Maximizing Readmission Reduction in Colon Cancer Patients.

INTRODUCTION: Multiple studies have identified risk factors for readmission in colon cancer patients. We need to determine which risk factors, when modified, produce the greatest decrease in readmission for patients so that limited resources can be used most effectively by implementing targeted evidence-based performance improvements. We determined the potential impact of various modifiable risk factors on reducing 30-d readmission in colon cancer patients. METHODS: We used a cohort design with the 2012-2020 American College of Surgeons' National Surgical Quality Improvement Program data to track colon cancer patients for 30 d following surgery. Colon cancer patients who received colectomies and were discharged alive were included. Readmission (to the same or another hospital) for any reason within 30 d of the resection was the outcome measure. Modifiable risk factors were the use of minimally invasive surgery (MIS) versus open colectomy, mechanical bowel preparation, preoperative antibiotic use, functional status, smoking, complications (deep vein thrombosis, pulmonary embolism, myocardial infarction, stroke, infections, anastomotic leakage, prolonged postoperative ileus, extensive blood loss, and sepsis), serum albumin, and hematocrit. RESULTS: 111,691 patients with colon cancer were included in the analysis. About half of the patients were male, most were aged 75 or older, and were discharged home. Overall, 11,138 patients (10.0%) were readmitted within 30 d of surgery. In adjusted analysis, the reduction in readmission would be largest by preventing both prolonged ileus and by switching open colectomies to MIS (28.0% relative reduction) followed by preventing anastomotic leaks (6.2% relative reduction). Improving other modifiable risk factors would have a more limited impact. CONCLUSIONS: The focus of readmission reduction should be on preventing prolonged ileus, increasing the use of MIS, and preventing anastomotic leaks.

Virtual Reality for Preoperative Planning in Complex Surgical Oncology: A Single-Center Experience.

INTRODUCTION: Virtual reality models (VRM) are three-dimensional (3D) simulations of two-dimensional (2D) images, creating a more accurate mental representation of patient-specific anatomy. METHODS: Patients were retrospectively identified who underwent complex oncologic resections whose operations differed from preoperative plans between April 2018 and April 2019. Virtual reality modeling was performed based on preoperative 2D images to assess feasibility of use of this technology to create models. Preoperative plans made based upon 2D imaging versus VRM were compared to the final operations performed. Once the use of VRM to create preoperative plans was deemed feasible, individuals undergoing complex oncologic resections whose operative plans were difficult to define preoperatively were enrolled prospectively from July 2019 to December 2021. Preoperative plans made based upon 2D imaging and VRM by both the operating surgeon and a consulting surgeon were compared to the operation performed. Confidence in each operative plan was also measured. RESULTS: Twenty patients were identified, seven retrospective and 13 prospective, with tumors of the liver, pancreas, retroperitoneum, stomach, and soft tissue. Retrospectively, VRM were unable to be created in one patient due to a poor quality 2D image; the remainder (86%) were successfully able to be created and examined. Virtual reality modeling more clearly defined the extent of resection in 50% of successful cases. Prospectively, all VRM were successfully performed. The concordance of the operative plan with VRM was higher than with 2D imaging (92% versus 54% for the operating surgeon and 69% versus 23% for the consulting surgeon). Confidence in the operative plan after VRM compared to 2D imaging also increased for both surgeons (by 15% and 8% for the operating and consulting surgeons, respectively). CONCLUSIONS: Virtual reality modeling is feasible and may improve preoperative planning compared to 2D imaging. Further investigation is warranted.

Adherence to Extended Venous Thromboembolism Prophylaxis and Outcomes After Complex Gastrointestinal Oncologic Surgery.

BACKGROUND: Clinical guidelines recommend extended venous thromboembolism (VTE) prophylaxis for cancer patients after major gastrointestinal (GI) operations. However, adherence to the guidelines has been low, and the clinical outcomes not well defined. METHODS: This study retrospectively analyzed a random 10 % sample of the 2009-2022 IQVIA LifeLink PharMetrics Plus database, an administrative claims database representative of the commercially insured population of the United States. The study selected cancer patients undergoing major pancreas, liver, gastric, or esophageal surgery. The primary outcomes were 90-day post-discharge VTE and bleeding. RESULTS: The study identified 2296 unique eligible operations. During the index hospitalization, 52 patients (2.2 %) experienced VTE, 74 patients (3.2 %) had postoperative bleeding, and 140 patients (6.1 %) had a hospital stay of at least 28 days. The remaining 2069 operations comprised 833 pancreatectomies, 664 hepatectomies, 295 gastrectomies, and 277 esophagectomies. The median age of the patients was 49 years, and 44 % were female. Extended VTE prophylaxis prescriptions were filled for 176 patients (10.4 % for pancreas, 8.1 % for liver, 5.8 % for gastric cancer, and 6.5 % for esophageal cancer), and the most used agent was enoxaparin (96 % of the patients). After discharge, VTE occurred for 5.2 % and bleeding for 5.2 % of the patients. The findings showed no association of extended VTE prophylaxis with post-discharge VTE (odds ratio [OR], 1.54; 95 % confidence interval [CI], 0.81-2.96) or bleeding (OR, 0.72, 95 % CI, 0.32-1.61). CONCLUSIONS: The majority of the cancer patients undergoing complex GI surgery did not receive extended VTE prophylaxis according to the current guidelines, and their VTE rate was not higher than for the patients who received it.

Symptomatic Extra-Adrenal Myelolipoma in the Spleen.

A 42-year-old male patient presented with intermittent abdominal pain and gastrointestinal discomfort present for 4 years. Work-up included ultrasound and computed tomography, which identified a fat-containing splenic mass 5.6 cm in size. Due to recurrent symptoms, the patient sought medical care again. Subsequent images showed an increase in size to 7.6 cm, which was concerning for neoplasm. This was removed via open splenectomy, which was challenging due to intra-abdominal adhesions despite never having had any abdominal surgery. The patient's recovery was uncomplicated. Pathologic assessment indicated that the mass was a myelolipoma. Extra-adrenal myelolipomas are rare and typically found within the retroperitoneum but are extremely rare within the spleen. This case report adds the 6th such case to the literature and demonstrates the need for it to remain in the differential diagnosis of patients with fatty splenic masses, as well as that splenectomy is an appropriate treatment.

Duplicate gallbladder: A case report of a patient with cholecystitis after cholecystectomy.

INTRODUCTION: Duplicate gallbladder is a congenital anomaly with various anatomical presentations that can pose difficult diagnostic dilemmas. This case presents the consequence of recurrent cholecystitis after prior cholecystectomy due to delay in diagnosis of a duplicate gallbladder and insufficient treatment at first presentation. It also provides the opportunity to discuss the anatomical variations of duplicate gallbladders and their clinical implications. PRESENTATION OF CASE: We report on a 46-year-old woman who presented with symptoms of cholecystitis despite a history of cholecystectomy. Magnetic resonance cholangiopancreatography (MRCP) as well as review of intraoperative cholangiogram from the index surgery identified a cystic structure continuous with the biliary tree. Laparoscopic cholecystectomy was performed and histology confirmed a duplicate gallbladder. The patient did well post-operatively without any complications. DISCUSSION: Harlaftis's classification of duplicate gallbladder categorizes anatomical variations based on embryological origin. Though rarity contributes to missed diagnosis, modern imaging techniques that delineate the biliary tree can identify these abnormalities. Recognizing these variations can identify risk for recurrent disease preoperatively and thereby guide surgical decision-making. CONCLUSION: Duplicate gallbladder poses a risk for the unique presentation of recurrent cholecystitis despite cholecystectomy. Advanced imaging techniques that demonstrate biliary anatomy can identify duplicate gallbladder perioperatively. For those presenting with disease in any one gallbladder, resection of both is ideal to prevent recurrence of disease.

Kinetic analysis of contralateral liver hypertrophy after radioembolization of primary and metastatic liver tumors.

BACKGROUND: Radioembolization induces liver hypertrophy, although the extent and rate of hypertrophy are unknown. Our goal was to examine the kinetics of contralateral liver hypertrophy after transarterial radioembolization. METHODS: A retrospective study (2010-2014) of treatment-naïve patients with primary/secondary liver malignancies undergoing right lobe radioembolization was performed. Computed tomography volumetry was performed before and 1, 3, and 6 months after radioembolization. Outcomes of interest were left lobe (standardized future liver remnant) degree of hypertrophy, kinetic growth rate, and ability to reach goal standardized future liver remnant ≥40%. Medians were compared with the Kruskall-Wallis test. Time to event analysis was used to estimate time to reach goal standardized future liver remnant. RESULTS: In the study, 25 patients were included. At 1, 3, and 6 months, median degree of hypertrophy was 4%, 8%, and 12% (P < .001), degree of hypertrophy relative to baseline future liver remnants was 11%, 17%, and 31% (P = .015), and kinetic growth rate was 0.8%, 0.5%, and 0.4%/week (P = .002). In patients with baseline standardized future liver remnant <40% (N= 16), median time to reach standardized future liver remnant ≥40% was 7.3 months, with 75% accomplishing standardized future liver remnant ≥40% at 8.2 months. CONCLUSION: Radioembolization induces hypertrophy of the contralateral lobe to a similar extent as existing methods, although at a lower rate. The role of radioembolization as a dual therapy (neoadjuvant and hypetrophy-inducing) for selected patients needs to be studied. (Surgery 2017;160:XXX-XXX.).

Liver Resection and Surgical Strategies for Management of Primary Liver Cancer.

Primary liver cancer-including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC)-incidence is increasing and is an important source of cancer-related mortality worldwide. Management of these cancers, even when localized, is challenging due to the association with underlying liver disease and the complex anatomy of the liver. Although for ICC, surgical resection provides the only potential cure, for HCC, the risks and benefits of the multiple curative intent options must be considered to individualize treatment based upon tumor factors, baseline liver function, and the functional status of the patient. The principles of surgical resection for both HCC and ICC include margin-negative resections with preservation of adequate function of the residual liver. As the safety of surgical resection has improved in recent years, the role of liver resection for HCC has expanded to include selected patients with preserved liver function and small tumors (ablation as an alternative), tumors within Milan criteria (transplant as an alternative), and patients with large (>5 cm) and giant (>10 cm) HCC or with poor prognostic features (for whom surgery is infrequently offered) due to a survival benefit with resection for selected patients. An important surgical consideration specifically for ICC includes the high risk of nodal metastasis, for which portal lymphadenectomy is recommended at the time of hepatectomy for staging. For both diseases, onco-surgical strategies including portal vein embolization and parenchymal-sparing resections have increased the number of patients eligible for curative liver resection by improving patient outcomes. Multidisciplinary evaluation is critical in the management of patients with primary liver cancer to provide and coordinate the best treatments possible for these patients.

Current standards of surgical management in primary melanoma.

Melanoma accounts for the majority of skin cancer-related deaths, and its incidence continues to rise worldwide. While advanced disease has historically been associated with poor long-term survival, early-stage disease has a favorable prognosis and therefore, early diagnosis is paramount. Resection of primary melanoma requires a balance of maximizing oncological outcome while minimizing morbidity. Wide excision with 1-2 cm margins, depending on depth of the tumor, is the standard of care for surgical treatment of primary, invasive melanoma. Sentinel lymph node biopsy is indicated for patients with clinically node-negative, intermediate-thickness primary melanomas but should also be considered in selected patients with thin and thick primaries. In this article, historical perspectives and key clinical trials regarding the current guidelines for the surgical management of primary melanoma are discussed.

Expanding Eligibility Criteria for Nipple-Sparing Mastectomy.

The use of mastectomy has increased in patients who are high-risk genetic carriers who need or desire mastectomy for prophylactic reasons, as well as for patients who have breast cancer and need or desire mastectomy for treatment of their cancer. Retaining the nipple and skin with a nipple-sparing mastectomy results in improved patient satisfaction as compared with traditional mastectomy, without compromise of oncologic principles. This technique has been performed in patients with small, peripherally located tumors and nonptotic breasts; in recent years, however, consideration has been given to patients with more centrally located, larger tumors, and patients undergoing radiation or with ptotic breasts with the potential for poor cosmetic outcome. As the use of nipple-sparing mastectomy increases, it is important to continually assess the eligibility of patients for this technique.

Case report: Irreversible electroporation for locally advanced pancreatic cancer.

INTRODUCTION: For patients with pancreatic adenocarcinoma who are not candidates for surgical resection, long-term survival is poor, even with currently available systemic and radiation therapy options. However, for those with locally advanced disease who do not have distant metastasis, locoregional control of the tumor has the potential to improve long-term outcomes. A newly developed technology, irreversible electroporation, has advantages over traditional thermal ablation with unresectable cancers in this location. PRESENTATION OF CASE: In our case report, we describe the first patient treated with irreversible electroporation at our institution for locally advanced pancreatic cancer. The patient is a 63-year-old man who had a partial response to standard chemotherapy and radiation, but was found on operative assessment to have persistently unresectable disease. He therefore underwent irreversible electroporation to the pancreatic mass. His postoperative course was complicated by delayed gastric emptying and wound infection. Three months after surgery, he had no evidence of distant or recurrent disease. DISCUSSION: Irreversible electroporation for locally advanced pancreatic cancer is an emerging technique which attempts to improve local control of locally advanced, non-metastatic pancreatic cancer. Early data have demonstrated the potential for improved long-term survival in these patients, although further studies are needed to confirm safety and efficacy of this technique. CONCLUSION: While there is a positive outlook for the use of irreversible electroporation for locally advanced pancreas cancer, there remain some uncertainties surrounding this therapy, which underscores the importance of future research in this area.

Minimally invasive appendectomy for resection of appendiceal mucocele: Case series and review of the literature.

INTRODUCTION: Appendiceal mucoceles encompass neoplastic and non-neoplastic causes of a distended Appendix filled with mucus. Appendectomy is recommended when an appendiceal mucocele is identified, incidentally or otherwise, in the event it is secondary to a malignancy. For an intact mucocele, it is critically important to avoid rupturing the mucocele during resection, as rupture of a neoplastic mucocele can result in pseudomyxoma peritonei, or mucin deposits in the peritoneum, which is associated with long-term morbidity and mortality. For this reason, laparotomy is the traditionally recommended surgical approach for treatment. PRESENTATION OF CASES: In our case series, we describe two patients, a 49-year-old woman and a 79-year-old man, with incidentally identified appendiceal mucoceles. These patients were successfully treated with minimally invasive approaches to appendectomy, one with a robotic approach and one with a hand-assisted laparoscopic approach. The mucoceles were removed without rupture, and both patients recovered well postoperatively without complication. DISCUSSION: While laparotomy is the traditionally recommended surgical approach for resection of appendiceal mucoceles, certain minimally invasive techniques allow for safe removal of the mucoceles while minimizing the morbidity of laparotomy. CONCLUSION: Minimally invasive approaches to appendenctomy, specifically the robotic-assisted approach and the hand-assisted laparoscopic approach, can be considered for safe resection of appendiceal mucoceles.

Ileostomy creation in colorectal cancer surgery: risk of acute kidney injury and chronic kidney disease.

BACKGROUND: Ileostomy creation is associated with postoperative dehydration and readmission; however, the effect on renal function is unknown. Our goal was to characterize the impact of ileostomy creation on acute and chronic renal function. MATERIALS AND METHODS: A retrospective cohort study with patients undergoing colorectal cancer surgery at a tertiary referral institution (2005-2011). The relationship between ileostomy creation and acute kidney injury (AKI)-related readmission, severe chronic kidney disease (CKD) at 12 mo (glomerular filtration rate <30 mL/min/1.73 m2), and onset of severe CKD over time was evaluated using multivariable logistic and Cox regression and adjusted using propensity score stratification. RESULTS: Among 619 patients, 84 (13%) had ileostomy. AKI-related readmission and severe CKD at 12 mo were more common among ileostomy patients (17% versus 2%, P < 0.01 and 13.3% versus 5%, P = 0.02, respectively). After propensity score adjustment, ileostomy was a significant predictor of AKI-related readmissions (odds ratio: 10.3; 95% confidence interval [CI], 3.9-27.2), severe CKD at 12 mo (odds ratio: 4.1; 95% CI, 1.4-11.9), and onset of severe CKD over time (hazard ratio: 4.2; 95% CI, 2.3-6.6). CONCLUSIONS: Ileostomy creation is associated with increased risk of AKI-related readmissions and development of severe CKD. Future studies must focus on strategies to minimize kidney injury when ileostomy is a necessary component of colorectal cancer surgery and revisiting current indications for ileostomy creation.

Patterns of Care for Colorectal Liver Metastasis Within an Integrated Health System: Secular Trends and Outcomes.

BACKGROUND: Utilization of evidence-based treatments for patients with colorectal liver metastasis (CRC-LM) outside high-volume centers is not well-characterized. We sought to describe trends in treatment and outcomes, and identify predictors of therapy within a nationwide integrated health system. METHODS: Observational cohort study of patients with CRC-LM treated within the Veterans Affairs (VA) health system (1998-2012). Secular trends and outcomes were compared on the basis of treatment type. Multivariate regression was used to identify predictors of no treatment (chemotherapy or surgery). RESULTS: Among 3270 patients, 57.3 % received treatment (chemotherapy and/or surgery) during the study period. The proportion receiving treatment doubled (38 % in 1998 vs. 68 % in 2012; trend test, p < 0.001), primarily driven by increased use of chemotherapy (26 vs. 57 %; trend test, p < 0.001). Among patients having surgery (16 %), the proportion having ablation (10 vs. 61.9 %; trend test, p < 0.001) and multimodality therapy (15 vs. 67 %; trend test, p < 0.001) increased significantly over time. Older patients [65-75 years: odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.39-1.97; >75 years: OR 3.84, 95 % CI 3.13-4.69] and those with high comorbidity index (Charlson ≥3: OR 1.47, 95 % CI 1.16-1.85) were more likely to be untreated. Overall survival was significantly different based on treatment strategy (log-rank p < 0.001). CONCLUSIONS: The proportion of CRC-LM patients receiving treatment within the largest integrated health system in the US (VA health system) has increased substantially over time; however, one in three patients still does not receive any treatment. Future initiatives should focus on increasing treatment among older patients as well as on evaluating reasons leading to the no-treatment approach and increased use of ablation procedures.

Combining radiomic features with a miRNA classifier may improve prediction of malignant pathology for pancreatic intraductal papillary mucinous neoplasms.

Intraductal papillary mucinous neoplasms (IPMNs) are pancreatic cancer precursors incidentally discovered by cross-sectional imaging. Consensus guidelines for IPMN management rely on standard radiologic features to predict pathology, but they lack accuracy. Using a retrospective cohort of 38 surgically-resected, pathologically-confirmed IPMNs (20 benign; 18 malignant) with preoperative computed tomography (CT) images and matched plasma-based 'miRNA genomic classifier (MGC)' data, we determined whether quantitative 'radiomic' CT features (+/- the MGC) can more accurately predict IPMN pathology than standard radiologic features 'high-risk' or 'worrisome' for malignancy. Logistic regression, principal component analyses, and cross-validation were used to examine associations. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were estimated. The MGC, 'high-risk,' and 'worrisome' radiologic features had area under the receiver operating characteristic curve (AUC) values of 0.83, 0.84, and 0.54, respectively. Fourteen radiomic features differentiated malignant from benign IPMNs (p<0.05) and collectively had an AUC=0.77. Combining radiomic features with the MGC revealed an AUC=0.92 and superior sensitivity (83%), specificity (89%), PPV (88%), and NPV (85%) than other models. Evaluation of uncertainty by 10-fold cross-validation retained an AUC>0.80 (0.87 (95% CI:0.84-0.89)). This proof-of-concept study suggests a noninvasive radiogenomic approach may more accurately predict IPMN pathology than 'worrisome' radiologic features considered in consensus guidelines.

Portal Vein Embolization as an Oncosurgical Strategy Prior to Major Hepatic Resection: Anatomic, Surgical, and Technical Considerations.

Preoperative portal vein embolization (PVE) is used to extend the indications for major hepatic resection, and it has become the standard of care for selected patients with hepatic malignancies treated at major hepatobiliary centers. To date, various techniques with different embolic materials have been used with similar results in the degree of liver hypertrophy. Regardless of the specific strategy used, both surgeons and interventional radiologists must be familiar with each other's techniques to be able to create the optimal plan for each individual patient. Knowledge of the segmental anatomy of the liver is paramount to fully understand the liver segments that need to be embolized and resected. Understanding the portal vein anatomy and the branching variations, along with the techniques used to transect the portal vein during hepatic resection, is important because these variables can affect the PVE procedure and the eventual surgical resection. Comprehension of the advantages and disadvantages of approaches to the portal venous system and the various embolic materials used for PVE is essential to best tailor the procedures for each patient and to avoid complications. Before PVE, meticulous assessment of the portal vein branching anatomy is performed with cross-sectional imaging, and embolization strategies are developed based on the patient's anatomy. The PVE procedure consists of several technical steps, and knowledge of these technical tips, potential complications, and how to avoid the complications in each step is of great importance for safe and successful PVE and ultimately successful hepatectomy. Because PVE is used as an adjunct to planned hepatic resection, priority must always be placed on safety, without compromising the integrity of the future liver remnant, and close collaboration between interventional radiologists and hepatobiliary surgeons is essential to achieve successful outcomes.

Ninety-day readmission after colorectal cancer surgery in a Veterans Affairs cohort.

BACKGROUND: Readmissions following colorectal surgery are common. However, there are limited data examining unplanned readmissions (URs) after colorectal cancer (CRC) surgery. The goal of this study was to identify reasons and predictors of UR, and to examine their clinical impact on CRC patients. METHODS: A retrospective cohort study using a prospective CRC surgery database of patients treated at a VA tertiary referral center was performed (2005-2011). Ninety-day URs were recorded and classified based on reason for readmission. Clinical impact of UR was measured using a validated classification for postoperative complications. Multivariate logistic regression analyses were performed to identify predictors of UR. RESULTS: 487 patients were included; 104 (21%) required UR. Although the majority of UR were due to surgical reasons (n = 72, 69%), medical complications contributed to 25% of all readmission events. Nearly half of UR (n = 44, 40%) had significant clinical implications requiring invasive interventions, intensive care unit stays, or led to death. After multivariate logistic regression, the following independent predictors of UR were identified: African-American race (odds ratio [OR] 0.47 [0.27-0.88]), ostomy creation (OR 2.50 [1.33-4.70]), and any postoperative complication (OR 4.36 [2.48-7.68]). CONCLUSIONS: Ninety-day URs following colorectal cancer surgery are common, and represent serious events associated with worse outcomes. In addition to postoperative complications, surgical details that can be anticipated (i.e., ileostomy creation) and medical events unrelated to surgery, both contribute as important and potentially preventable reasons for UR. Future studies should focus on developing and examining interventions focused at improving the process of perioperative care for this high-risk population.

Colloid Carcinoma of the Pancreas: Case Report and Review of the Literature.

Background: Colloid carcinoma of the pancreas is a rare type of pancreatic cancer that has a more indolent course and superior long-term survival compared to ductal adenocarcinoma. There is a dearth of literature describing this diagnosis due to its rarity and its only recent recognition as a distinct clinical entity. We present two cases of patients with colloid carcinoma and discuss the presentation and management of this disease. Case Presentation: A 58-year-old man with repeated bouts of pancreatitis and a 72-year-old woman with symptoms of pancreatic exocrine and endocrine insufficiency were both found to have cystic masses in the head of the pancreas. Both were identified as having at least mixed main duct/side branch intraductal papillary mucinous neoplasms (IPMNs) on appropriate workup with additional imaging and endoscopy. Pancreaticoduodenectomy was recommended. Both patients, however, were noted to have high-grade dysplasia at the resection margin intraoperatively on frozen section, and thus, total pancreatectomies were performed. Final pathology in each case demonstrated colloid carcinoma with no nodal spread of disease. The patients recovered well. Adjuvant chemotherapy was recommended. Conclusion: Colloid carcinoma of the pancreas is a rare pathologic diagnosis and is frequently associated with IPMN. Colloid carcinomas tend to present at earlier stages than do ductal adenocarcinomas and are known to have improved long-term survival. Surgical and systemic options for treatment parallel that of ductal adenocarcinoma due to the rarity of the diagnosis and the lack of trials assessing therapy for this specific diagnosis.

Infectious postoperative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer: a study of 12,075 patients.

OBJECTIVE: We sought to characterize the effect of postoperative complications on long-term survival after colorectal cancer (CRC) resection. BACKGROUND: The impact of early morbidity on long-term survival after curative-intent CRC surgery remains controversial. METHODS: The Veterans Affairs Surgical Quality Improvement Program and Central Cancer Registry databases were linked to acquire perioperative and cancer-specific data for 12,075 patients undergoing resection for nonmetastatic CRC (1999-2009). Patients were categorized by presence of any complication within 30 days and by type of complication (noninfectious vs infectious). Univariate and multivariate survival analyses adjusted for patient, disease, and treatment factors were performed, excluding early deaths (<90 days). Subset analysis was performed to determine the specific impact of severe postoperative infections. RESULTS: The overall morbidity and infectious complication rates were 27.8% and 22.5%, respectively. Patients with noninfectious postoperative complications were older, had lower preoperative serum albumin, had worse functional status, and had higher American Society of Anesthesiologists scores than patients with infectious complications and without complications (all P < 0.001). The presence of any complication was independently associated with decreased long-term survival [hazard ratio, 1.24; 95% confidence interval (1.15-1.34)]. Multivariate analysis by complication type demonstrated increased risk only with infectious complications [hazard ratio, 1.31; 95% confidence interval (1.21-1.42)]. Subset analysis demonstrated this effect predominantly in patients with severe infections [hazard ratio, 1.41; 95% confidence interval (1.15-1.73)]. CONCLUSIONS: The presence of postoperative complications after CRC resection is associated with decreased long-term survival, independent of patient, disease, and treatment factors. The impact on long-term outcome is primarily driven by infectious complications, particularly severe postoperative infections.