Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer

INTRODUCTION

The UK Medical Research Council CLASICC trial assessed the safety and efficacy of laparoscopically assisted surgery in comparison with open surgery for colorectal cancer. The results of the 5-year follow-up analysis are presented.

METHODS

Five-year outcomes were analysed and included overall and disease-free survival, and local, distant and wound/port-site recurrences. Two exploratory analyses were performed to evaluate the effect of age (70 years or less, or more than 70 years) on overall survival between the two groups, and the effect of the learning curve.

RESULTS

No differences were found between laparoscopically assisted and open surgery in terms of overall survival, disease-free survival, and local and distant recurrence. Wound/port-site recurrence rates in the laparoscopic arm remained stable at 2.4 per cent. Conversion to open operation was associated with significantly worse overall but not disease-free survival, which was most marked in the early follow-up period. The effect of surgery did not differ between the age groups, and surgical experience did not impact on the 5-year results.

CONCLUSION

The 5-year analyses confirm the oncological safety of laparoscopic surgery for both colonic and rectal cancer. The use of laparoscopic surgery to maximize short-term outcomes does not compromise the long-term oncological results.

REGISTRATION NUMBER

ISRCTN74883561 (http://www.controlled-trials.com).

Peritoneal carcinomatosis from colorectal cancer

BACKGROUND

Aggressive therapeutic regimens have been advocated for the treatment of peritoneal carcinomatosis from colorectal cancer. It is essential to understand the clinical and histological features that govern the natural history of this condition if the efficacies of novel therapeutic approaches are to be assessed adequately.

METHODS

A database of 3019 colorectal cancers was used to identify patients with synchronous peritoneal carcinomatosis, patients who developed metachronous peritoneal carcinomatosis, and those without carcinomatosis. Clinical, histological and survival data for the groups were collated and subjected to statistical analysis.

RESULTS

Some 349 patients (13 per cent) with peritoneal carcinomatosis were identified; 214 had synchronous disease and 135 had metachronous carcinomatosis. Some 125 patients (58 per cent) in the synchronous group were free of systemic metastases; 80 of these patients had localized disease. Liver metastases, tumour (T) stage, nodal stage, and venous and perineural invasion were independent predictors of metachronous carcinomatosis. The median survival of patients with synchronous disease was 7 months; survival was adversely affected by the extent of peritoneal carcinomatosis and the T stage of the primary cancer.

CONCLUSION

Peritoneal carcinomatosis is a common mode of disease progression in patients with colorectal cancer. For the majority of patients the prognosis is poor, but a small number with localized disease may be suitable for further aggressive therapy.

Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer

BACKGROUND

Laparoscopic resection is used widely in the management of colorectal cancer; however, the data on long-term outcomes, particularly those related to rectal cancer, are limited. The results of long-term follow-up of the UK Medical Research Council trial of laparoscopically assisted versus open surgery for colorectal cancer are presented.

METHODS

A total of 794 patients from 27 UK centres were randomized to laparoscopic or open surgery in a 2:1 ratio between 1996 and 2002. Long-term follow-up data were analysed to determine differences in survival outcomes and recurrences for intention-to-treat and actual treatment groups.

RESULTS

Median follow-up of all patients was 62·9 (interquartile range 22·9 - 92·8) months. There were no statistically significant differences between open and laparoscopic groups in overall survival (78·3 (95 per cent confidence interval (c.i.) 65·8 to 106·6) versus 82·7 (69·1 to 94·8) months respectively; P = 0·780) and disease-free survival (DFS) (89·5 (67·1 to 121·7) versus 77·0 (63·3 to 94·0) months; P = 0·589). In colonic cancer intraoperative conversions to open surgery were associated with worse overall survival (hazard ratio (HR) 2·28, 95 per cent c.i. 1·47 to 3·53; P < 0·001) and DFS (HR 2·20, 1·31 to 3·67; P = 0·007). In terms of recurrence, no significant differences were observed by randomized procedure. However, at 10 years, right colonic cancers showed an increased propensity for local recurrence compared with left colonic cancers: 14·7 versus 5·2 per cent (difference 9·5 (95 per cent c.i. 2·3 to 16·6) per cent; P = 0·019).

CONCLUSION

Long-term results continue to support the use of laparoscopic surgery for both colonic and rectal cancer.

Bladder and sexual function following resection for rectal cancer in a randomized clinical trial of laparoscopic versus open technique

BACKGROUND

Bladder and sexual dysfunction are recognized complications of mesorectal resection. Their incidence following laparoscopic surgery is unknown.

METHODS

Bladder and sexual function were assessed in patients who had undergone laparoscopic rectal, open rectal or laparoscopic colonic resection as part of the UK Medical Research Council Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) trial, using the International Prostatic Symptom Score, the International Index of Erectile Function and the Female Sexual Function Index. Sexual and bladder function data from the European Organization for Research and Treatment of Cancer QLQ-CR38 collected in the CLASICC trial were used for comparison.

RESULTS

Two hundred and forty-seven (71.2 per cent) of 347 patients completed questionnaires. Bladder function was similar after laparoscopic and open rectal operations for rectal cancer. Overall sexual function and erectile function tended to be worse in men after laparoscopic rectal surgery than after open rectal surgery (overall function: difference - 11.18 (95 per cent confidence interval (c.i.) -22.99 to 0.63), P = 0.063; erectile function: difference -5.84 (95 per cent c.i. -10.94 to -0.74), P = 0.068). Total mesorectal excision (TME) was more commonly performed in the laparoscopic rectal group than in the open rectal group. TME (odds ratio (OR) 6.38, P = 0.054) and conversion to open operation (OR 2.86, P = 0.041) were independent predictors of postoperative male sexual dysfunction. No differences were detected in female sexual function.

CONCLUSION

Laparoscopic rectal resection did not adversely affect bladder function, but there was a trend towards worse male sexual function. This may be explained by the higher rate of TME in the laparoscopic rectal resection group.

Bladder and sexual dysfunction following laparoscopically assisted and conventional open mesorectal resection for cancer

BACKGROUND

Bladder and sexual dysfunction, secondary to pelvic nerve injury, are recognized complications of rectal resection. This study investigated the frequency of these complications following laparoscopically assisted and conventional open mesorectal resection for cancer.

METHODS

A total of 170 patients with rectal cancer was identified from a previous randomized trial of laparoscopic versus open resection. A retrospective analysis of bladder and sexual function before and after operation was performed by means of postal questionnaires and telephone interviews.

RESULTS

At the time of the study, 111 (65 per cent) of the 170 patients were alive, of whom 80 (72 per cent) responded. Of the responders, 40 patients had undergone laparoscopically assisted resection and 40 had had an open operation. No significant deterioration in bladder function following operation was observed, although two patients in the laparoscopic group required long-term intermittent self-catheterization. A significant difference in male, but not female, sexual function was noted, with seven of 15 sexually active men in the laparoscopic group reporting impotence or impaired ejaculation, compared with only one of 22 patients having an open operation (P = 0.004). All patients with bladder or sexual dysfunction in the laparoscopic group had resection of either bulky or low rectal cancers.

CONCLUSION

Laparoscopically assisted rectal resection is associated with a higher rate of male sexual dysfunction, but not bladder dysfunction, compared with the open approach. This has implications, particularly for sexually active males with bulky or low rectal cancers, when deciding the best operative approach.

Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASICC trial

BACKGROUND

This study investigated adhesive intestinal obstruction (AIO) and incisional hernia (IH) in patients undergoing laparoscopically assisted and open surgery for colorectal cancer.

METHODS

In a case-note review of patients randomized to the Medical Research Council's Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) trial, primary and key secondary endpoints were AIO and IH admission rates respectively.

RESULTS

Of 411 patients, 11 were admitted for AIO: four (3.1 per cent) of 131 patients in the open arm of the trial versus seven (2.5 per cent) of 280 in the laparoscopic arm (difference 0.6 (95 per cent confidence interval (c.i.) - 2.9 to 4.0) per cent). Thirty-six patients developed IH: 12 (9.2 per cent) after open versus 24 (8.6 per cent) after laparoscopic surgery (difference 0.6 (95 per cent c.i. - 5.3 to 6.5) per cent). Results by actual procedure showed higher AIO and IH rates in the 24.5 per cent of patients who converted from laparoscopic to open surgery (AIO: 2.3, 2.0 and 6 per cent; IH: 8.6, 7.4 and 11 per cent-for open, laparoscopic and converted operations respectively).

CONCLUSION

Although this study has not confirmed that laparoscopic surgery reduces rates of AIO and IH after colorectal cancer surgery, trends suggest that a reduction in conversion to open surgery and elimination of port-site hernias may produce such an effect. Registration number for CLASICC trial: ISRCTN74883561 (http://www.controlled-trials.com).

Dichloroacetate induces apoptosis and cell-cycle arrest in colorectal cancer cells

BACKGROUND

Cancer cells are highly dependent on glycolysis. Our aim was to determine if switching metabolism from glycolysis towards mitochondrial respiration would reduce growth preferentially in colorectal cancer cells over normal cells, and to examine the underlying mechanisms.

METHODS

Representative colorectal cancer and non-cancerous cell lines were treated with dichloroacetate (DCA), an inhibitor of pyruvate dehydrogenase kinase.

RESULTS

Dichloroacetate (20 mM) did not reduce growth of non-cancerous cells but caused significant decrease in cancer cell proliferation (P=0.009), which was associated with apoptosis and G(2) phase cell-cycle arrest. The largest apoptotic effect was evident in metastatic LoVo cells, in which DCA induced up to a ten-fold increase in apoptotic cell counts after 48 h. The most striking G(2) arrest was evident in well-differentiated HT29 cells, in which DCA caused an eight-fold increase in cells in G(2) phase after 48 h. Dichloroacetate reduced lactate levels in growth media and induced dephosphorylation of E1alpha subunit of pyruvate dehydrogenase complex in all cell lines, but the intrinsic mitochondrial membrane potential was reduced in only cancer cells (P=0.04).

CONCLUSIONS

Pyruvate dehydrogenase kinase inhibition attenuates glycolysis and facilitates mitochondrial oxidative phosphorylation, leading to reduced growth of colorectal cancer cells but not of non-cancerous cells.

Patient factors influencing conversion from laparoscopically assisted to open surgery for colorectal cancer

BACKGROUND

Intraoperative conversion from laparoscopically assisted to open surgery for colorectal cancer is thought to be influenced by several patient factors. Analysis of the Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) Trial data aimed to identify these risk factors.

METHODS

Of 488 laparoscopically assisted procedures attempted, 143 (29.3 per cent) were converted to open operation. Patient factors considered in multivariable analyses were age, sex, previous abdominal incisions, body mass index (BMI), tumour site, tumour diameter, pathological tumour (pT) and pathological node (pN) stage, extent of tumour spread from the muscularis propria, liver and peritoneal metastases, and American Society of Anesthesiologists (ASA) grade. As BMI was missing for 30.7 per cent of patients, two approaches were employed: one considered BMI as a possible risk factor and one did not.

RESULTS

When BMI was taken into consideration, male sex (odds ratio (OR) 2.07; P = 0.020), BMI (OR 1.10; P = 0.006) and extent of tumour spread from the muscularis propria (OR 1.08; P < 0.001) were independent predictors of conversion. When BMI was not considered, extent of tumour spread (OR 1.07; P < 0.001) and male sex (OR 2.05; P = 0.004) were again identified, as were tumour site (OR 2.11; P = 0.005) and ASA grade (II versus I, OR 0.92; III versus I, OR 2.74; P = 0.012).

CONCLUSION

Intraoperative conversion is more likely with larger BMI, in men, patients with rectal cancer, those graded ASA III or when there is greater local tumour spread.

Consensus conference on the stapled transanal rectal resection (STARR) for disordered defaecation

An international working party was convened in Rome, Italy on 16-17 June, 2005, with the purpose of developing a consensus on the application of the circular stapling instrument to the treatment of certain rectal conditions, the so-called Stapled Transanal Rectal Resection (STARR). Since the procedure has been submitted to only limited objective analysis it was felt prudent to hold a meeting of interested individuals for the purpose of evaluating the current status and to make conclusions and recommendations concerning the applicability of this new approach.

Postoperative ileus following major colorectal surgery

BACKGROUND

Postoperative ileus (POI) is characterized by delayed gastrointestinal recovery following surgery. Current knowledge of pathophysiology, clinical interventions and methodological challenges was reviewed to inform modern practice and future research.

METHODS

A systematic search of MEDLINE and Embase databases was performed using search terms related to ileus and colorectal surgery. All RCTs involving an intervention to prevent or reduce POI published between 1990 and 2016 were identified. Grey literature, non-full-text manuscripts, and reanalyses of previous RCTs were excluded. Eligible articles were assessed using the Cochrane tool for assessing risk of bias.

RESULTS

Of 5614 studies screened, 86 eligible articles describing 88 RCTs were identified. Current knowledge of pathophysiology acknowledges neurogenic, inflammatory and pharmacological mechanisms, but much of the evidence arises from animal studies. The most common interventions tested were chewing gum (11 trials) and early enteral feeding (11), which are safe but of unclear benefit for actively reducing POI. Others, including thoracic epidural analgesia (8), systemic lidocaine (8) and peripheral μ antagonists (5), show benefit but require further investigation for safety and cost-effectiveness.

CONCLUSION

POI is a common condition with no established definition, aetiology or treatment. According to current literature, minimally invasive surgery, protocol-driven recovery (including early feeding and opioid avoidance strategies) and measures to avoid major inflammatory events (such as anastomotic leak) offer the best chances of reducing POI.

Systematic review of methods to predict and detect anastomotic leakage in colorectal surgery

AIM

Anastomotic leakage is a serious complication of gastrointestinal surgery resulting in increased morbidity and mortality, poor function and predisposing to cancer recurrence. Earlier diagnosis and intervention can minimize systemic complications but is hindered by current diagnostic methods that are non-specific and often uninformative. The purpose of this paper is to review current developments in the field and to identify strategies for early detection and treatment of anastomotic leakage.

METHOD

A systematic literature search was performed using the MEDLINE, Embase, PubMed and Cochrane Library databases. Search terms included 'anastomosis' and 'leak' and 'diagnosis' or 'detection' and 'gastrointestinal' or 'colorectal'. Papers concentrating on the diagnosis of gastrointestinal anastomotic leak were identified and further searches were performed by cross-referencing.

RESULTS

Computerized tomography CT scanning and water-soluble contrast studies are the current preferred techniques for diagnosing anastomotic leakage but suffer from variable sensitivity and specificity, have logistical constraints and may delay timely intervention. Intra-operative endoscopy and imaging may offer certain advantages, but the ability to predict anastomotic leakage is unproven. Newer techniques involve measurement of biomarkers for anastomotic leakage and have the potential advantage of providing cheap real-time monitoring for postoperative complications.

CONCLUSION

Current diagnostic tests often fail to diagnose anastomotic leak at an early stage that enables timely intervention and minimizes serious morbidity and mortality. Emerging technologies, based on detection of local biomarkers, have achieved proof of concept status but require further evaluation to determine whether they translate into improved patient outcomes. Further research is needed to address this important, yet relatively unrecognized, area of unmet clinical need.

The impact of continuous versus intermittent vital signs monitoring in hospitals: A systematic review and narrative synthesis

BACKGROUND

Continuous vital signs monitoring on general hospital wards may allow earlier detection of patient deterioration and improve patient outcomes. This systematic review will assess if continuous monitoring is practical outside of the critical care setting, and whether it confers any clinical benefit to patients.

METHODS

MEDLINE^®, MEDLINE^® In-Process, EMBASE, CINAHL and The Cochrane Library were searched for articles that evaluated the clinical or non-clinical outcomes of continuous vital signs monitoring in adults outside of the critical care setting. The protocol was registered with PROSPERO (CRD42017058098).

FINDINGS

Twenty-four studies met the inclusion criteria and reported outcomes on a total of 40,274 patients and 59 ward staff in nine countries. The majority of studies showed benefits in terms of critical care use and length of hospital stay. Larger studies were more likely to demonstrate clinical benefit, particularly critical care use and length of hospital stay. Three studies showed cost-effectiveness. Barriers to implementation included nursing and patient satisfaction and the burden of false alerts.

CONCLUSIONS

Continuous vital signs monitoring outside the critical care setting is feasible and may provide a benefit in terms of improved patient outcomes and cost efficiency. Large, well-controlled studies in high-risk populations are required to evaluate the clinical benefit of continuous monitoring systems.

Systemic neutrophil-to-lymphocyte ratio in colorectal cancer: the relationship to patient survival, tumour biology and local lymphocytic response to tumour

Background:

Colorectal cancer (CRC) is a major cause of mortality and morbidity. The impact of inflammatory biomarkers (C-reactive protein etc.) on CRC is increasingly studied including systemic neutrophil-to-lymphocyte ratio (NLR) as they seem to predict outcome.

Methods:

All patients who underwent curative resection for CRC from 2000 to 2004 at Leeds Teaching Hospitals NHS Trust had pre-operative NLR calculated. Demographic, histopathological and survival data were collected. Tissue microarrays were created and stained to determine the mismatch repair (MMR) protein status of each tumour. Local lymphocytic response to the tumour was assessed and graded.

Results:

About 358 patients were eligible. Of these 88 had an NLR ⩾5, which predicted lower overall survival and greater disease recurrence. A high NLR is associated with higher pT- and pN-stage and a greater incidence of extramural venous invasion. MMR protein status was not associated with NLR. A pronounced lymphocytic reaction at the invasive margin (IM) indicated a better prognosis and was associated with a lower NLR.

Conclusion:

Neutrophil-to-lymphocyte ratio predicts disease-free and overall survival and is associated with a more aggressive tumour phenotype. The lymphocytic response to tumour at the IM is associated with NLR however dMMR is not. Neutrophil-to-lymphocyte ratio is a cheap, easy-to-access test that predicts outcome in CRC.

Fibrin glue for fistula-in-ano: the evidence reviewed

Fibrin glue is increasingly used in the treatment of anal fistulae. This review aims to establish its longterm efficacy and clarify its role in this setting. A search of Medline and Pubmed databases was performed from 1966 to 2004. Data were collated regarding the type of study, fistula aetiology and complexity, technical aspects of glue application, and short- and long-term healing rates. The majority of studies comprised prospective series with fistulae of mixed aetiology. The overall healing rate was 53% with a wide variation between studies (10%-78%). The only factor that could account for this diversity was fistula complexity, with series including a high proportion of complex fistulae reporting worse outcomes. The quality of data to assess the efficacy of fibrin glue in the treatment of anal fistulae is poor and further clinical trials are needed. Fistula complexity is the main factor that adversely influences long-term healing rates.

A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery

The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.

Randomized clinical trial of Ligasure versus conventional diathermy for day-case haemorrhoidectomy

BACKGROUND

Haemorrhoidectomy is frequently associated with postoperative pain and prolonged hospital stay. A new technique of haemorrhoidectomy using the Ligasure device suited to day-case surgery is described. This technique was compared with conventional open diathermy haemorrhoidectomy.

METHODS

Forty patients with grade III or IV haemorrhoids were randomized to Ligasure (group 1) or conventional diathermy (group 2) haemorrhoidectomy. Operative details were recorded and patients recorded daily pain scores on a linear analogue scale. Follow-up was at 1, 3, 6 and 12 weeks to evaluate complications, return to normal activity, ongoing symptoms and patient satisfaction.

RESULTS

Reduced intraoperative blood loss (median (range) 0 (0-5) ml versus 20 (12-22) ml; P < 0.001) and a shorter operating time (10 (8-11) versus 20 (18-25) min; P < 0.001) was observed in group 1 compared with group 2. More patients in group 1 were discharged on the day of operation (18 of 20 versus 11 of 20; P < 0.05) and there was a trend towards lower postoperative pain scores on day 1 (group 1 median 5 (95 per cent confidence interval (c.i.) 2.6 to 6.8) versus group 2 7 (95 per cent c.i. 4.2 to 7.7); P = 0.36). There was no difference between the two groups in the degree of patient satisfaction or number of postoperative complications.

CONCLUSION

Ligasure diathermy may be used safely in the treatment of patients with grade III or IV haemorrhoids. It reduces intraoperative blood loss and operating time, and facilitates same-day discharge.

The influence of invasive growth pattern and microvessel density on prognosis in colorectal cancer and colorectal liver metastases

The nature of the invasive growth pattern and microvessel density (MVD) have been suggested to be predictors of prognosis in primary colorectal cancer (CRC) and colorectal liver metastases. The purpose of the present study was to determine whether these two histological features were interrelated and to assess their relative influence on disease recurrence and survival following surgical resection. Archival tissue was retrieved from 55 patients who had undergone surgical resection for primary CRC and matching liver metastases. The nature of the invasive margin was determined by haematoxylin and eosin (H&E) histochemistry. Microvessel density was visualised using immunohistochemical detection of CD31 antigen and quantified using image capture computer software. Clinical details and outcome data were retrieved by case note review and collated with invasive margin and MVD data in a statistical database. Primary CRCs with a pushing margin tended to form capsulated liver metastases (P<0.001) and had a significantly better disease-free survival than the infiltrative margin tumours (log rank P=0.01). Primary cancers with a high MVD tended to form high MVD liver metastases (P=0.007). Microvessel density was a significant predictor of disease recurrence in primary CRCs (P=0.006), but not liver metastases. These results suggest that primary CRCs and their liver metastases show common histological features. This may reflect common mechanisms underlying the tumour–host interaction.

Stapled haemorrhoidopexy compared to Milligan-Morgan and Ferguson haemorrhoidectomy: a systematic review

PURPOSE

The aim of this study was to perform a systematic review and meta-analysis of the short- and long-term outcomes of stapled haemorrhoidopexy.

METHODS

A literature search identified randomised controlled trials comparing stapled haemorrhoidopexy with Milligan-Morgan/Ferguson haemorrhoidectomy. Data were extracted independently for each study and differences analysed with fixed and random effects models.

RESULTS

Thirty-four randomised trials and two systematic reviews were identified, and 29 trials included. Stapled haemorrhoidopexy was statistically superior for hospital stay (p < 0.001) and numerically superior for post-operative pain (peri-operative and mid-term), operation time and bleeding (post-operative and long-term). Recurrent prolapse and re-intervention for recurrence were more frequent following stapled haemorrhoidopexy. No difference was observed in the rates of complications.

CONCLUSIONS

Stapled haemorrhoidopexy reduces the length of hospital stay and may have an advantage in terms of decreased operating time, reduced post-operative pain and less bleeding but is associated with an increased rate of recurrent prolapse.

Tumour-induced apoptosis in human mesothelial cells: a mechanism of peritoneal invasion by Fas Ligand/Fas interaction

Gastrointestinal carcinomas frequently disseminate within the abdominal cavity to form secondary peritoneal metastases. Invasion of the peritoneal mesothelium is fundamental to this process, yet the underlying invasive mechanisms remain unclear. Preliminary in vitro work suggested that tumour cells can induce mesothelial apoptosis, representing a novel mechanism of peritoneal invasion. We examined the role of tumour cell-induced mesothelial apoptosis and explored the role of the death ligand/receptor system, Fas Ligand/Fas, as mediators of the apoptotic process. Cultured human mesothelial cells were used to establish in vitro co-culture models with the SW480 colonic cancer cell line. Tumour-induced mesothelial apoptosis was confirmed by phase-contrast microscopy and apoptotic detection assays. Human mesothelial cells and SW480 tumour cells constitutively expressed Fas and Fas Ligand mRNA and protein as determined by RT-PCR and confocal fluorescent microscopy. Stimulation of human mesothelial cells with anti-Fas monoclonal antibody or crosslinked soluble Fas Ligand-induced apoptosis, confirming the functional status of the Fas receptor. Pretreatment of SW480 cells with a blocking recombinant anti-Fas Ligand monoclonal antibody significantly reduced mesothelial apoptosis, indicating that tumour-induced mesothelial apoptosis may, in part, be mediated via a Fas-dependent mechanism. This represents a novel mechanism of mesothelial invasion and offers several new targets for therapeutic intervention.

A systematic review of outcome reporting in colorectal cancer surgery

AIM

Evaluation of surgery for colorectal cancer (CRC) is necessary to inform clinical decision-making and healthcare policy. The standards of outcome reporting after CRC surgery have not previously been considered.

METHOD

Systematic literature searches identified randomized and nonrandomized prospective studies reporting clinical outcomes of CRC surgery. Outcomes were listed verbatim, categorized into broad groups (outcome domains) and examined for a definition (an appropriate textual explanation or a supporting citation). Outcome reporting was considered inconsistent if results of the outcome specified in the methods were not reported. Outcome reporting was compared between randomized and nonrandomized studies.

RESULTS

Of 5644 abstracts, 194 articles (34 randomized and 160 nonrandomized studies) were included reporting 766 different clinical outcomes, categorized into seven domains. A mean of 14 ± 8 individual outcomes were reported per study. 'Anastomotic leak', 'overall survival' and 'wound infection' were the three most frequently reported outcomes in 72, 60 and 44 (37.1%, 30.9% and 22.7%) studies, respectively, and no single outcome was reported in every publication. Outcome definitions were significantly more often provided in randomized studies than in nonrandomized studies (19.0% vs 14.9%, P = 0.015). One-hundred and twenty-seven (65.5%) papers reported results of all outcomes specified in the methods (randomized studies, n = 21, 61.5%; nonrandomized studies, n = 106, 66.2%; P = 0.617).

CONCLUSION

Outcome reporting in CRC surgery lacks consistency and method. Improved standards of outcome measurement are recommended to permit data synthesis and transparent cross-study comparisons.

The impact of spontaneous tumour perforation on outcome following colon cancer surgery

OBJECTIVE

The impact of spontaneous tumour perforation on survival following surgery for colon cancer is unclear. This study compares survival outcomes for patients with perforated colonic cancer with stage-matched nonperforated cancer.

METHOD

A prospective histological database was searched for all patients undergoing resection for adenocarcinoma of the colon between 1996 and 2002. Patients with T4 cancer were selected and classified into those with spontaneous perforation at the tumour site and those with nonperforated tumour. Patients with synchronous colonic and rectal cancers, familial polyposis, inflammatory bowel disease, iatrogenic or remote colonic perforation were excluded. Histological variables were combined with clinical data obtained by case note review. Data were analysed for differences in demographics, histological variables, operative mortality, disease-free and overall survival. Multivariate analysis of factors predictive of overall survival in both groups was performed.

RESULTS

Of 960 patients identified, 52 patients had spontaneous tumour perforation and 82 patients served as the T-stage matched control group. Overall survival at 2 years was 47% and 54% and at 5 years was 28% and 33% for perforated and nonperforated cancers respectively. Patients with perforated cancers were more likely to present with metastatic disease and undergo emergency surgery with a higher 30-day mortality. There was a trend towards reduced overall survival in the perforated group (P = 0.06), but no difference in disease-free survival (P = 0.43). On multivariate testing, 'emergency surgery' and 'age >75 years' were the only independent predictors of mortality in the perforated and nonperforated group respectively.

CONCLUSION

Both perforated and nonperforated T4 colon cancers have a poor prognosis. Spontaneous perforation of the cancer is associated with reduced overall survival, due to higher 30-day mortality, but in itself does not appear to significantly impact on disease-free survival. Rather, it is the advanced oncological stage at which perforated cancers present that determines outcome.

Comparative study of Contour Transtar and STARR procedure for the treatment of obstructed defecation syndrome (ODS)--feasibility, morbidity and early functional results

AIM

Stapled transanal rectal resection (STARR) is a promising new treatment for obstructed defecation syndrome (ODS). It may be performed using either a double-stapling technique (PPH-STARR) or with the new Contour Transtar (CT) device. The aim of this study was to evaluate the two techniques with respect to morbidity and functional outcomes.

METHOD

Patients presenting with ODS were evaluated using standardized clinical and radiological investigations and prospectively entered into a database. A total of 150 Patients were treated with either PPH-STARR (n = 68) or CT (n = 82) and further evaluated at 12 month postoperatively.

RESULTS

The mean size of the resected specimen was 27 cm(2) (SD +/-4.86 cm(2)) in the PPH-STARR group and 46 cm(2) (SD +/-10.6 cm(2)) in the CT group [P < 0.001]. Morbidity was 7.3% (n = 5) in the PPH-STARR group and 7.5% (n = 6) in the CT group. The most common complication was minor postoperative bleeding in both groups (PPH-STARR: n = 2, 2.9%; CT: n = 2, 2.4%) Overall there were no septic complications and no surgical re-interventions. There was a tendency for more postoperative pain following CT (n = 3, 3.6%) as compared with PPH-STARR (n = 1, 1.4%). Constipation Scores (CCS) were 15.50 +/- 5.71 in the PPH-STARR group and 15.70 +/- 5.84 in the CT group preoperatively and decreased significantly to 8.25 (SD +/-1.45) and 8.01 (SD +/-2.31) 12-months after surgery. Values did not differ significantly between the two groups.

CONCLUSIONS

Contour Transtar is as safe and effective as PPH-STARR and provides a true circumferential resection of rectal intussusception. This may benefit selected patients and result in improved long-term durability of the technique.

Stapled transanal rectal resection for obstructed defaecation and evidence-based practice

A cautious approach is advocated

Synthesis and summary of patient-reported outcome measures to inform the development of a core outcome set in colorectal cancer surgery

AIM

Patient-reported outcome (PRO) measures (PROMs) are standard measures in the assessment of colorectal cancer (CRC) treatment, but the range and complexity of available PROMs may be hindering the synthesis of evidence. This systematic review aimed to: (i) summarize PROMs in studies of CRC surgery and (ii) categorize PRO content to inform the future development of an agreed minimum 'core' outcome set to be measured in all trials.

METHOD

All PROMs were identified from a systematic review of prospective CRC surgical studies. The type and frequency of PROMs in each study were summarized, and the number of items documented. All items were extracted and independently categorized by content by two researchers into 'health domains', and discrepancies were discussed with a patient and expert. Domain popularity and the distribution of items were summarized.

RESULTS

Fifty-eight different PROMs were identified from the 104 included studies. There were 23 generic, four cancer-specific, 11 disease-specific and 16 symptom-specific questionnaires, and three ad hoc measures. The most frequently used PROM was the EORTC QLQ-C30 (50 studies), and most PROMs (n = 40, 69%) were used in only one study. Detailed examination of the 50 available measures identified 917 items, which were categorized into 51 domains. The domains comprising the most items were 'anxiety' (n = 85, 9.2%), 'fatigue' (n = 67, 7.3%) and 'physical function' (n = 63, 6.9%). No domains were included in all PROMs.

CONCLUSION

There is major heterogeneity of PRO measurement and a wide variation in content assessed in the PROMs available for CRC. A core outcome set will improve PRO outcome measurement and reporting in CRC trials.

Impact of hepatobiliary service centralization on treatment and outcomes in patients with colorectal cancer and liver metastases

Background

Centralization of specialist surgical services can improve patient outcomes. The aim of this cohort study was to compare liver resection rates and survival in patients with primary colorectal cancer and synchronous metastases limited to the liver diagnosed at hepatobiliary surgical units (hubs) with those diagnosed at hospital Trusts without hepatobiliary services (spokes).

Methods

The study included patients from the National Bowel Cancer Audit diagnosed with primary colorectal cancer between 1 April 2010 and 31 March 2014 who underwent colorectal cancer resection in the English National Health Service. Patients were linked to Hospital Episode Statistics data to identify those with liver metastases and those who underwent liver resection. Multivariable random‐effects logistic regression was used to estimate the odds ratio of liver resection by presence of specialist hepatobiliary services on site. Survival curves were estimated using the Kaplan–Meier method.

Results

Of 4547 patients, 1956 (43·0 per cent) underwent liver resection. The 1081 patients diagnosed at hubs were more likely to undergo liver resection (adjusted odds ratio 1·52, 95 per cent c.i. 1·20 to 1·91). Patients diagnosed at hubs had better median survival (30·6 months compared with 25·3 months for spokes; adjusted hazard ratio 0·83, 0·75 to 0·91). There was no difference in survival between hubs and spokes when the analysis was restricted to patients who had liver resection (P = 0·620) or those who did not undergo liver resection (P = 0·749).

Conclusion

Patients with colorectal cancer and synchronous metastases limited to the liver who are diagnosed at hospital Trusts with a hepatobiliary team on site are more likely to undergo liver resection and have better survival.

Better survival