizumab between January 2010 and December 2017. The primary outcomes were 30-day, 60-day, and in-hospital mortality; the secondary outcomes were hospital stay, 30-day readmission rate, and surgical complications. Multivariate analysis was used to adjust for confounders.

RESULTS

This study included 2,047 patients. In the multivariate analysis, patients who underwent emergent operation and had higher Charlson scores had a significantly higher mortality rate. Patients with a longer interval to surgery, more cycles of bevacizumab treatment, and distal metastectomy had the opposite result. In subgroup analysis, patients who received emergent operation within 28 days had the highest surgical mortality.

CONCLUSIONS

The interval to operation among mCRC patients who receive bevacizumab treatment should exceed 4 weeks to avoid additional risk of mortality whether patients receiving elective or emergent operation. Patients who received emergent operation within 28 days of bevcizumab infusion had the highest risk of mortality.

Determinants of emergency presentation in patients with colorectal cancer: a systematic review and meta-analysis

Colorectal cancer remains a significant cause of morbidity and mortality, even despite curative treatment. A significant proportion of patients present emergently and have poorer outcomes compared to elective presentations, independent of TNM stage. In this systematic review and meta-analysis, differences between elective/emergency presentations of colorectal cancer were examined to determine which factors were associated with emergency presentation. A literature search was carried out from 1990 to 2018 comparing elective and emergency presentations of colon and/or rectal cancer. All reported clinicopathological variables were extracted from identified studies. Variables were analysed through either systematic review or, if appropriate, meta-analysis. This study identified multiple differences between elective and emergency presentations of colorectal cancer. On meta-analysis, emergency presentations were associated with more advanced tumour stage, both overall (OR 2.05) and T/N/M/ subclassification (OR 2.56/1.59/1.75), more: lymphovascular invasion (OR 1.76), vascular invasion (OR 1.92), perineural invasion (OR 1.89), and ASA (OR 1.83). Emergencies were more likely to be of ethnic minority (OR 1.58). There are multiple tumour/host factors that differ between elective and emergency presentations of colorectal cancer. Further work is required to determine which of these factors are independently associated with emergency presentation and subsequently which factors have the most significant effect on outcomes.

Pancreatic Cancer Surgery Following Emergency Department Admission: Understanding Poor Outcomes and Disparities in Care

BACKGROUND

The impact of emergency department admission prior to pancreatic resection on perioperative outcomes is not well described. We compared patients who underwent pancreatic cancer surgery following admission through the emergency department (ED-surgery) with patients receiving elective pancreatic cancer surgery (elective) and outcomes.

STUDY DESIGN

The Nationwide Inpatient Sample database was used to identify patients undergoing pancreatectomy for cancer over 5 years (2008-2012). Demographics and hospital characteristics were assessed, along with perioperative outcomes and disposition status.

RESULTS

A total of 8158 patients were identified, of which 516 (6.3%) underwent surgery after admission through the ED. ED-surgery patients were more often socioeconomically disadvantaged (non-White 39% vs. 18%, Medicaid or uninsured 24% vs. 7%, from lowest income area 33% vs. 21%; all p < .0001), had higher comorbidity (Elixhauser score > 6: 44% vs. 26%, p < .0001), and often had pancreatectomy performed at sites with lower annual case volume (< 7 resections/year: 53% vs. 24%, p < .0001). ED-surgery patients were less likely to be discharged home after surgery (70% vs. 82%, p < .0001) and had higher mortality (7.4% vs. 3.5%, p < .0001). On multivariate analysis, ED-surgery was independently associated with a lower likelihood of being discharged home (aOR 0.55 (95%CI 0.43-0.70)).

CONCLUSION

Patients undergoing pancreatectomy following ED admission experience worse outcomes compared with those who undergo surgery after elective admission. The excess of socioeconomically disadvantaged patients in this group suggests factors other than clinical considerations alone drive this decision. This study demonstrates the need to consider presenting patient circumstances and preoperative oncologic coordination to reduce disparities and improve outcomes for pancreatic cancer surgery.

Long-term trends in colorectal cancer: incidence, localization, and presentation

Background

The purpose of this study was to assess trends in incidence and presentation of colorectal cancer (CRC) over a period of 37 years in a stable population in Mid-Norway. Secondarily, we wanted to predict the future burden of CRC in the same catchment area.

Methods

All 2268 patients diagnosed with CRC at Levanger Hospital between 1980 and 2016 were included in this study. We used Poisson regression to calculate the incidence rate ratio (IRR) and analyse factors associated with incidence.

Results

The incidence of CRC increased from 43/100,000 person-years during 1980–1984 to 84/100,000 person-years during 2012–2016. Unadjusted IRR increased by 1.8% per year, corresponding to an overall increase in incidence of 94.5%. Changes in population (ageing and sex distribution) contributed to 28% of this increase, whereas 72% must be attributed to primary preventable factors associated with lifestyle. Compared with the last observational period, we predict a further 40% increase by 2030, and a 70% increase by 2040. Acute colorectal obstruction was associated with tumours in the left flexure and descending colon. Spontaneous colorectal perforation was associated with tumours in the descending colon, caecum, and sigmoid colon. The incidence of obstruction remained stable, while the incidence of perforation decreased throughout the observational period. The proportion of earlier stages at diagnosis increased significantly in recent decades.

Conclusion

CRC incidence increased substantially from 1980 to 2016, mainly due to primary preventable factors. The incidence will continue to increase during the next two decades, mainly due to further ageing of the population.

The factors that affect the mortality of emergency operated ASA 3 colon cancer patients

Introduction

colorectal cancers take third place among cancer-related deaths and 10-28% of these patients are admitted with the necessity of emergency surgical intervention. The main propose of this study was to investigate the factors affecting mortality in ASA 3 colorectal cancer patients who undergo emergency surgery.

Methods

between 2010 and 2017 ASA 3 patients who underwent emergency colon cancer surgery were included in the study. All of the study group was evaluated within the first 30-day time-frame. The results were obtained by a statistical comparison of the data of patients with and without mortality.

Results

one hundred and twenty eight patients included in the study. There was no statistical difference in the demographic data of the groups and the indications of the operation. The differences and durations of surgery also did not make any statistical difference. The complication rate was the same according to the Clavien-Dindo classification.

Conclusion

despite the screening programs applied in colorectal cancers, applications to emergency services and procedures performed under emergency conditions are still at high levels. Surgical operations, which have to be performed in patients with impaired metabolic status, carry major risks for patients, but their outcomes are also satisfactory for them.

Obstructing Left-Sided Colonic Cancer: Is Endoscopic Stenting a Bridge to Surgery or a Bridge to Nowhere?

For the 8-29% colorectal cancers that initially manifest with obstruction, emergency surgery (ES) was traditionally considered the only available therapy, despite high morbidity and mortality rates and the need for colostomy creation. More recently, malignant obstruction of the left colon can be temporized by endoscopic placement of a self-expanding metallic stent (SEMS), used as bridge to surgery (BTS), facilitating a laparoscopic approach and increasing the likelihood that a primary anastomosis instead of stoma would be used. Despite these attractive outcomes, the superiority of the BTS approach is not clearly established. Few authors have stressed the potential cancer risk associated with perforations that may occur during endoscopic stent placement, facilitating neoplastic spread and negatively impacting prognosis. For this reason, the current literature focuses on long-term oncologic outcomes such as disease-free survival, overall survival and recurrence rate that do seem not to differ between the ES and BTS approaches. This lack of consensus has spawned differing and sometimes discordant guidelines worldwide. In conclusion, 20 years after the first description of a colonic stent as BTS, the debate is still open, but the growing number of articles about the use of SEMS as a BTS signifies a great interest in the topic. We hope that these data will finally converge on a single set of recommendations supporting a management strategy with well-demonstrated superiority.

Individualized prediction of survival benefit from primary tumor resection for patients with unresectable metastatic colorectal cancer

Background

The impact of primary tumor resection (PTR) on the prognosis of unresectable metastatic colorectal cancer (mCRC) patients remains debatable. We aimed to develop several prognostic nomograms which could be useful in predicting whether patients might benefit from PTR or not.

Methods

Patients diagnosed as mCRC without resected metastasis were identified from the Surveillance Epidemiology and End Results database and randomly assigned into two groups: a training cohort (6369 patients) and a validation cohort (2774 patients). Univariate and multivariable Cox analyses were performed to identify the independent predictors and construct nomograms that could independently predict the overall survival (OS) of unresectable mCRC patients in PTR and non-PTR groups, respectively. The performance of these nomograms was assessed by the concordance index (C-index), calibration curves, and decision curve analysis (DCA).

Results

Based on the result of univariate and multivariable Cox analyses, two nomograms were respectively constructed to predict the 1-year OS rates of unresectable mCRC patients when receiving PTR and not. The first one included age, gender, tumor grade, proximal colon, N stage, CEA, chemotherapy, radiotherapy, histology type, brain metastasis, liver metastasis, lung metastasis, and bone metastasis. The second nomogram included age, race, tumor grade, primary site, CEA, chemotherapy, brain metastasis, and bone metastasis. These nomograms showed favorable sensitivity with the C-index range of 0.700–0.725. The calibration curves and DCAs also exhibited adequate fit and ideal net benefits in prognosis prediction and clinical application.

Conclusions

These practical prognosis nomograms could assist clinicians in making appropriate treatment decisions to effectively manage the disease.

Factors Associated With Minimally Invasive Surgery for Colorectal Cancer in Emergency Settings

BACKGROUND

Minimally invasive surgery (MIS) is associated with improved colorectal cancer (CRC) outcomes, but it is used less frequently in emergency settings. We aimed to assess patient-level factors associated with emergency presentation for CRC and the use of MIS in emergency versus elective settings.

METHODS

This retrospective study examined the clinical data of patients who underwent emergency and elective resections for CRC from 2013 to 2015 using the Florida Inpatient Discharge Dataset. Multivariable analyses were performed to assess differences in gender, age, race, urbanization, region, insurance, and clinical characteristics associated with mode of presentation and surgical approach. In-hospital mortality and length of stay by mode of presentation were recorded.

RESULTS

Of 16,277 patients identified, 10,224 (61%) had elective surgery and 6503 (39%) had emergency surgery. Emergency presentations were more likely to be black (14.2% versus 9.5%), Hispanic (18.9% versus 15.4%), Medicaid-insured (9.7% versus 4.2%), and have metastatic cancer (34.4% versus 20.2%) or multiple comorbidities (12.6% versus 4.0%). MIS was the surgical approach in 31.8% of emergency cases versus 48.1% of elective cases. Factors associated with lower odds of MIS for emergencies include Medicaid (odds ratio (OR) 0.79, 95% confidence interval (CI) 0.63-0.99), metastases (OR 0.56, CI 0.5-0.63), and multiple comorbidities (OR 0.53, CI 0.4-0.7). Emergency cases experienced higher in-hospital mortality (3.7% versus 1.0%) and a longer median length of stay (10 d versus 5 d).

CONCLUSIONS

Emergency CRC presentations are associated with racial minorities, Medicaid insurance, metastatic disease, and multiple comorbidities. Odds of MIS in emergency settings are lowest for patients with Medicaid insurance and highest clinical disease burden.

Urgent surgery in colon cancer has no impact on survival

BACKGROUND AND OBJECTIVES

Despite advances in early detection of colon cancer, a minority of patients still require urgent surgery. Whether such urgent conditions result in poor outcome remains a topic of debate.

METHODS

Using a prospectively maintained database, patients suffering exclusively from colon cancer and receiving either elective or emergent resection between 2001 and 2014 were analyzed with respect to overall, disease-specific, and relative survival using Cox regression and propensity score analyses.

RESULTS

From a total of 877 patients analyzed, 2.7% (24) presented with complications requiring urgent surgery. Propensity-scoring identified strongly biased patient characteristics (0.097 ± 0.069 vs 0.028 ± 0.043; P < 0.001). An unadjusted Cox proportional hazards regression analysis revealed urgent surgery as a statistically significant prognostic factor with an approximately 207% increased risk of mortality (hazard ratio [HR] = 3.07; 95% confidence interval [CI]: 1.62-5.81; P = 0.003). After adjusting the data according to the propensity score analysis, urgent surgery was not associated with a decreased overall (HR = 1.67; 95%CI; 0.84-3.36; P = 0.174), disease-specific (HR = 1.62; 95% CI; 0.81-3.24; P = 0.201) or relative survival (HR = 1.86; 95% CI: 0.92-3.79; P = 0.086).

CONCLUSIONS

After risk-adjustment, using multivariable Cox regression and propensity score analyses, no significant disadvantage could be noted with regard to overall, disease-specific, or relative survival in patients with exclusively colon cancer who received emergent oncological resection.

Enzyme-Based Electrochemical Biosensor for Therapeutic Drug Monitoring of Anticancer Drug Irinotecan

Therapeutic drug monitoring (TDM) is the clinical practice of measuring pharmaceutical drug concentrations in patients' biofluids at designated intervals, thus allowing a close and timely control of their dosage. To date, TDM in oncology can only be performed by trained personnel in centralized laboratories and core facilities employing conventional analytical techniques (e.g., MS). CPT-11 is an antineoplastic drug that inhibits topoisomerase type I, causing cell death, and is widely used in the treatment of colorectal cancer. CPT-11 was also found to directly inhibit acetylcholine esterase (AChE), an enzyme involved in neuromuscular junction. In this work, we describe an enzymatic biosensor, based on AChE and choline oxidase (ChOx), which can quantify CPT-11. ACh (acetylcholine) substrate is converted to choline, which is subsequently metabolized by ChOx to give betaine aldehyde and hydrogen peroxide. The latter one is then oxidized at a suitably polarized platinum electrode, providing a current transient proportional to the amount of ACh. Such an enzymatic process is hampered by CPT-11. The biosensor showed a ∼60% maximal inhibition toward AChE activity in the clinically relevant concentration range 10-10 000 ng/mL of CPT-11 in both simple (phosphate buffer) and complex (fetal bovine serum) matrixes, while its metabolites showed negligible effects. These findings could open new routes toward a real-time TDM in oncology, thus improving the therapeutic treatments and lowering the related costs.

[Emergency endoscopic surgery of colon cancer]

AIM

To assess the role of endoscopic technologies in treatment of complicated forms of colorectal cancer.

MATERIAL AND METHODS

Our trial included patients after endoscopic intervention (n=18) and open surgery (n=11).

RESULTS

Mean time of surgery in this group was 158.8±10.7 minutes. In elective surgery group this value was 161.3 minutes (p>0.05). Mean blood loss was not great (near 122.5±17.9 ml). Overall and postoperative hospital-stay was 23.1±2.4 and 8.6±0.5 days, respectively. There were no intraoperative and postoperative complications.

CONCLUSION

Endoscopic interventions may be performed for colon cancer for emergency indications including patients with severe complications.