Laparoscopic surgery facilitates administration of adjuvant chemotherapy in locally advanced colon cancer: propensity score analyses

Short-term morbidity and mortality after right hemicolectomy: an update of national performance in the Netherlands

AIM

The purpose of this Dutch retrospective population-based study was to evaluate how short-term outcomes and inter-hospital variability after right hemicolectomy for colon cancer have evolved between 2012 and 2020.

METHOD

Patients who underwent right hemicolectomy for primary solitary colon cancer between 1 January 2012 and 31 December 2020 and were registered in the Dutch Colorectal Audit were included. Surgical characteristics and outcomes were assessed during three time periods (2012-2014, 2015-2017, 2018-2020). Complications and mortality were the primary outcomes, and reintervention, readmission and length of stay secondary outcomes.

RESULTS

In total, 29 274 patients were included. Significant increase in minimally invasive surgery (51.1% 2012-2014, 73.2% 2015-2017, 85.0% 2018-2020), increase in conversion (6.6%, 7.8%, 9.1%, P < 0.001) and decrease in acute/urgent resections (15.9%, 11.7%, 10.9%, P < 0.001) were found. The overall complication rate was slightly lower in the third period (30.9%, 30.6%, 28.8%, P = 0.004), primarily because of decreasing non-surgical complications (19.7%, 20.6%, 17.6%, P < 0.001), while surgical complications remained unchanged (17.5%, 18.3%, 18.2%, P = 0.277). Postoperative mortality was 3.4%, 2.3% and 3.5%, respectively. Reintervention rate slightly decreased (9.4%, 8.3%, 8.6%, P < 0.001). The proportion of patients admitted for more than 6 days decreased over time (54.3%, 42.4%, 34.3%, P < 0.001), with an increase in readmission rate (7.4%, 6.8%, 9.3%, P < 0.001). Inter-hospital variability decreased over time for complications, length of stay and conversion.

CONCLUSION

This study shows a national decreasing inter-hospital variability in clinical outcomes after right hemicolectomy and a decrease in postoperative complications. Despite increasing use of laparoscopy, surgical complications and mortality remained stable over time.

Return to intended oncologic therapy after colectomy for stage III colon adenocarcinoma: Does surgical approach matter?

AIM

Return to intended oncologic treatment (RIOT) is an important paradigm for surgically resected cancers requiring multimodal treatment. Benefits of minimally invasive colectomy (MIC) may allow earlier initiation of adjuvant chemotherapy (ACT) and have associated survival benefits. We sought to determine if operative approach affects RIOT timing in resected stage III colon cancer.

METHODS

NCDB identified pathological stage III colon adenocarcinoma patients who underwent resection and received ACT. Propensity score matching and kernel density estimation compared operative approaches and conversion impact on intervals to RIOT.

RESULTS

A total of 15,132 open colectomies (OC) versus 14,107 MIC were included. MIC patients had two-days shorter median length of stay (LOS) (4 vs. 6 days; p < 0.001), one-week shorter median time to RIOT (6 vs. 7 weeks; p = 0.015) comparing 12,867 matched pairs. There was no difference in time interval to RIOT between the LC versus RC, converted MIC vs. OC groups. MIC was a favourable predictor of earlier RIOT (HR 1.14 [1.07-1.22]; p < 0.001).

CONCLUSION

MIC in stage III colon cancer is associated with a shorter time to RIOT when compared to OC. Since timely initiation of ACT may influence cancer outcome, MIC may be oncologically preferable. Prospective studies are needed to assess RIOT and survival outcomes in stage III colon cancer.

Mid-term outcomes of laparoscopic vs open colectomy for pathological T4 and/or N2 colon cancer patients: Multicenter study using propensity score matched analysis

OBJECTIVES

We aimed to assess mid-term outcomes after laparoscopic surgery (LAP) vs open surgery (OP) for pathological T4 (pT4) and/or N2 (pN2) colon cancer.

METHODS

We retrospectively reviewed 255 primary tumor resections for pT4 and/or pN2 colon cancer performed from 2015 to 2020 at six hospitals, divided into LAP (n = 204) and OP groups (n = 51). After propensity score matching to minimize selection bias, 47 matched patients per group were assessed.

RESULTS

Before matching, the rate of males (53.9% vs. 37.3%, P = .042), left sided colon cancer (53.9% vs 37.3%, P = .042), D3 lymph node dissection (90.7% vs 68.6%, P < .001) and body mass index (kg/m2 ) (22.3 vs 21.8, P = .039) were significantly greater in the LAP group. The rate of pT4b (7.8% vs 40.4%, P < .001) was lower and pN2 was higher (57.4% vs 37.3%, P = .012) in the LAP group. After matching, preoperative characteristics and pathologic status were equivalent between the groups. The LAP and OP groups showed comparable overall survival (OS) (2-year OS, 84.5% vs 76.8%, P = .055) and recurrence-free survival (RFS) (2-year RFS, 73.9% vs 52.8%, P = .359). In the patients with pT4, OS (2-year OS, 79.4% vs 75.7%, P = .359) and RFS (2-year RFS, 71.3% vs 58.7%) were comparable. In the patients with pN2, OS (2-year OS, 83.4% vs 76.3%) and RFS (2-year RFS, 69.6% vs 36.2%) were also comparable.

CONCLUSIONS

LAP for pT4 and/or pN2 colon cancer showed comparable mid-term outcomes compared with OP. LAP was an acceptable surgical approach in this cohort.

Short- and Long-term Outcomes After Laparoscopic Emergency Resection of Left-Sided Obstructive Colon Cancer: A Nationwide Propensity Score-Matched Analysis

BACKGROUND

The role of laparoscopy for emergency resection of left-sided obstructive colon cancer remains unclear, especially regarding impact on survival.

OBJECTIVE

This study aimed to determine short- and long-term outcomes after laparoscopic versus open emergency resection of left-sided obstructive colon cancer.

DESIGN

This observational cohort study compared patients who underwent laparoscopic emergency resection to those who underwent open emergency resection between 2009 and 2016 by using 1:3 propensity-score matching. Matching variables included sex, age, BMI, ASA score, previous abdominal surgery, tumor location, cT4, cM1, multivisceral resection, small-bowel distention on CT, and subtotal colectomy.

SETTING

This was a nationwide, population-based study.

PATIENTS

Of 2002 eligible patients with left-sided obstructive colon cancer, 158 patients who underwent laparoscopic emergency resection were matched with 474 patients who underwent open emergency resection.

INTERVENTIONS

The intervention was laparoscopic versus open emergency resection.

MAIN OUTCOME MEASURES

The main outcome measures were 90-day mortality, 90-day complications, permanent stoma, disease recurrence, overall survival, and disease-free survival.

RESULTS

Intentional laparoscopy resulted in significantly fewer 90-day complications (26.6% vs 38.4%; conditional OR, 0.59; 95% CI, 0.39-0.87) and similar 90-day mortality. Laparoscopy resulted in better 3-year overall survival (81.0% vs 69.4%; HR, 0.54; 95% CI, 0.37-0.79) and disease-free survival (68.3% vs 52.3%; HR, 0.64; 95% CI, 0.47-0.87). Multivariable regression analyses of the unmatched 2002 patients confirmed an independent association of laparoscopy with fewer 90-day complications and better 3-year survival.

LIMITATIONS

Selection bias was the limitation that cannot be completely ruled out because of the retrospective nature of this study.

CONCLUSIONS

This population-based study with propensity score-matched analysis suggests that intentional laparoscopic emergency resection might improve outcomes in patients with left-sided obstructive colon cancer compared to open emergency resection. Management of those patients in the emergency setting requires proper selection for intentional laparoscopic resection if relevant expertise is available, thereby considering other alternatives to avoid open emergency resection (ie, decompressing stoma). See Video Abstract at http://links.lww.com/DCR/B972 .

RESULTADOS A CORTO Y LARGO PLAZO DESPUS DE LA RESECCIN LAPAROSCPICA DE EMERGENCIA EN CNCER DE COLON IZQUIERDO OBSTRUCTIVO UN ANLISIS EMPAREJADO POR PUNTAJE DE PROPENSIN A NIVEL NACIONAL

ANTECEDENTES:El papel de la laparoscopia en la resección de emergencia en cáncer de colon izquierdo obstructivo sigue sin estar claro, especialmente con respecto al impacto en la supervivencia.OBJETIVO:El objetivo de este estudio fue determinar los resultados a corto y largo plazo después de la resección de emergencia laparoscópica versus abierta en cáncer de colon izquierdo obstructivo.DISEÑO:Estudio observacional de cohortes comparó pacientes que se sometieron a resección de laparoscópica de emergencia versus resección abierta de emergencia entre 2009 y 2016, mediante el uso de emparejamineto por puntaje de propensión 1: 3. Las variables emparejadas incluyeron sexo, edad, IMC, puntaje ASA, cirugía abdominal previa, ubicación del tumor, cT4, cM1, resección multivisceral, distensión del intestino delgado en la TAC y colectomía subtotal.ENTORNO CLINICO:A nivel nacional, basado en la población.PACIENTES:De 2002 pacientes elegibles con cáncer de colon izquierdo obstructivo, 158 pacientes con resección laparoscópica s de emergencia e emparejaron con 474 pacientes con resección abierta de emergencia.INTERVENCIONES:Resección laparoscópica de emergencia versus abierta.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas primarias fueron la mortalidad a 90 días, complicaciones a 90 días, estoma permanente, recurrencia de la enfermedad, supervivencia general y supervivencia libre de enfermedad.RESULTADOS:La laparoscopia intencional dió como resultado significativamente menos complicaciones a los 90 días (26,6 % vs 38,4 %, cOR 0,59, IC del 95 %: 0,39-0,87) y una mortalidad similar a los 90 días. La laparoscopia resultó en una mejor supervivencia general a los 3 años (81,0 % vs 69,4 %, HR 0,54, IC del 95 % 0,37-0,79) y supervivencia libre de enfermedad (68,3 % vs 52,3 %, HR 0,64, IC del 95 % 0,47-0,87). Los análisis de regresión multivariable de los 2002 pacientes no emparejados confirmaron una asociación independiente de la laparoscopia con menos complicaciones a los 90 días y una mejor supervivencia a los 3 años.LIMITACIONES:El sesgo de selección no se puede descartar por completo debido a la naturaleza retrospectiva de este estudio.CONCLUSIONES:Estudio poblacional con análisis emparejado por puntaje de propensión sugiere que la resección laparoscópica de emergencia intencional podría mejorar los resultados a corto y largo plazo en pacientes con cáncer de colon izquierdo obstructivo en comparación con resección abierta de emergencia, lo que justifica la confirmación en estudios futuros. El manejo de esos pacientes en el entorno de emergencia requiere una selección adecuada para la resección laparoscópica intencional si se dispone de experiencia relevante, considerando así otras alternativas para evitar la resección abierta de emergencia (es decir, ostomia descompresiva). Consulte Video Resumen en http://links.lww.com/DCR/B972 . (Traducción- Dr. Francisco M. Abarca-Rendon & Dr. Fidel Ruiz Healy).

Surgical treatment of locally advanced right colon cancer invading neighboring organs

Purpose

Invasion of the pancreas and/or duodenum with/without neighboring organs by locally advanced right colon cancer (LARCC) is a very rare clinical phenomenon that is difficult to manage. The purpose of this review is to suggest the most reasonable surgical approach for primary right colon cancer invading neighboring organs such as the pancreas and/or duodenum.

Methods

An extensive systematic research was conducted in PubMed, Medline, Embase, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) using the MeSH terms and keywords. Data were extracted from the patients who underwent en bloc resection and local resection with right hemicolectomy (RHC), the analysis was performed with the survival rate as the outcome parameters.

Results

As a result of the analysis of 117 patient data with locally advanced colon cancer (LACC) (73 for males, 39 for females) aged 25-85 years old from 11 articles between 2008 and 2021, the survival rate of en bloc resection was 72% with invasion of the duodenum, 71.43% with invasion of the pancreas, 55.56% with simultaneous invasion of the duodenum and pancreas, and 57.9% with invasion of neighboring organs with/without invasion of duodenum and/or pancreas. These survival results were higher than with local resection of the affected organ plus RHC.

Conclusion

When the LARCC has invaded neighboring organs, particularly when duodenum or pancreas are invaded simultaneously or individually, en bloc resection is a reasonable option to increase patient survival after surgery.

Metachronous peritoneal metastases in patients with pT4b colon cancer: An international multicenter analysis of intraperitoneal versus retroperitoneal tumor invasion

BACKGROUND

It was hypothesized that colon cancer with only retroperitoneal invasion is associated with a low risk of peritoneal dissemination. This study aimed to compare the risk of metachronous peritoneal metastases (mPM) between intraperitoneal and retroperitoneal invasion.

METHODS

In this international, multicenter cohort study, patients with pT4bN0-2M0 colon cancer who underwent curative surgery were categorized as having intraperitoneal invasion (e.g. bladder, small bowel, stomach, omentum, liver, abdominal wall) or retroperitoneal invasion only (e.g. ureter, pancreas, psoas muscle, Gerota's fascia). Primary outcome was 5-year mPM cumulative rate, assessed by Kaplan-Meier analysis.

RESULTS

Out of 907 patients with pT4N0-2M0 colon cancer, 198 had a documented pT4b category, comprising 170 patients with intraperitoneal invasion only, 12 with combined intra- and retroperitoneal invasion, and 16 patients with retroperitoneal invasion only. At baseline, only R1 resection rate significantly differed: 4/16 for retroperitoneal invasion only versus 8/172 for intra- +/- retroperitoneal invasion (p = 0.010). Overall, 22 patients developed mPM during a median follow-up of 45 months. Two patients with only retroperitoneal invasion developed mPM, both following R1 resection. The overall 5-year mPM cumulative rate was 13% for any intraperitoneal invasion and 14% for retroperitoneal invasion only (Log Rank, p = 0.878), which was 13% and 0%, respectively, in patients who had an R0 resection (Log Rank, p = 0.235).

CONCLUSION

This study suggests that pT4b colon cancer patients with only retroperitoneal invasion who undergo an R0 resection have a negligible risk of mPM, but this is difficult to prove because of its rarity. This observation might have implications regarding individualized follow-up.

Laparoscopic versus open colectomy for locally advanced T4 colonic cancer: meta-analysis of clinical and oncological outcomes

BACKGROUND

The aim of this study was to review the early postoperative and oncological outcomes after laparoscopic colectomy for T4 cancer compared with open surgery.

METHOD

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for any relevant clinical study comparing laparoscopic and open colectomy as treatment for T4 colonic cancer. The risk ratio (RR) with 95 per cent c.i. was calculated for dichotomous variables, and the mean difference (m.d.) with 95 per cent confidence interval for continuous variables. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was implemented for assessing quality of evidence (QoE).

RESULTS

Twenty-four observational studies (21 retrospective and 3 prospective cohort studies) were included, analysing a total of 18 123 patients: 9024 received laparoscopic colectomy and 9099 underwent open surgery. Laparoscopic colectomy was associated with lower rates of mortality (RR 0.48, 95 per cent c.i. 0.41 to 0.56; P < 0.001; I2 = 0 per cent, fixed-effect model; QoE moderate) and complications (RR 0.61, 0.49 to 0.76; P < 0.001; I2 = 20 per cent, random-effects model; QoE very low) compared with an open procedure. No differences in R0 resection rate (RR 1.01, 1.00 to 1.03; P = 0.12; I2 = 37 per cent, random-effects model; QoE very low) and recurrence rate (RR 0.98, 0.84 to 1.14; P = 0.81; I2 = 0 per cent, fixed-effect model; QoE very low) were found.

CONCLUSION

Laparoscopic colectomy for T4 colonic cancer is safe, and is associated with better clinical outcomes than open surgery and similar oncological outcomes.

Should be a locally advanced colon cancer still considered a contraindication to laparoscopic resection?

BACKGROUND

The role of elective laparoscopic resection (LR) for the treatment of locally advanced colon cancer (LACC) is unclear. Most studies have retrospectively investigated the outcomes of LR for pT4 cancers, while clinical T4 (cT4) cancers are excluded in the large randomized controlled trials comparing LR and open resection (OR). The aim of this study was to investigate the outcomes in patients undergoing elective LR for LACC.

METHODS

A prospective single-institution database including consecutive patients undergoing elective LR for clinical LACC (high-risk T3 or T4 N0-2) between March 1996 and March 2017 was retrospectively reviewed. A multivariate analysis was performed to identify predictors of conversion to OR and risk factors for adverse oncologic outcomes.

RESULTS

A total of 300 patients undergoing LR for LACC were included. A multi-visceral resection was needed in 17 (5.7%) patients. A total of 63 (21%) LRs were converted to OR, mainly due to suspected adjacent organ invasion (82.5%) or obesity (9.5%). Overall postoperative Clavien-Dindo 3-4 complication rate was 4.7%, with no significant differences between completed and converted LRs. Final pathology showed 18 (6%) pT2, 215 (71.7%) pT3, 54 (18%) pT4a, and 13 (4.3%) pT4b cancers. A R0 resection was achieved in 98.3% of patients. On multivariate analysis, tumor size ≥ 7 cm and tumor site (splenic flexure) were the independent risk factors for conversion to OR. A pT4 colon cancer and LNR of 0.25 or greater, but not conversion to OR, were independently associated with both poorer OS and DFS.

CONCLUSION(S)

Clinical LACC should not be considered a contraindication to LR itself. Bulky tumors ≥ 7 cm and splenic flexure cancers are at higher risk of conversion to OR; however, there is no increased postoperative morbidity or adverse oncologic outcomes in converted patients.

Minimally Invasive Surgical Approaches Are Safe and Appropriate in N2 Colorectal Cancer

BACKGROUND

There is emerging evidence of the oncological safety of minimally invasive surgery in T4 colorectal cancer; however, such support is lacking in N2 disease.

OBJECTIVE

This study aimed to compare oncological and perioperative outcomes of surgical resection for N2 colorectal cancer using an open versus minimally invasive approach.

DESIGN

We conducted a retrospective cohort study using the National Surgical Quality Improvement Program's generic and targeted colectomy data sets.

SETTINGS

Data about surgery for N2 colorectal cancer were obtained regarding North American hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.

PATIENTS

All patients undergoing elective surgical resection for N2 colorectal cancer in participating hospitals between 2014 and 2018 were selected.

INTERVENTIONS

Surgical resection of N2 colorectal cancer was performed.

MAIN OUTCOME MEASURES

Our primary outcome was nodal yield. Secondary outcomes included perioperative complications and mortality.

RESULTS

A total of 1837 patients underwent open and 3907 patients underwent minimally invasive surgery colectomies for N2 colorectal cancer (n = 5744). Median nodal yield was 20 (interquartile range, 15-27) in the open group and 21 (interquartile range, 16-28) in the minimally invasive group (p < 0.0001); however, nodal harvest between the 2 groups was not significantly different on multivariate analysis. Perioperative complications were higher on univariate analysis in the open surgery group, with respect to key outcomes including anastomotic leak and death (p < 0.001).

LIMITATIONS

This study is limited by its retrospective design and by the fact that the staging data collected by the National Surgical Quality Improvement Program are pathological rather than clinical; however, prior studies found a 97% concordance between pathological and clinical N2 determination.

CONCLUSIONS

Minimally invasive surgery approaches to colorectal cancer with N2 disease result in equivalent nodal harvests compared with open approaches. Our group supports the use of a minimally invasive approach in advanced nodal stage colorectal cancer in the appropriately selected patient. See Video Abstract at http://links.lww.com/DCR/B417.

LOS ABORDAJES QUIRRGICOS MNIMAMENTE INVASIVOS SON SEGUROS Y APROPIADOS EN EL CNCER COLORRECTAL N

ANTECEDENTES:Existe evidencia emergente de la seguridad oncológica de la cirugía mínimamente invasiva en el cáncer colorrectal T4; sin embargo, semenjante apoyo falta en la enfermedad N2.OBJETIVO:comparar los resultados oncológicos y perioperatorios de la resección quirúrgica para el cáncer colorrectal N2 utilizando un abordaje abierto versus mínimamente invasivo.DISEÑO:Realizamos un estudio de cohorte retrospectivo utilizando los conjuntos de datos de colectomía genéricos y específicos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica.AJUSTE:Hospitales de Norte America que participan en el Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Americano de Cirujanos.PACIENTES:Todos los pacientes sometidos a resección quirúrgica electiva por cáncer colorrectal N2 en los hospitales participantes entre 2014 y 2018.INTERVENCIONES:Resección quirúrgica de cáncer colorrectal N2.PRINCIPALES MEDIDAS DE VOLORACION:Nuestro resultado principal fue el rendimiento nodal. Los resultados secundarios incluyeron complicaciones perioperatorias y mortalidad.RESULTADOS:1837 pacientes fueron sometidos a cirugía abierta y 3907 pacientes fueron sometidos a colectomías de cirugía mínimamente invasiva por cáncer colorrectal N2 (n = 5744). La mediana del rendimiento nodal fue 20 (IQR 15-27) en el grupo abierto y 21 (IQR 16-28) en el grupo mínimamente invasivo (p <0,0001); sin embargo, el rendimiento nodal entre los dos grupos no fue significativamente diferente en el análisis multivariado. Las complicaciones perioperatorias fueron mayores en el análisis univariado en el grupo de cirugía abierta, con respecto a los resultados clave, incluida la fuga anastomótica y la muerte (p <0,001).LIMITACIONES:Este estudio está limitado por su diseño retrospectivo y por el hecho de que los datos de estadificación recopilados por NSQIP son patológicos más que clínicos; sin embargo, estudios previos encontraron una concordancia del 97% entre la determinación patológica y clínica de N2.CONCLUSIONES:Los enfoques de cirugía mínimamente invasiva para el cáncer colorrectal con enfermedad N2 dan rendimientos nodales equivalentes a abordajes abiertos. Nuestro grupo apoya el uso de abordaje mínimamente invasivo en el cáncer colorrectal avanzado en estadio ganglionar en el paciente adecuadamente seleccionado. Consulte Video Resumenhttp://links.lww.com/DCR/B417.