The Impact of Operative Approach on Postoperative Complications Following Colectomy for Colon Caner

Risk factors for postoperative anastomotic leakage in obstructive left colonic carcinoma

Anastomotic leakage (AL) is one of the most severe complications of colon carcinoma surgery. This study aims to investigate the related factors of AL and evaluate the independent risk factors in predicting AL after one-stage resection and primary anastomosis (RPA) for obstructive left colonic carcinoma (OLCC) patients. The demographic and clinical data, intra-operative indexes, pathologic characteristics, and ileocecal valve status shown on CT of the patients with OLCC who submitted to one-stage RPA were retrospectively analyzed. They were divided into AL group and no AL group. All indexes of the two groups were compared and the independent risk factors for AL were investigated. Receiver operating characteristic (ROC) curve analysis was used to explore the ability of the statistically significant parameters to predict AL. A total of 141 patients (AL group, 15; no AL group, 126) were enrolled. There were no statistical differences in these indexes between the two groups except for BMI (P = 0.001), ALB (P = 0.020), lymphatic metastasis (P = 0.027), and ileocecal valve status (P < 0.001). BMI, ALB, and ileocecal valve status shown on CT were the independent risk factors for AL. A BMI and ALB cutoff value of 22.2 kg/m2 and 27.9 g/L showed the area under the curve (AUC 0.765; 95% CI 0.686-0.832 and 0.684; 95% CI 0.601-0.760) in predicting AL, separately. Higher BMI, lower ALB, and incontinent ileocecal valve shown on preoperative CT may indicate an increased risk of postoperative AL after one-stage RPA for OLCC patients.

Low muscle mass-to-fat ratio is an independent factor that predicts worse overall survival and complications in patients with colon cancer: a retrospective single-center cohort study

PURPOSE

This study was performed to investigate influencing factors of preoperative muscle mass-to-fat ratio (MMFR) and its impact on overall survival and postoperative complications of colon cancer.

METHODS

Patients who underwent colectomy for stage I-III colon cancer at the Second Affiliated Hospital of Soochow University between January 2016 and December 2022 were included. The skeletal muscle and fat area at the third lumbar vertebra were measured with preoperative CT measurement. MMFR was defined as the ratio of skeletal muscle area to total fat area, and low MMFR was defined as the 2 lowest tertiles (≤0.585). Univariate and multivariable analyses were conducted to assess the impact of MMFR on overall complications and survival outcomes. Kaplan-Meier survival curves and log-rank test were used to compare the overall survival between high MMFR and low MMFR groups.

RESULTS

A total of 885 patients were analyzed. Female sex, older age, high body mass index, sarcopenia, and high cancer stage were more likely to result in low MMFR. Complications, including intestinal fistula, chylous fistula and organ space surgical site infection were significantly higher in the low MMFR group. Low MMFR was an independent factor associated with overall complications (odds ratio, 1.940; 95% confidence interval [CI], 1.252-3.007; P < 0.01) and long-term survival (hazard ratio, 2.222; 95% CI, 1.443-3.425; P < 0.01). Furthermore, patients with high MMFR had a higher survival rate than patients with low MMFR (P < 0.01).

CONCLUSION

Low MMFR is an independent factor that predicts worse overall survival and complications in patients with colon cancer.

Association between Unplanned Conversion and Patient Survival after Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Propensity Score Matched Analysis

Unplanned conversion (UPC) is considered to be a predictor of poor postoperative outcomes. However, the effects of UPC on the survival of patients with hepatocellular carcinoma (HCC) remain controversial. The aim of this study is to compare the outcomes between patients who underwent laparoscopic liver resection (LLR) and those who underwent UPC for HCC. Among 1029 patients with HCC who underwent hepatectomy between 2004 and 2021, 251 were eligible for the study. Of 251 patients who underwent hepatectomy for HCC in PS segments, 29 (26.0%) required UPC, and 222 underwent LLR. After 1:5 PSM, 25 patients were selected for the UPC group and 125 for the LLR group. Blood loss, transfusion rate, hospital stay, and postoperative complication were higher in the UPC group. Regarding oncologic outcomes, although the 5-year overall survival rate was similar in both groups (p = 0.544), the recurrence-free survival rate was lower in the UPC group (p < 0.001). UPC was associated with poor short-term as well as inferior long-term outcomes compared with LLR for HCC in PS segments. Therefore, surgeons must carefully select patients and consider early conversion if unexpected bleeding occurs to maintain safety and oncologic outcomes.

A machine learning model to predict the need for conversion of operative approach in patients undergoing colectomy for neoplasm

BACKGROUND

Studies comparing conversion from laparoscopic to open approaches to colectomy have found an association between conversion and morbidity, mortality, and length of stay, suggesting that certain patients may benefit from an open approach "up-front."

AIM

The objective of this study was to use machine learning algorithms to develop a model enabling the prediction of which patients are likely to require conversion.

METHODS AND RESULTS

We used ACS NSQIP data to identify patients undergoing colectomy (2014-2019). We included patients undergoing elective colectomy for colorectal neoplasm via a minimally invasive approach or a converted approach. The outcome of interest was conversion. Variables were included in the model based on their correlation with conversion by logistic regression (p < .05). Two models were used: weighted logistic regression with regularization, and Random Forest classifier. The data was randomly split into training (70%) and test (30%) cohorts, and prediction performance was calculated. 24 327 cases were included (17 028 training, 7299 test). When applied to the test cohort, the models had an accuracy of 0.675 (range 0.65-0.70) in predicting conversion; c-index ranged from 0.62-0.63. This machine learning model achieved a moderate area under the curve and a high negative predictive value, but a low positive predictive value; therefore, this model can predict (with 95% accuracy) whether a colectomy for neoplasm can be successfully completed using a minimally invasive approach.

CONCLUSION

This model can be used to reassure surgeons of the appropriateness of a minimally invasive approach when planning for an elective colectomy.

Anastomotic leak risk factors following colon cancer resection: a systematic review and meta-analysis

BACKGROUND

Despite improved surgical techniques, anastomotic leakage is still a serious complication that can occur after colon cancer resection, resulting in increased morbidity and mortality. The aim of this study was to evaluate the risk factors for anastomotic leakage after colon cancer surgery, provide a theoretical basis for reducing its occurrence, and guide the practice of clinicians.

METHODS

A systematic review of PubMed, Ovid, Web of Science and Cochrane Central Register of Controlled Trials databases was conducted by using a combination of subject terms and free words for online searches. The databases were searched from their inception to 31 March 2022, and all cross-sectional, cohort or case‒control studies examining the risk factors for the development of anastomotic fistula after surgery for colon cancer were identified.

RESULT

A total of 2133 articles were searched for this study, and 16 publications were ultimately included, all of which were cohort studies. A total of 115,462 subjects were included, and a total of 3959 cases of anastomotic leakage occurred postoperatively, with an incidence of 3.4%. The odds ratio (OR) and 95% confidence interval (CI) were used for evaluation. Male sex (OR = 1.37, 95% CI: 1.29-1.46, P < 0.00001), BMI (OR = 1.04, 95% CI: 1.00-1.08, P = 0.03), diabetes (OR = 2.80, 95% CI: 1.81-4.33, P < 0.00001), combined lung disease (OR = 1.28, 95% CI: 1.15-1.42, P < 0.00001), anaesthesia ASA score (OR = 1.35, 95% CI: 1.24-1.46, P < 0.00001), ASA class ≥ III (OR = 1.34, 95% CI: 1.22-1.47, P < 0.00001), emergency surgery (OR = 1.31, 95% CI: 1.11-1.55, P = 0.001), open surgery (OR = 1.94, 95% CI: 1.69-2.24, P < 0.00001) and type of surgical resection (OR = 1.34, 95% CI: 1.12-1.61, P = 0.002) are risk factors for anastomotic leakage after colon cancer surgery. There is still a lack of strong evidence on whether age (OR = 1.00, 95% CI: 0.99-1.01, P = 0.36) and cardiovascular disease (OR = 1.18, 95% CI: 0.94-1.47, P = 0.16) are factors influencing the occurrence of anastomotic leakage after colon cancer surgery.

CONCLUSIONS

Male sex, BMI, obesity, coexisting pulmonary disease, anaesthesia ASA score, emergency surgery, open surgery and type of resection were risk factors for anastomotic leakage after colon cancer surgery. The effect of age and cardiovascular disease on postoperative anastomotic leakage in patients with colon cancer needs further study.

The impact of operative approach on postoperative outcomes and healthcare utilization after colectomy

BACKGROUND

To evaluate national trends in adoption of different surgical approaches for colectomy and compare clinical outcomes and resource utilization between approaches.

METHODS

Retrospective study of patients aged ≥18 years who underwent elective inpatient left or right colectomy between 2010 and 2019 from the Premier Healthcare Database. Patients were classified by operative approach: open, minimally invasive: either laparoscopic or robotic. Postoperative outcomes assessed within index hospitalization include operating room time, hospital length of stay, rates of conversion to open surgery, reoperation, and complications. Post-discharge readmission, hospital-based encounters, and costs were collected to 30 days post-discharge. Multivariable regression models were used to compare outcomes between operative approaches adjusted for patient baseline characteristics and clustering within hospitals.

RESULTS

Among 206,967 patients, the robotic approach rates increased from 2.1%/1.6% (2010) to 32.6%/26.8% (2019) for left/right colectomy, offset by a decrease in both open and laparoscopic approaches. Median length of stay for both left and right colectomies was significantly longer in open (6 days) and laparoscopic (5 days) compared to robotic surgery (4 days; all P values <.001). Robotic surgery compared to open and laparoscopic was associated with a significantly lower conversion rate, development of ileus, overall complications, and 30-day hospital encounters. Robotic surgery further demonstrated lower mortality, reoperations, postoperative bleeding, and readmission rates for left and right colectomies than open. Robotic surgery had significantly longer operating room times and higher costs than either open or laparoscopic.

CONCLUSIONS

Robotic surgery is increasingly being used in colon surgery, with outcomes equivalent and in some domains superior to laparoscopic.

Impact of Conversion from Laparoscopy to Open Surgery in Patients with Right Colon Cancer

Conversion to open surgery is reported in up to 20 per cent of laparoscopic colectomies for cancer. This study aims to compare postoperative outcomes and survival between converted and successful laparoscopic right colectomy for cancer. Records of patients who underwent laparoscopic right colectomy for cancer between 2005 and 2015 were retrieved from the CLermontFerrand Ircad Mondor Hopital European Tours (CLIMHET) database. Perioperative, postoperative, and survival outcomes were evaluated. Multivariate analysis was performed to identify predictive factors for conversion. Overall, 445 patients underwent a successfully completed laparoscopic right colectomy and 28 (5.9%) were converted to open surgery. A higher rate of minor complications was found in the conversion group, whereas patient recovery outcomes were similar. Previous open and laparoscopic surgeries were significant predictors of conversion. No significant difference was found in overall and disease-free survival rates between converted and nonconverted procedures. In the setting of laparoscopic right colectomy for cancer, the conversion rate is low and does not have an impact on patient survival. Conversion is associated with higher rates of minor postoperative complications but recovery and survival outcomes are comparable with successful laparoscopic colectomies. The present results support the use of laparoscopy for right colon resection even in patients at risk of conversion.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery

Every colorectal surgeon during his or her career is faced with anastomotic leakage (AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

The triune of intestinal microbiome, genetics and inflammatory status and its impact on the healing of lower gastrointestinal anastomoses

Gastrointestinal resections are a common operation and most involve an anastomosis to rejoin the ends of the remaining bowel to restore gastrointestinal (GIT) continuity. While most joins heal uneventfully, in up to 26% of patients healing fails and an anastomotic leak (AL) develops. Despite advances in surgical technology and techniques, the rate of anastomotic leaks has not decreased over the last few decades raising the possibility that perhaps we do not yet fully understand the phenomenon of AL and are thus ill-equipped to prevent it. As in all complex conditions, it is necessary to isolate each different aspect of disease for interrogation of its specific role, but, as we hope to demonstrate in this article, it is a dangerous oversimplification to consider any single aspect as the full answer to the problem. Instead, consideration of important individual observations in parallel could illuminate the way forward towards a possibly simple solution amidst the complexity. This article details three aspects that we believe intertwine, and therefore should be considered together in wound healing within the GIT during postsurgical recovery: the microbiome, the host genetic make-up and their relationship to the perioperative inflammatory status. Each of these, alone or in combination, has been linked with various states of health and disease, and in combining these three aspects in the case of postoperative recovery from bowel resection, we may be nearer an answer to preventing anastomotic leaks than might have been thought just a few years ago.