CANOPTIPHYS study protocol: Optimising PHYSical function before CANcer surgery: effects of pre-operative optimisation on complications and physical function after gastrointestinal cancer surgery in older people at risk-a multicentre, randomised, parallel-group study

BACKGROUND

This multicentre study explores the effects of pre-operative exercise on physical fitness, post-operative complications, recovery, and health-related quality of life in older individuals with low pre-operative physical capacity scheduled to undergo surgery for colorectal cancer. We hypothesise that this group of patients benefit from pre-operative exercise in terms of improved pre-operative physical function and lower rates of post-operative complications after surgery compared to usual care. Standardised cancer pathways in Sweden dictate a timeframe of 14-28 days from suspicion of cancer to surgery for colorectal cancer. Therefore, an exercise programme aimed to enhance physical function in the limited timeframe requires a high-intensity and high-frequency approach.

METHODS

Participants will be included from four sites in Stockholm, Sweden. A total of 160 participants will be randomly assigned to intervention or control conditions. Simple randomisation (permuted block randomisation) is applied with a 1:1 allocation ratio. The intervention group will perform home-based exercises (inspiratory muscle training, aerobic exercises, and strength exercises) supervised by a physiotherapist (PT) for a minimum of 6 sessions in the pre-operative period, complemented with unsupervised exercise sessions in between PT visits. The control group will receive usual care with the addition of advice on health-enhancing physical activity. The physical activity behaviour in both groups will be monitored using an activity monitor. The primary outcomes are (1) change in physical performance (6-min walking distance) in the pre-operative period and (2) post-operative complications 30 days after surgery (based on Clavien-Dindo surgical score).

DISCUSSION

If patients achieve functional benefits by exercise in the short period before surgery, this supports the implementation of exercise training as a clinical routine. If such benefits translate into lower complication rates and better post-operative recovery or health-related quality of life is not known but would further strengthen the case for pre-operative optimisation in colorectal cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04878185. Registered on 7 May 2021. https://clinicaltrials.gov/ct2/home.

Associations between a composite score of hemoglobin, CRP and albumin and physical performance in older patients undergoing gastrointestinal cancer surgery

BACKGROUND & AIMS

Abnormal levels of hemoglobin, C-reactive protein (CRP) and albumin are common in people with gastrointestinal cancer. The hypothesis was that this is of importance for physical performance in older persons in the perioperative context. Thus, the aim was to evaluate the association between hemoglobin, CRP and albumin and physical performance before and after abdominal cancer surgery in older patients.

METHODS

Patients ≥70 years of age scheduled for abdominal cancer surgery were invited to take part in the study. Data on levels of hemoglobin, CRP and albumin and physical performance (Six-Minute Walk Test, functional leg strength [chair-stands completed in 30 s], and maximal inspiratory muscle strength), were collected at baseline (n = 178) and physical performance was reassessed before discharge (n = 120). A composite score of 0-3 points was used, based on the presence or not of anemia, elevated CRP or hypoalbuminemia. Multivariable linear regressions were used for statistical analysis.

RESULTS

Before surgery, walking distance in patients scoring 2-3 (presence of 2 or 3 abnormal values) was shorter in comparison to patients scoring 0 (all values within normal range) in the multivariable model (-39.1 m; 95% CI -74.2, -3.9, p = 0.030). The number of chair stands performed during 30 s was lower in patients scoring 1 (-1.7; 95% CI -3.2, -0.2, p = 0.028) and 2-3 (-1.6; 95% CI -3.0, -0.1, p = 0.037) compared to patients scoring 0. No significant differences were seen between score groups and inspiratory muscle strength. After surgery, no differences were seen in walking distance or chair stands between patients with different scores.

CONCLUSIONS

Older patients with abnormal concentrations of hemoglobin, CRP and albumin before gastrointestinal cancer surgery showed impaired physical performance before surgery. Knowledge about potentially modifiable factors prior to cancer surgery increases the possibility to prepare the individual, which in turn might contribute to reduced morbidity and faster recovery after surgery.

[Patient blood management - to transfuse blood on appropriate indications]

During the last decade, the varying use and the lack of consistent indications for blood transfusions have been questioned. Comparisons of liberal and restrictive transfusion policies, most often support a restrictive policy. This has led to an evidence-based approach to optimizing the care of patients who might need transfusion, Patient Blood Management (PBM). There is evidence that both anemia and allogeneic blood transfusions are independently associated with increased morbidity and mortality. In elective surgery it is possible to adapt the three pillars of PBM in a structured way; i.e. optimization of red blood cell mass, reduction of blood loss and bleeding, and optimization of the patient's physiological tolerance towards anemia. These activities should be included in the pre-peri- and postoperative routines, in all surgical units.

Prediction of outcome after curative surgery for colorectal cancer: preoperative haemoglobin, C-reactive protein and albumin

AIM

The aim was to evaluate a scoring system using the values of preoperative haemoglobin, C-reactive protein (CRP) and albumin to predict colorectal cancer recurrence and survival.

METHOD

Data on all curative resections for Stages I-III colorectal cancer performed at a tertiary referral hospital in 2007-2010 were recorded in the Swedish Colorectal Cancer Registry and were matched to local databases for laboratory results and blood transfusion. Patients who died within 30 days or during primary hospital admission were excluded. Preoperative haemoglobin, CRP and albumin levels were recorded for 417 patients. A score (0-3) was derived on the presence of anaemia (Hb < 120 g/l for women and < 130 g/l for men), raised CRP (> 10 mg/ml) and low albumin (< 35 g/dl). The risks for recurrence and impaired overall survival were assessed using Cox regression analyses.

RESULTS

Impaired overall survival was found when one, two or three of the criteria anaemia, elevated CRP and low albumin were present prior to surgery [hazard ratio (HR) 3.61, 95% CI 1.66-7.85; HR 3.91, 95% CI 1.75-8.74; HR 4.85, 95% CI 2.15-10.93, respectively]. The risk for recurrence, however, was not related to the presence of these criteria.

CONCLUSION

Overall survival after curative surgery for Stages I-III colorectal cancer is impaired when anaemia, elevated CRP or low albumin exist prior to surgery.

One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis

Background

Recent randomized trials demonstrated that laparoscopic lavage compared with resection for Hinchey III perforated diverticulitis was associated with similar mortality, less stoma formation but a higher rate of early reintervention. The aim of this study was to compare 1-year outcomes in patients who participated in the randomized Scandinavian Diverticulitis (SCANDIV) trial.

Methods

Between February 2010 and June 2014, patients from 21 hospitals in Norway and Sweden presenting with suspected perforated diverticulitis were enrolled in a multicentre RCT comparing laparoscopic lavage and sigmoid resection. All patients with perforated diverticulitis confirmed during surgery were included in a modified intention-to-treat analysis of 1-year results.

Results

Of 199 enrolled patients, 101 were assigned randomly to laparoscopic lavage and 98 to colonic resection. Perforated diverticulitis was confirmed at the time of surgery in 89 and 83 patients respectively. Within 1 year after surgery, neither severe complications (34 versus 27 per cent; P = 0·323) nor disease-related mortality (12 versus 11 per cent) differed significantly between the lavage and surgery groups. Among the 144 patients with purulent peritonitis, the rate of severe complications (27 per cent (20 of 74) versus 21 per cent (15 of 70) respectively; P = 0·445) and disease-related mortality (8 versus 9 per cent) were similar. Laparoscopic lavage was associated with more deep surgical-site infections (32 versus 13 per cent; P = 0·006) but fewer superficial surgical-site infections (1 versus 17 per cent; P = 0·001). More patients in the lavage group underwent unplanned reoperations (27 versus 10 per cent; P = 0·010). Including stoma reversals, a similar proportion of patients required a secondary operation (28 versus 29 per cent). The stoma rate at 1 year was lower in the lavage group (14 versus 42 per cent in the resection group; P &lt; 0·001); however, the Cleveland Global Quality of Life score did not differ between groups.

Conclusion

The advantages of laparoscopic lavage should be weighed against the risk of secondary intervention (if sepsis is unresolved). Assessment to exclude malignancy (although uncommon) is advised. Registration number: NCT01047462 (http://www.clinicaltrials.gov).

Preoperative anaemia and perioperative red blood cell transfusion as prognostic factors for recurrence and mortality in colorectal cancer-a Swedish cohort study

PURPOSE

The hypothesis in this study was that anaemia prior to surgery and perioperative red blood cell transfusion increases the risk for recurrence and overall mortality in patients with stages I-III colorectal cancer after abdominal resection with curative intent.

METHODS

This is a Swedish single centre retrospective cohort study. Data on 496 consecutive radical abdominal resections stages I-III colorectal cancer performed at the Karolinska University Hospital 2007-2010 were extracted from the Swedish Colorectal Cancer Registry. Data were linked to local laboratory and transfusion databases to identify preoperative anaemia and perioperative transfusion. Disease recurrence was validated by scrutiny of patient records. A total of 496 stages I-III colorectal cancer patients were included in the analysis. Multivariate Cox regression analysis adjusted for tumour and patient characteristics were performed to assess risk for recurrence and overall mortality.

RESULTS

Anaemia prior to surgery was associated with increased risk for overall mortality (HR 2.1, 95% CI 1.4-3.2). There was no association between anaemia and risk for recurrence (HR 1.6, 95% CI 0.97-2.6). Transfusion was not associated with increased risk of recurrence (HR 0.7, 95% CI 0.4-1.3) or overall mortality (HR 1.04, 95% CI 0.7-1.6).

CONCLUSIONS

Anaemia prior to colorectal cancer surgery was associated with increased risk for overall mortality while a no increased risk was seen for recurrence. Previous findings indicating an association between blood transfusion and increased risk for recurrence could not be confirmed.

Inappropriate drug use in elderly patients is associated with prolonged hospital stay and increased postoperative mortality after colorectal cancer surgery: a population-based study

AIM

The study aimed to investigate whether continuing potentially inappropriate medication (PIM) is associated with length of hospital stay (LOS) and postoperative mortality in elderly people undergoing colorectal cancer surgery.

METHOD

The Swedish National Colorectal Cancer Register and the Swedish Prescribed Drug Register provided matched data on 7279 patients aged 75 years or more who had undergone bowel resection for colorectal cancer between 2007 and 2010. Patients were divided into two groups depending on whether or not they were taking PIM at the time of surgery. The primary efficacy variables were the LOS and 30-day postoperative mortality.

RESULTS

Of the 7279 patients, 22.5% (1641) of the patients were exposed to at least one PIM and the total number of drugs taken in this group was six, compared with three in the non-PIM group (P < 0.001). Postoperative mortality was higher in the PIM group (7.1% vs 4.5%, P < 0.001), and LOS was longer (10 days vs 9, P = 0.001). When adjusted for independent predictors, the differences in LOS (odds ratio 1.14; 95% confidence interval 1.00-1.29, P = 0.046) and postoperative mortality (odds ratio 1.43; 95% confidence interval 1.11-1.85, P = 0.006) remained significant.

CONCLUSION

The use of PIM prior to surgery is associated with increased postoperative mortality and prolonged hospital stay. Although no causal relationship is proved, the results add a further aspect to preoperative optimization of elderly patients about to have major colorectal surgery.

Accuracy of preoperative T and N staging in colon cancer--a national population-based study

AIM

To select patients for neoadjuvant therapy in colon cancer, there is a need to improve pre-therapeutic locoregional staging. There are now data showing that the TN stage can be adequately assessed by preoperative CT in dedicated centres. In Sweden the use of preoperative CT of the abdomen for staging of the primary tumour is increasing. The aim of this study was to determine to what extent the preoperatively reported radiological TN stage correlates with the histopathological TN stage in an entire population.

METHOD

Data were collected on the preoperative cTN stage according to the radiologist and postoperative pTN stage according to the pathologist on all patients operated on for colon cancer in Sweden 2007-2010. The correlation between cTN stage and pTN stage was calculated using kappa statistics.

RESULTS

T stage was compared in 4373 patients with cT and pT stage. The correlation coefficient was 0.44, indicating fair agreement. The cN and pN correlation coefficient was 0.28, indicating a slight correlation. There was no difference in correlation related to age, gender, tumour location, body mass index or emergent vs elective surgery. A slight difference was seen between different geographical regions.

CONCLUSION

Preoperative CT in an unselected population does not result in an accurate cTN staging as previously reported from dedicated centres. To achieve adequate preoperative cTN staging nationally, the education of radiologists and optimization of the radiological method will be necessary.

Relation of intraoperative temperature to postoperative mortality in open colon surgery--an analysis of two randomized controlled trials

INTRODUCTION

The open surgical wound is exposed to cold and dry ambient air resulting in heat loss mainly through radiation and convection. This cools the wound and promotes local vasoconstriction and hypoxia. Carbon dioxide (CO2) and water vapor are greenhouse gases with a warming effect. The aim was to evaluate if warm humidified CO2 insufflated in surgical wound can affect long-term overall mortality

METHODS

This is a retrospective study of two clinical trials, where patients were randomized to warm humidified CO2 (n = 80) or not (n = 78). All patients underwent elective major open colon surgery. Patients in the treatment group received insufflation of warm humidified CO2 into the open wound cavity via a gas diffuser to create a local atmosphere of 100% CO2. Temperature in the wound cavity was measured with a heat-sensitive infrared camera. Core temperature was measured at the tympanic membrane. Median follow-up was 70.9 months.

RESULTS

A multivariate analysis adjusted for age (p = 0.001) and cancer (p = 0.165) showed that the larger the temperature difference between final core temperature and wound edge temperature, the lower the overall survival rate (p = 0.050). Patients receiving insufflation of warm humidified CO2 had a tendency to a better overall survival compared with control patients (p = 0.508). End-of-operation wound edge temperature was negatively associated with mortality (OR = 0.80, 95% CI = 0.68-0.95, p = 0.011), whereas mortality was positively associated with age (10-year increase, OR = 1.78, 95% CI = 1.37-2.33, p < 0.001) and cancer (OR = 8.1, 95% CI = 1.95-33.7, p = 0.004).

CONCLUSIONS

A small end-of-operation temperature difference between final core and wound edge temperature was positively associated with patient survival in open colon surgery.

Degree of blood loss during surgery for rectal cancer: a population-based epidemiologic study of surgical complications and survival

AIM

The hypothesis tested in this study was that major blood loss during surgery for rectal cancer increases the risk for surgical complications and for small bowel obstruction (SBO) as a result of adhesions or tumour recurrence, and reduces overall survival.

METHOD

Data were retrieved from the Uppsala/Örebro Regional Rectal Cancer Registry for all patients undergoing radical resection for rectal cancer during 1997-2003 (n = 1843) and were matched against the Swedish National Patient Registry regarding surgery and admission for SBO. These patient records were scrutinized to determine the etiology of surgery for SBO. The registry was scrutinized for blood loss and other surgical complications associated with surgery. Uni- and multivariate Cox analysis and logistic regression were used.

RESULTS

Ninety-four (5.1%) patients underwent surgery for SBO > 30 days after the index operation: 82 for adhesions and 12 for tumour recurrence. The volume of blood lost did not influence the risk of surgery for SBO as a result of adhesions, but blood loss above the median (≥ 800 ml) increased the risk for surgery for SBO caused by tumour recurrence (hazard ratio = 10.52; 95% CI: 1.36-81.51). Increased blood loss increased the risk of surgical complications (OR = 1.78; 95% CI: 1.35-2.35 with blood loss of ≥ 450 ml) but did not reduce overall survival. Irradiation before surgery increased blood loss, complications and admission for SBO.

CONCLUSION

Major blood loss during surgery for rectal cancer increases the risk of later surgery for SBO caused by tumour recurrence and surgical complications, but overall survival is not affected.

Management of colon cancer in the elderly: a population-based study

AIM

Although the median age of patients diagnosed with colon cancer is over 70 years, little is known about specific characteristics and management in the elderly. The aim of this study was to define the characteristics of colon cancer in elderly patients and compare the quality of preoperative assessment and surgery with that of younger patients undergoing surgery for colon cancer.

METHOD

Data on 15,255 patients diagnosed with colon cancer between 2007 and 2010 were retrieved from the Swedish National Colon Cancer Register. Of these, 12,959 underwent surgical resection: 6141 were 75 years or older while 6818 were younger. The χ(2) test, Mann-Whitney U-test and univariable and multivariable logistic regression analyses were used for between-group comparison.

RESULTS

Older patients were more likely to be female (54% older/48% younger) and have right-sided cancer (60% older/49% younger). Among patients who underwent resection, the elderly were less often evaluated regarding tumour stage prior to surgery (59% older/65% younger) and they were less often evaluated at a multidisciplinary team conference (26% older/34% younger). Elderly patients more frequently underwent emergency surgery (22% older/19% younger) despite having an earlier cancer stage. When adjusted for stage, fewer elderly patients underwent a radical curative procedure (OR for noncurative resection 1.19; 95% CI 1.06-1.33).

CONCLUSION

Routine management of patients with colon cancer is age-dependent. Patients aged 75 years and older are less often completely staged and less often evaluated at a multidisciplinary team conference prior to surgery. Adjusted for stage, fewer elderly patients undergo curative resection.