Results after multivisceral resections of locally advanced colorectal cancers: an analysis on clinical and pathological t4 tumors. World J Surg Oncol. 2012;10:39. [PMID: 22336589 PMCID: PMC3305513 DOI: 10.1186/1477-7819-10-39]

Systematic Review of Neoadjuvant Immunotherapy for Mismatch Repair Deficient Locally Advanced Colon Cancer: An Emerging Strategy

BACKGROUND

In April 2023, the National Comprehensive Cancer Network endorsed neoadjuvant immunotherapy for select patients with nonmetastatic mismatch repair deficient colon cancer. Approximately 15% of incident colon cancers are mismatch repair deficient, resulting in a distinct molecular subtype with high microsatellite instability that is responsive to immune checkpoint inhibition.

OBJECTIVE

To describe the existing evidence supporting neoadjuvant immunotherapy for mismatch repair deficient, microsatellite unstable nonmetastatic colon cancer.

DATA SOURCES

A medical librarian performed PubMed, Embase, and Web of Science searches most recently on April 24, 2023. The PubMed search was re-run on September 26, 2023, to identify any additional studies published between April 24 and September 26, 2023.

STUDY SELECTION

Two authors screened titles and abstracts in the published studies. The inclusion criteria were 1) English language, 2) adults with primary cancer of the colon, 3) nonmetastatic disease, 4) neoadjuvant immunotherapy, and 5) reporting on 10 or more cases.

INTERVENTION

Neoadjuvant immunotherapy.

MAIN OUTCOME MEASURES

Safety (grade 3+ treatment-related adverse events) and efficacy (complete pathologic responses).

RESULTS

From 7691 studies identified, 6370 were screened and 8 were included. Various agents, dosing regimens, and treatment durations were used, with durations of immunotherapy ranging from 1 to 16 cycles. Complete R0 resections were consistently achieved in 98% to 100% of resections. Of patients who received neoadjuvant immunotherapy and underwent resection, 50% to 91% had ypT0N0 pathology. The safety profiles were generally favorable, with grade 1 to 2 treatment-related adverse events (mostly immune-related) during immunotherapy reported in 22.2% to 70% of patients. Postoperative complications after neoadjuvant immunotherapy were reassuring, with no severe complications reported.

LIMITATIONS

Small number of heterogeneous and uncontrolled studies precluding a meta-analysis.

CONCLUSIONS

Neoadjuvant immune checkpoint inhibition is associated with high rates of pathologic complete responses in locally advanced colon cancer. The literature is limited, particularly for postoperative outcomes, and more studies are needed to understand the safety and positioning of these regimens in the neoadjuvant context.

Outcomes Following Treatment of Pelvic Exenteration for Rectal Cancer in a Tertiary Care Center

Pelvic exenteration is potentially curative for operable locally advanced primary and locally recurrent rectal cancers. R0 resection is associated with higher survival. This procedure is associated with low mortality rates but high postoperative morbidity proportional to the extent of resection. This study was done to find out the survival outcome and morbidity associated with this procedure and to determine prognostic factors associated with postoperative outcomes. Seventy-three patients with rectal cancer underwent pelvic exenteration between January 2009 and December 2020. Sixty-six patients had locally advanced rectal cancer and 7 patients had recurrent cancer. All patients with primary tumors were evaluated with MRI pelvis and CT scan of the chest and abdomen while patients with recurrence were evaluated with a PET scan. The median follow-up duration was 39 months. The majority of patients were in the age group 40-69 years. Thirty patients were males and 43 were females. The 30-day postoperative major morbidity was reported in 28 patients (38.4%). The most common morbidity was wound dehiscence. The mean overall survival (OS) was 110.6 months (95% CI, 97.5-123.7) and mean disease free survival (DFS) was 85 months (95% CI, 71.0-100.4). R0 resection was associated with favorable overall survival. Tailored exenterations were associated with low morbidity. En bloc partial sacrectomy helped achieve R0 resection in patients who underwent the procedure. Extended resections yielded high R0 resection rates with favorable survival (65 months) but were associated with high morbidity. These procedures shall be best practiced in high-volume institutes of expertise.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-01918-w.

Analysis of Patient Outcomes following Curative R0 Multiorgan Resections for Locally Advanced Gastric Cancer: A Systematic Review and Meta-Analysis

Background: This systematic review examines the efficacy of multiorgan resection (MOR) in treating locally advanced gastric cancer (LAGC), focusing on survival outcomes, postoperative morbidity, and mortality. Methods: We conducted a comprehensive search of studies in PubMed, Scopus, and Embase up to November 2023, based on the PRISMA guidelines. The inclusion criteria focused on clinical trials, observational studies, case-control studies, and qualitative research, involving patients of any age and gender diagnosed with LAGC undergoing MOR aimed at R0 resection, with secondary outcomes focusing on survival rates, postoperative outcomes, and the effects of adjuvant and neoadjuvant therapies. Exclusion criteria ruled out non-human studies, research not specifically focused on LAGC patients undergoing MOR, and studies lacking clear, quantifiable outcomes. The quality assessment was performed using the Newcastle-Ottawa Scale. The final analysis included twenty studies, involving a total of 2489 patients across a time span from 2001 to 2023. Results highlighted a significant variation in median survival times ranging from 10 to 27 months and R0 resection rates from 32.1% to 94.3%. Survival rates one-year post-R0 resection varied between 46.7% and 84.8%, with an adjusted weighted mean of 66.95%. Key predictors of reduced survival included esophageal invasion and peritoneal dissemination, the presence of more than six lymph nodes, and tumor sizes over 10 cm. Nevertheless, the meta-analysis revealed a significant heterogeneity (I2 = 87%), indicating substantial variability across studies, that might be caused by differences in surgical techniques, patient demographics, and treatment settings which influence survival outcomes. Results: The review underlines the important role of achieving R0 resection status in improving survival outcomes, despite the high risks associated with MOR. Variability across studies suggests that local practice patterns and patient demographics significantly influence results. Conclusions: The findings emphasize the need for aggressive surgical strategies to improve survival in LAGC treatment, highlighting the importance of achieving curative resection despite inherent challenges.

Is an uncomplicated postoperative recovery following total pelvic exenteration a more important prognostic factor than achieving R0 in the first 2 years?

AIM

Total pelvic exenteration (TPE) can achieve an R0 resection in locally advanced and recurrent rectal cancer (LARC and RRC) and remains the only curative option. The resultant high morbidity creates prolonged complex recoveries, rendering patients unfit for adjuvant chemotherapy. This study aims to evaluate the impact of this on overall survival (OS) and disease-free survival (DFS) as it has not been studied previously.

METHOD

This is a retrospective single-centre study from 2017 to 2021 evaluating patients with LARC or RRC who underwent a curative TPE. Demographics, oncological history, perioperative data [using Clavien-Dindo (CD) scoring], disease recurrence and mortality were analysed using multivariate Cox regression to assess the impact of variables on DFS and OS.

RESULTS

A total of 120 patients were included with a median follow-up of 3 years. 28% of patients received adjuvant chemotherapy, 27.5% had surgical follow-up and 44% missed systemic treatment. Missed treatment was predominantly due to prolonged recovery or poor performance status (59%). Patients who missed adjuvant chemotherapy experienced significantly higher CD scores (p = 0.0031), reintervention rates (p=0.0056) and further related surgeriesp (p = 0.0314). Missing adjuvant chemotherpy is a significant factor for poorer survival, with almost a three times higher mortality (p=0.0096, hazard ratio 2.7). R status was not a significant factor for OS following multivariate analysis (p = 0.336), indicating that another factor has an impact on survival within the first 2 years.

CONCLUSIONS

In the initial 2 years after exenteration, an uncomplicated postoperative recovery allows for the delivery of adjuvant chemotherapy, prolonging survival. R0/R1 status was not the main prognostic factor. Longer follow-up and further multivariate analysis may influence decisions about aggressive R0 resection balanced against the patient being fit for chemotherapy postoperatively.

Multivisceral resection of advanced colon and rectal cancer: a prospective multicenter observational study with propensity score analysis of the morbidity, mortality, and survival

Objectives

In the surgical treatment of colorectal carcinoma (CRC), 1 in 10 patients has a peritumorous adhesion or tumor infiltration in the adjacent tissue or organs. Accordingly, multivisceral resection (MVR) must be performed in these patients. This prospective multicenter observational study aimed to analyze the possible differences between non-multivisceral resection (nMVR) and MVR in terms of early postoperative and long-term oncological treatment outcomes. We also aimed to determine the factors influencing overall survival.

Methods

The data of 25,321 patients from 364 hospitals who had undergone surgery for CRC (the Union for International Cancer Control stages I-III) during a defined period were evaluated. MVR was defined as (partial) resection of the tumor-bearing organ along with resection of the adherent and adjacent organs or tissues. In addition to the patients' personal, diagnosis (tumor findings), and therapy data, demographic data were also recorded and the early postoperative outcome was determined. Furthermore, the long-term survival of each patient was investigated, and a "matched-pair" analysis was performed.

Results

From 2008 to 2015, the MVR rates were 9.9 % (n=1,551) for colon cancer (colon CA) and 10.6 % (n=1,027) for rectal cancer (rectal CA). CRC was more common in men (colon CA: 53.4 %; rectal CA: 62.0 %) than in women; all MVR groups had high proportions of women (53.6 % vs. 55.2 %; pairs of values in previously mentioned order). Resection of another organ frequently occurred (75.6 % vs. 63.7 %). The MVR group had a high prevalence of intraoperative (5.8 %; 12.1 %) and postoperative surgical complications (30.8 % vs. 36.4 %; each p<0.001). Wound infections (colon CA: 7.1 %) and anastomotic insufficiencies (rectal CA: 8.3 %) frequently occurred after MVR. The morbidity rates of the MVR groups were also determined (43.7 % vs. 47.2 %). The hospital mortality rates were 4.9 % in the colon CA-related MVR group and 3.8 % in the rectal CA-related MVR group and were significantly increased compared with those of the nMVR group (both p<0.001). Results of the matched-pair analysis showed that the morbidity rates in both MVR groups (colon CA: 42.9 % vs. 34.3 %; rectal CA: 46.3 % vs. 37.2 %; each p<0.001) were significantly increased. The hospital lethality rate tended to increase in the colon CA-related MVR group (4.8 % vs. 3.7 %; p=0.084), while it significantly increased in the rectal CA-related MVR group (3.4 % vs. 3.0 %; p=0.005). Moreover, the 5-year (yr) overall survival rates were 53.9 % (nMVR: 69.5 %; p<0.001) in the colon CA group and 56.8 % (nMVR: 69.4 %; p<0.001) in the rectal CA group. Comparison of individual T stages (MVR vs. nMVR) showed no significant differences in the survival outcomes (p<0.05); however, according to the matched-pair analysis, a significant difference was observed in the survival outcomes of those with pT4 colon CA (40.6 % vs. 50.2 %; p=0.017). By contrast, the local recurrence rates after MVR were not significantly different (7.0 % vs. 5.8 %; both p>0.05). The risk factors common to both tumor types were advanced age (>79 yr), pT stage, sex, and morbidity (each hazard ratio: >1; p<0.05).

Conclusions

MVR allows curation by R0 resection with adequate long-term survival. For colon or rectal CA, MVR tended to be associated with reduced 5-year overall survival rates (significant only for pT4 colon CA based on the MPA results), as well as, with a significant increase in morbidity rates in both tumor entities. In the overall data, MVR was associated with significant increases in hospital lethality rates, as indicated by the matched-pair analysis (significant only for rectal CA).

Short term results in a population based study indicate advantage for laparoscopic colon cancer surgery versus open

The aim of this study was to compare LAP with OPEN regarding short-term mortality, morbidity and completeness of the cancer resection for colon cancer in a routine health care setting using population based register data. All 13,683 patients who were diagnosed 2012-2018 and underwent elective surgery for right-sided or sigmoid colon cancer were included from the Swedish Colorectal Cancer Registry and the National Patient Registry. Primary outcome was 30-day mortality. Secondary outcomes were 90-day mortality, length of hospital stay, reoperation, readmission and positive resection margin (R1). Weighted and unweighted multi regression analyses were performed. There were no difference in 30-day mortality: LAP (0.9%) and OPEN (1.3%) (OR 0.89, 95% CI 0.62-1.29, P = 0.545). The weighted analyses showed an increased 90-day mortality following OPEN, P < 0.001. Re-operations and re-admission were more frequent after OPEN and length of hospital stay was 2.9 days shorter following LAP (P < 0.001). R1 resections were significantly more common in the OPEN group in the unweighted and weighted analysis with P = 0.004 and P < 0.001 respectively. Therefore, the favourable short-term outcomes following elective LAP versus OPEN resection for colon cancer in routine health care indicate an advantage of laparoscopic surgery.

Laparoscopic and robotic multivisceral resection in colorectal cancer: A case series and systematic review

PURPOSE

Multivisceral resection (MVR) with open approach is the standard surgical treatment for locally advanced colorectal cancer. However, the medical literature concerning the practice of minimally invasive MVR in order to reduce postoperative complications and hospital stay has been growing exponentially over the last years. The present study aimed to examine our experience and to provide a systematic review about the results and complications of minimally invasive MVR.

METHODS

Data of patients that underwent minimally invasive MVR for locally advanced colorectal cancer from 2015 to 2021 were retrospectively reviewed. The literature was searched for studies concerning minimally invasive MVR for colorectal cancer.

RESULTS

A total of 39 laparoscopic MVR were performed in our department. Complications occurred in 14 patients (35.9%) with major complications in five patients (18.82%) according to Clavien-Dindo classification. Conversion was required in one case (2.56%) with subsequent mortality (2.56%). Pathologic adjacent organs or structures invasion was observed in 30 patients (76.9%) and positive resection margin occurred in two cases (5.2%). Twenty-two studies including 1055 patients were identified after literature search. In these studies, laparoscopic surgery and robotic surgery were performed in 90.15% and 9.85% of the patients, respectively. R0 resection was established in 95% of cases, conversion rate varied between 0% and 41.7%, and postoperative mortality ranged between 0% and 7.7% in the included articles.

CONCLUSION

Minimally invasive approach may be a safe option for patients requiring MVR for locally advanced colorectal cancer, with equivalent oncological results and could result in better early postoperative outcomes to open approach. However, further studies on this topic are needed to confirm the results of the current study.

En-bloc resection including SMV and duodenum in patient of locally advanced colon cancer

Tumor could directly invade or is adherent to other organs, but superior mesentery vein (SMV) and duodenum invasion are very rare. A 62-year-old woman was diagnosed with abdominal pain for several months. Multiple erythematous brownish skin patches and palpable mass were found at epigastric area. Computed tomography imaging showed focal wall thickening at the transverse colon that invaded to the rectus muscle and anterior abdominal wall. On exploration, we identified tumor invaded or was adherent to the duodenum and superior mesenteric vein and performed en-bloc resection. After surgery, the patient received chemotherapy and was followed up without any recurrence for 16 months. Adhesion and invasion of tumor to surrounding organs can be unexpectedly found during surgery. In our case, we found duodenum and SMV invasion and achieved R0 resection by SMV and duodenum resection, which could improve the patient's prognosis.

Oncologic outcomes after laparoscopic versus open multivisceral resection for local advanced colorectal cancer: A meta-analysis

Laparoscopic (lap) colectomies for advanced colorectal cancer (CRC) often require resection of other organs. We systematically reviewed currently available literature on lap multi-visceral resection for CRC, with regard to short- and long-term oncological outcomes, and compared them with open procedures. We performed a systematic literature search in MEDLINE, EMBASE, Google Scholar and PubMed from inception to November 30, 2020. The aim of this study was to synthesize short-term and oncological outcomes associated with laparoscopic versus open surgery. Pooled proportions and risk ratios (RRs) were calculated using an inverse variance method. We included six observational cohort studies published between 2012 and 2020 (lap procedures: n = 262; open procedures: n = 273). Collectively, they indicated that postoperative complications were significantly more common after open surgeries than lap surgeries (RR: 0.53; 95% confidence interval [CI]: 0.39-0.72; P < 0.00001), but the two approaches did not significantly differ in positive resection margins (RR: 0.75; 95% CI: 0.38-1.50; P = 0.42), local recurrence (RR: 0.66; 95% CI: 0.28-1.62; P = 0.37), or (based on two evaluable studies) 5-year OS (RR: 0.70; 95% CI: 0.46-1.04; P = 0.08) or 5-year DFS (RR: 0.86; 95% CI: 0.67-1.11) for T4b disease. In conclusion, laparoscopic and open multi-visceral resections for advanced CRC have comparable oncologic outcomes. Although a randomized study would be ideal for further research, no such studies are currently available.

Surgery for T4 Colorectal Cancer in Older Patients: Determinants of Outcomes

Background: This study aimed to compare the outcomes of older and younger patients with T4 colorectal cancer (CRC) treated with surgery. Methods: Consecutive patients with T4 CRC treated surgically at Henri Mondor Hospital between 2008 and 2016 were retrospectively analyzed in age subgroups (1) 50−69 years and (2) ≥70 years for overall and relative survival. The multivariable analyses were adjusted for adjusted for age, margin status, lymph node involvement, CEA level, postoperative complications (POC), synchronous metastases, and type of surgery. Results: Of 106 patients with T4 CRC, 57 patients (53.8%) were 70 years or older. The baseline characteristics were generally balanced between the two age groups. Older patients underwent adjuvant therapy less commonly (42.9 vs. 57.1%; p = 0.006) and had a longer delay between surgery and chemotherapy (median 40 vs. 34 days; p < 0.001). A higher trend for POC was reported among the older patients but did not impact the survival outcomes. After adjusting for confounding factors, the overall survival was shorter among the older patients (HR = 3.322, 95% CI 1.49−7.39), but relative survival was not statistically correlated to the age group (HR = 0.873, 95% CI 0.383−1.992). Conclusions: Older patients with CRC were more prone to severe POC, but age did not impact the relative survival of patients with T4 colorectal cancer. Older patients should not be denied surgery based on age alone.

Neoadjuvant therapy versus direct to surgery for T4 colon cancer: meta-analysis

BACKGROUND

Despite persistently poor oncological outcomes, approaches to the management of T4 colonic cancer remain variable, with the role of neoadjuvant therapy unclear. The aim of this review was to compare oncological outcomes between direct-to-surgery and neoadjuvant therapy approaches to T4 colon cancer.

METHODS

A librarian-led systematic search of MEDLINE, Embase, the Cochrane Library, Web of Science, and CINAHL up to 11 February 2020 was performed. Inclusion criteria were primary research articles comparing oncological outcomes between neoadjuvant therapies or direct to surgery for primary T4 colonic cancer. Based on PRISMA guidelines, screening and data abstraction were undertaken in duplicate. Quality assessment was carried out using Cochrane risk-of-bias tools. Random-effects models were used to pool effect estimates. This study compared pathological resection margins, postoperative morbidity, and oncological outcomes of cancer recurrence and overall survival.

RESULTS

Four studies with a total of 43 063 patients met the inclusion criteria. Compared with direct to surgery, neoadjuvant therapy was associated with increased rates of margin-negative resection (odds ratio (OR) 2.60, 95 per cent c.i. 1.12 to 6.02; n = 15 487) and 5-year overall survival (pooled hazard ratio 1.42, 1.10 to 1.82, I2 = 0 per cent; n = 15 338). No difference was observed in rates of cancer recurrence (OR 0.42, 0.15 to 1.22; n = 131), 30-day minor (OR 1.12, 0.68 to 1.84; n = 15 488) or major (OR 0.62, 0.27 to 1.44; n = 15 488) morbidity, or rates of treatment-related adverse effects.

CONCLUSION

Compared with direct to surgery, neoadjuvant therapy improves margin-negative resection rates and overall survival.

Predictors of undergoing multivisceral resection, margin status and survival in Dutch patients with locally advanced colorectal cancer

BACKGROUND

The aim of this nationwide observational study was to evaluate factors associated with multivisceral resection (MVR), margin status and overall survival in locally advanced colorectal cancer (CRC).

MATERIAL AND METHODS

Patients with (y)pT4, cM0 CRC between 2006 and 2017 were selected from the Netherlands Cancer Registry. Cox-proportional hazards modelling was used for survival analysis, stratified for T4a and T4b. Annual hospital volume cut-off was 75 for colon and 40 for rectal resections.

RESULTS

A total of 11.930 patients were included and 2410 patients (20.2%) underwent MVR. Factors associated with MVR for colon and rectal cancer besides cT4 category were more recent diagnosis (OR 3.61, CI 95% 3.06-4.25 (colon) and OR 2.72, CI 95% 1.82-4.08 (rectum)) and high hospital volume (OR 1.20, CI 95% 1.05-1.38 (colon) and OR 2.17, CI 95% 1.55-3.04 (rectum)). Patients ≥70 year were less likely to undergo MVR for colon cancer (OR 0.80, 95% CI 0.70-0.90). Risk factors for incomplete resection were cT4 (OR 3.08, CI 95% 2.35-4.04 (colon) and OR 1.82, CI 95% 1.13-2.94 (rectum)) and poor/undifferentiated tumors (OR 1.41, CI 95% 1.14-1.72 (colon) and OR 1.69, CI 95% 1.05-2.74 (rectum)). More recent diagnosis was independently associated with less incomplete resections in colon cancer (OR 0.58, CI 95% 0.40-0.76). Independent predictors of survival were age, resection margin, nodal status and adjuvant chemotherapy, but not MVR.

CONCLUSION

Treatment of locally advanced CRC with MVR at population level was influenced by year of diagnosis and hospital volume. Margin status in colon cancer improved substantially over time.

A Minimally Invasive Pelvic Multivisceral Resection Approach for Locally Advanced Primary Colorectal Cancers: A Single-Institution Experience

Background: The role of minimally invasive surgery (MIS) in locally advanced colorectal cancers (CRCs) suspected of direct invasion to adjacent organs or structures remains controversial. The aim of this study is to verify the safety and feasibility of minimally invasive multivisceral resection (MVR) surgery for locally advanced CRCs compared with conventional open surgery. Materials and Methods: Prospectively collected data from patients who underwent MVR for locally advanced CRCs from 2007 to 2017 were retrospectively reviewed. Patients with preoperative clinically suspected T4b stage cancers were enrolled in the study. Results: There were 30 and 19 patients in the MIS and open surgery groups, respectively. Seven patients in the MIS group required conversion, and the most common reason for conversion was ureter and bladder invasion. Tumor sizes were significantly larger in the open group (5.46 cm versus 7.48 cm, P = .010), whereas the MIS group included more patients with rectal cancers (56.7% versus 21%, P = .021). No differences were observed between the two groups in terms of operation time, estimated blood loss, and postoperative hospital stay. Curative (R0) resection was achieved in all patients, and the median follow-up period was 23 months. The 3-year overall survival in the MIS group was 73.6% and 77.9% in the open group (P = .445), and the 3-year total disease-free survival (DFS) was 59.2% and 51.4%, respectively (P = .695). Three-year local DFS was 83.3% for the MIS group, and 51.4% for the open group (P = .120). Conclusion: MIS for primary T4b CRCs without urinary tract invasion is safe and feasible.

Feasibility and Outcomes of Multivisceral Resection in Locally Advanced Colorectal Cancer: Experience of a Tertiary Cancer Center in North-East India

Purpose

Locally advanced colorectal cancer may require an en bloc resection of surrounding organs or structures to achieve complete tumor removal. This decision must weigh the risk of complications of multivisceral resection against the potential survival benefit. The purpose of this study is to review a single-center experience of feasibility of en bloc multivisceral resections for locally advanced colorectal carcinoma and to examine the effect of surgical experience on immediate outcome and rate of R0 resections.

Methods

This is a study of 27 patients who underwent multivisceral resection for locally advanced colorectal carcinoma which was performed at our institute from January 2016 to December 2019. Among the 27 patients aged between 21 and 76 years (mean age, 48.67±7.3 years), 13 were males and 14 were females. Overall 18 patients had primary colon carcinoma and 9 had primary rectal carcinoma. All rectal cancer patients received neoadjuvant chemoradiation. All patients underwent surgery with curative intent. All patients underwent open surgery of which 66.7% underwent colectomy, 14.8% underwent anterior resection, 11.1% underwent Miles procedure, and 7.4% underwent pelvic exenteration.

Results

The mean operative time was 268.14±72.2 minutes and the median amount of blood units transfused was 2.07 units. The mean hospital stay was 13.67±3.4 days. Histologically, 44.4% of patients had well-differentiated adenocarcinoma and 55.6% had moderately differentiated adenocarcinoma. The final histopathological examinatio n revealed malignant infiltration of the adjacent organs in 19/27 patients (70.4%). Pathological complete response was seen in 2 patients. R0 resection rate achieved was 96.3%. Lymph node metastasis was seen in 66.7% of patients with colon cancer and 11.1% with rectal cancer with overall mean number of harvested lymph nodes being 12.44±3.01. Postoperative complications were identified in 7 patients (25.9%), while mortality was seen in 2 (7.4%).

Conclusion

Multivisceral resection for advanced colorectal cancer invading into the adjacent organ may be performed with acceptable morbidity and mortality.

Preoperative multidisciplinary team assessment is associated with improved survival in patients with locally advanced colon cancer; a nationwide cohort study in 3157 patients

INTRODUCTION

Multidisciplinary team (MDT) assessment is associated with improved survival in locally advanced rectal cancer, but the effect of an MDT assessment on survival in locally advanced colon cancer has not been reported. The aim of this national population-based cohort study was to establish if preoperative MDT assessment affects prognosis in patients with primary locally advanced colon cancer.

MATERIAL AND METHODS

All patients in Sweden with locally advanced colon cancer, without metastatic disease, who underwent an elective colon resection between 2010 and 2017 were identified through the Swedish Colorectal Cancer Registry (SCRCR), and the cohort was linked to national registers. Data on patient characteristics, preoperative staging, surgical procedures, recurrence and survival were collected from SCRCR. The association between MDT assessment and colon cancer-specific survival was evaluated using Kaplan-Meier survival curves and Cox proportional hazards models. The multivariable analysis was adjusted for sex, age, ASA grade, CCI, time period, pN, region and preoperative MDT.

RESULTS

MDT assessment was performed in 2663 patients (84.4%) of 3157 eligible patients. The 3-year colon cancer-specific survival was higher following MDT, compared with no MDT assessment (80% versus 68%). MDT assessment was independently associated with reduced colon cancer-specific mortality (HR 0.70, 0.57-0.84 95% CI).

CONCLUSION

Preoperative MDT assessment is associated with an improved long-term survival in patients with locally advanced colon cancer and should be mandatory in patients with suspected locally advanced colon cancer.

Differences in effectiveness and use of laparoscopic surgery in locally advanced colon cancer patients

Patients with locally advanced colon cancer have worse outcomes. Guidelines of various organizations are conflicting about the use of laparoscopic colectomy (LC) in locally advanced colon cancer. We determined whether patient outcomes of LC and open colectomy (OC) for locally advanced (T4) colon cancer are comparable in all colon cancer patients, T4a versus T4b patients, obese versus non-obese patients, and tumors located in the ascending, descending, and transverse colon. We used data from the 2013–2015 American College of Surgeons’ National Surgical Quality Improvement Program. Patients were diagnosed with nonmetastatic pT4 colon cancer, with or without obstruction, and underwent LC (n = 563) or OC (n = 807). We used a composite outcome score (mortality, readmission, re-operation, wound infection, bleeding transfusion, and prolonged postoperative ileus); length of stay; and length of operation. Patients undergoing LC exhibited a composite outcome score that was 9.5% lower (95% CI − 15.4; − 3.5) versus those undergoing OC. LC patients experienced a 11.3% reduction in postoperative ileus (95% CI − 16.0; − 6.5) and an average of 2 days shorter length of stay (95% CI − 2.9; − 1.0). Patients undergoing LC were in the operating room an average of 13.5 min longer (95% CI 1.5; 25.6). We found no evidence for treatment heterogeneity across subgroups (p > 0.05). Patients with locally advanced colon cancer who receive LC had better overall outcomes and shorter lengths of stay compared with OC patients. LC was equally effective in obese/nonobese patients, in T4a/T4b patients, and regardless of the location of the tumor.

The First Report of Laparoscopic Multivisceral Resection for a Gastrocolic Fistula Secondary to Colon Cancer

BACKGROUND

Colon cancer rarely presents with a gastrocolic fistula and resection, if feasible, is usually carried out by open surgery. The authors present the first literature case report of laparoscopic multivisceral resection for gastrocolic fistula secondary to locally advanced colon cancer.

MATERIALS AND METHODS

A 54-year-old man presented with feculant vomiting, cachexia, and severe iron deficiency anemia. Investigations confirmed a large nonmetastatic splenic flexure colon cancer with fistulation into the stomach. After 10 weeks of nutritional support and laparoscopic defunctioning proximal transverse loop colostomy, we proceeded to laparoscopic extended left hemicolectomy with en bloc sleeve gastrectomy and partial splenectomy.

RESULT

The procedure was completed laparoscopically (operating time, 400 min; blood loss, 150 mL). He was discharged on the 6th postoperative day after an uneventful recovery. Histology showed an R0 resection of a pT4N1a (1/45 lymph nodes involved) colon cancer with gastrocolic fistula.

CONCLUSION

Laparoscopic multivisceral en bloc R0 resection of locally advanced colon cancer with gastrocolic fistula can be accomplished safely in experienced hands.

Results of systematic second-look surgery plus hipec in perforated or pt4 colon cancer. Case series

Background

Perforated or pT4 colonic tumors have a bad prognosis with a high rate of relapse, including peritoneal relapse (20–30%). Our aim is to analyze the effectiveness of Second Look surgery (SLS) + hyperthermic intraperitoneal chemotherapy (HIPEC) in these patients for early treatment of peritoneal relapse (PR) or for preventing it.

Patients and methods

Patients previously operated for colon cancer, either pT4 or perforated (M0), with no evidence of disease at any level after adjuvant chemotherapy, who undergo systematic SLS + HIPEC (Oxaliplatin 30 min) one year after the initial surgery.

Results

Since February 2014 to July 2018, we performed SLS + HIPEC in 42 patients with M0, either pT4 (n = 33) or perforated (n = 9) colon cancer. Although during SLS there were suspicious lesions in 15 cases (37.5%), they were histologically confirmed in only 4 (9.5%). Histologically confirmed peritoneal relapse (PR) rate at SLS was 6% in pT4 (2/33) and 22.2% in perforated tumors (2/9). Prophylactic HIPEC was performed in all the cases. There was no postoperative mortality. Grade III-IV morbidity occurred in 19% (8/42). With a median follow-up of 33.8 months after primary tumor surgery, 6/42 patients (14.3%) presented peritoneal relapse (PR). 3-year peritoneal disease free survival was 86%, with 3-year disease free survival of 78.6% and 5-year overall survival (OS) of 97.4%.

Conclusion

Peritoneal relapse and survival rates are remarkable in these groups of, a priori, very bad prognosis, which could suggest a beneficial effect of HIPEC.

•

Prospective study trying to decrease peritoneal relapse in perforated or pT4 CRC.

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20–30% of perforated or pT4 CRC develop peritoneal metastases in the follow-up.

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We find peritoneal disease at Second Look surgery before seen in the image tests.

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Second-Look Surgery + HIPEC decreases peritoneal relapse and gets better survival.

ERCC overexpression associated with a poor response of cT4b colorectal cancer with FOLFOX-based neoadjuvant concurrent chemoradiation

Colorectal cancer (CRC) of the clinical tumor stage T4b (cT4b) refers to advanced tumors with direct invasion of adjacent structures and the tumors are considered unresectable. Despite advancements in aggressive surgery and combination chemotherapy, the prognosis of cT4b CRC remains poor. Optimizing the therapeutic sequence administered to patients with cT4b CRC to improve clinical outcomes is crucial. In the present study, patients with unresectable cT4b and nodal stage N1-2 CRC were investigated at a single institution. A total of 20 consecutive patients were treated with pre-operative concurrent chemoradiation by using 5-fluorouracil/leucovorin/oxaliplatin (FOLFOX) since February 2015 and were regularly followed up until March 2020. Due to their poor response to concurrent chemoradiation (CCRT) with FOLFOX, the chemotherapy regimen was changed to irinotecan plus 5-fluorouracil/leucovorin (FOLFIRI) as the second-line neoadjuvant treatment. Genetic alterations, such as microsatellite instability (MSI), were documented, and the expression levels of excision repair cross-complementing group 1 (ERCC1) and ERCC2 were examined. Of the 20 patients, the tumors of 14 patients (70%) became resectable after FOLFIRI administration. The median duration between the last date of radiotherapy and surgery was 32.7 weeks (range, 10.1–59.3 weeks). Of note, 4 of the 14 patients with resectable tumors (28.6%) achieved a pathologic complete response. The median overall survival and progression-free survival were 27.5 months (range, 12–39 months) and 27.5 months (range, 8–39 months), respectively. The cancerous specimens of all of the patients (100%) exhibited ERCC2 overexpression and 18 specimens (90%) had ERCC1 overexpression. Only one tumor (5%) exhibited high MSI. The present study indicated that ERCC overexpression associated with the poor response of FOLFOX-based CCRT and FOLFIRI after FOLFOX-based CCRT failure may have a potential role in conversion to resectable tumors by neoadjuvant treatment in cT4b CRC. However, a further prospective study with more patients is required to improve the precision of the conclusions.

Surgical management and hyperthermic intraperitoneal chemotherapy for locally advanced colorectal cancer

Locally advanced colorectal cancers (CRC) pose several management challenges, including local recurrence and the development of peritoneal metastases (PM). These recurrences are associated with a poor prognosis and onerous complications. In selected patients with PM, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) have shown to confer survival benefit. However, its effectiveness depends on the disease extent and this combined treatment is associated with significant morbidity. Additionally, early detection of PM is difficult even with state-of-the-art imaging techniques. Due to the high-risk of developing PM, locally advanced CRC are currently being investigated in several trials, including adjuvant HIPEC in an attempt to reduce the risk of PM. This review article sets out to examine the current data available on this topic, in an attempt to determine the suitability and effectiveness of HIPEC in the management of locally advanced CRC.

Standard and multivisceral colectomy in locally advanced colon cancer

Background

Management of locally advanced colon cancer (LACC) is challenging. Surgery is the mainstay of the treatment, yet its outcomes remain unclear, especially in the setting of multivisceral resections. The aim of the study was to examine the outcomes of standard and multivisceral colectomy in patients with LACC.

Patients and methods

Patients demographics, clinical and perioperative data of patients operated within study period 2004–2018 were collected. LACC was defined as stage T4 colon cancer including tumor invasion either through the visceral peritoneum or to the adjacent organs/structures. Accordingly, either standard or multivisceral colectomy (SC and MVC) was performed.

Results

Two hundred and three patients underwent colectomy for LACC. Of those, 112 had SC (55.2%) and 91 (44.8%) had MVC. Severe morbidity and mortality rates were 5.9% and 2.5%, respectively. MVC was associated with an increased blood loss (200 ml vs. 100 ml, p = 0.01), blood transfusion (22% vs. 8.9%, p = 0.01), longer operative time (180 minutes vs. 140 minutes, p < 0.01) and postoperative hospital stay (11 days vs. 10 days, p < 0.01) compared with SC. The complication-associated parameters were similar. Male gender, presence of ≥ 3 comorbidities, tumor location in the left colon and perioperative blood transfusion were associated with complications in the univariable analysis. In the multivariable model, the presence of ≥ 3 comorbidities was the only independent predictor of complications.

Conclusions

Colectomy with or without multivisceral resection is a safe procedure in LACC. In experienced hands, the postoperative outcomes are similar for SC and MVC. Given the complexity of the latter, these procedures should be reserved to qualified expert centers.

Recurrence pattern and outcomes in T4 colon cancer: A single institution analysis

BACKGROUND AND OBJECTIVES

Patients with T4 colon adenocarcinoma have an increased risk of locoregional and distant recurrence. This study defines the metastatic pattern, predictors of recurrence, and efficacy of adjuvant treatment in T4 colon cancer.

METHODS

A retrospective review was performed of patients with T4 colon adenocarcinoma from May 2005 to November 2015 at a tertiary care hospital. Baseline factors, follow-up, recurrence, and survival were collected and analyzed.

RESULTS

Locoregional recurrence (LR) rates for N0, N1, and N2 were 21/85 (24.7%), 14/50 (28%), and 21/46 (45.7%), respectively (P = .014). Multivariate analysis for distant recurrence was significant for positive nodes (hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.1-9.9). Multivariate analysis for LR was significant for the following variables: perforation (HR, 2.7; 95% CI, 1.2-6.2), lymphovascular invasion (HR, 2.7; 95% CI, 1.1-6.7), positive nodes (HR, 2.8; 95% CI, 1.2-6.9), and positive margins (HR, 5.0; 95% CI, 2.1-12.1). Multivariate analysis for overall survival was significant for: signet ring histology (HR, 2.5; 95% CI, 1.2-5.8), positive nodes (HR, 2.3; 95% CI, 1.2-4.4), and positive margin (HR, 2.8; 95% CI, 1.4-5.8).

CONCLUSION

T4 colon adenocarcinoma has a high risk of LR and mortality. Clinical trials utilizing the aforementioned high-risk features may increase the ability to demonstrate beneficial intervention.

Subclassification of Multivisceral Resections for T4b Colon Cancer with Relevance for Postoperative Complications and Oncological Risks

BACKGROUND

Multivisceral resection for T4b colon cancer constitutes a heterogeneous group of surgical procedures. The purpose of this study was to explore clinically distinct categories of multivisceral resection, with subsequent correlation to postoperative complications and oncological outcomes.

METHODS

In this multicenter cohort study, all consecutive patients without metastases who underwent multivisceral resection for pT4bN0-2M0 colon cancer between 2000 and 2014 were included. Multivisceral resection was divided into four categories: (i) gastrointestinal (including the stomach), (ii) urologic ((partial) bladder and ureter), (iii) solid organ (spleen, kidney, liver, pancreas, and uterus), and (iv) abdominal wall/omentum/ovaries. The primary outcome was surgical complications and secondary outcomes were 5-year intra-abdominal recurrence, disease-free survival, and overall survival.

RESULTS

In total, 130 patients who underwent curative intent resection of pT4 colon cancer were included. Patients who underwent multivisceral resection within multiple categories were assigned to one of the categories based on hierarchy of clinical impact after exploratory analysis. For the primary endpoint, 55 patients were assigned to gastrointestinal, 14 to urologic, 14 to solid organ, and 47 to abdominal wall/omentum/ovaries multivisceral resection. Gastrointestinal multivisceral resection was independently associated with surgical complications (HR 3.9, 95% CI 1.4-10.6). Abdominal wall/omentum/ovaries multivisceral resection was significantly related with intra-abdominal recurrence (HR 7.8, 95% CI 1.0-57.8). The 5-year disease-free survival and overall survival showed no significant differences per multivisceral resection category.

CONCLUSIONS

Multivisceral resections for T4b colon cancer are heterogeneous procedures considering risk profiles. The proposed multivisceral resection subclassification needs validation, but might improve comparability between studies and hospitals (auditing).

Is the non-metastatic, locally advanced colon adenocarinoma a distinct biological tumor variant? A study based on pathological evaluation, immunohistochemical panel and survival

OBJECTIVE

to evaluate the clinical and pathological differences between locally advanced colonic adenocarcinomas (LACA) with adhesions between adjacent organs or structures, and colonic adenocarcinomas with other clinical presentations.

METHODS

we conducted a retrospective study from a convenience sample of patients with colonic adenocarcinoma, pathological stage pT3, distributed according to clinical and pathological characteristics in three groups: locally advanced tumors (LACA), pT3 tumors without adhesions or distant metastases (SF) and tumors with metastatic disease (M1). We evaluated clinical and pathological characteristics and the expression of seven immunohistochemical markers related to proliferation/apoptosis, cell invasion/migration and metastasis.

RESULTS

we studied 101 patients: 30 LACA, 44 SF and 27 M1. Locally advanced tumors presented larger dimensions and were associated with increased lymphocyte infiltration rates, lower levels of bax expression, and CD 44v6 when compared with SF and M1 groups. We observed significant differences between LACA and M1 in relation to colonic location, histology, lymph node status and bax and CD44v6 expression. We found differences were observed between the three groups for tumor size and lymphocytic infiltrate. Survival was similar in the LACA and SF groups (p=0.66) and was lower in the M1 group (p<0.001).

CONCLUSION

the data suggest that locally advanced colonic adenocarcinomas with adhesions between adjacent organs or structures represent a distinct entity.

Adjuvant hyperthermic intraperitoneal chemotherapy in patients with locally advanced colon cancer (COLOPEC): a multicentre, open-label, randomised trial

BACKGROUND

Nearly a quarter of patients with locally advanced (T4 stage) or perforated colon cancer are at risk of developing peritoneal metastases, often without curative treatment options. We aimed to determine the efficacy of adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with locally advanced colon cancer.

METHODS

This multicentre, open-label trial was done in nine hospitals that specialised in HIPEC in the Netherlands. Patients with clinical or pathological T4N0-2M0-stage tumours or perforated colon cancer were randomly assigned (1:1), with a web-based randomisation application, before resection of the primary tumour, to adjuvant HIPEC followed by routine adjuvant systemic chemotherapy (experimental group) or to adjuvant systemic chemotherapy alone (control group). Patients were stratified by tumour characteristic (T4 or perforation), age (<65 years or ≥65 years), and surgical approach of the primary tumour resection (laparoscopic or open). Key eligibility criteria included age between 18 and 75 years, adequate clinical condition for HIPEC, and intention to start adjuvant systemic chemotherapy. Patients with metastatic disease were ineligible. Adjuvant HIPEC consisted of fluorouracil (400 mg/m²) and leucovorin (20 mg/m²) delivered intravenously followed by intraperitoneal delivery of oxaliplatin (460 mg/m²) for 30 min at 42°C, delivered simultaneously or within 5-8 weeks after primary tumour resection. In all patients without evidence of recurrent disease at 18 months, a diagnostic laparoscopy was done. The primary endpoint was peritoneal metastasis free-survival at 18 months, measured in the intention-to-treat population, with the Kaplan-Meier method. Adverse events were assessed in all patients who received assigned treatment. This study is registered with ClinicalTrials.gov, number NCT02231086.

FINDINGS

Between April 1, 2015, and Feb 20, 2017, 204 patients were randomly assigned to treatment (102 in each group). In the HIPEC group, two patients withdrew consent after randomisation. In this group, 19 (19%) of 100 patients were diagnosed with peritoneal metastases: nine (47%) during surgical exploration preceding intentional adjuvant HIPEC, eight (42%) during routine follow-up, and two (11%) during diagnostic laparoscopy at 18-months. In the control group, 23 (23%) of 102 patients were diagnosed with peritoneal metastases, of whom seven (30%) were diagnosed by laparoscopy at 18-months and 16 during regular follow-up (therefore making them ineligible for diagnostic laparoscopy). In the intention-to-treat analysis (n=202), there was no difference in peritoneal-free survival at 18-months (80·9% [95% CI 73·3-88·5] for the experimental group vs 76·2% [68·0-84·4] for the control group, log-rank one-sided p=0·28). 12 (14%) of 87 patients who received adjuvant HIPEC developed postoperative complications and one (1%) encapsulating peritoneal sclerosis.

INTERPRETATION

In patients with T4 or perforated colon cancer, treatment with adjuvant HIPEC with oxaliplatin did not improve peritoneal metastasis-free survival at 18 months. Routine use of adjuvant HIPEC is not advocated on the basis of this trial.

FUNDING

Organization for Health Research and Development and the Dutch Cancer Society.

Significance of multivisceral resections in oncologic surgery: A systematic review of the literature

BACKGROUND

Multivisceral resections (MVR) are often necessary to reach clear resections margins but are associated with relevant morbidity and mortality. Factors associated with favorable oncologic outcomes and elevated morbidity rates are not clearly defined.

AIM

To systematically review the literature on oncologic long-term outcomes and morbidity and mortality in cancer surgery a systematic review of the literature was performed.

METHODS

PubMed was searched for relevant articles (published from 2000 to 2018). Retrieved abstracts were independently screened for relevance and data were extracted from selected studies by two researchers.

RESULTS

Included were 37 studies with 3112 patients receiving MVR for colorectal cancer (1095 for colon cancer, 1357 for rectal cancer, and in 660 patients origin was not specified). The most common resected organs were the small intestine, bladder and reproductive organs. Median postoperative morbidity rate was 37.9% (range: 7% to 76.6%) and median postoperative mortality rate was 1.3% (range: 0% to 10%). The median conversion rate for laparoscopic MVR was 7.9% (range: 4.5% to 33%). The median blood loss was lower after laparoscopic MVR compared to the open approach (60 mL vs 638 mL). Lymph-node harvest after laparoscopic MVR was comparable. Report on survival rates was heterogeneous, but the 5-year overall-survival rate ranged from 36.7% to 90%, being worst in recurrent rectal cancer patients with a median 5-year overall survival of 23%. R0 -resection, primary disease setting and no lymph-node or lymphovascular involvement were the strongest predictors for long-term survival. The presence of true malignant adhesions was not exclusively associated with poorer prognosis.

Included were 16 studies with 1.600 patients receiving MVR for gastric cancer. The rate of morbidity ranged from 11.8% to 59.8%, and the main postoperative complications were pancreatic fistulas and pancreatitis, anastomotic leakage, cardiopulmonary events and post-operative bleedings. Total mortality was between 0% and 13.6% with an R0 -resection achieved in 38.4% to 100% of patients. Patients after R0 resection had 5-year overall survival rates of 24.1% to 37.8%.

CONCLUSION

MVR provides, in a selected subset of patients, the possibility for good long-term results with acceptable morbidity rates. Unlikelihood of achieving R0 -status, lymphovascular- and lymph -node involvement, recurrent disease setting and the presence of metastatic disease should be regarded as relative contraindications for MVR.

Short- and Long-term Outcomes of Minimally Invasive Versus Open Multivisceral Resection for Locally Advanced Colorectal Cancer

BACKGROUND

Colorectal cancer invading the adjacent organs/structures is detected in 5% to 20% of all surgical interventions performed for the management of colorectal cancer.

OBJECTIVE

Our purpose is to verify the safety and feasibility of laparoscopic surgery for the treatment of locally advanced colorectal cancer invading the adjacent organs.

DESIGN

This is a retrospective study.

SETTINGS

The study was conducted at a single institution in Japan.

PATIENTS

We compared the morbidity, appropriate oncological resection, and disease-free survival of laparoscopic and open multivisceral resection in patients with colorectal carcinoma in the period between 2007 and 2015.

MAIN OUTCOME MEASURES

The primary outcome measures were curative resection rate, morbidity rate, and recurrence of laparoscopic and open multivisceral resection in patients with colorectal cancer.

RESULTS

Thirty-one patients received laparoscopic surgery, and 50 received open surgery. The amount of blood loss was smaller in the laparoscopic group than in the open group (60 vs 595 mL, p < 0.01). Curative surgery was performed in 46 patients of the open group (92.0%) and in 30 patients of the laparoscopic group (96.8%). Days until oral intake (5 vs 7 days, p < 0.01) and postoperative hospital stay (14 vs 19 days, p < 0.01) were shorter in the laparoscopic group. Overall morbidity was not different between the groups (22.5% vs 40.0%). Three-year disease-free survival rates were 62.7% in the open group and 56.7% in the laparoscopic group (p = 0.5776).

LIMITATION

This study was a retrospective small study conducted at a single institute.

CONCLUSION

Laparoscopic multivisceral resection may be a safe, less invasive alternative to open surgery, with less blood loss and shorter hospital stay, and was not inferior to open surgery based on long-term oncological end points. See Video Abstract at http://links.lww.com/DCR/A785.

Laparoscopy-assisted colectomy as an Oncologically safe alternative for patients with stage T4 Colon Cancer: a propensity-matched cohort study

Background

It is still controversial whether laparoscopy-assisted colectomy (LAC) is suitable for patients with stage T4 colon cancer. This study aimed to compare the short- and long-term outcomes of LAC and open colectomy (OC) for patients with pathologic T4 colon cancer.

Methods

Data of eligible patients with colon cancer in our institution from March 2004 to September 2014 were retrospectively reviewed. The patients were followed up to September 2016. Propensity score matching was performed to control the bias.

Results

Two hundred and forty two patients were selected by propensity score matching, with 121 patients in the LAC group and 121 in the OC group. Mean operating time and rate of intraoperative blood transfusion were similar between two groups. In LAC group, shorter time to first flatus and first liquid intake were observed in patients with pT4b stage disease, but not for patients with pT4a stage disease. Less blood loss and shorter length of postoperative hospital stay were examined in LAC group, including pT4a and pT4b stages. Conversion was required in 9.1% (11 out of 121) cases. DFS and OS were similar between LAC and OC groups. The 5-year DFS rate was 64.2% for pT4a stage and 35.5% for pT4b stage in LAC group, and 62.9% and 33.7% in OC group for pT4a (p = 0.374) and pT4b (p = 0.385) stage respectively. For 5-year OS rates, two groups did not differ in pT4a stage (LAC 69.2% vs. OC 66.0%, p = 0.151) and pT4b stage (LAC 37.5% vs. OC 38.1%, p = 0.510).

Conclusions

Laparoscopic colectomy appears to be safe for selected patients with pT4 colon cancer in centres with expertise in minimally invasive surgery.

Management and Outcome After Multivisceral Resections in Patients with Locally Advanced Primary Colon Cancer

BACKGROUND

Locally advanced colon cancer invading surrounding organs or structures is challenging to surgeons and oncologists. Multivisceral resections with tumor removal en bloc with invaded tissues provide the best chance for cure.

OBJECTIVE

We aimed to assess the management and outcomes after multivisceral resections in patients with clinically infiltrative, locally advanced primary colon cancer.

DESIGN

This is a descriptive retrospective cohort study.

SETTINGS

A total of 121 consecutive patients with locally advanced primary colon cancer underwent en bloc multivisceral resections at a tertiary referral unit for colorectal cancer between 2007 and 2014.

MAIN OUTCOME MEASURES

Patient demographics, surgical details, histopathological findings, and outcomes were analyzed through registry data and reviews of patient files.

RESULTS

An R0 resection was achieved in 112 patients (92.6%), and an R1 resection was achieved in 9 patients (7.4%). Actual tumor cell infiltration in resected tissues was found in 77 patients (63.6%), and inflammation was found in 44 patients (36.4%). The estimated 5-year overall survival was 60.8% and 86.9%. Survival was significantly better after R0 than after R1 resections. After a median follow-up of 28 months, recurrent disease was diagnosed in 25 patients (20.7%). Female sex, low tumor stage, and adjuvant chemotherapy, but not tumor infiltration per se, were independently associated with better overall survival in a multivariate analysis.

LIMITATIONS

The main limitations of the study are the retrospective design and the fact that all patients were operated on at 1 institution by a small number of surgeons.

CONCLUSIONS

Patients with locally advanced colon cancer can be cured with an R0 resection. All involved surrounding tissues should be removed en bloc with the primary tumor. See Video Abstract at http://links.lww.com/DCR/A548.

Short- and Long-Term Outcomes of Laparoscopic Multivisceral Resection for Clinically Suspected T4 Colon Cancer

BACKGROUND

The use of laparoscopic surgery for colorectal cancer has become widespread recently. However, the safety and oncological outcomes of laparoscopic surgery for primary advanced colorectal cancer need extensive investigation. We analyzed the short- and long-term outcomes after laparoscopic multivisceral resection for primary colon cancer with suspected invasion of other organs at a single institution.

METHODS

Between January 2000 and December 2014, 118 patients underwent laparoscopic multivisceral resection for primary colon cancer invading or adhering to adjacent organs or structures; their short- and long-term outcomes were retrospectively evaluated.

RESULTS

The median operating time was 254 min (range 130-1051 min), and median blood loss was 48 ml (range 0-2777 ml). The overall conversion rate was 6.8%. The postoperative complication rate was 17.8%. The number of patients with R0 and R1 resection was 112 (94.9%) and 6 (5.1%), respectively. At a median follow-up period of 32 months (range 0-157 months), the local recurrence rate in patients who underwent R0 resection was 1.8%, while for R1 resection it was 66.7%. In multivariate analysis, R1 resection and LN metastases were found to be predictors of poor prognosis. The cancer-specific 5-year survival was 87% when R0 resection was achieved; within these, the 5-year survival rates for patients with stages II, III, and IV disease were 94, 81, and 40%, respectively.

CONCLUSIONS

Laparoscopic en bloc multivisceral resection for clinically suspected T4 colon cancer is a safe and feasible procedure for precisely selected patients, attaining satisfactory oncological outcomes when R0 resection is achieved.

Multivisceral resections for locally advanced colorectal cancer after preoperative treatment

Multivisceral resection for colorectal cancer invading into the adjacent organs may often be difficult and may involve serious complications. Preoperative therapy may facilitate resection with safe margins. Between August 2007 and July 2016, 23 patients with colorectal cancer invading into the adjacent organs treated with preoperative treatment (chemoradiotherpay, chemotherapy, radiotherapy) were retrospectively investigated. All 23 patients received surgery with curative intent. Four patients had distant metastases at the time of diagnosis. Two patients had distant metastasis after preoperative treatment. The mean operative time was 535.3±185.5 min and the median amount of blood loss was 1,050 ml. Histopathological examination revealed malignant infiltration of the adjacent organs in 14 patients (60.9%). R0 resection rate was 73.9%. Postoperative complications were identified in nine patients (39.1%) and a high incidence of infectious complications was observed. Patients with curative resection showed a significantly better survival than patients with R1 or R2 resection (P<0.01). Multivisceral resection for locally advanced colorectal cancer invading into the adjacent organ after preoperative treatment may be performed with acceptable morbidity and minimal mortality. R0 resection improves the prognosis of patients with locally advanced colorectal cancer invading into the adjacent organ after preoperative treatment.

T4 Colon Cancer - Current Management

Colorectal cancer is the third most often encountered type of cancer and represents the third leading cause of cancer related deaths, on both sexes. One of the most important prognostic parameters is the tumor’s stage at the time of the diagnosis. T4 cancers represent advanced tumors associated with penetration of the visceral peritoneum (T4a) and/or direct invasion in adjacent structures (T4b). Preoperative diagnosis is influenced by the inability of the existent imaging modalities to accurately differentiate the true invasion from the simple, inflammatory adherence to the neighboring structures. As a consequence surgical treatment must follow the principle of en bloc resection; however the ability of achieving an R0 resection depends on the tumor location, invaded organ, and the type of the surgical procedure required. Neoadjuvant treatment for advanced colon cancer it may be very difficult to be applied. This review is focused on preoperative workup, therapeutic strategies and subsequent results in advanced T4 colon cancers.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Colon Cancer

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than to dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.

Oncologic outcomes following laparoscopic colon cancer resection for T4 lesions: a case-control analysis of 7-years' experience

BACKGROUND

According to many Societies' guidelines, patients presenting with clinical T4 colorectal cancer should conventionally be approached by a laparotomy. Results of emerging series are questioning this attitude.

METHODS

We retrospectively analysed the oncologic outcomes of 147 patients operated on between June 2008 and September 2015 for histologically proven pT4 colon cancers. All patients were treated with curative intent, either by a laparoscopic or open "en bloc" resection.

RESULTS

Median operative time, blood loss and hospital length of stay were significantly reduced in the laparoscopic group. Postoperative surgical complication rate and 30-day mortality did not significantly differ between the two groups ( p = 0.09 and p = 0.99, respectively). R1 resection rate and lymph nodes harvest, as well, did not remarkably differ when comparing the two groups. In the laparoscopic group, conversion rate was 19%. Long-term outcomes were not affected in patients who had undergone conversion. Five-year overall survival and disease-free survival did not significantly differ between the two groups (44.6% and 40.3% vs. 39.4% and 38.9%). Locally advanced stages (IIIB-IIIC) and R1 resections were detected as independent prognostic factors for overall survival.

CONCLUSION

Laparoscopic approach might be safe and acceptable for locally advanced colon cancer and does not jeopardize the oncologic results. Conversion to open surgery should be a part of a strategy as it does not seem to adversely affect perioperative and long-term outcomes. We consider laparoscopy, in expert hands, the last diagnostic tool and the first therapeutic approach for well-selected locally advanced colon cancers. Larger prospective studies are needed to widely assess this issue.

Safety and feasibility of laparoscopic multivisceral resection for surgical T4b colon cancers: Retrospective analyses

INTRODUCTION

Laparoscopic (Lap) surgery has not been established as a standard procedure for locally advanced colon cancers. Here, we evaluated the safety and feasibility of Lap multivisceral resection (MVR) for tumors that had invaded adjacent organs (T4b).

METHODS

We performed retrospective analyses using a single institutional database. Eighty-four patients who underwent Lap or open MVR for surgical T4b primary colon cancers satisfied the inclusion criteria.

RESULTS

Among the 84 patients, 48 underwent Lap MVR and 36 underwent open MVR. More patients in the open group were clinical T4b and were receiving neoadjuvant chemotherapy. Patients in the open group had worse performance status (P = 0.037) and tumors of greater diameter. Lap completion was achieved in 42 cases (87.5%); the conversion rate was highest in cases involving the urinary tract (40.0%). Lap reconstruction of the bladder or ureter was extremely challenging, and therefore, adjacent organ reconstruction influenced Lap completion. Regarding perioperative outcomes, Lap was superior to open surgery in terms of intraoperative blood loss, morbidity, and postoperative hospital stay. Conversion was required in six cases; five were strategic conversions, and conversion was not associated with severe morbidity. The microscopic positive surgical margin rate was not higher in the Lap group than in the open group. Kaplan-Meier analyses of overall and disease-free survival were comparable between the groups. Cox regression analyses revealed that the operative approach did not have a significant adverse effect on long-term outcomes.

CONCLUSION

The Lap approach could be considered for surgical T4b cancers, except for urinary tract invasion cases that require complicated reconstruction.

Prognostic factors affecting outcomes in multivisceral en bloc resection for colorectal cancer

OBJECTIVES:

This study sought to determine the clinical and pathological factors associated with perioperative morbidity, mortality and oncological outcomes after multivisceral en bloc resection in patients with colorectal cancer.

METHODS:

Between January 2009 and February 2014, 105 patients with primary colorectal cancer selected for multivisceral resection were identified from a prospective database. Clinical and pathological factors, perioperative morbidity and mortality and outcomes were obtained from medical records. Estimated local recurrence and overall survival were compared using the log-rank method, and Cox regression analysis was used to determine the independence of the studied parameters. ClinicalTrials.gov: NCT02859155.

RESULTS:

The median age of the patients was 60 (range 23-86) years, 66.7% were female, 80% of tumors were located in the rectum, 11.4% had stage-IV disease, and 54.3% received neoadjuvant chemoradiotherapy. The organs most frequently resected were ovaries and annexes (37%). Additionally, 30.5% of patients received abdominoperineal resection. Invasion of other organs was confirmed histologically in 53.5% of patients, and R0 resection was obtained in 72% of patients. The overall morbidity rate of patients in this study was 37.1%. Ureter resection and intraoperative blood transfusion were independently associated with an increased number of complications. The 30-day postoperative mortality rate was 1.9%. After 27 (range 5-57) months of follow-up, the mortality and local recurrence rates were 23% and 15%, respectively. Positive margins were associated with a higher recurrence rate. Positive margins, lymph node involvement, stage III/IV disease, and stage IV disease alone were associated with lower overall survival rates. On multivariate analysis, the only factor associated with reduced survival was lymph node involvement.

CONCLUSIONS:

Multivisceral en bloc resection for primary colorectal cancer can be performed with acceptable rates of morbidity and mortality and may lead to favorable oncological outcomes.

Locally advanced colon cancer with cutaneous invasion: case report

BACKGROUND

Locally advanced colon cancer with direct abdominal wall and skin invasion is an extremely rare finding with most data being derived from case reports, historical autopsy-based or single-center retrospective studies. We present a unique case of a colon cancer with direct cutaneous invasion and colocutaneous fistulization.

CASE PRESENTATION

Eighty-six year old Caucasian female with multiple comorbidities, referred to Surgical Consultation due to ulcerated skin lesion in the abdomen. She had a long-standing large umbilical hernia but with no previous episodes of incarceration or occlusive symptoms. She denied any digestive or constitutional symptoms. Physical examination showed a large non-reducible umbilical hernia, with an associated painless firm mass within the hernia sac and cutaneous ulcerated growth. Colonoscopy revealed transverse colon cancer (endoscopic biopsy of the tumor and skin punch biopsy confirmed adenocarcinoma of the colon). Computed tomography showed a tumoral mass within the umbilical hernia, with cutaneous infiltration and enlarged regional lymph nodes. Rapid local progression led to colocutaneous fistula with total fecal diversion. We performed an extended right hemicolectomy with en bloc excision of the hernia sac and infiltrating cutaneous mass.

CONCLUSIONS

In the current era of widespread use of screening colonoscopies, initial diagnosis of locally advanced colon cancer is decreasing. However, this unique case presented an opportunity to recall the advantages of multivisceral resections.

The Efficacy of Dextran-40 as a Venous Thromboembolism Prophylaxis Strategy in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

The incidence of venous thromboembolism (VTE) in peritoneal malignancies can approach 30 to 50 per cent without prophylaxis. Prophylaxis in cytoreductive surgeries (CRS) presents a challenge to preoperative heparin-based therapy because of an increased risk of coagulopathy and potential for bleeding. Herein, we report the large series of CRS and hyperthermic intraperitoneal chemotherapy receiving dextran-40 prophylaxis. Retrospective chart review of peritoneal malignancies patients undergoing CRS at University of Nebraska Medical Center identified 69 individuals who received dextran-40 between 2010 and 2013. The incidences of VTEs, perioperative bleeding, complications, morbidity, and mortality were determined in-hospital and at 90 days. Of the 69 patients treated, the 30-day VTE rate was 8.7 per cent, and no pulmonary embolisms, bleeding, anaphylactoid reaction, or mortality were observed with dextran usage. The specific VTE events included three upper extremity and three lower extremity VTEs. No additional VTE events were identified between 30 and 90 days. In conclusion, dextran-40 prophylaxis was not associated with any perioperative bleeding events, and the observed incidence of VTE was comparable to reported heparin-based prophylaxis in CRS/hyperthermic intraperitoneal chemotherapy patients. This data supports further exploration of dextran-40 as a VTE prophylactic agent in complex surgical oncology cases.

Fortune of temporary ileostomies in patients treated with laparoscopic low anterior resection for rectal cancer

PURPOSE

The current study aims to analyze the risk factors for the failure of ileostomy reversal after laparoscopic low anterior resection for rectal cancer.

METHODS

All patients who underwent a laparoscopic low anterior resection for rectal cancer with a diverting ileostomy between 2007 and 2014 were abstracted. The patients who underwent and did not undergo a diverting ileostomy procedure were compared regarding patient, tumor, treatment related parameters, and survival.

RESULTS

Among 160 (103 males [64.4%], mean [± standard deviation] age was 58.1 ± 11.9 years) patients, stoma reversal was achieved in 136 cases (85%). Anastomotic stricture (n = 13, 52.4%) was the most common reason for stoma reversal. These were the risk factors for the failure of stoma reversal: Male sex (P = 0.035), having complications (P = 0.01), particularly an anastomotic leak (P < 0.001), or surgical site infection (P = 0.019) especially evisceration (P = 0.011), requirement for reoperation (P = 0.003) and longer hospital stay (P = 0.004). Multivariate analysis revealed that male sex (odds ratio [OR], 7.82; P = 0.022) and additional organ resection (OR, 6.71; P = 0.027) were the risk factors. Five-year survival rates were similar (P = 0.143).

CONCLUSION

Fifteen percent of patients cannot receive a stoma reversal after laparoscopic low anterior resection for rectal cancer. Anastomotic stricture is the most common reason for the failure of stoma takedown. Having complications, particularly an anastomotic leak and the necessity of reoperation, limits the stoma closure rate. Male sex and additional organ resection are the risk factors for the failure in multivariate analyses. These patients require a longer hospitalization period, but have similar survival rates as those who receive stoma closure procedure.

The short-term outcomes of laparoscopic multivisceral resection for locally advanced colorectal cancer: our experience of 39 cases

PURPOSE

Laparoscopic surgery for locally advanced colorectal cancer suspected of direct invasion to adjacent organs or structures remains controversial because of its high conversion rate, inadequate oncologic clearance and surgical outcomes. This study retrospectively evaluated the short-term outcomes of laparoscopic multivisceral resection for colorectal cancer and investigated the factors influencing conversion to open surgery.

METHODS

Between 2010 and 2015, 39 patients who underwent laparoscopic multivisceral resection for colorectal cancer intraoperatively suspected of direct invasion to adjacent organs or structures were included. The conversion rate, resection margin status, surgical results, and morbidity and mortality rates were evaluated. We also investigated the factors influencing conversion.

RESULTS

The conversion rate was 28 %. The resection margin was negative in all cases. The median operative time was 247 min, and the median blood loss was 80 ml. The postoperative mortality rate was 0 %, and the morbidity rate was 28 %; complications of Grade 3 or more were observed in 2 patients (5 %). The factors influencing conversion were ≥2 adherent organs (p = 0.028) and clinical suspicion of direct invasion to adjacent organs (cT4b) (p = 0.076).

CONCLUSION

Laparoscopic multivisceral resection for colorectal cancer intraoperatively suspected of direct invasion to adjacent organs or structures is feasible in selected patients. Conversion is more likely with ≥2 adherent organs and cT4b.

Long-Term Outcomes of Colon Cancer Patients Undergoing Standardized Technique Operation With Curative Intent

There is no defined standard surgical technique accepted worldwide for colon cancer, especially on the extent of resection and lymphadenectomy, resulting in technical variations among surgeons. Nearly all analyses employ more than one surgeon, thus giving heterogeneous results on surgical treatment. This study aims to evaluate long-term follow-up results of colon cancer patients who were operated on by a single senior colorectal surgeon using a standardized technique with curative intent, and to compare these results with the literature. A total of 269 consecutive patients who were operated on with standardized technique between January 2003 and June 2013 were enrolled in this study. Standardized technique means separation of the mesocolic fascia from the parietal plane with sharp dissection and ligation of the supplying vessels closely to their roots. Patients were assessed in terms of postoperative morbidity, mortality, disease recurrence, and survival. Operations were carried out with a 99.3% R0 resection rate and mean lymph node count of 17.7 nodes per patient. Surviving patients were followed up for a mean period of 57.8 months, and a total of 19.7% disease recurrence was recorded. Mean survival was 113.9 months. The 5- and 10-year survival rates were 78% and 75.8% for disease-free survival, 82.6% and 72.9% for overall survival, and 87.5% and 82.9% for cancer-specific survival, respectively. R1 resection and pathologic characteristics of the tumor were found to be the most important prognostic factors according to univariate and Cox regression analyses. Standardization of surgical therapy and a dedicated team are thought to make significant contributions to the improvement of prognosis.

Multivisceral resection for advanced rectal cancer: outcomes and experience at a single institution

BACKGROUND

Multivisceral resection is often required in the treatment of locally advanced rectal cancers. Such resections are relatively rare and oncologic outcomes, especially when sphincter preservation is performed, are not fully demonstrated.

METHODS

A retrospective review was conducted of patients who underwent multivisceral resection for locally advanced rectal cancer with and without sphincter preservation.

RESULTS

Sixty-one patients underwent multivisceral resection for rectal cancer from 2005 to 2013 with a median follow-up of 27.8 months. Five-year overall and disease-free survival were 49.2% and 45.3%, respectively. Thirty-four patients (55.7%) had sphincter-sparing operations with primary coloanal anastomosis and temporary stoma. There was no significant difference in overall or disease-free survival, or recurrence with sphincter preservation compared with those with permanent stoma.

CONCLUSIONS

Multivisceral resection for locally advanced rectal cancer has acceptable oncologic and clinical outcomes. Sphincter preservation and subsequent reestablishment of gastrointestinal continuity does not impact oncologic outcomes and should be considered in many patients.

Laparoscopy for colorectal cancer

The laparoscopic approach for colorectal cancer resection has been evolved from an experimental procedure with oncological concerns to routine daily practice within a period of two decades. Numerous randomized controlled trials and meta-analyses have shown that laparoscopic resection results in faster recovery with similar oncological outcome compared to an open approach, both for colon and rectal cancer. Besides improved cosmesis, other long-term advantages seem to be less adhesion related small bowel obstruction and reduced incisional hernia rate. Adequate patient selection and surgical experience are of crucial importance. Experience can be gradually expanded step by step, by increasing the complexity of the procedure. A decision to convert should be made early in the procedure, because the outcome after a reactive conversion is worse than initial open resection or strategic conversion. The additive value of new techniques such as robotic surgery has to be proven in randomized studies including a cost-effectiveness assessment.

T4 rectal cancer: do we always need an exenteration?

The management of rectal cancer has changed dramatically over the last few decades. Due to improvements in the multimodality treatment and the introduction of neoadjuvant chemoradiation, previously irresectable tumours can nowadays be cured by extensive multivisceral resections. These highly complex operations are associated with significant morbidity and mortality. Due to optimization of chemoradiotherapy, the introduction of IORT, increasing knowledge of tumour pathology and patterns of recurrence the need for extensive surgery diminishes. The question arises which patients with T4 rectal cancer really need extensive surgery and who can safely be considered for an organ preserving approach.

Clinical review: surgical management of locally advanced and recurrent colorectal cancer

AIM

Recurrent and locally advanced colorectal cancers frequently require en bloc resection of involved organs to achieve negative margins. The aim of this review is to evaluate the most current literature related to the surgical management of locally advanced and recurrent colorectal cancer.

METHODS

A literature review was performed on the electronic databases MEDLINE from PubMed, EMBASE and the Cochrane library for publications in the English language from January 1993 to July 2013. The MeSH search terms 'locally advanced colorectal cancer', 'recurrent colorectal cancer' and 'surgical management' were used.

RESULTS

A total of 1,470 patients with recurrent or locally advanced primary colorectal cancer were included in 22 studies. Surgical removal of the tumour with negative margins (R0) offers the best prognosis in term of survival with a 5-year survival of up to 70 %. MVR is needed in approximately 10 % with the most commonly involved organ being the bladder. The mean post-operative morbidity is 40 %, mainly relating to superficial surgical site infection, pelvic collections and delayed wound healing. Most patients will undergo radiotherapy and/or chemotherapy pre- or post-operatively. The mean 5-year overall survival for R0 resection is 50 % for recurrent and locally advanced primary tumours while survival following R1 or R2 is 12 and <5 %, respectively.

CONCLUSION

Multimodal therapy and extended surgery to achieve clear margins offers good prognosis to patients with recurrent and locally advanced colorectal cancers.