Laparoscopic colectomy reduces complications and hospital length of stay in colon cancer patients with liver disease and ascites

EASL Clinical Practice Guidelines on extrahepatic abdominal surgery in patients with cirrhosis and advanced chronic liver disease

Extrahepatic surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.

Colectomy in patients with liver disease: albumin-bilirubin score accurately predicts outcomes

BACKGROUND

Patients with liver disease undergoing colectomy have higher rates of complications and mortality. The Albumin-Bilirubin score is a recently developed system, established to predict outcomes after hepatectomy, that accounts for liver dysfunction.

METHODS

All patients undergoing colectomy were identified in the 2015-2018 American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database. Demographics and outcomes were compared between patients with Albumin-Bilirubin Grade 1 vs. 2/3. Multivariable regression was performed for outcomes including colorectal-specific complications. Areas under the receiver operative characteristic curves were calculated to determine accuracy of the Albumin-Bilirubin score.

RESULTS

Of 86,273 patients identified, 48% (N = 41,624) were Albumin-Bilirubin Grade 1, 45% (N = 38,370) Grade 2 and 7% (N = 6,279) Grade 3. Patents with Grade 2/3 compared to Grade 1 had significantly increased mortality (7.2% vs. 0.9%, p < 0.001) and serious morbidity (31% vs. 12%, p < 0.001). Colorectal-specific complications including anastomotic leak (3.7% vs. 2.8%, p < 0.001) and prolonged ileus (26% vs. 14%, p < 0.001) were higher in patients with Grade 2/3. Grade 2/3 had increased risk of mortality (odds ratio 3.07, p < 0.001) and serious morbidity (1.78, p < 0.001). Albumin-Bilirubin had excellent accuracy in predicting mortality (area under the curve 0.81, p < 0.001) and serious morbidity (0.70, p < 0.001).

CONCLUSION

Albumin-Bilirubin is easily calculated using only serum albumin and total bilirubin values. Grade 2/3 is associated with increased rates of mortality and morbidity following colectomy. Albumin-Bilirubin can be applied to risk-stratify patients prior to colectomy.

Outcomes of Colectomy in United States Veterans With Cirrhosis: Predicting Outcomes Using Nomogram

INTRODUCTION

With growing incidence of liver cirrhosis worldwide, there is more need for a risk assessment tool to aid in perioperative management of cirrhotic patients undergoing colorectal procedures. We aim to assess the association of open (OC) versus laparoscopic (LC) approach with colorectal procedures' outcomes and develop an easy-to-use nomogram to predict outcomes.

METHODS

We analyzed the Veterans Affairs Surgical Quality Improvement Program to identify all patients with cirrhosis and ascites who underwent colorectal procedures from 2008 to 2015. Model for End-stage Liver Disease score was calculated as well as five-items modified frailty index. The chi-square test was utilized to analyze categorical variables. Two-sided unpaired Student's t-test or Mann-Whitney U-test were used for numerical variables as appropriate. Multivariate logistic regression adjusting for demographics, comorbidities, and other preoperative factors was used to analyze postoperative outcomes. A predictive nomogram was constructed and internally validated.

RESULTS

A total of 731 patients were identified. Overall, complications occurred in 48.2% of patients, and 30-d mortality was 24.8%, with 57.5% were performed emergently. Malignant neoplasm was the most common indication (25.4%). LC was performed in 22.4%, with shorter operative time, less blood transfusions, shorter length of stay, and lower morbidity compared to OC. Overall, Model for End-stage Liver Disease score was an independent factor of mortality, while laparoscopic approach had a protective effect on morbidity. An easy-to-use nomogram was generated for morbidity and 30-d mortality with calculated area under cure of 74.5% and 77.9%, respectively, indicating reliability.

CONCLUSIONS

Although colectomy is a high-risk operation in cirrhotic veterans, LC may have favorable outcomes than OC in selected patients. An easy-to-use nomogram to predict morbidity and mortality for cirrhotic patients undergoing colectomy is proposed.

Assessing the risk of surgery in patients with cirrhosis

Patients with cirrhosis have an increased perioperative risk relative to patients without cirrhosis. This is related to numerous cirrhosis-specific factors, including severity of liver disease, impaired synthetic function, sarcopenia and malnutrition, and portal hypertension, among others. Nonhepatic comorbidities and surgery-related factors further modify the surgical risk, adding to the complexity of the preoperative assessment. In this review, we discuss the pathophysiological contributors to surgical risk in cirrhosis, key elements of the preoperative risk assessment, and application of risk prediction tools including the Child-Turcotte-Pugh score, Model for End-Stage Liver Disease-Sodium, Mayo Risk Score, and the VOCAL-Penn Score. We also detail the limitations of current approaches to risk assessment and highlight areas for future research.

Effects of acupuncture treatment on postoperative gastrointestinal dysfunction in colorectal cancer: study protocol for randomized controlled trials

Background

Postoperative gastrointestinal dysfunction (PGID) is a common complication arising from colorectal cancer surgery. Attributing factors, such as anesthesia, surgical retraction, and early intake of water, can inhibit gastrointestinal motility, causing constipation, reduction or absence of bowel sounds, nausea, vomiting, and other symptoms. Delayed recovery in gastrointestinal function can lead to intestinal obstructions or paralysis, anastomotic leaks, and other complications, affecting the patient’s recovery and quality of life negatively. Due to its complex pathophysiology, treatment for PGID in colorectal patients has remained a challenge. Acupuncture is an alternative therapy commonly used for postoperative recovery. This study aims to evaluate the therapeutic efficacy and safety of acupuncture on PGID. Through the complementation of acupuncture and enhanced recovery after surgery (ERAS) protocols, the advantages of acupuncture treatments could be demonstrated to promote its application in future clinical practice.

Methods

The study design is a prospective randomized controlled trial (RCT). One hundred sixty postoperative colorectal cancer patients will be recruited from Cancer Hospital Chinese Academy of Medical Sciences (CICAMS). Subjects who fulfill inclusion criteria will be randomly assigned into the acupuncture group (AG) (n = 80) or control group (CG) (n = 80). AG will receive acupuncture treatment and perioperative care guided by ERAS protocols, and CG will only receive perioperative care guided by ERAS protocols. The intervention will begin on the first day post-surgery, continuing for 4 days, with a follow-up assessment in a month. Time of first postoperative flatus would be the primary outcome measure. Secondary outcome measures include the time of first postoperative defecation, time of first fluid intake, time of first ambulation, postoperative hospital stay, gastrointestinal reaction score, acupuncture sensation evaluation scale, laboratory tests, postoperative quality of life, readmission rate, and postoperative complications. All results are evaluated from baseline, post-treatment, and upon follow-up.

Discussion

The results of the study would help elucidate evidence of the therapeutic effects of acupuncture on the recovery of postoperative gastrointestinal function. The objective of the study aims for the eventual inclusion of acupuncture in the ERAS protocol, allowing for wider application in clinical practice.

Trial registration

ClinicalTrials.gov ChiCTR2000036351. Registered on August 22, 2020

Regional Variation in Laparoscopy Use for Elective Colon Cancer Treatment in Canada: The Importance of Fellowship Training Sites

BACKGROUND

Over the last decade, use of laparoscopy for the treatment of colon cancer has been variable despite evidence of benefit, possibly reflecting surgeon expertise rather than other factors.

OBJECTIVE

The purpose of this study was to examine the spatial variation in the use of laparoscopy for colon cancer surgery and to determine what factors may influence use.

DESIGN

This was a population-based retrospective analysis from April 2008 to March 2015.

SETTINGS

All Canadian provinces (excluding Quebec) were included.

PATIENTS

The study included all patients ≥18 years of age undergoing elective colectomy for colon cancer.

MAIN OUTCOME MEASURES

The primary outcome was laparoscopy use rates. Predictors of use included patient and disease characteristics, year of surgery, rurality, hospital and surgeon volumes, and distance from a colorectal fellowship training center.

RESULTS

A total of 34,725 patients were identified, and 42% underwent laparoscopic surgery. Significant spatial variations in laparoscopy use were identified, with 95% of high-use clusters located ≤100 km and 98% of low-use clusters located >100 km from a colorectal fellowship center. There were no high-use clusters located around large academic centers without colorectal fellowships. At the individual level, patients living within 25 km and 26 to 100 km of a fellowship center were 2.6 and 1.6 times more likely to undergo laparoscopic surgery compared with those >100 km away (95% CI, 2.47-2.79, p < 0.00; 95% CI, 1.53-1.71, p < 0.001). Surgeon and hospital volumes were associated with increased rates of laparoscopy use (p < 0.001).

LIMITATIONS

Data were obtained from an administrative database, and despite 85% to 95% published validity, they remain subject to misclassification, response, and measurement bias.

CONCLUSIONS

Significant spatial variations in the use of laparoscopy for colon cancer surgery exist. After adjusting for patient and system factors, proximity to a colorectal fellowship training center remained a strong predictor of laparoscopy use. There remain regional variations in colon cancer treatment, with discrepancies in the surgical care offered to Canadian patients based solely on location. See Video Abstract at http://links.lww.com/DCR/B595.

VARIACIN REGIONAL EN EL USO DE LAPAROSCOPIA PARA EL TRATAMIENTO ELECTIVO DEL CNCER DE COLON EN CANAD LA IMPORTANCIA DE LOS SITIOS DE CAPACITACIN PARA RESIDENTES

ANTECEDENTES:Durante la última década, la utilización de la laparoscopia para el tratamiento del cáncer de colon ha sido variable a pesar de la evidencia de beneficio; posiblemente reflejando la experiencia del cirujano, más que otros factores.OBJETIVO:Examinar la variación espacial en el uso de la laparoscopia para la cirugía del cáncer de colon y determinar qué factores pueden influir en la utilización.DISEÑO:Análisis retrospectivo poblacional de abril de 2008 a marzo de 2015.ENTORNO CLÍNICO:Todas las provincias canadienses (excepto Quebec).PACIENTES:Todos los pacientes> 18 años sometidos a colectomía electiva por cáncer de colon.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fueron las tasas de utilización de laparoscopia. Los predictores de uso incluyeron las características del paciente y la enfermedad, el año de la cirugía, la ruralidad, los volúmenes de hospitales y cirujanos, y la distancia a un centro de formación de residentes colorectales.RESULTADOS:Se identificaron 34.725 pacientes, 42% fueron sometidos a cirugía laparoscópica. Se identificaron variaciones espaciales significativas en el uso de laparoscopia, con el 95% de los conglomerados de alto uso ubicados a <100 km y el 98% de los conglomerados de bajo uso ubicados a> 100 km, desde un centro de residencia colorectal. No había grupos de alto uso ubicados alrededor de grandes centros académicos sin residentes colorrectales. A nivel individual, los pacientes que vivían dentro de los 25 km y 26-100 km de un centro de residentes tenían 2,6 y 1,6 veces más probabilidades de someterse a una cirugía laparoscópica, respectivamente, en comparación con aquellos a> 100 km de distancia (95% CI 2,47-2,79, p <0,00; IC del 95% 1,53-1,71, p <0,001). Los volúmenes de cirujanos y hospitales se asociaron con mayores tasas de utilización de laparoscopia (p <0,001).LIMITACIONES:Los datos se obtuvieron de una base de datos administrativa y, a pesar de una validez publicada del 85-95%, siguen sujetos a errores de clasificación, respuesta y sesgo de medición.CONCLUSIONES:Existen variaciones espaciales significativas en el uso de la laparoscopia para la cirugía del cáncer de colon. Después de ajustar por factores del paciente y del sistema, la proximidad a un centro de formación de residentes colorectales siguió siendo un fuerte predictor del uso de laparoscopia. Sigue habiendo variaciones regionales en el tratamiento del cáncer de colon, con discrepancias en la atención quirúrgica ofrecida a los pacientes canadienses basadas únicamente en la ubicación. Consulte Video Resumen en http://links.lww.com/DCR/B595.

Patient-Generated Subjective Global Assessment (PG-SGA) predicts length of hospital stay in lung adenocarcinoma patients

The prevalence of malnutrition is high among oncology patients in Northern China. Malnutrition is related to the longer hospital stay, and it can be used to predict the prognostic outcome of patients. This work focused on investigating the relationship of nutritional condition with the length of hospital stay (LOS) in Northern Chinese patients with lung adenocarcinoma (LUAD). The Patient-Generated Subjective Global Assessment (PG-SGA), Nutritional Risk Screening 2002 (NRS 2002) score, recent weight loss and BMI were assessed in a probabilistic sample of 389 LUAD patients without epidermal growth factor receptor (EGFR) mutations. This study collected the demographic and clinical features of patients in a prospective manner. Then, we examined the association of nutritional status with LOS among the population developing LUAD. According to the PG-SGA, 63 (16·3 %), 174 (44·7 %) and 78 (20·1 %) patients were at risk for undernutrition, moderate undernutrition and severe undernutrition, respectively. Nutritional risk was found in 141 (36·2 %) patients based on the NRS 2002. The average LOS for tumour patients in Northern China was 12·5 d. At admission, a risk of undernutrition or undernutrition according to the PG-SGA (P < 0·001), NRS 2002 (P < 0·001) and latest weight loss (P < 0·001) predicted the longer LOS. LOS was related to nutritional status and hospitalisation expenses (P < 0·001). LUAD patients who stayed in the ICU had a poorer nutritional status and a longer LOS (P < 0·001). In Northern Chinese patients with LUAD, a risk for undernutrition evaluated by the PG-SGA, the NRS 2002 and recent weight loss, but not BMI, could predict a longer LOS.