Elective Colon Cancer Resection Research Articles

Inequalities in quality metrics for colorectal cancer surgery in older adults: A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program registry

BackgroundWith a growing proportion of patients undergoing surgery for colorectal cancer being older adults, it is unknown whether traditional quality metrics are achieved as often compared with younger adults. This work was done with a view to understand tailoring needs of quality metrics for older adults with colorectal cancer. MethodsThis retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program registry to identify adults (≥18 years) between 2016 and 2021 who underwent elective colorectal cancer surgery for nonmetastatic cancer. older adults was defined as adults ≥65 years. The association between older adults and attainment of consensus quality metrics were evaluated using multivariable logistic regression adjusting for patient, cancer, and treatment factors. ResultsOf 46,159 patients undergoing elective colon cancer resection, 18,592 (40.3%) were older adults. Being an older adult was independently associated with a 14% reduction in odds of harvest of ≥12 nodes and 4.3 times increase in odds of 30-day mortality. Of 9,106 patients undergoing elective rectal cancer resection 5,143 (56.5%) were older adults. Being an older adult was independently associated with a 19% reduction in odds of harvest of ≥12 nodes, 2.3 times increase in odds of 30-day mortality and a 44% reduction in odds of receiving neoadjuvant radiation. Findings were robust to sensitivity analyses of alternate methods of handling missing data and alternate analytic approaches. ConclusionGiven unique needs of the older adult population, interpretation of disparities in quality metrics is challenging because of an inability to differentiate between patient factors, tailored care, or bias. Monitoring and reporting of quality metrics for older adults need to be re-evaluated with consideration to stratification, unique benchmarks, and older adult–specific quality metrics.

Racial disparities in complications following elective colon cancer resection: Impact of laparoscopic versus robotic approaches

BackgroundWe sought to examine differences in outcomes for Black and White patients undergoing robotic or laparoscopic colectomy to assess the potential impact of technological advancement. MethodsWe queried the ACS-NSQIP database for elective robotic (RC) and laparoscopic (LC) colectomy for cancer from 2012 to 2020. Outcomes included 30-day mortality and complications. We analyzed the association between outcomes, operative approach, and race using multivariable logistic regression. ResultsWe identified 64,460 patients, 80.9% laparoscopic and 19.1% robotic. RC patients were most frequently younger, male, and White, with fewer comorbidities (P ​< ​0.001). After adjustment, there was no difference in mortality by approach or race. Black patients who underwent LC had higher complications (OR 1.10, 95% CI 1.03–1.08, P ​= ​0.005) than their White LC counterparts and RC patients. ConclusionsRobotic colectomy was associated with lower rates of complications in minority patients. Further investigation is required to identify the causal pathway that leads to our finding.

Clinical outcomes of elective robotic vs laparoscopic surgery for colon cancer utilizing a large national database.

Prior studies have shown comparable outcomes between laparoscopic and robotic approaches across a range of surgeries; however, these have been limited in size. This study investigates differences in outcomes following robotic (RC) vs laparoscopic (LC) colectomy across several years utilizing a large national database. We analyzed data from ACS NSQIP for patients who underwent elective minimally invasive colectomies for colon cancer from 2012 to 2020. Inverse probability weighting with regression adjustment (IPWRA) incorporating demographics, operative factors, and comorbidities was used. Outcomes included mortality, complications, return to the operating room (OR), post-operative length of stay (LOS), operative time, readmission, and anastomotic leak. Secondary analysis was performed to further assess anastomotic leak rate following right and left colectomies. We identified 83,841 patients who underwent elective minimally invasive colectomies: 14,122 (16.8%) RC and 69,719 (83.2%) LC. Patients who underwent RC were younger, more likely to be male, non-Hispanic White, with higher body mass index (BMI) and fewer comorbidities (for all, P < 0.05). After adjustment, there were no differences between RC and LC for 30-day mortality (0.8% vs 0.9% respectively, P = 0.457) or overall complications (16.9% vs 17.2%, P = 0.432). RC was associated with higher return to OR (5.1% vs 3.6%, P < 0.001), lower LOS (4.9 vs 5.1days, P < 0.001), longer operative time (247 vs 184min, P < 0.001), and higher rates of readmission (8.8% vs 7.2%, P < 0.001). Anastomotic leak rates were comparable for right-sided RC vs LC (2.1% vs 2.2%, P = 0.713), higher for left-sided LC (2.7%, P < 0.001), and highest for left-sided RC (3.4%, P < 0.001). Robotic approach for elective colon cancer resection has similar outcomes to its laparoscopic counterpart. There were no differences in mortality or overall complications, however anastomotic leaks were highest after left RC. Further investigation is imperative to better understand the potential impact of technological advancement such as robotic surgery on patient outcomes.

Does Fellowship Matter? A Comparison of Overall Survival and Lymph Node Sampling in Colon Cancer Resections amongst Colorectal Fellowship Trained Surgeons vs. Non-Colorectal Specialty Trained Surgeons

Background: Approximately 1 in 23 people will be diagnosed with colorectal cancer, resulting in nearly 50,000 cancer related deaths per year in the United States. An effective surgical resection plays an integral role in the success or failure of these patients' oncologic treatment. Objective: This study was designed to focus on lymph node sampling and survival of patients undergoing resections for colon cancer to determine if additional training leads to better outcomes. Design: This is a retrospective review from 2006–2017. Patients who presented through the emergency room were considered elective if their surgery was performed &gt;72 hours after admission. One-hundred and thirty-five surgeons were included, and 13 were colorectal trained. We excluded patients with metachronous or synchronous tumors. Analysis was performed using the Wilcoxon rank sum test. Settings: Twenty-three hospitals within a single healthcare system. Patients: Final analysis included patients undergoing a primary, elective resection for colon cancer. Sample Size: We focused at 2335 patients. Main Outcome Measure: Survival after resection and number of lymph nodes sampled. Results: Among the patients, 2657 met the inclusion criteria, with only 322 resections being considered nonelective. In the elective population of 2335 patients, 536 underwent resection by a colorectal specialty trained surgeon. The survival probability was greater for patients who underwent resection by colorectal surgeons than those for patients who underwent resection by non-colorectal surgeons (p = 9e-05). Lymph node sampling in elective resections by colorectal surgeons was significantly higher (p = &lt; 2e-16), with the mean being 23.8 vs 19.1, respectively. Conclusion: Colorectal trained surgeons have significantly better outcomes than non-specialty trained surgeons considering the overall survival rates and number of lymph nodes sampled for elective resections. Limitations: There was insufficient evidence to conclude that any difference existed in the outcomes when considering the non-elective patient population given the low numbers of these resections being performed by colorectal surgeons. Conflict of Interest: The authors have no conflict of interest to declare.

O103 The relationship between routine pre-operative clinicopathological factors and post-operative infective complications in patients undergoing elective potentially curative colon cancer resection

Abstract Introduction Post-operative complications, in particular infective complications, following elective colon cancer resection remain common. The present cohort study was designed to determine the influence of routinely reported clinicopathological factors on post-operative infective complications in a large regional cohort undergoing potentially curative colon cancer. Methods Patients who underwent elective potentially curative colon cancer resection between January 2011 and December 2014 were assessed for post-operative complications. Clinicopathological data were recorded in a prospectively maintained database. A multivariate binary logistic regression model was used to identify independent risk factors for infective complications. Results A total of 1887 patients were included with 29% of patients developing post-operative infective complications (POI). Multivariate analysis showed that factors associated for both POI complications and surgical site infections (SSI) were higher body mass index (BMI) (POI OR 1.29, 95% CI 1.15–1.46, p&amp;lt;0.001 and SSI OR 1.4, 95% CI 1.23–1.60, p&amp;lt;0.001), diabetes (POI OR 1.45, 95% CI 1.06–1.99, p=0.022 and SSI OR 1.58, 95% 1.12–2.22, p=0.009) and open or laparoscopic converted to open surgical approach (POI OR 0.66, 95% CI 0.52–0.84, p=0.001 and SSI OR 0.70, 95% CI 0.53–0.93, p=0.012). While 30-day mortality was associated with older age, high ASA grade and pre-operative systematic inflammatory grade. Conclusion Elevated BMI and diabetes were independently associated with infective complications and surgical site infections. Therefore, the BMI and diabetes status should be routinely determined in patients undergoing elective surgery for colon cancer. Take-home message Body mass index and diabetes status should be actively determined prior to elective surgical intervention to allow for risk stratification and pre-operative optimisations.

Development and Validation of a Clinical Risk Score for Intensive Care Resource Utilization After Colon Cancer Surgery: a Practical Guide to the Selection of Patients During COVID-19

BackgroundThe purpose of this study was to develop and validate a prediction model and clinical risk score for Intensive Care Resource Utilization after colon cancer surgery. MethodsAdult (≥ 18 years old) patients from the 2012 to 2018 ACS-NSQIP colectomy-targeted database who underwent elective colon cancer surgery were identified. A prediction model for 30-day postoperative Intensive Care Resource Utilization was developed and transformed into a clinical risk score based on the regression coefficients. Model performance was assessed using the area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow goodness-of-fit test. The model was validated in a separate test set of similar patients. ResultsIn total, 54,893 patients underwent an elective colon cancer resection, of which 1224 (2.2%) required postoperative Intensive Care Resource Utilization. The final prediction model retained six variables: age (≥ 70; OR 1.90, 95% CI 1.68–2.14), sex (male; OR 1.73, 95% CI 1.54–1.95), American Society of Anesthesiologists score (III/IV; OR 2.52, 95% CI 2.15–2.95), cardiorespiratory disease (yes; OR 2.22, 95% CI 1.94–2.53), functional status (dependent; OR 2.81, 95% CI 2.22–3.56), and operative approach (open surgery; OR 1.70, 95% CI 1.51–1.93). The model demonstrated good discrimination (AUC = 0.73). A clinical risk score was developed, and the risk of requiring postoperative Intensive Care Resource Utilization ranged from 0.03 (0 points) to 19.0% (8 points). The model performed well on test set validation (AUC = 0.73). ConclusionA prediction model and clinical risk score for postoperative Intensive Care Resource Utilization after colon cancer surgery was developed and validated.

Possible dose dependent effect of perioperative dexamethasone and laparoscopic surgery on the postoperative systemic inflammatory response and complications following surgery for colon cancer

BackgroundPerioperative dexamethasone is associated with attenuation of the postoperative systemic inflammatory response and fewer postoperative complications following elective surgery for colorectal cancer.This study examined the impact of different doses of dexamethasone, given to reduce postoperative nausea and vomiting (PONV) after elective colonic resection for cancer, on the postoperative Glasgow Prognostic Score (poGPS) and morbidity. MethodsPatients from a single centre were included if they underwent potentially curative resection of colonic cancer from 2008 to 2017 (n = 480). Patients received no dexamethasone (209, 44%), or either 4 mg (166, 35%), or 8 mg (105, 21%), intravenously during anaesthesia, at the discretion of the anaesthetist. The postoperative Glasgow Prognostic Score (poGPS) on day 3 and 4, and complication rate at discharge were recorded. ResultsWhen patients were grouped by surgical approach (open or laparoscopic) and dexamethasone dose (0 mg, 4 mg or 8 mg), there was a statistically significant linear trend toward a lower postoperative systemic inflammatory response (day 3 poGPS) with the use of minimally invasive surgery and higher doses of dexamethasone (p < 0.001). Furthermore, this combination of laparoscopic surgery and higher doses of dexamethasone was significantly associated with a lower proportion of postoperative complications (p < 0.001).At multivariate Cox regression, dexamethasone was not significantly associated with either improved or poorer cancer specific or overall survival. ConclusionsHigher doses of perioperative dexamethasone are associated with greater reduction in postoperative systemic inflammation and complications following surgery for colonic cancer without negative impact on survival.

Anastomotic Location Predicts Anastomotic Leakage After Elective Colonic Resection for Cancer

BackgroundAnastomotic leakage (AL) is a potential feared complication after colorectal resection, which is associated with an increased risk of postoperative mortality and frequently requires additional surgery. The aim of this study was to assess major independent risk factors for AL after elective colonic resection for cancer, including anastomotic location. MethodsAmong 1940 consecutive patients referred to our institution for colorectal adenocarcinoma, 1025 patients had elective colonic resection with intraperitoneal anastomosis without diverting stoma. Risk factors were assessed among preoperative, operative, and histological data. ResultsClinical AL was observed in 36 patients (3.5%) with 24 patients requiring revisional surgery (67%). In multivariate analysis, endoscopic impassable tumor and colo-colic or ileo-colic anastomosis were independent risk factors for AL. The occurrence of AL was associated with poor overall (43.1 months vs. 146.4 months; p < 0.001) and disease-free survival (40.5 months vs. 137.3 months; p = 0.003). ConclusionAnastomotic leakage occurs more frequently after colo-colic and ileo-colic anastomosis than after intraperitoneal colorectal anastomosis.The right colectomy appears to be at higher risk of AL, with a greater risk of surgical intervention than after an elective left colectomy. Ileo-colic anastomosis should be avoided in cases of suboptimal conditions.

Perirenal fat surface area as a risk factor for perioperative difficulties and 30-day postoperative complications in elective colon cancer surgery.

Visceral obesity is associated with perioperative and postoperative complications in colorectal surgery. We aimed to investigate the association between the perirenal fat surface area (PRF) and postoperative complications. Data on 610 patients undergoing curative, elective colon cancer resection between 2006 and 2016 at Stockholm South General Hospital were retrieved from a local quality register. We assessed perioperative and postoperative outcomes using a multinomial regression model adjusted for age, sex, American Society of Anesthesiologists classification and surgical approach (open/laparoscopy) in relation to PRF. PRF could be measured in 605 patients; the median area was 24 cm2 . Patients with PRF ≥ 40 cm2 had longer operation time (median 223 vs 184 min), more intra-operative bleeding (250 vs 125 ml), reoperations (11% vs 6%), surgical complications (27% vs 13%) and nonsurgical infectious complications (16% vs 9%) than patients with PRF < 40 cm2 , but there were no differences in the need for intensive care or duration of hospital stay. The multivariate analyses revealed an increased risk of any complication [OR 1.68 (95% CI 1.1-2.6)], which was even more pronounced for moderate complications [Clavien-Dindo II, OR 2.14 (CI 1.2-2.4]; Clavien-Dindo III, OR 2.35 (CI 1.0-5.5)] in patients with PRF ≥ 40 vs < 40 cm2 . The absolute risk of complications was similar in men and women with PRF ≥ 40 cm2 . PRF, an easily measured indirect marker of visceral obesity, was associated with overall and moderate complications in men and women and could serve as a useful tool in the assessment of preoperative risk.

Laparoscopic surgery in colon cancer patients treated with chronic anti-thrombotic therapy.

Anti-thrombotic medications are commonly used for the treatment and prevention of cardiovascular diseases. Laparoscopic resection of colon cancer has generally been accepted with favorable outcomes being reported in randomized control trials. However, the safety and efficacy of laparoscopic surgery for colon cancer patients receiving chronic anti-thrombotic therapy (AT) remain unclear. We identified 951 patients who underwent elective resection for colon cancer between 2009 and 2016 from our database. Patients were classified according to the surgical approach and chronic AT. Clinicopathological factors and surgical outcomes were analyzed between patient groups. Patients' backgrounds were matched using propensity scores in laparoscopic surgery. Anti-thrombotic drugs were chronically used in 135 patients. Among 714 patients who underwent laparoscopy-assisted surgery, 96 received AT. The laparoscopic approach was superior to open surgery in terms of bleeding, surgical site infections, and hospital stay in patients receiving AT. In laparoscopy-assisted surgery, the AT group patients were older and showed lower hemoglobin and albumin levels than those not receiving AT (non-AT group), and were predominantly male. After propensity score matching, estimated blood loss and operative times were similar between the two groups (93 matched patients). The frequencies of postoperative bleeding (2.2%) and thrombotic complications (0%) in the AT group did not significantly differ from those in the non-AT group (1.1 and 0%, respectively). Moreover, AT did not affect survivals. Laparoscopic approach appears to be safer and beneficial for colonic cancer patients receiving long-term AT. Bleeding and thrombotic events associated with laparoscopic surgery were not significantly affected by AT.

Laparoscopy may decrease morbidity and length of stay after elective colon cancer resection, especially in frail patients: results from an observational real-life study.

Advantages of laparoscopic approach in colon cancer surgery have been previously demonstrated in controlled, randomized trials and in retrospective analysis of large administrative databases. Nevertheless, evidence of these advantages in prospective, observational studies from real-life settings is scarce. This is a prospective, observational study, including a consecutive series of patients that underwent elective colonic resection for cancer in 52 Spanish hospitals. Pre-/intraoperative data, related to patient, tumor, surgical procedure, and hospital, were recorded as well as 60-day post-operative outcomes, including wound infection, complications, anastomotic leak, length of stay, and mortality. A univariate and multivariate analysis was performed to determine the influence of laparoscopy on short-term post-operative outcome. A sub-analysis of the effect of laparoscopy according to patients' pre-operative risk (ASA Score I-II vs. III-IV) was also performed. 2968 patients were included: 44.2% were initially operated by laparoscopy, with a 13.9% conversion rate to laparotomy. At univariate analysis, laparoscopy was associated with a decreased mortality (p=0.015), morbidity (p<0.0001), wound infection (p<0.0001), and post-operative length of stay (p<0.0001). At multivariate analysis, laparoscopy resulted as an independent protective factor for morbidity (OR 0.7; p=0.004), wound infection (OR 0.6; p<0.0001), and length of post-operative stay (Effect-2days; p<0.0001), compared to open approach. These advantages were more relevant in high-risk patients (ASA III-IV), even if the majority of them were operated by open approach (67.1%). In a real-life setting, laparoscopy decreases wound infection rate, post-operative complications, and length of stay, especially in ASA III-IV patients.

Reviewing the Management of Obstructive Left Colon Cancer: Assessing the Feasibility of the One-stage Resection and Anastomosis After Intraoperative Colonic Irrigation

BackgroundThe management of obstructive left colon cancer (OLCC) remains debatable with the single-stage procedure of primary colonic anastomosis after cancer resection and on-table intracolonic lavage now being supported. Patients and MethodsPatients with acute OLCC who were admitted between January 2008 and January 2015 were distributed into 5 different groups. Group ICI underwent emergency laparotomy for primary anastomosis following colonic resection and intraoperative colonic lavage; Group HP underwent emergency Hartmann's Procedure; Group CON consisted of patients treated by conservative management with subsequent elective open cancer resection; Group COL were colostomy patients; and Group INT consisted of patients who had interventional radiology followed by open elective colon cancer resection. The demographics of the patients and comorbidity, intraoperative data, and postoperative data were collected, with P < .05 as significant. ResultsThere were 4 deaths in 138 cases (2.90%). There was only 1 patient who had anastomotic leakage (5.56%) in Group ICI, compared with none in Group HP and Group COL, 1 case in Group INT (7.69%), and 2 cases in Group CON (6.06%) (P > .05). Group INT and Group CON, when compared to the three surgical groups, Groups ICI, Group COL, and Group HP, individually, were statistically significant for the duration of surgery (P < .05). ConclusionsPrimary anastomosis following colonic resection after irrigation can be safely performed in selected patients, with the necessary surgical expertise, with no increased risk in mortality, anastomotic leakage, and other postoperative complications.

Anastomotic leakage after colon cancer resection: does the individual surgeon matter?

Anastomotic leakage is one of the most feared complications after colonic resection. Many risk factors for anastomotic leakage have been reported, but the impact of an individual surgeon as a risk factor has scarcely been reported. The aim of this study was to assess if the individual surgeon is an independent risk factor for anastomotic leakage in colonic cancer surgery. This was a retrospective analysis of prospectively collected data from patients who underwent elective resection for colon cancer with anastomosis at a specialized colorectal unit from January 1993 to December 2010. Anastomotic leaks were diagnosed according to standardized criteria. Patient and tumour characteristics, surgical procedure and operating surgeons were analysed. A logistic regression model was used to discriminate statistical variation and identify risk factors for anastomotic leakage. A total of 1045 patients underwent elective colon cancer resection with primary anastomosis. Anastomotic leakage occurred in 6.4% of patients. Ileocolic anastomosis had an anastomotic leakage rate of 7.2%, colo-colonic/colorectal anastomosis 5.2% and ileorectal anastomosis 12.7%, with intersurgeon variability. The independent risk factors associated with anastomotic leakage were the use of perioperative blood transfusion (OR 2.83, CI 1.59-5.06, P<0.0001) and the individual surgeon performing the procedure (OR up to 8.44, P<0.0001). In addition to perioperative blood transfusion, the individual surgeon was identified as an important risk factor for anastomotic leakage. Efforts should be made to reduce performance variability amongst surgeons.

Colorectal Cancer, Systemic Inflammation, and Outcome: Staging the Tumor and Staging the Host.

This study aims to examine the clinical utility of the combination of TNM stage and modified Glasgow Prognostic Score (mGPS) in patients undergoing potentially curative resection of colorectal cancer (CRC). Of measures of the systemic inflammatory response, the mGPS has been most extensively validated in patients with cancer. Data from 1000 consecutive patients undergoing potentially curative CRC resection from a single institution (January 1997-May 2013) were included. The relationship between mGPS [0-C-reactive protein (CRP) ≤ 10 mg/L, 1-CRP > 10 mg/L and albumin ≥35 g/L, 2-CRP > 10 mg/L and albumin < 35 g/L], TNM stage, and cancer-specific survival (CSS) and overall survival (OS) was examined using Kaplan-Meier log-rank survival analysis and multivariate Cox regression analysis. An mGPS of 0, 1, and 2 was observed in 63%, 21%, and 16% of patients, respectively. Median follow-up was 56 months (interquartile range: 28-107 months). TNM and mGPS were independently associated with CSS and OS (all P < 0.001). In all patients, TNM and mGPS stratified 5-year CSS and OS from 97% and 87% (stage I, mGPS = 0) to 32% and 26% (stage III, mGPS = 2), respectively. In patients undergoing elective resection of colon cancer (n = 575), 5-year CSS and OS ranged from 100% and 87% (stage I, mGPS = 0) to 37% and 30% (stage III, mGPS = 2), respectively. This study shows how the combination of TNM and mGPS effectively stratifies outcome in patients undergoing potentially curative resection of CRC. These data support routine staging of both the tumor and the host in patients with CRC.

Validation of nomogram for disease free survival for colon cancer in UK population: A prospective cohort study

AimsTo externally validate the MSKCC nomogram in a UK population, and determine if it could be used in our practice here in the UK. MethodsThe colon cancer database from a district general hospital in England was used to extract all patients who had a curative colon cancer resection. Inclusion criteria were all patients who had curative elective colon cancer resection between 01/01/1998 and 31/12/2003. Patients were followed up for up to ten years. Five and ten year predictions were calculated for each patient, and plotted against the actual recurrence using a ROC curve, and AUC was calculated for both the five and ten year nomogram. Results138 patients were included in the study. Overall five year recurrence rate was 26.8% with a mean follow up of 60.24 months (SD = 38.6). 118 patients were included in the five year nomogram validation, and 102 patients were included in the ten year nomogram validation. A ROC curve was plotted for both the five and ten year nomogram and AUC was calculated. For the five year nomogram AUC was 0.673, and for the ten year nomogram AUC was 0.687. Two cut off points were identified for each nomogram and this divided the cohort into low, medium and high risk groups for recurrence. Cox regression showed there was significant difference between all groups for both nomograms. ConclusionThe MSKCC colon cancer nomogram was validated in our cohort, but it is recommended to be used in conjunction with AJCC TNM staging system.

PTH-296 Validation of nomogram to calculate disease free survival in colon cancer in uk population

Introduction Currently, the Dukes and AJCC TNM staging systems are widely used to predict survival from colon cancer and assist with clinical decision making. The Memorial Sloan Kettering cancer Centre (MSKCC) nomogram has been developed as an adjunct to these, to predict the five and ten year recurrence free survival probability for patients who had curative resection for colon cancer. The aim of this study is to externally validate the MSKCC nomogram in the UK population, and determine its usefulness. Method The colon cancer database from a district general hospital in England was used to extract all patients who had a curative colon cancer resection. Inclusion criteria were all patients who had curative elective colon cancer resection over a five year period. Patients included in the study were followed up for up to ten years. Variables required for the nomogram were: age, sex, tumour location, CEA levels, T stage, positive lymph nodes, negative lymph nodes, tumour differentiation, lymphovascular invasion, perineural invasion and whether post-operative chemotherapy was given. Five and ten year predictions were calculated for each patient, and plotted against the actual recurrence using a Receiver Operator Characteristic (ROC) curve, and Area Under the Curve (AUC) was calculated for both the five and ten year nomogram. Two cut off points were identified for each nomogram, and this helped to stratify our cohort into three risk groups depending on risk of recurrence. Results 138 patients were included in the study. 49.2% were males with mean age of 69.47 years (SD= 10.81). Overall five year recurrence rate was 26.8% with a mean follow up of 60.24 months (SD= 38.6). 118 patients were included in the five year nomogram validation, and 102 patients were included in the ten year nomogram validation. A ROC curve was plotted for both the five and ten year nomogram and AUC was calculated. For the five year nomogram AUC was 0.673, and for the ten year nomogram AUC was 0.687. Two cut off points were identified for each nomogram and this allowed the groups to be stratified into low, medium and high risk for recurrence. Cox regression showed a significant difference between all groups for both nomograms. Conclusion The MSKCC colon cancer nomogram was validated in our cohort, but is recommended to be used in conjunction with AJCC TNM staging system. The use of risk groups to stratify patients may allow the nomogram to be used simply and effectively in clinical practice. Disclosure of interest None Declared.

Eight years of experience with Enhanced Recovery After Surgery in patients with colon cancer: Impact of measures to improve adherence

Perioperative treatment of patients with colorectal cancer according to the Enhanced Recovery After Surgery (ERAS) protocol has proven to reduce complications and duration of stay. However, strict adherence remains a challenge and the benefits may decrease with lower adherence. In this study, we report on 8 years of adherence to the ERAS protocol and its effect on postoperative outcome in patients with colon cancer. In 2006, the ERAS protocol was introduced for treatment of colon cancer patients in the Medical Center Alkmaar, a large teaching hospital. Patients scheduled for elective colon cancer resection were included in this study. Adherence to ERAS items was monitored and along with clinical data prospectively gathered in a database. In 2011, several measures to improve adherence were implemented. In total, 816 patients were included. Mean adherence rate was 73% in 2006 and 2007, 66% in 2008 and 2009, 63% in 2010 and 2011, and 82% in 2012 and 2013. There was a shorter duration of stay in the years with high adherence (5.7 days) compared with the years with low adherence (7.3 days; P < .001). The ERAS items that were the strongest predictors for a shorter duration of stay were no nasogastric tube, early mobilization, early oral nutrition, early removal of epidural, early removal of catheter, and nonopioid oral analgesia. It is possible to improve adherence to the ERAS protocol and related outcomes with specific measures. Adherence to the ERAS protocol was related inversely to duration of stay. Only postoperative items of the ERAS protocol were predictive for a shorter duration of stay. Keeping adherence optimal remains an ongoing challenge that requires repeated training and dedicated personnel.

Visceral obesity, body mass index and risk of complications after colon cancer resection: A retrospective cohort study

The aim of our study was to assess the influence of visceral obesity (VO), as measured by preoperative abdominal CT scan, in relation to body mass index (BMI) on the incidence of postoperative complications and duration of hospital stay after colon cancer surgery. Patients who underwent elective resection for colon cancer between January 1, 2006, and December 31, 2013, and had a preoperative CT scan were entered in the study. Visceral fat area (VFA) was determined by using the preoperative CT scan at the L3-L4 level. The effect of VO, defined as a VFA of >100 cm², on postoperative complications and duration of hospital stay was analyzed. Of 564 included patients, 65% had VO. VO was associated with more anastomotic leakage (P = .04), pneumonia (P = .02), wound infection (P = .03), reoperations (P = .04), and longer duration of hospital stay (P = .05). Of patients with a BMI < 25 kg/m², 44% had VO. In this group, VO was associated significantly with postoperative complications, cardiac (P < .01) and pulmonary (P = .01) comorbidity, hypertension (P < .01), and diabetes (P < .01). In the overweight (BMI 25-30 kg/m²) and obese (BMI > 30 kg/m²) groups, the rate of VO was much higher (81% and 90%, respectively), but was not associated significantly with complications or comorbidity, except for cardiac comorbidity (P < .02) in the BMI = 25-30 kg/m² group. After multivariable analysis, VO was shown to be an independent predictor of anastomotic leakage and wound infection. The association of VO with worse outcome after colon cancer surgery is most pronounced in patients with a BMI < 25 kg/m².

Surgeon volume and elective resection for colon cancer: an analysis of outcomes and use of laparoscopy.

Surgeon volume may be an important predictor of quality and cost outcomes. We evaluated the association between surgeon volume and quality and cost of surgical care in patients with colon cancer. We performed a retrospective study of patients who underwent resection for colon cancer, using data from the University HealthSystem Consortium from 2008 to 2011. Outcomes evaluated included use of laparoscopy, ICU admission, postoperative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized according to high (HVS), medium (MVS), and low (LVS) average annual volumes. A total of 17,749 patients were included in this study. The average age of the cohort was 65 years and 51% of patients were female. After adjustment for potential confounders, compared with LVS, HVS and MVS were more likely to use laparoscopy (HVS, odds ratio [OR] 1.27, 95% CI 1.15, 1.39; MVS, OR 1.16 95% CI 1.65, 1.26). Postoperative complications were significantly lower in patients operated on by HVS than LVS (OR 0.77 95% CI 0.76, 0.91). The HVS patients were less likely to require reoperation than those in the LVS group (OR 0.70, 95% CI 0.53, 0.92) Total direct costs were $927 (95% CI -$1,567 to -$287) lower in the HVS group compared with the LVS group. Higher quality, lower cost care was achieved by HVS in patients undergoing surgery for colon cancer. An assessment of differences in processes of care by surgeon volume may help further define the mechanism for this observed association.

The impact of Model for End-Stage Liver Disease-Na in predicting morbidity and mortality following elective colon cancer surgery irrespective of underlying liver disease

BackgroundThe Model for End-Stage Liver Disease Sodium Model (MELD-Na) is a validated scoring system that uses bilirubin, international normalized ratio, serum creatinine, and sodium to predict mortality in cirrhotic patients awaiting liver transplantation. The aim of this study was to identify the utility of MELD-Na to predict patient outcomes, with and without liver disease, after elective colon cancer surgery. MethodsA review of the American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2010) was conducted to calculate risk-adjusted 30-day outcomes using regression modeling. ResultsA total of 10,842 patients (mean age, 68 years; 51% women) were included. MELD-Na scores were higher in men (10.2 vs 9.1, P < .001) and in open procedures (9.9 vs 9.1, P < .001). The overall complication and mortality rates were 26.3% and 3.3%, respectively. Incremental increases in MELD-Na score correlated with a 1.2% increase in mortality and a 1.1% increase in complications. On multivariate analysis, complications increased with MELD-Na score (odds ratio [OR], 1.05 per 1 point increase; 95% confidence interval [CI], 1.038 to 1.066). MELD-Na score was also associated with increased mortality (OR, 1.13; 95% CI, 1.1 to 1.16), along with ascites (OR, 5.7; 95% CI, 3.7 to 8.8) and corticosteroids (OR, 2.1; 95% CI, 1.3 to 3.3). ConclusionsElevated preoperative MELD-Na score is significantly associated with worse outcomes after elective resection for colon cancer.