The Relationship Between Clavien-Dindo Morbidity Classification and Oncologic Outcomes After Colorectal Cancer Resection

Validation of the Clavien-Madadi Classification for Unexpected Events in Pediatric Surgery: A Collaborative ERNICA Project

BACKGROUND

The Clavien-Madadi classification is a novel instrument for the assessment and grading of unexpected events in pediatric surgery, based on the Clavien-Dindo classification. The system has been adjusted to better fit the pediatric population in a prospective single-center study. There is a need now to validate the Clavien-Madadi classification within an international expert network.

METHODS

A pediatric surgical working group created 19 case scenarios with unexpected events in a multi-staged process. Those were circulated within the European Reference Network of Inherited and Congenital Anomalies (ERNICA) and surgeons were instructed to rate the scenarios according to the Clavien-Madadi vs. Clavien-Dindo classification.

RESULTS

59 surgeons from 12 European countries completed the questionnaire. Based on ratings of the case scenarios, the Clavien-Madadi classification showed significantly superior agreement rates of the respondents (85.9% vs 76.2%; p < 0.05) and was less frequently considered inaccurate for rating the pediatric population compared to Clavien-Dindo (2.1% vs 11.1%; p = 0.05). Fleiss' kappa analysis showed slightly higher strength of agreement using the Clavien-Madadi classification (0.74 vs 0.69). Additionally, intraclass correlation coefficient was slightly higher for the Clavien-Madadi compared to the Clavien-Dindo classification (ICCjust 0.93 vs 0.89; ICCunjust 0.93 vs 0.89). More pediatric surgeons preferred the Clavien-Madadi classification for the case scenarios (43.0% vs 11.8%; p = 0.002) and advantages of the Clavien-Madadi were confirmed by 81.4% of the surgeons.

CONCLUSION

The Clavien-Madadi classification is an accurate and reliable instrument for the grading of unexpected events in pediatric surgery. We therefore recommend its application in clinical and academic pediatric surgical practice.

LEVEL OF EVIDENCE

III.

Effects of Clavien-Dindo Classification on Long-Term Survival of Patients With Advanced Gastric Cancer After Radical Resection: A Propensity Score-matched Study

BACKGROUND

The impact of postoperative complications (POCs) classified by the Clavien-Dindo (C-D) system on long-term survival after radical resection in patients with advanced gastric cancer (AGC) is not yet clear.

METHODS

This study analyzed 531 patients with AGC who underwent radical resection in an institution between January 2015 and December 2017. Patients were divided into 2 groups according to the occurrence of POCs and recorded according to C-D classifications. The long-term survival outcomes of the entire cohort after propensity score matching (PSM) were compared.

RESULTS

After PSM, there was no significant difference in baseline data between the complications (C) group (n = 92) and the non-complications (NC) group (n = 92). Survival analysis showed that the 5-year overall survival (OS) and relapse-free survival (RFS) were lower in the C group (48.9% vs 62.0%, P = .040; 38.5% vs 54.9%, P = .005; respectively). Subgroup analysis showed that severe complications (C-D grade > II) were associated with a decrease in 5-year OS and RFS compared with the matched NC group (40.0% vs 62.0%, P = .008; 29.4% vs 54.9%, P = .001; respectively). Multivariate analysis confirmed adjuvant chemotherapy, tumor size, and complications were independent risk factors for poor survival outcomes. Further multivariate analysis showed that older age, combined excision, and comorbidities were independent risk factors for POCs.

CONCLUSIONS

Severe complications reduced the survival outcome of patients. More attention should be paid to perioperative management of patients with high risk factors for complications.

Evaluation of the usefulness of the Clavien-Dindo classification of surgical complications

The Clavien-Dindo (CD) classification is widely used in the reporting of surgical complications in scientific literature. It groups complications based on the level of intervention required to resolve them, and benefits from simplicity and ease of use, both of which contribute its to high inter-rater reliability. It has been validated for use in many specialties due to strong correlation with key outcome measures including length of stay, postsurgical quality of life and case-related renumeration. Limitations of the classification include concerns over differentiating grade III and IV complications and not classifying intraoperative complications. The Comprehensive Complication Index is an adaptation of the CD classification which generates a morbidity score from 0 to 100. It has been proposed as a more effective method of assessing the morbidity burden of surgical procedures. However, it remains less popular as calculations of morbidity are complicated and time-consuming. In recent years there have been suggestions of adaptations to the CD classification such as the Clavien-Dindo-Sink classification, while in some specialties, completely new classifications have been proposed due to evidence the CD classification is not reliable. Similarly, the Surgical Expertise and Validity Evaluation project aims to determine benchmarks against which surgeons may compare their own practice.

New scoring system combining computed tomography body composition analysis and inflammatory-nutritional indicators to predict postoperative complications in stage II-III colon cancer

BACKGROUND AND AIM

Postoperative complications are important clinical outcomes for colon cancer patients. This study aimed to investigate the predictive value of inflammatory-nutritional indicators combined with computed tomography body composition on postoperative complications in patients with stage II-III colon cancer.

METHODS

We retrospectively collected data from patients with stage II-III colon cancer admitted to our hospital from 2017 to 2021, including 198 patients in the training cohort and 50 patients in the validation cohort. Inflammatory-nutritional indicators and body composition were included in the univariate and multivariate analyses. Binary regression was used to develop a nomogram and evaluate its predictive value.

RESULTS

In the multivariate analysis, the monocyte-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), nutritional risk score (NRS), skeletal muscle index (SMI), and visceral fat index (VFI) were independent risk factors for postoperative complications of stage II-III colon cancer. In the training cohort, the area under the receiver operating characteristic curve of the predictive model was 0.825 (95% confidence interval [CI] 0.764-0.886). In the validation cohort, it was 0.901 (95% CI 0.816-0.986). The calibration curve showed that the prediction results were in good agreement with the observational results. Decision curve analysis showed that colon cancer patients could benefit from the predictive model.

CONCLUSIONS

A nomogram combining MLR, SII, NRS, SMI, and VFI with good accuracy and reliability in predicting postoperative complications in patients with stage II-III colon cancer was established, which can help guide treatment decisions.

Social inequalities in health: How do they influence the natural history of colorectal cancer?

As regards colorectal cancer (CRC) in France, social inequalities in health (SIH) exist. Underprivileged patients are characterized by reduced incidence of CRC and, conversely, by excess mortality. The explanatory mechanisms of the SIHs influencing survival are complex, multidimensional and variable according to healthcare system. Among the most deprived compared to the least deprived patients, SIHs are reflected by lower participation in screening campaigns, and CRC diagnosis is more frequently given at a later stage in an emergency context. During treatment, disadvantaged patients are more at risk of having to undergo open surgery and of enduring severe postoperative complications and belated chemotherapy (when recommended). Study of SIHs poses unusual challenges, as it is necessary not only to pinpoint social deprivation, but also to locate the different treatment facilities existing in a given territorial expanse. In the absence of individualized socioeconomic information, research in France on the social determinants of health is based on duly constituted cancer registries, in which an ecological index of social deprivation, the European Deprivation Index (EDI), provides an aggregate measure of the socioeconomic environment of a given individual in a given geographical setting at a given point in time. All in all, studies on SIHs are justified as means of identification and comprehension of the mechanisms underlying social deprivation, the objective being to more precisely orient programs and practices aimed at combating SIH.

Neoadjuvant pazopanib in nonrhabdomyosarcoma soft tissue sarcomas (ARST1321): A report of major wound complications from the Children's Oncology Group and NRG Oncology

BACKGROUND AND OBJECTIVES

The impact upon wound healing of targeted molecular therapies, when incorporated into neoadjuvant therapy of soft tissue sarcoma, is largely unknown. Here, we describe wound complications following addition of pazopanib, a tyrosine kinase inhibitor (TKI), to neoadjuvant radiotherapy (RT) +/- chemotherapy for soft tissue sarcoma.

METHODS

Wound complications were evaluated on dose-finding and randomized arms of ARST1321, a phase II/III study incorporating neoadjuvant RT, +/- pazopanib, +/- ifosfamide/doxorubicin (ID) for sarcoma therapy.

RESULTS

Of 85 evaluable patients, 35 (41%) experienced postoperative wound complications. Most (57%) were grade III. Randomization to pazopanib + RT + ID carried a 50% wound complication rate (17/34, with 47% grade III), compared to 22% (5/23) with ID + RT alone. In nonchemotherapy study arms, pazopanib + RT resulted in a 59% wound complication rate versus 25% for those receiving RT alone. Grade III wound complications occurred among 26% (15/58) of all patients receiving pazopanib. Wound complications occurred a median of 35 days postoperatively. Some occurred following diagnostic biopsies and at remote surgical sites.

CONCLUSION

The addition of pazopanib to neoadjuvant chemotherapy and RT resulted in a higher wound complication rate following therapy of soft tissue sarcoma. The rate of grade III complications remained comparable to that reported in contemporary literature.

Prognostic Value of Combined Hematological/Biochemical Indexes and Tumor Clinicopathologic Features in Colorectal Cancer Patients—A Pilot Single Center Study

Colorectal cancer (CRC) is a significant public health problem. There is increasing evidence that the host’s immune response and nutritional status play a role in the development and progression of cancer. The aim of our study was to examine the prognostic value of clinical markers/indexes of inflammation, nutritional and pathohistological status in relation to overall survival and disease free-survival in CRC. The total number of CRC patients included in the study was 111 and they underwent laboratory analyses within a week before surgery. Detailed pathohistological analysis and laboratory parameters were part of the standard hospital pre-operative procedure. Medical data were collected from archived hospital data. Data on the exact date of death were obtained by inspecting the death registers for the territory of the Republic of Serbia. All parameters were analyzed in relation to the overall survival and survival period without disease relapse. The follow-up median was 42 (24−48) months. The patients with the III, IV and V degrees of the Clavien–Dindo classification had 2.609 (HR: 2.609; 95% CI: 1.437−4.737; p = 0.002) times higher risk of death. The modified Glasgow prognostic score (mGPS) 2 and higher lymph node ratio carried a 2.188 (HR: 2.188; 95% CI: 1.413−3.387; p < 0.001) and 6.862 (HR: 6.862; 95% CI: 1.635−28.808; p = 0.009) times higher risk of death in the postoperative period, respectively; the risk was 3.089 times higher (HR: 3.089; 95% CI: 1.447−6.593; p = 0.004) in patients with verified tumor deposits. The patients with tumor deposits had 1.888 (HR: 1.888; 95% CI: 1024−3481; p = 0.042) and 3.049 (HR: 3.049; 95% CI: 1.206−7.706; p = 0.018) times higher risk of disease recurrence, respectively. The emphasized peritumoral lymphocyte response reduced the risk of recurrence by 61% (HR: 0.391; 95% CI: 0.196−0.780; p = 0.005). Standard perioperative laboratory and pathohistological parameters, which do not present any additional cost for the health system, may provide information on the CRC patient outcome and lay the groundwork for a larger prospective examination.

Clinical impact of lactate on postoperative pancreatic fistula after pancreaticoduodenectomy: A single-center retrospective study of 1,043 patients

BACKGROUND/OBJECTIVES

Several hemodynamic markers have been studied to predict postoperative complication which is a risk factor for poor quality of life and prognosis. The aim of this study was to determine whether postoperative lactate clearance could affect clinical outcome based on complications in one surgical patient group.

METHODS

We retrospectively reviewed data from all patients who underwent pancreaticoduodenectomy (PD) at Samsung Medical Center from January 2015 to December 2019. Differences in baseline characteristics of patients, intraoperative outcome, and postoperative outcome were evaluated according to the presence or absence of clinically relevant postoperative pancreatic fistula (CR-POPF).

RESULTS

Among a total of 1107 patients, 1043 patients were tested for arterial lactate levels immediately after surgery, and the day after surgery. Immediately postoperative hyperlactatemia (lactate ≥2.0 mmol/L) was not related to CR-POPF (P = 0.269). However, immediately postoperative hyperlactatemia with a negative lactic clearance on postoperative day (POD) 1 was related to CR-POPF (P = 0.003). In multivariate analyses, non-pancreatic cancer (hazard ratio (HR): 2.545, P < 0.001), soft pancreatic texture (HR: 1.884, P < 0.001), and postoperative hyperlactatemia with negative lactate clearance on POD 1 (HR: 1.805, P = 0.008) were independent risk factors for CR-POPF.

CONCLUSIONS

Hyperlactatemia with negative lactate clearance after PD, one of the high-risk surgeries requiring postoperative ICU care, is a risk factor for CR-POPF. In case of immediately postoperative hyperlactatemia after PD, lactate clearance with serial lactate level follow-up can be used for achieving the hemodynamic goal to prevent CR-POPF.

Permanent stoma after sphincter preservation for rectal cancer. A situation that occurs more often than you might think

Objectives

This study aimed: (i) to assess the cumulative incidence of permanent stoma (PS) after sphincter-preserving surgery (SPS) for rectal cancer (RC): (ii) to analyze associated risk factors for primary and secondary PS; and (iii) to compare the long-term survival of patients according to the stoma state.

Methods

We conducted a retrospective single-center cohort study based on a prospectively maintained database of SRC patients undergoing SPS from January 2007 to December 2017. Incidence of both primary (no reversal of defunctioning stoma) and secondary (created after closure of defunctioning stoma) PS were investigated. Associations between potential risk factors and PS were analyzed using a logistic regression model. Cumulative survival curve was drawn by Kaplan-Meier method.

Results

Of the 257 eligible patients, 43 patients (16.7%) had a PS (16 primary PS and 27 secondary PS) after a median follow-up of 4.8 years. In multivariate analysis, the independent risk factors for primary PS were severe post-operative complications (OR 3.66; 95% CI, 1.19-11.20, p=0.022), and old age (OR 1.11; 95% CI 1.04-1.18, p=0.001) and those for secondary PS were local recurrence (OR 38.07; 95% CI 11.07-130.9, p<0.0001), anastomotic leakage (OR 7.01; 95% CI, 2.23-22.04, p=0.009), and severe post-operative complications (OR 3.67; 95% CI, 1.22-11.04, p=0.02), respectively. Both overall survival (OS) and disease-free survival (DFS) were significantly lower in patients with a PS compared with patients with SPS (p < 0.01).

Conclusions

This present study suggests that one out of 6 patients has a PS, 5 years after rectal resection with SPS for SRC.

Do postoperative infectious complications really affect long-term survival in colorectal cancer surgery? A multicenter retrospective cohort study

Aim

To investigate the impact of postoperative infection (PI), surgical site infection, and remote infection (RI), on long-term outcomes in patients with colorectal cancer (CRC).

Methods

The Japan Society for Surgical Infection conducted a multicenter retrospective cohort study involving 1817 curative stage I/II/III CRC patients from April 2013 to March 2015. Patients were divided into the No-PI group and the PI group. We examined the association between PI and oncological outcomes for cancer-specific survival (CSS) and overall survival (OS) using Cox proportional hazards models and propensity score matching.

Results

Two hundred and ninety-nine patients (16.5%) had PIs. The 5-year CSS and OS rates in the No-PI and PI groups were 92.8% and 87.6%, and 87.4% and 83.8%, respectively. Both the Cox proportional hazards models and propensity score matching demonstrated a significantly worse prognosis in the PI group than that in the No-PI group for CSS (hazard ratio: 1.60; 95% confidence interval: 1.10-2.34; P = .015 and P = .031, respectively) but not for OS. RI and the PI severity were not associated with oncological outcomes. The presence of PI abolished the survival benefit of adjuvant chemotherapy.

Conclusions

These results suggest that PI after curative CRC surgery is associated with impaired oncological outcomes. This survival disadvantage of PI was primarily derived from surgical site infection, not RI, and PI induced lower efficacy of adjuvant chemotherapy. Strategies to prevent PI and implement appropriate postoperative treatment may improve the quality of care and oncological outcomes in patients undergoing curative CRC surgery.

The impact of postoperative complications severity on stoma reversal following sphincter-preserving surgery for rectal cancer

BACKGROUND

Currently, the relationship between temporary stoma reversal and the severity of postoperative complications (POCs) after the index surgery based on the Clavien-Dindo classification has not yet been explored.

METHODS

From July 2010 to June 2016, 380 patients undergoing sphincter-preserving surgery for rectal cancer with a temporary stoma in our hospital were included. Temporary stoma nonclosure rates, disease-free survival rates, and overall survival rates were estimated utilizing the Kaplan-Meier method.

RESULTS

Of all the 380 patients, primary stomas were created in 335 patients and secondary stomas in 45 patients. After the index surgery, 36.6% (139/380) of patients developed at least one postoperative complication. In the first analysis, which included all the patients, 24.7% of temporary stomas remained unclosed. In the second analysis for 335 patients with a primary stoma, 23.3% were left with unclosed stomas. After the COX regression analysis, both major POCs and minor POCs were found to be independent risk factors for the permanent stoma, and there was an increasing tendency toward the risk of permanent stoma with the increase in POC severity.

CONCLUSION

POCs are independent predictors of permanent stoma after rectal cancer surgery. Even minor POCs may affect the outcome, while there is a clear direct relationship between POC severity and permanent stoma rates.

Local complications are related to poor long-term outcome in patients undergoing curative gastrectomy for advanced gastric cancer

PURPOSE

The present study was performed to investigate the effects of local complications (LC) on long-term survival and cancer recurrence in patients undergoing curative gastrectomy for gastric cancer.

METHODS

We analyzed 2,627 patients after curative gastrectomy for gastric cancer between January 2001 and December 2006. Patients were classified into groups no complications (NC), LC, or systemic complications (SC).

RESULTS

Among the 2,627 patients, 475 patients developed complications (LC group [n=374, 14.2%] and SC group [n=101, 3.9%]). The 5-year cancer-specific survival rate was significantly poorer in the LC group compared to the NC and SC groups (LC, 78.0%; NC, 85.4%; SC, 80.2%; P=0.007). The occurrence of LC was identified as a significant independent prognostic factor for overall and cancer-specific survival (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.46-2.97; P=0.001 and HR, 1.77; 95% CI, 1.12-2.81; P=0.015). The tumor recurrence rates were higher in the LC group than the in other two groups (LC, 23.5%; NC, 15.4%; SC, 15.8%; P<0.001). The occurrence of LC was an independent predictor of tumor recurrence in patients undergoing curative gastrectomy for gastric cancer (HR, 1.55; 95% CI, 1.11-2.17; P=0.011).

CONCLUSION

LC are associated with adverse long-term outcomes in patients after curative gastrectomy for advanced gastric cancer.

Poor Pre-operative Nutritional Status Is a Risk Factor of Post-operative Infections in Patients With Gastrointestinal Cancer—A Multicenter Prospective Cohort Study

Objective

This study aimed to assess the prognostic value of the Nutritional Risk Score 2002 (NRS2002) and patient-generated subjective global assessment (PG-SGA) for post-operative infections in patients with gastric cancer (GC) and colorectal cancer (CRC) who underwent curative surgery.

Methods

This prospective study included 1,493 GC patients and 879 CRC patients who underwent curative surgery at 18 hospitals in China between April 2017 and March 2020. The NRS2002 and PG-SGA were performed on the day of admission. The relationship between the nutritional status of patients before surgery and post-surgical incidence of infection was analyzed using univariate and multiple logistic regression analyses.

Results

According to NRS2002, the prevalence of nutritional risk was 51.1% in GC patients and 63.9% in CRC patients. According to the PG-SGA, 38.9% of GC patients and 54.2% of CRC patients had malnutrition. Approximately 4.4% of the GC patients and 9.9% of the CRC patients developed infectious complications after surgery. The univariate and multiple logistic regression analyses showed that the risk of infections was significantly higher in GC patients with a high nutritional risk score (NRS2002 ≥5) than in those with a low score (NRS2002 <3), and the PG-SGA score was identified as a predictor of post-operative infection complications of CRC.

Conclusion

The pre-operative nutritional status of patients with GC or CRC has an impact on post-operative infection occurrence. NRS2002 ≥5 was a risk factor for post-operative infection in patients with GC, and the PG-SGA B/C was a predictor of infections in patients with CRC.

Training prediction models for individual risk assessment of postoperative complications after surgery for colorectal cancer

BACKGROUND

The occurrence of postoperative complications and anastomotic leakage are major drivers of mortality in the immediate phase after colorectal cancer surgery. We trained prediction models for calculating patients' individual risk of complications based only on preoperatively available data in a multidisciplinary team setting. Knowing prior to surgery the probability of developing a complication could aid in improving informed decision-making by surgeon and patient and individualize surgical treatment trajectories.

METHODS

All patients over 18 years of age undergoing any resection for colorectal cancer between January 1, 2014 and December 31, 2019 from the nationwide Danish Colorectal Cancer Group database were included. Data from the database were converted into Observational Medical Outcomes Partnership Common Data Model maintained by the Observation Health Data Science and Informatics initiative. Multiple machine learning models were trained to predict postoperative complications of Clavien-Dindo grade ≥ 3B and anastomotic leakage within 30 days after surgery.

RESULTS

Between 2014 and 2019, 23,907 patients underwent resection for colorectal cancer in Denmark. A Clavien-Dindo complication grade ≥ 3B occurred in 2,958 patients (12.4%). Of 17,190 patients that received an anastomosis, 929 experienced anastomotic leakage (5.4%). Among the compared machine learning models, Lasso Logistic Regression performed best. The predictive model for complications had an area under the receiver operating characteristic curve (AUROC) of 0.704 (95%CI 0.683-0.724) and an AUROC of 0.690 (95%CI 0.655-0.724) for anastomotic leakage.

CONCLUSIONS

The prediction of postoperative complications based only on preoperative variables using a national quality assurance colorectal cancer database shows promise for calculating patient's individual risk. Future work will focus on assessing the value of adding laboratory parameters and drug exposure as candidate predictors. Furthermore, we plan to assess the external validity of our proposed model.

Total Risk Points Predict Short- and Long-term Outcomes Following Colorectal Cancer Resection in Older Patients

BACKGROUND/AIM

Estimation of physiological ability and surgical stress (E-PASS) is reported to be useful as a predictor of postoperative complications and poor long-term survival after colorectal cancer. The total risk points (TRP) system is a simplified scoring system of E-PASS, and this study evaluated the utility of TRP in colorectal cancer resection in older patients.

PATIENTS AND METHODS

The clinicopathological data of 237 patients who underwent curative resection for colorectal cancer from 2015 to 2020 were analyzed retrospectively. The data were compared between a high TRP group (≥1,000, n=38) and a low TRP group (<1,000, n=199). We also conducted an analysis to determine risk factors of postoperative complications and poor long-term survival.

RESULTS

TRP showed statistically significant correlations with the comprehensive risk score (CRS) of E-PASS (R=0.999, p<0.001). The high TRP group experienced postoperative complications (Clavien-Dindo grade ≥2) more frequently (42.1% vs. 11.1%, p<0.001). Multivariate analysis showed that high TRP [odds ratio (OR)=5.214; 95% confidence interval (95%CI)=2.338-11.629; p<0.001] and age ≥80 (OR=2.760; 95%CI=1.308-5.826; p=0.008) were independent predictors of postoperative complications. Overall survival (OS) was poor in the high TRP group (5-year OS, 61.2% vs. 82.6%, p<0.001) compared with the low TRP group, and in the low prognostic nutritional index (<45) group (5-year OS, 70.9% vs. 86.3%, p=0.013) compared with the high prognostic nutritional index (≥45) group. Multivariate analysis showed that high TRP [hazard ratio (HR)=3.202; 95%CI=1.324-7,745; p=0.010] was an independent prognostic factor for poor OS.

CONCLUSION

Patients aged ≥80 years should be closely monitored regarding postoperative complications. Reducing TRP to less than 1,000 is important to reduce postoperative complications and improve OS.

Surgical site infection after laparoscopic resection of colorectal cancer is associated with compromised long-term oncological outcome

Background

We evaluated the influence of infectious complications, particularly surgical site infection (SSI), on long-term oncological results after elective laparoscopic resection of colorectal cancer.

Methods

A total of 199 patients who underwent laparoscopic elective resection with negative resection margins for stage I–III colorectal cancer were retrospectively examined. The postoperative course was recorded based on hospital records, and cancer relapse was diagnosed based on radiological or pathological findings under a standardized follow-up program. The severity of complications was graded using Clavien-Dindo (CD) classification.

Results

SSI was found in 25 patients (12.6%), with 12 (6.0%) showing anastomotic leak. The postoperative relapse-free survival (RFS) rate was significantly lower in patients with SSI (49.2%) than in patients without SSI (87.2%, P<0.001). Differences in RFS were found after both colectomy and rectal resection (P<0.001 and P<0.001, respectively). RFS did not differ between patients who had major SSI CD (grade III) and those who had minor SSI CD (grades I or II). Multivariate Cox regression analysis identified the occurrence of SSI and pathological stage as independent co-factors for RFS (P<0.001 and P=0.003).

Conclusion

These results suggest that postoperative SSI compromises long-term oncological results after laparoscopic colorectal resection. Further improvements in surgical technique and refinements in perioperative care may improve long-term oncological results.

Pre- and Perioperative Inflammatory Biomarkers in Older Patients Resected for Localized Colorectal Cancer: Associations with Complications and Prognosis

Simple Summary

Colorectal cancer is the second most common cancer worldwide, and the incidence increases with age. The primary treatment for localized disease is surgical resection. Biomarkers identifying older patients at risk of complications following surgery are desirable to create a more individualized treatment plan. The purpose of this study is to investigate if circulating proteins related to inflammation (CRP, Il-6, and YKL-40) can provide information about the risk of complications and survival in older patients undergoing resection, and, furthermore, to investigate if this relation is different in older patients as compared to younger patients. We investigated 401 patients with localized colorectal cancer and found that older patients (n = 210) had higher levels of preoperative inflammatory biomarkers compared to younger patients (n = 191). High levels were associated with major complications after resection in older, but not in younger, patients. This may be useful in the future to design more personalized treatment plans.

Abstract

The association between pre- and perioperative inflammatory biomarkers, major complications, and survival rates after resection of colorectal cancer (CRC) in older patients is largely unknown. The aim was to investigate age-dependent differences in these associations. Serum CRP, IL-6, and YKL-40 were measured preoperatively and on the first and second day after resection of CRC (stages I–III) in 210 older (≥70 years) and 191 younger patients (<70 years). The results from the complications was presented as an odds ratio (OR, with a 95% confidence interval (CI)) with logistic regression. Results from the mortality rates were presented as a hazard ratio (HR, with a 95% CI) using Cox proportional hazards regression. The preoperative inflammatory biomarkers were higher in the older vs. the younger patients. The risk of complications was increased in older patients with a high preoperative CRP (OR = 1.25, 95% CI 1.03–1.53), IL-6 (OR = 1.57, 95% CI 1.18–2.08), and YKL-40 (OR = 1.66, 95% CI 1.20–2.28), but not in younger patients. Mortality was higher in younger patients with high preoperative YKL-40 (HR = 1.66, 95% CI 1.06–2.60). This was not found in older patients. Elevated preoperative inflammatory biomarkers among older patients were associated with an increased risk of complications, but not mortality. Preoperative inflammatory biomarkers may be useful in assessing the risk of a complicated surgical course in older patients with CRC.

Postoperative complications after robotic resection of colorectal cancer: An analysis based on 5-year experience at a large-scale center

BACKGROUND

As a common gastrointestinal malignancy, colorectal cancer (CRC) poses a serious health threat globally. Robotic surgery is one of the future trends in surgical treatment of CRC. Robotic surgery has several technical advantages over laparoscopic surgery, including 3D visualization, elimination of the fulcrum effect, and better ergonomic positioning, which together lead to better surgical outcomes and faster recovery. However, analysis of independent factors of postoperative complications after robotic surgery is still insufficient.

AIM

To analyze the incidence and risk factors for postoperative complications after robotic surgery in patients with CRC.

METHODS

In total, 1040 patients who had undergone robotic surgical resection for CRC between May 2015 and May 2020 were analyzed retrospectively. Postoperative complications were categorized according to the Clavien-Dindo (C-D) classification, and possible risk factors were evaluated.

RESULTS

Among 1040 patients who had undergone robotic surgery for CRC, the overall, severe, local, and systemic complication rates were 12.2%, 2.4%, 8.8%, and 3.5%, respectively. Multivariate analysis revealed that multiple organ resection (P < 0.001) and level III American Society of Anesthesiologists (ASA) score (P = 0.006) were independent risk factors for overall complications. Multivariate analysis identified multiple organ resection (P < 0.001) and comorbidities (P = 0.029) as independent risk factors for severe complications (C-D grade III or higher). Regarding local complications, multiple organ resection (P = 0.002) and multiple bowel resection (P = 0.027) were independent risk factors. Multiple organ resection (P < 0.001) and level III ASA score (P = 0.007) were independent risk factors for systemic complications. Additionally, sigmoid colectomy had a lower incidence of overall complications (6.4%; P = 0.006) and local complications (4.7%; P = 0.028) than other types of colorectal surgery.

CONCLUSION

Multiple organ resection, level III ASA score, comorbidities, and multiple bowel resection were risk factors for postoperative complications, with multiple organ resection being the most likely.

The Clinical Utility of the Geriatric Nutritional Risk Index in Predicting Postoperative Complications and Long-Term Survival in Elderly Patients with Colorectal Cancer after Curative Surgery

Simple Summary

Elderly cancer patients usually suffer with malnutrition. Preoperative malnutrition has been considered a poorer prognostic factor in cancer treatment. The geriatric nutritional risk index (GNRI) is a simple tool for predicting the risk of morbidity and mortality in elderly patients by using albumin, height, and body weight parameters. In this study, we evaluated whether GNRI is a reliable marker for postoperative complications and long-term survival. By retrospectively evaluating 1206 CRC patients aged over 75 years who underwent curative-intent surgery at Chang Gung Memorial Hospital, there were significantly more postoperative complications in the low GNRI group (p < 0.001) and GNRI was an independent risk factor for postoperative complications (HR: 1.774, p = 0.037). Overall survival and disease-free survival were significantly worse in the low GNRI group (both p < 0.001) and a GNRI < 98 was statistically identified as an independent prognostic factor for survival. Conclusively, GNRI can be a reliable biomarker in clinical practice.

Abstract

Research on the relationship between the geriatric nutritional risk index (GNRI) and postoperative complications/oncological outcomes in elderly colorectal cancer (CRC) patients is limited. This study investigated the prognostic value of the GNRI in aged CRC patients. We retrospectively analyzed 1206 consecutive CRC patients aged over 75 years who underwent curative-intent surgery from January 2008 to December 2015 and categorized them into high GNRI (≥98) and low GNRI (<98) groups according to a receiver operating characteristic (ROC) curve analysis. Uni- and multivariate logistic regression analysis were used to explore the association of the GNRI with postoperative complications. Kaplan–Meier survival analyses and the Cox proportional hazard model were used to explore the association between GNRI and survival. We discovered that GNRI is an independent risk factor for postoperative complications (HR: 1.774, p = 0.037). Surgical site infection, wound dehiscence and pneumonia were more common in patients with GNRI < 98. Survival analysis showed significantly worse overall survival and disease-free survival in the low GNRI group (both p < 0.001). In the multivariate analysis, GNRI < 98 was an independent risk factor for OS (HR: 1.329, p = 0.031) and DFS (HR: 1.312, p = 0.034). Thus, preoperative GNRI can be effectively used to predict postoperative complications and long-term survival in elderly CRC patients after curative surgery.

Prognostic impact of neoadjuvant chemotherapy in patients with synchronous colorectal liver metastasis: A propensity score matching comparative study

BACKGROUND

Synchronous colorectal liver metastasis (SCRLM) is at an advanced tumor stage and requires multidisciplinary treatments. Neoadjuvant chemotherapy (NAC) is thought to be an effective treatment modality, but its prognostic impact is still unclear.

MATERIALS AND METHODS

Patients with resectable SCRLM presented to eight university hospitals between 2007 and 2017 were retrospectively reviewed. Propensity score matching (PSM) was performed to adjust baseline characteristics between patients who received NAC with those who underwent up-front hepatectomy. The prognostic impact of NAC was then evaluated.

RESULTS

The cohort comprised of 320 patients: 151 patients received NAC and the remaining 169 patients underwent up-front hepatectomy. After a 1:1 ratio of PSM, 102 patients per group were selected. Within the PSM cohort, 66% patients had multiple liver tumors, with 15% having five or more liver tumors. The median survival (95% confidence interval) periods for patients with and without NAC in the PSM cohort were 88.5 (68.4 - not reached) and 84.2 (52.1 - not reached) months, respectively (P = 0.51). On multivariate analysis, the postoperative events in these patients including operative complications and use of adjuvant chemotherapy after hepatectomy were prognostic factors with hazards (95% confidence interval) being 1.88 (1.18-2.98) and 0.65 (0.42-1.01), respectively.

CONCLUSION

This PSM study was restricted to patients with SCRLM and relatively advanced tumor stagings. NAC did not show any significant prognostic impact. While operative complications had a significant prognostic impact, use of adjuvant chemotherapy after hepatectomy had only a marginal prognostic impact. Reconsideration of indications for NAC is needed.

Evaluation of Postoperative Complication with Medically Necessary, Time-Sensitive Scoring System During Acute COVID-19 Pandemic: A Prospective Observational Study

Background

High scores in the Medically Necessary, Time-Sensitive (MeNTS) scoring system, used for elective surgical prioritization during the coronavirus disease 2019 pandemic, are assumed to be associated with worse outcomes. We aimed to evaluate the MeNTS scoring system in patients undergoing elective surgery during restricted capacity of our institution, with or without moderate or severe postoperative complications.

Study Design

In this prospective observational study, MeNTS scores of patients undergoing elective operations during May and June 2020 were calculated. Postoperative complication severity (classified as Group Clavien-Dindo < II or Group Clavien-Dindo ≥ II), as well as Duke Activity Index, American Society of Anesthesiologists (ASA) physical status, presence of smoking, leukocytosis, lymphopenia, elevated C-reactive protein (CRP), operation and anesthesia characteristics, intensive care requirement and duration, length of hospital stay, rehospitalization, and mortality were noted.

Results

There were 223 patients analyzed. MeNTS score was higher in the Clavien-Dindo ≥ II Group compared with the Clavien-Dindo < II Group (50.98 ± 8.98 vs 44.27 ± 8.90 respectively, p < 0.001). Duke activity status index (DASI) scores were lower, and American Society of Anesthesiologists physical status class, presence of smoking, leukocytosis, lymphopenia, elevated CRP, and intensive care requirement were higher in the Clavien-Dindo ≥ II Group (p < 0.01). Length of hospital stay was longer in the Clavien-Dindo ≥ II Group (15 [range 2–90] vs 4 [1–30] days; p < 0.001). Mortality was observed in 8 patients. Area under the receiver operating characteristic curve of MeNTS and DASI were 0.69 and 0.71, respectively, for predicting moderate/severe complications.

Conclusions

Although significant, MeNTS score had low discriminating power in distinguishing patients with moderate/severe complications. Incorporation of a cardiovascular functional capacity measure could improve the scoring system.

The impact of postoperative complications and delay of adjuvant chemotherapy on oncological outcomes in patients with colorectal cancer

AIM

Postoperative complications are believed to result in poorer long-term oncological outcomes. The contribution of time to chemotherapy has not been analysed in detail. Our aim was to examine the association between postoperative complications and long-term oncological outcomes and overall survival, and the influence of delay in chemotherapy on these outcomes.

METHOD

The study was a nationwide register-based observational study that included patients undergoing surgery for colorectal cancer and receiving adjuvant chemotherapy in Denmark between 2010 and 2015. Information regarding postoperative complications was obtained from the Danish Colorectal Cancer Group national clinical registry. A Cox regression model was used to estimate disease-free survival, recurrence-free survival and all-cause mortality in patients surviving for 180 days or more after surgery.

RESULTS

A total of 4083 patients were included, of whom 690 had postoperative complications. Postoperative complications were associated with increased odds of delay to adjuvant chemotherapy (odds ratio 4.56, 95% CI 3.67-5.66, p < 0.0001). An unadjusted analysis revealed that patients with complications had poorer disease-free survival and recurrence-free survival and had increased all-cause mortality. In multivariate analysis, postoperative complications were not associated with poorer disease-free survival [hazard ratio (HR) 1.02, 95% CI 0.88-1.18, p = 0.80] recurrence-free survival (HR 1.05, 95% CI 0.89-1.25, p = 0.56) or all-cause mortality (HR 1.04, 95% CI 0.86-1.26, p = 0.67).

CONCLUSION

This study showed no association between the occurrence of postoperative complications and long-term prognosis when adjusting for time to adjuvant chemotherapy.

Clinical Validation of the Comprehensive Complication Index in Colon Cancer Surgery

(1) Introduction: To date, the sensitivity of the Comprehensive Complication Index (CCI) in a homogeneous cohort of colonic resections for oncologic purposes has not been reported. The present study aims to compare the CCI with the conventional Clavien-Dindo classification (CDC) in colon cancer patients. (2) Methods: The clinical data of patients submitted to an elective colectomy for adenocarcinoma were retrieved from a prospectively maintained database. Postoperative complications and length of stay were reviewed, and CDC and CCI scores were calculated for each patient. The association of the CCI and the CDC with the length of stay, prolongation of stay and readmission rate were assessed and compared. (3) Results: The overall postoperative morbidity was 26.9%. In particular, 157 (20.4%) patients had more than one complication. A strong correlation between the two scoring systems was observed (r = 99.4%; 95%CI: 99.3-99.5%). In multivariate analysis, CCI had a higher predictive ability for all endpoints. Regarding subgroup analysis, the difference between the CCI and CDC was progressively increased when evaluating outcome measures in complicated and multi-complicated patients. (4) Conclusion: Both scoring systems adequately report the overall burden of postoperative complications. The CCI showed a greater ability than the CDC to predict hospital stay, particularly in patients with multiple postoperative complications.

Computed tomography-measured body composition parameters do not influence survival in non-metastatic colorectal cancer

BACKGROUND

There is an increasing interest in studying the impact of altered body composition parameters and colorectal cancer (CRC) treatment outcomes. The aim of this study is to explore the impact of computed tomography (CT)-measured visceral obesity, sarcopenia and myosteatosis on survival of non-metastatic CRC.

METHODS

Consecutive patients with stage I-III CRC who underwent curative-intent treatment between January 2010 and December 2015 were included. By measuring the visceral fat area, and the skeletal muscle index and radiodensity in the pre-operative staging CT, patients were classified as visceral obese, sarcopenic or myosteatotic. The associations between CT-based body composition parameters and survival were assessed using log-rank tests and a Cox regression analysis.

RESULTS

Of 359 patients, 263 (73.3%) were visceral obese, 85 (23.7%) sarcopenic and 80 (22.3%) myosteatotic. Overall (OS), cancer-specific (CSS) and disease-free survivals (DFS) at 5 years were 78.8%, 84.7% and 75%, respectively. Myosteatosis and the combination of myosteatosis and visceral obesity were associated with a reduced DFS (hazard ratio 1.67; 95% confidence interval 1.06-2.61 and hazard ratio 1.85; 95% confidence interval 1.15-2.96, respectively). However, after performing a multivariate analysis including other relevant clinicopathological factors, none of the body composition parameters were associated with any long-term outcome measures, even after stratifying by cancer stage.

CONCLUSIONS

CT-measured body composition parameters do not independently influence survival in non-metastatic CRC. There is a need for larger cohort studies with standardized patient selection and methodology to confirm these findings.

The Impact of Postoperative Complications on Long-Term Oncological Outcomes Following Curative Resection of Colorectal Cancer (Stage I-III): A Systematic Review and Meta-Analysis

Background and objective

The incidence of post-surgical complications (PSCs) after curative resection of non-metastatic colorectal cancer (CRC) is very widespread and evident. Some studies suggest that PSCs often predict poor long-term oncological outcomes. However, the available data on the topic is often controversial. The aim of this systematic review and meta-analysis was to study the effect of postoperative complications (POCs) on long-term oncological outcomes following curative resection of non-metastatic (stage I-III) CRC.

Methods

A comprehensive search of MEDLINE® and Excerpta Medica dataBASE (EMBASE) databases was performed via the Ovid platform, by using controlled vocabulary as well as natural language terms for POCs, outcomes, and CRC. Two authors independently screened the studies and extracted data. Conflicts were resolved by discussion among authors and also independently with the help of a third author. Meta-analysis was performed using a random-effects model (REM) to calculate pooled estimates for overall survival (OS), disease-free survival (DFS), and overall recurrence.

Results

Overall, 3,836 studies were initially screened, and 16 studies involving 37,192 patients were ultimately selected for final inclusion in the analysis. Meta-analysis of these studies showed that PSCs following non-metastatic CRC surgery predicted worse OS rates [hazard ratio (HR): 1.36; 95% CI: 1.15-1.61; p<0.00001], DFS (HR: 1.41; 95% CI: 1.11-1.80; p<0.00001), and overall recurrence (HR: 1.19; 95% CI: 1.04-1.37; p=0.01).

Conclusion

Based on our findings, PSCs predict poor OS rates, DFS, and overall recurrence following curative resection of non-metastatic CRC.

The impact of comorbidities on post-operative complications following colorectal cancer surgery

Background

Colorectal cancer surgery is complex and can result in severe post-operative complications. Optimisation of surgical outcomes requires a thorough understanding of the background complexity and comorbid status of patients.

Aim

The aim of this study is to determine whether certain pre-existing comorbidities are associated with high grade post-operative complications following colorectal cancer surgery. The study also aims to define the prevalence of demographic, comorbid and surgical features in a population undergoing colorectal cancer resection.

Method

A colorectal cancer database at The Prince Charles Hospital was established to capture detailed information on patient background, comorbidities and clinicopathological features. A single-centre retrospective study was undertaken to assess the effect of comorbidities on post-operative outcomes following colorectal cancer resection. Five hundred and thirty-three patients were reviewed between 2010–2018 to assess if specific comorbidities were associated with higher grade post-operative complications. A Clavien-Dindo grade of three or higher was defined as a high grade complication.

Results

Fifty-eight percent of all patients had an ASA grade of ASA III or above. The average BMI of patients undergoing resection was 28 ± 6.0. Sixteen percent of all patients experienced a high grade complications. Patients with high grade complications had a higher mean average age compared to patients with low grade or no post-operative complications (74 years vs 70 years, p = 0.01). Univariate analysis revealed patients with atrial fibrillation, COPD, ischaemic heart disease and heart failure had an increased risk of high grade complications. Multivariate analysis revealed pre-existing atrial fibrillation (OR 2.70, 95% CI 1.53–4.89, p <0.01) and COPD (OR 2.02 1.07–3.80, p = 0.029) were independently associated with an increased risk of high grade complications.

Conclusion

Pre-existing atrial fibrillation and COPD are independent risk factors for high grade complications. Targeted perioperative management is necessary to optimise outcomes.

Associations of Postoperative Complications Assessed by Clavien-Dindo Classification and Comprehensive Complication Index with Long-Term Overall Survival in Elderly Patients after Radical CRC Resection

Background

Advancing age is associated with high incidence of colorectal cancer (CRC) and high rates of postoperative complications (POCs). However, the impact of of POC severity — evaluated by Clavien–Dindo classification (CDC) or comprehensive complication index (CCI) — on long-term overall survival (OS) in elderly patients after radical CRC resection is not clear.

Methods

Elderly patients aged 65 years or more with CRC undergoing radical resection were retrospectively recruited. POC details were collected and evaluated using CDC grades and the CCI, blinded to patients’ other information. Risk factors for CDC grade ≥II POCs were analyzed by multivariate logistic regression. Effects of CDC grade II–IV POCs on long-term OS were analyzed via propensity-score matching (PSM) analysis followed by Kaplan–Meier curve plotting and multivariate Cox proportional-hazard regression adjusted for all potential confounders. The prognostic value of the CCI was also explored and compared with CDC grades.

Results

A total of 614 elderly patients were identified, of which 20, 106, 25, 11, and 13 cases experienced CDC grade I, II, III, IV, and V POCs, respectively. Higher age, female sex, coronary heart diseases, family history of tumors, preoperative anemia, high amount of bleeding during operation, and high positive dissected lymph–node ratio were found to be risk factors for CDC grade II–V POCs. After PSM analyses, CDC grade II–IV POCs were identified to be associated with poor long-term OS, which was also verified in the entire cohort. The CCI was also found to be significantly associated with decreased long-term OS and showed prognostic values similar to CDC grades.

Conclusion

Both CDC grades and the CCI can be used to evaluate POCs and are associated with long-term OS in elderly patients undergoing radical CRC resection.

Are oncological long-term outcomes equal after laproscopic completed and converted laparoscopic converted rectal resection for cancer?

BACKGROUND

The aim of this study was to compare long-term survival after laproscopic completed and laparoscopic converted rectal resection for cancer.

METHODS

All consecutive patients who underwent curative laparoscopic rectal surgery for cancer at our institution between January 2001 and December 2016 were included in a single-center retrospective study. Patients were divided into two groups: the converted (CONV) group and the totally laparoscopic (LAP) group. The primary outcomes were long-term oncologic outcomes including overall survival (OS) and disease-free survival (DFS), as well as local and distant recurrence (LR, DR). The secondary outcomes included postoperative mortality and morbidity as defined as death or any complication occurring within 90 days postoperatively.

RESULTS

Of 214 consecutive patients included, 57 were converted to open surgery (CONV group), leading to a 26.6% conversion rate. Mean length of follow-up was 68 ± 42 months in the LAP group and 70 ± 41 months in the CONV group. Five-year OS was significantly shorter in the CONV group compared to the LAP group (p = 0.0016). On multivariate analysis, rectal tumor location (middle and low) and conversion to open surgery were predictors of both OS and DFS.

CONCLUSIONS

This study suggests that conversion to open surgery after laparoscopic rectal resection appears to significantly reduce OS without having a significant impact on DFS and recurrence rates.

Social deprivation aggravates post-operative morbidity in carcinologic colorectal surgery: Results of the COINCIDE multicenter study

AIM OF THE STUDY

Evaluate the impact of social deprivation on morbidity and mortality in surgery for colorectal cancer.

METHODS

The COINCIDE prospective cohort included nearly 2,000 consecutive patients operated on for colorectal cancer at the Assistance Publique-Hospitals of Paris (AP-HP) from 2008 to 2010. The data on these patients were crossed with the PMSI administrative database. The European Social Deprivation Index (EDI) was calculated for each patient and classified into five quintiles (quintiles 4 and 5 being the most disadvantaged patients). Thirty-day post-operative morbidity was determined according to the Dindo-Clavien classification, with a Had®Hoc re-analysis of each file. Statistical analysis was performed using the proprietary Q-finder® algorithm.

RESULTS

One thousand two hundred and fifty nine curative colorectal resections were analyzed. Mortality was 2.7% and severe morbidity (Dindo-Clavien≥3) occurred in 16.4%. Mortality was not statistically significantly increased among the most disadvantaged who made up almost two thirds of the population (64.2%). Patients in quintiles 4 and 5 had a statistically significant increase in severe morbidity. The relative risk remained 1.5 even after adjustment for the known risk factors found in the analysis: age>70 years, ASA score, urgency, and laparotomy.

CONCLUSIONS

The EDI represents an independent risk factor for severe morbidity after carcinologic colorectal resection. This study suggests that the determinants of health are multidimensional and do not depend solely on the quality and performance of the care system. The inclusion of this index in our surgical databases is therefore necessary, as is its use in health policy for the distribution of resources.

Examination of Prognostic Factors Affecting Long-Term Survival of Patients with Stage 3/4 Gallbladder Cancer without Distant Metastasis

In advanced gallbladder cancer (GBC) radical resection, if multiple prognostic factors are present, the outcome may be poor; however, the details remain unclear. To investigate the poor prognostic factors affecting long-term surgical outcome, we examined 157 cases of resected stage 3/4 GBC without distant metastasis between 1985 and 2017. Poor prognostic factors for overall survival and treatment outcomes of a number of predictable preoperative poor prognostic factors were evaluated. The surgical mortality was 4.5%. In multivariate analysis, blood loss, poor histology, liver invasion, and ≥4 regional lymph node metastases (LNMs) were independent prognostic factors for poor surgical outcomes; invasion of the left margin or the entire area of the hepatoduodenal ligament and a Clavien–Dindo classification ≥3 were marginal factors. The analysis identified outcomes of patients with factors that could be predicted preoperatively, such as liver invasion ≥5 mm, invasion of the left margin or the entire area of the hepatoduodenal ligament, and ≥4 regional LNMs. Thus, the five-year overall survival was 54% for zero factors, 34% for one factor, and 4% for two factors (p < 0.05). A poor surgical outcome was likely when two or more factors were predicted preoperatively; therefore, new treatment strategies are required for such patients.

The Geriatric Nutritional Risk Index predicts postoperative complications and prognosis in elderly patients with colorectal cancer after curative surgery

Malnutrition has been considered to be associated with the prognosis of cancer. The Geriatric Nutritional Risk Index (GNRI), based on serum albumin levels, present body weight, and ideal body weight, is a simple screening tool to predict the risk of nutrition-related morbidity and mortality in elderly patients. We aimed to evaluate whether preoperative GNRI was associated with postoperative complications and prognosis in elderly patients with colorectal cancer (CRC). We retrospectively enrolled 313 CRC patients aged ≥65 years after curative surgery and classified them into an all-risk GNRI (≤98) group and a no-risk GNRI (>98) group. Kaplan-Meier analysis showed overall survival was significantly worse in the all-risk GNRI group than in the no-risk GNRI group (P = 0.009). Multivariable analyses showed low GNRI (≤98) was an independent risk factor for postoperative complications (P = 0.048) and overall survival (P = 0.001) in the patients. Among the complications, the incidence of surgical site infection, in particular, was significantly higher in the all-risk GNRI group (P = 0.008). In conclusion, low preoperative GNRI (≤98) was associated with increased postoperative complications and poor prognosis. Preoperative GNRI can be used as an identifier for potential high-risk group of morbidity and mortality in elderly CRC patients.

L-Arginine/NO Pathway Metabolites in Colorectal Cancer: Relevance as Disease Biomarkers and Predictors of Adverse Clinical Outcomes Following Surgery

The L-Arginine/NO pathway is involved in carcinogenesis and immunity. Its diagnostic and prognostic value in colorectal cancer (CRC) was determined using tandem mass spectrometry in 199 individuals (137 with CRC) and, during a three-day follow up, in 60 patients undergoing colorectal surgery. Citrulline was decreased and asymmetric (ADMA) and symmetric (SDMA) dimethylarginines and dimethylamine (DMA) were increased in CRC. The DMA increase corresponded with CRC advancement while arginine, ADMA, and SDMA levels were higher in left-sided cancers. Arginine, citrulline, ADMA, and DMA dropped and SDMA increased post incision. Females experienced a more substantial drop in arginine. The arginine and ADMA dynamics depended on blood loss. The initial SDMA increase was higher in patients requiring transfusions. Postoperative dynamics in arginine and dimethylarginines differed in robot-assisted and open surgery. Concomitant SDMA, citrulline, and DMA quantification displayed a 92% accuracy in detecting CRC. Monitoring changes in arginine, ADMA, and SDMA in the early postoperative period predicted postoperative ileus with 84% and surgical site infections with 90% accuracy. Changes in ADMA predicted operative morbidity with 90% and anastomotic leakage with 77% accuracy. If positively validated, L-arginine/NO pathway metabolites may facilitate CRC screening and surveillance, support differential diagnosis, and assist in clinical decision-making regarding patients recovering from colorectal surgery.

Can better surgical outcomes be obtained in the learning process of robotic rectal cancer surgery? A propensity score-matched comparison between learning phases

BACKGROUND

Although studies of robotic rectal cancer surgery have demonstrated the effects of learning on operation time, comparisons have failed to demonstrate differences in clinicopathological outcomes between unadjusted learning phases. This study aimed to investigate the learning curve of robotic rectal cancer surgery for clinicopathological outcomes and compare surgical outcomes between adjusted learning phases. Study design We enrolled 506 consecutive patients with rectal adenocarcinoma who underwent robotic resection by a single surgeon between 2007 and 2018. Risk-adjusted cumulative sum (RA-CUSUM) for surgical failure was used to analyze the learning curve. Surgical failure was defined as the occurrence of any of the following: conversion to open surgery, severe complications (Clavien-Dindo grade ≥ 3a), insufficient number of harvested lymph nodes (LNs), or R1 resection. Comparisons between learning phases analyzed by RA-CUSUM were performed before and after propensity score matching.

RESULTS

In RA-CUSUM analysis, the learning curve was divided into two learning phases: phase 1 (1st-177th cases, n = 177) and phase 2 (178th-506th cases, n = 329). Before matching, patients in phase 2 had deeper tumor invasion and higher rates of positive LNs on pretreatment images and preoperative chemoradiotherapy. After matching, phase 1 (n = 150) and phase 2 (n = 150) patients exhibited similar clinical characteristics. Phase 2 patients had lower rates of surgical failure overall and these components: conversion to open surgery, severe complications, and insufficient harvested LNs.

CONCLUSIONS

For robotic rectal cancer surgery, surgical outcomes improved after the 177th case. Further studies by other robotic surgeons are required to validate our results.

The association between preoperative fatigue and instrumental activities in daily living with complications and length of hospital stay in patients undergoing colorectal surgery

BACKGROUND

The incidence of colorectal cancer (CRC) is highest among the elderly. An important treatment modality is surgery. After surgery, due to poor functional recovery, some elderly have an increased risk for complications and prolonged length of hospital stay (LOS). Preoperative elevated levels of fatigue and impaired functioning in instrumental activities of daily living (iADL) might be associated with these outcomes, and may, therefore, be helpful to recognize patients with elevated risk for complications or prolonged LOS, who should undergo more thorough functional assessment.

AIMS

This exploratory study aims to assess whether physical fatigue, reduced activity and/or iADL, assessed preoperatively, are associated with postoperative complications and prolonged LOS, in elderly patients undergoing surgery for CRC.

METHODS

We performed an exploratory prospective study in older (≥ 65 years) patients (n = 57) who were scheduled to undergo elective surgery for colorectal cancer. Fatigue and iADL functioning were assessed with questionnaires. Multivariable regression analyses were used to examine the relationship of fatigue and iADL with complications and LOS.

RESULTS

IADL was not associated with complications or LOS. Fatigue was not associated with complications. Patients with higher fatigue had increased LOS in the univariable analyses but not in the multivariable analyses after adjustment for nutritional status and neoadjuvant treatment.

DISCUSSION

We found that fatigue was associated with increased LOS in the univariable analysis. The results from the multivariable analysis and path analysis indicate, however, that this is likely not a causal relationship; the observed relationship between physical fatigue and LOS appears to be confounded by nutritional status and by having received neoadjuvant treatment.

CONCLUSIONS

Although fatigue is a predictor for increased LOS, assessment of fatigue and iADL has no additional value for identifying elderly at risk for poor functional outcome after CRC surgery.

The influence of postoperative complications on long-term prognosis in patients with colorectal carcinoma

BACKGROUND

The impact of postoperative complications (POCs) on the long-term prognosis of patients with colorectal carcinoma was analysed with respect to their severity according to the Clavien-Dindo classification (CDC).

METHODS

The prospectively collected data of 2158 patients who underwent curative resection of a colorectal carcinoma (1168 rectal carcinomas, 990 colon carcinomas) without distant metastases from 1995 to 2014 were analysed. The POCs were documented in a standardized form and graded with the CDC. Patients who died postoperatively (CDC grade V, 1.7%) were excluded.

RESULTS

In total, 467 patients (21.6%) had POCs: CDC I, 141 (6.5%); CDC II, 162 (7.5%); CDC III, 112 (5.2%); and CDC IV, 52 (2.4%). More POCs and higher CDC grades were found in men, ASA III-IV patients, rectal carcinoma patients, and patients who underwent abdominoperineal excisions or multivisceral resections. The 5-year locoregional recurrence rate was 5.3% in patients without POCs and 6.6% in patients with POCs. It was highest in CDC III patients (12.9%), which was confirmed in multivariate analysis (HR 2.2; p = 0.005). The 5-year distant metastasis rate was 15.9% in CDC 0 patients and 19.5% in CDC I-IV patients. In multivariate analysis, distant metastasis was highest in CDC III patients (HR 1.7; p = 0.020). The 5-year overall survival rate was 83.5% in patients without POCs and 73.5% in patients with POCs. It was worst in CDC IV patients (63.1%), which was confirmed by multivariate analysis (HR 1.9; p = 0.001).

CONCLUSION

Patients with POCs after colorectal surgery have a poor long-term prognosis. As the CDC grade increases, survival deteriorates.

Systematic assessment of complications after robotic-assisted total versus distal gastrectomy for advanced gastric cancer: A retrospective propensity score-matched study using Clavien-Dindo classification

BACKGROUND

Despite increasing evidence demonstrated robot-assisted distal gastrectomy (RADG) is safe and feasible for the treatment of advanced gastric cancer (AGC), robot-assisted total gastrectomy (RATG) remains a challenging procedure due to its technical difficulties and possible postoperative complications (POCs). This study aimed to systematically evaluate POCs following RATG.

METHODS

Between January 2017 and January 2019, 319 AGC patients with pathological stage T2-4aN0-3M0 who underwent RADG or RATG were enrolled. POCs were stratified using the Clavien-Dindo classification. One-to-one propensity score matching was performed to reduce confounding differences.

RESULTS

After matching, 266 patients met the criteria for further analysis. Ultimately, 64 patients (24.1%) who developed POCs had 126 clinical manifestation events. Overall the POCs rate was significantly greater after RATG in comparison with RADG (29.3% vs. 18.8%; P = 0.045), and more major POCs (Clavien-Dindo grade ≥ IIIa) were observed in the RATG group (14.3% vs. 5.3%; P = 0.013). The POCs were then classified into local and systemic POCs. The rates of local POCs (35.3% vs. 19.5%; P = 0.004) and systemic POCs (24.8% vs. 15.0%; P = 0.046) were significantly higher in the RATG group than the RADG group. Subgroup analysis showed that the anastomotic leakage rate was higher after RATG (5.3% vs. 0.8%; P = 0.031), whereas the remaining POCs were similar between the two groups. Patients with higher POCs significantly had longer postoperative length of stay (R = 0.895, P = 0.003). Multivariate analysis confirmed age, extent of resection, and TNM stage were risk factors for all POCs.

CONCLUSIONS

These findings demonstrated that RATG is technically feasible and safe for treatment of AGC with acceptable morbidity and mortality rates. The POCs rate of RATG was higher than RADG, especially for anastomotic leakage. More effective anastomotic techniques are needed in RATG to prevent leakage.

Distinct Prognosis of High Versus Mid/Low Rectal Cancer: a Propensity Score-Matched Cohort Study

BACKGROUND

Rectal cancers have long been treated as a single-entity disease; however, whether the prognosis of high rectal cancer (inferior margin located 10.1 to 15.0 cm from the anal verge) differs from that of mid/low rectal cancer (0 to 10.0 cm) remains disputed.

METHODS

Patients with stages I-III rectal adenocarcinomas undergoing curative-intent surgery were enrolled between 2007 and 2013 in this retrospective analysis. Exclusion criteria were neoadjuvant therapy or concurrent cancers. Propensity score matching and Cox regression analysis were performed to compare a 5-year overall and cancer-specific survival between patients with high and mid/low rectal cancer.

RESULTS

Of 613 patients who met the inclusion criteria, 199 (32.5%) and 414 (67.5%) had high and mid/low rectal cancer, respectively. After propensity score matching (187 cases for each group), the high group showed a better overall survival (70.9 vs. 56.9%, p = 0.042) and cancer-specific survival (77.4 vs. 60.3%, p = 0.028) at 5 years compared with the mid/low group with stage III disease. However, high rectal cancer did not demonstrate prognostic superiority in stages I-II disease. Multivariate analysis identified high tumor location as an independent prognostic factor for cancer-specific survival (hazards ratio = 0.422, 95% confidence interval 0.226-0.786, p = 0.007) and overall survival (hazards ratio = 0.613, 95% confidence interval 0.379-0.991, p = 0.046).

CONCLUSIONS

Patients with stage III high rectal adenocarcinoma demonstrated better overall and cancer-specific survival than those with mid/low type, and tumor location was an independent prognostic factor for patients with rectal carcinomas.

Perioperative lymphocytopenia predicts mortality and severe complications after intestinal surgery

Background

Patterns of white blood cells differential count with low lymphocyte number have been associated with poor outcome following sepsis, burns and trauma. Lymphocytopenia, measured preoperatively or in response to surgical stress, may affect complications after bowel resection.

Methods

Clinical characteristics and white blood cells differential count values, measured both pre- and post-operatively of a cohort of patients submitted to intestinal resection and anastomosis from June 2014 to June 2017 in our General Surgery Division, were retrospectively analyzed. Multivariate logistic regression was used to determine the dependence of mortality and postoperative complications from the clinical characteristics of patients and white blood cells differential count values.

Results

A total of 301 consecutive patients were studied; 165 (54.8%) were male; mean age was 70 years. Overall, the rate of in-hospital 30-day mortality was 4%. Post-operative morbidity was observed in 124 (41.2%). On multivariate analysis, age adjusted Charlson Comorbidity Index, low preoperatively lymphocyte count, high preoperative monocyte count, high postoperative neutrophil count and anastomotic leak were independently associated with increased in-hospital mortality. Preoperative lymphocytopenia and rectal resection were independently associated with high morbidity rate, while low postoperative lymphocyte count was associated with an increased risk of anastomotic leak.

Conclusions

Perioperative lymphocytopenia is associated with 30-days mortality, severe complications and anastomotic leak after bowel resection surgery. These routinely available laboratory data could help to identify patients at high-risk for developing complications.

Postoperative complications following colonic resection for cancer are associated with impaired long-term survival

AIM

Surgery for colorectal cancer is associated with a high incidence of postoperative complications. The aim of this study was to analyse whether postoperative complications following radical resection for colorectal cancer are associated with increased recurrence rate and impaired survival.

METHOD

Patients operated for colon cancer between 2007 and 2009 with curative intent were identified through the Swedish Colorectal Cancer Registry. The cohort was divided into three subgroups: patients who developed severe postoperative complications, patients who developed non-severe complications and patients who did not develop any complication (controls).

RESULTS

Of 6779 patients included in the study, 640 (9%) developed severe complications, 994 (15%) non-severe complications and 5145 (76%) had no complications. The 5-year overall survival rate was 60.3% in the severe complication group, 64.2% in the non-severe complication group and 72.8% in the control group (P < 0.01). The 3-year disease-free survival rate was 66.8%, 70.9% and 77.8% respectively (P < 0.01). The recurrence rate did not differ between the three groups. In multivariate analysis, both severe and non-severe complications were found to be risk factors for decreased overall survival at 5 years [hazard ratio (HR) 1.38, 95% CI 1.47-1.92, and HR 1.18, 95% CI 1.27-1.60 respectively; P < 0.05) as well as for decreased 3-year disease-free survival (HR 1.37, 95% CI 1.14-1.65, and HR 1.26, 95% CI 1.08-1.48 respectively; P < 0.05).

CONCLUSION

Complications after colonic resection for cancer are associated with impaired 5-year overall survival and 3-year disease-free survival and exhibit more severe postoperative complications, mainly via mechanisms other than cancer recurrence.

Severity and incidence of complications assessed by the Clavien-Dindo classification following robotic and laparoscopic gastrectomy for advanced gastric cancer: a retrospective and propensity score-matched study

BACKGROUND

Robot-assisted gastrectomy (RAG) has been increasingly used for the treatment of advanced gastric cancer (AGC), and many advantages over laparoscopy-assisted gastrectomy (LAG) have been reported. However, its postgastrectomy complications still under investigation and the results remain controversial. This study aimed to objectively assess the incidence and severity of complications following RAG vs. LAG using Clavien-Dindo (C-D) classification and to identify risk factors related to complications.

METHODS

Five hundred and twenty-seven patients with AGC who underwent RAG or LAG between January 2016 and May 2018 were enrolled in this study. Complications were categorized according to the C-D classification. The complications following RAG and LAG were compared using one-to-one propensity score matching (PSM) analysis and subgroup analyses. Logistic regression analyses were performed to identify risk factors related to complications.

RESULTS

RAG was performed in 251 patients (47.6%) and LAG in 276 patients (52.4%). Before PSM, the RAG group had a smaller tumour size (P = 0.004) and less patients with previous abdominal operation (P = 0.013). After PSM, a well-balanced cohort of 446 patients (223 in each group) was further analyzed. Of interest, the incidence of overall and severe complications (C-D grade ≥ IIIa) following the RAG group were significantly fewer than the LAG group (overall, 24.5% vs. 18.8%, P < 0.001; severe, 8.9% vs. 17.5%, P = 0.002). Subgroup analyses showed statistically significant difference were also observed in most stratified parameters. Multivariable analysis identified age ≥ 65 years, total gastrectomy, stage T3-T4a, stage II-III, and operation time ≥ 250 min as independent predictors of overall complications. Additionally, age ≥ 65 years, stage II-III, and operation time ≥ 250 min were confirmed as independent risk factors for severe complications.

CONCLUSIONS

RAG with D2 lymphadenectomy is feasible and safe for the treatment of AGC in terms of the lower incidence and severity of complications.

Relationship between Clavien-Dindo classification and long-term survival outcomes after curative resection for gastric cancer: A propensity score-matched analysis

BACKGROUND

The impact of postoperative complications (POCs) on the long-term survival outcomes after curative resection for gastric cancer has seldom been reported. The purpose of this study was to evaluate the relationship between the severity of POCs and long-term survival outcomes after curative resection for gastric cancer.

METHODS

The study analyzed 3091 patients who underwent curative resection for gastric cancer in a single center between June 2009 and June 2015. Patients were divided into two groups based on the occurrence or absence of postoperative complications which were recorded using the Clavien-Dindo classification. Long-term survival outcomes were compared between groups after propensity score matching (PSM).

RESULTS

A total of 3091 patients were included in the entire cohort. After PSM, no significant difference in baseline data was observed between the complications (C) group (n = 375) and no complications (NC) group (n = 375). With a median follow-up of 51 months, POCs were associated with decreased 5-year overall survival (OS) (51.7% vs. 67.5%, P < 0.001), disease-free survival (DFS) (49.9% vs. 65.6%, P < 0.001), and disease-specific survival (DSS) (53.9% vs. 68.8%, P < 0.001). Increasing Clavien-Dindo grades from II to IV was significantly associated with a corresponding decrease in OS (60, 48.3, 34%, P = 0.010), DFS (58.3, 46.3, 32.1%, P < 0.001) and DSS (62.9, 50.3, 34%, P < 0.001). Multivariate analysis confirmed POCs was an independent prognostic factor for decreased OS, DFS, and DSS (all P < 0.05).

CONCLUSIONS

POCs had a negative impact on long-term survival outcomes after curative resection for gastric cancer. The negative effects were also increased with higher Clavien-Dindo grades.

Severity of complications and long-term survival after laparoscopic total gastrectomy with D2 lymph node dissection for advanced gastric cancer: A propensity score-matched, case-control study

BACKGROUND

Increasing numbers of studies have shown that postoperative complication is a negative predictor of long-term survival outcomes in various malignancies. However, the impact of severity of complications on long-term survival for patients with gastric cancer still remains unclear. This study aimed to explore the relationship between the severity of complications and long-term survival outcomes after laparoscopic total gastrectomy (LTG) for advanced gastric cancer (AGC).

METHODS

The study analyzed 571 patients with AGC who underwent LTG in a single institution between April 2008 and June 2015. Patients were divided into two groups based on the occurrence or absence of postoperative complications which were recorded using the Clavien-Dindo (C-D) classification. Long-term survival outcomes were compared between groups in the propensity score-matched cohort.

RESULTS

The groups were well balanced after the propensity score matched. The complication (C) group was associated with decreased 5-year cancer-specific survival (CSS) (65.1% vs. 76.2%, P=0.049). Subgroup analysis showed that the severe complication (C-D grade > II) group was associated with decreased 5-year overall survival (OS) (46.3% vs. 65.9%, P = 0.042) and cancer-specific survival (CSS) (53.7% vs. 74.4%, P = 0.030). However, a comparative analysis of 5-year OS and CCS showed no significant differences between the minor complication (C-D grade II) group and matched NC group (68.9% vs. 72.2%, P = 0.578; 75.6% vs. 77.8%, P = 0.649; respectively). Multivariate analysis confirmed severe complication was an independent risk factor for decreased OS. Further analysis showed that older age, lower body mass index (BMI), and combined resection were independent risk factor for the occurrence of severe complications.

CONCLUSIONS

Severe complications adversely affected long-term survival outcomes after LTG with D2 lymph node dissection for AGC. More attention should be paid to patients at high risk for severe complications in preoperative assessment and postoperative management.