The Association Between Revised Cardiac Risk Index and Postoperative Mortality Following Elective Colon Cancer Surgery: A Retrospective Nationwide Cohort Study

Introduction: Despite improvements in the perioperative care during the last decades for oncologic colon resection, there is still a substantial risk for postoperative complications and mortality. Opportunities exist for improvement in preoperative risk stratification in this patient population. We hypothesize that the Revised Cardiac Risk Index, a user-friendly tool, could better identify patients with high postoperative mortality risks. Methods: A retrospective analysis of operated patients between the years 2007 and 2017 was undertaken, using the prospectively recorded Swedish Colorectal Cancer Registry, which has a 99.5% national coverage for all cases of colon cancer. Patients were cross-referenced with the Swedish National Board of Health and Welfare dataset, a government registry of mortality and comorbidity data. Revised Cardiac Risk Index (RCRI) scores were calculated for each patient and stratified into four groups (RCRI 1, 2, 3, ⩾ 4). A Poisson regression model with robust standard errors of variance was employed to correlate the 90-day postoperative survival with each level of the Revised Cardiac Risk Index. Results: A total of 24,198 patients met the study inclusion criteria. 90-day postoperative mortality increased from 2.4% in patients with RCRI 1 to 10.1% in patients with RCRI ⩾ 4 ( p < 0.001). Adjusted 90-day postoperative mortality increased linearly with an increasing RCRI, where an RCRI of 2, 3, and ≥ 4 respectively led to a 46%, 80%, and 167% increased risk of mortality compared to RCRI 1 ( p < 0.001). Conclusions: A strong association between an increasing Revised Cardiac Risk Index score and increased 90-day postoperative mortality risk was detected. The Revised Cardiac Risk Index may facilitate risk stratification of patients undergoing elective colon cancer surgery.

P85 Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

Aim This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic. Method This was an international cohort study of patients undergoing elective colon or rectal cancer resection, without preoperative suspicion of SARS-CoV-2. Centres entered data from their first recorded case of COVID-19 until 19 April 2020. The primary outcome was 30-day mortality. Secondary outcomes included anastomotic leak, postoperative SARS-CoV-2, and a comparison with a pre-pandemic European Society of Coloproctology cohort data. Results From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. 30-day mortality was 1.8% (38/2073), the incidence of postoperative SARS-CoV-2 was 3.8% (78/2073), and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS-CoV2 (14/1601, 0.9%), and highest in patients with both a leak and SARS-CoV-2 (5/13, 38.5%). Mortality was independently associated with an anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58-14.06), postoperative SARS-CoV-2 (16.90, 7.86-36.38), male sex (2.46, 1.01-5.93), age &gt;70 years (2.87, 1.32-6.20), and advanced cancer stage (3.43, 1.16-10.21). Compared to pre-pandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%), an overall shorter length of stay (6 versus 7 days), but higher mortality (1.7% versus 1.1%). Conclusion Surgeons need to further mitigate against both SARS-CoV-2 and anastomotic leak when offering surgery during current and future COVID-19 waves based on patient, operative, and organisational risks.

Perioperative Antibiotic Selection and Surgical Site Infection in Elective Colon Surgery

Objectives The highest rates of surgical site infections (SSIs) are associated with colorectal operations (up to 30%). A sentinel paper showed that the use of intravenous (IV) cefazolin and metronidazole was associated with decreased rates of SSI compared with cefoxitin (6% vs 13%). We reviewed the association of SSI with prophylactic antibiotic choice. We specifically investigated the regimens of ceftriaxone and metronidazole IV, cefoxitin IV, or ertapenem. Methods We conducted a retrospective review of 532 colon surgeries between 2016 and 2018. Inclusion criteria were patients 18-89 years of age undergoing elective colon surgery who received ceftriaxone/metronidazole, cefoxitin, or ertapenem for prophylaxis. All emergent cases were excluded. This resulted in 241 elective colon cases for review. The primary endpoint was to determine if the use of ceftriaxone/metronidazole decreased the rate of SSI. Results In total, there were 241 elective colon cases with 21 SSI. We compared SSI rates in the ceftriaxone/metronidazole group to those patients receiving either cefoxitin or ertapenem (4.5% vs 12.2%; P = .035). We then compared SSI in ceftriaxone/metronidazole to SSI in cefoxitin (4.5% vs 10%; P = .13). Finally, we compared SSI in the ceftriaxone/metronidazole group to SSI in the ertapenem group (4.5% vs 14%; P = .03). Comorbidities and underlying factors were similar across all antibiotic groups. Conclusion In our experience, the use of ceftriaxone/metronidazole is associated with a decreased SSI rate. Furthermore, ceftriaxone/metronidazole use is superior to the use of ertapenem, with a trend toward superiority over cefoxitin. Based on this study, we recommend ceftriaxone/metronidazole as antibiotic prophylaxis for elective colon surgery.

Effects of beta-blocker therapy on mortality after elective colon cancer surgery: a Swedish nationwide cohort study

ObjectiveColon cancer surgery remains associated with substantial postoperative morbidity and mortality despite advances in surgical techniques and care. The trauma of surgery triggers adrenergic hyperactivation which drives adverse stress responses. We hypothesised that outcome benefits are gained by reducing the effects of hyperadrenergic activity with beta-blocker therapy in patients undergoing colon cancer surgery. This study aims to test this hypothesis.DesignRetrospective cohort study.Setting and participantsThis is a nationwide study which includes all adult patients undergoing elective colon cancer surgery in Sweden over 10 years. Patient data were collected from the Swedish Colorectal Cancer Registry. The national drugs registry was used to obtain information about beta-blocker use. Patients were subdivided into exposed and unexposed groups. The association between beta-blockade, short-term and long-term mortality was evaluated using Poisson regression, Kaplan-Meier curves and Cox regression.Primary and secondary outcomesPrimary outcome of interest was 1-year all-cause mortality. Secondary outcomes included 90-day all-cause and 5-year cancer-specific mortality.ResultsThe study included 22 337 patients of whom 36.1% were prescribed preoperative beta-blockers. Survival was higher in patients on beta-blockers up to 1 year after surgery despite this group being significantly older and of higher comorbidity. Regression analysis demonstrated significant reductions in 90-day deaths (IRR 0.29, 95% CI 0.24 to 0.35, p<0.001) and a 43% risk reduction in 1-year all-cause mortality (adjusted HR 0.57, 95% CI 0.52 to 0.63, p<0.001) in beta-blocked patients. In addition, cancer-specific mortality up to 5 years after surgery was reduced in beta-blocked patients (adjusted HR 0.80, 95% CI 0.73 to 0.88, p<0.001).ConclusionPreoperative beta-blockade is associated with significant reductions in postoperative short-term and long-term mortality following elective colon cancer surgery. Its potential prophylactic effect warrants further interventional studies to determine whether beta-blockade can be used as a way of improving outcomes for this patient group.