Population-based audit of colorectal cancer management in two UK health regions. Colorectal Cancer Working Group, Royal College of Surgeons of England Clinical Epidemiology and Audit Unit

Expandable metal stents for malignant colorectal strictures

The surgical management of malignant colorectal obstruction is still controversial and has higher associated mortality and complication rates compared with elective surgery. Placement of self-expanding metallic stents (SEMS) has been proposed as an alternative therapeutic approach for colonic decompression of patients with acute malignant obstruction. SEMS placement may be used both as a bridge to surgery in patients who are good candidates for curative resection and for palliation of those patients presenting with advanced stage disease or with severe comorbid medical illnesses.

Emergency presentation of colon cancer is most frequent during summer

AIM

The frequency of emergency colon cancer (ECC) was determined using a reproducible definition of 'emergency' to analyse the impact of mode of presentation on long-term prognosis and to search for risk factors for an emergency presentation.

METHOD

All patients with colon cancer treated at one Swedish GDH between 1996 and 2005 (N = 604) were eligible. Patients admitted through the emergency room, operated on within three days and with an emergency condition confirmed at surgery were classified as ECC. Survival was analysed by Kaplan-Meier estimates and risk of death by Cox regression.

RESULTS

The rate of ECC was 97/585 (17%). Patients with ECC were older (median 77 vs 74, P = 0.02), they had more stage III and IV cancers (65%vs 47%; χ(2) = 9.4, P < 0.001) and had a cancer located in the caecum less often (20%vs 33%, χ(2) = 4.3 P = 0.04). ECC were most frequent between June and August (36%), whereas elective cases were evenly distributed throughout the year (χ(2) = 7.8; P = 0.049), Crude 5-year survival was 18% in ECC and 38% in the elective group (P < 0.001). The hazard ratio for death within five years in ECC, with 30-day mortality excluded and adjusted for age and sex was 2.25 (95% CI; 1.42-3.55).

CONCLUSION

Emergency presentation of colon cancer is an independent and adverse risk factor for long-term survival. The causes of a seasonal variation need to be clarified.

Self-expanding metallic stents for acute left-sided large-bowel obstruction: a review of 130 patients

AIM

The aim of this study was to evaluate the outcomes of self-expanding metallic stent (SEMS) placement in acute left-sided large-bowel obstruction.

METHOD

From 1997 to 2008, 130 patients [mean 67 (SD 14.7)] underwent SEMS insertion for acute left-sided large-bowel obstruction. One-hundred and one procedures were palliative, and 29 patients underwent stent insertion as a bridge for surgery. The success rate and the outcome were analysed.

RESULTS

The chief causes of obstruction were primary (67%) and recurrent (16%) colorectal carcinoma. The success rate was 88% after insertion of the first stent. In nine patients, insertion of a second stent was required. Complications occurred in 20% of the insertions, with migration (10.8%) being the most common. Perforation occurred in two patients and one developed a colovesical fistula. In patients with palliative stenting, 14 (13.9%) required subsequent surgery, with a stoma placed in all except three. Among the 29 patients who underwent SEMS insertion as a bridge to surgery, subsequent surgical resection was performed in 26 patients at a mean interval of 12 days (SD 18.0). Primary anastomosis was performed in 24 patients. The mean survival for those who underwent SEMS insertion as a bridge to surgery was 40 (95% confidence interval: 24-55) months.

CONCLUSION

SEMS placement is safe and effective in relieving acute left-sided colonic obstruction. It allows subsequent definitive surgery on an elective setting and also serves as good palliation for advanced or disseminated disease.

Management and outcome of colorectal anastomotic leaks

PURPOSE

Anastomotic leak is a devastating complication of an intestinal anastomosis. Optimal management and outcome is not routinely described, and much of our knowledge relies upon historical data. We wished to examine the management and outcome of anastomotic leaks on a colorectal surgery unit in the twenty-first century.

METHOD

A retrospective audit of all patients who had a colorectal anastomotic leak between January 2002 and December 2008 in a large university teaching hospital. Data collected included patient characteristics, primary diagnosis, mode of diagnosis and time to diagnosis of anastomotic leak, inpatient management, morbidity and mortality, permanent stoma rate, use of hospital resources.

RESULTS

Thirty patients (16 male, 14 female), with a median age of 60 years (range 25-84 years), had an anastomotic leak. The median time to presentation of clinically suspected leaks was 12 days (range 3-56 days). Fourteen patients required reoperation, with ten needing the anastomosis take down. Average hospital stay was 40 days. The permanent stoma rate following a rectal anastomotic leak was 27% and 57.1% from a colonic leak. Overall mortality in this series was 27%. Mortality was higher after leak from a colonic anastomosis than after leak from a rectal anastomosis (43.8% vs. 7.1%, respectively).

CONCLUSIONS

Anastomotic leaks are not detected until late in the post-operative period and are associated with a high mortality. Demand on hospital resources is high. In this series, patients who leaked after a colonic anastomosis had a higher mortality and permanent stoma rate than after leaks from a rectal anastomosis.

The impact of the introduction of total mesorectal excision on local recurrence rate and survival in rectal cancer: long-term results

PURPOSE

To investigate the influence of the introduction of total mesorectal excision (TME) on local recurrence rate and survival in patients with rectal cancer.

METHODS

A total of 171 consecutive patients underwent anterior or abdominoperineal resection for primary rectal cancer. When the TME technique was introduced, the clinical setting, including the surgeons, remained the same. Group 1 (1993-95, n =53) underwent conventional surgery and group 2 (1995-2001, n = 118) underwent TME. All patients were followed for 7 years or until death.

RESULTS

Between the two groups, no statistically significant differences were present with regards to patient-, treatment-, or tumor-related characteristics apart from the time point of radiotherapy. The total local recurrence rates were 11 of 53 (20.8%) in group 1 and 7 of 118 (5.9%) in group 2, and the rates of isolated local recurrences were 6 of 53 (11.3%) in group 1 and 2 of 118 (1.7%) in group 2. Both differences were highly statistically significant. The disease-free survival in groups 1 and 2 was 60.4 and 65.3% at 5 years, and 58.5 and 65.3% at 7 years, respectively. Excluding patients with synchronous or metachronous distant metastasis from the analysis, both the disease-free survival and the cancer-specific survival were statistically significantly better in group 2 than in group 1. No statistically significant difference between the two groups was detected regarding the overall survival.

CONCLUSIONS

The introduction of TME led to an impressive reduction of the local recurrence rate. Survival is mainly determined by the occurrence of distant metastasis, but TME seems to improve survival in patients without systemic disease.

Neoadjuvant chemotherapy affects staging of colorectal liver metastasis--a comparison of PET, CT and intraoperative ultrasound

PURPOSE

Surgery for colorectal liver metastasis facilitates long-term survival, and neoadjuvant chemotherapy improves resectability but may also alter staging accuracy. The aim of this study was to evaluate the effects of neoadjuvant chemotherapy on the efficacy of positron emission tomography (PET), PET-computed tomography (CT), CT and intraoperative ultrasound (IUS) in the detection of liver metastasis.

METHODS

Between January 2007 and January 2010, 34 patients with resectable colorectal liver metastasis were included in this retrospective analysis. Seventeen patients had received neoadjuvant chemotherapy. PET or PET-CT, CT or magnetic resonance imaging (MRI) and IUS were performed in all patients. Sensitivity, specificity, positive predictive value and negative predictive value were analysed. Histopathological examination of the resected specimens served as standard reference.

RESULTS

A total of 109 liver segments were resected, of which 50 showed no metastatic involvement (45.9%). For patients without systemic chemotherapy, sensitivities for PET, CT/MRI and IUS were 92%, 64% and 100% respectively as compared with 63%, 65% and 94% for patients after neoadjuvant chemotherapy in a segment-based analysis. For PET, standardised uptake values were decreased by 3.9 in 10 patients after chemotherapy whereas lesion diameters were similar (3.0 vs. 3.2 cm). Additional metastases were detected by IUS in seven patients resulting in a change of operative procedure in 20.6%.

CONCLUSION

Staging accuracy of colorectal liver metastasis is influenced by neoadjuvant chemotherapy. For PET, decreased tumour metabolism rather than downsizing may account for a drop in sensitivity after neoadjuvant chemotherapy. IUS is critical to avoid incomplete resections.

Elective palliative resection of incurable stage IV colorectal cancer: who really benefits from it?

PURPOSE

Despite the encouraging results of chemotherapy in patients affected by incurable colorectal cancer (CRC), surgical resection of a primitive tumor is still a common approach worldwide. The identification of prognostic factors related to short survival (<6 months) may allow excluding from resective surgery those who may not benefit from it.

METHODS

A retrospective analysis was performed of 15 variables in a population of 71 patients undergoing nonemergency palliative primary resections of incurable CRC, including patients' demographics and clinical/histopathological characteristics of the tumor.

RESULTS

No variables were related to perioperative mortality (8.5% overall). A multivariate analysis revealed that older age (≥80 years) and metastasis to more than 25% of the lymph nodes were associated with survival (4 and 6 months, respectively). Mucoid adenocarcinoma therefore tends to be associated with the prognosis (P = 0.070).

CONCLUSIONS

An elderly age tends to be a contraindication to an elective primary tumor resection in patients affected by incurable CRC. Massive lymph node involvement and mucoid adenocarcinoma should also be considered before planning major colonic surgery.

Guidelenines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society

BACKGROUND

Obstructive left colon carcinoma (OLCC) is a challenging matter in terms of obstruction release as well of oncological issues. Several options are available and no guidelines are established. The paper aims to generate evidenced based recommendations on management of OLCC.

METHODS

The PubMed and Cochrane Library databases were queried for publications focusing on OLCC published prior to April 2010. A extensive retrieval, analyses, and grading of the literature was undertaken. The findings of the research were presented and largely discussed among panellist and audience at the Consensus Conference of the World Society of Emergency Surgery (WSES) and Peritoneum and Surgery (PnS) Society held in Bologna July 2010. Comparisons of techniques are presented and final committee recommendation are enounced.

RESULTS

Hartmann's procedure should be preferred to loop colostomy (Grade 2B). Hartmann's procedure offers no survival benefit compared to segmental colonic resection with primary anastomosis (Grade 2C+); Hartmann's procedure should be considered in patients with high surgical risk (Grade 2C). Total colectomy and segmental colectomy with intraoperative colonic irrigation are associated with same mortality/morbidity, however total colectomy is associated with higher rates impaired bowel function (Grade 1A). Segmental resection and primary anastomosis either with manual decompression or intraoperative colonic irrigation are associated with same mortality/morbidity rate (Grade 1A). In palliation stent placement is associated with similar mortality/morbidity rates and shorter hospital stay (Grade 2B). Stents as a bridge to surgery seems associated with lower mortality rate, shorter hospital stay, and a lower colostomy formation rate (Grade 1B).

CONCLUSIONS

Loop colostomy and staged procedure should be adopted in case of dramatic scenario, when neoadjuvant therapy could be expected. Hartmann's procedure should be performed in case of high risk of anastomotic dehiscence. Subtotal and total colectomy should be attempted when cecal perforation or in case of synchronous colonic neoplasm. Primary resection and anastomosis with manual decompression seems the procedure of choice. Colonic stents represent the best option when skills are available. The literature power is relatively poor and the existing RCT are often not sufficiently robust in design thus, among 6 possible treatment modalities, only 2 reached the Grade A.

Nonresectional palliative abdominal surgery for patients with advanced colorectal cancer

OBJECTIVE

Nonresectional palliative abdominal surgery (e.g. defunctioning stoma/bypass) may be appropriate for patients unsuitable for curative resection, to deal with complications of advanced colorectal malignancy such as obstruction. Our aim was to review the outcome of surgery in these patients within our institution.

METHOD

All patients undergoing palliative surgery without resection for colorectal carcinoma between July 1998 and January 2007 were identified from our prospectively compiled colorectal cancer database. Data were extracted related to patients' demographics, presentation, tumour site, operative intervention, complications, oncological therapies, length of hospital stay and postoperative survival.

RESULTS

One hundred and ninety-three patients were identified with a median age of 79 years (31-94 years). Fifty per cent were operated on an emergent basis for obstruction or perforation, and 50% on an elective basis. One hundred and sixty-nine patients had defunctioning stomas formed of which 156 were loop stomas. Twenty-four patients underwent bypass procedures. Thirty-day mortality rate was 13.5% and postoperative morbidity rate 47%. Median survival was 247 days, with 1-year survival of 38%. Patients undergoing operation on an emergent basis had poorer long-term survival (127 vs 320 days, P = 0.002).

CONCLUSION

Nonresectional palliative abdominal surgery is associated with relatively high morbidity and mortality, particularly when performed in the emergency setting. However, in this patient group with a very poor outlook, it may be offered with reasonable survival expectations.

The National Bowel Cancer Audit: the risks and benefits of moving to open reporting of clinical outcomes

BACKGROUND

The government's proposals to openly report clinical outcomes poses challenges to the National Bowel Cancer Audit now funded by the UK department of health.

AIM

To identify the benefits and risks of open reporting and to propose ways the risks might be minimized.

METHODS

A review of the literature on clinical audit and the consequences of open reporting.

RESULTS

There are significant potential benefits of a national audit of bowel cancer including protecting patients from sub-standard care, providing clinicians with externally validated evidence of their performance, outcome data for clinical governance and evidence that increases in government expenditure are achieving improvements in survival from bowel cancer. These benefits will only be achieved if the audit captures most of the cases of bowel cancer in the UK, the data collected is complete and accurate, the results are risk adjusted and these are presented to the public in a way that is fair, clear and understandable. Involvement of clinicians who have confidence in the results of the audit and who actively compare their own results against a national standard is essential. It is suggested that a staged move to open reporting should minimise the risk of falsely identifying an outlying unit.

CONCLUSION

The fundamental aim of the National Bowel Cancer Audit is the pursuit of excellence by identification and adoption of best practice. This could achieve a continuous improvement in the care of all patients with bowel cancer in the UK. The ACPGBI suggests a safer way of transition to open reporting to avoid at least some of its pitfalls.

Utility or futility of prognostic scoring systems for colorectal liver metastases in an era of advanced multimodal therapy

OBJECTIVES

To assess the general applicability of prognostic scores for colorectal liver metastases (CRLM).

METHODS

Review of English language studies from 1980 to 2008 (Medline and Embase). Search keywords included "Colorectal neoplasms", "liver metastases", "liver resection", "prognostic scoring system".

RESULTS

Six scoring systems and fourteen prognostic factors within these studies were identified. No prognostic factor was common in all scoring methods. Five scores retained the number of metastases as a prognostic factor. Size of metastases and time between the onset of the primary tumor and the discovery of metastases were present in four scores. Three scores predicted 5-year survival using carcinoembryonic antigen (CEA) and R1 resection. Only two scores were assessed preoperatively. Successive scoring methods had improved predictive accuracy compared to earlier systems. However, their applicability in general populations remains debatable. An evaluation of the scores applicability to different patient populations demonstrated that the models were minimally effective in predicting disease-specific survival and recurrence, suggesting that stratification of patients by clinical and pathologic factors alone, may be clinically unreliable and not applicable for selection of patients for surgery.

CONCLUSION

The utility of prognostic models on general populations is inconsistent. Current clinicopathologic factors may be inadequate to determine disease prognosis in CRLM. Future attempts to develop prognostic scores should include additional biologic and clinical variables, and be validated in larger populations.

[Postoperative mortality risk factors in colorectal cancer: follow up of a cohort in a specialised unit]

INTRODUCTION

The treatment of colorectal cancer (CRC) is usually surgical and involves morbidity-mortality. The aim of this study is to quantify the postoperative mortality in our hospital and to determine their risk factors.

MATERIALS AND METHODS

Prospective observational study from 1996 to 2007 included 1017 patients who underwent surgery for CRC in our hospital. Identification of independent risk factors for postoperative mortality by multivariate analysis.

RESULTS

The mean age was 67.8 years. The surgery was elective in 879 (86.5%) and was considered curative in 878 (86.1%). The postoperative mortality was 3.6% (37 patients), 2.5% in the elective surgery and 10.9% in the urgent. The independent risk factors identified were: type of surgery (odds ratio for urgent vs. elective=2.8), American Society of Anesthesiologists (ASA) grade (odds ratio for ASA III-IV vs. I-II=2.4), age (odds ratio for age > or = 85 vs. < or = 74=7.6 and age 75-84 vs. < or = 74=2.4).

CONCLUSIONS

We found a low postoperative mortality, which was mainly associated with age over 75 years, ASA III or IV stages and urgent surgery.

Management of the asymptomatic primary in the palliative treatment of metastatic colorectal cancer

OBJECTIVE

The management of the asymptomatic primary in stage IV colorectal cancer presents a dilemma. There is an increased morbidity and mortality from surgical resection. Nonresectional management of the primary is associated with the risks of obstruction, perforation or haemorrhage. Our practice in patients with stage IV disease is palliative chemotherapy and symptom control. We reviewed our nonoperatively managed patients with colorectal liver metastases in order to identify the percentage of patients requiring urgent operative interventions for symptoms related to the primary. SUBJECTS/PATIENTS AND METHOD: A retrospective review of all patients treated for stage IV disease at our institution from 2003-2006 was undertaken. Patients were identified from multidisciplinary team (MDT) records. Demographic detail, treatment, and follow-up data were extracted from hospital records. These were analysed with Microsoft Excel.

RESULTS

Thirty-seven patients were identified. 26 Male:11 Female. Median age 63 years (range 38-78). The median survival from diagnosis was 14 months. Three (8%) patients developed obstruction whilst having palliative chemotherapy. Two required a defunctioning stoma, and one was treated by means of a stent. There were no similarities between these three patients in terms of age, sex, site or stage of primary, volume of liver metastases, and alkaline phosphatase (ALP) or carcinoembryonic antigen (CEA) levels.

CONCLUSION

Of 37 patients initially treated palliatively for stage IV colorectal cancer, 92% required no surgical treatment of their primary. Therefore it is the experience of this MDT that it is acceptable to treat such patients in an expectant manner. It is not possible to predict those patients, likely to require surgical intervention.

Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer

PURPOSE

The benefit of elective primary tumor resection for non-curable stage IV colorectal cancer (CRC) remains largely undefined. We wanted to identify risk factors for postoperative complications and short survival.

METHODS

Using a prospective database, we analyzed potential risk factors in 233 patients, who were electively operated for non-curable stage IV CRC between 1996 and 2002. Patients with recurrent tumors, resectable metastases, emergency operations, and non-resective surgery were excluded. Risk factors for increased postoperative morbidity and limited postoperative survival were identified by multivariate analyses.

RESULTS

Patients with colon cancer (CC = 156) and rectal cancer (RC = 77) were comparable with regard to age, sex, comorbidity, American Society of Anesthesiologists score, carcinoembryonic antigen levels, hepatic spread, tumor grade, resection margins, 30-day mortality (CC 5.1%, RC 3.9%) and postoperative chemotherapy. pT4 tumors, carcinomatosis, and non-anatomical resections were more common in colon cancer patients, whereas enterostomies (CC 1.3%, RC 67.5%, p < 0.0001), anastomotic leaks (CC 7.7%, RC 24.2%, p = 0.002), and total surgical complications (CC 19.9%, RC 40.3%, p = 0.001) were more frequent after rectal surgery. Independent determinants of an increased postoperative morbidity were primary rectal cancer, hepatic tumor load >50%, and comorbidity >1 organ. Prognostic factors for limited postoperative survival were hepatic tumor load >50%, pT4 tumors, lymphatic spread, R1-2 resection, and lack of chemotherapy.

CONCLUSIONS

Palliative resection is associated with a particularly unfavorable outcome in rectal cancer patients presenting with a locally advanced tumor (pT4, expected R2 resection) or an extensive comorbidity, and in all CRC patients who show a hepatic tumor load >50%. For such patients, surgery might be contraindicated unless the tumor is immediately life-threatening.

Short term outcome after emergency and elective surgery for colon cancer

OBJECTIVE

Emergency presentation of colon cancer is common and associated with high mortality and morbidity following surgical treatment. The purpose of this study was to evaluate postoperative mortality and complications in a consecutive and population based series.

METHOD

All patients with adenocarcinoma of the colon diagnosed between 1993 and 2007 were registered prospectively. Postoperative mortality and complication rates in elective and emergency patients were compared. Logistic regression analysis was used to identify independent risk factors for postoperative complications.

RESULTS

In the study period 1129 patients were admitted, of whom 279 (25%) presented as an emergency. A total of 999 (89%) patients underwent surgical treatment; 924 patients (82%) had a major resection. The mortality rate was 3.5% after elective and 10% after emergency operation with resection (P < 0.01), and the complication rate was 24% and 38% (P < 0.01), respectively. In patients with left-sided obstruction, the mortality rate after Hartmann's procedure was 19% compared to 3% after resection with primary anastomosis (P < 0.01). Multivariate analyses demonstrated that emergency operation, increasing age, advanced tumour stage and ASA class IV were independent risk factors for postoperative mortality.

CONCLUSION

Emergency operation for colon cancer was associated with high rates of complications and mortality, indicating that immediate surgery should be avoided if possible. Decompression of left sided obstruction with a stent seems promising, whereas no conclusion can be made with regard to optimal procedure if stent placement fails; in this study Hartmann's procedure was associated with high mortality and morbidity.

Outcome of primary tumor in patients with synchronous stage IV colorectal cancer receiving combination chemotherapy without surgery as initial treatment

PURPOSE

The purpose of this study was to describe the frequency of interventions necessary to palliate the intact primary tumor in patients who present with synchronous, stage IV colorectal cancer (CRC) and who receive up-front modern combination chemotherapy without prophylactic surgery.

PATIENTS AND METHODS

By using a prospective institutional database, we identified 233 consecutive patients from 2000 through 2006 with synchronous metastatic CRC and an unresected primary tumor who received oxaliplatin- or irinotecan-based, triple-drug chemotherapy (infusional fluorouracil, leucovorin, and oxaliplatin; bolus fluorouracil, leucovorin, and irinotecan; or fluorouracil, leucovorin, and irinotecan) with or without bevacizumab as their initial treatment. The incidence of subsequent use of surgery, radiotherapy, and/or endoluminal stenting to manage primary tumor complications was recorded.

RESULTS

Of 233 patients, 217 (93%) never required surgical palliation of their primary tumor. Sixteen patients (7%) required emergent surgery for primary tumor obstruction or perforation, 10 patients (4%) required nonoperative intervention (ie, stent or radiotherapy), and 213 (89%) never required any direct symptomatic management for their intact primary tumor. Of those 213 patients, 47 patients (20%) ultimately underwent elective colon resection at the time of metastasectomy, and eight patients (3%) underwent this resection during laparotomy for hepatic artery infusion pump placement. Use of bevacizumab, location of the primary tumor in the rectum, and metastatic disease burden were not associated with increased intervention rate.

CONCLUSION

Most patients with synchronous, stage IV CRC who receive up-front modern combination chemotherapy never require palliative surgery for their intact primary tumor. These data support the use of chemotherapy, without routine prophylactic resection, as the appropriate standard practice for patients with neither obstructed nor hemorrhaging primary colorectal tumors in the setting of metastatic disease.

Response of the primary tumor in symptomatic and asymptomatic stage IV colorectal cancer to combined interventional endoscopy and palliative chemotherapy

BACKGROUND

The treatment of the primary tumor in advanced metastatic colorectal cancer (CRC) is still a matter of discussion. Little attention has thus far been paid to the endoscopically observable changes of the primary in non-curatively resectable stage IV disease.

METHODS

20 patients [14 men, 6 women, median age 67 (39-82) years] were observed after initial diagnosis of non-curatively resectable metastasized symptomatic (83%) or asymptomatic (17%) CRC, from June 2002 to April 2009. If necessary, endoscopic tumor debulking was performed. 5-FU based chemotherapy was given immediately thereafter. In 10 patients, chemotherapy was combined with antibody therapy.

RESULTS

Response of the primary was observed in all patients. Local symptoms were treated endoscopically whenever necessary (obstruction or bleeding), and further improved after chemotherapy was started: Four patients showed initial complete endoscopic disappearance of the primary. In an additional 6 patients, only adenomatous tissue was histologically detected. In both these groups, two patients revealed local tumor relapse after interruption of therapy. Local tumor regression or stable disease was achieved in the remaining 10 patients. 15 patients died during the observation time. In 13 cases, death was related to metastatic disease progression. The mean overall survival time was 19.6 (3-71) months. No complications due to the primary were observed.

CONCLUSION

This study shows that modern anti-cancer drugs combined with endoscopic therapy are an effective and safe treatment of the symptomatic primary and ameliorate local complaints without the need for surgical intervention in advanced UICC stage IV CRC.

Neoadjuvant treatment does not influence perioperative outcome in rectal cancer surgery

PURPOSE

To identify the risk factors for perioperative morbidity in patients undergoing resection of primary rectal cancer, with a specific focus on the effect of neoadjuvant therapy.

METHODS AND MATERIALS

This exploratory analysis of prospectively collected data included all patients who underwent anterior resection/low anterior resection or abdominoperineal resection for primary rectal cancer between October 2001 and October 2006. The study endpoints were perioperative surgical and medical morbidity. Univariate and multivariate analyses of potential risk factors were performed.

RESULTS

A total of 485 patients were included in this study; 425 patients (88%) underwent a sphincter-saving anterior resection/low anterior resection, 47 (10%) abdominoperineal resection, and 13 (2%) multivisceral resection. Neoadjuvant chemoradiotherapy was performed in 100 patients (21%), and 168 (35%) underwent neoadjuvant short-term radiotherapy (5 x 5 Gy). Patient age and operative time were independently associated with perioperative morbidity, and operative time, body mass index >27 kg/m(2) (overweight), and resection type were associated with surgical morbidity. Age and a history of smoking were confirmed as independent prognostic risk factors for medical complications. Neoadjuvant therapy was not associated with a worse outcome.

CONCLUSION

The results of this prospective study have identified several risk factors associated with an adverse perioperative outcome after rectal cancer surgery. In addition, neoadjuvant therapy was not associated with increased perioperative complications.

Outcomes of resection and non-resection strategies in management of patients with advanced colorectal cancer

BACKGROUND

The management of patients with surgically incurable bowel cancer at presentation is controversial. The aims of treatment are to optimise quality of life and prolong survival. It has been believed that the most effective palliation is achieved by resection of the primary cancer in order to pre-empt future complications. This study reviews and compares the outcomes of patients with incurable bowel cancer managed by resection and non-resection strategies over a 7-year period in a single District General Hospital.

PATIENTS AND METHODS

All patients with surgically incurable bowel cancer at presentation were identified from the prospectively collected local ACPGBI database. Survival, using Kaplan-Meier method and log-rank test, was compared between patients managed by resection of the primary, non-resectional intervention (surgery, stent & oncological treatments) and those managed with supportive care only. The primary endpoint of the study was survival on an intention to treat basis, compared using Kaplan-Meier and log-rank tests.

RESULTS

Of 646 consecutive newly diagnosed bowel cancer patients over a 7 year period 154 cases (24%) were deemed surgically incurable at presentation. Of these surgical resection was carried out in 45 patients (29%), non-resectional intervention was followed in 52 patients (34%) and supportive treatment alone in 57 patients (37%). Median survival of each group was as follows: resected patients 11 months (I.Q range 3-18 months), non-resectional intervention 7 months (I.Q range 2-15 months) and supportive care alone 2 months (I.Q range 1-8 months). Only one patient (2%) managed by non-resectional intervention required later surgery to treat primary tumour related complications. Survival was not significantly different between resection and non-resection treatments. The overall operative mortality for the resection group was 16% (7/45 cases), with an elective mortality of 14% (4/28 cases) and emergency mortality 18% (3/17 cases).

CONCLUSION

In an unselected bowel cancer population surgical resection of the primary tumour in patients presenting with incurable disease does not improve survival and is associated with a high risk of post-operative mortality.

Risk factors for mortality-morbidity after emergency-urgent colorectal surgery

BACKGROUND

The aim of this study was to assess the risk factors associated with mortality and morbidity following emergency or urgent colorectal surgery.

MATERIALS AND METHODS

All data regarding the 462 patients who underwent emergency colonic resection in our institution between November 2002 and December 2007 were prospectively entered into a computerized database.

RESULTS

The median age of patients was 73 (range 17-98) years. The most common indications for surgery were: 171 adenocarcinomas (37%), 129 complicated diverticulitis (28%), and 35 colonic ischemia (7.5%). Overall mortality and morbidity rates were 14% and 36%, respectively. In multivariate analysis, the only parameter significantly associated with postoperative mortality was blood loss >500 cm(3) (odds ratio (OR) = 3.33, 95% confidence interval (CI) 1.63-6.82, p = 0.001). There were three parameters which correlated with postoperative morbidity: ASA score > or =3 (OR = 2.9, 95% CI 1.9-4.5, p < 0.001), colonic ischemia (OR = 3.4, 95% CI 1.4-7.7, p = 0.006), and stoma creation (OR = 2.2, 95% CI 1.4-3.4, p = 0.0003).

CONCLUSIONS

The main risk factors for postoperative morbidity and mortality following emergency colorectal surgery are related to: (1) patients' ASA score, (2) colonic ischemia, and (3) perioperative bleeding. These variables should be considered in the elaboration of future scoring systems to predict outcome of emergency colorectal surgery.

Involvement of surgical trainees in surgery for colorectal cancer and their effect on outcome

OBJECTIVE

Surgical training in the UK is undergoing substantial changes. This study assessed: 1) the training opportunities available to trainees in operations for colorectal cancer, 2) the effect of colorectal specialization on training, and 3) the effect of consultant supervision on anastomotic complications, postoperative stay, operative mortality and 5-year survival.

METHOD

Unadjusted and adjusted comparisons of outcomes were made for unsupervised trainees, supervised trainees and consultants as the primary surgeon in 7411 operated patients included in the Northern Region Colorectal Cancer Audit between 1998 and 2002.

RESULTS

Surgery was performed in 656 (8.8%) patients by unsupervised trainees and in 1578 (21.3%) patients by supervised trainees. Unsupervised operations reduced from 182 (12.4%) in 1998 to 82 (6.1%) in 2002 (P < 0.001). Consultants with a colorectal specialist interest were more likely than nonspecialists to be present at surgical resections (OR 1.35, 1.12-1.63, P = 0.001) and to provide supervised training (OR 1.34, 1.17-1.53, P < 0.001). Patients operated on by unsupervised trainees were more often high-risk patients, however, consultant presence was not significantly associated with operative mortality (OR 0.83, 0.63-1.09, P = 0.186) or survival (HR 1.02, 0.92-1.13, P = 0.735) in risk-adjusted analysis. Supervised trainees had a case-mix similar to consultants, with shorter length of hospital stay (11.4 vs 12.4 days, P < 0.001), but similar mortality (OR 0.90, 0.71-1.16, 0.418) and survival (HR 0.96, 0.89-1.05, P = 0.378).

CONCLUSION

One third of patients were operated on by trainees, who were more likely to perform supervised resections in colorectal teams. There was no difference in anastomotic leaks rates, operative mortality or survival between unsupervised trainees, supervised trainees and consultants when case-mix adjustment was applied. This study would suggest that there is considerable underused training capacity available.

Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery

BACKGROUND

The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR).

METHODS

Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravity.

RESULTS

There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age (p<0.05), lower (<20 per year) centre case volume (p<0.05), obesity (p<0.05), malnutrition (p<0.01) and intraoperative contamination (p<0.05), and was lower in patients with a colonic J-pouch reservoir (p<0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits (p<0.05) while the absence of a diverting stoma was borderline significant (p<0.07).

CONCLUSION

Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies.

Survival and symptomatic benefit from palliative primary tumor resection in patients with metastatic colorectal cancer: a review

BACKGROUND AND AIMS

Patients with metastatic colorectal cancer have a limited life expectancy and are at risk for life-threatening tumor-related obstruction, perforation, and hemorrhage. Though surgical resection is performed frequently in this setting, its true benefit is not well-established.

MATERIALS AND METHODS

We reviewed the medical literature from 1996-2006 using the search terms metastatic colorectal cancer and primary resection to find studies that evaluated the management of primary tumors in metastatic colorectal cancer. All search results were included in our analysis and were assessed on the basis of methodologic quality.

RESULTS/FINDINGS

Twelve relevant studies were identified; ten were single-institution retrospective reviews and two were population-based studies using National Cancer Institute's Surveillance, Epidemiology, and End-Results database. No prospective or randomized studies were identified. Approximately 70% of patients diagnosed with metastatic colorectal cancer in the USA undergo primary tumor resection; only a minority have this done for tumor-related symptoms or as part of potentially curative resection. The postoperative mortality ranged from 9.0-11.2% in large cancer registries but was often lower in major cancer centers. Resection of asymptomatic primary tumors was frequently associated with prolonged survival but was not found to reduce significantly the incidence of life-threatening tumor-related complications.

INTERPRETATION/CONCLUSION

Retrospective data suggest that non-curative resection of asymptomatic colorectal primary tumors may prolong survival; however, selection bias and unaccounted clinical factors may explain this observation. Prospective, randomized surgical trials are needed to test the role of primary tumor resection in this setting, especially because of its current widespread use, and its associated cost, morbidity, and high postoperative mortality.

Emergency management of malignant acute left-sided colonic obstruction

INTRODUCTION

The management of acute left-sided colonic obstruction still remains a challenging problem despite significant progress.

METHODS

A literature search was undertaken using PubMed and the Cochrane Library regarding the options in emergency management of left-sided colonic obstruction focusing on outcomes such as mortality, morbidity, long-term prognosis and cost effectiveness.

DISCUSSION

Colonic stenting is the best option either for palliation or as a bridge to surgery. It reduces morbidity and mortality rate and the need for colostomy formation. Stenting is likely to be cost effective, but data are variable depending on the individual healthcare system. Nevertheless, surgical management remains relevant as colonic stenting has a small rate of failure, and it is not always available. There are various surgical options. One-stage primary resection and anastomosis is the preferred choice for low-risk patients. Intra-operative colonic irrigation has no proven benefit. Subtotal colectomy is useful in cases of proximal bowel damage or synchronous tumours. Hartmann's procedure should be reserved for high-risk patients. Simple colostomy has no role other than for use in very ill patients who are not fit for any other procedure.

Mortality and utilisation of critical care resources amongst high-risk surgical patients in a large NHS trust

Previous reports describe a population of non-cardiac surgical patients at high risk of complications and death. Outcomes are sub-optimal for such patients, perhaps in part related to inadequate provision or ineffective utilisation of critical care resources. In this study, data describing 26,051 in-patient non-cardiac surgical procedures performed in a large NHS Trust between April 2002 and March 2005 were extracted from local databases. Of these procedures, 2 414 (9.3%) were high risk with an overall mortality rate of 12.2% and a prolonged hospital stay (high-risk population median (IQR) 16 (9-30) days vs standard risk 3 (2-6) days). Mortality rates for specific procedures were consistent with UK averages. However, only 852 (35.3%) high-risk patients were admitted to a critical care unit at any stage after surgery. Of 294 high-risk patients who died, only 144 (49.0%) were admitted to a critical care unit at any time and only 75 (25.6%) of these deaths occurred within a critical care area. Mortality rates were high amongst patients discharged and readmitted to critical care (37.7%) and amongst those admitted to critical care following initial postoperative care on a standard ward (29.9%). These data suggest that the outcome of high-risk general surgical patients could be improved by adequate provision and more effective utilisation of critical care resources.

Local excision and transanal endoscopic microsurgery in the management of rectal cancer with a focus on early carcinoma

Transanal endoscopic microsurgery (TEMS) will play an even greater role in the treatment of rectal cancer as the UK national colorectal cancer screening program becomes national. With more rectal tumors being uncovered at earlier stages, a greater emphasis will be placed on treatment options that do not involve radical surgery and the possibility of a stoma. This article reviews the data surrounding TEMS, focusing on its current role in the treatment of early rectal cancer but with a view on how this option may develop in the future, particularly with regards to the more advanced rectal cancers and in view of the improved chemoradiotherapy regimens available. The data is reviewed and some of the more controversial issues discussed.

Morbidity and mortality following multivisceral resections in complex hepatic and pancreatic surgery

Complex multivisceral resections in major hepatic and pancreatic surgery are relatively infrequent, and information regarding the morbidity and mortality associated with such resections is scant. The purpose of this paper is to describe the outcomes following such aggressive surgical treatment. A retrospective review of the outcomes following multiorgan resection in the setting of major liver or pancreatic resection was conducted from 2002 until July 2006. Patients who had a major hepatic or pancreatic resection plus resection of at least one other organ were included. The primary outcome measures analyzed were the postoperative morbidity and mortality. Secondary outcomes included recurrence rates and survival. Twenty-seven patients met the inclusion criteria. There were two postoperative deaths (7%). Complications occurred in 59% of patients. Complications were minor in 26% and severe in 33%. Complications were more frequent in older patients and in patients with pancreatic resections. Mortality was significantly increased in the setting of a pancreaticoduodenectomy. These more aggressive procedures should be considered to carry a higher risk of complications, particularly in patients undergoing pancreaticoduodenectomies. Patients should be selected carefully when undertaking complex multivisceral resections in major hepatic and pancreatic surgery.

Transanal endoscopic microsurgery for rectal tumors: the St. Mary's experience

BACKGROUND

The aim of this study is to describe a single institution's experience in the use of transanal endoscopic microsurgery for rectal tumors.

METHODS

Between 1996 and 2005, transanal endoscopic microsurgery was performed in 76 patients. The histologic diagnosis was adenoma in 48 and adenocarcinoma in 28 patients.

RESULTS

Clear resection margins were achieved in 71 of 74 patients (95.9%). Overall morbidity was 18.9% because 14 patients developed minor (10 patients) or major complications (4 patients). During the follow-up, benign tumor recurrence was detected in 3 patients (6.3%). The recurrence rates among patients with T1, T2, and T3 malignant tumors were 7.1%, 42.8%, and 66.6%, respectively.

COMMENTS

Transanal endoscopic microsurgery is a safe and feasible technique with low incomplete excision rates and may be the preferred method in patients with benign rectal tumors. Its role in the management of malignant tumors should be limited to selected patients with T1 lesions.

Simultaneous versus staged liver resection of synchronous liver metastases from colorectal cancer

BACKGROUND AND AIMS

The surgical strategy for treatment of synchronous liver metastases from colorectal cancer remains controversial. This retrospective analysis was conducted to compare the postoperative outcome and survival of patients receiving simultaneous resection of liver metastases and primary colorectal cancer to those receiving staged resection.

MATERIALS AND METHODS

Between January 1988 and September 2005, 219 patients underwent liver resection for synchronous colorectal liver metastases, of whom, 40 patients received simultaneous resection of liver metastases and primary colorectal cancer, and 179 patients staged resections. Patients were identified from a prospective database, and records were retrospectively reviewed. Patient, tumor, and operative parameters were analyzed for their influence on postoperative morbidity and mortality as well as on long-term survival.

RESULTS

Simultaneous liver resections tend to be performed for colon primaries rather than for rectal cancer (p = 0.004) and used less extensive liver resections (p < 0.001). The postoperative morbidity was comparable between both groups, whereas the mortality was significantly higher in patients with simultaneous liver resection (p = 0.012). The mortality after simultaneous liver resection (n = 4) occurred after major hepatectomies, and three of these four patients were 70 years of age or older. There was no significant difference in long-term survival after formally curative simultaneous and staged liver resection.

CONCLUSION

Simultaneous liver and colorectal resection is as efficient as staged resections in the treatment of patients with colorectal cancer and synchronous liver metastases. To perform simultaneous resections safely a careful patient selection is necessary. The most important criteria to select patients for simultaneous liver resection are age of the patient and extent of liver resection.

Results after change of treatment policy for rectal cancer – report from a single hospital in China

BACKGROUND

Great changes have occurred in the management of rectal cancer. This study presents the outcome of total mesorectal excision (TME) for rectal cancer in a single Chinese institution and evaluates TME's role in the comprehensive management of rectal cancer.

METHODS

We reviewed the data of rectal cancer patients surgically treated by three colorectal surgeons from January 2000 to August 2004. Patients who received surgical resection for rectal cancer from January 1996 to December 1999, before the introduction of TME, were chosen as controls. Data regarding characteristics of patients and tumors, surgical procedures, postoperative complications, and results of follow-up were collected for analysis.

RESULTS

Three hundred and seventy-seven patients with rectal cancer were enrolled in our study, with 175 patients in the TME group and 202 as controls. Mortality and morbidity rates were 1% and 14% in TME patients and 1% and 31% in controls, respectively. The TME group had a shorter operation time and hospital stay, and less bleeding, wound and urinary complications. The local recurrence (LR) rate was 6% and 12% in the TME and the control groups, respectively (P<0.05). With a median follow-up of 35 months, the actuarial 5-year survival rate was 66%. Consistent with the univariate analysis result, multivariate analysis demonstrated that TNM stage, tumor grade, age, and surgeons were independent prognostic factors. TME was not an independent prognostic factor for patients' survival.

CONCLUSIONS

TME is a safe and efficient option in reducing LR. However, it is not an independent predictor for patients' survival. In addition to the standardized usage of TME, further knowledge on the molecular mechanism of cancer is needed.

Laparoscopy for metastatic colorectal cancer

Patients with metastatic disease from colorectal cancer are now living twice as long as they were one decade ago. With this increasing life expectancy, we are beginning to see these patients strive for an acceptable and improved quality of life. Medical advances have led to unanswered questions regarding the role of surgery in metastatic colorectal cancer. Despite the increasing application of laparoscopy for primary treatment of colorectal cancer, the appropriate role for laparoscopy in patients with stage IV disease has yet to be defined. This review addresses this topic and suggests treatment algorithms for patients with metastatic colorectal cancer. While unresectable, metastatic colorectal cancer remains incurable at the current time, continued advances will inevitably challenge this presumption and it is crucial to outline the role of laparoscopy in this patient population.

Palliative resection of colorectal cancer: does it prolong survival?

BACKGROUND

It is still a matter of debate as to whether resective surgery of the primary tumor may prolong the survival of patients affected by incurable colorectal cancer (CRC). The main goal of this retrospective study, carried out on patients not undergoing any therapy other than surgery, was to quantify the benefit of primary tumor removal in patients with differently presenting incurable CRC.

METHODS

One hundred and thirty consecutive patients were operated on for incurable CRC (83 undergoing resective and 47 non-resective procedures). With the purpose of comparing homogenous populations and of identifying patients who may benefit from primary tumor resection, the patients were classified according to classes of disease, based on the "metastatic pattern" and the "resectability of primary tumor."

RESULTS

In patients with "resectable" primary tumors, resective procedures are associated with longer median survival than after non-resective ones (9 months vs 3). Only patients with distant spread without neoplastic ascites/carcinosis benefit from primary tumor removal (median survival: 9 months vs 3). Morbidity and mortality of resective procedures is not significantly different from that of non-resective surgery, either in the population studied or in any of the groups considered.

CONCLUSIONS

Palliative resection of primary CRC should be pursued in patients with unresectable distant metastasis (without carcinomatosis), and, intraoperatively, whenever the primary tumor is technically resectable.

Complete response of highly advanced colon cancer with multiple lymph node metastases to irinotecan combined with UFT: report of a case

Massive lymph node metastasis of the para-aortic region and supraclavicular lymph nodes, Virchow's lymph node metastasis due to colon cancer, is extremely rare. We herein report a case of such systemic lymph node metastasis that was successfully treated with a combination of irinotecan (CPT-11) and UFT, a combination drug of tegafur and uracil. The patient was a 57-year-old woman who had a tumor in the ascending colon, and massively swollen para-aortic and supraclavicular lymph node metastasis. She was treated with combination chemotherapy of CPT-11 and UFT. The main tumor was detected as a decompressed scar, and the supraclavicular and para-aortic lymph nodes had completely disappeared after the second cycle of treatment. A histopathological examination and immunohistochemistry with cytokeratin showed complete remission of adenocarcinoma in the tumor and para-aortic lymph nodes. She remains alive without recurrence 52 months after chemotherapy. Combination chemotherapy of CPT-11 and UFT may be of potential value in the treatment of advanced colorectal carcinoma, and both histopathological and immunohistochemical confirmation of a complete remission may indicate prolonged disease-free survival.

The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's colorectal cancer patients

The 1995 Calman-Hine plan outlined radical reform of the UK's cancer services with the aim of improving outcomes and reducing inequalities in NHS cancer care. Its main recommendation was to concentrate care into the hands of site-specialist, multi-disciplinary teams. This study aimed to determine if the implementation of Calman-Hine cancer teams was associated with improved processes and outcomes of care for colorectal cancer patients. The design included longitudinal survey of 13 colorectal cancer teams in Yorkshire and retrospective study of population-based data collected by the Northern and Yorkshire Cancer Registry and Information Service. The population was all colorectal cancer patients diagnosed and treated in Yorkshire between 1995 and 2000. The main outcome measures were: variations in the use of anterior resection and preoperative radiotherapy in rectal cancer, chemotherapy in Dukes stage C and D patients, and five-year survival. Using multilevel models, these outcomes were assessed in relation to measures of the extent of Calman-Hine implementation throughout the study period, namely: (i) each team's degree of adherence to the Manual of Cancer Service Standards (which outlines the specification of the 'ideal' colorectal cancer team) and (ii) the extent of site specialisation of each team's surgeons. Variation was observed in the extent to which the colorectal cancer teams in Yorkshire had conformed to the Calman-Hine recommendations. An increase in surgical site specialisation was associated with increased use of preoperative radiotherapy (OR=1.43, 95% CI=1.04-1.98, P<0.04) and anterior resection (OR=1.43, 95% CI=1.16-1.76, P<0.01) in rectal cancer patients. Increases in adherence to the Manual of Cancer Service Standards was associated with improved five-year survival after adjustment for the casemix factors of age, stage of disease, socioeconomic status and year of diagnosis, especially for colon cancer (HR=0.97, 95% CI=0.94-0.99 P<0.01). There was a similar trend of improved survival in relation to increased surgical site specialisation for rectal cancer, although the effect was not statistically significant (HR=0.93, 95% CI=0.84-1.03, P=0.15). In conclusion, the extent of implementation of the Calman-Hine report has been variable and its recommendations are associated with improvements in processes and outcomes of care for colorectal cancer patients.

Prediction of postoperative mortality in elderly patients with colorectal cancer

PURPOSE

This study was designed to develop a model for predicting postoperative mortality in elderly patients undergoing surgery for colorectal cancer.

METHODS

This multicenter study was conducted by using routinely collected clinical data, assessing patients older than aged 80 years, with 30-day operative mortality as the primary end point. Data were collected from The Association of Coloproctology of Great Britain and Ireland database, encompassing 8,077 newly diagnosed colorectal cancer patients undergoing resectional surgery in 79 hospitals between April 2000 to March 2002, The Association of Coloproctology Malignant Bowel Obstruction Study, encompassing 1,046 patients with malignant bowel obstruction in 148 hospitals, between April 1998 to March 1999, and The Wales-Trent audit, encompassing 3,522 newly diagnosed colorectal cancer patients, between July 1992 to June 1993. A multilevel logistic regression model was developed to adjust for case-mix and to accommodate the variability of outcomes between the three study populations. The model was internally validated using a Bayesian resampling technique and tested using measures of discrimination, calibration, and subgroup analysis.

RESULTS

A total of 2,533 patients satisfied the inclusion criteria, with a 30-day mortality of 15.6 percent. Multivariate analysis identified the following independent risk factors: age (odds ratio for 85-90, 90-95, >95 vs. 80-85 = 1.1, 1.8, 2.9), American Society of Anesthesiology grade (odds ratio for Grade III, IV vs. I-II = 2.7, 6.1), operative urgency (odds ratio for emergency vs. elective = 1.9), no cancer excision vs. resection (odds ratio = 1.2), and metastatic disease (odds ratio for metastases vs. no metastases = 1.9). The model offered adequate discrimination (area under receiver operator curve = 0.732) and excellent agreement between observed and predicted outcomes during eight colorectal procedures (P = 0.885).

CONCLUSIONS

The elderly colorectal cancer model can accurately estimate 30-day mortality in patients older than aged 80 years undergoing surgery for colorectal cancer. Because the mortality can be considerable, this may have important implications when determining management for this group of patients.

Follow-up of patients with colorectal cancer: the evidence is in favour but we are still in need of a protocol

The prevalence of colorectal cancer is high in the western world and follow-up after treatment of the primary tumour is claimed to consume resources that could be used in improving screening and early diagnosis. Although some patients with recurrent disease can be treated successfully there has been a debate on whether an overall improvement in survival is achieved by follow-up. There is no agreement on a follow-up protocol of investigations. A review via a Medline search of all published studies and reports on the issue of follow-up of colorectal cancer dated from 1975-2006. We examined retrospective and prospective studies, randomised controlled trials, and meta-analyses attempting to identify the optimum follow-up protocol. There is widespread diversity of follow-up policies for colorectal cancer. Follow-up of colorectal cancer does not have a negative impact on Quality of life. There is no evidence that annual colonoscopy provides any survival advantage. It has been shown that intensive follow-up with frequent carcinoembryonic antigen measurement has a survival advantage and is cost-efficient. Similar evidence seems to be gathering about liver imaging with CT scan although it is less conclusive.

Endoscopic therapy of lower gastrointestinal cancer

Since the 1960's, endoscopy has revolutionised the practice of gastroenterology. Although initially diagnostic, endoscopy is now playing an increasingly therapeutic role. There are many reasons to believe that therapeutic endoscopy will shape the practice of gastroenterology further in the future. Only a few years ago we relied on low-resolution fibreoptic endoscopes. Nowadays even standard equipment allows the mucosa to be scrutinised in great detail. Dedicated training in endoscopy together with attention to quality indicators such as polyp detection and caecal intubation rates will ensure that fewer early gastrointestinal cancers are missed in the future. Open access endoscopy and screening programs are being introduced in many Western countries which will also lead to more lesions being detected in their early stages. This chapter discusses the main issues surrounding the endoscopic therapy of lower gastrointestinal cancers.

Cancer staging and survival in colon cancer is dependent on the quality of the pathologists' specimen examination

Correct staging of colon cancer is decisive regarding further oncological treatment, surveillance and prediction of long-term survival. This study investigated the variability in accuracy of pathology reports with focus on differences between pathology departments and their compliance to regional guidelines. Data from the colon cancer register (1997-2002) of the Uppsala/Orebro, Sweden, health care region were analysed and the seven pathology departments in this region were compared. Included were 3735 patients who had undergone resection of a colon cancer. Cumulative 5-year survival was the main end-point. For 64% (n = 2390) of the cases, the number of lymph nodes examined was given (median 8). Survival in stage II was lower when fewer than 12 nodes were examined or when the number of nodes sampled was not given (P = 0.001, log-rank test). In stage III, those with at the most 3 nodes positive (N1) had a better survival than those with 4 or more nodes positive (N2) (P < 0.001, log-rank test). An index of metastases (IM), derived from the number of nodes with metastases divided by the number of nodes examined, was calculated for stage III tumours. Examination of 12 nodes is necessary to assure stage III cases with the median IM (0.32), whereas 20 nodes are necessary to assure 90% of cases with the lower quartile of IM (0.16). Irrespective of the number of nodes investigated, overall survival was better among patients with IM < 0.33 vs. IM > or = 33 (P < 0.001, log-rank test). The prognostic information of the IM was higher than that of the N-stage. Quality of a pathology department, measured by the median number of lymph nodes investigated and by the proportion of reports where the number is given, was determined to indicate correct staging and management of the patient. An index of metastases (IM) is a possible basis for guidance in the choice of adjuvant treatments that appears superior to that of N-stage.

Factors predicting survival in stage IV colorectal carcinoma patients after palliative treatment: a multivariate analysis

BACKGROUND

The prognostic impact of primary tumor resection in patients presenting with unresectable synchronous metastases from colorectal carcinoma (CRC) is not well established. In the present study, we analyzed fifteen factors to define the value of primary tumor resection with regard to prognosis.

PATIENTS AND METHODS

We identified 186 consecutive patients with proven stage IV CRC from the year 1995 to 2001. Variables were tested for their relationship to survival in univariate analyses with the Kaplan-Meier method and the log rank test. Factors that showed a significant impact were included in a Cox proportional hazards model. The tests were repeated for 107 patients who had no symptoms from their primary tumor.

RESULTS

Overall there were six independent variables with a relationship to survival: performance status, ASA-class, CEA level, metastatic load, extent of primary tumor, and chemotherapy. In the asymptomatic patients we investigated 13 factors, 3 of which proved to be independent predictors of survival: performance status, CEA level, and chemotherapy. Resection of primary tumor was only predictive of survival if in-hospital mortality was excluded.

CONCLUSION

Resection of the tumor, if possible, is doubtless the best option for stage IV CRC patients with severe symptoms caused by their primary tumor. In asymptomatic patients, chemotherapy is preferable to surgery.

Colorectal cancer with non-resectable synchronous metastases: should the primary tumor be resected?

OBJECTIVES

In asymptomatic patients presenting with non-resectable synchronous metastatic disease from colorectal adenocarcinoma, the beneficial effect of resecting the primary tumor remains to be documented. The aim of this study was to compare survival of patients with metastatic colorectal cancer who underwent elective resection of the primary tumor to those who did not.

METHODS

A retrospective analysis of patients with metastatic colo-rectal cancer treated between June, 1996 and December, 1999 was performed. Overall survival was compared between patients who underwent first-line resection of the primary colorectal tumor (group 1) or those who did not undergo elective resection of the primary (group 2). The probability of surgical resection of the primary tumor for gastrointestinal complications in group 2 was evaluated.

RESULTS

Thirty-one and 23 patients were included in groups 1 and 2 respectively. Five patients (21.7%, 95% confidence interval CI95% 4.9-38.5%) in group 2 required surgical treatment for intestinal obstruction due to the primary tumor. Two clinical characteristics were significantly different between groups 1 and 2: rectal localization (9.7% versus 34.7%; P=0.03) and presence of fewer than three metastases (29.0% versus 4.3%; P=0.03). Survival curves were not significantly different (logrank). Median duration of survival was 21 and 14 Months, respectively (P=0.718).

CONCLUSION

In patients with non-resectable synchronous metastatic disease, non-surgical management of the primary tumor is a rational alternative if asymptomatic. A prospective randomized trial integrating the quality-of-life factor should be organized.

Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis

BACKGROUND

Acute colonic obstruction because of malignancy is often a surgical emergency. Surgical decompression with colostomy with or without resection and eventual re-anastomosis is the traditional treatment of choice. Endoscopic colonic stent insertion effectively decompresses the obstructed colon, allowing for surgery to be performed electively. This study sought to determine the cost-effectiveness of colonic stent vs. surgery for emergent management of acute malignant colonic obstruction.

METHODS

Decision analysis was used to calculate the cost-effectiveness of two competing strategies in a hypothetical patient presenting with acute, complete, malignant colonic obstruction: (1) emergent colonic stent followed by elective surgical resection and re-anastomosis; (2) emergent surgical resection followed by diversion (Hartmann's procedure) or primary anastomosis. Cost estimates were obtained from a third-party payer perspective. Primary outcome measures were mortality, stoma requirement, and total number of operative procedures.

RESULTS

Colonic stent resulted in 23% fewer operative procedures per patient (1.01 vs. 1.32 operations per patient), an 83% reduction in stoma requirement (7% vs. 43%), and lower procedure-related mortality (5% vs. 11%). Colonic stent was associated with a lower mean cost per patient ($45,709 vs. $49,941).

CONCLUSIONS

Colonic stent insertion followed by elective surgery appears more effective and less costly than emergency surgery under base-case conditions. This finding remains robust over a wide range of assumptions for clinical inputs in sensitivity analysis. Our findings suggest that colonic stent insertion should be offered, whenever feasible, as a bridge to elective surgery in patients presenting with malignant colonic obstruction.

Outcomes in elderly patients following surgery for colorectal cancer in the veterans affairs health care system

AIM

To compare 30-day and 5-year mortality in elderly vs. younger patients following surgical resection for colorectal cancer.

METHODS

A cohort study of patients admitted to VA hospitals with a new diagnosis of colorectal cancer who underwent surgical resection between October 1990 and September 2000. Cumulative survival rates (30-day and 5-year) were calculated from Kaplan-Meier estimates and adjusted risks of death were estimated using Cox proportional hazards models.

RESULTS

We identified 34,888 individuals with a new diagnosis of colorectal cancer between October 1990 and September 2000, of whom 22 633 (65%) underwent surgical resection. The 30-day mortality following resection for rectal and colon cancer, respectively, for patients <65 years was 2.1 and 2.8% compared with 4.9 and 5.6% for those > or =65 years. The 5-year cumulative survival for rectal and colon cancer for patients <65 years was 54.0 and 57.6% compared with 44.5 and 46.6% for those > or =65 years. In patients > or =65 years with rectal or colon cancer, after adjustment, 30-day mortality was 2 times greater and 5-year mortality was 1 times greater than in younger patients.

CONCLUSIONS

Older age is an independent predictor of increased short-term and long-term mortality following surgery in patients with rectal and colon cancer.

The influence of training level and surgical experience on survival in colorectal cancer

BACKGROUND AND AIMS

The effect of surgical training level, experience, and operation volume on complications and survival in colorectal cancer during a 10-year period in a medium-volume university hospital was retrospectively studied.

PATIENTS AND METHODS

Four hundred and fifty-six patients were resected for primary colorectal adenocarcinoma during the 10-year period of 1981-1990, and of these, 387 patients underwent resection with curative intent. The surgeons were divided into three groups according to training level and volume: group 1, surgeons in training and other surgeons operating annually on only 1-4 patients; group 2, surgeons specializing in gastrointestinal surgery (average annual volume 4-13 operations); group 3, specialists in gastrointestinal surgery (average annual volume 3-8 operations). Postoperative morbidity and mortality rates, as well as long-term survival rates, were analysed, and comparisons were made between the patients in the three groups.

RESULTS

There were no statistically significant differences between the three groups in postoperative morbidity or mortality. Cancer-specific 5-year survival rate of all patients was 57%, and that of those resected in the aforementioned three groups was 51%, 63%, and 55%, respectively, P=0.087. The 5-year survival rates for colon cancer were 59% (total), 52%, 69%, and 58%, respectively, P=0.067, and for rectal cancer were 51% (total), 42%, 53%, and 52%, respectively, P=0.585.

CONCLUSION

There were no significant differences in the rates of postoperative mortality, morbidity, and long-term overall survival between the volume groups. However, in patients with colon cancer, there was a trend for better survival for those operated on by the surgeons specializing in gastrointestinal surgery, and in rectal cancer patients, a tendency of fewer local recurrences in those operated on by the specialist surgeons.

Supervivencia y recidiva en el tratamiento multidisciplinario del carcinoma colorrectal

BACKGROUND AND OBJECTIVE

Colorectal cancer is one of the most frequent causes of death in the general population. Our aim was to analyze our experience in the multidisciplinary approach of colorectal carcinoma during a three year period.

PATIENTS AND METHOD

Between January 1996 and December 1998, we studied prospectively 807 patients with colorectal cancer. The epidemiology, treatment and outcome(recurrence and survival) were analyzed. The minimum follow-up was 3 years.

RESULTS

There were 598 colon (65.5%) and 279 rectal (34.5%) tumors in all the series. Surgical treatment was elective in 84% and urgent in 16%, and was considered radical in 598 cases (74.1%). Chemotherapy or radiotherapy was administered in 49.6% and 18.3% patients, respectively. The overall 3-year survival was as follows: stage I 97.5%, stage II 90.6%, stage III 75.2%, and stage IV 12.6%. The 3-year free-disease survival was as follows: in colon cancer 97.8% for stage I, 87.3% for stage II, and 71.4% for stage III; and in rectal cancer 96.8% for stage I, 85.1% for stage II, and 75.4% for stage III. During the follow-up 124 patients (20.7%) developed recurrence: local (2.8%), systemic (15.9%) or both (2%). The three-year survival in operated patients with liver metastases was 61.9%.

CONCLUSIONS

We have observed adequate survival and recurrence rates which are the result are of systematic protocols established by a multidisciplinary team.