Principles of low-rate complications in colorectal cancer patients with large bowel resectionsPenchev D, Vladova L, Dobrev G, Staneva D, Hamdiev M, Gornev R*

Medical University - So�a, Medical Faculty, IVth grade.So�a University, Medical Faculty, Department of General Surgery

BackgroundColorectal cancer (CRC) is the most common neoplasm of thegastro-intestinal system and the third most common cancer in theworld[1,2] .The rate of complications in patients with CRC surgical procedurescorrelate with patients’ survival and quality of life[9].Early and late complications depend on the specific risk profile ofpatient with CRC[10].It is important to create an algorithm in order to reducecomplications’ rate in patients after large bowel resections[5,6,7].

AIMWe aim to create an algorithm for reducing early and late

complications in patient with CRC and large bowel resection.

Materials and methods

For a period of ten years (2002-2012) 363 patients were operated with CRC in University Hospital “Lozenetz”, Department of General surgery. Patients were categorized according to variable tumor locations and different type of surgical procedures. All of the patients had cancer staging, surgical planning, bowel preparations, preoperative, intraoperative and postoperative work up - such as colonoscopy, intraoperative hermetic test of anastomosis, anticoagulant and antibiotic prophylactics. Statistical analysis were done with SPSS 19 and using frequence, correlation and comparative analysis.

Baseline characteristics

DemographicsN=363

Values

Age (years), mean ± SD 67 ± 11Sex, N (%)MaleFemale

208 (57,3)155 (42,7)

BMI,(kg/m2), mean ± SD 25 ± 5

Algorithm of low rate complication in CRC

N=363 ValuesPrinciples of oncological security % 100General surgical principles (dreinage,haemostasisetc.) %

100

Hermetic anastomotic test % 89 Antibiotic prevention (preoperative) % 98,5 Anticoagulant prophylaxis % 86,4Large bowel preparation % 97,7

Antibiotic prevention (postoperative) % 96

Additional intraoperative colonoscopy(in cases with low ware localization of the tumor) %

24,3

Topographic localization by AJCC 7th edition

9,1 9,9

28,3

2,8 3,3

16,6

0 05,8

39,1

2,8 0,3 0,305

1015202530354045

22,3

8,2

0,8

23,4

13,5

4,4

10,48,8

0,31,6

6

0,3

Operative Intervention

TNM Cancer Staging by AJCC 7th edition

0

5

10

15

20

25

30

0 I II a II b III a III b III c IV a IV b

ClinicalPathologic

Greadingof the tumorN=363

(%)

1.GX2.G03.G14.G25.G36.G47.G5

1. 0,5 2. 2,5 3. 3 4. 10,1 5. 58,3 6. 22,1 7. 3,5

Metastatic disease

Nodal metastasisN=363

(%)

NXN0N1N1aN1bN1cN2N2aN2b

1. 14,6 2. 35,1 3. 9,3 4. 4,4 5. 7,3 6. 2,4 7. 7,3 8. 5,9 9. 13,7

Organ metastasis (M)N=363 Liver metastasis (H)

(%)

М1a H1 16,3 8,6

М1b Hx 8,1 68,2

M0 H0 47,6 10,6

MX H2 7,8 2,5

H3 10,1

11%

89%

Complication No-complication

ComplicationsN=363

(%)

Infections 3,3

Anastomotic leakage 2,8

Bleeding 1,4

Cardio-pulmonary 1,9

Obstruction (perioperative) 1,9

Death 0

Early Complications

5%

95%

Complication No-complication

ComplicationsN=363

(%)

Residual tumor 4

Stricture 0

Obstruction 0,5

Late complications

Correlations between postoperative stay and intensive stay in daysPearson Correlation ,266**

**. Correlation is significant at the 0.01 level (2-tailed).P < 0,005

N=363 Mean + SD Max /min Mode

Preoperative stay

3 days ± 3 days 0-17 days 1 day (40%)

Postoperative stay

11 days± 6 days

3-52 days 8 days (18,8%)

Intensive care 2 days ± 2 days 0 – 13 days 0 days (48%)

Relationship between complications and postoperative stay

Blood transfusionN=363 P < 0,005

Early Late

Intraoperative 13 % 5,2 %

Perioperative 17 % 5 %

Without 4 % 2,6 %

Blood lossN=363 P < 0,005

Early Late

100 ml. 6,5 % 2,6 %

100-500 ml. 9 % 5,2 %

> 500 ml.31,6 % 5,2 %

Relationship between complications and blood transfusion and blood loss

Operation timeN=363 P < 0,005

Early complications Late complications

(0-180 min. ) 9,2 % 1,7 %

(180-600 min. ) 11,5 % 4,3 %

Co-morbidityN=363 P < 0,005

Early

Yes 11,9 %

No 2,1 %

Relationship between complications and co-morbidity and operation time

N=363P < 0,005

In (%) of cases Without complications

Without early complications

Without late complications

CPA in large bowel operations

68 % 60,2 % 62,6 % 65,5 %

CPA + additional intraoperativecolonoscopy

22,1 % 19,3 % 19,9 % 21,1 %

Complication prevention algorithm (CPA) and complication rate

0

5

10

15

Early complications

Early complications and antibiotic prevention

YesNo

0

5

10

15

Early complications

Early complications and anticoagulant prophylaxis

YesNo

0

5

10

15

20

Early complications

Early complications and large bowel preparation

YesNo

0

5

10

15

20

Early Late

Early and late complications hermetic anastomotic test

YesNo

DiscussionIn our study we analyze a package of peri-, intra- and postoperative procedures as means to reduce early and late complications in CRC surgery. The rate of early and late complications thoroughly depend on an algorithm that include principles of oncological security, general surgical principles, hermetic anastomotic test, antibiotic prevention, anticoagulant prophylaxis, large bowel preparation and additional intraoperative colonoscopy.David and Dietz report that the highest rates of anastomotic complications are after coloanal anastomoses (10-20%) and wound infections occur in 5-15% of patients following colorectal surgical procedures. The authors identify malnutrition, diabetes, immunosuppression and age greater than 60 years as risk factors for complications [9].Kirchhoff and all present analogical algorithm that include co-morbidity, blood loss, blood transfusion, age, obesity, operation time and surgical experiencea nd point out that mechanical bowel preparation is related to increased rate of postoperative infection and anastomotic leakage.The average anastomotic leakage rate in most of the studies is between 2,9 – 15,3% and in our study anastomotic leakage is 2,8%.

Conclusion1. Operation time, emergency operations, co-morbidity, operative blood

loss and size of operation are specific risk factors for early and late complications after large bowel resection.

2. Strict follow up of an algorithm that include principles of oncological security, general surgical principles, hermetic anastomosis test, antibiotic prevention, anticoagulant prophylaxis, large bowel preparation and additional intraoperative colonoscopy is a reliable method for reducing early and late complication rate after large bowel resection.

Refferences1. World health organization (WHO)[internet]. Globocan world cancer report

2008[cited 20013]. Available from http://globocan.iarc.fr/2. Dimitrova N, Vukov M, Valerianova Z. BULGARIAN NATIONAL CANCER REGISTRY

11th edition AVIS-24;2012 3. Rozen P, Young GP, Levin B and Spann SJ.Colorectal cancer in clinical practice,Early

Detection and management.N Engl J Med.2002 Jul;347(1):71-724. Markowitz SD, and Bertagnolli MM.Molecular Basis of Colorectal Cancer.N engl J

Med.2009 Dec;361 (25):2449-24605. Townsend JR, Beauchamp RD,Evars BM, MattoxKL. Sabiston textbook of surgery

18th edition Saunders Elsevier;20086. Brunicardi FC, Dana KA,Timothy RB, David LD,John GH, Jeffrey BM,et al., editors.

Schwartz's Principles of Surgery, 9th Edition, New York: McGraw Hill; 2009. 7. Damianov D. Surgical oncology –modern standard Medart; 20098. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging

Manual 7th edition Springer;20099. American society of colon and rectal surgeons. Complications in Colorectal

Surgery David W. Dietz, MD 10. Philipp Kirchhoff,Pierre-Alain Clavien, and Dieter Hahnloser Complications in

colorectal surgery: risk factors and preventive strategies. Patient SafSurg. 2010; 4: 5.

Specific risk factors for complications

N=363 ValuesOperation time (minutes) mean ± SD/mode 222 ±99/180Emergency operations % 6,3Co-morbidity % 75 Lack of intestinal motility after operation % 14,5Operative blood loss ml./ % Up to 100 ml/ 44,3

Up to 500ml/ 44,8

Above 500ml/ 10,9

Blood transfusion %IntraoperativePerioperative

21,8

34,5

Size of operation %Only tumor resectionMulti-resection operation

69,1

30,9

0 20 40 60 80 100

(+)Late - (+)Early

(-)Late - (+)Early

(+)Late - (-)Early

(-)Late - (-)Early

0

9

3

87

Combination of complications