Morbidity and Mortality after Colorectal Surgery for Cancer

doi:10.4236/ss.2013.411101

Paper Menu >>

Journal Menu >>

Surgical Science, 2013, 4, 520-524

Published Online November 2013 (http://www.scirp.org/journal/ss)

http://dx.doi.org/10.4236/ss.2013.411101

Open Access SS

Morbidity and Mortality after Colorectal Surgery

for Cancer

Giulio Paolo Angelucci1*, Giovanni Sinibaldi2, Paolo Orsaria1, Claudio Arcudi1, Sergio Colizza2

1University of Rome “Tor Vergata”, Policlinico Tor Vergata, Surgery, Rome, Italy

2Hospital San Giovanni Calibita Fatebenefratelli, Isola Tiberina, Surgery, Rome, Italy

Email: *[email protected]

Received October 31, 2013; revised November 19, 2013; accepted November 25, 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Colorectal Cancer is the second most common cancer in western countries and, currently, surgical resection is still the

principal treatment for this pathology. However, the operation carries significant morbidity and mortality, which is

associated with an enormous use of healthcare resources. The aim of our study is to evaluate the incidence and the

management of complications, and to understand how pre-exisiting comorbidities can influence the recovery of the

patients. Between 2007 an d 2012, a total of 534 patients und erwent elective or emergency surgery for color ectal cancer

in our department. Patients were identified for this study from a prospectively entered computerized database. Case

notes of patients documented comorbidities, type of surgery performed, complication in the early postoperative period

(30 days after surgery) and the management. Postoperative morbidity affected 89 patients (17%), of these 25 (27%)

were anastomotic leakage (AL). 22 (24%) patients experienced intra-abdominal abscess. 16 patients (17%) had wound

infections. 11 patients (13%) experienced post-operative bleeding and five of them had a re-operation within the I and

the II day after surgery. 12 (13%) complained medical (cardiologic/respiratory) complications. We had 1 (1%) Small

Bowel Obstruction, treated with a conservative therapy. Reoperation rate was 3% with 11 for AL, and 5 for bleeding.

The mortality rate was 0.55% (3 patients). In our experience, we ev idenced that surgery performed for advanced rectal

cancer in the lower rectum, especially in urgency settings is associated with an increase of morbidity and mortality in

the early post-operative period. Pre-existing comorbidities are involved in the morbidity of the patients, and a more

accurate approach both in surgical technique and in the post-operative management can be proposed to the surgeon.

Derivative stoma in high risk patients gave us the possibility of a conservative treatment of the Anastomotic Leak, the

most common complication in our study, with antibiotics and CT-drainage.

Keywords: Colorectal; Colorectal Surgery; Morbidity; Mortality; Surgery; Complications; Early Post-Operative

Complication; Management; Anastomotic Leak; Leakage

1. Introduction

Colorectal Cancer is the second most common cancer in

western countries [1] and, currently, surgical resection is

still the principal treatment for this pathology. The op-

eration carries significant morbidity which is associated

with an enormous use of healthcare resources, and mor-

tality bet ween 1% an d 2% [2 ].

Anastomotic Leak (AL) is the most fearful complica-

tion by the colorectal surgeon. The reported rate of colo-

nic anastomotic leak is in the range fro m 1.5% up to 16%,

with mortality ranging between 10% and 20% [2,3]. To-

tal Mesorectal Excision (TME) which is mandatory for

the treatment of carcinoma of the lower and mid rectum

is associated with an increased risk of clinical anastomo-

tic leakage [4]. In addition, patients who experienced a

complication in the early postoperative period have been

demonstrated to have poorer long-term functional results,

increased local recurrence rate and reduced 5-year cancer

survival [5].

The aim of our study is to evaluate the incidence and

the management of complications, and to understand

how pre-existing comorbidities can influence the recov-

ery of the patients.

2. Methods

Between 2007 and the 2012 a total of 534 patients un-

derwent elective or emergency surgery for colorectal

*Corresponding a uthor.

G. P. ANGELUCCI ET AL. 521

cancer in our department; 68 (13%) of these were oper-

ated using laparoscopic approach. Patients were identi-

fied for this study from a prospectively entered comput-

erized database. Case notes of patients documented co-

morbidities, type of surgery performed, complications in

the early postoperativ e period (30 days after surg ery) and

its management.

Age, gender, physical status and comorbidities were

evaluated (Table 1).

Antibiotics prophylaxis was given with intravenous

administration for a mean time of three days, using Pi-

peracillin and Gentamycin.

The indication for surgery was malignant disease as

rectal cancer in 161 patients, colonic cancer in 368 pa-

tients. 5 patients underwent total colectomy for Familial

Adenomatous Polyposis. The distribution of Duke’s

stages was: A (invasion into but not through the bowel

wall) 105 (19%), B (invasion through the bowel wall but

not involving lymph nodes) 150 (28%), C (involvement

of lymph nodes) 183 (34%). 84 patients (13%) had be-

nign disease or incomplete staging.

Surgical procedures were: 190 Right Colectomies, 177

Left Colectomies, 162 Low Anterior Resection, 5 Total

Colectomies. Patients who had only explorative laparo-

tomy or laparoscopy were excluded from the study.

The decision in favour of laparoscopic approach was

based on surgeon experience, patient’s characteristics,

tumor size, and tumor staging. Drains were always used

for 2 - 3 days.

The great part of the anastomoses was made by stapler,

except for few right haemicolectomies. Oral fluid and

food intake was started gradually b etw een the second an d

the third day after surgery.

The definition of an anastomotic leakage was clinical:

peritonitis caused by leakage, pelvic abscess, pus or gas

from the abdominal drain. All anastomotic leakage was

confirmed by one or more of the following: CT scan, Ba-

rium Enema, and reoperation.

Incidence of wound infections, Small Bowel Obstruc-

tion (SBO), postoperative bleeding, abdominal abscess

Table 1. Patients’ demography .

Number of patients 53 4 Male 282 (53%) Female 252 (47%)

Age 68.1 (SD 11.3 )

Mean hospital stay 11.6 days, range 1 - 71, S D 8.4

Type of surgery

190 Right Colectomies

177 Left Colectomies

162 Low Anterior Resection

5 Total Colectomies

Comorbidities

86 pts (16%)

Cardiovascular 68

Diabetes 16

Others 2

Approach Open 466 (87%)

Laparoscopic 68 (13%)

and medical complication were also recorded.

Statistical analysis was made using Fisher’s exact test.

3. Results

The total number of patients who underwent Colorectal

Surgery (CRS) in our department was 618 (Male 316

51%/Female 302 48.9%), the mean age was 68.1 (SD

11.3). Of these, 534 patients underwent elective or emer-

gency surgery for CRS for cancer. Mean Hospital stay

was 11. 6 days, SD 8.4 .

Postoperative morbidity affected 89 patients (17%), 25

of these (27%) w ere anastomotic leakage, occurring with

in the III and the IX day after surgery. 4 of these patients

were re-operated with laparoscopic technique, 7 with

open surgery (Table 2).

22 (24%) patients experienced intra-abdominal abscess

usually treated with intra venous antibiotics adminis-

tration and CT-Scan monitoring. In 4 of them, CT drain-

age was performed.

16 out of 89 patients (17%) had wound infections. 11

patients (13%) experienced post-operative bleeding and

five of them a re-operation within the I and the II day

after surgery. 12 (13%) complained medical (cardio-

logic/respiratory) complications, one patient of these died

in the immediate postoperative period. 2 patients (2%)

complained ileus treated with conservative therapy. We

had 1 (1%) Small Bowel Obstruction, treated with a

conservative therapy (Table 3).

16 patients (17% of the complicated patients) under-

went laparotomy for surgical complications: 1 1 for anas-

tomotic leakage, between the III and IX day after surgery

mean time (5.1 SD 2.4). 5 patients underwent reoperation

for bleeding the same day after the procedure or the day

after (Table 4). We also evaluated the Duke’s stage re-

lated complications since the tumor invasion could be

associated with an increased risk of AL, as reported in

literature [1,2], however, in our study there was not a

statistical evidence (Table 5).

Otherwise we found correlation between pre-existing

comorbidities and complications rate to be statistically

significant (p = 0.00775).

4. Discussion

In this population based study of 534 patients operated

Table 2. Anastomotic leakage and mortality.

Total num.

procedures Number of

leaks Leak rate (%)Mortality

Anterior Resection162 12 7% 2 (1.2%)

L Hemicolectomy177 5 3%

R Hemicolectomy190 7 4% 1 (0.5%)

Total Colectomy5 1 20%

Total 534 25 4.7% 3 (0.55%)

Open Access SS

G. P. ANGELUCCI ET AL.

522

Table 3. Overall morbidity.

Complications n

Anastomotic Leakage 25 (4.7%)

Intra-Abdominal Abscess 22 (4.1%)

Wound Infections 16 (3%)

Bleeding 11 (2%)

Cardiological/Respiratory 12 (2%)

Ileus 2 (0.3%)

SBO 1 (0.2%)

Total 89/534 (17%)

Table 4. Re-operation rate and morbidity.

Bleeding AL

Reoperations (3%) 5 11

Table 5. TNM related complications.

Duke stage A: 19% experienced AL

Duke stage B: 28% experienced AL

Duke stage C: 34% experienced AL

for colorectal cancer 89 (17%) experienced a compli-

cation. 25 (28%) of them had an anastomotic leakage, a

total of 4.7% with an associated mortality of 0.55%. 12

of them after an anterior resection and a TME. One well

recognized risk factor is shown to be the level of the an-

astomosis, usually between 7 cm and 5 cm from the anal

verge [6]. In present study low anastomosis was an inde-

pendent risk factor. In 69% of cases the reoperation per-

formed was laparotomy, drainage and stoma formation.

In 58 out of 162 patients treated by anterior resection of

the rectum had a contemporary right colostomy (very

rarely, Ileostomy). Such approach was usually limited to

patients who had a primary radio-chemotherapy. In case

of AL, these patients were cured by CT-scan drainage (8

cases), even though the role of temporary stoma is still

controversial [7].

In our experience, the major advantage was a less

dramatic consequences when the leak occurs, giving us

the possibility of a con serv a tive treatment. Disadv an tag es

were the cost of a second operation and the possible

stoma related complications.

Identifying possible risk factor for an anastomotic

leakage could be useful to select patients who may need

a temporary stoma. Pre-existing comorbidities (cardio-

respiratory), reduced preoperative nutritional status (ane-

mia, hypoprotidedemia and weight loss), set of surgery

(emergency and elective) previous radiation and gender

(male > risk) [8] were recorded as a guide for in-

tra-operative decisions i n our experience.

Previous studies concluded that significant clinical in-

dicators of leakage were fever (>38˚C) on day 2, absence

of bowel action on day 4, diarrhea before day 7, more

than 400 ml of fluid in the abdominal drain by day 3,

renal failure on day 3 and leukocytosis on day 7 [7].

However, our analysis shows that the majority of patients

who experienced an anastomotic leakage had a radio-

logical diagnosis. The decision of a reoperation was usu-

ally made on the data from the CT scanning with rectal

contrast associated on the clinical findings.

4 of the 68 (13%) patients who underwent a colonic

resection using laparoscopic technique experienced an

anastomotic leak. Such figure is greater than the mean

incidence (4.7%) but it is not statistically significant. We

can not also demonstrate a reduction of complication

such bleeding, wound infection and medical complica-

tions in short term postoperative outcome.

Intra-abdominal abscess were the second most fre-

quent complication that our patients experienced. Ac-

cording with the literature the treatment consisted in

percutaneous CT-guided abscess drainage that is shown

to be an effective method for treating intra-abdominal

abscess following elective colorectal surgery with a ran-

ge of success between 65% after the first and 85% after a

second attempt [9].

Postoperative wound infection occurred in 16 (3%) of

the patients. In contaminated surgery, such as elective

major colorectal surgery, has a reported incidence of in-

cisional Surgical Site Infections (SSI), ranging from 10%

- 15% to 20% - 25% associated with significant morbid-

ity, prolonged hospital length of stay, and a high cost to

the patient and the institution [10]. In our experience

intravenous antibiotics were given 30 minutes before the

surgery, as suggested in literature. Preoperative cleaning

of the patient’s skin was made by chlorhexidine-alcohol.

It is shown that is superior to povidoneiodine for pre-

venting surgical-site in fection after contaminated surgery,

including colorectal procedures [11]. Wound Infection

occurred more frequently in emergency surgery. Two

cases after perforation of the colon for a large bowel ob-

struction due to advanced cancer. Five patients were

diabetics and obese. The treatment of the wound infec-

tion was based on out-patient clinic medications and in

three cases with a prolonged antibiotic therapy.

16 patients (3%) underwent a reoperation, five for an

immediate bleeding after surgery, and eleven for an an-

astomotic leakage, two of these died after the reoperation.

In literature the data regarding reoperation after colorec-

tal surgery is variable. In a large series of patients the

re-operation rate is shown to be up to 12.5% and the ap-

proach is performed with laparotomy between the 60%

and the 85% of the patients [8]. However, the li mit in our

study to compare these results is evident for the great

number of patients undergoing a right haemicolectomy,

so with a lower risk of anastomotic leakage and without

the risk of the mobilization of the splenic flexure.

12 patients experienced medical complications. The

management of colorectal surgical patients requires me-

Open Access SS

G. P. ANGELUCCI ET AL.

Open Access SS

523

ticulous fluid and electrolyte therapy, and the involve-

ment of a multidisciplinary team comprehensive of an-

esthesiologist for the understanding of the pre-existing

comorbidities that are involved in the morbidity of the

patients [12]. Age was non-related with the morbidity

and mortality. Patients with ASA grade >2, or cardio-

vascular disease and/or respiratory disease had higher

incidence of morbidity and experienced longer recovery

in Intensive Care Unit. Four of them died for heart failure,

and one for respiratory failure.

It is also demonstrated a significant ongoing risk of

SBO after colorectal surgery, mainly during the 1st year

after surgery. It is usually associated with the adhesions

formation, especially after open surgery [13]. We had

two cases of postoperative ileus and one patient experi-

enced a SBO treated with no oral intake, gastric tube and

fluid therapy. The diagnosis of SBO was based on clini-

cal and imaging criteria. Current practice for manage-

ment of SBO is to give patients who are clinically stable

and without evidence of bowel ischemia or strangulation

a trial of conservative manage ment. Previously published

data suggest that 43% to 70% of these patients have

resolution of their SBO [14].

5. Conclusions

Our study is a retrospective case review, focusing on

how comorbidities can influence the outcome of the pa-

tients and on the management of the surgical complica-

tion. The limit of our clinical records is related to the

short-term follow-up, the number of the patients, and the

few patients treated with a laparoscopic approach.

In our experience, we evidenced that surgery perfor-

med for advanced rectal cancer in the lower rectum, es-

pecially in urgency settings is associated with an increase

of morbidity and mortality in the early post-operative

period, higher than colonic resections.

Pre-existing comorbidities are involved in the morbid-

ity of the patients: obesity, diabetes, cardiovascular dis-

ease, respiratory disease and renal failure. And a more

accurate approach both in surgical technique and in

post-operative management can be proposed to the sur-

geon. In our experience, age per-se is not a serious inde-

pendent risk factor unless the patient has one of the pre-

vious comorbidities.

It seems that derivative stoma in high risk patients

does not decrease the incidence of AL, but may give us

the possibility of a conservative treatment with antibiot-

ics and CT-drainage.

REFERENCES

[1] La Ries, “The Annual Report to the Nation on the Status

of Cancer, 1973-1997,” Cancer, Vol. 88, No. 10, 2000,

pp. 2390-2424.

[2] N. C. Buchs, et al., “Incidence Consequences and Risk

Factors for Anastomotic Dehiscence after Colorectal Sur-

gery: A Prospective Monocentric Study,” International

Journal of Colorectal Disease, Vol. 23, No. 3, 2008, pp.

265-270. http://dx.doi.org/10.1007/s00384-007-0399-3

[3] J. A. Smith, et al., “Evidence of the Effect of Specializa-

tion on the Management, Surgical Outcome and Survival

from Colorectal Cancer in Wessex,” British Journal of

Surgery, Vol. 90, No. 5, 2003, pp. 583-592.

http://dx.doi.org/10.1002/bjs.4085

[4] R. J. Aitken, “Mesorectal Excision for Rectal Cancer,”

British Journal of Surgery, Vol. 83, No. 2, 1996, pp. 214-

216. http://dx.doi.org/10.1002/bjs.1800830218

[5] G. Branagan, “Prognosis after Anastomotic Leakage in

Colorectal Surgery,” Diseases of the Colon & Rectum,

Vol. 48, No. 5, 2005, pp. 1021-1026.

http://dx.doi.org/10.1007/s10350-004-0869-4

[6] N. D. Karanjia, “Risk of Peritonitis and Fatal Septicemia

and the Need to Defuncion the Low Anastomosis,” Brit-

ish Journal of Surgery, Vol. 78, No. 2, 1991, pp. 196-198.

http://dx.doi.org/10.1002/bjs.1800780221

[7] A. Alves, “Management of Anastomotic Leakage after

Nondiverted Large Bowel Resection,” Journal of the

American College of Surgeons, Vol. 189, No. 6, 1999, pp.

554-559.

http://dx.doi.org/10.1016/S1072-7515(99)00207-0

[8] P. Matthiessen, “Risk Factors for Anastomotic Leakage

after Anterior Resection of the Rectum,” Colorectal Dis-

ease, Vol. 6, No. 6, 2004, pp. 462-469.

http://dx.doi.org/10.1111/j.1463-1318.2004.00657.x

[9] M. Khurrum Baig, “Percutaneous Postoperative Intra-

Abdominal Abscess Drainage after Elective Colorectal

Surgery,” Techniques in Coloproctology, Vol. 6, No. 3,

2002, pp. 159-164.

http://dx.doi.org/10.1007/s101510200036

[10] R. Tang, “Risk Factors for Surgical Site Infection after

Elective Resection of the Colon and Rectum: A Sin-

gle-Center Prospective Study of 2809 Consecutive Pa-

tients,” Annals of Surgery, Vol. 234, No. 2, 2001, pp.

181-189.

http://dx.doi.org/10.1097/00000658-200108000-00007

[11] R. O. Darouiche, “Chlorhexidine-Alcohol versus Povi-

done-Iodine for Surgical-Site Antisepsis,” New England

Journal of Medicine, Vol. 362, No. 1, 2010, pp. 18-26.

http://dx.doi.org/10.1056/NEJMoa0810988

[12] P. Santosh, et al., “Anesthesia and Perioperative Man-

agement of Colorectal Surgical Patients,” Journal of An-

aesthesiology Clinical Pharmacology, Vol. 28, No. 3,

2012, pp. 304-313.

http://dx.doi.org/10.4103/0970-9185.98321

[13] G. Miller, “Natural History of Patients with Adhesive

Small Bowel Obstruction,” British Journal of Surgery,

Vol. 87, No. 9, 2000, pp. 1240-1247.

http://dx.doi.org/10.1046/j.1365-2168.2000.01530.x

[14] M. C. Parker, et al., “Postoperative Adhesions: Ten-Year

Follow-Up of 12,584 Patients Undergoing Lower Ab-

dominal Surgery,” Diseases of the Colon & Rectum, Vol.

44, No. 6, 2001, pp. 822-829.

http://dx.doi.org/10.1007/BF02234701

G. P. ANGELUCCI ET AL.

524

Abbreviations

AL: Anastomotic Leak;

TME: Total Mesorectal Excision;

SBO: Small Bowel Obstruction;

CRS: Colorectal Surgery;

SSI: Surgical Site Infections.

Open Access SS