Delaying surgery for optimization after colonic stent bridging is safe for left-sided malignant large bowel obstruction: Result from 10-year experience and risks factor analysis

AimTo evaluate the operative and oncological results after colonic stent bridging for left-sided malignant large bowel intestinal obstruction and the risk factors for survival and recurrence after definitive surgery.MethodologyConsecutive patients who underwent colonic stenting for malignant left-sided colonic obstruction were included. Patients for palliative stenting or emergency surgery, patient with low rectal tumour or peritoneal metastasis were excluded. The primary outcome was overall survival. Secondary outcomes included stent success rate, stenting related complications, rate of stoma formation and long-term oncological outcome including recurrence rate and recurrence free survival rate.ResultsFrom June 2011 to June 2021, a total of 222 patients underwent colonic stenting. 112 patients were bridged to surgery after initial stenting, but 7 patients dropped out. Overall survival was 35 months (IQR = 17.75–75.25 months) in the early operation group, 30 months (IQR = 17.5–49.5 months) in the delayed surgery group HR 0.981 (95%CI 0.70–1.395, p = 0.907). Sensitivity analysis performed by excluding stent complications and emergency surgery yielded the same conclusion. Overall stenting complications rate was 17.1%. 11 patients (10.4%) required emergency surgery.ConclusionThere was no difference between early and delayed surgery groups (>4weeks) in the overall survival and recurrence in patients who had stent-bridge to surgery for malignant left colonic obstruction. It is safe to defer definitive surgery to optimize patients and allow better recovery from initial obstruction after colonic stenting before definitive surgery without adversely affecting the oncological outcomes.     

Acute left-sided malignant colonic obstruction: Is there a role for endoscopic stenting?

The therapy of left-sided malignant colonic obstruction continues to be one of the largest problems in clinical practice. Numerous studies on colonic stenting for neoplastic colonic obstruction have been reported in the last decades. Thereby the role of self-expandable metal stents (SEMS) in the treatment of malignant colonic obstruction has become better defined. However, numerous prospective and retrospective investigations have highlighted serious concerns about a possible worse outcome after endoscopic colorectal stenting as a bridge to surgery, particularly in case of perforation. This review analyzes the most recent evidence in order to highlight pros and cons of SEMS placement in left-sided malignant colonic obstruction.     

Oncologic outcomes of preoperative stent insertion first versus immediate surgery for obstructing left-sided colorectal cancer

Background

Colonic self-expanding metallic stenting (SEMS) is widely used for the treatment of malignant colonic obstruction as a bridge to elective surgery. However, the effects of colonic stenting on long-term oncologic outcomes are debatable. This study aimed to compare the long-term oncologic outcomes of preoperative SEMS insertion with those of immediate surgery in patients with obstructing left-sided colorectal cancer.

Oncologic safety of colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction: Current evidence and prospects

Approximately 7%-29% of patients with colorectal cancer present with colonic obstruction. The concept of self-expandable metal stent (SEMS) insertion as a bridge to surgery (BTS) is appealing. However, concerns on colonic stenting possibly impairing oncologic outcomes have been raised. This study aimed to review current evidence on the short- and long-term oncologic outcomes of SEMS insertion as BTS for left-sided malignant colonic obstruction. For short-term outcomes, colonic stenting facilitates a laparoscopic approach, increases the likelihood of primary anastomosis without a stoma, and may decrease postoperative morbidity. However, SEMS-related perforation also increases local recurrence and impairs overall survival. Moreover, colonic stenting may cause negative oncologic outcomes even without perforation. SEMS can induce shear forces on the tumor, leading to increased circulating cancer cells and aggressive pathological characteristics, including perineural and lymphovascular invasion. The conflicting evidence has led to discordant guidelines. Well-designed collaborative studies that integrate both oncologic outcomes and data on basic research (e.g., alteration of circulating tumors) are needed to clarify the actual benefit of colonic stenting as BTS.     

Clinical Outcomes of Stenting for Colorectal Obstruction at a Tertiary Centre

Purpose

Self-expandable metal stents (SEMS) have been used to manage large bowel obstruction as a palliative treatment or to initially decompress the colon as a bridge to definitive surgery. Our goal was to review clinical outcomes in patients undergoing placement of a SEMS for colorectal obstruction at a tertiary care hospital.

Methods

A retrospective review was done of patients undergoing placement of a colorectal SEMS at a single centre between August 2005 and March 2011 for obstructing lesions. Outcomes identified included clinical relief of obstruction, successful bridging to surgery or palliation, and stent-related complications.

Results

SEMS were placed in a total of 58 patients. The intent of stenting was to bridge to definitive surgery in 11 patients and palliation in 47 patients. Stent placement was clinically successful in relieving obstruction without early complication in 45 (78 %) patients. Of the patients intended to bridge to surgery, 7/11 (64 %) were successfully bridged to surgery. One patient suffered a perforation, two failed to relieve obstruction, and one re-obstructed. Of the patients stented for palliation, 32/47 (68 %) were successfully palliated at a mean follow-up of 7.5 months. Five patients had perforations, six re-obstructed, two had stent migration, and two failed to relieve obstruction. The overall rates for perforation, re-obstruction, and stent migration were 10, 12, and 7 %, respectively.

Conclusion

SEMS placement as a bridge to surgery and for palliation of colorectal obstruction is associated with moderate rates of clinical success but a high rate of perforation.     

Surgical outcomes of colonic stents as a bridge to surgery versus emergency surgery for malignant colorectal obstruction: A systematic review and meta-analysis of high quality prospective and randomised controlled trials

Self-expanding metallic stent placement as a bridge to surgery has been reported as an alternative to emergency surgery for acute malignant colorectal obstruction. However, results from clinical trials and previous meta-analyses are conflicting. We carried out a meta-analysis to compare the surgical and oncological outcomes between emergency surgery and self-expanding metallic stents for malignant large bowel obstruction. Pubmed, Embase, CINAHL, Web of Science and Cochrane were searched for prospective and randomised controlled trials. The outcomes of focus included 3- and 5-year overall and disease-free survival, overall tumour recurrence, overall complication and 30-day mortality rate, length of hospital and ICU stay, overall blood loss, number of patients requiring transfusion, total number of lymph nodes harvested, stoma and primary anastomosis rate. Twenty-seven studies were included with a total of 3894 patients. There was no significant difference in terms of 3-year and 5-year disease-free and overall survival. Stenting resulted in less blood loss (mean difference −234.72, P < 0.00001) and higher primary anastomosis rate (RR 1.25, P < 0.00001). For curative cases, bridge to surgery groups had lower 30-day mortality rate (RR 0.65, P = 0.01), lower overall complication rate (RR 0.65, P < 0.0001), more lymph nodes harvested (mean difference 2.51, P = 0.005), shorter ICU stay (mean difference −2.27, P = 0.02) and hospital stay (mean difference −7.24, 95% P < 0.0001). Compared to emergency surgery, self-expanding metallic stent interventions improve short-term surgical outcomes, especially in the curative setting, but have similar long-term oncological and survival outcomes.     

Endoscopic palliation of colorectal cancer

Multiple endoscopic options exist for physicians seeking to provide palliative therapy for patients with colorectal cancer. Endoscopic decompression tubes can allow urgent stabilization for patients with malignant obstruction requiring some form of surgical palliation. Patients who are not candidates for palliative surgery can experience good symptomatic relief from malignant large bowel obstruction via laser therapy or placement of a colonic stent. Laser therapy can be used in conjunction with SEMS to recanalize and decompress large bowel in certain situations. The use of colonic stents is rapidly becoming more commonplace as acceptance of the technique becomes more widespread. Patients with unresectable disease may be able to avoid surgery altogether and achieve successful and lasting palliation of large bowel obstruction. Overall, they provide effective and durable palliation in patients with malignant obstruction, have an excellent risk/benefit profile, and are within the technical means of both gastroenterologists and interventional radiologists.     

Safety and efficacy of endoscopic colonic stenting as a bridge to surgery in the management of intestinal obstruction due to left colon and rectal cancer: A systematic review and meta-analysis

IntroductionColorectal carcinoma can present with acute intestinal obstruction in 7%–30% of cases, especially if tumor is located at or distal to the splenic flexure. In these cases, emergency surgical decompression becomes mandatory as the traditional treatment option. It involves defunctioning stoma with or without primary resection of obstructing tumor. An alternative to surgery is endoluminal decompression. The aim of this review is to assess the effectiveness of colonic stents, used as a bridge to surgery, in the management of malignant left colonic and rectal obstruction.MethodsWe considered only randomized trials which compared stent vs surgery for intestinal obstruction from left sided colorectal cancer (as a bridge to surgery) irrespective of their size. No language or publication status restrictions were imposed. A systematic search was conducted in Medline, Cochrane Central Register of Controlled Trials and the Science Citation Index (from inception to December 2011)ResultsWe identified 3109 citations through our electronic search and 3 through other sources. Initial screening of the titles and abstracts resulted in the exclusion of 3104 citations. A further 5 citations were excluded after detailed screening of full articles. Three published studies were included in this systematic review. A total of 197 patients were included in our analysis, 97 of them had colorectal stent vs 100 who had emergency surgery. Clinical success has been defined in different manners. In included trials the clinical success rate was significantly higher in the emergency surgery group (99%) compared with the stent group (52.5%) (p < 0.00001). There was no difference in the overall complication rate in the stent group (48.5%) vs emergency surgery group (51%) (p = 0.86). There was no difference in 30-days postoperative mortality (p = 0.97). The overall survival was analyzed in none trial. When used as a bridge to surgery, colorectal stents provide some advantages: the primary anastomosis rate was significantly higher in the stent group (64.9%) vs emergency surgery group (55%) (p = 0.003); the overall stoma rate was significantly lower in the stent group (45.3%) compared with the emergency surgery group (62%) (p = 0.02).There were no significant differences between the two groups as to permanent stoma rate (46.7% in stent group vs 51.8% in surgical group, p = 0.56), anastomotic leakage rate (9% in stent group vs 3.7% in surgical group, p = 0.35) and intra-abdominal abscess rate (5.1% in stent group vs 4.9% in surgical group, p = 0.97).ConclusionAlthough colonic stenting appears to be an effective treatment of malignant large bowel obstruction, the clinical success resulted significantly higher in the emergency surgery group without any advantages in terms of overall complication rate and 30-days postoperative mortality. On the other hand, the colonic stenting as a bridge to surgery provides surgical advantages, as higher primary anastomosis rate and a lower overall stoma rate, without increasing the risk of anastomotic leak or intra-abdominal abscess. However, these results should be interpreted with caution because few studies reported data on these outcomes. Due to the small and variable sample size of the included trials, further RCTs are needed including a larger number of patients and evaluating long term results (overall survival and quality of life) and cost-effectiveness analysis.     

Outcomes following small bowel obstruction due to malignancy in the national audit of small bowel obstruction

IntroductionPatients with cancer who develop small bowel obstruction are at high risk of malnutrition and morbidity following compromise of gastrointestinal tract continuity. This study aimed to characterise current management and outcomes following malignant small bowel obstruction.MethodsA prospective, multicentre cohort study of patients with small bowel obstruction who presented to UK hospitals between 16th January and 13th March 2017. Patients who presented with small bowel obstruction due to primary tumours of the intestine (excluding left-sided colonic tumours) or disseminated intra-abdominal malignancy were included. Outcomes included 30-day mortality and in-hospital complications. Cox-proportional hazards models were used to generate adjusted effects estimates, which are presented as hazard ratios (HR) alongside the corresponding 95% confidence interval (95% CI). The threshold for statistical significance was set at the level of P ≤ 0.05 a-priori.Results205 patients with malignant small bowel obstruction presented to emergency surgery services during the study period. Of these patients, 50 had obstruction due to right sided colon cancer, 143 due to disseminated intraabdominal malignancy, 10 had primary tumours of the small bowel and 2 patients had gastrointestinal stromal tumours. In total 100 out of 205 patients underwent a surgical intervention for obstruction. 30-day in-hospital mortality rate was 11.3% for those with primary tumours and 19.6% for those with disseminated malignancy. Severe risk of malnutrition was an independent predictor for poor mortality in this cohort (adjusted HR 16.18, 95% CI 1.86 to 140.84, p = 0.012). Patients with right-sided colon cancer had high rates of morbidity.ConclusionsMortality rates were high in patients with disseminated malignancy and in those with right sided colon cancer. Further research should identify optimal management strategy to reduce morbidity for these patient groups.     

Oncologic impact of colonic stents for obstructive left-sided colon cancer

Colonic stenting has had a significant positive impact on the management of obstructive left-sided colon cancer (OLCC) in terms of both palliative treatment and bridge-to-surgery (BTS). Notably, many studies have convincingly demonstrated the effectiveness of stenting as a BTS, resulting in improvements in short-term outcomes and quality of life, safety, and efficacy in subsequent curative surgery, and increased cost-effectiveness, whereas the safety of chemotherapy after stenting and the long-term outcomes of stenting as a BTS are controversial. Several studies have suggested an increased risk of perforation in patients receiving bevacizumab chemotherapy after colonic stenting. In addition, several pathological analyses have suggested a negative oncological impact of colonic stenting. In contrast, many recent studies have demonstrated that colonic stenting for OLCC does not negatively impact the safety of chemotherapy or long-term oncological outcomes. The updated version of the European Society of Gastrointestinal Endoscopy guidelines released in 2020 included colonic stenting as a BTS for OLCC as a recommended treatment. It should be noted that the experience of endoscopists is involved in determining technical and clinical success rates and possibly oncological outcomes. This review discusses the positive and negative impacts of colonic stenting on OLCC treatment, particularly in terms of oncology.     

Safety and Oncological Outcomes of Bevacizumab Therapy in Patients With Advanced Colorectal Cancer and Self-expandable Metal Stents

BackgroundMalignant bowel obstruction can occur in 18% of cases. Self-expandable metal stents (SEMS) can be an alternative to surgery. Bevacizumab (BV) has been associated with bowel perforation, but data on the safety of SEMS for occlusive colon cancer during BV-containing regimens are lacking.Material and MethodsThis is a retrospective analysis of 78 patients with malignant bowel obstruction who underwent placement of SEMS as a palliative intent for stage IV disease. Chemotherapy and BV-containing regimens, stent-related complications, and outcomes were recorded.ResultsOverall, major stent-related complications were observed in 27 (35%) patients: Re-obstruction occurred in 14 (52%) patients, and there were 7 (26%) perforations, 4 (15%) minor bleeding, and 2 (7%) migrations. Sixteen patients received BV; 2 (12.5%) had a perforation. No differences were observed between chemotherapy alone and BV in overall complications. Univariate analysis did not show that BV was more likely to develop perforations, although the incidence was higher in this subset of patients. Kaplan-Meier analysis showed a significant association with longer overall survival for patients treated with systemic therapy (27 vs. 11 months; P ≤ .00001). Also, there is a significant benefit of BV compared with chemotherapy alone (43 vs. 39 months; P = .02).ConclusionPlacement of SEMS is effective and relatively safe but with an overall complication rate of 35% in the metastatic setting. The major early risk is perforation, which can increase up to 12% during BV treatment. In patients with obstructing advanced colorectal cancer that would benefit from SEMS, we should consider the risks associated with systemic therapies, taking into account the improvement in survival observed with BV.     

Prospective multicentre study of a new bowel obstruction treatment in colorectal surgery: Reduced morbidity and mortality

IntroductionBowel obstruction patients are at increased risk of emergency surgery and have poor nutritional and physical conditions. These patients could benefit from prehabilitation and prevention of emergency surgery. This study assessed the effect of a multimodal obstruction treatment for bowel obstruction patients in colorectal surgery on the risk of emergency surgery and postoperative morbidity and mortality.Materials and methodsThis multicenter observational cohort study included all consecutive bowel obstruction patients who received obstruction treatment (obstruction protocol) in the period 2019–2020 in two Dutch hospitals. Benign and malignant causes of bowel obstruction were included. Treatment consisted of 1. dietary adjustments, 2. postponing surgery for three weeks, 3. laxatives, and 4. prehabilitation. We compared emergency surgery and postoperative morbidity and mortality rates to known rates from the literature.ResultsEighty-nine patients were included: obstruction treatment was successful in 77 patients (87%) who underwent elective surgery and unsuccessful in 12 patients (13%) who underwent emergency surgery. Sixty-six (74%) had colorectal cancer, and 22 (25%) had benign disease. Thirty-day mortality of 0% in our study was significantly lower than the national average of 4% in colorectal cancer patients in the Netherlands (p = 0.049). Anastomotic leakage rate was 3%, severe complications (Clavien-Dindo ≥ III) 8%, and bowel perforation 0%. These rates did not differ significantly from rates reported in literature.ConclusionThe obstruction treatment prevented emergency surgery in most patients with bowel obstruction and reduced postoperative morbidity and mortality. The obstruction treatment seems to be a safe and efficient alternative to emergency surgery.     

Promising results of a new treatment in patients with bowel obstruction in colorectal surgery

IntroductionBowel obstruction increases risk of emergency surgery and leads to suboptimal physical and nutritional condition. Preventing emergency surgery and prehabilitation might improve outcomes. This pilot study aimed to examine the effect of a multimodal obstruction protocol for bowel obstruction patients on the risk of emergency surgery and postoperative morbidity and mortality.Materials and methodsAll bowel obstruction patients treated according to the obstruction protocol in the period 2013–2017 were included in this uncontrolled observational cohort study. Benign and malignant causes of bowel obstruction were included. The protocol consisted of: 1. specific dietary adjustments to reduce prestenotic dilatation, 2. oral laxatives and 3. prehabilitation. Emergency surgery and postoperative morbidity and mortality rates were compared to known rates from the literature.ResultsSixty-one patients were included: 44 (72%) were treated for colorectal cancer and 17 (28%) for Crohn's disease or diverticulitis. Four patients (7%) underwent emergency surgery. Primary anastomosis was constructed in 49 out of 57 elective patients (86%). Severe complications (Clavien-Dindo ≥ III) occurred in four patients (7%). No bowel perforation, anastomotic leakages or 30-day mortality was observed. These rates were much lower than rates reported in the literature after surgery for colorectal cancer (3% bowel perforation, 8% anastomotic leakage, 4% 30-day mortality, 15% severe complications) and benign disease (30-day mortality 17%, severe complications 7%).ConclusionUsing the obstruction protocol in patients with bowel obstruction reduced emergency surgery and postoperative morbidity and mortality in this pilot study. This protocol seems to be a viable and efficient alternative to emergency surgery.     

Management of obstructive colon cancer: Current status,obstacles, and future directions

Approximately 10%–18% of patients with colon cancer present with obstruction at the initial diagnosis. Despite active screening efforts, the incidence of obstructive colon cancer remains stable. Traditionally, emergency surgery has been indicated to treat patients with obstructive colon cancer. However, compared to patients undergoing elective surgery, the morbidity and mortality rates of patients requiring emergency surgery for obstructive colon cancer are high. With the advancement of colonoscopic techniques and equipment, a self-expandable metal stent (SEMS) was introduced to relieve obstructive symptoms, allowing the patient’s general condition to be restored and for them undergo elective surgery. As the use of SEMS placement is growing, controversies about its application in potentially curable diseases have been raised. In this review, the short- and long-term outcomes of different treatment strategies, particularly emergency surgery vs SEMS placement followed by elective surgery in resectable, locally advanced obstructive colon cancer, are described based on the location of the obstructive cancer lesion. Controversies regarding each treatment strategy are discussed. To overcome current obstacles, a potential diagnostic method using circulating tumor DNA and further research directions incorporating neoadjuvant chemotherapy are introduced.     

Isotope-Only Localization for Sentinel Lymph Node Biopsy - Medium-Term Oncological Outcomes

AimsIsotope and blue dye dual localization in sentinel lymph node biopsy (SLNB) gives localization rates of over 98% and is the recommended technique. However blue dye risks a range of adverse reactions. Since 2010, for clinically node negative disease, we have only used blue dye if there is no clear isotope signal at surgery.MethodsElectronic records of patients who underwent isotope-only SLN localization between July 2010 and April 2012 were examined. Data were collected on localization and oncological outcomes.Results426 patients were included. Isotope-only localization rate was 97.4% (415/426). The median follow-up was 63.5 months (IQR: 60.7-70.9). Median age was 57 (IQR: 48-67). Median SLN yield was 2 (range: 1-5). Axillary recurrence rate was 1.4% with median time to recurrence of 39.3 months. In-breast recurrence, distant disease and contralateral breast cancer rates were 2.8%, 7%, and 1.9% respectively and 15 (3.5%) patients died of metastatic breast cancer.ConclusionIsotope-only SLNB has a comparable localization rate to dual isotope/blue dye SLNB and can spare the risk of blue dye adverse reactions. The low axillary recurrence rate, maintained to more than 5 years, confirms that isotope-only SLNB is a feasible and safe alternative to dual blue dye/isotope localization.     

A prospective longitudinal study of quality of life in robotic-assisted salvage surgery for oropharyngeal cancer

ObjectiveWe investigated the quality of life (QoL), functional, and oncological outcomes after robotic-assisted transoral or combined cervical-transoral salvage surgery for oropharyngeal carcinoma following radiotherapy.Material and methodsWe performed a single tertiary referral center, prospective, observational cohort study of all consecutive patients who underwent salvage robotic-assisted surgery for oropharyngeal carcinoma between 2015 and 2021. The primary outcomes were quality of life assessments using the MDADI, EORTC-QLQC30, and EORTC-QLQH&N35. Secondary endpoints were the functional and oncological outcomes based on overall survival, disease-free survival, and local control.ResultsA consecutive cohort of 53 patients were included. The median Charlson comorbidity index was 5. The p16 status was negative in 87%, and 22.6% were T3-4. A flap reconstruction was performed in 90.6%, with a free flap in 67.9%. Margins were negative in 81.1%. The preoperative, 1-year, and 2-year MDADI total scores were 71.4, 64.3, and 57.5, respectively. The preoperative, 1-year, and 2-year QLQ-C30 global scores were 61.2, 59.4, and 80.6, respectively. Decannulation was possible in 97.1% of the tracheotomized patients. The two-year enteral tube dependence was 23.1%. The two-year overall survival, disease-free survival, and local control rates were 59%, 46.1%, and 80.9%, respectively.ConclusionRobotic-assisted salvage surgery for oropharyngeal carcinoma following radiotherapy demonstrated a very satisfactory quality of life, good functional sequelae, and good oncological outcomes compared to historical approaches.     

Association of primary tumor location with long-term oncological prognosis following hepatectomy for hepatocellular carcinoma:A multicenter propensity score matching analysis

PurposeThere is a striking laterality in the site of hepatocellular carcinoma (HCC), with a strong predominance for the right side; however, the impact of primary tumor location on long-term prognosis after hepatectomy of HCC remains unclear. This study aimed to investigate the effect of primary tumor location on long-term oncological prognosis after hepatectomy for HCC.Patients and methodsData of consecutive patients undergoing curative hepatectomy for HCC between 2008 and 2017 were analyzed. Overall survival (OS) and recurrence-free survival (RFS) of left-sided HCC (LS group) and right-sided HCC (RS group) were compared by using propensity score matching (PSM) analysis. COX regression analysis was performed to assess the adjusted effect of tumor location on long-term oncological prognosis.ResultsOf the 2799 included patients, 707 (25.3%) and 2092 (74.7%) were in the LS and RS groups, respectively. Using PSM analysis, 650 matched pairs of patients were created. In the PSM cohort, median OS (66.0 vs. 72.0 months, P = 0.001) and RFS (28.0 vs. 51.0 months, P < 0.001) were worse among patients in the LS group compared to individuals in the RS group. After further adjustment for other confounders using multivariable COX regression analyses, HCC located on the left side remained independently associated with worse OS and RFS.ConclusionTumors located on the left side are associated with poorer OS and RFS after hepatectomy for HCC. Careful surgical options selection and frequent follow-up to improve long-term survival may be justified for HCC patients with left-sided primary tumors.     

Expandable metallic stent for the treatment of left-sided colonic obstruction with malignant disease

Recently, it was reported that an EMS (expandable metallic stent) was useful for treatment of colorectal obstruction. In our department, EMSs were used for seven patients with left-sided colonic obstruction with unresectable malignant disease. After these treatments with EMS, their symptoms were improved and they were able to intake food. Stomal formation was avoided except in one patient with severe soiling. In conclusion, EMS is thought to be useful for the improvement of quality of life in the patients with unresectable malignant colonic obstruction.     

Salvage surgery for local regrowths in Watch & Wait - Are we harming our patients by deferring the surgery?

BackgroundRectal cancer surgery conveys significant morbidity/mortality, long-term functional impairment and urinary & sexual dysfunction, especially if associated with neoadjuvant chemoradiotherapy (ChRT). Watch & Wait (W&W) is gaining momentum as an option for patients with clinical complete response (cCR) after ChRT. Approximately 30% will develop a local regrowth (RG) and need deferred surgery. Our study aimed to assess the short-term clinical outcomes after surgery for regrowths.Patients and methodsConsecutive rectal cancer patients from a tertiary institution who underwent neoadjuvant ChRT, between January 2013 and October 2018, were identified from a prospectively maintained database. Patients with RG under W&W surveillance were operated - regrowth deferred surgery (RDS) group - and compared to those with persistent disease after ChRT who did undergo surgery - non-deferred surgery (NDS) group.ResultsTotal of 124 patients received neoadjuvant treatment: 46 (37%) underwent surgery for persistent disease; 78 (63%) with cCR entered W&W. Twenty three developed RG and underwent surgery, while 55 remain under surveillance. RDS group had lower tumors than NDS group (2.3 cm ± 2 vs 4.5 cm ± 3, p = 0.002). All RG underwent minimally invasive surgery (MIS). Anastomotic leaks, 30-day morbidity, reintervention and readmission rates were similar. Pathology features and 3-year oncological outcomes were identical between groups.ConclusionPatients with initial cCR and local regrowth may be safely managed by deferred surgery. Short-term outcomes suggest equivalent results to patients with incomplete clinical response and immediate radical surgery. Delayed MIS appears to have no negative impact on oncological outcomes.     

Long-term outcomes after laparoscopic colectomy

AIM:To evaluate long-term outcomes in a large series of patients who randomly received laparoscopic or open colorectal resection.METHODS:From February 2000 to December 2004,six hundred sixty-two patients with colorectal disease were randomly assigned to laparoscopic(LPS,n = 330) or open(n = 332) colorectal resection.All patients were analyzed on an intention-to-treat basis.Long-term follow-up was carried out every 6 mo by office visits.In 526 cancer patients five-year overall and disease-free survival were evaluated.Median oncologic follow-up was 96 mo.RESULTS:Eight(4.2%) LPS group patients needed conversion to open surgery.Overall long-term morbidity rate was 7.6%(25/330) in the LPS vs 11.1%(37/332) in the open group(P = 0.17).In cancer patients,fiveyear overall survival was 68.6% in the LPS group and 64.0% in the Open group(P = 0.27).Excluding stage Ⅳ patients,five-year local and distant recurrence rates were 32.5% in the LPS group and 36.8% in the Open group(P = 0.36).Further,no difference in recurrence rate was found when patients were stratified according to cancer stage.CONCLUSION:LPS colorectal resection was associated with a slightly lower incidence of long-term complications than open surgery.No difference between groups was found in overall and disease-free survival rates.