Malignancy is a risk factor for postoperative infectious complications after elective colorectal resection

Purpose

Patient and technical factors influencing the postoperative infectious complications (ICs) after elective colorectal resections are satisfactorily described. However, the underlying disease-related factors have not been extensively evaluated. This study aimed to measure the effect of malignancy on postoperative surgical site and extra surgical site infections after elective colorectal resection.

Methods

This study is a bicentric retrospective matched pair study of prospectively gathered data. Between 2004 and 2013, 1104 consecutive patients underwent colorectal resection in two centers. Patients undergoing elective resection with supraperitoneal anastomosis for benign diseases (excluding inflammatory bowel disease) (group B, n?=?305) were matched to randomly selected patients with malignancy (group M, n?=?305). The matching variables were age, gender, American Society of Anesthesiologists (ASA) score, malnutrition, type of resection, and surgical approach. We compared the 30-day IC rates between patients with benign diseases (group B) and malignancy (group M). Multivariate logistic regression analysis was performed to identify the risk factors for ICs.

Results

Group M had a higher overall rate of IC (25.6 vs 16.1 %, P?=?0.004) as well as a higher risk of extra surgical site infections (P?=?0.007) and anastomotic leakage (P?=?0.039). The independent risk factors for ICs were malignancy (odds ratio (OR)?=?2.02; P?=?0.002), age ≥70 years (OR?=?1.73, P?=?0.018), tobacco history (OR?=?1.87; P?=?0.030), and obesity (OR?=?1.68; P?=?0.039).

Conclusion

Malignancy, age, tobacco history, and obesity increase the risk of ICs after colorectal resection. Improvement of the modifiable risk factors, increased compliance with an enhanced recovery after surgery (ERAS) program in the overall population, and optimization of immune function in patients with malignancy should be considered.

     

Risk factors for metachronous adenoma in the residual colon of patients undergoing curative surgery for colorectal cancer

Purpose

Adenoma detection in colorectal cancer survivors is poorly characterised with insufficient evidence to inform frequency of surveillance schedule. The aim of this study was to examine adenoma incidence and recurrence in patients who have undergone colorectal cancer resection with curative intent. Survival outcomes were compared to determine if the presence of adenomas could be used to identify patients at higher risk of local recurrence.

Methods

This is a retrospective observational cohort study at a single tertiary institution between 2006 and 2012. Five hundred fifteen consecutive patients with stage I–III colorectal cancer who had preoperative colonoscopy and curative surgery were included (median follow-up 56 months (36–75 months).

Results

In total, 352/515 (68%) patients underwent postoperative surveillance colonoscopy in the first 5 years after resection. Male gender was associated with greater risk of detecting synchronous adenoma at index colonoscopy or in the resection specimen (OR 2.35, p < 0.001). In the first 5 years after cancer surgery, synchronous adenoma, male gender and right sided primary tumour were independent predictors of metachronous lesions (OR 2.13, p = 0.009; OR 2.07, p = 0.027 and OR 2.34, p = 0.004, respectively). Presence of synchronous or metachronous adenoma had no impact upon incidence of local recurrence, overall or disease free survival.

Conclusions

Patients with synchronous adenoma remain at high risk of adenoma recurrence despite undergoing colonic resection and should be considered for early endoscopic surveillance. Men and those undergoing right-sided resection have a higher risk of metachronous adenoma in the long term and may benefit from more frequent endoscopic surveillance post resection.

     

Surgical recurrence in Crohn’s disease: a comparison between different types of bowel resections

Purpose

To compare recurrence frequency and location between different types of bowel resections in Crohn’s disease patients.

Methods

This was a retrospective study of consecutive patients undergoing bowel resection for Crohn’s disease between 2006 and 2016. Type of primary operation was recorded and grouped as ileocolic resection, small bowel resection, segmental colon resection with colocolic anastomosis or colorectal anastomosis, colectomy with ileorectal anastomosis, or end stoma operation. Binary logistic regression was used to compare surgical recurrence frequency between groups. We also investigated how Crohn’s disease location at reoperations was related to the primary bowel resection type.

Results

Altogether, 218 patients with a median follow-up of 4.7 years were included in our study. Reoperation was performed in 42 (19.3%) patients. The risk of reoperation using the ileocolic resection group as reference was the following: small bowel resection (odds ratio (OR) 2.95, 95% confidence interval (CI) 1.01–8.66; P?=?0.049), segmental colon resection with colocolic or colorectal anastomosis (OR 6.20, 95% CI 2.04–18.87; P?=?0.001), colectomy with ileorectal anastomosis (OR 26.57, 95% CI 2.59–273.01; P?=?0.006), and end stoma operation (OR 4.62, 95% CI 1.90–11.26; P?=?0.001). In case of surgical recurrence, the reoperation type and location correlated with the primary bowel resection type.

Conclusions

Reoperation frequency in Crohn’s disease is lower after ileocolic resection than after other types of bowel resections. Surgical recurrence in Crohn’s disease tends to maintain the disease location of the primary operation. One third of Crohn’s patients undergoing an end stoma operation will still need new bowel resections due to recurrence.

     

The efficacy of endoscopic submucosal dissection for colorectal tumors extending to the dentate line

Purpose

Although endoscopic submucosal dissection (ESD) is becoming the mainstay of the treatment strategies, rather than surgical treatment, for colorectal tumors extending to the dentate line, ESD is technically more difficult. This study was aimed at assessing the usefulness of ESD for the treatment of colorectal tumors extending to the dentate line.

Methods

This study included 531 patients with colorectal tumors who underwent colorectal ESD between 2008 and 2015. They were divided into three groups: rectal tumors extending to the dentate line (anorectal group), those not extending to the dentate line (proximal rectal group), and colonic tumors (colonic group), and a retrospective comparative analysis was carried out.

Results

Of the total patients, 18 (3.4%) had lesions extending to the dentate line area. The procedure times were 103.4 ± 84.0, 80.4 ± 64.3, and 71.8 ± 52.3 min, respectively (P = 0.0318). All the patients in the anorectal group were operated by operators who had performed at least 20 colorectal ESDs (P < 0.0001). No significant difference among the three groups was found in the en bloc resection rate, complete resection rate, or curative resection rate. Although no significant difference in the incidence of perforation was observed among the three groups, intraoperative bleeding was observed in 61% of the patients in the anorectal group (P < 0.0001).

Conclusions

ESD is an effective treatment strategy for colorectal tumors extending to the dentate line. However, it seems that anorectal ESD, which is technically more difficult than colorectal ESD, should be performed by operators with ample experience in performing ESD.

     

Risk factors for surgical site infection following colorectal resection: a multi-institutional study

Introduction

Surgical site infection (SSI) is an infection occurring in an incisional wound within 30 days of surgery and significantly affects patients undergoing colorectal surgery. This study examined a multi-institutional dataset to determine risk factors for SSI following colorectal resection.

Methods

Data on 386 patients who underwent colorectal resection in three institutions were accrued. Patients were identified using a prospective SSI database and hospital records. Data are presented as median (interquartile range), and logistic regression analysis was used to identify risk factors.

Results

Patients (21.5 %) developed a postoperative SSI. The median time to the development of SSI was 7 days (5–10). Of all infections, 67.5 % were superficial, 22.9 % were deep and 9.6 % were organ space. In univariate analysis, an ASA grade of II (RR 0.6, CI 0.3–0.9, P?=?0.019), having an elective procedure (RR 0.4, CI 0.2–0.6, P?<?0.001), using a laparoscopic approach (RR 0.5, CI 0.3–0.9, P?=?0.019), having a daytime procedure (RR 0.3, CI 0.1–0.7, P?=?0.006) and having a clean/contaminated wound (RR 0.4, CI 0.2–0.7, P?=?0.001) were associated with reduced risk of SSI. In multivariate analysis, an ASA grade of IV (RR 3.9, CI 1.1–13.7, P?=?0.034), a procedure duration over 3 h (RR 4.3, CI 2.3–8.2, P?<?0.001) and undergoing a panproctocolectomy (RR 6.5, CI 1.0–40.9, P?=?0.044) were independent risk factors for SSI. Those who developed an SSI had a longer duration of inpatient stay (22 days [16–31] vs 15 days [10–26], P?<?0.001).

Conclusions

Patients who develop an SSI have a longer duration of inpatient stay. Independent risk factors for SSI following colorectal resection include being ASA grade IV, having a procedure duration over 3 h, and undergoing a panproctocolectomy.

     

The effect of metformin on the recurrence of colorectal adenoma in diabetic patients with previous colorectal adenoma

Purpose

Existing studies suggest that metformin lowers the risk and mortality of colorectal cancer. However, the effect of metformin on the suppression and prevention of colorectal adenomas is not clear. The aim of this study was to evaluate the effect of metformin on the recurrence of colorectal adenoma in diabetic patients with previous colorectal adenoma.

Methods

Among 423 diabetic patients who underwent surveillance colonoscopy after resection of colorectal adenoma between 2005 and 2011, 257 patients were retrospectively reviewed. The patients were divided into two groups: one group comprising 106 patients who took metformin and another group comprising 151 patients who did not take metformin. The clinical characteristics, colorectal adenoma recurrence, and valuable factors for adenoma recurrence were analyzed.

Results

At surveillance colonoscopy after colonoscopic polypectomy for adenoma, 38 patients (35.8%) exhibited colorectal adenoma among 106 patients who took metformin, compared with 85 patients (56.3%) with colorectal adenoma among 151 patients who did not take metformin (odds ratio 0.434, 95% confidence interval 0.260–0.723, P = 0.001). Multivariate Cox analysis showed that metformin was associated with decreased recurrence of colorectal adenoma (hazard ratio 0.572, 95% confidence interval 0.385–0.852, P = 0.006) in diabetic patients with previous colorectal adenoma. The cumulative probability of colorectal adenoma recurrence was significantly lower in the metformin group than in the non-metformin group (P = 0.001).

Conclusion

Metformin use in diabetic patients with previous colorectal adenoma is associated with a lower risk of colorectal adenoma recurrence.

     

Nicotine chewing gum for the prevention of postoperative ileus after colorectal surgery: a multicenter,double-blind,randomised, controlled pilot study

Purpose

When postoperative ileus is not resolved after 5 days or recurs after resolution, prolonged POI (PPOI) is diagnosed. PPOI increases discomfort, morbidity and hospitalisation length, and is mainly caused by an inflammatory response following intestinal manipulation. This response can be weakened by targeting the cholinergic anti-inflammatory pathway, with nicotine as essential regulator. Chewing gum, already known to stimulate gastrointestinal motility itself, combined with nicotine is hypothesised to improve gastrointestinal recovery and prevent PPOI. This pilot study is the first to assess efficacy and safety of nicotine gum in colorectal surgery.

Methods

Patients undergoing elective oncological colorectal surgery were enrolled in this double-blind, parallel-group, controlled trial and randomly assigned to a treatment protocol with normal or nicotine gum (2 mg). Patient reported outcomes (PROMS), clinical characteristics and blood samples were collected. Primary endpoint was defined as time to first passage of faeces and toleration of solid food for at least 24 h.

Results

In total, 40 patients were enrolled (20 vs. 20). In both groups, six patients developed PPOI. Time to primary endpoint (4.50 [3.00–7.25] vs. 3.50 days [3.00–4.25], p = 0.398) and length of stay (5.50 [4.00–8.50] vs. 4.50 days [4.00–6.00], p = 0.738) did not differ significantly between normal and nicotine gum. There were no differences in PROMS, inflammatory parameters and postoperative complications.

Conclusions

We proved nicotine gum to be safe but ineffective in improving gastrointestinal recovery and prevention of PPOI after colorectal surgery. Other dosages and administration routes of nicotine should be tested in future research.

     

Multiple behavioral factors are associated with occurrence of large,flat colorectal polyps

Purpose

The prevalence of advanced dysplasia and synchronous lesions is particularly high in patients with large, flat colorectal polyps. However, the impact of lifestyle on the development of such polyps is poorly investigated. Hence, this study aims to identify associations between behavioral factors and the occurrence of large, flat colorectal polyps.

Methods

Behavioral factors were retrospectively analyzed in patients with large, flat polyps and control patients with at most one diminutive polyp. Information on lifestyle factors, comorbidities, and demographic parameters were determined by a structured, self-administered questionnaire.

Results

Questionnaires of 350 patients with large, flat polyps and 489 control patients were included in the analysis. Most large, flat colorectal polyps contained adenoma with low-grade neoplasia and were located in the right colon. Multivariate analysis showed that advanced age (per 1-year increase—OR 1.09, CI 1.07–1.11, p < 0.0001), frequent cigarette smoking (OR 2.04, CI 1.25–3.32, p = 0.0041), daily consumption of red meat (OR 3.61, CI 1.00–12.96, p = 0.0492), and frequent bowel movements (OR 1.62, CI 1.13–2.33, p = 0.0093) were independent risk factors for occurrence of large, flat colorectal polyps. In contrast, frequent intake of cereals (OR 0.62, CI 0.44–0.88, p = 0.0074) was associated with a reduced risk.

Conclusion

Multiple behavioral factors modulate the risk for developing large, flat colorectal polyps. This knowledge can be used to improve prevention of colorectal cancer.

     

Cholecystectomy and the risk of colorectal cancer by tumor mismatch repair deficiency status

Purpose

Gallbladder diseases and cholecystectomy may play a role in the development of colorectal cancer (CRC). Our aim was to investigate the association between cholecystectomy and CRC risk overall and by sex, family history, anatomical location, and tumor mismatch repair (MMR) status.

Methods

This study comprised 5847 incident CRC cases recruited from population cancer registries in Australia, Canada, and the USA into the Colon Cancer Family Registry between 1997 and 2012 and 4970 controls with no personal history of CRC who were either randomly selected from the general population or were spouses of the cases. The association between cholecystectomy and CRC was estimated using logistic regression, after adjusting for confounding factors.

Results

Overall, there was no evidence for an association between cholecystectomy and CRC (odds ratio [OR] = 0.88, 95 % confidence interval 0.73, 1.08). In the stratified analyses, there was no evidence for a difference in the association between women and men (P = 0.54), between individuals with and without family history of CRC in first-degree relative (P = 0.64), between tumor anatomical locations (P = 0.45), or between MMR-proficient and MMR-deficient cases (P = 0.54).

Conclusion

Cholecystectomy is not a substantial risk factor for CRC, regardless of sex, family history, anatomical location, or tumor MMR status.

     

Prognostic influence of hepatic margin after resection of colorectal liver metastasis: role of modern preoperative chemotherapy

Purpose

Modern chemotherapy (CTX) increases survival in stage IV colorectal cancer. In colorectal liver metastases (CLM), neoadjuvant (neo) CTX may increase resectability and improve survival. Due to widespread use of CTX in CLM, recent studies assessed the role of the hepatic margin after CTX, with conflicting results. We evaluated the outcome after resection of CLM in relation to CTX and hepatic resection status.

Methods

Since 2000, 334 patients with first hepatic resection for isolated CLM were analyzed. Thirty-two percent had neoadjuvant chemotherapy (targeted therapy in 42%). Sixty-eight percent never had CTX before hepatectomy or longer than 6 months before resection. The results were gained by analysis of our prospective database.

Results

Positive hepatic margins occurred in 8% (independent of neoCTx). Patients after neoCTX had higher numbers of CLM (p < 0.01) and a longer duration of surgery (p < 0.03). After hepatectomy, 5-year survival was 45% and correlated strongly with the margin status (47% in R-0 and 21% in R-1; p < 0.001). Survival also correlated with margin status in the subgroups with neoCTX (p < 0.01) or without neoCTx (p < 0.01). In multivariate analysis of the entire group, hepatic margin status (RR 3.2; p < 0.001) and age > 65 years (RR 1.6; p < 0.01) were associated with poorer survival. In the subgroup of patients after neoCTX (n = 106), only the resection margin was an independent predictor of survival (p < 0.001).

Conclusion

In patients with isolated colorectal liver metastases undergoing resection, the hepatic margin status was the strongest independent prognostic factor. This effect was also present after neoadjuvant chemotherapy for CLM.

     

To drain or not to drain in colorectal anastomosis: a meta-analysis

Background

Currently, many surgeons place a prophylactic drain in the abdominal or pelvic cavity after colorectal anastomosis as a conventional treatment. However, some trials have demonstrated that this procedure may not be beneficial to the patients.

Objective

To determine whether prophylactic placement of a drain in colorectal anastomosis can reduce postoperative complications.

Methods

We systematically searched all the electronic databases for randomized controlled trials (RCTs) that compared routine use of drainage to non-drainage regimes after colorectal anastomosis, using the terms “colorectal” or “colon/colonic” or “rectum/rectal” and “anastomo*” and “drain or drainage.” Reference lists of relevant articles, conference proceedings, and ongoing trial databases were also screened. Primary outcome measures were clinical and radiological anastomotic leakage. Secondary outcome measures included mortality, wound infection, re-operation, and respiratory complications. We assessed the eligible studies for risk of bias using the Cochrane Risk of Bias Tool. Two authors independently extracted data.

Results

Eleven RCTs were included (1803 patients in total, 939 patients in the drain group and 864 patients in the no drain group). Meta-analysis showed that there was no statistically significant differences between the drain group and the no drain group in (1) overall anastomotic leakage (relative risk (RR)?=?1.14, 95 % confidence interval (CI) 0.80–1.62, P?=?0.47), (2) clinical anastomotic leakage (RR?=?1.39, 95 % CI 0.80–2.39, P?=?0.24), (3) radiologic anastomotic leakage (RR?=?0.92, 95 % CI 0.56–1.51, P?=?0.74), (4) mortality (RR?=?0.94, 95 % CI 0.57–1.55, P?=?0.81), (5) wound infection (RR?=?1.19, 95 % CI 0.84–1.69, P?=?0.34), (6) re-operation (RR?=?1.18, 95 % CI 0.75–1.85, P?=?0.47), and (7) respiratory complications (RR?=?0.82, 95 % CI 0.55–1.23, P?=?0.34).

Conclusions

Routine use of prophylactic drainage in colorectal anastomosis does not benefit in decreasing postoperative complications.

     

Gefahr der Anastomoseninsuffizienz nach laparoskopischer und offener kolorektaler Resektion

Background

Anastomotic leak following colorectal surgery is associated with significant morbidity and mortality. With the widespread adoption of laparoscopy, data from initial clinical trials evaluating the efficacy of laparoscopic when compared to open surgery may not currently be generalizable. We assess the risk of anastomotic leak after laparoscopic versus open colorectal resection using a nationwide database with standardized definitions.

Methods

The 2012–2013 ACS-NSQIP targeted colectomy data were queried for all elective colorectal resections. Characteristics were compared for those patients undergoing laparoscopic versus open operations. Univariable and multivariable analyses, followed by a propensity score-matched analysis, were performed to assess the impact of laparoscopy on the development of an anastomotic leak.

Results

Of 23,568 patients, 3.4% developed an anastomotic leak. Laparoscopic surgery was associated with a leak rate of 2.8% (n = 425) and open surgery, 4.5% (n = 378, p <0.0001). Patients who developed a leak were more likely to die within 30 days of surgery (5.7 vs 0.6%, p <0.0001). Patients who underwent laparoscopic surgery compared to open were younger (61 vs 63 years, p = 0, p = 0.045) and with fewer comorbidities. On univariable analysis laparoscopic surgery was associated with reduced odds of developing an anastomotic leak (OR 0.60, p <0.0001), and this remained after adjusting for all significant preoperative and disease-related confounders (OR 0.69, 95% CI 0.58–0.82). A propensity score-matched analysis confirmed benefit of laparoscopic surgery over open surgery for anastomotic leak.

Conclusion

Laparoscopic colectomy is safe and associated with reduced odds of developing an anastomotic leak following colectomy when controlling for patient-, disease and procedure-related factors.

     

Influence of <Emphasis Type="Italic">TGFB1</Emphasis>+<Emphasis Type="Italic">869T</Emphasis>>C functional polymorphism in non-small cell lung cancer (NSCLC) risk

Purpose

Lung cancer is the third most common type of cancer in Europe and is the first cause of death by cancer worldwide. Non-small cell lung cancer accounts for 75–85% of all histological types of LC. The transforming growth factor beta 1 is a multifunctional regulatory polypeptide that controls many aspects of cellular function (cellular proliferation, differentiation, migration, apoptosis, immune surveillance). TGFB1+869T>C is a functional polymorphism described in TGFB1 gene and this transition has been associated with higher circulating levels of TGFß1 that may modulate cellular microenvironment and consequently LC development and prognosis.

Methods

We studied TGFB + 869T > C functional polymorphism by allelic discrimination using 7300 real-time polymerase chain reaction system in 305 patients with NSCLC and 380 healthy individuals.

Results

We found an increased risk for C carriers to develop NSCLC, both epidermoid NSCLC and non-epidermoid NSCLC (odds ratio (OR) = 2.03, P < 0.0001, OR = 2.37, P < 0.001 and OR = 1.83, P = 0.001, respectively). TGFB1+869T>C functional polymorphism may influence NSCLC susceptibility with impact in cellular microenvironment.

Conclusions

Our results suggest that individual differences influence the susceptibility to LC and tumoral behavior. This genetic profiling may help define higher risk groups for an individualized chemoprevention strategy and therapy.

     

Downstream Breast Imaging Following Screening Mammography in Medicare Patients with Advanced Cancer: A Population-Based Study

Background

Screening tests are generally not recommended in patients with advanced cancer and limited life expectancy. Nonetheless, screening mammography still occurs and may lead to follow-up testing.

Objective

We assessed the frequency of downstream breast imaging following screening mammography in patients with advanced colorectal or lung cancer.

Design

Population-based study.

Participants

The study included continuously enrolled female fee-for-service Medicare beneficiaries ≥65 years of age with advanced colorectal (stage IV) or lung (stage IIIB-IV) cancer reported to a Surveillance, Epidemiology, and End Results (SEER) registry between 2000 and 2011.

Main Measures

We assessed the utilization of diagnostic mammography, breast ultrasound, and breast MRI following screening mammography. Logistic regression models were used to explore independent predictors of utilization of downstream tests while controlling for cancer type and patient sociodemographic and regional characteristics.

Key Results

Among 34,127 women with advanced cancer (23% colorectal; 77% lung cancer; mean age at diagnosis 75 years), 9% (n = 3159) underwent a total of 5750 screening mammograms. Of these, 11% (n = 639) resulted in at least one subsequent diagnostic breast imaging examination within 9 months. Diagnostic mammography was most common (9%; n = 532), followed by ultrasound (6%; n = 334) and MRI (0.2%; n = 14). Diagnostic mammography rates were higher in whites than African Americans (OR, 1.6; p <0.05). Higher ultrasound utilization was associated with more favorable economic status (OR, 1.8; p <0.05).

Conclusions

Among women with advanced colorectal and lung cancer, 9% continued screening mammography, and 11% of these screening studies led to at least one additional downstream test, resulting in costs with little likelihood of meaningful benefit.

     

Factors associated with the location of local rectal cancer recurrence and predictors of survival

Purpose

The location of locally recurrent rectal cancer (LRRC) may influence survival. This study examines factors affecting the location of LRRC, the effect of LRRC location on survival, and predictive factors for survival in patients with LRRC.

Methods

Patients undergoing initial proctectomy and subsequent management of LRRC at the Cleveland Clinic (1980–2011) were included. Data regarding index surgery, LRRC, and survival were obtained from a prospectively maintained database.

Results

One hundred and fifty-seven patients were identified with a mean follow-up 59.8?±?50.1 months and time to LRRC of 31.7?±?30.1 months. Sixty patients underwent surgery with curative intent. Anastomotic leak and retrieving less than 12 lymph nodes at index proctectomy were associated with posterior (P?=?0.019) and lateral (P?=?0.036) recurrences, respectively. Having an axial relative to an anterior, posterior, or lateral recurrence was associated with improved overall survival (P?=?0.001). On multivariable analysis, undergoing primarily palliative treatment (OR, 5.2; 95 % confidence interval (CI), 3.2–8.4; P?<?0.001), age at LRRC >60 years (OR, 1.9; 95 % CI, 1.3–2.7, P?<?0.001), advanced primary tumour stage (OR, 1.5; 95 % CI, 1.1–2.1; P?=?0.021), and anastomotic leak at index surgery (OR, 1.8; 95 % CI, 1.2–2.7; P?=?0.008) were associated with reduced LRRC 5-year survival.

Conclusions

The current study suggests that features of the primary tumour and technical factors at the time of index proctectomy influence both the location of LRRC and survival.

     

Sigmoid resection for diverticulitis is more difficult than for malignancies

Purpose

Sigmoid resection for diverticulitis is usually the first procedure performed when starting the learning process for laparoscopic colorectal surgery. The aim of this study is to evaluate the difficulty of laparoscopic sigmoid resection for diverticulitis in comparison to sigmoid malignancy in order to assess its role in the residents training program.

Methods

A cohort of patients was selected who suffered either from malignancy or recurrent diverticulitis in the sigmoid colon. Laparoscopic sigmoid resection was performed. The degree of difficulty was assessed by intraoperative complications and intraoperative technical challenges. Furthermore, take-overs from assistant to surgeon, surgeon to surgeon, and conversion were reported.

Results

A total of 224 patients were included, 119 (53.1%) men and 105 (46.9%) women.Patients suffering from diverticulitis had significantly less co-morbidities than those with malignancies. In the diverticulitis group, there were significantly more technical challenges. There was a higher rate in take-overs from residents (p = 0.02) as well as surgeon to surgeon (p = 0.04). The rate of conversions was also significantly higher in the diverticulitis group (p = 0.03) when compared to the malignancy group.

Conclusions

The outcomes of our study show that diverticulitis may not be the ideal condition to start the learning process for laparoscopic colorectal surgery.

     

Long-term efficacy of comprehensive multidisciplinary antibiotic stewardship programs centered on weekly prospective audit and feedback

Objective

To evaluate the long-term effects of comprehensive antibiotic stewardship programs (ASPs) on antibiotic use, antimicrobial-resistant bacteria, and clinical outcomes.

Design

Before–after study.

Setting

National university hospital with 934 beds.

Intervention

Implementation in March 2010 of a comprehensive ASPs including, among other strategies, weekly prospective audit and feedback with multidisciplinary collaboration.

Methods

The primary outcome was the use of antipseudomonal antibiotics as measured by the monthly mean days of therapy per 1000 patient days each year. Secondary outcomes included overall antibiotic use and that of each antibiotic class, susceptibility of Pseudomonas aeruginosa, the proportion of patients isolated methicillin-resistant Staphylococcus aureus (MRSA) among all patients isolated S. aureus, the incidence of MRSA, and the 30-day mortality attributable to bacteremia.

Results

The mean monthly use of antipseudomonal antibiotics significantly decreased in 2011 and after as compared with 2009. Susceptibility to levofloxacin was significantly increased from 2009 to 2016 (P = 0.01 for trend). Its susceptibility to other antibiotics remained over 84% and did not change significantly during the study period. The proportion of patients isolated MRSA and the incidence of MRSA decreased significantly from 2009 to 2016 (P < 0.001 and = 0.02 for trend, respectively). There were no significant changes in the 30-day mortality attributable to bacteremia during the study period (P = 0.57 for trend).

Conclusion

The comprehensive ASPs had long-term efficacy for reducing the use of the targeted broad-spectrum antibiotics, maintaining the antibiotic susceptibility of P. aeruginosa, and decreasing the prevalence of MRSA, without adversely affecting clinical outcome.

     

A meta-analysis of the clinicopathological characteristics and survival outcomes of inflammatory bowel disease associated colorectal cancer

Purpose

The current study aims to use meta-analytical techniques to compare the clinicopathological characteristics and survival outcomes of inflammatory bowel disease (IBD) associated and sporadic colorectal carcinoma (CRC). Patients with IBD have an established increased risk of developing CRC. There is no consensus, however, on the clinicopathological characteristics and survival outcomes of IBD associated CRC when compared to sporadic CRC.

Methods

A comprehensive search for published studies comparing IBD associated and sporadic CRC was performed. Random effect methods were used to combine data. This study adhered to the recommendations of the MOOSE guidelines.

Results

Data were retrieved from 20 studies describing 571,278 patients. IBD associated CRC had an increased rate of synchronous tumors (OR 4.403, 95% CI 2.320–8.359; p < 0.001), poor differentiation (OR 1.875, 95% CI 1.425–2.466; p < 0.001), and a reduced rate of rectal cancer (OR 0.827, 95% CI 0.735–0.930; p = 0.002). IBD associated CRC however did not affect the frequency of T3/T4 tumors (OR 0.931, 95% CI 0.782–1.108; p = 0.421), lymph node positivity (OR 1.061, 95% CI 0.929–1.213; p = 0.381), metastasis at presentation (OR 0.970, 95% CI 0.776–1.211; p = 0.786), sex distribution (OR 0.978, 95% CI 0.890–1.074; p = 0.640), or 5-year overall survival (OR 1.105, 95% CI 0.414–2.949; p = 0.842).

Conclusions

In this large analysis of available data, IBD associated CRC was characterized by less rectal tumors and more synchronous and poorly differentiated tumors compared with sporadic cancers, but no discernable difference in sex distribution, stage at presentation, or survival could be identified.

     

The Use of Oral Beta-Blockers and Clinical Outcomes in Patients with Non-ST-Segment Elevation Acute Coronary Syndromes: a Long-Term Follow-Up Study

Background

The role of beta-blockers in patients with acute coronary syndromes is mainly derived from studies including patients with ST-segment elevation myocardial infarction. Little is known about the use of beta-blockers and associated long-term clinical outcomes in patients with non-ST-elevation acute coronary syndromes (NSTEACS).

Methods

We analyzed short- and long-term clinical outcomes of 2921 patients with NSTEACS using or not oral beta-blockers in the first 24 h of the acute coronary syndromes (ACS) presentation. The association between beta-blocker use and mortality was assessed using a propensity score adjusted analysis (N =?1378).

Results

Patients starting oral beta-blockers in the first 24 h of hospitalization, compared with patients who did not, had lower rates of in-hospital mortality (OR?=?0.52, 95% CI 0.33 to 0.74, P =?0.002) and higher mean survival times in the long-term follow-up (11.86±0.4 years vs. 9.92±0.39 years, P <?0.001).

Conclusion

The use of beta-blockers in the first 24 h of patients presenting with NSTEACS was associated with better in-hospital and long-term mortality outcomes.

     

Colorectal cancer in the elderly and the influence of lead time bias: better survival does not equate with improved life expectancy

Aims

Poorer outcomes in those aged ≥80 years who undergo colorectal cancer surgery have been previously reported. Little is known about the natural history of those managed non-operatively. We explored outcomes in all patients with colorectal cancer aged ≥80 years at time of diagnosis based on treatment received.

Methods

Patients ≥80 years diagnosed with colorectal cancer in one hospital trust between 1998 and 2011 were identified from a prospectively maintained database. Primary endpoints were age at diagnosis, age at death/censor and mortality at 30, 90 and 365 days.

Results

Six hundred sixty-eight patients were identified. Four hundred twelve (61.7 %) underwent surgery, 44 (6.6 %) received endoscopic therapy and 212 (31.7 %) had no active treatment. Of those who underwent surgery, 359 (87.1 %) had resectional surgery, 34 (8.3 %) defunctioning only, 13 (3.2 %) received bypass surgery and 6 (1.5 %) had an open and close laparotomy. The mean age at diagnosis was younger in those who underwent surgical resection (83.7 years) compared to those having defunctioning surgery (84.9 years, P?=?0.043), endoscopic therapy (85.1 years, P?=?0.008) or no surgical intervention (85.6 years, P?<?0.001). There was no significant difference in the mean age of death or censor between groups.

Conclusions

There was no significant difference in age at death or censor between treatment groups among patients aged ≥80 years presenting with colorectal cancer, suggesting that differences in the observed survival time are heavily influenced by lead time bias. Age at death or censor should be reported in addition to survival times in this age group to enable fair comparison of outcomes.