Aspects of low anterior resection syndrome : prevalence, risk factors and treatment

After sphincter sparing rectal cancer surgery an impaired bowel function, i.e. Low Anterior Resection Syndrome (LARS), is common. The symptoms included in LARS are incontinence for flatus and/or feces, urgency, fragmentation and frequent bowel movements. The cause is thought to be multifactorial and involves sphincter impairment, reduced compliance and capacity of the neorectum and altered motility, among others. With improved cancer survival the importance and focus on functional outcomes is increasing. The LARS-score is a validated questionnaire aimed to evaluate LARS and consists of five questions where each question has response alternatives with weighted scores. According to responses the total score is registered and depending on score a patient is classified into no, minor or major LARS group. The overall aim of this thesis was to gain knowledge about Low Anterior Resection Syndrome, in order to better understand and manage patients post rectal cancer surgery. Study I was a longitudinal cohort study evaluating long-term LARS and quality of life (QoL) at two different time-points (mean 5 years apart). In total, 282 patients were included in the final analysis and results showed no significant difference in proportion major LARS, comparing the different time-points (p=0.455). At second follow-up 49% of patients still experienced major LARS and the major LARS group reported inferior QoL, compared to the no/minor LARS group, at both time-points. This was one of the first studies with long-term longitudinal data on LARS and concluded that difficulties with LARS and the impact on patients QoL persists over time. Study II was a population-based cross-sectional study with the aim to measure the prevalence of LARS and impact of QoL in a, clearly defined, Swedish cohort. The prevalence of LARS was 77.4% and the proportion with major LARS was 53.1%. Major LARS was associated to worse QoL reported with the EORTC QLQ-C30 questionnaire as well as worse bowel related QoL (BQoL). The study confirmed that major LARS is common after rectal cancer surgery and associated to significantly impaired QoL. This was one of the first studies providing population-based prevalence data in a Swedish cohort. The conclusion was that after anterior resection for rectal cancer a majority of patients suffer from major LARS which have a negative impact on QoL. In Study III we evaluated the role of a defunctioning stoma and the association to major LARS. The adjusted OR for major LARS (vs. no LARS) was 2.43 (95% CI 1.14-5.20) comparing defunctioning stoma to no stoma. The results failed to show any evident association between time to stoma reversal and major LARS. This was one of the largest studies regarding this topic and one of a few with defunctioning stoma and association to major LARS, as primary endpoint. The study concluded that the results indicates that the presence of a defunctioning stoma is associated with major LARS in a long-term perspective, while failing to show any clear association to time to stoma reversal. In the last Study (IV) the aim was to evaluate transanal irrigation (TAI) as a treatment strategy in patients with major LARS. In this RCT patients were randomized to either intervention group (TAI) or control group (conservative treatment). Patients were followup for 12 months and the primary endpoint was differences in bowel function at end of follow-up. In addition to the LARS-score three more outcome measures were used: CCFFIS questionnaire, four study specific questions and the EORTC QLQ-C30 quality of life instrument. An interim analysis was performed after 40 included patients with complete follow-up and the results from this analysis was clearly in favor of TAI which resulted in termination of further inclusion. The final results included follow-up data from 16 patients in the intervention group and 23 in the control group. At end of follow-up, statistical significant differences were reported in a majority of the outcome measures in favor of TAI. In LARS-score there were no differences at baseline but at 12 month of follow-up there were a 9.3 points mean difference in LARS-score (p=0.002) and 2.8 points mean difference in CCFFIS (p=0.050). Also, statistical significant results in 2 out of 4 study specific questions and 7 of 15 subscales on EORTC QLQ-C30. This study was the first RCT evaluating TAI as treatment for major LARS and concluded that TAI reduces symptoms of LARS with improved QoL

Cholecystostomy as Bridge to Surgery and as Definitive Treatment or Acute Cholecystectomy in Patients with Acute Cholecystitis

Purpose. Percutaneous cholecystostomy (PC) has increasingly been used as bridge to surgery as well as sole treatment for patients with acute cholecystitis (AC). The aim of the study was to assess the outcome after PC compared to acute cholecystectomy in patients with AC. Methods. A review of medical records was performed on all patients residing in Stockholm County treated for AC in the years 2003 and 2008. Results. In 2003 and 2008 altogether 799 and 833 patients were admitted for AC. The number of patients treated with PC was 21/799 (2.6%) in 2003 and 50/833 (6.0%) in 2008. The complication rate (Clavien-Dindo ≥ 2) was 4/71 (5.6%) after PC and 135/736 (18.3%) after acute cholecystectomy. Mean (standard deviation) hospital stay was 11.4 (10.5) days for patients treated with PC and 5.1 (4.3) days for patients undergoing acute cholecystectomy. After adjusting for age, gender, Charlson comorbidity index, and degree of cholecystitis, the hospital stay was significantly longer for patients treated with PC than for those undergoing acute cholecystectomy (P<0.001) but the risk for intervention-related complications was found to be significantly lower (P=0.001) in the PC group. Conclusion. PC can be performed with few serious complications, albeit with a longer hospital stay

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit