Aim
Prehabilitation, defined as enhancement of the preoperative condition of a patient, is a possible strategy for improving postoperative outcome. Lack of muscle strength and poor physical ...condition, increasingly prevalent in older patients, are risk factors for postoperative complications. Eighty‐five per cent of patients with colorectal cancer are aged over 60 years. Since surgery is the cornerstone of their treatment, this review systemically examined the literature on the effect of physical prehabilitation in older patients undergoing colorectal surgery.
Method
Trials and case–control studies investigating the effect of physical prehabilitation in patients over 60 years undergoing colorectal surgery were retrieved from MEDLINE, EMBASE, CINAHL and the Cochrane library. Patient characteristics, the type of intervention and outcome measurements were recorded. The risk of bias and heterogeneity was assessed.
Results
Five studies including 353 patients were identified. They were small, containing an average of 77 patients and were of moderate methodological quality. Compliance rates of the prehabilitation programme varied from 16 to 97%. None of the studies could identify a significant reduction of postoperative complications or length of hospital stay. Four studies showed physical improvement (walking distance, respiratory endurance) in the prehabilitation group. Clinical heterogeneity precluded a meta‐analysis.
Conclusion
Prehabilitation is a possible means of enhancing the physical condition of patients preoperatively. The quality of studies in older patients undergoing colorectal surgery is poor, despite the increase in elderly people with colorectal cancer. Defining specific patient groups at risk and standardizing the outcome are essential for improving the results of treatment.
Background
Evidence for an association between hospital volume and outcomes for liver surgery is abundant. The current Dutch guideline requires a minimum volume of 20 annual procedures per centre. ...The aim of this study was to investigate the association between hospital volume and postoperative outcomes using data from the nationwide Dutch Hepato Biliary Audit.
Methods
This was a nationwide study in the Netherlands. All liver resections reported in the Dutch Hepato Biliary Audit between 2014 and 2017 were included. Annual centre volume was calculated and classified in categories of 20 procedures per year. Main outcomes were major morbidity (Clavien–Dindo grade IIIA or higher) and 30‐day or in‐hospital mortality.
Results
A total of 5590 liver resections were done across 34 centres with a median annual centre volume of 35 (i.q.r. 20–69) procedures. Overall major morbidity and mortality rates were 11·2 and 2·0 per cent respectively. The mortality rate was 1·9 per cent after resection for colorectal liver metastases (CRLMs), 1·2 per cent for non‐CRLMs, 0·4 per cent for benign tumours, 4·9 per cent for hepatocellular carcinoma and 10·3 per cent for biliary tumours. Higher‐volume centres performed more major liver resections, and more resections for hepatocellular carcinoma and biliary cancer. There was no association between hospital volume and either major morbidity or mortality in multivariable analysis, after adjustment for known risk factors for adverse events.
Conclusion
Hospital volume and postoperative outcomes were not associated.
Antecedentes
La asociación entre el volumen hospitalario y los resultados de la cirugía hepática no está clara. Según la recomendación actual de las guías holandesas se requiere un volumen mínimo de 20 procedimientos anuales por centro. El objetivo de este estudio fue analizar la asociación entre el volumen hospitalario con los resultados postoperatorios en la auditoría hepatobiliar obligatoria holandesa a nivel nacional.
Métodos
Se realizó un estudio a nivel nacional en los Países Bajos. Se incluyeron todas las resecciones hepáticas registradas en la auditoría hepatobiliar holandesa entre 2014 y 2017. El volumen anual del centro se calculó y se clasificó en categorías de 20 procedimientos por año. Los objetivos principales fueron la morbilidad de mayor grado (Clavien‐Dindo grado IIIA o superior) y la mortalidad hospitalaria o la mortalidad a los 30 días.
Resultados
Se realizaron un total de 5.590 resecciones en 34 centros con una mediana (rango intercuartílico) de volumen anual de 35 procedimientos (20‐69). La tasa global de morbilidad mayor fue del 11% y la mortalidad del 2%. La mortalidad fue de 1,9% después de la resección por metástasis hepáticas colorrectales (colorectal liver metastases, CRLM), 1,2% para no CRLM, 0,4% para tumores benignos, 4,9% para carcinoma hepatocelular, y 10,3% para tumores biliares. Los centros de mayor volumen realizaron más resecciones hepáticas mayores y más resecciones por carcinoma hepatocelular y cáncer biliar. En el análisis multivariable después de ajustar por factores de riesgo conocidos de eventos adversos, no se observó ninguna asociación entre el volumen hospitalario y la morbilidad o mortalidad mayor.
Conclusión
No hubo asociación entre el volumen hospitalario y los resultados postoperatorios de la cirugía hepática en los Países Bajos.
This study analysed the association between hospital volume and postoperative outcomes in the nationwide Dutch Hepato Biliary Audit. A total of 5590 resections was performed across 34 centres with a median annual centre volume of 35 (i.q.r. 20–69) procedures. No association was found between hospital and postoperative outcomes.
Cut‐off about right
Background
Treatment strategies for diverticulitis with abscess formation have shifted from (emergency) surgical treatment to non‐surgical management (antibiotics with or without percutaneous ...drainage (PCD)). The aim was to assess outcomes of non‐surgical treatment and to identify risk factors for adverse outcomes.
Methods
Patients with a first episode of CT‐diagnosed diverticular abscess (modified Hinchey Ib or II) between January 2008 and January 2015 were included retrospectively, if initially treated non‐surgically. Baseline characteristics, short‐term (within 30 days) and long‐term treatment outcomes were recorded. Treatment failure was a composite outcome of complications (perforation, colonic obstruction and fistula formation), readmissions, persistent diverticulitis, emergency surgery, death, or need for PCD in the no‐PCD group. Regression analyses were used to analyse risk factors for treatment failure, recurrences and surgery.
Results
Overall, 447 patients from ten hospitals were included (Hinchey Ib 215; Hinchey II 232), with a median follow‐up of 72 (i.q.r. 55–93) months. Most patients were treated without PCD (332 of 447, 74·3 per cent). Univariable analyses, stratified by Hinchey grade, showed no differences between no PCD and PCD in short‐term treatment failure (Hinchey I: 22·3 versus 33 per cent, P = 0·359; Hinchey II: 25·9 versus 36 per cent, P = 0·149) or emergency surgery (Hinchey I: 5·1 versus 6 per cent, P = 0·693; Hinchey II: 10·4 versus 15 per cent, P = 0·117), but significantly more complications were found in patients with Hinchey II disease undergoing PCD (12 versus 3·7 per cent; P = 0·032). Multivariable analyses showed that treatment strategy (PCD versus no PCD) was not independently associated with short‐term treatment failure (odds ratio (OR) 1·47, 95 per cent c.i. 0·81 to 2·68), emergency surgery (OR 1·29, 0·56 to 2·99) or long‐term surgery (hazard ratio 1·08, 95 per cent c.i. 0·69 to 1·69). Abscesses of at least 3 cm in diameter were associated with short‐term treatment failure (OR 2·05, 1·09 to 3·86), and abscesses of 5 cm or larger with the need for surgery during short‐term follow‐up (OR 2·96, 1·03 to 8·13).
Conclusion
The choice between PCD with antibiotics or antibiotics alone as initial non‐surgical treatment of Hinchey Ib and II diverticulitis does not seem to influence outcomes.
This multicentre retrospective cohort study included 447 patients with Hinchey Ib and II diverticular abscesses, who were treated with antibiotics, with or without percutaneous drainage. Abscesses of 3 and 5 cm in size were at higher risk of short‐term treatment failure and emergency surgery respectively. Initial non‐surgical treatment of Hinchey Ib and II diverticular abscesses was comparable between patients treated with antibiotics only and those who underwent percutaneous drainage in combination with antibiotics, with regard to short‐ and long‐term outcomes.
Most do not need drainage
Aim
The aim of this study was to validate the Dutch translation of the low anterior resection syndrome (LARS) score in a population of Dutch rectal cancer patients.
Method
Patients who underwent ...surgery for rectal cancer received the LARS score questionnaire, a single quality of life (QoL) category question and the European Organization for Research and Treatment of Cancer (EORTC) QLQ‐C30 questionnaire. A subgroup of patients received the LARS score twice to assess the test–retest reliability.
Results
A total of 165 patients were included in the analysis, identified in six Dutch centres. The response rate was 62.0%. The percentage of patients who reported ‘major LARS’ was 59.4%. There was a high proportion of patients with a perfect or moderate fit between the QoL category question and the LARS score, showing a good convergent validity. The LARS score was able to discriminate between patients with or without neoadjuvant radiotherapy (P = 0.003), between total and partial mesorectal excision (P = 0.008) and between age groups (P = 0.039). There was a statistically significant association between a higher LARS score and an impaired function on the global QoL subscale and the physical, role, emotional and social functioning subscales of the EORTC QLQ‐C30 questionnaire. The test–retest reliability of the LARS score was good, with an interclass correlation coefficient of 0.79.
Conclusion
The good psychometric properties of the Dutch version of the LARS score are comparable overall to the earlier validations in other countries. Therefore, the Dutch translation can be considered to be a valid tool for assessing LARS in Dutch rectal cancer patients.
Background
Ileostomy construction is a common procedure but can be associated with morbidity. The stoma is commonly secured to the skin using transcutaneous sutures. It is hypothesized that ...intracutaneous sutures result in a tighter adherence of the peristomal skin to the stoma plate to prevent faecal leakage. The study aimed to compare the effect of intracutaneous versus transcutaneous suturing of ileostomies on faecal leakage and quality of life.
Methods
This randomized trial was undertaken in 11 hospitals in the Netherlands. Patients scheduled to receive an ileostomy for any reason were randomized to intracutaneous or transcutaneous suturing (IC and TC groups respectively). The primary outcome was faecal leakage. Secondary outcomes were stoma‐related quality of life and costs of stoma‐related materials and reinterventions.
Results
Between April 2011 and February 2016, 339 patients were randomized to the IC (170) or TC (169) group. Leakage rates were higher in the IC than in the TC group (52·4 versus 41·4 per cent respectively; risk difference 11·0 (95 per cent c.i. 0·3 to 21·2) per cent). Skin irritation rates were high (78·2 versus 72·2 per cent), but did not differ significantly between the groups (risk difference 6·1 (95 per cent c.i. –3·2 to 15·10) per cent). There were no significant differences in quality of life or costs between the groups.
Conclusion
Intracutaneous suturing of an ileostomy is associated with more peristomal leakage than transcutaneous suturing. Overall stoma‐related complications did not differ between the two techniques. Registration number: NTR2369 (
http://www.trialregister.nl).
More leaks with intracutaneous
Abdominal cancer surgery is associated with considerable morbidity in older patients. Assessment of preoperative physical status is therefore essential. The aim of this review was to describe and ...compare the objective physical tests that are currently used in abdominal cancer surgery in the older patient population with regard to postoperative outcomes.
Medline, Embase, CINAHL and Web of Science were searched until 31 December 2020. Non-interventional cohort studies were eligible if they included patients ≥65 years undergoing abdominal cancer surgery, reported results on objective preoperative physical assessment such as Cardiopulmonary Exercise Testing (CPET), field walk tests or muscle strength, and on postoperative outcomes.
23 publications were included (10 CPET, 13 non-CPET including Timed Up & Go, grip strength, 6-minute walking test (6MWT) and incremental shuttle walk test (ISWT)). Meta-analysis was precluded due to heterogeneity between study cohorts, different cut-off points, and inconsistent reporting of outcomes. In CPET studies, ventilatory anaerobic threshold and minute ventilation/carbon dioxide production gradient were associated with adverse outcomes. ISWT and 6MWT predicted outcomes in two studies. Tests addressing muscle strength and function were of limited value. No study compared different physical tests.
CPET has the ability to predict adverse postoperative outcomes, but it is time-consuming and requires expert assessment. ISWT or 6MWT might be a feasible alternative to estimate aerobic capacity. Muscle strength and function tests currently have limited value in risk prediction. Future research should compare the predictive value of different physical instruments with regard to postoperative outcomes in older surgical patients.
Abstract Background Reduced muscle density is associated with an increased risk of postoperative complications. We examined the prognostic value of muscle density as a predictor of postoperative ...complications in elderly patients undergoing surgery for colorectal cancer. Methods Patients (≥70 years) who underwent surgery for colorectal cancer between 2006 and 2013 were selected from a prospective single centre database. The Hounsfield Unit Average (HUA or HU/mm2 ) of the psoas muscles at the level of the third lumbar vertebra was calculated on the scan. High and low muscle density groups were identified based on the lowest gender specific HUAC quartile. Major postoperative complications (Clavien-Dindo (CD) ≥3) within 30 days after surgery were retrospectively documented. Logistic regression analysis was used to identify risk factors for postoperative complications. Results A total of 373 patients (median age = 78 years) were included in this study. The mean muscle density score was 24.5 ± 4.3 HU/mm2 for males and 26.3 ± 5.0 HU/mm2 for females. The cut-off point for the lowest gender specific quartile was ≤22.0 HU/mm2 for males and ≤23.5 HU/mm2 for females. After multivariable regression, there was a statistically significant association between muscle density and CD ≥ 3 (OR = 1.84 (95% CI 1.11–3.06), p = 0.019). Anastomotic leakage in patients with a primary anastomosis (n = 287) occurred more often in patients with low muscle density (11.7% vs 23.3%, p = 0.016). The associations remained significant after correction for confounders. Conclusion Low muscle density is associated with major postoperative complications in older patients who undergo surgery for colorectal cancer.
Among esophagogastric cancer patients, the probability of having undergone treatment with curative intent has been shown to vary, depending on the hospital of diagnosis. However, little is known ...about the factors that contribute to this variation. In this study, we sought to understand the organization of clinical pathways and their association with variation in practice.
A mixed-method study using quantitative and qualitative data was conducted. Quantitative data were obtained from the Netherlands Cancer Registry (e.g., outpatient clinic consultations and diagnostic procedures). For qualitative data, thematic content analysis was performed using semi-structured interviews (n = 30), observations of outpatient clinic consultations (n = 26), and multidisciplinary team meetings (MDTM, n = 16) in eight hospitals, to assess clinicians' perspectives regarding the clinical pathways.
Quantitative analyses showed that patients more often underwent surgical consultation prior to the MDTM in hospitals associated with a high probability of receiving treatment with curative intent, but more often consulted with a geriatrician in hospitals associated with a low probability of such treatment. The organization of clinical pathways was analyzed quantitatively at three levels: regional, local, and patient levels. At a regional level, hospitals differed in terms of the number of patients discussed during the MDTM. At the local level, the revision of radiological images and restaging after neoadjuvant treatment varied. At the patient level, some hospitals routinely conduct fitness tests, whereas others estimated the patient's physical fitness during an outpatient clinic consultation. Few clinicians performed a standard geriatric consultation in older patients to assess their mental fitness and frailty.
Surgical consultation prior to MDTM was more often conducted in hospitals associated with a high probability of receiving treatment with curative intent, whereas a geriatrician was consulted more often in hospitals associated with a low probability of receiving such treatment.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background
The standard surgical treatment for rectal cancer is total mesorectal excision (TME), which may negatively affect patients’ functional outcomes and quality of life (QoL). However, it is ...unclear how different TME techniques may impact patients’ functional outcomes and QoL. This systematic review and meta-analysis evaluated functional outcomes of urinary, sexual, and fecal functioning as well as QoL after open, laparoscopic (L-TME), robot-assisted (R-TME), and transanal total mesorectal excision (TaTME).
Methods
A systematic review and meta-analysis, based on the preferred reporting items for systematic reviews and meta-analysis statement, were conducted (PROSPERO: CRD42021240851). A literature review was performed (sources: PubMed, Medline, Embase, Scopus, Web of Science, and Cochrane Library databases; end-of-search date: September 1, 2023), and a quality assessment was performed using the Methodological index for non-randomized studies. A random-effects model was used to pool the data for the meta-analyses.
Results
Nineteen studies were included, reporting on 2495 patients (88 open, 1171 L-TME, 995 R-TME, and 241 TaTME). Quantitative analyses comparing L-TME vs. R-TME showed no significant differences regarding urinary and sexual functioning, except for urinary function at three months post-surgery, which favoured R-TME (SMD CI –0 .15 − 0.24 to − 0.06,
p
= 0.02;
n
= 401). Qualitative analyses identified most studies did not find significant differences in urinary, sexual, and fecal functioning and QoL between different techniques.
Conclusions
This systematic review and meta-analysis highlight a significant gap in the literature concerning the evaluation of functional outcomes and QoL after TME for rectal cancer treatment. This study emphasizes the need for high-quality, randomized-controlled, and prospective cohort studies evaluating these outcomes. Based on the limited available evidence, this systematic review and meta-analysis suggests no significant differences in patients' urinary, sexual, and fecal functioning and their QoL across various TME techniques.
Purpose
The aim of this research was to study the effectiveness on return to work (RTW) of an early tailored work-related support intervention in patients diagnosed with curative gastrointestinal ...cancer.
Methods
A multicenter randomized controlled trial was undertaken, in which patients were assigned randomly to the intervention or the control group (usual care). The intervention encompassed three psychosocial work-related support meetings, starting before treatment. Five self-reported questionnaires were sent over twelve months of follow-up. Primary outcome was days until RTW (fulltime or partial) and secondary outcomes included work status, quality of life, work ability, and work limitations. Descriptive analysis, Kaplan–Meier analysis, relative risk ratio and linear mixed models were applied.
Results
Participants (N = 88) had a mean age of 55 years; 67% were male and the most common cancer type was colon cancer (66%). Of the participants, 42 were randomized to the intervention group. The median time from sick leave until RTW was 233 days (range 187–279 days) for the control group, versus 190 days (range 139–240 days) for the intervention group (log-rank p = 0.37). The RTW rate at twelve months after baseline was 83.3% for the intervention group and 73.5% for the control group. Work limitations did statistically differ between the groups over time (p = 0.01), but quality of life and work ability did not.
Conclusion
Patients in the intervention group seem to take fewer days to RTW, albeit not to a statistically significant extent.
Trial registration
Trial NL4920 (NTR5022) (Dutch Trial Register
https://www.trialregister.nl
)
PDF
