Elective Laparoscopic Colorectal Cancer Surgery Research Articles

Is triggering receptor expressed on myeloid cell 1 (TREM-1) protein a new marker of serious infectious complications in colorectal surgery?: case-matched pilot study

PurposeThe purpose of the study was to evaluate the usefulness of the triggering receptor expressed on myeloid cell 1 (TREM-1) protein as a marker for serious infectious complications during laparoscopic colorectal surgery.MethodsSixty-four patients with colon or rectal cancer, who underwent an elective laparoscopic colorectal cancer surgery from November 2018 to February 2020, were included in the analysis. Blood samples of the TREM-1 protein testing were collected four times from each patient: before and on three following postoperative days (PODs). Patients were divided into two groups according to the presence of infectious complications. Subsequently, patients with infectious complications (group 1) were matched 1:1 with patients without complications (group 2). The case-matched analysis was done by selecting patients from the control group by age, ASA scale, cancer stage, and type of surgery.ResultsThere was no significant difference in demographic and operative characteristics between the two groups. The median length of hospital stay was longer in group 1 than in group 2 (11 days vs. 5 days, p < 0.001). Preoperative measurements of TREM-1 protein did not differ between the two groups. There were no significant differences in the measurements on the first and third postoperative days. However, the median TREM-1 measurement was higher in group 1 on the second postoperative day (542 pg/ml vs. 399 pg/ml; p = 0.040). The difference was more apparent when only severe postoperative complications were considered. When compared to the group without any complications, the median TREM-1 level was significantly higher in the group with severe infection complications in POD 1, POD 2, and POD 3 (p < 0.05). The receiver operating characteristic (ROC) curve demonstrated that TREM-1 readings in POD 2 had a sensitivity of 83% and a specificity of 84% for the presence of severe infection complications at a value of 579.3 pg/ml (AUC 0.8, 95%CI 0.65–0.96).ConclusionTREM-1 measurements might become a helpful predictive marker in the early diagnosis of serious infectious complications in patients following laparoscopic colorectal surgery.

Effects of anesthetic depth on perioperative T lymphocyte subsets in patients undergoing laparoscopic colorectal cancer surgery: a prospective, parallel-controlled randomized trial

BackgroundDuring the perioperative period, the surgical stress response induced by surgical trauma tends to cause a decrease in peripheral lymphocytes. Anesthetics could reduce the stress response during surgery and prevent sympathetic nerve overexcitation. The goal of this study was to investigate how BIS-guided anesthetic depth affected peripheral T lymphocytes in patients undergoing laparoscopic colorectal cancer surgery.MethodsA total of 60 patients having elective laparoscopic colorectal cancer surgery were randomly assigned and analyzed (n = 30 for deep general anesthesia, BIS 35, n = 30 for light general anesthesia, BIS 55). Blood samples were collected immediately before anesthesia induction and immediately after operation, 24 h and 5 days postoperatively. The CD4+/CD8 + ratio, T lymphocyte subsets (including CD3 + T cells, CD4 + T cells, and CD8 + T cells), and natural killer (NK) cells were analyzed by flow cytometry. Serum interleukin-6 (IL-6), interferon -ɣ (IFN-ɣ), and vascular endothelial growth factor-α (VEGF-α) were also measured.ResultsThe CD4+/CD8 + ratio decreased 24 h after surgery in two groups, but the reduction did not differ between the two groups (P > 0.05). The concentration of IL-6 and the numerical rating scale (NRS) score in the BIS 55 group were significantly higher than that in the BIS 35 group 24 h after surgery (P = 0.001). There were no intergroup differences in CD3 + T cells, CD4 + T cells, CD8 + T cells, NK cells, VEGF-α, or the IFN-ɣ. Statistical analyses showed no differences between the two groups in the incidence of fever and surgical site infection during hospitalization.ConclusionsDespite the fact that patients in deep general anesthesia group had low levels of the IL-6 24 h after surgery, the deep general anesthesia was not associated to a positive effect on patients’ peripheral T lymphocytes during colorectal cancer surgery. We found no evidence that peripheral T lymphocyte subsets and natural killer cells were affected by the targeting a BIS of either 55 or 35 in patients undergoing laparoscopic colorectal cancer surgery in this trial.Trial registrationChiCTR2200056624 (www.chictr.org.cn).

Triclosan-coated barbed sutures in elective laparoscopic colorectal cancer surgery: a propensity score matched cohort study

BackgroundMost of the studies published to date which assess the role of antibacterial sutures in surgical site infection (SSI) prevention include heterogeneous groups of patients, and it is therefore difficult to draw conclusions. The objective of the present study was to investigate whether the use of Triclosan-coated barbed sutures (TCBS) was associated with a lower incidence of incisional SSI and lower duration of hospital stay compared to standard sutures, in elective laparoscopic colorectal cancer surgery.MethodObservational including patients who underwent elective colorectal cancer laparoscopic surgery between January 2015 and December 2020. The patients were divided into two groups according to the suture used for fascial closure of the extraction incision, TCBS vs conventional non-coated sutures (CNCS), and the rate of SSI was analysed. The TCBS cases were matched to CNCS cases by propensity score matching to obtain comparable groups of patients.Results488 patients met the inclusion criteria. After adjusting the patients with the propensity score, two new groups of patients were generated: 143 TCBS cases versus 143 CNCS cases. Overall incisional SSI appeared in 16 (5.6%) of the patients with a significant difference between groups depending on the type of suture used, 9.8% in the group of CNCS and 1.4% in the group of TCBS (OR 0.239 (CI 95%: 0.065–0.880)). Hospital stay was significantly shorter in TCBS group than in CNCS, 5 vs 6 days (p < 0.001).ConclusionTCBS was associated with a lower incidence of incisional SSI compared to standard sutures in a cohort of patients undergoing elective laparoscopic colorectal cancer surgery.Graphical abstract

Application of Artificial Neural Networks to Predict Prolonged Operative Timing during Laparoscopic Colorectal Cancer Surgery

Aim: Prolonged operative timing is likely to negatively impact clinical outcomes and accurate preoperative prediction of those likely to undergo longer procedures can assist theatre planning and postoperative care. We aimed to apply artificial neural networks (ANN) as a predictive tool for prolonged operating time in laparoscopic colorectal surgery. Methods: A dedicated, prospectively populated database of elective laparoscopic colorectal cancer surgery with curative intent was utilised. Primary endpoint was the prediction of operative time. Variables included in the network were: age, gender, ASA, BMI, stage, location of cancer, and neoadjuvant therapy. A multi-layered perceptron ANN (MLPNN) model was trained and tested alongside unit and multivariate analyses. Results: Data from 554 patients were included. 400 (72.2%) were used for ANN training and 154 (27.8%) to test predictive accuracy. 59.3% male, mean age 70 years, and BMI of 26. 161 (29%) were ASA III. 261 (47%) had rectal cancer and 8.5% underwent neoadjuvant treatment. Mean operative time was 218 minutes (95% CI 210-226) with 436 (78.7%) of less than 5 hours and 16% conversion rate. ANN accurately identified and predicted operative timing overall 87%, and those having surgery less than 5 hours with an accuracy of 93.3%; AUC 0.843 and 93.3%. The ANN findings were accurately cross-validated with a logistic regression model. Conclusion: Artificial neural network using patient demographic and tumour data successfully predicted the timing of surgery and the likelihood of prolonged laparoscopic procedures. This finding could assist the personalisation of peri-operative care to enhance the efficiency of theatre utilisation.

Impact of anaemia at discharge following colorectal cancer surgery

ObjectivesPreoperative anaemia is common in patients with colorectal cancer and increasingly optimised prior to surgery. Comparably little attention is given to the prevalence and consequences of postoperative anaemia. We aimed to investigate the frequency and short- or long-term impact of anaemia at discharge following colorectal cancer resection.MethodsA dedicated, prospectively populated database of elective laparoscopic colorectal cancer procedures undertaken with curative intent within a fully implemented ERAS protocol was utilised. The primary endpoint was anaemia at time of discharge (haemoglobin (Hb) < 120 g/L for women and < 135 g/L for men). Patient demographics, tumour characteristics, operative details and postoperative outcomes were captured. Median follow-up was 61 months with overall survival calculated with the Kaplan-Meier log rank method and Cox proportional hazard regression based on anaemia at time of hospital discharge.ResultsA total of 532 patients with median 61-month follow-up were included. 46.4% were anaemic preoperatively (cohort mean Hb 129.4 g/L ± 18.7). Median surgical blood loss was 100 mL (IQR 0–200 mL). Upon discharge, most patients were anaemic (76.6%, Hb 116.3 g/L ± 14, mean 19 g/L ± 11 below lower limit of normal, p < 0.001). 16.7% experienced postoperative complications which were associated with lower discharge Hb (112 g/L ± 12 vs. 117 g/L ± 14, p = 0.001). Patients discharged anaemic had longer hospital stays (7 [5–11] vs. 6 [5–8], p = 0.037). Anaemia at discharge was independently associated with reduced overall survival (82% vs. 70%, p = 0.018; HR 1.6 (95% CI 1.04–2.5), p = 0.034).ConclusionAnaemia at time of discharge following elective laparoscopic colorectal cancer surgery and ERAS care is common with associated negative impacts upon short-term clinical outcomes and long-term overall survival.

Efficacy and safety of anticoagulant prophylaxis for prevention of postoperative venous thromboembolism in Japanese patients undergoing laparoscopic colorectal cancer surgery.

AimTo investigate the efficacy and safety of anticoagulant prophylaxis to prevent postoperative venous thromboembolism (VTE) during laparoscopic colorectal cancer (CRC) surgery, which is unknown in Japanese patients.MethodsWe conducted this randomized controlled trial at nine institutions in Japan from 2011 to 2015. It included 302 eligible patients aged 20 years or older who underwent elective laparoscopic surgery for CRC. Patients were randomly assigned to an intermittent pneumatic compression (IPC) therapy group or to an IPC + anticoagulation therapy group. Anticoagulation therapy comprised fondaparinux or enoxaparin for postoperative VTE prophylaxis. Postoperative VTE was diagnosed based on enhanced multi‐detector helical computed tomography. The primary endpoint was VTE incidence, including asymptomatic cases, the secondary endpoint was incidence of major bleeding, and we conducted an intention‐to‐treat analysis. This study is registered in UMINCTR (UMIN000008435).ResultsPostoperative VTE incidence was 5.10% with IPC therapy (n = 157) and 2.76% with IPC + anticoagulant therapy (n = 145; P = .293). We identified no symptomatic VTE cases. The major bleeding rates were 1.27% with IPC alone and 1.38% with the combination (P = .936). The overall bleeding rates were 7.69% for enoxaparin and 13.6% for fondaparinux (P = .500), and there were no bleeding‐related deaths.ConclusionAnticoagulant prophylaxis did not reduce the incidence of VTE and the incidence of major bleeding was comparable between the two groups. Usefulness of perioperative anticoagulation was not demonstrated in this study. Pharmacological prophylaxis must be restricted in Japanese patients with higher risk of VTE.

Postoperative Urinary Retention After Laparoscopic Colorectal Resection with Early Catheter Removal: A Prospective Observational Study.

Early catheter removal is essential to enhance postoperative mobilization and recovery, but may carry a risk of urinary retention. This study aimed to evaluate a standardized regimen for early postoperative catheter removal and re-catheterization in patients undergoing elective laparoscopic colorectal cancer surgery within an optimal ERAS setting. This was a single-center prospective study of patients undergoing elective minimally invasive colorectal resection and postoperative catheter removal within 24h, with a re-catheterization threshold of 800ml bladder volume. The primary outcome was postoperative urinary retention rate, and the secondary outcomes were time of catheter removal and length of stay with a special focus on differences between colon and rectal resections. A total of 113 patients were included in the study, and 87 patients were eligible for the final analysis. Rectal resection was performed in 22 of 87 patients, and all operations were performed with minimally invasive technique. The conversion rate was 3.5%, and 30-day mortality was 0%. More than 95% of the patients had their catheter removed within 24h with no difference between rectal and colonic resections. Postoperative urinary retention was observed in 9% of all patients (rectum 18% vs. colon 6%, p = 0.11). One patient had an indwelling catheter at discharge, but all patients had free voluntary micturition at 30-day follow-up. Median length of stay was 3days (1-13days). Catheter removal within 24h of surgery using a re-catheterization threshold of 800ml is safe and reduces unnecessary re-catheterizations following minimally invasive colorectal resection.

Effect of the application of a bundle of three measures (intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples) on the surgical site infection after elective laparoscopic colorectal cancer surgery.

Surgical site infection (SSI) prevention bundles include the simultaneous use of different measures, which individually have demonstrated an effect on prevention of SSI. The implementation of bundles can yield superior results to the implementation of individual measures. The aim of this study was to address the effect of the application of a bundle including intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, on the surgical site infection after elective laparoscopic colorectal cancer surgery. A prospective, randomized study was performed, including patients with diagnosis of colorectal neoplasms and plans to undergo an elective laparoscopic surgery. The patients were randomized into two groups: those patients following standard bundles (Group 1) and those ones following the experimental bundle with three additional measures, added to the standard bundle. Incisional and organ space SSI were investigated. The study was assessor-blinded. A total of 198 patients were included in the study, 99 in each group. The incisional SSI rate was 16% in Group 1 and 2% in Group 2 [p = 0.007; RR = 5.6; CI 95% (1.4-17.8)]. The organ-space SSI rate was 4% in Group 1 and 0% in Group 2 [p = 0.039; RR = 1.7; CI 95% (1.1-11.6)]. Median hospital stay was 5.5 days in Group 1 and 4 days in Group 2 (p = 0.028). The addition of intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, to a standard bundle of SSI prevention, reduces the incisional and organ-space SSI and consequently the hospital stay, after elective laparoscopic colorectal cancer surgery (ClinicalTrials.gov Identifier: NCT03081962).

Does a Combination of Laparoscopic Approach and Full Fast Track Multimodal Management Decrease Postoperative Morbidity?: A Multicenter Randomized Controlled Trial.

The aim of this study was to assess whether association of laparoscopic approach and full fast track multimodal (FFT) management can reduce postoperative morbidity after colorectal cancer surgery, as compared to laparoscopic approach with limited fast-track program (LFT). Recent advances in colorectal cancer surgery are introduction of laparoscopy and FFT implementation. Patients eligible for elective laparoscopic colorectal cancer surgery were randomized into 2 groups: FFT or LFT care (with only early oral intake and mobilization starting on Day 1). Primary outcome was postoperative 30-day morbidity, according to Clavien-Dindo classification. Two hundred seventy patients were randomized and 263 were analyzed: 130 in FFT group and 133 in LFT group, including 106 colon (FFT: n = 52 and LFT: n = 54) and 157 rectal cancer (FFT: n = 78 and LFT: n = 79). Postoperative 30-day mortality was nil. Overall postoperative 30-day morbidity did not show any difference between the groups (FFT: 35% vs LFT: 29%, P = 0.290), neither regarding the overall population, nor in the colon (FFT: 23% vs LFT: 19%, P = 0.636) or rectal (FFT: 44% vs LFT: 35%, P = 0.330) cancer subgroups. Severe postoperative morbidity was also not different between groups (FFT: 12% vs LFT: 8%, P = 0.266). After multivariate regression analysis, only early intravenous catheter removal (on day 2) [odds ratio: 0.390; 95% confidence interval: (95% CI 0.181-0.842); P = 0.017] and the absence of intraoperative lidocaine intravenous perfusion (odds ratio: 0.182, 95% CI 0.042-0.788; P = 0.019) were identified as independent predictive factors of reduced postoperative morbidity. Addition of FFT multimodal management to laparoscopic approach with early oral intake and mobilization does not reduce postoperative morbidity after colorectal cancer surgery.

Effect of Subcutaneous Sterile Vitamin E Ointment on Incisional Surgical Site Infection after Elective Laparoscopic Colorectal Cancer Surgery.

Despite several interventions having been adopted to reduce the incidence of incisional surgical site infection (SSI), it still remains a challenge for surgeons, because incisional SSI is a common cause of health-care-associated infection, leading to increased morbidity, prolonged hospital stay, patient discomfort, and increased sanitary costs. The aim of this study was to evaluate the effect on incisional SSI of vitamin E ointment in the subcutaneous tissue of patients undergoing a laparoscopic colorectal surgical procedure. A randomized study was performed. Patients with colorectal neoplasms undergoing an elective laparoscopic surgical procedure were included. The patients were randomized into two groups: Those patients undergoing a subcutaneous vitamin E ointment application (Group 1) and those patients who did not receive it (Group 2). Incisional SSI, post-operative pain, and analytical acute phase reactants were analyzed. There were 108 patients who were assessed for eligibility, and 101 patients were analyzed. The incisional SSI rate was 4% in Group 1 and 17.6% in Group 2 (p = 0.03). Mean post-operative pain, 24 hours after operation, was 17.3 ± 10.5 mm in Group 1 and 31.9 ± 18.9 mm in Group 2 (p < 0.001). Median hospital stay was six days in Group 1 and eight days in Group 2 (p < 0.001). White blood cell count was significantly lower in Group 1 (p < 0.001). The subcutaneous application of sterile vitamin E acetate ointment leads to a reduction in the incisional SSI rate, lower post-operative pain, and decrease in C-reactive protein and white blood cell count.

Early oral feeding following laparoscopic colorectal cancer surgery

Early oral feeding (EOF) following colorectal surgery can accelerate patient recovery and shorten hospital stay. However, some patients are intolerable to postoperative early oral feeding. The aim of this study was to evaluate the tolerability of EOF following laparoscopic colorectal cancer surgery and the effects of intravenous lidocaine. The cohort in this randomized, placebo-controlled trial (ClinicalTrial.gov, NCT01346917) comprised of 77 patients undergoing elective laparoscopic colorectal cancer surgery. For patients randomized to the lidocaine group, a loading dose of 1 mg/kg lidocaine prior to skin incision, and a continuous dose of 1 mg/kg/h lidocaine with 90 mg ketorolac (non-steroidal anti-inflammatory drug) (in normal saline, total 240 mL) was administered for 24 h. Patients randomized to the placebo group received a loading dose of 5 mL saline and a continuous dose of 90 mg ketorolac in 240 mL saline. The primary outcome measure was prevalence of postoperative nausea/vomiting and intolerance to EOF. Altogether, 68 patients completed the study and were analyzed. Postoperative nausea and vomiting were higher in the control group but did not reach statistical significance (P = 0.054). Tolerability of EOF was 96.9% in the lidocaine group and 91.7% in the control group (P = 0.62). There was no difference in postoperative pain, opioid consumption, bowel function recovery or postoperative hospital stay. Perioperative intravenous lidocaine administered for laparoscopic colorectal cancer surgery might reduce postoperative nausea and vomiting. However, a high tolerability to EOF following colorectal surgery can be achieved by laparoscopic surgery alone without other supportive treatment.