Minimally invasive treatment of colon cancer

Sleep, immunity and inflammation in gastrointestinal disorders

Sleep disorders have become a global issue, and discovering their causes and consequences are the focus of many research endeavors. An estimated 70 million Americans suffer from some form of sleep disorder. Certain sleep disorders have been shown to cause neurocognitive impairment such as decreased cognitive ability, slower response times and performance detriments. Recent research suggests that individuals with sleep abnormalities are also at greater risk of serious adverse health, economic consequences, and most importantly increased all-cause mortality. Several research studies support the associations among sleep, immune function and inflammation. Here, we review the current research linking sleep, immune function, and gastrointestinal diseases and discuss the interdependent relationship between sleep and these gastrointestinal disorders. Different physiologic processes including immune system and inflammatory cytokines help regulate the sleep. The inflammatory cytokines such as tumor necrosis factor, interleukin-1 (IL-1), and IL-6 have been shown to be a significant contributor of sleep disturbances. On the other hand, sleep disturbances such as sleep deprivation have been shown to up regulate these inflammatory cytokines. Alterations in these cytokine levels have been demonstrated in certain gastrointestinal diseases such as inflammatory bowel disease, gastro-esophageal reflux, liver disorders and colorectal cancer. In turn, abnormal sleep brought on by these diseases is shown to contribute to the severity of these same gastrointestinal diseases. Knowledge of these relationships will allow gastroenterologists a great opportunity to enhance the care of their patients.

Minimally invasive surgery for colorectal cancer: quality of life and satisfaction with care in elderly patients

BACKGROUND

The purpose of this multicentric prospective study was to evaluate postoperative HRQL and satisfaction with care after laparoscopic colonic resection for colorectal cancer in elderly patients.

METHODS

A total of 116 patients were enrolled in this study: 33 patients older than age 70 years had laparoscopic colectomy, whereas 24 had open colectomy; 44 patients younger than age 70 years had laparoscopic colectomy and 15 of them had open colectomy. The patients answered to three questionnaires about generic (EORTC QLQ C30) and disease-specific quality of life (EORTC CR29) and about treatment satisfaction (EORTC IN-PATSAT32). Nonparametric tests and forward stepwise multiple regression analysis were used for statistical analysis.

RESULTS

One month after surgery, global quality of life (QL2 item) was significantly impaired in elderly patients who had laparoscopic colectomy compared with younger patients who had the same operation (p = 0.003). Similarly, role function (RF), physical function (PF), emotional function (EF), cognitive function (CF), and social function (SF) were impaired in elderly patients who had laparoscopic colectomy compared with younger patients (p < 0.001, p < 0.001, p = 0.013, p < 0.001, p = 0.01, respectively). Fatigue (FA), sleep disturbances (SL), appetite loss (AP), and dyspnea (DY) affected the quality of life of these patients more than younger patients (p < 0.001, p = 0.055, p = 0.051, and p = 0.003, respectively).

CONCLUSIONS

Elderly patients undergoing laparoscopic colectomy for cancer experience less postoperative local complications than elderly patients undergoing open colectomy. Nevertheless, in the first postoperative month, these patients experience a worse global quality of life than younger patients undergoing the same operation with impairment of all the functions and the presence of fatigue, sleep disturbances, appetite loss, and dyspnea.

Long-term follow-up and individual item analysis of quality of life assessments related to laparoscopic-assisted colectomy in the COST trial 93-46-53 (INT 0146)

BACKGROUND

Postoperative outcomes of patients undergoing laparoscopic-assisted colectomy (LAC) have shown modest improvements in recovery but only minimal differences in quality of life (QOL) compared with open colectomy. We therefore sought to assess the effect of LAC on QOL in the short and long term, using individual item analysis of multi-item QOL assessments.

METHODS

QOL variables were analyzed in 449 randomized patients from the COST trial 93-46-53 (INT 0146). Both cross-sectional single-time and change from baseline assessments were run at day 2, week 2, month 2, and month 18 postoperatively in an intention-to-treat analysis using Wilcoxon rank-sum tests. Stepwise regression models were used to determine predictors of QOL.

RESULTS

Of 449 colon cancer patients, 230 underwent LAC and 219 underwent open colectomy. Subdomain analysis revealed a clinically moderate improvement from baseline for LAC in total QOL index at 18 months (P = 0.02) as well as other small symptomatic improvements. Poor preoperative QOL as indicated by a rating scale of ≤ 50 was an independent predictor of poor QOL at 2 months postoperatively. QOL variables related to survival were baseline support (P = 0.001) and baseline outlook (P = 0.01).

CONCLUSIONS

Eighteen months after surgery, any differences in quality of life between patients randomized to LAC or open colectomy favored LAC. However, the magnitude of the benefits was small. Patients with poor preoperative QOL appear to be at higher risk for difficult postoperative courses, and may be candidates for enhanced ancillary services to address their particular needs.

Fatigue and other variables during adjuvant chemotherapy for colon and rectal cancer

PURPOSE/OBJECTIVES

To examine patterns of fatigue and other variables (sleep quality, sleep-wake variables, activity and rest, circadian rhythms, quality of life [QOL], blood counts, and demographic and medical variables) during colon and rectal cancer adjuvant chemotherapy, as well as feasibility of the study.

DESIGN

Longitudinal, descriptive feasibility study.

SETTING

Two oncology clinics in the midwestern region of the United States.

SAMPLE

From April 2006-December 2008, 27% of screened subjects (n = 21) enrolled and 14 completed the study. Participants were middle aged, partnered, and employed and had postsecondary education.

METHODS

Measurements completed during the first week of three two-week cycles (chemotherapy 1-3) and at six weeks (before chemotherapy 4) were the Piper Fatigue Scale, Pittsburgh Sleep Quality Index, wrist actigraphy, Functional Assessment of Cancer Therapy-Colon, blood counts, and demographic and medical data form. Analysis included descriptive statistics and repeated-measures analysis of variance.

MAIN RESEARCH VARIABLES

Fatigue, sleep quality, sleep-wake variables, activity-rest, circadian activity rhythms, and QOL.

FINDINGS

Fatigue was mild at baseline and rose to moderate levels during chemotherapy 1-3. Sleep quality was poor the months prior to chemotherapy 1 and chemotherapy 4. Actigraphy data revealed disturbed sleep, low daytime activity, and impaired circadian activity rhythms during the first week after chemotherapy 1-3. QOL ratings were similar to those in other cancer populations. Fatigue increased, and white blood cell counts decreased significantly over time.

CONCLUSIONS

During adjuvant chemotherapy, patients reported moderate fatigue and poor sleep quality; actigraphs confirmed problems with sleep maintenance as well as low daytime activity and disturbed circadian rhythms. Multiple barriers were encountered during the study.

IMPLICATIONS FOR NURSING

Clinicians should screen for fatigue and sleep-wake variables and use guidelines to select interventions.

Training in laparoscopic colorectal surgery - experience of training in a specialist unit

INTRODUCTION

Laparoscopic colorectal surgery, although technically demanding, is an increasingly desirable skill for coloproctologists. We believe that trainees with adequate supervision from an experienced trainer may perform these procedures safely with good outcome.

PATIENTS AND METHODS

Surgical logbooks of two senior trainees were reviewed over a 2-year period. A case note analysis was then undertaken. Patient data were recorded with regards to age, sex, operation type, American Society of Anesthesia (ASA) grade, conversion, length of hospital stay and complications. Lymph node yield, resection margins and grade of total mesorectal excision were recorded in oncological procedures.

RESULTS

Over the 2-year period, trainees were involved in 140 resections (age range, 23-88 years; ASA grades I-III). Seventy patients were male. Trainees were first assistant in at least 20 cases prior to undertaking the procedures themselves. Trainees performed a total of 71 operations. Median hospital stay was 7 days (range, 2-48 days). There were three conversions. Anastomotic leaks developed in two patients, one requiring a laparotomy. One patient developed small bowel obstruction secondary to a port site hernia, which was repaired laparoscopically. There was one postoperative death. All oncological resection margins were clear with adequate lymphadenectomies. All total mesorectal excisions were Quirke grade III.

CONCLUSIONS

Adequately trained and supervised trainees may perform major colorectal resections without compromising outcome.

Prospective Evaluation of Health-Related Quality of Life in a Homogeneous Mediterranean Group of Colorectal Cancer Patients

This study was designed to prospectively evaluate health-related quality of life in a homogeneous Mediterranean group of colorectal cancer patients. Ninety-five colorectal cancer patients were preoperatively assessed and followed-up with by skilled investigators using the Short Form-36 Health Survey questionnaire. Overall, patients showed deterioration in all domains, except for pain, when baseline values were compared with 3 and 6 months postoperatively ( P = 0.0001). A significant improvement of all Short Form-36 Health Survey questionnaire domains was noted between 6 and 12 months ( P = 0.0001). Scores for general health, pain, emotional well-being, and role limitations due to emotional problems at 1 year were shown better than preoperative ( P < 0.001). Improved scores in role limitations due to physical health and emotional problems were found at baseline and at 1 year, when laparoscopic were compared with open resections ( P < 0.05). Patients that received chemotherapy proved to be more vulnerable regarding their energy, social functioning, and role limitations at 3 months ( P < 0.05), whereas older patients had diminished physical functioning at 3 and 6 and 12 months ( P < 0.05) postoperatively. Greek colorectal cancer patients remain fragile up to 6 months after surgery, with significant improvements at 1 year, whereas certain aspects of health-related quality of life at 1 year may be even better than before surgery

Minimally invasive surgery for colorectal cancer: quality of life, body image, cosmesis, and functional results

BACKGROUND

The aims of this cross-sectional study were to assess the long-term quality of life, the body image, and the cosmetic and functional results in patients who had laparoscopic-assisted for colorectal cancer.

METHODS

Forty-two patients were enrolled in this study: 21 consecutive patients who had undergone laparoscopic-assisted colonic resection and 21 patients who had open colonic resection, selected according to stage, gender, age, cancer site, and type of resection. The patients answered four questionnaires about their quality of life, body image, functional, and cosmetic results. Nonparametric tests were used for statistical analysis.

RESULTS

Postoperative hospital stay was shorter in patients who had laparoscopic-assisted resection. The cosmetic score was significantly better in the laparoscopic-assisted group than in the open group (p < 0.01). In spite of similar overall body image score, patients who had a laparoscopic-assisted resection reported a significantly better satisfaction with their own body (p = 0.05). Quality-of-life and functional results were similar in both groups.

CONCLUSIONS

The cosmetic results and the consequent satisfaction with the body were significantly better after laparoscopic assisted resection compared to equivalent open procedure. These effects seemed to be temporary but they could help patients to accept the burden of surgery.