The Elephant in the Operating Room

Editor’s Comment: For this post I’d like to introduce guest blogger Michael Goldfarb, MD, who has generously agreed to contribute a few posts leveraging his surgical expertise and passion for the prevention of SSI. With a diverse career spanning the United States Army, hospital adminstration and leadership positions, and private and academic surgical practice, Dr. Goldfarb provides a unique perspective on the challenges of SSI. The post below is abstracted from an article Dr. Goldfarb wrote previously, entitled: “The Elephant in the OR,” General Surgery News, May 2014, volume 41, Issue 5.

Key Takeaway Points:

  • In patients with infectious complications after surgery for colorectal cancer, the survival rate was more than 50% lower than in patients without infections.
  • The presence of postoperative complications was an independent factor associated with a worse overall survival and a higher overall recurrence rate in colorectal cancer patients. Also, there is a significant association between colorectal anastomotic leak and reduced long-term cancer-specific survival.
  • What biological mechanisms might underlie this link? Consider the following:
    • Host–tumor interactions under surgical stress may act synergistically as potent tumor growth factors, and may thus influence long-term survival. Controlling surgical insults and/or regulating perioperative inflammatory responses may therefore lead to new therapeutic approaches for controlling disease recurrence.
    • Intravital microscopy showed that cancer cells adhered directly on top of arrested neutrophils, indicating that neutrophils may act as a bridge to facilitate interactions between cancer cells and the liver parenchyma.
  • If surgeons accept the notion that postoperative infection reduces survival, then certain algorithms in surgery should be modified.

Patient pain and suffering from any infectious complication after surgery, as well as the massive costs associated with treating these complications, have been well documented. But the awareness of the reduction in disease-free survival due to these postoperative infectious complications has not diffused among surgeons. In contrast, the evidence for blood transfusion reducing survival, in colon cancer surgery, has diffused among surgeons, providing hope that we may yet recognize other long-term consequences of infectious complications.

The evidence supporting this link is strong. In an article, “Correlation Between Postoperative Infections and Long-term Survival After Colorectal Resection for Cancer,” by Nespoli et al (Tumori 2004;90:485-490),  Dukes’ stage (P=0.048) and occurrence of postoperative infectious complications (P=0.011) were independently associated with outcome. The authors reported: “In patients with infectious complications, the survival rate was more than 50% lower than in patients without infections.” They excluded emergency and palliative operations (intestinal bypass), elderly subjects, previous cancer, immunosuppressive therapy, severe organ dysfunction, and Dukes

There is further support published in the Annals of Surgical Oncology (2007;14:2559-2566) by Law et al in the study “The Impact of Postoperative Complications on Long-term Outcomes Following Curative Resection for Colorectal Cancer.”  The presence of postoperative complications was an independent factor associated with a worse overall survival (P=0.023; HR, 1.26; 95% CI, 1.03-1.52) and a higher overall recurrence rate (P=0.04, HR, 1.26; 95% CI, 1.01-1.57). The presence of postoperative complication not only affects the short- term results of resection of colorectal cancer, but the long-term oncologic outcomes are also adversely affected.”

In 2011, Mirnezami et al published a very convincing study in the Annals of Surgery: “Increased Local Recurrence and Reduced Survival from Colorectal Cancer Following Anastomotic Leak (AL)” (2011;253:890-899). The analysis included 21,902 patients from 21 studies. The authors concluded “AL has a negative prognostic impact on local recurrence after restorative resection of rectal cancer. A significant association between colorectal AL and reduced long-term cancer specific survival was also noted.”

So what are we to do? The reality is that we, use do everything we can to prevent infectious complications. The first step is to get surgeons on board, just as they have accepted the risk for transfusion in colon cancer surgery. If surgeons accept the notion that postoperative infection reduces survival, then certain algorithms in surgery should be modified. For example, sometimes a surgeon does a low-anterior resection and considers adding a loop ileostomy, because he or she is not “sure” about the anastomosis. If the survival of that patient is reduced because of a leak, the decision for a loop ileostomy should be easier.

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