Laparoscopic versus open colectomy: the impact of frailty on outcomes

The effect of minimally invasive surgery on thirty-day postoperative outcomes of frail patients undergoing emergency colon resections

BACKGROUND

Frail patients have poor outcomes after emergent colon surgery. While minimally invasive surgery has shown improved outcomes in the general patient population undergoing colectomy, the benefits in frail patients are unknown.

METHODS

We identified frail patients who underwent urgent or emergent colon resections from 2017 to 2021 in the National Surgical Quality Improvement Program database. We defined frail as a score of 2 or greater on the modified frailty index. We used inverse probability of treatment weighted analysis to determine the association of surgical technique with 30-day postoperative outcomes independent of confounding variables.

RESULTS

Of the 11,976 frail patients, 10,293 (87.2%) underwent open surgery and 1,503 (12.7%) underwent minimally invasive surgery. Patients who underwent open surgery had significantly more comorbid conditions. The most common diagnosis for patients who underwent open surgery was intra-abdominal sepsis (59.6%) and neoplasms for patients who underwent minimally invasive surgery (42%). After the inverse probability of treatment weighted analysis, the standardized difference was reduced to 1.7% or less. At 30 days from surgery, minimally invasive surgery was independently associated with reduced risk of death: 4.6% (odds ratio, 0.95; 95% confidence interval, 0.93-0.97; P < .001), severe complications: 6.9% (odds ratio, 0.93; 95% confidence interval, 0.90-0.95, P < .001), any complication: 8.8% (odds ratio, 0.91; 95% confidence interval, 0.88-0.94, P < .001), septic shock: 5.9% (odds ratio, 0.94; 95% confidence interval, 0.92-0.96 P < .001), postoperative bleeding: 4% (odds ratio, 0.95; 95% confidence interval, 0.93-0.98, P < .001), hospital stay >14 days: 4.2% (odds ratio, 0.95; 95% confidence interval, 0.92-0.99, P = .02).

CONCLUSION

In this vulnerable population of frail patients, minimally invasive surgery was associated with reduced risk of morbidity and mortality in the 30 days after emergency colectomy. A minimally invasive surgery approach should be considered in emergency colon surgeries, provided proficient resources are available.

Cost-effectiveness and readmission rates of laparoscopic vs. open surgery for colorectal cancer: evidence from the health insurance review and assessment service dataset in South Korea

Introduction

We aimed to compare and analyze the cost-effectiveness of laparoscopic vs. open colorectal surgery (CRS) for colorectal cancer using health insurance claims data derived from multiple institutions in South Korea as well as the differences in hospital length of stay (LOS) and 30-day readmission rates related to postoperative complications.

Methods

We retrospectively reviewed the clinical data of patients who underwent curative resection for colorectal cancer between January 1, 2020 and December 31, 2022 using national health insurance claims data in South Korea. We determined the surgical approach based on the presence or absence of treatment material codes specific to laparoscopic surgery, and divided the patients into the laparoscopic-CRS (lap-CRS) and open-CRS groups.

Results

A total of 34,779 patients were included [open-CRS: 3,262 patients [9.4%]; lap-CRS: 31,517 patients [90.6%]]. The mean LOS was 14.11 and 11.27 days for the open- and lap-CRS groups, respectively (p < 0.001). The mean medical costs were 9,163 USD and 8,963 USD in the open- and lap-CRS groups, respectively (p < 0.001). A total of 1,192 (3.4%) patients were readmitted within 30 days of discharge, with a rate of 5.4% (176 cases) and 3.2% (1,016 cases) in the open- and lap-CRS groups, respectively (p < 0.001). Open surgery, male sex, and rectal surgery were identified as factors that increased medical cost.

Discussion

According to this South Korean nationwide population-based study, laparoscopic surgery demonstrated a reduction in LOS, medical costs, and readmission rates compared with open surgery in patients with colorectal cancer.

Use of a 5-Item Modified Frailty Index for Assessing Outcomes After Hartmann's Reversal: An ACS-NSQIP Study

BACKGROUND

Half of all patients with an end colostomy after sigmoid colectomy (Hartmann's procedure) never undergo Hartmann's reversal, frequently secondary to frailty. This retrospective cohort study evaluates the utility of a five-item modified frailty index (mFI-5) in predicting post-operative outcomes after Hartmann's reversal.

METHODS

The National Surgery Quality Improvement Program (NSQIP) database captured patients with elective Hartmann's reversals from 2011 to 2020. Clinical covariates were evaluated with univariate analysis and modified Poisson regression to determine association with overall morbidity, overall mortality, and extended length of stay (eLOS) when categorized by mFI-5 score.

RESULTS

15,172 patients underwent elective Hartmann's reversal (91.6% open and 8.4% laparoscopic). Patients were grouped by mFI-5 score (0: 48.7%, 1: 38.2%, ≥ 2: 13.1%). Adjusted multivariable analysis showed frail patients (mFI-5≥2) had increased overall mortality (OR 2.23, 95% CI 1.21-4.11), morbidity (OR 1.23, 95% CI 1.12-1.35), and eLOS (OR 1.12, 95% 1.02-1.23). Among frail patients, a laparoscopic approach was associated with decreased overall morbidity (OR .64, 95% CI 0.56-.73) and decreased eLOS (OR .46, 95% CI 0.39-.54) when compared to open approach.

DISCUSSION

An mFI-5 of ≥2 was associated with greater morbidity, mortality, and eLOS following Hartmann's reversal. However, there were no mortality or eLOS differences in patients with an mFI-5 of 1 and only a 14% increase in any morbidity, making these patients potentially good candidates for Hartmann's reversal. Furthermore, laparoscopic surgery was associated with a protective effect for overall morbidity and eLOS, potentially mitigating some of the risk associated with higher frailty scores.

Comparison of short-term outcomes and survival between minimally invasive colectomy and open colectomy in patients 80 years of age and older

We investigated the short- and long-term outcomes of patients 80 years of age and older with colon cancer who underwent robotic colectomy versus laparoscopic colectomy. Data for patients treated at a comprehensive cancer center between January 2006 and November 2018 were collected retrospectively. Outcomes from minimally invasive laparoscopic or robotic colectomy were compared. Survival was analyzed by the Kaplan-Meier method with significance evaluated by the log-rank test. The laparoscopic (n = 104) and the robotic (n = 75) colectomy groups did not differ across baseline characteristics. Patients who underwent a robotic colectomy had a shorter median length of hospital stay (5 versus 6 days; p < 0.001) and underwent fewer conversions to open surgery (3% versus 17%; p = 0.002) compared to the laparoscopic cohort. The groups did not differ in postoperative complication rates, overall survival or disease-free survival. Elderly patients undergoing robotic colectomy for colon cancer have a shorter hospital stay and lower rates of conversion without compromise to oncologic outcomes.

Redo laparoscopic colorectal resection: a retrospective analysis with propensity score matching

PURPOSE

Reports of redo laparoscopic colorectal resection (Re-LCRR) are scarce. In order to evaluate the safety and short-term outcomes of Re-LCRR, we performed a matched case-control analysis of patients who underwent this procedure for colorectal cancer.

METHOD

This was a retrospective, monocentric study that included patients who underwent Re-LCRR for colorectal cancer between January 2011 and December 2019 at our institution. The patients were compared to a 2:1 matched sample. Matching was conducted based on age, sex, BMI, surgical procedure, and clinical stage.

RESULT

Twenty-nine patients underwent Re-LCRR (RCRR group) and were compared to 58 patients selected by matching who underwent LCRR as primary resection (PCRR group). The median of age of the 29 patients of RCRR group was 75 (IQR 56-81) years and the RCRR group included 14 males. The median operative time of the RCRR group was 167 (IQR 126-232) minutes, and the median intraoperative blood loss was 5 (IQR 2-35) ml. In the RCRR group, there were no cases that required conversion to laparotomy. The short-term outcomes of the two groups did not differ to a statistical extent with respect to operative time (p = 0.415), intraoperative blood loss (p = 0.971), rate of conversion to laparotomy (p = 0.477), comorbidity (p = 0.215), and postoperative hospital stay (p = 0.809). No patients in either group experienced postoperative anastomotic leakage or required re-operation due to postoperative complications, and there was no procedure-related death. However, in terms of oncological factors, although there was no difference in the number of cases with a positive radical margin between the two groups (p = 1.000), the number of harvested lymph nodes in the RCRR group was significantly lower than that in the PCRR group (p = 0.015) and the RCRR group included 10 cases with less than 12 harvested lymph nodes.

CONCLUSION

Re-LCRR is associated with good short-term results and can be safely performed; however, the number of harvested lymph nodes is significantly reduced in comparison to primary resection cases, and further studies are needed to evaluate its long-term prognosis.

Frailty and surgical outcomes in gastrointestinal cancer: Integration of geriatric assessment and prehabilitation into surgical practice for vulnerable patients

As life expectancy increases, the older population continues to grow rapidly, resulting in increased requirement for surgery for older patients with gastrointestinal cancer. Older individuals represent a heterogeneous group in terms of physiological reserves, co-morbidity, cognitive impairment, and disability. Owing to the lack of treatment guidelines for vulnerable patients with gastrointestinal cancer, these patients are more likely to be at risk of undertreatment or overtreatment. Hence, the identification of frail patients with gastrointestinal cancer would improve cancer treatment outcomes. Although there is no standardized geriatric assessment tool, a growing body of research has shown associations of frailty with adverse postoperative outcomes and poor prognosis after resection of gastrointestinal tract and hepatobiliary-pancreatic cancers. Emerging evidence suggests that prehabilitation, which includes exercise and nutritional support, can improve preoperative functional capacity, postoperative recovery, and surgical outcomes, particularly in frail patients with gastrointestinal cancer. We reviewed major geriatric assessment tools for identification of frail patients and summarized clinical studies on frailty and surgical outcomes, as well as prehabilitation or rehabilitation in gastrointestinal tract and hepatobiliary-pancreatic cancers. The integration of preoperative geriatric assessment and prehabilitation of frail patients in clinical practice may improve surgical outcomes. In addition, improving preoperative vulnerability and preventing functional decline after surgery is important in providing favorable long-term survival in patients with gastrointestinal cancer. Further clinical trials are needed to examine the effects of minimally invasive surgery, and chemotherapy in frail patients with gastrointestinal cancer.

Association of frailty with outcomes of resection for colonic volvulus: A national analysis

Background

With limited national studies available, we characterized the association of frailty with outcomes of surgical resection for colonic volvulus.

Methods

Adults with sigmoid or cecal volvulus undergoing non-elective colectomy were identified in the 2010–2019 Nationwide Readmissions Database. Frailty was identified using the Johns Hopkins indicator which utilizes administrative codes. Multivariable models were developed to examine the association of frailty with in-hospital mortality, perioperative complications, stoma use, length of stay, hospitalization costs, non-home discharge, and 30-day non-elective readmissions.

Results

An estimated 66,767 patients underwent resection for colonic volvulus (Sigmoid: 39.6%; Cecal: 60.4%). Using the Johns Hopkins indicator, 30.3% of patients with sigmoid volvulus and 15.9% of those with cecal volvulus were considered frail. After adjustment, frail patients had higher risk of mortality compared to non-frail in both sigmoid (10.6% [95% CI 9.47–11.7] vs 5.7% [95% CI 5.2–6.2]) and cecal (10.4% [95% CI 9.2–11.6] vs 3.5% [95% CI 3.2–3.8]) volvulus cohorts. Frailty was associated with greater odds of acute venous thromboembolism occurrences (Sigmoid: AOR 1.50 [95% CI 1.18–1.94]; Cecal: AOR 2.0 [95% CI 1.50–2.72]), colostomy formation (Sigmoid: AOR 1.73 [95% CI 1.57–1.91]; Cecal: AOR 1.48 [95% CI 1.10–2.00]), non-home discharge (Sigmoid: AOR 1.97 [95% CI 1.77–2.20]; Cecal: AOR 2.56 [95% CI 2.27–2.89]), and 30-day readmission (Sigmoid: AOR 1.15 [95% CI 1.01–1.30]; Cecal: AOR 1.26 [95% CI 1.10–1.45]). Frailty was associated with incremental increase in length of stay (Sigmoid: +3.4 days [95% CI 2.8–3.9]; Cecal: +3.8 days [95% CI 3.3–4.4]) and costs (Sigmoid: +$7.5k [95% CI 5.9–9.1]; Cecal: +$12.1k [95% CI 10.1–14.1]).

Conclusion

Frailty, measured using a simplified administrative tool, is associated with significantly worse clinical and financial outcomes following non-elective resections for colonic volvulus. Standard assessment of frailty may aid risk-stratification, better inform shared-decision making, and guide healthcare teams in targeted resource allocation in this vulnerable patient population.

Impact of Frailty on Short-Term Outcomes After Laparoscopic and Open Hepatectomy

BACKGROUND

Although laparoscopic hepatectomy (LH) is associated with improved short-term outcomes compared to open hepatectomy (OH), it is unknown whether frail patients also benefit from LH. The aim of this study was to evaluate the impact of frailty on post-operative outcomes after LH and OH.

PATIENTS AND METHODS

Consecutive patients who underwent LH and OH between January 2011 and December 2018 were identified from a prospective database. Frailty was assessed using the modified Frailty Index (mFI), with patients scoring mFI ≥ 1 deemed to be frail.

RESULTS

Of 1826 patients, 34.7% (N = 634) were frail and 18.6% (N = 340) were elderly (≥ 75 years). Frail patients had significantly higher 90-day mortality (6.6% vs. 2.9%, p < 0.001) and post-operative complications (36.3% vs. 26.1%, p < 0.001) than those who were not frail, effects that were independent of patient age on multivariate analysis. For those undergoing minor resections, the benefits of LH vs. OH were similar for frail and non-frail patients. Length of hospital stay was 53% longer in OH (vs. LH) in frail patients, compared to 58% longer in the subgroup of non-frail patients.

CONCLUSIONS

Frailty is independently associated with inferior post-operative outcomes in patients undergoing hepatectomy. However, the benefits of laparoscopic (compared to open) hepatectomy are similar for frail and non-frail patients. Frailty should not be a contraindication to laparoscopic minor hepatectomy in carefully selected patients.

Association of frailty with outcomes after elective colon resection for diverticular disease

BACKGROUND

Frailty has been associated with greater postoperative morbidity and mortality but its impact has not been investigated in patients with diverticulitis undergoing elective colon resection. Therefore, the present study examined the association of frailty with perioperative outcomes following elective colectomy for diverticular disease.

METHODS

The 2017-2019 American College of Surgeons-National Surgical Quality Improvement Program data registry was queried to identify patients (aged ≥18 years) undergoing elective colon resection for diverticular disease. The 5-factor modified frailty index (mFI-5) was used to stratify patients into non-frail (mFI 0), prefrail (mFI 1), and frail (mFI ≥2) cohorts. Major adverse events, surgical site infection, and postoperative ileus as well as prolonged length of stay, nonhome discharge, and unplanned readmission were evaluated using multivariable logistic models.

RESULTS

Of the 20,966 patients, 10.0% were frail. Compared to others, frail patients were generally older (non-frail: 55 years, [46-63], prefrail: 62, [54-70], frail: 64, [57-71]) and more commonly female (non-frail: 53.1%, prefrail: 58.6, frail: 64.4, P < .001). Frail patients more frequently underwent open colectomy and stoma creation compared with others. Frailty was associated with greater adjusted odds of major adverse event (adjusted odds ratio 1.25, 95% confidence interval 1.06-1.48), surgical site infection (adjusted odds ratio 1.28, 95% confidence interval 1.06-1.54), and postoperative ileus (adjusted odds ratio 1.59, 95% confidence interval 1.27-1.98). Similarly, frailty portended greater odds of prolonged length of stay, nonhome discharge, and unplanned readmission.

CONCLUSION

Frailty as defined by the mFI-5 was associated with greater morbidity and hospital resource use. Deployment of frailty instruments may augment traditional risk calculators and improve patient selection for elective colectomy.

Evaluation of the Comprehensive Geriatric Assessment (CGA) tool as a predictor of postoperative complications following major oncological abdominal surgery in geriatric patients

Introduction

The concept of frailty extends beyond chronological age. Identifying frailty using a two-step approach, starting with the use of a screening tool (G8) followed by comprehensive geriatric assessment (CGA), may be useful in guiding treatment decisions and follow-up. This study evaluated the association between G8 and CGA, and the risk of 90-day postoperative complications risk, in oncogeriatric patients.

Methods

Data on geriatric patients with major oncological abdominal surgery was retrospectively collected from our hospital records between 2016 and 2019. Patients with an impaired G8 screening score, who subsequently underwent CGA geriatric screening, were included. Postoperative complications were classified using the Clavien-Dindo classification (CD), and the Comprehensive Complication Index (CCI). The association between the individual components of the geriatric assessment tools and the 90-day postoperative complications risk was analyzed.

Results

One hundred and twelve patients, aged ≥ 70 years, operated for an intra-abdominal tumor with curative intent, were included. Seventy-six patients (67.9%) presented with an impaired G8, out of whom sixty-six (58.9%) had a CGA performed. On univariate analysis, altered nutritional status assessed by the Mini-Nutritional Assessment-Short Form was the only variable associated with higher postoperative total complication rate (p = 0.01). Patients with an impaired G8 had significantly more postoperative complications and higher 1-year mortality rates than patients with normal G8. Fifteen patients (13.4%) had grade III-IVb complications. A CCI > 50 was recorded in 16 patients (14.3%). All-cause 90-day postoperative mortality was 10.7%.

Conclusion

Identifying an altered preoperative nutritional status, as part of the CGA, in patients screening positive for frailty, is a potentially modifiable risk factor that can enhance preoperative management and optimize treatment decision making. G8 may be a predictive factor for postoperative complications in oncogeriatric patients.

A Machine Learning Approach in Predicting Mortality Following Emergency General Surgery

BACKGROUND

There is a significant mortality burden associated with emergency general surgery (EGS) procedures. The objective of this study was to develop and validate the use of a machine learning approach to predict mortality following EGS.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent EGS between 2012 and 2017. We developed a machine learning algorithm to predict mortality following EGS and compared its performance with existing risk-prediction models of American Society of Anesthesiologists (ASA) classification, American College of Surgeon Surgical Risk Calculator (ACS-SRC), and the modified frailty index (mFI) using the area under receiver operative curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

The machine learning algorithm had a very high performance for predicting mortality following EGS, and it had superior performance compared to the ASA classification, ACS-SRC, and the mFI, as measured by the AUC, sensitivity, specificity, PPV, and NPV.

DISCUSSION

Machine learning approaches may be a promising tool to predict outcomes for EGS, aiding clinicians in surgical decision-making and counseling of patients and family, improving clinical outcomes by identifying modifiable risk factors than can be optimized, and decreasing treatment costs through resource allocation.

Impact of Frailty on Clinical Outcomes and Hospitalization Costs Following Elective Colectomy

BACKGROUND

Frailty has been increasingly recognized as a risk factor for inferior surgical outcomes and greater resource use. The present study evaluated the impact of a coding-based frailty tool on outcomes of elective colectomy in a national cohort.

STUDY DESIGN

Adults undergoing elective colectomy were identified in the 2016-17 Nationwide Readmissions Database. Frailty was defined using the Johns Hopkins 10-domain coding-based binary tool. Generalized linear models were used to examine the association of frailty with in-hospital mortality, nonhome discharge, hospitalization duration (LOS), and inflation-adjusted costs. Kaplan-Meier survival analysis and log-rank test was used to compare readmissions up to 1-year.

RESULTS

Of 133 175 patients, 10.6% were considered frail. The most common resections were sigmoid (43.9%) and right (34.7%) while total colectomy was least common (2.8%). After adjustment, frailty was associated with greater odds of mortality (3.2, 95% CI 2.8-3.8) and nonhome discharge (6.0, 95% CI 5.5-6.4) as well as a $13,400-increment (95% CI 12,400-14,400) in costs and 4.4-day (95% CI 4.1-4.6) increase in LOS. Nonelective readmissions at 30 days were greater in frail than non-frail groups (14.7% vs. 10.4%, P < .001).

CONCLUSION

Frailty is associated with inferior clinical outcomes and increased resource use following elective colectomy. Inclusion of frailty in risk models may facilitate risk stratification and shared decision-making.

The Impact of Chronic Liver Disease on Postoperative Outcomes and Resource Utilization

BACKGROUND

Multiple studies have shown high rates of postoperative morbidity and mortality in individuals with chronic liver disease (CLD). However, analyses from comparisons with individuals without CLD are not available. Such analyses might provide opportunities to improve outcomes.

METHODS

Data from The National Surgical Quality Improvement Program (NSQIP) from 2008 to 2011 were analyzed comparing CLD patients undergoing non-liver surgery propensity matched to those without CLD. Patients with CLD were stratified by Model of End Stage Liver Disease (MELD) scores <15 and ≥15. Primary outcome was all cause mortality, and secondary outcomes were composite and individual morbidity, hospital length of stay, readmission, reoperation, and discharge destination. Odds ratios (OR) were calculated, and length of hospital stay was estimated using Poisson regression.

RESULTS

There were 6,209 patients with CLD (4,013 with low MELD, 2,196 with high MELD) matched to 18,627 patients without. Patients with CLD had 1.8- and 3.3-times higher odds of mortality (95% CI 1.6-2.1 for Low MELD (10.6%), 2.9-3.8 for high MELD (35.2%), and 1.8- and 2.2-times higher odds of any morbidity (1.6-1.9 and 1.9-2.4). Complications specific to CLD were increased based on MELD specifically coma (OR 1.6, 0.9-2.9 for Low MELD, 2.2, 1.5-3.2 for High MELD), renal failure (OR 1.4, 1.1-1.8 and 2.4, 2.0-2.9), and bleeding (OR 1.7, 1.5-1.9 and 2.0, 1.8-2.3). They also had a 20% and 80% longer length of stay, 2.2- and 3.4-times higher odds of being discharged somewhere other than home, 1.7- and 1.6-times higher odds of readmission, and 1.5- and 1.6-times higher odds of reoperation.

CONCLUSION

Patients with CLD have significantly higher odds of mortality and morbidity, which is increased with a higher MELD. Interventions that decrease those morbidities are needed and have the potential to decrease mortality and resource utilization.

A Systematic Review and Meta-Analysis of Preoperative Frailty Instruments Derived From Electronic Health Data

BACKGROUND

Frailty is a strong predictor of adverse outcomes in the perioperative period. Given the increasing availability of electronic medical data, we performed a systematic review and meta-analysis with primary objectives of describing available frailty instruments applied to electronic data and synthesizing their prognostic value. Our secondary objectives were to assess the construct validity of frailty instruments that have been applied to perioperative electronic data and the feasibility of electronic frailty assessment.

METHODS

Following protocol registration, a peer-reviewed search strategy was applied to Medline, Excerpta Medica dataBASE (EMBASE), Cochrane databases, and the Comprehensive Index to Nursing and Allied Health literature from inception to December 31, 2019. All stages of the review were completed in duplicate. The primary outcome was mortality; secondary outcomes included nonhome discharge, health care costs, and length of stay. Effect estimates adjusted for baseline illness, sex, age, procedure, and urgency were of primary interest; unadjusted and adjusted estimates were pooled using random-effects models where appropriate or narratively synthesized. Risk of bias was assessed.

RESULTS

Ninety studies were included; 83 contributed to the meta-analysis. Frailty was defined using 22 different instruments. In adjusted data, frailty identified from electronic data using any instrument was associated with a 3.57-fold increase in the odds of mortality (95% confidence interval [CI], 2.68-4.75), increased odds of institutional discharge (odds ratio [OR], 2.40; 95% CI, 1.99-2.89), and increased costs (ratio of means, 1.54; 95% CI, 1.46-1.63). Most instruments were not multidimensional, head-to-head comparisons were lacking, and no feasibility data were reported.

CONCLUSIONS

Frailty status derived from electronic data provides prognostic value as it is associated with adverse outcomes, even after adjustment for typical risk factors. However, future research is required to evaluate multidimensional instruments and their head-to-head performance and to assess their feasibility and clinical impact.

Frailer Patients Undergoing Robotic Colectomies for Colon Cancer Experience Increased Complication Rates Compared With Open or Laparoscopic Approaches

BACKGROUND

Minimally invasive surgical techniques are routinely promoted as alternatives to open surgery because of improved outcomes. However, the impact of robotic surgery on certain subsets of the population, such as frail patients, is poorly understood.

OBJECTIVE

The purpose of our study was to examine the association between frailty and minimally invasive surgical approaches with colon cancer surgery.

DESIGN

This is a retrospective study of prospectively collected outcomes data. Thirty-day surgical outcomes were compared by frailty and surgical approach using doubly robust multivariable logistic regression with propensity score weighting, and testing for interaction effects between frailty and surgical approach.

SETTING

Patients undergoing an open, laparoscopic, or robotic colectomy for primary colon cancer, 2012 to 2016, were identified from the American College of Surgeons National Surgical Quality Improvement Program database.

PATIENTS

Patients undergoing a colectomy with an operative indication for primary colon cancer were selected.

MAIN OUTCOME MEASURES

The primary outcomes measured were 30-day postoperative complications.

RESULTS

After propensity score weighting of patients undergoing colectomy, 33.8% (n = 27,649) underwent an open approach versus 34.3% (n = 28,058) underwent laparoscopic surgery versus 31.9% (n = 26,096) underwent robotic surgery. Robotic (OR, 0.53; 95% CI, 0.42-0.69, p < 0.001) and laparoscopic (OR, 0.58; 95% CI, 0.52-0.66, p < 0.001) surgeries were independently associated with decreased rates of major complications. Frailer patients had increased complication rates (OR, 1.56; 95% CI, 1.07-2.25, p = 0.018). When considering the interaction effects between surgical approach and frailty, frailer patients undergoing robotic surgery were more likely to develop a major complication (combined adjusted OR, 3.15; 95% CI, 1.34-7.45, p = 0.009) compared with patients undergoing open surgery.

LIMITATIONS

Use of the modified Frailty Index as an associative proxy for frailty was a limitation of this study.

CONCLUSIONS

Although minimally invasive surgical approaches have decreased postoperative complications, this effect may be reversed in frail patients. These findings challenge the belief that robotic surgery provides a favorable alternative to open surgery in frail patients. See Video Abstract at http://links.lww.com/DCR/B163. LOS PACIENTES MÁS FRÁGILES SOMETIDOS A COLECTOMÍA ROBÓTICA POR CÁNCER DE COLON EXPERIMENTAN MAYORES TASAS DE COMPLICACIONES EN COMPARACIÓN CON ABORDAJES LAPAROSCÓPICO O ABIERTO: Las técnicas quirúrgicas mínimamente invasivas estan frecuentement promovidas como alternativas a la cirugía abierta debido a sus mejores resultados. Sin embargo, el impacto de la cirugía robótica en ciertos subgrupos de población, como el caso de los pacientes endebles, es poco conocido.El propósito de nuestro estudio fue examinar la asociación entre la fragilidad de los pacientes y el aborgaje quirúrgico mínimamente invasivo para la cirugía de cáncer de colon.Estudio retrospectivo de datos de resultados recolectados prospectivamente. Los resultados quirúrgicos a 30 días se compararon entre fragilidad y abordaje quirúrgico utilizando la regresión logística multivariable doblemente robusta con ponderación de puntaje de propensión y pruebas de efectos de interacción entre fragilidad y abordaje quirúrgico.Los pacientes identificados en la base de datos del Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Estadounidense de Cirujanos, que fueron sometidos a una colectomía abierta, laparoscópica o robótica por cáncer de colon primario, de 2012 a 2016.Todos aquellos pacientes seleccionados con indicación quirúrgica de cáncer primario de colon que fueron sometidos a una colectomía.Las complicaciones postoperatorias a 30 días.Luego de ponderar el puntaje de propensión de los pacientes colectomizados, el 33.8% (n = 27,649) fué sometido a laparotomía versus el 34.3% (n = 28,058) operados por laparoscopía versus el 31.9% (n = 26,096) operados con tecnica robótica. Las cirugías robóticas (OR 0.53, IC 95% 0.42-0.69, p < 0.001) y laparoscópicas (OR 0.58, IC 95% 0.52-0.66, p < 0.001) se asociaron de forma independiente con una disminución de las tasas de complicaciones mayores. Los pacientes más delicados tenían mayores tasas de complicaciones (OR 1.56, IC 95% 1.07-2.25, p = 0.018). Al considerar los efectos de interacción entre el abordaje quirúrgico y la fragilidad, los pacientes más débiles sometidos a cirugía robótica tenían más probabilidades de desarrollar una complicación mayor (OR ajustado combinado 3.15, IC 95% 1.34-7.45, p = 0.009) en comparación con los pacientes sometidos a cirugía abierta.El uso del índice de fragilidad modificado como apoderado asociativo de la fragilidad.Si bien los abordajes quirúrgicos mínimamente invasivos han disminuido las complicaciones postoperatorias, este efecto puede revertirse en pacientes lábiles. Estos hallazgos desafían la creencia de que la cirugía robótica proporciona una alternativa favorable a la cirugía abierta en pacientes frágiles. Consulte Video Resumen en http://links.lww.com/DCR/B163. (Traducción-Dr. Xavier Delgadillo).

Preoperative Hypoalbuminemia Predicts Early Mortality Following Open Abdominal Surgery in Patients Above 60 Years of Age

BACKGROUND

Major abdominal surgery in older and frail patients is associated with considerable morbidity and mortality. Plasma albumin is routinely measured in the clinic and has been proposed as an indicator of frailty. This study aimed to investigate if plasma albumin is a predictor of mortality in older patients undergoing open abdominal surgery.

MATERIALS AND METHODS

We conducted a single-center, register-based retrospective study of patients, aged ⩾60 years who underwent one of 81 open abdominal surgical procedures. Patients operated on during the period from January 1^st, 2000 to May 31^st, 2013 were consecutively identified in the Danish National Patient Registry. Plasma albumin was measured within 30 days prior to surgery and the primary endpoint was 30-day postoperative mortality.

RESULTS

3,639 patients were included of whom 68.2% underwent emergency surgery. The rate of severe hypoalbuminemia (plasma albumin < 28 g/L) was 43.4%. Preoperative plasma albumin was lower in patients with a fatal 30-day outcome (mean 20.6 g/L vs 30.1 g/L in survivors, p < 0.0001). Other independent predictive parameters of 30-day mortality were age, male sex, and emergency surgery. We present an algorithm including these four variables for the prediction of 30-day mortality for patients aged ⩾60 years undergoing open abdominal surgery.

CONCLUSION

Preoperative plasma albumin is a predictor of 30-day mortality in patients above 60 years of age following open abdominal surgery. Assessment of plasma albumin in conjunction with other risk factors such as age, sex, and surgical priority may improve preoperative decision-making.

Safety and feasibility of repeat laparoscopic colorectal resection: a matched case-control study

BACKGROUND

Perioperative outcomes of repeat laparoscopic colorectal resection (LCRR) have not been extensively reported.

METHODS

Patients who underwent LCRR from 2010 to 2018 in an expert center were retrieved from a prospectively collected database and compared to 2:1 matched sample. Matching was based on demographics, surgical indication [colorectal cancer (CRC) or benign condition], and type of resection (right-sided resection or left-sided resection or proctectomy).

RESULTS

Twenty-three patients underwent repeat LCRR with a median time of 36 months between the primary and the repeat LCRR. They were 12 (52%) men with a mean age of 64.9 years (31-87) and a median BMI of 21.4 kg/m² (17.7-34). Indication for repeat LCRR was CRC, dysplasia, anastomotic stricture, and inflammatory bowel disease in 11 (48%), 5 (22%), 4 (17%), and 3 (13%) patients, respectively. A right-sided resection, a left-sided resection, and proctectomy were reported in 11 (48%), 8 (35%), and 4 (17%) patients, respectively. Median blood loss reached 211 mL (range 0-2000 mL). Thirteen (57%) patients required conversion to laparotomy including 12 for intense adhesions. The median length of hospital stay was 7.5 days (5-20). Two (9%) major complications (Clavien-Dindo ≥ 3) were reported: 1 (4%) anastomotic fistula and 1 (4%) postoperative hemorrhage, without mortality. Among patients who underwent repeat LCRR for CRC, histopathological examination showed R0 resection in all patients, with at least 12 lymph nodes harvested in ten (91%) patients. After matched case-control analysis that compared to primary LCRR, conversion rate (p = 0.03), operative time (p = 0.03), and intraoperative blood loss (p = 0.0016) were significantly increased in repeat LCRR, without impact on postoperative outcomes.

CONCLUSIONS

Repeat LCRR seems to be feasible and safe in expert hands without compromising the oncologic outcomes. Intense postoperative adhesions and misidentification of blood supply might lead to conversion to laparotomy. Real benefits of laparoscopic approach for repeat LCRR should be assessed in further studies.

Laparoscopic colectomy after transcatheter aortic valve implantation in an elderly patient with obstructive descending colon cancer and severe aortic stenosis: a case report

BACKGROUND

The demand for laparoscopic colectomy is increasing due to greater number of elderly colon cancer patients, and it is important to evaluate existing comorbidities to ensure perioperative safety. Aortic stenosis (AS) is one of the most common heart diseases in the elderly, and elderly cancer patients with severe AS may be considered ineligible for optimal cancer treatment if they cannot endure surgical aortic valve replacement (SAVR). Recently, transcatheter aortic valve implantation (TAVI) has become a valid option in patients who are high risk for SAVR. We herein present the first case of an elderly cancer patient with severe AS who underwent laparoscopic colectomy after TAVI.

CASE PRESENTATION

An 87-year-old woman with a history of multiple cardiovascular diseases was diagnosed with obstructive descending colon cancer and initially underwent colonic stenting. However, as preoperative echocardiography revealed severe AS, she underwent TAVI prior to the colectomy to reduce perioperative risk. TAVI was chosen instead of SAVR due to high SAVR mortality risk, and laparoscopic colectomy was performed 22 days after TAVI. Her postoperative course was uneventful, and she was discharged 14 days later without any deterioration in general condition. No recurrence was observed at more than 1 year, even without adjuvant therapy.

CONCLUSION

TAVI facilitated subsequent laparoscopic colectomy in an elderly cancer patient with severe AS. Our case report shows that TAVI may enable further cancer treatment even in patients with severe AS, who may otherwise be considered not suitable for such treatments.