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Peterson KJ, Drezdzon MK, Sparapani R, Calata JF, Ridolfi TJ, Ludwig KA, Peterson CY. Traveling Long Distances for Rectal Cancer Care: Institutional Outcomes and Patient Experiences. J Surg Res 2024; 302:916-924. [PMID: 39265279 DOI: 10.1016/j.jss.2024.07.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 07/18/2024] [Accepted: 07/24/2024] [Indexed: 09/14/2024]
Abstract
INTRODUCTION Mounting evidence supports traveling to high-volume centers for complex surgical procedures, such as a proctectomy, yet the burden of travel and outcomes of patients traveling long distances is not yet clear. Thus, we aimed to evaluate oncologic outcomes, quality of life, and travel burdens for patients treated for rectal cancer at a single tertiary-care institution. METHODS A retrospective study of patients treated with proctectomy for locally advanced rectal cancer was performed comparing long and short travel distance (STD) cohorts. Primary outcome measures included overall mortality, disease recurrence, and quality of life. Secondary outcomes included out-of-pocket expenses. The cohorts were compared using Wilcoxon rank-sum and Chi-square tests for continuous and categorical variables, respectively. Kaplan-Meier plots were created to evaluate overall and disease-free survival. RESULTS Among 102 patients, 51 (50%) were classified as long travel distance (LTD, mean 57.8 miles) and 51 (50%) were classified as STD (mean 12.8 miles). There was no statistical difference in 5-y mortality (4% LTD versus 4% STD, P = 1.000), disease recurrence (26% LTD versus 18% STD, P = 0.336), or quality of life (0.85 LTD versus 0.87 STD, P = 0.690). The LTD cohort did have significantly lower postresection compliance with surveillance (84% LTD versus 96% STD, P = 0.046). LTD cohort also had significantly more lodging ($77.1 LTD versus $0 STD, P = 0.025) and transportation expenses ($133.6 LTD versus $92.6 STD, P = 0.010). CONCLUSIONS As the surgical management of rectal cancer becomes increasingly centralized, this study found patients who traveled long-distances received comparable care with outcomes similar to those who lived locally. Higher travel costs and lower compliance with surveillance were identified as barriers to care in the long-distance population, but a number of solutions can be implemented to address these issues.
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Affiliation(s)
- Kent J Peterson
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Melissa K Drezdzon
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Rodney Sparapani
- Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jed F Calata
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Timothy J Ridolfi
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Kirk A Ludwig
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin
| | - Carrie Y Peterson
- Division of Colon and Rectal Surgery, Department of Surgery, Milwaukee, Wisconsin.
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Sancho-Muriel J, Giner F, Cholewa H, Garcia-Granero Á, Roselló S, Flor-Lorente B, Cervantes A, Garcia-Granero E, Frasson M. The percentage of mesorectal infiltration as a prognostic factor after curative surgery for pT3 rectal cancer. Colorectal Dis 2023. [PMID: 36790134 DOI: 10.1111/codi.16522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/16/2023]
Abstract
AIM The aim of this study is to evaluate the prognostic value of a novel variable - the percentage of mesorectal infiltration (PMI) - in pT3 rectal cancer. METHOD A cohort of 241 patients with pT3 rectal adenocarcinoma, operated on between February 2002 and May 2019, was selected for the analysis. Data concerning patient, treatment and tumour characteristics were collected. The depth of mesorectal infiltration (DMI) and the distance between the deepest invasion and the circumferential resection margin (CRM) were measured. The PMI was calculated using a formula combining these parameters. RESULTS Neoadjuvant therapy was administered in 33.2% of cases. A complete mesorectal excision was achieved in 74% of patients. The CRM was affected in 24 patients (9.9%). The 5-year actuarial local recurrence (LR), overall recurrence (OR) and overall survival (OS) rates were 7.5%, 22.9% and 72.4%, respectively. The PMI was significantly associated with worse oncological outcomes regarding LR (p = 0.009), OR (p = 0.001) and OS (p = 0.016) rates. A cut-off value of PMI >60% had the highest specificity (80%) for LR (p = 0.026), OR (p = 0.04) and OS (p = 0.07). CONCLUSION The PMI has an adverse prognostic impact on the oncological results following surgery for pT3 rectal cancer. It allows prediction of the risk of both LR and distant recurrence with higher accuracy than the DMI or the distance to the CRM. A PMI >60% may be used as a cut off value while subclassifying pT3 rectal tumours. It may influence decision-making while establishing adjuvant treatment and the follow-up schedule.
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Affiliation(s)
| | - Francisco Giner
- University of Valencia, Valencia, Spain.,Department of Pathology, University Hospital La Fe, Valencia, Spain
| | - Hanna Cholewa
- Colorectal Unit, University Hospital La Fe, Valencia, Spain
| | | | - Susana Roselló
- Department of Medical Oncology, Biomedical Research Institute Incliva, University of Valencia, Valencia, Spain
| | - Blas Flor-Lorente
- Colorectal Unit, University Hospital La Fe, Valencia, Spain.,University of Valencia, Valencia, Spain
| | - Andres Cervantes
- University of Valencia, Valencia, Spain.,Department of Medical Oncology, Biomedical Research Institute Incliva, University of Valencia, Valencia, Spain
| | - Eduardo Garcia-Granero
- Colorectal Unit, University Hospital La Fe, Valencia, Spain.,University of Valencia, Valencia, Spain
| | - Matteo Frasson
- Colorectal Unit, University Hospital La Fe, Valencia, Spain.,University of Valencia, Valencia, Spain
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Chioreso C, Gao X, Gribovskaja-Rupp I, Lin C, Ward MM, Schroeder MC, Lynch CF, Chrischilles EA, Charlton ME. Hospital and Surgeon Selection for Medicare Beneficiaries With Stage II/III Rectal Cancer: The Role of Rurality, Distance to Care, and Colonoscopy Provider. Ann Surg 2021; 274:e336-e344. [PMID: 31714306 PMCID: PMC7176526 DOI: 10.1097/sla.0000000000003673] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine factors associated with rectal cancer surgery performed at high-volume hospitals (HVHs) and by high-volume surgeons (HVSs), including the roles of rurality and diagnostic colonoscopy provider characteristics. SUMMARY OF BACKGROUND DATA Although higher-volume hospitals/surgeons often achieve superior surgical outcomes, many rectal cancer resections are performed by lower-volume hospitals/surgeons, especially among rural populations. METHODS Patients age 66+ diagnosed from 2007 to 2011 with stage II/III primary rectal adenocarcinoma were selected from surveillance, epidemiology, and end results-medicare data. Patient ZIP codes were used to classify rural status. Hierarchical logistic regression was used to determine factors associated with surgery by HVH and HVS. RESULTS Of 1601 patients, 22% were rural and 78% were urban. Fewer rural patients received surgery at a HVH compared to urban patients (44% vs 65%; P < 0.0001). Compared to urban patients, rural patients more often had colonoscopies performed by general surgeons (and less often from gastroenterologists or colorectal surgeons), and lived substantially further from HVHs; these factors were both associated with lower odds of surgery at a HVH or by a HVS. In addition, whereas over half of both rural and urban patients received their colonoscopy and surgery at the same hospital, rural patients who stayed at the same hospital were significantly less likely to receive surgery at a HVH or by a HVS compared to urban patients. CONCLUSIONS Rural rectal cancer patients are less likely to receive surgery from a HVH/HVS. The role of the colonoscopy provider has important implications for referral patterns and initiatives seeking to increase centralization.
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Affiliation(s)
- Catherine Chioreso
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Xiang Gao
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Chi Lin
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Marcia M. Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA
| | - Mary C. Schroeder
- Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, IA
| | - Charles F. Lynch
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
- Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, IA
| | | | - Mary E. Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
- Iowa Cancer Registry, University of Iowa College of Public Health, Iowa City, IA
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Bogveradze N, Lambregts DMJ, El Khababi N, Dresen RC, Maas M, Kusters M, Tanis PJ, Beets-Tan RGH. The sigmoid take-off as a landmark to distinguish rectal from sigmoid tumours on MRI: Reproducibility, pitfalls and potential impact on treatment stratification. Eur J Surg Oncol 2021; 48:237-244. [PMID: 34583878 DOI: 10.1016/j.ejso.2021.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/10/2021] [Accepted: 09/13/2021] [Indexed: 12/28/2022] Open
Abstract
PURPOSE The sigmoid take-off (STO) was recently introduced as a preferred landmark, agreed upon by expert consensus recommendation, to discern rectal from sigmoid cancer on imaging. Aim of this study was to assess the reproducibility of the STO, explore its potential treatment impact and identify its main interpretation pitfalls. METHODS Eleven international radiologists (with varying expertise) retrospectively assessed n = 155 patients with previously clinically staged upper rectal/rectosigmoid tumours and re-classified them using the STO as completely below (rectum), straddling the STO (rectosigmoid) or completely above (sigmoid), after which scores were dichotomized as rectum (below/straddling STO) and sigmoid (above STO), being the clinically most relevant distinction. A random subset of n = 48 was assessed likewise by 6 colorectal surgeons. . RESULTS Interobserver agreement (IOA) for the 3-category score ranged from κ0.19-0.82 (radiologists) and κ0.32-0.72 (surgeons), with highest scores for the most experienced radiologists (κ0.69-0.76). Of the 155 cases, 44 (28%) were re-classified by ≥ 80% of radiologists as sigmoid cancers; 36 of these originally received neoadjuvant treatment which in retrospect might have been omitted if the STO had been applied. Main interpretation pitfalls were related to anatomical variations, borderline cases near the STO and angulation of axial imaging planes. CONCLUSIONS Good agreement was reached for experienced radiologists. Despite considerable variation among less-expert readers, use of the STO could have changed treatment in ±1/4 of patients in our cohort. Identified interpretation pitfalls may serve as a basis for teaching and to further optimize MR protocols.
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Affiliation(s)
- Nino Bogveradze
- Dept. of Radiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; GROW School for Oncology & Developmental Biology - University of Maastricht, Maastricht, the Netherlands; Dept. of Radiology, Acad. F. Todua Medical Center, Research Institute of Clinical Medicine, Tbilisi, Georgia
| | - Doenja M J Lambregts
- Dept. of Radiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Najim El Khababi
- Dept. of Radiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; GROW School for Oncology & Developmental Biology - University of Maastricht, Maastricht, the Netherlands
| | | | - Monique Maas
- Dept. of Radiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Miranda Kusters
- Dept. of Surgery, Amsterdam University Medical Centres, Cancer Centre Amsterdam, the Netherlands
| | - Pieter J Tanis
- Dept. of Surgery, Amsterdam University Medical Centres, Cancer Centre Amsterdam, the Netherlands
| | - Regina G H Beets-Tan
- Dept. of Radiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; GROW School for Oncology & Developmental Biology - University of Maastricht, Maastricht, the Netherlands
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Evaluation of the learning curve of transanal total mesorectal excision: single-centre experience. Wideochir Inne Tech Maloinwazyjne 2019; 15:36-42. [PMID: 32117484 PMCID: PMC7020721 DOI: 10.5114/wiitm.2019.82733] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 01/13/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction Transanal total mesorectal excision (TaTME) has been recently proposed to overcome the difficulties of the standard TME approach, allowing better visualization and dissection of the mesorectal fascia. Although TaTME seems very promising, the evidence and body of knowledge on achieving proficiency in performing it are still sparse. Aim To evaluate the learning curve of TaTME based on a single centre’s experience. Material and methods Consecutive patients undergoing TaTME since 2014 in a tertiary referral department were included in the study. All procedures were performed by one experienced surgeon. CUSUM curve analyses were performed to evaluate learning curves. Results Sixty-six patients underwent TaTME. After analysis of postoperative morbidity rate, intraoperative adverse effects and operative time, we estimated that 40 cases are needed to achieve TaTME proficiency. Subsequently, patients were divided into two groups: before (40 patients) and after overcoming the learning curve (26 patients). Group 1 had higher readmission (p = 0.041) and complication rates (p = 0.019). There were no statistically significant differences in terms of intraoperative adverse effects, length of stay or pathological quality of the specimen. Conclusions Transanal total mesorectal excision is a promising yet technically demanding procedure and requires at least 40 cases to complete the learning curve. More data are needed to introduce it as a standard procedure for low rectal cancer treatment.
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Brown LR, McLean RC, Perren D, O'Loughlin P, McCallum IJ. Evaluating the effects of surgical subspecialisation on patient outcomes following emergency laparotomy: A retrospective cohort study. Int J Surg 2019; 62:67-73. [PMID: 30673595 DOI: 10.1016/j.ijsu.2019.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 12/27/2018] [Accepted: 01/12/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND General surgeons have become increasingly subspecialised in their elective practice. Emergency laparotomies, however, are performed by a range of subspecialists who may or may not have an interest in the affected area of gastrointestinal tract. This retrospective cohort study evaluates the impact of surgical subspecialisation on patient outcomes following emergency laparotomy. METHODS Data was collected for patients who underwent an emergency abdominal procedure on the gastrointestinal tract in the North of England from 2001 to 2016. This included demographics, co-morbidities, diagnoses and procedures undertaken. Patients were grouped according to consultants' subspecialist interest. The primary outcome of interest was 30-day postoperative mortality. RESULTS 24,291 emergency laparotomies were performed with an associated 30-day postoperative mortality of 11.7%. Laparotomies undertaken by upper gastrointestinal (UGI) or colorectal surgeons have significantly lower mortality (10.1%) when compared with other subspecialities (13.5%). More specifically, mortality was decreased for UGI (7.9% vs. 12.9%) and colorectal procedures (10.9% vs. 14.2%) when performed by surgeons with a specialist interest in the relevant area of the gastrointestinal tract (both p < 0.001). The utilisation of laparoscopic surgery is higher, in both UGI (21.8% vs. 9.0%) and colorectal procedures (7.2% vs. 3.5%), when the causative pathology is relevant to the surgeon's subspeciality (both p < 0.001). CONCLUSION Mortality following emergency laparotomy is improved when performed under the care of gastrointestinal surgeons. Both UGI and colorectal emergency procedures have improved outcomes, with lower mortality and higher rates of laparoscopy, when under the care of a surgeon with a subspecialist interest in the affected area of the gastrointestinal tract.
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Affiliation(s)
- Leo R Brown
- Health Education England North East, Waterfront 4 Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, UK.
| | - Ross C McLean
- Health Education England North East, Waterfront 4 Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, UK
| | - Daniel Perren
- Health Education England North East, Waterfront 4 Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, UK
| | - Paul O'Loughlin
- Department of Colorectal Surgery, Queen Elizabeth Hospital, Gateshead, NE9 6SX, UK
| | - Iain Jd McCallum
- Department of Colorectal Surgery, North Tyneside Hospital, North Shields, Northumbria, NE29 8NH, UK
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Li N, Tan F, Qiu B, Li J, Zhao J, Gao Y, Wang D, Mao Y, Xue Q, Mu J, Gao S, He J. [Effect of Thoracic Surgeons on Lung Cancer Patients' Survival]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2018. [PMID: 29526177 PMCID: PMC5973014 DOI: 10.3779/j.issn.1009-3419.2018.02.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
背景与目的 外科医生是肺癌患者手术治疗的直接决策者和执行者,是否医生间的差异会影响到患者生存尚不清楚。本研究分析不同的胸外科医生手术治疗的患者5年生存率,评估医生的影响和作用。 方法 回顾性分析2002年-2007年5年间,在中国医学科学院肿瘤医院胸外科进行手术治疗的肺癌患者。依据不同主刀医生进行分组,比较患者基本信息、手术方式、短期结果和长期生存之间的差异。 结果 共有11位经验丰富的胸外科医生主刀治疗的712例患者纳入本研究。各位医生诊治患者的性别、年龄、吸烟、病理类型间无明显差异。而在临床分期、手术方式、手术时间、术中输血率、淋巴结清扫个数和姑息性切除比例、术后严重并发症发生率、围手术期死亡率等方面都存在显著差异。不同医生治疗患者5年生存率存在显著差异,这种差异在各临床期别分析中均可见到,具有一致性。多因素分析中提示主刀医生是影响患者预后生存的独立因素。 结论 主刀医生对于肺癌患者的治疗效果存在显著影响。
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Affiliation(s)
- Ning Li
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Fengwei Tan
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Bin Qiu
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Jiagen Li
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Jun Zhao
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Yushun Gao
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Dali Wang
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Yousheng Mao
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Qi Xue
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Juwei Mu
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Shugeng Gao
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
| | - Jie He
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100021, China
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Roselló S, Papaccio F, Roda D, Tarazona N, Cervantes A. The role of chemotherapy in localized and locally advanced rectal cancer: A systematic revision. Cancer Treat Rev 2018; 63:156-171. [PMID: 29407455 DOI: 10.1016/j.ctrv.2018.01.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 01/07/2018] [Accepted: 01/09/2018] [Indexed: 12/28/2022]
Abstract
Curative treatment of rectal cancer depends on an optimal surgical resection, with the addition of neoadjuvant radiotherapy (RT) with or without concomitant chemotherapy (ChT) in more advanced tumors. The role of adjuvant ChT is controversial and a more intensified neoadjuvant approach with the addition of ChT before or after RT, or even as single modality, is currently being explored in trials. A systematic review selecting randomised phase II and III trials on the role of ChT in localized rectal cancer was performed. Data show that neoadjuvant ChRT improves locoregional control in resected rectal cancer. Short-course RT (SCRT) could give similar outcomes to ChRT. The addition of oxaliplatin to neoadjuvant ChRT marginally increases the pathological complete remission rate without improving survival and increasing toxicity. A more intensified approach remains investigational as trials to date have not shown significant advantages. Adjuvant ChT trials after preoperative ChRT are contentious, although the addition of oxaliplatin in high risk patients may benefit outcomes. Despite a wide heterogeneity in the target population, different staging procedures and diverse treatment approaches among different trials, this systematic review confirms the role of ChT in combination with neoadjuvant long-course RT. Adjuvant ChT could be of value in selected patients with high-risk features, mainly if they do not respond to neoadjuvant RT. Further investigation is warranted on more intensified neoadjuvant regimens including ChT for MRI-defined high-risk patients.
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Affiliation(s)
- Susana Roselló
- CIBERONC, Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - Federica Papaccio
- Oncologia Medica, Dipartimento di Internistica Clinica e Sperimentale "F. Magrassi", Università degli Studi della Campania Luigi Vanvitelli, Napoli, Italy
| | - Desamparados Roda
- CIBERONC, Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - Noelia Tarazona
- CIBERONC, Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - Andrés Cervantes
- CIBERONC, Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain.
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Svensson Neufert R, Teurneau-Hermansson K, Lydrup ML, Jörgren F, Buchwald P. Rectal washout in rectal cancer surgery: A survey of Swedish practice – Questionnaire. INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2018.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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10
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García-Granero E, Navarro F, Cerdán Santacruz C, Frasson M, García-Granero A, Marinello F, Flor-Lorente B, Espí A. Individual surgeon is an independent risk factor for leak after double-stapled colorectal anastomosis: An institutional analysis of 800 patients. Surgery 2017; 162:1006-1016. [PMID: 28739093 DOI: 10.1016/j.surg.2017.05.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 05/14/2017] [Accepted: 05/26/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Our aim was to assess whether the individual surgeon is an independent risk factor for anastomotic leak in double-stapled colorectal anastomosis after left colon and rectal cancer resection. METHODS This retrospective analysis of a prospectively collected database consists of a consecutive series of 800 patients who underwent an elective left colon and rectal resection with a colorectal, double-stapled anastomosis between 1993 and 2009 in a specialized colorectal unit of a tertiary hospital with 7 participating surgeons. The main outcome variable was anastomotic leak, defined as leak of luminal contents from a colorectal anastomosis between 2 hollow viscera diagnosed radiologically, clinically, endoscopically, or intraoperatively. Pelvic abscesses were also considered to be an anastomotic leak. Radiologic examination was performed when there was clinical suspicion of leak. RESULTS Anastomotic leak occurred in 6.1% of patients, of which 33 (67%) were treated operatively, 6 (12%) with radiologic drains, and 10 (21%) by medical treatment. Postoperative mortality rate was 2.9% for the whole group of 800 patients. In patients with anastomotic leak, mortality rate increased up to 16% vs 2.0% in patients without anastomotic leak (P < .0001). At multivariate analysis, rectal location of tumor, male sex, bowel obstruction preoperatively, tobacco use, diabetes, perioperative transfusion, and the individual surgeon were independent risk factors for anastomotic leak. The surgeon was the most important factor (mean odds ratio 4.9; range 1.0 to 13.5). The variance of anastomotic leak between the different surgeons was 0.56 in the logit scale. CONCLUSION The individual surgeon is an independent risk factor for leakage in double-stapled, colorectal, end-to-end anastomosis after oncologic left-sided colorectal resection.
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Affiliation(s)
- Eduardo García-Granero
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain
| | - Francisco Navarro
- Department of General Surgery, Colorectal Surgery Unit. Hospital de Manises, Manises, Valencia, Spain
| | - Carlos Cerdán Santacruz
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain.
| | - Matteo Frasson
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain
| | - Alvaro García-Granero
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain
| | - Franco Marinello
- Department of General Surgery, Colorectal Surgery Unit, Hospital Vall D´Hebrón, Barcelona, Spain
| | - Blas Flor-Lorente
- Department of General Surgery, Digestive Surgery Unit. Hospital Universitario y Politécnico la Fe, University of Valencia, Valencia, Spain
| | - Alejandro Espí
- Department of General Surgery, Hospital Clínico Universitario, Valencia, Spain
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Self-expanding metallic stent as a bridge to surgery in the treatment of left colon cancer obstruction: Cost-benefit analysis and oncologic results. Cir Esp 2017; 95:143-151. [PMID: 28336185 DOI: 10.1016/j.ciresp.2016.12.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 12/26/2016] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The use of a self-expanding metallic stent as a bridge to surgery in acute malignant left colonic obstruction has been suggested as an alternative treatment to emergency surgery. The aim of the present study was to compare the morbi-mortality, cost-benefit and long-term oncological outcomes of both therapeutic options. METHODS This is a prospective, comparative, controlled, non-randomized study (2005-2010) performed in a specialized unit. The study included 82 patients with left colon cancer obstruction treated by stent as a bridge to surgery (n=27) or emergency surgery (n=55) operated with local curative intention. The main outcome measures (postoperative morbi-mortaliy, cost-benefit, stoma rate and long-term oncological outcomes) were compared based on an "intention-to-treat" analysis. RESULTS There were no significant statistical differences between the two groups in terms of preoperative data and tumor characteristics. The technically successful stenting rate was 88.9% (11.1% perforation during stent placement) and clinical success was 81.4%. No difference was observed in postoperative morbi-mortality rates. The primary anastomosis rate was higher in the bridge to surgery group compared to the emergency surgery group (77.8% vs. 56.4%; P=.05). The mean costs in the emergency surgery group resulted to be €1,391.9 more expensive per patient than in the bridge to surgery group. There was no significant statistical difference in oncological long-term outcomes. CONCLUSIONS The use of self-expanding metalllic stents as a bridge to surgery is a safe option in the urgent treatment of obstructive left colon cancer, with similar short and long-term results compared to direct surgery, inferior mean costs and a higher rate of primary anastomosis.
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Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Kelly KN, Hensley BJ, Rickles AS, Noyes K, Fleming FJ, Monson JR. High volume improves outcomes: The argument for centralization of rectal cancer surgery. Surgery 2016; 159:736-48. [DOI: 10.1016/j.surg.2015.09.021] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/04/2015] [Accepted: 09/23/2015] [Indexed: 11/28/2022]
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Selective approach for upper rectal cancer treatment: total mesorectal excision and preoperative chemoradiation are seldom necessary. Dis Colon Rectum 2015; 58:556-65. [PMID: 25944427 DOI: 10.1097/dcr.0000000000000349] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The implementation of preoperative chemoradiation combined with total mesorectal excision has reduced local recurrence rates in rectal cancer. However, the use of both types of treatment in upper rectal cancer is controversial. OBJECTIVE The purpose of this work was to assess oncological results after radical resection of upper rectal cancers compared with sigmoid, middle, and lower rectal cancers and to determine risk factors for local recurrence in upper rectal cancer. DESIGN This was a retrospective analysis of prospectively collected data. SETTINGS This study was conducted in a tertiary care referral hospital in Valencia, Spain. PATIENTS Analysis included 1145 patients who underwent colorectal resection with primary curative intent for primary sigmoid (n = 450), rectosigmoid (n = 70), upper rectal (n = 178), middle rectal (n = 186), or lower rectal (n = 261) cancer. MAIN OUTCOME MEASURES Oncological results, including local recurrence, disease-free survival, and cancer-specific survival, were compared between the different tumor locations. Univariate and multivariate analyses were performed to identify risk factors for local recurrence in upper rectal cancer. RESULTS A total of 147 patients (82.6%) with upper rectal tumors underwent partial mesorectal excision, and only 10 patients (5.6%) of that group received preoperative chemoradiation. The 5-year actuarial local recurrence, disease-free survival, and cancer-specific survival rates for upper rectal tumors were 4.9%, 82.0%, and 91.6%. Local recurrence rates showed no differences when compared among all of the locations (p = 0.20), whereas disease-free survival and cancer-specific survival were shorter for lower rectal tumors (p = 0.006; p = 0.003). The only independent risk factor for local recurrence in upper rectal cancer was an involved circumferential resection margin at pathologic analysis (HR, 14.23 (95% CI, 2.75-73.71); p = 0.002). LIMITATIONS This was a single-institution, retrospective study. CONCLUSIONS Most upper rectal tumors can be treated with partial mesorectal excision without the systematic use of preoperative chemoradiation. Involvement of the mesorectal fascia was the only independent risk factor for local recurrence in these tumors.
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Evaluation of mesorectal fascia in mid and low anterior rectal cancer using endorectal ultrasound is feasible and reliable: a comparison with MRI findings. Dis Colon Rectum 2014; 57:709-14. [PMID: 24807595 DOI: 10.1097/dcr.0000000000000096] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Accuracy of MRI in assessing mesorectal fascia and predicting circumferential resection margin decreases in low anterior rectal tumors. OBJECTIVE The purpose of this work was to evaluate the accuracy of endorectal ultrasound in predicting the pathologic circumferential resection margin in low rectal anterior tumors and to compare it with MRI findings. DESIGN This was a prospective series comparing the preoperative circumferential resection margin assessed by endorectal ultrasound and MRI with pathologic examination. SETTINGS The study was conducted by a specialized colorectal multidisciplinary team at a tertiary teaching hospital. PATIENTS Between 2002 and 2008, 76 patients with mid to low rectal cancer were preoperatively evaluated by endorectal ultrasound and MRI and underwent total mesorectal excision without neoadjuvant radiochemotherapy. Twenty-seven patients with posterior or postero-lateral tumors were excluded, leaving 49 patients with anterior or antero-lateral tumors for the present subanalysis. We compared preoperative circumferential resection margin status using endorectal ultrasound and MRI with pathologic examination. INTERVENTIONS We conducted a comparison between preoperative circumferential resection margin status and pathologic examination after total mesorectal excision surgery. MAIN OUTCOME MEASURES Accuracy in predicting pathologic circumferential resection margin status was measured. RESULTS Overall accuracy of endorectal ultrasound and MRI in assessing circumferential resection margin status was 83.7% and 91.8%, with negative predictive values of 97.2% and 97.5%. When focusing on low rectal tumors, the overall accuracy of endorectal ultrasound increased to 87.5%, whereas the accuracy of MRI decreased to 87.5%, with a negative predictive value of 95.6% for both diagnostic tests. LIMITATIONS The sample size is small, and interobserver variability in radiologic assessment was not evaluated. CONCLUSIONS Endorectal ultrasound can help MRI in predicting circumferential resection margin involvement in mid to low anterior rectal cancer, especially at the low third of the rectum, with a high negative predictive value.
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Chawla N, Butler EN, Lund J, Warren JL, Harlan LC, Yabroff KR. Patterns of colorectal cancer care in Europe, Australia, and New Zealand. J Natl Cancer Inst Monogr 2014; 2013:36-61. [PMID: 23962509 DOI: 10.1093/jncimonographs/lgt009] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Colorectal cancer is the second most common cancer in women and the third most common in men worldwide. In this study, we used MEDLINE to conduct a systematic review of existing literature published in English between 2000 and 2010 on patterns of colorectal cancer care. Specifically, this review examined 66 studies conducted in Europe, Australia, and New Zealand to assess patterns of initial care, post-diagnostic surveillance, and end-of-life care for colorectal cancer. The majority of studies in this review reported rates of initial care, and limited research examined either post-diagnostic surveillance or end-of-life care for colorectal cancer. Older colorectal cancer patients and individuals with comorbidities generally received less surgery, chemotherapy, or radiotherapy. Patients with lower socioeconomic status were less likely to receive treatment, and variations in patterns of care were observed by patient demographic and clinical characteristics, geographical location, and hospital setting. However, there was wide variability in data collection and measures, health-care systems, patient populations, and population representativeness, making direct comparisons challenging. Future research and policy efforts should emphasize increased comparability of data systems, promote data standardization, and encourage collaboration between and within European cancer registries and administrative databases.
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Affiliation(s)
- Neetu Chawla
- Health Services and Economics Branch/Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Dr, Room 3E346, Rockville, MD 20852, USA
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Advancing standards of rectal cancer care: lessons from Europe adapted to the vast expanse of North America. Dis Colon Rectum 2014; 57:260-6. [PMID: 24401890 DOI: 10.1097/dcr.0000000000000021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Screening for colorectal cancer: What is the impact on the determinants of outcome? Crit Rev Oncol Hematol 2013; 85:342-9. [DOI: 10.1016/j.critrevonc.2012.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 07/23/2012] [Accepted: 08/14/2012] [Indexed: 12/17/2022] Open
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Levine RA, Chawla B, Bergeron S, Wasvary H. Multidisciplinary management of colorectal cancer enhances access to multimodal therapy and compliance with National Comprehensive Cancer Network (NCCN) guidelines. Int J Colorectal Dis 2012; 27:1531-8. [PMID: 22645076 DOI: 10.1007/s00384-012-1501-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2012] [Indexed: 02/06/2023]
Abstract
PURPOSE Multidisciplinary teams have become increasingly desirable for managing complex disease but little objective data exist to support this approach. The aim of our study was to determine the impact of a multidisciplinary clinic on the management of colorectal cancer. METHODS Data were prospectively collected on all patients with newly diagnosed colorectal cancer referred to the multidisciplinary clinic at our institution in 2009 and compared to a control group of all patients managed outside the clinic from 2008 to 2009. Comprehensiveness of preoperative evaluation was determined by frequency of abdominal and chest CT, CEA testing, and transrectal ultrasound. Access to multimodal care was measured by frequency of oncology consultation and treatment, advanced pathology testing, genetics counseling, and trial enrollment. RESULTS Two hundred eighty-eight patients met inclusion criteria; 88 patients were referred to the clinic (40 preoperative, 48 postoperative) and 200 patients were managed outside. Complete preoperative evaluation was accomplished three times more frequently in clinic patients (85 vs. 23 %, p < 0.0001) with significant improvements in all parameters. Enhanced access to multimodal therapy was demonstrated in clinic patients by increased frequency of oncology consultation (98.9 vs. 61.5 %, p < 0.0001) and treatment (62.5 vs. 41.5 %, p = 0.02), advanced pathology testing (29.6 vs. 10.6 %, p = 0.0001), and genetics counseling (6.8 vs. 1.6 %, p = 0.28). Clinic patients also received significantly higher rates of neoadjuvant therapy for stage II or greater rectal cancer (82.6 vs. 30.9 %, p = 0.0001). CONCLUSIONS Multidisciplinary clinic management of colorectal cancer is associated with a significantly more complete preoperative evaluation as well as improved access to multimodal therapy.
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Affiliation(s)
- Rebecca A Levine
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, 1575 Blondell Ave, Ste 125, Bronx, New York, NY 10461, USA.
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Anwar S, Fraser S, Hill J. Surgical specialization and training - its relation to clinical outcome for colorectal cancer surgery. J Eval Clin Pract 2012; 18:5-11. [PMID: 20704632 DOI: 10.1111/j.1365-2753.2010.01525.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES Surgical sub-specialization has been considered to be a major factor in improving cancer surgery-related outcomes in terms of 5-year survival and disease-free intervals. In this article we have looked at the evidence supporting the improvement in colorectal cancer outcomes with 'colorectal specialists' performing colon and rectal surgery. METHODS A literature review was carried out using search engines such as Pubmed, Ovid and Cochrane Databases. Only studies looking at colorectal cancer outcome related to surgery were included in our review. RESULTS Specialist surgeons performing a high volume of colorectal cancer surgery demonstrated better 5-year survival rates in patients, with less local recurrence. This was most evident in surgery for rectal cancer, where an association with increased sphincter saving surgery was also seen. Total mesorectal excision is now the accepted treatment for rectal cancer and has markedly improved survival rates and decreased local recurrence. CONCLUSION The outcomes in colorectal surgery continue to steadily improve. The training of specialized colorectal surgeons is a major contributing factor towards this improvement.
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Affiliation(s)
- Suhail Anwar
- Department of General Surgery, Huddersfield Royal Infirmary, Huddersfield, UK.
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Can acute care surgeons perform emergency colorectal procedures with good outcomes? ACTA ACUST UNITED AC 2011; 71:94-100; discussion 100-1. [PMID: 21818018 DOI: 10.1097/ta.0b013e31821e43d2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute care surgeons (ACS) perform emergency colorectal procedures but may have lower case volumes when compared with their general surgical and colorectal colleagues, which may compromise outcomes. In the acute populations, the elderly may be at particular risk. METHODS Records of all elderly patients (age >65 years) presenting to a tertiary center with a colorectal emergency requiring operation over a 7-year period were reviewed. Data abstracted included presenting characteristics, pre- and postoperative diagnosis, procedural details, surgeon, and outcomes. Surgeons were stratified based on the number of elective colorectal cases they performed over the same time period. Chi-square test, Fisher's exact test, and t test were used, and logistic regression models controlled for patient characteristics. p < 0.05 was significant. RESULTS There were 293 emergent colorectal operations. Mortality before stratification for perioperative risk factors was 15% (43 of 293). ACS mortality was higher than other surgeons (23.2% versus 12.4%; odds ratio, 2.14; p = 0.034). Length of stay, intensive care unit length of stay, and ventilator days were longer for ACS although not significant. On risk stratification by multivariate analysis preoperative hypotension, American Society of Anesthesiology class, age, time to operating room, and management with an open abdominal technique predicted mortality but surgeon type did not. CONCLUSIONS ACS caring for colorectal emergencies encounter critically ill patients with significant comorbidities, often from extended care facilities. If patient characteristics are considered when scrutinizing outcomes of emergency colorectal procedures, ACS perform as well as their colleagues who perform a higher volume of elective resections.
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Frasson M, Garcia-Granero E, Roda D, Flor-Lorente B, Roselló S, Esclapez P, Faus C, Navarro S, Campos S, Cervantes A. Preoperative chemoradiation may not always be needed for patients with T3 and T2N+ rectal cancer. Cancer 2011; 117:3118-3125. [DOI: 10.1002/cncr.25866] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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García-Granero E, Faiz O, Flor-Lorente B, García-Botello S, Esclápez P, Cervantes A. Prognostic implications of circumferential location of distal rectal cancer. Colorectal Dis 2011; 13:650-7. [PMID: 20236143 DOI: 10.1111/j.1463-1318.2010.02249.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM This study evaluated the prognostic importance of circumferential tumour position of mid and low rectal cancers. METHOD All uT2, uT3 and uT4 tumours of the middle and lower rectum that underwent total mesorectal excision (TME) with curative intent between 1996 and 2006 were included. The predominant circumferential tumour position (anterior, posterior or circumferential) was defined on preoperative endorectal ultrasound examination (ERUS). The relationships between tumour position and other characteristics and recurrence were explored. RESULTS Two hundred and five patients with distal rectal cancer were operated on for a uT2-T4 tumour. Median follow up was 49 months. The location of the tumour was predominantly anterior, posterior or circumferential in 128, 49 and 27 patients, respectively. Anterior tumours were more likely to receive neoadjuvant therapy (P = 0.016) and perioperative blood transfusion (P = 0.012). No significant differences were observed between circumferential position and pT or pN stage, circumferential resection margin involvement or mesorectal excision quality. Sixty-three (30.7%) patients developed recurrence, which was local only in 16 (7.8%). Although tumours involving 360° of the rectal wall had a higher risk of local recurrence (P = 0.048), those with a predominant anterior or posterior position were not related to a higher risk of local or overall recurrence. CONCLUSION Anterior rectal tumours do not differ in pathological characteristics from posterior tumours, and their prognosis is no worse when circumferential resection is complete.
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Affiliation(s)
- E García-Granero
- Department of General Surgery, Coloproctology Unit, Hospital Clínico Universitario, University of Valencia, Valencia, Spain.
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How P, Shihab O, Tekkis P, Brown G, Quirke P, Heald R, Moran B. A systematic review of cancer related patient outcomes after anterior resection and abdominoperineal excision for rectal cancer in the total mesorectal excision era. Surg Oncol 2011; 20:e149-55. [PMID: 21632237 DOI: 10.1016/j.suronc.2011.05.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 05/04/2011] [Accepted: 05/05/2011] [Indexed: 01/29/2023]
Abstract
PURPOSE It is a widely held view that anterior resection (AR) for rectal cancer is an oncologically superior operation to abdominoperineal excision (APE). However, some centres have demonstrated better outcomes with APE. We conducted a systematic review of high-quality studies within the total mesorectal excision (TME) era comparing outcomes of AR and APE. METHODS A literature search was performed to identify studies within the TME era comparing AR and APE with regard to the following: circumferential resection margin (CRM) status, tumour perforation rates, specimen quality, local recurrence, overall survival (OS; 3 or 5 year), cancer-specific survival (CSS) and disease-free survival (DFS). Additional data regarding patient demographics and tumour characteristics was collected. RESULTS Twenty four studies fulfilled the eligibility criteria with Newcastle-Ottawa scores of six or greater. Where a significant difference was found, all studies reported lower and more advanced tumours for APE and 4/5 studies observed more frequent use of neoadjuvant and adjuvant therapies in APE patients. Tumour perforation rates and CRM involvement where reported, were significantly greater for APE. 8 out of 10 studies showing significant differences in local recurrence reported higher rates for APE but no differences were observed with distant recurrence. Where differences were noted, AR was reported to have increased DFS, CSS and OS compared to APE. CONCLUSIONS Patients treated with AR have lower rates of tumour perforation and CRM involvement and tend to have better outcomes with regard to disease recurrence and survival. However, tumours treated by APE are lower and more locally advanced.
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Affiliation(s)
- P How
- Pelican Cancer Foundation, The Ark, Dinwoodie Drive, Basingstoke, RG24 9NN, UK.
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Abstract
AIM In 1996, rectal cancer surgery in the Swedish county of Vstmanland was centralized to a single colorectal unit. At the same time, total mesorectal excision and multidisciplinary team meetings were introduced. The aim of this audit was to determine the long-term results before and after centralization. METHOD All consecutive rectal cancer patients who underwent curative or palliative surgery at one of the county's four hospitals between 1993 and 1996 (n = 133, group 1) were compared with patients operated at the new centralized colorectal unit between 1996 and 1999 (n = 144, group 2). RESULTS Preoperative radiotherapy was common in both groups, but in group 2, it was planned using MRI. Local recurrences were detected in 8% of all patients operated in group 1 vs 3.5% in group 2 (P = 0.043). The overall 5-year survival for all patients in group 1 was 38 vs 62% in group 2 (P = 0.003). According to multivariate analysis, the new colorectal unit was an independent predictor for improved long-term survival. CONCLUSION This population-based audit shows reduced local recurrence rate and prolonged overall survival for rectal cancer patients after centralization to a single colorectal unit with multidisciplinary management and increased subspecialization.
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Affiliation(s)
- M Hosseinali Khani
- Colorectal Unit, Department of Surgery and Centre for Clinical Research of Uppsala University, Central Hospital, Västerås, Sweden.
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Ais Conde G, Fadrique Fernández B, Vázquez Santos P, López Pérez J, Picatoste Merino M, Manzanares Sacristán J. [Rectal cancer: which patients benefit from radiotherapy?]. Cir Esp 2010; 87:350-5. [PMID: 20413110 DOI: 10.1016/j.ciresp.2010.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Revised: 02/23/2010] [Accepted: 03/06/2010] [Indexed: 02/07/2023]
Abstract
The prognosis of patients with rectal cancer has improved in recent years, particularly as regards the lower probability of local recurrence. These positive results are obtained through correct preoperative staging and an adequate surgical resection of the affected lesion, as well as a multidisciplinary therapeutic approach. Based on the available scientific evidence, our aim is to clarify the framework in which options for the right therapy can be taken, especially in relation to the preoperative staging and its limitations, with regards to radiotherapy and its indications. We also emphasize the need of a tailor-made approach for each case.
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Affiliation(s)
- Guillermo Ais Conde
- Unidad de Coloproctología, Servicio de Cirugía General, Hospital General de Segovia, Segovia, Spain.
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Ugolini G, Rosati G, Montroni I, Manaresi A, Blume JF, Schifano D, Zattoni D, Taffurelli M. A Preliminary Audit Experience of Surgery for Rectal Cancer after Neoadjuvant Chemoradiation Therapy. TUMORI JOURNAL 2010; 96:260-5. [DOI: 10.1177/030089161009600212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background A surgical audit is a systematic critical analysis of surgical performance, with the goal to improve the quality of patient care. Rectal cancer surgery is one of the most delicate procedures in the field of surgical oncology, with significant variations in terms of complications from center to center. Neoadjuvant chemoradiation therapy leads to a significant reduction in local recurrences in patients with locally advanced lower and medium rectal cancer. The aim of the study was to evaluate the influence of neoadjuvant chemoradiation therapy on postoperative morbidity and mortality in patients with rectal cancer. Methods and study design From January 1,2003, to December 31, 2007, patients who underwent elective surgical resection for lower and medium rectal cancer in our Surgical Unit were prospectively analyzed. Patients (n = 42) were divided into two groups: 1) those treated with neoadjuvant chemotherapy and consequent surgical resection (19/42); 2) those treated with primary surgical treatment (23/42). P-POSSUM (Portsmouth Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity) and CR-POSSUM (ColoRectal-POSSUM) scores were calculated for each patient group. Thirty-day mortality and morbidity rates were prospectively collected in a comprehensive data base. Data were evaluated by comparing the predictions of the two scoring systems in both study groups with clinically observed mortality and morbidity rates. Results In group 1, no death was registered (0/19). The P-POSSUM and CR-POSSUM expected mortality was 2.43% and 4.52%, respectively (P >0.05). In group 2, a single death was documented (1/23, 4.35%). The P-POSSUM and CR-POSSUM expected mortality was 2.1% and 4.94%, respectively. The postoperative complications rate for group 1 was 10.52% (2/19) compared to 34.88% as expected from the P-POSSUM score (P <0.05). In group 2, a postoperative complication rate of 39.13% (9/23) was observed compared to 34.26% as expected from the P-POSSUM score (P >0.05). Conclusions No significant influence on morbidity or mortality was detected in patients who underwent neoadjuvant radio-chemotherapy.
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Affiliation(s)
- Giampaolo Ugolini
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | - Giancarlo Rosati
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | - Isacco Montroni
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | - Alessio Manaresi
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | | | - Domenico Schifano
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | - Davide Zattoni
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | - Mario Taffurelli
- Department of General Surgery, Emergency and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
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The Learning Curve for the Laparoscopic Approach to Conservative Mesorectal Excision for Rectal Cancer. Ann Surg 2010; 251:249-53. [DOI: 10.1097/sla.0b013e3181b7fdb0] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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García-Granero E, Faiz O, Muñoz E, Flor B, Navarro S, Faus C, García-Botello SA, Lledó S, Cervantes A. Macroscopic assessment of mesorectal excision in rectal cancer. Cancer 2009; 115:3400-11. [DOI: 10.1002/cncr.24387] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Esclapez P, Garcia-Granero E, Flor B, García-Botello S, Cervantes A, Navarro S, Lledó S. Prognostic heterogeneity of endosonographic T3 rectal cancer. Dis Colon Rectum 2009; 52:685-91. [PMID: 19404075 DOI: 10.1007/dcr.0b013e31819ed03d] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE This study aimed to assess the prognostic implications of uT3 rectal carcinomas according to the tumor thickness and to analyze the correlation between this ultrasound-based parameter and other prognostic factors. METHODS Seventy-four patients with uT3(pM0) rectal tumors underwent primary surgery from 1996 to 2003. Preoperative endorectal ultrasound was used to assess uN stage, maximum tumor perimeter, and maximum tumor thickness. An ultrasound maximum tumor thickness cutoff point for local recurrence subdividing T3 tumors into uT3a and uT3b was established. RESULTS Median follow-up was 41 months (range, 24-59). The 5-year actuarial local and overall recurrence rates were 9.82 percent (n = 7) and 42.46 percent (n = 23), respectively. uN stage(P = 0.05), circumferential resection margin involvement (P = 0.002), an ultrasound maximum tumor thickness (P = 0.01), and locally advanced tumors (P = 0.001) were related to a significantly increased risk of local recurrence. An ultrasound maximum tumor thickness (hazard ratio, 1.15; 95 percent confidence interval, 1.0-1.2) and locally advanced tumor (hazard ratio, 17.21; 95 percent confidence interval, 2.99-98.84) were preoperative independent variables for predicting local recurrence. Locally advanced tumor was the only preoperative independent prognostic factor for overall recurrence (P = 0.004; hazard ratio, 1.09; 95 percent confidence interval, 1.0-1.1). An ultrasound maximum tumor thickness with a 19-mm cutoff point, subdividing the T3 tumors into uT3a and uT3b, can be used to predict local recurrence. Locally advanced tumors (P = 0.02) and circumferential resection margin involvement (P = 0.005) showed a significant association with an ultrasound maximum tumor thickness >19 mm. CONCLUSIONS A maximum tumor thickness measured by endorectal ultrasound in pT3 rectal cancer is an independent prognostic factor for local and overall recurrence. An ultrasound maximum tumor thickness cutoff point of 19 mm may be useful to classify patients preoperatively and to select them for primary surgery or neoadjuvant therapy.
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Affiliation(s)
- Pedro Esclapez
- Coloproctology Unit, Multidisciplinary Rectal Cancer Team, Hospital Clinico, University of Valencia, Valencia, Spain
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Di Cataldo A, Scilletta B, Latino R, Cocuzza A, Li Destri G. The surgeon as a prognostic factor in the surgical treatment of rectal cancer. Surg Oncol 2007; 16 Suppl 1:S53-6. [PMID: 18023175 DOI: 10.1016/j.suronc.2007.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Over the past 2 decades the surgeon and the hospital where he or she works have been considered to play an important role in the prognosis of the rectal cancer patients. The rate of sphincter-sparing rectal resection, local recurrence and survival are the factors more frequently utilized in the literature to evaluate if surgeons are able to affect the natural history of the rectal cancer. The quantitative aspect, high volume of the surgeon, is not enough but in order to achieve better results in the treatment of rectal cancer a specific interest in colorectal surgery is more important. While retrospective studies show a positive influence of the surgeon on the prognosis of these patients, prospective studies are very few so that we need to get more data to reach valid conclusions. The high number of rectal cancer patients does not allow a centralization of these patients into specialist Units, but we should get up everywhere colorectal programmes so that every department can reach a high standard of efficiency.
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Affiliation(s)
- Antonio Di Cataldo
- Department of General and Colorectal Surgery, University of Catania, Via S.Sofia 84, 95100 Catania, Italy.
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Navarro GV, Mompeán JAL, Agüera QH, Flores DP, Bernal DF, Martínez JG, Paricio PP. Influence of the neo-adjuvant radiochemotherapy as a factor in the surgical treatment of rectal cancer by expert surgeon. A comparative study. Int J Colorectal Dis 2007; 22:1233-8. [PMID: 17410369 DOI: 10.1007/s00384-007-0301-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Total mesorectal excision and surgeon experience are prognostic factors in rectal cancer surgery, in terms of local recurrence and conservative sphincter surgery. Pre-operative radiation-chemotherapy can even improve those results. The aim of this study is to assess the utility of pre-operative radiation therapy (PRT) on the results of surgical treatment for rectal cancer comparing two consecutive series of patients operated on by surgeons with experience in rectal cancer surgery according to whether they had received PRT. MATERIALS AND METHODS Retrospective review of 118 patients with rectal cancer, divided into two groups: group I, 57 patients without pre-operative radiation-chemotherapy, and group II, 61 patients with rectal cancer who received pre-operative radiation-chemotherapy. Both groups were homogeneous. The short-term results (surgical technique, post-operative stay, post-operative complications) and long-term results (local recurrences, liver metastases and both overall and tumour-related survival) were analysed. RESULTS The rate of anterior resection in the lower third was significantly higher (p = 0.037) in group II than in group I (56 vs 23%), the rate of abdominoperineal resection in the middle third was significantly lower (p = 0.046) in group II (3.5 vs 21%). The incidence of post-operative complications was similar in both groups, but the rate of anastomotic leaks was higher in group II. The local recurrences was lower in group II (p = 0.002), but the disease free survival and the overall survival was similar in both groups. At the multivariate analysis, the only prognostic factor for the local recurrence was the use of pre-operative radiation-chemotherapy. CONCLUSION Besides surgeon experience and total mesorectal excision, a very important prognostic factor is the administration of pre-operative radiation-chemotherapy in cases of locally advanced rectal cancer, as it does not increase post-operative morbidity and mortality and significantly influences the rate of local recurrences and the conservative sphincter surgery.
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Affiliation(s)
- G Valero Navarro
- Department of General Surgery, Virgen de la Arrixaca Hospital University, University of Murcia, Murcia, Spain.
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Iversen LH, Harling H, Laurberg S, Wille-Jørgensen P. Influence of caseload and surgical speciality on outcome following surgery for colorectal cancer: a review of evidence. Part 1: short-term outcome. Colorectal Dis 2007; 9:28-37. [PMID: 17181843 DOI: 10.1111/j.1463-1318.2006.01100.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE An association between caseload and outcome has been reported for complex surgical procedures. We systematically reviewed recent literature to determine whether caseload and surgical speciality are associated with short-term outcome following colorectal cancer surgery. METHOD We searched the MEDLINE and Cochrane Library databases for relevant publications starting in 1992. We selected hospital caseload and type, and surgeon's caseload, education and experience as variables of interest. Measures of outcome were postoperative morbidity, in-hospital and 30-day mortality, and for rectal cancer anastomotic leak. We stratified the 35 reviewed studies by tumor location: colonic cancer, rectal cancer, or colorectal cancer and described the studies individually. A meta-analysis was performed only when it was considered appropriate. RESULTS For colonic cancer, postoperative morbidity was associated with surgeon's caseload and education. Postoperative mortality was strongly associated with hospital caseload (OR 0.64, 95% CI 0.55-0.73), and surgeon's caseload (OR 0.50, 95% CI 0.39-0.64). It was also influenced by surgeon's education and experience. For rectal cancer, we found no evidence of an association between the selected variables and short-term outcome, including frequency of anastomotic leak. For colorectal cancer, there was evidence for an association between postoperative morbidity and hospital caseload. CONCLUSION Our review offers evidence for a positive association between high hospital caseload, surgeon's caseload, sub-speciality and experience and improved short-term outcome in colonic cancer surgery. We failed to find evidence of a relationship for rectal cancer surgery, possibly owing to methodological artifacts. No study reported an inverse relation.
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Affiliation(s)
- L H Iversen
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark.
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Chiappa A, Biffi R, Bertani E, Zbar AP, Pace U, Crotti C, Biella F, Viale G, Orecchia R, Pruneri G, Poldi D, Andreoni B. Surgical outcomes after total mesorectal excision for rectal cancer. J Surg Oncol 2006; 94:182-93; discussion 181. [PMID: 16900534 DOI: 10.1002/jso.20518] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES This study reviewed the results of surgery for distal rectal cancer following the introduction of total mesorectal excision (TME) for rectal cancer. METHODS Two hundred sixty-four patients who had undergone elective curative surgical resection of rectal cancer within 12 cm of the anal verge were included. Comparisons were made between patients who had different surgical procedures. RESULTS The overall operative mortality rate was nil, and the morbidity 39.4%. With a mean follow-up of 34 months (range 5-105 months), local recurrence occurred in 21 of the patients. The 3- and 5-year actuarial local recurrence rates were 9% and 12%, respectively for the whole group. Abdominoperineal resection (APR) was necessary in 65 of 264 (24.6%) of the patients, with a very low local recurrence rate in this subgroup (5% at 3 years). On multivariate analysis, only stage was a significant prognosticator of overall survival (P = 0.012). CONCLUSIONS With the practice of TME, APR was still necessary in 25% of patients with rectal cancer within 12 cm of the anal verge. Type of surgery and tumor distance from the anal verge influenced local recurrence rates, but only initial tumor stage was associated with long-term survival.
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Affiliation(s)
- Antonio Chiappa
- Department of General Surgery, European Institute of Oncology, University of Milan, Milan, Italy.
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Luján J, Hernández Q, Valero G, de las Heras M, Gil J, Frutos D, Parrilla P. Influencia del factor cirujano en el tratamiento quirúrgico del cáncer de recto con radioquimioterapia preoperatoria. Estudio comparativo. Cir Esp 2006; 79:89-94. [PMID: 16539946 DOI: 10.1016/s0009-739x(06)70826-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION In the last few years, changes have been introduced in rectal cancer surgery that have improved its results. These changes include autosuture devices, total mesorectal excision, and neoadjuvant treatment. The aim of the present study was to determine whether the surgeon influences the results of surgical treatment for rectal cancer. PATIENTS AND METHODS A comparative, retrospective study was performed in 194 consecutive patients with rectal cancer who underwent preoperative radiotherapy. The patients were divided into two groups according to the type of surgeon performing the intervention: group I: 3 surgeons with 101 patients; group II: 16 surgeons with 93 patients. RESULTS Sphincter-preserving surgery was performed in 77% of patients in group I and in 52% of those in group II (p < 0.001). In group I anterior resection was performed in 100%, 100% and 58% when the tumor was between 11-15 cm, 6-10 cm and 1-5 cm, respectively, compared with 100%, 69% and 23.5% in group II. Complications occurred in 41% of patients in group I and in 48% of those in group II (p = 0.037). Length of hospital stay was 9.9 days in group I and 13.9 days in group II (p < 0.001). Local recurrence occurred in 3.5% of patients in group I and in 11.3% of those in group II (p = 0.054). Survival was similar in both groups. CONCLUSIONS The surgeon is a key factor in rectal cancer, despite the introduction of autosuture devices, neoadjuvant treatment, and total mesorectal excision. These patients should be operated on by experts in this type of surgery and not by surgeons who perform these interventions only occasionally.
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Affiliation(s)
- Juan Luján
- Servicio de Cirugía General, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain.
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García-Granero E. El factor cirujano y la calidad de la cirugía en el pronóstico del cáncer de recto. Implicaciones en la especialización y organización. Cir Esp 2006; 79:75-7. [PMID: 16539943 DOI: 10.1016/s0009-739x(06)70823-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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McGrath DR, Leong DC, Gibberd R, Armstrong B, Spigelman AD. Surgeon and hospital volume and the management of colorectal cancer patients in Australia. ANZ J Surg 2005; 75:901-10. [PMID: 16176237 DOI: 10.1111/j.1445-2197.2005.03543.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The evidence for a relationship between patient outcomes and clinician and hospital volume is increasing. The National Colorectal Cancer Care Survey was undertaken to determine the management patterns in Australia for individuals newly diagnosed with colorectal cancer in a 3 month period in the year 2000. METHODS All new cases of colorectal cancer registered at each Australian State Cancer Registry were entered into the survey. This generated a questionnaire that was sent to the treating surgeon. Chi-squared tests and logistic regression analyses were used to determine levels of statistical significance. RESULTS Of 2,383 surgical questionnaires generated, 2,015 (85%) were completed. The majority (58%) of surgeons treated one or two patients with colorectal cancer over the 3 months of the survey. There was variation across surgeon cohorts for preoperative measures including the use of deep vein thrombosis prophylaxis. Patients seen by low volume surgeons were most likely to be given a permanent stoma (P < 0.0001). Patients with rectal cancer who were operated on by high volume surgeons were significantly more likely to receive a colonic pouch (P < 0.0001). CONCLUSION This nationwide population-based survey of the treatment of colorectal cancer patients suggests that the delivery of care by surgeons (the majority) who treat patients with rectal cancer infrequently should be evaluated.
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Affiliation(s)
- Daniel R McGrath
- Surgical Science, Faculty of Health, University of Newcastle, Newcastle, New South Wales, Australia
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Chiappa A, Biffi R, Zbar AP, Luca F, Crotti C, Bertani E, Biella F, Zampino G, Orecchia R, Fazio N, Venturino M, Crosta C, Pruneri GC, Grassi C, Andreoni B. Results of treatment of distal rectal carcinoma since the introduction of total mesorectal excision: a single unit experience, 1994-2003. Int J Colorectal Dis 2005; 20:221-30. [PMID: 15602647 DOI: 10.1007/s00384-004-0670-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2004] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS This study reviewed the results of surgery for distal rectal cancer (where the tumour was within 6 cm of the anal verge) following the introduction of total mesorectal excision for rectal cancer in one institution. PATIENTS AND METHODS One hundred and fifty-three patients who had undergone elective curative surgical resection of rectal cancer within 6 cm of the anal verge were included. The demographic, operative and follow-up data were collected retrospectively. Comparisons were made between patients who had different surgical procedures. RESULTS The overall operative mortality rate was nil, and the morbidity 41%. With a mean follow-up of 37 months (range 5-100 months), local recurrence occurred in 18 of the patients. The 5-year actuarial local recurrence rates for double-stapled anastomosis, low-strength anastomosis and abdominoperineal resection (APR) were 39, 17 and 11% respectively. The local recurrence rate was significantly higher for double-stapled low anterior resection than for the other types of operation (P=0.007). On multivariate analysis type of surgery (P=0.025) and tumour stage (P=0.043), were associated with local recurrence, but only stage was a significant prognosticator of overall survival (P=0.0006). CONCLUSION With the practice of total mesorectal excision, APR was still necessary in 40% of patients with rectal cancer within 6 cm of the anal verge. The local recurrence rate was lower in patients treated with APR than in those with double-stapled low anterior resection; however, survival rates were similar in these two groups.
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Affiliation(s)
- Antonio Chiappa
- Department of General Surgery, European Institute of Oncology, Via G. Ripamonti 435, 20141 Milan, Italy.
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Renzulli P, Laffer UT. Learning curve: the surgeon as a prognostic factor in colorectal cancer surgery. Recent Results Cancer Res 2005; 165:86-104. [PMID: 15865024 DOI: 10.1007/3-540-27449-9_11] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The individual surgeon is an independent prognostic factor for outcome in colorectal cancer surgery. The surgeon's learning curve is therefore directly related to the patient's outcome. The exact shape of the learning curve, however, is unknown. The present study reviewed supervision, training/teaching, specialization, surgeon's caseload, and hospital's caseload as the five main surgeon- and hospital-related confounding factors for outcome, and examined their influence on the learning curve as well as their interactions and prognostic significance. All five confounding factors were related to outcome. The highest degree of evidence, however, was found for training/teaching (introduction of total mesorectal excision), specialization in colorectal surgery (special interest, board-certification, specialized colorectal cancer units), and the surgeon's caseload. Five surgeon- and hospital-related factors directly influence the surgeon's learning curve and are therefore rightly considered predictors of outcome in colorectal cancer surgery. Improvements in supervision, training/teaching, specialization, the surgeon's caseload, and the hospital's caseload will therefore translate into enhanced patient outcome.
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Affiliation(s)
- Pietro Renzulli
- Department of Visceral and Transplantation Surgery, Inselspital, University of Berne, 3010 Berne, Switzerland.
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Abstract
OBJECTIVE The association between hospital volumen and outcome of major cancer surgery is being debated at present. We analysed the outcome of rectal cancer surgery in Denmark during the period 1994-99. METHODS All patients with a first-time rectal cancer were registered in a national database during the 5-year period. In this observational cohort study, the influence of hospital case volume on resectional procedure, complications, 30-day mortality and 5-year mortality was analysed. RESULTS The register comprised 5021 patients. Surgery was performed in 27 hospitals with <15 operations per year, 15 hospitals with 15-30 operations per year and 11 hospitals with >30 operations per year. In a multivariate model, the risk of permanent colostomy was significantly increased in the group of low-volume hospitals. On the contrary, volume did not influence the risk of anastomotic leakage, 30-day mortality and 5-year mortality. However, a large variation in 5-year mortality was observed particularly within the low-volume group of hospitals. CONCLUSIONS In this study, only risk of having a permanent colostomy during surgery for rectal cancer was significantly related to hospital case volume. When individual hospitals were analysed, a large variation in 5-year mortality was observed within the low-volume group of hospitals.
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Affiliation(s)
- H Harling
- Department of Surgery, H:S Bispebjerg Hospital, Denmark.
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Martí-Ragué J, Parés D, Biondo S, Navarro M, Figueras J, de Oca J, Pareja L, Cambray M, del Río C, Osorio A, Novell V, Jaurrieta E. Supervivencia y recidiva en el tratamiento multidisciplinario del carcinoma colorrectal. Med Clin (Barc) 2004; 123:291-6. [PMID: 15373975 DOI: 10.1016/s0025-7753(04)74495-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Juan Martí-Ragué
- Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
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Hohenberger W, Bittorf B, Papadopoulos T, Merkel S. Survival after surgical treatment of cancer of the rectum. Langenbecks Arch Surg 2004; 390:363-72. [PMID: 15309541 DOI: 10.1007/s00423-004-0497-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2004] [Accepted: 05/01/2004] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Rectal carcinoma is one of the most prevalent tumour types. Prognostic factors are of special interest to estimate prognosis of the individual patient. PATIENTS/METHODS The data of 1,067 consecutive patients with solitary invasive rectal carcinoma, resected between 1988 and 1999 at the Department of Surgery of the University of Erlangen, were analysed. Cancer-related survival rate was calculated by univariate and multivariate analysis with respect to all relevant proven and probable prognostic factors. RESULTS The R classification was found to be the parameter with the greatest influence on survival of patients with rectal carcinoma. Other tumour-related prognostic factors that influenced prognosis significantly were the anatomical extent, described by the TNM classification of the UICC, tumour grade and extramural venous invasion (EVI). In addition, the operating surgeon, a therapy-related factor, and the preoperative serum CEA level were found to influence prognosis. CONCLUSION Tumour-related prognostic factors have the greatest influence on clinical decisions with regard to choice of a therapeutic concept. The increasing survival rates after treatment of rectal carcinoma have led to a focus on postoperative quality of life. Postoperative long-term global quality of life is similar to the preoperative level. Oncological outcome is still the most important factor, and tumour recurrence leads to a strong impairment of quality of life.
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Affiliation(s)
- W Hohenberger
- Department of Surgery, University of Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany.
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Lledó Matoses S, García-Granero E, García-Armengol J. Tratamiento quirúrgico y resultados del cáncer de recto. Cir Esp 2003. [DOI: 10.1016/s0009-739x(03)72086-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ortega Serrano J, Sala Palau C, Lledó Matoses S. Utilidad de la especialización en cirugía endocrina de una unidad del servicio de cirugía general: análisis tras 500 tiroidectomías consecutivas. Cir Esp 2002. [DOI: 10.1016/s0009-739x(02)72055-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Biondo S, Martí-Ragué J. Cáncer colorrectal. ¿Qué factores pueden ser determinantes en su curación o recidiva? Cir Esp 2001. [DOI: 10.1016/s0009-739x(01)71897-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Five cases are described where minute foci of adenocarcinoma have been demonstrated in the mesorectum several centimetres distal to the apparent lower edge of a rectal cancer. In 2 of these there was no other evidence of lymphatic spread of the tumour. In orthodox anterior resection much of this tissue remains in the pelvis, and its is suggested that these foci might lead to suture-line or pelvic recurrence. Total excision of the mesorectum has, therefore, been carried out as a part of over 100 consecutive anterior resections. Fifty of these, which were classified as 'curative' or 'conceivably curative' operations, have now been followed for over 2 years with no pelvic or staple-line recurrence.
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