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

Can synthetic data be a proxy for real clinical trial data? A validation study

OBJECTIVES

There are increasing requirements to make research data, especially clinical trial data, more broadly available for secondary analyses. However, data availability remains a challenge due to complex privacy requirements. This challenge can potentially be addressed using synthetic data.

SETTING

Replication of a published stage III colon cancer trial secondary analysis using synthetic data generated by a machine learning method.

PARTICIPANTS

There were 1543 patients in the control arm that were included in our analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Analyses from a study published on the real dataset were replicated on synthetic data to investigate the relationship between bowel obstruction and event-free survival. Information theoretic metrics were used to compare the univariate distributions between real and synthetic data. Percentage CI overlap was used to assess the similarity in the size of the bivariate relationships, and similarly for the multivariate Cox models derived from the two datasets.

RESULTS

Analysis results were similar between the real and synthetic datasets. The univariate distributions were within 1% of difference on an information theoretic metric. All of the bivariate relationships had CI overlap on the tau statistic above 50%. The main conclusion from the published study, that lack of bowel obstruction has a strong impact on survival, was replicated directionally and the HR CI overlap between the real and synthetic data was 61% for overall survival (real data: HR 1.56, 95% CI 1.11 to 2.2; synthetic data: HR 2.03, 95% CI 1.44 to 2.87) and 86% for disease-free survival (real data: HR 1.51, 95% CI 1.18 to 1.95; synthetic data: HR 1.63, 95% CI 1.26 to 2.1).

CONCLUSIONS

The high concordance between the analytical results and conclusions from synthetic and real data suggests that synthetic data can be used as a reasonable proxy for real clinical trial datasets.

TRIAL REGISTRATION NUMBER

NCT00079274.

Colorectal Cancer: How Familiar Are Our Future Doctors with the Cancer of Tomorrow?

Background

Colorectal cancer (CRC) is one of the common cancers affecting both genders. Although the incidence of CRC is low in India there has been an increase in the past few decades.

Objective

To assess the awareness regarding colorectal cancer and its screening among medical students and interns.

Methods

This cross-sectional study was conducted among 290 participants (final year medical students and interns) from Kasturba Medical College, Mangalore. A pretested semistructured questionnaire was used to collect information. Data was analyzed using SPSS 17.0.

Results

Majority of participants had satisfactory knowledge regarding CRC. 38% of them scored excellently, 64.8% had good knowledge, and 5.2% scored poorly. Knowledge regarding CRC symptoms was good (95%). 92% of the participants were aware of risk factors of CRC. Only 49% of the participants identified FOBT as a screening tool and 30.7% participants knew that 50 years is the recommended age to begin CRC screening. Interns and international students had better knowledge than final year medical students and Indian students and this was found to be statistically significant.

Conclusion

There is a need to improve participant's knowledge regarding CRC screening although majority of them are aware of CRC symptoms and risk factors.

Computed Tomography Image Texture: A Noninvasive Prognostic Marker of Hepatic Recurrence After Hepatectomy for Metastatic Colorectal Cancer

BACKGROUND

Recurrence after resection of colorectal liver metastases (CRLMs) occurs in up to 75% of patients. Preoperative prediction of hepatic recurrence may inform therapeutic strategies at the time of initial resection. Texture analysis (TA) is an established technique that quantifies pixel intensity variations (heterogeneity) on cross-sectional imaging. We hypothesized that tumoral and parenchymal changes that are predictive of overall survival (OS) and recurrence in the future liver remnant (FLR) can be detected using TA on preoperative computed tomography (CT) images.

METHODS

Patients who underwent resection for CRLM between 2003 and 2007 with appropriate preoperative CT scans were included (n = 198) in this retrospective study. Texture features extracted from the tumor and FLR, and clinicopathologic variables, were incorporated into a multivariable survival model.

RESULTS

Quantitative imaging features of the FLR were an independent predictor of both OS and hepatic disease-free survival (HDFS). Tumor texture showed significant association with OS. TA of the FLR allowed patient stratification into two groups, with significantly different risks of hepatic recurrence (hazard ratio 2.09, 95% confidence interval 1.33-3.28; p = 0.001). Patients with homogeneous parenchyma had approximately twice the risk of hepatic recurrence (41 vs. 20%).

CONCLUSION

TA of the tumor and FLR are independently associated with OS, and TA of the FLR is independently associated with HDFS. Patients with homogeneous parenchyma had a significantly higher risk of hepatic recurrence. Preoperative TA of the liver represents a potential biomarker to identify patients at risk of liver recurrence after resection for CRLM.

Reviewing the Management of Obstructive Left Colon Cancer: Assessing the Feasibility of the One-stage Resection and Anastomosis After Intraoperative Colonic Irrigation

BACKGROUND

The management of obstructive left colon cancer (OLCC) remains debatable with the single-stage procedure of primary colonic anastomosis after cancer resection and on-table intracolonic lavage now being supported.

PATIENTS AND METHODS

Patients with acute OLCC who were admitted between January 2008 and January 2015 were distributed into 5 different groups. Group ICI underwent emergency laparotomy for primary anastomosis following colonic resection and intraoperative colonic lavage; Group HP underwent emergency Hartmann's Procedure; Group CON consisted of patients treated by conservative management with subsequent elective open cancer resection; Group COL were colostomy patients; and Group INT consisted of patients who had interventional radiology followed by open elective colon cancer resection. The demographics of the patients and comorbidity, intraoperative data, and postoperative data were collected, with P < .05 as significant.

RESULTS

There were 4 deaths in 138 cases (2.90%). There was only 1 patient who had anastomotic leakage (5.56%) in Group ICI, compared with none in Group HP and Group COL, 1 case in Group INT (7.69%), and 2 cases in Group CON (6.06%) (P > .05). Group INT and Group CON, when compared to the three surgical groups, Groups ICI, Group COL, and Group HP, individually, were statistically significant for the duration of surgery (P < .05).

CONCLUSIONS

Primary anastomosis following colonic resection after irrigation can be safely performed in selected patients, with the necessary surgical expertise, with no increased risk in mortality, anastomotic leakage, and other postoperative complications.

Second-look surgery following Hartmann's procedure for obstructive left-sided colorectal cancer

The aim of the present study was to investigate the short- and long-term outcomes of patients undergoing second-look surgery following Hartmann's procedure for obstructive left-sided colorectal cancer (LSCC). All patients included in the present study had undergone radical surgery with Hartmann's procedure for obstructive LSCC. Adjuvant chemotherapy was recommended for all patients, and patients with no signs of recurrence following six months of surveillance were planned to undergo second-look surgery. The aim of second-look surgery was early detection of local recurrence and determination of the efficacy of laparoscopic Hartmann procedure reversal. A total of 15 patients with locally advanced colorectal cancer were included in the study. Three patients exhibited peritoneal dissemination at the time of laparoscopic Hartmann procedure reversal and underwent partial peritonectomy. Following adjuvant chemotherapy treatment, laparoscopic Hartmann procedure reversal was performed in all patients. However, two patients underwent colo-anal anastomosis, and two patients underwent right-sided colon or ileum reconstruction. Regarding the oncological outcomes, two of three patients in whom peritoneal dissemination was identified during laparoscopic Hartmann procedure reversal were eventually in remission following the initial surgery and the second-look surgery with partial peritonectomy. Favorable long-term outcomes were observed in 12/15 patients due to no recurrence, which may be due to the surgical techniques used and the timing of the second-look surgery following Hartmann's procedure for the treatment of obstructive LSCC.

Palliative resection of a primary tumor in patients with unresectable colorectal cancer: could resection type improve survival?

PURPOSE

The aim of this study was to evaluate the impact of extended resection of primary tumor on survival outcome in unresectable colorectal cancer (UCRC).

METHODS

A retrospective analysis was conducted for 190 patients undergoing palliative surgery for UCRC between 1998 and 2007 at a single institution. Variables including demographics, histopathological characteristics of tumors, surgical procedures, and course of the disease were examined.

RESULTS

Kaplan-Meier survival curve indicated a significant increase in survival times in patients undergoing extended resection of the primary tumor (P < 0.001). Multivariate analysis showed that extra-abdominal metastasis (P = 0.03), minimal resection of the primary tumor (P = 0.034), and the absence of multimodality adjuvant therapy (P < 0.001) were significantly associated poor survival outcome. The histological characteristics were significantly associated with survival times. Patients with well to moderate differentiation tumors that were extensively resected had significantly increased survival time (P < 0.001), while those with poor differentiation tumors that were extensively resected did not have increase survival time (P = 0.786).

CONCLUSION

Extended resection of primary tumors significantly improved overall survival compared to minimal resection, especially in well to moderately differentiated tumors (survival time: extended resection, 27.8 ± 2.80 months; minimal resection, 16.5 ± 2.19 months; P = 0.002).

Prognostic impact of carcinoembryonic antigen and carbohydrate antigen 19-9 in stage IV colorectal cancer patients after R0 resection

BACKGROUND

Although preoperative carcinoembryonic antigen (pre-CEA) and carbohydrate antigen 19-9 (pre-CA 19-9) are reportedly prognostic indicators for colorectal cancer (CRC), the prognostic roles of postoperative CEA (post-CEA) and CA 19-9 (post-CA 19-9) shortly after surgery have not been clarified in patients with curatively resected stage IV CRC. The aim of this study was to evaluate the predictive abilities of post-CEA and post-CA 19-9.

METHODS

A total of 129 consecutive patients who had stage IV CRC and underwent R0 resection were retrospectively analyzed. Pre-CEA and post-CEA and CA 19-9 levels were measured within 1 mo before and 3 mo after surgery, respectively. Relapse-free survival (RFS) and overall survival were estimated using the Kaplan-Meier method, and multivariate analysis was performed using the Cox proportional hazards model.

RESULTS

Pre-CEA was elevated (≥5.0 ng/mL) in 73.6% of the patients and remained elevated after surgery in 32.7% of the patients. Elevated post-CA 19-9 (≥50 U/mL) was observed in 9.5% of the patients. Neither elevated pre-CEA nor elevated pre-CA 19-9 was significantly associated with RFS but both elevated post-CEA and elevated post-CA 19-9 were associated with markedly reduced RFS (P = 0.0002 and P = 0.0004, respectively). When considered in combination, post-CEA and post-CA 19-9 significantly stratified RFS and was an independent predictive factor for recurrence (P = 0.0035), as was lymphatic invasion (P = 0.0015). Post-CA 19-9 was the only evident independent predictive factor for overall survival (P = 0.0336).

CONCLUSIONS

In patients with stage IV CRC who underwent curative resection, the combination of post-CEA and post-CA 19-9 at 3 mo after surgery was a potent prognostic indicator for recurrence.

One-Stage Colectomy with Intraoperative Colonic Irrigation for Acute Left-Sided Malignant Colonic Obstruction

BACKGROUND

One-stage colectomy with intraoperative colonic irrigation (OCICI) may be useful in early resolution of acute left-sided malignant colonic obstruction (ALMCO). However, the clinical benefit of this technique has not been fully investigated.

METHODS

Between January 2007 and July 2014, 451 patients underwent left hemicolectomy or sigmoidectomy for colon cancer, of whom 25 underwent OCICI for ALMCO. The medical records of the patients who underwent OCICI for ALMCO were compared to 174 medical records of a control population (without ALMCO) who were matched for tumor characteristics.

RESULTS

There were no statistically significant differences between the two groups in regard to age, sex, American Society of Anesthesiologists Physical Status, location of tumor, preoperative CEA levels, and previous abdominal surgeries. The OCICI for ALMCO group was associated with a longer operation time (153 ± 33 vs. 111 ± 47 min, p < 0.001). However, no significant differences were found in patient morbidity, the duration of the postoperative hospital stay, or the tumor pathology between the two groups. Univariate and multivariate analyses indicated that OCICI for ALMCO did not increase the risk of postoperative morbidity in patients with left-sided colon cancer.

CONCLUSION

OCICI for ALMCO did not increase the rate of morbidity or prolong the hospital stay duration compared to treatment of a control population.

Colonic Stents for Colorectal Cancer Are Seldom Used and Mainly for Palliation of Obstruction: A Population-Based Study

Self-expandable stents for obstructing colorectal cancer (CRC) offer an alternative to operative management. The objective of the study was to determine stent utilization for CRC obstruction in the province of Ontario between April 1, 2000, and March 30, 2009. Colonic stent utilization characteristics, poststent insertion health outcomes, and health care encounters were recorded. 225 patients were identified over the study period. Median age was 69 years, 2/3 were male, and 2/3 had metastatic disease. Stent use for CRC increased over the study period and gastroenterologists inserted most stents. The median survival after stent insertion was 199 (IQR, 69-834) days. 37% of patients required an additional procedure. Patients with metastatic disease were less likely to go on to surgery (HR 0.14, 95% CI 0.06-0.32, p < 0.0001). There were 2.4/person-year emergency department visits (95% CI 2.2-2.7) and 2.3 hospital admissions/person-year (95% CI 2.1-2.5) following stent insertion. Most admissions were cancer or procedure related or for palliation. Factors associated with hospital admissions were presence of metastatic disease, lack of chemotherapy treatment, and stoma surgery. Overall the use of stents for CRC obstruction remains low. Stents are predominantly used for palliation with low rates of postinsertion health care encounters.

Complications from the primary tumour are not related with survival in patients with synchronous stage IV colorectal cancer receiving chemotherapy without primary tumour resection

BACKGROUND

The aim of this study was to evaluate the rate of complications from the primary tumour (CPT) requiring surgical or endoscopic intervention during chemotherapy treatment in patients with incurable synchronous stage IV colorectal cancer, the possibility of predicting such complications and their influence on survival.

METHODS

One hundred and twenty-five patients were initially treated with chemotherapy. Patients were grouped on the basis of appearance or not of CPT. We assessed the relation between age, gender, carcinoembryonic antigen (CEA) level, primary tumour location, alkaline phosphatase level, unilobar or bilobar liver involvement, presence of peritoneal carcinomatosis, the number of sites of metastatic disease, the addition of target therapies to chemotherapy, the ability to traverse the tumour with an endoscope and the appearance of complications due to the primary tumour and overall survival.

RESULTS

Mean age was 64.9 years, and 89 patients were men. Over a mean of 234 days, 25 patients (20 %) developed a CPT. Eighteen patients required surgery, and seven were treated exclusively by an endoscopic procedure. Mean survival was 15.8 months. We found a statistically relevant correlation between the inability to traverse the tumour with an endoscope and the occurrence of a CPT. There was no statistical differences in survival between both groups, but patients receiving target therapies had better survival.

CONCLUSION

Twenty percent of patients will suffer a CPT during chemotherapy treatment. The inability to pass the tumour with an endoscope can predict the CPT. Survival was only related to the addition of target therapies to chemotherapy.

Hepatic arterial infusional chemotherapy in the management of colorectal cancer liver metastases

Colorectal liver metastases (CRLM) receive their blood supply predominantly through the hepatic artery. Intra-arterial drug delivery can optimize the dose and time exposure of chemotherapy to tumor cells while limiting systemic toxicity. Chemotherapy is most commonly administered through a catheter surgically placed in the gastroduodenal artery and connected to a subcutaneous pump. Due to its pharmacokinetics features, floxuridine is the most commonly used drug in the USA with hepatic arterial infusional (HAI) chemotherapy. To date, many clinical trials have shown the positive impact of HAI in the management of CRLM. Hence, in unresectable patients, HAI is associated with high response rates and commonly enables subsequent resection in both chemonaive and previously treated patients. Outcomes in patients converted to complete resection are similar to patients who present with initially resectable disease. In the adjuvant setting, HAI with floxuridine improves survival as well as hepatic and overall disease-free survival after complete resection of CRLM, as compared with 5-FU alone, in three of four randomized studies. To date, no trials have compared HAI combined with modern chemotherapy alone to modern chemotherapy alone in the adjuvant setting.

Colorectal preOperative Surgical Score (CrOSS) for mortality in major colorectal surgery

BACKGROUND

Colorectal surgery carries a significant mortality risk, with reported rates of 1-6% for elective surgery and up to 22% in the emergency setting. Both clinicians and patients will benefit from being able to predict the likelihood of death before surgery. Recently, we have described and validated two risk stratification models for colorectal surgery, the Barwon Health 2012 and Association Française de Chirurgie models. However, these models are not suitable for assessment at patient's bedside. The purpose of this study is to develop a simplified preoperative model capable of predicting mortality following colorectal surgery.

METHODS

The new model is termed Colorectal preOperative Surgical Score (CrOSS). The development and internal validation of CrOSS was performed using a prospectively maintained colorectal database. External validation was performed using retrospective data. Univariate and multivariate analyses were performed in model development. Calibration and discrimination were used for model validation.

RESULTS

There were 474 and 389 consecutive colorectal surgeries at Geelong Hospital and Western Hospital. Overall mortality rates were 5.16% and 1.03%, respectively. Significant predictors for mortality were as follows: age ≥70, urgent operation, albumin ≤30 g/L and congestive heart failure (receiver operating characteristic (ROC) = 0.870, calibration P-value = 0.937). The predicted risk of mortality was stratified according to the risk profile of 0.39-66.51%. When validated externally, CrOSS predicted mortality accurately (ROC = 0.847, calibration P-value = 0.199).

CONCLUSIONS

A robust and simple preoperative model has been created to risk-stratify patients for colorectal surgery. This was successfully validated at another tertiary hospital.

Current outcomes of emergency large bowel surgery

INTRODUCTION

Emergency large bowel surgery (ELBS) is known to carry an increased risk of morbidity and mortality. Previous studies have reported morbidity and mortality rates up to 14.3%. However, there has not been a recent study to document the outcomes of ELBS following several major changes in surgical training and provision of emergency surgery. The aim of this study was therefore to explore the current outcomes of ELBS.

METHODS

A retrospective review was performed of a prospectively maintained database of the clinical records of all patients who had ELBS between 2006 and 2013. Data pertaining to patient demographics, ASA (American Society of Anesthesiologists) grade, diagnosis, surgical procedure performed, grade of operating surgeon and assistant, length of hospital stay, postoperative complications and in-hospital mortality were analysed.

RESULTS

A total of 202 patients underwent ELBS during the study period. The mean patient age was 62 years and the most common cause was colonic carcinoma (n=67, 33%). There were 32 patients (15.8%) who presented with obstruction and 64 (31.7%) had bowel perforation. The overall in-hospital mortality rate was 14.8% (n=30). A consultant surgeon was involved in 187 cases (92.6%) as either first operator, assistant or available in theatre.

CONCLUSIONS

ELBS continues to carry a high risk despite several major changes in the provision of emergency surgery. Further developments are needed to improve postoperative outcomes in these patients.

Short-term outcomes following the use of self-expanding metallic stents in acute malignant colonic obstruction--a single centre experience

BACKGROUND

Colonic self-expanding metallic stents (SEMS) may provide prompt relief of acute malignant colorectal obstruction (AMCO) and are increasingly used either palliatively or as a bridge to surgery (BTS) in patients in whom a definitive surgical approach is unsuitable. We evaluated short-term outcomes of malignant colorectal obstructive patients who underwent SEMS insertion in our institution over a 3-year period.

METHODS

A prospectively maintained database was reviewed to identify all patients who presented to our institution with AMCO between August 2010 and 2013 and who were treated with a SEMS either temporarily or permanently. Additional data was retrieved from chart reviews and operation notes.

RESULTS

Sixteen patients (12 males, 4 females) each had a single stent inserted during the study period, either palliatively (n = 11) or as a BTS (n = 5). The technical and clinical success rates were both 87.5% (14/16). The two unsuccessful stenting cases both had disseminated disease and required emergency surgery while five patients with curable disease proceeded to elective resections. There was no procedure-related mortality or stent-related perforations. The mean (standard deviation) length of stay post acute surgery was longer than elective surgery [45 ± 21.2 vs. 15.8 ± 4.0, days]. All patients in the BTS group were stoma-free post-operatively, while both patients who had emergency surgery ended up with permanent stomas. Finally, the stent complication rate was 6.2% (1/16), secondary to migration.

CONCLUSIONS

Although limited by a small sample size, the study shows that SEMS have favourable short-term outcomes. Further adequately powered trials are needed to confirm those findings.

Novel methods for clinical risk stratification in patients with colorectal liver metastases

Purpose

Colorectal cancer patients with liver-confined metastases are classified as stage IV, but their prognoses can differ from metastases at other sites. In this study, we suggest a novel method for risk stratification using clinically effective factors.

Materials and Methods

Data on 566 consecutive patients with colorectal liver metastasis (CLM) between 1989 and 2010 were analyzed. This analysis was based on principal component analysis (PCA).

Results

The survival rate was affected by carcinoembryonic antigen (CEA) level (p < 0.001; risk ratio, 1.90), distribution of liver metastasis (p=0.014; risk ratio, 1.46), and disease-free interval (DFI; p < 0.001; risk ratio, 1.98). When patients were divided into three groups according to PCA score using significantly affected factors, they showed significantly different survival patterns (p < 0.001).

Conclusion

The PCA scoring system based on CEA level, distribution of liver metastasis, and DFI may be useful for preoperatively determining prognoses in order to assist in clinical decisionmaking and designing future clinical trials for CLM treatment.

The impact of surgical specialisation on survival following elective colon cancer surgery

PURPOSE

Reorganisation of cancer services in the UK and across Europe has led to elective surgery for colon cancer being increasingly, but not exclusively, delivered by specialist colorectal surgeons. This study examines survival after elective colon cancer surgery performed by specialist compared to non-specialist surgeons.

METHOD

Patients undergoing elective surgery for colon cancer in 16 hospitals between 2001 and 2004 were identified from a prospectively maintained regional audit database. Post-operative mortality (<30 days) and 5-year relative survival in those receiving surgery under the care of a specialist or non-specialist surgeon were compared.

RESULTS

A total of 1,856 patients were included, of which, 1,367 (73.7%) were treated by a specialist and 489 (26.4%) by a non-specialist surgeon. Those treated by a specialist were more likely to be deprived, undergo surgery in a high volume unit and have higher lymph node yields than those treated by a non-specialist. Post-operative mortality was lower (4.5 versus 7.0%; P = 0.032) and 5-year relative survival was higher (72.2 versus 65.6%; P = 0.012) among those treated by a specialist surgeon. In multivariate analysis, surgery by non-specialists was independently associated with increased post-operative mortality (adjusted odds ratio (OR) 1.69; P < 0.001) and poorer 5-year relative survival (adjusted relative excess risk (RER) 1.17; P = 0.045). After exclusion of post-operative deaths, there was no difference in long-term survival (adjusted RER 1.08; P = 0.505).

CONCLUSION

Five-year relative survival after elective colon cancer surgery was higher among those treated by specialist colorectal surgeons due to increased post-operative mortality among those treated by non-specialists.

Clinical outcomes of colonic stent in a tertiary care center

Introduction. Colonic obstruction is one of the manifestations of colon cancer for which self-expanding metal stents (SEMS) have been effectively used, to restore the luminal patency either for palliative care or as a bridge to resective surgery. The aim of our study is to evaluate the efficacy and safety of large diameter SEMS in patients with malignant colorectal obstruction. Methods and Results. A four-year retrospective review of the Medical Archival System was performed and identified 16 patients. The average age was 70.8 years, of which 56% were females. The most common cause of obstruction was colon cancer (9/16, 56%). Rectosigmoid was the main site of obstruction (9/16) and complete obstruction occurred in 31% of cases. The overall technical and clinical success rates were 100% and 87%, respectively. There were no immediate complications (<24 hours), but stent stenosis due to kinking occurred within one week of stent placement in 2 patients. Stent migration occurred in 2 patients at 34 and 91 days, respectively. There were no perforations or bleeding complications. Conclusion. Large diameter SEMS provide a safe method for palliation or as a bridge to therapy in patients with malignant colonic obstruction with high technical success and very low complication rates.

Status and literature review of self-expandable metallic stents for malignant colorectal obstruction

Use of colorectal stents has increased dramatically over the last decades. Colorectal stents offer an alternative way to relieve fatal intestinal obstruction and can take place of emergency surgery, which associated with significant morbidity and mortality and a high incidence of stoma creation, to elective resection. Although there remain a few concerns regarding the use of stents as a bridge to surgical resection, use of self-expandable metallic stents for palliation in patients with unresectable disease has come to be generally accepted. Advantages of colorectal stents include acute restoration of luminal patency and allowance of time for proper staging and surgical optimization, and the well-known disadvantages are procedure-related complications including perforation, migration, and stent failure. General indications, procedures, and clinical outcomes as well as recent evidences regarding the use of colorectal stents will be discussed in this review.

[Treatment of colorectal cancer with unresectable metastasis with chemotherapy without primary tumor resection: analysis of tumor-related complications]

INTRODUCTION

Although the conventional treatment of patients with stage iv colorectal cancer involves resection of the primary tumor followed by chemotherapy, several studies suggest that in patients with few symptoms the first and only treatment should be chemotherapy. The objective of this study is to analyze the complications related to the primary tumor in a series of patients with unresectable metastatic colorectal cancer treated with chemotherapy without surgery.

MATERIAL AND METHODS

Retrospective descriptive study. The study included all patients with unresectable metastatic colorectal cancer treated with chemotherapy without resection of the primary tumor (January 2007-February 2011).

RESULTS

The mean age of the 61 patients analyzed was 67±13 years and the performance status was 0-1 in 53 (87%). Twenty (33%) patients developed complications during follow-up. The most common complication was intestinal obstruction in 15 (25%) patients followed by perforation. Complications required surgery in 6 (10%) cases. We did not find differences in patient characteristics between those who had a complication and those without, although the complication rate in patients with a colonic stent (53%) was twice that of other patients (26%).

CONCLUSIONS

Chemotherapy without surgery is a good option in most patients with unresectable metastatic colorectal cancer. However, although the percentage of patients requiring surgery is low, the total number of complications related to the primary tumor is not negligible. Studies are needed to identify those patients in whom a prophylactic colectomy could be indicated.

Colectomies performed at a rural Australian hospital: a 7-year analysis

INTRODUCTION

Little published data exists documenting the reasons for and outcomes of colectomies in rural Australia. It remains unclear whether patient characteristics, diagnoses, complications and outcomes differ to metropolitan locations.

METHODS

A retrospective review of prospectively collected data for patients coded with International Classification of Diseases procedure code block 934 and 935 (colectomies) performed at Wimmera Health Care Group: Horsham Campus between July 2004 and July 2011. Records were additionally sought from transfer hospitals.

RESULTS

Two hundred thirty-eight colectomies were performed over the 7-year period: 164 for a colorectal cancer diagnosis, 74 for a non-colorectal cancer diagnosis. For the colorectal cancer colectomies, 80.5% were elective and 19.5% emergency. There were five (3.0%) intraoperative complications. Postoperatively, there were 16 (9.8%) surgical complications. There was a 3.7% return to theatre rate and a 3.0% unplanned readmission rate. There were no anastomotic leaks. The perioperative mortality rate was 5.5%. For the non-colorectal cancer colectomies, 85.1% were emergency and 14.9% elective. There were five (6.8%) intraoperative complications. Postoperatively, there were 14 (18.9%) surgical complications. There was a 12.2% return to theatre rate, a 5.4% unplanned readmission rate and three anastomotic leaks. The perioperative mortality rate was 10.8%.

CONCLUSIONS

The outcomes and complications for colectomies appear similar to the accepted standard of surgery in other rural and metropolitan centres. Areas have been identified for improved surgical performance at Wimmera Health Care Group: Horsham Campus.

Variations in surgical management from a national bowel cancer screening programme

OBJECTIVE

Population screening for colorectal cancer (CRC) was introduced to Wales in October 2008. The aim of this study was to evaluate the early impact of screening on CRC services.

DESIGN

Prospectively collected data from the Bowel Screening Wales (BSW) programme and the Welsh Bowel Cancer Audit (WBCA) were used to identify all screen-detected (SD) CRC diagnoses in Wales between April 2009 and March 2011. Data from the WBCA were used to calculate surgical outcomes.

RESULTS

444 SD cancers were registered during the study period representing 11% of all CRC diagnoses. There was a 9.9% increase in CRC incidence following the introduction of the BSW. SD patients presented with earlier stage disease; SD Dukes' A 35.1% vs 13.9% symptomatic patients (p<0.001) and SD Dukes' D 7.4% vs 21.8% symptomatic, (p<0.001). There were more colonic cancers among the SD population (p<0.001). The resection rate for SD cancers was 89%, significantly higher than symptomatic cancers (67.7%; p<0.0001). There was variability in the use of polypectomy as a definitive procedure to treat CRC between units. Overall laparoscopic resection was used in 52% of cases but with considerable interunit variability (0-92%).

CONCLUSIONS

The introduction of screening has increased the workload of the colorectal multidisciplinary teams in Wales. This has occurred through both an increase in case volume and the identification of more patients with early stage disease. There is considerable interunit variability in the use of techniques of local excision and rates of laparoscopic resection that need to be addressed.

Should bypass or stoma creation be undertaken for unresectable stage IV colorectal carcinoma?

BACKGROUND

When patients with stage IV colorectal cancer are deemed to have an unresectable primary colorectal cancer or extensive metastases at surgery, bypass or stoma creation may be the only surgical options. Whether this surgical approach provides extra months of life or instead leads to prohibitive post-operative morbidity and mortality has not previously been well characterized. This study was conducted to evaluate early and long-term outcomes for stage IV colorectal cancer patients with unresectable primary tumour.

METHODS

Patients with unresectable colorectal cancer who underwent palliative bypass or stoma creation were identified from a prospective colorectal cancer database. Early and long-term outcomes were evaluated. Survival was determined using Kaplan-Meier survival curves.

RESULTS

From 1980 to 2008, 81 patients with stage IV colorectal cancer had an unresectable primary or extensive metastases and underwent palliative bypass or stoma creation. Mean age was 61.5 ± 13.9 years, 44 (54.3%) were male. Location of the colorectal cancer was left-sided in 82.7%. Of the patients, 38.3% had emergency or urgent surgery. Sixty-two (76.5%) patients underwent a diverting stoma, 15 (18.5%) underwent enteric bypass procedures and 4 (4.9%) had both a diverting stoma and proximal bypass created. Twenty-five complications occurred in 24 patients (29.6%) with 2 patients (2.5%) requiring further re-operation. There was no anastomotic leak. Mean length of hospital stay was 13.8 ± 11.2 days. Thirty-day mortality rate was 16%. The median overall survival was 4.7 months, while the overall survival at 1 year was 24.7%. At 2 years, 6.1% patients were alive, all with a stoma.

CONCLUSION

Palliative bypass or stoma creation is associated with survival for several months for a significant proportion of patients with stage IV colorectal cancers, who have unresectable primaries or extensive metastases. The findings of this study support the use of bypass or diversion when faced with an unresectable primary in patients with colorectal cancer with metastases.

Use of the high dependency unit, increased consultant involvement and reduction in adverse events in patients who die after colorectal cancer surgery

AIM

We prospectively audited adverse events for surgical patients with colorectal cancer who died under surgical care to test the hypothesis that increased critical care and consultant input could be associated with a reduction in adverse events.

METHOD

Patients with a diagnosis of colorectal cancer who died under surgical care in Scotland from 1996 to 2005 underwent peer review audit using established methodologies through the Scottish Audit of Surgical Mortality.

RESULTS

In the 10-year study period, 3029 patients with colorectal cancer, mean age 76 (13-105) years, died under surgical care, of whom 80% had presented as an emergency admission. Operative intervention was performed in 1557 (51%) patients of whom 1030 (34%) patients had a resection of the cancer. The annual number of patients dying after a cancer resection decreased significantly (P = 0.009). Significant decreases in adverse events were noted over time with a 67% fall in adverse events relating to critical care (P = 0.009), a 37% fall for surgical care (P = 0.04) and a significant increase in consultant anaesthetist and consultant surgeon input, but there was a 9% increase in delay as an adverse event (P = 0.006). The documented anastomotic leakage rate in patients who died increased from 8% in 1996 to 19% in 2005 (P = 0.016).

CONCLUSION

The number of patients dying with colorectal cancer after surgery has decreased in recent years. Adverse events in these patients have significantly reduced over a decade with increased consultant involvement although there is the potential for further improvement.

A comparative study of colorectal surgical outcome in a national audit separated by 15 years

AIM

The Wales-Trent Bowel Cancer Audit (WTBA) was carried out in 1993, and since 2001 Welsh Bowel Cancer Audits (WBCA) have taken place annually. Screening for bowel cancer in Wales was introduced in 2008. This study compared patient variables, the role of surgery and operative mortality rates over the 15-year interval between the WTBA and the last WBCA before the introduction of population screening.

METHOD

Data from the WTBA in 1993 were compared with those of the WBCA including patients diagnosed between April 2007 and March 2008.

RESULTS

In 1993, 1536 patients were diagnosed with colorectal cancer (CRC) compared with 1793 in 2007-2008. Patient demographics and American Society of Anesthesiology (ASA) score did not change during these periods. Surgical treatment for CRC decreased (93% in 1993 vs 80% in 2007-2008; P < 0.001) particularly in the use of resectional surgery (84% in 1993 vs 71% in 2007-2008; P < 0.001). The 30-day postoperative mortality rate fell from 7.4% in 1993 to 5.9% in 2007-2008 (P = 0.097). Advanced disease at operation was more prevalent in the WTBA (25% of all operated patients were Stage IV in 1993 vs 13% in 2007-2008; P < 0.001). The use of surgery in patients with metastatic disease also declined over this period.

CONCLUSION

Surgery is used less frequently in the management of CRC compared with 15 years previously, and is a factor in the reduction of the interpreted 30-day operative mortality.

Emergency department visits after hours by lung cancer patients in Japan

PURPOSE

The aims of this study were to clarify frequency with which Japanese lung cancer patients visited an emergency department (ED) after hours and their final outcome.

METHODS

This is a retrospective and single institutional study. We reviewed medical records of patients who died of lung cancer from January 2008 to June 2012 at Osaka Police Hospital who had been followed up since diagnosis of lung cancer until death. We compared patients who had visited the ED after hours on weekdays, weekends, or holidays over their lives with cancer (ED visitors) and patients who had never visited the ED (non-ED visitors).

RESULTS

Overall, 245 patients met the inclusion criteria for analysis. There were 149 after hours ED visits by 106 lung cancer patients. Mean number of ED visits was 0.6 for all patients. Median interval from ED visit to death was 49 days. The most common chief compliant for these patients was respiratory problems (37.6%). Most patients visited the ED during chemotherapy (32.9%) or for best supportive care (42.3%). Directly after ED visits, 56.4% of ED visitors were finally hospitalized. In a multivariate analysis, performance status (PS) (odds ratio [OR]: 11.2, 95% confidence interval [CI]: 2.1-59.0, p = 0.004) and cancer stage (OR: 0.003, 95% CI: 0.0006-0.014, p < 0.001) at diagnosis were statistically associated with ED visits after hours.

CONCLUSIONS

Japanese patients with lung cancer frequently visit ED after hours. An ED visit is itself an indicator of poor prognosis.

A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction

BACKGROUND

The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies.

METHODS

Subjects admitted to the authors' department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon.

RESULTS

Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan-Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %.

CONCLUSIONS

In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.

Intra-operative tumour detection and staging in colorectal cancer surgery

AIM

Surgical resection for colorectal cancer involves segmental resection and regional lymphadenectomy. The appropriateness of this 'one-size-fits-all' strategy is questioned as bowel cancer screening programmes result in a shift to earlier stage disease. Currently, the nodal status of a colorectal cancer can only be reliably determined by histopathological examination of the resected specimen. New methods of intra-operative staging are required to allow surgical resection to be tailored to the stage of the disease.

METHOD

A literature search was performed of PubMed and Embase databases using the terms 'colon' OR 'colorectal' AND 'intra-operative detection' OR 'intra-operative staging' OR 'intra-operative detection' OR 'radioimmunoguided surgery'. Articles published between January 1980 and January 2012 were included. Technologies that have the potential to allow intra-operative staging and treatment stratification were identified and further searches performed.

RESULTS

Established techniques such as sentinel lymph node mapping and radioimmunoguided surgery have benefited from combination with other technologies to allow real-time intra-operative staging. Intra-operative fluorescence, using naturally fluorescent biomarkers or fluorescent tumour probes, probably offers the most practical means of intra-operative lymph node staging and may be facilitated using nanotechnology. Optical coherence tomography and real-time elastography have the potential to provide an in vivo'virtual biopsy'.

CONCLUSION

Technological advances may allow accurate intra-operative lymph node staging to facilitate tailored surgical resection. This may become the next paradigm shift in colorectal cancer surgery.

Treatment strategy for colorectal cancer with resectable synchronous liver metastases: Is any evidence-based strategy possible?

Fifteen percent to twenty-five percent of patients affected by colorectal cancer presents with liver metastases at diagnosis. In resectable cases, surgery is the only potentially curative treatment and achieves survival rates up to 50% at 5 years. Management is complex, as colorectal resection, liver resection, chemotherapy, and, in locally advanced mid/low rectal tumors, radiotherapy have to be integrated. Modern medical practice usually relies on evidence-based protocols. Levels of evidence for synchronous metastases are poor: published studies include few recent prospective series and several retrospective analyses collecting a limited number of patients across long periods of time. Data are difficult to be generalized and are mainly representative of single centre's experience, biased by local recruitment, indications and surgical technique. In this context, surgeons have to renounce to "evidence-based medicine" and to adopt a sort of "experience-based medicine". Anyway, some suggestions are possible. Simultaneous colorectal and liver resection can be safely performed whenever minor hepatectomies are planned, while a case-by-case evaluation is mandatory in case of more complex procedures. Neoadjuvant chemotherapy is preferentially scheduled for patients with advanced metastatic tumors to assess disease biology and to control lesions. It can be safely performed with primary tumor in situ, even planning simultaneous resection at its end. Locally advanced mid/low rectal tumor represents a further indication to neoadjuvant therapies, even if treatment's schedule is not yet standardized. In summary, several issues have to be solved, but every single HPB centre should define its proper strategy to optimize patient's selection, disease control and safety and completeness of surgery.

Long-term outcome following surgery for colorectal cancers in octogenarians: a single institution's experience of 204 patients

BACKGROUND

The incidence of colorectal cancer in elderly patients is likely to increase with an aging population. The aims of this study are to review our experience in the surgical management of octogenarians with colorectal cancers and to identify factors that influence the short-term and long-term outcomes.

METHODS

A retrospective review of all octogenarians who underwent surgery for colorectal cancer from December 2002 to October 2008 was performed.

RESULTS

We identified 204 patients with a median age of 84 years (range, 80-97 years). The majority of patients had an American Society of Anesthesiologists score ≥3 (n = 142, 69.6%) and a Charlson Comorbidity Index of ≤3 (n = 128, 62.7%). Emergency surgery was performed in 83 (40.7%) patients. Left-sided malignancy was seen in 138 patients (67.6%). Most of the patients had either stage II (n = 75, 36.8%) or III (n = 69, 33.8%) diseases. The 30-day mortality rate was 16.2% (n = 33). After multivariate analysis, the independent variables predicting worse perioperative complications and death were age >85 years old, emergency surgery, and Charlson Comorbidity Index >3. The median follow-up for the 171 remaining patients was 27 months (range, 2-92 months). The 30-day readmission rate was 2.9% (n = 5). Thirty-one (21.2%) of 146 patients who survived curative surgery developed recurrent disease. Seventy (34.3%) patients died from various etiologies after their first 30 days postoperatively (60% cancer-specific with median survival of 15 months and 40% noncancer-related with median survival of 14 months). Overall and disease-free survivals were adversely affected in patients with advanced malignancy and in those with severe perioperative complications.

CONCLUSIONS

Surgery for octogenarians with colorectal cancers is associated with significant morbidity and mortality rates which are associated with advanced age, emergency surgery, and Charlson Comorbidity Index >3. Long-term survival is dependent on the stage of the malignancy and the presence of severe perioperative complications.

Current state of medical-advice-seeking behaviour for symptoms of colorectal cancer: determinants of failure and delay in medical consultation

AIM

There are few data on the factors associated with healthcare-seeking behaviour for symptoms of colorectal cancer. This study describes the determinants of failure and delay in seeking medical advice for rectal bleeding and change in bowel habit.

METHOD

In total, 1592 persons (56-88 years) were randomly selected from the Hunter Community Study and mailed a questionnaire.

RESULTS

In all, 18% (60/332) of respondents experiencing rectal bleeding and 20% (39/195) reporting change in bowel habit had never consulted a doctor. The rate of delay (>1 month) for each symptom was 18% and 37%. The reasons for delay included the assumption that the symptoms were not serious or that they were benign. Triggers for seeking medical advice varied. Healthcare-seeking behaviour for rectal bleeding had not significantly improved compared with a previous community-based study.

CONCLUSION

The seriousness of symptoms, importance of early detection and prompt medical consultation must be articulated in health messages to at-risk persons.

Resection of the primary tumour versus no resection prior to systemic therapy in patients with colon cancer and synchronous unresectable metastases (UICC stage IV): SYNCHRONOUS--a randomised controlled multicentre trial (ISRCTN30964555)

Background

Currently, it remains unclear, if patients with colon cancer and synchronous unresectable metastases who present without severe symptoms should undergo resection of the primary tumour prior to systemic chemotherapy. Resection of the primary tumour may be associated with significant morbidity and delays the beginning of chemotherapy. However, it may prevent local symptoms and may, moreover, prolong survival as has been demonstrated in patients with metastatic renal cell carcinoma. It is the aim of the present randomised controlled trial to evaluate the efficacy of primary tumour resection prior to systemic chemotherapy to prolong survival in patients with newly diagnosed colon cancer who are not amenable to curative therapy.

Methods/design

The SYNCHRONOUS trial is a multicentre, randomised, controlled, superiority trial with a two-group parallel design. Colon cancer patients with synchronous unresectable metastases are eligible for inclusion. Exclusion criteria are primary tumour-related symptoms, inability to tolerate surgery and/or systemic chemotherapy and history of another primary cancer. Resection of the primary tumour as well as systemic chemotherapy is provided according to the standards of the participating institution. The primary endpoint is overall survival that is assessed with a minimum follow-up of 36 months. Furthermore, it is the objective of the trial to assess the safety of both treatment strategies as well as quality of life.

Discussion

The SYNCHRONOUS trial is a multicentre, randomised, controlled trial to assess the efficacy and safety of primary tumour resection before beginning of systemic chemotherapy in patients with metastatic colon cancer not amenable to curative therapy.

Trial registration

ISRCTN30964555

Laparoscopic versus open colorectal resections in patients with symptomatic stage IV colorectal cancer

BACKGROUND

The purpose of this study was to evaluate short-term and oncologic outcomes of laparoscopic resection (LR) for patients with symptomatic stage IV colorectal cancer compared with open resection (OR).

METHODS

This study is a retrospective analysis of a prospective database. Patients with a minimum follow-up of 12 months after LR or OR for metastatic colorectal cancer were included. All analyses were performed on an "intention-to-treat" basis.

RESULTS

A total of 162 consecutive patients submitted to LR and 127 submitted to OR were included. In the LR group, conversion rate was 26.5 %, mostly due to locally advanced disease (88.4 %). A greater risk of conversion was observed among patients with a tumor size greater than 5 cm regardless the tumor site (P = 0.07). Early postoperative outcome was significantly better for LR group, with a shorter hospital stay (P = 0.008), earlier onset of adjuvant treatment, and similar postoperative complications (P = 0.853) and mortality rates (P = 0.958). LR for rectal cancer was associated with a higher morbidity compared with colon cancer (P = 0.058). During a median follow-up time of 72 months, there was no significant difference in overall survival between the two groups (P = 0.622).

CONCLUSIONS

LR for symptomatic metastatic CRC is safe and, compared with OR, is associated with a shorter hospital stay and with similar survival rates. Concerns remain about LR of bulky tumors and rectal cancers due to the increased risk of conversion and postoperative complications.

Workload and surgeon's specialty for outcome after colorectal cancer surgery

BACKGROUND

A large body of research has focused on investigating the effects of healthcare provider volume and specialization on patient outcomes including outcomes of colorectal cancer surgery. However there is conflicting evidence about the role of such healthcare provider characteristics in the management of colorectal cancer.

OBJECTIVES

To examine the available literature for the effects of hospital volume, surgeon caseload and specialization on the outcomes of colorectal, colon and rectal cancer surgery.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL), and LILACS using free text search words (as well as MESH-terms). We also searched Medline (January 1990-September 2011), Embase (January 1990-September 2011) and registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Non-randomised and observational studies that compared outcomes for colorectal cancer, colon cancer and rectal cancer surgery (overall 5-year survival, five year disease specific survival, operative mortality, 5-year local recurrence rate, anastomotic leak rate, permanent stoma rate and abdominoperineal excision of the rectum rate) between high volume/specialist hospitals and surgeons and low volume/specialist hospitals and surgeons.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias in included studies. Results were pooled using the random effects model in unadjusted and case-mix adjusted meta-analyses.

MAIN RESULTS

Overall five year survival was significantly improved for patients with colorectal cancer treated in high-volume hospitals (HR=0.90, 95% CI 0.85 to 0.96), by high-volume surgeons (HR=0.88, 95% CI 0.83 to 0.93) and colorectal specialists (HR=0.81, 95% CI 0.71 to 0.94). Operative mortality was significantly better for high-volume surgeons (OR=0.77, 95% CI 0.66 to 0.91) and specialists (OR=0.74, 95% CI 0.60 to 0.91), but there was no significant association with higher hospital caseload (OR=0.93, 95% CI 0.84 to 1.04) when only case-mix adjusted studies were included. There were differences in the effects of caseload depending on the level of case-mix adjustment and also whether the studies originated in the US or in other countries. For rectal cancer, there was a significant association between high-volume hospitals and improved 5-year survival (HR=0.85, 95% CI 0.77 to 0.93), but not with operative mortality (OR=0.97, 95% CI 0.70 to 1.33); surgeon caseload had no significant association with either 5-year survival (HR=0.99, 95% CI 0.86 to 1.14) or operative mortality (OR=0.86, 95% CI 0.62 to 1.19) when case-mix adjusted studies were reviewed. Higher hospital volume was associated with significantly lower rates of permanent stomas (OR=0.64, 95% CI 0.45 to 0.90) and APER (OR=0.55, 95% CI 0.42 to 0.72). High-volume surgeons and specialists also achieved lower rates of permanent stoma formation (0.75, 95% CI 0.64 to 0.88) and (0.70, 95% CI 0.53 to 0.94, respectively).

AUTHORS' CONCLUSIONS

The results confirm clearly the presence of a volume-outcome relationship in colorectal cancer surgery, based on hospital and surgeon caseload, and specialisation. The volume-outcome relationship appears somewhat stronger for the individual surgeon than for the hospital; particularly for overall 5-year survival and operative mortality, there were differences between US and non-US data, suggesting provider variability at hospital level between different countries, making it imperative that every country or healthcare system must establish audit systems to guide changes in the service provision based on local data, and facilitate centralisation of services as required. Overall quality of the evidence was low as all included studies were observational by design. In addition there were discrepancies in the definitions of caseload and colorectal specialist. However ethical challenges associated with the conception of randomised controlled trials addressing the volume outcome relationship makes this the best available evidence.

Lesson learned from early and long-term results of 327 cases of coexisting surgical abdominal diseases and aortic aneurysms treated in open and endovascular surgery

Patients with abdominal aortic aneurysm (AAA) frequently have other abdominal pathologies of surgical interest (other diseases, OD). Out of 1,375 elective open aortic replacements for AAA, 315 cases with OD were subdivided in Group 1 (82 patients with "clean wound" OD) and Group 2 (233 patients with "clean-contaminated wound" OD). The results of the sub-groups in which OD was treated at the same time as AAA were analysed (1a, 66 cases and 2a, 86 cases) and compared with OD not treated at the same time as AAA (1b, 16 cases and 2b, 147 cases). EVAR was done in 12 patients with a infrarenal AAA and concomitant abdominal disease. In this group post-operative complications occurred in two patients (endoleaks) and no sign of endograft infection was developed. Mean follow-up was 36 months. Mortality was 0% in Group 1a, 1b, 2b and 5.8% in Group 2a. In Group 1a there were one haemoperitoneum, one ischaemic colitis and one graft infection. In Group 1b there were 4 nefrectomies for renal carcinoma and three emergency hernia repairs within 18 months from AAA operation. In Group 2a the follow-up was uneventful. In Group 2b there was no acute complication of OD and 57.2% of patients were subsequently operated for OD. In the EVAR group the 30-day and late mortality rates were 0 and 25%, respectively and all deaths were cancer-related. Contemporary correction of OD in open surgery for AAA should be performed in clean wound cases, while clean-contaminated operations can be done only in selected cases. EVAR is a valid alternative technique to open vascular surgery for the concomitant treatment of aortic aneurysms and abdominal pathologies.

A century of abdominoperineal excision for rectal cancer

SUMMARY Abdominoperineal excision (APE) for rectal cancer was described by Miles over 100 years ago. The technique and approach have undergone a number of modifications, however, the essence of the procedure remains essentially unchanged. Management of rectal cancer has changed significantly over the century as surgery and adjuvant therapies have evolved, with improved outcome and a marked decline in incidence of APE. It has been widely recognized that tumors requiring APE are associated with higher rates of local recurrence and positive resection margins compared with anterior resection. The modern challenge remains in obtaining oncological equivalence for both procedures. This article reviews the history and evolution of APE, assesses its current status and explores modern perspectives on optimizing the surgical approach.

Multivariate Analysis of the Survival Rate for Treatment Modalities in Incurable Stage IV Colorectal Cancer

PURPOSE

The aim of this study was to compare survival in patients that underwent palliative resection treatment versus non-resection for incurable colorectal cancer (ICRC).

METHODS

The case records of 201 patients with ICRC between January 2000 and December 2009 were reviewed. Demographics, American Society of Anesthesiologists (ASA) score, carcinoembryonic antigen (CEA) level, the location of the colon cancer, histology, metastasis, treatment options and median survival were analyzed retrospectively. We divided the patients into four groups according to the treatment modalities: resection alone, resection with post-operative chemotherapy, non-resection treatment by chemotherapy alone, and stent or bypass. Median survival times were compared according to each treatment option, and the survival rates were analyzed.

RESULTS

105 patients underwent palliative resection whereas 96 were treated with non-resection modalities. A palliative resection was performed in 44 cases for resection alone and in 61 cases for resection with post-operative chemotherapy. In patients treated with non-resection of the primary tumor, chemotherapy alone was done in 65 cases and stent or bypass in 31 cases. Multivariate analysis showed a median survival of 14 months in patients with palliative resections with post-operative chemotherapy, which was significantly higher than those for chemotherapy alone (8 months), primary tumor resection alone (5 months), and stent or bypass (5 months). Gender, age, ASA score, CEA level, the location of colon cancer, histology and the presence of multiple metastases were not independent factors in association with the median survival rate.

CONCLUSION

In the treatment of ICRC, palliative resection followed by post-operative chemotherapy shows the most favorable median survival compared to other treatment options.

Treatment dilemmas in patients with synchronous colorectal liver metastases

Approximately 20 % of patients with colorectal cancer have synchronous liver metastases at the time of diagnosis. In some instances it is difficult to determine the best treatment strategy in these patients. For example, should the primary tumor be removed in those patients with unresectable liver metastases and who do not have any symptoms of the primary tumor? Or which operation should be performed first in patients with rectal cancer and synchronous resectable liver metastases? Unfortunately, there are no clear answers to these questions from prospective randomized trials. In the present article retrospective studies are analyzed in order to define the best possible treatment strategy for patients with synchronous colorectal liver metastases.

Repeat hepatectomy for metastatic colorectal cancer is safe but marginally effective

BACKGROUND

Although hepatectomy for metastatic colorectal cancer (mCRC) offers prolonged survival in up to 40% of people, recurrence rates are high, approaching 70%. Many patients experience recurrent disease in the liver after initial hepatectomy. We examined our experience with repeat hepatectomy for mCRC.

METHODS

After Institutional Review Board approval, we reviewed the records of all patients at a single institution who underwent hepatectomy for mCRC. Repeat hepatectomy was defined as partial liver resection any time after the initial hepatectomy for recurrent mCRC. We estimated time to recurrence and survival by using the Kaplan-Meier method and compared outcomes between groups by using the log-rank test.

RESULTS

From 1998 to 2008, 405 patients underwent hepatectomy for mCRC, and 215 (53%) experienced disease recurrence at a median of 13 months. Of 150 patients with liver-only or liver-predominant recurrence, 52 (35%) underwent repeat hepatectomy. The median time to recurrence after repeat hepatectomy was 10 months, and median overall survival was 19 months. There was one (1.9%) perioperative death, and there were 14 (27%) major complications. The median overall survival in the repeat hepatectomy group from the time of recurrence after initial hepatectomy was 22 months, compared with 15 months in the 98 patients with liver recurrence who were not selected for repeat hepatectomy (P=0.02).

CONCLUSIONS

Repeat hepatectomy for mCRC is feasible in highly selected patients, with acceptable perioperative morbidity and mortality. Although repeat hepatectomy should be considered, recurrence rates are high. Although the initial hepatectomy for mCRC is potentially curative, recurrence of metastatic disease in the liver is unlikely to be cured.

Colorectal cancer with multiple metastases: is palliative surgery needed?

In patients with symptomatic incurable metastatic colorectal cancer (mCRC), the goal of resection of the primary lesion is to palliate cancer-related morbidity, including obstruction, bleeding, or perforation. In patients with asymptomatic primary tumors and incurable metastatic disease, however, the necessity of primary tumor resection is less clear. Although several retrospective analyses suggest survival benefit in patients who undergo resection of the primary tumor, applying this older evidence to modern patients is out of date for several reasons. Modern chemotherapy regimens incorporating the novel cytotoxic agents oxaliplatin and irinotecan, as well as the target agents bevacizumab and cetuximab, have improved median survival from less than 1 year with the only available single-agent 5-fluorouracil until the mid-1990s to over 2 years. In addition to significant prolongation of overall survival, combinations of novel chemotherapeutic and target agents have allowed improved local and distant tumor control, decreasing the likelihood of local tumor-related complications requiring surgical resection. Resection of an asymptomatic primary tumor risks surgical complications and may postpone the administration of chemotherapy that may offer both systemic and local control. In conclusion, the morbidity and the mortality of unnecessary surgery or surgery that does not improve quality of life or survival in patients with mCRC of a limited life expectancy should be carefully evaluated. With the availability of effective combinations of chemotherapy and target agents, systemic therapy for the treatment of life-threatening metastases would be a preferable treatment strategy for unresectable asymptomatic patients with mCRC.

Reassessing the need for primary tumor surgery in unresectable metastatic colorectal cancer: overview and perspective

In the absence of symptoms, primary tumor resection in patients who present with unresectable metastatic colorectal cancer is of uncertain benefit. Prophylactic surgery has been traditionally considered in this setting in order to prevent subsequent complications of perforation, obstruction, or bleeding later during the treatment course, which may require urgent surgery associated with higher mortality. However, recent data have called into question the efficacy of this upfront surgical strategy. We provide a brief overview of how current combinations of systemic chemotherapy including fluorouracil, oxaliplatin, irinotecan, and targeted biologic agents have allowed improved local (in addition to distant) tumor control, significantly decreasing the incidence of late primary-related complications requiring surgery from roughly 20% in the era of single-agent fluoropyrimidine chemotherapy to almost 7% in the era of modern triple-drug chemotherapy. In addition, we attempt to highlight those factors most associated with subsequent primary tumor-related complications in an effort to identify the subset of patients with synchronous metastatic colorectal cancer who might benefit from a surgery-first approach. Finally, we discuss modern nonsurgical options available for palliation of the primary colorectal tumor and review the outcome of patients for which emergent surgery is eventually required to address primary-related symptoms.

Availability of acute care surgeons improves outcomes in patients requiring emergent colon surgery

BACKGROUND

The need for emergent colon surgery is a common cause of severe sepsis/septic shock and mortality among surgical patients. We wanted to benchmark our outcomes against those of the National Surgical Quality Improvement Program (NSQIP). We hypothesized that having acute care surgeons to provide comprehensive perioperative care and rapid source control surgery would improve outcome.

METHODS

We queried the 2005 to 2007 NSQIP dataset and our prospective database for patients with severe sepsis/septic shock requiring emergency colon surgery. Demographics, Acute Physiology and Chronic Health Evaluation II score, sepsis source, and hospital mortality data were obtained for all patients.

RESULTS

Both cohorts were similar with regard to age and sex. The overall mortality rate for patients in our dataset was 28.3% compared with 40.1% in the NSQIP dataset (P = .06). The average Acute Physiology and Chronic Health Evaluation II score for our patients was 31 ± 8.2 with a predicted mortality rate of 73% (P < .0001 when compared with actual mortality rate of 28.3%).

CONCLUSIONS

Patients with severe sepsis/septic shock requiring emergent colon surgery have a high mortality rate. Delivery of comprehensive emergency surgical care by acute care surgeons appears to improve survival.

Decisions to operate: the ASA grade 5 dilemma

INTRODUCTION

Deciding to operate on high risk patients suffering catastrophic surgical emergencies can be problematic. Patients are frequently classed as American Society of Anesthesiologists (ASA) grade 5 and, as a result, aggressive but potentially lifesaving intervention is withheld. The aim of our study was to review the short-term outcomes in patients who were classed as ASA grade 5 but subsequently underwent surgery despite this and to compare the ASA scoring model to other predictors of surgical outcome.

METHODS

All patients undergoing emergency surgery with an ASA grade of 5 were identified. Patient demographics, indications for surgery, intraoperative findings and outcomes were recorded. In addition to the ASA scores, retrospective Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P POSSUM) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated and compared to the observed outcomes.

RESULTS

Nine patients (39%) survived to discharge. ASA grade was a poor predictor of outcome. P POSSUM and APACHE II scores correlated significantly with each other and with observed outcomes when predicting surgical mortality. The median stay for survivors in the intensive care unit was nine days.

CONCLUSIONS

In times of an ageing population, the number of patients suffering catastrophic surgical events will increase. Intervention, with little hope of a cure, a return to independent living or an acceptable quality of life, leads to unnecessary end-of-life suffering for patients and their relatives, and consumes sparse resources. The accuracy and reliability of ASA grade 5 as an outcome predictor has been questioned. P POSSUM and APACHE II scoring systems are significantly better predictors of outcome and should be used more frequently to aid surgical decision-making in high risk patients.