Postoperative Complications: Looking Forward to a Safer Future

Viable approach for preventing skin wound infections using bioactive dressing films from chitosan-furfural/α-aminophosphonate nanocomposite

Bioactive chitosan (Cs)-based films containing newly synthesized chitosan-furfural aminophosphonate (F) or chitosan-hydroxymethyl furfural aminophosphonate (HMF) derivatives have been investigated as potential wound dressing material. The chemical structure of the two derivatives was monitored by observing the absorption peaks of P-O-C bonds on the FTIR chart at 883 and 802 cm-1 for F and HMF, respectively. To improve the bioavailability and bio-absorbability, F and HMF nanoemulsions were prepared and loaded separately with three different concentrations (6, 12, and 18 mL) to chitosan solution for obtaining F-loaded Cs films (CsF1, CsF2, and CsF3) and HMF-loaded Cs films (Cs-HMF1, Cs-HMF2, and Cs-HMF3). The F- and HMF-loaded Cs films were investigated via FTIR, XRD, TGA-DTG, SEM-EDX, contact angle, mechanical, and swelling behavior. CsF3 and Cs-HMF3 films (that contain highest concentration of F and HMF nanoemulsion) exhibited optimal texture properties e.g. tensile strength was 8.82 and 8.92 MPa, and swelling ratio was 53.55 and 57.7 % respectively. The films were tested against pathogenic bacteria as a model for skin-causing bacterial infection. The findings signified those films containing F or HMF exhibited larger inhibition zones than bare Cs films. The films exhibited excellent antibacterial activity against skin-infecting pathogens. In addition, Cs-HMF3 films showed exceptional antibiofilm activity against all tested bacterial strains, including multidrug-resistant pathogens. Biocompatibility assessments confirmed the safety and non-toxicity of the films, making them suitable for wound dressings. These findings highlight the potential of F and HMF-modified chitosan films as advanced wound dressing materials with enhanced mechanical properties, antibacterial efficacy, and biocompatibility, offering a promising solution for managing bacterial infections in wound care.

Home care visits: The key to reducing loss to follow-up in emergency colorectal surgery

BACKGROUND

Emergency colorectal surgery has a high incidence of postdischarge complications, and loss to follow-up can delay the identification of complications. Amid evolving postdischarge care practices, it is important to assess predictors of loss to follow-up. We aimed to characterize the predictors of loss to follow-up.

METHODS

We conducted a retrospective institutional cohort study of patients ≥18 years undergoing emergency colorectal surgery at a tertiary hospital from 2016 to 2022. We excluded patients with in-hospital or 30-day mortality or a postoperative stay >30 days. We defined loss to follow-up as the absence of a postdischarge 30-day in-person or telehealth visit. The predictors of loss to follow-up were evaluated using stepwise regression analysis. We performed a subgroup analysis evaluating predictors of loss to follow-up among patients discharged post-telehealth availability at our institution (March 2020).

RESULTS

We included 426 patients, of whom 95 (22.3%) were loss to follow-up and 58.9% were discharged post-telehealth availability. Almost one half of patients were female (52.3%), and the majority were of White race (89.2%), and non-Hispanic (92.0%). Being male, being discharged to a skilled nursing facility, and prolonged hospitalization were risk factors for loss to follow-up, whereas receiving home care visits was protective. Post-telehealth availability, being male, and prolonged hospitalization were risk factors for loss to follow-up, whereas receiving homecare visits was protective. Patients who had a follow-up visit were less likely to be readmitted to the hospital and have a visit to the emergency department.

CONCLUSION

Receiving home care visits was the most protective factor for preventing loss to follow-up. Living far from the hospital remained a risk factor even post-telehealth availability. High-risk patients may benefit from targeted interventions that include scheduled home care visits.

Does surgeon or hospital volume influence outcome in dedicated colorectal units?-A Viennese perspective

OBJECTIVE

A clear relationship between higher surgeon volume and improved outcomes has not been convincingly established in rectal cancer surgery. The aim of this study was to evaluate the impact of individual surgeon's caseload and hospital volume on perioperative outcome.

METHODS

We retrospectively analyzed 336 consecutive patients undergoing oncological resection for rectal cancer at two Viennese hospitals between 1 January 2015 and 31 December 2020. The effect of baseline characteristics as well as surgeons' caseloads (low volume: 0-5 cases per year, high volume > 5 cases per year) on postoperative complication rates (Clavien-Dindo Classification groups of < 3 and ≥ 3) were evaluated.

RESULTS

No differences in baseline characteristics were found between centers in terms of sex, smoking status, or comorbidities of patients. Interestingly, only 14.7% of surgeons met the criteria to be classified as high-volume surgeons, while accounting for 66.3% of all operations. There was a significant difference in outcomes depending on the treating center in univariate and multivariate binary logistic regression analysis (odds ratio (OR) = 2.403, p = 0.008). Open surgery was associated with lower complication rates than minimally invasive approaches in univariate analysis (OR = 0.417, p = 0.003, 95%CI = 0.232-0.739) but not multivariate analysis. This indicated that the center's policy rather than surgeon volume or mode of surgery impact on postoperative outcomes.

CONCLUSION

Treating center standards impacted on outcome, while individual caseload of surgeons or mode of surgery did not independently affect complication rates in this analysis. The majority of rectal cancer resections are performed by a small number of surgeons in Viennese hospitals.

How aging may impact the failure to rescue after colorectal laparoscopic surgery. Analysis of 1000 patients in a single high-volume center

This study aimed to evaluate the FTR after laparoscopic colorectal surgery in an Italian high-volume centre. A retrospective analysis was conducted in a consecutive series of patients who underwent elective laparoscopic colorectal surgery for neoplastic disease between January 2010 and December 2023 at the General Surgery Department of the San Eugenio Hospital, Rome, Italy. Patients were grouped by age in adult (vs. < 75 years) and elderly group (≥ 75 years). A multivariate analysis of the predictive factors of complications was performed. A total of 1,000 patients met the inclusion criteria, excluding those who underwent open or robotic surgery, either in emergency or elective settings. 53 patients (5.3%) experienced major complications. The mean age of patients with no or mild complications was 65.60 years (± 10.61), whereas patients with severe complications were older (69.94 years ± 12.02, p = 0.0041). Gender distribution and BMI do not represent a risk factor for major complications (p = 0.2555 and p = 0.2686, respectively), unlike the ASA score III or IV (p = 0.0001). The overall FTR rate for adult patients is 9%, while it is slightly higher at 10% for elderly patients. No statistical differences were found between the 2 groups. Elderly patients had more frequent FTR due to infective complications, while the FTR rate for cardiovascular disease was more frequent in the adult group. Minimally invasive approach, skilled team, well-established rapid response and standardized complication management protocols can positively impact FTR regardless of patients' age.

Has the Use of Enhanced Recovery Protocols in Colorectal Surgery Increased Postoperative Bleeding Complications?

BACKGROUND

Enhanced recovery after surgery protocols are multimodal perioperative care pathways shown to improve postoperative complications and decrease the length of stay after surgery. A critical component of an enhanced recovery after surgery protocol is the use of multimodal nonopiate analgesia using nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors.

OBJECTIVE

To compare the incidence of postoperative GI bleeding between patients treated with and without an enhanced recovery after surgery protocol.

DESIGN

Retrospective review of a prospectively maintained colorectal registry.

SETTINGS

Large colorectal referral center.

PATIENTS

Preoperative elective colorectal surgery requiring an anastomosis.

INTERVENTION

Standardized enhanced recovery after surgery protocol included celecoxib and ketorolac.

MAIN OUTCOME

Postoperative outcomes included bleeding (±sequelae), reduction in hematocrit after the operation, intervention for bleeding (transfusion, endoscopy, or surgery), length of stay, and hospital readmission.

RESULTS

The enhanced recovery after surgery group (n = 630) and nonenhanced recovery after surgery group (n = 739) were comparable in baseline clinical features except for surgical indication, with more IBD and less malignant disease in the enhanced recovery after surgery group. Minimally invasive surgery was more commonly performed in the enhanced recovery after surgery group. Both bleeding with sequelae ( p < 0.0001) and bleeding without sequelae ( p = 0.0004) were significantly more common in the enhanced recovery after surgery group compared to the nonenhanced recovery after surgery group. In addition, a significantly larger hematocrit decline after the operation was noted in the enhanced recovery after surgery group ( p < 0.0001). However, both the need for transfusion and intervention for bleeding did not significantly differ between patient groups. Factors associated with bleeding were the use of an enhanced recovery after surgery protocol (OR 2.96; 95% CI, 1.57-5.58; p < 0.001) and performing a small to large bowel anastomosis (OR 2.68; 95% CI, 1.49-4.81; p < 0.001).

LIMITATIONS

Retrospective observational design and inability to determine which component of the enhanced recovery after surgery protocol increased the risk of bleeding.

CONCLUSIONS

Use of an enhanced recovery after surgery protocol in patients undergoing colorectal surgery with an anastomosis is associated with an increased incidence of bleeding without significant difference in the need for transfusion or intervention. See Video Abstract .

EL USO DE PROTOCOLOS DE RECUPERACIN MEJORADA EN CIRUGA COLORRECTAL HA AUMENTADO LAS COMPLICACIONES HEMORRGICAS POSTOPERATORIAS

ANTECEDENTES:Los protocolos de recuperación mejorada después de la cirugía (ERAS) son vías de atención perioperatoria multimodal que han demostrado mejorar las complicaciones posoperatorias y disminuir la duración de la estancia después de la cirugía. Un componente crítico de un protocolo ERAS es el uso de analgesia multimodal no opiácea mediante fármacos antiinflamatorios no esteroideos e inhibidores de la COX-2.OBJETIVO:Comparar la incidencia de sangrado gastrointestinal posoperatorio entre pacientes tratados con y sin un protocolo ERAS.DISEÑO:Revisión retrospectiva de un registro colorrectal prospectivo mantenido.ESCENARIO:Centro de referencia colorrectal grande.PACIENTES:Cirugía colorrectal electiva preoperatoria que requiere una anastomosis.INTERVENCIÓN:El protocolo ERAS estandarizado incluyó celecoxib y ketorolaco.RESULTADO PRINCIPAL:Los resultados posoperatorios incluyeron sangrado (+/- secuelas), reducción del hematocrito después de la operación, intervención para el sangrado (transfusión, endoscopia o cirugía), duración de la estancia hospitalaria y reingreso hospitalario.RESULTADOS:El grupo ERAS (n = 630) y los grupos no ERAS (n = 739) fueron comparables en las características clínicas iniciales excepto por la indicación quirúrgica, con más enfermedad inflamatoria intestinal y menos enfermedad maligna en el grupo ERAS (Tabla 1). La cirugía mínimamente invasiva se realizó con mayor frecuencia en el grupo ERAS. Tanto el sangrado con secuelas ( p < 0,0001) como el sangrado sin secuelas ( p = 0,0004) fueron significativamente más comunes en el grupo ERAS en comparación con el grupo no ERAS. Además, se observó una disminución significativamente mayor del hematocrito después de la operación en el grupo ERAS ( p < 0,0001). Sin embargo, tanto la necesidad de transfusión como la intervención por sangrado no difirieron significativamente entre los grupos de pacientes. Los factores asociados con el sangrado fueron el uso de un protocolo ERAS (OR=2,96; IC del 95% 1,57-5,58; p < 0,001) y la realización de una anastomosis de intestino delgado a grueso (OR= 2,68; IC del 95% 1,49-4,81; p < 0,001).LIMITACIÓN:Diseño observacional retrospectivo e imposibilidad de determinar qué componente del protocolo ERAS causó el sangrado.CONCLUSIÓN:El uso de un protocolo ERAS en pacientes sometidos a cirugía colorrectal con anastomosis se asocia con una mayor incidencia de sangrado sin diferencia significativa en la necesidad de transfusión o intervención. (Traducción-Dr Yolanda Colorado ).

New alternative colorectal anastomotic devices: A systematic review and meta-analysis

BACKGROUND

Colorectal anastomotic devices have been used for nearly a century, with stapled anastomoses being the most common despite leak rates up to 20 ​%. This review aimed to evaluate newer alternative devices.

METHOD

A systematic review and meta-analysis of publications from the last decade were conducted, focusing on devices forming colorectal anastomoses, excluding those facilitating sutured or stapled anastomoses or designed to prevent leaks. Data from MEDLINE, Embase, Cochrane, and ClinicalTrials.gov were analysed.

RESULTS

Eighteen studies (7 human, 10 animal, 1 ex-vivo) involving 955 anastomoses were included. Compression mechanisms were the most common. The pooled complication rate in human studies was 9.7 ​% (95 ​% CI: 4.3-15.2 ​%) with significant heterogeneity (I2 ​= ​81.7 ​%). The leak rate after compression anastomoses was 3.3 ​% (95 ​% CI: 1.9-4.7 ​%) with no heterogeneity (I2 ​= ​0 ​%). A novel device with transanal catheters allowed intraoperative and postoperative assessment.

CONCLUSIONS

Outcomes are comparable to existing methods, with new technologies offering promising advancements.

Peripheral nerve stimulation for lower-limb postoperative recovery: A systematic review and meta-analysis of randomized controlled trials

Patients undergoing lower-limb orthopedic surgery may experience multiple postoperative complications. Although peripheral nerve stimulation (PNS) is a promising non-pharmacological approach that has been used in lower-limb postoperative recovery, the clinical efficacy of PNS remains inconclusive. This study systematically searched three databases (PubMed, Embase, and Cochrane Library) for randomized controlled trials (RCTs) that examined the treatment effects of PNSs in patients who underwent lower-limb orthopedic surgery up to September 29, 2023. Two investigators independently identified studies, extracted data, and conducted meta-analyses with Review Manager 5.4. The outcomes were pain relief (measured by reductions in pain intensity and analgesic consumption) and functional improvements (range of motion [ROM] and length of hospitalization [LOH]). A total of 633 patients including 321 in the experimental groups and 312 in the control groups from eight RCTs were included. PNS showed no significant effect on pain intensity, while analgesic consumption was marginally significantly reduced in the experimental group. Furthermore, no significant differences were observed regarding functional improvements in ROM or LOH after the intervention. Although PNS had no significant effect on pain relief or functional improvements, the intervention exhibited a marginally significant reduction in analgesic consumption. Future trials should be conducted with larger sample sizes, longer follow-up periods, and more varied stimulation parameters.

First clinical report of the international single-port robotic rectal cancer registry

BACKGROUND

Rectal cancer surgery remains a significant technical challenge. The development and implementation of a new technology offer hope for more accurate and precise surgery. To evaluate whether single-port robotic (SPr) technology helps achieve this goal, an international SPr registry was established. This study reported short-term clinical and oncologic outcomes from an international SPr registry for rectal cancer.

METHODS

A review of a prospective international registry of SPr technology approved for colorectal surgery with an investigational design exemption was conducted. Patients with rectal adenocarcinoma who had resection for curative intent using the SPr platform between November 2018 and September 2022 were included. Frequency statistics described patient and tumor characteristics and intraoperative, oncologic, and clinical outcome variables. The main outcome measure was the quality of the total mesorectal excision (TME) specimen. The secondary outcome measures were intraoperative conversion and 30-day postoperative morbidity and mortality.

RESULTS

A total of 113 SPr procedures for rectal cancer were performed at 2 centers by 4 colorectal surgeons. Of note, 9 local excisions were excluded, leaving 104 cases analyzed. The cohort consisted of 53 men (50.96%), had a mean age of 60.00 years (SD, 11.29), and had a body mass index of 25.80 kg/m2 (SD, 6.18). The most common T stage was 3 (55 [52.8%]), followed by 2 (19 [18.26%]). More than 60% of patients had preoperative neoadjuvant chemoradiation. The mean tumor distance from the anorectal ring was 2.90 cm (SD, 2.62), and the mean tumor size was 4.52 cm (SD, 1.82). The procedures performed included transanal abdominal transanal/transanal TME (52 [46%]), low anterior resection (49 [43.3%]), and abdominoperineal resection (3 [2.7%]). The mean operating time was 168.0 min (SD, 56.9). There were no intraoperative complications and 2 (1.9%) conversions to laparoscopy. There was a median of 2 incisions, with a mean size of 2.30 cm (SD, 1.31). The TME specimens were complete in 101 cases (97.1%) and near complete in 3 cases (2.9%). The R1 rate was 3.8%, with 3 positive distal margins and 1 positive circumferential margin. Postoperatively, there were 15 total complications, of which 4 were major complications and 11 were minor complications. There were 2 readmissions (ileus and small bowel obstruction). There were no mortalities.

CONCLUSION

This early international experience with the SPr procedure showed that it is a safe and effective technique for distal rectal cancers, with excellent specimen quality. The complication and conversion rates observed with other techniques and platforms used in rectal cancer surgery were not demonstrated. An international registry was used to better understand the opportunities and limitations of SPr technology in rectal cancer surgery as the technology is adopted and applied more widely. Although structured training and controlled trials will be required to develop best practices and define the use of the SPr technology, initial international registry data are encouraging.

Effectiveness of rehabilitation interventions in patients with colorectal cancer: an overview of systematic reviews

OBJECTIVE

To evaluate existing evidence from published systematic reviews for the effectiveness and safety of rehabilitation interventions in adult patients with colorectal cancer.

METHODS

A comprehensive literature search was conducted using medical/health science databases up to October 2024. Bibliographies of pertinent articles, journals, and grey literature were searched. Three reviewers independently selected potential reviews, assessed methodological quality, and graded the quality of evidence for outcomes using validated tools.

RESULTS

Sixty systematic reviews (761 randomized controlled trials) evaluated 5 categories of rehabilitation interventions. Over half of the included reviews (n = 31) were of moderate-high quality. The findings suggest: moderate-quality evidence for exercise interventions for improving physical fitness and quality of life; high-quality evidence for nutritional interventions in reducing postoperative infections; high-quality evidence for multimodal prehabilitation for improved preoperative functional capacity; moderate-quality evidence for nutritional interventions for improving humoral immunity, reducing inflammation, and length of stay; moderate-quality evidence for acupuncture in improving gastrointestinal functional recovery; psychosocial interventions in improving short-term quality of life and mental health, and lifestyle interventions for improved quality of life.

CONCLUSION

Rehabilitation interventions yielded positive effects across multiple outcomes. However, high-quality evidence is still needed to determine the most effective rehabilitation approaches for patients with colorectal cancer.

Current evidence on powered versus manual circular staplers in colorectal surgery: a systematic review and meta-analysis

PURPOSE

This meta-analysis aims to evaluate the efficacy of powered circular staplers (PCS) compared to manual circular staplers (MCS) in reducing anastomotic leakage (AL) and postoperative bleeding (AB) in colorectal surgery.

METHODS

Extensive searches were performed in the Embase, PubMed, and SCOPUS electronic bibliographic databases. Most studies were of an observational nature, and only one randomized clinical trial was identified.

RESULTS

Twelve studies met the inclusion criteria for anastomotic leakage and five for anastomotic hemorrhage. The number of patients included for AL analysis was 4524. The leakage rate was 4.6% (208 cases). The number of patients with AB was 2868 with a bleeding rate of 4.99% (143 patients). After identifying outliers and studies with possible selection bias, the odds ratio (OR) for leaks and PCS was 0.38 (95% CI 0.26-0.55), the relative risk was - 0.05 (95% CI - 0.07 to 0.03), and the number needed to treat to prevent one leak was 20. For bleeding, the PCS OR for PCS was 0.20 (95% CI 0.0772-0.5177).

CONCLUSION

Powered circular staplers could be associated with a significantly lower risk of leakage and anastomotic bleeding than two-row manual circular staplers. Further prospective randomized trials are needed to validate these findings.

Efficacy and Safety of a Combination of Enteral and Parenteral Nutrition Support in the Postoperative Period for Patients with Gastrointestinal Cancer: A Systematic Review and Meta-Analysis

Background

Postoperative nutritional support in gastrointestinal cancer, including enteral nutrition (EN), parenteral nutrition (PN), and combined nutrition strategies, is vital for enhancing recovery and patient outcomes.

Aims

We aimed to comprehensively evaluate the impact of postoperative EN, PN, and EN + PN in patients with gastrointestinal cancer.

Methods

PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wan Fang, and VIP were searched from conception until January 2, 2024. Randomized controlled trials (RCTs) that compared different postoperative nutritional support (EN, PN, or EN + PN) in patients with gastrointestinal cancer were included. The Cochrane Risk of Bias Assessment tool was used to assess the quality of the RCTs. Fixed- and random-effects models were chosen according to the heterogeneity of variables for the synthesis of results. Continuous and categorical variables were analyzed using the weighted mean difference or relative risk (RR) and 95% confidence interval (CI).

Results

In this meta-analysis, 11 RCTs were included. The PN + EN group exhibited significantly improved postoperative recovery, nutritional function, and immune indicators than the PN and EN groups (p < 0.05). Additionally, a higher incidence of postoperative complications such as abdominal distension (RR: 2.53; 95% CI: 1.17-5.49), nausea/vomiting (RR: 2.01; 95% CI: 1.09-3.71), and diarrhea (RR: 3.17; 95% CI: 1.41-7.10) was observed in the EN group than in the PN + EN group.

Conclusion

Combining supplemental PN with enteral support improves energy intake and prognosis in gastrointestinal cancer, though limited studies restrict publication bias evaluation.

Achieving Health Equity: Advancing Colorectal Surgery among Racial and Ethnic Minorities in America

Racial inequities in short and long-term outcomes following colorectal surgery continue to persist. Using inflammatory bowel disease and colorectal cancer as disease foci, we review existing racial inequities in surgical outcomes and complications, discuss how social determinants of health and biopsychosocial factors can contribute to these inequities, and highlight potential mechanisms for building interventions to achieve health equity following colorectal surgery for minority populations.

Postoperative Innate Immune Dysregulation, Proteomic, and Monocyte Epigenomic Changes After Colorectal Surgery: A Substudy of a Randomized Controlled Trial

BACKGROUND

Colorectal surgery is associated with moderate-to-severe postoperative complications in over 25% of patients, predominantly infections. Monocyte epigenetic alterations leading to immune tolerance could explain postoperative increased susceptibility to infections. This research explores whether changes in monocyte DNA accessibility contribute to postoperative innate immune dysregulation.

METHODS

Damage-associated molecular patterns (DAMPs) and ex vivo cytokine production capacity were measured in a randomized controlled trial (n = 100) in colorectal surgery patients, with additional exploratory subgroup proteomic (proximity extension assay; Olink) and epigenomic analyses (Assay for Transposase-Accessible Chromatin [ATAC sequencing]). Monocytes of healthy volunteers were used to study the effect of high-mobility group box 1 (HMGB1) and heat shock protein 70 (HSP70) on cytokine production capacity in vitro.

RESULTS

Plasma DAMPs were increased after surgery. HMGB1 showed a mean 235% increase from before- (preop) to the end of surgery (95% confidence interval [CI] [166 - 305], P < .0001) and 90% increase (95% CI [63-118], P = .0004) preop to postoperative day 1 (POD1). HSP70 increased by a mean 12% from preop to the end of surgery (95% CI [3-21], not significant) and 30% to POD1 (95% CI [18-41], P < .0001). Nuclear deoxyribonucleic acid (nDNA) increases by 66% (95% CI [40-92], P < .0001) at the end of surgery and 94% on POD1 (95% CI [60-127], P < .0001). Mitochondrial DNA (mtDNA) increases by 370% at the end of surgery (95% CI [225-515], P < .0001) and by 503% on POD1 (95% CI [332-673], P < .0001). In vitro incubation of monocytes with HSP70 decreased cytokine production capacity of tumor necrosis factor (TNF) by 46% (95% CI [29-64], P < .0001), IL-6 by 22% (95% CI [12-32], P = .0004) and IL-10 by 19% (95% CI [12-26], P = .0015). In vitro incubation with HMGB1 decreased cytokine production capacity of TNF by 34% (95% CI [3-65], P = .0003), interleukin 1β (IL-1β) by 24% (95% CI [16-32], P < .0001), and IL-10 by 40% (95% CI [21-58], P = .0009). Analysis of the inflammatory proteome alongside epigenetic shifts in monocytes indicated significant changes in gene accessibility, particularly in inflammatory markers such as CXCL8 (IL-8), IL-6, and interferon-gamma (IFN-γ). A significant enrichment of interferon regulatory factors (IRFs) was found in loci exhibiting decreased accessibility, whereas enrichment of activating protein-1 (AP-1) family motifs was found in loci with increased accessibility.

CONCLUSIONS

These findings illuminate the complex epigenetic modulation influencing monocytes' response to surgical stress, shedding light on potential biomarkers for immune dysregulation. Our results advocate for further research into the role of anesthesia in these molecular pathways and the development of personalized interventions to mitigate immune dysfunction after surgery.

The baseline fecal microbiome differs in patients with and without anastomotic leakage after colorectal cancer surgery

Background

Anastomotic leakage (AL) is a severe complication of colorectal surgery. The risk of AL is affected by both surgery and patient factors. Gut microbiomes can be generated from the residual material from the fecal immunochemical test (FIT). We, therefore, examined if AL after colorectal cancer surgery could be associated with specific baseline microbiomes in the FIT screening sampling tubes collected weeks before surgery.

Methods

Samples from patients participating in the Danish colorectal cancer screening program were biobanked from 2016 to 2018, and samples from patients who had surgery for screening-detected cancer were included. They were matched with patients without AL in a 1:2 ratio based on age, sex, location of anastomosis (colonic/rectal), ASA classification, and smoking habits. Bacterial DNA was extracted from the sampling tubes, and the fecal microbiomes were analyzed with targeted 16S ribosomal RNA third-generation sequencing.

Results

18 patients who developed AL after surgery were matched with 36 without AL. The alpha diversity was lower in the AL group (p = 0.035), and the AL group separated from the Controls in the PCoA plot (p < 0.001). This was due to the patients undergoing rectal resections, with significant differences in alpha- and beta diversity (p = 0.025 and p = 0.002, respectively). The prevalence of bacteria with the potential to produce collagenase was higher in patients who developed AL (odds ratio 1.29 (95% CI 1.28-1.30), p < 0.001).

Conclusions

We found differences in the baseline microbiome profile associated with subsequent development of AL after surgery for screening-detected rectal cancer.

Comparison of erector spinae plane block and transverse abdominis plane block in postoperative recovery after laparoscopic colorectal surgery: a randomized, double-blind, controlled trial

BACKGROUND

Patients experience significant postoperative pain after laparoscopic resection of colorectal cancer. Transversus abdominis plane block (TAPB) provides effective analgesia, and recent studies have also shown that erector spinae plane block (ESPB) can be used for postoperative analgesia in abdominal surgery. However, there is a lack of comparison between the two methods regarding recovery quality following laparoscopic colorectal surgery.

METHODS

Sixty patients scheduled for laparoscopic radical resection of colorectal cancer were randomly assigned to receive either a ESPB with TAPB (n = 30). Both groups received a single injection of 20 mL of 0.25% ropivacaine bilaterally. The primary outcome was the quality of recovery (QoR) at 24 h postoperatively, using the quality of recovery-15 (QoR-15) scale. Secondary outcomes included the QoR at 48 h postoperatively, visual analogue scale (VAS) pain scores during the first 48 h postoperatively in both resting and active states, requirements for rescue analgesia, cumulative postoperative opioid consumption, patient satisfaction, incidence of postoperative nausea and vomiting (PONV), time to first flatus and ambulation, the Comprehensive Complication Index (CCI) score, and postoperative hospital stay.

RESULTS

At 24 h postoperatively, the QoR-15 score (mean ± standard deviation) was significantly higher in the ESPB group (109.2 ± 8.7) compared to the TAPB group (101 ± 10.1) (p = 0.001). Similarly, at 48 h postoperatively, the QoR-15 score remained higher in the ESPB group (118.5 ± 8.8) than in the TAPB group (113.8 ± 8.1) (p = 0.035). Patients in the ESPB group reported lower visual analog scale (VAS) pain scores during the first 24 h postoperatively (all p < 0.05) compared to those in the TAPB group. The sufentanil consumption median (interquartile range) in the ESPB group at 24 h postoperatively was lower (62, 61-65 μg) compared to the TAPB group (66, 63-70 μg) (p < 0.001). Hospital stay median was 7 (6-9) days for the ESPB group and 8 (7-10) days for the TAPB group (p = 0.037).

CONCLUSIONS

Patients who received ESPB showed better recovery quality, improved analgesic effects, and higher postoperative satisfaction compared to those who underwent preoperative TAPB.

TRIAL REGISTRATION

https://www.chictr.org.cn (ChiCTR2400081157); date of registration: February 24, 2024. The first participant was enrolled on February 27, 2024.

Beyond the Operating Room: A Narrative Review of Enhanced Recovery Strategies in Colorectal Surgery

Enhanced Recovery After Surgery (ERAS) protocols have significantly transformed the management of patients undergoing colorectal surgery. This comprehensive review explores the key components and benefits of ERAS in colorectal procedures, focusing on preoperative, perioperative, and postoperative strategies aimed at improving patient outcomes. These strategies include preoperative patient education, multimodal analgesia, minimally invasive surgical techniques, and early mobilization. ERAS protocols reduce postoperative complications, shorten hospital stays, and enhance overall recovery, leading to better patient satisfaction and decreased healthcare costs. However, challenges such as patient adherence and managing high-risk patients remain critical areas for further research. Additionally, future research should focus on refining ERAS protocols, integrating novel technologies such as minimally invasive techniques, and evaluating long-term outcomes to further enhance the recovery process.

C-reactive Protein as a Negative Predictor of Anastomotic Leak Following Elective Colorectal Resection: A Beacon of Assurance?

Background To evaluate the accuracy and optimal C-reactive protein (CRP) level for detecting anastomotic leak (AL) in patients following elective colorectal resection. Methods A retrospective data collection of patients undergoing elective colorectal resection with primary anastomosis at a single institution was performed. Data were collected between June 2021 and November 2022. All colorectal resections and any anastomosis type were included. The following information was collected: basic patient demographics, operative and postoperative complications, and daily CRP results for the first seven postoperative days (POD). SPSS version 27 (IBM Corp., Armonk, NY) was used for all data analysis. Results A total of 231 patients with a mean age of 68.8 ± 14.4 years were included. The most common surgical procedure was a right hemicolectomy (46.3%), followed by anterior resection (42.8%), segmental colectomy (7.4%), and subtotal colectomy (3.4%). The overall AL rate for this cohort was 3%, and the median length of hospital stay was six days (mean: 7.6 ± 5.1 days). POD3, POD4, and POD5 showed an area under the curve of 0.73 (P = 0.07), 0.90 (P = 0.001), and 0.95 (P = 0.002), respectively. An optimal CRP cut-off value of 160 mg/L on POD4 resulted in a sensitivity of 85%, specificity of 83%, negative predictive value of 98%, and positive predictive value of 24%. Conclusion CRP is an excellent negative predictor of AL following colorectal resection and primary anastomosis. Patients with a POD4 CRP of <160 mg/L may be earmarked for hospital discharge if clinically appropriate.

For whom the bell tolls: assessing the incremental costs associated with failure to rescue after elective colorectal surgery

BACKGROUND

Failure to rescue after elective surgery is associated with increased healthcare costs. These costs are poorly understood and have not been reported for colorectal surgery. This study aimed to assess the incremental costs of failure to rescue after elective colorectal surgery.

METHODS

This was a retrospective study of adult patients identified in the National Inpatient Sample from 2016 to 2019 who underwent an elective colectomy or proctectomy. Patients were stratified into 4 groups: uneventful recovery, successfully rescued, failure to rescue, and died without rescue attempts. "Rescue" was defined as admissions with ≥1 procedure code ≥1 day after the initial procedure. The primary outcome was total admission costs.

RESULTS

Of 451,490 admissions for elective colorectal resection, 94.6% had an uneventful recovery, 4.8% were successfully rescued, 0.4% were failure to rescue, and 0.3% died without rescue attempts. The median total hospital cost for the uneventful recovery cohort was $16,751 (IQR, $12,611-$23,116), for the successfully rescued cohort was $42,295 (IQR, $27,959-$67,077), for the failure-to-rescue cohort was $53,182 (IQR, $30,852-$95,615), and for the died without attempted rescue cohort was $29,296 (IQR, $19,812-$45,919). When comparing cost quantiles by regression analysis, failure-to-rescue patients had significantly higher costs than the successfully rescued patients for the last 3 quantiles (fifth quantile [90th percentile], $163,963 vs $106,521; P < .001).

CONCLUSION

Across a nationally representative cohort, the median total hospital costs for patients who failed to be rescued were $10,887 more than for those who were successfully rescued. These findings emphasize the importance of shared decision making and medical futility and highlight opportunities for resource optimization after postoperative complications.

Analyzing postoperative complications in colorectal cancer surgery: a systematic review enhanced by artificial intelligence

INTRODUCTION

Colorectal cancer stands as a predominant cause of cancer-related mortality worldwide. Despite progressive strides in surgical methodologies, the specter of postoperative complications is very large, significantly impacting both morbidity and mortality rates. This review aims to meticulously examine existing scholarly works to gauge the prevalence, severity, and therapeutic approaches to postoperative complications arising from colorectal cancer surgeries.

METHODS

Employing a systematic approach, this study reviewed 135 peer-reviewed publications from the period of 2000-2023. The corpus was organized into categories reflective of the postoperative complications discussed: anastomotic leakage, port-site metastases, small bowel adhesions and obstructions, thrombosis, ileus, postoperative infections, urinary dysfunctions, and cardiovascular dysfunctions. Advanced artificial intelligence tools were leveraged for in-depth literature searches and semantic analyses to pinpoint research lacunae.

RESULTS

The analysis revealed that anastomotic leakage and postoperative infections garnered the majority of academic focus, representing 35% and 25% of the studies, respectively. Conversely, port-site metastases and cardiovascular dysfunctions were less frequently examined, accounting for merely 5% and 3% of the literature. The reviewed studies indicate a disparity in the reported prevalence rates of each complication, oscillating between 3% and 20%. Furthermore, the review identified a dearth of evidence-based management protocols, underscored by a pronounced heterogeneity in treatment guidelines.

CONCLUSIONS

The literature is replete with analyses on anastomotic leakage and postoperative infections; however, there exists a glaring scarcity of exhaustive research on other postoperative complications. This review emphasizes the pressing need for uniform treatment guidelines and spotlights areas in dire need of further research, aiming at the comprehensive enhancement of patient outcomes following colorectal cancer surgery.

The Value of Systemic Inflammatory Indices for Predicting Early Postoperative Complications in Colorectal Cancer

Background and Objectives: Systemic inflammatory indices have been largely investigated for their potential predictive value in multiple inflammatory, infectious, and oncological diseases; however, their value in colorectal cancer is still a subject of research. This study investigates the dynamics of pre- and postoperative values of NLR, PLR, SII, and MLR in patients with colorectal cancer and their predictive value for early postoperative outcomes. Materials and Methods: A 2-year retrospective cohort study was performed on 200 patients operated for colorectal adenocarcinoma. Systemic inflammatory indices were calculated based on complete blood count preoperatively and on the first and sixth postoperative days. The patients were divided into two groups based on their emergency or elective presentation. The pre- and postoperative values of serum inflammatory biomarkers and their correlations with postoperative outcomes were separately analyzed for the two study subgroups. Results: There were no significant differences in sex distribution, addressability, associated comorbidities, or types of surgery between the two groups. Patients in the emergency group presented higher preoperative and postoperative values of WBC, neutrophils, NLR, and SII compared to elective patients. The postsurgery hospital stays correlated well with pre- and postoperative day one and day six values of NLR (p = 0.001; 0.02; and <0.001), PLR (p < 0.001), SII (p = 0.037; <0.001; <0.001), and MLR (p = 0.002; p = 0.002; <0.001). In a multivariate analysis, reintervention risk was higher for emergency presentation and anemia, and lower in right colon cancer. In the emergency group, a multivariate model including age, MLR PO1, and pTNM stage was predictive for severe postoperative complications (AUC ROC 0.818). First-day postoperative inflammatory indices correlated well with sepsis, with the best predictive value being observed for the first postoperative day NLR (AUC 0.836; sensibility 88.8%; specificity 66.7%) and SII (AUC 0.796; sensitivity 66.6%; specificity 90%). For elective patients, the first postoperative day PLR and anemia were included in a multivariate model to predict Clavien-Dindo complications graded 3 or more (AUC ROC 0.818) and reintervention (AUC ROC 0.796). Conclusions: Easy-to-calculate and inexpensive systemic inflammatory biomarkers could be useful in predicting early postoperative outcomes in colorectal cancer for both elective and emergency surgery.

Inter-rater reliability of ACS-NSQIP colorectal procedure coding in Canada

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) uses Current Procedural Terminology (CPT) codes for risk-adjusted calculations. This study evaluates the inter-rater reliability of coding colorectal resections across Canada by ACS-NSQIP surgical clinical nurse reviewers (SCNR) and its impact on risk predictions.

METHODS

SCNRs in Canada were asked to code simulated operative reports. Percent agreement and free-marginal kappa correlation were calculated. The ACS-NSQIP risk calculator was utilized to illustrate its impact on risk prediction.

RESULTS

Responses from 44 of 150 (29.3 ​%) SCNRs revealed 3 to 6 different codes chosen per case, with agreement ranging from 6.7 ​% to 62.3 ​%. Free-marginal kappa correlation ranged from moderate agreement (0.53) to high disagreement (-0.17). ACS-NSQIP risk calculator predicted large absolute differences in risk for serious complications (0.2 ​%-13.7 ​%) and mortality (0.2 ​%-6.3 ​%).

CONCLUSION

This study demonstrated low inter-rater reliability in coding ACS-NSQIP colorectal procedures in Canada among SCNRs, impacting risk predictions.

[Postoperative Imaging Findings of Colorectal Surgery: A Pictorial Essay]

Postoperative colorectal imaging studies play an important role in the detection of surgical complications and disease recurrence. In this pictorial essay, we briefly describe methods of surgery, imaging findings of their early and late complications, and postsurgical recurrence of cancer and inflammatory bowel disease.

AI-Enhanced evaluation of YouTube content on post-surgical incontinence following pelvic cancer treatment

Background

Several pelvic area cancers exhibit high incidence rates, and their surgical treatment can result in adverse effects such as urinary and fecal incontinence, significantly impacting patients' quality of life. Post-surgery incontinence is a significant concern, with prevalence rates ranging from 25 to 45% for urinary incontinence and 9-68% for fecal incontinence. Cancer survivors are increasingly turning to YouTube as a platform to connect with others, yet caution is warranted as misinformation is prevalent.

Objective

This study aims to evaluate the information quality in YouTube videos about post-surgical incontinence after pelvic area cancer surgery.

Methods

A YouTube search for "Incontinence after cancer surgery" yielded 108 videos, which were subsequently analyzed. To evaluate these videos, several quality assessment tools were utilized, including DISCERN, GQS, JAMA, PEMAT, and MQ-VET. Statistical analyses, such as descriptive statistics and intercorrelation tests, were employed to assess various video attributes, including characteristics, popularity, educational value, quality, and reliability. Also, artificial intelligence techniques like PCA, t-SNE, and UMAP were used for data analysis. HeatMap and Hierarchical Clustering Dendrogram techniques validated the Machine Learning results.

Results

The quality scales presented a high level of correlation one with each other (p < 0.01) and the Artificial Intelligence-based techniques presented clear clustering representations of the dataset samples, which were reinforced by the Heat Map and Hierarchical Clustering Dendrogram.

Conclusions

YouTube videos on "Incontinence after Cancer Surgery" present a "High" quality across multiple scales. The use of AI tools, like PCA, t-SNE, and UMAP, is highlighted for clustering large health datasets, improving data visualization, pattern recognition, and complex healthcare analysis.

The efficacy of omega-3 fatty acids (O3FAs) as a complementary in colorectal cancer patients: A systematic review and meta-analysis

BACKGROUND & AIMS

Colorectal cancer (CRC) is the third most common malignancy in developed countries. Therefore, omega-3 fatty acids (O3FAs) have been suggested as a beneficial complementary treatment due to their ability to regulate inflammatory responses and improve nutrition levels.This study aimed to evaluate the effects of O3FAs as a complementary treatment for inflammation, nutrition levels, post-operative infectious complications, and enhancement of recovery in CRC patients.

METHODS

The literature search was carried out through three databases. The outcomes of interest were assessed by measuring pro-inflammatory cytokines (IL-1β, IL-6, and TNF-α) and CRP levels, serum albumin levels for nutrition assessment, post-operative infectious complications, and length of stay for recovery evaluation. Quality appraisal and meta-analysis were performed using RoB 2.0 and RevMan 5.4, respectively.

RESULTS

The result showed that O3FAs significantly reduced IL-6, CRP, and TNF-α, but did not affect IL-1β. Furthermore, the variable slightly increased serum albumin levels and the supplementation led to a decrease in post-operative infectious complications and shortened hospital stays.

CONCLUSION

O3FAs as a complementary treatment provided advantages for CRC patients, Further clinical trials and experiments should also be made emphasizing the impact and clinical implementation of O3FA in the nutritional status of CRC patients.

Is transanal irrigation the best treatment possibility for low anterior resection syndrome? A multicenter, randomized clinical trial: study protocol

Background

Up to 50% of patients who undergo rectal resection suffer from various and partly severe functional problems, despite the preservation of the anal sphincter. These complaints are defined as low anterior resection syndrome (LARS). So far, there are no randomized clinical trials regarding the most effective treatment for LARS. Our aim is to evaluate whether transanal irrigation improves bowel function and quality of life in patients following low anterior resection compared to best supportive care.

Methods

Patients who have undergone low anterior resection will be approached for this study. On patient's visit, complaints regarding the defecation as well as any deterioration in their overall quality of life will be assessed using questionnaires such as the Low Anterior Resection Syndromes score, Wexner score, European Organization for Research and Treatment of Cancer (EORTC) Quality of Life (QOL) CR-29, and Measure Yourself Medical Outcome Profile tool. Few additional target questions will be also asked, such as "Would you recommend the treatment to anybody; did you expect the improvement following the treatment; etc." Questionnaires and scales will be filled on follow-up visits every 3 months for 1 year.

Discussion

This multicenter, randomized controlled trial will lead to a better understanding of LARS treatment. Moreover, it will be a hypothesis-generating study and will inform areas needing future prospective studies.

Clinical Trial Registration

ClinicalTrials.gov, identifier (NCT05920681).

Colorectal anastomotic leakage: a narrative review of definitions, grading systems, and consequences of leaks

Background

Anastomotic leaks (ALs) are a significant and feared postoperative complication, with incidence of up to 30% despite advances in surgical techniques. With implications such as additional interventions, prolonged hospital stays, and hospital readmission, ALs have important impacts at the level of individual patients and healthcare providers, as well as healthcare systems as a whole. Challenges in developing unified definitions and grading systems for leaks have proved problematic, despite acknowledgement that colorectal AL is a critical issue in intestinal surgery with serious consequences. The aim of this study was to construct a narrative review of literature surrounding definitions and grading systems for ALs, and consequences of this postoperative complication.

Methods

A literature review was conducted by examining databases including PubMed, Web of Science, OVID Embase, Google Scholar, and Cochrane library databases. Searches were performed with the following keywords: anastomosis, anastomotic leak, colorectal, surgery, grading system, complications, risk factors, and consequences. Publications that were retrieved underwent further assessment to ensure other relevant publications were identified and included.

Results

A universally accepted definition and grading system for ALs continues to be lacking, leading to variability in reported incidence in the literature. Additional factors add to variability in estimates, including differences in the anastomotic site and institutional/individual differences in operative technique. Various groups have worked to publish guidelines for defining and grading AL, with the International Study Group of Rectal Cancer (ISGRC/ISREC) definition the current most recommended universal definition for colorectal AL. The burden of AL on patients, healthcare providers, and hospitals is well documented in evidence from leak consequences, such as increased morbidity and mortality, higher reoperation rates, and increased readmission rates, among others.

Conclusions

Colorectal AL remains a significant challenge in intestinal surgery, despite medical advancements. Understanding the progress made in defining and grading leaks, as well as the range of negative outcomes that arise from AL, is crucial in improving patient care, reduce surgical mortality, and drive further advancements in earlier detection and treatment of AL.

Lessons following implementation of a colorectal enhanced recovery after surgery (ERAS) protocol in a rural hospital setting

INTRODUCTION

Enhanced recovery after surgery (ERAS) programs have become increasingly popular in the management of patients undergoing colorectal resection. However, the validity of ERAS in rural hospital settings without intensive care facilities has not been primarily evaluated. This study aimed to assess an ERAS protocol in a rural surgical department based in Invercargill New Zealand.

METHODS

Ten years of prospectively collected data were analysed retrospectively from an ERAS database of all patients undergoing open, converted, or laparoscopic colorectal resections. Data were collected between two time periods: before the implementation of an ERAS protocol, from January 2011 to December 2013; as well as after the implementation of an ERAS protocol, from January 2014 to December 2020. The primary outcome measures were hospital length of stay (LOS) and LOS in the critical care unit (LOS-CCU). Secondary outcomes were compliance with ERAS protocol, mortality, readmission, and reoperation rates.

RESULTS

A total of 118 and 558 colorectal resections were performed in the pre-ERAS and ERAS groups respectively. A statistically significant reduction in hospital LOS was achieved from a median of 8 to 7 days (P = 0.038) when comparing pre-ERAS to ERAS groups respectively. Furthermore, a significant reduction in re-operation rates was observed (7.6% vs. 3% in the ERAS group, P = 0.033) which was seen without a rise in readmission rates (13.6% vs. 13.6% in the ERAS group).

CONCLUSION

The implementation of ERAS in a rural surgical setting is feasible, and these initial findings suggest ERAS adds value in optimizing the colorectal patient's surgical journey.

Association of time to resection with survival in patients with colon cancer

PURPOSE

Colon cancer (CC) remains a leading cause of cancer-related mortality worldwide, for which colectomy represents the standard of care. Yet, the impact of delayed resection on survival outcomes remains controversial. We assessed the association between time to surgery and 10-year survival in a national cohort of CC patients.

METHODS

This retrospective cohort study identified all adults who underwent colectomy for Stage I-III CC in the 2004-2020 National Cancer Database. Those who required neoadjuvant therapy or emergent resection < 7 days from diagnosis were excluded. Patients were classified into Early (< 25 days) and Delayed (≥ 25 days) cohorts after an adjusted analysis of the relationship between time to surgery and 10-year survival. Survival at 1-, 5-, and 10-years was assessed via Kaplan-Meier analyses and Cox proportional hazard modeling, adjusting for age, sex, race, income quartile, insurance coverage, Charlson-Deyo comorbidity index, disease stage, location of tumor, receipt of adjuvant chemotherapy, as well as hospital type, location, and case volume.

RESULTS

Of 165,991 patients, 84,665 (51%) were classified as Early and 81,326 (49%) Delayed. Following risk adjustment, Delayed resection was associated with similar 1-year [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.97-1.04, P = 0.72], but inferior 5- (HR 1.24, CI 1.22-1.26; P < 0.001) and 10-year survival (HR 1.22, CI 1.20-1.23; P < 0.001). Black race [adjusted odds ratio (AOR) 1.36, CI 1.31-1.41; P < 0.001], Medicaid insurance coverage (AOR 1.34, CI 1.26-1.42; P < 0.001), and care at high-volume hospitals (AOR 1.12, 95%CI 1.08-1.17; P < 0.001) were linked with greater likelihood of Delayed resection.

CONCLUSIONS

Patients with CC who underwent resection ≥ 25 days following diagnosis demonstrated similar 1-year, but inferior 5- and 10-year survival, compared to those who underwent surgery within 25 days. Socioeconomic factors, including race and Medicaid insurance, were linked with greater odds of delayed resection. Efforts to balance appropriate preoperative evaluation with expedited resection are needed to optimize patient outcomes.

Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery

OBJECTIVE

To provide procedure-specific estimates of symptomatic venous thromboembolism (VTE) and major bleeding after abdominal surgery.

BACKGROUND

The use of pharmacological thromboprophylaxis represents a trade-off that depends on VTE and bleeding risks that vary between procedures; their magnitude remains uncertain.

METHODS

We identified observational studies reporting procedure-specific risks of symptomatic VTE or major bleeding after abdominal surgery, adjusted the reported estimates for thromboprophylaxis and length of follow-up, and estimated cumulative incidence at 4 weeks postsurgery, stratified by VTE risk groups, and rated evidence certainty.

RESULTS

After eligibility screening, 285 studies (8,048,635 patients) reporting on 40 general abdominal, 36 colorectal, 15 upper gastrointestinal, and 24 hepatopancreatobiliary surgery procedures proved eligible. Evidence certainty proved generally moderate or low for VTE and low or very low for bleeding requiring reintervention. The risk of VTE varied substantially among procedures: in general abdominal surgery from a median of <0.1% in laparoscopic cholecystectomy to a median of 3.7% in open small bowel resection, in colorectal from 0.3% in minimally invasive sigmoid colectomy to 10.0% in emergency open total proctocolectomy, and in upper gastrointestinal/hepatopancreatobiliary from 0.2% in laparoscopic sleeve gastrectomy to 6.8% in open distal pancreatectomy for cancer.

CONCLUSIONS

VTE thromboprophylaxis provides net benefit through VTE reduction with a small increase in bleeding in some procedures (eg, open colectomy and open pancreaticoduodenectomy), whereas the opposite is true in others (eg, laparoscopic cholecystectomy and elective groin hernia repairs). In many procedures, thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding VTE and bleeding.

Treatment interval in curative treatment of colon cancer, does it impact (cancer free) survival? A non-inferiority analysis

BACKGROUND

In treatment of colon cancer, strict waiting-time targets are enforced, leaving professionals no room to lengthen treatment intervals when advisable, for instance to optimise a patient's health status by means of prehabilitation. Good quality studies supporting these targets are lacking. With this study we aim to establish whether a prolonged treatment interval is associated with a clinically relevant deterioration in overall and cancer free survival.

METHODS

This retrospective multicenter non-inferiority study includes all consecutive patients who underwent elective oncological resection of a biopsy-proven primary non-metastatic colon carcinoma between 2010 and 2016 in six hospitals in the Southern Netherlands. Treatment interval was defined as time between diagnosis and surgical treatment. Cut-off points for treatment interval were ≤35 days and ≤49 days.

FINDINGS

3376 patients were included. Cancer recurred in 505 patients (15.0%) For cancer free survival, a treatment interval >35 days and >49 days was non-inferior to a treatment interval ≤35 days. Results for overall survival were inconclusive, but no association was found.

CONCLUSION

For cancer free survival, a prolonged treatment interval, even over 49 days, is non-inferior to the currently set waiting-time target of ≤35 days. Therefore, the waiting-time targets set as fundamental objective in current treatment guidelines should become directional instead of strict targets.

Preparing for and Not Waiting for Surgery

Cancer surgery is an essential treatment strategy but can disrupt patients' physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, 'surgery schools', and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.

Assessing the Quality of YouTube's Incontinence Information after Cancer Surgery: An Innovative Graphical Analysis

BACKGROUND

Prostate and colorectum cancers rank among the most common cancers, and incontinence is a significant postsurgical issue affecting the physical and psychological well-being of cancer survivors. Social media, particularly YouTube, has emerged as a vital source of health information. While YouTube offers valuable content, users must exercise caution due to potential misinformation.

OBJECTIVE

This study aims to assess the quality of publicly available YouTube videos related to incontinence after pelvic cancer surgery.

METHODS

A search on YouTube related to "Incontinence after cancer surgery" was performed, and 108 videos were analyzed. Multiple quality assessment tools (DISCERN, GQS, JAMA, PEMAT, and MQ-VET) and statistical analyses (descriptive statistics and intercorrelation tests) were used to evaluate the characteristics and popularity, educational value, quality, and reliability of these videos, relying on novel graphical representation techniques such as Sankey and Chord diagrams.

RESULTS

Strong positive correlations were found among quality rating scales, emphasizing agreement. The performed graphical analysis reinforced the reliability and validity of quality assessments.

CONCLUSIONS

This study found strong correlations among five quality scales, suggesting their effectiveness in assessing health information quality. The evaluation of YouTube videos consistently revealed "high" quality content. Considering the source is mandatory when assessing quality, healthcare and academic institutions are reliable sources. Caution is advised with ad-containing videos. Future research should focus on policy improvements and tools to aid patients in finding high-quality health content.

The enhanced recovery after surgery (ERAS) protocol implementation in a national tertiary-level hospital: a prospective cohort study

Introduction

Successful colorectal surgery is determined based on postoperative mortality and morbidity rates, complication rates, and cost-effectiveness. One of the methods to obtain an excellent postoperative outcome is the enhanced recovery after surgery (ERAS) protocol. This study aims to see the effects of implementing an ERAS protocol in colorectal surgery patients.

Methods

Eighty-four patients who underwent elective colorectal surgery at National Tertiary-level Hospital were included between January 2021 and July 2022. Patients were then placed into ERAS (42) and control groups (42) according to the criteria. The Patients in the ERAS group underwent a customized 18-component ERAS protocol and were assessed for adherence. Postoperatively, both groups were monitored for up to 30 days and assessed for complications and readmission. The authors then analyzed the length of stay and total patient costs in both groups.

Results

The length of stay in the ERAS group was shorter than the control group [median (interquartile range) 6 (5-7) vs. 13 (11-19), P<0.001], with a lower total cost of [USD 1875 (1234-3722) vs. USD 3063 (2251-4907), P<0.001]. Patients in the ERAS group had a lower incidence of complications, 10% vs. 21%, and readmission 5% vs. 10%, within 30 days after discharge than patients in the control group; however, the differences were not statistically significant. The adherence to the ERAS protocol within the ERAS group was 97%.

Conclusion

Implementing the ERAS protocol in colorectal patients reduces the length of stay and total costs.

Digital postoperative follow-up after colorectal resection: a multi-center preliminary qualitative study on a patient reporting and monitoring application

The development of minimally invasive colorectal surgery in the last decades led to a decrease in length of hospital stay. However, readmission and postoperative complications were still observed. Several studies have shown that close postoperative follow-up is required to decrease postoperative morbidity through patient education and by detecting early signs of complications. To help in this task, multiple monitoring programs have been set up to follow patients at home, allowing detection of several complications at an early stage. To evaluate acceptance, satisfaction, usability, compliance and safety of a mobile application following postoperative colorectal patients during the first 15 days post-discharge from hospital. A mobile application enabling the communication between the patient and medical staff during the recovery phase was developed and tested in four hospitals. Patients who underwent a colorectal resection were included in this prospective qualitative study. Questionnaires to assess satisfaction and usability were handed out to patients at the end of the test period. Overall, 118 patients (52% females, median age 52.5 years) were included. Median adherence-rate during 15 days was 89.6%. Satisfaction-rate for the application was 76% and usability was high. Overall, 1220 notifications were collected, of which 722 were orange, 466 red and 32 purple, colours used to rate the severeness of complaints. We analyzed the most common notifications, showing trends in different subgroups of the study with higher risks of complications (pain (409 notifications), abnormal stools (196 notifications), and wound problems (118 notifications)). A mobile application could be used to follow patients at home after colorectal resection. Future studies should evaluate whether these applications can detect complications and prevent readmission.

Preoperative 6-minute walk distance is associated with postoperative complications in patients undergoing laparoscopic gastrointestinal cancer surgery

OBJECTIVE

The 6-min walk test (6MWT) is a simple and valid method to evaluate cardiopulmonary function. We performed this prospective study in patients undergoing laparoscopic gastrointestinal cancer surgery to explore the association between preoperative 6MWT performance and overall postoperative complications.

METHODS

This study was registered at clinicaltrials.gov (NCT03711526). The study consecutively enrolled patients receiving laparoscopic gastrointestinal cancer surgery in our institution. All patients performed the 6MWT upon recruitment and received 30 days of postoperative follow-up. The primary outcome was overall complications, defined by ≥ grade I Clavien-Dindo (CD) classification (2004) complications. Multivariable logistic regression was used to test the association of 6-min walk distance (6MWD) with the outcome.

RESULTS

A total of 184 patients were included in the final analyses. In the 37 (20.1 %) patients with overall complications, the mean (standard deviation) preoperative 6MWD was 469.1 (86.8) m. In patients with no complications, the 6MWD was 502.6 (90.2) m. The mean difference was 33.5 m (95 % confidence interval, 1.3, 65.7; P = 0.042). A longer preoperative 6MWD was associated with a lower odds of developing postoperative complications (odds ratio, 0.994 per meter increase; 95 % confidence interval, 0.989, 0.999; p = 0.023).

CONCLUSION

This study indicated an association between the preoperative 6MWD and postoperative complications in patients undergoing laparoscopic gastrointestinal cancer surgery.

Evaluation of Factors That Contribute to Intraoperative and Postoperative Complications Following Colorectal Cancer Surgeries at King Abdulaziz University Hospital, Jeddah, Saudi Arabia

BACKGROUND

Colorectal cancer (CRC) is a major contributor to cancer-related mortality and morbidity due to its high prevalence. Surgery remains the curative option. Colorectal cancer patients come to our institute at an advanced stage due to the lack of adequate national screening programs in developing countries. This carries a particularly high risk of morbidity and mortality. In this study, we aim to provide an overview of the complications of colorectal cancer surgery and to describe the preoperative and intraoperative factors associated with it.

METHODS

This retrospective record review was done at King Abdulaziz University Hospital (KAUH), a tertiary center in Jeddah, Saudi Arabia. It included all patients aged 18 and older who have undergone colorectal cancer surgeries from January 2017 until August 2022.

RESULTS

In our sample of 195 patients, 52.3% of the patients were males. The mean age of our sample was 59.32 ± 13.21. We found that 19 (9.7%) patients had an intraoperative complication (IOC). The most frequent IOC was bleeding reported in seven patients (3.6%), followed by intestinal injury in three (1.2%), bladder injury in three (1.2%), and ureter injury in three (1.2%). Regarding preoperative lab tests, patients who had low blood albumin levels (P = 0.004) and high preoperative white blood cell count (WBC; P = 0.015) were more likely to experience IOC. There was a statistically significant relationship between the patient's ASA score and IOC (P = 0.011). Postoperative complications (POC) occurred in 58 patients (29.7%). The most frequent POC was surgical site infection (SSI; 16.4%), followed by urinary tract infections (UTI) (6.7%) and prolonged postoperative ileus (5.6%). Patients who initially presented with vomiting (P = 0.015), had free air on a preoperative abdominal computed tomography (CT) scan (P = 0.028), required intraoperative blood transfusions (P = 0.033), were diagnosed with transverse colon tumors (P = 0.045), and required longer hospital stays (P = 0.011) were found to have a higher rate of POC.

CONCLUSION

The incidence of colorectal cancer is increasing, and surgery is a successful treatment option. However, complications from surgery may result in morbidities and prolonged hospital stays. The risk of IOC is increased by preoperative variables such as high WBC levels, low albumin, and ASA scores. Patients with initial obstruction signs, free air on CT scans, intraoperative blood transfusions, transverse colon tumors, and longer hospital stays have a higher rate of POC. Patient monitoring and the provision of standardized clinical tools enhance general survival and quality of life.

Influence of perioperative step volume on complication rate and length of hospital stay after colorectal cancer surgery (IPOS trial): study protocol for a randomised controlled single-centre trial at a German university hospital

BACKGROUND

Perioperative mobilisation and physical activity are critical components of postoperative rehabilitation. Physical inactivity is a significant risk factor for complications and prolonged hospitalisation. However, specific recommendations for preoperative and postoperative physical activity levels are currently lacking. Evidence suggests that daily step count before and after surgery may impact the length of hospital stay and complication rate.The goal of this study is to determine the effectiveness of perioperative step volume recommendations, measured by pedometers, in reducing the length of hospital stay and complication rate for patients undergoing colorectal cancer surgery.

METHODS

This study is a single-centre randomised controlled trial with two arms, allocated at a 1:1 ratio. The trial includes individuals undergoing colorectal surgery for either suspected or confirmed colorectal malignancy. A total of 222 patients will be randomly assigned to either an intervention or a control group. Step counts will be measured using a pedometer. Patients assigned to the intervention group will be given a predetermined preoperative and postoperative step count goal. The analysis will be conducted on preoperative and postoperative physical activity, quality of life, health, duration of hospitalisation, complication rate and bowel function, among other factors.

ETHICS AND DISSEMINATION

The trial was approved by the ethics committee of the Ludwig-Maximilians-University of Munich, Germany (reference number: 22-0758, protocol version 2022.02). Results will be published in peer-reviewed journals and shared at academic conferences. After the publication of the results, a fully anonymised data set and the statistical code can be made available on justified scientific request and after ethical approval has been granted.

TRIAL REGISTRATION NUMBER

DRKS00030017.

Neoadjuvant Immune Checkpoint Inhibitor Therapy for Localized Deficient Mismatch Repair Colorectal Cancer: A Review

Importance

Colorectal cancers (CRCs) with deficient DNA mismatch repair (dMMR) account for 15% of all CRCs. Deficient MMR is a predictive biomarker associated with responsiveness to immune checkpoint inhibitors (ICIs) in solid tumors, including CRC. The remarkable effectiveness of ICIs in metastatic CRC has led to their evaluation in the neoadjuvant and adjuvant treatment of localized disease.

Observations

Multiple prospective phase 2 studies in limited numbers of patients with localized dMMR CRC demonstrate high complete clinical and pathological response rates (60%-100%) to neoadjuvant ICIs, with low rates of grade 3 or higher ICI-related toxic effects. Given the median follow-up of 12 to 25 months in these studies, longer-term monitoring is needed to determine the durability of response and to ensure that oncologic outcomes are not compromised in patients undergoing nonoperative management. Neoadjuvant ICI therapy is especially attractive for patients with rectal cancer given the significant morbidity that accompanies pelvic irradiation and total mesorectal excision. Ongoing and planned prospective phase 2 trials will provide further data on important issues, including optimal neoadjuvant treatment duration, ICI monotherapy vs combination, and the need for adjuvant ICI therapy.

Conclusions and Relevance

While this review found that early results of neoadjuvant immunotherapy for localized dMMR CRC show high rates of major and complete pathological response, longer-term follow-up data are needed to ensure that oncologic outcomes are not compromised and are ideally improved. Neoadjuvant ICI therapy in localized dMMR CRC represents a potential paradigm shift with implications for organ preservation.

Rectal cancer surgery: does low volume imply worse outcome-a single surgeon experience

BACKGROUND

The centralisation of rectal cancer management to high-volume oncology centres has translated to improved oncological and survival outcomes. We hypothesise that individual surgeon caseload, specialisation, and experience may be as significant in determining oncologic and postoperative outcomes in rectal cancer surgery.

METHODS

A prospectively maintained colorectal surgery database was reviewed for patients undergoing rectal cancer surgery between January 2004 and June 2020. Data studied included demographics, Dukes' and TNM staging, neoadjuvant treatment, preoperative risk assessment scores, postoperative complications, 30-day readmission rates, length of stay (LOS), and long-term survival. Primary outcome measures were 30-day mortality and long-term survival compared to national and international standards and best practice guidelines.

RESULTS

In total, 87 patients were included (mean age: 66 years [range: 36-88]). The mean length of stay (LOS) was 16.5 days (SD 6.0). The median ICU LOS was 3 days (range 2-17). Overall, 30-day readmission rate was 16.4%. Twenty-four patients (26.4%) experienced ≥ 1 postoperative complication. The 30-day operative mortality rate was 3.45%. Overall 5-year survival rate was 66.6%. A significant correlation was observed between P-POSSUM scores and postoperative complications (p = 0.041), and all four variants of POSSUM, CR-POSSUM, and P-POSSUM scores and 30-day mortality.

CONCLUSION

Despite improved outcomes seen with centralisation of rectal cancer services at an institutional level, surgeon caseload, experience, and specialisation is of similar importance in obtaining optimal outcomes within institutions.

Multiple Thrombotic, Infectious, and Cardiopulmonary Complications Following Laparoscopic Converted to Open Colectomy Procedure: A Case Report and Literature Review

All surgeries, from minor procedures, such as sutures, to major surgeries, such as open abdominal surgery, carry with them risk for complications. Among the most frequently encountered complications are surgical site infections and thrombotic complications. Less frequently, cardiac complications such as atrial fibrillation are seen. In this case report, we discuss the various complications encountered during the hospital stay of a 61-year-old male following a laparoscopic converted to open colectomy procedure for the treatment of a colorectal mass. Following surgery, a surgical pathology report revealed a newly diagnosed stage 3b colorectal adenocarcinoma. Multiple abscesses in the abdominopelvic cavity were discovered on computed tomography (CT), revealing a major surgical site infectious process. These findings warranted emergent surgical intervention and placement of multiple Jackson-Pratt drains. Due to previously untreated carcinoma promoting a prothrombotic state, the patient developed numerous thrombotic complications such as segmental pulmonary embolism, superior mesenteric vein thrombosis, and superficial thrombophlebitis of the saphenous veins. He also developed new-onset paroxysmal atrial fibrillation secondary to postoperative pain, as well as bilateral pleural effusions. Here, we shed light on the mechanisms of development of such complications, as well as the management and methods for prevention.

Factors associated with 30-day mortality and morbidity in patients undergoing emergency colorectal surgery

BACKGROUND

The 30-day period following emergency colorectal surgery (ECRS) is associated with high mortality and morbidity. There is a lack of data assessing factors associated with outcomes of ECRS in the Saudi population.

OBJECTIVES

Assess factors associated with 30-day postoperative mortality and complications following ECRS.

DESIGN

Retrospective cohort study.

SETTING

Single tertiary care center, Riyadh, Saudi Arabia.

PATIENTS AND METHODS

Demographic characteristics (age, sex, diagnosis, American Society of Anesthesiologists classification, pre-operative septic state, smoking, and comorbidities), operative characteristics (urgency, diverting ostomy, and procedure performed), and postoperative characteristics (length of stay, 30-day mortality, intensive care unit [ICU] admission, ICU length of stay, surgical site infection [SSI], readmission, reoperation, and complications) were collected from electronic medical records. Univariate logistic regression was used to evaluate association with the outcome measures (30-day mortality and postoperative complications). Multivariate logistic regression was applied to evaluate independent variables.

MAIN OUTCOME MEASURE

Thirty-day postoperative mortality and morbidity.

SAMPLE SIZE

241 patients.

RESULTS

Among 241 patients, 145 (60.2%) were men, and 80 (33.2%) patients were between 50-64 years of age. The most common indication for surgery was malignancy 138 (57%). The overall complication rate was 26.6% and the 30-day mortality rate was 11.2%. Left hemicolectomy was the most commonly performed procedure, performed in 69 (28.6%) patients. Patients between the age of 65-74 had an increased odds of death within 30 days (OR 5.25 [95% CI 1.03-26.5]) on univariate analysis. Preoperative sepsis was associated with a fourfold increase in the likelihood of 30-day mortality (OR 4.44, 95% CI 1.21-16.24, P=.024) on multivariate analysis. The likelihood of hospital re-admission increased by fivefold in patients who developed a postoperative complication (OR 5.33, 95% CI 1.30-21.78, P=.02).

CONCLUSION

Preoperative sepsis was independently associated with 30-day mortality in patients undergoing ECRS, while the likelihood of hospital readmission increased in patients with postoperative complications. Expeditious control of sepsis in the emergency surgical setting by both surgical and medical interventions may reduce the likelihood of postoperative mortality. Establishing discharge protocols for postoperative ECRS patients is advocated.

LIMITATIONS

Retrospective design, small sample size, and single setting.

Changes in the Gut Microbiota Composition during Implantation of Composite Scaffolds Based on Poly(3-hydroxybutyrate) and Alginate on the Large-Intestine Wall

The development of biopolymer scaffolds for intestine regeneration is one of the most actively developing areas in tissue engineering. However, intestinal regenerative processes after scaffold implantation depend on the activity of the intestinal microbial community that is in close symbiosis with intestinal epithelial cells. In this work, we study the impact of different scaffolds based on biocompatible poly(3-hydroxybutyrate) (PHB) and alginate (ALG) as well as PHB/ALG scaffolds seeded with probiotic bacteria on the composition of gut microbiota of Wistar rats. Implantation of PHB/ALG scaffolds on the large-intestine wall to close its injury showed that alpha diversity of the gut microbiota was not reduced in rats implanted with different PHB/ALG scaffolds except for the PHB/ALG scaffolds with the inclusion of Lactobacillus spheres (PHB/ALG-L). The composition of the gut microbiota of rats implanted with PHB/ALG scaffolds with probiotic bacteria or in simultaneous use of an antimicrobial agent (PHB/ALG-AB) differed significantly from other experimental groups. All rats with implanted scaffolds demonstrated shifts in the composition of the gut microbiota by individual operational taxonomic units. The PHB/ALG-AB construct led to increased abundance of butyrate-producing bacteria: Ileibacterium sp. dominated in rats with implanted PHB/ALG-L and Lactobacillus sp. and Bifidobacterium sp. dominated in the control group. In addition, the PHB/ALG scaffolds had a favourable effect on the growth of commensal bacteria. Thus, the effect of implantation of the PHB/ALG scaffold compared to other scaffolds on the composition of the gut microbiota was closest to the control variant, which may demonstrate the biocompatibility of this device with the microbiota.

Association between early mobilisation after abdominal cancer surgery and postoperative complications

INTRODUCTION

Postoperative complications and readmission to hospital after major cancer surgery are common. Early mobilisation in hospital is thought to reduce complications, and patients are recommended to mobilise for at least 2 h on the day of surgery, and thereafter at least 6 h per day. Evidence for early mobilisation is limited and therefore also how early mobilisation may influence the development of postoperative complications. The aim of this study was to evaluate the association between early mobilisation after abdominal cancer surgery and readmission to hospital due to postoperative complications.

MATERIAL AND METHODS

Adult patients who had abdominal cancer surgery due to ovarian, colorectal, or urinary bladder cancer between January 2017 and May 2018 were included in the study. Exposure was set to the mean number of steps taken over the first three postoperative days, measured with an activity monitor. Primary outcome was readmission to hospital within 30 days after discharge, and secondary outcome was severity of complications. Data were obtained from medical records. Logistic regression was used to investigate the association between exposure and outcomes.

RESULTS

Of 133 patients included in the study, 25 were readmitted to the hospital within 30 days after discharge. The analysis showed no association between early mobilisation and readmission or severity of complications.

CONCLUSION

Early mobilisation does not seem to increase the odds of readmission, nor the severity of complications. This study contributes to the limited research on the association between early mobilisation and postoperative complications after abdominal cancer surgery.

Healthcare Cost and Outcomes Associated With Surgical Site Infection and Patient Outcomes in Low- and Middle-Income Countries

Surgical site infection (SSI) is a growing global concern. The principal explanation for this is its adverse clinical outcomes, such as morbidity and mortality. However, the link between the economic burden of SSIs and patient outcomes needs to be sufficiently characterized. This review aims to describe the financial implications of SSIs on patient outcomes in low- and middle-income countries (LMIC). Despite the heterogeneity in study designs from multiple LMIC countries, there is a significant correlation between SSI-associated healthcare costs from increased length of stay (LOS), readmissions, reoperations, and adverse patient outcomes. This varies based on the size, degree of infection, or other patient comorbidities. SSIs are much more prevalent in LMICs. The additional financial burden incurred in managing SSIs reinforces the need to prioritize practicing interventions to prevent this complication, which resource-limited health institutions are unequipped to do and consequently have significant adverse patient outcomes.

Biologically inspired gastrointestinal stapler design: "Getting to Zero" complications

As next generation stapling devices enter the marketplace with robotic adaptations, tri-staple technology, preloaded reinforcement materials, etc., in this perspective piece we assert that a "refresh" in our understanding of the mechanisms of action of these devices is needed. While much attention has been paid to explain the mechanical features of one device versus another, it seems that little to no attention is being paid to understand how an intestinal anastomosis responds biologically to the variations in their use and design. Here we will review various aspects of gastrointestinal stapling in the context of emerging technology in the field and expose the gaps in knowledge that exist regarding the effect of gastrointestinal stapling on the biology of healing.

Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery

BACKGROUND

Surgery is the cornerstone in curative treatment of colorectal cancer. Unfortunately, surgery itself can adversely affect patient health. 'Enhanced Recovery After Surgery' programmes, which include multimodal interventions, have improved patient outcomes substantially. However, these are mainly applied peri- and postoperatively. Multimodal prehabilitation includes multiple preoperative interventions to prepare patients for surgery with the aim of increasing resilience, thereby improving postoperative outcomes.

OBJECTIVES

To determine the effects of multimodal prehabilitation programmes on functional capacity, postoperative complications, and quality of life in adult patients undergoing surgery for colorectal cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and PsycINFO in January 2021. We also searched trial registries up to March 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adult patients with non-metastatic colorectal cancer, scheduled for surgery, comparing multimodal prehabilitation programmes (defined as comprising at least two preoperative interventions) with no prehabilitation. We focused on the following outcomes: functional capacity (i.e. 6-minute walk test, VO2peak, handgrip strength), postoperative outcomes (i.e. complications, mortality, length of hospital stay, emergency department visits, re-admissions), health-related quality of life, compliance, safety of prehabilitation, and return to normal activities.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data, assessed risk of bias and used GRADE to assess the certainty of the evidence. Any disagreements were solved with discussion and consensus. We pooled data to perform meta-analyses, where possible.

MAIN RESULTS

We included three RCTs that enrolled 250 participants with non-metastatic colorectal cancer, scheduled for elective (mainly laparoscopic) surgery. Included trials were conducted in tertiary care centres and recruited patients during periods ranging from 17 months to 45 months. A total of 130 participants enrolled in a preoperative four-week trimodal prehabilitation programme consisting of exercise, nutritional intervention, and anxiety reduction techniques. Outcomes of these participants were compared to those of 120 participants who started an identical but postoperative programme. Postoperatively, prehabilitation may improve functional capacity, determined with the 6-minute walk test at four and eight weeks (mean difference (MD) 26.02, 95% confidence interval (CI) -13.81 to 65.85; 2 studies; n = 131; and MD 26.58, 95% CI -8.88 to 62.04; 2 studies; n = 140); however, the certainty of evidence is low and very low, respectively, due to serious risk of bias, imprecision, and inconsistency. After prehabilitation, the functional capacity before surgery improved, with a clinically relevant mean difference of 24.91 metres (95% CI 11.24 to 38.57; 3 studies; n = 225). The certainty of evidence was moderate due to downgrading for serious risk of bias. The effects of prehabilitation on the number of complications (RR 0.95, 95% CI 0.70 to 1.29; 3 studies; n = 250), emergency department visits (RR 0.72, 95% CI 0.39 to 1.32; 3 studies; n = 250) and re-admissions (RR 1.20, 95% CI 0.54 to 2.65; 3 studies; n = 250) were small or even trivial. The certainty of evidence was low due to downgrading for serious risk of bias and imprecision. The effects on VO2peak, handgrip strength, length of hospital stay, mortality rate, health-related quality of life, return to normal activities, safety of the programme, and compliance rate could not be analysed quantitatively due to missing or insufficient data. The included studies did not report a difference between groups for health-related quality of life and length of hospital stay. Data on remaining outcomes were not reported or were reported inadequately in the included studies.

AUTHORS' CONCLUSIONS

Prehabilitation may result in an improved functional capacity, determined with the 6-minute walk test both preoperatively and postoperatively. A solid effect on the number of omplications, postoperative emergency department visits and re-admissions could not be established. The certainty of evidence ranges from moderate to very low, due to downgrading for serious risk of bias, imprecision and inconsistency. In addition, only three heterogeneous studies were included in this review. Therefore, the findings of this review should be interpreted with caution. Numerous relevant RCTs are ongoing and will be included in a future update of this review.

Surgical and non-surgical complications after colorectal cancer surgery in older patients; time-trends and age-specific differences

BACKGROUND

Trends of surgical and non-surgical complications among the old, older and oldest patients after colorectal cancer (CRC) surgery could help to identify the best target outcome to further improve postoperative outcome.

MATERIALS AND METHODS

All consecutive patients ≥70 years receiving curative elective CRC resection between 2011 and 2019 in The Netherlands were included. Baseline variables and postoperative complications were prospectively collected by the Dutch ColoRectal audit (DCRA). We assessed surgical and non-surgical complications over time and within age categories (70-74, 75-79 and ≥ 80 years) and determined the impact of age on the risk of both types of complications by using multivariate logistic regression analyses.

RESULTS

Overall, 38648 patients with a median age of 76 years were included. Between 2011 and 2019 the proportion of ASA score ≥3 and laparoscopic surgery increased. Non-surgical complications significantly improved between 2011 (21.8%) and 2019 (17.1%) and surgical complications remained constant (from 17.6% to 16.8%). Surgical complications were stable over time for each age group. Non-surgical complications improved in the oldest two age groups. Increasing age was only associated with non-surgical complications (75-79 years; OR 1.17 (95% CI 1.10-1.25), ≥80 years; OR 1.46 (95% CI 1.37-1.55) compared to 70-74 years), not with surgical complications.

CONCLUSION

The reduction of postoperative complications in the older CRC population was predominantly driven by a decrease in non-surgical complications. Moreover, increasing age was only associated with non-surgical complications and not with surgical complications. Future care developments should focus on non-surgical complications, especially in patients ≥75 years.

Impact of a digital surgical workflow including Digital Device Briefing Tool on morbidity and mortality in a patient population undergoing primary stapled colorectal anastomosis for benign or malignant colorectal disease: protocol for a multicentre prospective cohort study

INTRODUCTION

With growing emphasis on surgical safety, it appears fundamental to assess the safety of colorectal resection involving primary stapled anastomosis. Surgical stapling devices can considerably foster patient safety in colorectal surgery, but their misuse or malfunction encompass a unique risk of postoperative complications. The Digital Device Briefing Tool (DDBT) is a digital cognitive aid developed to enhance safe use of the Ethicon circular stapling device during colorectal resection. The purpose of this study is to evaluate how a digital operative workflow, including DDBT, compared with routine surgical care, affects morbidity and mortality in patients undergoing left-sided colorectal resection with primary stapled colorectal anastomosis for colorectal cancer or benign disease.

METHODS AND ANALYSIS

A multicentre, prospective cohort study will be conducted at five certified academic colorectal centres in Germany. It compares a non-digital with a Johnson & Johnson digital solution (Surgical Process Institute Deutschland (SPI))-guided operative workflow in patients undergoing left hemicolectomy, sigmoidectomy, anterior rectal resection and Hartmann reversal procedure. The sample size is set at 528 cases in total, divided into 3 groups (a non-digital and two SPI-guided workflow cohorts, with and without DDBT) in a ratio of 1:1:1, with 176 patients each. The primary endpoint is a composite outcome comprising the overall rate of surgical complications, including death, during hospitalisation and within the first 30 days after colorectal resection. Secondary endpoints include operating time, length of hospital stay and 30-day hospital readmission rate.

ETHICS AND DISSEMINATION

This study will be performed in line with the Declaration of Helsinki. The ethics committee of the Charité-University Medicine Berlin, Germany, approved the study (No: 22-0277-EA2/060/22). Study Investigators will obtain written informed consent from each patient before a patient may participate in this study. The study results will be submitted to an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

DRKS00029682.

Enhanced recovery pathway in open and minimally invasive colorectal cancer surgery: a prospective study on feasibility, compliance, and outcomes in a high-volume resource limited tertiary cancer center

BACKGROUND

Enhanced recovery program (ERP) has demonstrated improved postoperative outcomes with increased compliance to pathway. However, there is scarce data on feasibility and safety in resource limited setting. The objective was to assess compliance with ERP and its impact on postoperative outcomes and return to intended oncological treatment (RIOT).

METHODS

A single center prospective observational audit was conducted from 2014 to 2019, in elective colorectal cancer surgery. Before implementation, multi-disciplinary team was educated regarding ERP. Compliance to ERP protocol and its elements was recorded. Impact of quantum of compliance (≥80% vs. <80%) to ERP on postoperative morbidity, mortality, readmission, stay, re-exploration, functional GI recovery, surgical-specific complications, and RIOT was evaluated for open and minimal invasive surgery (MIS).

RESULTS

During study, 937 patients underwent elective colorectal cancer surgery. Overall compliance with ERP was 73.3%. More than 80% compliance was observed in 332 (35.4%) patients in the entire cohort. Patients with <80% compliance had significantly higher overall, minor and surgery-specific complications, longer postoperative stay, delayed functional GI recovery for both open and MIS procedures. RIOT was observed in 96.5% patients. Duration to RIOT was significantly shorter following open surgery with ≥80% compliance. Compliance <80% to ERP was identified as one of the independent predictors for developing postoperative complications.

CONCLUSION

The study demonstrates beneficial impact of increased compliance to ERP on postoperative outcomes following open and minimally invasive surgery for colorectal cancer. Within a resource limited setting, ERP was found to feasible, safe, and effective in both open and minimally invasive colorectal cancer surgery.

Efficacy and Safety of Enhanced Recovery After Surgery Pathway in Minimally Invasive Colorectal Cancer Surgery: A Systemic Review and Meta-Analysis

Background: Enhanced recovery after surgery (ERAS) has been proven valuable for colorectal cancer (CRC) patients who received traditional surgery. While for those receiving minimally invasive surgery (MIS), its efficacy and safety remain debatable. Materials and Methods: Databases, including PubMed, EMBASE, Cochrane libraries, and Web of science, were searched for relevant articles from their inception to February 23, 2022. Eligible articles were subjected to quality assessment and data extraction. The comparison between ERAS and traditional care (TC) was performed. Primary outcomes of this study were postoperative length of stay (LOS), postoperative complications, and mortality. Secondary outcomes were 30-day readmission, 30-day reoperation, time to the first anal exhaust, and defecation. Results: Thirteen cohort studies covering 4308 patients were included. Patients in the ERAS group had significantly shorter LOS (weight mean differences [WMD]: -1.89; 95% confidence interval [CI]: -2.33 to -1.45; P < .001), lower incidence of postoperative complications (risk ratios [RR]: 0.73; 95% CI: 0.5-0.88; P < .001), lower 30-day readmission rate (RR: 0.75; 95% CI: 0.61-0.92; P < .05), and shorter time to the first defecation (WMD: -1.93; 95% CI: -3.26 to -0.59; P < .001), but unimproved mortality, reoperation rate, and time to the first anal exhaust (P > .05) compared with those in the TC group. Conclusions: ERAS was effective and safe for CRC patients receiving MIS from a real-world perspective. Hence, the implementation of ERAS should be recommended for minimally invasive CRC surgery. Clinical Trial Registration Number: CRD42022321333.