Impact of Body Mass Index on Early Postoperative and Long-Term Outcome after Rectal Cancer Surgery

Analysis of Local Recurrence After Robotic-Assisted Total Mesorectal Excision (ALRITE): An International, Multicentre, Retrospective Cohort

BACKGROUND/OBJECTIVES

Rectal cancer is a major global health issue with high morbidity and mortality rates. Local recurrence (LR) significantly impacts patient outcomes, decreasing survival rates and often necessitating extensive secondary treatments. While robot-assisted total mesorectal excision (R-TME) is becoming a preferred method for rectal cancer surgery due to its improved precision and visualisation, long-term data on LR and predictors of recurrence remain limited. This study aims to determine the 3-year LR rate following R-TME and to identify predictors of recurrence to enhance patient selection and the personalisation of treatment.

METHODS

This retrospective international multicentre cohort study included 1039 consecutive rectal cancer patients who underwent R-TME between 2013 and 2020, with a minimum of 3 years of follow-up. Data from tertiary colorectal centres in the United Kingdom, the Netherlands, Spain, France, Italy, and Belgium were analysed. Potential predictors of LR were identified using backward elimination, and four machine learning models were evaluated for predicting LR.

RESULTS

The 3-year LR rate was 3.8%. Significant predictors of LR included advanced clinical M-staging, length of the hospital stay, postoperative ileus, postoperative complications, pathological N-staging, the completeness of resection, and the resection margin distance. The eXtreme Gradient Boosting model performed best for LR prediction, with a final accuracy of 77.1% and an AUC of 0.76.

CONCLUSIONS

R-TME in high-volume centres achieves low 3-year LR rates, suggesting that robot-assisted surgery offers oncological safety and advantages in rectal cancer management. This study underscores the importance of surgical precision, patient selection, and standardised perioperative care, supporting further investment in robotic training to improve long-term patient outcomes.

Risk factors for local recurrence in patients with clinical stage II/III low rectal cancer: A multicenter retrospective cohort study in Japan

Background

Identifying risk factors for local recurrence (LR) is pivotal in optimizing rectal cancer treatment. Total mesorectal excision (TME) and lateral lymph node dissection (LLND) are the standard treatment for advanced low rectal cancer in Japan. However, large-scale studies to evaluate risk factors for LR are limited.

Methods

Data from 1479 patients with clinical stage II/III low rectal cancer below the peritoneal reflection, surgically treated between January 2010 and December 2011 across 69 hospitals, were analyzed. Fine-Gray multivariable regression modeling was used to identify risk factors associated with LR. Two models were developed: one using preoperative factors only, and the other incorporating operative and postoperative factors.

Results

Across the entire cohort, the 5-year cumulative incidence of LR was 12.3% (95% confidence interval, 10.7-14.1). The multivariable analysis associated LR with various preoperative (body mass index, distance from anal verge, cN category, and histological subtype), treatment-related (neoadjuvant therapy, and LLND), and postoperative (pT, pN, and resection margins) risk factors. For patients without neoadjuvant treatment, LR risk was unacceptably high with two or three preoperative risk factors (body mass index ≥25 kg/m2, distance from anal verge ≤4.0 cm, non-well/moderately differentiated adenocarcinoma). The 5-year cumulative incidence of LR was 24.7% in patients treated without LLND and 22.9% in patients treated with LLND.

Conclusion

This large multicenter cohort study identified some risk factors for LR in the setting where upfront TME was predominant, offering insights to optimize rectal cancer treatment.

Post-diagnosis adiposity and colorectal cancer prognosis: A Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis

The adiposity influence on colorectal cancer prognosis remains poorly characterised. We performed a systematic review and meta-analysis on post-diagnosis adiposity measures (body mass index [BMI], waist circumference, waist-to-hip ratio, weight) or their changes and colorectal cancer outcomes. PubMed and Embase were searched through 28 February 2022. Random-effects meta-analyses were conducted when at least three studies had sufficient information. The quality of evidence was interpreted and graded by the Global Cancer Update Programme (CUP Global) independent Expert Committee on Cancer Survivorship and Expert Panel. We reviewed 124 observational studies (85 publications). Meta-analyses were possible for BMI and all-cause mortality, colorectal cancer-specific mortality, and cancer recurrence/disease-free survival. Non-linear meta-analysis indicated a reverse J-shaped association between BMI and colorectal cancer outcomes (nadir at BMI 28 kg/m2). The highest risk, relative to the nadir, was observed at both ends of the BMI distribution (18 and 38 kg/m2), namely 60% and 23% higher risk for all-cause mortality; 95% and 26% for colorectal cancer-specific mortality; and 37% and 24% for cancer recurrence/disease-free survival, respectively. The higher risk with low BMI was attenuated in secondary analyses of RCTs (compared to cohort studies), among studies with longer follow-up, and in women suggesting potential methodological limitations and/or altered physiological state. Descriptively synthesised studies on other adiposity-outcome associations of interest were limited in number and methodological quality. All the associations were graded as limited (likelihood of causality: no conclusion) due to potential methodological limitations (reverse causation, confounding, selection bias). Additional well-designed observational studies and interventional trials are needed to provide further clarification.

Body Mass Index, Sex, and Age Are Predictors of Discharge to a Post-acute Care Facility Following Total Ankle Arthroplasty

BACKGROUND

The utilization of total ankle arthroplasty (TAA) continues to increase. Discharge to a post-acute care (PAC) facility can increase patient morbidity and postoperative costs. The purpose of this study is to investigate the effects of age and body mass index (BMI) on discharge to a PAC facility and hospital length of stay (LOS) following TAA.

METHODS

A retrospective review of patients who underwent TAA from the National Surgical Quality Improvement Program (NSQIP) database was performed. Using overweight patients as the reference BMI group, sex- and age-adjusted log-binomial regression models were utilized to estimate risk ratios of BMI categories for being discharged to a PAC facility. A linear regression was utilized to estimate the effect of BMI category on hospital LOS.

RESULTS

Obese patients had 1.36 times the risk of overweight patients (P = .040), and morbidly obese patients had 2 times risk of overweight patients (P = .001) of being discharged to a PAC facility after TAA. Men had 0.48 times the risk of women (P < .001). Compared with patients aged 18 to 44 years, patients aged ≥65 years had 4.13 times the risk (P = .012) of being discharged to a PAC facility after TAA. Relative to overweight patients, on average there was no difference in hospital LOS for underweight patients, but healthy weight patients stayed an additional 0.30 days (P=.003), obese patients stayed an additional 0.18 days (P = .011), and morbidly obese patients stayed an additional 0.33 days (P = .009). Men stayed 0.29 fewer hospital days than women (P < .001) on average.

CONCLUSION

Women and patients who are obese or morbidly obese have a longer hospital LOS and an increased chance of being discharged to a PAC facility. Increasing age is also associated with an increased risk of being discharged to a PAC. These may be important factors when developing and discussing the postoperative plan with patients prior to TAA.

LEVELS OF EVIDENCE

Level III.

Impact of obesity on patients undergoing surgery for rectal cancer in Australia and New Zealand

PURPOSE

Patients with obesity undergoing rectal cancer surgery may have an increased risk of developing complications, though evidence is inconclusive. The aim of this study was to determine the direct impact of obesity on postoperative outcomes using data from a large clinical registry.

METHOD

The Binational Colorectal Cancer Audit registry was used to identify patients who underwent rectal cancer surgery in Australia and New Zealand from 2007-2021. Primary outcomes were inpatient surgical and medical complications. Logistic regression models were developed to describe the association between body-mass index (BMI) and outcomes.

RESULTS

Among 3,708 patients (median age 66 years [IQR 56.75-75], 65.0% male), 2.0% had a BMI < 18.5 kg/m2, 35.4% had a BMI of 18.5-24.9 kg/m2, 37.6% had a BMI of 25.0-29.9 kg/m2, 16.7% had a BMI of 30.0-34.9 kg/m2, and 8.2% had a BMI ≥ 35.0 kg/m2. Surgical complications occurred in 27.7% of patients with a BMI of 18.5-24.9 kg/m2, 26.6% of patients with a BMI of 25.0-29.9 kg/m2 (OR 0.91, 95% CI 0.76-1.10), 28.5% with a BMI of 30.0-34.9 kg/m2 (OR 0.96, 95% CI 0.76-1.21), and 33.2% with a BMI ≥ 35.0 kg/m2 (OR 1.27, 95% CI 0.94-1.71). Modelling BMI as a continuous variable confirmed a J-shaped relationship. The association between BMI and medical complications was more linear.

CONCLUSION

Risk of postoperative complications is increased in patients with obesity undergoing rectal cancer surgery.

Body mass index-based predictions and personalized clinical strategies for colorectal cancer in the context of PPPM

Currently colorectal cancer (CRC) is the third most prevalent cancer worldwide. Body mass index (BMI) is frequently used in CRC screening and risk assessment to quantitatively evaluate weight. However, the impact of BMI on clinical strategies for CRC has received little attention. Within the framework of the predictive, preventive, and personalized medicine (3PM/PPPM), we hypothesized that BMI stratification would affect the primary, secondary, and tertiary care options for CRC and we conducted a critical evidence-based review. BMI dynamically influences CRC outcomes, which helps avoiding adverse treatment effects. The outcome of surgical and radiation treatment is adversely affected by overweight (BMI ≥ 30) or underweight (BMI < 20). A number of interventions, such as enhanced recovery after surgery and robotic surgery, can be applied to CRC at all levels of BMI. BMI-controlling modalities such as exercise, diet control, nutritional therapy, and medications may be potentially beneficial for patients with CRC. Patients with overweight are advised to lose weight through diet, medication, and physical activity while patients suffering of underweight require more focus on nutrition. BMI assists patients with CRC in better managing their weight, which decreases the incidence of adverse prognostic events during treatment. BMI is accessible, noninvasive, and highly predictive of clinical outcomes in CRC. The cost-benefit of the PPPM paradigm in developing countries can be advanced, and the clinical benefit for patients can be improved with the promotion of BMI-based clinical strategy models for CRC.

Relation of Malnutrition and Nosocomical Infections in Cancer Patients in Hospital: An Observational Study

Aim

To investigate the relation between malnutrition and nosocomial infections (NI) in hospitalized cancer patients.

Methods

This observational, cross-sectional, noninterventional, descriptive study was conducted in a 500-bed university hospital in Valencia (Spain). Adult cancer patients admitted to the oncology ward were consecutively enrolled regardless of their nutritional status between November 2019 and March 2020. Patients were nutritionally assessed 24 to 48 hours after admission. Body weight, height and BMI, body composition through measurement of bioelectrical impedance analysis (BIA), and muscle strength and functionality using hand grip strength (HGS) were prospectively collected. The diagnosis of malnutrition and sarcopenia was assessed using the Global Leadership Initiative on Malnutrition (GLIM) criteria and the European Working Group on Sarcopenia in Older People (EWGSOP) criteria, respectively. Patients were followed up during their hospital stay or outpatient oncology visits to identify possible NI.

Results

A total of 107 patients were included in this study (mean age 66 years; 66.4% were men). The most frequent reason for admission was cancer treatment (19.6%), followed by infections (18.7%) and digestive tract symptoms (18.7%). Overall, 77.5% (83/107) of the patients were malnourished at admission according to the GLIM criteria, while 52.3% (56/107) were sarcopenic. Nosocomial infections (NI) were significantly more frequent in malnourished (52.1%; 25/48) and severely malnourished (42.1%; 8/19) patients, compared with well-nourished patients without malnutrition (25%; 10/40; p=0.035). The mean length of hospital stay was 13.9 days, significantly longer in patients with an NI compared to those without infections (18.6 vs. 10.8 days, p < 0.024).

Conclusion

This study evidenced the need to implement a routine protocol for the nutritional assessment and support of cancer patients at risk of malnutrition and sarcopenia to reduce the risk of NI during their hospital stay.

Association of skeletal muscle index with postoperative acute kidney injury in living donor hepatectomy: A retrospective single-centre cohort study

BACKGROUND

Although living donor liver transplantation (LDLT) is the standard treatment option for patients with end-stage liver disease, it always entails ethical concerns about the risk of living donors. Recent studies have reported a correlation between sarcopenia and surgical prognosis in recipients. However, there are few studies of donor sarcopenia and the surgical prognosis of donors. This study investigated the association between sarcopenia and postoperative acute kidney injury in liver donors.

METHODS

This retrospective study analysed 2892 donors who underwent donor hepatectomy for LDLT between January 2008 and January 2018. Sarcopenia was classified into pre-sarcopenia and severe sarcopenia, which were determined to be -1 standard deviation (SD), and -2 SD from the mean baseline of the skeletal muscle index, respectively. Multivariate regression analysis was performed to evaluate the association between donor sarcopenia and postoperative AKI. Additionally, we assessed the association between donor sarcopenia and delayed recovery of liver function (DRHF).

RESULTS

In the multivariate analysis, donor sarcopenia was significantly associated a higher incidence of postoperative AKI (adjusted odds ratio [OR]: 2.65, 95% confidence interval [CI]: 1.15-6.11, P = .022 in pre-sarcopenia, OR: 5.59, 95% CI: 1.11-28.15, P = .037 in severe sarcopenia, respectively). Additionally, hypertension and synthetic colloid use were significantly associated with postoperative AKI. In the multivariate analysis, risk factors of DRHF were male gender, indocyanine green retention rate at 15 minutes, and graft type, however, donor sarcopenia was not a risk factor.

CONCLUSIONS

Donor sarcopenia is associated with postoperative AKI following donor hepatectomy.

Impact of body-mass index on treatment and outcome in locally advanced rectal cancer: A secondary, post-hoc analysis of the CAO/ARO/AIO-04 randomized phase III trial

BACKGROUND

A better understanding of the impact of body-mass index (BMI) on the course of multimodal therapy and oncologic outcome in locally advanced rectal cancer could provide new insights for optimization of treatment and supportive strategies.

PATIENTS AND METHODS

Correlations of BMI with pretreatment clinical, surgical, and pathological characteristics, toxicity and treatment adherence using the Pearson's Chi-squared test or logistic regression were analyzed in the CAO/ARO/AIO-04 III trial cohort (n = 1236). One-way ANOVA or Welch test were used to analyze correlations of baseline blood-parameters and BMI. The prognostic role of BMI was examined with log-rank test and multivariate cox regression.

RESULTS

Obese had a better ECOG performance status (P = 0.027) but were less likely to undergo sphincter preserving surgery (P = 0.01). Post-surgical complications did not differ significantly between BMI classes, whereas underweight was associated with increased neutrophil (P = 0.025) and platelet counts (P < 0.001), poorer TME quality (P = 0.007) and increased incidence of acute organ toxicity (P < 0.001). After a median follow-up of 50 months, underweight [HR 1.896, P = 0.014] and overweight [HR 1.392, P = 0.042] were associated with worse DFS. Obese patients had an increased risk of death [HR 1.653, P = 0.032]. Normalweight men showed superior OS compared to underweight [HR 4.070, P = 0.002], overweight [HR 2.077, P = 0.010], severe overweight [HR 1.886, P = 0.026] and obese [HR 2.046, P = 0.015] men. Adding oxaliplatin to standard CRT significantly improved DFS in obese patients (P = 0.034).

CONCLUSION

In our study, underweight and overweight correlated with inferior DFS, underweight experienced more organ toxicity and obesity was associated with an increased risk of abdominoperineal resection and poorer overall survival.

T stage-dependent lymph node and distant metastasis and the accuracy of lymph node assessment in rectal cancer

Objective

To analyze data obtained in a representative number of patients with primary rectal cancer with respect to lymph node diagnostics and related tumor stages.

Methods

In pT2-, pT3-, and pT4 rectal cancer lesions, the impact of investigated lymph nodes on the frequency of pN+ status, the cumulative risk of metachronous distant metastases, and overall survival was studied by means of a prospective multicenter observational study over a defined period of time.

Results

From 2000 to 2011, the proportion of surgical specimens with ≥ 12 investigated lymph nodes increased significantly, from 73.6% to 93.2% (p < 0.001; the number of investigated lymph nodes from 16.2 to 20.8; p < 0.001). Despite this, the percentage of pN+ rectal cancer lesions varied only non-significantly (39.9% to 45.9%; p = 0.130; median, 44.1%). For pT2-, pT3-, and pT4 rectal cancer lesions, there was an increasing proportion of pN+ findings correlating significantly with the number of investigated lymph nodes up to n = 12 investigated lymph nodes. Only in pT3 rectal cancer was there a significant increase in pN+ findings in case of > 12 lymph nodes (p = 0.001), but not in pT2 (p = 0.655) and pT4 cancer lesions (p = 0.256). For pT3pN0cM0 rectal cancer, the risk of metachronous distant metastases and overall survival did not depend on the number of investigated lymph nodes.

Conclusion

In rectal cancer, at least n = 12 lymph nodes are to be minimally investigated. The investigation of fewer lymph nodes is associated with a higher risk of false-negative pN0 findings. In particular, in pT3 rectal cancer, the investigation of more than 12 lymph nodes lowers the risk of false-negative pN0 findings. An upstaging effect by the investigation of a possibly maximal number of lymph nodes could not be detected.

The usefulness of transanal tube for reducing anastomotic leak in mid rectal cancer: compared to diverting stoma

Purpose

Diverting stoma (DS) and transanal tube (TAT) are the 2 main procedures for reducing anastomotic leak (AL) in rectal cancer surgery. However, few studies have compared the protective effect of the 2 modalities against AL.

Methods

Total of 165 patients with mid rectal cancer, who underwent curative resection from 2012 to 2017, were included. Clinical characteristics and outcomes were compared. Risk factors for AL were identified using multivariate analysis.

Results

The DS group had lower tumor location, higher rates of neoadjuvant concurrent chemoradiotherapy, and longer operative time than the TAT group. However, the level of the anastomosis did not show statistically significant differences (DS: 4.6 cm vs. TAT: 4.9 cm, P = 0.061). AL occurred in 14 of the 165 patients (8.5%), with 10 (10.2%) in the DS group and 4 (6.0%) in the TAT group (P = 0.405). On multivariate analysis, only low body mass index (BMI) and smoking were significantly related to AL. Neither the protection method nor neoadjuvant chemoradiotherapy demonstrated statistical differences in AL. Seven of 10 patients in the DS group who experienced AL were treated conservatively, while all 4 in the TAT group underwent reoperation.

Conclusion

TAT seems to have comparable protective effect against AL to DS. However, in AL, DS appeared to be more effective in preventing reoperation. Therefore, DS is recommended in patients with low BMI or smoking, and with an expected higher probability of morbidity or mortality in case of reoperation. In other cases, TAT may be considered as an alternative to DS.

Influence of Body Mass Index on Long-Term Outcome in Patients with Rectal Cancer-A Single Centre Experience

BACKGROUND

Excess bodyweight is known to influence the risk of colorectal cancer; however, little evidence exists for the influence of the body mass index (BMI) on the long-term outcome of patients with rectal cancer.

METHODS

We assessed the impact of the BMI on the risk of local recurrence, distant metastasis and overall-survival in 612 patients between 2003 and 2010 after rectal cancer diagnosis and treatment at the University Hospital Erlangen. A Cox-regression model was used to estimate the hazard ratio and multivariate risk of mortality and distant-metastasis. Median follow up-time was 58 months.

RESULTS

Patients with obesity class II or higher (BMI ≥ 35 kg/m², n = 25) and patients with underweight (BMI < 18.5 kg/m², n = 5) had reduced overall survival (hazard ratio (HR) = 1.6; 95% confidence interval (CI) 0.9-2.7) as well as higher rates of distant metastases (hazard ratio HR = 1.7; 95% CI 0.9-3.3) as compared to patients with normal bodyweight (18.5 ≤ BMI < 25 kg/m², n = 209), overweight (25 ≤ BMI <30 kg/m², n = 257) or obesity class I (30 ≤ BMI <35 kg/m², n = 102). There were no significant differences for local recurrence.

CONCLUSIONS

Underweight and excess bodyweight are associated with lower overall survival and higher rates of distant metastasis in patients with rectal cancer.