Prognostic impact of the length of the longitudinal resection margin in colon cancer

Best Evidence for Each Surgical Step in Minimally Invasive Right Hemicolectomy: A Systematic Review

Objective

The aim of this study was to systematically review the literature for each surgical step of the minimally invasive right hemicolectomy (MIRH) for non-locally advanced colon cancer, to define the most optimal procedure with the highest level of evidence.

Background

High variability exists in the way MIRH is performed between surgeons and hospitals, which could affect patients' postoperative and oncological outcomes.

Methods

A systematic search using PubMed was performed to first identify systematic reviews and meta-analyses, and if there were none then landmark papers and consensus statements were systematically searched for each key step of MIRH. Systematic reviews were assessed using the AMSTAR-2 tool, and selection was based on highest quality followed by year of publication.

Results

Low (less than 12 mmHg) intra-abdominal pressure (IAP) gives higher mean quality of recovery compared to standard IAP. Complete mesocolic excision (CME) is associated with lowest recurrence and highest 5-year overall survival rates, without worsening short-term outcomes. Routine D3 versus D2 lymphadenectomy showed higher LN yield, but more vascular injuries, and no difference in overall and disease-free survival. Intracorporeal anastomosis is associated with better intra- and postoperative outcomes. The Pfannenstiel incision gives the lowest chance of incisional hernias compared to all other extraction sites.

Conclusion

According to the best available evidence, the most optimal MIRH for colon cancer without clinically involved D3 nodes entails at least low IAP, CME with D2 lymphadenectomy, an intracorporeal anastomosis and specimen extraction through a Pfannenstiel incision.

The effect of pericolic lymph nodes metastasis beyond 10 cm proximal to the tumor on patients with rectal cancer

Background

This study aims to determine the real incidence of pericolic lymph nodes metastasis beyond 10 cm proximal to the tumor (pPCN) and its prognostic significance in rectal cancer patients.

Methods

Consecutive patients with rectal cancer underwent curative resection between 2015 and 2017 were included. Margin distance was marked and measured in vivo and lymph nodes were harvested on fresh specimens. Clinicopathological characteristics and oncological outcomes (3-year overall survival (OS) and disease-free survival (DFS)) were analyzed between patients with pPCN and patients without pPCN (nPCN).

Results

There were 298 patients in the nPCN group and 14 patients (4.5%) in pPCN group. Baseline characteristics were balanced except more patients received preoperative or postoperative chemoradiotherapy in pPCN group. Preoperative more advanced cTNM stage (log-rank p = 0.005) and intraoperative more pericolic lymph nodes beyond 10 cm proximal to the tumor (PCNs) (log-rank p = 0.002) were independent risk factors for pPCN. The maximum short-axis diameter of mesenteric lymph nodes ≥8 mm was also contributed to predicting the pPCN. pPCN was an independent prognostic indicator and associated with worse 3-year OS (66% vs 91%, Cox p = 0.033) and DFS (58% vs 92%, Cox p = 0.012).

Conclusion

The incidence of pPCN was higher than expected. Patients with high-risk factors (cTNM stage III or more PCNs) might get benefits from an extended proximal bowel resection to avoid residual positive PCNs.

Comparison of survival of stage I-III colon cancer by travel distance and hospital volume

BACKGROUND

Previous studies have demonstrated improved outcomes at high-volume colorectal surgery centers; however, the benefit for patients who live far from such centers has not been assessed relative to local, low-volume facilities.

METHODS

The 2010-2015 National Cancer Database (NCDB) was queried for patients with stage I-III colon adenocarcinoma undergoing treatment at a single center. A 'local, low-volume' cohort was constructed of 12,768 patients in the bottom quartile of travel distance at the bottom quartile of institution surgical volume and a 'travel, high-volume' cohort of 11,349 patients in the top quartile of travel distance at the top quartile of institution surgical volume.

RESULTS

In unadjusted analysis, patients in the travel cohort had improved rates of positive resection margins (3.7% vs. 5.5%, p < 0.001), adequate lymph-node harvests (92% vs. 83.6%, p < 0.001), and 30- (2.2% vs. 3.9%, p < 0.001) and 90-day mortality (3.7% vs. 6.4%, p < 0.001). On multivariable logistic regression analysis adjusting for patient demographic, tumor, and facility characteristics, the cohorts demonstrated equivalent overall survival (HR: 0.972, p = 0.39), with improved secondary outcomes in the 'travel' cohort of adequate lymph-node harvesting (OR: 0.57, p < 0.001), and 30- (OR 0.79, p = 0.019) and 90-day mortality (OR 0.80, p = 0.004).

CONCLUSIONS

For patients with stage I-III colon cancer, traveling to high-volume institutions compared to local, low-volume centers does not convey an overall survival benefit. However, given advantages including 30- and 90-day mortality and adequate lymph-node harvest, nuanced patient recommendations should consider both these differences and the unquantified benefits to local care, including cost, travel time, and support systems.