Is limited surgery justified in the treatment of T1 colorectal cancer?

Background

Surgical treatment of colorectal cancer (CRC) should be aimed primarily at achieving a combination of surgical-oncologic radicalness and the highest possible quality of life. In recent years, surgical therapy for T1 CRC has tended toward less radical interventions. The question regarding changes in survival and recurrence rates still is unanswered.

Methods

A retrospective medical chart review of patients surgically treated in our department for T1 CRC from January 1990 to December 2010 (n = 223) was performed. Charts were reviewed for tumor-specific parameters, local recurrence, distant metastasis, and patient survival. The different treatment options used were strictly separated for a more detailed workup.

Results

Radical resection (RR) was performed for 57.1 %, local resection (LR) for 14.8 %, and an endoscopic approach (EA) for 28.1 % of the study population. After receipt of the histology report, 35.7 % of the patients initially resected nonradically underwent reoperation, mostly using RR. Seven patients experienced a local recurrence over time (3.6 %): one after initial RR, three after LR, and three after EA. Systemic recurrence occurred for nine patients (4.6 %) over time, six of whom had undergone initial RR. High-risk criteria were shown for 20 T1 CRCs. For 60 % (12/20) of the patients, initial RR was performed. Radical reoperation was performed for 75 % of the nonradically treated high-risk tumors. One high-risk patient without reoperation experienced metastatic disease over time. The 5-year overall survival rate was 87.2 %, itemized for the defined subgroups as follows: 83.9 % for RR, 82.8 % for LR, and 58.2 % for EA.

Conclusion

Patients with T1 CRC had a distinctly higher incidence of local recurrence after EA or LR. Explicit workup in terms of risk classification is crucial to reducing the risk of local and systemic recurrence. A nonradical approach should be only a second option for patients with T1 CRC, namely, those solely in clearly low-risk situations or those with distinct comorbidities.     

Is laparoscopic colorectal cancer surgery equal to open surgery? An evidence based perspective

Laparoscopic colorectal surgery (LCS) is an evolving subject. Recent studies show that LCS can not only offer safe surgery but evidence is growing that this new technique can be superior to classical open procedures. Fewer perioperative complications and faster postoperative recovery are regularly mentioned when studies of LCS are presented. Even though the learning curve of LCS is frequently debated when limitations of laparoscopic surgeries are reviewed, studies show that in experienced hands LCS can be a safe procedure for colorectal cancer treatment. The learning curve however, is associated with high conversion rates and economical aspects such as higher costs and prolonged hospital stay. Nevertheless, laparoscopic colorectal cancer surgery (LCCR) offers several advantages such as less co-morbidity and less postoperative pain in comparison with open procedures. Furthermore, the good exposure of the pelvic cavity by laparoscopy and the magnification of anatomical structures seem to facilitate pelvic dissection laparoscopically. Moreover, recent studies describe no difference in safety and oncological radicalness in LCCR compared to the open total mesorectal excision (TME). The oncological adequacy of LCCR still remains unproven today, because long-term results do not yet exist. To date, only a few studies have described the results of laparoscopic TME combined with preoperative adjuvant treatment for colorectal cancer. The aim of this review is to examine the various areas of development andcontroversy of LCCR in comparison to the conventional open approach.     

Is lung cancer surgery justified in patients with direct mediastinal invasion?

OBJECTIVE: To assess the results of the surgical treatment of patients with stage IIIB non-small cell lung carcinoma (NSCLC) invading the mediastinum (T4). METHODS: Twenty-nine patients were operated on from 1986 to 1999. Histology was squamous cell carcinoma in 17 patients, adenocarcinoma in eight, large cell carcinoma in two and neuroendocrinal carcinoma in two. Three patients received a preoperative chemotherapy (n = 2) or radiochemotherapy (n = 1). The lung resection consisted of a pneumonectomy in 25 patients and a lobectomy in four. The procedure was extended to one of the following structures: superior vena cava (SVC) (n = 17), aorta (n = 1), left atrium (n = 5) and carina (n = 6). Seventeen patients had a postoperative regimen including radiochemotherapy (n = 12), radiotherapy (n = 4), or chemotherapy (n = 1). RESULTS: Complete R0 resection was achieved in 25 patients, whereas four patients had a microscopically (n = 1) or macroscopically (n = 3) residual disease. The operative mortality rate was 7% (n = 2). Non-fatal major complications occurred in eight patients (28%). Overall 5-year survival rate was 28% (median 11 months), including the operative mortality. The median survival of the 18 patients with an N0 or N1 disease was 16 months whereas the median survival of the 11 patients with an N2 disease was 9 months. At completion of the study, 22 patients have died, two postoperatively and 10 from pulmonary causes without evidence of cancer. CONCLUSIONS: Surgical management of T4 NSC lung cancer invading the mediastinum should be considered, in the absence of N2 disease, when a complete resection is achievable.     

Is blood transfusion a risk factor in colorectal surgery for cancer?

Personal experience in the treatment of 93 cases of cancer of the large bowel and rectal localization is reported 32 patients (A group) received blood transfusions, 61 patients (B group) hadn't any transfusions or autotransfusions. Postoperative morbidity was 34.37% in A group and 14.75% in B group. The Authors stress the basic importance of autotransfusions as well in patients surgically treated for colorectal cancer.     

Is liver resection justified for patients with hepatic metastases from breast cancer?

OBJECTIVE: The purpose of this study was to examine our experience with hepatic resection (HR) in a relatively unselected group of patients with breast cancer liver metastases (BCLM). BACKGROUND: Although medical therapies provide limited survival benefit (median survival, 3-15 months), inclusion of HR into the multimodality treatment of patients with BCLM remains controversial. Our approach has been to offer HR to all patients with BCLM, provided that curative hepatic resection was feasible and extrahepatic disease was controlled with medical and/or surgical therapy. METHODS: Outcomes for 85 consecutive patients (all female, median age, 47 years) with BCLM treated with HR from 1984 to 2004 were reviewed. Extrahepatic metastases had been treated prior to HR or were synchronously present in 27 patients (32%). BCLM were solitary in 32 patients (38%) and numbered more than 3 in 26 patients (31%). The prognostic value of each study variable was assessed with log rank tests for univariate analysis and Cox proportional hazard models for multivariate analysis. RESULTS: Within 60 days of major hepatectomy (> or =3 segments, 54 patients) or minor hepatectomy (<3 segments, 31 patients), there was no mortality. The median hospital stay was 9 days with complications occurring in 26% of patients. Microscopically and macroscopically positive margins were present in 18% (R1) and 17% (R2) of patients. Following HR, 28 patients (33%) developed isolated hepatic recurrences, 12 of whom were treated with repeat hepatectomy. At a median follow-up interval of 38 months, 32 patients were alive, yielding median and 5-year overall survivals of 32 months and 37%. Median and 5-year disease-free survivals were 20 months and 21%. Study variables independently associated with poor survival were failure to respond to preoperative chemotherapy (P = 0.008), an R2 resection (P = 0.0001), and the absence of repeat hepatectomy (P = 0.01). CONCLUSIONS: For patients with BCLM, HR is safe and may provide a significant survival benefit over medical therapy alone. Response to preoperative chemotherapy, resection margin, and rehepatectomy for intrahepatic recurrence are key prognostic factors. Importantly, favorable outcomes can be achieved even in patients with medically controlled or surgically resectable extrahepatic disease, indicating that surgery should be considered more frequently in the multidisciplinary care of patients with BCLM.     

GIST identified during bariatric surgery: to treat or not to treat?

BackgroundGastrointestinal stromal tumors (GIST) are rare GI tumors that compose 1% of GI tumors. With the rise in obesity, bariatric surgery is becoming an increasingly common procedure and the incidental GISTs in this population have been noted more often than in the general population.ObjectiveWe evaluated and characterized the incidental GISTs in our bariatric surgical population.SettingThe study was completed at a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program–accredited academic hospital system.MethodsAll GISTs identified during Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy between January 1, 2005 and December 31, 2016 were evaluated. Typical demographic, clinicopathologic, treatment, follow-up, and outcome data were recorded.ResultsWithin the 2655 bariatric surgeries at our institution, 17 GISTs were identified (.64%). Mean age was 54 years; 94% of lesions were identified intraoperatively. Lesions were identified in the fundus (29.4%) or body (70.6%), were unifocal, and <1 cm; 94.1% of resections had clear margins. Histology revealed 88.2% spindle cell and 11.8% mixed histology with <5 mitoses/50 fields, portending a low malignancy potential. Follow-up included the bariatric surgeon and oncology consult; 17.6% were recommended by oncology for computed tomography surveillance. No recurrences were recorded.ConclusionWe present the largest cohort to date of incidental GISTs in a bariatric population. A diligent intraoperative examination of the serosa in the left-behind portion of the remnant in bypass and the discarded remnant in sleeves allows the bariatric surgeon the opportunity to leave the patient cancer-free after removal of incidental tumor.     

Can radical surgery improve survival in colorectal cancer?

Prospective, randomized trials that study the best surgical technique to prevent local and distal metastases in colorectal cancer have not yet been performed. Prevention of local recurrence must be a major effort achieved by radical resection of the tumor area, by minimizing the possibility of suture line recurrence and of tumor remnants in intramesenteric lymph nodes or surrounding tissue, and by avoiding spillage of tumor cells. Extended resections of mesenteric lymph nodes or pelvic lymphadenectomy did not prove to be of significant benefit in most retrospective studies. In the case of adjacent organ involvement, en bloc resection is indicated since long-term survival can be obtained. This operation can be performed with low operative mortality rates even in the case of pancreas or duodenum involvement as is shown in our series of 34 patients (3% operative mortality). Frozen sections of the resection area have to be included in the operative procedure. For prevention of distant metastases, the no-touch technique of Turnbull should be performed. In a prospective, randomized trial of 236 patients operated on for colon cancer, liver metastases appeared later and to a lesser degree in patients operated on with the no-touch isolation technique, particularly in the case of angioinvasive growth of the tumor.

---

Resumen Aún no se han realizado ensayos clínicos prospectivos y aleatorizados con el fin de estudiar la mejor técnica quirúrgica para prevenir metástasis locales y distales en cáncer colorectal. La prevención de la recurrencia local debe ser un propósito mayor mediante la resectión radical del área tumoral, minimizando las posibilidades de recurrencia en la línea de sutura, eliminando remanentes del tumor en los ganglios linfáticos intramesentéricos o en los tejidos vecinos, y evitando la contaminación con células tumorales. Las resecciones extensas de los ganglios mesentéricos o las linfadenectomías pélvicas no han demostrado beneficio de significación en la mayoría de los estudios prospectivos. En casos de invasión de órganos adyacentes, la resección en bloque tiene justificación porque se pueden lograr supervivencias prolongadas. Esta operación puede ser realizada con una baja mortalidad operatoria aún en casos de invasión de páncreas o de duodeno, como se ve en nuestra serie de 34 pacientes con 3% de mortalidad operatoria. Cortes por congelación del área de resección deben ser incluidos en el procedimiento operatorio. Con el objeto de prevenir el desarrollo de metástasis distales debe realizarse la técnica de aislamiento (no touch) de Turnbull. En un ensayo clínico prospectivo con 236 pacientes operados por cáncer de colon, las metatasis hepáticas hicieron su aparicón mas tardíamente y en menor grado en los pacientes operados con la técnica de aislamiento, especialmente cuando hay crecimiento angioinvasivo del tumor.

---

Résumé Des essais prospectifs randomisés pour étudier la meilleure opération susceptible de prévenir les métastases locales et distales en cas de cancer colo-rectal n'ont pas été entrepris. La prévention de la récidive locale doit être l'objectif à atteindre. Pour ce faire il convient de procéder à la résection radicale de la zone tumorale, de réduire au minimum la possibilité d'une récidive au niveau de la suture, d'éviter de laisser en place des éléments tumoraux dans les ganglions mésentériques et les tissus voisins, et de s'abstenir de tout essaimage des cellules tumorales. La résection étendue des ganglions mésentériques ou la lymphadenectomie pelvienne ne semble pas d'un grand bénéfice d'après les études rétrospectives. Lorsque les organes adjacents sont envahis, la résection en bloc est indiquée si l'on veut obtenir une bonne survie. Elle peut être entreprise avec un taux faible de mortalité même si le pancréas ou le duodénum est envahi ainsi que le montre notre série de 34 opérés dont le taux de mortalité a été de 3%. L'examen histologique extemporané de la zone réséquée lors de l'intervention fait partie intégrante de celle-ci. En ce qui concerne la prévention des métastases à distance, la technique no touch de Turnbull doit être appliquée. Dans un essai prospectif randomisé concernant 236 malades opérés de cancer du colon, les métastases hépatiques sont apparues plus tardivement et à un taux plus faible chez les sujets opérés en suivant ce principe. Ce fait a été observé particulièrement lorsqu'il s'agissait d'un processus tumoral à envahissement vasculaire.

     

Liver metastases from colorectal cancer. Is the practice of surgery based on the best clinical evidence possible?

To date, surgical resection remains the only curative treatment for liver metastases from colorectal cancer. However, the evidence supporting this treatment is based on retrospective studies. The lack of level I clinical evidence has stimulated strong interest in identifying the factors predictive of recurrence, and even to use them to create clinical risk scores (assigning one point to each factor for poor prognosis), in which a higher score indicates a poorer prognosis. In the present review, we discuss all these factors, as well as the therapeutic alternatives that improve local disease control. Next, we review all the prospective randomized studies published on this topic, which mainly focus on adjuvant chemotherapy associated with curative surgery with negative margins, with the aim of validating or rejecting this treatment. Lastly, we include the algorithm of the University of California at San Francisco for surgery in liver metastases from colorectal cancer.     

Is video-assisted thoracic surgery justified at first spontaneous pneumothorax?

OBJECTIVE: The fundamental role of video-assisted thoracic surgery (VATS) in the treatment of spontaneous pneumothorax is generally acknowledged today. This study intends to evaluate whether VATS is justified at the onset of a first spontaneous pneumothorax through analysis of parameters tested on two group of patients treated respectively with pleural drainage and VATS. PATIENTS/METHODS: The study includes 70 patients affected by first spontaneous pneumothorax divided into two groups of 35 patients for the purpose of therapeutic treatment. The first group underwent pleural drainage while the second underwent VATS. Parameters analyzed were as follows: (1) prolonged air leaks (more than 6 days); (2) time required for pleural drainage; (3) time of hospital stay; (4) management costs; (5) recurrences (follow-up at 12 months). RESULTS: Prolonged air leaks occurred in four patients (11.4%) in the first group and two patients (5.7%) in the second; recurrences occurred in eight patients in the first group (22.8%), and only one in the second group (2.8%). Mean time for drainage and hospitalization was, respectively, 9 and 12 days in patients with pleural drainage against 3.9 and 6 days of those using VATS. Average management costs per patients including hospitalization was calculated at $2,750.00 per patient for the first group compared with $1,925.00 for the second group. CONCLUSIONS: The use of VATS at first spontaneous pneumothorax is justified in the interest of both patients and health administrations as demonstrated by the number of recurrences in patients in the first group and economy savings resulting from use of VATS.     

Do elderly patients benefit from laparoscopic colorectal surgery?

Background The steadily increasing age of the population mandates that potential benefits of new techniques and technologies be considered for older patients. Aim To analyze the short-term outcomes of laparoscopic (LAP) colorectal surgery in elderly compared to younger patients, and to patients who underwent laparotomy (OP). Methods A retrospective analysis of patients who underwent elective sigmoid colectomies for diverticular disease or ileo-colic resections for benign disorders; patients with stomas were excluded. There were two groups: age < 65 years (A) and age ≥ 65 years (B). Parameters included demographics, body mass index (BMI), length of operation (LO), incision length (LI), length of hospitalization (LOS), morbidity and mortality. Results 641 patients (M/F – 292/349) were included between July 1991 and June 2006; 407 in group A and 234 in group B. There were significantly more LAP procedures in group A (244/407 – 60%) than in group B (106/234 – 45%) – p = 0.0003. Conversion rates were similar: 61/244 (25%) in group A, and 25/106 (24%) in group B (p = 0.78). There was no difference in LO between the groups in any type of operation. LOS was shorter in patients in group A who underwent OP: 7.1 (3–17) days versus 8.7 (4–22) days in group B (p <0.0001), and LAP: 5.3 (2–19) days versus 6.4 (2–34) days in group B (p = 0.01). In both groups LOS in the LAP group was significantly shorter than in OP group. There were no significant differences in major complications or mortality between the two groups; however, the complication rates in the OP groups were significantly higher than in LAP and CON combined (p = 0.003). Conclusions Elderly patients who undergo LAP have a significantly shorter LOS and fewer complications compared to elderly patients who undergo OP. Laparoscopy should be considered in all patients in whom ileo-colic or sigmoid resection is planned regardless of age. The study was accepted as a podium presentation in SAGES Scientific Sessions April 2007, Las Vegas, Nevada