Network meta-analysis of protocol-driven care and laparoscopic surgery for colorectal cancer

Practice-changing clinical trials in radiation oncology for gastrointestinal malignancies in 2021-2023

Gastrointestinal cancers are one of the most frequent cancers and a leading cause of cancer deaths worldwide. We provide an overview of the most important practice-changing trials that were either published or presented at the international scientific meetings in 2021-2023. Highlights included reports on three phase III trials (CONCORDE/PRODIGE 26, ARTDECO, and a study by Xu et al.) that evaluated dose escalation in the definitive setting for locally advanced oesophageal cancers, as well as two phase III trials that evaluated the role of chemotherapy (neo-AEGIS) and targeted therapy (NRG/RTOG 1010) in the neoadjuvant setting for adenocarcinoma oesophageal cancers or gastroesophageal junction cancer. CheckMate 577 evaluated nivolumab in patients who had residual pathological disease after neoadjuvant chemoradiation followed by complete resection. The use of radiation therapy for borderline and locally advanced pancreatic cancer is also discussed (SMART and CONKO-007 trials). Stereotactic body radiation therapy followed by sorafenib was compared to sorafenib alone in patients with hepatocellular carcinoma in the NRG/RTOG 1112 study. New options in the management of rectal cancer are emerging such as total neoadjuvant treatment (PRODIGE 23, RAPIDO, PROSPECT), organ preservation (OPRA, OPERA), and the role of immunotherapy in patients with DNA mismatch-repair deficient/microsatellite instability. Finally, preliminary results of the ACT 4 trial that evaluated de-escalation in anal cancer are presented.

Effect of perioperative airway management on postoperative outcomes of colorectal cancer patients with sarcopenia

BACKGROUND

It is common for colorectal cancer patients to have sarcopenia as a comorbidity, which has been shown to have a negative impact on prognosis after surgery. This study explored whether implementing a novel care program could improve postoperative outcomes in colorectal cancer patients with sarcopenia.

METHODS

We retrospectively analyzed the clinical data of patients diagnosed with sarcopenia before undergoing radical colorectal cancer surgery. We divided the patients into two groups according to the time point of program implementation and, compared the clinical characteristics and postoperative outcomes of these two groups.

RESULTS

A total of 227 patients were included in the study. The baseline clinical characteristics of the two groups were similar. Compared with the control group, patients in the implementation group had a significantly lower rate of total complications (18.5% vs. 30.3%, P = 0.041), a significantly lower rate of pulmonary complications (2.8% vs. 10.9%, P = 0.017), and a significantly shorter postoperative hospital stay (12 days vs. 14 days, P = 0.001). Implementation of perioperative airway management (P = 0.018) was shown to be a protective factor against pulmonary complications in colorectal cancer patients with sarcopenia.

CONCLUSION

The perioperative airway management program implemented at our center was easy to perform and can effectively improve short-term postoperative outcomes in colorectal cancer patients with sarcopenia.

Postoperative inpatient exercise facilitates recovery after laparoscopic surgery in colorectal cancer patients: a randomized controlled trial

BACKGROUND

Early mobilization is an integral part of an enhanced recovery program after colorectal cancer surgery. The safety and efficacy of postoperative inpatient exercise are not well known. The primary objective was to determine the efficacy of a postoperative exercise program on postsurgical recovery of stage I-III colorectal cancer patients.

METHODS

We randomly allocated participants to postoperative exercise or usual care (1:1 ratio). The postoperative exercise intervention consisted of 15 min of supervised exercise two times per day for the duration of their hospital stay. The primary outcome was the length of stay (LOS) at the tertiary care center. Secondary outcomes included patient-perceived readiness for hospital discharge, anthropometrics (e.g., muscle mass), and physical function (e.g., balance, strength).

RESULTS

A total of 52 (83%) participants (mean [SD] age, 56.6 [8.9] years; 23 [44%] male) completed the trial. The median LOS was 6.0 days (interquartile range; IQR 5-7 days) in the exercise group and 6.5 days (IQR 6-7 days) in the usual-care group (P = 0.021). The exercise group met the targeted LOS 64% of the time, while 36% of the usual care group met the targeted LOS (colon cancer, 5 days; rectal cancer, 7 days). Participants in the exercise group felt greater readiness for discharge from the hospital than those in the usual care group (Adjusted group difference = 14.4; 95% CI, 6.2 to 22.6; P < 0.01). We observed a small but statistically significant increase in muscle mass in the exercise group compared to usual care (Adjusted group difference = 0.63 kg; 95% CI, 0.16 to 1.1; P = 0.03).

CONCLUSION

Postsurgical inpatient exercise may promote faster recovery and discharge after curative-intent colorectal cancer surgery.

TRIAL REGISTRATION

The study was registered at WHO International Clinical Trials Registry Platform (ICTRP; URL http://apps.who.int/trialsearch ); Trial number: KCT0003920 .

Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

Efficacy of various adjuvant chemotherapy methods in preventing liver metastasis from potentially curative colorectal cancer: A systematic review network meta-analysis of randomized clinical trials

PURPOSE

Various chemotherapy administration methods have been used to prevent liver metastasis (LM) in patients with colorectal cancer (CRC). This network meta-analysis evaluated the efficacy of these different methods in preventing LM in CRC patients who underwent curative surgery.

METHOD

A systematic search of randomized controlled trials reporting the efficacy of various adjuvant chemotherapy methods in patients with colorectal cancer who underwent curative surgery was conducted. The primary outcome was the LM rate.

RESULTS

This network meta-analysis included 19 studies reporting on 12,588 participants, comparing portal vein infusion chemotherapy (PVIC) versus hepatic arterial infusion chemotherapy (HAIC) versus systematic chemotherapy (SC) versus surgery alone. The HAIC group had the lowest LM rate when compared to the other three groups (odds ratio [OR] of PVIC vs. HAIC: 1.86; OR of SC vs. HAIC: 1.98; and HAIC vs. surgery alone: 0.43). The LM rate did not differ significantly between PVIC, SC, and surgery alone. The recurrence rates were lower for PVIC and HAIC than for surgery alone (the ORs for PVIC and HAIC were 0.73 [95% CI: 0.58-0.92] and 0.45 [95% CI: 0.26-0.77]). The mortality rates of patients undergoing PVIC and HAIC were lower than that of patients undergoing surgery alone (the ORs for PVIC and HAIC were 0.77 [95% CI: 0.64-0.93] and 0.49 [95% CI: 0.24-0.98]). Anastomotic leakage, cardiopulmonary leakage, diarrhea, nausea and vomiting, oral ulceration, wound infection, or ileus did not differ significantly between the four groups. PVIC showed the highest hepatic toxicity rate compared to those for SC, HAIC, and surgery alone.

CONCLUSION

HAIC might be a satisfactory method for preventing LM in patients with CRC undergoing curative surgery.

Laparoscopic Radical Resection of Colorectal Cancer in the Treatment of Elderly Colorectal Cancer and Its Effect on Gastrointestinal Function

Objective

To explore the efficacy and safety of laparoscopic radical resection of colorectal cancer in the elderly patients and its impact on gastrointestinal function.

Methods

A total of 122 elderly patients with colorectal cancer admitted to our hospital from March 2020 to June 2021 were selected as the research subjects, and they were divided into the control group (n = 61) and the observation group (n = 61). The control group was treated with traditional laparotomy, and the observation group was treated with laparoscopic radical resection of colorectal cancer. The clinical data of operation time, incision length, intraoperative bleeding volume, and hospitalization time in the two groups were recorded. Serum motilin (MTL) and gastrin (GAS) levels were measured pre- and post-operatively. The duration of abdominal distension, the time for the abdominal sound to return to normal, the time for the anal exhaust to normal, and the time for normal food intake were recorded after operation. The patients were followed up for 6 months post-operatively, and the complications during follow-up were recorded.

Results

The total response rate of the observation group (95.08%) was higher than that of the control group (81.97%) (P < 0.05). The operation time, incision length, intraoperative bleeding volume, and hospitalization time of the observation group were lower than those of the control group (P < 0.05). The duration of abdominal distension, the time for bowel sounds to return to normal, the time for the anus to exhaust gas to normal, and the normal eating time in the observation group were all lower than those in the control group (P < 0.05). After surgery, the levels of MTL and GAS in the two groups were lower than those before surgery, and those in the observation group were lower than those in the control group (P < 0.05). The total incidence of complications in the observation group (3.28%) was lower than that in the control group (13.12%) (P < 0.05).

Conclusion

Laparoscopic radical resection of colorectal cancer in the elderly patients has good effect, short operation time, less trauma, less blood loss during operation, short hospital stay, good recovery of gastrointestinal function, fewer complications, and high safety.

Enhanced Recovery After Surgery: Are Benefits Demonstrated in International Studies Replicable in Pakistan?

Objectives

To determine the efficacy of enhanced recovery after surgery (ERAS) protocols in terms of frequency of surgical site infection (SSI) and length of hospital stay in patients undergoing colorectal surgeries for colorectal carcinoma.

Study design

Quasi-experimental study.

Setting/Duration of study

Department of Surgery, Shifa International Hospital, Islamabad, from May 7, 2019 to November 6, 2019.

Methodology

A total of 120 patients with colorectal carcinomas who fulfilled that sample selection criteria were studied. After randomization, patients were divided into two equal groups; one group received management under ERAS while the second group received conventional management. All patients were recorded for length of hospital stay and the development of SSIs. Data were analyzed using SPSS 26.0.

Results

The mean age was 42.34 ± 14.45 years, with a male majority, i.e., 72 (60%). The mean duration of in-patient stay was 3.45 ± 1.73 days with ERAS and 8.25 ± 1.58 days with conventional management (p < 0.001). A total of 28 (23.3%) SSIs developed, of which nine (7.5%) SSIs occurred with ERAS, while 19 (15.8%) occurred with traditional management (p = 0.031).

Conclusion

ERAS protocols have been demonstrated to be effective, cheap, and safe. There is a tangible reduction in length of hospital stay and incidence of SSIs which translates into reduced utilization of resources and financial costs. However, strict adherence to the protocol may be necessary to obtain the aforementioned benefits, which may be difficult to do in the face of professional, institutional, and personal inertia. Intensive efforts are required to make these protocols more convenient and attractive to implement, so as to facilitate conversion to this management approach.

Safety and feasibility of laparoscopic surgery for elderly rectal cancer patients in Japan: a nationwide study

Background

This study aimed to analyse the perioperative results from a national dataset of rectal cancer resections in elderly patients.

Methods

The clinical records of patients undergoing rectal cancer surgery between 2012 and 2014 were retrieved from the Japanese National Clinical Database and analysed retrospectively. Patients were categorized according to age and those 80 years or older were defined as elderly. Subgroups were also defined according to the surgical approach (laparoscopy versus open surgery). The short-term outcomes, including mortality, anastomotic leak, surgical site infections and medical complications were compared between subgroups.

Results

Of 56 175 patients undergoing rectal cancer surgery, some 6717 patients were elderly and laparoscopy was performed in 46.8 per cent of the sample. When comparing laparoscopy and open surgery in elderly patients, the operative mortality rate (1.5 versus 2.8 per cent; P < 0.001), the incidence of anastomotic leakage (5.2 versus 6.5 per cent; P = 0.026), surgical site infections (6.0 versus 8.0 per cent; P = 0.001), pneumonia (1.4 versus 2.5 per cent; P = 0.001), renal failure (0.7 versus 1.3 per cent; P = 0.016) and cardiac events (0.3 versus 0.8 per cent; P = 0.008) were lower for laparoscopy than for open surgery. The overall complication rate in elderly patients (19.5 per cent) was comparable to that in the younger group (P = 0.07). However, incidence of systemic complications was significantly higher in elderly than in younger patients (all P < 0.001).

Conclusion

Laparoscopy was safe and feasible in elderly patients compared with open surgery. However, the rates of systemic complications were significantly higher than in younger patients.

Laparoscopic versus open resection for elderly patients with gastric cancer: a double-center study with propensity score matching method

PURPOSE

The applicability of laparoscopic-assisted radical gastrectomy for elderly patients with gastric cancer is still not well clarified. The aim of this double-center study was to explore the feasibility and effectiveness of laparoscopic-assisted radical gastrectomy on elderly patients with gastric cancer.

METHODS

We prospectively collected data of patients who underwent gastrectomy for cancer in two centers from June 2016 to December 2019. Propensity score matching was performed at a ratio of 1:1 to compare the laparoscopic-assisted radical gastrectomy group and open radical gastrectomy group. Univariate analyses and multivariate logistic regression analyses evaluating the risk factors for total, surgical, and medical complications were performed.

RESULTS

A total of 481 patients with gastric cancer met the inclusion criteria and were included in this study. After propensity score analysis, 258 patients were matched each other (laparoscopic-assisted radical gastrectomy (LAG) group, n = 129; open radical gastrectomy (OG) group, n = 129). LAG group had lower rate of surgical complications (P = 0.009), lower rate of severe complications (P = 0.046), shorter postoperative hospital stay (P = 0.001), and lower readmission rate (P = 0.039). Multivariate analyses revealed that anemia, Charlson comorbidity index, and combined resection were independent risk factors in the LAG group, whereas body mass index and American Society of Anesthesiology grade in the OG group.

CONCLUSION

Laparoscopic-assisted radical gastrectomy was relative safe even effective in elderly gastric cancer patients. We should pay attention to the different risk factors when performing different surgical procedures for gastric cancer in elderly patients.

Trocar-site incisional hernia after laparoscopic colorectal surgery: a significant problem? Incidence and risk factors from a single-center cohort

BACKGROUND

Trocar-site incisional hernia (TSIH) after laparoscopic surgery has been scarcely studied. TSIH incidence and risk factors have never been properly studied for laparoscopic colorectal surgery.

METHODS

A retrospective analytic study in a tertiary hospital was performed including patients who underwent elective laparoscopic colorectal surgery between 2014 and 2016. Clinical and radiological TSIH were analyzed.

RESULTS

272 patients with a mean age of 70.7 years were included. 205 (75.4%) underwent surgery for a malignant disease. The most common procedure was right colectomy (108 patients, 39.7%). After a mean follow-up of 30.8 months 64 (23.5%) patients developed a TSIH. However, only 7 out of 64 (10.9%) patients with a TSIH underwent incisional hernia repair. That means that 2.6% of all the patients underwent TSIH repair. 44 (68.8%) patients had TSIH in the umbilical Hasson trocar. In the multivariate analysis, the existence of an umbilical Hasson trocar orifice was the only statistically significant risk factor for TSIH development.

CONCLUSIONS

Incidence of TSIH was high, although few patients underwent incisional hernia repair. Most TSIH were observed in the umbilical Hasson trocar, which was the only risk factor for TSIH development in the multivariate analysis. Efforts should be addressed to avoid TSIH in the umbilical Hasson trocar.

Value of an interactive phone application in an established enhanced recovery program

PURPOSE

An interactive mobile phone application was added to an established Enhanced Recovery After Surgery (ERAS) program to determine the impact on ERAS compliance as well as clinical outcomes.

METHODS

We identified patients undergoing elective colorectal surgery enrolled in our ERAS program from February 2017 to July 2018. Patients enrolled in a phone application were compared with those not enrolled in terms of age, sex, diagnosis, operative approach, bowel preparation, oral intake and solid food intake, ERAS pathway adherence, and clinical outcomes.

RESULTS

A total of 289 patients were included: 147 enrolled and 142 not enrolled in the phone application. The mean age of enrollees was 53.0 years, compared with 58.3 years for the non-enrollees (p = 0.003). The mean ERAS pathway medication adherence for enrollees was 82.1% versus 76.8% for those not enrolled (p = 0.005). The mean LOS and SSI rates for those enrolled versus not enrolled in the phone application was 4.4 days versus 6.4 days (p = 0.006) and 3.4% versus 11.3% (p = 0.019), respectively. There was no significant difference in readmission rates between enrollees and non-enrollees (15% versus 10.6%, p = 0.345). The mean total cost of patients enrolled was $11,560; total cost of those not enrolled was $13,946 (p = 0.024).

CONCLUSIONS

Use of an interactive phone application is associated with improved medication ERAS adherence along with significant reduction in length of stay and SSI rates without increasing total cost.

Robotic versus laparoscopic right colectomy within a systematic ERAS protocol: a propensity-weighted analysis

The purpose of this study is to compare the early postoperative and pathological outcomes of robotic right colectomy (RRC) to those of laparoscopic right colectomy (LRC) with intracorporeal anastomosis (IA) within the systematic application of an enhanced recovery after surgery (ERAS) program. A single-institution prospective database of patients who underwent elective RRC or LRC with IA for neoplastic lesions between April 2010 and June 2018 was retrospectively reviewed. The patients' demographic characteristics, and perioperative and pathological outcomes were analyzed. Propensity-weighted analysis was employed to address potential selection biases of treatment allocation. A total of 216 patients (46 RRC, 170 LRC) were included. RRC demonstrated a significantly longer operative time (mean 242.43 min, SD 47.51) compared to LRC (mean 187.60 min, SD 56.60) (p = 0.001), confirmed by the propensity-weighted analysis (Coefficient 50.65; p < 0.001). Conversion rate between the two groups was comparable (p = 0.99). Median length of hospital stay (LOS) was the same in the RRC and the LRC group (4 days, p = 0.35). Readmission rate within 30 days in the RRC and LRC group was 2.2% and 2.4%, respectively (p = 0.99). Overall 30-day morbidity and 30-day mortality was 32.6% versus 27.1% (p = 0.46), and 0% versus 1.2% (p = 0.99) in the robotic and laparoscopic groups, respectively. No difference was found in the number of harvested lymph nodes (p = 0.75). In an ERAS environment, without the bias of mixed techniques of anastomosis, RRC had similar postoperative and pathological outcomes compared to the laparoscopic approach, but was associated with a longer operative time.

Minimally Invasive Versus Open Pancreaticoduodenectomy: A Propensity-matched Study From a National Cohort of Patients

OBJECTIVE

To compare the perioperative outcomes of minimally invasive pancreaticoduodenectomy (MIPD) in comparison with open pancreaticoduodenectomy (OPD) in a national cohort of patients.

BACKGROUND

Limited well-controlled studies exist comparing perioperative outcomes between MIPD and OPD.

METHODS

Patients who underwent MIPD and OPD were abstracted from the 2014 to 2015 pancreas-targeted American College of Surgeons National Surgical Quality Improvement Program. OPD and MIPD patients were matched 3:1 using propensity score, and perioperative outcomes were compared.

RESULTS

A total of 4484 patients were identified with 334 (7.4%) undergoing MIPD. MIPD patients were younger, more likely to be White, and had a lower rate of weight loss. They were more likely to undergo classic Whipple and to have a drain placed. After 3:1 matching, 1002 OPD patients were compared with 334 MIPD patients. MIPD was associated with longer mean operative time (426.6 vs 359.6 minutes; P < 0.01), higher readmission rate (19.2% vs 14.3%; P = 0.04) and lower rate of prolonged length of stay >14 days (16.5% vs 21.6%; P = 0.047). The 2 groups had a similar rate of 30-day mortality (MIPD 1.8% vs OPD 1.3%; P = 0.51), overall complications, postoperative pancreatic fistula, and delayed gastric emptying. A secondary analysis comparing MIPD without conversion or open assist with OPD showed that MIPD patients had lower rates of overall surgical site infection (13.4% vs 19.6%; P = 0.04) and transfusion (7.9% vs 14.4%; P = 0.02).

CONCLUSIONS

MIPD had an equivalent morbidity and mortality rate to OPD, with the benefit of a decreased rate of prolonged length of stay, though this is partially offset by an increased readmission rate.

The Association of Preoperative Anemia and the Postoperative Course and Oncological Outcome in Patients Undergoing Rectal Cancer Surgery: A Multicenter Snapshot Study

BACKGROUND

There is still controversy about the relationship between preoperative anemia and outcomes after rectal cancer surgery.

OBJECTIVE

The aim of this study was to analyze the association between preoperative anemia and postoperative complications and the survival of patients undergoing surgery for rectal cancer in the era of laparoscopic surgery and modern perioperative care.

DESIGN

This was a cohort study.

SETTINGS

Data were gathered from 71 hospitals in The Netherlands.

PATIENTS

Patients who underwent resection for rectal cancer in 2011, for whom preoperative hemoglobin level was registered, were included.

INTERVENTIONS(S)

There were no interventions.

MAIN OUTCOME MEASURES

Short-term outcome parameters were any postoperative complication or mortality within 30 days postoperatively, and pelvic infectious complications defined as anastomotic leakage and presacral abscess. Long-term outcomes were chronic sinus diagnosed at any time during 3-year follow-up, 3-year local and distant recurrence rates, and 3-year overall survival.

RESULTS

Of 2095 patients, 1857 had a registered preoperative hemoglobin level; 576 (31%) of these patients anemic and 1281 (69%) were nonanemic. Preoperative anemia was not independently associated with postoperative complications (HR, 1.1; 95% CI, 0.9-1.4; p = 0·24) or 30-day mortality (HR, 1.4, 95% CI, 0.7-2.8; p = 0·29). Preoperative anemia was associated with 3-year overall survival (HR, 2.1; 95% CI, 1.7-2.5; p < 0.0001), after multivariable analysis (HR, 1.4; 95% CI, 1.1-1.8; p = 0·008), and with local recurrence rate (HR, 1.6; 95% CI, 1.1-2.4; p = 0.026), but not with distant recurrence rate (HR, 1.2; 95% CI, 1.0-1.5; p = 0.054).

LIMITATIONS

Preoperative anemia appeared to have only limited association with postoperative and disease-specific outcome after rectal cancer surgery in contrast to published meta-analysis of small historical series.

CONCLUSIONS

Anemia is associated with overall survival. It might be considered as one of the warning signs in identifying high-risk patients. See Video Abstract at http://links.lww.com/DCR/A913.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Receiver operating characteristic analysis to determine optimal fluid management during open colorectal surgery

AIM

The present study aimed to analyse fluid management and to define optimal fluid-related thresholds for elective open colorectal surgery.

METHOD

A retrospective analysis was made of all consecutive elective open colorectal resections performed in our tertiary centre between May 2011 and May 2017. The main outcomes were postoperative complications [overall (I-V) and severe (IIIB-V) according to the Clavien classification], respiratory complications and postoperative ileus (POI). Critical thresholds regarding perioperative fluid management and postoperative weight gain were identified by using receiver operator characteristic (ROC) analysis. Independent risk factors for overall complications were identified by multivariable logistic regression analysis.

RESULTS

Of 121 patients who had open operations, 84 (69%) had some complication and 26 (21%) had severe complications. Respiratory complications and POI occurred in 15 (12%) and 46 patients (38%), respectively. The thresholds for intravenous fluids were 3.5 l at postoperative day (POD) 0 [area under ROC curve (AUROC) 0.7 for any 0.69 for respiratory complications] and 3.5 kg weight gain at POD 2 (AUROC 0.82 for respiratory complications). Multivariable analysis revealed weight gain of > 3.5 kg at POD 2 (OR 5.9; 95% CI 1.3-16.6) as a significant risk factor for overall complications. Acute kidney injury was observed in five patients (4%), three (5%) in the group with > 3.5 l at POD 0 and two (3%) in the group with < 3.5 l at POD 0 (P = 0.64). Creatinine increase was transitory and all patients regained baseline levels before discharge.

CONCLUSION

A weight gain of > 3.5 kg at POD 2 has been identified as the critical threshold for overall and respiratory complications and prolonged length of stay after open elective colorectal surgery.

Comparison of robot-assisted surgery, laparoscopic-assisted surgery, and open surgery for the treatment of colorectal cancer: A network meta-analysis

BACKGROUND

The aim of this study was to find the better treatment for colorectal cancer (CRC) by comparing robot-assisted colorectal surgery (RACS), laparoscopic-assisted colorectal surgery (LACS), and open surgery using network meta-analysis.

METHODS

A literature search updated to August 15, 2017 was performed. All the included literatures were evaluated according to the quality evaluation criteria of bias risk recommended by the Cochrane Collaboration. All data were comprehensively analyzed by ADDIS. Odds ratio (OR), mean difference (MD), and 95% confidence interval (CI) were used to show the effect index of all data. The degree of convergence of the model was evaluated by the Brooks-Gelman-Rubin method with the potential scale reduction factor (PSRF) as the evaluation indicator.

RESULTS

The PSRF values of operation time, estimated blood loss, length of hospital stay, complication, mortality, and anastomotic leakage ranged from 1.00 to 1.01, and those of wound infection, bleeding, and ileus ranged from 1.00 to 1.02. Open surgery had the shortest operation time compared with LACS and RACS. Furthermore, compared with LACS, the amount of blood loss, complication, mortality, bleeding rate, and ileus rate for RACS were the least, and the length of hospital stay for RACS was the shortest. The anastomotic leakage rate for LACS was the least, but there was no significant difference compared with those of RACS and open surgery. The wound infection rate for LACS was the least, but there was no significant difference compared with that of RACS.

CONCLUSION

RACS might be a better treatment for patients with CRC.

Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery

Enhanced Recovery After Surgery (ERAS) is an evidence-based paradigm shift in perioperative care, proven to lower both recovery time and postoperative complication rates. The role of ERAS in several surgical disciplines was reviewed. In colorectal surgery, ERAS protocol is currently well established as the best care. In gastric surgery, 2014 saw an establishment of ERAS protocol for gastrectomies with resulting meta-analysis showing ERAS effectiveness. ERAS has also been shown to be beneficial in liver surgery with many centers starting implementation. The advantages of ERAS in pancreatic surgery have been strongly established, but there is still a need for large-scale, multicenter randomized trials. Barriers to implementation were analyzed, with recent studies concluding that successful implementation requires a multidisciplinary team, a willingness to change and a clear understanding of the protocol. Additionally, the difficulty in accomplishing necessary compliance to all protocol items calls for new implementation strategies. ERAS success in different patient populations was analyzed, and it was found that in the elderly population, ERAS shortened the length of hospitalization and did not lead to a higher risk of postoperative complications or readmissions. ERAS utilization in the emergency setting is possible and effective; however, certain changes to the protocol may need to be adapted. Therefore, further research is needed. There remains insufficient evidence on whether ERAS actually improves patients’ course in the long term. However, since most centers started to implement ERAS protocol less than 5 years ago, more data are expected.

Attitudes of surgeons to the use of postoperative markers of the systemic inflammatory response following elective surgery

Background

Cancer is responsible for 7.6 million deaths worldwide and surgery is the primary modality of a curative outcome. Postoperative care is of considerable importance and it is against this backdrop that a questionnaire based study assessing the attitudes of surgeons to monitoring postoperative systemic inflammation was carried out.

Method

A Web based survey including 10 questions on the “attitudes of surgeons to the use of postoperative markers of the systemic inflammatory response following elective surgery” was distributed via email. Two cohorts were approached to participate in the survey. Cohort 1 consisted of 1092 surgeons on the “Association of Coloproctology of Great Britain and Ireland (ACPGBI)” membership list. Cohort 2 consisted of 270 surgeons who had published in this field in the past as identified by two recent reviews. A reminder email was sent out 21 days after the initial email in both cases and the survey was closed after 42 days in both cases.

Result

In total 29 surgeons (2.7%) from cohort 1 and 40 surgeons (14.8%) from cohort 2 responded to the survey. The majority of responders were from Europe (77%), were colorectal specialists (64%) and were consultants (84%) and worked in teaching hospitals (54%) and used minimally invasive techniques (87%). The majority of responders measured CRP routinely in the post-operative period (85%) and used CRP to guide their decision making (91%) and believed that CRP monitoring should be incorporated into postoperative guidelines (81%).

Conclusion

Although there was a limited response the majority of surgeons surveyed measure the systemic inflammatory response following elective surgery and use CRP measurements together with clinical findings to guide postoperative care. The present results provide a baseline against which future surveys can be compared.

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Shows that there is a widespread interest in the use of markers of the systemic inflammatory response in managing patients.

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This is particularly true when managing complications post operatively.

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There would seem to be scope for incorporation of markers of the SIR into formal post operative guidelines.