Overall survival comparing laparoscopic to open surgery for right-sided colon cancer: propensity score inverse probability weighting population study.

BACKGROUND: This retrospective cohort study reports on overall survival and short-term complications, comparing laparoscopic to open resection for right-sided colon cancers. It is one of the largest studies in the field with generalizable population-level results. METHOD: This study on right sided colon cancers used prospectively collected administrative data linked to a death registry over 5 years from 2014 to 2018. Exclusion criteria were private patients, patients aged less than 10 years, synchronous and metachronous cancers. Propensity score weighting was used to balance cohorts and Cox proportional hazards regression was used to assess the hazard of death. In addition, logistic regression analysis was used to assess secondary outcomes. For completeness, unweighted data was similarly analysed. RESULTS: There were 3603 patients identified for the analysis: 1729 open patients and 1874 laparoscopic patients. Cox proportional hazards regression analysis of the weighted data showed no evidence of a statistically significant effect of laparoscopic surgery compared to open surgery on overall survival for right-sided colon cancers (HR 0.86, 95% CI 0.71-1.04, P = 0.112). The weighted data showed lower odds of prolonged length of stay, return to theatre and discharge destination other than home in the laparoscopic cohort compared to the open cohort. There was no difference in inpatient mortality. Unweighted results were similar. CONCLUSION: This study validates the use of laparoscopic surgery for right-sided colon cancer, showing similar long-term overall survival and inpatient mortality compared to open surgery. It is superior to open surgery for the short-term outcomes of LOS, return to theatre and discharge destination other than home.

Delayed ileostomy closure increases the odds of Clostridium difficile infection.

AIM: A diverting ileostomy is typically performed to divert intestinal contents in high-risk colorectal anastomoses. Ileostomy closure is associated with high rates of postoperative Clostridium difficile infection (CDI). Risk factors for the development of CDI are unclear; however, a correlation has been observed with delayed closure. This study aimed to assess the odds of developing CDI in patients who had a delay to reversal of ileostomy, compared to those who had no delay. METHODS: A retrospective cohort study was conducted of patients undergoing reversal of ileostomy between 2010 and 2019 at a single tertiary centre. A delay to reversal of ileostomy was defined if the procedure was performed at >365 days following the index procedure. CDI was defined as the presence of Clostridium difficile toxin associated with diarrhoea. Univariable logistic regression analysis was performed to estimate odds of CDI for each covariable, comparing patients who had a delay to reversal of ileostomy with those who did not. Multivariable logistic regression analysis was used to adjust for the potential confounding effects of covariables. RESULTS: Of 195 patients, 11 (5.6%), developed postoperative CDI. Multivariable analysis showed that delay to reversal of ileostomy was associated with a nearly 7-fold increase in odds of CDI (OR = 6.95, CI: 1.06-81.6; p-value = 0.03). CONCLUSION: A delay to reversal of ileostomy of >365 days was associated with a higher incidence of CDI postoperatively. Careful consideration should be given to the timing of reversal and appropriate preoperative counselling of patients.

Impact of hospital geographic remoteness on overall survival after colorectal cancer resection using state-wide administrative data.

BACKGROUND: This study aimed to use administrative data (AD) linked to the Victorian death index (VDI) to report on overall long-term survival following colorectal cancer (CRC) surgery, comparing regional to metropolitan hospitals. METHODS: A retrospective cohort study using prospectively gathered AD linked to VDI. The primary outcome was overall survival (OS). Outcomes were adjusted for potential confounders via multivariable Cox proportional hazard regression analysis. RESULTS: Total of 17 533 patients: 12 879 metropolitan patients, 3835 inner regional patients and 719 outer regional patients. Multivariable Cox regression, adjusted for the effects of age, ASA score, Charlson score, position of tumour, mode of access, admission type, lymph node metastases, distant metastases, return to theatre, length of stay, HDU admission and discharge destination showed no difference in OS comparing CRC resection patients from inner or outer regional hospitals to metropolitan ((HR 1.02, 95% CI 0.95-1.09, P = 0.59) and (HR 0.97, 95% CI 0.85-1.11, P = 0.68) respectively). CONCLUSION: This is the largest and most detailed study concerning OS after CRC resection involving Victorian public hospitals. There was no difference in OS following CRC resection when inner or outer regional hospitals were compared to metropolitan hospitals in Victoria. The study demonstrated the utility of AD with validated algorithms, linked to death data for reporting CRC survival outcomes.

Impact of hospital geographic remoteness on short-term outcomes after colorectal cancer resection using state-wide administrative data.

BACKGROUND: This study aimed to use validated coding algorithms, applied to a central repository of administrative data (AD), to report on short-term outcomes following resection for colorectal cancer (CRC) comparing regional to metropolitan Victorian hospitals. METHODS: This is a retrospective cohort study using prospectively gathered AD. The primary outcome was prolonged length of stay (LOS). Secondary outcomes were: inpatient mortality, return to theatre, discharge destination and need for mechanical ventilation/intensive care unit support. Outcomes were adjusted for potential confounders via multivariable logistic regression analysis. RESULTS: This study of 18 470 patients found strong evidence for lower odds of prolonged LOS (odds ratio (OR) 0.53, 95% confidence interval (CI) 0.48-0.58, P ≤ 0.001) and inpatient mortality (OR 0.67, 95% CI 0.49-0.91, P = 0.01) in inner regional hospital compared with metropolitan hospitals. For outer regional hospitals, there was strong evidence of decreased odds of prolonged LOS (OR 0.64, 95% CI 0.52-0.77, P = <0.001) and return to theatre (OR 0.67, 95% CI 0.47-0.95, P = 0.03). CONCLUSION: This is the largest and most detailed study concerning short-term outcomes following CRC resection in Victorian public hospitals. Inner and outer regional centres had similar or better short-term outcomes than metropolitan hospitals after CRC resection. AD with validated algorithms serves as a large accurate database to report on CRC outcomes.

Laparoscopic Compared With Open Resection for Colorectal Cancer and Long-term Incidence of Adhesional Intestinal Obstruction and Incisional Hernia: A Systematic Review and Meta-analysis.

BACKGROUND: Incisional hernia and adhesional intestinal obstruction are important complications of laparoscopic and open resection for colorectal cancer. This is the largest systematic review of comparative studies on this topic. OBJECTIVE: This study aimed to investigate whether laparoscopic surgery decreases the incidence of incisional hernia and adhesional intestinal obstruction compared to open surgery for colorectal cancer. DATA SOURCES: Online databases PubMed, EMBASE, and the Cochrane Library were searched. Abstracts from the annual meetings of the American Society of Colon and Rectal Surgeons and the European Society of Coloproctology were performed to cover gray literature. STUDY SELECTION: We included both randomized and nonrandomized comparative studies. INTERVENTIONS: Laparoscopic resection was compared to open resection for patients with colorectal cancer. MAIN OUTCOMES MEASURES: The primary outcomes measured were incisional hernia and adhesional intestinal obstruction. RESULTS: Fifteen studies met inclusion criteria (6 randomized comparative studies/9 nonrandomized comparative studies); 84,172 patients. Meta-analysis showed decreased odds of developing incisional hernia in the laparoscopic cohort (OR, 0.79; 95% CI, 0.66-0.95; p = 0.01) but no difference in requirement for surgery (OR, 1.07; 95% CI, 0.64-1.79; p = 0.79). Similarly, there were decreased odds of developing adhesional intestinal obstruction in the laparoscopic cohort (OR, 0.81; 95% CI, 0.72-0.92, p = 0.001), but no difference in requirement for surgery (OR, 0.84; 95% CI, 0.53-1.35; p = 0.48). LIMITATIONS: Incisional hernia and adhesional intestinal obstruction were poorly defined in many studies. CONCLUSION: Laparoscopic surgery is associated with decreased odds of incisional hernias and adhesional intestinal obstructions compared with open surgery for colorectal cancer.