The impact of obesity on perioperative outcomes after laparoscopic colorectal resection. Ann Surg. 2012;255:228-236. [PMID: 22190113 DOI: 10.1097/sla.0b013e31823dcbf7]

Comparison of short‑ and long‑term outcomes between laparoscopic and open pancreaticoduodenectomy in overweight patients: a propensity score‑matched study

BACKGROUND

Overweight is thought to affect the outcome of minimally invasive surgery. There is still a lack of controlled studies of laparoscopic pancreaticoduodenectomy (LPD) versus open pancreaticoduodenectomy (OPD) in overweight patients. This study was designed to compare short-term and long-term outcomes in overweight patients treated with LPD and OPD.

METHODS

Clinical and follow-up data on overweight patients who received LPD or OPD at Shandong Provincial Hospital from January 2015 to December 2022 were analyzed retrospectively. The bias between groups were balanced by 1:1 propensity score matching (PSM). Kaplan-Meier survival curves described long-term survival outcomes in overweight pancreatic ductal adenocarcinoma (PDAC) patients.

RESULTS

A total of 502 overweight patients were enrolled in the study. There were 276 patients in the LPD group and 226 in the OPD group. After matching, 196 patients were enrolled in each group. Compared with the OPD group, the LPD group had fewer estimated blood loss (EBL) (140 vs. 200 mL, P < 0.001), more lymph node dissection (14 vs. 12, P = 0.010), and shorter postoperative length of stay (LOS) (13 vs. 16 days, P < 0.001). There were no significant differences in severe complications, 90-day readmission and mortality rates (all P > 0.05). The subgroup analysis of obese patients also showed that the LPD group had fewer intraoperative EBL, more lymph node dissection, and shorter LOS. The survival analysis showed that overweight patients with PDAC who underwent LPD or OPD had similar overall survival (OS) (23.8 vs.25.7 months, P = 0.963) after PSM.

CONCLUSION

It is safe and feasible for overweight patients undergoing LPD to have less EBL, more lymph node harvesting, and a shorter LOS. There was no statistically significant difference in long-term survival outcomes among overweight PDAC patients between the two approaches.

Influence of BMI on robotic rectal cancer surgery: a systematic review and meta-analysis

Obesity presents a significant public health challenge, known to escalate the risk of colorectal cancer twofold. The potential advantages of employing robotic technology in colorectal surgery for obese individuals remain mostly unexplored. A comprehensive search of articles retrieved from Scopus, PubMed, and the Cochrane Library for the duration of January 2014 to March 2024 was performed, without language limitations. Meta-analysis was conducted in accordance with PRISMA guidelines. The study compared results of robotic rectal cancer resections in obese patients (BMI ≥ 30 kg/m2) with those in non-obese counterparts. Out of 2410 full-text articles studied, 7 met the inclusion criteria and underwent final analysis. The study included 963 non-obese and 371 obese patients. Operative time produce significant variance in non-obese patients. However, DRM, CRM, HLN, length of hospital stays, conversion rate, and overall complications did not show any statistically significant differences. Robotic surgery for rectal cancer had no clinically significant influence in obese group patients, and postoperative complications are same as in non-obese group except duration of surgery.

Morbid obesity among Crohn's disease patients is on the rise and is associated with a higher rate of surgical complications after ileocolic resection

AIM

Crohn's disease (CD) is regarded as a wasting disease, yet there is a growing population of CD patients with a body mass index (BMI) of 35 and above. The rate of postoperative complications is relatively high in CD patients but might be even higher in CD with morbid obesity (MO).

METHODS

This was a retrospective study using a prospectively maintained database of all patients undergoing Ileocolic resection for CD between 2014 and 2021 in two referral centres, comparing postoperative complication rates according to BMI.

RESULTS

Three hundred and forty-six patients were identified. Sixty patients (17%) had a BMI over 30 kg/m2, and 28 (8.1%) had a BMI of over 35 kg/m2 (>35 group). The BMI >35 group had more women (78.6% vs. 52%, P < 0.1), a higher rate of patients not receiving an anastomosis (7.1% vs. 2.5%, P = 0.02), a higher rate of any postoperative surgical complication (32.1% vs. 25.2%, P = 0.4), with a higher rate of Clavien-Dindo ≥3 (14.3% vs. 7.2%, P = 0.25), a higher rate of stoma creation on reoperation for complications (7.2% vs. 1.7%, P = 0.04), a higher rate of 30-day readmission due to intra-abdominal abscess (10.7% vs. 4.7%, P = 0.2), but a lower rate of postoperative medical complications (3.6% vs. 15.7%, P < 0.01).

CONCLUSIONS

The rate of MO among CD patients requiring ileocolonic resection is on the rise. MO in this setting is associated with statistically non-significant increases in all surgical complications, severe complications, readmission, and a higher chance for a bailout stoma creation upon reoperation. However, MO seems to be a protective factor for medical postoperative complications, which might suggest better nutritional status.

Risk factors for postoperative complications in patients undergoing cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy: A meta-analysis and systematic review

OBJECTIVE

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is one of the most effective treatments for intraperitoneal malignancies. However, current research on risk factors for postoperative complications needs to be more consistent. This study aimed to conduct a meta-analysis of the risk factors for postoperative complications in CRS + HIPEC patients.

METHODS

Studies meeting the inclusion criteria were screened by searching the Embase, PubMed, Cochrane and Web of Science databases. RevMan and STATA software were used to analyze the data extracted from the included articles.

RESULTS

A total of 15 articles with 4021 patients were included in the meta-analysis. The results revealed that sex, elevated peritoneal cancer index, prolonged duration of surgery and smoking habits were risk factors for postoperative complications in CRS + HIPEC patients. In contrast, BMI, eGFR, age, history of preoperative chemotherapy, history of preoperative surgery, and history of neoadjuvant therapy had no significant effect on postoperative complications in the CRS + HIPEC group. The effects of diabetes, hypertension, preoperative albumin level, tumor location and chemotherapy regimen on the occurrence of complications need to be further investigated.

CONCLUSIONS

We identified several risk factors for postoperative complications after CRS + HIPEC, which should help clinicians minimize the incidence of postoperative complications and make more beneficial decisions for cancer patients who need treatment.

Bariatric Surgery as a Bridge to a Successful Kidney Transplantation: A Case Report

BACKGROUND

Severe obesity impairs renal function and outcomes in kidney transplant recipients. Bariatric surgery benefits those unresponsive to medical treatments. Limited case reports exist on its efficacy and long-term prognosis for transplant candidates. Thus, this study aims to present a case in which laparoscopic sleeve gastrectomy was safely performed on a patient with severe obesity awaiting kidney transplantation.

CASE PRESENTATION

This study included a dialysis patient with a body mass index of 47 kg/m2. Living-donor kidney transplantation using his younger sister as a donor was considered, but it was determined that the risk of complications during and after surgery was high. Medical treatment was first performed, but the obesity did not improve; therefore, a laparoscopic sleeve gastrectomy was performed. Although postoperative bleeding occurred, the patient was discharged from the hospital on the 14th postoperative day. Subsequently, his weight steadily decreased, and living-donor kidney transplantation was performed 13 months after laparoscopic sleeve gastrectomy was performed. Furthermore, the patient's progress after kidney transplantation was good, and he was freed from hemodialysis.

CONCLUSION

Improving severe obesity before kidney transplantation is effective in improving prognosis, and bariatric surgery should be considered when medical treatment is ineffective. Future research are needed to determine the optimal time between the performance of this procedure and kidney transplantation, as well as the long-term prognosis after kidney transplantation.

Risk factors analyses associated with postoperative infection in choledochoscopy for intrahepatic bile duct stones (IHDs): a single-center retrospective study in real-world setting

BACKGROUND

Choledochoscopy is a highly effective approach for managing intrahepatic bile duct stones (IHDs). However, postoperative infection is a common complication that significantly impacts treatment outcomes. Despite its clinical relevance, the risk factors associated with this procedure remain largely unexplored.

METHODS

This study focused on a consecutive cohort of patients who underwent choledochoscopy for IHDs at our institution between January 2016 and December 2022. The primary objective was to analyze the relationship between various clinical factors and postoperative infection, and to compare the postoperative infection of different choledochoscopic procedures.

RESULTS

The study cohort consisted of 126 patients, with 60 individuals (47.6%) experiencing postoperative infection. Notably, preoperative biliary obstruction (odds ratio [OR] 1.861; 95% confidence interval [CI] 1.314-8.699; p = 0.010) and operation time (OR 4.414; 95% CI 1.635-12.376; p = 0.004) were identified as risk factors for postoperative infection. Additionally, biliary tract infections (60.00%) were primarily responsible for postoperative infection, with Escherichia coli (47.22%) being the predominant bacterial strain identified in bile cultures. Furthermore, biliary tract obstruction (OR 4.563; 95% CI 1.554-13.401; p = 0.006) and body mass index (BMI) (OR 1.186; 95% CI 1.015-1.386; p = 0.031) were determined to be independent risk factors for postoperative biliary tract infection.

CONCLUSIONS

The occurrence of postoperative infection in patients undergoing choledochoscopy was primarily associated with the duration of the operation and the presence of preoperative biliary obstruction.

Pelvic Floor Peritoneum Closure Reduces Severe Postoperative Complications in Rectal Cancer Patients After Laparoscopic Anterior Rectal Resection

BACKGROUND

Laparoscopic anterior rectal resection (LAR) is a commonly performed surgery for rectal cancer patients. Pelvic floor peritoneum closure (PC), a vital procedure in conventional anterior rectal resection, is not routinely performed in LAR.

STUDY DESIGN

A total of 1118 consecutive patients with rectal cancer receiving LAR were included in this retrospective study. Patients were allocated into the PC group and the non-PC group. The occurrence of postoperative complications was compared between the 2 groups. Influential factors in anastomotic leakage (AL) were explored using univariate and multivariate logistic regression.

RESULTS

There was no difference between the groups in terms of baseline characteristics. The occurrence of postoperative complications was similar between the groups. The PC group had significantly shorter postoperative hospitalization and longer operation duration compared with the non-PC group. The occurrences of Clavien-Dindo (CD) III-IV complications, CD III-IV AL, and reoperation were significantly lower in the PC group than the non-PC group. PC and a protective ileostomy were independent protective factors for CD III-IV AL.

CONCLUSION

PC could reduce the occurrence of CD III-IV complications, especially CD III-IV AL, and the rate of secondary surgery, especially in patients with a lower body mass index and patients who did not receive protective ileostomies.

Evaluating body mass index's impact on Da Vinci Robotic rectal cancer surgery, a retrospective study

Robotic surgery addresses laparoscopic shortcomings and yields comparable results for low and high body mass index (BMI) patients. However, the impact of BMI on postoperative complications in robotic colorectal surgery remains debated. This study assessed the implications of BMI on short outcomes and postoperative complications, highlighting its unique role in the outcomes. Retrospective analysis of 119 patients who underwent robotic-assisted surgery for rectal cancer (January 2022 to March 2023). Patients grouped by BMI: normal weight (BMI < 23.9 kg/m2), overweight (BMI ≥ 23.9 kg/m2 and BMI < 27.9 kg/m2), and obese (BMI ≥ 27.9 kg/m2). Investigated BMI's impact on surgical outcomes and postoperative complications. Statistically significant differences (P < 0.05) in Clavien-Dindo, ASA scores. The obese group had a longer time to flatus (P = 0.002) and a higher re-operation rate than other groups (P = 0.01). The overweight group had a higher anastomotic fistula rate than the obese group. Overall complications showed no significant differences among BMI cohorts (P = 0.0295). There were no significant differences in TNM stages and comorbidities. BMI had no significant impact on overall postoperative complications in robotic surgery for rectal cancer. However, higher BMI correlated with a longer time to flatus and increased re-operation rate.

Clinical impact of sarcopenia for overweight or obese patients with colorectal cancer

BACKGROUND

Sarcopenia, overweight and obesity are all dynamic changes in body composition, which may have a negative effect on the prognosis for patients with colorectal cancer. The aim of this study was to investigate the predictive role of sarcopenia on overweight or obese patients with colorectal cancer.

METHODS

We conducted an observative study on the population of overweight or obese patients with colorectal cancer who underwent curative surgeries in two centers between 2015 and 2021. They were grouped by the presence of sarcopenia. Propensity score match analysis was used to balance the baseline of clinicopathologic characteristics of the two groups. Then, the postoperative outcomes between the two groups were compared. Independent risk factors were evaluated for complications using univariate and multivariate analysis.

RESULTS

Of 827 patients enrolled, 126 patients were matched for analysis. Patients with sarcopenia had a higher incidence of total complication and medical complications, a higher rate of laparoscopic surgery performed and higher hospitalization costs. Old age (≥65 years, P = 0.012), ASA grade (III, P = 0.008) and sarcopenia (P = 0.036) were independent risk factors for total complications. ASA grade (III, P = 0.002) and sarcopenia (P = 0.017) were independent risk factors for medical complications.

CONCLUSIONS

Sarcopenia was prevalent among overweight or obese patients with colorectal cancer and was associated with negative postoperative outcomes. Early recognition of changes in body composition could help surgeons be well prepared for surgical treatment for overweight or obese patients.

A meta-analysis of the risk factors for surgical site infection in patients with colorectal cancer

The purpose of the meta-analysis was to evaluate and compare the surgical site infection (SSI) risk factors in patients with colorectal cancer (CC). The results of this meta-analysis were analysed, and the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated using dichotomous or contentious random or fixed-effect models. For the current meta-analysis, 23 examinations spanning from 2001 to 2023 were included, encompassing 89 859 cases of CC. Clean-contaminated surgical site wounds had significantly lower infections (OR, 0.36; 95% CI, 0.20-0.64, p < 0.001) compared to contaminated surgical site wounds in patients with CCs. Males had significantly higher SSIs (OR, 1.18; 95% CI, 1.12-1.24, p < 0.001) compared to females in patients with CC. American Society of Anesthesiology score ≥3 h had a significantly higher SSI (OR, 1.42; 95% CI, 1.18-1.71, p < 0.001) compared to <3 score in patients with CCs. Body mass index ≥25 had significantly higher SSIs (OR, 1.54; 95% CI, 1.11-2.14, p = 0.01) compared to <25 in patients with CCs. The presence of stoma creation had a significantly higher SSI rate (OR, 2.28; 95% CI, 1.37-3.79, p = 0.001) compared to its absence in patients with CC. Laparoscopic surgery had significantly lower SSIs (OR, 0.68; 95% CI, 0.59-0.78, p < 0.001) compared to open surgery in patients with CC. The presence of diabetes mellitus had a significantly higher SSI rate (OR, 1.24; 95% CI, 1.15-1.33, p < 0.001) compared to its absence in patients with CCs. No significant difference was found in SSI rate in patients with CCs between <3 and ≥3 h of operative time (OR, 1.07; 95% CI, 0.75-1.51, p = 0.72), between the presence and absence of blood transfusion (OR, 1.60; 95% CI, 0.69-3.66, p = 0.27) and between the presence and absence of previous laparotomies (OR, 1.47; 95% CI, 0.93-2.32, p = 0.10). The examined data revealed that contaminated wounds, male sex, an American Society of Anesthesiology score ≥3 h, a body mass index ≥25, stoma creation, open surgery and diabetes mellitus are all risk factors for SSIs in patients with CC. However, operative time, blood transfusion and previous laparotomies were not found to be risk factors for SSIs in patients with CC. However, given that several comparisons had a small number of chosen research, consideration should be given to their values.

Impact of laparoscopic surgery on short-term and long-term outcomes in elderly obese patients with colon cancer

Background

Laparoscopic surgery is reported to be useful in obese or elderly patients with colon cancer, who are at increased risk of postoperative complications because of comorbidities and physical decline. However, its usefulness is less clear in patients who are both elderly and obese and may be at high risk of complications.

Methods

Data for obese patients (body mass index ≥25) who underwent laparoscopic or open surgery for stage II or III colon cancer between January 2009 and December 2013 were collected by the Japan Society of Laparoscopic Colorectal Surgery. Surgical outcomes, postoperative complications, and relapse-free survival (RFS) were compared between patients who underwent open surgery and those who underwent laparoscopic surgery according to whether they were elderly (≥70 y) or nonelderly (<70 y).

Results

Data of 1549 patients (elderly, n = 598; nonelderly, n = 951) satisfied the selection criteria for analysis. Length of stay was shorter and surgical wound infection was less common in elderly obese patients who underwent laparoscopic surgery than in those underwent open surgery. There were no significant between-group differences in overall complications, anastomotic leakage, ileus/small bowel obstruction, or RFS. There were also no significant differences in RFS after laparoscopic surgery according to patient age.

Conclusion

Laparoscopic surgery is safe in elderly obese patients with colon cancer and does not worsen their prognosis. There was no significant difference in the effectiveness of laparoscopic surgery between obese patients who were elderly and those who were nonelderly.

[Obesity and Colorectal Cancer]

The prevalence of obesity has increased significantly worldwide, and this trend is likely to continue in the coming years. There is substantial evidence that obesity plays a crucial role in the development of colorectal cancer. Epidemiological data have consistently demonstrated a correlation between obesity and colorectal cancer. Insulin resistance, hyperinsulinemia, chronic inflammation, altered levels of growth factors, adipocytokines, and various hormones are plausible biological mechanisms. In addition, obesity has been shown to have an impact on recurrence, treatment success, and overall survival. There are some reports, although the evidence is not conclusive, that weight loss and lifestyle changes such as dietary modification and physical activity can reduce the risk of colorectal cancer. The understanding that obesity is a potentially modifiable risk factor that can affect the incidence and prognosis of colorectal cancer is crucial knowledge that can have an impact on the prevention and treatment of the condition.

The association between obesity and postoperative outcomes in a broad surgical population: A 7-year American College of Surgeons National Surgical Quality Improvement analysis

BACKGROUND

The number of obese surgical patients continues to grow, and yet obesity's association with surgical outcomes is not totally clear. This study examined the association between obesity and surgical outcomes across a broad surgical population using a very large sample size.

METHODS

This was an analysis of the 2012 to 2018 American College of Surgeons National Surgical Quality Improvement database, including all patients from 9 surgical specialties (general, gynecology, neurosurgery, orthopedics, otolaryngology, plastics, thoracic, urology, and vascular). Preoperative characteristics and postoperative outcomes were compared by body mass index class (normal weight 18.5-24.9 kg/m², overweight 25.0-29.9, obese class I 30.0-34.9, obese II 35.0-39.9, obese III ≥40). Adjusted odds ratios were computed for adverse outcomes by body mass index class.

RESULTS

A total of 5,572,019 patients were included; 44.6% were obese. Median operative times were marginally higher for obese patients (89 vs 83 minutes, P < .001). Compared to normal weight patients, overweight and obese patients in classes I, II, and III all had higher adjusted odds of developing infection, venous thromboembolism, and renal complications, but they did not exhibit elevated odds of other postoperative complications (mortality, overall morbidity, pulmonary, urinary tract infection, cardiac, bleeding, stroke, unplanned readmission, or discharge not home (except for class III patients).

CONCLUSION

Obesity was associated with increased odds of postoperative infection, venous thromboembolism, and renal but not the other American College of Surgeons National Surgical Quality Improvement complications. Obese patients need to be carefully managed for these complications.

Impact of obesity on morbidity and oncologic outcomes after total mesorectal excision for mid and low rectal cancer

BACKGROUND

A recent meta-analysis showed that obesity increased the conversion rate and postoperative morbidity of rectal cancer surgery, but did not influence pathological results. However, this meta-analysis included patients with cancer of the upper rectum and had many biases. The aim of the present retrospective study was to investigate the impact of obesity, defined as a body mass index (BMI) ≥ 30 kg/m², on postoperative morbidity and short- and long-term oncologic outcomes of total mesorectal excision for mid and low rectal cancer in consecutive patients.

METHODS

This study included all eligible patients who were operated on for mid and lower rectal cancer between 1999 and 2018 in our hospital. We compared 90-day postoperative morbidity and mortality, and short- and long-term oncologic outcomes between obese and non-obese patients.

RESULTS

Three hundred and ninety patients [280 males, mean age 65.7 ± 11.3 years, 59 obese individuals (15.1%)] were included. There was no difference in the 90-day mortality rate between obese and non-obese groups (p = 0.068). There was a difference in the overall 90-day morbidity rate between the obese and non-obese groups that disappeared after propensity score matching of the patients. There was no difference in short-term oncological parameters, with a median follow-up of 43 (20-84) months, and there were no significant differences in disease-free and overall survival between obese and non-obese patients (p = 0.42 and p = 0.11, respectively).

CONCLUSIONS

Obesity does not affect the 90-day morbidity rate, or short- and long-term oncologic results in patients operated on for mid and lower rectal cancer.

Surgeons' workload assessment during indocyanine-assisted deep endometriosis surgery using the surgery task load index: The impact of the learning curve

Objective

Assess the surgeons' workload during deep endometriosis surgery after ureteral ICG

Design

Prospective, consecutive, comparative, single-center study

Population

41 patients enrolled to deep endometriosis surgery with ureteral ICG from January 2019 to July 2021 at La Paz University Hospital

Methods

Patients were divided into 2 groups: patients operated during the learning curve of ureteral ICG instillation and patients operated after the technique was implemented and routinely performed. After surgery, the SURG-TLX form was completed by the surgeons. We evaluated whether a workload reduction occurred.

Main outcomes measures

Surgeon's workload was measured using the SURG-TLX form, obtaining the total workload and 6 different dimensions (distractions, temporal demands, task complexity, mental demands, situational stress and physical demands)

Results

A significant positive correlation was found between surgical complexity and situational stress (p = 0.04). Mental demands (p = 0.021), physical demands (p = 0.03), and total workload (p = 0.025) were significantly lower when the technique was routinely performed. The mental demand, physical demands, and total workload perceived by the surgeons at the beginning of the implementation was higher (68 [39–72], 27 [11–46.5], 229 [163–240], respectively) than in the latter ones (40 [9–63], 11.5 [0–32.8], 152 [133.3–213.8], respectively). Distractions appeared to be higher in the latter surgeries (8.5 [0–27.8]) than in the first surgeries (0 [0–7]; p = 0.057).

Conclusions

Ureter ICG instillation prior to DE surgery significantly reduces the mental and physical demands and total workload of the surgeons in DE surgeries after overcoming the learning curve. Distractions appear to increase as surgical stress decreases.

Bariatric Surgery in Patients With Inflammatory Bowel Disease: A Case-Control Study from the GETAID

BACKGROUND

The prevalence of obesity and the number of bariatric surgeries in both the general population and in patients with inflammatory bowel disease (IBD) have increased significantly in recent years. Due to small sample sizes and the lack of adequate controls, no definite conclusions can be drawn from the available studies on the safety and efficacy of bariatric surgery (BS) in patients with IBD. Our aim was to assess safety, weight loss, and deficiencies in patients with IBD and obesity who underwent BS and compare findings to a control group.

METHODS

Patients with IBD and a history of BS were retrospectively recruited to centers belonging to the Groupe d'Etude Thérapeutique des Affections Inflammatoires du Tube Digestif (GETAID). Patients were matched 1:2 for age, sex, body mass index (BMI), hospital of surgery, and type of BS with non-IBD patients who underwent BS. Complications, rehospitalizations, weight, and deficiencies after BS were collected in cases and controls.

RESULTS

We included 88 procedures in 85 patients (64 Crohn's disease, 20 ulcerative colitis, 1 unclassified IBD) with a mean BMI of 41.6 ± 5.9 kg/m2. Bariatric surgery included Roux-en-Y gastric bypass (n = 3), sleeve gastrectomy (n = 73), and gastric banding (n = 12). Eight (9%) complications were reported, including 4 (5%) requiring surgery. At a mean follow-up of 34 months, mean weight was 88.6 ± 22.4 kg. No difference was observed between cases and controls for postoperative complications (P = .31), proportion of weight loss (P = .27), or postoperative deficiencies (P = .99).

CONCLUSIONS

Bariatric surgery is a safe and effective procedure in patients with IBD and obesity; outcomes in this patient group were similar to those observed in a control population.

Review article: obesity and colorectal cancer

BACKGROUND

Obesity is a growing global public health problem. More than half the European and North American population is overweight or obese. Colon and rectum cancers are still the second leading cause of cancer death worldwide, and epidemiological data support an association between obesity and colorectal cancers (CRCs).

AIM

To review the literature on CRC epidemiology in obese subjects, assessing the effects of obesity, including childhood or maternal obesity, on CRC, diagnosis, management, and prognosis, and discussing targeted prophylactic measures.

METHOD

We searched PubMed for obesity/overweight/metabolic syndrome and CRC. Other key words included 'staging', 'screening', 'treatment', 'weight loss', 'bariatric surgery' and 'chemotherapy'.

RESULTS

In Europe, about 11% of CRCs are attributed to overweight and obesity. Epidemiological data suggest that obesity is associated with a 30%-70% increased risk of colon cancer in men, the association being less consistent in women. Visceral fat or abdominal obesity seems to be of greater concern than subcutaneous fat obesity, and any 1 kg/m² increase in body mass index confers more risk (hazard ratio 1.03). Obesity might increase the likelihood of recurrence or mortality of the primary cancer and may affect initial management, including accurate staging. The risk maybe confounded by different factors, including lower adherence to organised CRC screening programmes. It is unclear whether bariatric surgery helps reduce rectal cancer risk.

CONCLUSIONS

Despite a growing body of evidence linking obesity to CRC, many questions remain unanswered, including whether we should screen patients with obesity earlier or propose prophylactic bariatric surgery for certain patients with obesity.

Laparoscopic surgery using 8 K ultra-high-definition technology: Outcomes of a phase II study

INTRODUCTION

Currently, laparoscopic surgery generally relies on 2 K high-definition image quality. The National Cancer Center Hospital, Olympus Corporation, and NHK Engineering System Inc. recently developed a new laparoscopic system with an 8 K ultra-high-definition (UHD) camera that provides images with a high-resolution, wide color range, high frame rate, and high dynamic range. This study aimed to investigate the effectiveness and safety of a new laparoscopic system which uses an 8 K UHD camera system (8K UHD system).

METHODS

This phase II study enrolled 23 patients with colon or rectosigmoid cancer who were indicated for radical resection with laparoscopic colectomy using the 8 K UHD system. The primary endpoint was the proportion of patients with ≥30 mL of intraoperative blood loss.

RESULTS

Of the 23 patients, 22 completed laparoscopic surgery with the 8 K UHD system. One patient was converted to the 2 K high-definition laparoscopic system due to technical difficulties with the 8 K UHD system during surgery. The median amount of intraoperative blood loss was 14 mL (range, 2-71 mL), and number of patients with intraoperative blood loss ≥30 mL was four (17.4%). None of the patients had >100 mL of intraoperative blood loss. No intraoperative complications were noted, and four (17.4%) patients developed postoperative complications. Pathological complete resection was achieved in all patients, and no conversion to open surgery was required.

CONCLUSIONS

Laparoscopic surgery using the 8 K UHD system appears to be both safe and effective. However, further refinements may be necessary to improve usability.

Risk factors for surgical site infection in patients undergoing colorectal surgery: A meta-analysis of observational studies

OBJECTIVE

Surgical site infection (SSI) is the second most prevalent hospital-based infection and affects the surgical therapeutic outcomes. However, the factors of SSI are not uniform. The main purpose of this study was to understand the risk factors for the different types of SSI in patients undergoing colorectal surgery (CRS).

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched using the relevant search terms. The data extraction was independently performed by two investigators using a standardized format, following the pre-agreed criteria. Meta-analysis for the risk factors of SSI in CRS patients was carried out using Review Manager 5.3 (RevMan 5.3) and Stata 15.1 software. The quality of evidence was evaluated using total sample size, Egger's P-value, and intergroup heterogeneity, which contained three levels: high-quality (Class I), moderate-quality (Class II/III), and low-quality (Class IV). The publication bias of the included studies was assessed using funnel plots, Begg's test, and Egger's test.

RESULTS

Of the 2660 potentially eligible studies, a total of 31 studies (22 retrospective and 9 prospective cohort studies) were included in the final analysis. Eventually, the high-quality evidence confirmed that SSI was correlated with obesity (RR = 1.60, 95% confidence interval (CI): 1.47-1.74), ASA score ≥3 (RR = 1.34, 95% CI: 1.19-1.51), and emergent surgery (RR = 1.36, 95% CI: 1.19-1.55). The moderate-quality evidence showed the correlation of SSI with male sex (RR = 1.30, 95% CI: 1.14-1.49), diabetes mellitus (RR = 1.65, 95% CI: 1.24-2.20), inflammatory bowel disease (RR = 2.12, 95% CI: 1.24-3.61), wound classification >2 (RR = 2.65, 95% CI: 1.52-4.61), surgery duration ≥180 min (RR = 1.88, 95% CI: 1.49-2.36), cigarette smoking (RR = 1.38, 95% CI: 1.14-1.67), open surgery (RR = 1.81, 95% CI: 1.57-2.10), stoma formation (RR = 1.89, 95% CI: 1.28-2.78), and blood transfusion (RR = 2.03, 95% CI:1.34-3.06). Moderate-quality evidence suggested no association with respiratory comorbidity (RR = 2.62, 95% CI:0.84-8.13) and neoplasm (RR = 1.24, 95% CI:0.58-2.26). Meanwhile, the moderate-quality evidence showed that the obesity (RR = 1.28, 95% CI: 1.24-1.32) and blood transfusion (RR = 2.32, 95% CI: 1.26-4.29) were independent risk factors for organ/space SSI (OS-SSI). The high-quality evidence showed that no correlation of OS-SSI with ASA score ≥3 and stoma formation. Furthermore, the moderate-quality evidence showed that no association of OS-SSI with open surgery (RR = 1.37, 95% CI: 0.62-3.04). The high-quality evidence demonstrated that I-SSI was correlated with stoma formation (RR = 2.55, 95% CI: 1.87-3.47). There were some certain publication bias in 2 parameters based on asymmetric graphs, including diabetes mellitus and wound classification >2. The situation was corrected using the trim and fill method.

CONCLUSIONS

The understanding of these factors might make it possible to detect and treat the different types of SSI more effectively in the earlier phase and might even improve the patient's clinical prognosis. Evidence should be continuously followed up and updated, eliminating the potential publication bias. In the future, additional high-level evidence is required to verify these findings.

Impact of obesity on short-term outcomes of laparoscopic colorectal surgery for Japanese patients with colorectal cancer: A multicenter study

INTRODUCTION

The impact of obesity on short-term outcomes after laparoscopic colorectal surgery (LAC) in Asian patients is unclear. The purpose of the present multicenter study was to evaluate the safety and feasibility of LAC in obese Japanese patients.

METHODS

We retrospectively reviewed 1705 patients who underwent LAC between April 2016 and February 2019. Patients were classified according to body mass index (BMI): non-obese (BMI < 25 kg/m² , n = 1335), obese I (BMI 25-29.9 kg/m² , n = 313), and obese II (BMI ≥30 kg/m² , n = 57). Clinical characteristics and surgical outcomes were compared among the three groups.

RESULTS

The proportion of patients with comorbidities (non-obese, 58.1%; obese I, 69.6%; obese II, 75.4%; P < .001) and median operation time (non-obese, 224 minutes; obese I, 235 minutes; obese II, 258 minutes; P = .004) increased significantly as BMI increased. The conversion rate was similar among the groups (P = .715). Infectious complications were significantly high in obese II patients (non-obese, 10.4%; obese I, 8.3%; obese II, 28.1%; P < .001). Multivariate analysis revealed that in obese II patients, BMI was an independent predictive factor of infectious postoperative complications (odds ratio 2.648; 95% confidence interval, 1.421-4.934; P = .002).

CONCLUSION

LAC has an increased risk of postoperative infectious complications in obese II patients, despite improvements in surgical technique. Management of obese II colorectal cancer patients requires meticulous perioperative management.

Laparoscopic vs. Open Surgery for Stage II/III Colon Cancer Patients With Body Mass Index >25 kg/m2

AIM

To compare long- and short-term outcomes of laparoscopic surgery with those of open surgery for patients with colorectal cancer and body mass index over 25 kg/m² Patients and Methods: This multicentre, retrospective study analysed clinical records and identified 178 patients with body mass index over 25 kg/m² who underwent surgery for colon and rectosigmoid cancer between 2000 and 2016. After applying propensity score matching, 96 patients were finally included. The primary outcome was the 3-year recurrence-free survival rate, and the secondary outcomes were short-term results during and after surgery.

RESULTS

The 3-year recurrence-free survival rates were similar for the laparoscopic and open surgery groups. The laparoscopic surgery group had longer operative times but less blood loss and shorter periods of hospital stay. There were no differences in incidence of postoperative complications.

CONCLUSION

Laparoscopic and open surgeries had similar long-term outcomes for obese patients. Laparoscopic surgery is an effective option for this population.

The impact of body mass index on outcomes in robotic colorectal surgery: a single-centre experience

Obesity is an independent risk factor for postoperative morbidity and mortality in laparoscopic colorectal surgery (LCRS). The technological advantages of robotic colorectal surgery (RCRS) may allow surgeons to overcome the limitations of LCRS in obese patients, but it is largely unknown if this translates to superior outcomes. The aim of this study was to compare perioperative, postoperative and short-term oncological outcomes in obese (BMI ≥ 30.0 kg/m²) and non-obese (BMI < 30 kg/m²) patients undergoing RCRS in a university teaching hospital. Demographic, perioperative and postoperative data along with short-term oncological outcomes of obese and non-obese patients that underwent RCRS for both benign and malignant colorectal disease were identified from a prospectively maintained database. A total of 107 patients (34 obese, 73 non-obese) underwent RCRS over a 4-year period. No statistically significant differences in the incidence of complications, 30-day reoperation, 30-day mortality, conversion to open surgery, anastomotic leak or length of inpatient stay were demonstrated. Obese patients had a significantly higher rate of surgical site infection (SSI) (p < 0.0001). Short-term oncological outcomes in both groups were favourable. There was no statistically significant difference in median duration of surgery between the two cohorts. The results demonstrate that obese patients undergoing RCRS in this institution experience similar outcomes to non-obese patients. These results suggest that RCRS is safe and feasible in obese patients and may be superior to LCRS in this cohort, where the literature suggests a higher complication rate compared to non-obese patients. The inherent advantages of robotic surgical platforms, such as improved visualisation, dexterity and ergonomics likely contribute to the improved outcomes in this challenging patient population.

The Safety of Preoperative Amino Acid (Elental) Loading in Colon Cancer Surgery: Prospective Cohort Study

The aim of this prospective study was to evaluate the safety of preoperative amino acid plus carbohydrate drink (Elental) loading in colon cancer surgery. Prolonged preoperative fasting increases insulin resistance, and current evidence recommends carbohydrate drinks 2 hours before surgery. We prospectively enrolled consecutive patients with a preoperative diagnosis of colon cancer who underwent surgery. The patients received 600 mL of Elental the night before surgery and 300 mL of Elental 3 hours prior to induction of anesthesia. Primary end point was the safety of preoperative amino acid (Elental) loading in colon cancer surgery. Safety measurement was anastomotic leakage and aspiration pneumonia. Secondary end points were incidence rate of incisional surgical site infection, recovery of bowel movement, length of hospital stay, postoperative nutritional status, and insulin resistance. A total of 80 consecutive patients were enrolled in this study from February 2013 to January 2014. The incidence of anastomotic leakage was 3 patients (3.8%), and there was no aspiration pneumonia. The incidence of incisional surgical site infection was 2 patients (2.5%). The median times of first flatus, defecation after surgery, and postoperative hospital stay were 1 day, 2 days, and 6 days, respectively. The insulin resistance recovered to a preoperative level after 3 days after surgery. The preoperative amino acid plus carbohydrate drink (Elental) loading 3 hours prior to induction of anesthesia in colon cancer surgery is safe, and incisional surgical site infection rate and recovery of bowel movement and insulin resistance are feasible.

Variation in Hospital Utilization of Minimally Invasive Distal Pancreatectomy for Localized Pancreatic Neoplasms

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) for localized neoplasms has been demonstrated to be feasible and safe. However, national adoption of the technique is poorly understood. Objectives of this study were to identify factors associated with use of minimally invasive distal pancreatectomy for localized neoplasms and assess hospital variation in MIDP utilization.

METHODS

Retrospective cohort study of patients with pancreatic cysts, stage I pancreatic ductal adenocarcinoma, and stage I pancreatic neuroendocrine tumors undergoing distal pancreatectomy from the ACS NSQIP Pancreas Targeted Dataset. Factors associated with use of MIDP were identified using multivariable logistic regression and hospital-level variation was assessed.

RESULTS

Analysis included 3,059 patients at 139 hospitals. Overall, 64.5% of patients underwent minimally invasive distal pancreatectomy. Patients were more likely to undergo MIDP if they had lower ASA classification (P = 0.004) or BMI ≥ 30 (P < 0.001) and less likely if they had pancreatic adenocarcinoma (P < 0.001). There was notable hospital variability in utilization (range 0 to 100% of cases). Hospital-level utilization of minimally invasive distal pancreatectomy did not appear to be driven by patient selection, as hierarchical analysis demonstrated that only 1.8% of observed hospital variation was attributable to measured patient selection factors.

CONCLUSION

Utilization of MIDP for localized pancreatic neoplasms is highly variable. While some patient-level factors are associated with MIDP use, hospital adoption of MIDP appears to be the primary driver of utilization. Monitoring hospital-level use of MIDP may be a useful quality measure to monitor uptake of emerging techniques in pancreatic surgery.

Update on risk factors of surgical site infection in colorectal cancer: a systematic review and meta-analysis

OBJECTIVE

Surgical site infection (SSI) in colorectal cancer (CRC) has been a serious health care problem due to the delay of postoperative recovery. Our present study aimed to explore the risk factors for SSI in CRC patients.

METHODOLOGY

We have systematically searched these databases: PubMed, Cochrane Library, and EMBASE as of March 2020 for studies on risk factors associated with SSI. Two investigators independently conducted the quality assessment and data extraction. Related risk factors in the studies were recorded, and a meta-analysis was performed.

RESULTS

The search initially provided 2262 hits, 1913 studies were screened by two independent investigators. Finally, 15 studies were identified to be relevant for this meta-analysis. In total, 25 risk factors were eligible. Our meta-analysis indicated that eight factors (obesity, male sex, diabetes mellitus, ASA score ≥ 3, stoma creation, intraoperative complications, perioperative blood transfusion, and operation time ≥ 180 min) were significant risk factors for SSI, and one factor (laparoscopic procedure) was protective for SSI.

CONCLUSIONS

Effective interventions targeting the above factors may reduce the risk of developing postoperative SSI in CRC patients and improve the clinical outcome of patients. Further prospective studies are needed to confirm these findings.

Technical Approach to Laparoscopic Examination of the Small Bowel in Gallstone Ileus

Background

Gallstone ileus is an infrequent cause of small bowel obstructions (SBO), accounting for only 0.1-5% of SBOs and 25% of nonstrangulating causes of SBO in the elderly population. There is scant literature available regarding the use of laparoscopy to treat gallstone ileus. Currently, much of the literature available is limited to case reports only.

Methods

A complete laparoscopic approach was utilized to manage a 65-year-old woman with morbid obesity who presented with gallstone ileus. With regard to our technical approach, we describe the technical approach that facilitates safe laparoscopic examination of the entire small bowel and can be applied to other acute care surgery cases involving small bowel pathology.

Results

The patient's postoperative course was complicated by new-onset atrial fibrillation which was treated medically with good response. She was safely discharged on postoperative day 2.

Conclusion

Laparoscopy is a feasible option for the management of gallstone ileus and can lead to decreased morbidity compared to laparotomy. The technique described allows for laparoscopic examination of the entire small bowel.

Comparison of minimal invasive versus open radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic ductal adenocarcinoma: a single center retrospective study

INTRODUCTION

Radical antegrade modular pancreatosplenectomy (RAMPS) was proposed a decade ago with the aim to achieve higher R0 tangential margin and radical N1 lymph node resection for left-sided pancreatic adenocarcinoma (PDAC), which has been widely accepted worldwide at present. Laparoscopic RAMPS (Lap-RAMPS) has been attempted for PDAC during last several years, however, no outcomes evaluation by comparison between laparoscopic vs open RAMPS has been reported yet.

MATERIALS AND METHODS

From August, 2012 to March, 2018, patients undergoing open or lap-RAMPS for the diagnosis of left-sided PDAC were reviewed from a prospective database. Patients excluded if they were related with combined organs or vessels resection, systematic metastasis as well as conversion from open RAMPS to lap RAMPS. The surgical and oncologic outcomes were compared.

RESULTS

A total of 48 PDAC patients were enrolled (25 underwent lap-RAMPS and 23 underwent open-RAMPS). There were no significant differences in demographic or perioperative morbidity. In the lap-RAMPS group, R0 transection margin and retroperitoneal margin were both achieved in 23 of 25 patients (92%). In the open RAMPS group, R0 transection margin was achieved in 21 of 23 patients (91.3%), R0 retroperitoneal margin was 22 of 23 patients (95.65%). There were no differences in pathological examinations. The number of lymph node (LN) retrieved between lap-RAMPS and open- RAMPS group was not significant difference (15.84 vs 18.22; P = 0.268). Median disease-free survival (DFS) was analogous in two groups (18.11 m vs 20.00 m, P = 0.999). Median overall survival (OS) was 24.53 m in lap-RAMPS group and 28.73 m in the open-RAMPS group (P = 0.633).

CONCLUSIONS

Lap-RAMPS is technically feasible, and has comparable long-term oncological outcome with open-RMAPS.

Obese patients and robotic colorectal surgery: systematic review and meta-analysis

BACKGROUND

Obesity is a major health problem, demonstrated to double the risk of colorectal cancer. The benefits of robotic colorectal surgery in obese patients remain largely unknown. This meta-analysis evaluated the clinical and pathological outcomes of robotic colorectal surgery in obese and non-obese patients.

METHODS

MEDLINE, Embase, Global Health, Healthcare Management Information Consortium (HMIC) and Midwives Information and Resources Service (MIDIRS) databases were searched on 1 August 2018 with no language restriction. Meta-analysis was performed according to PRISMA guidelines. Obese patients (BMI 30 kg/m2 or above) undergoing robotic colorectal cancer resections were compared with non-obese patients. Included outcome measures were: operative outcomes (duration of surgery, conversion to laparotomy, blood loss), postoperative complications, hospital length of stay and pathological outcomes (number of retrieved lymph nodes, positive circumferential resection margins and length of distal margin in rectal surgery).

RESULTS

A total of 131 full-text articles were reviewed, of which 12 met the inclusion criteria and were included in the final analysis. There were 3166 non-obese and 1420 obese patients. A longer duration of surgery was documented in obese compared with non-obese patients (weighted mean difference -21·99 (95 per cent c.i. -31·52 to -12·46) min; P < 0·001). Obese patients had a higher rate of conversion to laparotomy than non-obese patients (odds ratio 1·99, 95 per cent c.i. 1·54 to 2·56; P < 0·001). Blood loss, postoperative complications, length of hospital stay and pathological outcomes were not significantly different in obese and non-obese patients.

CONCLUSION

Robotic surgery in obese patients results in a significantly longer duration of surgery and higher conversion rates than in non-obese patients. Further studies should focus on better stratification of the obese population with colorectal disease as candidates for robotic procedures.

The role of older age and obesity in minimally invasive and open pancreatic surgery: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

The aim of this study was to assess the impact of older age (≥70 years) and obesity (BMI ≥30) on surgical outcomes of minimally invasive pancreatic resections (MIPR). Subsequently, open pancreatic resections or MIPR were compared for elderly and/or obese patients.

METHODS

A systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on MIPR (IG-MIPR). Study quality assessment was according to The Scottish Intercollegiate Guidelines Network (SIGN). A meta-analysis was performed to assess the impact of MIPR or open pancreatic resections in elderly patients.

RESULTS

After screening 682 studies, 13 observational studies with 4629 patients were included. Elderly patients undergoing laparoscopic distal pancreatectomy (LDP) had less blood loss (117 mL, p < 0.001) and a shorter hospital stay (3.5 days p < 0.001) than elderly patients undergoing open distal pancreatectomy (ODP). Postoperative pancreatic fistula (POPF) B/C, major complication and reoperation rate were not significantly different in elderly patients undergoing either laparoscopic or open pancreatoduodenectomy (OPD). One study compared robot PD with OPD in obese patients, indicating that patients with robotic surgery had less blood loss (mean 250 ml vs 500 ml, p = 0.001), shorter operative time (mean 381 min vs 428 min, p = 0.003), and lower rate of POPF B/C (13% vs 28%, p = 0.039).

CONCLUSION

The current available limited evidence does not suggest that MIPR is contraindicated in elderly or obese patients. Additionally, outcomes in MIPR are equal or more beneficial compared to the open approach when applied in these patient groups.

Body Composition Using Air Displacement Plethysmography in Children With Inflammatory Bowel Disease

OBJECTIVE

The aim of the study was to assess the body composition of children with inflammatory bowel disease (IBD) and to study the accuracy of clinically available tools in predicting excess body fatness. We aimed at also exploring the influence of adiposity on pharmacokinetics during early Infliximab exposure.

METHODS

Prospective cohort study in 5- to 17-year-old children with IBD initiating Infliximab therapy. Patient demographic, phenotypic, and laboratory data at the time of Infliximab initiation were recorded. Body composition was assessed using air displacement plethysmography (ADP). fat mass index (FMI = fat mass [kg]/(height [m])) was calculated to determine excess adiposity (defined as FMI ≥75th centile). Anthropometrics (weight, height, mid upper arm circumference [MUAC] and triceps skin fold thickness [TSF]) were obtained and MUAC and TSF measurements were used to calculate arm fat area (AFA) and arm muscle area z-scores. Statistical analysis was applied as appropriate.

RESULTS

Fifty-three (68% male; 55% Crohn disease [CD], 45% ulcerative colitis [UC], median [IQR] age 15 [13-16] years) children with IBD were included. Twenty-four percentage of children with IBD (21% CD, 29% UC) had excess adiposity. Four children (31%) with FMI ≥75th centile were not identified by body mass index (BMI) alone (kappa of 0.60), and 2 children (15%) were not identified by AFA z-score alone. The intra- and interobserver reliability of MUAC and TSFT measurements was excellent. There was no difference in Infliximab trough levels at the end of induction between those with FMI less than or ≥75th centile.

CONCLUSIONS

Excess adiposity affects approximately 1 in 4 young patients with IBD and can be missed by routine obesity screening. Our exploratory study did not raise concerns of underexposure to infliximab in those children with excess adiposity during early drug exposure.

Effect of Lifestyle Factors on Outcomes in Patients With Inflammatory Bowel Diseases

Various lifestyle factors including physical activity and obesity, stress, sleep, and smoking may modify the risk of developing inflammatory bowel diseases (IBDs). In patients with established IBD, these lifestyle factors may significantly impact the natural history and clinical outcomes. Recreational exercise decreases the risk of flare and fatigue in patients with IBD. In contrast, obesity increases the risk of relapse and is associated with higher anxiety, depression, fatigue, and pain and higher health care utilization. Obesity also modifies pharmacokinetics of biologic agents unfavorably and is associated with a higher risk of treatment failure. Sleep disturbance is highly prevalent in patients with IBD, independent of disease activity, and increases the risk of relapse and chronic fatigue. Similarly, stress, particularly perceived stress rather than major life events, may trigger symptomatic flare in patients with IBD, although its impact on inflammation is unclear. Cigarette smoking is associated with unfavorable outcomes including the risk of corticosteroid dependence, surgery, and disease progression in patients with Crohn's disease; in contrast, smoking does not significantly impact outcomes in patients with ulcerative colitis, although some studies suggest that it may be associated with a lower risk of flare. The effect of alcohol and cannabis use in patients with IBD is inconsistent, with some studies suggesting that cannabis may decrease chronic pain in patients with IBD, without a significant effect of biological remission. Although these lifestyle factors are potentially modifiable, only a few interventional studies have been conducted. Trials of structured exercise and psychological therapy including mindfulness-based therapies such as meditation and yoga and gut-directed hypnotherapy have not consistently demonstrated benefit in clinical and/or endoscopic disease activity in IBD, although may improve overall quality of life.

Management of Inflammatory Bowel Diseases in Special Populations: Obese, Old, or Obstetric

The epidemiology of inflammatory bowel disease (IBD) is progressively evolving impacting the type of patients with IBD we will see in clinical practice. In this review, we discuss specific challenges and solutions in the management of (1) obese, (2) older and (3) obstetric (pregnant) patients with IBD. With the global obesity epidemic, almost 1 in 3 patients with IBD are obese. Obesity is associated with greater difficulty in achieving remission, higher risk of disease relapse and higher burden and costs of hospitalization in patients with IBD. Obese patients also have inferior response to biologic therapy related to altered pharmacokinetics and obesity-mediated chronic inflammation. Surgical management of obese patients with IBD is also challenging. Similar to obesity, the prevalence of IBD in older patients is rising and it is anticipated that almost one-third of patients with IBD will be older than 60 years within the next decade. Older patients present unique diagnostic and therapeutic dilemmas, and management of these individuals warrants careful consideration of the risks of disease-related versus treatment-related complications, non-IBD-related extra-intestinal complications (eg, cardiovascular disease, malignancy), in the context of individual values, preferences, functional status and comorbidities. With evolving therapeutics, medical management of IBD surrounding pregnancy continues to be challenging. Overall, the management of pregnant patients requires a pro-active, multidisciplinary approach, with an emphasis on optimal disease control not just during, but prior to pregnancy. This often involves continuation of highly effective therapies, of which the vast majority are safe during pregnancy and breastfeeding, resulting in a reduction of risk of adverse maternal fetal outcomes.

Open colectomy vs. laparoscopic colectomy in Japan: a retrospective study using real-world data from the diagnosis procedure combination database

PURPOSE

To compare the short-term outcomes of conventional open colectomy with those of laparoscopic colectomy for colon cancer.

METHODS

We retrieved data between January 2014 and March 2016 from the Diagnosis Procedure Combination database. A total of 69,418 patients who underwent colectomy for colon cancer were analyzed from among 15,901,766 cases of colorectal cancer. We applied a multilevel logistic regression model using a 2-level structure of individuals nested from 1065 hospitals.

RESULTS

A total of 22,440 open colectomy and 46,978 laparoscopic colectomy procedures were performed. The in-hospital mortality rate was significantly lower in the laparoscopic group than in the open group (0.28% vs. 0.06%, odds ratio [OR] 0.40, p < 0.001). Similarly, the 30-day postoperative mortality rate (0.14% vs. 0.03%, OR 0.47, p = 0.019) and surgical morbidity rate (43.0% vs. 25.3%, OR 0.47, p < 0.001) were significantly lower in the laparoscopic group than in the open group. The postoperative length of stay was significantly longer in the open group (mean difference - 5.6 days, p < 0.001) than in the open group. The admission cost was significantly greater in the open group than in the laparoscopic group (mean difference - 95,080 yen, p < 0.001).

CONCLUSIONS

Laparoscopic colectomy is safe and effective in the short term.

Perioperative Heart-Brain Axis Protection in Obese Surgical Patients: The Nutrigenomic Approach

The number of obese patients undergoing cardiac and noncardiac surgery is rapidly increasing because they are more prone to concomitant diseases, such as diabetes, thrombosis, sleep-disordered breathing, cardiovascular and cerebrovascular disorders. Even if guidelines are already available to manage anesthesia and surgery of obese patients, the assessment of the perioperative morbidity and mortality from heart and brain disorders in morbidly obese surgical patients will be challenging in the next years. The present review will recapitulate the new mechanisms underlying the Heart-brain Axis (HBA) vulnerability during the perioperative period in healthy and morbidly obese patients. Finally, we will describe the nutrigenomics approach, an emerging noninvasive dietary tool, to maintain a healthy body weight and to minimize the HBA propensity to injury in obese individuals undergoing all types of surgery by personalized intake of plant compounds that may regulate the switch from health to disease in an epigenetic manner. Our review provides current insights into the mechanisms underlying HBA response in obese surgical patients and how they are modulated by epigenetically active food constituents.

The effect of body mass index on the risk of surgical site infection

OBJECTIVE

Obesity is considered a risk factor for surgical site infection (SSI). We quantified impact of body mass index (BMI) on the risk of SSI for a variety of surgical procedures.

METHODS

We included 2012-2017 data from the Dutch national surveillance network PREZIES on a selection of frequently performed surgical procedures across different specialties. Patients were stratified into 5 categories: underweight (BMI, &lt;18.5 kg/m2), normal weight (BMI, 18.5-25), overweight (BMI, 25-30), obese (BMI, 30-40) and morbidly obese (BMI, ≥40). Multilevel log binomial regression analyses were performed to assess the effect of BMI category on the risk of superficial, deep (including organ-space) and total SSI.

RESULTS

Of the 387,919 included patients (ranging from 2,616 for laparoscopic appendectomy to 119,834 for total hip prosthesis), 3,676 (1%) were underweight, 116,778 (30%) had normal weight, 154,339 (40%) were overweight, 104,288 (27%) had obesity, and 8,838 (2%) were morbidly obese. A trend of increasing risk of SSI when BMI increased from normal to morbidly obese was observed for almost all surgery types. The increase was most profound in surgeries with clean wounds, with relative risks for morbidly obese patients ranging up to 7.8 (95% CI, 6.0-10.2) for deep SSI in total hip prosthesis. In chest and abdominal surgeries, the impact was larger for superficial SSI than for deep SSI.

CONCLUSIONS

The results of our research provide evidence for the need of preventive programs targeting SSI in overweight and obese patients, as well as for the prevention of obesity in the general population.

Complete mesocolic excision for colonic cancer

INTRODUCTION

Complete mesocolic excision for colonic cancer is similar in concept to total mesorectal excision for rectal cancer. This review aims to provide the embryological and anatomical rationale behind CME, and to review the current literature on CME, relative to the feasibility via laparoscopy, the oncological adequacy and outcomes.

EVIDENCE ACQUISITION

A literature search was performed at the end of 2017 according the PRISMA guidelines for systematic reviews. Of 3980 articles found, we analyzed 96 articles. Of note, many case series had overlapping populations; there were five review articles, two consensus conference proceedings, six comparative but only one randomized trial.

EVIDENCE SYNTHESIS

The embryonic and anatomical rationale is well described. CME is feasible via laparoscopy, which may facilitate dissection and anatomic precision: no statistically significant differences were found when compared to open CME regarding overall survival. However, morbidity may be higher in the hands of non-expert laparoscopic surgeons.

CONCLUSIONS

Oncological adequacy can be obtained with laparoscopic CME, with increased lymph node retrieval. However, until now, there is no formal proof that CME improves local recurrence or survival.

Obesity Is Independently Associated With Higher Annual Burden and Costs of Hospitalization in Patients With Inflammatory Bowel Diseases

BACKGROUND & AIMS

Approximately 15%-40% patients with inflammatory bowel diseases (IBD) are obese. There is an inconsistent association between obesity and IBD phenotype and course. We conducted a nationally representative cohort study to estimate and compare the burden, costs, and causes for hospitalization in obese vs non-obese patients with IBD.

METHODS

Using the Nationwide Readmissions Database 2013, we identified obese (based on administrative claims code) and non-obese patients who had been hospitalized at least once, from January through June 2013, and followed them for re-hospitalization until December 2013. We compared annual burden (total days spent in hospital), costs, causes, and outcomes of hospitalization between obese and non-obese patients after 1:1 propensity score matching.

RESULTS

We identified 42,285 patients with IBD, of which 12.4% were obese. After propensity score matching, we included 5128 obese and 5128 non-obese IBD patients in our analysis. Compared to non-obese patients, obese patients spent more days in hospital annually (median, 8 vs 5 days) (P < .01), with higher hospitalization-related costs (median, $17,277 vs $11,847) (P < .01); this pattern persisted in subsets of high-need and high-cost patients. Compared to non-obese patients, obese patients were more likely to be hospitalized with preventable admissions (19% vs 15%) or cardiopulmonary complications (16% vs 12%).

CONCLUSIONS

In an analysis of data on patients with IBD from the Nationwide Readmissions Database 2013, we found obesity to be independently associated with higher burden and costs of hospitalizations. Strategies should be considered to target obesity as adjunctive therapy for patients with IBD.

The relationship between body mass index, sex, and postoperative outcomes in patients undergoing potentially curative surgery for colorectal cancer

BACKGROUND

There is increasing evidence that an increased BMI is associated with increased complications after surgery for colorectal cancer (CRC). However, the basis of this relationship is not clear. Since men and women have different fat distribution, with men more likely to have excess visceral fat in BMI defined obesity, there may be a sex difference in the surgical site infection (SSIs) rate in the obese. Therefore, the aim of this study was to examine the relationship between sex, BMI, clinic-pathological characteristics and the development of postoperative infective complications after surgery for CRC and to establish whether there were gender differences in complication following surgery for CRC.

DESIGN

Data were recorded prospectively for patients undergoing potentially curative surgery for CRC in a single centre between 1997 and 2016. Patient characteristics were recorded and complications were classified as either infective or non-infective. The relationship between sex, BMI, associated clinicopathological characteristics and presences of complications were examined by Chi-square test for linear association and multivariate binary logistic regression model.

RESULTS

A total of 1039 patients were included. There were significant differences in the presence of complications between male and female (p ≤ 0.001), the rate of complication was higher in obese male (44%); in particular SSIs, wound infection and anastomotic leak (p ≤ 0.05). The rate of surgical site infection was 12% in male patients with normal BMI compared with 26% in those with a BMI ≥30 (p ≤ 0.001), while the rate of SSIs in female patients was 10% in those with normal BMI and those with a BMI ≥30. In males, BMI remained significantly associated with SSI on multivariate analysis [(OR = 1.42, 95% CI 1.13-1.78) P = 0,002].

CONCLUSIONS

Obesity prior to surgery for CRC increases the risk of infective complications in both male and female. Increased BMI in male patients was associated greater risk of SSIs and wound infection compared to female patients. Male obese patients should be considered at high risk of developing post-operative infective complications.

The Impact of Preoperative Low Body Mass Index on Postoperative Complications and Long-term Survival Outcomes in Gastric Cancer Patients

PURPOSE

The aim of this study was to investigate the impact of preoperative low body mass index (BMI) on both the short- and long-term outcomes in patients with gastric cancer.

MATERIALS AND METHODS

A total of 510 patients with gastric cancer were divided into the following 3 groups: low BMI group (≤18.5 kg/m2, n=51), normal BMI group (18.6-24.9 kg/m2, n=308), and high BMI group (≥25.0 kg/m2, n=151).

RESULTS

There were significantly more stage III/IV patients in the low BMI group than in the other groups (P=0.001). Severe postoperative complications were more frequent (P=0.010) and the survival was worse (P<0.001) in the low BMI group. The subgroup analysis indicated that survival was worse in the low BMI group of the stage I/II subgroup (P=0.008). The severe postoperative complication rate was higher in the low BMI group of the stage III/IV subgroup (P=0.001), although the recurrence rate and survival did not differ in the stage III/IV subgroup among all the BMI groups. Low BMI was an independent poor prognostic factor in the stage I/II subgroup (disease-free survival: hazard ratio [HR], 13.521; 95% confidence interval [CI], 1.186-154.197; P=0.036 and overall survival: HR, 5.130; 95% CI, 1.644-16.010; P=0.005), whereas low BMI was an independent risk factor for severe postoperative complications in the stage III/IV subgroup (HR, 17.158; 95% CI, 1.383-212.940; P=0.027).

CONCLUSIONS

Preoperative low BMI in patients with gastric cancer adversely affects survival among those with stage I/II disease and increases the severe postoperative complication rate among those with stage III/IV disease.

Visceral fat area, not body mass index, predicts postoperative 30-day morbidity in patients undergoing colon resection for cancer

PURPOSE

Colectomy for cancer in obese patients is technically challenging and may be associated with worse outcomes. Whether visceral obesity, as measured on computed tomography, is a better predictor of complication than body mass index (BMI) or determines long-term oncologic outcomes has not been well characterized. This study examines the association between derived anthropometrics and postoperative complication and long-term oncologic outcomes.

METHODS

Retrospective review of patients undergoing elective colectomy for cancer at a single tertiary-care center from 2010 to 2016. Adipose tissue distribution measurements, including visceral fat area (VFA), were determined from preoperative imaging. The primary outcome was 30-day postoperative complication; secondary outcomes included overall and disease-free survival. Multivariable logistic regression was performed to determine association between obesity metrics and outcome.

RESULTS

Two hundred and sixty-four patients underwent 266 primary resections of colon cancer. Twenty-eight patients (10.5%) developed major morbidity (Clavien-Dindo grade ≥ III). VFA but not BMI was significantly associated with morbidity in multivariate analysis (p = 0.004, odds ratio 1.99, 95% confidence interval 1.25-3.19). No other imaging-derived anthropometric was associated with increased morbidity. In receiver operating characteristic analysis, VFA was predictive of major morbidity (area under curve 0.660). A cutoff value of VFA ≥ 191 cm² was associated with 50% sensitivity and 76% specificity for predicting major morbidity. Patients with VFA ≥ 191cm² had 19.4% risk of morbidity, whereas those with < 191 cm² had 7.2% risk (relative risk ratio 2.69, unadjusted p = 0.004). Neither VFA nor BMI was associated with overall or disease-free survival.

CONCLUSION

VFA but not BMI predicts morbidity following elective surgery for colon cancer.

Surgical outcomes for diverticulitis in young patients: results from the NSQIP database

BACKGROUND

The incidence of diverticulitis is increasing among young patients (≤ 50 years), as are rates of recurrent disease. There is ongoing controversy regarding the best management strategy for this patient group. Guidelines have changed from elective colectomy after a single episode to a more individualized approach no longer based on patient age. This study investigated the clinical presentation and surgical outcomes of young patients undergoing surgery for diverticulitis over two time periods.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was searched from 2005 to 2014 to identify all patients ≤ 50 with a diagnosis of diverticulitis. Data were obtained on patient demographics, comorbidity, perioperative details, and 30-day post-operative outcomes. Data were compared between two time periods, being 2005-2010 (Group 1) and 2011-2014 (Group 2).

RESULTS

10,844 patients were included in the analysis. The mean patient age was 43 years (range 18-50), and 35% were female. Significantly more patients were obese (BMI > 30) in Group 2 (52%) versus Group 1 (47%). Laparoscopic surgery and emergency surgery and perforation rates were significantly higher in Group 2. Wound infection was significantly less in Group 2. Post-operative organ/space infection and medical morbidity were significantly higher in Group 2.

CONCLUSIONS

In recent years, there has been a change to a more conservative approach for elective colonic resection in young patients with a history of diverticulitis. Increasingly young patients presenting for surgery for diverticulitis are male and obese, and increased rates of post-operative medical morbidity have been observed. The laparoscopic approach is more common, with resultant increased operative times, and decreased wound infection rates. The observed increased in emergency surgery and perforation rates may be explained by the change in management approach with less elective resections.

The effect of metabolic syndrome on postoperative outcomes following laparoscopic colectomy

BACKGROUND

Among the criteria used to diagnose metabolic syndrome (MS), obesity and diabetes mellitus (DM) are associated with poor postoperative outcomes following colectomy. MS is also associated with colorectal cancer (CRC) and diverticulosis, both of which may be treated with colectomy. However, the effect of MS on postoperative outcomes following laparoscopic colectomy has yet to be clarified.

METHODS

In an academic tertiary hospital, data from all consecutive patients undergoing laparoscopic colectomy from 2005 to 2014 were prospectively recorded and analysed. Patients presenting with MS [defined by the presence of three or more of the following criteria: elevated blood pressure, body mass index > 28 kg/m², dyslipidemia (decreased serum HDL cholesterol, increased serum triglycerides) and increased fasting glucose/DM] were compared with patients without MS regarding peri-operative outcome [mainly anastomotic leaks, severe postoperative complications (Clavien-Dindo III and IV)] and mortality.

RESULTS

Overall, 1236 patients were included: 508 (41.1%) right colectomies and 728 (58.9%) left colectomies. Seven hundred seventy-two (62.4%) of these procedures were performed for CRC. MS was diagnosed in 85 (6.9%) patients, who were significantly older than the others (70 vs. 64.2 years, p < 0.001), and presented with more cardiac comorbidities (p < 0.001). MS was associated with increased blood loss (122.5 vs. 79.9 mL p = 0.001) and blood transfusion requirement (5.9 vs. 1.7%, p = 0.021). The anastomotic leak rate was 6.6% (with 2.2% of anastomotic leaks requiring surgical treatment), and the overall reoperation rate was 6.9%. The incidence of severe postoperative complications was 11.5%, and the overall mortality rate 0.6%. No differences were found between the groups in overall postoperative morbidity and mortality. Median length of stay was similar in both groups (7 days).

CONCLUSIONS

MS does not jeopardize postoperative outcomes following laparoscopic colectomy.

Conversion is a risk factor for postoperative anastomotic leak in rectal cancer patients - A retrospective cohort study

AIM

The impact of conversion from laparoscopic surgery to laparotomy on the development of anastomotic leak (AL) in rectal cancer patients following laparoscopic low anterior resection (LAR) with total mesorectal excision (TME) has not been evaluated. The aim of this study was to evaluate the impact of conversion on the risk of AL and develop a prediction nomogram for postoperative AL.

METHODS

All rectal cancer patients following laparoscopic LAR with TME from January 2010 to October 2014 were enrolled in the primary cohort. Comparisons of the postoperative anastomotic leak incidence rate between converted patients and non-converted patients were performed using both univariate and multivariate logistic regression analyses. The result of multivariable analysis was used to develop the predicting model and the performance of nomogram was assessed with respect to its calibration, discrimination, and clinical usefulness. An independent validation cohort containing 200 patients from November 2014 to October 2015 was assessed.

RESULTS

Of all patients enrolled (n=646), 592 (91.6%) patients underwent totally laparoscopic surgery, and 54 (8.4%) were converted from laparoscopic surgery to laparotomy. Converted group patients were more likely to have a higher body mass index (BMI), prolonged length of stay (LOS), increased overall postoperative complication rates and advanced clinical T stage (T3 or T4), pathological N stage (N1 or N2) and pathological TNM stage (III or IV). The percentage of patients who had preoperative radiotherapy for rectal cancer was higher in non-converted patients. Patients who underwent conversion to laparotomy (n=10, 18.5%) were more likely to suffer from postoperative AL than those undergoing totally laparoscopic surgery (n=38, 6.4%) (P=0.004). Multivariate logistic regression analyses confirmed the association between conversion and postoperative AL (Odds ratio [OR], 95% confidence interval [CI]: 2.71 [1.31-5.63], P=0.007). Conversion, gender, and clinical N stage incorporated in the individualized prediction nomogram showed good discrimination, with a C-index of 0.697 (C-index, 0.621 and 0.772 through internal validation), and good calibration. In the validation cohort, the main results were consistent with the findings of the primary cohort, with a C-index of 0.670 (C-index, 0.562 and 0.777 through internal validation). Decision curve analysis demonstrated that the prediction nomogram was clinically useful.

CONCLUSION

Conversion during laparoscopic LAR was found to be associated with an increased risk for the postoperative AL in RC patients. A nomogram model incorporating conversion, gender and patient's clinical N stage seems to offers a useful tool for predicting postoperative AL in these patients.

Impact of radiofrequency energy on intraoperative outcomes of laparoscopic colectomy for cancer in obese patients

Nowadays laparoscopic approach is accepted as a valid alternative to open surgery for the treatment of colorectal cancer. Several studies consider this approach to be safe and feasible also in obese patients, even if dissection in these patients may require a longer operative time and involve higher blood loss. To facilitate laparoscopic approach, more difficult in these patients, several energy sources for laparoscopic dissection and sealing, has been adopted recently. The aim of this study is to investigate the possible intraoperative advantages of radiofrequency energy in terms of blood loss and operative time in obese patients undergoing laparoscopic resection for cancer. All patients who underwent laparoscopic surgery for colorectal cancer from January 2010 to December 2015 were registered in a prospective database. Patients with a body mass index BMI (kg/m2) ≥30 were defined as obese, and patients with a BMI (kg/m2) <30 were defined as non-obese. All 136 obese patients observed were divided retrospectively into 2 groups according to the devices used for dissection: 83 patients (Historical group: B) on whom dissection and coagulation were performed using other energy sources (monopolar electrocautery scissors, bipolar electrical energy, ultrasonic coagulating shears) and 53 patients who were treated with electrothermal bipolar vessel sealing (Caiman group: A). In group A, the Laparoscopic Caiman 5 (Aesculap AG, Tuttlingen, Germany) was the only instrument employed in the whole procedure. The study examined only three types of operation: right colectomy (RC), left colectomy (LC), and anterior resection (AR). Preoperative data were similar for RC, LC, and AR in both groups (A and B). The mean operative time was statistically shorter in the Caiman group than in the Historical group [104 vs 124 min (p 0.004), 116 vs 140 min (p 0.004), and 125 vs 151 min (p 0.003) for RC, LC, and AR between group A and B, respectively]. Also intraoperative blood loss results significantly lower in the Caiman group than in the historical one [52 ml vs 93 for RC (p 0.003); 65 vs 120 ml for LC (p 0.001); 93 vs 145 ml for AR (p 0.002) between group A and B, respectively]. No intraoperative complications were recorded in either group. The mean conversion rate was 4.4% (6 patients). There were no statistical differences in intensive care unit (ICU) stay, functional outcomes, mean hospital stay and overall morbidity rate between the two groups. There was no mortality in either group. The use of the Caiman EBVS instrument shows significant advantages with respect to a small number of intraoperative parameters. We can conclude that use of this radiofrequency device, in the laparoscopic approach, offers advantages in terms of lower intraoperative blood loss and shorter operative time in obese patients with colorectal cancer.

Trends in laparoscopic colorectal surgery over time from 2005-2014 using the NSQIP database

BACKGROUND

Laparoscopy, originally pioneered by gynecologists, was first adopted by general surgeons in the late 1980s. Since then, laparoscopy has been adopted in the surgical specialties and colorectal surgery for treatment of benign and malignant disease. Formal laparoscopic training became a required component of surgery residency programs as validated by the Fundamentals of Laparoscopic Surgery curriculum; however, some surgeons may be more apprehensive of widespread adoption of minimally invasive techniques. Although an overall increase in the use of laparoscopy in colorectal surgery is anticipated over a 10-year period, it is unknown if a similar increase will be seen in higher risk or more acutely ill patients.

METHODS

Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2005-2014, colorectal procedures were identified by Current Procedural Terminology codes and categorized to open or laparoscopic surgery. The proportion of colorectal surgeries performed laparoscopically was calculated for each year. Separate descriptive statistics was performed and categorized by age and body mass index (BMI). American Society of Anesthesiology (ASA) classification and emergency case status variables were added to the project to help assess complexity of cases.

RESULTS

During the 10-year study period, the number of colorectal cases increased from 3114 in 2005 to 51,611 in 2014 as more hospitals joined NSQIP. A total of 277,376 colorectal cases were identified; of which, 114,359 (41.2%) were performed laparoscopically. The use of laparoscopy gradually increased each year, from 22.7% in 2005 to 49.8% in 2014. Laparoscopic procedures were most commonly performed in the youngest age group (18-49 years), overweight and obese patients (BMI 25-34.9), and in ASA class 1-2 patients. Over the 10-year period, there was a noted increase in the use of laparoscopy in every age, BMI, and ASA category, except ASA 5. The percent of emergency cases receiving laparoscopic surgery also doubled from 5.5% in 2005 to 11.5% in 2014.

CONCLUSIONS

Over a 10-year period, there was a gradual increase in the use of laparoscopy in colorectal surgery. Further, there was a consistent increase of laparoscopic surgery in all age groups, including the elderly, in all BMI classes, including the obese and morbidly obese, and in most ASA classes, including ASA 3-4, as well as in emergency surgeries. These trends suggest that minimally invasive colorectal surgery appears to be widely adopted and performed on more complex or higher risk patients.