Abstract
Background
The aim of this study was to identify the incidence of surgical site infections (SSIs) and postoperative complications, as defined by the Clavien–Dindo classification, after hepatic resection for metastatic colorectal cancer in patients with and without associated neoadjuvant chemotherapy.
Methods
A total of 181 patients were studied retrospectively. Patients were divided into two groups: the first group comprised patients with associated neoadjuvant chemotherapeutic treatment for liver metastases with a latency time <8 wk and the second group comprised patients without associated neoadjuvant chemotherapy.
Results
Variables of duration of liver surgery, length of total hospital stay, and length of postoperative hospital stay seem to be correlated with SSIs and postoperative complications, P < 0.005 and P < 0.0001, respectively. Duration of surgery is a risk factor for SSIs, with an odds ratio of 1.15, and for complications according to the Clavien–Dindo classification, with an odds ratio of 1.35.
Conclusions
Neoadjuvant chemotherapy was not a significant risk factor for SSIs, whereas the total length of hospital stay, length of postoperative hospital stay, and duration of surgery were independent predictors of SSIs and complications according to the Clavien–Dindo classification.
Keywords
1. Introduction
Postoperative infections are frequent complications and have a significant impact on the length of hospital stay, morbidity, and mortality [
[1]
]. Surgical site infections (SSIs) are the most common hospital-acquired infections among surgical patients, with a significant impact on both patient morbidity and health care costs according to the U.S. Centers for Disease Control and Prevention through the National Nosocomial Infections Surveillance program [[2]
].An SSI is defined as an infection either with incisional involvement of the skin alone or with the involvement of deep tissues or organs. The criteria for defining SSIs are as follows: superficial incisional SSI if only the skin and subcutaneous tissue are involved; deep incisional SSI with the involvement of deep soft tissues, such as fascia and muscles; and organ-space SSI when the organ or space is involved [
[3]
]. In recent years, a decreasing incidence of perioperative septic complications has been reported, the result of advances in surgical techniques, new suturing materials, better perioperative management, and the implementation of infection surveillance [[4]
]. Neoadjuvant chemotherapy for colorectal cancer seems to enhance the risk of surgical complications and infections [[1]
], suppressing the hematopoietic system, and causing neutropenia. It is also associated with the risk of life-threatening infections [[5]
].The aim of this study was to identify the incidence of SSIs and postoperative complications according to the Clavien–Dindo classification, (Table 1) [
[6]
], after hepatic resection for metastatic colorectal cancer in patients with and without associated neoadjuvant chemotherapy. The latter are increasingly being used to enlarge the cohort of patients who can be offered hepatic resection for malignancy.Table 1Clavien–Dindo classification of postoperative surgical complications.
| Grades | Definitions |
|---|---|
| I | Any deviation from the normal postoperative course without the need of pharmacologic treatment or surgical, endoscopic, and radiologic interventions. Allowed therapeutic regimens are drugs as antiemetic, antipyretics, analgesics, diuretics, electrolytes, and physiotherapy. This grade also includes the wound infections opened at the bedside |
| II | Requiring pharmacologic treatment with drugs other than such allowed for grade I complications: blood transfusions and parenteral nutrition are also included |
| III | Requiring surgical, endoscopic, and radiologic interventions: a. Intervention not under general anesthesia b. Intervention under general anesthesia |
| IV | Life-threatening complication (including CNS complications) requiring IC-ICU management: a. Single organ dysfunction (including dialysis) b. Multiorgan dysfunction |
| V | Death of the patient |
CNS = central venous system; IC = intermediate care; ICU = intensive care unit.
∗ Brain hemorrhage, ischemic stroke, subarachnoid bleeding, but excluding transient ischemic stroke.
Modern management of colorectal liver metastases is multimodal and incorporates open and laparoscopic surgery, ablative therapies such as radio frequency ablation or microwave ablation, and (neo)adjuvant chemotherapy. Most patients with hepatic metastases should be considered for resectional surgery if all the tumor(s) can be resected, as this offers the only opportunity for prolonged survival.
However, the real impact of these agents on clinical outcomes after hepatic resection remains unclear.
2. Materials and methods
A total of 181 patients who had undergone hepatic surgery for metastatic colorectal cancer in three surgical units, the Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy, Azienda Ospedaliero-Universitaria Policlinico-Vittorio Emanuele, and Humanitas Centro Catanese di Oncologia, Catania, Italy, between January 2006 and December 2011 were investigated retrospectively. Data were collected on patient age, gender, comorbidities, site of primary tumor, type of hepatic resection, duration of surgery, and the total length of hospital stay and the length of postoperative stay and are reported in Table 2. Patients were divided into two groups: the first group comprised patients who had undergone hepatic resection for metastatic colorectal cancer after a latency time <8 wk since the end of the neoadjuvant chemotherapy and the second group comprised patients who had undergone hepatic resection without associated neoadjuvant chemotherapy [
[7]
]. The two groups differed in the volume of type of resection. Patients with significant progression of metastatic disease and-or the development of new lesions during neoadjuvant chemotherapy were not included in this series.Table 2General characteristics of patients who underwent hepatic resection for metastatic colorectal cancer.
| No. of patients | 181 |
|---|---|
| Median age (y) ± standard deviation | 63 ± 10 y |
| Gender, n (%) | |
| Male | 103 (56.9%) |
| Female | 78 (43.1%) |
| Location of primary tumor, n (%) | |
| Right colon | 41 (22.7%) |
| Transverse colon | 4 (2.2%) |
| Left colon | 29 (16%) |
| Sigmoid colon | 66 (36.5%) |
| Rectosigmoid joint | 2 (1.1%) |
| Transverse + sigmoid colon | 1 (0.5%) |
| Rectum | 37 (20.5%) |
| Anus | 1 (0.5%) |
| Associated risk factors, n (%) | |
| Diabetes | 21 (11.6%) |
| Obesity | 11 (6%) |
| Smoking | 28 (15.4%) |
| Respiratory problems | 14 (7.7%) |
| Cardiovascular disease | 70 (38.6%) |
| Renal failure | 3 (1.6%) |
| Liver disease | 10 (5.5%) |
| Major liver resection, n (%) | 83 (45.8%) |
| Left hepatectomy | 24 (29%) |
| Right hepatectomy | 48 (57.8%) |
| Left lobectomy | 11 (13.2%) |
| Minor liver resection, n (%) | 98 (54.2%) |
| Wedge resection | 81 (82.6%) |
| Bisegmentectomy | 13 (13.4%) |
| Right sectorectomy | 4 (4%) |
| Duration of liver surgery (min): mean ± SD | 404 ± 154 |
| Length of total hospital stay (d): mean ± SD | 10 ± 6 |
| Length of postoperative hospital stay (d): mean ± SD | 9 ± 7 |
| Neoadjuvant chemotherapy, n (%) | 52 (28.7%) |
| No chemotherapy, n (%) | 129 (71.2%) |
In the first group, patients were assigned to six cycles of FOLFOX4 (Folinic acid, Fluorouracil, Oxaliplatin) before surgery; each cycle of chemotherapy lasted 14 d, with the subsequent cycle set to start on day 15, as previously described by Nordlinger et al. [
8
, 20
]. The incidence of SSIs classified as superficial, deep incisional, and organ/space, and all other infectious complications were evaluated in the two groups. We also used the Clavien–Dindo classification for postoperative complications.A comparison of means for quantitative variables was done using the Student t-test at a P = 0.05 significance level using Analyse-it for Microsoft Excel (version 3.0; Analyse-it Software, Ltd, http://www.analyse-it.com/; Leeds, United Kingdom 2012). Univariate contingency table analysis was done using χ2 tests at the P = 0.05 significance level also using Analyse-it for Excel.
Multivariate logistic analysis was done with Epi Info (version 3.5.4, 2012; Centers for Disease Control and Prevention, Atlanta, GA). Regression factors were both quantitative (age and the length of intervention) and qualitative dichotomous (presence-absence). Risk was expressed as an odds ratio (OR) approximating the relative risk of having the outcome given the factor with 95% confidence limits.
3. Results
This study enrolled 181 patients with a median age of 63 ± 10 y. There were 103 males (56.9%) and 78 females (43.1%) as shown in Table 2.
The first group (Table 3) included 129 patients without associated chemotherapeutic treatment. The median age was 63 ± 9 y with 74 males (57%) and 55 females (43%). Duration of surgery was estimated at 408 ± 158 min, and all patients underwent an initial time of adhesiolysis, which lengthened the intervention. The total length of hospital stay and length of postoperative hospital stay were 10 ± 6 and 9 ± 8 d, respectively.
Table 3General characteristics of patients who underwent hepatic resection for metastatic colorectal cancer with and without associated chemotherapy treatment.
| Variables | No chemotherapy | Neoadjuvant chemotherapy | Student's t-test |
|---|---|---|---|
| No. of patients | 129 | 52 | |
| Mean age (y) ± SD | 63 ± 9 | 64 ± 13 | |
| Male | 74 (57%) | 29 (56%) | N.S. χ2 test |
| Female | 55 (43%) | 23 (44%) | N.S. χ2 test |
| Location of primary tumor, n (%) | N.S. χ2 test | ||
| Right colon | 30 (23.2%) | 11 (21.2%) | |
| Transverse colon | 3 (2.4%) | 1 (1.9%) | |
| Left colon | 21 (16.3%) | 8 (15.4%) | |
| Sigmoid colon | 49 (38%) | 17 (32.7%) | |
| Rectosigmoid joint | 2 (1.4%) | 1 (1.9%) | |
| Transverse + sigmoid colon | 0 (0%) | 1 (1.9%) | |
| Rectum | 24 (18.7%) | 13 (25%) | |
| Associated risk factors, n (%) | N.S. χ2 test | ||
| Diabetes | 13 (10%) | 8 (15.4%) | |
| Obesity | 7 (5.4%) | 4 (7.7%) | |
| Smoking | 20 (15.5%) | 8 (15.4%) | |
| Respiratory problems | 8 (62%) | 6 (11.6%) | |
| Cardiovascular disease | 39 (30.2%) | 20 (38.4%) | |
| Renal failure | 3 (2.3%) | 0 (0%) | |
| Liver disease | 6 (4.6%) | 4 (7.7%) | |
| Major liver resection, n (%) | 56 (43.4%) | 27 (51.9%) | N.S. χ2 test |
| Left hepatectomy | 8 (14.2%) | 16 (59.2%) | |
| Right hepatectomy | 42 (75%) | 6 (22.2%) | |
| Left lobectomy | 6 (10.8%) | 5 (18.6%) | |
| Minor liver resection, n (%) | 73 (56.6%) | 25 (48.1%) | N.S. χ2 test |
| Wedge resection | 63 (86.3%) | 18 (72%) | |
| Bisegmentectomy | 8 (11%) | 5 (20%) | |
| Right sectorectomy | 2 (2.7%) | 2 (8%) | |
| Duration of liver surgery (min): mean ± SD | 408 ± 158 | 396 ± 145 | N.S. Student t-test |
| Length of total hospital stay (d): mean ± SD | 10 ± 6 | 9 ± 5 | N.S. Student t-test |
| Length of postoperative hospital stay (d): mean ± SD | 9 ± 8 | 8 ± 4 | N.S. Student t-test |
N.S. = nonsignificant.
The location of the primary tumor was the sigmoid colon in 49 patients (38%), the right colon in 30 (23.2%), the rectum in 24 (18.7%), the left colon in 21 (16.3%), the transverse colon in 3 (1.9%), and the rectosigmoid joint in 2 (1.4%). Major liver resection was performed in 56 patients (43.4%), with 8 (14.2%) left hepatectomies, 42 (75%) right hepatectomies, and 6 (10.8%) left lobectomies. Minor liver resection was performed in 73 patients (56.6%) with 63 (86.3%) wedge resections, 8 (11%) bisegmentectomies, and 2 (2.7%) right sectorectomies.
Forty-one patients (31.7%) experienced SSIs as defined by the SSI classification with 7 (17%) superficial incisional, 17 (41.5%) deep incisional, and 17 (41.5%) organ/space infections, with the last infection leading to an increase in the total hospital stay. In the remaining 88 patients (68.3%) there were no SSIs.
In 61 patients (47.29) there were postoperative complications, which we defined according to the Clavien–Dindo classification: grade I in 14 patients (23%), grade II in 23 (37.7%), grade IIIa in 16 (26.2%), grade IIIb in 4 (6.5%), grade IVa in 3 (5%), and grade V in 1 patient (1.6%). There were no postoperative complications in the remaining 68 patients (52.8%).
The second group (Table 4) consisted of 52 patients who had undergone neoadjuvant chemotherapy. The median age was 64 ± 13 y with 29 males (56%) and 23 females (44%). The duration of surgery was estimated at 396 ± 145 min, and all patients underwent an initial time of adhesiolysis, which lengthened the intervention. The total length of hospital stay and length of postoperative hospital stay were 9 ± 5 and 8 ± 4 d, respectively.
Table 4Postoperative complications according to the SSI and Clavien–Dindo classification.
| Variables | No chemotherapy | Neoadjuvant chemotherapy | Test |
|---|---|---|---|
| Number of patients | 129 | 52 | |
| SSI, n (%) | 41 (31.8%) | 16 (30.8%) | N.S. |
| Superficial incisional SSI | 7 (17%) | 5 (31.3%) | |
| Deep incisional SSI | 17 (41.5%) | 7 (43.7%) | |
| Organ/space SSI | 17 (41.5%) | 4 (25%) | |
| Number of SSIs, n (%) | 88 (68.2%) | 36 (69.2%) | |
| Clavien–Dindo surgical complications, n (%) | 61 (47.3%) | 19 (36.5%) | N.S. |
| I | 14 (23%) | 4 (21%) | |
| II | 23 (37.7%) | 9 (47.4%) | |
| IIIa | 16 (26.2%) | 4 (21%) | |
| IIIb | 4 (6.5%) | 1 (5.3%) | |
| IVa | 3 (5%) | 1 (5.3%) | |
| IVb | — | — | |
| V | 1 (1.6%) | — | |
| No Clavien–Dindo surgical complications, n (%) | 68 (52.7%) | 33 (63.5%) |
∗ Chi-squared tests between proportions of chemotherapy and occurrence of SSI or complications according to the Clavien–Dindo classification yielded nonsignificant results.
The location of the primary tumor was the sigmoid colon in 17 patients (32.7%), the rectum in 13 (25%), the left colon in 8 (15.4%), the right colon in 11 (21.2%), the transverse colon in 1 (1.9%), the rectosigmoid joint in 1 (1.9%), and the transverse and sigmoid colon in 1 (1.9%). Major liver resection was performed in 27 patients (51.9%) with 16 (59.2%) left hepatectomies, 6 (22.2%) right hepatectomies, and 5 (18.6%) left lobectomies. Minor liver resection was performed in 25 patients (48.1%) with 18 (72%) wedge resections, 5 (20%) bisegmentectomies, and 2 (8%) right sectorectomies.
Sixteen patients (30.7%) experienced SSI as defined by the SSI classification, with 5 (31.3%) superficial incisional, 7 (43.7%) deep incisional, and 4 (25%) organ/space infections, the last infection led to an increase in total hospital stay. There were no SSIs in the other 36 patients (69.3%).
In 19 patients (36.5%) there were postoperative complications as defined by the Clavien–Dindo classification: grade I in four patients (21%), grade II in nine (47.4%), IIIa in four (21%), IIIb in one (5.3%), and IVa in one patient (5.3%). There were no postoperative complications in the other 33 patients (63.5%).
There were no statistically significant preoperative patient characteristics shared by the two groups. Statistical analyses of two-by-two contingency tables of exposure (to chemotherapy) versus outcome (SSI or complications according to the Clavien–Dindo classification) showed no significant differences in the proportion of cases according to the presence of chemotherapy (Table 4).
Statistical analyses of two-by-two contingency tables of various preoperative and intraoperative characteristics versus outcome (SSI or complications according to the Clavien–Dindo classification) showed no significant differences in the proportion of cases related to the presence of chemotherapy (Table 5). The duration of surgical intervention was found to have been significantly higher in patients who then developed SSIs or complications according to the Clavien–Dindo classification (Table 5). None of the operations were performed with a mini-invasive approach.
Table 5Preoperative and intraoperative characteristics of patients who developed SSI or complications according to the Clavien–Dindo classification.
| Variables | SSI | No SSI | Test (significance) |
|---|---|---|---|
| Number of patients | 57 | 124 | |
| Gender, n (%) | |||
| Male | 37 (64.9%) | 66 (53.2%) | N.S. |
| Female | 20 (35.1%) | 58 (46.8%) | |
| Associated risk factors, n (%) | |||
| Diabetes | 4 (7.0%) | 17 (13.7%) | N.S. |
| Obesity | 2 (3.5%) | 9 (7.3%) | N.S. |
| Smoking | 9 (15.8%) | 19 (15.3%) | N.S. |
| Respiratory problems | 3 (5.3%) | 11 (8.9%) | N.S. |
| Cardiovascular disease | 5 (8.8%) | 8 (6.5%) | N.S. |
| Renal failure | 1 (1.8%) | 2 (1.6%) | N.S. |
| Liver disease | 4 (7%) | 6 (4.8%) | N.S. |
| Major liver resection, n (%) | 26 (45.6%) | 57 (46.0%) | N.S. |
| Duration of liver surgery (min): mean ± SD | 444 ± 153 | 386 ± 151 | P < 0.02 |
| Length of total hospital stay (d): mean ± SD | 13.2 ± 8 | 8.5 ± 3.4 | P < 0.0001 |
| Length of postoperative hospital stay (d): mean ± SD | 12.2 ± 10.3 | 7.2 ± 3 | P < 0.0001 |
| Complication | No complication | ||
| Gender, n (%) | |||
| Male | 51 (63.8%) | 52 (51.5%) | N.S. |
| Female | 29 (36.3%) | 49 (48.5%) | |
| Associated risk factors, n (%) | |||
| Diabetes | 7 (8.8%) | 14 (13.9%) | N.S. |
| Obesity | 4 (5%) | 7 (6.9%) | N.S. |
| Smoking | 16 (20%) | 12 (11.9%) | N.S. |
| Respiratory problems | 6 (7.5%) | 8 (7.9%) | N.S. |
| Cardiovascular disease | 7 (8.8%) | 6 (5.9%) | N.S. |
| Renal failure | 1 (1.3%) | 2 (2%) | N.S. |
| Liver disease | 4 (5%) | 6 (5.9%) | N.S. |
| Major liver resection, n (%) | 31 (38.8%) | 52 (51.5%) | N.S. |
| Duration of liver surgery (min): mean ± SD | 460 ± 154 | 360 ± 139 | P < 0.0001 |
| Length of total hospital stay (d): mean ± SD | 12.4 ± 7 | 8 ± 4 | P < 0.0001 |
| Length of postoperative hospital stay (d): mean ± SD | 11 ± 9 | 7 ± 3 | P < 0.0001 |
The total length of hospital stay and the length of postoperative stay were significantly higher in patients who later developed complications.
Despite the small number of patients, the two study groups were comparable. To better evaluate the available data and to partly overcome the constraints because of the limited number of cases, a multiple logistic regression analysis was used to explore the independent risk of complications (SSI or complications according to the Clavien–Dindo classification) because of preoperative and intraoperative (length of surgery) factors. Preoperative factors considered were gender and age, the presence of neoadjuvant chemotherapy, and associated risk factors (diabetes, smoking, respiratory, and cardiovascular problems). For both SSIs and complications according to the Clavien–Dindo classification, a reduced model was also used, removing factors with a P value farther from the chosen significance level.
In neither case did the reduced model show a significant worsening of goodness-of-fit, and the regression was at least marginally (borderline) statistically significant, as indicated in Table 6.
Table 6Multivariate OR for significant independent predictors of SSI and complications according to the Clavien–Dindo classification.
| Variables | OR (95% Cl) | P value |
|---|---|---|
| SSI | ||
| Duration of liver surgery (h) | 1.15 (1.01–1.31) | 0.03 |
| Gender | 0.69 (0.35–1.35) | 0.28 |
| Diabetes | 0.59 (0.18–1.94) | 0.39 |
| Respiratory problems | 0.53 (0.13–2.09) | 0.36 |
| Cardiovascular disease | 1.78 (0.50–6.23) | 0.36 |
| Clavien–Dindo complications | ||
| Neoadjuvant chemotherapy | 0.61 (0.30–1.26) | 0.18 |
| Duration of liver surgery (h) | 1.32 (1.15–1.51) | 0.0001 |
| Gender | 0.68 (0.36–1.30) | 0.25 |
| Smoking | 1.55 (0.64–3.78) | 0.33 |
| Cardiovascular disease | 2.20 (0.60–8.11) | 0.23 |
Number of cases: 181. In boldface are given the factors exceeding the significance level of P < 0.05.
∗ Likelihood ratio test for goodness-of-fit = 9.42 (5 df), P = 0.093 borderline significant.
† Likelihood ratio test for goodness-of-fit = 25.3 (5 df), P = 0.0001.
For both the SSI and the complication outcomes, logistic regression analysis (Table 6) indicated that after adjusting the demographics and all other factors, only length of intervention was related to a significantly higher risk of complications in patients after neoadjuvant chemotherapy, with an OR of 1.15 (1.01–1.31) for SSI and 1.32 (1.15–1.51) for complications according to the Clavien–Dindo classification (ORs and 95% confidence intervals [CIs] from logistic regression).
Although these results derive from an exploratory analysis, which at least for SSI is only bordering on significance, the results seem to suggest that the risk of SSIs increases 15% per hour of intervention and the risk of complications according to the Clavien–Dindo classification increases 32% per hour of intervention.
4. Discussion
Surgical resection plays a major role in the treatment of colorectal liver metastases [
[9]
]. The safety of this procedure has been established, and several studies have reported satisfactory results with the reported 5-y survival rate after initial hepatectomy in the range of 20%–50% [[7]
].Liver metastases can be divided into three categories: (1) resectable, (2) not optimally resectable, and (3) unresectable [
10
, 11
]. A recent expert consensus statement recommends that neoadjuvant chemotherapy should be done even for metastases that are resectable at the time of presentation [[12]
]. In addition, liver metastases are regarded as not optimally resectable, and chemotherapy is administered first if any of the following conditions are present: four or more metastases; 5 cm or larger metastases; synchronous liver metastases; positive lymph nodes surrounding the primary lesion; tumors adjacent to hepatic veins; and tumors adjacent to the bilateral portal branches. If the chemotherapy is effective, resection is undertaken [13
, 14
].This clinical scenario presents a risk factor for the development of SSIs [
[15]
] because of a more general susceptibility to infection in patients who have undergone chemotherapeutic treatment and experienced postoperative complications according to the Clavien–Dindo classification, which result from the so-called chemotherapy-associated liver injury [16
, 17
, 18
] and which are brought on by steatosis, steatohepatitis, and sinusoidal obstruction syndrome.Despite the presence of considerable evidence to justify the use of adjuvant chemotherapy with oxaliplatin and irinotecan for patients with advanced colorectal cancer [
[19]
], the efficacy of neoadjuvant therapy before the resection of colorectal liver metastases has yet to be proven and remains controversial. An EORTC [8
, 20
] (European Organization for the Research and Treatment of Cancer) study of 364 patients randomized to surgery alone or six cycles of FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) found that chemotherapy led to a decrease in the size of lesions on radiologic imaging, which was then confirmed by pathologic examinations of resected specimens. Survival data on these patients indicated that treatment with FOLFOX is associated with better progression-free survival compared with surgery alone. There is also evidence on the benefit of preoperative chemotherapy from studies that used agents to reduce metastases to render them resectable. The first such study, conducted by Bismuth et al. [[21]
] in 1996, analyzed 53 patients with colorectal metastases treated with 5-fluorouracil, folinic acid, and oxaliplatin. After chemotherapy, 37 patients underwent major surgery and 16 had minor resections with 3- and 5-y survival rates of 54% and 40%, respectively, indicating that chemotherapy had benefited patients by rendering them candidates for hepatic resection [[22]
].One limitation of our study is the small sample size in both groups. However, with regard to SSIs and postoperative complications according to the Clavien–Dindo classification in hepatic surgery, there was no statistically significant correlation between the patients who underwent neoadjuvant chemotherapy and those who did not, as reported in Tables 4 and 5. These results are consistent with those from other studies [
23
, 24
, 25
].In the 1980s and 1990s, the development of organ/space SSIs after hepatectomy was reported as a fatal complication causing liver failure and death. Although rates of organ/space SSIs after hepatectomy have been reported as ranging from 4.7%–25%, rates of hospital mortality caused by organ/space SSIs have declined [
26
, 27
, - Campbell Jr., D.A.
- Henderson W.G.
- Englesbe M.J.
- et al.
Surgical site infection prevention: the importance of operative duration and blood transfusion—results of the first American College of Surgeons-National Surgical Quality Improvement Program Best Practices Initiative.
J Am Coll Surg. 2008; 207: 810
28
]. Some studies have assessed the effect of multiple factors such as diabetes, obesity, smoking, and liver resection on complications in this type of surgery [29
, 30
, 31
].Our study found no statistically significant correlation between these risk factors and the incidence of SSIs or complications according to the Clavien–Dindo classification in hepatic surgery for colorectal liver metastases, although multicenter studies would help better define the problem.
Other variables related to the duration of liver surgery, length of total hospital stay, and length of postoperative hospital stay seem to have some correlation with the SSIs and postoperative complications according to the Clavien–Dindo classification, with P < 0.005 and P < 0.0001, respectively, as reported in Table 5.
We found that the duration of liver surgery is a risk factor for SSIs, with an OR of 1.15 (CI, 1.01–1.31), and for complications according to the Clavien–Dindo classification, with an OR of 1.35 (CI, 1.17–1.55).
5. Conclusions
To sum up, our study found that neoadjuvant chemotherapy is not a significant risk factor for SSIs or complications according to the Clavien–Dindo classification, and that the total length of hospital stay, length of postoperative hospital stay, and duration of liver surgery were independent predictors of SSIs and complications according to the Clavien–Dindo classification.
Acknowledgment
The authors would like to thank Warren Blumberg of ISMETT's Language Services Department for his help in revising this article.
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Article info
Publication history
Published online: November 25, 2013
Accepted:
November 15,
2013
Received in revised form:
November 1,
2013
Received:
August 19,
2013
Identification
Copyright
© 2014 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
