Extent of lymph node resection does not increase perioperative morbidity and mortality after surgery for stage I lung cancer in the elderly

Background & objectives

Pathologic evaluation of >10 lymph nodes (LNs) is considered necessary for accurate lung cancer staging. However, physicians have concerns about increased risk in perioperative mortality (POM) and morbidity with more extensive LN sampling, particularly in the elderly. In this study, we compared the outcomes in elderly patients with stage I non-small cell lung cancer (NSCLC) undergoing extensive (>10 nodes) and limited (≤10 nodes) LN resections.

Methods

Using data from the Surveillance, Epidemiology and End Results registry linked to Medicare records, we identified 4975 patients ≥65 years of age with stage I NSCLC who underwent a lobectomy between 1992 and 2002. Risk of perioperative morbidity and POM after the evaluation of ≤10 vs. >10 LNs was compared among patients after adjusting for propensity scores.

Results

Multiple regression analysis showed similar POM between the two groups (OR, 1,01; 95% CI, 0,71–1,44). Other postoperative complications were similar across groups except for thromboembolic events, which were more common among patients undergoing resection of >10 LNs (OR, 1,72; 95% CI, 1,12–2,63).

Conclusions

These data suggest that evaluation of >10 LNs, which allows for more accurate staging, appears to be safe in the elderly patients undergoing lobectomy for stage I NSCLC without compromising postoperative recovery.     

Morbidity of diaphragmatic surgery for advanced ovarian cancer: Retrospective study of 148 cases

Background

Treatment of Advanced Ovarian Cancer (AOC) includes surgery with complete cytoreduction, one of the strongest prognostic factors. To achieve complete cytoreduction, diaphragmatic surgery is often required. There is currently a lack of information in the literature regarding the morbidity and impact of this type of surgery. The aim of this study is to report specific pulmonary morbidity and overall morbidity associated with diaphragmatic surgery in patients with AOC.

Materials and methods

We conducted a multicentric (6 centres), retrospective study that included 148 patients operated on between 2004 and 2008. Patient characteristics, surgical course and postoperative complications were collected.

Results

The complete cytoreduction rate was 84%. The surgery was categorised by timing as initial, interval or recurrence surgery in 38%, 51% and 11% of patients, respectively. In 69% of patients, one or more postoperative complications occurred: pulmonary complication (42%), digestive fistula (7%) or lymphocyst (18%). The pulmonary complications were pleural effusion (37%), pulmonary embolism (5%), pneumothorax (4%) and pulmonary infection (2%). These complications required revision surgery, pleural evacuation, or lymphocyst evacuation in 13%, 14%, and 11% of the cases, respectively. Postoperative mortality was 3%. Risk factors for pulmonary complications were the addition of extensive upper surgery to the diaphragmatic surgery (p = 0.014) and the size of the diaphragmatic resection (p = 0.012).

Conclusions

Diaphragmatic surgery achieved complete removal of the tumour but resulted in pulmonary complications in addition to complications of radical surgery.     

Morbidity and mortality outcomes of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with primary and recurrent advanced ovarian cancer

Background

The aim of this study is to report the perioperative outcomes of CRS and HIPEC from a single institution and review those factors that are associated with a poor perioperative outcome in patients with peritoneal dissemination from primary or recurrent ovarian cancer.

Patients and method

A retrospective cohort study setting was conducted in a third level hospital peritoneal surface malignancy program. Ninety one patients diagnosed with ovarian peritoneal carcinomatosis, primary and recurrent without extraperitoneal metastasis were included for cytoreductive surgery and HIPEC with paclitaxel. We analyzed the postoperative morbidity rates and a univariate and multivariate analysis of factors associated with overall (grade I–IV) and major (grade III–IV) postoperative morbidity were performed.

Results

Peritoneal Cancer Index (PCI) upper than 12 (OR = 2.942 95%: 1.892–9.594 p = 0.044) was an independent factor associated with the occurrence of I–IV postoperative morbidity. Regarding major complications (grade III–IV), on multivariate analysis, in addition to PCI >12 (OR = 6.692, 95% CI: 1974–45, 674, p = 0.032), the need to carry out intestinal resection (OR = 4.987, 95% CI: 1350–27, 620, p = 0.046) was an independent factor related with major morbidity (grade III–IV).

Conclusions

The use of HIPEC after aggressive cytoreductive surgery in patients with ovarian cancer with peritoneal dissemination can be performed with acceptable postoperative morbidity rates. Knowledge of the factors associated with the onset of these postoperative adverse events allows better management of the same and offers the patient a safe procedure.     

Asian perspective on debulking surgery for advanced ovarian cancer: An E-survey

PurposeWe performed an E-survey to evaluate the practice patterns in debulking surgery for advanced ovarian cancer in Asia.MethodsWe designed a questionnaire, including 50 questions related to debulking surgery for advanced ovarian cancer. The questionnaire was sent to Gynecologic Oncologic Groups in Asia from December 2016 to February 2017.ResultsA total of 253 gynecologic oncologists from Japan (58.9%), the Republic of Korea (19%), Taiwan (12.6%), and the other counties including China (7.5%), Malaysia (0.8%), Indonesia (0.8%), and Thailand (0.4%) participated in this E-survey. The median number of debulking surgeries per year was 20, and 46.8% of the respondents preferred <1 cm as the criterion for optimal debulking surgery (ODS). The most common barrier and surgical finding precluding ODS were performance status (74.3%) and disease involving the porta hepatis (71.5%). Moreover, 63.2% had a fellowship program, and only 15% or less had opportunities to receive additional training courses in general, thoracic, or urologic surgery. The median percentage of patients receiving neoadjuvant chemotherapy (NAC) was 30%, and the achieved rate of ODS in primary debulking surgery (PDS) and interval debulking surgery (IDS) was 65% and 80%, respectively. Most of the respondents required three to 6 h for PDS (48.6%) and IDS (58.9%). Moreover, more than 50% depended on ultra-radical surgery conducted by specialists.ConclusionsThe ODS criteria are relatively lenient with a preference for NAC in 30% of the respondents in Asia. This trend might be associated with the dependence on aggressive surgery performed by specialists.     

Peri-operative management of ablative and reconstructive surgery for invasive bladder cancer in the elderly

INTRODUCTION AND OBJECTIVES: Radical cystectomy and urinary diversion for muscle invasive bladder cancer is a demanding surgical procedure usually followed by a variable period of inability. It might be even more delicate in the elderly. We describe our protocol of pre, intra, and post operative management aimed at minimising the impact of bladder cancer surgery. MATERIALS AND METHODS: The patients were submitted to reduced pre-operative fasting (6-8 hours), no mechanical bowel preparation, and insertion of an epidural cannula. Intra-operative Intra-operatively the protocol included: combined anesthesia (general+epidural), controlled hypotension, correction of blood losses in excess of 10% of the estimated total blood volume, O2 supplementation and insertion of a je, junal cannula for nutrition. Post-operatively: early removal of naso-gastric tubing (2-6 hours), parenteral and enteral nutrition started ion POD1. RESULTS: The feasibility study was conducted on 18 patients, 14 males and 4 women, median age 70 years (range 55 to 82). Six patients belonged to category ASA II, and 12 to ASA III-IV. The protocol was completed by 10 patients and no completed by 8. The only step of the protocol that was not completed was the enteral nutrition that caused symptoms of bowel distension. Among the patients who completed the protocol the return of peristalsis and of normal bowel function were observed on POD 1, and POD 2, respectively, whereas, the recovery required one day more in the remaining patients. DISCUSSION: The protocol was feasible, and contributed to an accelerated recovery of intestinal function. Compliance to the protocol was independent from age. The study is ongoing for a more precise evaluation of the outcomes of the protocol.     

Impact of metformin on survival outcome in ovarian cancer: a nationwide population-based cohort study

ObjectiveInvestigation of new drugs (INDs) is a tremendously inefficient process in terms of time and cost. Drug repositioning is another method used to investigate potential new agents in well-known drugs. This study assessed the survival impact of metformin medication on ovarian cancer.MethodsA national sample cohort of the Korean National Health Insurance Service Data was analyzed. Cox proportional hazards regression was used to analyzing hazard ratios (HRs) and 95% confidence intervals (CIs) after adjusting for underlying diseases and medications as confounding factors for overall survival (OS) and cancer-specific survival (CSS).ResultsA total of 866 eligible patients were included from among 1,025,340 cohort participants. Among them, 101 (11.7%) were metformin users. No difference in OS was observed between non-users and users. No difference in OS was observed according to age and Charlson Comorbidity Index. Long-term metformin use (≥720 days) was associated with better OS (adjusted HR=0.244; 95% CI=0.090–0.664; p=0.006). A multivariate Cox proportional hazards model showed that long-term metformin use was an independent favorable prognostic factor for OS (HR=0.193; 95% CI=0.070–0.528; p=0.001) but not for CSS (HR=0.599; 95% CI=0.178–2.017; p=0.408).ConclusionLong-term metformin use reduced all-cause mortality, but not CSS in ovarian cancer. Whether metformin itself reduces deaths because of ovarian cancer requires further investigation.     

Perioperative morbidity and outcome of secondary cytoreduction for recurrent epithelial ovarian cancer

Background

Despite radical surgical and chemotherapeutic treatment of ovarian cancer, the majority of patients develop recurrent disease. Secondary cytoreductive surgery can result in favourable outcome in selected patients, but information regarding feasibility, safety and perioperative outcome of these often complex procedures is limited.

Methods

Surgical parameters in patients with recurrent epithelial ovarian cancer selected for secondary cytoreduction were analysed and compared to patients undergoing primary cytoreduction.

Results

In total, 222 patients undergoing radical cytoreduction were analysed (48 patients for relapsed disease and 174 patients at primary diagnosis of advanced ovarian cancer). The range of surgical procedures was similar in both groups. In 48% of secondary cytoreductions ‘optimal surgical results’ (residual tumour <1 cm) were obtained and 33% of the patients had no residual disease compared to 82% and 58% at primary cytoreduction. There was no significant difference in perioperative complication rates. The duration of surgery was shorter and the number of transfused blood products was smaller at secondary cytoreduction (p < 0.001 and p = 0.001).

Conclusion

Secondary cytoreduction in relapsed ovarian cancer is safe and feasible and perioperative outcome is not inferior compared to primary cytoreduction. Surgery-associated morbidity should represent a minor aspect in the selection and counselling of patients regarding treatment options for recurrent ovarian cancer.     

Factors predicting postoperative morbidity after cytoreductive surgery for ovarian cancer: a systematic review and meta-analysis

ObjectiveAdvances in ovarian cancer cytoreductive surgery have enabled more extensive procedures to achieve maximal cytoreduction but with a consequent increase in postoperative morbidity and mortality. The aim of this study was to evaluate factors for postoperative morbidity after extensive cytoreductive surgery for primary epithelial ovarian cancer (EOC), particularly those which may be modifiable.MethodsElectronic databases were searched. Meta-analysis was conducted using random-effects models.ResultsFifteen relevant studies, involving 15,325 ovarian cancer patients, were included in this review. Severe 30-day postoperative complications occurred in 2,357 (15.4%) patients. The postoperative mortality rate was 1.92%. Meta-analysis demonstrated that patient with following risk factors; age (p<0.001), Eastern Cooperative Oncology Group score >0 (p=0.001), albumin level <3.5 g/dL (p<0.001), presence of ascites on CT scan (p=0.013), stage IV disease (p<0.001) and extensive surgical procedure (p<0.001) has a significantly increase risk of developing postoperative complications. Surgical procedures including peritonectomy (p=0.012), splenectomy (p<0.001) and colon surgery (p<0.001) were significant predictors for postoperative complications. Moreover, we found that patients who received neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) had a lower risk of developing severe complications compared to those who underwent primary debulking surgery (PDS) (p<0.001).ConclusionOur study demonstrated that patient performance status and hypoalbuminemia were the only significant adjustable preoperative risk factors associated with postoperative complications. Patients who underwent NACT-IDS had a lower risk of developing severe complications compared to PDS.Trial RegistrationInternational Prospective Register of Systematic Reviews (PROSPERO) Identifier: CRD42021282770     

Lymphocele and ovarian cancer: risk factors and impact on survival

Introduction. We describe the incidence, impact on survival, and the risk factors for symptomatic lymphoceles in patients with ovarian cancer. Methods. This retrospective study includes patients with ovarian cancer who had complete cytoreductive surgery and para-aortic and pelvic lymphadenectomy performed in our institute from 2005 to 2011. Patients were classified into two groups: patients with symptomatic lymphoceles and a control group. Results. During the study period, 194 patients with epithelial ovarian cancer underwent cytoreductive surgery and a lymphadenectomy without macroscopic residual disease. Fifty-four patients had symptomatic lymphoceles (28%). In the multivariate analysis, only supraradical surgery was significantly and independently associated with the risk of symptomatic lymphoceles occurring postoperatively. Median follow-up was 24.8 months (range, 1-74 months). Survival rates were not significantly different between the symptomatic lymphocele group and the control group. Two-year disease-free survival rates were 54% for the lymphocele group and 48% for the control group. Two-year overall survival rates were 90% for the lymphocele group and 88% for the control group. Conclusions. Symptomatic lymphoceles occur frequently after cytoreductive surgery in ovarian cancer. Supraradical surgery is an independent risk factor. The occurrence of symptomatic lymphoceles does not decrease survival. Nevertheless, further studies are needed to reduce the risk of lymphoceles in such patients.     

Outcomes and patterns of secondary relapse in platinum-sensitive ovarian cancer: Implications for tertiary cytoreductive surgery

Aim

To evaluate the outcomes and patterns of patients with secondary relapsed ovarian cancer.

Methods

A retrospective study was conducted. The cases comprised 83 patients who underwent tertiary cytoreductive surgery (TCS) followed by chemotherapy, whereas the controls consisted of 76 patients who received chemotherapy alone.

Results

The median survival was 20 months in 159 patients. Patients with microscopic residual disease after TCS had a median survival of 32.9 months compared with 14.6 months in those with macroscopic residual disease [hazard ratio (HR), 2.82; P = 0.001) and 15.0 months in patients with chemotherapy alone (HR, 2.23; P = 0.001). When stratified by a progression-free interval (PFI) after secondary cytoreduction (SCR), TCS showed no benefit in patients with a PFI ≤12 months or a PFI >12 months compared with those with chemotherapy alone. TCS improved survival in patients with recurrent disease in the pelvis compared with those with recurrent disease in the middle or upper abdomen, with a median survival of 34.9 months and 14.6 months, respectively (HR, 2.94; P = 0.010). However, TCS was not a survival determinant by multivariate analysis. A multivariate analysis identified a PFI after SCR (≤12 mos vs. >12 mos; HR, 2.34; 95% CI, 1.29–4.24; P = 0.005), mesenteric lymph node metastasis at SCR (yes vs. no; HR, 4.18; 95% CI, 1.93–9.03; P < 0.001) and treatment arms at secondary relapse (chemotherapy alone vs. TCS; HR, 1.56; 95% CI, 1.03–2.38; P = 0.037) as independent predictors of survival.

Conclusions

Limited survival benefit from tertiary cytoreductive surgery was observed in patients with platinum-sensitive secondary relapsed ovarian cancer.     

Systematic review of laparoscopic vs open surgery for colorectal cancer in elderly patients

AIM: To verify the safety and validity of laparoscopic surgery for the treatment of colorectal cancer in elderly patients. METHODS: A meta-analysis was performed of a systematic search of studies on an electronic database. Studies that compared laparoscopic colectomy (LAC) in elderly colorectal cancer patients with open colectomy (OC) were retrieved, and their short and long-term outcomes compared. Elderly people were defined as 65 years old or more. Inclusion criteria were set at: Resection of colorectal cancer, comparison between laparoscopic and OC and no significant difference in backgrounds between groups. RESULTS: Fifteen studies were identified for analysis. LAC was performed on 1436 patients, and OC performed on 1810 patients. In analyses of short-term outcomes, operation time for LAC was longer than for OC (mean difference = 34.4162, 95%CI: 17.8473-50.9851, P < 0.0001). The following clinical parameters were lower in LAC than in OC: Amount of estimated blood loss (mean difference = -93.3738, 95%CI: -132.3437 to -54.4039, P < 0.0001), overall morbidity (OR = 0.5427, 95%CI: 0.4425-0.6655, P < 0.0001), incisional surgical site infection (OR = 0.6262, 95%CI: 0.4310-0.9097, P = 0.0140), bowel obstruction and ileus (OR = 0.6248, 95%CI: 0.4519-0.8638, P = 0.0044) and cardiovascular complications (OR = 0.4767, 95%CI: 0.2805-0.8101, P = 0.0062). In analyses of long-term outcomes (median follow-up period: 36.4 mo in LAC, 34.3 mo in OC), there was no significant difference in overall survival (mean difference = 0.8321, 95%CI: 0.5331-1.2990, P = 0.4187) and disease specific survival (mean difference = 1.0254, 95%CI: 0.6707-1.5675, P = 0.9209). There was also no significant difference in the number of dissected lymph nodes (mean difference = -0.1360, 95%CI: -4.0553-3.7833, P = 0.9458). CONCLUSION: LAC in elderly colorectal cancer patients had benefits in short-term outcomes compared with OC except operation time. The long-term outcomes and oncological clearance of LAC were similar to that of OC. These results support the assertion that LAC is an effective procedure for elderly patients with colorectal cancer.     

Doublet Chemotherapy in the Elderly Patient With Ovarian Cancer

The aging of the population has focused on the need to evaluate older patients with cancer. Approximately 50% of patients with ovarian cancer will be older than age 65 years. Increasing age has been associated with decreased survival. It is uncertain whether this relates to biologic factors, treatment factors, or both. There is concern that undertreatment may be associated with decreased survival. Older patients with ovarian cancer have been underrepresented in clinical trials. Therefore, the evidence base on which make decisions is lacking. Clinicians need to be aware of the currently available data to aid in treatment decisions. Doublet therapy is the most common standard treatment in epithelial ovarian cancer. It usually consists of a taxane and a platinum compound. A series of cooperative group studies in both the United States and Europe established intravenous paclitaxel and carboplatin as the most common standard in optimally debulked patients. The recent introduction of intraperitoneal therapy has complicated decision making in terms of which older patients would benefit from this more toxic therapy. In relapsed patients, the issue of platinum sensitivity is critical in deciding whether to reutilize platinum compounds. It is unclear whether single agents or combinations are superior, particularly in older patients. Geriatric assessment is an important component of decision making. Prospective studies are needed to develop strategies to determine the optimal treatment for older patients with ovarian cancer.     

外科治疗70岁以上老年肺癌患者的预后因素分析

背景与目的随着手术和麻醉技术的提高,越来越多的老年肺癌患者接受手术治疗。本研究的目的是探讨70岁以上老年肺癌患者术后生存情况及其影响因素,为老年肺癌的治疗提供依据。方法回顾性分析192例手术治疗的70岁以上老年肺癌患者的术后生存情况,采用单因素和多因素方法分析各种预后因素的影响度。结果全组总的5年生存率为33.5%。手术方式、手术性质、病理类型及分期均可显著影响患者的预后,其中后三者为独立预后因素。结论老年肺癌患者术前应全面检查,尽量避免单纯探查手术和姑息手术。手术以肺叶切除为标准术式,某些特殊情况下,也可行部分肺叶切除术。     

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2–3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non‐operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum‐assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.     

Distal pancreatectomy with splenectomy for the management of splenic hilum metastasis in cytoreductive surgery of epithelial ovarian cancer

ObjectiveDistal pancreatectomy with splenectomy may be required for optimal cytoreductive surgery in patients with epithelial ovarian cancer (EOC) metastasized to splenic hilum. This study evaluates the morbidity and treatment outcomes of the uncommon procedure in the management of advanced or recurrent EOC.MethodsThis study recruited 18 patients who underwent distal pancreatectomy with splenectomy during cytoreductive surgery of EOC. Their clinicopathological characteristics and follow-up data were retrospectively analyzed.ResultsAll tumors were confirmed as high-grade serous carcinomas. The median diameter of metastatic tumors located in splenic hilum was 3.5 cm (range, 1 to 10 cm). Optimal cytoreduction was achieved in all patients. Eight patients (44.4%) suffered from postoperative complications. The morbidity associated with distal pancreatectomy and splenectomy included pancreatic leakage (22.2%), encapsulated effusion in the left upper quadrant (11.1%), intra-abdominal infection (11.1%), pleural effusion with or without pulmonary atelectasis (11.1%), intestinal obstruction (5.6%), pneumonia (5.6%), postoperative hemorrhage (5.6%), and pancreatic pseudocyst (5.6%). There was no perioperative mortality. The majority of complications were treated successfully with conservative management. During the median follow-up duration of 25 months, nine patients experienced recurrence, and three patients died of the disease. The 2-year progression-free survival and overall survival were 40.2% and 84.8%, respectively.ConclusionThe inclusion of distal pancreatectomy with splenectomy as part of cytoreduction for the management of ovarian cancer was associated with high morbidity; however, the majority of complications could be managed with conservative therapy.     

老年结直肠癌患者腹腔镜手术中快速康复理念应用的价值

目的探讨老年结直肠癌患者腹腔镜手术中快速康复理念应用的价值。方法 2012年1月至2014年1月收治的50例老年结直肠癌患者,依据随机数字表法将分为快速康复组和对照组,每组25例。结果快速康复组患者的下地时间、排气时间、排便时间、饮水时间、住院时间均明显低于对照组(P<0.05),但两组患者的麻醉时间、手术时间、术中出血量、清扫淋巴结数目间的差异均无统计学差异(P>0.05)。快速康复组患者术后并发症发生率为8%(2/25),对照组为28%,差异有统计学意义(P<0.05)。结论老年结直肠癌患者腹腔镜手术中快速康复理念具有较高的应用价值。     

Colorectal cancer screening: Systematic review of screen-related morbidity and mortality

BackgroundImplementation of mass colorectal cancer screening, using faecal occult blood test or colonoscopy, is recommended by the European Union in order to increase cancer-specific survival by diagnosing disease in an earlier stage. Post-colonoscopy complications have been addressed by previous systematic reviews, but morbidity of colorectal cancer screening on multiple levels has never been evaluated before.AimTo evaluate potential harm as a result of mass colorectal cancer screening in terms of complications after colonoscopy, morbidity and mortality following surgery, psychological distress and inappropriate use of the screening test.MethodsA systematic review of all literature on morbidity and mortality attributed to colorectal cancer screening, using faecal occult blood test or colonoscopy, from each databases’ inception to August 2016 was performed. A meta-analysis was conducted to examine the pooled incidence of major complications of colonoscopy (major bleedings and perforations).ResultsSixty studies were included. Five out of seven included prospective studies on psychological morbidity reported an association between participation in a colorectal screening program and psychological distress. Serious morbidity from colonoscopy in asymptomatic patients included major bleedings (0.8/1000 procedures, 95% CI 0.18–1.63) and perforations (0.07/1000 procedures, 95% CI 0.006–0.17).ConclusionsParticipation in a colorectal cancer screening program is associated with psychological distress and can cause serious adverse events. Nevertheless, the short duration of psychological impact as well as the low colonoscopy complication rate seems reassuring. Because of limited literature on harms other than perforation and bleeding, future research on this topic is greatly needed to contribute to future screening recommendations.     

Rectosigmoid resection during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer: morbidity of gynecologic oncology vs. colorectal team

ObjectiveThis study investigates the specific morbidity of rectosigmoid resection (RSR) during Visceral-Peritoneal Debulking (VPD) in a consecutive series of patients with stage IIIC-IV ovarian cancer and compares the results of the colo-rectal vs. the gynaecologic oncology team.MethodsAll patients with the International Federation of Gynecology and Obstetrics (FIGO) stage IIIC–IV ovarian cancer who had VPD and RSR were included in the study. Between 2009 and 2013 all operations were performed by the gynecologic oncology team alone (group 1). Since 2013 the RSR was performed by the colorectal team together with the gynecologic oncologist (group 2). All pre-operative information and surgical details were compared to exclude significant bias. Intra- and post-operative morbidity events were recorded and compared between groups.ResultsOne hundred and sixty-two patients had a RSR during VPD, 93 in group 1 and 69 in group 2. Groups were comparable for all pre-operative features other than: albumin (1<2) hemoglobin (2<1) and up-front surgery (1>2). Overall morbidity was 33% vs. 40% (p=0.53), bowel specific morbidity 11.8% vs. 11.5% (p=0.81), anastomotic leak 4.1% vs. 6.1% (p=0.43) and re-operation rate 9.6% vs. 6.1% (p=0.71) in groups 1 and 2, respectively. None of them were significantly different. The rate of bowel diversion was 36.5% in group 1 vs. 46.3% in group 2 (p=0.26).ConclusionsOur study failed to demonstrate any significant difference in the morbidity rate of RSR based on the team performing the surgery. These data warrant further investigation as they are interesting with regards to education, finance, and medico-legal aspects.     

Colorectal cancer surgery in elderly patients 80 years and older: a comparison with younger age groups

BackgroundA reduction in complications and mortality can be observed over the last few decades among elderly patients in the early postoperative period for colorectal cancer (CRC) surgery, but long-term outcomes are largely unknown. This study aimed to investigate the long-term outcomes of elderly patients 80 years and older after CRC surgery in comparison with younger age groups. The influence of clinical, oncological, and physical parameters on outcome were retrospectively analyzed.MethodsA total of 346 patients underwent CRC surgery with curative intent between January 2013 and December 2017. Patients were divided into three age groups: younger than 60 (n=47), between 60 and 79 (n=218), and 80 and older (n=81). Clinicopathological variables including comorbidity, modified frailty index, prognostic nutrition index (PNI), operative/postoperative data, and outcome including cause of death were compared among age groups. To identify factors associated with death from CRC and other causes, univariate and multivariate analyses using the Cox proportional hazards model were performed.ResultsImmediate postoperative morbidity of patients with Clavien-Dindo grades of III or greater (16.0%) and the 30-day mortality rate (2.5%) of patients 80 years and older were not statistically different from those of younger age groups. Long-term disease-free survival was also similar among age groups, suggesting CRC surgery provides oncological benefit to patients irrespective of age. Multivariate analysis revealed that R1 resection, advanced tumor stage, carcinoembryonic antigen (CEA) level of >5 ng/mL, undifferentiated tumor, and longer postoperative hospital stay were risk factors for CRC death. Long-term overall survival was significantly reduced in comparison to younger age groups. Seventy percent of deaths in elderly patients during follow-up were primarily from respiratory failure and cardiovascular disease. Multivariate analysis demonstrated that advanced age, frailty, low PNI, and open procedure were risk factors for other causes of mortality.ConclusionsElderly patients undergoing CRC surgery appeared to enjoy similar oncological benefits as younger age groups. Since both modified frailty index and PNI were correlated with mortality unrelated to CRC, preoperative assessment of these factors can be important for predicting outcome and selecting patients for prehabilitation.     

Douglas peritonectomy compared to recto-sigmoid resection in optimally cytoreduced advanced ovarian cancer patients: analysis of morbidity and oncological outcome

Background

Rectosigmoidectomy (RR) with primary anastomosis or pelvic peritonectomy (PP) are often part of an optimal en bloc tumor resection in advanced ovarian cancer (AOC) patients with contiguous extension to or encasement of the reproductive organs, peritoneum of the cul-de-sac and sigmoid colon. We report our experience with two different surgical approaches in optimally cytoreduced AOC patients evaluating oncologic outcome and surgically associated morbidities

Methods

Data from all consecutive AOC patients undergoing PP or RR as part of the surgical procedure during primary cytoreduction from 2004 through 2009 were extrapolated and analyzed using the chi-squared test, Cox proportional hazard model and Kaplan-Meier method including log-rank test.

Results

During the study period, we identified 187 AOC patients, fitting the inclusion criteria: 71 (38%) were submitted to RR and 116 (62%) were managed with PP. The estimated mean disease-free survival (DFS) was 30.7 months (95% CI 24.6-36.8) in the RR arm vs. 25.9 months in the PP arm (95% CI 21.9-29.9) (p 0.299); similarly, the estimated mean overall survival (OS) was 38.8 months (95% CI 33.4-44.2) in the RR arm and 48.2 months in the PP arm (95% CI 43.1-53.3) (p = 0.122). No statistically significant differences were found in terms of DFS and OS according to the mesocolic lymphnode status (p = 0.65 and p = 0.81, respectively).

Conclusions

In conclusion, the current study clearly supports evidence that survival rates are similar for patients who achieved optimal residual tumor (RT), independent to whether they had RR or PP.