The impact of postoperative complications on long-term outcomes following curative resection for colorectal cancer

Quantification of indocyanine green fluorescence angiography in colorectal surgery: a systematic review of the literature

BACKGROUND

Indocyanine green fluorescence angiography (ICGFA) during colorectal surgery associates with reduced post-operative anastomotic complication rates. Because its interpretation is subjective, quantification has been proposed to address inter-user variability. This study reviews the published literature regarding ICGFA quantification during colorectal surgery with a focus on impactful clinical deployment.

METHODS

A systematic review was performed of English language publications regarding clinical studies of ICGFA quantification in colorectal surgery in PubMed, Scopus, Web of Science and Cochrane Library on 29th August 2024, updated to 18th November 2024, following PRISMA guidelines. Newcastle Ottawa scale (NOS) was used to assess quality.

RESULTS

A total of 1428 studies were screened with 22 studies (1469 patients) selected. There was significant heterogeneity of ICGFA methodology, quantification methods and parameter selection and only three studies were NOS "high" quality. Extracorporeal application was most common. Four studies (154 patients) conducted real-time ICGFA analyses (others were post hoc) and four utilised artificial intelligence methods. Eleven studies only included patients undergoing left-sided resection (six focusing specifically on rectal resections). Only one study employed the quantification method to guide intra-operative decision-making regarding colonic transection. Twenty-six different perfusion parameters were assessed, with time from injection to visible fluorescence and maximum intensity the most commonly (but not only) correlated parameters regarding anastomotic complication (n = 18). Other grounding correlates were tissue oxygenation (n = 3, two with hyperspectral imagery), metabolites (n = 2) and surgeon interpretation (n = 5).

CONCLUSION

Quantification of the ICGFA signal for colorectal surgery is feasible but has so far seen limited academic advancement beyond feasibility.

Minimal invasive surgery protects against severe postoperative complications regardless of body composition in patients undergoing colorectal surgery

BACKGROUND

For many colorectal cancer patients, primary surgery is the standard care of treatment. Further insights in perioperative care are crucial. The aim of this study is to assess the prognostic value of body composition for postoperative complications after laparoscopic and open colorectal surgery.

METHODS

From January 2013 to 2018 all consecutive patients who underwent surgery for colorectal cancer were enrolled in this study. Patients with a preoperative CT-scan <90 days before surgery were included. All CT-scans were obtained retrospectively, and body composition was analysed using a single transverse slice at the level of the third lumbar vertebra (L3) within the Slice-O-Matic-software. The studied outcome measure was the occurrence of major postoperative complications (Clavien-Dindo grade ≥3b).

RESULTS

A total of 1213 patients were included in the final analyses. Multivariable analyses showed that patients with low-skeletal muscle mass Z-score (OR 0.67, 95 % CI 0.45-0.97, p = 0.036) or a high visceral adipose tissue Z-score (OR 1.56, 95 % CI 1.06-2.29, p = 0.023) were significantly associated with an increased risk of developing major postoperative complications after open surgery. In the laparoscopic group, all six body composition parameters were not significantly associated with an increased risk of developing a major postoperative complication.

CONCLUSIONS

In this study, open colorectal surgery in patients with either low skeletal muscle mass or high visceral adipose tissue mass was associated with increased risk of postoperative complications. Laparoscopic surgery did not show this correlation. This demonstrates the importance of using minimal invasive surgery in colorectal cancer patients and implementing this as standard care.

Comparison of prognosis for T4b rectal cancer with different pelvic compartment involvement treated using neoadjuvant chemoradiotherapy and implications for refinement of the current T staging system: A retrospective cohort study

PURPOSE

Although classified as one stage, T4b rectal cancer actually represents a group of heterogeneous diseases. Our study aimed to assess the prognosis difference of T4b rectal cancer involving inferior pelvic and other pelvic compartments. This information may be helpful in refinement of the current T staging system.

METHODS

We retrospectively analysed data from 195 patients with magnetic resonance imaging-identified locally advanced T4b rectal cancer who received neoadjuvant chemoradiotherapy between January 2010 and December 2019. 104 patients had only inferior pelvic compartment involvement (group A) while 91 patients had anterior, posterior or lateral pelvic compartment involvement (group B). Short-term and long-term outcomes were compared between the two groups.

RESULTS

After neoadjuvant therapy, 80.8 % patients (84/104) in group A and 92.3 % patients (84/91) in group B underwent surgery. The R0 resection rates were 97.6 % and 89.3 %, respectively. 8.7 % patients (9/104) in group A achieved clinical complete response and adopted watch-and-wait strategy. Patients in group A had significantly superior 5-year progression-free survival (PFS) (67.8 % vs. 55.5 %, P = 0.032) and overall survival (OS) (89.6 % vs. 71.8 %, P = 0.001) than group B. Multivariable Cox regression analysis also identified pelvic compartment involvement classification as an independent predictor of PFS (hazard ratio 1.776, P = 0.046) and OS (hazard ratio 3.477, P = 0.004).

CONCLUSION

T4b rectal cancers with involvement limited to the inferior pelvic compartment had superior prognosis compared to those involving other pelvic compartments. These differences should be investigated further and taken into consideration in refinement of the current T staging system.

Impact of indocyanine green fluorescence angiography on surgeon action and anastomotic leak in colorectal resections. A systematic review and meta-analysis

BACKGROUND

Indocyanine green fluorescence angiography (ICGFA) during colorectal surgery either reassures surgeons regarding intestinal perfusion sufficiency or prompts changed surgical strategy by indicating unsuspected insufficiency. This study describes existing evidence supporting ICGFA use in colorectal surgery, particularly regarding impact on intraoperative decisions.

METHODS

Searches were performed on PubMed, ScienceDirect, Scopus, Web of Science, Cochrane Collaboration databases on 5th December 2023, updated to 19th August 2024. Full English language publications of clinical studies in human patients undergoing colorectal resection with primary anastomosis with the use of ICGFA to assess bowel perfusion intraoperatively, with a control group, were included. Pooling of anastomotic leak (AL) rates was performed for primary outcome analysis with odds ratio (OR) and number-needed-to-treat (NNT) calculated regarding leak reduction.

RESULTS

45 studies comprising 14,333 patients were included, with 7 randomised controlled trials (2911 patients). Overall, AL rate was 6.8%, 4.5% with ICGFA and 8.5% without (OR:0.47, p < 0.001, NNT 23), increasing to 9.5%, 7.5% and 11.6%, respectively, in randomised controlled trials (OR:0.62, p < 0.01, NNT 25). In rectal resections, AL rate was 4.7% with ICGFA vs 11.5% without (OR: 0.38, p < 0.0001). 26 studies performed ICGFA before and after anastomosis formation and 19 used ICGFA only prior to bowel transection, with no significant difference of AL rate reduction on subgroup testing. ICGFA prompted a change in surgical plan in 8.4% of thirty-four studies reporting this. Interestingly, in these studies, leak rates overall were 3.7% when ICGFA matched surgeon judgement versus 5.7% when it prompted change (OR 0.51, p < 0.0025), versus 7.7% without (OR 0.45, p < 0.0001). In rectal resections, these figures were 5%, 8.8% (OR 0.42, p = 0.01) and 12.0% (OR0.39, p < 0.0001), respectively.

CONCLUSIONS

ICGFA colorectal perfusion assessment is associated with lower anastomotic leak rates, especially when confirming surgeons' judgement, and may so stratify patients post-operatively regarding subsequent anastomotic leak rate.

Prognostic determinants in surgical critial patients undergoing emergency surgery for Stage III or higher colorectal cancer

PURPOSE

Emergency surgery in patients with colorectal cancer (CRC) is associated with elevated mortality and morbidity compared to elective operations. This study was conducted to identify the factors influencing both short and long term outcomes in emergent CRC operations, particularly in critically ill patients.

METHOD

This single center retrospective analysis focuses on patients with stage III or higher CRC who underwent emergency surgery and were admitted to the intensive care unit postoperatively.

RESULTS

Among 64 patients, 46 presented with generalized peritonitis due to free perforation. Non-survivors at 90 days had a higher incidence of preoperative shock (53.3% vs. 4.1%, P = 0.000), elevated perioperative Sequential Organ Failure Assessment scores (P = 0.000; P = 0.013), and fewer retrieved lymph nodes (LN) (P = 0.010). Multivariate analysis identified LNs retrieval as a significant predictor of 90-day mortality (AUC = 0.727). For overall survival, younger age, lower American Society of Anesthesiologists (ASA) physical status, absence of metastasis, adjuvant chemotherapy (CTx), and lower LN ratio (LNR) were associated with improved outcomes. Multivariate analysis showed ASA physical status and adjuvant CTx as significant predictors. In predicting 3-year recurrence (51% of patients), the Random Forest model achieved 65% accuracy. Age and LNR were major predictors, with 0.01 unit increase in LNR raising recurrence risk by 1.025-fold and each additional year of age by 1.035-fold.

CONCLUSION

The number of retrieved LNs was identified as a predictor of 90 day survival, ASA physical status and adjuvant CTx were identified as prognostic factors for overall survival, and age and the LNR were found to be predictors of disease recurrence within three years.

Association between the antibiotics use and recurrence in patients with resected colorectal cancer: EVADER-1, a nation-wide pharmaco-epidemiologic study

BACKGROUND

The impact of antibiotics (ATBs) on the risk of colorectal cancer (CRC) recurrence after curative resection remains unknown.

METHODS

Using the French nation-wide database of cancer patients, all newly diagnosed non-metastatic CRC patients resected between 01/2012 and 12/2014 were included. The perioperative ATB intake (from 6 months before surgery until 1 year after) was classified according to the class, the period of use (pre- vs post-resection), the disease stage (localized and locally advanced), and the primary tumor location (colon and rectum/junction). The primary endpoint was the 3-year disease-free survival (DFS). The impact of ATB was assessed using time-dependent multivariate Cox models.

RESULTS

A total of 35,496 CRC patients were included. Seventy-nine percent of patients had at least one ATB intake. Outpatient ATB intake after surgery was associated with unfavorable 3-year DFS. The ATBs associated with decreased 3-year DFS were cephalosporins, streptogramins, quinolones, penicillin A with beta-lactamase inhibitors, and antifungals with differential effects according to the primary tumor location and disease stage.

CONCLUSION

These findings suggest that ATBs modulate the risk of recurrence after early CRC resection with a differential impact of the ATB classes depending on disease stage and tumor site.

Short-term and three-year long-term outcomes of laparoscopic surgery versus open surgery for obstructive colorectal cancer following self-expandable metallic stent placement: a meta-analysis

BACKGROUND

A bridge to surgery (BTS) after self-expandable metallic stent (SEMS) placement is a widely recognized treatment strategy for obstructive colorectal cancer. However, there is still a lack of evidence for the efficacy and safety of laparoscopic surgery following SEMS placement. The aim of this systematic review and meta-analysis was to compare the short-term and long-term outcomes of laparoscopic surgery with those of open surgery following SEMS placement in patients with obstructive colorectal cancer.

METHODS

An electronic literature search through to December 2022 was performed to identify studies comparing short-term and long-term outcomes between laparoscopic and open surgery following SEMS placement for obstructive colorectal cancer. The main outcome measures were postoperative complication rates and mortality. Secondary outcome measures were the 3-year recurrence-free survival (RFS) and 3-year overall survival (OS) rates. The meta-analysis was performed using fixed-effect or random-effects methods to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

The meta-analysis included 15 studies and 883 patients, of whom 467 (52.9%) underwent laparoscopic surgery and 416 (47.1%) underwent open surgery following SEMS placement. The postoperative complication rate was significantly lower in the laparoscopic surgery group than in the open surgery group (OR 0.47, 95% CI 0.32-0.67, P < 0.001). There was no significant difference in the 3-year RFS rate or 3-year OS rate between the laparoscopic and open surgery groups (3-year RFS, OR 0.78, 95% CI 0.50-1.24, P = 0.30; 3-year OS, OR 0.68, 95% CI 0.41-1.12, P = 0.13).

CONCLUSION

This meta-analysis found that the short-term outcome was better in patients who underwent laparoscopic surgery following SEMS placement than in those who underwent open surgery. Furthermore, there was no significant difference in long-term outcomes between the two groups. Laparoscopic surgery following SEMS placement may be a safe and effective treatment option for obstructive colorectal cancer.

Oncologic investigation of the interval from stent placement to surgery in patients with obstructive colorectal cancer

PURPOSE

Self-expandable metallic stent (SEMS) placement is widely used as a bridge to surgery (BTS) procedure for obstructive colorectal cancer. However, evidence regarding the optimal interval between SEMS placement and elective surgery is lacking.

METHODS

We retrospectively collected data from patients with BTS between January 2013 and October 2021. Inverse probability treatment-weighted propensity score analyses were used to compare short- and long-term outcomes between the short-interval (SI) and long-interval (LI) groups, using a cutoff of 20 days.

RESULTS

In total, 138 patients were enrolled in this study (SI group, n = 63; LI group, n = 75). In the matched cohort, the patients' backgrounds were well balanced. The incidence of Clavien-Dindo grade ≥ II postoperative complications was not significantly different between the SI and LI groups (19.0% vs. 14.0%, P = 0.47). There were no significant differences between the SI and LI groups in the 3-year recurrence-free survival (68.0% vs. 76.4%, P = 0.73) or 3-year overall survival rates (86.0% vs. 90.6%, P = 0.72).

CONCLUSIONS

A longer interval did not deteriorate the oncological outcomes. Individual perioperative management with an appropriate interval to improve the patient's condition is required to ensure safe surgery.

Negative and Positive Predictors of Anastomotic Leakage in Colorectal Cancer Patients-The Case of Neutrophil-to-Lymphocyte Ratio

Colorectal surgery for cancer is associated with a high rate of surgical complications, including anastomotic leakage. The ability to predict the risk of leakage early enough seems to be of high value, since it would facilitate the design of personalized treatment and duration of hospitalization. Although different studies present the neutrophil-to-lymphocyte ratio [NLR] as having a strong predictive value, there is a discrepancy with respect to which postoperative day is the most reliable. We evaluated a series of NLR values, from the day before surgery up to the POD7, in a cohort of 245 colorectal surgery patients in order to clarify the best predictable score for the identification of the risk of anastomotic leakage. There were 28 patients with leaks. ROC curve analysis of NLR on POD1 indicates that a cut-off point ≥ 7.4 exerts a negative prediction for leakage (AUC 0.881, sensitivity 68.7%, specificity 96.4%, PPV 28.4%, and NPV of 99.3%), thus excluding 150 patients from the risk of leakage. Furthermore, the ROC curve analysis of NLR on POD4 indicates that a cut-off point ≥ 6.5 gives a positive prediction of leakage (AUC 0.698, sensitivity 82.1%, specificity 51.6%, PPV 17.6%, and NPV of 95.6%), thus indicating 52 patients as being at high risk of leakage. Finally, NLR failed to identify five leaks out of twenty-eight. These results strongly indicate the ability of NLR on POD1 to predict patients at low risk of developing a leak and then on POD4 to predict the high-risk patients. This makes our study particularly innovative, in that it enables doctors to concentrate on potential high-risk patients from POD1.

Postoperative Complications Result in Poor Oncological Outcomes: What Is the Evidence?

The majority of patients with solid tumors undergo a curative resection of their tumor burden. However, the reported rate of postoperative complications varies widely, ranging from 10% to 70%. This narrative review aims to determine the impact of postoperative complications on recurrence and overall survival rates following elective cancer surgeries, thereby providing valuable insights into perioperative cancer care. A systematic electronic search of published studies and meta-analyses from January 2000 to August 2023 was conducted to examine the effect of postoperative complications on long-term survival after cancer surgeries. This comprehensive search identified fifty-one eligible studies and nine meta-analyses for review. Recurrence-free survival (RFS) and overall survival (OS) rates were extracted from the selected studies. Additionally, other oncological outcomes, such as recurrence and cancer-specific survival rates, were noted when RFS and OS were not reported as primary outcomes. Pooled hazard ratios and 95% confidence intervals were recorded from the meta-analyses, ensuring the robustness of the data. The analysis revealed that long-term cancer outcomes progressively worsen, from patients with no postoperative complications to those with minor postoperative complications (Clavien-Dindo grade ≤ II) and further to those with major postoperative complications (Clavien-Dindo grade III-IV), irrespective of cancer type. This study underscores the detrimental effect of postoperative complications on long-term oncological outcomes, particularly after thoracoabdominal surgeries. Importantly, we found a significant gap in the data regarding postoperative complications in surface and soft tissue surgical procedures, highlighting the need for further research in this area.

Postoperative complications and emergency surgeries in colorectal cancer patients <50 years-a national cohort study

AIM

The incidence of colorectal cancer (CRC) in Sweden is increasing in individuals <50 years. This study aimed to examine differences in postoperative 30-day complications and rate of emergency surgeries in CRC patients <50 years at diagnosis compared to older age groups since population-based research on this topic is scarce.

METHOD

This population-based study included data from the Swedish Colorectal Cancer Registry for patients undergoing CRC resection between 2010 and 2018. Bivariate analysis and logistic regression were used to analyse the relationship between age groups (<50, 50-79 and ≥80 years) and probability of postoperative 30-day complications adjusted for gender, tumour localization, neoadjuvant (chemo)radiotherapy and American Society of Anesthesiologists score.

RESULTS

In total 33 320 patients were included. Patients <50 years had a lower American Society of Anesthesiologists score, more advanced tumours and received more neoadjuvant treatment. Emergency surgeries were less common in the youngest age group (P < 0.001) as well as overall postoperative 30-day complications: ORadj 0.84 (95% CI 0.74-0.96) compared to those ≥80 years. Surgical complications were more common in age groups <50 and 50-79 years (16.5% and 16.9% respectively) compared to patients ≥80 years (14.1%) (P < 0.001). Anastomotic leakage and intra-abdominal infections were more frequent in patients <50 years (5.7% and 3.5% respectively) compared to age groups 50-79 years (5.1% and 2.8% respectively) and ≥80 years (3.5% and 2.1% respectively) (P < 0.001). Wound infections were more common in the two youngest age groups compared to patients ≥80 years (5.3% vs. 3.7% respectively) (P < 0.001).

CONCLUSION

Colorectal cancer patients <50 years and 50-79 years had a higher proportion of surgical complications regarding anastomotic leakage, intra-abdominal infections and wound infections but lower overall postoperative complications. The incidence of surgical emergencies was highest amongst patients ≥80 years. Postoperative diagnostic workup in symptomatic individuals <50 years is warranted.

Enhancing surgical outcomes in elderly gastric cancer patients: the role of comprehensive preoperative assessment and support

BACKGROUND

As the prevalence of gastric cancer rises in aging populations, managing surgical risks and comorbidities in elderly patients presents a unique challenge. The Comprehensive Preoperative Assessment and Support (CPAS) program, through comprehensive preoperative assessments, aims to mitigate surgical stress and improve outcomes by enhancing patient awareness and preparation. This study investigates the efficacy of a CPAS program, incorporating frailty and sarcopenia evaluations, to improve short-term outcomes in elderly gastric cancer patients.

METHODS

A retrospective analysis was conducted on 127 patients aged 75 or older who underwent surgery with CPAS between 2018 and August 2023, compared to 170 historical controls from 2012 to 2017. Propensity score matching balanced both groups based on age-adjusted Charlson Comorbidity Index and surgical details. The primary focus was on the impact of CPAS elements such as rehabilitation, nutrition, psychological support, oral frailty, and social support on short-term surgical outcomes.

RESULTS

Among 83 matched pairs, the CPAS group, despite 40.4% of patients in the CPAS group and 21.2% in the control group had an ASA-PS score of 3 or higher (P < 0.001), demonstrated significantly reduced blood loss (100 ml vs. 190 ml, P = 0.026) and lower incidence of serious complications (19.3% vs. 33.7%, P = 0.034), especially in infections and respiratory issues. Sarcopenia was identified in 38.6% of CPAS patients who received tailored support. Additionally, the median postoperative hospital stay was notably shorter in the CPAS group (10 days vs. 15 days, P < 0.001), with no in-hospital deaths. These results suggest that personalized preoperative care effectively mitigates operative stress and postoperative complications.

CONCLUSION

Implementing CPAS significantly enhances surgical safety and reduces complication rates in elderly gastric cancer patients, emphasizing the critical role of personalized preoperative care in surgical oncology for this demographic.

Effects of Clavien-Dindo Classification on Long-Term Survival of Patients With Advanced Gastric Cancer After Radical Resection: A Propensity Score-matched Study

BACKGROUND

The impact of postoperative complications (POCs) classified by the Clavien-Dindo (C-D) system on long-term survival after radical resection in patients with advanced gastric cancer (AGC) is not yet clear.

METHODS

This study analyzed 531 patients with AGC who underwent radical resection in an institution between January 2015 and December 2017. Patients were divided into 2 groups according to the occurrence of POCs and recorded according to C-D classifications. The long-term survival outcomes of the entire cohort after propensity score matching (PSM) were compared.

RESULTS

After PSM, there was no significant difference in baseline data between the complications (C) group (n = 92) and the non-complications (NC) group (n = 92). Survival analysis showed that the 5-year overall survival (OS) and relapse-free survival (RFS) were lower in the C group (48.9% vs 62.0%, P = .040; 38.5% vs 54.9%, P = .005; respectively). Subgroup analysis showed that severe complications (C-D grade > II) were associated with a decrease in 5-year OS and RFS compared with the matched NC group (40.0% vs 62.0%, P = .008; 29.4% vs 54.9%, P = .001; respectively). Multivariate analysis confirmed adjuvant chemotherapy, tumor size, and complications were independent risk factors for poor survival outcomes. Further multivariate analysis showed that older age, combined excision, and comorbidities were independent risk factors for POCs.

CONCLUSIONS

Severe complications reduced the survival outcome of patients. More attention should be paid to perioperative management of patients with high risk factors for complications.

Predicting futility of upfront surgery in perihilar cholangiocarcinoma: Machine learning analytics model to optimize treatment allocation

BACKGROUND

While resection remains the only curative option for perihilar cholangiocarcinoma, it is well known that such surgery is associated with a high risk of morbidity and mortality. Nevertheless, beyond facing life-threatening complications, patients may also develop early disease recurrence, defining a "futile" outcome in perihilar cholangiocarcinoma surgery. The aim of this study is to predict the high-risk category (futile group) where surgical benefits are reversed and alternative treatments may be considered.

METHODS

The study cohort included prospectively maintained data from 27 Western tertiary referral centers: the population was divided into a development and a validation cohort. The Framingham Heart Study methodology was used to develop a preoperative scoring system predicting the "futile" outcome.

RESULTS

A total of 2271 cases were analyzed: among them, 309 were classified within the "futile group" (13.6%). American Society of Anesthesiology (ASA) score ≥ 3 (OR 1.60; p = 0.005), bilirubin at diagnosis ≥50 mmol/L (OR 1.50; p = 0.025), Ca 19-9 ≥ 100 U/mL (OR 1.73; p = 0.013), preoperative cholangitis (OR 1.75; p = 0.002), portal vein involvement (OR 1.61; p = 0.020), tumor diameter ≥3 cm (OR 1.76; p < 0.001), and left-sided resection (OR 2.00; p < 0.001) were identified as independent predictors of futility. The point system developed, defined three (ie, low, intermediate, and high) risk classes, which showed good accuracy (AUC 0.755) when tested on the validation cohort.

CONCLUSIONS

The possibility to accurately estimate, through a point system, the risk of severe postoperative morbidity and early recurrence, could be helpful in defining the best management strategy (surgery vs. nonsurgical treatments) according to preoperative features.

Outcomes following major thoracoabdominal cancer resection in adults with congenital heart disease

BACKGROUND

While advances in medical and surgical management have allowed >97% of congenital heart disease (CHD) patients to reach adulthood, a growing number are presenting with non-cardiovascular malignancies. Indeed, adults with CHD are reported to face a 20% increase in cancer risk, relative to others, and cancer has become the fourth leading cause of death among this population. Surgical resection remains a mainstay in management of thoracoabdominal cancers. However, outcomes following cancer resection among these patients have not been well established. Thus, we sought to characterize clinical and financial outcomes following major cancer resections among adult CHD patients.

METHODS

The 2012-2020 National Inpatient Sample was queried for all adults (CHD or non-CHD) undergoing lobectomy, esophagectomy, gastrectomy, pancreatectomy, hepatectomy, or colectomy for cancer. To adjust for intergroup differences in baseline characteristics, entropy balancing was applied to generate balanced patient groups. Multivariable models were constructed to assess outcomes of interest.

RESULTS

Of 905,830 patients undergoing cancer resection, 1,480 (0.2%) had concomitant CHD. The overall prevalence of such patients increased from <0.1% in 2012 to 0.3% in 2012 (P for trend<0.001). Following risk adjustment, CHD was linked with greater in-hospital mortality (AOR 2.00, 95%CI 1.06-3.76), as well as a notable increase in odds of stroke (AOR 8.94, 95%CI 4.54-17.60), but no statistically significant difference in cardiac (AOR 1.33, 95%CI 0.69-2.59) or renal complications (AOR 1.35, 95%CI 0.92-1.97). Further, CHD was associated with a +2.39 day incremental increase in duration of hospitalization (95%CI +1.04-3.74) and a +$11,760 per-patient increase in hospitalization expenditures (95%CI +$4,160-19,360).

CONCLUSIONS

While a growing number of patients with CHD are undergoing cancer resection, they demonstrate inferior clinical and financial outcomes, relative to others. Novel screening, risk stratification, and perioperative management guidelines are needed for these patients to provide evidence-based recommendations for this complex and unique cohort.

The Relationship Between BMI and Postoperative Complications Among Colorectal Cancer Patients Undergoing Surgery

INTRODUCTION

Colorectal cancer (CRC) is common worldwide, and surgery is one of the main treatments. Postoperative complications are a concern. The primary objective of this study is to determine whether elevated body mass index (BMI), the presence of comorbidities, tumor characteristics, and the type of surgery are associated with an increased risk of postoperative complications such as wound infections, pulmonary complications, anastomotic leak, venous thromboembolism (VTE), bowel obstruction, and incisional hernia. The secondary objective is to describe the characteristics of colorectal cancer patients with different BMI groups.

METHODOLOGY

A retrospective cohort study was conducted using a non-probability sampling technique at a tertiary National Guard Hospital in Riyadh, Saudi Arabia. This study involved 122 patients aged 18 years or more who underwent elective or emergency surgery for colorectal cancer between the years 2015 and 2022. Data analysis was performed using Statistical Package for Social Sciences (SPSS) version 27 (IBM SPSS Statistics, Armonk, NY). Descriptive statistics (mean and standard deviation) were used for quantitative variables, while qualitative variables were presented as percentages and frequencies. Non-parametric tests were applied to compare qualitative variables. Quantitative variables were analyzed using the analysis of variance (ANOVA) test. Significance was established at a p-value of 0.05. Ethical considerations were followed throughout the study. Prior to conducting the study, ethical approval was obtained from the Institutional Review Board of King Abdullah International Medical Research Center (KAIMRC) (approval number: IRB/1598/23).

RESULTS

High BMI scores were observed in patients with postoperative complications. A statistically significant variation in BMI scores (p-value < 0.05) was found between patients with complications and without complications. This observation suggests that factors beyond excessive body weight might contribute to the onset of postoperative complications. Moreover, elevated BMI scores were more prevalent in males and were associated with reduced hemoglobin (Hgb) levels, underscoring the potential influence of physiological variables on the emergence of postoperative complications (p-value < 0.05). Tumors located in the rectum or rectosigmoid regions, as well as partial colectomy procedures, exhibited a higher risk of postoperative complications (p-value < 0.05). However, no significant connections were identified between the presence of comorbidities and the occurrence of postoperative complications (p-value > 0.05).

CONCLUSION

This study highlights the impact of BMI on postoperative outcomes in colorectal cancer patients. Higher BMI was associated with unfavorable postoperative outcomes, such as an increased risk of VTE and fluid collection. However, no significant differences in mortality rates or length of hospital stay (LOS) were observed across various BMI categories. Factors beyond BMI, including tumor characteristics, the type of surgical intervention, and preoperative care, play a significant role in determining postoperative outcomes. Therefore, it is essential to adopt a comprehensive approach that considers multiple factors when managing postoperative complications in colorectal cancer patients, particularly those with higher BMI.

Prognostic impact of postoperative infection after resection of biliary malignancy: A multicenter retrospective cohort study

BACKGROUND

The aim of this study was to investigate the prognostic impact of postoperative infections in patients who underwent resection for biliary malignancy, including intrahepatic cholangiocarcinoma, perihilar cholangiocarcinoma, distal cholangiocarcinoma, gallbladder carcinoma, and carcinoma of the ampulla of Vater.

METHODS

This study was conducted in an 11-center retrospective cohort study. Patients with biliary tract cancer who underwent curative resection between April 2013 and March 2015 at 11 institutions in Japan were enrolled. We analyzed the prevalence of postoperative infection, infection-related factors, and prognostic factors.

RESULTS

Of the total 290 cases, 33 were intrahepatic cholangiocarcinoma, 60 were perihilar cholangiocarcinoma, 120 were distal cholangiocarcinoma, 55 were gallbladder carcinoma, and 22 were carcinoma of the ampulla of Vater. Postoperative infectious complications, including remote infection, were observed in 146 patients (50.3%), and Clavien-Dindo ≥III in 115 patients (39.7%). Postoperative infections occurred more commonly in the patients who received pancreaticoduodenectomy and bile duct resection. Patients with infectious complications had a significantly poorer prognosis than those without (median overall survival 38 months vs 62 months, P = .046). In a diagnosis-specific analysis, although there was no correlation between infectious complications and overall survival in intrahepatic cholangiocarcinoma, perihilar cholangiocarcinoma, distal cholangiocarcinoma, and carcinoma of the ampulla of Vater, infectious complications were a significantly poor prognostic factor in gallbladder carcinoma (P = .031).

CONCLUSION

Postoperative infection after surgery for biliary tract cancer commonly occurred, especially in patients who underwent pancreaticoduodenectomy and bile duct resection. Postoperative infection is relatively associated with the prognosis of patients with biliary malignancy, especially gallbladder carcinoma.

Prognostic Value of C-reactive Protein-to-albumin Ratio after Curative Resection in Patients with Colorectal Cancer

Objectives

The current retrospective study aimed to evaluate the association between combined preoperative and postoperative C-reactive protein-to-albumin ratio, which is correlated with prognosis in different types of malignancies, and prognosis after curative resection in patients with colorectal cancer.

Methods

This study enrolled 263 patients who underwent curative resection for stage II/III colorectal cancer. C-reactive protein-to-albumin ratio was calculated within 30 days before and 7 days after surgery. Receiver operating characteristic curve analyses were performed to determine the optimal cutoff values of preoperative and postoperative C-reactive protein-to-albumin ratio. The correlations between combined preoperative and postoperative C-reactive protein-to-albumin ratio and prognosis were analyzed.

Results

The cutoff values of preoperative and postoperative C-reactive protein-to-albumin ratio were 0.223 and 0.813, respectively; higher ratios were significantly associated with poor overall survival, based on the Kaplan-Meier curves (p < 0.001, p = 0.003, respectively). Further, preoperative and postoperative C-reactive protein-to-albumin ratios were correlated with poor progression-free survival (p < 0.001, p = 0.064, respectively). In the multivariate analysis, combined preoperative and postoperative C-reactive protein-to-albumin ratio was an independent predictor of overall survival and progression-free survival (p = 0.012, p = 0.044, respectively). Compared with low preoperative and postoperative C-reactive protein-to-albumin ratio, high ratios of that were significantly associated with poor overall survival (hazard ratio = 3.897, p = 0.006) and progression-free survival (hazard ratio = 2.130, p = 0.029).

Conclusions

Combined preoperative and postoperative C-reactive protein-to-albumin ratio, useful for prognostic prediction, can be a promising prognostic marker after curative resection in patients with colorectal cancer.

Postoperative complications and prognosis based on type of surgery in ulcerative colitis patients with colorectal cancer: A multicenter observational study of data from the Japanese Society for Cancer of the Colon and Rectum

Background

Patients with ulcerative colitis are reported to be at increased risk of colorectal cancer and are also at high risk of postoperative complications. However, the incidence of postoperative complications in these patients and how the type of surgery performed affects prognosis are not well understood.

Methods

Data collected by the Japanese Society for Cancer of the Colon and Rectum on ulcerative colitis patients with colorectal cancer between January 1983 and December 2020 were analyzed according to whether total colorectal resection was performed with ileoanal anastomosis (IAA), ileoanal canal anastomosis (IACA), or permanent stoma creation. The incidence of postoperative complications and the prognosis for each surgical technique were investigated.

Results

The incidence of overall complications was not significantly different among the IAA, IACA, and stoma groups (32.7%, 32.3%, and 37.7%, respectively; p = 0.510). The incidence of infectious complications was significantly higher in the stoma group (21.2%) than in the IAA (12.9%) and IACA (14.6%) groups (p = 0.048); however, the noninfectious complication rate was lower in the stoma group (13.7%) than in the IAA (21.1%) and IACA (16.2%) groups (p = 0.088). Five-year relapse-free survival was higher in patients without complications than in those with complications in the IACA group (92.8% vs. 75.2%; p = 0.041) and the stoma group (78.1% vs. 71.2%, p = 0.333) but not in the IAA group (90.3% vs. 90.0%, p = 0.888).

Conclusion

The risks of infectious and noninfectious complications differed according to the type of surgical technique used. Postoperative complications worsened prognosis.

Textbook outcome contributes to long-term prognosis in elderly colorectal cancer patients

PURPOSE

Textbook outcome (TO) has been used to define achievement of multiple "ideal" or "optimal" surgical and postoperative quality measures from the patient's perspective. However, TO has not been reported for their impact on survival in elderly, including CRC surgery. This study determined whether TO is associated with long-term outcomes after curative colorectomy in patients with colorectal cancer (CRC).

METHODS

Patient who underwent curative surgery over 75 years old for CRC between March 2005 and December 2016. TO included five separate parameters: surgery within 6 weeks, radical resection, Lymph node (LN) yield ≥ 12, no stoma, and no adverse outcome. When all 5 short-term quality of care parameters were realized, TO was achieved (TO). If any one of the 5 parameters was not met, the treatment was not considered TO (nTO).

RESULTS

TO was realized in 80 patients (43.0%). Differences in surgical-related characteristics and pathological characteristics according to TO had no statistically significant differences in baseline characteristics, except for Lymph node dissection. The Kaplan-Meier curves for OS and RFS association between TO and nTO had significantly poor 5-year OS and 5-year RFS compared with the TO groups (OS, 77.8% vs. 60.8%, P < 0.01; RFS, 69.6% vs. 50.8%, P = 0.01). In the multivariate analysis, nTO was an independent predictive factor for worse OS (HR, 2.04; 95% confidence interval (CI), 1.175-3.557; P = 0.01) and RFS (HR, 1.72; 95% CI, 1.043-2.842; P = 0.03).

CONCLUSIONS

TO can be a useful predictor for postoperative morbidity and prognosis after curative colorectomy for CRC.

The clinical impacts of postoperative complications after colon cancer surgery for the clinical course of adjuvant treatment and survival

AIM

We investigated whether or not postoperative complications (POCs) themselves have a negative survival impact or indirectly worsen the survival due to insufficient adjuvant chemotherapy in a pooled analysis of two large phase III studies performed in Japan PATIENTS AND METHODS: The study examined the patients who enrolled in 1304, phase III study comparing the efficacy of 6 and 12 months of capecitabine as adjuvant chemotherapy for stage III colon cancer patients and in 882, a phase III study to confirm the tolerability of oxaliplatin, fluorouracil, and l-leucovorin in Japanese stage II/III colon cancer patients. In our study, POCs were defined as the following major surgical complications: anastomotic leakage, pneumonia, bowel obstruction/ileus, surgical site infection, postoperative bleeding, urinary tract infection, and fistula. Patients were classified as those with POCs (C group) and those without POCs (NC group).

RESULTS

A total of 2095 patients were examined in the present study. POCs were observed in 169 patients (8.1%). The overall survival (OS) rates at 5 years after surgery were 75.3% in the C group and 86.5% in the NC group (p = 0.0017). The hazard ratio of POCs for the OS in multivariate analysis was 1.70 (95% confidence interval, 1.19 to 2.45; p = 0.0040). The time to adjuvant treatment failure (TTF) of adjuvant chemotherapy was similar between the groups, being 68.6% in the C group and 67.1% in the NC group for the 6-month continuation rate of adjuvant chemotherapy. The dose reduction rate of adjuvant chemotherapy and adjuvant treatment suspension rate were also similar between the groups (C vs. NC groups: 45.0% vs. 48.7%, p = 0.3520; and 52.7% vs. 55.0%, p = 0.5522, respectively).

CONCLUSION

POCs were associated with a poor prognosis but did not affect the intensity of adjuvant chemotherapy. These results suggested that POCs themselves negatively influence the survival.

Risk Factors for Esophagojejunal Anastomotic Leakage in Gastric Cancer Patients after Total Gastrectomy

BACKGROUND

Leakage at the esophagojejunal anastomosis site is an important postoperative complication of total gastrectomy. We analyzed our surgical cases to determine the risk factors for esophagojejunal anastomotic leakage.

METHODS

This study included 309 patients who underwent total gastrectomy and esophagojejunal anastomosis. The onset of esophagojejunal anastomotic leakage according to age, gender, performance status, American Society of Anesthesiologists classification, body mass index, presence or absence of diabetes, invasion depth, lymph node metastasis, histological type, presence or absence of esophageal infiltration, operative duration, amount of blood loss, experience of blood transfusion, procedural approach, and the prognostic nutritional index was analyzed.

RESULTS

Univariate analyses revealed a significant difference in the rate of esophagojejunal anastomotic leakage due to advanced age, male gender, the presence of diabetes, the presence of esophageal infiltration, and blood loss ≥1,100 g. In the multivariate analysis, which included factors identified in the univariate analyses, advanced age, male gender, the presence of diabetes, and blood loss ≥1,100 g were identified as independent risk factors for esophagojejunal anastomotic leakage.

CONCLUSIONS

Advanced age (≥68 years), male gender, diabetes, and massive blood loss are risk factors for esophagojejunal anastomotic leakage.

Marked paper: Type 2 diabetes mellitus indicates increased postoperative complications and poor prognosis in colorectal cancer patients receiving curative surgery

Purpose

This study aimed to evaluate the impact of type 2 diabetes mellitus (T2DM) on the short-term outcomes and long-term survival of patients with colorectal cancer (CRC) who underwent curative resection.

Methods

This study retrospectively included 136 patients (T2DM group) with resectable CRC and T2DM from Jan 2013 to Dec 2017. Propensity score-matched control group consisting of 136 patients (non-T2DM group) were selected from 1143 CRC patients without T2DM. The short-term outcomes and prognosis were compared between the T2DM and non-T2DM group.

Results

A total of 272 patients (136 patients for each group) were included in this study. Patients in T2DM group had higher body mass index (BMI), higher proportion of hypertension and cerebrovascular diseases (P<0.05). T2DM group had more overall complications (P=0.001), more major complications (P=0.003) and higher risk of reoperation (P=0.007) when compared with non-T2DM patients. T2DM patients had longer hospitalization time than non-T2DM (20.7 ± 10.2 vs. 17.5 ± 6.2, P=0.002). As for the prognosis, T2DM patients had worse 5-year overall survival (OS) (P=0.024) and 5-year disease-free survival (DFS) (P=0.019) in all stage. Moreover, T2DM and TNM stage were the independent predictors of OS and DFS for CRC patients.

Conclusions

T2DM increases overall complications and major complications, and prolongs the hospitalization time after CRC surgery. In addition, T2DM indicates the poor prognosis of CRC patients. A prospective study with large sample size is required to confirm our findings.

A National Cancer Database analysis of the predictors of unplanned 30-day readmission after proctectomy for rectal adenocarcinoma: The CCF RETURN-30 Score

BACKGROUND

Unplanned 30-day readmission is common after major surgery, including rectal cancer surgery. The present study aimed to assess the rate and predictors of unplanned 30-day readmission after proctectomy for rectal cancer.

METHODS

This was a retrospective case-control study using data from the National Cancer Database. Patients with non-metastatic rectal cancer who underwent proctectomy were included, and patients who required readmission within 30 days after discharge were compared to patients who were not readmitted in regard to patient and treatment baseline factors to determine the predictors of 30-day readmission after proctectomy. The main outcome measures were the rate and predictors of 30-day unplanned readmission and the impact of readmission on short-term mortality and overall survival.

RESULTS

A total of 55,181 patients (60.9% men) with a mean age of 61.2 years were included. The 30-day readmission rate was 7.07% (95% confidence interval: 6.9-7.3). A Charlson score of 0 (odds ratio: 0.75, P < .001), Medicare insurance (odds ratio: 0.836, P = .04), and private insurance (odds ratio: 0.73, P = .0003) were predictive of a lower likelihood of 30-day readmission, whereas urban living area (odds ratio: 1.18, P = .01), rural living area (odds ratio: 1.65%, P = .0004), neoadjuvant radiation therapy (odds ratio: 1.37, P = .001), pull-through coloanal anastomosis (odds ratio: 1.37, P = .0005), conversion to open surgery (odds ratio: 1.25, P = .001), and hospital stay ≥6 days (odds ratio: 1.02, P < .001) were predictive of a higher likelihood of 30-day readmission. Readmitted patients had a higher rate of 90-day mortality (3.1% vs 2.1%, P < .001) and a lower 5-year overall survival (67.0% vs 72.7%, P < .001) than non-readmitted patients. Using the weighted ORs of the significant predictors of 30-day readmission, a risk score, the Cleveland Clinic Florida REadmission afTer sUrgery for Rectal caNcer in 30 days (RETURN-30) score, was developed.

CONCLUSION

Comorbidities, residence in urban or rural areas, neoadjuvant radiation therapy, pull-through coloanal anastomosis, conversion to open surgery, and extended hospital stay were predictive of a higher risk of 30-day readmission. Patients who were readmitted had a higher rate of 90-day mortality and a lower 5-year overall survival.

High tumor mutation burden indicates better prognosis in colorectal cancer patients with KRAS mutations

OBJECTIVE

Colorectal cancer (CRC) is a common type of malignant tumor of the digestive tract. Tumor mutation burden (TMB) is a potential prognostic indicator of numerous malignant tumors. This study investigated the prognostic value of TMB in CRC.

METHODS

This study analyzed the clinical and somatic mutation data of patients with CRC from the Memorial Sloan Kettering Cancer Center (MSKCC) and The Cancer Genome Atlas (TCGA) cohorts. The genetic landscape was visualized using the maftools package in R software. Survival curves were constructed using the Kaplan-Meier method, and Cox regression analysis was performed to confirm that TMB is an independent prognostic indicator. A nomogram was developed to construct the prognostic model, which was evaluated using the C-index, calibration curve, and decision curve analysis.

RESULTS

In patients with CRC, APC mutations indicated longer overall survival (OS), whereas KRAS mutations indicated shorter OS. For all included patients, there was no significant difference in the OS between the TMB-high and TMB-low groups. For patients with KRAS mutations, the OS in the TMB-high group was longer than that in the TMB-low group. Cox regression analysis showed that TMB was an independent prognostic factor in CRC patients with KRAS mutations. This explains the good accuracy of the nomogram prognostic model using TMB and indicates its good prospect in clinical applications.

CONCLUSIONS

A high TMB indicates better prognosis in CRC patients with KRAS mutations, thus confirming the value of TMB in clinical applications.

Minimally invasivE versus open total GAstrectomy (MEGA): study protocol for a multicentre randomised controlled trial (DRKS00025765)

INTRODUCTION

The only curative treatment for most gastric cancer is radical gastrectomy with D2 lymphadenectomy (LAD). Minimally invasive total gastrectomy (MIG) aims to reduce postoperative morbidity, but its use has not yet been widely established in Western countries. Minimally invasivE versus open total GAstrectomy is the first Western multicentre randomised controlled trial (RCT) to compare postoperative morbidity following MIG vs open total gastrectomy (OG).

METHODS AND ANALYSIS

This superiority multicentre RCT compares MIG (intervention) to OG (control) for oncological total gastrectomy with D2 or D2+LAD. Recruitment is expected to last for 2 years. Inclusion criteria comprise age between 18 and 84 years and planned total gastrectomy after initial diagnosis of gastric carcinoma. Exclusion criteria include Eastern Co-operative Oncology Group (ECOG) performance status >2, tumours requiring extended gastrectomy or less than total gastrectomy, previous abdominal surgery or extensive adhesions seriously complicating MIG, other active oncological disease, advanced stages (T4 or M1), emergency setting and pregnancy.The sample size was calculated at 80 participants per group. The primary endpoint is 30-day postoperative morbidity as measured by the Comprehensive Complications Index. Secondary endpoints include postoperative morbidity and mortality, adherence to a fast-track protocol and patient-reported quality of life (QoL) scores (QoR-15, EUROQOL EuroQol-5 Dimensions-5 Levels (EQ-5D), EORTC QLQ-C30, EORTC QLQ-STO22, activities of daily living and Body Image Scale). Oncological endpoints include rate of R0 resection, lymph node yield, disease-free survival and overall survival at 60-month follow-up.

ETHICS AND DISSEMINATION

Ethical approval has been received by the independent Ethics Committee of the Medical Faculty, University of Heidelberg (S-816/2021) and will be received from each responsible ethics committee for each individual participating centre prior to recruitment. Results will be published open access.

TRIAL REGISTRATION NUMBER

DRKS00025765.

Prognostic nutrition index predicts short-term surgical complications in patients with rectal cancer after laparoscopic surgery

Purpose

Surgical complications following laparoscopic rectal cancer surgery remain a major clinical problem. The prognostic nutritional index (PNI) is reportedly associated with postoperative outcomes. We aimed to evaluate the correlation between PNI and short-term surgical complications in patients with rectal cancer after laparoscopic surgery.

Methods

The prospective clinical data of 225 patients with rectal cancer receiving laparoscopic surgery between January 2021 and April 2022 were retrospectively analyzed. The cut-off values and diagnostic accuracy of PNI preoperatively and on postoperative day (POD) 1 were determined using receiver operating characteristic (ROC) curves. Univariate and multivariate analyses were performed to identify clinical characteristics and risk factors for surgical complications.

Results

In total, 81 (36.0%) patients developed surgical complications. The optimal cut-off value for preoperative PNI was 40.15, and that for PNI on POD 1 was 35.28. The DeLong test found no statistically between–group difference in the area under the ROC curve (P = 0.598). Multivariate analysis identified that a preoperative PNI ≤40.15 [odds ratio (OR): 2.856, 95% confidence interval (CI): 1.287–6.341, P = 0.010] and PNI on POD 1 ≤35.28 (OR: 2.773, 95% CI: 1.533–5.016, P = 0.001) were independent risk factors for surgical complications. Patients with a preoperative PNI ≤40.15 or PNI on POD 1 ≤35.28 were more likely to have surgical complications after laparoscopic surgery for rectal cancer (61.1% vs. 31.2%, P = 0.001; 53.0% vs. 28.9%, P = 0.001).

Conclusion

Preoperative and POD 1 PNI were independent predictors of short-term surgical complications after laparoscopic surgery for rectal cancer.

Oncological outcomes of rectal cancer patients with anastomotic leakage: A multicenter case-control study

Introduction

This study aimed to evaluate the impact of anastomotic leakage (AL) on oncological outcomes after restorative rectal cancer surgery.

Methods

Patients who underwent anterior resection for rectal adenocarcinoma between January 2011 and December 2017 were retrospectively reviewed. Data were collected from three colorectal surgery centers. Patients with grade B and C leaks according to the International Study Group of Rectal Cancer classification were identified and compared with the control group. Estimated recurrence and survival rates were compared using the log-rank method and Cox regression analysis.

Results

A total of 367 patients were included in the study, with a mean follow-up of 59.21 months. AL occurred in 64 patients (17.4%). Fifteen patients with AL (23.5%) developed local recurrence (LR) compared to 17 (4.8%) in the control group (p < 0.001). However, distant recurrence rates were similar (10.9% vs. 9.6%; p = 0.914) between the groups. Kaplan-Meier curves showed that patients with AL had a reduced 5-years local recurrence-free survival (96% vs. 78%, log-rank p < 0.001). AL (OR 4.576; 95% CI, 2.046–10.237; p < 0.001) and node involvement (OR 2.911; 95% CI, 1.240–6.835; p = 0.014) were significantly associated with LR in multivariate analysis. AL was significantly associated with DFS only at univariate analysis (HR 1.654; 95% CI: 1.024–2.672; p = 0.037), with a difference between 5-year DFS of patients with and without AL (71.6% vs. 86.4%, log-rank p = 0.04). Only male gender, pT3-4 stage, and node involvement were identified as independent prognostic factors for reduced DFS in the multivariate Cox regression analysis.

Conclusion

In this cohort of patients, AL was associated with a significant risk of LR after rectal cancer surgery.

Prolonged postoperative length of stay may be a valuable marker for susceptibility to relapse beyond established risk factors in patients with stage III colon cancer

Background

Delay from surgery to adjuvant chemotherapy causes impaired survival among patients undergoing radical resection for stage III colon cancer, and the underlying mechanism for this is incompletely clarified. It is established that prolonged postoperative hospital length of stay (LOS) is associated with delayed initiation of the adjuvant treatment driving the assumption that prolonged LOS is prognostically unfavorable due to this fact and case mix factors. We hypothesize that prolonged LOS after surgery is a valuable marker for susceptibility to relapse that is not detected in established prognostic factors and, alone, associated with a shorter disease-free survival (DFS).

Materials and methods

A total of 690 consecutive patients undergoing elective radical resection for stage III colon cancer in 2000–2015 were identified in a prospective detailed facility database. Univariate and multivariate analyses were performed using Cox proportional hazards model in the evaluation of LOS as an independent prognostic factor.

Results

Short postoperative LOS, low comorbidity, and few complications were associated with longer DFS (p < 0.01). Fewer patients in the short and intermediate LOS groups had a relapse in their disease (28% and 33%, respectively), compared to the patients with longer LOS (40%, p < 0.05). LOS was a prognostic factor for DFS in the unadjusted univariate model (HR 1.04 per unit change) and remained statistically significant in the adjusted multivariate analysis, with a HR of 1.03 per hospital day (p < 0.01).

Conclusions

Postoperative LOS independently correlates with the risk of recurrence and DFS, regardless of if adjuvant chemotherapy is given, along with the factors such as age, comorbidity, complications, and tumor features. We propose a further investigation into the causal mechanisms based on tumor and host biology linking LOS to DFS beyond established risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02742-8.

The utility of serum osteopontin levels for predicting postoperative complications after colorectal cancer surgery

BACKGROUND/AIM

Osteopontin (OPN) is a secretory glycoprotein, which is expressed not only in osteoblasts, but immune cells including macrophages and activated T cells. Its pleiotropic immune functions, such as bone remodeling, cancer progression, immune response, and inflammation have been reported previously. However, the association between OPN and postoperative complications (POC) after colorectal cancer (CRC) surgery has not been studied, so far.

METHODS

Peripheral blood samples were collected before (pre) and immediately after surgery (post), and on postoperative days (POD) 1, 3, 5, and 7. Serum OPN levels were measured by ELISA. In total, 78 patients who underwent elective CRC surgery were divided into the No-POC (n = 54) and POC (n = 24) groups.

RESULTS

The POC group had significantly higher OPN levels than the No-POC group throughout the postoperative observation period. The maximum OPN levels from pre- to postsurgical samples showed the best predictive potential for POCs (cut off: 20.75 ng/mL, area under the curve: 0.724) and were correlated with length of postoperative stays. OPN values were significantly correlated with C-reactive protein on POD3 and were identified as an independent predictive marker for POCs (odds ratio: 3.88, 95% CI: 1.175-12.798, P = 0.026). The severity of POCs was reflected in increased OPN levels.

CONCLUSION

Increased postoperative OPN was associated with increased postoperative inflammatory host responses and POC after CRC surgery. Serum OPN level may be a useful biomarker for early prediction of POC and it may provide additional information for treatment decisions to prevent POC.

Prognostic Factors and Treatment of Recurrence after Local Excision of Rectal Cancer

PURPOSE

Indications for local excision in patients with rectal cancer remain controversial. We reviewed factors affecting survival rate and treatment effectiveness in cancer recurrence after local excision among patients with rectal cancer.

MATERIALS AND METHODS

A total of 831 patients was enrolled. Of these, 391 patients were diagnosed with primary rectal cancer and underwent local excision. A retrospective observational study was performed on patients who underwent full-thickness local excision for rectal cancer.

RESULTS

The median duration of follow-up was 61 months. The overall recurrence rate was 11.5%. The rate of local recurrence was 5.1%. Five-year overall survival rate among recurrent patients was 66.8%; the rate among patients who underwent salvage operation due to recurrence was 84.7%, compared with 44.2% among patients treated with non-operative management (p<0.001). Multivariate analysis of disease-free survival identified distance from the anal verge (p=0.038) and histologic grade (p=0.047) as factors predicting poor prognosis. Multivariate analysis of overall survival showed that age (p<0.001), serum carcinoembryonic antigen (CEA) levels (p=0.001), and histologic grade (p=0.013) also affected poor prognosis. In subgroup analysis of patients with recurrence, 25 patients underwent reoperation, while 20 patients did not. For 5-year overall survival rate, there was a significant difference between 84.7% of the reoperation group and 44.2% of the non-operation group (p<0.001).

CONCLUSION

The risk factors affecting overall survival rate after local excision were age 65 years or older, preoperative CEA level 5 or higher, and high histologic grade. In cases of recurrence after local excision of rectal cancer, salvage operation might improve overall survival.

Postoperative complications after colorectal cancer surgery and the association with long-term survival

BACKGROUND

Complications after colorectal cancer surgery can worsen long-term survival. The aim of this nationwide study was to determine the impact of different types of complications on overall survival (OS) and conditional survival if still alive one year postoperatively (CS-1) after colorectal cancer surgery.

MATERIALS AND METHODS

All patients registered in the Dutch ColoRectal Audit after resection of primary colorectal cancer between 2011 and 2017 and with known survival status were included. Multivariable Cox regression models were used to assess the association of complications with OS and CS-1, thereby calculating the Hazard Ratio (HR) with 95% Confidence Interval.

RESULTS

43,908 colon and 16,955 rectal cancer patients were included. Median follow-up time was 66.1 and 66.5 months, respectively. Five-year OS after colon cancer resection was 73.2% without complications, and 65.4% with surgical, 52.9% with non-surgical and 51.8% with combined type of complications (p < 0.001). Corresponding 5-year OS for rectal cancer patients was 76.9%, 72.7%, 64.9%, and 63.2% (p < 0.001). In colon cancer, multivariable analyses revealed HR 1.198 (1.136-1.264) for surgical, HR 1.489 (1.423-1.558) for non-surgical and HR 1.590 (1.505-1.681) for combined type of complications. For rectal cancer, these HRs were 1.193 (1.097-1.2297), 1.456 (1.346-1.329), and 1.489 (1.357-1.633). Surgical complications were associated with worse CS-1 in rectal cancer (HR 1.140 (1.050-1.260), but not in colon cancer (HR 1.007 (0.943-1.075)).

CONCLUSION

Non-surgical complications have higher impact on survival than surgical complications. The impact of surgical complications on survival was still measurable after surviving the first year in rectal cancer but not in colon cancer patients.

Prognostic significance of the preoperative C-reactive protein-to-albumin ratio in patients with colorectal cancer

Background

The aim of the present study was to determine the utility of the C-reactive protein-to-albumin ratio (CAR) for predicting the overall survival (OS) in locally advanced colorectal cancer (CRC) patients.

Patients and Methods

This retrospective multicenter study was performed using data from a prospectively maintained database of pathological Stage II or III patients undergoing CRC surgery at the Yokohama City University, Department of Surgery, and its affiliated institutions between April 2000 and March 2016. The risk factors for the OS were identified.

Results

A CAR of 0.03 was considered to be the optimal cutoff point for classification based on the 1-, 3-, and 5-year survival rates and receiver operating characteristic curve. The OS rates at 3 and 5 years after surgery were 92.4% and 85.7% in the CAR-low group, respectively, and 86.7% and 81.1% in the CAR-high group. A multivariate analysis showed that the CAR was a significant independent risk factor for the OS. When comparing the patients' demographic and clinical characteristics between the CAR ≤0.03 and >0.03 groups, the incidence of patients who received adjuvant chemotherapy and the incidence of postoperative complications were significantly different between the two groups.

Conclusion

The present study showed that the preoperative CAR was a risk factor for the OS in patients who underwent surgery for CRC. To improve the patients' survival, CAR might be a useful tool for devising treatment strategies.

The Association Between Treatment Interval and Survival in Patients With Colon or Rectal Cancer: A Systematic Review

BACKGROUND

Surgery for colon or rectal cancer is associated with a high incidence of complications, especially in patients with a low aerobic fitness. Those patients might benefit from a comprehensive preoperative workup including prehabilitation. However, time between diagnosis and treatment is often limited due to current treatment guidelines. To date, it is unclear whether the treatment interval can be extended without compromising survival.

METHODS

A systematic review concerning the association between treatment intervals and survival in patients who underwent elective curative surgery for colon or rectal cancer was performed. A search up to December 2020 was conducted in PubMed, Cinahl and Embase. Original research articles were eligible. Quality assessment was performed using the Downs and Black checklist.

RESULTS

Eleven observational studies were included (897 947 patients). In colon cancer, treatment intervals that were statistically significant associated with reduced overall survival or cancer-specific survival ranged between > 30 and > 84 days. In rectal cancer, only one out of four studies showed that treatment intervals > 49 days was associated with reduced cancer-specific survival.

CONCLUSIONS

This systematic review identified that studies investigating the association between treatment intervals and survival are heterogeneous with regard to treatment interval definitions, treatment interval time intervals and used outcome measures. These aspects need standardization before a reliable estimate of an optimal treatment interval can be made. In addition, further research should focus on establishing optimal treatment intervals in patients at high risk for postoperative complications, as particularly these patients might benefit from extended diagnosis to treatment intervals permitting comprehensive preoperative preparation.

Laparoscopic Versus Open Colorectal Surgery in the Emergency Setting: A Systematic Review and Meta-analysis

Objective

This systematic review and meta-analysis aimed to compare published outcomes of patients undergoing laparoscopic versus open emergency colorectal surgery, with mortality as primary outcome.

Background

In contrast to the elective setting, the value of laparoscopic emergency colorectal surgery remains unclear.

Methods

PubMed, Embase, the Cochrane Library, and CINAHL were searched until January 6, 2021. Only comparative studies were included. Meta-analyses were performed using a random-effect model. The Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale were used for quality assessment.

Results

Overall, 28 observational studies and 1 randomized controlled trial were included, comprising 7865 laparoscopy patients and 55,862 open surgery patients. Quality assessment revealed 'good quality' in 16 of 28 observational studies, and low to intermediate risk of bias for the randomized trial. Laparoscopy was associated with significantly lower postoperative mortality compared to open surgery (odds ratio [OR] 0.44; 95% confidence interval [CI], 0.35-0.54). Laparoscopy resulted in significantly less postoperative overall morbidity (OR, 0.53; 95% CI, 0.43-0.65), wound infection (OR, 0.63; 95% CI, 0.45-0.88), wound dehiscence (OR, 0.37; 95% CI, 0.18-0.77), ileus (OR, 0.68; 95% CI 0.51-0.91), pulmonary (OR, 0.43; 95% CI, 0.24-0.78) and cardiac complications (OR, 0.56; 95% CI, 0.35-0.90), and shorter length of stay. No meta-analyses were performed for long-term outcomes due to scarcity of data.

Conclusions

The systematic review and meta-analysis suggest a benefit of laparoscopy for emergency colorectal surgery, with a lower risk of postoperative mortality and morbidity. However, the almost exclusive use of retrospective observational study designs with inherent biases should be taken into account.

On the predictability of postoperative complications for cancer patients: a Portuguese cohort study

Postoperative complications are still hard to predict despite the efforts towards the creation of clinical risk scores. The published scores contribute for the creation of specialized tools, but with limited predictive performance and reusability for implementation in the oncological context. This work aims to predict postoperative complications risk for cancer patients, offering two major contributions. First, to develop and evaluate a machine learning-based risk score, specific for the Portuguese population using a retrospective cohort of 847 cancer patients undergoing surgery between 2016 and 2018, for 4 outcomes of interest: (1) existence of postoperative complications, (2) severity level of complications, (3) number of days in the Intermediate Care Unit (ICU), and (4) postoperative mortality within 1 year. An additional cohort of 137 cancer patients from the same center was used for validation. Second, to improve the interpretability of the predictive models. In order to achieve these objectives, we propose an approach for the learning of risk predictors, offering new perspectives and insights into the clinical decision process. For postoperative complications the Receiver Operating Characteristic Curve (AUC) was 0.69, for complications’ severity AUC was 0.65, for the days in the ICU the mean absolute error was 1.07 days, and for 1-year postoperative mortality the AUC was 0.74, calculated on the development cohort. In this study, predictive models which could help to guide physicians at organizational and clinical decision making were developed. Additionally, a web-based decision support tool is further provided to this end.

Predicting Postoperative Complications in Cancer Patients: A Survey Bridging Classical and Machine Learning Contributions to Postsurgical Risk Analysis

Simple Summary

Structured survey on the predictive analysis of postoperative complications in oncology, bridging classic risk scores with machine learning advances, and further establishing principles to guide the design of cohort studies and the predictive modeling of postsurgical risks.

Abstract

Postoperative complications can impose a significant burden, increasing morbidity, mortality, and the in-hospital length of stay. Today, the number of studies available on the prognostication of postsurgical complications in cancer patients is growing and has already created a considerable set of dispersed contributions. This work provides a comprehensive survey on postoperative risk analysis, integrating principles from classic risk scores and machine-learning approaches within a coherent frame. A qualitative comparison is offered, taking into consideration the available cohort data and the targeted postsurgical outcomes of morbidity (such as the occurrence, nature or severity of postsurgical complications and hospitalization needs) and mortality. This work further establishes a taxonomy to assess the adequacy of cohort studies and guide the development and assessment of new learning approaches for the study and prediction of postoperative complications.

Postoperative Complications Predict Long-term Outcome After Curative Resection for Perforated Colorectal Cancer

BACKGROUND/AIM

Perforation and postoperative complications have a negative effect on long-term outcomes in patients with colorectal cancer (CRC). The aim of this study was to evaluate the clinical factors with special reference to postoperative complications predicting the long-term outcome in those for whom curative resection for perforated CRC was performed.

PATIENTS AND METHODS

Patients who underwent curative resection for perforated CRC at stage II or III from April 2003 to March 2020 were included. Clinical factors were retrospectively analyzed.

RESULTS

Forty-four patients met the selection criteria. The 30-day mortality rate was 4.5% and the complication rate was 47.7%. Excluding 30-day mortality, five-year recurrence-free survival (RFS) and overall survival (OS) were 62.3% and 73.6%, respectively. Multivariate analysis showed that postoperative complications (p=0.005) and pT4 pathological factor (p=0.009) were independent prognostic factors for RFS. Only postoperative complications (p=0.023) were an independent prognostic factor for OS.

CONCLUSION

Postoperative complications were significantly associated with RFS and OS, and pT4 was associated with RFS. The prevention and management of postoperative adverse events may be important for perforated CRC.

Prognostic effect of sarcopenia in colorectal cancer recurrence

OBJECTIVES

Nutritional status significantly influences postoperative prognosis in gastrointestinal cancers. It has been evaluated using sarcopenia before treatments such as surgery and chemotherapy, despite constant changes in nutritional status. We consider that nutritional status at cancer recurrence is one of the important factors that affect treatment choice and intensity. This study evaluated the prognostic effects of improved postoperative nutritional status for people with colorectal cancer recurrence.

METHODS

We enrolled 209 participants with pathologically confirmed stage II or III colorectal cancer who underwent radical resection. Sarcopenia was diagnosed using the psoas muscle index obtained from analysis of three-dimensional computed tomographic images. We adopted the cutoff value that was proposed by Hamaguchi et al. (psoas muscle index < 6.36 cm²/m² for men and < 3.92 cm²/m² for women). Evaluation was performed before surgery and at the time of recurrence. Participants with preoperative sarcopenia who relapsed were divided into two groups at the time of recurrence: sarcopenia continuation and sarcopenia improvement. We compared the prognosis of the two groups and examined the effect of postoperative nutritional improvement.

RESULTS

Among the 209 participants, 81 (38.8%) had preoperative sarcopenia; this group had significantly lower overall survival than those without sarcopenia (P = 0.028). Colorectal cancer recurred in 48 participants. Of those 46, sarcopenia was evaluated at the time of recurrence; 19 of those 46 had preoperative sarcopenia. Preoperative sarcopenia did not affect the cancer recurrence ratio (sarcopenia, 23.5%; non-sarcopenia, 21.3%; P = 0.893). The sarcopenia-improvement group had higher overall survival than the sarcopenia-continuation group (P = 0.042).

CONCLUSIONS

Among participants with preoperative sarcopenia, the prognosis at the time of recurrence improved for the sarcopenia-improvement group compared to the sarcopenia-continuation group. In people with colorectal cancer and sarcopenia, nutritional management is important not only before but also after surgery.

Impact of postoperative complications after primary tumor resection on survival in patients with incurable stage IV colorectal cancer: A multicenter retrospective cohort study

AIMS

Primary tumor resection for patients with incurable stage IV colorectal cancer can prevent tumor-related complications but may cause postoperative complications. Postoperative complications delay the administration of chemotherapy and can lead to the spread of malignancy. However, the impact of postoperative complications after primary tumor resection on survival in patients with incurable stage IV colorectal cancer remains unclear. Therefore, this study aimed to investigate how postoperative complications after primary tumor resection affect survival in this patient group.

METHODS

We reviewed data on 966 patients with stage IV colorectal cancer who underwent palliative primary tumor resection between January 2006 and December 2007. We examined the association between major complications (National Cancer Institute Common Terminology Criteria for Adverse Events v3.0 grade 3 or more) and overall survival using Cox proportional hazard model and explored risk factors associated with major complications using multivariable logistic regression analysis.

RESULTS

Ninety-three patients (9.6%) had major complications. The 2-year overall survival rate was 32.7% in the group with major complications and 50.3% in the group with no major complications. Patients with major complications had a significantly poorer prognosis than those without major complications (hazard ratio: 1.62; 95% confidence interval: 1.21-2.18; P < .01). Male, rectal tumor, and open surgery were identified to be risk factors for major complications.

CONCLUSIONS

Postoperative complications after primary tumor resection was associated with decreased long-term survival in patients with incurable stage IV colorectal cancer.

Association of day of the week with mortality after elective right hemicolectomy for colon cancer: Case analysis from the National Clinical Database

AIM

We aimed to investigate whether later weekdays are related to worse short-term outcomes after elective right hemicolectomy for colon cancer.

METHODS

We retrospectively analyzed adult patients who underwent elective right hemicolectomy for colon cancer between 2012 and 2017. Records lacking details about surgical mortality were excluded, and multiple imputation was performed for other missing data (variables). The primary endpoint was surgical mortality, defined as the sum of 30-day mortality and in-hospital deaths within 90 days postoperatively. Using 22 clinical variables, hierarchal logistic regression modeling with clustering of patients from the same institutes was performed.

RESULTS

Of the 112 658 patients undergoing elective right hemicolectomy for colon cancer, the 30-day mortality and surgical mortality were 0.6% and 1.1%, respectively. Surgery on Friday was less frequent, accounting for 17.1% of all cases. The occurrence of severe postoperative complications, anastomotic leakage, or unadjusted odds ratio for surgical mortality did not show significant differences between weekdays. A hierarchal logistic regression model identified 19 independent factors for surgical mortality. Adjusted odds ratios for surgical mortality were 1.01 (95% confidence interval: 0.83-1.22, P = .915), 0.86 (95% confidence interval: 0.71-1.05, P = .144), 0.86 (95% confidence interval: 0.71-1.05, P = .408), and 0.83 (95% confidence interval: 0.68-1.03, P = .176) for Tuesday, Wednesday, Thursday, and Friday, respectively, showing no significant differences.

CONCLUSION

This study did not identify an evident difference in surgical mortality between weekdays; a safe elective right hemicolectomy for colon cancer is being offered throughout the week in Japan.

Postoperative morbidity adversely impacts long-term oncologic prognosis following hepatectomy for hepatocellular carcinoma: A multicenter observational study

BACKGROUND & AIMS

Postoperative morbidity following hepatectomy for hepatocellular carcinoma (HCC) is common and its impact on long-term oncological outcome remains unclear. This study aimed to investigate if postoperative morbidity impacts long-term survival and recurrence following hepatectomy for HCC.

METHODS

The data from a multicenter Chinese database of curative-intent hepatectomy for HCC were analyzed, and independent risks of postoperative 30-day morbidity were identified. After excluding patients with postoperative early deaths (≤90 days), early (≤2 years) and late (>2 years) recurrence rates, overall survival (OS), and time-to-recurrence (TTR) were compared between patients with and without postoperative morbidity.

RESULTS

Among 2,161 patients eligible for the study, 758 (35.1%) had postoperative 30-day morbidity. Multivariable logistic regression analysis showed that diabetes mellitus, obesity, Child-Pugh grade B, cirrhosis, and intraoperative blood transfusion were independent risks of postoperative morbidity. The rates of early and late recurrence among patients with postoperative morbidity were higher than those without (50.7% vs. 38.8%, P < 0.001; and 41.7% vs. 34.1%, P = 0.017). Postoperative morbidity was associated with decreased OS (median: 48.1 vs. 91.6 months, P < 0.001) and TTR (median: 19.8 vs. 46.1 months; P < 0.001). After adjustment of confounding factors, multivariable Cox-regression analyses revealed that postoperative morbidity was associated with a 27.8% and 18.7% greater likelihood of mortality (hazard ratio 1.278; 95% confidence interval: 1.126-1.451; P < 0.001) and recurrence (1.187; 1.058-1.331; P = 0.004).

CONCLUSION

This large multicenter study provides strong evidence that postoperative morbidity adversely impacts long-term oncologic prognosis after hepatectomy for HCC. The prevention and management of postoperative morbidity may be oncologically important.

Laparoscopic Versus Open Liver Resection for Hepatocellular Carcinoma: A Case Controlled Study with Propensity Score Matching

BACKGROUND

Several studies have suggested that laparoscopic liver resection (LLR) is associated with fewer postoperative complications than open liver resection (OLR) for hepatocellular carcinoma (HCC). However, this issue remains controversial since the data may have been attributable to an imbalance in patients' background.

METHODS

We retrospectively analyzed 290 hepatectomies for HCC undertaken between 2011 and 2019. Liver resection difficulty was based on the 3 levels of the Institut Mutualiste Montsouris classification. Resection ratio was calculated using computed tomography volumetry. Patient characteristics were compared between the LLR and OLR groups. Propensity score matching (PSM) was adopted to adjust the imbalance between the cohorts, and the incidence of postoperative complications was compared.

RESULTS

The difficulty and resection ratio were significantly lower in LLR (n = 112) than in OLR (n = 178) (difficulty grade I/II/III: 84/10/18 vs. 43/39/96, p < 0.001; resection ratio: 11.4 ± 12.7 vs. 22.7 ± 17.2%, p < 0.001). The incidence of postoperative complications (Clavien-Dindo grade III or more) was lower in LLR (2.7% vs. 21.9%, p < 0.001), which was mainly attributable to fewer incidences of ascites and pleural effusion. PSM generated 68 well-matched patients in each group. The lower incidence of postoperative complications in LLR was also maintained in the PSM cohort (2.9% vs. 16.2%, p = 0.017). On multivariate analysis, LLR was the independent predictor of postoperative complications (OR 0.184, 95% CI 0.051-0.672, p = 0.010).

CONCLUSION

The present study demonstrated that a laparoscopic approach reduces the incidence of postoperative complications in liver resection for HCC.

Clinical Significance of Serum Antithrombin III Activity After Hepatectomy for Hepatocellular Carcinoma

Background

As antithrombin III (AT-III) is produced in the hepatocytes, its serum activity decreases at the time of liver failure, in addition to ischemia reperfusion injury, vascular endothelial dysfunction, and disseminated intravascular coagulation (DIC). Here, we examined whether the serum AT-III value after hepatectomy could be a prognostic factor for hepatocellular carcinoma (HCC).

Methods

Of 141 patients who underwent hepatectomy for HCC, data for 101 patients in whom serum AT-III activity was measured on the first postoperative day were extracted. Patients with serum AT-III activity > 50% and ≤ 50% were assigned to high value (72 cases) and low value (29 cases) groups, respectively. We examined the clinical and prognostic differences between these two groups.

Results

The average age of enrolled patients (83 men and 18 women) was 68.0 years. The 5-year overall survival rate was 88% and 60% in the high and low value groups, respectively (P < 0.01). Furthermore, the 2-year relapse-free survival rate was 71% and 54% in the high and low value groups, respectively (P = 0.03).

Conclusion

This is the first study to demonstrate that serum AT-III levels on the first postoperative day may serve as a prognostic factor in HCC patients.

Predictive Risk Factors for Postoperative Complications and Its Impact on Survival in Laparoscopic Resection for Colon Cancer

BACKGROUND

Laparoscopic resection is the ideal treatment of colon cancer. The aim of the study was to analyze the predictive factors for postoperative complications and their impact on oncologic outcomes in laparoscopic resections in colon cancer.

MATERIALS AND METHODS

In all patients undergoing elective laparoscopic surgery the number and degree of severity of postoperative complications were recorded and classified according to Clavien-Dindo. A univariate analysis was made of the demographic, surgical, and oncologic variables of patients with and without complications. The statistically significant variables were then entered into a multivariate model. In both groups overall and disease-free survival were analyzed using Kaplan-Meier estimates.

RESULTS

Of 524 patients, 138 (26.3%) experienced some type of complication, 110 less severe (79.7%) and 28 (20.4%) severe. Twenty-nine conversions to open surgery occurred (5.5%) and hospital mortality was 0.2%.In the multivariate analysis, use of corticosteroids [odds ratio (OR): 3.619], oral anticoagulants (OR: 3.49), blood transfusions (OR: 4.30), and conversion to open surgery (OR: 3.93) were significantly associated with the development of complications. However, sigmoid resections were associated with fewer complications (OR: 0.45).Overall 5-year and 10-year survival in both groups, was 83.3%, 74.1%, 76.0%, and 67.1%, respectively (P=0.18). Disease-free survival at 5 and 10 years, excluding stage IV tumors, was 88.6% and 90.4%, respectively (P=0.881).

CONCLUSIONS

The use of corticosteroids, oral anticoagulants, blood transfusions, and conversion to open surgery are all independent predictive factors of postoperative complications. Sigmoid resections are associated with fewer complications. In laparoscopic resections of the colon, complications do not negatively affect long-term oncologic outcomes.

Impact of Psychiatric Diagnoses and Treatment on Postoperative Outcomes Among Patients Undergoing Surgery for Colorectal Cancer

OBJECTIVE

Psychiatric diagnoses may be a risk factor for poor colorectal cancer (CRC) surgery outcomes. The authors investigated the risk of psychiatric diagnoses and benefit of mental health treatment for surgery outcomes among CRC patients.

METHODS

This retrospective cohort study of patients undergoing CRC surgery in the 2000-2014 period identified documentation of psychiatric diagnosis and mental health treatment (no treatment, medication only, psychotherapy only, or both medication and psychotherapy) 30 days before surgery. Associations between psychiatric diagnoses, mental health treatment, and postoperative outcomes (postoperative complications, length of stay [LOS], and 90-day readmission rate) were evaluated with multivariable generalized estimating equations.

RESULTS

Among 58,961 patients undergoing CRC surgery, 9,029 (15.3%) had psychiatric diagnoses, 4,601 (51.0%) of whom received preoperative mental health treatment (90.0% psychiatric medication, 6.7% psychotherapy, and 3.0% medication and psychotherapy). Patients with psychiatric diagnoses had an increased risk for postoperative complications (odds ratio [OR]=1.09, 95% confidence interval [CI]=1.03-1.15) and 90-day readmission (OR=1.11, 95% CI=1.06-1.17) compared with patients without psychiatric diagnoses. Patients with psychiatric diagnoses who received no mental health treatment or only medication had a 7%-17% increased risk for postoperative complications and 90-day readmission compared with patients without psychiatric diagnoses. Patients who received medication only also had a 4% increase in LOS relative to patients without psychiatric diagnoses. Patients with psychiatric diagnoses receiving only psychotherapy and patients without psychiatric diagnoses had similar postoperative outcomes.

CONCLUSIONS

Preoperative psychiatric diagnoses were associated with worse postoperative outcomes. Surgical quality-improvement efforts should focus on identifying patients with preoperative psychiatric diagnoses and addressing these conditions presurgery.

A prediction model of major complications after radiofrequency ablation for recurrent hepatocellular carcinoma patients

BACKGROUND

Postoperative major complications are potentially fatal to recurrent hepatocellular carcinoma (RHCC) patients. We aimed to construct a prediction model of major complications after RFA for RHCC patients.

METHODS

We retrospectively reviewed the medical records of 407 RHCC patients who underwent RFA as second treatment. Patients were divided into two groups according to the date of RFA: training cohort (277 patients treated in 2010-2016) and validation cohort (130 patients treated in 2017-2019). 23 clinicopathological variables were recorded and analyzed. The logistic regression model was used to build a prediction model.

RESULT

Major complications developed in 3.6 % of RHCC patients after RFA. In the multivariate analysis, tumor adjacent vessels (p = 0.004) and hepatitis C (p = 0.022) were associated with postoperative complications. The prediction model was described as follow: Risk score (major complication) = 5.180 + 3.391*tumor location+3.389*hepatic etiology, the Youden index was 0.642, the best cut-off value of the model was 8.57 (sensitivity, 78.57 %, specificity, 84.03 %). The area under the receiver operating characteristic curve of the predictive model was 0.85 (95 % CI, 0.82 to 0.88). The validation of the model demonstrated acceptable results, the sensitivity was 80.00 %, specificity was 98.40 %.

CONCLUSIONS

This study developed a simple and reliable prediction model of postoperative major complications after RFA for RHCC patients.

Outcomes following major resection for colorectal cancer in patients aged 65+ years: a population-based study in Queensland, Australia

BACKGROUND

The risk of developing colorectal cancer (CRC) increases with increasing age. As surgery is the primary treatment for CRC, our aim was to examine outcomes following major resection for CRC in a cohort of individuals aged ≥65 years.

METHODS

This population-based retrospective study included 18 339 patients aged ≥65 years diagnosed with CRC from 2007 to 2016. Multivariate logistic regression was used to examine factors associated with the likelihood of having major resection, 30-day mortality and laparoscopic surgical procedure. Cox proportional hazards was used to examine factors associated with risk of death at 2 years post-surgery.

RESULTS

Overall, 77.8% (n = 14 274) of patients had a major resection. Males and patients ≥75 years were significantly less likely to have a major resection (P < 0.001 and P < 0.001, respectively). Thirty-day mortality was 3.1% and 2-year overall survival was 78.7%. After adjustment, factors such as increasing age (≥75 years), ≥2 comorbidities, emergency admission, open surgical procedure and treatment in a public hospital were all independently and significantly associated with poorer outcomes. The likelihood a patient had a laparoscopic procedure was significantly lower for those from a disadvantaged area (P < 0.001), emergency admission (P < 0.001) as well as for those treated in a public versus private hospital (P < 0.001).

CONCLUSIONS

Post-operative mortality increased, and 2-year survival decreased after age 75 years. The finding of significantly lower rates of laparoscopic surgery for patients from disadvantaged areas and those treated in a public hospital requires further investigation.

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).

The Impact of Postoperative Complications on Long-Term Oncological Outcomes Following Curative Resection of Colorectal Cancer (Stage I-III): A Systematic Review and Meta-Analysis

Background and objective The incidence of post-surgical complications (PSCs) after curative resection of non-metastatic colorectal cancer (CRC) is very widespread and evident. Some studies suggest that PSCs often predict poor long-term oncological outcomes. However, the available data on the topic is often controversial. The aim of this systematic review and meta-analysis was to study the effect of postoperative complications (POCs) on long-term oncological outcomes following curative resection of non-metastatic (stage I-III) CRC. Methods A comprehensive search of MEDLINE® and Excerpta Medica dataBASE (EMBASE) databases was performed via the Ovid platform, by using controlled vocabulary as well as natural language terms for POCs, outcomes, and CRC. Two authors independently screened the studies and extracted data. Conflicts were resolved by discussion among authors and also independently with the help of a third author. Meta-analysis was performed using a random-effects model (REM) to calculate pooled estimates for overall survival (OS), disease-free survival (DFS), and overall recurrence. Results Overall, 3,836 studies were initially screened, and 16 studies involving 37,192 patients were ultimately selected for final inclusion in the analysis. Meta-analysis of these studies showed that PSCs following non-metastatic CRC surgery predicted worse OS rates [hazard ratio (HR): 1.36; 95% CI: 1.15-1.61; p<0.00001], DFS (HR: 1.41; 95% CI: 1.11-1.80; p<0.00001), and overall recurrence (HR: 1.19; 95% CI: 1.04-1.37; p=0.01). Conclusion Based on our findings, PSCs predict poor OS rates, DFS, and overall recurrence following curative resection of non-metastatic CRC.