Body composition assessment by artificial intelligence can be a predictive tool for short-term postoperative complications in Hartmann's reversals.

BACKGROUND: Hartmann's reversal, a complex elective surgery, reverses and closes the colostomy in individuals who previously underwent a Hartmann's procedure due to colonic pathology like cancer or diverticulitis. It demands careful planning and patient optimisation to help reduce postoperative complications. Preoperative evaluation of body composition has been useful in identifying patients at high risk of short-term postoperative outcomes following colorectal cancer surgery. We sought to explore the use of our in-house derived Artificial Intelligence (AI) algorithm to measure body composition within patients undergoing Hartmann's reversal procedure in the prediction of short-term postoperative complications. METHODS: A retrospective study of all patients who underwent Hartmann's reversal within a single tertiary referral centre (Western) in Melbourne, Australia and who had a preoperative Computerised Tomography (CT) scan performed. Body composition was measured using our previously validated AI algorithm for body segmentation developed by the Department of Surgery, Western Precinct, University of Melbourne. Sarcopenia in our study was defined as a skeletal muscle index (SMI), calculated as Skeletal Muscle Area (SMA) /height2 < 38.5 cm2/m2 in women and < 52.4 cm2/m2 in men. RESULTS: Between 2010 and 2020, 47 patients (mean age 63.1 ± 12.3 years; male, n = 28 (59.6%) underwent body composition analysis. Twenty-one patients (44.7%) were sarcopenic, and 12 (25.5%) had evidence of sarcopenic obesity. The most common postoperative complication was surgical site infection (SSI) (n = 8, 17%). Sarcopenia (n = 7, 87.5%, p = 0.02) and sarcopenic obesity (n = 5, 62.5%, p = 0.02) were significantly associated with SSIs. The risks of developing an SSI were 8.7 times greater when sarcopenia was present. CONCLUSION: Sarcopenia and sarcopenic obesity were related to postoperative complications following Hartmann's reversal. Body composition measured by a validated AI algorithm may be a beneficial tool for predicting short-term surgical outcomes for these patients.

Understanding patient-reported outcome measures in colorectal cancer.

Quality of life has become increasingly regarded as a key outcome measurement for cancer patients. Patient-reported outcome measures (PROMs) represent the tools used to ascertain self-reported quality of life. This review provides a summary of the literature regarding the use of PROMs in colorectal cancer and evaluates the advantages and limitations of generic and disease specific questionnaires that can be utilized in clinical practice. Factors that influence PROMs are outlined, including cancer characteristics, patient factors and treatment methods. Finally, future directions for the use of PROMs in colorectal cancer to inform healthcare delivery at an individual- and systems-based level are discussed.

Improving Quality of Life for People with Incurable Large-Bowel Obstruction: Randomized Control Trial of Colonic Stent Insertion.

BACKGROUND: Surgery remains the dominant treatment for large-bowel obstruction, with emerging data on self-expanding metallic stents. OBJECTIVE: The aim of this study was to assess whether stent insertion improves quality of life and survival in comparison with surgical decompression. DESIGN: This study reports on a randomized control trial (registry number ACTRN012606000199516). SETTING: This study was conducted at Royal Prince Alfred Hospital, Sydney, and Western Hospital, Melbourne. PATIENTS AND INTERVENTION: Patients with malignant incurable large-bowel obstruction were randomly assigned to surgical decompression or stent insertion. MAIN OUTCOME MEASURES: The primary end point was differences in EuroQOL EQ-5D quality of life. Secondary end points included overall survival, 30-day mortality, stoma rates, postoperative recovery, complications, and readmissions. RESULTS: Fifty-two patients of 58 needed to reach the calculated sample size were evaluated. Stent insertion was successful in 19 of 26 (73%) patients. The remaining 7 patients required a stoma compared with 24 of 26 (92%) surgery group patients (p < 0.001). There were no stent-related perforations or deaths. The surgery group had significantly reduced quality of life compared with the stent group from baseline to 1 and 2 weeks (p = 0.001 and p = 0.012), and from baseline to 12 months (p = 0.01) in favor of the stent group, whereas both reported reduced quality of life. The stent group had an 8% 30-day mortality compared with 15% for the surgery group (p = 0.668). Median survival was 5.2 and 5.5 months for the groups (p = 0.613). The stent group had significantly reduced procedure time (p = 0.014), postprocedure stay (p = 0.027), days nothing by mouth (p = 0.002), and days before free access to solids (p = 0.022). LIMITATIONS: This study was limited by the lack of an EQ-5D Australian-based population set. CONCLUSIONS: Stent use in patients with incurable large-bowel obstruction has a number of advantages with faster return to diet, decreased stoma rates, reduced postprocedure stay, and some quality-of-life benefits.

Artificial intelligence measured 3D body composition to predict pathological response in rectal cancer patients.

BACKGROUND: The treatment of locally advanced rectal cancer (LARC) is moving towards total neoadjuvant therapy and potential organ preservation. Of particular interest are predictors of pathological complete response (pCR) that can guide personalized treatment. There are currently no clinical biomarkers which can accurately predict neoadjuvant therapy (NAT) response but body composition (BC) measures present as an emerging contender. The primary aim of the study was to determine if artificial intelligence (AI) derived body composition variables can predict pCR in patients with LARC. METHODS: LARC patients who underwent NAT followed by surgery from 2012 to 2023 were identified from the Australian Comprehensive Cancer Outcomes and Research Database registry (ACCORD). A validated in-house pre-trained 3D AI model was used to measure body composition via computed tomography images of the entire Lumbar-3 vertebral level to produce a volumetric measurement of visceral fat (VF), subcutaneous fat (SCF) and skeletal muscle (SM). Multivariate analysis between patient body composition and histological outcomes was performed. RESULTS: Of 214 LARC patients treated with NAT, 22.4% of patients achieved pCR. SM volume (P = 0.015) and age (P = 0.03) were positively associated with pCR in both male and female patients. SCF volume was associated with decreased likelihood of pCR (P = 0.059). CONCLUSION: This is the first study in the literature utilizing AI-measured 3D Body composition in LARC patients to assess their impact on pathological response. SM volume and age were positive predictors of pCR disease in both male and female patients following NAT for LARC. Future studies investigating the impact of body composition on clinical outcomes and patients on other neoadjuvant regimens such as TNT are potential avenues for further research.

Recalibration and validation of a preoperative risk prediction model for mortality in major colorectal surgery.

BACKGROUND: In 2009, Barwon Health designed a risk stratification model for mortality in major colorectal surgery with the use of only preoperative risk factors. The Barwon Health 2009 model was shown to predict mortality reliably, and it was comparable to other models, such as the original, POSSUM. However, the Barwon Health 2009 model was never validated with data other than those used to develop the model. OBJECTIVE: The aim of this study was to perform temporal and external validation of the Barwon Health 2009 model and to compare it with other published models. DESIGN: : The temporal validation was a prospective observational study, whereas the external validation was a retrospective observational study. The discrimination and calibration of the models were assessed by using the area under receiver operator characteristic and χ test of Hosmer-Lemeshow goodness-of-fi technique. SETTINGS: This is a multi-institutional study. Data were collected from 2008 to 2010. RESULTS: There were 474 major colorectal cases at Geelong Hospital (temporal validation) and 389 cases at Western Hospital (external validation). The overall mortality rate was 5.10% and 1.03%. In the comparison of the 2 demographics, Geelong Hospital had a higher proportion of patients who were older and had higher ASA scores and comorbidity counts, whereas Western Hospital surgeons were operating on a higher number of urgent cases. Despite the differences, the Barwon Health 2009 model was able to discriminate mortality reliably (area under receiver operator characteristic = 0.753) but had poor model calibration (p < 0.001) on temporal validation. Hence, the model was recalibrated to predict mortality accurately(area under receiver operator characteristic = 0.772; p = 0.83), and this was successfully validated at Western Hospital (area under receiver operator characteristic = 0.788; p = 0.24). CONCLUSIONS: We have developed a model that can accurately predict mortality after major colorectal surgery by using only data that are available preoperatively. After recalibration, the model was successfully validated in a second hospital.

Time to readiness for discharge is a valid and reliable measure of short-term recovery after colorectal surgery.

BACKGROUND: Short-term recovery after colorectal surgery has been traditionally investigated through length of stay (LOS). However, this measure is influenced by several confounding factors. This study aimed to investigate the construct validity and reliability of assessing the time to achieve standardized discharge criteria (time to readiness for discharge, or TRD) as a measure of short-term recovery. In a secondary analysis, we compared sample size requirements for randomized controlled trials (RCTs) using TRD or LOS as outcome measures. METHODS: Seventy patients participated in the construct validity study and 21 patients participated in the reliability study. TRD was defined as the number of days to achieve discharge criteria previously defined by consensus. Construct validity was investigated by testing six hypothesis based on the assumption that TRD measures short-term recovery. Reliability was calculated by comparing measures of TRD by two independent assessors. Variability estimates (standard deviations) of LOS and TRD were used for sample size calculations. RESULTS: Five of the six hypotheses were supported by the data (p < 0.05). Interobserver reliability was excellent (ICC2.1 = 0.99). Sample size estimations showed that RCTs using TRD as an outcome measure require approximately 23 % less participants compared to RCTs using LOS. CONCLUSIONS: The results of this research support the construct-validity and reliability of TRD as a measure of short-term recovery. Using TRD as an alternative to LOS may reduce sample size requirements in future RCTs.

Reversal of Hartmann's procedure: timelines, preoperative investigations and early outcomes. A single Australian institution's ten-year experience.

BACKGROUND: Real-world data on outcomes following Hartmann's reversal is necessary to help optimize the patient experience. We have explored the timing between the index operation and its reversal; what investigations were carried out prior to this, and the associated short-term outcomes. METHODS: A retrospective study of all patients who underwent Hartmann's reversal from 2010 to 2020 within a tertiary referral centre in Melbourne, Australia. One hundred from a total of 406 (25%) who underwent an emergency Hartmann's procedure had a subsequent reversal. Complete patient data was available for 83 of these patients. RESULTS: The average patient age was 60 years, and the median time for reversal was 14.0 (IQR 10-23) months. Seventy-nine of 83 (95%) reversals had a preoperative endoscopic evaluation of both their rectal stump and a complete colonoscopy. Stoma stenosis (n = 2), patient refusal (n = 1) and emergency reversal (n = 1) were cited reasons for not undergoing preoperative endoscopic evaluation. A third (n = 28, 34%) had a computed tomography prior to reversal; the majority was due to their underlying cancer surveillance (n = 21, 75%). Reversal was associated with a morbidity rate of 47% (n = 39). Surgical site infections (SSIs) (n = 21, 25%) were the most common type of complications encountered, with the majority being superficial (n = 15, 71%). SSIs were associated with steroid use (5/21 versus 4/62, p = 0.03) and greater hospital length of stay (6 versus 10 days, p = 0.03). CONCLUSION: Only a quarter of emergency Hartmann's procedures within our institution were reversed. A significant proportion developed postoperative complications. Surgical site infection was the most common morbidity.

Criteria to determine readiness for hospital discharge following colorectal surgery: an international consensus using the Delphi technique.

BACKGROUND: Standardized discharge criteria are considered valuable to reduce the risk of premature discharge and avoid unnecessary hospital stays. The most appropriate criteria to indicate readiness for discharge after colorectal surgery are unknown. OBJECTIVE: The aim of this study is to achieve an international consensus on hospital discharge criteria for patients undergoing colorectal surgery. DESIGN: Fifteen experts from different countries participated in a 3-round Delphi process. In round 1, experts determined which criteria best indicate readiness for discharge and described specific end points for each criterion. In rounds 2 and 3, experts rated their agreement with the use of a 5-point Likert scale. MAIN OUTCOME MEASURES: Consensus was defined when criteria and end points were rated as agree or strongly agree by at least 75% of the experts in round 3. RESULTS: Experts reached consensus that patients should be considered ready for hospital discharge when there is tolerance of oral intake, recovery of lower gastrointestinal function, adequate pain control with oral analgesia, ability to mobilize and self-care, and no evidence of complications or untreated medical problems. Specific end points were defined for each of the criteria. Experts also agreed that after these criteria are achieved, discharge may take place as soon as the patient has adequate postdischarge support and is willing to leave the hospital. If a stoma was constructed, the patient or the patient's family should have received training on stoma care or had outpatient training arranged. LIMITATIONS: The panel comprised mostly experts from developed countries. This may restrict the applicability of these discharge criteria in countries where there are dissimilar health care resources. CONCLUSION: This Delphi study has provided substantial consensus on discharge criteria for patients undergoing colorectal surgery. We recommend that these criteria be used in clinical practice to guide decisions regarding patient discharge and applied in future research to increase the comparability of study results.

Chronic rectal anastomosis complications prior to ileostomy reversal: development of a pilot classification system and associated outcomes.

BACKGROUNDS: A loop ileostomy may reduce the severity of acute anastomotic complications after low rectal resection, but some patients have persistent rectal anastomotic problems. No consensus exists for the management of patients with a chronic low rectal anastomosis complication and a loop ileostomy. There is need for a standard description of these anastomotic complications and to determine whether it is safe to reverse the ileostomy. This study proposes a classification of chronic rectal anastomotic complications and to report the correlation with successful restoration of rectal continuity. METHODS: This was a retrospective project from a prospectively maintained database at a single colorectal unit in a large tertiary hospital in Metropolitan Melbourne. Patients with rectal anastomotic complications following rectal cancer resections between March 2012 and October 2019 were included. A classification of chronic rectal anastomotic complication was developed by reviewing the interval assessments of the rectal anastomosis. The classification categories were correlated with outcomes after stoma closure. RESULTS: Of the 149 patients, 20 patients had an anastomotic complication identified during work up prior to loop ileostomy reversal. Eleven patients had an anastomotic stenosis and nine had an anastomotic defect. Eighteen patients were eligible for stomal closure. The majority (11/12) of patients with a Type 1 stenosis or defect had no rectal complications after stoma closure. CONCLUSION: The classification system helps to describe chronic rectal anastomotic abnormalities and guide management. Although these patients may be a challenge, many can undergo successful ileostomy reversal.

Investigations and time trends in loop ileostomy reversals following anterior resections: a single Australian institution seven-years' experience.

BACKGROUND: Currently no consensus exists regarding what pre-reversal investigations are required to assess integrity of the rectal anastomosis. The objective of this study was to compare pre-reversal assessments of anastomotic integrity and to evaluate trends that might have influenced timings for reversal. METHODS: From a prospectively maintained database, patients with colorectal cancer resections between March 2012 and October 2019 were identified. Patient characteristics, pre-reversal contrast enema and flexible sigmoidoscopy findings were recorded, and management of complications were recorded. Time-to-ileostomy reversal and time series for trends were analysed. RESULTS: There were 154 patients included. Pre-reversal contrast enema or sigmoidoscopy detected a possible stricture or leak at the rectal anastomotic site in 11% (15/132) and 15% (18/112), respectively. When both modalities were used there was concordance of 86.1% and a positive likelihood ratio of 5.73. Of 125 (81.2%) ileostomies reversed, the median time-to-reversal was 11.99 months; time series analysis over the 7-year period showed no significant trend for average patient-days from booking to reversal (P = 0.60). Cox regression modelling did not identify any influential risk factors for the times taken to reversal. CONCLUSION: This study supports the use of both contrast enema and flexible sigmoidoscopy in the assessment of rectal anastomosis integrity. Most patients with complications can have their ileostomies reversed. Patients who have adjuvant chemotherapy have a prolonged time to reversal.

Positive lateral pelvic lymph nodes in low rectal cancer: should we change our practice now?

BACKGROUND: The role of lateral lymph node dissection (LLND) in the treatment of patients with low rectal cancer with enlarged lateral lymph nodes (LLN+) is under investigation. Enthusiasm for LLND stems from a perceived reduction in local recurrence (LR). We aimed to compare the LR rate for LLN+ patients with LLN- patients, treated with neoadjuvant chemoradiotherapy (nCRT) and surgery, in a hospital that does not perform LLND. METHODS: A retrospective study of all patients with clinical stage 3 low rectal cancer who completed nCRT and surgery between 2008 and 2017 at Western Health was performed. Outcomes for LLN+ patients were compared with LLN- patients. The primary outcome was LR. Secondary outcomes included distant metastases, disease-free survival and overall survival. RESULTS: There were 110 patients treated for stage 3 low rectal cancer over 10 years. There was no significant difference in the LR rate, with one LR from 28 LLN+ patients and one LR from 82 LLN- patients (4% versus 1.2%, P = 0.44). There were no significant differences in median disease-free survival (41 versus 52 months, P = 0.19) or mean overall survival (62 versus 60 months, P = 0.80). Of all patients studied, 21% developed distant metastases. CONCLUSION: LR after nCRT and surgery in patients with stage 3 rectal cancer is rare, irrespective of lateral pelvic node status. These data, along with the uncertain benefit and known risks of LLND, supports the continued use of standard therapy in these patients. Strategies to address distant failure in these patients should be explored.

Patterns of surveillance for colorectal cancer: Experience from a single large tertiary institution.

AIM: Colorectal cancer surveillance is an essential part of care and should include clinical review and follow-up investigations. There is limited information regarding postoperative surveillance and survivorship care in the Australian context. This study investigated patterns of colorectal cancer surveillance at a large tertiary institution. METHODS: A retrospective review of hospital records was conducted for all patients treated with curative surgery between January 2012 and June 2017. Provision of clinical surveillance, colonoscopy, computed tomography (CT), and carcinoembryonic antigen (CEA) within 24 months postoperatively were recorded. Kaplan-Meier estimates were used to evaluate time-to-surveillance review and associated investigations. RESULTS: A total of 675 patients were included in the study. Median time to first postoperative clinical review was 20 days (95% confidence interval (CI), 18-21) with only 31% of patients having their first postoperative clinic review within 2 weeks. Median time to first CEA was 100 days (95% CI, 92-109), with 47% of patients having their CEA checked within the first 3 months, increasing to 68% at 6 months. Median time to first follow-up CT scan was 262 days (95% CI, 242-278) and for colonoscopy, 560 days (95% CI, 477-625). Poor uptake of surveillance testing was more prevalent in patients from older age groups, those with multiple comorbidities, and higher stage cancers. CONCLUSION: Colorectal cancer surveillance is multi-disciplinary and involves several parallel processes, many of which lead to inconsistent follow-up. Further prospective work is required to identify the reasons for variation in care and which aspects are most important to cancer patients.

The place of elective surgery following acute diverticulitis in young patients: when is surgery indicated? An analysis of the literature.

Diverticulitis in the young is often regarded as a specific entity. Resection after a single attack because of a more "virulent" course of the disease has been accepted as conventional wisdom. The evidence for such a recommendation and the place of elective surgery was reviewed by a search of Medline, PubMed, Embase, and the Cochrane library for articles published between January 1965 and March 2008 using the terms diverticular disease and diverticulitis. Publications had to give specific information on at least ten younger patients (age

Treatment of colonoscopic perforation: outcomes from a major single tertiary institution.

BACKGROUND: The use of colonoscopy has been increasing in Australia. This case series describes management and outcomes of colonoscopic perforation managed by a single tertiary referral unit. METHODS: An analysis of 13 years (2003-2015) of prospectively collected data on patients who had a colonoscopic perforation and were managed by the colorectal unit at a single tertiary referral centre was performed. Main outcomes were time of diagnosis, modality of management, time to theatre, length of stay, cost of admission and complications. RESULTS: Sixty-two patients had perforations (median age of 69 years). Thirty-eight (61.2%) patients had their colonoscopy performed in another institution. The incidence rate decreased to 0.37 perforations per 1000 colonoscopies within Western Health. Overall, diagnostic colonoscopies accounted for 56% of perforations and perforations were likely to occur in the left colon (P = 0.006). Fifty-one (82%) patients underwent surgery during their admission, with 24% of these being laparoscopic procedures. An earlier diagnosis was associated with significantly less intra-abdominal contamination. Gross peritoneal contamination was more likely to be associated with the decision to form a stoma (37%, n = 19, P = 0.04). Thirty-day mortality was 1.6% (n = 1). CONCLUSIONS: Colonoscopic perforations occur in experienced hands and may have serious implications. We demonstrated a difference in patterns of injury between therapeutic and diagnostic colonoscopies. Those who have an earlier diagnosis are less likely to have severe intra-abdominal contamination requiring a stoma formation.

State-wide outcomes in elective rectal cancer resection: is there a case for centralization in Victoria?

BACKGROUND: The role of service centralization in rectal cancer surgery is controversial. Recent studies suggest centralization to high-volume centres may improve postoperative mortality. We used a state-wide administrative data set to determine the inpatient mortality for patients undergoing elective rectal cancer surgery and to compare individual hospital volumes. METHODS: The Victorian Admitted Episodes Dataset was explored using the Dr Foster Quality Investigator tool. The inpatient mortality rate, 30-day readmission rate and the proportion of patients with increased length of stay were measured for all elective admissions for rectal cancer resections between 2012 and 2016. A peer group of 14 hospitals were studied using funnel plots to determine inter-hospital variation in mortality. Procedure types were compared between the groups. RESULTS: There were 2241 elective resections performed for rectal cancer in Victoria over 4 years. The crude inpatient mortality rate was 1.1%. There were no significant differences in mortality among 14 hospitals within the peer group. The number of elective resections over 4 years ranged from 14 to 136 (median 65) within these institutions. Ultralow anterior resection was the commonest procedure performed. CONCLUSION: Inpatient mortality after elective rectal cancer surgery in Victoria is rare and compares favourably internationally. Based on inpatient mortality alone, there is no compelling evidence to further centralize elective rectal cancer surgery in Victoria. More work is needed to develop data sets with oncological information capable of providing accurate complete state-wide data which will be essential for future service planning, training and innovation.

Complete state-wide outcomes in elective colon cancer surgery.

BACKGROUND: Maintaining high standards in colon cancer surgery requires the measurement of quality indicators and the re-allocation of resources to address deficiencies. We used state-wide administrative data to determine the inpatient mortality for patients undergoing elective colon cancer surgery and to compare individual hospital rates. METHODS: The Dr Foster Quality Investigator Tool was used to explore the Victorian Admitted Episodes Dataset for elective admissions for colon cancer surgery between 2012 and 2016. The inpatient mortality rate, 30-day readmission rate and the proportion of patients with increased length of stay were measured. Risk-adjusted rates were used to compare public and private hospitals. A peer group of 14 hospitals were studied using funnel plots to determine inter-hospital variation in mortality. RESULTS: There were 6120 colectomies performed for colon cancer in Victoria over 3 years. The crude inpatient mortality rate was 1.3%. It was significantly higher in public than private hospitals, even after risk adjustment. Variation in crude mortality was demonstrated among 14 selected hospitals. The lowest volume hospitals had significantly higher inpatient mortality rates. Right hemicolectomy was the commonest procedure performed. CONCLUSION: Using an efficient method of complete state-wide data capture, we have demonstrated that the inpatient mortality rate after elective colon cancer surgery in Victoria is low. However, complexity remains around the interpretation of inter-hospital variation, defining outliers, and comparing outcomes between public and private hospitals. Resolving these complexities and defining additional quality indicators remain a priority in the use of administrative data to audit the quality of colon cancer care.