Resultados iniciales de la cirugía de cáncer de colon tras la implementación del programa de screening en el Hospital San Jorge

Introducción: El cáncer colorrectal es el tumor más frecuente considerando ambos sexos tanto a nivel mundial como en España, donde también es el segundo cáncer con mayor mortalidad, después del cáncer de pulmón. Esta prevalencia se prevee que aumente debido al envejecimiento poblacional y al estilo de vida. Sin embargo, se ha demostrado que la aplicación de programas de cribado sobre la población en este tipo de cáncer, reduce la recurrencia tumoral y la mortalidad, gracias al diagnóstico de la enfermedad en estadios precoces. Es por ello que en la actualidad se están implantando, a nivel nacional, programas de cribado en las diferentes comunidades autónomas, como ha sucedido en Aragón. En concreto en el Hospital San Jorge de Huesca, el programa de cribado comenzó en 2016 y se mantiene hasta la actualidad. Objetivos Exponer los resultados iniciales a corto plazo sobre la morbilidad del postoperatorio inmediato a 90 días del cáncer de colon, la mortalidad y la estancia hospitalaria tras la implantación de un programa de cribado en nuestro centro. Material y métodos Se ha realizado un estudio retrospectivo a partir de una base de datos completada de forma prospectiva, en el que se incluyen a 73 pacientes, con una edad comprendida entre los 60 a 69 años, diagnosticados de cáncer de colon e intervenidos quirúrgicamente de forma programada de cualquier tipo de resección colónica con intención curativa, desde enero de 2010 hasta diciembre de 2017. Todos los pacientes fueron diagnosticados, de forma convencional o a través de programa de cribado, este último según el plan implantado en nuestra comunidad, mediante sangre oculta en heces (FIT) y colonoscopia. Se ha dividido la muestra en dos grupos de pacientes en función de la forma de diagnóstico ( Grupo Si screening=25 pacientes, Grupo No screening= 48 pacientes) y se han comparado en función de 16 variables, que se agrupan principalmente en cuatro grupos: Factores dependientes del paciente, del cáncer de colon, de la resección del cáncer de colon y del seguimiento. Para el análisis estadístico, se ha utilizado en la estadística descriptiva medidas de tendencia central y en el análisis inferencial, los test estadísticos correspondientes para cada tipo de variable. Resultados Ambos grupos fueron homogéneos y comparables en todas las variables del estudio, ya que no se han observado diferencias estadísticamente significativas al comparar ninguna de las características clínico-patológicas estudiadas: edad (p=0.179), sexo (p=0.297), riesgo ASA (p=0.628), localización CCR (p=0.092), número de ganglios resecados (p=0.118), estadio tumoral (p=0,276), intervención quirúrgica (p=0,512), resección tumoral (p=0,999), tipo de abordaje (p=0,872) ni necesidad de conversión de la técnica quirúrgica (p=0,095). En cuanto a las variables englobadas en el seguimiento, no se encontraron diferencias estadísticamente significativas en cuanto a la mortalidad postoperatoria-Clavien-Dindo V (p=0,202), pero sí en la morbilidad postoperatoria (p=0,006) y en su clasificación según Clavien Dindo I-IV (p=0,018). Las complicaciones analizadas de forma independiente como la dehiscencia de anastomosis (p=0,023) o el íleo postoperatorio (p=0,033) también han presentado diferencias significativas, al contrario que la infección de herida quirúrgica (p=0,115). Tampoco se han observado diferencias significativas al comparar la estancia hospitalaria (p=0,166). Conclusión En nuestro centro, la aplicación del programa de screening no ha influido en el estadio del cáncer de colon ni en su enfoque quirúrgico. Sin embargo, hemos hallado una menor tasa de morbilidad global y de complicaciones menores, justificadas por una menor incidencia de dehiscencia de anastomosis e íleo postoperatorio. Introduction Colorectal cancer is the most frequent tumor attending to both gender in the world and even in Spain, where it is also the second most frequent cancer and it has the highest mortality after lung cancer. This prevalence is expected to increase due to population aging and lifestyle. However, the application of screening programs on the population in this type of cancer has been shown that reduces tumor recurrence and mortality, thanks to the diagnosis of the disease in early stages. For this reason, screening programs are being implemented at the national level in the different Spanish regions, as has happened in Aragón. Specifically, at the San Jorge Hospital in Huesca, the screening program began in 2016 and its application continues until now. Objective To present the initial short-term results on the morbidity of the immediate postoperative period to 90 days of colon cancer, mortality and hospital stay after the implementation of a screening program in our center. Material and methods A retrospective study was performed based on a prospectively completed database. We included 73 patients aged between 60 and 69 years, diagnosed with colon cancer. They underwent surgery on a scheduled, with any type of colonic resection and curative intent, from January 2010 to December 2017. All patients were diagnosed, conventionally or through a screening program, the latter according to the plan implemented in our community, using fecal occult blood ( FIT) and colonoscopy. The sample was divided into two groups of patients according to the way of being diagnosed (Group Si screening = 25 patients, Group No screening = 48 patients) and they were compared according to 16 variables, which are grouped mainly into four groups: Dependent factors of the patient, factor of type colon cancer, factors of colon cancer resection and follow-up. For the statistical analysis, measures of central tendency were used in the descriptive statistics and the corresponding statistical tests for each type of variable were used for inferential analysis. Results Both groups were homogeneous and comparable in all study variables, because no statistically significant differences were observed comparing any of the clinical-pathological characteristics studied: age (p = 0.179), sex (p= 0.297), ASA risk ( p = 0.628), CCR localization (p = 0.092), number of resected lymph nodes (p = 0.118), tumor stage (p = 0.276), surgical intervention (p = 0.512), tumor resection (p = 0.999), type of surgical approach (p = 0.872) or need for conversion to open approach of the surgical technique (p = 0.095). Regarding the variables included in the follow-up, no statistically significant differences were found in terms of postoperative mortality-Clavien-Dindo V (p = 0.202). However we found differences statistically significant in postoperative morbidity (p = 0.006) and in its classification according to Clavien Dindo I-IV (p = 0.018). The complications analyzed independently , such as anastomotic dehiscence (p = 0.023) or postoperative ileus (p = 0.033), have also presented significant differences, unlike surgical wound infection (p = 0.115). No significant differences were observed when we compared hospital stay (p = 0.166). Conclusion At our center, the application of the screening program has not influenced in the initial stage of colon cancer or its surgical approach. However, we have found a lower overall morbidity rate and minor complications, justified by a lower incidence of anastomotic dehiscence and postoperative ileus.<br /

Immigrant IBD Patients in Spain Are Younger, Have More Extraintestinal Manifestations and Use More Biologics Than Native Patients

BackgroundPrevious studies comparing immigrant ethnic groups and native patients with IBD have yielded clinical and phenotypic differences. To date, no study has focused on the immigrant IBD population in Spain. MethodsProspective, observational, multicenter study comparing cohorts of IBD patients from ENEIDA-registry who were born outside Spain with a cohort of native patients. ResultsWe included 13,524 patients (1,864 immigrant and 11,660 native). The immigrants were younger (45 +/- 12 vs. 54 +/- 16 years, p < 0.001), had been diagnosed younger (31 +/- 12 vs. 36 +/- 15 years, p < 0.001), and had a shorter disease duration (14 +/- 7 vs. 18 +/- 8 years, p < 0.001) than native patients. Family history of IBD (9 vs. 14%, p < 0.001) and smoking (30 vs. 40%, p < 0.001) were more frequent among native patients. The most prevalent ethnic groups among immigrants were Caucasian (41.5%), followed by Latin American (30.8%), Arab (18.3%), and Asian (6.7%). Extraintestinal manifestations, mainly musculoskeletal affections, were more frequent in immigrants (19 vs. 11%, p < 0.001). Use of biologics, mainly anti-TNF, was greater in immigrants (36 vs. 29%, p < 0.001). The risk of having extraintestinal manifestations [OR: 2.23 (1.92-2.58, p < 0.001)] and using biologics [OR: 1.13 (1.0-1.26, p = 0.042)] was independently associated with immigrant status in the multivariate analyses. ConclusionsCompared with native-born patients, first-generation-immigrant IBD patients in Spain were younger at disease onset and showed an increased risk of having extraintestinal manifestations and using biologics. Our study suggests a featured phenotype of immigrant IBD patients in Spain, and constitutes a new landmark in the epidemiological characterization of immigrant IBD populations in Southern Europe

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Effects of pre-operative isolation on postoperative pulmonary complications after elective surgery: an international prospective cohort study an international prospective cohort study

We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care. We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care

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

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

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AimThe SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery.MethodsThis was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin.ResultsOverall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P ConclusionOne in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease