Prehabilitation and functional recovery for colorectal cancer patients

Cancer and its treatments are associated with functional decline that has impactful consequences on quality of life, and care continuum. Thus, optimizing perioperative functional capacity has been identified as a research and clinical priority in cancer care. The process of enhancing physical fitness before an operation to enable the patient to withstand the stress of surgery has been termed prehabilitation. Main elements are preoperative exercise, nutrition therapy, and anxiety-reduction techniques. Given the growing body of evidence on prehabilitation efficacy, this narrative review will summarize the rational underlying preoperative interventions, and propose a structured clinical pathway aimed at optimizing preoperative functional capacity.     

Exercise prehabilitation in lung cancer: Getting stronger to recover faster

Despite several recent advances, lung cancer surgery is still associated with potentially severe postoperative complications. It has been suggested that preoperative exercise training could render patients with borderline functional parameters eligible for surgery, improve perioperative outcomes and that these benefits might reduce healthcare costs. Nevertheless, given the substantial heterogeneity of the available studies, no specific guidelines for preoperative exercise training have been released so far.This narrative review aims to provide an overview of the potential benefits of exercise training in the preoperative period as a central intervention for lung cancer patients. In detail, the effects of exercise (with different regimens) were evaluated in terms of physical functions, patients’ eligibility for curative surgery, postoperative complications and length of stay, with an exploratory focus on healthcare costs and long-term outcomes. Furthermore, a feasible approach for every-day clinical practice is proposed in order to increase the expected benefit deriving from a more extensive and methodical application of prehabilitation exercise, ideally in the context of a comprehensive approach to lung cancer patients, including nutritional and psychological support.     

Implementation of enhanced recovery after surgery in patients undergoing radical cystectomy: A retrospective cohort study

BackgroundTo evaluate the feasibility and effect of implementing enhanced recovery after surgery (ERAS) in patients undergoing radical cystectomy (RC) and urinary diversion.Materials and methodsSince October 2016, a 15-point ERAS protocol has been implemented for patients undergoing elective RC and urinary diversion at Fudan University Shanghai Cancer Center (FUSCC). We retrospectively assessed patients who underwent RC performed between January 2014 and June 2018. The effects of implanting ERAS for RC were validated.ResultsA total of 443 patients were included. The ERAS and non-ERAS groups included 185 and 258 patients, respectively. There was no significant difference in the patients’ demographic characteristics, operative variables, perioperative systemic inflammation-based scores or mortality rates. Compared with the non-ERAS group, our study showed decreases in intraoperative blood loss volumes and transfusion rates in the ERAS group. Patients in the ERAS group also had earlier times to tolerate a clean liquid diet intake, first ambulation and first flatus. The incidences of postoperative pneumonia, urine leakage, intestinal obstruction and deep venous thrombosis were also significantly lower in the ERAS group. The time to pelvic drainage tube removal and the length of stay (LOS) were significantly shorter in the ERAS group than in the non-ERAS group, and the ERAS group also had a significantly lower incidence of 30-day readmission.ConclusionsThe results of this study suggest that ERAS protocols can accelerate the rehabilitation of patients undergoing RC, reduce the incidence of postoperative complications, shorten the LOS, and are safe and feasible in the field of RC. This study provides experience from FUSCC to further optimize ERAS protocols for patients with bladder cancer.     

Identification of factors predictive of postoperative morbidity and short-term mortality in older patients after colorectal carcinoma resection: A single-center retrospective study

Objectives

The aim of this study is to investigate the effect of age on patient outcome after colorectal carcinoma (CRC) resection in patients over 65?years of age.

Post-discharge complications in frail older patients after surgery for colorectal cancer

Background

The incidence of postoperative complications after colorectal cancer surgery varies between publications. Complications occurring after discharge from hospital are often not reported. The aims of this study were to investigate the proportion of frail older colorectal cancer patients who developed complications only after discharge, the severity of post-discharge complications, and the time point at which the most frequent complications occurred.

Adding diagnostic laparoscopy to computed tomography for the evaluation of peritoneal metastases in patients with colorectal cancer: A retrospective cohort study

BackgroundDespite its widespread use, computed tomography (CT) is not perfect for evaluating peritoneal metastases of colorectal origin before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). We therefore evaluated the value of adding diagnostic laparoscopy to CT when assessing patient eligibility for CRS + HIPEC.MethodsThis was a retrospective study of a consecutive series of 112 patients evaluated systematically by diagnostic laparoscopy and CT between January 2012 and January 2018. Patient eligibility for CRS + HIPEC was assessed by the peritoneal cancer index (PCI) both at the time of initial diagnostic laparoscopy and during the retrospective review of CT images. Two experienced radiologists who were blinded to the PCI result at laparoscopy then independently estimated the PCI based on CT imaging. The primary outcome was the number of patients eligible for CRS + HIPEC by each method.ResultsWe identified 112 patients, of whom 95 (85%) were eligible for CRS + HIPEC based on diagnostic laparoscopy and 84 underwent CRS + HIPEC. Overall, 14 patients (17%) experienced an “open-and-close” procedure. In contrast to diagnostic laparoscopy, 100 patients (89%) were identified as being eligible for CRS + HIPEC by CT (p = 0.13), which would have resulted in an additional five open-and-close procedures.ConclusionsAdding diagnostic laparoscopy to CT produced a clinically relevant, but statistically non-significant, reduction in the number of patients eligible for CRS + HIPEC. We conclude that diagnostic laparoscopy may be of use in preoperative assessments when systematic analysis by CT scores the PCI as greater than ten. Future research should focus on the cost-effectiveness of this approach.     

Regional lymph node involvement in patients undergoing liver resection for colorectal cancer metastases

Background

While the indications for surgery among patients with colorectal cancer liver metastases (CRCLM) are expanding, the role of surgery in patients with hepatic lymph node involvement remains controversial. We report management and outcomes in a population-based cohort of patients undergoing hepatectomy with concomitant hepatic lymphadenectomy for CRCLM.

Proposal of a stage-specific surveillance strategy for colorectal cancer patients: A retrospective analysis of Japanese large cohort

Background

Frequency and duration of postoperative surveillance for colorectal cancer patients remain debatable, and follow-up data regarding stage I or resected stage IV patients are limited.

Management of liver metastases in colorectal cancer patients: A retrospective case-control study of systemic therapy versus liver resection

ObjectiveTo evaluate and compare the overall survival (OS) in case-matched patient groups treated either with systemic therapy or surgery for colorectal liver metastases (CRLM).MethodsPatients with CRLM, without extra-hepatic disease, treated with chemotherapy with or without targeted therapy in two phase III studies (n = 480) were selected and case-matched to patients who underwent liver resection (n = 632). Matching criteria were sex, age, established prognostic factors for survival (clinical risk score). Available computed tomography (CT)-scans of patients treated with systemic therapies were reviewed by three independent liver surgeons for resectability. Survival was compared between patients with resectable CRLM (based on CT-scan review) who were treated with systemic therapy versus patients who underwent liver resection.ResultsA total of 96 patients treated with systemic therapy were included. Pre-treatment CT-scans of the liver were available for review in 56 of the systemically treated patients, and metastases were unanimously considered resectable in 36 patients (64.3%) (complex resectable: n = 25; 69%). These 36 patients were case-matched with 36 patients who underwent liver resection (wedge resection or segmentectomy: n = 26; 72%). Median OS in the patient group treated with systemic therapy was 26.5 months (range 0–81 months), which was significantly lower than that in case-matched patients who underwent liver resection (median OS 56 months; range 6–116) (p = 0.027).ConclusionsIn this case-matched control study, surgery provided superior OS rates compared to systemic therapy for CRLM. Resection of CRLM should always be considered, preferably in a dedicated liver centre, since not all patients that qualify for resection are identified as such.     

Preoperative systemic inflammation predicts postoperative infectious complications in patients undergoing curative resection for colorectal cancer

The presence of systemic inflammation before surgery, as evidenced by the glasgow prognostic score (mGPS), predicts poor long-term survival in colorectal cancer. The aim was to examine the relationship between the preoperative mGPS and the development of postoperative complications in patients undergoing potentially curative resection for colorectal cancer. Patients (n=455) who underwent potentially curative resections between 2003 and 2007 were assessed consecutively, and details were recorded in a database. The majority of patients presented for elective surgery (85%) were over the age of 65 years (70%), were male (58%), were deprived (53%), and had TNM stage I/II disease (61%), had preoperative haemoglobin (56%), white cell count (87%) and mGPS 0 (58%) in the normal range. After surgery, 86 (19%) patients developed a postoperative complication; 70 (81%) of which were infectious complications. On multivariate analysis, peritoneal soiling (P<0.01), elevated preoperative white cell count (P<0.05) and mGPS (P<0.01) were independently associated with increased risk of developing a postoperative infection. In elective patients, only the mGPS (OR=1.75, 95% CI=1.17–2.63, P=0.007) was significantly associated with increased risk of developing a postoperative infection. Preoperative elevated mGPS predicts increased postoperative infectious complications in patients undergoing potentially curative resection for colorectal cancer.     

Outcomes of colorectal cancer surgery in nonagenarian patients: a multicenter retrospective study

BackgroundThe use of surgery in patients with colorectal cancer (CRC) aged ≥90 years remains controversial. This study aimed to evaluate the short-term postoperative and long-term oncologic outcomes of CRC surgery in patients within this age group.MethodsA total of 151 consecutive nonagenarian patients who underwent CRC surgery were included from 3 different hospitals. The Comprehensive Complication Index (CCI) was used to grade postoperative complications. Univariate and multivariate analyses were conducted to identify factors associated with CCI and overall survival (OS).ResultsThe patients had a mean age of 92.8 years (standard deviation ±1.9 years). Forty-six patients (30.5%) underwent emergency surgery, and 105 patients (69.5%) underwent elective surgery. The postoperative complications rate was 66.2% (100/151), and the mean CCI was 26.3 (±30.8). Twenty-three patients (15.2%) died postoperatively, and the perioperative mortality rates for elective surgery and emergency surgery were 7.6% (8/105) and 32.6% (15/46), respectively (P<0.001). The 1-, 3-, and 5-year survival rates were 77.5%, 53.9%, and 38.6%, respectively. Multivariate analysis revealed emergency surgery and American Society of Anesthesiologists (ASA) score to be predictors of postoperative complications. Advanced tumor stage, palliative surgery, ASA score ≥4, and CCI >17 were associated with poor OS.ConclusionsCRC surgery should not be denied to nonagenarian patients. Surgical treatment can be performed with acceptable morbidity and mortality, and achieves long-term survival in a select group.     

Colonoscopy,imaging, and carcinoembryonic antigen: Comparison of guideline adherence to surveillance strategies in patients who underwent resection of colorectal cancer - A systematic review and meta-analysis

IntroductionAlmost one-third of patients with colorectal cancer (CRC) experience recurrence after resection. Adherence to surveillance guidelines largely dictates efficacy in early detection of recurrence. We sought to assess and compare adherence to postoperative surveillance guidelines for colonoscopy, imaging, and Carcinoembryonic Antigen (CEA).MethodsPubMed, Medline, Embase, Scopus, Cochrane, Web of Science, and CINAHL were systematically searched. Random-effects meta-analysis was performed and pooled adherence to each surveillance strategy was assessed for CEA, imaging, and colonoscopy.ResultsOverall 14 studies (55,895 patients) met the inclusion criteria. Adherence to colonoscopy guidelines was the highest (70%, 95%CI 67–73), followed by imaging (63%, 95%CI 47–80), and CEA (54%; 95%CI 42–66). Among 7 (50%) studies that examined adherence to the American Society of Clinical Oncology guidelines, compliance with colonoscopy was the highest (73%; 95% CI 70–76), followed by imaging (58%; 95% CI 37–78), and CEA (45%; 95%CI 37–52). Of note, guideline adherence to CEA testing was much lower than colonoscopy among patients with colon (OR 0.21; 95%CI 0.20–0.22) and rectal cancer (OR 0.25; 95%CI 0.23–0.28) (both p < 0.05). This was also noted when compared with imaging recommendations among older patients (OR = 0.62; 95%CI 0.42–0.93) and patients with stage II, (OR = 0.80; 95%CI 0.76–0.84) and stage III disease (OR = 0.88; 95%CI 0.82–0.94) (all p < 0.05).ConclusionWhile guideline adherence to postoperative surveillance with colonoscopy was high, adherence to CEA testing and imaging surveillance strategies was markedly lower following CRC resection. Future studies should investigate avenues to improve compliance with surveillance guidelines among health care providers and patients to optimize postoperative follow-up for CRC.     

Evidence base for exercise prehabilitation suggests favourable outcomes for patients undergoing surgery for non-small cell lung cancer despite being of low therapeutic quality: a systematic review and meta-analysis

ObjectiveThe aim of this systematic review was to evaluate whether exercise prehabilitation programs reduce postoperative complications, postoperative mortality, and length of hospital stay (LoS) in patients undergoing surgery for non-small cell lung cancer (NSCLC), thereby accounting for the quality of the physical exercise program.MethodsTwo reviewers independently selected randomized controlled trials (RCTs) and observational studies and assessed them for methodological quality and therapeutic quality of the exercise prehabilitation program (i-CONTENT tool). Eligible studies included patients with NSCLC performing exercise prehabilitation and reported the occurrence of 90-day postoperative complications, postoperative mortality, and LoS. Meta-analyses were performed and the certainty of the evidence was graded (Grading of Recommendations Assessment, Development and Evaluation (GRADE)) for each outcome.ResultsSixteen studies, comprising 2,096 patients, were included. Pooled analyses of RCTs and observational studies showed that prehabilitation reduces postoperative pulmonary complications (OR 0.45), postoperative severe complications (OR 0.51), and LoS (mean difference −2.46 days), but not postoperative mortality (OR 1.11). The certainty of evidence was very low to moderate for all outcomes. Risk of ineffectiveness of the prehabilitation program was high in half of the studies due to an inadequate reporting of the dosage of the exercise program, inadequate type and timing of the outcome assessment, and low adherence.ConclusionAlthough risk of ineffectiveness was high for half of the prehabilitation programs and certainty of evidence was very low to moderate, prehabilitation seems to result in a reduction of postoperative pulmonary and severe complications, as well as LoS in patients undergoing surgery for NSCLC.     

癌症患者生命质量测定量表体系之大肠癌量表QLICP-GR的研制

背景与目的:癌症患者生命质量测定量表体系(quality of life instruments for cancer patients,QLICP)共性模块的研制已有报道,本研究在此基础上将研制大肠癌患者生命质量测定量表(QLICP-colorectal cancer,QLICP-CR).方法:采用量表开发的程序化决策方式研制适合中国文化背景下使用的QLICP-CR,并通过110例大肠癌患者的生存质量测定对量表进行评价.采用统计描述、相关分析、配对t检验和聚类分析等进行统计学处理.结果:总量表及各个领域的重测相关系数均在0.78以上;各领域内部一致性信度的α值除社会功能及共性症状和副作用领域分别为0.66、0.63外,其余均在0.85以上;各条目与其领域的相关均大于与其它领域的相关,相关系数r值大多都在0.6以上;总量表、共性模块、特异模块、心理功能及共性症状和副作用领域得分均显示治疗前后差异有统计学意义.结论:QLICP-CR具有较好的信度、效度及反应度,可作为我国大肠癌患者生命质量的测评工具.     

伴呼吸功能障碍的结直肠癌患者腹腔镜治疗的可行性分析

 目的　探讨伴呼吸功能障碍的结直肠癌患者接受腹腔镜治疗的可行性。方法　总结2007年8月至2009年11月收治的伴呼吸功能障碍的结直肠癌患者64例。遵循肿瘤根治原则,36例接受腹腔镜手术,28例行常规开腹手术。结果　腹腔镜组术后吸氧时间平均3.5 d,开腹组平均4.6 d（P＜0.05）;自主咳痰能力优于开腹组（P＜0.05）;腹腔镜组术后气管插管拔除时间平均21.2 min、开腹组平均23.9 min,差异无统计学意义（P＞0.05）;两组患者术后血氧饱和度波动范围腹腔镜组略优于开腹组,但差异无统计学意义（P＞0.05）;开腹组肺部感染1例,两组患者均无肺不张、呼吸衰竭及泌尿系感染病例。结论　伴呼吸功能障碍的结直肠癌患者适合应用腹腔镜手术治疗。     

Primary tumor resection in colorectal cancer with unresectable synchronous metastases: A review

At the time of diagnosis, 25% of patients with colorectal cancer (CRC) present with synchronous metastases, which are unresectable in the majority of patients. Whether primary tumor resection (PTR) followed by chemotherapy or immediate chemotherapy without PTR is the best therapeutic option in patients with asymptomatic CRC and unresectable metastases is a major issue, although unanswered to date. The aim of this study was to review all published data on whether PTR should be performed in patients with CRC and unresectable synchronous metastases. All aspects of the management of CRC were taken into account, especially prognostic factors in patients with CRC and unresectable metastases. The impact of PTR on survival and quality of life were reviewed, in addition to the characteristics of patients that could benefit from PTR and the possible underlying mechanisms. The risks of both approaches are reported. As no randomized study has been performed to date, we finally discussed how a therapeutic strategy’s trial should be designed to provide answer to this issue.     

Preoperative misdiagnosis of pancreatic and periampullary cancer in patients undergoing pancreatoduodenectomy: A multicentre retrospective cohort study

IntroductionWhereas neoadjuvant chemo(radio)therapy is increasingly used in pancreatic cancer, it is currently not recommended for other periampullary (non-pancreatic) cancers. This has important implications for the relevance of the preoperative diagnosis for pancreatoduodenectomy. This retrospective multicentre cohort study aimed to determine the frequency of clinically relevant misdiagnoses in patients undergoing pancreatoduodenectomy for pancreatic or other periampullary cancer.MethodsData from all consecutive patients who underwent a pancreatoduodenectomy between 2014 and 2018 were obtained from the prospective Dutch Pancreatic Cancer Audit. The preoperative diagnosis as concluded by the multidisciplinary team (MDT) meeting was compared with the final postoperative diagnosis at pathology to determine the rate of clinically relevant misdiagnosis (defined as missed pancreatic cancer or incorrect diagnosis of pancreatic cancer).ResultsIn total, 1244 patients underwent pancreatoduodenectomy of whom 203 (16%) had a clinically relevant misdiagnosis preoperatively. Of all patients with a final diagnosis of pancreatic cancer, 13% (87/679) were preoperatively misdiagnosed as distal cholangiocarcinoma (n = 41, 6.0%), ampullary cancer (n = 27, 4.0%) duodenal cancer (n = 16, 2.4%), or other (n = 3, 0.4%). Of all patients with a final diagnosis of periampullary (non-pancreatic) cancer, 21% (116/565) were preoperatively incorrectly diagnosed as pancreatic cancer. Accuracy of preoperative diagnosis was 84% for pancreatic cancer, 71% for distal cholangiocarcinoma, 73% for ampullary cancer and 73% for duodenal cancer. A prediction model for the preoperative likelihood of pancreatic cancer (versus other periampullary cancer) prior to pancreatoduodenectomy demonstrated an AUC of 0.88.DiscussionThis retrospective multicentre cohort study showed that 16% of patients have a clinically relevant misdiagnosis that could result in either missing the opportunity of neoadjuvant chemotherapy in patients with pancreatic cancer or inappropriate administration of neoadjuvant chemotherapy in patients with non-pancreatic periampullary cancer. A preoperative prediction model is available on www.pancreascalculator.com.     

Major vascular reconstruction in colorectal adenocarcinoma and retroperitoneal sarcoma: A retrospective study of safety and margins in a tertiary referral centre

BackgroundThe role of en bloc vascular resection and reconstruction (EVRR) is controversial in colorectal adenocarcinoma (CRC), but well-established in retroperitoneal sarcoma (RPS). Sparse data exists regarding these complex procedures.MethodsPatients undergoing curative intent EVRR for advanced CRC and RPS between 2014 and 2021 at a tertiary centre were included. Morbidity, margins, recurrence, and survival were evaluated.Results24 patients underwent EVRR with 48 reconstructions (11 CRC and 13 RPS). For CRC, 100% of patients underwent Iliac system reconstructions. For RPS, inferior vena cava reconstructions were the most common (69.2%). There were 2 arterial and 1 venous graft thromboses. Primary graft patency was 89.4% arterial and 93.1% venous, while secondary patency was 100% arterial and 96.5% venous at last follow up. 1 venous and 1 arterial graft required reoperation for bleeding. There were no compromised limbs. Major complications occurred in 6 patients (25.0%) with no observed difference between CRC and RPS (OR 0.43 95%CI[0.60,3.19], P = 0.41). R1 margins occurred 1 CRC (90.9%) and 3 RPS (76.9%), with no R2 resections. All vascular resection margins were clear. There were 6 CRC (50%) and 4 RPS (33.3%) recurrences. Median recurrence time was 20.9 months for CRC and ‘not yet reached’ for RPS. Median follow-up was 19.4 months for CRC and 21.4 months for RPS.ConclusionEVRR for locally advanced CRC or RPS is safe and achieves favorable R0 resection rates. CRC patients with major vascular invasion can still be considered for curative intent surgery. Larger cohorts with longer follow up are needed to assess oncologic outcomes.