The prevalence of sarcopenia and cachexia in older patients with localized colorectal cancer

INTRODUCTION

The incidence of colorectal cancer (CRC) increases with age. In combination with an ageing population, the number of older patients undergoing surgical treatment for CRC is therefore expected to increase. Sarcopenia and cachexia are potentially modifiable risk factors of a negative surgical outcome. Sarcopenia can be categorized into primary (age-related) and secondary where diseases, such as malignancy, are influential factors. We aimed to investigate the prevalence of preoperative sarcopenia and cachexia in older (≥65 years) vulnerable patients with localized CRC.

MATERIALS AND METHODS

Patients included in the randomized study "Geriatric assessment and intervention in older vulnerable patients undergoing resection for colorectal cancer," were screened for sarcopenia and cachexia prior to surgery. All patients in the present cohort were considered vulnerable with Geriatric 8 ≤ 14 points. Sarcopenia was defined according to European Guidelines (EWGSOP2), based on low muscle strength-low handgrip-strength and/or slow 5xChair-Stand-Test-and low appendicular lean mass assessed by dual-energy X-ray absorptiometry. Cachexia was defined as self-reported unintended weight loss >5% within three months or 2-5% with body mass index <20 kg/m².

RESULTS

Sixty-four patients (mean age 79.6 years ±6.4 years, 36 women) were assessed. Of these, 28% (n = 18, 11 women) had low muscle strength and 13% (n = 8, 4 women) fulfilled the criteria for sarcopenia, however, 33% (n = 21, 13 women) had low muscle mass. There was no correlation between low muscle strength and low muscle mass (r = 0.16, P = 0.22). The prevalence of cachexia was 36% (n = 23, 16 women). Low muscle mass was associated with cachexia (φ = 0.38, P = 0.005), but there was no association between sarcopenia and cachexia (φ = 0.01, P = 1.0).

DISCUSSION

Despite the included patients who fulfilled the criteria for vulnerability according to G8, relatively few (28%) had low muscle strength. Moreover, there was poor overlap between the prevalence of sarcopenia according to the EWGSOP2 guidelines (13%) and prevalence of low muscle mass (33%) in older patients with CRC. Of note also, there was no association between sarcopenia and cachexia, but an association between cachexia and low muscle mass, which highlights the importance of assessing muscle mass in patients with cancer.

TRIAL REGISTRATION

The GEPOC trial has been prospectively registered at http://clinicaltrials.gov (NCT03719573).

Electrochemotherapy for colorectal cancer using endoscopic electroporation: a phase 1 clinical study

Background and study aims  Electrochemotherapy is an anticancer treatment that uses electric pulses to facilitate uptake of chemotherapeutic drugs in tumor cells and has proven to have a high local cytotoxic effect with minimal adverse events. Electrochemotherapy has mostly been used in treatment of cutaneous metastases but development of a new endoscopic electrode device has made treatment of colorectal tumors possible. This first-in-man multicenter phase I study investigated safety and efficacy of electrochemotherapy using endoscopic electroporation in patients with colorectal tumors. Patients and methods  Seven patients with colorectal tumors who were deemed ineligible for or had declined standard treatment were included. They were treated with bleomycin either intratumorally or intravenously and the electric pulses were delivered through the endoscopic electrode device. Safety and efficacy were assessed clinically and by scans immediately after treatment and adverse events were reported. Response was evaluated up to 6 months after treatment by scans (magnetic resonance imaging or computed tomography) and endoscopic examinations. Results  Seven patients aged 62 to 88 years with multiple comorbidities were included and had one or two treatments each. Post-treatment scans showed tumor responses in the treated areas and no damage to surrounding tissues. Only a few grade one adverse events were reported. Three patients had preoperative rectal bleeding, of which two reported cessation of bleeding and one reported decreased bleeding. Conclusion  This first-in-man study shows that electrochemotherapy for colorectal tumors using the endoscopic electrode device can induce local tumor response and is safe also for fragile elderly patients with comorbidities.

Surgeons' posture and muscle strain during laparoscopic and robotic surgery

Background

It is assumed that conventional laparoscopy (LAP) and robotic-assisted laparoscopic surgery (RALS) differ in terms of the surgeon's comfort. This study compared muscle workload, work posture and perceived physical exertion of surgeons performing LAP or RALS.

Methods

Colorectal surgeons with experience in advanced LAP and RALS performed one of each operation. Bipolar surface electromyography (EMG) recordings were made from forearm, shoulder and neck muscles, and expressed relative to EMG maximum (%EMGmax). The static, median and peak levels of muscle activity were calculated, and an exposure variation analysis undertaken. Postural observations were carried out every 10 min, and ratings of perceived physical exertion before and after surgery were recorded.

Results

The study included 13 surgeons. Surgeons performing LAP showed higher static, median, and peak forearm muscle activity than those undertaking RALS. Muscle activity at peak level was higher during RALS than LAP. Exposure variation analysis demonstrated long-lasting periods of low-level intensity muscle activity in the shoulders for LAP, in the forearms for RALS, and in the neck for both procedures. Postural observations revealed a greater need for a change in work posture when performing LAP compared with RALS. Perceived physical exertion was no different between the surgical modalities.

Conclusion

Minimally invasive surgery requires long-term static muscle activity with a high physical workload for surgeons. RALS is less demanding on posture.

Implementation of a multidisciplinary robotic centre in a high-volume university hospital

INTRODUCTION

We describe the initiation of a multidisciplinary centre for robotic surgery including the implementation of robotic-assisted procedures as standard procedure for the majority of cancer operations in urology, gynaecology and gastrointestinal surgery.

METHODS

All robotic procedures performed from 2008 to 2013 were included. The information gathered included body mass index, the American Society of Anesthesiologists' physical status classification value (ASA), age, sex, time and type of surgery, duration of procedure, conversion to open surgery, length and type of anaesthesia, re-operations, length of hospital stay and 30-day mortality.

RESULTS

The implementation strategy was to start with one specialty at a time, passing on experience from one specialty to the next. The surgical strategy was to begin with standard procedures for which international experience was available and subsequently perform more complex procedures, ending up with robotic-assisted procedures as the standard for most cancer surgery procedures. A total of 2,473 procedures were performed. The operative time was reduced over the period for the main procedures of all three specialties. For prostatectomies, hysterectomies and colectomies, conversion to open surgery occurred in 1.2, 3.8 and 7.7%; the risk of re-operation was 0.2, 2.3 and 7.3%; and, finally, the 30-day mortality was 0.1, 0 and 1%, respectively.

CONCLUSION

The implementation was possible as a stepwise introduction across three specialties with low conversion and re-operation rates and a low mortality. A high-volume centre for robotic surgery was developed and patients with malignant diagnoses were offered robotic-assisted surgery within the framework of multidisciplinary cooperation.

FUNDING

not relevant.

TRIAL REGISTRATION

The study was approved by the Danish Data Protection Agency R. No.: 2007-58-0015.

Randomized multicentre feasibility trial of intermediate care versus standard ward care after emergency abdominal surgery (InCare trial)

Background

Emergency abdominal surgery carries a considerable risk of death and postoperative complications. Early detection and timely management of complications may reduce mortality. The aim was to evaluate the effect and feasibility of intermediate care compared with standard ward care in patients who had emergency abdominal surgery.

Methods

This was a randomized clinical trial carried out in seven Danish hospitals. Eligible for inclusion were patients with an Acute Physiology And Chronic Health Evaluation (APACHE) II score of at least 10 who were ready to be transferred to the surgical ward within 24 h of emergency abdominal surgery. Participants were randomized to either intermediate care or standard surgical ward care after surgery. The primary outcome was 30-day mortality.

Results

In total, 286 patients were included in the modified intention-to-treat analysis. The trial was terminated after the interim analysis owing to slow recruitment and a lower than expected mortality rate. Eleven (7·6 per cent) of 144 patients assigned to intermediate care and 12 (8·5 per cent) of 142 patients assigned to ward care died within 30 days of surgery (odds ratio 0·91, 95 per cent c.i. 0·38 to 2·16; P = 0·828). Thirty (20·8 per cent) of 144 patients assigned to intermediate care and 37 (26·1 per cent) of 142 assigned to ward care died within the total observation period (hazard ratio 0·78, 95 per cent c.i. 0·48 to 1·26; P = 0·310).

Conclusion

Postoperative intermediate care had no statistically significant effect on 30-day mortality after emergency abdominal surgery, nor any effect on secondary outcomes. The trial was stopped prematurely owing to slow recruitment and a much lower than expected mortality rate among the enrolled patients. Registration number: NCT01209663 (http://www.clinicaltrials.gov).

Robot-assisted rectopexy is a safe and feasible option for treatment of rectal prolapse

INTRODUCTION

Rectal prolapse is seen in up to one in 100 elderly women and results in symptoms such as incontinence, mucus secretion and constipation. The aim of this study was to present short- and longterm outcomes after robot-assisted rectopexy in patients with rectal prolapse.

MATERIAL AND METHODS

All patients diagnosed with rectal prolapse at our institution underwent robot-assisted rectopexy. Data regarding the surgical procedure and post-operative morbidity were collected retrospectively. Patients were contacted to register long-term results regarding recurrence, incontinence and satisfaction.

RESULTS

A total of 24 consecutive patients underwent robot-assisted rectopexy from October 2010 to July 2012. Data regarding their long-term outcome was available for 18 patients at follow-up (average ten months). 50% of the patients suffered from faecal incontinence before surgery (n = 9/18, 50%). The mean age at surgery was 72 years (28-93 years). The mean duration of surgery was 123 min. (70-245 min.). The median length of stay in hospital was 4.1 days (0-15 days). There was one procedure-related complication (small-bowel obstruction) resulting in reoperation. At the time of follow-up, two patients (11%) had a subjective recurrence of rectal prolapse, and three patients (17%) had faecal incontinence. 89% were satisfied with the operation, and 94% would recommend this operation to other patients with the same condition.

CONCLUSION

Robot-assisted rectopexy is a safe procedure for patients with rectal prolapse and is associated with acceptable functional outcomes and recurrence rates. There is no evidence in the literature of advantages compared with the corresponding laparoscopic procedure.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Early results after robot-assisted colorectal surgery

INTRODUCTION

Implementation of robotic technology in surgery is challenging in many ways. The aim of this study was to present the implementation process and results of the first two years of consecutive robot-assisted laparoscopic (RAL) colorectal procedures.

MATERIAL AND METHODS

The study was a retrospective study of a consecutive, unselected patient population. All outcome parameters were predefined and all patients completed 30-day follow-up. All parameters were reported, including complication rate, reoperation rate and mortality.

RESULTS

From April 2010 to April 2012, a total of 223 elective RAL colorectal procedures were performed. The procedures were grouped as follows: left colectomy/sigmoid resection (n = 65), low anterior resection (n = 50), abdominoperineal resection (n = 10), right colectomy (n = 56), rectopexia (n = 21), colectomy (n = 8), palliative procedure (n = 8) and stoma reversal (n = 8). The overall mortality rate was 0.4%; intra- and post-operative complication rates were 5.4% and 16%, respectively; and the reoperation rate was 9%. Conversion to open surgery was necessary in 9% of cases. A positive learning curve was found for low anterior resections with a significant decrease in duration of surgery over the course of the study period.

CONCLUSION

RAL colorectal surgery can be performed as a standard procedure for most colorectal procedures. Appropriate staff education, surgical plan and quality assessment are necessary and we recommend a credentialing system for robotic surgery certification. Future randomized clinical trials should be performed to evaluate the short- and long-term results in these patients.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

No differences in short-term morbidity and mortality after robot-assisted laparoscopic versus laparoscopic resection for colonic cancer: a case-control study of 263 patients

BACKGROUND

Robot-assisted laparoscopy has been reported to be a safe and feasible alternative to traditional laparoscopy. The aim of this study was to compare short-term results in patients with colonic cancer who underwent robot-assisted laparoscopic colonic resection (RC) or laparoscopic colonic resection (LC).

METHODS

The study was a retrospective case control study of all patients with colonic cancer who underwent RC from March 2010 to March 2012 or LC from January 2009 to December 2011 at a tertiary-care university hospital. Data were retrieved from the national chart database and patient journals. Biochemical markers [C-reactive protein (CRP), hemoglobin, white blood cell count, and thrombocyte count] were recorded before surgery and for the first 3 days after surgery.

RESULTS

A total of 101 patients underwent RC and 162 patients underwent LC. There were no significant differences in the rate of conversion to open surgery, number of permanent enterostomies, number of intraoperative complications, level of postoperative cellular stress response, number of postoperative complications, length of postoperative hospital stay, or 30-day mortality between the two groups. There was a significantly longer setup time for RC (77.1 vs. 69.7 min, P = 0.000), but surgical time was significantly shorter for RC (165.8 vs. 183.4 min, P = 0.006) and there was no difference in the overall procedure time (254.0 vs. 243.6 min, P = 0.086).

CONCLUSION

We found RC to be a safe and feasible alternative to LC for colonic cancer. We found that for RC surgical time was shorter and overall procedure time was comparable to that for LC; however, these results should be confirmed in future randomized clinical trials.

Effect of intermediate care on mortality following emergency abdominal surgery. The InCare trial: study protocol, rationale and feasibility of a randomised multicentre trial

Background

Emergency abdominal surgery carries a 15% to 20% short-term mortality rate. Postoperative medical complications are strongly associated with increased mortality. Recent research suggests that timely recognition and effective management of complications may reduce mortality. The aim of the present trial is to evaluate the effect of postoperative intermediate care following emergency major abdominal surgery in high-risk patients.

Methods and design

The InCare trial is a randomised, parallel-group, non-blinded clinical trial with 1:1 allocation. Patients undergoing emergency laparotomy or laparoscopic surgery with a perioperative Acute Physiology and Chronic Health Evaluation II score of 10 or above, who are ready to be transferred to the surgical ward within 24 h of surgery are allocated to either intermediate care for 48 h, or surgical ward care. The primary outcome measure is all-cause 30-day mortality. We aim to enrol 400 patients in seven Danish hospitals. The sample size allows us to detect or refute a 34% relative risk reduction of mortality with 80% power.

Discussion

This trial evaluates the benefits and possible harm of intermediate care. The results may potentially influence the survival of many high-risk surgical patients. As a pioneer trial in the area, it will provide important data on the feasibility of future large-scale randomised clinical trials evaluating different levels of postoperative care.

Trial registration

Clinicaltrials.gov identifier: NCT01209663

A clinical evaluation of endoscopically placed self-expanding metallic stents in patients with acute large bowel obstruction

BACKGROUND AND AIMS

Self-expanding metallic stents (SEMS) have since 1991 established themselves as an option in the treatment of large bowel obstruction. The aim of this study was to evaluate the use of SEMS in management of acute colorectal obstructions at a Danish Surgical Gastroenterology center.

MATERIAL AND METHODS

Retrospective review of charts from all patients who, in the period Marts 2002 to December 2007 underwent insertion of a SEMS for an acute large bowel obstruction.

RESULTS

Of 45 patients included, SEMS was intended as a bridge to surgery in 20 patients and as palliation in 25 patients. For malignant etiology, the SEMS procedure was a technical and clinical success in 97.4% of the cases. Complications occurred in 21%, mortality rate 2,6%. For benign etiology, the SEMS procedure was a technical success in 85.7%, and a clinical success in 71.4%. Complications occurred in 71.4% of the benign cases with a mortality rate of 28,6%.

CONCLUSIONS

Placement of SEMS for acute large bowel obstruction with malignant etiology is an effective and safe procedure with low mortality and morbidity. However results for benign obstructions are questionable and more research is needed to determine the role of SEMS.

Randomized clinical trial comparing radially expanding trocars with conventional cutting trocars for the effects on pain after laparoscopic cholecystectomy

BACKGROUND

Trocar incisions are important sources of pain the first days after laparoscopic cholecystectomy. Radially expanding trocars may cause less pain than conventional cutting trocars.

METHODS

In a patient- and observer-blinded trial, 80 patients were randomized to undergo laparoscopic cholecystectomy using either radially expanding trocars (radial group) or conventional cutting trocars (cutting group). Two 10-mm and two 5-mm trocars were used in both treatment groups. All the patients received standardized anesthetic and analgesic treatment. The primary outcome was incisional pain. Pain was registered during mobilization using a visual analog scale (VAS) and a verbal rating scale (VRS) before and 6 h after the operation, and at postoperative days 1 and 2. The needs for a fascial incision to retract the gallbladder, active surgical hemostasis, and supplementary requirements of opioids during the hospital stay were registered. In addition, 2 days after the operation, the incidence and severity of suggilations at the trocar incisions were measured.

RESULTS

Data from 77 patients were available for statistical analysis. In the radial group, 23 patients needed fascial incision for gallbladder retraction compared with 11 patients in the cutting group (p = 0.006). No significant intergroup differences in VAS or VRS pain scores or any other variable were found.

CONCLUSIONS

The use of radially expanding trocars has no effect on incisional pain after laparoscopic cholecystectomy.

No-Trocar Laparoscopic Stoma Creation

Creation of an intestinal stoma may be necessary in a wide variety of colorectal diseases of both benign and malignant character. Open and laparoscopic techniques can be used for the fecal diversion. We report a case of a patient with a diverticulitis of the sigmoid colon with abscess formation and fistulation to the abdominal wall and vagina. Owing to severe comorbidity, a permanent fecal diversion was prepared. We performed a laparoscopic no-trocar technique. Only 1 incision, at the planned stoma site, was used. The abdominal wall was elevated with gaspers, no pneumoperitoneum or trocars were used. The laparoscope and reuseable laparoscopic graspers were introduced through the stoma site to correctly identify and grasp a loop of the terminal ileum. Finally, the loop ileostomy was placed on a bar. This laparoscopic technique is a valid alternative to standard laparoscopic stoma creation. Different techniques for stoma creation are discussed.

[Treatment of gallstone pancreatitis in Denmark]

INTRODUCTION

The aim of the study was to describe the treatment of gallstone pancreatitis in Denmark and to compare it to the recommendations given in the National Reference Programme for the treatment of patients with gallstone disease.

MATERIALS AND METHODS

A questionnaire was sent to the 42 general surgical hospital departments in Denmark.

RESULTS

All of the departments returned the questionnaire. All of them treated patients with gallstone pancreatitis; 40 of them performed laparoscopic cholecystectomy. The severity of gallstone pancreatitis was estimated in 29 departments. In patients with mild gallstone pancreatitis, 6 departments used ERCP in the evaluation of choledocholithiasis. In patients with mild gallstone pancreatitis who did not undergo an ERCP procedure with sphincterotomy, 13 departments performed laparoscopic cholecystectomy during the same admission after an acute attack.

DISCUSSION

In agreement with the recommendations given in the National Reference Programme, the majority of Danish surgical departments used laparoscopic cholecystectomy in the treatment of patients with gallstone pancreatitis who had not undergone ERCP with sphincterotomy. To avoid the high recurrence of gallstone pancreatitis, laparoscopic cholecystectomy during the same admission is recommended. This recommendation was, however, followed by less than half of the surgical departments.

[Laparoscopic cholecystectomy as an outpatient procedure]

INTRODUCTION

The aim of this study was to describe our experience with laparoscopic cholecystectomy as an outpatient procedure in terms of complications, same-day discharge, and a registration of patient' postoperative pain, convalescence and contact with general practitioners.

MATERIALS AND METHODS

A prospective evaluation was done of the first 231 patients undergoing laparoscopic cholecystectomy in an outpatient clinic.

RESULTS

Ninety per cent of the patients were discharged directly from the outpatient clinic, and a total of 93% of the patients were discharged within 24 hours of the operation. The readmission rate was 1%. Leakage from the cystic duct occurred in one case (0.4%), and no other injuries to the bile ducts were observed. The conversion rate was 1%. Within a week 54% of the patients had no pain and 55% of the patients had resumed normal activity. Postoperatively, 25% of the patients had contact with a general practitioner due to wound and other complaints that required no intervention.

DISCUSSION

Laparoscopic cholecystectomy is very suitable as an outpatient procedure due to its high same-day discharge rate and high patient satisfaction combined with low readmission and complication rates. Our study did expose, however, a high number of postoperative contacts with general practitioners due to non-surgical problems, which emphasizes the need for better patient information and cooperation with general practitioners to optimize the outpatient procedure further.

Severe impairment of graft flow without electrocardiographic changes during coronary artery bypass grafting

Early graft occlusion after coronary artery bypass grafting may have deleterious consequences. We routinely use transit-time flowmetry after termination of cardiopulmonary bypass, and we report five cases of early graft failure detected by the flowmeter. Electrocardiographic (ECG) changes were seen in only one of these five cases, and none of the patients had low cardiac output or other signs of graft failure at the end of the operation. The cause of graft failure was tagging in one case, rotation of internal mammary artery grafts in two and kinking of vein grafts in two cases. All errors were corrected, and control flowmetry showed normal flow rates after correction. Flowmetry takes less than 10 min, even with multiple bypass grafts. Based on our results, we advocate routine quality control with flowmetry after termination of cardiopulmonary bypass, since ECG changes are insufficient as checks of flow in bypass grafts.

Below-knee popliteal and distal bypass with PTFE and vein cuff

OBJECTIVES

To determine the value of PTFE grafts with a distal vein cuff as a conduit for below-knee (BK) popliteal and distal bypass in the absence of autologous vein.

DESIGN

Retrospective study.

MATERIALS AND METHODS

Forty below BK popliteal and distal bypass procedures in 39 patients with PTFE and distal vein cuff (Miller cuff n = 31, Wolfe cuff and adjuvant arteriovenous fistula n = 9). Nineteen primary and 21 secondary reconstruction procedures.

RESULTS

The primary patency rate was 62.5% at 1 year falling to 50% at 2 years. The secondary patency rates were very similar owing to poor outcome of thrombectomy. Ten cases (25%) resulted in major amputation postoperatively. There was a tendency towards better outcome for primary procedures compared to secondary/redo procedures.

CONCLUSIONS

BK popliteal and distal bypass with PTFE and distal vein cuff is a worthwhile procedure in the absence of autologous vein. The value of thrombectomy following thrombosis of a secondary bypass procedure with PTFE and distal vein cuff is questionable.

[Waiting lists for men with benign urinary disorders]

This paper reflects the problems in having a large non-specific waiting-list. One hundred and twenty-eight patients were on a waiting-list under the main diagnosis of prostatism. This diagnosis revealed seven patients with cancer in the urinary tract system. Only two-thirds of the patients on the waiting-list were interested in further examination and treatment. This paper emphasizes the need for a more specific referral, when dealing with symptoms from the lower urinary tract system.

[Necrotizing pancreatitis]

Acute pancreatitis is in the majority of patients a mild, self-limiting illness. Five to fifteen percent of the patients develop acute necrotizing pancreatitis, a severe illness with a high morbidity and mortality. Secondary infection of the pancreatic necrosis (infected pancreatic necrosis) is the main cause of death. Pancreatic necrosis is identified with a high accuracy by contrast-enhanced computed tomography. The differentiation between sterile and infected necrosis requires demonstration of bacteria or fungi isolated from the necrosis. Surgical treatment of a sterile necrosis remains controversial, but there is a tendency towards conservative non-operative treatment. Infected pancreatic necrosis is regarded as an absolute indication for surgery, untreated the mortality is approximately 100%. The aim of modern treatment is to remove the pancreatic necrosis continuously. This has successfully been done by the open packing method, with or without subsequent drainage. At present no randomized trials comparing the different treatment modalities are available. The question of prophylactic antibiotics still remains unanswered. For the present imipenem 0,5 g x 3 is recommended.