Background
1st Author (reference), year, country | Study period | Duration of FU (months) | Compared morbidity | Number of patients | % of T4 (n) | Post-op complications (%) | AL rate (%) | Impact of morbidity on OS (at 5 years) | Location of cancer | Independent predictor of OS hazard ratio |
---|---|---|---|---|---|---|---|---|---|---|
Law et al. [31] 2004, Hong Kong | 1993–2002 | 40 (3–109)a | AL versus No AL | 563 | NA | 6 | 6 | 8/30 vs 156/533, p = 0.7600 | R | p = 0.004 |
Eriksen et al. [32] 2004, Norway | 1993–1995 | 45 (0–98)a | AL versus No AL | 1958 | 6 (117/1958) | NA | 22 (T4) | 93/228 vs 564/1730, p = 0.014 | R | NA |
Walker et al. [33] 2004, Australia | 1971–1999 | ≥60a | AL versus No AL | 1722 | NA | NA | 5 | 44.3% vs 64%, p = 0.0001 | R/C | 1.6 (CI 1.3–2.1) |
Nespoli et al. [34] 2004, Italy | ≥60a | Yes, versus No | 192 | NA | NA | NA | p = 0.0006 | C | NA | |
Branagan and Finnis et al. [35] 2005, UK | 1991–1995 | ≥60a | AL versus No AL | 1759 | NA | NA | 4 | R: 17/36 vs 210/581, p = 0.1840 C: 9/22 vs 430/112, p = 0.8100 | R/C | NA |
McArdle et al. [36] 2005, UK | 1991–1994 | ≥60a | AL versus No AL | 2235 | NA | NA | 4 | 43/86 vs 688/2149, p = 0.0010 | R/C | 1·61 (CI 1·19, 2·16) |
Ptok et al. [37] 2007, Germany | 2000–2001 | ≥40a | AL versus No AL | 1625 | 50 for (AL group) 26 (for Non-AL group) | 15 | 74/255 vs 337/1370, p = 0.1360 | R | NA | |
Law et al. [22] 2007, Hong Kong | 1996–2004 | 46c | Yes, versus No | 1657 | NA | 27 | 4 | 26/60 vs 366/1520, p = 0.0010 | R/C | 1.26, p = 0.023 |
Lee et al. [38] 2008, Korea | 1996–2006 | 44.6 (2–157)a | AL versus No AL | 1278 | 73 (933/1278) (T3/T4) | NA | 4 | 80.2% vs 64.9%, p = 0.17 | R | NA |
Eberhardt et al. [34] 2009, USA | 1979–2007 | ≥60a | AL versus No AL | 468 | NA | NA | 33 | 13/59 vs 16/118, p = 0.1550 | R/C | NA |
Den Dulk et al. [39] 2009, Multinational | 1987–2002 | 70.8 (2–179)a | AL versus No AL | 2726 | NA | NA | 10 | 46/220 vs 427/2199, p = 0.5950 | R | 1.48 |
Bertelsen et al. [40] 2009, Denmark | 2001–2004 | 45.2 (1–74)a | AL versus No AL | 1494 | NA | NA | 11 | 50/357 vs 95/1077, p = 0.005 | R | 1.63 (CI 1.21–2.19) |
Jogren et al. [41] 2009, Sweden | 1995–1997 | 60c | AL versus No AL | 250 | 10 (25/250) | NA | NA | 63% vs 66%, p = 0.38 | R | 1 |
Mirnezami et al. [42] 2011, UK | 1965–2009 | – | AL versus No AL | 21,902 | – | – | – | R/C | 1.75 (CI 1.47–2.1), p = 0.0001 | |
Gooiker et al. [43] 2012, Netherland | 2006–2008 | 48c | Yes, versus No | 2131 | NA | 20 | NA | 12% vs 26%, p = 0.02 (1 year) | R/C | 5.9 (CI 1.3–26.8) |
Smith et al. [28] 2013, USA | 1992–2010 | 35c | AL versus No AL | 184 | 7 | 11 | 32 vs 72%, p = 0.01 | R | NA | |
Henneman et al. [44] 2014, Netherland | 2011–2012 | NA | Yes, versus No | 10,184 | NA | NA | C: 27 R: 36.5 | NA | R/C | NA |
Odermatt et al. [45] 2015, UK | 2003–2012 | ≥60a | AL versus No AL | 844 | 10 (84/844) | 5 | 3 | p = 0.80 | R/C | 1.04 (CI 0.76–1.42) |
Ebinger et al. [46] 2015, Germany | 1991–2010 | 62 (2–254)a | AL versus No AL | 584 | NA | NA | 11 | p = 0.701 | R | 0.91 (CI 0.56–1.47) |
Kulu et al. [30] 2015, Switzerland | 2002–2011 | 56 ± 35b | AL versus No AL | 570 | NA | NA | 9 | 65% vs 83% | R | 2.27 (CI 1.33–3.88), p = 0.005 |
Hain et al. [29] 2016, France | 2005–2014 | 40 ± 27b | AL versus No AL | 428 | 50 (214/428) (pT3/T4) | 50 | 28 | 78·6% vs 88·4%, p = 0.001 | R | NA |
Breugom et al. [47] 2016, Netherland | 2006–2008 | 64.8 (56.4–74.4)a | Yes, versus No | 761 | 75 (570/761) (T3/T4) | 42 | 5 | 65% vs 35%, p = 0.001 | C | 1.59 (CI 1.25–2.04), p = 0.001 |
Jamnagerwalla et al. [48] 2016, Australia | 2003–2014 | 46c | Chemotherapy versus No Chemotherapy | 517 | 100 (517/517) (T3/T4) | 28 | 3.5 | NA | R | 0.53, p = 0.04 |
Nordholm-Carstensen et al. [49] 2017, Denmark | 2009–2013 | 37 (25–50)a | Yes, versus No | 774 | NA | NA | 9 | C: 18.7% vs 44.6% p < 0.001 R: 53.7% vs 73.3% p = 0.0600 | R/C | C: 1.67 (CI 1.03–2.68), p = 0.04 R: 0.93 (CI 0.24–3.57), p = 0.91 |
Present study 2017, France | 2004–2013 | 42 | Yes, versus No | 106 | 100 (106/106) | 43 | 4 | 65% vs. 69%; p = 0.72 | R/C | p > 0.05 |
Methods
Patients
Perioperative management and surgical techniques
Definitions and study design
Statistical analysis
Results
Study population
Variable | Total n = 106 | No complication n = 60 (56%) | Any complication n = 46 (44%) |
P
|
---|---|---|---|---|
Age (years) | 69 ± 14 | 70 ± 14 | 67 ± 14 | 0.27 |
Male sex | 46 (43%) | 25 (42%) | 21 (46%) | 0.68 |
ASA score > 2 | 13 (12%) | 8 (61.5%) | 5 (38.5%) | 0.70 |
BMI | 24 ± 6 | 24 ± 6 | 25 ± 6 | 0.32 |
Comorbidity | ||||
Cardiovascular | 45 (42%) | 25 (55.5%) | 20 (44.5%) | 0.85 |
Pulmonary | 20 (19%) | 6 (30%) | 14 (70%) | 0.01 |
Diabetes | 17 (16%) | 11 (65%) | 6 (35%) | 0.46 |
Localization | ||||
Rectum | 14 (13%) | 9 (64%) | 5 (36%) | 0.53 |
Colon | 92 (86%) | 51 (55%) | 41 (45%) | |
Synchronous metastasis | 27 (25%) | 15 (55.5%) | 12 (44.5%) | 0.90 |
Stage IVA (liver only) | 18 (67%) | 9 (50%) | 9 (50%) | |
Stage IVA (lung only) | 4 (15%) | 3 (75%) | 1 (25%) | |
Stage IVB | 5 (19%) | 3 (60%) | 2 (40%) | |
Serum CEA (μ/L) | 54 ± 116 | 71 ± 140 | 37 ± 82 | 0.25 |
Neoadjuvant radiotherapy or chemotherapy | 16 (15%) | 9 (56%) | 7 (44%) | 0.98 |
Operative setting | 0.51 | |||
Elective | 84 (79%) | 48 (57%) | 36 (43%) | |
Emergent | 22 (21%) | 12 (54.5%) | 10 (45.5%) | |
Surgical procedure | 0.85 | |||
Abdominoperineal resection | 2 (1.8%) | 1 (50%) | 1 (50%) | |
Hartmann’s procedure | 7 (6.6%) | 3 (43%) | 4 (57%) | |
Anterior resection | 17 (16%) | 11 (65%) | 6 (35%) | |
Segmental resection | 80 (75.5%) | 45 (56%) | 35 (44%) | |
Surgical approach | 0.75 | |||
Open | 78 (74%) | 43 (55%) | 35 (45%) | |
Laparoscopic | 28 (26%) | 11 (39%) | 17 (61%) | |
Associated resection | 40 (37.8%) | 23 (57.5%) | 17 (42.5%) | |
1 organ | 23 (49%) | 15 (65%) | 8 (35%) | 0.51 |
> 1 organ | 17 (51%) | 8 (47%) | 9 (53%) | |
Synchronous liver resection | 11 (10.3%) | 5 (45%) | 6 (55%) | 0.88 |
Stoma | 42 (39.6%) | 21 (50%) | 21 (50%) | 0.27 |
Specimen analysis N+ | 60 (56.6%) | 35 (58%) | 25 (42%) | 0.68 |
Surgical margins status | 0.35 | |||
R0 | 85 (80%) | 35 (41%) | 50 (59%) | |
R1 | 21 (20%) | 11 (52%) | 10 (48%) | |
Adjuvant chemotherapy | 65 (61%) | 32 (53%) | 33 (72%) | 0.06 |
Delay from surgery to chemotherapy (days) | 52 ± 50 | 55 ± 62 | 49 ± 33 | 0.69 |
Perioperative data and specimen analysis
Post-operative complications
No. of patients (%) | |
---|---|
Anastomotic leakage | 4 (3.7%) |
Infectious complications | |
Pelvic abscess | 6 (5.6%) |
Intra-abdominal abscess | 6 (5.6%) |
Urinary infection | 4 (3.7%) |
Wound infection | 10 (9.4%) |
Non-infectious complications | |
Ileus | 6 (5.6%) |
Kidney failure | 2 (1.8%) |
Pulmonary failure/pleuresia | 4 (3.7%) |
Intra-abdominal bleeding | 1 (0.9%) |
Cardiac problems | 2 (1.8%) |
Adjuvant therapy
Impact of POCs on long-term outcomes
All stages combined
Variable | Univariate P value | Multivariate P value | Hazard Ratio (95% Confidence Interval) |
---|---|---|---|
Age ≥ 60 (years) | 0.76 | ||
Male sex | 0.37 | ||
BMI ≥ 30 (kg/m2) | 0.79 | ||
ASA score ≥ 2 | 0.12 | ||
Elevated CEA | 0.03 | 0.46 | |
Colon vs rectum | 0.59 | ||
Synchronous metastases | 0.03 | 0.21 | |
Neoadjuvant treatment | 0.45 | ||
Emergent surgery | 0.46 | ||
Laparoscopic approach | 0.51 | ||
Multiple organ resection | 0.88 | ||
Synchronous liver resection | 0.43 | ||
N+ status | 0.009 | 0.01 | 3 (1–7) |
R1 margins | 0.03 | 0.08 | |
Postoperative complications | 0.37 | ||
Grade III-IV complications | 0.57 | ||
Adjuvant chemotherapy | 0.80 |
Stage I–III disease
Variable | Univariate P Value | Multivariate P Value | Hazard Ratio (95% Confidence Interval) |
---|---|---|---|
Age ≥ 60 years | 0.39 | ||
Male sex | 0.28 | ||
BMI ≥ 30 kg/m2 | 0.79 | ||
ASA ≥ 2 | 0.03 | 0.03 | 4 (1–13) |
Elevated CEA | 0.17 | ||
Colon vs rectum | 0.77 | ||
Synchronous metastases | – | ||
Neoadjuvant treatment | 0.17 | ||
Emergent surgery | 0.55 | ||
Laparoscopic approach | 0.96 | ||
Multiple organ resection | 0.81 | ||
Synchronous liver resection | – | ||
N+ status | 0.03 | 0.01 | 4 (1–13) |
R1 margins | 0.05 | 0.02 | 3 (1–8) |
Postoperative complications | 0.90 | ||
Grade III-IV complications | 0.82 | ||
Adjuvant chemotherapy | 0.70 |