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Dapper H, Fleischmann M, Tselis N, Diefenhardt M, Hofheinz RD, Weiß C, Grabenbauer GG, Merten R, Grosu AL, Kirste S, Rieken S, Claßen J, Langer C, Kuhnt T, Schmidberger H, Ghadimi M, Giordano F, Nestle U, Koerber SA, Bock F, Geiger M, Polat B, Bruns CJ, Dieplinger G, Popp F, Zander T, Brunner T, Tribius S, Arnold D, Wurschi G, Piso P, Friede T, Hörner-Rieber J, Gkika E, Rödel C, Fokas E, on behalf of the German Rectal Cancer Study Group. ACO/ARO/AIO-22 - External beam radiotherapy combined with endorectal high-dose-rate brachytherapy in elderly and frail patients with rectal cancer: A prospective multicentre trial of the German Rectal Cancer Study Group. Clin Transl Radiat Oncol 2025; 53:100958. [PMID: 40276115 PMCID: PMC12020863 DOI: 10.1016/j.ctro.2025.100958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2025] [Revised: 04/01/2025] [Accepted: 04/05/2025] [Indexed: 04/26/2025] Open
Abstract
Purpose Rectal cancer disproportionately affects the elderly population, with more than half of cases diagnosed in individuals aged 70 years or older. Frail patients in this group often face significant challenges tolerating the standard treatment of total mesorectal excision (TME), due to elevated risks of surgical complications and perioperative morbidity. Advances in radiotherapy techniques offer a viable alternative, providing effective tumor control while minimizing treatment-related toxicity. Recent clinical trials, including OPERA and MORPEUS, have demonstrated that dose-escalated radiotherapy, which integrates external beam (chemo)radiotherapy (EBRT) with high-dose-rate endorectal brachytherapy (HDR-BT) or contact X-ray brachytherapy (CXB), can achieve high clinical response rates and facilitate organ preservation in younger, healthier patient cohorts. Building on these findings, the ACO/ARO/AIO-22 study seeks to adapt these innovative approaches to meet the needs of elderly and frail patients with rectal cancer. Methods/Design The ACO/ARO/AIO-22 trial is a prospective multicentre controlled trial. Elderly (age ≥70 years) and/or frail patients with non-metastatic rectal adenocarcinoma (cT1-3d N0/+ M0, mrCRM - / +) localized 0-16 cm from the ano-cutaneous line, unable to undergo radical surgery can be included. The initial treatment comprises an external beam radiation (EBRT) regime with 13 × 3 Gy (total: 39 Gy) over a period of two and a half weeks. Following initial restaging 6.5 weeks after completion of EBRT, endorectal HDR-BT will be delivered with 3 weekly fractions of 8 Gy to a total dose of 24 Gy (prescribed at the radial margin of the tumor; with a maximum prescription depth of 10 mm); alternatively, with CXB with 90 Gy in 3 weekly fractions. The primary objective is complete or near complete clinical response (cCR or ncCR) and the second primary endpoint is quality of life (QoL) measured with the EORTC QLQ-ELD14, both at 12 months after treatment start. Discussion The ACO/ARO/AIO-22 prospective multicentre trial will evaluate organ preservation rates and QoL after combining EBRT with endorectal HDR-BT in elderly and/or frail patients with rectal cancer.Trial Registration:Clinicialtrials.gov number: NCT06729645.
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Affiliation(s)
- Hendrik Dapper
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Maximilian Fleischmann
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Nikolaos Tselis
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Markus Diefenhardt
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Christian Weiß
- Department of Radiotherapy and Oncology, Community Hospital, Darmstadt, Germany
| | - Gerhard G. Grabenbauer
- Department of Radiation Oncology and Radiotherapy, DiaCura & Klinikum Coburg, Coburg, Germany
| | - Ricarda Merten
- Department of Radiation Therapy, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, Freiburg, Germany
- German Cancer Research Center, German Cancer Consortium, Freiburg, Germany
| | - Simon Kirste
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Comprehensive Cancer Center Lower Saxony (CCC-N), University Hospital Göttingen (UMG), Göttingen, Germany
| | - Johannes Claßen
- Department of Radiation Oncology, St. Vincentius-Kliniken gAG, Karlsruhe, Germany
| | | | - Thomas Kuhnt
- Department of Radiation Therapy, University of Leipzig, Leipzig, Germany
| | - Heinz Schmidberger
- Department of Radiation Oncology and Radiation Therapy, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center, Göttingen, Germany
| | - Frank Giordano
- Department of Radiation Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Ursula Nestle
- Department of Radiation Oncology, Kliniken Maria Hilf, Moenchengladbach, Germany
| | - Stefan A. Koerber
- Department of Radiation Oncology, Barmherzige Brüder Hospital Regensburg, Regensburg, Germany
| | - Felix Bock
- Department of Radiotherapy and Oncology, University of Rostock, Rostock, Germany
| | - Matthias Geiger
- Department of Radiotherapy and Oncology, Ostfildern Medius Kliniken, Ostfildern, Germany
| | - Bülent Polat
- Department of Radiation Oncology, University of Würzburg, Würzburg, Germany
| | | | - Georg Dieplinger
- Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Felix Popp
- Department of Visceral Surgery, University of Cologne, Cologne, Germany
| | - Thomas Zander
- Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Thomas Brunner
- Department of Radiation Oncology, Medical University of Graz, Graz, Austria
| | - Silke Tribius
- Asklepios Tumorzentrum Hamburg, AK St. Georg, Hermann-Holthusen Institute for Radiotherapy, Hamburg, Germany
| | - Dirk Arnold
- Asklepios Tumorzentrum Hamburg, AK Altona, Department of Oncology and Hematology, Hamburg, Germany
| | - Georg Wurschi
- Department of Radiotherapy and Radiation Oncology, Jena University Hospital, Jena, Germany
| | - Pompiliu Piso
- Department of General Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | | | - Eleni Gkika
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
| | - Claus Rödel
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Emmanouil Fokas
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - on behalf of the German Rectal Cancer Study Group
- Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
- Department of Radiation Oncology, University Hospital Johann Wolfgang Goethe University, Frankfurt, Germany
- Frankfurt Cancer Institute, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Mannheim Cancer Center, University Hospital Mannheim, Mannheim, Germany
- Department of Radiotherapy and Oncology, Community Hospital, Darmstadt, Germany
- Department of Radiation Oncology and Radiotherapy, DiaCura & Klinikum Coburg, Coburg, Germany
- Department of Radiation Therapy, University of Erlangen-Nürnberg, Erlangen, Germany
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, Freiburg, Germany
- German Cancer Research Center, German Cancer Consortium, Freiburg, Germany
- Department of Radiation Oncology, Comprehensive Cancer Center Lower Saxony (CCC-N), University Hospital Göttingen (UMG), Göttingen, Germany
- Department of Radiation Oncology, St. Vincentius-Kliniken gAG, Karlsruhe, Germany
- Kempten Clinic, Kempten, Germany
- Department of Radiation Therapy, University of Leipzig, Leipzig, Germany
- Department of Radiation Oncology and Radiation Therapy, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of General, Visceral and Pediatric Surgery, University Medical Center, Göttingen, Germany
- Department of Radiation Oncology, University Hospital Mannheim, Mannheim, Germany
- Department of Radiation Oncology, Kliniken Maria Hilf, Moenchengladbach, Germany
- Department of Radiation Oncology, Barmherzige Brüder Hospital Regensburg, Regensburg, Germany
- Department of Radiotherapy and Oncology, University of Rostock, Rostock, Germany
- Department of Radiotherapy and Oncology, Ostfildern Medius Kliniken, Ostfildern, Germany
- Department of Radiation Oncology, University of Würzburg, Würzburg, Germany
- Department of Visceral Surgery, University of Cologne, Cologne, Germany
- Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Düesseldorf, University Hospital of Cologne, Cologne, Germany
- Department of Radiation Oncology, Medical University of Graz, Graz, Austria
- Asklepios Tumorzentrum Hamburg, AK St. Georg, Hermann-Holthusen Institute for Radiotherapy, Hamburg, Germany
- Asklepios Tumorzentrum Hamburg, AK Altona, Department of Oncology and Hematology, Hamburg, Germany
- Department of Radiotherapy and Radiation Oncology, Jena University Hospital, Jena, Germany
- Department of General Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
- Department of Radiation Oncology, University Hospital Düsseldorf, Germany
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany
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Khan I, Belkovsky M, Gorgun E. The Old: Is There Any Role for Screening Colonoscopy after the Age of 75? The Surgeon's Perspective. Clin Colon Rectal Surg 2025; 38:212-218. [PMID: 40291997 PMCID: PMC12020639 DOI: 10.1055/s-0044-1787893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
Guidelines recommend individualized decision making for screening colonoscopy for colorectal cancer (CRC) in patients after the age of 75 years due to low additional benefits. That should be taken with a grain of salt, as these recommendations are based on expert opinion and simulation models which do not consider (1) the differences in pathogenesis and cancer biology of CRC in elderly; (2) the risks of colonoscopy in this patient population; (3) and the impact of new surgical and nonsurgical therapies for CRC. In this review, our goal is to bring a surgeon's perspective to understand the role of screening colonoscopy in patients older than 75 years.
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Affiliation(s)
- Imran Khan
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mikhael Belkovsky
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio
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Falola AF, Adeyeye A, Shekoni O, Oluwagbemi A, Effiong-John B, Ogbodu E, Dada OS, Ndong A. Robotic and laparoscopic minimally invasive surgery for colorectal cancer in Africa: an outcome comparison endorsed by the Nigerian society for colorectal disorders. Surg Endosc 2025; 39:122-140. [PMID: 39658673 DOI: 10.1007/s00464-024-11416-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Accepted: 11/03/2024] [Indexed: 12/12/2024]
Abstract
BACKGROUND Minimally invasive surgery for colorectal cancer (CRC) offer superior outcomes compared to open surgery. This study aimed to review the robotic and laparoscopic procedures for CRC performed in Africa, and compare the mean surgery duration, blood loss, hospital stay, rate of conversion, and prevalence of morbidity and mortality. This is the first study to compare the outcomes of robotic and laparoscopic surgeries for CRC in Africa. METHODS A systematic review following the PRISMA guidelines was conducted. PubMed, Google Scholar, Web of Science, AJOL, EMBASE, and CENTRAL were searched, identifying 2,259 publications, 33 of which were deemed eligible. Statistical analysis of outcomes was performed using "R". Methodological quality of the included studies was assessed using the Cochrane ROBINS-I tool. RESULTS The minimally invasive approach has been applied for CRC treatment in seven African countries: Algeria, Cameroon, Egypt, Morocco, Nigeria, Senegal, and South Africa. Laparoscopic surgeries accounted for 1,485 (95%) of cases, while 71 (5%) were robotic. Robotic procedures were associated with a longer surgery duration (256.41 min vs. 190.45 min, p < 0.0001), higher blood loss (226.48 mL vs. 141.55 mL, p < 0.0001), and a shorter hospital stay (4.52 days vs. 6.06 days, p = 0.85). Robotic procedures had a lower rate of conversion (3% vs. 8%, p = 0.29) and a lower prevalence of morbidity (19% vs. 26%, p = 0.26). Wound infection (24.49%) and ileus (57.14%) were the most common complications following laparoscopic and robotic procedures, respectively. There was no mortality from robotic surgeries; however, a prevalence of 0.39% (95% CI: 0;1.19) was recorded from laparoscopy. CONCLUSIONS This study establishes and compares the outcomes of advances in the treatment of CRC in the African setting, providing insights for policymakers, healthcare providers, and international organizations to make decisions regarding optimizing care for CRC patients in Africa.
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Affiliation(s)
- Adebayo Feranmi Falola
- University of Ibadan College of Medicine, Ibadan, Nigeria.
- General Surgery Community, Surgery Interest Group of Africa, Lagos, Nigeria.
| | - Ademola Adeyeye
- Significant Polyp and Early Colorectal Cancer Service, King's College Hospital, London, UK
- Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria
- Department of Medicine and Surgery, Afe Babalola University, Ado-Ekiti, Nigeria
| | - Oluwatobi Shekoni
- General Surgery Community, Surgery Interest Group of Africa, Lagos, Nigeria
- Mid and South Essex NHS Foundation Trust, Chelmsford, UK
| | | | - Blessing Effiong-John
- University of Ibadan College of Medicine, Ibadan, Nigeria
- General Surgery Community, Surgery Interest Group of Africa, Lagos, Nigeria
| | - Emmanuella Ogbodu
- General Surgery Community, Surgery Interest Group of Africa, Lagos, Nigeria
- Asaba Specialist Hospital, Asaba, Nigeria
| | - Oluwasina Samuel Dada
- General Surgery Community, Surgery Interest Group of Africa, Lagos, Nigeria
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Abdourahmane Ndong
- General Surgery Community, Surgery Interest Group of Africa, Lagos, Nigeria
- Department of Surgery, Gaston Berger University, Saint-Louis, Senegal
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Rajeev-Kumar G, Katipally RR, Li S, Shogan BD, Olortegui KS, Chin J, Polite BN, Liauw SL. Point/Counterpoint #2: Current Clinical Considerations With Nonoperative Management of Rectal Cancer. Cancer J 2024; 30:256-263. [PMID: 39042777 DOI: 10.1097/ppo.0000000000000732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
ABSTRACT Locally advanced rectal cancer has historically been treated with multimodal therapy consisting of radiation therapy, chemotherapy, and total mesorectal excision. However, recent prospective trials and registry studies have demonstrated similar disease outcomes with nonoperative management for patients who experience an excellent clinical response to radiation and chemotherapy. This article reviews data regarding nonoperative management for rectal cancer, and highlights current challenges and limitations in a point-counterpoint format, in the context of two clinical cases.
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Affiliation(s)
| | | | - Shen Li
- Sections of Surgical Oncology
| | | | | | - Janet Chin
- Department of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL
| | - Blase N Polite
- Department of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL
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Bürtin F, Ludwig T, Leuchter M, Hendricks A, Schafmayer C, Philipp M. More than 30 Years of POSSUM: Are Scoring Systems Still Relevant Today for Colorectal Surgery? J Clin Med 2023; 13:173. [PMID: 38202180 PMCID: PMC10779462 DOI: 10.3390/jcm13010173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/23/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) weights the patient's individual health status and the extent of the surgical procedure to estimate the probability of postoperative complications and death of general surgery patients. The variations Portsmouth-POSSUM (P-POSSUM) and colorectal POSSUM (CR-POSSUM) were developed for estimating mortality in patients with low perioperative risk and for patients with colorectal carcinoma, respectively. The aim of the present study was to evaluate the significance of POSSUM, P-POSSUM, and CR-POSSUM in two independent colorectal cancer cohorts undergoing surgery, with an emphasis on laparoscopic procedures. METHODS For each patient, an individual physiological score (PS) and operative severity score (OS) was attributed to calculate the predicted morbidity and mortality, respectively. Logistic regression analysis was used to evaluate the possible correlation between the subscores and the probability of postoperative complications and mortality. RESULTS The POSSUM equation significantly overpredicted postoperative morbidity, and all three scoring systems considerably overpredicted in-hospital mortality. However, the POSSUM score identified patients at risk of anastomotic leakage, sepsis, and the need for reoperation. Logistic regression analysis demonstrated a strong correlation between the subscores and the probability of postoperative complications and mortality, respectively. CONCLUSION Our results suggest that the three scoring systems are too imprecise for the estimation of perioperative complications and mortality of patients undergoing colorectal surgery in the present day. Since the subscores proved valid, a revision of the scoring systems could increase their reliability in the clinical setting.
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Affiliation(s)
- Florian Bürtin
- Department of General, Visceral, Thoracic, Vascular and Transplantation Surgery, University Medical Center Rostock, 18057 Rostock, Germany (C.S.); (M.P.)
| | - Tobias Ludwig
- Department of General, Visceral, Thoracic, Vascular and Transplantation Surgery, University Medical Center Rostock, 18057 Rostock, Germany (C.S.); (M.P.)
| | - Matthias Leuchter
- Institute of Implant Technology and Biomaterials e.V., 18119 Rostock, Germany;
| | - Alexander Hendricks
- Department of General, Visceral, Thoracic, Vascular and Transplantation Surgery, University Medical Center Rostock, 18057 Rostock, Germany (C.S.); (M.P.)
| | - Clemens Schafmayer
- Department of General, Visceral, Thoracic, Vascular and Transplantation Surgery, University Medical Center Rostock, 18057 Rostock, Germany (C.S.); (M.P.)
| | - Mark Philipp
- Department of General, Visceral, Thoracic, Vascular and Transplantation Surgery, University Medical Center Rostock, 18057 Rostock, Germany (C.S.); (M.P.)
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Ketelaers SHJ, Jacobs A, van der Linden CMJ, Nieuwenhuijzen GAP, Tolenaar JL, Rutten HJT, Burger JWA, Bloemen JG. An evaluation of postoperative outcomes and treatment changes after frailty screening and geriatric assessment and management in a cohort of older patients with colorectal cancer. J Geriatr Oncol 2023; 14:101647. [PMID: 37862736 DOI: 10.1016/j.jgo.2023.101647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 07/23/2023] [Accepted: 10/10/2023] [Indexed: 10/22/2023]
Abstract
INTRODUCTION Adequate patient selection is crucial within the treatment of older patients with colorectal cancer (CRC). While previous studies report increased morbidity and mortality in older patients screened positive for frailty, improvements in the perioperative care and postoperative outcomes have raised the question of whether older patients screened positive for frailty still face worse outcomes. This study aimed to investigate the postoperative outcomes of older patients with CRC screened positive for frailty, and to evaluate changes in treatment after frailty screening and geriatric assessment. MATERIALS AND METHODS Patients ≥70 years with primary CRC who underwent frailty screening between 1 January 2019 and 31 October 2021 were included. Frailty screening was performed by the Geriatric-8 (G8) screening tool. If the G8 indicated frailty (G8 ≤ 14), patients were referred for a comprehensive geriatric assessment (CGA). Postoperative outcomes and changes in treatment based on frailty screening and CGA were evaluated. RESULTS A total of 170 patients were included, of whom 74 (43.5%) screened positive for frailty (G8 ≤ 14). Based on the CGA, the initially proposed treatment plan was altered to a less intensive regimen in five (8.9%) patients, and to a more intensive regimen in one (1.8%) patient. Surgery was performed in 87.8% of patients with G8 ≤ 14 and 96.9% of patients with G8 > 14 (p = 0.03). Overall postoperative complications were similar between patients with G8 ≤ 14 and G8 > 14 (46.2% vs. 47.3%, p = 0.89). Postoperative delirium was observed in 7.7% of patients with G8 ≤ 14 and 1.1% of patients with G8 > 14 (p = 0.08). No differences in 30-day mortality (1.1% vs. 1.5%, p > 0.99) or one-year and two-year survival rates were observed (log rank, p = 0.26). DISCUSSION Although patients screened positive for frailty underwent CRC surgery less often, those considered eligible for surgery can safely undergo CRC resection within current clinical care pathways, without increased morbidity and mortality. Efforts to optimise perioperative care and minimise the risk of postoperative complications, in particular delirium, seem warranted. A multidisciplinary onco-geriatric pathway may support tailored decision-making in patients at risk of frailty.
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Affiliation(s)
- Stijn H J Ketelaers
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands.
| | - Anne Jacobs
- Department of Gerontology and Geriatrics, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| | - Carolien M J van der Linden
- Department of Gerontology and Geriatrics, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| | | | - Jip L Tolenaar
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands; Department of GROW, School for Oncology & Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Jacobus W A Burger
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
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Pisarska-Adamczyk M, Rzepa A, Kapusta M, Zawadzka K, Kuśnierz-Cabala B, Wysocki M, Małczak P, Major P, Zub-Pokrowiecka A, Wierdak M, Pędziwiatr M. Is triggering receptor expressed on myeloid cell 1 (TREM-1) protein a new marker of serious infectious complications in colorectal surgery?: case-matched pilot study. Langenbecks Arch Surg 2023; 408:368. [PMID: 37733081 PMCID: PMC10514102 DOI: 10.1007/s00423-023-03103-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/09/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE The purpose of the study was to evaluate the usefulness of the triggering receptor expressed on myeloid cell 1 (TREM-1) protein as a marker for serious infectious complications during laparoscopic colorectal surgery. METHODS Sixty-four patients with colon or rectal cancer, who underwent an elective laparoscopic colorectal cancer surgery from November 2018 to February 2020, were included in the analysis. Blood samples of the TREM-1 protein testing were collected four times from each patient: before and on three following postoperative days (PODs). Patients were divided into two groups according to the presence of infectious complications. Subsequently, patients with infectious complications (group 1) were matched 1:1 with patients without complications (group 2). The case-matched analysis was done by selecting patients from the control group by age, ASA scale, cancer stage, and type of surgery. RESULTS There was no significant difference in demographic and operative characteristics between the two groups. The median length of hospital stay was longer in group 1 than in group 2 (11 days vs. 5 days, p < 0.001). Preoperative measurements of TREM-1 protein did not differ between the two groups. There were no significant differences in the measurements on the first and third postoperative days. However, the median TREM-1 measurement was higher in group 1 on the second postoperative day (542 pg/ml vs. 399 pg/ml; p = 0.040). The difference was more apparent when only severe postoperative complications were considered. When compared to the group without any complications, the median TREM-1 level was significantly higher in the group with severe infection complications in POD 1, POD 2, and POD 3 (p < 0.05). The receiver operating characteristic (ROC) curve demonstrated that TREM-1 readings in POD 2 had a sensitivity of 83% and a specificity of 84% for the presence of severe infection complications at a value of 579.3 pg/ml (AUC 0.8, 95%CI 0.65-0.96). CONCLUSION TREM-1 measurements might become a helpful predictive marker in the early diagnosis of serious infectious complications in patients following laparoscopic colorectal surgery.
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Affiliation(s)
| | - Anna Rzepa
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2, 30-688, Krakow, Poland
| | - Maria Kapusta
- Department of Diagnostics, Jagiellonian University Medical College, Chair of Clinical Biochemistry, Krakow, Poland
| | - Karolina Zawadzka
- Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Beata Kuśnierz-Cabala
- Faculty of Medicine, Chair of Medical Biochemistry, Jagiellonian University Medical College, Krakow, Poland
| | - Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital in Krakow, Krakow, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2, 30-688, Krakow, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2, 30-688, Krakow, Poland
| | - Anna Zub-Pokrowiecka
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2, 30-688, Krakow, Poland
| | - Mateusz Wierdak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2, 30-688, Krakow, Poland.
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2, 30-688, Krakow, Poland
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Boeding JRE, Cuperus IE, Rijken AM, Crolla RMPH, Verhoef C, Gobardhan PD, Schreinemakers JMJ. Postponing surgery to optimise patients with acute right-sided obstructing colon cancer - A pilot study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106906. [PMID: 37061403 DOI: 10.1016/j.ejso.2023.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 04/01/2023] [Accepted: 04/06/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND Right-sided obstructing colon cancer is most often treated with acute resection. Recent studies on right-sided obstructing colon cancer report higher mortality and morbidity rates than those in patients without obstruction. The aim of this study is to retrospectively analyse whether it is possible to optimise the health condition of patients with acute right-sided obstructing colon cancer, prior to surgery, and whether this improves postoperative outcomes. METHOD All consecutive patients with high suspicion of, or histologically proven, right-sided obstructing colon cancer, treated with curative intent between March 2013 and December 2019, were analysed retrospectively. Patients were divided into two groups: optimised group and non-optimised group. Pre-operative optimisation included additional nutrition, physiotherapy, and, if needed, bowel decompression. RESULTS In total, 54 patients were analysed in this study. Twenty-four patients received optimisation before elective surgery, and thirty patients received emergency surgery, without optimisation. Scheduled surgery was performed after a median of eight days (IQR 7-12). Postoperative complications were found in twelve (50%) patients in the optimised group, compared to twenty-three (77%) patients in the non-optimised group (p = 0.051). Major complications were diagnosed in three (13%) patients with optimisation, compared to ten (33%) patients without optimisation (p = 0.111). Postoperative in-hospital stay, 30-day mortality, as well as primary anastomosis were comparable in both groups. CONCLUSION This pilot study suggests that pre-operative optimisation of patients with obstructing right sided colonic cancer may be feasible and safe but is associated with longer in-patient stay.
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Affiliation(s)
- Jeske R E Boeding
- Department of Surgery, Amphia Hospital, Breda, the Netherlands; Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - Iris E Cuperus
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Arjen M Rijken
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | | | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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9
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Wells CI, Varghese C, Boyle LJ, McGuinness MJ, Keane C, O'Grady G, Gurney J, Koea J, Harmston C, Bissett IP. "Failure to Rescue" following Colorectal Cancer Resection: Variation and Improvements in a National Study of Postoperative Mortality. Ann Surg 2023; 278:87-95. [PMID: 35920564 DOI: 10.1097/sla.0000000000005650] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To examine variation in "failure to rescue" (FTR) as a driver of differences in mortality between centres and over time for patients undergoing colorectal cancer surgery. BACKGROUND Wide variation exists in postoperative mortality following colorectal cancer surgery. FTR has been identified as an important determinant of variation in postoperative outcomes. We hypothesized that differences in mortality both between hospitals and over time are driven by variation in FTR. METHODS A national population-based study of patients undergoing colorectal cancer resection from 2010 to 2019 in Aotearoa New Zealand was conducted. Rates of 90-day FTR, mortality, and complications were calculated overall, and for surgical and nonoperative complications. Twenty District Health Boards (DHBs) were ranked into quartiles using risk- and reliability-adjusted 90-day mortality rates. Variation between DHBs and trends over the 10-year period were examined. RESULTS Overall, 15,686 patients undergoing resection for colorectal adenocarcinoma were included. Increased postoperative mortality at high-mortality centers (OR 2.4, 95% CI 1.8-3.3) was driven by higher rates of FTR (OR 2.0, 95% CI 1.5-2.8), and postoperative complications (OR 1.4, 95% CI 1.3-1.6). These trends were consistent across operative and nonoperative complications. Over the 2010 to 2019 period, postoperative mortality halved (OR 0.5, 95% CI 0.4-0.6), associated with a greater improvement in FTR (OR 0.5, 95% CI 0.4-0.7) than complications (OR 0.8, 95% CI 0.8-0.9). Differences between centers and over time remained when only analyzing patients undergoing elective surgery. CONCLUSION Mortality following colorectal cancer resection has halved over the past decade, predominantly driven by improvements in "rescue" from complications. Differences in FTR also drive hospital-level variation in mortality, highlighting the central importance of "rescue" as a target for surgical quality improvement.
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Affiliation(s)
- Cameron I Wells
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Chris Varghese
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Luke J Boyle
- Department of Statistics, The University of Auckland, Auckland, New Zealand
| | | | - Celia Keane
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland District Health Board, Auckland, New Zealand
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Jason Gurney
- Department of Public Health, University of Otago Wellington, Wellington, New Zealand
| | - Jonathan Koea
- Department of General Surgery, Waitemata District Health Board, Takapuna, New Zealand
| | - Chris Harmston
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Northland District Health Board, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland District Health Board, Auckland, New Zealand
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10
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Clausen J, Hansen HF, Walbech JS, Gögenur I. Incidence and clinical predictors of 30-day emergency readmission after colorectal cancer surgery - A nationwide cohort study. Colorectal Dis 2023; 25:222-233. [PMID: 36196793 DOI: 10.1111/codi.16349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/15/2022] [Accepted: 09/11/2022] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to investigate the risk and predictors of 30-day emergency readmission and surgical reintervention after discharge from colorectal cancer surgery with curative intent in Denmark. METHOD This is a retrospective cohort study using Danish nationwide registry data. We included all patients who underwent colorectal tumour resection with curative intent between 1 January 2005 and 1 December 2018. The primary outcome was 30-day emergency readmission, defined as any emergency hospital visit within 30 days of discharge. Secondary outcomes were 30-day emergency readmission with a minimum duration of 2 days and 30-day emergency readmission including any abdominal procedure. Twenty-three candidate predictors including patient comorbidities, tumour characteristics, surgical treatment and length of stay were evaluated using multivariate logistic regression models. Length of stay was categorized into percentiles and standardized according to year of surgery. RESULTS Of the 40 782 patients included in the study, 8360 (20.5%) were readmitted within 30 days of discharge. Median time to readmission was 6 days (interquartile range 2-15 days). A total of 4968 patients (12.2%) were readmitted for at least 2 days, and 793 patients (1.9%) underwent an abdominal procedure during their readmission. The strongest predictors of 30-day readmission were length of stay below the fifth percentile (OR 2.36; P < 0.001) and American Society of Anesthesiologists score IV (OR 2.21; P < 0.001). CONCLUSION Emergency readmission is frequent after colorectal cancer surgery with curative intent, and almost 10% of readmitted patients require surgical reintervention. An increased focus on predicting preventable readmissions might facilitate interventions to reduce morbidity and hospital expenses.
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Affiliation(s)
- Johan Clausen
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | | | | | - Ismail Gögenur
- Department of Surgery, Zealand University Hospital, Koege, Denmark
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11
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Organ Preservation in Rectal Cancer: An Overview of the Dutch Perspective and Recent Developments. Clin Oncol (R Coll Radiol) 2023; 35:107-116. [PMID: 36253320 DOI: 10.1016/j.clon.2022.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/17/2022] [Accepted: 09/22/2022] [Indexed: 01/20/2023]
Abstract
Although current guidelines on rectal cancer treatment often recommend rectal resection with or without neoadjuvant (chemo)radiotherapy, there is growing interest in organ-preserving treatment approaches among patients and clinicians in the Netherlands. Currently, multiple ongoing studies are investigating the value of different non-operative treatment modalities to improve tumour response rates and increase the chance of successful organ preservation. Papillon contact X-ray brachytherapy is a promising treatment modality to improve the chance of organ preservation, which seems especially relevant for elderly and frail patients unable or refusing to undergo total mesorectal excision surgery. The elderly and frail patient with rectal cancer poses a significant challenge and warrants a thorough multidisciplinary approach to provide the most optimal organ-preserving treatment. In this overview, an insight into the Dutch perspectives and developments within the field of organ preservation and the set-up of a Papillon facility to complete the spectrum of organ-preserving treatment options in a tertiary referral centre for rectal cancer treatment has been provided.
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12
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Fokas E, Glynne-Jones R, Fleischmann M, Piso P, Tselis N, Ghadimi M, Hofheinz RD, Rödel C. Radiotherapy dose escalation using endorectal brachytherapy in elderly and frail patients with rectal cancer unsuitable for surgery: Lessons from studies in fit patients and future perspectives. Cancer Treat Rev 2023; 112:102490. [PMID: 36463667 DOI: 10.1016/j.ctrv.2022.102490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022]
Abstract
Epidemiological data indicate that more than 50 % of patients with newly-diagnosed rectal cancer are older than 70 years, with rising numbers expected over the next decades. Treatment decision-making is challenging in elderly and frail patients with rectal cancer, whereas standardized treatment guidelines for this patient cohort are lacking. Elderly and frail rectal cancer patients are often considered by surgeons as unfit to undergo radical surgery as the risk of surgical complications and postoperative mortality rises with increasing age and comorbidity. Furthermore, these patients often receive no treatment at all, resulting in local and/or systemic disease progression with associated symptoms and impaired quality of life (QoL). Recent data from randomized trials in young fit patients with early stage rectal cancer indicate that RT dose escalation can be safely delivered using external beam (chemo)radiotherapy (EBRT) followed by endoluminal radiotherapeutic modalities, such as contact X-ray brachytherapy (CXB) or high-dose rate endorectal brachytherapy (HDR-BT). However, prospective studies testing this therapeutic concept in elderly and frail patients remain limited. Here, we review the current evidence in the epidemiology and the management of elderly and frail patients with rectal cancer. We summarize the potential of RT dose escalation to achieve long-term local control of the primary tumour, prevent disease-related morbidity, improve QoL and even organ preservation. Future perspectives and open questions will be discussed as well.
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Affiliation(s)
- Emmanouil Fokas
- Department of Radiotherapy of Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany, German Cancer Consortium (DKTK), Partner Site, Frankfurt, Germany; Frankfurt Cancer Institute (FCI), Germany.
| | - Robert Glynne-Jones
- Department of Radiotherapy, Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex, UK
| | - Maximillian Fleischmann
- Department of Radiotherapy of Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany, German Cancer Consortium (DKTK), Partner Site, Frankfurt, Germany; Frankfurt Cancer Institute (FCI), Germany
| | - Pompiliu Piso
- Department of General and Visceral Surgery, Barmherzige Brüder Hospital, 93049 Regensburg, Germany
| | - Nikolaos Tselis
- Department of Radiotherapy of Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany, German Cancer Consortium (DKTK), Partner Site, Frankfurt, Germany; Frankfurt Cancer Institute (FCI), Germany
| | - Michael Ghadimi
- Department of General, Visceral, and Pediatric Surgery, University Medical Center, Göttingen, Germany
| | - Ralf-Dieter Hofheinz
- Department of Medical Oncology, University Hospital Mannheim, University Heidelberg, Heidelberg, Germany
| | - Claus Rödel
- Department of Radiotherapy of Oncology, University of Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany, German Cancer Consortium (DKTK), Partner Site, Frankfurt, Germany; Frankfurt Cancer Institute (FCI), Germany
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13
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van Kooten RT, Elske van den Akker-Marle M, Putter H, Meershoek-Klein Kranenbarg E, van de Velde CJH, Wouters MWJM, Tollenaar RAEM, Peeters KCMJ. The Impact of Postoperative Complications on Short- and Long-Term Health-Related Quality of Life After Total Mesorectal Excision for Rectal Cancer. Clin Colorectal Cancer 2022; 21:325-338. [PMID: 36210321 DOI: 10.1016/j.clcc.2022.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Survival for rectal cancer patients has improved over the past decades. In parallel, long-term health-related quality of life (HRQoL) is gaining interest. This study focuses on the effect of complications following rectal cancer surgery on HRQoL and survival. METHODS The TME-trial (1996-1999) randomized patients with operable rectal cancer between surgery with preoperative short-course radiotherapy and surgery. Questionnaires including the Rotterdam Symptom Checklist were sent at 6 time points within the first 24 months and after 14 years the EORTC QLQ-C30 and EORTC QLQ-CR29 questionnaires. Differences in HRQoL and survival between patients with and without complications were analyzed. RESULTS A total of 1207 patients were included, of which 482 (39.9%) patients experienced complications, surgical complications occurred in 177 (14.6%) patients, non-surgical complications in 197 (16.3%) and 108 patients (8.9%) had a combination of both types of complications. Three months after surgery, patients with a combination of surgical- and non-surgical complications, especially patients with anastomotic leakage, had the worst HRQoL. Twelve months postoperative HRQoL returned to a similar level as before surgery, regardless of complications. In patients who survived 14 years, no significant differences in HRQoL were seen between patients with and without complications. However, patients with complications did have lower overall survival. CONCLUSION This study shows that survival and short-term HRQoL are negatively affected by complications. Twelve months after surgery HRQoL had returned to the preoperative level regardless, of complications. Also, in patients that survived 14 years, there was no effect of complications on HRQoL detected.
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Affiliation(s)
- Robert T van Kooten
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
| | | | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Cornelis J H van de Velde
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands; Leiden University Medical Center, Leiden, The Netherlands
| | - Michel W J M Wouters
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands; Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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14
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Turri G, Caliskan G, Conti C, Martinelli L, De Giulio E, Ruzzenente A, Guglielmi A, Verlato G, Pedrazzani C. Impact of age and comorbidities on short- and long-term outcomes of patients undergoing surgery for colorectal cancer. Front Oncol 2022; 12:959650. [PMID: 36338732 PMCID: PMC9633938 DOI: 10.3389/fonc.2022.959650] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background As the world population is progressively ageing, more and more elderly patients will require cancer surgery. Although curative surgery is the treatment of choice for resectable colorectal cancer (CRC), it is still debated whether elderly frail patients should undergo major cancer surgery due to the increased risk of postoperative and long-term mortality. The aim of this retrospective study was to evaluate the impact of age and comorbidities on postoperative mortality/morbidity and long-term outcomes, looking for potential age-related survival differences. Methods A total of 1,482 patients operated for CRC at our institution between January 2005 and October 2020 were analysed. The independent effect of age and comorbidities on postoperative complications was assessed by a logistic model, while the effect on overall survival (OS) and cancer-related survival (CRS) was estimated by a Cox regression model. Results The median age in the cohort was 67.8 years. Postoperative mortality was very low in the whole cohort (0.8%) and contained even in older age groups (3.2% in patients aged 80–84 years, 4% in the 85–90-year age group). The cumulative incidence of postoperative complications was doubled in patients with comorbidities (32.8% vs. 15.1%, p = 0.002). With regard to OS, as expected, it exponentially decreased with advancing age. Conversely, differences in CRS were less pronounced between age groups and absent in patients with stage 0–I CRC. Analysis of all causes and cancer-related mortality revealed a peak within 2 years from surgery, suggesting a prolonged impact of surgery. In patients aged 75 years and above, all-cause mortality showed a steep increase 1 year after surgery, while cancer-related mortality plateaued at about 4 years after surgery. On multivariable analysis, OS, but not CRS, was significantly influenced by age. Conclusions Although acceptable results of surgery in elderly patients, OS is strongly dependent on age: older people die more from competing causes than cancer-related treatments compared to younger age classes. The preoperative identification of risk factors for low OS may help the selection of those elderly patients who would benefit from curative CRC surgery.
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Affiliation(s)
- Giulia Turri
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Gulser Caliskan
- Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Cristian Conti
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Luigi Martinelli
- Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Ernesto De Giulio
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Andrea Ruzzenente
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Alfredo Guglielmi
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Giuseppe Verlato
- Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Corrado Pedrazzani
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
- *Correspondence: Corrado Pedrazzani,
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15
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Ketelaers SHJ, Dhondt L, van Ham N, Harms AS, Scholten HJ, Nieuwenhuijzen GAP, Rutten HJT, Burger JWA, Bloemen JG, Vogelaar FJ. A prospective cohort study to evaluate continuous wound infusion with local analgesics within an enhanced recovery protocol after colorectal cancer surgery. Colorectal Dis 2022; 24:1172-1183. [PMID: 35637573 DOI: 10.1111/codi.16201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/29/2022] [Accepted: 05/22/2022] [Indexed: 02/08/2023]
Abstract
AIM To reduce detrimental opioid-related side effects, minimising the postoperative opioid consumption is needed, especially in older patients. Continuous wound infusion (CWI) with local analgesics appears to be an effective opioid-sparing alternative. However, the added value of CWI to an enhanced recovery protocol after colorectal cancer (CRC) surgery is unclear. The aim of this study was to evaluate the outcomes of CWI after CRC surgery within a strictly adhered to enhanced recovery protocol. METHODS In this multicentre prospective observational cohort study, patients who underwent CRC surgery between May 2019 and January 2021 were included. Patients were treated with CWI as adjunct to multimodal pain management within an enhanced recovery protocol. Postoperative opioid consumption, pain scores and outcomes regarding functional recovery were evaluated. RESULTS A cohort of 130 consecutive patients were included, of whom 36.2% were ≥75 years. Postoperative opioids were consumed by 80 (61.5%) patients on postoperative day 0, and by 28 (21.5%), 27 (20.8%), and 18 (13.8%) patients on postoperative days 1, 2, and 3, respectively. Median pain scores were <4 on all days. The median time until first passage of stool was 1.0 (IQR: 1.0-2.0) day. Postoperative delirium occurred in 0.8%. Median length of hospital stay was 3.0 days (IQR: 2.0-5.0). CONCLUSION In patients treated with CWI, low amounts of postoperative opioid consumption, adequate postoperative pain control, and enhanced recovery were observed. CWI seems a beneficial opioid-sparing alternative and may further improve the outcomes of an enhanced recovery protocol after CRC surgery, which seems especially valuable for older patients.
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Affiliation(s)
| | - Lieke Dhondt
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| | - Nikki van Ham
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Ansgar S Harms
- Department of Anaesthesiology, VieCuri Medical Centre, Venlo, The Netherlands
| | - Harm J Scholten
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | | | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands.,GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
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16
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Bräuner KB, Rosen AW, Tsouchnika A, Walbech JS, Gögenur M, Lin VA, Clausen JSR, Gögenur I. Developing prediction models for short-term mortality after surgery for colorectal cancer using a Danish national quality assurance database. Int J Colorectal Dis 2022; 37:1835-1843. [PMID: 35849195 DOI: 10.1007/s00384-022-04207-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The majority of colorectal cancer surgeries are performed electively, and treatment is often decided at the multidisciplinary team conference. Although the average 30-day mortality rate is low, there is substantial population heterogeneity from young, healthy patients to frail, elderly patients. The individual risk of surgery can vary widely, and tailoring treatment for colorectal cancer may lead to better outcomes. This requires prediction of risk that is accurate and available prior to surgery. METHODS Data from the Danish Colorectal Cancer Group database was transformed into the Observational Medical Outcomes Partnership Common Data Model. Models were developed to predict the risk of mortality within 30, 90, and 180 days after colorectal cancer surgery using only covariates decided at the multidisciplinary team conference. Several machine-learning models were trained, but due to superior performance, a Least Absolute Shrinkage and Selection Operator logistic regression was used for the final model. Performance was assessed with discrimination (area under the receiver operating characteristic and precision recall curve) and calibration measures (calibration in large, intercept, slope, and Brier score). RESULTS The cohort contained 65,612 patients operated for colorectal cancer in the period from 2001 to 2019 in Denmark. The Least Absolute Shrinkage and Selection Operator model showed an area under the receiver operating characteristic for 30-, 90-, and 180-day mortality after colorectal cancer surgery of 0.871 (95% CI: 0.86-0.882), 0.874 (95% CI: 0.864-0.882), and 0.876 (95% CI: 0.867-0.883) and calibration in large of 1.01, 0.98, and 1.01, respectively. CONCLUSION The postoperative short-term mortality prediction model showed excellent discrimination and calibration using only preoperatively known predictors.
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Affiliation(s)
- Karoline B Bräuner
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark.
| | - Andreas W Rosen
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark
| | - Adamantia Tsouchnika
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark
| | - Julie S Walbech
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark
| | - Mikail Gögenur
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark
| | - Viviane A Lin
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark
| | - Johan S R Clausen
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark.,The Faculty of Health Science, University of Copenhagen, Blegdamsvej 6, 2200, Copenhagen N, Denmark
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17
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Ketelaers SHJ, Jacobs A, Verrijssen ASE, Cnossen JS, van Hellemond IEG, Creemers GJM, Schreuder RM, Scholten HJ, Tolenaar JL, Bloemen JG, Rutten HJT, Burger JWA. A Multidisciplinary Approach for the Personalised Non-Operative Management of Elderly and Frail Rectal Cancer Patients Unable to Undergo TME Surgery. Cancers (Basel) 2022; 14:2368. [PMID: 35625976 PMCID: PMC9139821 DOI: 10.3390/cancers14102368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023] Open
Abstract
Despite it being the optimal curative approach, elderly and frail rectal cancer patients may not be able to undergo a total mesorectal excision. Frequently, no treatment is offered at all and the natural course of the disease is allowed to unfold. These patients are at risk for developing debilitating symptoms that impair quality of life and require palliative treatment. Recent advancements in non-operative treatment modalities have enhanced the toolbox of alternative treatment strategies in patients unable to undergo surgery. Therefore, a proposed strategy is to aim for the maximal non-operative treatment, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The complexity of treating elderly and frail patients requires a patient-centred approach to personalise treatment. The main challenge is to optimise the balance between local control of disease, patient preferences, and the burden of treatment. A comprehensive geriatric assessment is a crucial element within the multidisciplinary dialogue. Since limited knowledge is available on the optimal non-operative treatment strategy, these patients should be treated by dedicated multidisciplinary rectal cancer experts with special interest in the elderly and frail. The aim of this narrative review was to discuss a multidisciplinary patient-centred treatment approach and provide a practical suggestion of a successfully implemented clinical care pathway.
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Affiliation(s)
- Stijn H. J. Ketelaers
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Anne Jacobs
- Department of Gerontology and Geriatrics, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - An-Sofie E. Verrijssen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Jeltsje S. Cnossen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Irene E. G. van Hellemond
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Geert-Jan M. Creemers
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Ramon-Michel Schreuder
- Department of Gastroenterology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Harm J. Scholten
- Department of Anaesthesiology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Jip L. Tolenaar
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Johanne G. Bloemen
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Harm J. T. Rutten
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
- GROW, School for Oncology and Reproduction, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Jacobus W. A. Burger
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
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18
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The survival gap between young and older patients after surgical resection for colorectal cancer remains largely based on early mortality: A EURECCA comparison of four European countries. J Geriatr Oncol 2022; 13:803-812. [DOI: 10.1016/j.jgo.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 03/21/2022] [Accepted: 04/15/2022] [Indexed: 11/18/2022]
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Ogata T, Yoshida N, Sadakari Y, Iwanaga A, Nakane H, Okawara K, Endo K, Kaneshiro K, Hirokata G, Aoyagi T, Shima H, Taniguchi M. Colorectal cancer surgery in elderly patients 80 years and older: a comparison with younger age groups. J Gastrointest Oncol 2022; 13:137-148. [PMID: 35284116 PMCID: PMC8899744 DOI: 10.21037/jgo-21-627] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 01/11/2022] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND A reduction in complications and mortality can be observed over the last few decades among elderly patients in the early postoperative period for colorectal cancer (CRC) surgery, but long-term outcomes are largely unknown. This study aimed to investigate the long-term outcomes of elderly patients 80 years and older after CRC surgery in comparison with younger age groups. The influence of clinical, oncological, and physical parameters on outcome were retrospectively analyzed. METHODS A total of 346 patients underwent CRC surgery with curative intent between January 2013 and December 2017. Patients were divided into three age groups: younger than 60 (n=47), between 60 and 79 (n=218), and 80 and older (n=81). Clinicopathological variables including comorbidity, modified frailty index, prognostic nutrition index (PNI), operative/postoperative data, and outcome including cause of death were compared among age groups. To identify factors associated with death from CRC and other causes, univariate and multivariate analyses using the Cox proportional hazards model were performed. RESULTS Immediate postoperative morbidity of patients with Clavien-Dindo grades of III or greater (16.0%) and the 30-day mortality rate (2.5%) of patients 80 years and older were not statistically different from those of younger age groups. Long-term disease-free survival was also similar among age groups, suggesting CRC surgery provides oncological benefit to patients irrespective of age. Multivariate analysis revealed that R1 resection, advanced tumor stage, carcinoembryonic antigen (CEA) level of >5 ng/mL, undifferentiated tumor, and longer postoperative hospital stay were risk factors for CRC death. Long-term overall survival was significantly reduced in comparison to younger age groups. Seventy percent of deaths in elderly patients during follow-up were primarily from respiratory failure and cardiovascular disease. Multivariate analysis demonstrated that advanced age, frailty, low PNI, and open procedure were risk factors for other causes of mortality. CONCLUSIONS Elderly patients undergoing CRC surgery appeared to enjoy similar oncological benefits as younger age groups. Since both modified frailty index and PNI were correlated with mortality unrelated to CRC, preoperative assessment of these factors can be important for predicting outcome and selecting patients for prehabilitation.
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Affiliation(s)
- Toshiro Ogata
- Department of Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Naohiro Yoshida
- Department of Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | | | - Ayako Iwanaga
- Department of Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Hiroyuki Nakane
- Department of Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Kazuma Okawara
- Department of Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Kayoko Endo
- Department of Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | | | - Gentaro Hirokata
- Department of Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Takeshi Aoyagi
- Department of Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
| | - Hiroji Shima
- Department of Surgery, St. Mary's Hospital, Kurume, Fukuoka, Japan
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20
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Custers PA, Geubels BM, Huibregtse IL, Peters FP, Engelhardt EG, Beets GL, Marijnen CAM, van Leerdam ME, van Triest B. Contact X-ray Brachytherapy for Older or Inoperable Rectal Cancer Patients: Short-Term Oncological and Functional Follow-Up. Cancers (Basel) 2021; 13:cancers13246333. [PMID: 34944953 PMCID: PMC8699080 DOI: 10.3390/cancers13246333] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 11/16/2022] Open
Abstract
Total mesorectal excision for rectal cancer is a major operation associated with morbidity and mortality. For older or inoperable patients, alternatives are necessary. This prospective study evaluated the oncological and functional outcome and quality of life of older or inoperable rectal cancer patients treated with a contact X-ray brachytherapy boost to avoid major surgery. During follow-up, tumor response and toxicity on endoscopy were scored. Functional outcome and quality of life were assessed with self-administered questionnaires. Additionally, in-depth interviews regarding patients' experiences were conducted. Nineteen patients were included with a median age of 80 years (range 72-91); nine patients achieved a clinical complete response and in another four local control of the tumor was established. The 12 month organ-preservation rate, progression-free survival, and overall survival were 88%, 78%, and 100%, respectively. A transient decrease in quality of life and bowel function was observed at 3 months, which was generally restored at 6 months. In-depth interviews revealed that patients' experience was positive despite the side-effects shortly after treatment. In older or inoperable rectal cancer patients, contact X-ray brachytherapy can be considered an option to avoid total mesorectal excision. Contact X-ray brachytherapy is well-tolerated and can provide good tumor control.
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Affiliation(s)
- Petra A. Custers
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1006 BE Amsterdam, The Netherlands; (P.A.C.); (B.M.G.); (G.L.B.)
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1006 BE Amsterdam, The Netherlands; (F.P.P.); (C.A.M.M.)
- GROW School for Oncology and Developmental Biology, Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Barbara M. Geubels
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1006 BE Amsterdam, The Netherlands; (P.A.C.); (B.M.G.); (G.L.B.)
- GROW School for Oncology and Developmental Biology, Maastricht University, 6200 MD Maastricht, The Netherlands
- Department of Surgery, Catharina Hospital, Postbox 1350, 5602 ZA Eindhoven, The Netherlands
| | - Inge L. Huibregtse
- Department of Gastroenterology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1006 BE Amsterdam, The Netherlands; (I.L.H.); (M.E.v.L.)
| | - Femke P. Peters
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1006 BE Amsterdam, The Netherlands; (F.P.P.); (C.A.M.M.)
- Department of Radiation Oncology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| | - Ellen G. Engelhardt
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1006 BE Amsterdam, The Netherlands;
| | - Geerard L. Beets
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1006 BE Amsterdam, The Netherlands; (P.A.C.); (B.M.G.); (G.L.B.)
- GROW School for Oncology and Developmental Biology, Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Corrie A. M. Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1006 BE Amsterdam, The Netherlands; (F.P.P.); (C.A.M.M.)
- Department of Radiation Oncology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| | - Monique E. van Leerdam
- Department of Gastroenterology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1006 BE Amsterdam, The Netherlands; (I.L.H.); (M.E.v.L.)
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| | - Baukelien van Triest
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, 1006 BE Amsterdam, The Netherlands; (F.P.P.); (C.A.M.M.)
- Correspondence: ; Tel.: +31-(0)20-512-9111
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21
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Statin therapy and its association with long-term survival after colon cancer surgery. Surgery 2021; 171:890-896. [PMID: 34507829 DOI: 10.1016/j.surg.2021.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/23/2021] [Accepted: 08/01/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND The current study aims to address the clinical equipoise regarding the association of ongoing statin therapy at time of surgery with long-term postoperative mortality rates after elective, curative, surgical resections of colon cancer by analyzing data from a large validated national register. METHODS All adults with stage I to III colon cancer who underwent elective surgery with curative intent between January 2007 and October 2016 were retrieved from the Swedish Colorectal Cancer Register, a prospectively collected national register. Patients were identified as having ongoing statin therapy if they filled a prescription within 12 months pre- and postoperatively. Study outcomes included 5-year all-cause and cancer-specific postoperative mortality. To reduce the impact of confounding from covariates owing to nonrandomization, the inverse probability of treatment weighting method was used. Subsequently, Cox proportional hazards models were fitted to the weighted cohorts. RESULTS In total, 19,118 patients underwent elective surgery for colon cancer in the specified period, of whom 31% (5,896) had ongoing statin therapy. Despite being older, having a higher preoperative risk, and having more comorbidities, patients with statin therapy had a higher postoperative survival. After inverse probability of treatment weighting, patients with statin therapy displayed a significantly lower mortality risk up to 5 years after surgery for both all-cause (hazard ratio 0.68, 95% confidence interval 0.63-0.74, P < .001) and cancer-specific mortality (hazard ratio 0.76, 95% confidence interval 0.66-0.89, P < .001). CONCLUSION The results of this study indicate that statin therapy is associated with a sustained reduction in all-cause and cancer-specific mortality up to 5 years after elective colon cancer surgery. The findings warrant validation in future prospective clinical trials.
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22
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Boeding JRE, Ramphal W, Rijken AM, Crolla RMPH, Verhoef C, Gobardhan PD, Schreinemakers JMJ. A Systematic Review Comparing Emergency Resection and Staged Treatment for Curable Obstructing Right-Sided Colon Cancer. Ann Surg Oncol 2021; 28:3545-3555. [PMID: 33067743 DOI: 10.1245/s10434-020-09124-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/31/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Treatment for obstructing colon cancer (OCC) is controversial because the outcome of acute resection is less favorable than for patients without obstruction. Few studies have investigated curable right-sided OCC, and patients with OCC usually undergo acute resection. This study aimed to better understand the outcome and best management of potentially curable right-sided OCC. METHODS A systematic review of studies was performed with a focus on differences in mortality and morbidity between emergency resection and staged treatment for patients with potentially curable right-sided OCC. In March 2019, the study searched Embase, Medline, Web of Science, Cochrane, and Google scholar databases according to PRISMA guidelines using search terms related to "colon tumour," "stenosis or obstruction and surgery," and "decompression or stents." All English-language studies reporting emergency or staged treatment for potentially curable right-sided OCC were included in the review. Emergency resection and staged resection were compared for mortality, morbidity, complications, and survival. RESULTS Nine studies were found to be eligible and comprised 600 patients treated with curative intent for their right-sided OCC by emergency resection or staged resection. The mean overall complication rate was 42% (range 19-54%) after emergency resection, and 30% (range 7-44%) after staged treatment. The average mortality rate was 7.2% (range 0-14.5%) after emergency resection and 1.2% (range 0-6.3%) after staged treatment. The 5-year disease-free and overall survival rates were comparable for the two treatments. CONCLUSIONS The patients who received staged treatment for right-sided OCC had lower mortality rates, fewer complications, and fewer anastomotic leaks and stoma creations than the patients who had emergency resection.
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Affiliation(s)
- Jeske R E Boeding
- Department of Surgery, Amphia Hospital, Breda, The Netherlands.
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Winesh Ramphal
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Arjen M Rijken
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | | | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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23
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Fahim M, Dijksman LM, Derksen WJM, Bloemen JG, Biesma DH, Smits AB. Prospective multicentre study of a new bowel obstruction treatment in colorectal surgery: Reduced morbidity and mortality. Eur J Surg Oncol 2021; 47:2414-2420. [PMID: 34023165 DOI: 10.1016/j.ejso.2021.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/06/2021] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Bowel obstruction patients are at increased risk of emergency surgery and have poor nutritional and physical conditions. These patients could benefit from prehabilitation and prevention of emergency surgery. This study assessed the effect of a multimodal obstruction treatment for bowel obstruction patients in colorectal surgery on the risk of emergency surgery and postoperative morbidity and mortality. MATERIALS AND METHODS This multicenter observational cohort study included all consecutive bowel obstruction patients who received obstruction treatment (obstruction protocol) in the period 2019-2020 in two Dutch hospitals. Benign and malignant causes of bowel obstruction were included. Treatment consisted of 1. dietary adjustments, 2. postponing surgery for three weeks, 3. laxatives, and 4. prehabilitation. We compared emergency surgery and postoperative morbidity and mortality rates to known rates from the literature. RESULTS Eighty-nine patients were included: obstruction treatment was successful in 77 patients (87%) who underwent elective surgery and unsuccessful in 12 patients (13%) who underwent emergency surgery. Sixty-six (74%) had colorectal cancer, and 22 (25%) had benign disease. Thirty-day mortality of 0% in our study was significantly lower than the national average of 4% in colorectal cancer patients in the Netherlands (p = 0.049). Anastomotic leakage rate was 3%, severe complications (Clavien-Dindo ≥ III) 8%, and bowel perforation 0%. These rates did not differ significantly from rates reported in literature. CONCLUSION The obstruction treatment prevented emergency surgery in most patients with bowel obstruction and reduced postoperative morbidity and mortality. The obstruction treatment seems to be a safe and efficient alternative to emergency surgery.
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Affiliation(s)
- M Fahim
- Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands; Department of Value-Based Healthcare, St. Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands.
| | - L M Dijksman
- Department of Value-Based Healthcare, St. Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands
| | - W J M Derksen
- Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands
| | - J G Bloemen
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623, EJ Eindhoven, the Netherlands
| | - D H Biesma
- Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands; Department of Value-Based Healthcare, St. Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands
| | - A B Smits
- Department of Surgery, St Antonius Hospital, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands
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24
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Janssen TL, de Vries J, Lodder P, Faes MC, Ho GH, Gobardhan PD, van der Laan L. The effects of elective aortic repair, colorectal cancer surgery and subsequent postoperative delirium on long-term quality of life, cognitive functioning and depressive symptoms in older patients. Aging Ment Health 2021; 25:896-905. [PMID: 32054299 DOI: 10.1080/13607863.2020.1725807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: This study aimed to demonstrate the impact of elective major abdominal surgery and subsequent postoperative delirium on quality of life (QOL; primary outcome), cognitive functioning and depressive symptoms (secondary outcomes) in older surgical patients.Method: A single-centre, longitudinal prospective cohort study was conducted between November 2015 and June 2018, including patients ≥70 years old who underwent surgery for colorectal cancer or an abdominal aortic aneurysm. They were followed-up at discharge and at 6 and 12 months postoperatively until June 2019. QOL was assessed with the World Health Organization Quality of Life-BREF questionnaire (WHOQOL-BREF). Cognitive functioning was measured with the Mini-Mental State Examination and depressive symptoms with the CES-D 16.Results: In all patients (n = 265), physical and psychological health were significantly lower at discharge compared to baseline (p < 0.001 for both domains). Physical health restored after 6 months, but psychological health remained decreased for the complete study period. Psychological, social and environmental QOL were significantly worse in patients with delirium compared to patients without (p = 0.001, p = 0.006 and p = 0.001 respectively). The cognitive functioning score was significantly lower at baseline in patients with delirium compared to those without (p = 0.006). Patients with delirium had a significantly higher CES-D 16 score compared to those without after 12 months (p = 0.027).Conclusion: Physical and psychological QOL were decreased in the early postoperative period. While physical health was restored after 6 and 12 months, psychological health remained decreased. After 12 months, postoperative delirium resulted in worse psychological, social and environmental QOL and more depressive symptoms. Decreased cognitive functioning may be a risk factor for delirium.
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Affiliation(s)
- Ties L Janssen
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Jolanda de Vries
- Department of Medical Psychology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Paul Lodder
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands.,Department of Methodology and Statistics, Tilburg University, Tilburg, The Netherlands
| | - Miriam C Faes
- Department of Geriatrics, Amphia Hospital, Breda, the Netherlands
| | - Gwan H Ho
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | | | - Lijckle van der Laan
- Department of Surgery, Amphia Hospital, Breda, the Netherlands.,Department of Cardiovascular Science, UZ Leuven, Leuven, Belgium
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25
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Ketelaers SHJ, Voogt ELK, Simkens GA, Bloemen JG, Nieuwenhuijzen GAP, de Hingh IHJ, Rutten HJT, Burger JWA, Orsini RG. Age-related differences in morbidity and mortality after surgery for primary clinical T4 and locally recurrent rectal cancer. Colorectal Dis 2021; 23:1141-1152. [PMID: 33492750 DOI: 10.1111/codi.15542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/24/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022]
Abstract
AIM Outcomes in elderly patients (≥75 years) with non-advanced colorectal cancer have improved. It is unclear whether this is also true for elderly patients with clinical T4 rectal cancer (cT4RC) or locally recurrent rectal cancer (LRRC). We aimed to compare age-related differences in morbidity and mortality after curative treatment for cT4RC and LRRC. METHODS All cT4RC and LRRC patients without distant metastasis who underwent curative surgery between 2005 and 2017 in the Catharina Hospital (Eindhoven, The Netherlands) were included. Morbidity and mortality were evaluated based on age (<75 and ≥75 years) and date of surgery (2005-2011 and 2012-2017). RESULTS Overall, 72 of 474 (15.2%) cT4RC and 53 of 293 (18.1%) LRRC patients were ≥75 years. No significant differences in the incidence of Clavien-Dindo I-IV complications were observed between age groups. However, in elderly cT4RC patients, cerebrovascular accidents occurred more frequently (4.2% vs. 0.5%, P = 0.03). Between 2005-2011 and 2012-2017, 30-day mortality improved from 7.5% to 3.1% and from 10.0% to 0.0% in elderly cT4RC and LRRC patients, respectively. The 1-year mortality during 2012-2017 was worse in elderly than in younger patients (28.1% vs. 6.2%, P = 0.001 for cT4RC and 27.3% vs. 13.8%, P = 0.06 for LRRC). In elderly cT4RC and LRRC patients, 44.4% and 46.2% died due to non-cancer-related causes, while only 27.8% and 23.1% died due to disease recurrence, respectively. CONCLUSION Although the 30-day mortality in elderly cT4RC and LRRC patients improved after curative treatment, the 1-year mortality in elderly patients continued to be high, which requires more awareness for the elderly after hospitalization.
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Affiliation(s)
- S H J Ketelaers
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - E L K Voogt
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - G A Simkens
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - I H J de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,GROW: School of Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,GROW: School of Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - R G Orsini
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
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26
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Bahadoer RR, Bastiaannet E, Claassen YHM, van der Mark M, van Eycken E, Verbeeck J, Guren MG, Kørner H, Martling A, Johansson R, van de Velde CJH, Dekker JWT. One-year excess mortality and treatment in surgically treated patients with colorectal cancer: A EURECCA European comparison. Eur J Surg Oncol 2021; 47:1651-1660. [PMID: 33518367 DOI: 10.1016/j.ejso.2021.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/14/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Mortality in the first postoperative year represents an accurate reflection of the perioperative risk after colorectal cancer surgery. This research compares one-year mortality after surgery divided into three age-categories (18-64, 65-74, ≥75 years), focusing on time trends and comparing treatment strategies. MATERIAL Population-based data of all patients diagnosed and treated surgically for stage I-III primary colorectal cancer from 2007 to 2016, were collected from Belgium, the Netherlands, Norway, and Sweden. Stratified for age-category and stage, treatment was evaluated, and 30-day, one-year and one-year excess mortality were calculated for colon and rectal cancer separately. Results were evaluated over two-year time periods. RESULTS Data of 206,024 patients were analysed. Postoperative 30-day and one-year mortality reduced significantly over time in all countries and age-categories. Within the oldest age category, in 2015-2016, one-year excess mortality varied from 9% in Belgium to 4% in Sweden for colon cancer and, from 9% in Belgium to 3% in the other countries for rectal cancer. With increasing age, patients were less likely to receive additional therapy besides surgery. In Belgium, colon cancer patients were more often treated with adjuvant chemotherapy (p < 0.001). For neoadjuvant treatment of rectal cancer, patients in Belgium and Norway were mostly treated with chemoradiotherapy. In the Netherlands and Sweden, radiotherapy alone was preferred (p < 0.001). CONCLUSIONS Despite improvement over time in all countries and age-categories, substantial variation exists in one-year postoperative mortality. Differences in one-year excess postoperative mortality could be due to differences in treatment strategies, highlighting the consequences of under- and over-treatment on cancer survival.
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Affiliation(s)
- Renu R Bahadoer
- Leiden University Medical Center, Department of Surgery, Albinusdreef 2, Postbus 9600, 2300, RC Leiden, the Netherlands.
| | - Esther Bastiaannet
- Leiden University Medical Center, Department of Surgery, Albinusdreef 2, Postbus 9600, 2300, RC Leiden, the Netherlands.
| | - Yvette H M Claassen
- Leiden University Medical Center, Department of Surgery, Albinusdreef 2, Postbus 9600, 2300, RC Leiden, the Netherlands.
| | - Marianne van der Mark
- Netherlands Comprehensive Cancer Organization, Department of Research and Development, Godebaldkwartier 419, Postbus 19079, 3501, DB Utrecht, the Netherlands.
| | | | - Julie Verbeeck
- Belgian Cancer Registry, Koningsstraat 215 Bus 7, 1210, Brussels, Belgium.
| | - Marianne G Guren
- Oslo University Hospital, Department of Oncology and K.G. Jebsen Colorectal Cancer Research Centre, PO 4953, Nydalen, Oslo, Norway.
| | - Hartwig Kørner
- Stavanger University Hospital, Stavanger, Department of Gastrointestinal Surgery, Postboks 8100, 4068, Stavanger, Norway; University of Bergen, Department of Clinical Medicine, Jonas Lies Veg 87, N-5021, Bergen, Norway.
| | - Anna Martling
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Solnavägen 1, 171 77, Stockholm, Sweden.
| | - Robert Johansson
- Umeå University, The Biobank Research Unit, 901 87, Umeå, Sweden.
| | - Cornelis J H van de Velde
- Leiden University Medical Center, Department of Surgery, Albinusdreef 2, Postbus 9600, 2300, RC Leiden, the Netherlands.
| | - Jan Willem T Dekker
- Reinier de Graaf Hospital, Department of Surgery, Reinier de Graafweg 5, Postbus 5011, 2600, GA Delft, the Netherlands.
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27
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Janssen TL, Steyerberg EW, van Hoof-de Lepper CCHA, Seerden TCJ, de Lange DC, Wijsman JH, Ho GH, Gobardhan PD, van der Laan L. Long-term outcomes of major abdominal surgery and postoperative delirium after multimodal prehabilitation of older patients. Surg Today 2020; 50:1461-1470. [PMID: 32542413 DOI: 10.1007/s00595-020-02044-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/09/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE The long-term outcomes of surgery followed by delirium after multimodal prehabilitation program are largely unknown. We conducted this study to assess the effects of prehabilitation on 1-year mortality and of postoperative delirium on 1-year mortality and functional outcomes. METHODS The subjects of this study were patients aged ≥ 70 years who underwent elective surgery for abdominal aortic aneurysm (AAA) or colorectal cancer (CRC) between January 2013, and June 2018. A prehabilitation program was implemented in November 2015, which aimed to optimize physical health, nutritional status, factors of frailty and preoperative anemia prior to surgery. The outcomes were assessed as mortality after 6 and 12 months, compared between the two treatment groups; and mortality and functional outcomes, compared between patients with and those without delirium. RESULTS There were 627 patients (controls N = 360, prehabilitation N = 267) included in this study. Prehabilitation did not reduce mortality after 1 year (HR 1.31 [95% CI 0.75-2.30]; p = 0.34). Delirium was significantly associated with 1-year mortality (HR 4.36 [95% CI 2.45-7.75]; p < 0.001) and with worse functional outcomes after 6 and 12 months (KATZ ADL p = 0.013 and p = 0.004; TUG test p = 0.041 and p = 0.011, respectively). CONCLUSIONS The prehabilitation program did not reduce 1-year mortality. Delirium and the burden of comorbidity are both independently associated with an increased risk of 1-year mortality and delirium is associated with worse functional outcomes. TRIAL REGISTRATION Dutch Trial Registration, NTR5932. https://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5932 .
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Affiliation(s)
- Ties L Janssen
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands.
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Tom C J Seerden
- Department of Gastroenterology, Amphia Hospital, Breda, The Netherlands
| | | | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Gwan H Ho
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Paul D Gobardhan
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands
| | - Lijckle van der Laan
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands.,Department of Cardiovascular Science, UZ Leuven, Leuven, Belgium
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Fahim M, Dijksman L, van Kessel C, Smeeing D, Braaksma A, Derksen W, Smits A. Promising results of a new treatment in patients with bowel obstruction in colorectal surgery. Eur J Surg Oncol 2020; 46:415-419. [DOI: 10.1016/j.ejso.2019.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 10/10/2019] [Indexed: 12/15/2022] Open
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Ketelaers SHJ, Fahim M, Rutten HJT, Smits AB, Orsini RG. When and how should surgery be performed in senior colorectal cancer patients? Eur J Surg Oncol 2020; 46:326-332. [PMID: 31955993 DOI: 10.1016/j.ejso.2020.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 01/03/2020] [Indexed: 12/28/2022] Open
Abstract
Older studies reported high rates of postoperative morbidity and mortality in the senior population, which lead to a tendency to withhold curative surgery in the older population. However, more recent studies showed impressing developments in postoperative outcomes in seniors. Probably, these improvements are due to enhancements in both surgical and non-surgical aspects in the pre-, peri- and postoperative period, such as minimally invasive techniques and anesthesiological insights. The postoperative survival gap seen earlier between younger and older patients is fading. For optimal treatment in the older population, special awareness and care on several aspects is needed. As only a minority of the seniors are frail, a quick frailty assessment is crucial to distinguish the fit from the frail in the decision-making process. In addition, it could be valuable to improve the lacks in physical condition in the preoperative period with the use of prehabilitation programs. Furthermore, it is important to evolve an emergency to an elective setting by postponing emergency surgery to prevent any high-risk situation. In conclusion, based on modern insights, surgery is a valid option in the curative treatment of colorectal cancer in seniors, however individual attention and care is required.
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Affiliation(s)
- S H J Ketelaers
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands.
| | - M Fahim
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands; GROW: School of Oncology and Developmental Biology, University of Maastricht, Maastricht, the Netherlands
| | - A B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - R G Orsini
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
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