Transanal drainage tube placement to prevent anastomotic leakage following colorectal cancer surgery with double stapling reconstruction

Purpose

Anastomotic leakage (AL) is a critical complication of colorectal cancer surgery. The transanal drainage tube (TDT) is designed to prevent AL caused by decompression and stasis at the anastomosis. We conducted this study to investigate the feasibility of using the TDT to prevent AL following double-stapling technique reconstruction (DST).

Methods

The subjects of this study were 179 patients who underwent curative resection and DST reconstruction for sigmoid colon and rectal cancer in our institution between 2008 and 2013. We analyzed the effectiveness of the TDT for preventing AL.

Results

A TDT was placed in 78 patients (43.6 %, TDT group) and not placed in the remaining 101 patients (56.4 %, NTDT group). AL developed in 2 (2.6 %) patients from the TDT group and in 14 (13.9 %) patients from the NTDT group (p = 0.009). Univariate analysis revealed that AL was significantly correlated with tumor distance from the anal verge (AV), the number of staples, and TDT placement. Multivariate analysis revealed a significantly positive correlation between AL and AV [OR 0.877 (0.783–0.982) p = 0.023] and a significantly negative correlation between AL and TDT placement [OR 0.07 (0.013–0.374) p = 0.002].

Conclusions

Anastomotic decompression with TDT placement may prevent AL after colorectal cancer surgery with DST reconstruction.

     

Loop ileostomy closure after laparoscopic versus open surgery: is there a difference?

Background

Temporary loop ileostomy is commonly performed to protect the distal anastomosis during both open and laparoscopic colectomies. This study aimed to evaluate the impact of initial open and laparoscopic colorectal resection on the outcomes of ileostomy closure.

Methods

After institutional review board approval, all patients who underwent loop ileostomy closure from January 2008 to July 2012 were identified. The patients’ demographics, diagnosis, American Society of Anesthesiology (ASA) classification, type of resection, approach (laparoscopic [LS] or open [OS] surgery), use of anti-adhesion barrier, and ileostomy closure outcomes were obtained from a chart review. The outcomes of ileostomy closure after LS and OS colorectal resections were compared using Chi-square for categorical variables and Student’s t test for continuous variables.

Results

The study identified 351 patients with a mean age of 51 years: 145 patients (41.2 %) in the LS group and 206 patients (58.8 %) in the OS group. The most common procedures performed were total proctocolectomy with ileal J pouch anal anastomosis (109 patients: 49 LS, 60 OS) and restorative proctectomy (99 patients: 34 LS, 65 OS). At the time of ileostomy closure, the patients in the LS group had a significantly shorter mean operative time (LS 60.9 vs OS 82.6 min; p < 0.001) and a shorter hospital stay (LS 4.9 vs OS 5.8 days; p = 0.042). The overall complication rate was 20.1 % (70 patients), and the rate in the OS group was significantly higher (p = 0.028). The most common complications were postoperative ileus (41 patients: 13 LS vs 28 OS) and enterocutaneous fistula (5 patients, all in the OS group).

Conclusions

Loop ileostomy closure after laparoscopic colorectal surgery is associated with a significantly shorter operative time and hospital stay as well as a lower rate of postoperative complications. Superior outcomes after loop ileostomy closure lend further support to the use of laparoscopy.     

Sinusoidal Obstruction Syndrome Impairs Long-Term Outcome of Colorectal Liver Metastases Treated with Resection after Neoadjuvant Chemotherapy

Background

Chemotherapy-induced liver injury is a considerable problem in patients undergoing surgery for colorectal liver metastases, since an increase in postoperative morbidity and mortality has been observed. We investigated whether liver damage had further implications on long-term outcome in these patients.

Materials and Methods

Liver specimens from 196 patients resected for colorectal liver metastases were evaluated for chemotherapy-associated hepatic damage in the nontumorous liver. Injury patterns were correlated with recurrence free (RFS) and overall survival (OS). Factors leading to sinusoidal injury were identified.

Results

Patients who developed grade 2 or 3 sinusoidal dilatation had a significantly shorter RFS (hazard ratio [HR] 2.05; 95% confidence interval [95% CI] 1.23–3.39, P = .005) and OS (HR 2.90; 95% CI 1.61–6.19, P < .001), compared to patients without this alteration. Those patients also had significantly more intrahepatic recurrences (66.7% vs 30.5%, P = .003). Other patterns of chemotherapy-associated liver damage (nonalcoholic steatohepatitis, fibrosis) were not associated with impaired survival. Factors indicating sinusoidal injury were oxaliplatin-based chemotherapy, tumor size >5 cm, and elevated alkaline phosphatase or gamma glutamyltransferase.

Conclusions

Sinusoidal obstruction syndrome due to oxaliplatin-based chemotherapy may not only compromise perioperative outcome, but can lead to early recurrence and decreased survival in the long term. Strategies to prevent this condition are clearly needed.     

A prospective randomised controlled trial to assess the efficacy of dynamic stabilisation of the lumbar spine with the Wallis ligament

Purpose

This prospective randomised control study is to demonstrate whether or not there is a clinical benefit from inserting a Wallis implant on the functional recovery of patients who have undergone lumbar decompression surgery.

Method

Sixty consecutive patients with an average age of 58 years (34–81) who were selected for primary lumbosacral decompression were randomly assigned into two groups with equal number of patients, decompression alone or decompression with Wallis implant. The patients had an average follow-up of 40 months. Patients were assessed by visual analogue scale (VAS) (Boonstra et al., Int J Rehabil Res 31:165–169, 2008; Price et al., Pain 17:45–56, 1983) pain score for back and leg pain, and the Oswestry Disability Index questionnaire (ODI) (Smeets et al., Arthritis Care Res (Hoboken) 63:S158–S173, 2011).

Results

The results in both the groups did not reveal a significant difference in the clinical outcome assessment of back pain score or ODI. With the Wilcoxon two-sample test, no difference in median values was achieved (p value 0.0787 for ODI and p value 0.1926 for back pain). The average ODI in the Wallis group dropped from 50.93 to 29.11. The average VAS for the Wallis group back pain dropped from 7.79 to 4.22.

Conclusion

The Wallis implant is a safe medical device. This study revealed a reduction in pain and functional disability in patients treated with decompression surgery for lumbar stenosis, with or without Wallis. The Wallis group improved more, but it was not statistically significant. The risk of complications is lower than other interspinous devices [18, 19].     

Survival following laparoscopic and open colorectal surgery

Background

Laparoscopic colorectal surgery is known to provide increased benefits to patients during the postoperative recovery period. Initial scepticism over the oncological adequacy of resection has been dismissed by a number of major randomized trials. Emerging evidence indicates that laparoscopic surgery may provide a potential survival benefit in colorectal cancer.

Methods

Patients undergoing elective laparoscopic or open resection for colorectal cancer between October 2003 and December 2010 were analyzed. Data were collated and a database compiled. Survival analysis was calculated by using the Kaplan–Meier method.

Results

A total of 665 resections were performed with 457 laparoscopically and 208 open. The median length of stay was 4 days following laparoscopic resection and 7 days following open (p < 0.0005). There was no significant difference between the two groups apart from gender (p = 0.03), ASA (p = 0.03), and the number of patients with extranodal metastatic disease (p = 0.01). The 5-year overall survival (OS) in the completed laparoscopic group was 75.8 versus 72.5 % in the open group (p = 0.12). The 5-year OS in patients who were converted was 52 %. The 5-year OS for nonmetastatic disease in the completed laparoscopic group was significantly greater at 79.4 versus 74 % in the open group (p = 0.03). There was no difference between the groups in OS for rectal cancer (p = 0.66), but there was an OS advantage for laparoscopically resected colon cancer (p = 0.02).

Conclusions

Laparoscopic resection for nonmetastatic colon cancer may provide an overall survival advantage.     

Neoadjuvant Chemotherapy with Bevacizumab May Improve Outcome after Cytoreduction and Hyperthermic Intraperitoneal Chemoperfusion (HIPEC) for Colorectal Carcinomatosis

Background

In selected patients with colorectal peritoneal carcinomatosis (PC), cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) may improve survival. We aimed to assess whether neoadjuvant chemotherapy with or without bevacizumab is indicated in this patient population.

Methods

Colorectal PC patients were treated with CRS and HIPEC using oxaliplatin (200–460 mg/m²) or mitomycin C (35 mg/m²). Postoperative outcome and long-term survival were prospectively recorded. The impact of clinical variables on overall survival (OS) was assessed using univariate and Cox multivariate analysis.

Results

Between October 2002 and May 2012, 166 patients were treated with CRS and HIPEC. Neoadjuvant chemotherapy alone was administered to 21 % and neoadjuvant chemotherapy with bevacizumab to 16 % of patients. Postoperative mortality and major morbidity were 2.4 and 35 %, respectively. Half of the patients received adjuvant chemotherapy. After a median follow-up of 18 months, OS was 27 months (95 % confidence interval 20.8–33.2). On univariate analysis, OS was associated with extent of disease (P < 0.001), neoadjuvant chemotherapy with bevacizumab (P = 0.021), completeness of cytoreduction (CC) (P < 0.001), and adjuvant chemotherapy (P = 0.04), but not with primary disease site, synchronous presentation, or chemoperfusion drug. In multivariate Cox regression, independent predictors of OS were CC (hazard ratio 0.29, P < 0.001) and neoadjuvant therapy containing bevacizumab (hazard ratio 0.31, P = 0.019).

Conclusions

Long-term OS after CRS and HIPEC for colorectal cancer is associated with CC and neoadjuvant therapy containing bevacizumab. This regimen merits prospective study in patients with resectable PC of colorectal origin.     

Modern Chemotherapy Mitigates Adverse Prognostic Effect of Regional Nodal Metastases in Stage IV Colorectal Cancer

Background

In colorectal cancer, the involvement of regional lymph nodes with metastasis is an established prognostic factor. The impact of the number of positive nodes on patient outcome with stage IV disease is not well defined.

Methods

A retrospective review was performed of 1,421 patients at two tertiary referral centers with stage IV colorectal cancer who underwent primary tumor resection. Associations between regional nodes, lymph node ratio (LNR), and overall survival (OS) from date of diagnosis were analyzed.

Results

The number of positive regional nodes and LNR correlated with multiple sites of metastases (p?<?0.001). Survival was significantly associated with the number of positive nodes and LNR, with a median OS of 43 months with negative nodes, compared to 20 months with ≥7 positive nodes (p?<?0.001). The number of regional nodal metastases correlated with OS among 400 patients undergoing resection of liver metastases (p?=?0.005) but lost prognostic significance in the subset of 223 patients who underwent hepatectomy with perioperative oxaliplatin- or irinotecan-based chemotherapy (p?=?0.48).

Conclusions

In stage IV colorectal cancer, an increasing number of positive regional nodes and LNR correlate with multiple sites of metastases and poorer survival. The number of metastatic regional lymph nodes loses prognostic significance with modern chemotherapy in patients undergoing resection of liver metastases.     

Recurrence Location After Resection of Colorectal Liver Metastases Influences Prognosis

Aim

To assess the impact of first recurrence location on survival following surgery of colorectal liver metastases.

Methods

A total of 265 consecutive patients with colorectal liver metastases undergoing liver surgery (2000–2011) were categorized according to first site of tumor recurrence. Time to recurrence (TTR) and overall survival (OS) were determined. Uni- and multivariate analysis were performed to identify factors associated with TTR and OS.

Results

Median TTR was 1.16 years following liver resection, and 0.56 years following radiofrequency ablation (RFA). Intrahepatic recurrence following liver resection resulted in a significantly shorter median TTR compared to extrahepatic recurrence. Intrapulmonary recurrence was associated with superior survival compared to other recurrence locations. Such patterns were not observed in the RFA-treated group. Multivariate analysis identified the type of surgical treatment and extra-hepatic first-site recurrence (other than lung) as independent predictors for OS. Pre-operative chemotherapy and simultaneous intrahepatic and extrahepatic recurrence were independent predictors for both TTR and OS.

Conclusions

Patients with intrahepatic recurrence following liver resection have a significantly shorter TTR and OS when compared to patients developing extrahepatic recurrence. Pulmonary recurrence following resection is associated with longer survival. Simultaneous intra- and extrahepatic recurrence is an independent prognostic factor for TTR and OS.     

Oxidative stress markers in laparoscopic versus open colectomy for cancer: a double-blind randomized study

Background

Colorectal cancer as well as colorectal surgery is associated with increased oxidative stress through different mechanisms. In this study the levels of different oxidative stress markers were comparatively assessed in patients who underwent laparoscopic or conventional resection for colorectal cancer.

Methods

Sixty patients with colorectal cancer were randomly assigned to undergo laparoscopic (LS) or open surgery (OS). Lipid, protein, RNA, and nitrogen damage was investigated by measuring serum 8-isoprostanes (8-epiPGF_2α), protein carbonyls (PC), 8-hydroxyguanosine (8-OHG), and 3-nitrotyrosine (3-NT), respectively. The primary end point of the study was to analyze and compare serum levels of the oxidative stress markers between the groups.

Results

Postoperative serum levels of 8-epiPGF_2α, 3-NT, and 8-OHG were significantly lower in the LS group at 24 h after surgery (p < 0.05). At 6 h postoperatively, the levels of 8-epiPGF_2α and 3-NT were significantly lower in the LS group (p < 0.05). No difference in the levels of PC was found between the two groups at any time point. In the OS group, postoperative levels of 8-epiPGF_2α were significantly lower than the preoperative values (p < 0.01). In the LS group, the postoperative values of 8-epiPGF_2α, 3-NT, and 8-OHG were significantly lower than the preoperative values (p < 0.05).

Conclusion

Laparoscopic surgery for colorectal cancer is associated with lower oxidative stress compared to open surgery. 8-epiPGF_2α was the most suitable marker for readily defining the oxidative status in patients who underwent surgery for colorectal cancer.     

One-Stage Hepatectomy Following Portal Vein Embolization for Colorectal Liver Metastasis

Background

Although portal vein embolization (PVE) has been applied for surgical resection of colorectal liver metastases (CLM), the clinical usefulness of liver surgery following PVE for CLM remains unknown.

Methods

A total of 115 patients were evaluated retrospectively. Among them, 49 underwent one-stage hepatectomy following PVE (PVE group). The remaining 66 patients underwent at least hemihepatectomy without PVE (non-PVE group). This analysis compared the short- and long-term outcomes between the PVE and non-PVE groups.

Results

There were no deaths in either group. Using the Clavien–Dindo classification, the rates of postoperative morbidity ≥ grade 1 were 34.7 % in the PVE group and 25.0 % in the non-PVE group (p = 0.26). The 3-year overall survival rates were 54.6 and 64.5 % in the PVE and non-PVE groups, respectively (p = 0.89). The multivariate analysis the variable performance/nonperformance of PVE was not detected as an independent predictor of poor survival.

Conclusions

Our one-stage hepatectomy policy of using PVE provides acceptable morbidity and favorable long-term outcomes.     

Surgery Is an Essential Component of Multimodality Therapy for Patients with Locally Advanced Esophageal Adenocarcinoma

Background

Experience with neoadjuvant chemoradiation (CXRT) has raised questions regarding the additional benefit of surgery after locally advanced esophageal adenocarcinoma patients achieve a clinical response to CXRT. We sought to quantify the value of surgery by comparing the overall (OS) and disease-free survival (DFS) of trimodality-eligible patients treated with definitive CXRT vs. CXRT followed by esophagectomy.

Methods

We identified 143 clinical stage III esophageal adenocarcinoma patients that were eligible for trimodality therapy. All patients successfully completed neoadjuvant CXRT and were considered appropriate candidates for resection. Patients that were medically inoperable were excluded. Cox regression models were used to identify significant predictors of survival.

Results

Among the 143 patients eligible for surgery after completing CXRT, 114 underwent resection and 29 did not. Poorly differentiated tumors (HR?=?2.041, 95% CI?=?1.235–3.373) and surgical resection (HR?=?0.504, 95% CI?=?0.283–0.899) were the only independent predictors of OS. Patients treated with surgery had a 50 and 54 % risk reduction in overall and cancer-specific mortality, respectively. Median OS (41.2 vs. 20.3 months, p?=?0.012) and DFS (21.5 vs. 11.4 months, p?=?0.007) were significantly improved with the addition of surgery compared to definitive CXRT.

Conclusions

Surgery provides a significant survival benefit to trimodality-eligible esophageal adenocarcinoma patients with locally advanced disease.     

A comparative study of patients with and without associated digestive surgery in a two-stage hepatectomy setting

Purpose

The purpose of this study was to compare the feasibility and outcomes of two-stage hepatectomy in patients with or without accompanying digestive surgery.

Methods

We analyzed prospectively data from 56 patients with colorectal liver metastases undergoing two-stage hepatectomy between 1995 and 2009. Patients undergoing associated digestive resection (group I, n?=?32) were compared with patients without associated digestive surgery (group II, n?=?17).

Results

The feasibility rate was 87.5?% (49 patients). Neither the type and extent of hepatectomy nor the type of chemotherapy administered differed between the two groups. The median interval between hepatectomies was 1.79 and 2.07?months for groups I and II, respectively (not significant). One patient (group I) died of liver failure after the second hepatectomy. Postoperative morbidity rates were comparable: 37.5?% (group I) vs. 35.5?% (group II) after the first hepatectomy and 46.9?% (group I) vs. 52.9?% (group II) after the second hepatectomy. The median hospital stay after the first hepatectomy was longer in group I (13.5?days) than in group II (10?days) (P?<?0.01). Median follow-up was 54?months. The median overall survival (OS) was 45.8?months, and 3- and 5-year OS were 58 and 31?%, respectively. Median OS was longer for group II (58?months) than for group I (34?months) (P?=?0.048).

Conclusions

Digestive tract resection associated with two-stage hepatectomy does not increase postoperative mortality or morbidity nor does it lead to delay in chemotherapy or a reduction in cycles administered. The need for digestive tract surgery should not affect the surgical management of two-stage hepatectomy patients.     

Resection Margin with Anatomic or Nonanatomic Hepatectomy for Liver Metastasis from Colorectal Cancer

Background

When hepatectomy is used as a primary treatment for liver metastasis from colorectal cancer (CRCLM), the balance between surgical curability and functional preservation of the remnant liver is of great importance.

Methods

A total of 108 patients who underwent initial hepatectomy for CRCLM were retrospectively analyzed with respect to tumor extent, operative method, and prognosis, including recurrence.

Results

The 1-, 2-, 3-, and 5-year overall survival rates (OS) for all patients were 90.5%, 77.8%, 63.2%, and 51.6%, respectively. Multivariate analysis indicated serum carbohydrate antigen 19-9 (CA 19-9) level after hepatectomy (<36 or ??36?mAU/mL) and presence of recurrence as independent prognostic factors of OS (P?=?0.0458 and 0.0249, respectively), and tumor depth of colorectal cancer (P?=?0.0025 and 0.00138, respectively). Neither resection margin nor type of hepatectomy (anatomic or nonanatomic) for CRCLM was a significant prognostic factor for OS or DFS or CRCLM recurrence, including intrahepatic recurrence.

Conclusions

In CRCLM, we believe that nonanatomic hepatectomy with narrow margin is indicated, and optimal treatment would include functional preservation of as much of the remnant liver as possible.     

Robot-Assisted Versus Conventional Laparoscopic Surgery for Colorectal Disease, Focusing on Rectal Cancer: A Meta-analysis

Background

Robotic colorectal surgery may solve some of the problems inherent to conventional laparoscopic surgery (CLS). We sought to evaluate the advantages of robot-assisted laparoscopic surgery (RALS) using the da Vinci Surgical System over CLS in patients with benign and malignant colorectal diseases.

Methods

PubMed and Embase databases were searched for relevant studies published before July 2011. Studies clearly documenting a comparison of RALS with CLS for benign and malignant colorectal diseases were selected. Operative and postoperative measures, resection margins, complications, and related outcomes were evaluated. Weighted mean differences, relative risks, and hazard ratios were calculated using a random-effects model.

Results

The meta-analysis included 16 studies comparing RALS and CLS in patients with colorectal diseases and 7 studies in rectal cancer. RALS was associated with lower estimated blood loss in colorectal diseases (P?=?0.04) and rectal cancer (P?<?0.001) and lower rates of intraoperative conversion in colorectal diseases (P?=?0.03) and rectal cancer (P?<?0.001) than CLS. In patients with colorectal diseases, however, operating time (P?<?0.001) and total hospitalization cost (P?=?0.06) were higher for RALS than for CLS.

Conclusions

RALS was associated with reduced estimated blood loss and a lower intraoperative conversion rate than CLS, with no differences in complication rates and surrogate markers of successful surgery. Robotic colorectal surgery is a promising tool, especially for patients with rectal cancer.     

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in Asian Patients: 100 Consecutive Patients in a Single Institution

Background

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been shown to improve survival in selected patients with peritoneal carcinomatosis. We review our institutional experience with the procedure and evaluate the overall survival (OS) and disease-free survival (DFS) rates in 100 consecutive patients.

Methods

Data were prospectively collected from 100 consecutive patients with peritoneal carcinomatosis treated by CRS and HIPEC at the National Cancer Centre Singapore between April 2001 and May 2012. Our primary end points were OS and DFS.

Results

Of the 100 patients, 84 were of Chinese ethnicity, 3 were Malay, 6 were Indian, and 7 were of other ethnicities. Primary tumors were ovarian cancer (n = 39), colorectal cancer (n = 28), primary peritoneal (n = 6), appendiceal cancer (n = 20), and mesothelioma (n = 7). Median follow-up duration was 21 months. At 5 years, the DFS was 26.3 % and OS was 50.9 %. Factors influencing OS and DFS were cytoreductive score, primary cancer, and disease-free interval of more than 12 months on univariate analysis. The only factors that remained significant for prognosis after multivariate analysis were primary cancer and cytoreductive score. Thirty-day morbidity was 56 %, and there were no 30-day mortalities.

Conclusions

CRS and HIPEC can be safely carried out in Asian patients with peritoneal carcinomatosis from ovarian, colorectal, appendiceal, mesothelioma, and primary peritoneal origins. Overall, the ovarian, appendiceal, mesothelioma, and primary peritoneal cancer patients tended to do better than the colorectal patients, but careful patient selection ensuring that optimal cytoreduction can be achieved is essential for the success of this procedure.     

Analysis of the efficacy of direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) according to the prognostic factors in patients with colorectal perforation

Purpose

Direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) has been reported to improve the outcomes in patients with colorectal perforation. We retrospectively identified prognostic factors in patients with colorectal perforation and considered the efficacy of PMX-DHP based on these prognostic factors.

Methods

One hundred and fifty-six patients who underwent surgery for colorectal perforation in our department between November 1995 and March 2011 were enrolled in this study. The clinicopathological factors were compared between the survivor and non-survivor groups.

Results

There were 28 patients (17.9 %) who died within 28 days after surgery. According to the multivariate analysis, an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 17 or more was a significant independent prognostic factor (P = 0.002, odds ratio = 5.39). There was a significant difference in the survival rates between the patients with APACHE II scores of 16 or less and those with scores of 17 or more who had received the PMX-DHP (+) (P < 0.0001).

Conclusion

The APACHE II score is useful as a prognostic factor in patients with colorectal perforation, and the survival rate was 50 % or lower among the patients with APACHE II scores of 17 or higher. Therefore, PMX-DHP appears to have limited efficacy in serious cases.     

Carpal tunnel release in patients with diabetes result in poorer outcome in long-term study

Background

The aim of this prospective study was to compare the results of surgical decompression of carpal tunnel syndrome (CTS) in patients with diabetes mellitus with those with idiopathic CTS.

Methods

The results of surgical decompression of CTS in 27 patients with diabetes mellitus were compared with 42 patients with idiopathic CTS. All patients underwent surgical release of transverse carpal ligament by the mini-incision of palm technique. Patient self-administered Boston Questionnaire (BQ) for the assessment of severity of CTS symptoms and hand functional status was evaluated before and 6 months and 10 years after surgery.

Results

After surgical release, all the patients of both groups reported an absence of pain, disappearance or reduction of paresthesia, and improvement in hand function. Six months after surgery, there was a significant improvement of symptomatic and functional BQ scores compared with preoperative state in both groups. Ten years after surgery, there was statistical difference in preoperative and postoperative 10th year functional BQ score between DM (?) and DM (+) (p < 0.01). DM status affected statistically functional BQ score between preoperative and postoperative 10th year.

Conclusion

Diabetes mellitus was a risk factor for poor outcome of surgical decompression of CTS. Patients with diabetes had worse surgical outcome compared with patients with idiopathic CTS in long-term follow-up.     

Comparison of One-Stage Managements of Obstructing Left-Sided Colon and Rectal Cancer: Stent-Laparoscopic Approach vs. Intraoperative Colonic Lavage

Purpose

We evaluated the operative outcomes of laparoscopic surgery following self-expandable metallic stent compared to one-stage emergency surgical treatment.

Methods

From April 1996 to October 2007, 95 consecutive patients with left-sided malignant colorectal obstruction were enrolled. Twenty-five patients were assigned to the preoperative stenting and elective laparoscopic surgical treatment group (SLAP) and 70 to the emergency open surgery with intraoperative colon lavage group (OLAV).

Results

Among the 25 patients in the SLAP group, a primary anastomosis was possible in all patients and a diverting stoma was needed in one patient. The operative time was shorter in the SLAP group (198.53 vs. 262.17 min, P?=?0.002). Tumor size, number of retrieved lymph nodes, and pathological stage were similar in both groups. The rate of anastomotic failure was similar and postoperative complications occurred less in the SLAP group (5.9% vs. 31.4%, P?=?0.034). The passage of flatus and oral intake were resumed earlier in the SLAP group (2.88 vs. 3.68 days, P?=?0.046 and 5.18 vs. 6.65 days, P?<?0.001, respectively). The postoperative hospital stay was shorter in the SLAP group (10 vs. 15.4 days, P?=?0.013).

Conclusions

In patients with left-sided malignant colon and rectal obstruction, laparoscopic surgery after SEMS could be safely performed with successful early postoperative outcomes.     

Impact of Aggressive Histology and Location of Primary Tumor on the Efficacy of Surgical Therapy for Peritoneal Carcinomatosis of Colorectal Origin

Background

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) for peritoneal carcinomatosis (PC) of colorectal origin increases survival (OS) compared to systemic chemotherapy alone. Signet ring histology demonstrates aggressive behavior with poor survival. We sought to determine whether CRS/HIPEC increases survival in this subset of patients.

Methods

We reviewed 67 patients with PC of appendiceal (AP, n = 37) or colorectal origin (CRC, n = 30) with signet cell histology from a prospective database between May 2001 and August 2011. Survival analysis and multivariate Cox regression were used to determine prognostic factors for survival.

Results

Complete CRS (CC-0/1) was achieved in 77 % (CRC) and 73 % (AP) of patients. Progression-free survival (PFS) and OS were 9 and 12 months in CRC and 12 and 21 months in AP patients. In the CRC group, univariate predictors of poor survival included female gender, age, American Society of Anesthesiologists score, preoperative albumin, completeness of cytoreduction, and morbidity. In a multivariate Cox regression model, incomplete cytoreduction (CC-2/3) and female gender were joint significant predictors of poor survival. In the AP group, significant univariate predictors of poor survival included higher EBL and PCI score. In a multivariate Cox regression model, blood loss of >500 ml and a body mass index of <25 kg/m² were joint significant predictors of poor survival.

Conclusions

AP signet cell tumors demonstrate a more favorable outcome than CRC signet cell tumors after CRC/HIPEC for carcinomatosis, suggesting an underlying difference in biology. CRS/HIPEC does not confer survival benefit in colorectal signet ring carcinomatosis unless complete cytoreduction can be achieved, whereas appendiceal signet ring carcinomatosis may benefit, regardless of resectability.