Tumor Biol. DOI 10.1007/s13277-014-2016-8
RESEARCH ARTICLE
Risk factor evaluation for postoperative complications in laparoscopic colorectal surgery by a classic severity grading system Xiang Xia & Gang Cen & Tao Jiang & Jun Cao & Kejian Huang & Chen Huang & Zhengjun Qiu
Received: 31 March 2014 / Accepted: 23 April 2014 # International Society of Oncology and BioMarkers (ISOBM) 2014
Abstract Using the uniform complication grading system to evaluate postoperative complications after laparoscopic colorectal surgery is the purpose of the present study. Surgical complications were defined as grades I, II, III, IV, and V recommended by Dindo et al. Patients were categorized into three pairs: complication group (CG) and non-complication group (NCG), minor complication group (MiCG, grades I–II) and non-minor complication group (NMiCG), and major complication group (MaCG, grades III–V) and non-major complication group (NMaCG); of the 570 patients, 431 patients were discharged with no complications, and 174 complications occurred in 119 patients. The percent of grades I, II, III, IV, and V complications were 4.7, 20, 4.7, 0.7, and 0.4 %, respectively. Complications were significantly associated with male gender, larger tumor volume, and more estimated blood loss (EBL). The multivariate analysis revealed that male and EBL ≥150 ml were found to be independent predictors of postoperative complications. In subgroup analysis, patients with larger tumor volume were at significantly higher risk of postoperative major complications, and male gender and EBL ≥150 ml remained independent predictors of developing minor postoperative complications. Patients with postoperative complications would significantly experience longer hospital stay, later fluid intake, and delayed urinary catheter removal. Male, larger tumor volume, and more EBL were significant risk factors for laparoscopic colorectomy.
Xiang Xia and Gang Cen contributed to this article equally. X. Xia : G. Cen : T. Jiang : J. Cao : K. Huang : C. Huang (*) : Z. Qiu (*) Department of General Surgery, Shanghai Jiaotong University Affiliated First People’s Hospital, 100 Hai Ning Road, 200080 Shanghai, People’s Republic of China e-mail: [email protected] e-mail: [email protected]
Keywords Risk factor . Postoperative complications . Laparoscopic colorectal cancer surgery . Severity grading system
Background Laparoscopic colorectal surgery was first reported 23 years ago and had been regarded as a highly challenging and technical procedure. With the evidences obtained from lots of randomized clinical trials (RCTs) concerning the safety and feasibility of this minimally invasive technique, it nowadays has shown the noninferiority of laparoscopic surgery in treatment of colorectal cancer compared to open surgery [1–4]. Some studies have even proven that laparoscopic surgery has several advantages over open surgery including less postoperative pain, earlier postoperative recovery, and shorter hospital stay [5, 6]. Consequently, laparoscopic surgery has been gradually applied to colorectal cancer patients as the standard therapeutic strategy due to its potential advantages in recent decades. Postoperative complications grading and survival rate calculating for laparoscopic surgery are indispensible to each clinical trial and study. Generally speaking, the definition of survival rate is always similar in most studies. However, the criteria for those postoperative complications evaluation in such articles varied from one another. For example, King et al. used hospital stay as their primary outcome, and meanwhile, other clinical endpoints included postoperative opioid analgesia usage, major morbidity such as hemorrhage (requiring transfusion), reoperation, readmission, anastomotic leakage, wound dehiscence, and sepsis as their complication items [6]. Veldkamp et al. categorized their patients’ postoperative complications into 12
Tumor Biol.
categories, including wound infection, wound dehiscence, pulmonary, cardiac, bleeding, urinary tract infection, anastomotic failure, bowel obstruction for more than 3 days, others, reintervention, and death [2]. Although these two investigations were both randomized clinical trials and their conclusions provided considerable constructive suggestions for treating colorectal cancer laparoscopically, their results for most postoperative complications were not comparable because their own complication grading systems are inconsistent. Currently, only a few surgical outcomes, such as length of hospital stay, 30-day mortality rate, conversion rate, operative time, and estimated blood loss, have identical definition which can be applied for unified evaluations. While a large number of surgical morbidities are still lacking of consensus on how to define [7]. Therefore, there is an urgent need to evaluate complications with more objective and uniform system by which surgeons could provide more comparative results for decision-making of individualized treatment. Hence, in this article, our study team utilized a wellknown surgical complication grading system proposed by Dindo et al. to evaluate the surgical short-term outcomes in our institution. Dindo et al. tested this complication classification system in a cohort of 6,336 patients that underwent elective general surgeries. Furthermore, the reproducibility was evaluated through an international survey in 10 surgical centers worldwide [8]. Moreover, in order to evaluate the feasibility of this system in preoperative evaluation for postoperative complications, we also investigate those risk factors associated with postoperative complications through Dindo grading system.
Methods Ethics statement This retrospective study was approved by the Clinical Trial Ethics Committee of Shanghai Jiaotong University Affiliated First People’s Hospital. Written consents were obtained from all patients enrolled. Patient selection From January 2008 to October 2013, 707 consecutive patients with colorectal cancer undergoing elective laparoscopic colorectal excision in Shanghai Jiaotong University Affiliated First People’s Hospital were recruited in a prospective database. Laparoscopic surgery was performed by a stable surgical team, and patients were assigned to laparoscopic surgery according to their target dates of treatment. All patients
enrolled accepted preoperative laboratory examination including tumor markers screening, coagulation test, chest x-ray, abdominal ultrasound, colonoscopy, and, if necessary, CT scan of the abdomen and pelvis. All patients were confirmed to have a malignant tumor after postoperative pathological examination. None of the patients had accepted preoperative radiotherapy or chemotherapy; exclusion criteria for our study were synchronous metastasis, emergency presentation, conversion to open surgery because of intraoperative events, missing any necessary data (such as height or weight), any combined resection, and none-R0 resection. Totally, 570 patients were analyzed in this study. Preoperative clinical characteristics included age, gender, BMI, and American Society of Anesthesiologists (ASA) classification. Surgical data consisted of operative time, estimated blood loss, harvested lymph nodes, operation type, and pathological results. Postoperative complications, urinary catheter removal time, start fluid intake time, and length of postoperative hospitalization were also analyzed. Surgical complications were defined as grades I, II, III, IV, and V as recommended by Dindo et al. [8]. The precise preoperative preparations, operation procedures, and postoperative management were described previously in detail [9]. Identical criteria were used for each group in terms of preoperative preparation, postoperative management, and hospital discharge. Statistics Data were presented as mean±SD (parametric data) or median±range (non-parametric data). Data were compared by using the student t test for paired and Mann-Whitney U test for unpaired continuous variables and the chi-squared or Fisher’s exact test for discrete variables. Independent variables with a P value
RESEARCH ARTICLE
Risk factor evaluation for postoperative complications in laparoscopic colorectal surgery by a classic severity grading system Xiang Xia & Gang Cen & Tao Jiang & Jun Cao & Kejian Huang & Chen Huang & Zhengjun Qiu
Received: 31 March 2014 / Accepted: 23 April 2014 # International Society of Oncology and BioMarkers (ISOBM) 2014
Abstract Using the uniform complication grading system to evaluate postoperative complications after laparoscopic colorectal surgery is the purpose of the present study. Surgical complications were defined as grades I, II, III, IV, and V recommended by Dindo et al. Patients were categorized into three pairs: complication group (CG) and non-complication group (NCG), minor complication group (MiCG, grades I–II) and non-minor complication group (NMiCG), and major complication group (MaCG, grades III–V) and non-major complication group (NMaCG); of the 570 patients, 431 patients were discharged with no complications, and 174 complications occurred in 119 patients. The percent of grades I, II, III, IV, and V complications were 4.7, 20, 4.7, 0.7, and 0.4 %, respectively. Complications were significantly associated with male gender, larger tumor volume, and more estimated blood loss (EBL). The multivariate analysis revealed that male and EBL ≥150 ml were found to be independent predictors of postoperative complications. In subgroup analysis, patients with larger tumor volume were at significantly higher risk of postoperative major complications, and male gender and EBL ≥150 ml remained independent predictors of developing minor postoperative complications. Patients with postoperative complications would significantly experience longer hospital stay, later fluid intake, and delayed urinary catheter removal. Male, larger tumor volume, and more EBL were significant risk factors for laparoscopic colorectomy.
Xiang Xia and Gang Cen contributed to this article equally. X. Xia : G. Cen : T. Jiang : J. Cao : K. Huang : C. Huang (*) : Z. Qiu (*) Department of General Surgery, Shanghai Jiaotong University Affiliated First People’s Hospital, 100 Hai Ning Road, 200080 Shanghai, People’s Republic of China e-mail: [email protected] e-mail: [email protected]
Keywords Risk factor . Postoperative complications . Laparoscopic colorectal cancer surgery . Severity grading system
Background Laparoscopic colorectal surgery was first reported 23 years ago and had been regarded as a highly challenging and technical procedure. With the evidences obtained from lots of randomized clinical trials (RCTs) concerning the safety and feasibility of this minimally invasive technique, it nowadays has shown the noninferiority of laparoscopic surgery in treatment of colorectal cancer compared to open surgery [1–4]. Some studies have even proven that laparoscopic surgery has several advantages over open surgery including less postoperative pain, earlier postoperative recovery, and shorter hospital stay [5, 6]. Consequently, laparoscopic surgery has been gradually applied to colorectal cancer patients as the standard therapeutic strategy due to its potential advantages in recent decades. Postoperative complications grading and survival rate calculating for laparoscopic surgery are indispensible to each clinical trial and study. Generally speaking, the definition of survival rate is always similar in most studies. However, the criteria for those postoperative complications evaluation in such articles varied from one another. For example, King et al. used hospital stay as their primary outcome, and meanwhile, other clinical endpoints included postoperative opioid analgesia usage, major morbidity such as hemorrhage (requiring transfusion), reoperation, readmission, anastomotic leakage, wound dehiscence, and sepsis as their complication items [6]. Veldkamp et al. categorized their patients’ postoperative complications into 12
Tumor Biol.
categories, including wound infection, wound dehiscence, pulmonary, cardiac, bleeding, urinary tract infection, anastomotic failure, bowel obstruction for more than 3 days, others, reintervention, and death [2]. Although these two investigations were both randomized clinical trials and their conclusions provided considerable constructive suggestions for treating colorectal cancer laparoscopically, their results for most postoperative complications were not comparable because their own complication grading systems are inconsistent. Currently, only a few surgical outcomes, such as length of hospital stay, 30-day mortality rate, conversion rate, operative time, and estimated blood loss, have identical definition which can be applied for unified evaluations. While a large number of surgical morbidities are still lacking of consensus on how to define [7]. Therefore, there is an urgent need to evaluate complications with more objective and uniform system by which surgeons could provide more comparative results for decision-making of individualized treatment. Hence, in this article, our study team utilized a wellknown surgical complication grading system proposed by Dindo et al. to evaluate the surgical short-term outcomes in our institution. Dindo et al. tested this complication classification system in a cohort of 6,336 patients that underwent elective general surgeries. Furthermore, the reproducibility was evaluated through an international survey in 10 surgical centers worldwide [8]. Moreover, in order to evaluate the feasibility of this system in preoperative evaluation for postoperative complications, we also investigate those risk factors associated with postoperative complications through Dindo grading system.
Methods Ethics statement This retrospective study was approved by the Clinical Trial Ethics Committee of Shanghai Jiaotong University Affiliated First People’s Hospital. Written consents were obtained from all patients enrolled. Patient selection From January 2008 to October 2013, 707 consecutive patients with colorectal cancer undergoing elective laparoscopic colorectal excision in Shanghai Jiaotong University Affiliated First People’s Hospital were recruited in a prospective database. Laparoscopic surgery was performed by a stable surgical team, and patients were assigned to laparoscopic surgery according to their target dates of treatment. All patients
enrolled accepted preoperative laboratory examination including tumor markers screening, coagulation test, chest x-ray, abdominal ultrasound, colonoscopy, and, if necessary, CT scan of the abdomen and pelvis. All patients were confirmed to have a malignant tumor after postoperative pathological examination. None of the patients had accepted preoperative radiotherapy or chemotherapy; exclusion criteria for our study were synchronous metastasis, emergency presentation, conversion to open surgery because of intraoperative events, missing any necessary data (such as height or weight), any combined resection, and none-R0 resection. Totally, 570 patients were analyzed in this study. Preoperative clinical characteristics included age, gender, BMI, and American Society of Anesthesiologists (ASA) classification. Surgical data consisted of operative time, estimated blood loss, harvested lymph nodes, operation type, and pathological results. Postoperative complications, urinary catheter removal time, start fluid intake time, and length of postoperative hospitalization were also analyzed. Surgical complications were defined as grades I, II, III, IV, and V as recommended by Dindo et al. [8]. The precise preoperative preparations, operation procedures, and postoperative management were described previously in detail [9]. Identical criteria were used for each group in terms of preoperative preparation, postoperative management, and hospital discharge. Statistics Data were presented as mean±SD (parametric data) or median±range (non-parametric data). Data were compared by using the student t test for paired and Mann-Whitney U test for unpaired continuous variables and the chi-squared or Fisher’s exact test for discrete variables. Independent variables with a P value
