Efficacy and safety of oral probiotic supplementation in mitigating postoperative surgical site infections in patients undergoing colorectal cancer surgery: A systematic review and meta-analysis

Surgical site infections (SSIs) pose significant risks to patients undergoing colorectal cancer (CRC) surgery. With increasing evidence on the benefits of oral probiotics in various clinical contexts, there is a need to assess their efficacy and safety in reducing SSIs following CRC surgery. A systematic review and meta-analysis were conducted in line with PRISMA guidelines using the PICO framework. On 19 September 2023, four major databases (PubMed, Embase, Web of Science and Cochrane Library) were searched without any temporal or language restrictions. Rigorous inclusion and exclusion criteria were employed. Data extraction was independently undertaken by two assessors, and any discrepancies were discussed. The Cochrane Collaboration's risk of bias instrument was utilized to assess study quality. The meta-analysis incorporated a fixed-effects model or random-effects model based on the I2 statistic to assess heterogeneity. The initial search yielded 1282 articles, of which 10 met the inclusion criteria and were analysed. Probiotic administration not only significantly reduced the incidence of SSIs but also curtailed the duration of hospital stays. Moreover, the subgroup analysis indicated that interventions employing multiple strains of probiotics were more effective in reducing postoperative infections than those utilizing a single strain. Probiotics effectively prevent postoperative infections and shorten hospital stays. Multi-strain probiotics outperform single strain in efficacy. Future studies should focus on their safety and optimal clinical use.

Mucinous Differentiation in Colorectal Cancer: A 10-Year Experience Audit at King Faisal Specialist Hospital and Research Centre, Jeddah

Given that colorectal cancer is one of the leading causes of mortality, mucinous adenocarcinoma is one of the subtypes and is characterized by the presence of mucin-producing tumor cells with mucin components and is more challenging to manage. In Saudi Arabia, it represents approximately 10-15% of all colorectal carcinoma. The main etiological cause of mucinous adenocarcinoma is yet not well understood. The main goal of our study is to discuss the histopathology and the molecular background of mucinous colorectal adenocarcinoma and also to provide an update on its prognosis and therapeutics from recent published literature. It is a retrospective cohort study that was conducted at King Faisal Specialist Hospital, Jeddah, Saudi Arabia. The study included 68 adult patients diagnosed with mucinous colon cancer, who did surgical resection alone or with or without adjuvant chemotherapy following from January 2011 to December 2020. The mucinous subtypes are found more commonly in the proximal colon. In our study, 26 patients (38.2% of the cases) were right-sided and 35 patients (51.5%) were from the left side, but these included the rectum as well and this reflects the higher incidence of diagnosis of rectal cancer in the region. Most tumors were classified as Grade II in 56 patients (82.4%), consistent with the intermediate differentiation status often associated with the mucinous subtypes. The most common symptom at presentation was abdominal pain in 38 patients (55.9%) followed by per rectal bleeding and abdominal mass. The management in our study was in line with the standard established practice and surgical resection as expected was the primary potentially curative approach. Notably of patients presenting with locally advanced rectal cancer, six patients underwent concomitant chemoradiotherapy followed by surgery and four patients had upfront surgery. The duration of the median follow-up was 32 months. At the time of analysis, 30 patients (44.1%) were alive and remained on regular follow-up, 17 patients (25%) had succumbed to the disease, and 21 patients (30.9%) were lost to follow-up. The median overall survival was not reached, and notably, 49 patients (71.6%) remained alive at the four-year mark. Whilst our study contributes to the current understanding of mucinous adenocarcinomas of the colon, further research in molecular profiling and genomic testing and larger clinical trials with tailored treatments is necessary to refine treatment strategies and improve outcomes.

Evaluating traditional Chinese medicine (TCM) Jie Geng and Huang Qi combination on reducing surgical site infections in colorectal cancer surgeries: A systematic review and meta-analysis

Postoperative wound infections (PWIs) pose a significant challenge in colorectal cancer surgeries, leading to prolonged hospital stays and increased morbidity. This systematic review and meta-analysis evaluated the efficacy of the traditional Chinese medicine (TCM) combination of Jie Geng and Huang Qi in reducing PWIs following colorectal cancer surgeries. Adhering to PRISMA guidelines, we focused on seven randomized controlled trials (RCTs) involving 1256 patients, examining the incidence of PWIs within 30 days post-surgery, alongside secondary outcomes such as length of hospital stay and antibiotic use. The analysis revealed a significant reduction in PWI incidence in the TCM-treated group compared to controls, with a Risk Ratio of 0.21 (95% CI: 0.14 to 0.30, p < 0.01), a notable decrease in hospital stay (Mean Difference: 1.2 days, 95% CI: 0.15 to 1.28 days, p < 0.01) and a significant reduction in antibiotic use (Risk Ratio: 0.24, 95% CI: 0.16 to 0.36, p < 0.01). These findings suggest that Jie Geng and Huang Qi in TCM could be an effective adjunct in postoperative care for colorectal cancer surgeries, underscoring the need for further high-quality RCTs to substantiate these results and explore the underlying mechanisms.

Unusual Presentation of a Granulocytic Sarcoma

A granulocytic sarcoma is an unusual tumor outside of bone marrow. It is composed of immature cells of the granulocytic cell line. We present a rare case of a 76-year-old male with a history of myelodysplastic syndrome who presented with a large bowel obstruction secondary to lesions at the cecum and transverse colon. He underwent exploratory laparotomy with extended right hemicolectomy. A pathological examination confirmed a granulocytic sarcoma as the cause of the obstruction.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Colorectal Cancer Surgery: Influence of Psychosocial Factors

(1) Background: In the treatment of colorectal cancer, it is important to consider different psychosocial factors. Our first objective was to measure the levels of perceived stress in subjects diagnosed with colorectal cancer awaiting potentially curative surgery. Also, we aimed to analyse what coping styles these patients used, how they perceived their illness, and the subsequent influence of these factors on their levels of stress. (2) Methods: Stress, coping styles and illness perception were assessed in a sample of 107 patients. The instruments used were the Perceived Stress Scale (PSS-14), the Stress Coping Questionnaire (SCQ) and the Brief Illness Perception Questionnaire (BIPQ-R). (3) Results: Patients using active coping styles have lower levels of perceived stress (p = 0.000; p = 0.002) than patients making use of passive coping styles (p = 0.000; p = 0.032; p = 0.001). A multi-linear regression model found that the perception of illness and the use of the negative approach coping style (p = 0.000; p = 0.001) influence an increase in perceived stress, and that a decrease in stress levels was influenced by the problem solving coping style (p = 0.001). (4) Conclusions: Based on our results, we recommend preventive interventions in care patients undergoing colorectal cancer surgery.

Incidence and clinical predictors of 30-day emergency readmission after colorectal cancer surgery - A nationwide cohort study

AIM

The aim of this study was to investigate the risk and predictors of 30-day emergency readmission and surgical reintervention after discharge from colorectal cancer surgery with curative intent in Denmark.

METHOD

This is a retrospective cohort study using Danish nationwide registry data. We included all patients who underwent colorectal tumour resection with curative intent between 1 January 2005 and 1 December 2018. The primary outcome was 30-day emergency readmission, defined as any emergency hospital visit within 30 days of discharge. Secondary outcomes were 30-day emergency readmission with a minimum duration of 2 days and 30-day emergency readmission including any abdominal procedure. Twenty-three candidate predictors including patient comorbidities, tumour characteristics, surgical treatment and length of stay were evaluated using multivariate logistic regression models. Length of stay was categorized into percentiles and standardized according to year of surgery.

RESULTS

Of the 40 782 patients included in the study, 8360 (20.5%) were readmitted within 30 days of discharge. Median time to readmission was 6 days (interquartile range 2-15 days). A total of 4968 patients (12.2%) were readmitted for at least 2 days, and 793 patients (1.9%) underwent an abdominal procedure during their readmission. The strongest predictors of 30-day readmission were length of stay below the fifth percentile (OR 2.36; P < 0.001) and American Society of Anesthesiologists score IV (OR 2.21; P < 0.001).

CONCLUSION

Emergency readmission is frequent after colorectal cancer surgery with curative intent, and almost 10% of readmitted patients require surgical reintervention. An increased focus on predicting preventable readmissions might facilitate interventions to reduce morbidity and hospital expenses.

Effect of a Patient Blood Management system on perioperative transfusion practice and short-term outcomes of colorectal cancer surgery

BACKGROUND

Patients undergoing colorectal cancer surgery may require a blood transfusion. However, blood transfusions are associated with postoperative complications and long-term oncologic outcomes. Patient blood management (PBM) is an evidence-based multimodal approach for blood transfusion optimisation. We sought to investigate the effects of PBM implementation in blood transfusion practice and on short-term postoperative outcomes.

MATERIALS AND METHODS

This study retrospectively reviewed data from 2,080 patients who had undergone colorectal cancer surgery at a single centre from 2015 to 2020. PBM was implemented in 2018, and outcomes were compared between the pre-PBM (2015-2017) and the post-PBM (2018-2020) periods.

RESULTS

A total of 951 patients in the pre-PBM group and 1,129 in the post-PBM group were included. The transfusion rate of the total number of packed red blood cells (PRBCs) used decreased after PBM implementation (16.3 vs 8.3%; p<0.001). The rate of appropriately transfused PRBCs increased from the pre-PBM period to the post-PBM period (42 vs 67%; p<0.001). There was no significant difference in rates of complications between the two groups (23.0 vs 21.5%; p=0.412); however, a reduction in both anastomosis leakage (5.8 vs 3.7%; p=0.026) and the length of stay after surgery (LOS) (10.3±11.2 vs 8.2±5.7 days; p<0.001) was reported after PBM implementation.

DISCUSSION

The PBM programme optimised the transfusion rate in patients undergoing colorectal cancer surgery. Implementation of the PBM programme had a positive effect on postoperative length of stay and anastomosis leakage while no increase in the risk of other complications was reported.

The patient perspective on the preoperative colorectal cancer care pathway and preparedness for surgery and postoperative recovery-a qualitative interview study

BACKGROUND AND OBJECTIVES

This study aimed to explore colorectal cancer (CRC) patients' perspectives and experiences regarding the preoperative surgical care pathway and their subsequent preparedness for surgery and postoperative recovery.

METHODS

CRC patients were recruited using purposive sampling and were interviewed three times (preoperatively, and 6 weeks and 3 months postoperatively) using semistructured telephone interviews. Interviews were audiotaped, transcribed verbatim and analysed independently by two researchers using thematic analysis with open coding.

RESULTS

Data saturation was achieved after including 18 patients. Preoperative factors that contributed to a feeling of preparedness for surgery and recovery were patient-centred- and professional healthcare organization, sincere and personal guidance, and thorough information provision. Postoperatively, patients with complications or physical complaints experienced unmet information needs regarding the impact of complications and what to expect from postoperative recovery.

CONCLUSIONS

The preoperative period is a vital period to prepare patients for surgery and recovery in which patients most value personalized information, personal guidance and professionalism. According to CRC patients, the feeling of preparedness for surgery and recovery can be improved by continually providing dosed information. This information should provide the patient with patient-tailored perspectives regarding the impact of (potential) complications and what to expect during recovery.

Inhalation anaesthesia compared with total intravenous anaesthesia and postoperative complications in colorectal cancer surgery: an observational registry-based study†

BACKGROUND

Postoperative complications are common after colorectal surgery, and possibly related to the type of anaesthesia. We aimed to determine associations between the type of anaesthesia and complications after colorectal cancer surgery using Danish registries.

METHODS

Patients undergoing colorectal cancer surgery (2004-18) were identified in the Danish Colorectal Cancer Group Database. The cohort was enriched with the Danish Anaesthesia Database and Danish National Prescription Registry data linked by Danish Central Person Registration number. Patients were classified according to type of general anaesthesia: inhalation or TIVA. Confounders were adjusted by propensity score matching. The primary outcome was complications within 30 days postoperatively. Secondarily, we assessed specific medical and surgical complications.

RESULTS

We identified 22 179 individuals undergoing colorectal cancer surgery with accompanying anaesthesia data. Propensity score matching yielded 8722 individuals per group. After propensity score matching, postoperative complications were seen in 1933 (22.2%) patients undergoing inhalation anaesthesia and in 2199 (25.2%) undergoing TIVA (odds ratio [OR]=0.84; 95% confidence interval [CI], 0.79-0.91). Although no difference was observed for medical complications, 1369 (15.7%) undergoing inhalation anaesthesia had surgical complications compared with 1708 (19.6%) undergoing TIVA (OR=0.76; 95% CI, 0.71-0.83). Rates of wound dehiscence, anastomotic leak, ileus, wound abscess, intra-abdominal abscess, and sepsis were statistically significantly lower in the inhalation anaesthesia group.

CONCLUSION

In this propensity score-matched registry study, use of inhalation anaesthesia was associated with fewer postoperative complications after colorectal cancer surgery than use of TIVA. Inhalation anaesthesia was associated with fewer complications related to wound healing and surgical infections.

The health-related quality of life changes following surgery in patients with colorectal cancer: a longitudinal study

BACKGROUND

Colorectal cancer (CRC) is commonly treated with surgery and its success is frequently defined by cure rates. Impact on other aspects of health and wellbeing are less frequently considered in clinical practice. Patient-reported outcome measures (PROMs) provide a useful means of assessing such impacts. This study examines changes in health-related quality of life (HRQoL) after surgical resection using PROMs.

METHODS

A prospective, longitudinal study was undertaken in 49 adults receiving curative surgery for CRC. Participants completed the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) before surgery, and at 2 to 4 weeks, 3 and 6 months post-surgery. Linear mixed models were used to analyse FACT-C wellbeing and subscale scores.

RESULTS

Patients reported a clinically important deterioration in functional and physical wellbeing 2 to 4 weeks post-surgery (both P < 0.05); differences at 6 months after surgery were trivial. Conversely, patients reported clinically important improvement in emotional wellbeing at 2 to 4 weeks post-surgery; this improvement was sustained at 3 and 6 months post-surgery (all P < 0.05). For social wellbeing and colorectal cancer-specific concerns, changes from before surgery at follow-up assessments were not statistically significant (all P > 0.05).

CONCLUSION

While physical aspects of HRQoL are affected in the short term by CRC surgery, clinically significant improvement in emotional wellbeing are reported early (2 to 4 weeks post-surgery). Future research may help identify patients who are at greater risk of surgical impacts on health and wellbeing.

Aerobic fitness and muscle density play a vital role in postoperative complications in colorectal cancer surgery

Background and Objectives

To assess the association of preoperative aerobic fitness and body composition variables with a patient's resilience to the development and impact of postoperative complications after elective colorectal cancer (CRC) surgery.

Methods

Preoperative aerobic fitness was assessed by steep ramp test performance. Preoperative body composition was assessed by muscle mass and density determined from preoperative computed tomography scan analysis at the L3‐level. Complication development and severity was graded according to Clavien‐Dindo. Complication impact was assessed by the time to recovery of physical functioning after complications. Multivariable logistic regression analyses adjusted for age, sex, comorbidities and tumour location was performed.

Results

Of 238 included patients, 96 (40.3%) developed postoperative complications. Better preoperative aerobic fitness decreased the likelihood to develop complications, independent of muscle mass (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.35−0.85) or muscle density (OR: 0.57, 95% CI: 0.36−0.89). A prolonged time to recovery following complications was associated with lower preoperative muscle density (OR: 4.14, 95% CI: 1.28−13.41), independent of aerobic fitness.

Conclusions

Lower aerobic fitness increases the risk of complication development, while low muscle density seems associated with a prolonged recovery from complications. Aerobic fitness and muscle density could be valuable additives to preoperative risk assessment.

Colorectal cancer surgery in elderly patients 80 years and older: a comparison with younger age groups

BACKGROUND

A reduction in complications and mortality can be observed over the last few decades among elderly patients in the early postoperative period for colorectal cancer (CRC) surgery, but long-term outcomes are largely unknown. This study aimed to investigate the long-term outcomes of elderly patients 80 years and older after CRC surgery in comparison with younger age groups. The influence of clinical, oncological, and physical parameters on outcome were retrospectively analyzed.

METHODS

A total of 346 patients underwent CRC surgery with curative intent between January 2013 and December 2017. Patients were divided into three age groups: younger than 60 (n=47), between 60 and 79 (n=218), and 80 and older (n=81). Clinicopathological variables including comorbidity, modified frailty index, prognostic nutrition index (PNI), operative/postoperative data, and outcome including cause of death were compared among age groups. To identify factors associated with death from CRC and other causes, univariate and multivariate analyses using the Cox proportional hazards model were performed.

RESULTS

Immediate postoperative morbidity of patients with Clavien-Dindo grades of III or greater (16.0%) and the 30-day mortality rate (2.5%) of patients 80 years and older were not statistically different from those of younger age groups. Long-term disease-free survival was also similar among age groups, suggesting CRC surgery provides oncological benefit to patients irrespective of age. Multivariate analysis revealed that R1 resection, advanced tumor stage, carcinoembryonic antigen (CEA) level of >5 ng/mL, undifferentiated tumor, and longer postoperative hospital stay were risk factors for CRC death. Long-term overall survival was significantly reduced in comparison to younger age groups. Seventy percent of deaths in elderly patients during follow-up were primarily from respiratory failure and cardiovascular disease. Multivariate analysis demonstrated that advanced age, frailty, low PNI, and open procedure were risk factors for other causes of mortality.

CONCLUSIONS

Elderly patients undergoing CRC surgery appeared to enjoy similar oncological benefits as younger age groups. Since both modified frailty index and PNI were correlated with mortality unrelated to CRC, preoperative assessment of these factors can be important for predicting outcome and selecting patients for prehabilitation.

Is Single-Dose Antimicrobial Prophylaxis Sufficient to Control Infections in Gastrointestinal Oncological Surgeries?

Surgical site infections (SSIs) represent one of the most important complications occurring postoperatively following surgical procedures. The SSI incidence is higher following gastrointestinal (GI) surgeries compared to any other surgery. It contributes to the majority of morbidity and mortality in patients undergoing GI surgeries. The accepted practice worldwide for the prevention and control of SSIs is providing antimicrobial prophylaxis. The appropriate antimicrobial and dose are chosen depending on the microbial flora, complications, and patient risk factors. The objective of this review was to determine the sufficient number of prophylactic antimicrobial doses that would be efficacious and safe in controlling the SSIs following GI oncological surgeries. Single-dose antimicrobial prophylaxis has shown the same efficacy as the multiple-dose antimicrobial regimen in controlling SSIs in esophageal, gastric, and colorectal surgeries. The advantages of a single-dose regimen include less chance of emergence of resistance, less chance for allergies or toxicity, and less cost. The addition of metronidazole with single-dose antimicrobial prophylaxis in colorectal surgery should be considered due to its beneficial effect in further reducing infections. Further randomized controlled trials are needed for the literature to determine the efficacy and safety of single-dose antimicrobial prophylaxis in patients undergoing esophageal and colorectal surgeries. In addition, studies are required to determine the individual effectiveness of metronidazole in controlling SSIs in colorectal surgeries.

Hyaluronate carboxymethylcellulose sheets for the prevention of adhesive complications: a model-based cost-utility analysis

AIM

Clinical trials suggest that hyaluronate carboxymethylcellulose (HA/CMC) prevents adhesion-related complications after intra-abdominal surgery, but at a high upfront cost. This study evaluated the cost-effectiveness of HA/CMC for patients undergoing curative-intent open colorectal cancer surgery.

METHODS

Using a Markov Monte Carlo microsimulation model, we conducted a cost-utility analysis comparing the cost-effectiveness of HA/CMC at curative-intent open colorectal cancer surgery versus standard management. We considered a scenario where HA/CMC was used at the index operation only, as well as where it was used at the index operation and any subsequent operations. The perspective was that of the third-party payer. Costs and utilities were discounted 1.5% annually, with a 1-month cycle length and 5-year time horizon. Model input data were obtained from a literature review. Outcomes included cost, quality-adjusted life-years (QALYs), small bowel obstructions (SBOs) and operations for SBO.

RESULTS

Using HA/CMC at the index operation results in an incremental cost increase of CA$316 and provides 0.001 additional QALYs, for an incremental cost-effectiveness ratio of CA$310,000 per QALY compared to standard management. In our simulated cohort of 10,000 patients, HA/CMC prevented 460 SBOs and 293 surgeries for SBO. Probabilistic sensitivity analysis found that HA/CMC was cost-effective in 18.5% of iterations, at a cost-effectiveness threshold of CA$50,000 per QALY. Results of the scenario analysis where HA/CMC was used at the index operation and any subsequent operations were similar.

CONCLUSIONS

Hyaluronate carboxymethylcellulose prevents adhesive bowel obstruction after open colorectal cancer surgery but is unlikely to be cost-effective given minimal long-term impact on healthcare costs and QALYs.

Indications and long-term outcomes of preoperative inferior vena caval filters in 111 patients at high risk of pulmonary embolism undergoing major abdominal surgery

AIMS

Patients with abdominal cancer requiring major surgical intervention are at high risk of venous thromboembolic events (VTE), particularly pulmonary emboli (PE). A proportion of patients with cancer can present with, or have had, major VTEs prior to definitive surgical treatment. Preoperative percutaneous inferior venal caval filters (IVCF) may reduce the risk of PE. The aim of this study was to assess the indications, complications, retrieval rates, and long-term outcome of IVCFs in patients undergoing major abdominal surgery.

METHODS

This was a retrospective analysis of a prospective IVCF database between 2007 and 2018 of all patients with IVCF insertion prior to major abdominal surgery. The indications for an IVCF, procedural complications and surgical interventions were recorded.

RESULTS

Overall, 111 patients had IVCF insertion. IVCF placement failed in one patient with gross abdominal disease. Indications for an IVCF were: prior PE in 65/111 (59%) and major vein thrombus in 42 (38%). Overall, 26/111 (23%) had the IVCF removed at a median of 91 days. In two patients IVCF removal failed. At follow-up of the 85 patients who had the IVCF left in situ, six developed filter-related thrombus and 13 a deep vein thrombosis (DVT). Four patients had a PE with an indwelling IVCF.

CONCLUSION

Preoperative IVCF may reduce perioperative PE in patients at high risk of thrombosis undergoing major abdominal surgery where early anticoagulation is contraindicated. Long-term follow-up of retained IVCF suggests that major problems are infrequent, though further thrombosis may occur and long-term anticoagulation may be needed.

Surgical Outcomes of Colorectal Cancer Surgery for ≥ 85-year-old Patients in Our Hospital: Retrospective Comparison of Short- and Long-term Outcomes with Younger Patients

OBJECTIVES

To evaluate future problems in colorectal cancer surgery for elderly patients.

METHODS

We conducted a retrospective review of patients receiving colorectal cancer surgery in our hospital from January 2010 to December 2018. Patients were divided into the ≥ 85-year-old patient group and the younger patient group. We compared patient backgrounds, surgical outcomes (surgical procedure, reduction of lymph node dissection range, operative duration, and blood loss), postoperative short-term outcomes (mortality, morbidity, and postoperative length of stay) and prognosis.

RESULTS

We performed colorectal cancer surgery on 1,240 patients during the study period. Of them, 109 (8.7%) were ≥ 85 years old, and 1,131 (91.2%) were < 85 years old. The American Society of Anesthesiologists physical status (ASA-PS) was significantly poorer in the elderly group than in the younger group and patients with a history of cardiac disease and anticoagulant use were significantly more in the elderly group. The rate of reduction of lymph node dissection range was significantly higher in the elderly group (16.8% vs. 3.8%, p < 0.05). Overall morbidity was significantly higher in the elderly group (42.2% vs. 21.9%, p < 0.05), as were the respective frequencies of pneumonia and thromboembolism (8.2% vs. 0.7%, p < 0.05 and 3.6% vs. 0.8%, p < 0.05, respectively). Postoperative hospital stay was significantly longer in the elderly group (17 vs. 12 days, p < 0.05). Overall survival was significantly lower in the elderly group (p < 0.05), but relapse-free survival and colorectal cancer-specific survival were not statistically different between the groups (p = 0.05 and p = 0.15, respectively).

CONCLUSIONS

Prevention of postoperative pneumonia and thromboembolism remains a problem. After proper assessment and careful management of peri-operative surgical risks, surgery can be indicated in elderly patients.

Long-term health-related quality of life following colorectal cancer surgery: patient-reported outcomes in a remote follow-up population

AIM

Remote follow-up (RFU) after colorectal cancer (CRC) surgery allows delivery of surveillance tests without the need for regular outpatient clinical appointments. However, little is known about health-related quality of life (HRQoL) in RFU patients. The main aim of this study was to quantify HRQoL in our RFU population to identify particular patient groups that may benefit from a more personalised approach to follow-up, including access to a survivorship clinic.

METHOD

EQ-5D, QLQ-C30 and QLQ-C29 questionnaires were distributed to CRC patients enrolled in a RFU programme. The primary outcome of HRQoL scores was analysed by year of RFU, demographics, operation type, stoma and adherence to RFU protocols.

RESULTS

A total of 428 respondents were included, with a mean age of 71 years (SD 10.1 years) and a median RFU time of 2.6 years [interquartile range (IQR) 1.6-4.8 years]. 'Perfect health' was reported by 26.6% of patients. The median EQ-5D index score was 0.785 (IQR 0.671-1) and the median QLQ-C30 Global HRQoL score was 75 (IQR 58.3-83.3). Women had a significantly lower EQ-5D median score of 0.767 (IQR 0.666-0.879, P = 0.0088). Lower QLQ-C30 HRQoL scores were seen in stoma patients (median 66.6, IQR 58.3-83.3, P = 0.0029). Erectile dysfunction (P = 0.0006) and poor body image (P = 0.001) were also reported more frequently in stoma patients. Patients undergoing right-sided resection reported a lower median EQ-5D score of 0.765 (IQR 0.666-0.879, P = 0.028) and higher pain severity (P = 0.0367) compared with left-sided resections. There were 128 (29.4%) patients who breached RFU protocol and were seen in ad hoc colorectal clinics. However, there was no statistical difference in HRQoL between patients who adhered to or breached RFU protocols.

CONCLUSION

Overall HRQoL in patients in RFU is good, with no difference in those strictly followed up remotely. However, women, patients with right-sided resection and patients with a stoma may require additional clinical reviews.

Clinical application of accelerated rehabilitation surgery in elderly patients with colorectal cancer

BACKGROUND

Gastrointestinal malignant tumors are the most common malignant tumors in elderly people in China, resulting in an increasing trend of morbidity and mortality. We conducted a non-randomized controlled trial to compare the effect of enhanced recovery after surgery (ERAS) versus Routine care on clinical outcomes in elderly patients after colorectal cancer surgery.

METHODS

This is a single center, non-random, parallel-controlled clinical trial, 60 patients aged ≥65 years will be randomized for Case group ERAS and Control group (routine care).

RESULTS

This study will help to evaluate the clinical feasibility, safety and effectiveness of ERAS in elderly patients undergoing colorectal resection compared with routine care.

PROTOCOL REGISTRATION NUMBER

ChiCTR2000034984.

SARS-CoV-2 pandemic: implications in the management of patients with colorectal cancer

The SARS-CoV-2 pandemic has already reached 3,207,248 patients with more than 225,000 deaths all over the world. Colorectal cancer is the third most diagnosed cancer worldwide, and the healthcare system is struggling to manage daily activities for elective cancer surgery. This review integrates clinical, microbiological, architectural and surgical aspects to develop indications on strategies to manage colorectal cancer patients and ensure safety during the pandemic. Telephone or virtual clinics must be encouraged and phone follow-up should be implemented. Indications for surgery must be rigorous, balancing the advantage of early surgical treatment and risks of treatment delay. To decrease the occupancy rate of intensive care unit beds, elective surgical treatment should be delayed until local endemic control, according to stage of disease. Patients with SARS-CoV-2 infection should be treated only after clinical recovery, two consecutive negative oropharyngeal swabs and, if available, a negative stool sample. Before any elective oncologic procedure, a multidisciplinary oncologic team including an anaesthesiologist and an infectious disease specialist must assess every patient to evaluate the risk of infection and its impact on perioperative morbidity, mortality and oncologic prognosis. The hospital should organise to manage all elective oncologic patients in an 'infection-free' area or refer them to a non-SARS-CoV-2 hospital.

Renin-angiotensin system blocker use and the risk of acute kidney injury after colorectal cancer surgery: a population-based cohort study

OBJECTIVES

It is unknown whether preoperative use of ACE inhibitors (ACE-I) or angiotensin receptor blockers (ARBs) affects the risk of acute kidney injury (AKI) after colorectal cancer (CRC) surgery. We assessed the impact of preoperative ACE-I/ARB use on risk of AKI after CRC surgery.

DESIGN

Observational cohort study. Patients were divided into three exposure groups-current, former and non-users-through reimbursed prescriptions within 365 days before the surgery. AKI within 7 days after surgery was defined according to the current Kidney Disease Improving Global Outcome consensus criteria.

SETTING

Population-based Danish medical databases.

PARTICIPANTS

A total of 9932 patients undergoing incident CRC surgery during 2005-2014 in northern Denmark were included through the Danish Colorectal Cancer Group Database.

OUTCOME MEASURE

We computed cumulative incidence proportions (risk) of AKI with 95% CIs for current, former and non-users of ACE-I/ARB, including death as a competing risk. We compared current and former users with non-users by computing adjusted risk ratios (aRRs) using log-binomial regression adjusted for demographics, comorbidities and CRC-related characteristics. We stratified the analyses of ACE-I/ARB users to address any difference in impact within relevant subgroups.

RESULTS

Twenty-one per cent were ACE-I/ARB current users, 6.4% former users and 72.3% non-users. The 7-day postoperative AKI risk for current, former and non-users was 26.4% (95% CI 24.6% to 28.3%), 25.2% (21.9% to 28.6%) and 17.8% (17.0% to 18.7%), respectively. The aRRs of AKI were 1.20 (1.09 to 1.32) and 1.16 (1.01 to 1.34) for current and former users, compared with non-users. The relative risk of AKI in current compared with non-users was consistent in all subgroups, except for higher aRR in patients with a history of hypertension.

CONCLUSIONS

Being a current or former user of ACE-I/ARBs is associated with an increased risk of postoperative AKI compared with non-users. Although it may not be a drug effect, users of ACE-I/ARBs should be considered a risk group for postoperative AKI.

Clinical analysis of preoperative deep vein thrombosis risk factors in patients with colorectal cancer: Retrospective observational study

AIM

Deep vein thrombosis (DVT) is a major complication of cancer. The postoperative prevalence of DVT in colorectal cancer (CRC) surgery is high, but the preoperative prevalence and the risk factors have not been clarified in detail. The objective of this retrospective study was to investigate the preoperative prevalence and risk factors of DVT in patients admitted to hospital for CRC surgery.

METHODS

From January 2013 to March 2017, 1006 patients admitted for CRC surgery were deemed eligible for this retrospective study. Diagnosis of preoperative DVT was confirmed by compression ultrasonography. Prevalence of silent DVT in lower limbs in patients before CRC surgery was assessed, and the risk factors for preoperative DVT were investigated regarding the correlation of DVT with the patient's background.

RESULTS

Preoperative DVT and asymptomatic pulmonary thromboembolism were diagnosed in 136 (13.5%) and in 10 (1.0%) of 1006 patients overall, respectively. Multivariate analysis showed that increased age (≥75 years), female gender, and an elevated d-dimer level (>1.0 μg/mL) were independent risk factors for preoperative DVT in this study. Notably, the prevalence of preoperative DVT exceeded 50% in patients with all three predictors.

CONCLUSIONS

A high prevalence (13.5%) of preoperative DVT was found in patients admitted to the hospital for CRC surgery. The present results suggest that instrumental screening should be encouraged, at least in subgroups at a higher risk of preoperative DVT.

Monitoring excess unplanned return to theatre following colorectal cancer surgery

BACKGROUND

To develop a risk-adjustment model for unplanned return to theatre (URTT) outcomes following colorectal surgeries in Australia and New Zealand hospitals and apply top-down and bottom-up statistical process control methods for fair comparison of hospitals and surgeons' URTT rates.

METHODS

We analysed URTT outcomes from hospitals contributing data to the Bi-National Colorectal Cancer Audit clinical registry between 2007 and 2016. Preoperative and intraoperative covariates were considered for risk adjustment. A risk-adjusted rate funnel plot was prepared for between-hospital comparisons and identification of outlying hospitals with unusually high rates of URTT. Cumulative observed-minus-expected charts with cumulative sum signals were then presented for surgeons within an outlying hospital.

RESULTS

The study included 15 134 patients and 166 surgeons across 70 hospitals. The weighted average URTT rate was 5.2%. The risk-adjustment model identified 12 preoperative and intraoperative variables that significantly raise the risk of URTT: male sex, American Society of Anesthesiologists score, emergency admissions, conversion entry, left hemicolectomy, total colectomy, proctocolectomy, lower anterior resection, ultra-low anterior resection, abdominoperineal resection, organ resection and excess lymph nodes harvested. Right hemicolectomy significantly reduced risk of URTT. URTT rates were not found to significantly vary across seniority of operator; however, comparisons were limited by lack of data on junior operators. The funnel plot identified five hospitals as 'possible outliers' and hospital T was identified as a 'definite outlier'. The cumulative observed-minus-expected charts with cumulative sum signals showed that within hospital T, one surgeon among three had a particularly bad run of URTTs.

CONCLUSION

Feedback from aggregated URTT outcomes using a risk-adjusted rate funnel plot is enhanced when follow-up examination of outlying hospitals is conducted with concurrent application of cumulative observed-minus-expected charts with cumulative sum signals.

Effect of perioperative oral management on the prevention of surgical site infection after colorectal cancer surgery: A multicenter retrospective analysis of 698 patients via analysis of covariance using propensity score

Surgical site infection (SSI) is 1 of the frequent postoperative complications after colorectal cancer surgery. Oral health care has been reported to reduce the risk of SSI or postoperative pneumonia in oral, esophageal, and lung cancer surgeries. The purpose of the study was to investigate the preventive effect of perioperative oral management on the development of SSI after a major colorectal cancer surgery.The medical records of 698 patients who underwent colorectal cancer surgery at 2 hospitals in Japan were reviewed. Among these patients, 563 patients received perioperative oral management (oral management group) and 135 did not (control group). Various demographic, cancer-related, and treatment-related variables including perioperative oral management intervention and the occurrence of SSI were investigated. The relationship between each variable and the occurrence of SSI was examined via univariate and multivariate analyses using Fisher exact test, 1-way analysis of variance (ANOVA), and logistic regression. The occurrence of SSI in the 2 groups was evaluated via logistic regression using propensity score as a covariate. The difference in mean postoperative hospital stay between the oral management and control groups was analyzed using Student's t test.SSI occurred in 68 (9.7%) of the 698 patients. Multivariate analysis showed that operation time, blood loss, and perioperative oral management were significantly correlated with the development of SSI. However, after the propensity score analysis, not receiving perioperative oral management also became a significant risk factor for SSI. The odds ratio of the oral management group was 0.484 (P = .014; 95% confidence interval: 0.272-0.862). Mean postoperative hospital stay was significantly shorter in the oral management group than in the control group.Perioperative oral management reduces the risk of SSI after colorectal cancer surgery and shortens postoperative hospital stay.

Worse Preoperative Status Based on Inflammation and Host Immunity Is a Risk Factor for Surgical Site Infections in Colorectal Cancer Surgery

OBJECTIVE

The modified Glasgow Prognostic Score (mGPS) is an inflammation-based measure of malnutrition that reflects a state of cachexia in cancer patients. We evaluated mGPS as an index to predict surgical site infection (SSI) incidence in patients undergoing colorectal cancer surgery.

SUBJECTS AND METHODS

We retrospectively analyzed 351 patients who underwent colon cancer resection. Factors correlated with the incidence of SSIs were identified by logistic analysis and stepwise selection.

RESULTS

SSIs were observed in 32 patients, with an incidence of 9.1%. Univariate logistic analysis revealed mGPS (Score 2), laparotomy, resection of other organs, colostomy, excessive blood loss (>423 mL), long duration of surgery (>279 minutes), pulmonary dysfunction, prognostic nutritional index (PNI) ≤40, neutrophil lymphocyte ratio (NLR)(>4), and controlling nutritional status (CONUT) ≥2 to be associated with an increased incidence of SSIs. Multivariate analysis with variables selected by the stepwise procedure also revealed mGPS (Score 2) (Odds ratio (OR) =3.55, 95% Confidence interval (CI) 1.30-9.56; p=0.01), colostomy (OR=6.56, 95%CI 1.60-31.38; p=0.01), excessive blood loss (OR=3.20, 95%CI 1.23-8.42; p=0.02), and NLR (>4)(OR=3.24, 95%CI 1.31-8.17; p=0.01) to be independent risk factors.

CONCLUSION

mGPS is an independent risk factor for SSIs. Our results suggest that cachexia before surgery in patients with colorectal cancer might predict the incidence of SSIs.

Risk factors for postoperative ileus after colorectal cancer surgery

AIM

To assess the rate and independent risk factors of postoperative ileus (POI) after colorectal cancer surgery.

METHODS

Three hundred consecutive patients underwent colorectal surgery for cancer at the State Scientific Centre of coloproctology, Moscow, Russia, between November 2015 and August 2016. POI was diagnosed as an absence of intestinal function for 72 hours or more after operation and confirmed by plain radiography. Uni- and multivariate logistic regression of the tumour-, patient- and treatment-related factors was performed. All patients had epidural catheters with multimodal analgesia.

RESULTS

Thirty-nine patients (13%) had postoperative ileus. The variables associated with this condition in univariate analysis were age < 64 y.o. (p = 0.02), male gender (p = 0.02), BMI ≥ 25 kg/m2 (p = 0.02), moderate drinking (p = 0.02), heavier drinking (p < 0.0001), opioids (p = 0.02), history of abdominal operation (p = 0.003), firm, extensive adhesions as a result of previous surgery (p = 0.005), multivisceral resection (p = 0.009), blood loss ≥ 150 mL (p = 0.006), haemotransfusion (p = 0.01) and open approach (p = 0.006). In the multivariate logistic regression, BMI ≥ 26 kg/m2 (p = 0.008), opioids (p = 0.04) history of abdominal operation (p = 0.04) and adhesions (p = 0.03) were identified as independent risk factors.

CONCLUSION

Postoperative ileus is a common complication in colorectal surgery. The results of our study suggest at least two surgeon-dependent risk factors, i.e., open approach and opioids in the postoperative period. This article is protected by copyright. All rights reserved.

[Influence of electroacupuncture pretreatment on intestinal function in the patients of colorectal cancer surgery]

OBJECTIVE

To observe the effects of electroacupuncture (EA) pretreatment on the intestinal function, inflammatory reaction and blood lactic acid in the patients of colorectal cancer surgery.

METHODS

Sixty patients of colorectal cancer laparotomy at selective period, aged from 18 to 59 years old were selected. According toⅠ-Ⅲ grade of American Society of Anesthesiologists (ASA), the patients were randomized into group A (total intravenous anesthesia), group B[total intravenous anesthesia combined with EA pretreatment at Zusanli (ST 36), Shangjuxu (ST 37) and Xiajuxu (ST 39) on the right side] and group C[total intravenous anesthesia combined with EA pretreatment at Zhongwan (CV 12), Tianshu (ST 25), Zusanli (ST 36), Shangjuxu (ST 37) and Xiajuxu (ST 39) on the right side], 20 cases in each one. The total intravenous anesthesia was applied to all of the three groups. EA pretreatment was used one day before surgery and 30 min before surgery at corresponding acupoints in the group B and group C separately, 30 min each time. After surgery, the recovery time of bowel sound, the recovery time of flatus, the recovery time of defecation, the duration of diet fasting, the time of peritoneal drainage tube withdrawal and the total peritoneal drainage volume were observed in the three groups. The venous blood was collected to determine white blood cell count (WBC) and neutrophil count (NEUT) before surgery (T₀), 24 h after surgery (T₁) and on the 5th day after surgery (T₂) separately. The arterial blood was collected to determine the level of lactic acid before surgery (T_Ⅰ), after peritoneal douching (T_Ⅱ) and 24 h after surgery (T_Ⅲ)separately.

RESULTS

The recovery time of bowel sound, the recovery time of flatus, the duration of diet fasting and the time of peritoneal drainage tube withdrawal in the group C were apparently earlier than those in the group A (all P<0.05). WBC and NEUT at T₁ in the group C were apparently less than those in the group A (both P<0.05). The differences in lactic acid at T_Ⅰ, T_Ⅱ and T_Ⅲ were not significant statistically in comparison of the three groups (all P>0.05).

CONCLUSIONS

The total intravenous anesthesia combined with EA pretreatment at Zusanli (ST 36), Shangjuxu (ST 37), Xiajuxu (ST 39), Tianshu (ST 25) and Zhongwan (CV 12) reduce the recovery time of bowel sound, the recovery time of flatus, the duration of diet fasting and the time of peritoneal drainage tube withdrawal so as to improve the recovery of intestinal function, reduce WBC in 24 h after surgery and alleviate inflammatory reaction. This therapy has no influence on blood lactic acid.

Impact of operation timing on post-operative infections following colorectal cancer surgery

BACKGROUND

To investigate the impact of operation timing on post-operative infections in a cohort of patients undergoing colorectal cancer surgery.

METHODS

We prospectively analysed surgical outcomes in patients who underwent colorectal cancer surgery at the First Affiliated Hospital, College of Medicine, Zhejiang University, from January to December in 2014. In this non-randomized trial, patients were divided into three groups according to the surgery start time: CT1 (07:00 to 12:00 h), CT2 (12:01 to 18:00 h), and CT3 (18:01 h to midnight). The primary outcome was the proportion of patients developing infections within 4 weeks of the surgical procedure.

RESULTS

Out of 756 patients that were enrolled in the study, 118 developed post-operative infections. The results from blood and pus culture showed 97.1% specimen as being pathogen-free. The overall incidence of post-operative infection was 14.5% (38 of 262), 15.3% (46 of 300) and 17.5% (34 of 194) in the CT1, CT2 and CT3 group, respectively, with no significant inter-group differences. However, white blood cell counts, C-reactive protein and glucose levels at 24 h after the surgical procedure showed significant differences between the three groups (one-way ANOVA, P < 0.05).

CONCLUSION

The occurrence of post-operative infection in patients undergoing colorectal cancer surgery was not associated with operation timing. The expression of several inflammatory markers, such as white blood cell counts, C-reactive protein and blood glucose levels tended to correlate with the surgery start time.

Inappropriate drug use in elderly patients is associated with prolonged hospital stay and increased postoperative mortality after colorectal cancer surgery: a population-based study

AIM

The study aimed to investigate whether continuing potentially inappropriate medication (PIM) is associated with length of hospital stay (LOS) and postoperative mortality in elderly people undergoing colorectal cancer surgery.

METHOD

The Swedish National Colorectal Cancer Register and the Swedish Prescribed Drug Register provided matched data on 7279 patients aged 75 years or more who had undergone bowel resection for colorectal cancer between 2007 and 2010. Patients were divided into two groups depending on whether or not they were taking PIM at the time of surgery. The primary efficacy variables were the LOS and 30-day postoperative mortality.

RESULTS

Of the 7279 patients, 22.5% (1641) of the patients were exposed to at least one PIM and the total number of drugs taken in this group was six, compared with three in the non-PIM group (P < 0.001). Postoperative mortality was higher in the PIM group (7.1% vs 4.5%, P < 0.001), and LOS was longer (10 days vs 9, P = 0.001). When adjusted for independent predictors, the differences in LOS (odds ratio 1.14; 95% confidence interval 1.00-1.29, P = 0.046) and postoperative mortality (odds ratio 1.43; 95% confidence interval 1.11-1.85, P = 0.006) remained significant.

CONCLUSION

The use of PIM prior to surgery is associated with increased postoperative mortality and prolonged hospital stay. Although no causal relationship is proved, the results add a further aspect to preoperative optimization of elderly patients about to have major colorectal surgery.

Impact of perioperative probiotic treatment for surgical site infections in patients with colorectal cancer

The aim of the present study was to estimate the effect of the perioperative administration of probiotics in patients undergoing colorectal cancer (CRC) surgery. The study focused on a total of 156 consecutive surgeries carried out from among all the elective CRC surgeries performed between April 2009 and March 2013. The patients involved in surgeries undertaken between April 2009 and October 2011 were placed in the non-probiotic group (group A, 81 patients) and those involved in surgeries between November 2011 and March 2013 were placed in the probiotic group (group B, 75 patients). Postoperative infectious complications were recorded, and the immune responses and fecal microbiota were determined. A breakdown of infectious complications showed that 21 (13.5%) patients experienced superficial incisional surgical site infections (SSIs), of which 16 patients were from group A (19.8%), and five patients from group B (6.7%) (P=0.016). The ImmuKnow® adenosine triphosphate values peaked on the first postoperative day (POD) in both groups. In group A, the ImmuKnow value of the first POD was increased significantly compared with the preoperative value (P=0.022). In group B, the value of the first POD did not increase compared with the preoperative value (P=0.28). In conclusion, probiotic treatment can reduce superficial incisional SSIs in patients undergoing CRC surgery. Perioperative probiotic treatment can enhance immune responses and improve the intestinal microbial environment.

Preoperative risk information and patient involvement in surgical treatment for rectal and sigmoid cancer

AIM

Surgery for rectal and sigmoid cancer is a model setting for investigating preoperative information provision and shared decision making (SDM), as the decision consists of a trade-off between the pros and cons of different treatment options. The aim of this study was to explore surgeons' opinion on the preoperative information that should be given to rectal and sigmoid cancer patients and to evaluate what is actually communicated. In addition, we assessed surgeons' attitudes towards SDM and compared these with patient involvement.

METHOD

A questionnaire was sent to Dutch surgeons with an interest in gastroenterology. Preoperative consultations were recorded. A checklist was used to code the information that surgeons communicated to the patients. The OPTION-scale was used to measure patient involvement.

RESULTS

Questionnaires were sent to 240 surgeons, and 103 (43%) responded. They stated that information on anastomotic leakage and its consequences, the benefits and risks of a defunctioning stoma and the impact of a stoma on quality of life were necessary preoperative information. In practice, patients were inconsistently informed of these items. Most participants agreed to using SDM in their consultations. However, in practice, most patients were offered only one treatment option and little SDM was seen. The mean OPTION-score was low (7/100).

CONCLUSION

Insufficient information is given to patients with rectal and sigmoid cancer to guide them on their preferred surgical option. Information should be given on all treatment options, together with their complications and outcome, before any decision is made.