Anne M. Dinaux

Risk Stratification for Surgical Site Infections in Colon Cancer

Importance Surgical site infections (SSIs) feature prominently in surgical quality improvement and pay-for-performance measures. Multiple approaches are used to prevent or reduce SSIs, prompted by the heavy toll they take on patients and health care budgets. Surgery for colon cancer is not an exception. Objective To identify a risk stratification score based on baseline and operative characteristics. Design, Setting, and Participants This retrospective cohort study included all patients treated surgically for colon cancer at Massachusetts General Hospital from 2004 through 2014 (n = 1481). Main Outcomes and Measures The incidence of SSI stratified over baseline and perioperative factors was compared and compounded in a risk score. Results Among the 1481 participants, 90 (6.1%) had SSI. Median (IQR) age was 66.9 (55.9-78.1) years. Surgical site infection rates were significantly higher among people who smoked (7.4% vs 4.8%; P = .04), people who abused alcohol (10.6% vs 5.7%; P = .04), people with type 2 diabetics (8.8% vs 5.5%; P = .046), and obese patients (11.7% vs 4.0%; P < .001). Surgical site infection rates were also higher among patients with an operation duration longer than 140 minutes (7.5% vs 5.0%; P = .05) and in nonlaparoscopic approaches (clinically significant only, 6.7% vs 4.1%; P = .07). These risk factors were also associated with an increase in SSI rates as a compounded score (P < .001). Patients with 1 or fewer risk factors (n = 427) had an SSI rate of 2.3%, equivalent to a relative risk of 0.4 (95% CI, 0.16-0.57; P < .001); patients with 2 risk factors (n = 445) had a 5.2% SSI rate (relative risk, 0.78; 95% CI, 0.49-1.22; P = .27); patients with 3 factors (n = 384) had a 7.8% SSI rate (relative risk, 1.38; 95% CI, 0.91-2.11; P = .13); and patients with 4 or more risk factors (n = 198) had a 13.6% SSI rate (relative risk, 2.71; 95% CI, 1.77-4.12; P < .001). Conclusions and Relevance This SSI risk assessment factor provides a simple tool using readily available characteristics to stratify patients by SSI risk and identify patients at risk during their postoperative admission. Thereby, it can be used to potentially focus frequent monitoring and more aggressive preventive efforts on high-risk patients.

Do packed red blood cell transfusions really worsen oncologic outcomes in colon cancer

Background: Data from small retrospective studies have argued that perioperative packed red blood cell transfusions may increase the risk of developing metastatic recurrence in cancer patients. This study tests this assumption in a large cohort spanning a decade of operatively treated colon cancer patients. Methods: All patients undergoing primary resection of a colon cancer at a tertiary care center between 2004–2014 (n = 1,423) were included in a retrospective review of a prospectively maintained data repository. Survival and disease‐free survival were compared and also adjusted in multivariable Cox regression standardized for follow‐up, American Society of Anesthesiologists score, age, sex, postoperative chemotherapy, baseline staging, and tumor grade. Results: Of the 1,423 patients, 305 (21.4%) received a perioperative packed red blood cell transfusion during their index admission. During follow‐up, overall mortality was greater in patients who received perioperative packed red blood cell (53.1% vs 30.9%; P < .001); however, there were no appreciable differences in rates of long‐term distant recurrence (in patients without baseline metastasis 11.1% vs 13.9%; P = .25), or disease‐specific mortality (21.3% vs 17.3%; P = .104; without baseline metastasis: 8.6% vs 8.9%; P = .89). Similarly, multivariable Cox regression showed no statistical difference in recurrence (hazard ratio: 0.83, 95% confidence interval, 0.83–1.26; P = .38) or disease‐specific mortality (hazard ratio: 1.12, 95% confidence interval, 0.83–1.51; P = .47). Conclusion: Mortality rates were significantly greater in patients with perioperative packed red blood cell transfusions, a finding that is backed by a body of evidence that associates perioperative packed red blood cell transfusion with comorbidity and serious illness, but contrary to earlier evidence, findings in our cohort do not support a hypothesis that perioperative perioperative packed red blood cell transfusions have a detrimental effect on recurrence rates of operatively treated colon cancer patients.

A Transverse Colectomy is as Safe as an Extended Right or Left Colectomy for Mid-Transverse Colon Cancer

BackgroundAlthough extended colectomy is often chosen for patients with transverse colon cancer, the optimal surgical approach for mid-transverse colon cancer has not been established.MethodsWe identified patients who underwent a transverse (TC) or an extended colectomy (EC) for mid-transverse colon cancer between 2004 and 2014. To adjust for potential selection bias between the groups, a propensity score matching analysis was performed.ResultsA total of 103 patients were included, of whom 63% underwent EC (right 47%, left 17%) and 37% TC. EC patients tend to have worse short-term outcomes. Although fewer lymph nodes were harvested after TC, 5-year overall (OS) ad disease-free survival (DFS) was comparable between the groups. When comparing long-term outcomes stage-by-stage, worse OS and DFS were seen in stage-II. All stage-II patients died of a non-cancer-related cause and recurrence occurred in pT4 TC patients who did not receive adjuvant therapy. The propensity-matched cohort demonstrated similar postoperative morbidity, but more laparoscopic procedures in EC. Additionally, TC tumors were correlated with poorer histopathological features and disease recurrence was only seen after TC.ConclusionOur study underlines the oncological safety of a transverse colectomy for mid-transverse colon cancer. Although TC tumors were associated with poorer histopathological features, survival rates were comparable.

Is There a Drawback of Converting a Laparoscopic Colectomy in Colon Cancer

BACKGROUND Laparoscopic resection is well established in the treatment of colon cancer. However, conversion rates remain high and the impact of conversion is disputed. MATERIAL AND METHODS We retrospectively identified 1347 patients who underwent surgery for colon cancer between 2004 and 2014 at our tertiary center. Morbidity and oncological outcomes were compared between patients who underwent successfully completed laparoscopic surgery (LS), planned open surgery (OS), and conversion to open surgery (CS). Long-term analysis included patients with stage I-III disease. In addition, we performed propensity score matching to adjust for the heterogeneity and selection bias between the treatment groups. RESULTS Of all patients, 505 underwent LS, 789 underwent OS, and 53 underwent CS, which corresponded to a conversion rate of 9.5%. Conversion was associated with male gender, left-sided tumors, and stage III disease. Length of stay, morbidity, and readmission rates were lower for LS patients. Kaplan-Meier curves demonstrated worse overall, disease-specific, and disease-free survival in CS than LS, with similar outcomes to OS. However, after propensity score matching, CS was only associated with admission duration and the requirement of blood transfusion, whereas survival outcomes were comparable between all groups. CONCLUSIONS CS is associated with adverse short- and long-term outcomes compared to LS. However, when accounting for differences in baseline and pathologic features, CS remained only associated with a longer length of stay and more blood transfusions. Because outcomes were comparable between CS and OS, regardless of stage and other risk factors, our data support a surgeons attempt to perform LS in patients with colon cancer.

Effects of local multivisceral resection for clinically locally advanced rectal cancer on long-term outcomes

Multivisceral resection is occasionally needed to obtain clear margins in patients with transmural rectal cancer. Most series demonstrate equivalent outcomes between those patients who undergo multivisceral resections and those who do not, provided an R0‐resection is achieved. This study focuses solely on patients who received neoadjuvant treatment for clinically transmural rectal cancers and underwent a local multivisceral R0‐resection.

The Influence of Screening on Outcomes of Clinically Locally Advanced Rectal Cancer

BackgroundScreening for colorectal cancer has resulted in declining incidence rates of both colon and rectal cancer and it may influence stage at presentation and improve survival. The aim of this study was to assess the impact of screening on patients diagnosed with locally advanced rectal cancer.MethodsA retrospective analysis of a consecutive series of patients who underwent neoadjuvant therapy and had an R0-resection for clinical AJCC stage II or stage III disease. All patients received surgery at a single center between 2004 and 2015. Patients diagnosed through screening were compared to patients diagnosed through symptomatic presentation.ResultsThree hundred nine patients were included, of whom 43 (13.9%) were diagnosed through screening. Screened patients had more often a white ethnicity, while there were no other differences in baseline characteristics or median household income. Screened patients had a lower rate of disease recurrence in addition to a longer disease free survival and overall survival.ConclusionsPatients with locally advanced rectal cancer diagnosed through screening demonstrated more favorable short and long-term outcomes than patients diagnosed through symptoms. Findings of this study reinforce the need for screening programs in addition to the need for research regarding optimization of screening adherence.

Outcomes of persistent lymph node involvement after neoadjuvant therapy for stage III rectal cancer

Introduction. Lymph node involvement is a well‐known predictor of recurrent rectal cancer in patient who did not undergo neoadjuvant therapy patients. The role of persistent lymph node disease after neoadjuvant treatment, however, is debatable. This study compares outcomes of patients with clinical, stage III rectal cancer who had nodal disease on surgical pathology after neoadjuvant treatment to patients with negative nodes. Methods. We reviewed retrospectively a consecutive cohort of all clinical, American Joint Committee on Cancer stage III rectal cancer patients who received neoadjuvant chemoradiotherapy and had an R0 resection at the Massachusetts General Hospital between 2004 and 2015. Results. A total of 166 patients met the inclusion criteria, of whom 53 had persistent nodal disease on pathologic examination. This group had a greater rate of local and distant disease recurrence and a shorter median recurrent disease‐free survival than patients with a complete nodal response. In multivariable analyses for disease recurrence, disease free survival was greater for patients without positive results in lymph nodes on pathologic examination. Conclusion. Persistent nodal involvement after neoadjuvant therapy is associated with an increased risk of distant metastases and a shorter disease‐free survival. Identifying patients with treatment‐resistant lymph nodes preoperatively and adjusting neoadjuvant treatment might result in better outcomes.

Rectal Cancer in Patients Under 50 Years of age

Background General population screening for colorectal cancer starts at 50, and incidence rates of rectal cancer in patients over 50 years old are decreasing. However, incidence of rectal cancer under age 50 is increasing. This paper analyzes short-and long-term outcomes for rectal cancer patients under 50 years of age.

The negative impact of understaging rectal cancer patients

BACKGROUND Neo-adjuvant chemoradiation followed by surgery and adjuvant therapy is standard treatment of clinical node positive rectal cancer. Understaging leads to delay in treatment with possible detrimental results. This study analyses effects of understaging stage III rectal cancer on long-term outcomes. METHODS A consecutive series of patients, operated on in MGH between 2004 and 2015 was included. Outcomes of non-neoadjuvantly treated clinical stage I patients who turned out to have pathological stage III disease and neoadjuvantly treated clinical stage III patients were retrospectively reviewed. The latter group was subdivided into patients who had persistent nodal disease (ypN+) and patients without positive lymph nodes after neoadjuvant treatment (ypN0). RESULTS Of the 204 included patients, 30 had unexpected nodal disease on pathology. Clinical stage I-patients had higher rates of local recurrence, and rectal cancer and overall mortality than ypN0-patients. CONCLUSION Understaging stage III rectal cancer led to poorer oncologic outcomes, when compared to patients without positive lymph nodes on pathology after neoadjuvant. Future research should focus on identifying patients with treatment susceptible lymph node involvement.