Elective Colorectal Cancer Resection Research Articles

A single centre audit: repeat pre-operative colonoscopy.

Repeat colonoscopy may be required for tumour localisation. The aim of the study is to explore the clinical settings it was used and benchmark the quality of initial colonoscopy against standardized guidelines for tumour localisation, tattooing and colonoscopy reporting amongst clinicians. A retrospective study from 2016 to 2021 has been performed on patients who underwent elective colorectal cancer resections at the Northern Hospital. Patient demographics, colonoscopic and operative details were retrieved from the Bi-National Colorectal Cancer Audit (BCCA) Registry database and hospital medical records. changes in operative approach and delays to operation. reasons for a repeat colonoscopy and complications from repeat colonoscopy. A total of 339 patients were included in this study. 94 (28.6%) underwent a repeat colonoscopy. Re-scoping rate was 29.6% for surgeons, and 26.2% for non-operating endoscopists. Surgeons had a 5.9% localisation error rate, and non-operating endoscopist 6.95% (p= 0.673). Surgeons did not have a lower rate of repeat colonoscopy (p= 0.462). Repeat endoscopy was associated with a longer time to definitive operation (p < 0.001). No complications were associated with a repeat colonoscopy. There was no difference in localisation error rates or repeat colonoscopy amongst surgeons (29.6%) and non-operating endoscopists (26.2%) (p= 0.462). This could be explained by the standardized endoscopy training in Australia governed by a common training board. Lack of tattooing at index colonoscopy and inadequate documentation often led to a repeat endoscopy, which was associated with a longer time to definitive operation. Standardized guidelines in tattooing of lesions and colonoscopy reporting should be implemented.

Preoperative non-selective administration of nutritional supplements to patients undergoing elective colorectal resection - standard of perioperative care?

Preoperative nutritional support for oncosurgical patients is recommended to minimize the negative effects of potential malnutrition. Nutritional support is intended to adjust the pathophysiological reactions to surgery, reduce postoperative complications, shorten the length of hospital stay and speed up convalescence. The aim of the present study was to evaluate the effect of preoperative nutritional supplements (ONS oral nutritional supplements) on the physical and nutritional status of patients undergoing elective colorectal resection for cancer and to assess patients self-sufficiency after surgery. This was a prospective, randomized, single-center clinical trial designed to assess self-sufficiency and return to normal activities in relation to preoperative ONS in patients undergoing elective colorectal surgery. Patients enrolled in the study were randomized to receive ONS twice daily for 7 days prior to surgery or no ONS. One hundred patients were included in the study. The rate of postoperative complications was comparable; no differences were found in postoperative values of laboratory nutritional parameters (albumin, prealbumin). The length of hospital stay was comparable; the stay in the ICU was shorter in patients taking ONS but the difference was not statistically significant. Differences between the study subgroups regarding muscle weight were not statistically significant. Patient self-sufficiency (assessed using the Barthel index) was comparable in both groups before and after surgery (p=0.717 and p=0.327). Non-selective preoperative administration of ONS to all patients undergoing elective colorectal resection does not reduce postoperative morbidity or speed up recovery. Patients self-sufficiency and their physical and nutritional status are not affected by preoperative nutritional support.

Supervised training of laparoscopic colorectal cancer resections does not adversely affect short- and long-term outcomes: a Propensity-score-matched cohort study

BackgroundSupervised training of laparoscopic colorectal cancer surgery to fellows and consultants (trainees) may raise doubts regarding safety and oncological adequacy. This study investigated these concerns by comparing the short- and long-term outcomes of matched supervised training cases to cases performed by the trainer himself.MethodsA prospective database was analysed retrospectively. All elective laparoscopic colorectal cancer resections in curative intent of adult patients (≥ 18 years) which were performed (non-training cases) or supervised to trainees (training cases) by a single laparoscopic expert surgeon (trainer) were identified. All trainees were specialist surgeons in training for laparoscopic colorectal surgery. Supervised training was standardised. Training cases were 1:1 propensity-score matched to non-training cases using age, American Society of Anesthesiologists (ASA) grade, tumour site (rectum, left and right colon) and American Joint Committee on Cancer (AJCC) tumour stage. The resulting groups were analysed for both short- (operative, oncological, complications) and long-term (time to recurrence, overall and disease-free survival) outcomes.ResultsFrom 10/2006 to 2/2016, a total of 675 resections met the inclusion criteria, of which 95 were training cases. These resections were matched to 95 non-training cases. None of the matched covariates exhibited an imbalance greater than 0.25 (│d│>0.25). There were no significant differences in short- (length of procedure, conversion rate, blood loss, postoperative complications, R0 resections, lymph node harvest) and long-term outcomes. When comparing training cases to non-training cases, 5-year overall and disease-free survival rates were 71.6% (62.4–82.2) versus 81.9% (74.2–90.4) and 70.0% (60.8–80.6) versus 73.6% (64.9–83.3), respectively (not significant). The corresponding hazard ratios (95% confidence intervals, p) were 0.57 (0.32–1.02, p = 0.057) and 0.87 (0.51–1.48, p = 0.61), respectively (univariate Cox proportional hazard model).ConclusionsStandardised supervised training of laparoscopic colorectal cancer procedures to specialist surgeons may not adversely impact short- and long-term outcomes. This result may also apply to newer surgical techniques as long as standardised teaching methods are followed.

Predictors of Quality of Life Six Years after Curative Colorectal Cancer Surgery: Results of the Prospective Multicenter Study.

Background and objectives: Improving early diagnosis and advances in colorectal cancer (CRC) treatment leads to longer survival of these patients. The purpose of this study was to identify the main surgical factors affecting long-term Quality of life (QoL) among colorectal cancer patients after surgery. Materials and Methods: QoL was prospectively evaluated in patients undergoing elective colorectal cancer resection operations in three CRC surgery centers of Lithuania using EORTC generic (QLQC-30) and disease-specific (QLQ-CR29) questionnaires at the time of preoperative admission and 1, 24, and 72 months after surgery. QoL was evaluated among different patient groups, diagnostic and treatment modalities, disease, and postoperative complications. Non-parametric tests and multivariate logistic regression models were used for statistical analysis. Results: Eighty-eight consecutive CRC patients from three institutions were included in the study over a three-month inclusion period, 42 (47.73%) women and 46 (52.27%) men, mean age 64.2 ± 11.5 years. Most tumors were localized in the sigmoid colon and rectum. The largest number of patients had stage III cancer. Twenty-nine patients died—a 6-year survival rate was 67%. 50 of 59 live patients (84.8%) responded to the questionnaire 6 years after their operation. Evaluating changes in quality of life 72 months after surgery with assessments before surgery, both questionnaire responses revealed good long-term CRC surgical treatment results: improved general and functional scale estimates and decreased symptom scale ratings. The multivariate analysis found that age, stoma formation, and rectal cancer were independent risk factors for having worse QoL six years after surgical intervention. Conclusions: Six years after surgery, QoL returns to preoperative levels. Age, stoma formation, adjuvant treatment, and rectal cancer reduce long-term QoL.

The predictive value of preoperative frailty screening for postoperative outcomes in older patients undergoing surgery for non-metastatic colorectal cancer

The predictive value of preoperative frailty screening for postoperative outcomes in older patients undergoing surgery for non-metastatic colorectal cancer

357 A Novel Protocol for Post-Operative Bloods Following Elective Colorectal Cancer Resections - a Re-Audit of a Closed Loop

Abstract Aim Indications for blood tests are often poorly considered. Appropriate blood requests reduce trauma for patients, improve laboratory workflow and reduce costs. We therefore created a novel protocol for bloods requested in the post-operative period for patients undergoing elective colorectal cancer resections. We performed two audit cycle loops to assess protocol adherence and evaluate financial savings. Method The protocol was agreed locally by consultant consensus, presented locally in February 2021, and displayed on surgical wards in May 2021. Bloods requested were reviewed retrospectively for patients undergoing elective colonic resection with an uncomplicated post-operative course. Data was collected prior to the local meeting between September-November 2020 (audit 1, cycle 1), after the meeting between March-April 2021 (audit 2, cycle 1), then after distribution of the protocol to wards between July-August 2021 (cycle 2). Results The locally agreed protocol was post-op day 1,5,7 FBC, U&amp;E, CRP; day 3 FBC, U&amp;E, CRP, LFT; day 2,4,6 no bloods. In audit 1 (cycle 1) 100% protocol adherence would have saved £15.96 per patient (n = 20). In audit 2 (cycle 1) the protocol was followed on 21.4% of days with further savings of £14.21 per patient (n = 23) had there been 100% adherence. In cycle 2, there was 40.74% protocol adherence with £6.62 further potential savings per patient (n = 15). Conclusions Following the post-elective colorectal resection bloods protocol may save our hospital £1700 per annum. Protocol adherence improved when displayed on surgical wards. With these exciting results, we are working with Medway EPR to create an order set containing this protocol.

Effect of Dexmedetomidine-Assisted Intravenous Inhalation Combined Anesthesia on Cerebral Oxygen Metabolism and Serum Th1/Th2 Level in Elderly Colorectal Cancer Patients.

ObjectiveTo observe the effect of dexmedetomidine-assisted intravenous inhalation combined anesthesia on cerebral oxygen metabolism and serum Th1/Th2 levels in elderly patients with colorectal cancer.MethodFrom April 2018 to May 2020,100 elderly patients undergoing elective laparoscopic radical resection of colorectal cancer were prospectively selected and randomly divided into observation group and control group. Before induction of anesthesia, the loading dose of dexmedetomidine was given at 0.5 μg/kg, and the infusion time was 15 min. After tracheal intubation, 0.4 μg/kg/h dexmedetomidine was continuously pumped, and the infusion was stopped 40 min before the end of the operation. In the control group, the same amount of 0.9% sodium chloride was injected intravenously in the same way. 30 min before induction of anesthesia (T0), immediately before induction of anesthesia (T1), immediately after tracheal intubation (T2), 40 min before operation (T3), and immediately after operation (T4), record the blood oxygen content of the artery and internal jugular vein Difference (D(a-jv)O2), brain oxygen uptake rate (COER%), brain oxygen saturation (rSO2) mean. VAS scale, Ramsay scale, MoCA scale were taken at 6, 12, 24, and 48 h postoperatively to evaluate analgesia, sedation, and cognitive function. And monitor the levels of interferon-γ (IFN-γ), interleukin-4 (IL-4), myelin basic protein (MBP), neuron-specific enolase (NSE) and S100β. The occurrence of restlessness and adverse reactions during the recovery period of the two groups were compared.ResultThe levels of D(a-jv)O2, COER%, and rSO2 in the control group and observation group were higher than the preoperative basic values at T2, T3, and T4 (P < 0.05); The levels of D(a-jv)O2, COER%, and rSO2 in the observation group were lower than those in the control group at T2, T3, and T4 (P < 0.05). The VAS score and Ramsay score of the observation group were lower than those of the control group at 6, 12, 24, and 48 h after surgery, while the MoCA score was higher than that of the control group (P < 0.05). In addition, the serum IFN-γ, MBP, NSE and S100β levels of the observation group were lower than those of the control group (P < 0.05), and the ratio of IFN-γ/IL-4 was higher than that of the control group (P < 0.05). The overall incidence of adverse reactions in the observation group was lower than that in the control group [32.0% (16/50) vs. 12.0% (6/50), P < 0.05].ConclusionDexmedetomidine-assisted combined intravenous and inhalation anesthesia is beneficial to reduce perioperative cerebral oxygen metabolism and improve postoperative immunosuppression in elderly patients with colorectal cancer. It has a certain protective effect on nerve injury after operation, thus improving the cognitive function of patients and reducing the occurrence of adverse reactions.

Intraoperative Fractions of Inspiratory Oxygen Are Associated With Recurrence-Free Survival After Elective Cancer Surgery.

Background: Choice of the fraction of inspiratory oxygen (FiO2) is controversial. The objective of this analysis was to evaluate whether intraoperative FiO2 was associated with recurrence-free survival after elective cancer surgery.Methods and Analysis: In this single-center, retrospective study, we analyzed 1,084 patients undergoing elective resection of pancreatic (n = 652), colorectal (n = 405), or hepatic cancer (n = 27) at Heidelberg University Hospital between 2009 and 2016. Intraoperative mean FiO2 values were calculated. For unstratified analyses, the study cohort was equally divided into a low- and a high-FiO2 group. For cancer-stratified analyses, this division was done within cancer-strata. The primary outcome measure was recurrence-free survival until the last known follow-up. Groups were compared using Kaplan–Meier analysis. A stratified log rank test was used to control for different FiO2 levels and survival times between the cancer strata. Cox-regression analyses were used to control for covariates. Sepsis, reoperations, surgical-site infections, and cardiovascular events during hospital stay and overall survival were secondary outcomes.Results: Median FiO2 was 40.9% (Q1–Q3, 38.3–42.9) in the low vs. 50.4% (Q1–Q3, 47.4–54.7) in the high-FiO2 group. Median follow-up was 3.28 (Q1–Q3, 1.68–4.97) years. Recurrence-free survival was considerable higher in the high-FiO2 group (p < 0.001). This effect was also confirmed when stratified for the different tumor entities (p = 0.007). In colorectal cancer surgery, increased FiO2 was independently associated with increased recurrence-free survival. The hazard for the primary outcome decreased by 3.5% with every 1% increase in FiO2. The effect was not seen in pancreatic cancer surgery and we did not find differences in any of the secondary endpoints.Conclusions: Until definite evidence from large-scale trials is available and in the absence of relevant clinical conditions warranting specific FiO2 values, perioperative care givers should aim for an intraoperative FiO2 of 50% in abdominal cancer surgery as this might benefit oncological outcomes.

EP.TU.826Using Indocyanine Green (ICG) during laparoscopic bowel resections for elective cancer patients reduces anastomotic leaks and length of stay

Abstract Introduction Anastomotic leakage (AL) after colorectal surgery is associated with significant morbidity and mortality. Poor perfusion of bowel anastomosis is a significant contributing factor. ICG is a dye administered during laparoscopic surgery to assess bowel perfusion by fluorescent imaging – the aim of this study was to determine whether its use in our centre during elective laparoscopic colorectal cancer resections led to improved patient outcomes. Method Single-centre comparative study of all patients who underwent elective colorectal laparoscopic resections for cancer January 2019- January 2021. Primary outcome investigated was AL. Secondary outcomes: in-patient length of stay, clinical suspicion of AL and post-operative ileus. Cohorts compared with χ2 test. Results 25 patients had resections with ICG, 60 without. None in ICG group, and three in non-ICG group (5%) had AL; p-value 0.29. The ICG group were less likely to have CT for suspected anastomotic leak 12% vs 23.3%, p-value 0.29; and, post-operative ileus 5.3% vs 19.6%, p-value 0.09. Statistically significant reduction in mean inpatient length of stay when ICG used (4.0 days, 95% CI 3.3-4.7) compared to when not used (6.7 days, 95% CI 5.0-8.3). Conclusion Only a small number of previous studies have compared AL rates with and without ICG, finding that its use leads to a significant reduction in AL. While sample size small, our findings supports this. Using ICG also led to a significant reduction in inpatient length of stay. ICG fluorescence angiography is now established as our normal practice for all colorectal resections as a safe, innovative, simple technology.

EP.FRI.476 Routine group and save sampling prior to elective laparoscopic colorectal cancer resection – Is it necessary?

Abstract Introduction Laparoscopic colorectal cancer resection (LCCS) has been shown to reduce blood loss when compared to open surgery. There are no national guidelines regarding need for pre-operative group and save(G&amp;S) sampling in LCCS patients. Our study aims to assess the necessity of G&amp;S samples through identifying rates of post-operative transfusion following LCCS. Methods Retrospective study of all patients who underwent LCCS between 1st January 2019 and 31st December 2019. Results Of 102 surgical procedures, 42 right hemicolectomy, 21 anterior resection, 19 sigmoid colectomy, 12 left hemicolectomy, and 8 APER. The median age was 67(range 56-86) years. All received two valid G&amp;S samples. 13 cases were converted. The median pre-operative haemoglobin was 127g/L, and median post-operative haemoglobin was 114g/L. The median blood loss was &amp;lt;100mls. Only 4(3.9%) patients required post-operative transfusion, 3 of whom were converted due to intra-operative bleeding. The fourth case had decreased haemoglobin post-operatively without need for return to theatre. A significant difference was evident in pre-operative haemoglobin level in patients who needed transfusion compared to those who did not (P = 0.031). A total of 9 units were transfused. Twenty-one pre-operative cross-matched units were not used. Conclusion Evidently, blood transfusion is most likely required in open conversion cases due to intra-operative blood loss, as well as in patients with low pre-operative haemoglobin. A patient specific approach to assessing requirement for pre-operative G&amp;S in elective LCCS patients is required to improve cost-effectiveness, particularly taking into account those with normal pre-operative haemoglobin.

1245 Enhanced Recovery Program in Colorectal Surgery at Basildon And Thurrock University Hospital

Abstract Introduction Enhanced recovery program (ERP) is an integrated multidisciplinary approach that requires participation and commitment from different member of staff, and the patient. This is an evidence-based protocol designed to standardize medical care, improve outcomes, and lower care costs. The aim of this study is to observe how ERP protocol is followed in our institution, and to monitor different outcomes. Data was compared to NICE guideline. Method We reviewed all patients who underwent elective colorectal resection for cancer between June 2018 and May 2019. data was collected retrospectively from patient electronic case notes. We monitored compliance with ERP protocol (NICE), as well as outcomes Results 114 patients were included in our study. We noted that just 35% of patients had intraoperative nasogastric tube. Antibiotics: 74.56%, Catheter 98.24%, PCA 79.82%, Spinal anaesthesia 52.63%, Drain 38.59%. In the post op period, patients were mobilized at 1.89 day (1.27) [mean (SD)], NGT removal: 1.81 day (2.31) Refeeding: 1.36 day (1.01). It has been proven that patients with inadequate perioperative analgesia are more prone to develop ileus, to have a prolonged hospital stay, and have an overall higher mortality (p0.001) Conclusions It seems that there is a room for improvement especially in analgesia and prophylactic antibiotics. Following ERP protocols improves overall outcomes.

Effect of warm-needle moxibustion intervention on immune function and intestinal flora in patients after colorectal cancer radical operation

To explore the effect of warm-needle moxibustion (WNM) on the levels of T cell subgroups and serum inflammatory factors, intestinal microecological balance and postoperative adverse reactions in patients with colorectal cancer. Eighty-four patients who underwent elective radical resection of colorectal cancer were randomly and equally divided into control (medication) group (23 men and 19 women) and WNM group (24 men and 18 women). Patients of the control group received conventional medication treatment (such as postoperative anti-infection and fluid supplementation), and those of the WNM group received conventional medication plus WNM stimulation (the acupuncture needle handle warmed by ignited moxa stick) of bilateral Zusanli(ST36), Sanyinjiao(SP6), Yinlingquan(SP9), Shangjuxu(ST37), and Zhaohai(KI6). The acupuncture needles were retained for 45 minutes every time, starting on the first day after surgery, once a day for 15 days. The number of T cell subsets (CD3+, CD4+, CD8+) positive cells was counted under fluorescence microscope, and the contents of serum tumor necrosis factor α(TNF-α) and interleukin-6 (IL-6) were detected by using ELISA, and the level of C-reactive protein (CRP) was detected by using immunoturbidimetry. The levels (logarithm of colony-forming units per gram of wet fecal weight) of Bifidobacterium, Lactobacillus, Escherichia coli and Enterococcus were determined. The adverse reactions (leukocyte decline, nausea and vomiting, peripheral phlebitis, cold stimulation sensitivity) were recorded after surgery. Before treatment, there were no significant differences between the two groups in the number of T cell subgroups, TNF-α and IL-6 contents, and intestinal flora numbers (P>0.05). After the treatment, self-comparison showed that the numbers of CD3+ and CD4+ positive cells, the ratio of CD4+/CD8+ and the intestinal Bifidobacterium and Lactobacillus levels in the WNM group were significantly increased (P<0.05), whereas the number of CD8+positive cells, intestinal Escherichia coli and Enterococcus levels in the WNM group, and the levels of TNF-α, IL-6 and CRP in both groups were obviously decreased in comparison with their own pretreatment (P<0.05), but no significant changes were found in the levels of CD3+ and CD4+ positive cells, CD4+/CD8+ and intestinal Bifidobacterium, Lactobacillus, Escherichia coli and Enterococcus in the control group (P>0.05). Comparison between two groups displayed that after the treatment, the numbers of CD3+ and CD4+ positive cells, the ratio of CD4+/CD8+, as well as the levels of Bifidobacterium and Lactobacillus were significantly higher in the WNM group than in the control group (P<0.05), whereas the number of CD8+ positive cells， TNF-a, IL-6 and CRP, and the levels of Escherichia coli and Enterococcus were obviously lower in the WNM group than in the control group (P<0.05). The incidence of adverse reactions including leukopenia, nausea and vomiting, peripheral phlebitis, and sensitivity to cold stimulation in the WNM group were markedly lower than those of the control group (P<0.05). WNM intervention can significantly improve the immune function, reduce the level of inflammatory factors, regulate the level of beneficial intestinal flora, and also reduce the incidence of postoperative adverse reactions in patients experiencing radical resection of colorectal cancer.

Men and Those With a History of Smoking Are Associated With the Development of Postoperative Ileus Following Elective Colorectal Cancer Resection at a Private Academic Hospital in Johannesburg, South Africa: A Retrospective Cohort Study.

Introduction: A scarcity of local published data on colorectal cancer (CRC) postoperative complications, including postoperative ileus (POI), exists. POI is a temporary gastrointestinal (GI) state of absent or reduced gastric motility shown to increase patient morbidity, prolong length-of-stay (LOS), and intensify the healthcare resource burden. The pathogenesis of POI involves a neurogenic and inflammatory phase plus a pharmacological component.Aim and Objectives: This study aimed to determine centre-specific preoperative risk factors associated with the development of ileus post elective therapeutic CRC resection. The objectives were to determine whether patient demographics; functional status; comorbidities; GI history; pharmacotherapy (including neoadjuvant chemotherapy); and lastly neoadjuvant radiation and chemoradiation were associated with the development of POI.Method: Patients who underwent CRC resection between January 2016 and May 2019 were retrospectively identified from an existing database. Urgent—or non-therapeutic surgeries; surgeries with the complication anastomotic leak or GI obstruction; patients under 18 at the time of surgery or surgeries preceded by preoperative parenteral nutrition were excluded. A comparison was done of the incidence of exposure in the study cohort to investigated variables as potential risk factors for the complication POI.Results: A total of 155 patient cases were included, and 56 (36%) of them developed POI. Univariate comparison of patients who developed POI with demographic characteristics of patients who did not suggested that women were at lower risk to develop POI compared to men (p = 0,013; RR 0,56; 95% CI 0,36–0,89). Functional status suggested that all previous smokers were at a higher risk to develop POI compared to lifetime non-smokers (p = 0,0069; RR 1,78; 95% CI 1,17–2,70). Multivariable comparison of ≤ 5 qualifying parameters showed no significance.Conclusion: The high local incidence of POI in this patient population shows that intervention is required to reduce the POI rate and improve postoperative outcomes. This study suggests that for men and all patients with a history of smoking both, CRC resection preoperative recommendations with the intention to prevent POI should include instructions initiating the activation of preventive strategies like the Enhanced Recovery After Surgery (ERAS) programme. More studies are needed to adequately determine local perioperative risk factors for POI.

A multimodal prehabilitation program in high-risk patients undergoing elective resection for colorectal cancer: A retrospective cohort study

AimUp to 50% of the patients experience complications after colorectal cancer (CRC) surgery. Improved preoperative physical and nutritional status can enhance clinical outcomes and reduce postoperative complications. This retrospective, single-center, observational cohort study assessed the impact of a four-week multimodal prehabilitation program on postoperative complications, unplanned readmissions, length of stay, and mortality in elective high-risk CRC patients. MethodElective high-risk CRC patients, defined as ASA ≥3 or ≥65yr, who attended the multimodal prehabilitation program (prehabilitation-group) were compared to a historical cohort receiving standard care (control-group). Differences in outcomes between these groups were tested using Fisher's Exact and Mann-Whitney U test. To adjust for confounding, multivariate logistic regression analysis was performed. The main study outcome was the occurrence of postoperative complications. Secondary outcomes included unplanned readmissions, length of hospital stay, and mortality. Results351 patients were included (n = 275 control-group, n = 76 prehabilitation-group). The complication rate was lower in the prehabilitation group compared to the control group, 26.3% (n = 20) versus 40% (n = 110) (p = .032). There were fewer unplanned readmissions in the prehabilitation group compared to the control group, 5.3% (n = 4) versus 16.4% (n = 45), p = .014. Median hospital days of stay was 1 day shorter for the prehabilitation-group (p = .004), mortality did not significantly differ between the groups. ConclusionThis study shows that the used multimodal prehabilitation program leads to a reduction of medical postoperative complications, unplanned readmissions, and shortens the median hospital stay compared with standard care in high-risk CRC patients undergoing elective CRC surgery.

Short- and long-term survival after curative resection for colorectal cancer in nonagenarian patients

Background/objectiveWith increased life expectancy, the incidence of colorectal cancer in oldest-old patients has been rising. Advanced age is a risk factor for adverse outcomes after surgery. This study aimed to evaluate the short- and long-term outcomes of curative resection for colorectal cancer in nonagenarians. MethodsPatients who had undergone curative resection for colorectal cancer (CRC) at Stage I to III from January 2010 to December 2019 were included. Cases of emergent surgery were excluded. The clinical characteristics were documented retrospectively, and factors affecting the long-term outcome were analyzed using multivariate analysis. ResultsFifty patients met the selection criteria. Most of them were women (58.0%), and the median age was 92 years. Among these patients, 29 (58.0%) had a poor performance status (ASA-PS≥3). Laparoscopic surgery was performed in 42.0% of the patients, and 50% of the patients had postoperative complications classified as Clavien–Dindo grade 2 or severer, including 3 patients (6.0%) with grade 3 disease. No postoperative mortality occurred. The 30-day, 180-day, 1-year, 3-year and 5-year survival rates were 100%, 80.4%, 71.0%, 46.3%, and 33.8%, respectively. Multivariate analysis showed that a preoperative poor performance status (ASA-PS≥3) (HR: 3.067; 95% CI: 1.220–7.709; p = 0.017) was an independent prognostic factor for OS. ConclusionCurative elective resections for CRC in nonagenarians were performed safely without postoperative mortality. The preoperative performance status was significantly associated with OS after curative elective resection of colorectal cancer in nonagenarians. Our results suggest that excellent long-term outcomes can be achieved in a selected group with a good performance status.

The impact of frailty on clinical outcomes in colorectal cancer surgery: a systematic literature review.

The majority of colorectal cancer is diagnosed in people aged >65 years, yet the elderly are less likely to undergo curative surgery. Chronological age is poorly correlated with post-operative outcomes and is not an acceptable measure of risk. Conversely, frailty is a strong predictor of poor post-operative outcomes and presents an opportunity for optimisation. This systematic review aims to assess the evidence between frailty and outcomes in patients of all ages undergoing colorectal cancer resections and to compare the predictive value of frailty status to that of age alone. The review was registered on Prospero, CRD42019150542. PubMed was searched for articles reporting outcomes for frail patients undergoing elective or emergency colorectal cancer resection up until August 2019. All studies reporting outcomes in frail patients were deemed eligible for inclusion and assessed according to the PRISMA guidelines. Of the 143 identified studies, 17 were eligible for inclusion. Study type, frailty assessments and outcomes measured were highly variable. 'Frailty' was associated with significantly higher rates of post-operative complications (7/7 studies), post-operative mortality (5/7 studies), readmission (3/4 studies) and length of stay (3/3 studies). Seven of 11 studies reported no association between age and adverse outcomes. Frailty is a predictor of poor clinical outcomes in patients undergoing surgery for colorectal cancer. Standardisation of frailty assessment and outcome measure is needed. Accurate risk stratification of patients will allow us to make informed treatment decisions, identify patients who may benefit from preoperative intervention and tailor post-operative care.

The intersection of tumor location and combined bowel preparation: Utilization differs but anastomotic leak risk reduction does not.

Whether bowel preparation utilization rates or effectiveness varies based on tumor location is unknown. The 2012-2016 American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted participant user file was queried for patients undergoing elective colorectal resection for cancer. Bowel preparation was classified as combined, mechanical bowel preparation alone, oral antibiotic alone, or none. Cochran-Armitage tests were used for trend analysis. Multivariable analyses stratified by tumor location were performed for the outcome of anastomotic leak. An additional multivariable model including all tumor locations assessed for interaction between bowel preparation and tumor location on an anastomotic leak. A total of 29,739 operations were included and the anastomotic leak rate was 1.9% with combined preparation versus 4.0% without preparation. Combined bowel preparation utilization increased over time as tumor location became more distal (both p < .0001). However, the adjusted effect of combined bowel preparation on anastomotic leak risk reduction did not differ by individual tumor location or across all tumor locations (p = .43 for interaction). Though the utilization rate of combined bowel preparation increased as tumor location became more distal, its risk-reducing effect remained similar. Quality improvement initiatives should focus on increased utilization of combined bowel preparation with an emphasis on tumors in the ascending colon.

Effect of two different pre-operative exercise training regimens before colorectal surgery on functional capacity: A randomised controlled trial.

Multimodal prehabilitation, including exercise training, nutritional therapy and anxiety reduction, has been shown to attenuate functional decline associated with surgery. Due to the growing interest in functional status as a targeted surgical outcome, a better understanding of the optimal prescription of exercise is critical. The objective is to compare peri-operative functional trajectory in response to two different exercise training protocols within a 4-week, supervised, multimodal prehabilitation programme. This was a single blinded, single centre, randomised controlled study. Participants performed four assessments: at baseline, after prehabilitation (just before surgery), and at 1 and 2 months after surgery. Adult patients scheduled for elective resection of nonmetastatic colorectal cancer were included provided there were no absolute contraindications to exercise nor poor language comprehension. Patients followed either high-intensity interval training (HIIT), or moderate intensity continuous training (MICT), as part of a 4-week multimodal prehabilitation programme. Both groups followed the same supervised resistance training, nutritional therapy and anxiety reduction interventions. All patients followed standardised peri-operative management. Changes in oxygen consumption at anaerobic threshold, measured with sequential cardio-pulmonary exercise testing, were assessed and compared between groups. Forty two patients were included in the primary analysis (HIIT n = 21 vs. MICT n = 21), with mean ± SD age 64.5 ± 11.2 years and 62% were men. At 2 months after surgery, 13/21 (62%) in HIIT and 11/21 (52%) in MICT attended the study visits. Both protocols significantly enhanced pre-operative functional capacity, with no difference between groups: mean (95% confidence interval) oxygen consumption at anaerobic threshold 1.97 (0.75 to 3.19) ml kg min in HIIT vs. 1.71 (0.56 to 2.85) in MICT, P = 0.753. At 2 months after surgery, the HIIT group showed a higher improvement in physical fitness: 2.36 (0.378 to 4.34) ml kg min, P = 0.021. No adverse events occurred during the intervention. Both MICT and HIIT enhanced pre-operative functional capacity. ClinicalTrials.gov Identifier: NCT03361150.

Early detection of infectious complications using C-reactive protein and the procalcitonin levels after laparoscopic colorectal resection: a prospective cohort study

PurposeThe predictive values of the C-reactive protein (CRP) and procalcitonin (PCT) levels for postoperative infectious complications were investigated in patients who underwent elective laparoscopic resection of colorectal cancer.MethodsA total of 154 consecutive patients who underwent elective laparoscopic resection for colorectal cancer (CRC) were prospectively studied. The CRP and PCT levels on the first postoperative day (POD1) and the fourth postoperative day (POD4) were measured. Any correlations between the CRP and PCT levels on POD1 and POD4 with the occurrence of infectious complications were examined.ResultsInfectious complications occurred in 18 (11.7%) patients. CRP on POD1 and CRP and PCT on POD4 were significantly higher in patients who developed infectious complications than in those who did not. The areas under the receiver operating characteristic curves of CRP on POD1 and CRP and PCT on POD4 were 0.597, 0.763 and 0.768, respectively. The cut-off values of CRP and PCT levels on POD4 were 14.33 mg/dl and 0,264 ng/ml, respectively. Whereas the positive predictive value of an elevated CRP level was high, the negative predictive value of an elevated PCT was high.ConclusionThe CRP and PCT levels on POD4 are both considered to be useful for the early detection of infectious complications after laparoscopic resection of CRC.

Age is an independent risk factor for increased morbidity in elective colorectal cancer surgery despite an ERAS protocol.

Elderly patients with colorectal cancer are high-risk surgical candidates. ERAS protocols have been developed to mitigate against these risks. We performed this study to quantify the risks which elderly patients face and then to determine independent risk factors for short-term ERAS-specific outcomes. An analysis of a prospectively collected audit database of all patients who underwent elective colorectal cancer resection within an ERAS framework from January 2018 to December 2018 was performed. Elderly was defined in our study as age ≥ 65years. There were 172 elective colorectal cancer resections performed. Ninety-seven (56.4%) were elderly. Elderly patients were at increased risk of developing post-operative complications (33.0% vs 16.0%, p= 0.011), longer time to diet (3.4 vs 2.2days, p= 0.001), and longer hospital stay (10.9 vs 6.7days, p= 0.007). Independent risk factors were determined for the abovementioned three outcomes. Elderly status was the only risk factor for increased complications (OR 2.61 95% CI (1.05-6.51), p= 0.040). For delayed time to soft diet, male gender (OR 6.67(1.92-20.0), p= 0.002), open approach (OR 9.06(2.26-36.30), p= 0.002), and increased operative time (OR 1.01(1.00-1.01) p= 0.014) were risk factors. Finally, elderly age (OR 5.53(1.82-16.84), p= 0.003), leucocyte count (OR 1.39(0.76-2.57), p= 0.038), open approach (OR 5.26(1.41-19.62), p= 0.013), operative time (OR 1.01(1.00-1.01), p= 0.021), and Clavien-Dindo classification (OR 7.97(1.27-49.88), p= 0.027) were risk factors for prolonged length of stay. Elderly patients are intrinsically at risk for increased complications, longer time to soft diet and longer hospital stay. ERAS protocols may need to be specifically tailored for elderly patients.