The impact of obesity on perioperative outcomes after laparoscopic colorectal resection. Ann Surg. 2012;255:228-236. [PMID: 22190113 DOI: 10.1097/sla.0b013e31823dcbf7]

Advances in Laparoscopic Colorectal Surgery

Laparoscopic colorectal surgery has now become widely adopted for the treatment of colorectal neoplasia, with steady increases in utilization over the past 15 years. Common minimally invasive techniques include multiport laparoscopy, single-incision laparoscopy, and hand-assisted laparoscopy, with the choice of technique depending on several patient and surgeon factors. Laparoscopic colorectal surgery involves a robust learning curve, and fellowship training often lays the foundation for a high-volume laparoscopic practice. This article provides a summary of the various techniques for laparoscopic colorectal surgery, including operative steps, the approach to difficult patients, and the learning curve for proficiency.

Impact of obesity on the short-term outcomes of single-port laparoscopic colectomy for colorectal cancer in the Asian population: A retrospective cohort study

Single-port laparoscopic surgery (SPLS) is being increasingly performed for treating colorectal cancer. Here, we aimed to assess the safety and feasibility of SPLS for colorectal cancer in obese patients through a comparison of their short-term outcomes with those of nonobese patients.A total of 323 patients who underwent SPLS for colorectal cancer at our center between March 2009 and August 2014 were enrolled. The outcomes were analyzed according to the body mass index (BMI) category: nonobese (BMI < 25), obese I (BMI: 25.0-29.9), and obese II (BMI ≥ 30).Of the 323 patients, 233 (72.1%), 80 (24.8%), and 10 (3.1%), were assigned to the nonobese, obese I, and obese II groups, respectively. The clinicopathologic patient characteristics, such as age, gender, tumor location, and previous laparotomy, were similar among the 3 groups. The mean operative time (nonobese vs obese I vs and obese II groups: 269.2 vs 270.4 vs 342.8 minutes, respectively) and estimated surgical blood loss (277.7 vs 260.5 vs 387.0 mL, respectively) were greater in the obese II group than in the nonobese and obese I groups, although the difference was not significant (P = .247 and P = .205, respectively). However, the time to passage of flatus significantly differed among the groups (P = .040); in particular, this value was significantly longer in the obese II group than in the obese I group (P = .031). None of the other parameters, including conversion to open or conventional laparoscopic surgery and intra- and postoperative morbidity, significantly differed among the 3 groups.SPLS for colorectal cancer can be safely performed in obese Asian patients with equivalent short-term outcomes as compared with that in nonobese patients. Hence, SPLS can be safely recommended for colorectal cancer in obese patients if the surgeon is experienced. Nevertheless, the technique used warrants further investigation, and a large-scale prospective study is required.

BMI as a Predictor for Perioperative Outcome of Laparoscopic Colorectal Surgery: a Pooled Analysis of Comparative Studies

BACKGROUND

There has been a long-lasting controversy about whether higher BMI is associated with worse perioperative outcomes of laparoscopic colorectal surgery. Recently, a number of newly published investigations have made it possible to draw a quantitative conclusion.

OBJECTIVE

We conducted this comprehensive meta-analysis to clarify the exact effect that BMI imposes on perioperative outcome of laparoscopic colorectal surgery.

DATA SOURCES

We systematically searched MEDLINE, Embase, and Cochrane Library databases to identify all relevant studies.

STUDY SELECTION

Comparative studies in English that investigated perioperative outcome of laparoscopic colorectal surgery for patients with different BMIs were included. Quality of studies was evaluated by using the Newcastle-Ottawa Scale.

INTERVENTION

The risk factor of interest was BMI.

MAIN OUTCOME MEASURES

Effective sizes were pooled under a random-effects model to evaluate preoperative, intraoperative, and postoperative outcomes.

RESULTS

A total of 43 studies were included. We found that higher BMI was associated with significantly longer operative time (p < 0.001), greater blood loss (p = 0.01), and higher incidence of conversion to open surgery (p < 0.001). Moreover, BMI was a risk factor for overall complication rates (p < 0.001), especially for ileus (p = 0.02) and events of the urinary system (p = 0.03). Significant association was identified between higher BMI and risk of surgical site infection (p < 0.001) and anastomotic leakage (p = 0.02). Higher BMI might also led to a reduced number of harvest lymph nodes for patients with colorectal cancer (p = 0.02). The heterogeneity test identified no significant cross-study heterogeneity, and the results of cumulative meta-analysis, sensitivity analysis, and the publication bias test verified the reliability of our study.

LIMITATIONS

Most studies included were retrospectively designed.

CONCLUSIONS

Body mass index is a practical and valuable measurement for the prediction of the perioperative outcome of laparoscopic colorectal surgery. Higher BMI is associated with worse perioperative outcome. More accurate conclusions, with more precise cutoff values, can be achieved by future well-designed prospective investigations.

Obesity in IBD: epidemiology, pathogenesis, disease course and treatment outcomes

Incidence of IBD is rising in parallel with overweight and obesity. Contrary to conventional belief, about 15-40% of patients with IBD are obese, which might contribute to the development of IBD. Findings from cross-sectional and retrospective cohort studies are conflicting on the effect of obesity on natural history and course of IBD. Most studies are limited by small sample size, low event rates, non-validated assessment of disease activity and lack robust longitudinal follow-up and have incomplete adjustment for confounding factors. The effect of obesity on the efficacy of IBD-related therapy remains to be studied, though data from other autoimmune diseases suggests that obesity results in suboptimal response to therapy, potentially by promoting rapid clearance of biologic agents leading to low trough concentrations. These data provide a rationale for using weight loss interventions as adjunctive therapy in patients with IBD who are obese. Obesity also makes colorectal surgery technically challenging and might increase the risk of perioperative complications. In this Review, we highlight the existing literature on the epidemiology of obesity in IBD, discuss its plausible role in disease pathogenesis and effect on disease course and treatment response, and identify high-priority areas of future research.

Obesity Increases Operative Time in Children Undergoing Laparoscopic Cholecystectomy

INTRODUCTION

Few studies have assessed the impact of obesity on laparoscopic cholecystectomy (LC) in pediatric patients.

MATERIALS AND METHODS

Children who underwent LC were identified from the 2012 to 2013 American College of Surgeons' National Surgical Quality Improvement Program Pediatrics data. Patient characteristics, operative details, and outcomes were compared. Multivariable logistic regression was utilized to identify predictors of increased operative time (OT) and duration of anesthesia (DOAn).

RESULTS

In total, 1757 patients were identified. Due to low rates of obesity in children <9 years old, analyses were limited to those 9-17 (n = 1611, 43% obese). Among obese children, 80.6% were girls. A higher proportion of obese patients had diabetes (3.0% versus 1.0%, P < .01) and contaminated or dirty/infected wounds (15.1% versus 9.4%, P < .01). Complication rates were low. The most frequent indications for surgery were cholelithiasis/biliary colic (34.3%), chronic cholecystitis (26.9%), and biliary dyskinesia (18.2%). On multivariable analysis, obesity was an independent predictor of OT >90 (odds ratio [OR] 2.02; 95% confidence interval [95% CI] 1.55-2.63), and DOAn >140 minutes (OR 1.86; 95% CI 1.42-2.43).

CONCLUSIONS

Obesity is an independent risk factor for increased OT in children undergoing LC. Pediatric surgeons and anesthesiologists should be prepared for the technical and physiological challenges that obesity may pose in this patient population.

Preoperative assessment of vascular anatomy by multidetector computed tomography before laparoscopic colectomy for transverse colon cancer: report of a case

Although the safety of laparoscopic surgery for colon cancer has been reported in many randomized controlled trials, concerns about the difficulty of surgery for transverse colon cancer has not been fully resolved, mainly because of the variation in the vascular anatomy of mesenteric vessels, which leads to difficulty in determining the optimal operative procedure and the extent of lymph node dissection. We present the case of a patient with transverse colon cancer who underwent laparoscopic surgery after preoperative assessment using a combination of endoscopic clipping and three-dimensional computed tomography angiography (3DCTA). A 68-year-old man was diagnosed with transverse colon cancer, and laparoscopic surgery has been planned. 3DCTA showed right-middle and left-middle colic arteries arising independently from the superior mesenteric artery. The relationship between the clip and vessels showed that the right-middle colic artery was the feeding artery of the tumor. Operative findings were consistent with 3DCTA findings, and transverse colectomy with lymph node dissection was successfully performed.

Laparoscopic colorectal cancer resections in the obese: a systematic review

BACKGROUND

Laparoscopic colorectal cancer operations in obese patients pose technical challenges that may negatively impact oncologic adequacy. A meta-analysis was performed to assess the oncologic outcomes of laparoscopic colorectal cancer resections in obese compared to non-obese patients. Short- and long-term outcomes were assessed secondarily.

METHODS

A systematic literature search was conducted from inception until October 01, 2014. Studies that compared outcomes of laparoscopic colorectal malignant neoplasms in obese and non-obese patients were selected for meta-analysis. Studies that defined obesity as body mass index (BMI) ≥ 30 kg/m² were included. Oncologic, operative, and postoperative outcomes were evaluated. Pooled odds ratios (OR) and weighted mean differences (WMD) with 95 % confidence intervals (CI) were calculated using fixed-effects models. For oncologic and survival outcomes, a subgroup analysis was conducted for rectal cancer and a secondary analysis was conducted for Asian studies that used a BMI cutoff of 25 kg/m².

RESULTS

Thirteen observational studies with a total of 4550 patients were included in the meta-analysis. Lymph node retrieval, distal, and circumferential margins, and 5-year disease-free and overall survival were similar in the obese and non-obese groups. Conversion rate (OR 2.11, 95 % CI 1.58-2.81), postoperative morbidity (OR 1.54, 95 % CI 1.21-1.97), wound infection (OR 2.43, 95 % CI 1.46-4.03), and anastomotic leak (OR 1.65, 95 % CI 1.01-2.71) were all significantly increased in the obese group.

CONCLUSIONS

Laparoscopic colorectal cancer operations in obese patients pose an increased technical challenge as demonstrated by higher conversion rates and higher risk of postoperative complications compared to non-obese patients. Despite these challenges, oncologic adequacy of laparoscopic colorectal cancer resections is comparable in both groups.

Conversions in laparoscopic surgery for rectal cancer

BACKGROUND

Laparoscopic surgery offers patients with rectal cancer short-term benefits and similar survival rates as open surgery. However, selecting patients who are suitable candidates for laparoscopic surgery is essential to prevent intra-operative conversion from laparoscopic to open surgery. Clinical and pathological variables were studied among patients who had converted laparoscopic surgeries within the COLOR II trial to improve patient selection for laparoscopic rectal cancer surgery.

METHODS

Between January 20, 2004, and May 4, 2010, 1044 patients with rectal cancer enrolled in the COLOR II trial and were randomized to either laparoscopic or open surgery. Of 693 patients who had laparoscopic surgery, 114 (16 %) were converted to open surgery. Predictive factors were studied using multivariate analyses, and morbidity and mortality rates were determined.

RESULTS

Factors correlating with conversion were as follows: age above 65 years (OR 1.9; 95 % CI 1.2-3.0: p = 0.003), BMI greater than 25 (OR 2.7; 95 % CI 1.7-4.3: p < 0.001), and tumor location more than 5 cm from the anal verge (OR 0.5; CI 0.3-0.9). Gender was not significantly related to conversion (p = 0.14). In the converted group, blood loss was greater (p < 0.001) and operating time was longer (p = 0.028) compared with the non-converted laparoscopies. Hospital stay did not differ (p = 0.06). Converted procedures were followed by more postoperative complications compared with laparoscopic or open surgery (p = 0.041 and p = 0.042, respectively). Mortality was similar in the laparoscopic and converted groups.

CONCLUSIONS

Age above 65 years, BMI greater than 25, and tumor location between 5 and 15 cm from the anal verge were risk factors for conversion of laparoscopic to open surgery in patients with rectal cancer.

Abdominal fat ratio - a novel parameter for predicting conversion in laparoscopic colorectal surgery

INTRODUCTION Laparoscopic surgery has become the standard for colorectal cancer resection in the UK but it can be technically challenging in patients who are obese. Patients whose body fat is mainly inside the abdominal cavity are more challenging than those whose fat is mainly outside the abdominal cavity. Abdominal fat ratio (AFR) is a simple parameter proposed by the authors to aid identification of this subgroup. MATERIALS AND METHODS All 195 patients who underwent elective, laparoscopic colorectal cancer resections from March 2010 to November 2013 were included in the study. For patients who were obese (body mass index greater than 30), preoperative staging computed tomography was used to determine AFR. This was assessed by two different, blinded observers and compared with conversion rate. RESULTS Of the 195 patients, 58 (29.7%) fell into the obese group and 137 (70.3%) into the non-obese group. The median AFR of the obese group that were converted to open surgery was significantly higher at 5.9 compared with those completed laparoscopically (3.3, P = 0.0001, Mann-Whitney). There was no significant difference in conversion rate when looking at body mass index, tumour site or size. DISCUSSION Previous studies have found body mass index, age, gender, previous abdominal surgery, site and locally advanced tumours to be associated with an increased risk of conversion. This study adds AFR to the list of risk factors. CONCLUSION AFR is a simple, reproducible parameter which can help to predict conversion risk in obese patients undergoing colorectal cancer resection.

Role of Minimally Invasive Surgery in the Reoperative Abdomen or Pelvis

Laparoscopy has become widely accepted as the preferred surgical approach in the management of benign and malignant colorectal diseases. Once considered a relative contraindication in patients with prior abdominal surgery (PAS), as surgeons have continued to gain expertise in advanced laparoscopy, minimally invasive approaches have been increasingly incorporated in the reoperative abdomen and pelvis. Although earlier studies have described conversion rates, most contemporary series evaluating the impact of PAS in laparoscopic colorectal resection have reported equivalent conversion and morbidity rates between reoperative and non-reoperative cases, and series evaluating the impact of laparoscopy in reoperative cases have demonstrated improved short-term outcomes with laparoscopy. The data overall highlight the importance of case selection, careful preoperative preparation and planning, and the critical role of surgeons' expertise in advanced laparoscopic techniques. Challenges to the widespread adoption of minimally invasive techniques in reoperative colorectal cases include the longer learning curve and longer operative time. However, with the steady increase in adoption of minimally invasive techniques worldwide, minimally invasive surgery (MIS) is likely to continue to be applied in the management of increasingly complex reoperative colorectal cases in an effort to improve patient outcomes. In the hands of experienced MIS surgeons and in carefully selected cases, laparoscopy is both safe and efficacious for reoperative procedures in the abdomen and pelvis, with measurable short-term benefits.

Effect of Visceral Obesity on Surgical Outcomes of Patients Undergoing Laparoscopic Colorectal Surgery

BACKGROUND

Visceral obesity has been known to be more pathogenic than body mass index (BMI). There have been a few reports about the association between visceral obesity and surgical outcomes in laparoscopic surgery. The aim of this study was to evaluate the effect of visceral obesity on surgical outcomes undergoing laparoscopic colorectal surgery.

METHODS

Between January 2005 and December 2012, a total of 543 patients who underwent laparoscopic resection for colorectal cancer and had available computed tomography (CT) scans were included in this retrospective study. Visceral fat volumes (VFVs) were measured in preoperative CT scans from S1 to 12.5 cm above. Patients were divided into an obese group and a non-obese group according to VFV and BMI. Obesity was defined by VFV ≥1.92 dm(3) (75% value of VFV) or BMI ≥25 kg/m(2).

RESULTS

There were 136 (25.0%) and 150 (27.6%) obese patients according to VFV and BMI, respectively. The high VFV group had a longer operative times (165.2 ± 84.4 vs. 146.1 ± 58.9 min; P = 0.016), higher blood loss during surgery (132.5 ± 144.8 vs. 98.3 ± 109.6 ml; P = 0.012), more frequent conversion to laparotomy (5.9 vs. 1.5%; P = 0.010), and more frequent major complications (Dindo score ≥3; 11.0 vs. 4.7%; P = 0.008), whereas there was no significant difference between the high and low BMI groups. High VFV was a significant independent risk factor for open conversion (odds ratio 4.964, 95% confidence interval 1.336-18.438, P = 0.017).

CONCLUSIONS

Visceral obesity can be a more clinically useful predictor than BMI in predicting surgical outcomes for laparoscopic colorectal cancer surgery.

Review of 500 single incision laparoscopic colorectal surgery cases - Lessons learned

Single incision laparoscopic surgery (SILS) is a minimally invasive platform with specific benefits over traditional multiport laparoscopic surgery. The safety and feasibility of SILS has been proven, and the applications continue to grow with experience. After 500 cases at a high-volume, single-institution, we were able to standardize instrumentation and operative steps, as well as develop adaptations in technique to help overcome technical and ergonomic challenges. These technical adaptations have allowed the successful application of SILS to technically difficult patient populations, such as pelvic cases, inflammatory bowel disease cases, and high body mass index patients. This review is a frame of reference for the application and wider integration of the single incision laparoscopic platform in colorectal surgery.

Global cancer surgery: delivering safe, affordable, and timely cancer surgery

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US $6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.

Elderly patients have more infectious complications following laparoscopic colorectal cancer surgery

AIM

Elderly patients may be at higher risk of postoperative complications, particularly infective, than younger patients.

METHOD

We prospectively followed 163 consecutive patients undergoing elective laparoscopic resection for cancer. We compared patients < 65, 65-80 and > 80 years of age at the time of surgery.

RESULTS

Seventy (42.9%) patients had no complication; 93 (57.1%) had at least one complication following surgery and in 20 (12.3%) this was major. There was no difference in major complications between the groups (P = 0.47). Patients over 65 years of age were more likely to have a complication of any severity [< 65 years, 39.3%; 65-80 years, 69.3%; and > 80 years, 63.0% (P = 0.002)]. The frequency of gastrointestinal complications (30.1%) was similar in the groups (P = 0.29), as was wound infection (25.2%) (P = 0.65). There was an increase in the frequency of infectious complications, especially chest infection, with age, from 14.8% in patients < 65 years, to 22.7% in patients 65-80 years, to 44.4% in patients > 80 years (P = 0.01). Multivariate analysis showed no increase in overall complications in elderly patients, but Stage II or Stage III cancer (OR = 2.59, P = 0.04) and increasing body mass index (BMI) (OR = 1.07 for each unit increase in BMI, P = 0.04) were related to complications. Age remained the only predictor of an infective complication on multivariate analysis. Patients > 80 years of age had 4.21 times the OR of an infective complication (P = 0.03).

CONCLUSION

Older patients are more susceptible to infective complications postoperatively, particularly chest complications. Surgeons should alter their practice to reduce morbidity, such as adopting protocols requiring early physiotherapy.

Obese patients have similar short-term outcomes to non-obese in laparoscopic colorectal surgery

AIM: To determine whether obese patients undergoing laparoscopic surgery within an enhanced recovery program had worse short-term outcomes.

METHODS: A prospective study of consecutive patients undergoing laparoscopic colorectal resection was carried out between 2008 and 2011 in a single institution. Patients were divided in groups based on body mass index (BMI). Short-term outcomes including operative data, length of stay, complications and readmission rates were recorded and compared between the groups. Continuous data were analysed using t-test or one-way Analysis of Variance. χ² test was used to compare categorical data.

RESULTS: Two hundred and fifty four patients were included over the study period. The majority of individuals (41.7%) recruited were of a healthy weight (BMI < 25), whilst 50 patients were classified as obese (19.6%). Patients were matched in terms of the presence of co-morbidities and previous abdominal surgery. Obese patients were found to have a statistically significant difference in The American Society of Anesthesiologists grade. Length of surgery and intra-operative blood loss were no different according to BMI.

CONCLUSION: Obesity (BMI > 25) does not lead to worse short-term outcomes in laparoscopic colorectal surgery and therefore such patients should not be precluded from laparoscopic surgery.

Open Versus Robotic Radical Prostatectomy in Obese Men

OBJECTIVES

Robotic-assisted radical prostatectomy (RARP) has been shown to reduce blood loss, peri-operative complications and length of stay when compared to open radical prostatectomy (ORP). We sought to determine whether the reported benefits of RARP over ORP translate to obese patients.

PATIENTS AND METHODS

We utilized the 2009-2010 Nationwide Inpatient Sample to identify all obese men with prostate cancer who underwent ORP and RARP. Our primary outcome was the presence of a peri-operative adverse event (i.e. blood transfusion, complication, prolonged length of stay). We fit multivariable logistic regression models to examine whether RARP in obese patients was independently associated with decreased odds of all three outcomes.

RESULTS

We identified 9,108 obese patients who underwent radical prostatectomy. On multivariable analysis, the use of RARP in the obese population was not independently associated with decreased odds of developing a peri-operative complication (OR = 0.81, CI: 0.58-1.13, p = 0.209). RARP was, however, associated with decreased odds of blood transfusion (OR = 0.17, CI: 0.10-0.30, p < 0.001) and prolonged length of stay (OR = 0.28, CI: 0.20-0.40, p < 0.001).

CONCLUSION

Our findings suggest that in obese patients, the use of RARP may reduce length of stay and blood transfusions compared to ORP. Both approaches, however, are associated with similar odds of developing a complication.

The influence of body mass index on clinical short-term outcomes in robotic colorectal surgery

BACKGROUND

Robotic surgery has been developed to address the technical limitations of laparoscopic surgery and might result in similar outcomes for patients with low and high body mass index (BMI).

METHODS

Demographic, peri-operative data and surrogate oncologic markers for colorectal cancer of patients that underwent robotic colorectal procedures were collected in a prospective database and analyzed.

RESULTS

103 consecutive patients (36 normal-weight, 33 overweight, 34 obese) underwent robotic colorectal surgery from 11/2011 to 05/2012. While operating room (OR) time was longer for the obese patients (123.4 vs 137.9 and 154.7 min), results for estimated blood loss (104.2 vs 153 and 155.9 mL), conversions (2.8 vs 6.1 and 5.9%), complications (19.4 vs 21.2 and 32.4%), re-admissions (11.1 vs 112.1 and 20.6) and mortality (0% for all) were comparable. BMI did not affect the surrogate markers in patients with malignancies.

CONCLUSIONS

Data demonstrates that patient BMI does not have a significant impact on short-term clinical outcomes during robotic colorectal surgery. Copyright © 2015 John Wiley & Sons, Ltd.

Single-incision laparoscopic surgery for diverticulitis in overweight patients

AIM

Single-incision laparoscopic surgery (SILS) has been introduced as a new technique for the treatment of various colorectal diseases. Recurrent or complicated diverticulitis of the sigmoid colon is a frequent indication for minimally invasive sigmoid colectomy. The aim of this study was to investigate the impact of obesity on the outcome of SILS sigmoid colectomy.

METHODS

From September 2009 to October 2014, data from 377 patients who had intended SILS sigmoid colectomy for diverticulitis at our institution were collected in a prospective database. The patients were categorized in the following subgroups: group 1 (normal weight, body mass index (BMI) < 25 kg/m(2)), group 2 (overweight, BMI 25-29.9 kg/m(2)), group 3 (obesity, BMI 30-34.9 kg/m(2)), and group 4 (morbid obesity, BMI > 35 kg/m(2)).

RESULTS

The groups were equivalent for sex, age, status of diverticulitis, the presence of acute inflammation in the specimen, and the percentage of teaching operations, but the percentage of patients with accompanying diseases was significantly more frequent in groups 2, 3, and 4 (p = 0.04, 0.008, and 0.018, respectively). As compared to group 1, the conversion rate was significantly increased in groups 2 and 4 (2.3 vs. 9.3% (p = 0.013) and 2.3 vs. 12.5% (p = 0.017), respectively). The duration of surgery, hospitalization, and morbidity did not differ between the four groups.

CONCLUSION

Up to a body mass index of 35 kg/m(2), increased body weight does not significantly reduce the feasibility and outcome of single-incision laparoscopic surgery for diverticulitis.

Are Adiponectin and Leptin Good Predictors of Surgical Infection after Colorectal Surgery? A Prospective Study

BACKGROUND

Infections are the most frequent complication after colorectal surgery. It has been suggested that adipose tissue metabolism could be related to the risk of post-operative infection, but this could be partially related to the body-mass index. The aim of this study was to look for a relation between adipocytokine levels and the risk of post-operative infection and its type.

METHODS

This prospective cohort study was conducted between March 2013 and March 2014 in two French teaching hospitals. Pre-operative plasma levels of adiponectin and leptin were measured in consecutive patients undergoing elective colorectal surgery. All infections in the 30 d following surgery were recorded.

RESULTS

Among the 142 patients included, 29 (20.4%) presented a post-operative infection: 26 surgical site infections and three extra-abdominal infections. Adiponectin and leptin levels correlated weakly but substantially with the body mass index (rspearman=-0.26 and +0.31, respectively). While there was no substantial difference between patients with and those without post-operative infection for adiponectin, median pre-operative leptin was substantially greater in patients with post-operative infection (8.67 vs. 4.37 ng/mL, p=0.003). A substantial interaction was found between leptin and cancer. In patients operated on for cancer, the area under the receiver-operating characteristic (ROC) curve was lower than in patients with benign diseases (0.597 vs. 0.858, p=0.011). Similar results were observed for intra-abdominal infection and surgical site infection.

CONCLUSION

Patients with greater levels of leptin before colorectal surgery have an increased risk of post-operative surgical infection. This effect is stronger in patients without cancer. Adiponectin levels are not related to the risk of infection in Western patients.

Increased health services use by severely obese patients undergoing emergency surgery: a retrospective cohort study

BACKGROUND

The aim of this study was to assess perioperative outcomes in obese patients undergoing emergency surgery.

METHODS

We retrospectively reviewed the charts of all adult (> 17 yr) patients admitted to the acute care emergency surgery service at the University of Alberta Hospital between January 2009 and December 2011 who had a body mass index (BMI) of 35 or higher. Patients were divided into subgroups for analysis based on "severe" (BMI 35-39.9) and "morbid" obesity (BMI ≥ 40). Multivariate logistic regression was performed to identify predictors of in-hospital mortality after controlling for confounding factors.

RESULTS

Data on 111 patients (55% women, median BMI 39) were included in the final analysis. Intensive care unit (ICU) support was required for 40% of patients. Postoperative complications occurred in 42% of patients, and 31% required reoperation. Overall in-hospital mortality was 17%. Morbidly obese patients had increased rates of reoperation (40% v. 23%, p = 0.05) and increased lengths of stay compared with severely obese patients (14.5 v. 6.0 d, p = 0.09). Age (odds ratio [OR] 1.08 per increment) and preoperative ICU stay (OR 12) were significantly associated with in-hospital mortality after controlling for confounding, but BMI was not.

CONCLUSION

Obese patients requiring emergency surgery represent a complex patient population at high risk for perioperative morbidity and mortality. Greater resources are required for their care, including ICU support, repeat surgery and prolonged ICU stay. Future studies could help identify predictors of reoperation and strategies to optimize nutrition, rehabilitation and resource allocation.

Techniques in total mesorectal excision surgery

Advances in the surgical management of rectal cancer have placed the quality of total mesorectal excision (TME) as the major predictor in overall survival. A standardized TME technique along with quality increases the percentage of patients undergoing a complete TME. Quality measurements of TME will place increasing demands on surgeons maintaining competence with present and future techniques. These efforts will improve the outcome of the rectal cancer patients.

Factors associated with conversion from laparoscopic to open colectomy using the National Surgical Quality Improvement Program (NSQIP) database

AIM

Conversion rates from laparoscopic to open colectomy and associated factors are traditionally reported in clinical trials or reviews of outcomes from experienced institutions. Indications and selection criteria for laparoscopic colectomy may be more narrowly defined in these circumstances. With the increased adoption of laparoscopy, conversion rates using national data need to be closely examined. The purpose of this study was to use data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to identify factors associated with conversion of laparoscopic to open colectomy at a national scale in the United States.

METHOD

The ACS-NSQIP Participant Use Data Files for 2006-2011 were used to identify patients who had undergone laparoscopic colectomy. Converted cases were identified using open colectomy as the primary procedure and laparoscopic colectomy as 'other procedure'. Preoperative variables were identified and statistics were calculated using sas version 9.3. Logistic regression was used to model the multivariate relationship between patient variables and conversion status.

RESULTS

Laparoscopy was successfully performed in 41 585 patients, of whom 2508 (5.8%) required conversion to an open procedure. On univariate analysis the following factors were significant: age, body mass index (BMI), American Society of Anesthesiologists (ASA) class, presence of diabetes, smoking, chronic obstructive pulmonary disease, ascites, stroke, weight loss and chemotherapy (P < 0.05). The following factors remained significant on multivariate analysis: age, BMI, ASA class, smoking, ascites and weight loss.

CONCLUSION

Multiple significant factors for conversion from laparoscopic to open colectomy were identified. A novel finding was the increased risk of conversion for underweight patients. As laparoscopic colectomy is become increasingly utilized, factors predictive of conversion to open procedures should be sought via large national cohorts.

Robotic Rectal Cancer Resection: A Retrospective Multicenter Analysis

BACKGROUND

Conventional laparoscopy has been applied to colorectal resections for more than 2 decades. However, laparoscopic rectal resection is technically demanding, especially when performing a tumor-specific mesorectal excision in a difficult pelvis. Robotic surgery is uniquely designed to overcome most of these technical limitations. The aim of this study was to confirm the feasibility of robotic rectal cancer surgery in a large multicenter study.

METHODS

Retrospective data of 425 patients who underwent robotic tumor-specific mesorectal excision for rectal lesions at seven institutions were collected. Outcome data were analyzed for the overall cohort and were stratified according to obese versus non-obese and low versus ultra-low resection patients.

RESULTS

Mean age was 60.9 years, and 57.9 % of patients were male. Overall, 51.3 % of patients underwent neoadjuvant therapy, while operative time was 240 min, mean blood loss 119 ml, and intraoperative complication rate 4.5 %. Mean number of lymph nodes was 17.4, with a positive circumferential margin rate of 0.9 %. Conversion rate to open was 5.9 %, anastomotic leak rate was 8.7 %, with a mean length of stay of 5.7 days. Operative times were significantly longer and re-admission rate higher for the obese population, with all other parameters comparable. Ultra-low resections also had longer operative times.

CONCLUSION

Robotic-assisted minimally invasive surgery for the treatment of rectal cancer is safe and can be performed according to current oncologic principles. BMI seems to play a minor role in influencing outcomes. Thus, robotics might be an excellent treatment option for the challenging patient undergoing resection for rectal cancer.

Technique of last resort: characteristics of patients undergoing open surgery in the laparoscopic era

BACKGROUND

The utilization rates for minimally invasive colorectal resection techniques (MICR) continue to increase. In some centers MICR methods are the preferred approach, however, open methods continue to be utilized for select patients. In this study, the profile and short-term outcomes of open colorectal resection (CR) and MICR patients are determined and compared.

METHODS

A retrospective review of patients who underwent elective CR over 11 years at two institutions was performed. The MICR group contained both laparoscopic-assisted and hand-assisted cases. The past medical and surgical histories, indications, operations performed, and short-term outcomes were assessed. The Charlson co-morbidity index (CMI) was used to assess risk.

RESULTS

During the study period 1080 patients underwent CR (Open, 141; MICR, 939). As judged by the CMI, there were more high-risk patients (score ≥2) in the Open group (34.38%) versus MICR (22.11%) p = 0.0029. Significantly more open patients had prior abdominal surgery and specifically CRs (Open, 15.60% vs. MICR, 2.13%, p < 0.001). Intraoperative transfusion (Open 25.7%; MICR 6.8%, p < 0.001) and diversion (25.53 vs. 11.50%, p < 0.001) were more common in the Open group. Not surprisingly, recovery of bowel function and length of stay were longer for the Open group. The overall complication rate was also higher for the Open patients (p < 0.001).

CONCLUSION

When MICR is the procedure of choice, patients selected for Open CR are higher risk and more complex as judged by the CMI and past operative history. Not surprisingly, this translates into a longer length of stay, higher rates of transfusion, diversion, and complications. This disparity in patients undergoing CRs makes direct comparison of MICR and Open resection outcomes not reasonable.

Sagittal abdominal diameter is a better predictor than body mass index for duration of laparoscopic left colectomy

BACKGROUND

Visceral obesity (VO) increases technical difficulty in laparoscopic surgery. The body mass index (BMI) does not always correlate to intra-abdominal fat distribution. Our hypothesis was that simple anthropometric measures that reflect VO, could predict technical difficulty in laparoscopic colorectal surgery, as reflected by the operative time, more accurately than the BMI.

METHODS

Charts of all consecutive patients who underwent laparoscopic left colon resection in our institution between 2007 and 2010 were reviewed retrospectively. On a preoperative CT scan, anthropometric measures were taken on an axial plane at the L4-L5 level. Demographic, operative and anthropometric CT measures were correlated with the operative time. Logistic regression analysis was performed to assess the value of anthropometric CT measures or BMI to predict the duration of the colectomy.

RESULTS

121 patients with elective left colon resection for benign (56%) or malignant disease (44%) were included. There were 74 sigmoid resections (61%), 21 left hemicolectomies (17%) and 26 low anterior resections (22%). A longer sagittal abdominal diameter (≥24.8 cm) was significantly associated with longer corrected operative time (248 vs. 228 min, p = 0.043). In multivariate analysis, greater sagittal abdominal diameter, sagittal internal diameter and abdominal perimeter were significantly associated with longer operative time. No significant association was found for the BMI neither in univariate nor in multivariate analysis.

CONCLUSIONS

This study suggests that simple linear measures taken on a CT scan, such as sagittal abdominal diameter, sagittal internal diameter and abdominal perimeter, may predict longer operative time in laparoscopic left colonic resections more accurately than BMI.

Evolution and future of laparoscopic colorectal surgery

The advances of laparoscopic surgery since the early 1990s have caused one of the largest technical revolutions in medicine since the detection of antibiotics (1922, Flemming), the discovery of DNA structure (1953, Watson and Crick), and solid organ transplantation (1954, Murray). Perseverance through a rocky start and increased familiarity with the chop-stick surgery in conjunction with technical refinements has resulted in a rapid expansion of the indications for minimally invasive surgery. Procedure-related factors initially contributed to this success and included the improved postoperative recovery and cosmesis, fewer wound complications, lower risk for incisional hernias and for subsequent adhesion-related small bowel obstructions; the major breakthrough however came with favorable long-term outcomes data on oncological parameters. The future will have to determine the specific role of various technical approaches, define prognostic factors of success and true progress, and consider directing further innovation while potentially limiting approaches that do not add to patient outcomes.

Improving the outcomes in oncological colorectal surgery

During the last several decades, colorectal cancer surgery has experienced some major perioperative improvements. Preoperative risk-assessment of nutrition, frailty, and sarcopenia followed by interventions for patient optimization or an adapted surgical strategy, contributed to improved postoperative outcomes. Enhanced recovery programs or fast-track surgery also resulted in reduced length of hospital stay and overall complications without affecting patient safety. After an initially indecisive start due to uncertainty about oncological safety, the most significant improvement in intraoperative care was the introduction of laparoscopy. Laparoscopic surgery for colon and rectal cancer is associated with better short-term outcomes, whereas long-term outcomes regarding survival and recurrence rates are comparable. Nevertheless, long-term results in rectal surgery remain to be seen. Early recognition of anastomotic leakage remains a challenge, though multiple improvements have allowed better management of this complication.

Short-term surgical outcomes from a randomized controlled trial to evaluate laparoscopic and open D3 dissection for stage II/III colon cancer: Japan Clinical Oncology Group Study JCOG 0404

OBJECTIVE

A randomized controlled trial to confirm the non-inferiority of laparoscopic surgery to open surgery in terms of overall survival was conducted, and short-term surgical outcomes are demonstrated.

BACKGROUND

The efficacy and safety outcome of laparoscopic surgery for clinical stages II/III colon cancer undergoing Japanese D3 dissection are still unclear.

METHODS

Eligibility criteria included colon cancer; tumor located in the cecum, ascending, sigmoid, or rectosigmoid colon; T3 or T4 without involvement of other organs; N0-2; and M0. Patients were randomized preoperatively and underwent tumor resection with D3 dissection. Safety analyses were conducted by per-protocol set.

RESULTS

A total of 1057 patients were randomized between October 2004 and March 2009. By per-protocol set, 524 patients who underwent open surgery and 533 patients who underwent laparoscopic surgery were analyzed. D3 dissection was performed in 521 (99.4%) patients in the open surgery arm and 529 (99.2%) patients in the laparoscopic surgery arm. Conversion to open surgery was needed for 29 (5.4%) patients. Patients assigned to laparoscopic surgery had less blood loss (P < 0.001), although laparoscopic surgery lasted 52 minutes longer (P < 0.001). Laparoscopic surgery was associated with a shorter time to pass first flatus, decreased use of analgesics after 5 postoperative days, and a shorter hospital stay. Morbidity [14.3% (76/533) vs 22.3% (117/524), P < 0.001] was lower in the laparoscopic surgery arm.

CONCLUSIONS

Short-term surgical safety and clinical benefits of laparoscopic D3 dissection were demonstrated. The primary endpoint will be reported after the primary analysis, planned for 2014.

Laparoscopic colorectal resections: a simple predictor model and a stratification risk for conversion to open surgery

BACKGROUND

The advantages associated with the laparoscopic approach are lost when conversion is required. Available predictive models have failed to show external validation. Body surface area is a recently described risk factor not included in these models.

OBJECTIVE

The aim of this study was to develop a clinical rule including body surface area for predicting conversion in patients undergoing elective laparoscopic colorectal surgery.

DESIGN

This was a prospective cohort study.

SETTING

This study was conducted at a single large tertiary care institution.

PATIENTS

Nine hundred sixteen patients (mean age, 63.9; range, 14-91 years; 53.2% female) who underwent surgery between January 2004 and August 2011 were identified from a prospective database.

MAIN OUTCOME MEASURES

Conversion rate was analyzed related to age, sex, obesity, disease location (colon vs rectum), type of disease (neoplastic vs nonneoplastic), history of previous surgery, and body surface area. A predictive model for conversion was developed with the use of logistic regression to identify independently associated variables, and a simple clinical prediction rule was derived. Internal validation of the model was performed by using bootstrapping.

RESULTS

The conversion rate was 9.9% (91/916). Rectal disease, large patient size, and male sex were independently associated with higher odds of conversion (OR, 2.28 95%CI, 1.47-3.46]), 1.88 [1.1-3.44], and 1.87 [1.04-3.24]). The prediction rule identified 3 risk groups: low risk (women and nonlarge males), average risk (large males with colon disease), and high risk (large males with rectal disease). Conversion rates among these groups were 5.7%, 11.3%, and 27.8% (p < 0.001). Compared with the low-risk group, ORs for average- and high-risk groups were 2.17 (1.30-3.62, p = 0.004) and 6.38 (3.57-11.4, p < 0.0001).

LIMITATIONS

The study was limited by the lack of external validation.

CONCLUSION

This predictive model, including body surface area, stratifies patients with different conversion risks and may help to inform patients, to select cases in the early learning curve, and to evaluate the standard of care. However, this prediction rule needs to be externally validated in other samples (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A137).

Is laparoscopic colorectal cancer surgery associated with an increased risk in obese patients? A retrospective study from China

Background

The impact of obesity on surgical outcomes after laparoscopic colorectal cancer resection in Chinese patients is still unclear.

Methods

We retrospectively reviewed the prospectively collected data from 527 consecutive colorectal cancer patients who under went laparoscopic resection from January 2008 to September 2013. Patients were categorized into three groups: nonobese (body mass index (BMI) <25.0 kg/m²), obese I (BMI 25.0 = to 29.9 kg/m²) and obese II (BMI ≥30.0 kg/m²). Clinical characteristics, surgical outcomes and postoperative complications were compared between nonobese, obese I and obese II patients.

Results

From among the 527 patients, there were 371 patients with in the nonobese group, 142 patients in the obese I group and 14 patients in the obese II group. The patients were well-matched for age, sex and American Society of Anesthesiologists class, except for BMI (P = 0.001). The median operative time correlated highly significantly with increasing weight (median: nonobese = 135 minutes, obese I = 145 minutes, obese II = 162.5 minutes; P = 0.001). There appeared to be a slight tendency toward grade III complications (rated according to the Clavien-Dindo Classification of Surgical Complications) in the obese II group, but this difference was not significant (nonobese = 5.1%, obese I = 3.5% and obese II = 14.3%; P = 0.178). None of the grade III complications which occurred in the obese II group were wound dehiscences that required a stitch. Other aspects, such as estimated blood loss, harvested lymph nodes, operation type, pathological results, conversion rate and overall postoperative complications, were not statistically significant.

Conclusion

With sufficient experience, laparoscopic colorectal cancer surgery is feasible and safe in obese Chinese patients.

Republished: obesity and colorectal cancer

Excess body weight, as defined by the body mass index (BMI), has been associated with several diseases and includes subjects who are overweight (BMI≥25-29.9 kg/m(2)) or obese (BMI≥30 kg/m(2)). Overweight and obesity constitute the fifth leading risk for overall mortality, accounting for at least 2.8 million adult deaths each year. In addition around 11% of colorectal cancer (CRC) cases have been attributed to overweight and obesity in Europe. Epidemiological data suggest that obesity is associated with a 30-70% increased risk of colon cancer in men, whereas the association is less consistent in women. Similar trends exist for colorectal adenoma, although the risk appears lower. Visceral fat, or abdominal obesity, seems to be of greater concern than subcutaneous fat obesity, and any 1 kg/m(2) increase in BMI confers additional risk (HR 1.03). Obesity might be associated with worse cancer outcomes, such as recurrence of the primary cancer or mortality. Several factors, including reduced sensitivity to antiangiogenic-therapeutic regimens, might explain these differences. Except for wound infection, obesity has no significant impact on surgical procedures. The underlying mechanisms linking obesity to CRC are still a matter of debate, but metabolic syndrome, insulin resistance and modifications in levels of adipocytokines seem to be of great importance. Other biological factors such as the gut microbita or bile acids are emerging. Many questions still remain unanswered: should preventive strategies specifically target obese patients? Is the risk of cancer great enough to propose prophylactic bariatric surgery in certain patients with obesity?

Impact of BMI on postoperative outcomes in patients undergoing proctectomy for rectal cancer: a national surgical quality improvement program analysis

BACKGROUND

There is a mounting body of evidence that suggests worsened postoperative outcomes at the extremes of BMI, yet few studies investigate this relationship in patients undergoing proctectomy for rectal cancer.

OBJECTIVE

We aimed to examine the relationship between BMI and short-term outcomes after proctectomy for cancer.

DESIGN

This was a retrospective study comparing the outcomes of patients undergoing proctectomy for rectal cancer as they relate to BMI.

SETTINGS

The American College of Surgeons-National Surgical Quality Improvement Program database was queried for this study.

PATIENTS

Patients included were those who underwent proctectomy for rectal neoplasm between 2005 and 2011.

MAIN OUTCOME MEASURES

Study end points included 30-day mortality and overall morbidity, including the receipt of blood transfusion, venous thromboembolic disease, wound dehiscence, renal failure, reintubation, cardiac complications, readmission, reoperation, and infectious complications (surgical site infection, intra-abdominal abscess, pneumonia, and urinary tract infection). Univariate logistic regression was used to analyze differences among patients of varying BMI ranges (kg/m; ≤20, 20-24, 25-29, 30-34, and ≥35). When significant differences were found, multivariable logistic regression, adjusting for preoperative demographic and clinical variables, was performed.

RESULTS

A total of 11,995 patients were analyzed in this study. The incidences of overall morbidity, wound infection, urinary tract infection, venous thromboembolic event, and sepsis were highest in those patients with a BMI of ≥35 kg/m (OR, 1.63, 3.42, 1.47, 1.64, and 1.50). Wound dehiscence was also significantly more common in heavier patients. Patients with a BMI <20 kg/m had significantly increased rates of mortality (OR, 1.72) and sepsis (OR, 1.30).

LIMITATIONS

This study was limited by its retrospective design. Furthermore, it only includes patients from the American College of Surgeons-National Surgical Quality Improvement Program database, limiting its generalizability to nonparticipating hospitals.

CONCLUSIONS

Obese and underweight patients undergoing proctectomy for neoplasm are at a higher risk for postoperative complications and death.

Obesity was associated with a decreased postoperative recurrence of rectal cancer in a Japanese population

PURPOSE

Obesity contributes to the technical difficulty of rectal surgery and is considered to be a risk factor for postoperative complications. The impact of obesity on the long-term outcomes of rectal cancer surgery remains unclear.

METHODS

A total of 263 consecutive rectal cancer patients who underwent surgery were categorized into two groups according to the body mass index (BMI) based on the Asian BMI classification: non-obese (BMI <25 kg/m(2)) and obese (BMI ≥25 kg/m(2)). The postoperative survival and recurrence rates and oncological surgical quality indicators were compared between groups using the univariate and multivariate analyses. The differences in recurrence patterns were assessed by a competing risk regression analysis.

RESULTS

64 (24%) patients were included in the obese group. The number of retrieved lymph nodes was significantly greater in the non-obese group than in the obese group (22.4 vs. 16.0, P < 0.01). The 5-year disease-free survival (DFS) rates were 86.5 and 68.8% in the obese and non-obese groups, respectively (P = 0.01). The multivariate analysis demonstrated that obesity significantly decreased the postoperative recurrence rate (P = 0.04). Moreover, the BMI was significantly associated with distant metastasis (P = 0.04).

CONCLUSIONS

Obese rectal cancer patients have high DFS rates and a decreased incidence of distant metastases compared to non-obese patients. The BMI may be a key factor for predicting the postoperative prognosis and determination of an appropriate strategy for the treatment of rectal cancer patients.

Risk factor evaluation for postoperative complications in laparoscopic colorectal surgery by a classic severity grading system

Using the uniform complication grading system to evaluate postoperative complications after laparoscopic colorectal surgery is the purpose of the present study. Surgical complications were defined as grades I, II, III, IV, and V recommended by Dindo et al. Patients were categorized into three pairs: complication group (CG) and non-complication group (NCG), minor complication group (MiCG, grades I-II) and non-minor complication group (NMiCG), and major complication group (MaCG, grades III-V) and non-major complication group (NMaCG); of the 570 patients, 431 patients were discharged with no complications, and 174 complications occurred in 119 patients. The percent of grades I, II, III, IV, and V complications were 4.7, 20, 4.7, 0.7, and 0.4 %, respectively. Complications were significantly associated with male gender, larger tumor volume, and more estimated blood loss (EBL). The multivariate analysis revealed that male and EBL ≥150 ml were found to be independent predictors of postoperative complications. In subgroup analysis, patients with larger tumor volume were at significantly higher risk of postoperative major complications, and male gender and EBL ≥150 ml remained independent predictors of developing minor postoperative complications. Patients with postoperative complications would significantly experience longer hospital stay, later fluid intake, and delayed urinary catheter removal. Male, larger tumor volume, and more EBL were significant risk factors for laparoscopic colorectomy.

Perioperative nutrition: what is the current landscape?

Poor nutrition status has long been linked to increases in postoperative complications and adverse outcomes for the patient undergoing elective surgery. While optimal planning for nutrition therapy should be comprehensive spanning throughout the perioperative period, recent advances have focused on the concept of "prehabilitation" to best prepare the patient prior to the insult of surgery. Adding immune/metabolic modulating formulas the week of surgery with carbohydrate drinks to optimize glycogen deposition immediately prior to surgery, enhances patient recovery and return to baseline function. Such nutrition strategies should now be combined with a host of other practices (such as smoking cessation, weight loss, glucose control, and specialized exercise program) as part of a structured protocol to maximize patients' chances for a full and rapid recovery from their elective surgical procedure.

Evaluation of a fast-track protocol for patients undergoing colorectal surgery

BACKGROUND AND AIMS

Fast-track protocols have been used to optimize the perioperative care and to enhance postoperative recovery. This study examined short-term clinical outcomes and determinants affecting the length of postoperative hospital stay.

MATERIAL AND METHODS

From 2007 to 2009, 180 patients underwent laparoscopic or open bowel resection (N = 138) or sacrocolporectopexy (N = 42) in the Central Hospital of Central Finland for various colorectal diseases in the fast-track setting. The main measures of outcome were time to functional recovery, 30-day morbidity, and readmission rates, with hospital stay and patient satisfaction as secondary outcomes.

RESULTS

There were no deaths. Time to functional recovery was median 2 (interquartile range 2-3) days. The overall 30-day postoperative morbidity was 14.5% after bowel resection and 0% after sacrocolporectopexy. Relaparotomy rate was 3.6% and 30-day readmission rate 7.2%. Postoperative hospital stay was median 3 days after small bowel and ileo-colic resection, 4 days after segmental colectomy, and 6 days after rectal resection and subtotal colectomy. Patient's body mass index > 30 kg/m², malignant disease, complexity of surgery, recovery of bowel function later than 2 days after surgery, time to functional recovery > 2 days and postoperative morbidity were patient- and treatment-related determinants increasing postoperative hospital stay. Protocol compliance-related determinants increasing postoperative hospital stay were intake of normal food and mobilization ≥ 6 h/day later than 2 days after surgery and removal of urinary catheter later than 1 day after surgery.

CONCLUSION

Postoperative functional recovery was fast, morbidity and readmission rates were low, and postoperative hospital stay short indicating that fast-track care should form the mainstay of elective colorectal surgery.

The influence of obesity on short- and long-term outcomes after laparoscopic surgery for colon cancer: a case-matched study of 152 patients

BACKGROUND

Despite the increasing prevalence of obesity and colonic diseases, the impact of obesity on short-term and oncologic outcomes of laparoscopic colorectal surgery still remains unclear.

STUDY DESIGN

Seventy-six consecutive obese patients with body mass index (BMI) ≥30 kg/m(2) who underwent laparoscopic colectomy were matched with 76 nonobese patients with BMI <30 kg/m(2). Perioperative parameters and oncologic outcomes were analyzed in the two groups.

RESULTS

Obesity was associated with greater operative time (obese vs nonobese, 182 ± 59 vs 157 ± 55 min, P = .0084) and multivariate analysis identified BMI (hazard ratio 2.11, 95% confidence interval 0.64-3.56, P = .0049) as an independent predicting factor for operative time together with cancer location (hazard ratio 28.6, 95% confidence interval 14.62-42.51, P < .0001). Obesity had no adverse influence on overall morbidity (25 vs 21%, P = .563), however, or postoperative duration of stay (median 6.0 vs 5.5 days, P = .22). Furthermore, the rate of conversion to open procedure was similar between the two groups (9 vs 9%, P > .99). Regarding oncologic outcomes, there was no statistical difference in overall and disease-free survival between the two groups (5-year overall survival rate 86 vs 89%, P = .72, 5-year disease survival rate 70 vs 77%, P = .70).

CONCLUSION

Laparoscopic colonic resection, when performed for selected patients, appears to be a safe and reasonable option in obese patients with colon cancer resulting in similar short-term and oncologic outcomes as nonobese patients.

The impact of visceral obesity on surgical outcomes of laparoscopic surgery for colon cancer

PURPOSE

Although obesity is considered as a risk factor for postoperative morbidity in abdominal surgery, its effect on the outcomes of laparoscopic-assisted colectomy (LAC) is still unclear. The technical difficulty and risk factor for postoperative complication in LAC are thought to be influenced by visceral obesity. The aim of this prospective study was to evaluate the impact of visceral fat on the surgical outcomes of LAC.

METHODS

Between April 2005 and December 2010, consecutive patients with preoperatively diagnosed colon cancer, excluding medium and low rectal cancer, who underwent LAC, were enrolled. Their visceral fat area (VFA) and body mass index (BMI) were prospectively collected. The VFA was assessed by Fat Scan software. The patients were classified into two groups as follows: VFA nonobese with VFA <100 cm(2) (VNO) and VFA obese with VFA ≧100 cm(2) (VO). The predictive factors for surgical complications of LAC were evaluated by univariate and logistic regression analyses.

RESULTS

A total of 338 consecutive patients were enrolled in this study. Of the 338 patients, 194 (57.4 %) and 138 (42.6 %) were classified into the VNO and VO groups, respectively. Logistic regression analysis showed that high BMI (≧25 kg/m(2)) and VO independently predicted the incidence of overall postoperative complications (p = 0.040 and 0.007, respectively). VO was more highly related to the incidence of overall postoperative complications, anastomotic leakage (p = 0.021), and surgical site infection (SSI) (p = 0.013) than high BMI.

CONCLUSIONS

VFA is a more useful parameter than BMI in predicting surgical outcomes after LAC.

Diabetes and cancer: two diseases with obesity as a common risk factor

There is a growing body of evidence to support a connection between diabetes (predominantly type 2), obesity and cancer. Multiple meta-analyses of epidemiological data show that people with diabetes are at increased risk of developing many different types of cancers, along with an increased risk of cancer mortality. Several pathophysiological mechanisms for this relationship have been postulated, including insulin resistance and hyperinsulinaemia, enhanced inflammatory processes, dysregulation of sex hormone production and hyperglycaemia. In addition to these potential mechanisms, a number of common risk factors, including obesity, may be behind the association between diabetes and cancer. Indeed, obesity is associated with an increased risk of cancer and diabetes. Abdominal adiposity has been shown to play a role in creating a systemic pro-inflammatory environment, which could result in the development of both diabetes and cancer. Here, we examine the relationship between diabetes, obesity and cancer, and investigate the potential underlying causes of increased cancer risk in individuals with diabetes. Current treatment recommendations for reducing the overall disease burden are also explored and possible areas for future research are considered.

Laparoscopy for colorectal cancer

The laparoscopic approach for colorectal cancer resection has been evolved from an experimental procedure with oncological concerns to routine daily practice within a period of two decades. Numerous randomized controlled trials and meta-analyses have shown that laparoscopic resection results in faster recovery with similar oncological outcome compared to an open approach, both for colon and rectal cancer. Besides improved cosmesis, other long-term advantages seem to be less adhesion related small bowel obstruction and reduced incisional hernia rate. Adequate patient selection and surgical experience are of crucial importance. Experience can be gradually expanded step by step, by increasing the complexity of the procedure. A decision to convert should be made early in the procedure, because the outcome after a reactive conversion is worse than initial open resection or strategic conversion. The additive value of new techniques such as robotic surgery has to be proven in randomized studies including a cost-effectiveness assessment.

Preoperative adipocytokines as a predictor of surgical infection after colorectal surgery: a prospective survey

BACKGROUND

Infections are the leading cause of morbidity and mortality after colorectal surgery. Obesity is a well-known risk factor for wound infection, but it does not seem to increase the risk of other infectious complications. The aim of this study was to look for a relationship between the fatty tissue metabolism measured by adipocytokine levels and the risk of postoperative infection.

PATIENTS AND METHODS

Preoperative plasma levels of eight adipocytokines, cholesterol, triglycerides, insulin and C-reactive protein (CRP) were measured in consecutive patients undergoing elective colorectal surgery between June 2008 and June 2011. Information about epidemiological and clinical characteristics was obtained for each patient. All infections in the 30 days following surgery were recorded.

RESULTS

Among the 174 patients included, 49 (28 %) presented with a postoperative infection: 41 surgical site infections and 8 other infections. Preoperative leptin, insulin and CRP were significantly higher in patients with postoperative infection (p = 0.025, p = 0.020 and p = 0.044, respectively), but only leptin was predictive of infection in multivariate analysis (odds ratio (OR) = 1.89, 95 % confidence interval (CI) 1.18-3.03, p = 0.008). The predictive value of leptin was slightly lower for surgical site infection (OR = 1.65, 95 % CI 1.06-2.55, p = 0.025). Leptin levels were independent of the other adipocytokine levels but not of the body mass index.

CONCLUSION

Although markers of inflammation and insulin resistance are also related to the onset of surgical infection, leptin correlates more closely with the risk of infection than does any other factor. However, its effect could be partially mediated by the body mass index.

Waist circumference and waist/hip ratio are better predictive risk factors for mortality and morbidity after colorectal surgery than body mass index and body surface area

OBJECTIVES

To determine whether body fat distribution, measured by waist circumference (WC) and waist/hip ratio (WHR), is a better predictor of mortality and morbidity after colorectal surgery than body mass index (BMI) or body surface area (BSA).

BACKGROUND

Obesity measured by BMI is not a consistent risk factor for postoperative mortality and morbidity after abdominal surgery. Studies in metabolic and cardiovascular diseases have shown WC and WHR to be better outcome predictors than BMI.

METHODS

A prospective multicenter international study was conducted among patients undergoing elective colorectal surgery. The WHR, BMI, and BSA were derived from body weight, height, and waist and hip circumferences measured preoperatively. Uni- and multivariate analyses were performed to identify risk factors for postoperative outcomes.

RESULTS

A total of 1349 patients (754 men) from 38 centers in 11 countries were included. Increasing WHR significantly increased the risk of conversion [odds ratio (OR) = 15.7, relative risk (RR) = 4.1], intraoperative complications (OR = 11.0, RR = 3.2), postoperative surgical complications (OR = 7.7, RR = 2.0), medical complications (OR = 13.2, RR = 2.5), anastomotic leak (OR = 13.7, RR = 3.3), reoperations (OR = 13.3, RR = 2.9), and death (OR = 653.1, RR = 21.8). Both BMI (OR = 39.5, RR = 1.1) and BSA (OR = 4.9, RR = 3.1) were associated with an increased risk of abdominal wound complication. In multivariate analysis, the WHR predicted intraoperative complications, conversion, medical complications, and reinterventions, whereas BMI was a risk factor only for abdominal wall complications; BSA did not reach significance for any outcome.

CONCLUSIONS

The WHR is predictive of adverse events after elective colorectal surgery. It should be used in routine clinical practice and in future risk-estimating systems.