Perioperative characterization of anastomotic doughnuts with high-resolution probe-based confocal laser endomicroscopy in colorectal cancer surgery: a feasibility study

Background

Confocal laser enables in vivo real-time histopathology of the mucosa layer of gastrointestinal tract. The aim of this study was to assess the feasibility and the role of probe-based confocal laser endomicroscopy in extemporary examination of staple rings of patients with colorectal cancer.

Methods

This was a prospective, single-center pilot study. Patients who underwent end-to-end stapled surgical resection for colorectal cancer were included. Confocal imaging was analyzed with great attention to image quality evaluation of cellular morphology and cellular structures of the serosal, muscular, and mucosal layers of the doughnuts than comparing results with definitive histopathology.

Results

Twenty-six doughnuts were analyzed. Real-time video sequences were obtained in all patients, with a total of 204 mosaic images. For each doughnut, most of the images were adequate for evaluation of cellular morphology and cellular structure of the serosal, muscular, and mucosal layers.

Conclusions

Perioperative assessment of doughnut tissues in patients with colorectal cancer by confocal laser endomicroscopy is feasible and safe. Prospective studies are warranted for further evaluation of the clinical impact of this technology during surgery.     

Retrospective cohort study of an enhanced recovery programme in oesophageal and gastric cancer surgery

Introduction

Enhanced recovery programmes have been established in some areas of elective surgery. This study applied enhanced recovery principles to elective oesophageal and gastric cancer surgery.

Methods

An enhanced recovery programme for patients undergoing open oesophagogastrectomy, total and subtotal gastrectomy for oesophageal and gastric malignancy was designed. A retrospective cohort study compared length of stay on the critical care unit (CCU), total length of inpatient stay, rates of complications and in-hospital mortality prior to (35 patients) and following (27 patients) implementation.

Results

In the cohort study, the median total length of stay was reduced by 3 days following oesophagogastrectomy and total gastrectomy. The median length of stay on the CCU remained the same for all patients. The rates of complications and mortality were the same.

Conclusions

The standardised protocol reduced the median overall length of stay but did not reduce CCU stay. Enhanced recovery principles can be applied to patients undergoing major oesophagogastrectomy and total gastrectomy as long as they have minimal or reversible co-morbidity.     

Intrasaccular caecal adenocarcinoma presenting as enlarging right inguinoscrotal hernia

INTRODUCTION

Colorectal cancer and inguinal hernias are both common surgical pathologies in the elderly but rarely co-exist. Where the conditions overlap, there can be difficulties in both diagnosis and treatment.

PRESENTATION OF CASE

A 78 year old man with unexplained iron deficiency anaemia was investigated for gastrointestinal cancer. He was found to have enlarging bilateral inguinoscrotal hernias. CT colonoscopy revealed a herniated caecal carcinoma contained within the scrotum. An open excision was performed.

DISCUSSION

Iron deficiency anaemia without obvious bleeding is associated with colorectal cancer and should be thoroughly investigated. Asymptomatic inguinal hernias are often ignored by patients. However, a change in an existing hernia may be associated with neoplasia.

CONCLUSION

Dual pathology raises new difficulties in assessment, investigation and management of colorectal cancer.     

The efficacy of adjuvant imatinib therapy in improving the prognosis of patients with colorectal gastrointestinal stromal tumourss

Introduction

Although it has now been accepted that imatinib is a valid treatment for gastrointestinal stromal tumour (GIST) patients in the adjuvant setting, information on its clinical efficacy in improving the prognosis for patients with colorectal GISTs is limited.

Methods

The clinical and follow-up records of 42 colorectal GIST patients who underwent surgical resection at our institution between January 2004 and December 2013 were reviewed retrospectively. The effect of postoperative imatinib treatment on recurrence free survival and overall survival time was analysed with the Kaplan–Meier method and the multivariate Cox proportional hazards model.

Results

Sixteen patients were assigned to imatinib treatment (imatinib group) after surgical tumour resection while twenty-six patients did not receive any adjuvant treatment (control group). The one, three and five-year recurrence free survival rates were 100%, 90% and 77% respectively. This was significantly higher than in the control group (92%, 53% and 36%) (logrank test, p=0.012). The one, three and five-year overall survival rates were 100%, 91% and 68% in the imatinib group compared with 96%, 77% and 39% in the control group (logrank test, p=0.021). Analysis with the multivariate Cox regression model yielded similar results on the efficacy of adjuvant imatinib in prolonging both recurrence free survival (hazard ratio [HR]: 0.23, 95% confidence interval [CI]: 0.07–0.80) and overall survival (HR: 0.20, 95% CI: 0.05–0.91).

Conclusions

Adjuvant imatinib therapy seems to be effective in decreasing the risk of tumour occurrence and prolonging the overall survival time in colorectal GIST patients.     

Impact of conversion on short and long-term outcome in laparoscopic resection of curable colorectal cancer

Introduction:

Long-term outcome of patients following conversion during laparoscopic surgery for colorectal cancer is not often reported. Recent data suggest a negative impact of conversion on long-term survival. This study aimed to evaluate the impact of conversion on the perioperative outcome and on long-term survival in patients who underwent laparoscopic resection for curable colorectal cancer.

Methods:

Evaluation of our prospective in-hospital collected data of patients who underwent laparoscopic surgery for curable colorectal cancer over a 5-year period. Long-term data were collected from our outpatient''s clinic data and personal contact when necessary.

Results:

During the study period, 175 patients were operated on laparoscopically for curable colon cancer (stage I-III). Mean follow-up was 33±18 months with a minimum follow-up of 12 months. For various reasons, 25 patients (14.4%) had to be converted to open surgery. Short-term outcome revealed a trend towards longer operations, a higher rate of surgical complications, and a longer hospital stay in the converted group. Five-year, Kaplan-Meier, disease-free analysis was worse for converted patients. Overall survival did not differ between the 2 groups. Cox proportional hazards regression analysis revealed that conversion and AJCC stage were independent risk factors for recurrence.

Conclusions:

Conversion in laparoscopic surgery for curable colorectal cancer is associated with a worse perioperative outcome and worse disease-free survival.     

Size of metastatic deposits affects prognosis in patients undergoing pulmonary metastectomy for colorectal cancer

INTRODUCTION

Pulmonary metastectomy for colorectal cancer (CRC) is a well accepted procedure although data regarding indications and prognostic outcomes are inconsistent. This study aimed to analyse our experience with resection of pulmonary CRC metastases to evaluate clinically relevant prognostic factors affecting survival.

METHODS

A retrospective analysis was undertaken of the records of all patients with pulmonary metastases from CRC who underwent a thoracotomy between 2004 and 2010 at a single surgical centre.

RESULTS

Sixty-six patients with pulmonary metastases from the colon (n=34) and the rectum (n=32) were identified. The 30-day hospital mortality rate was 0%, with 63 patients undergoing a R0 resection and 3 having a R1 resection. The median survival was 45 months and the cumulative 3-year survival rate was 61%. Size of pulmonary metastasis and ASA (American Society of Anesthesiologists) grade were statistically significant prognostic factors (p=0.047 and p=0.009 respectively) with lesions over 20mm associated with a worse prognosis. Sex, age, site, disease free interval (cut-off 36 months), primary tumour stage, hepatic metastases, number of metastases (solitary vs multiple), type of operation (wedge vs lobe resection), hilar lymph node involvement and administration of adjuvant chemotherapy were not found to be statistically significant prognostic factors.

CONCLUSIONS

Pulmonary metastectomy has a potential survival benefit for patients with metastatic CRC. Improved survival even in the presence of hepatic metastases or multiple pulmonary lesions justifies aggressive surgical management in carefully selected patients. In our cohort, size of metastatic deposit was a statistically significant poor prognostic factor.     

Information on the Internet about colorectal cancer: patient attitude and potential toward Web browsing. A prospective observational study

Background

Patients with colorectal cancer who seek to improve their knowledge of health and treatment options can now access in a few seconds data that would previously have required hours of research. Our aim was to evaluate the attitudes of patients toward Web browsing for information on colorectal cancer.

Methods

We surveyed all patients attending a colorectal cancer follow-up clinic between January and August 2007 on their use of the Internet to obtain information on colorectal cancer.

Results

In all, 439 patients with mean age of 68.6 years participated in the study. Of these, 24% reported using the Internet to obtain colorectal cancer information. Most participants used the Google search engine. Only 13% of participants confirmed that colorectal cancer information on the Internet was helpful in decision-making. Patients under the age of 65 years were more likely to have Internet access (p < 0.001), more likely to use the Internet to find colorectal cancer information (p = 0.005) and more likely to access a site recommended by a colorectal specialist (p = 0.002). Among Internet users, men were slightly more likely than women to use the Internet, although the difference was not significant (p = 0.20).

Conclusion

The Internet is a useful tool for disseminating information about colorectal cancer. The best sites are still difficult for patients to distinguish from the thousands of sites returned by search engines. This study demonstrates that the level of potential interest is sufficient to justify the development of a departmental or regional colorectal cancer network of websites and indicates areas of interest for patients.     

Prognostic value of lymph node ratio in survival of patients with locally advanced rectal cancer

Background

The lymph node ratio (LNR) has been shown to be an important prognostic factor in patients with gastric, breast, pancreatic and colorectal cancer. We investigated the prognostic impact of the LNR in addition to TNM classification in patients with locally advanced rectal cancer.

Methods

We retrospectively analyzed patients who underwent curative resection for locally advanced rectal cancer between July 2005 and December 2010. We determined the LNR cutoff value using a receiver operating characteristic curve. The Kaplan–Meier method was used to estimate survival curves, while Cox regression analyses were used to evaluate the relationship between LNR and survival.

Results

We included 180 patients aged 28–83 years with median follow-up of 41.8 months. The median number of lymph nodes examined and lymph nodes involved were 11.5 and 4, respectively, and the median LNR was 0.366. An LNR of 0.19 (19%) was the cutoff point to separate patients with regard to median overall survival. Median overall survival was 64.2 months for patients with an LNR of 0, 59.1 for an LNR of 0.19 or less and 37.6 for an LNR greater than 0.19 (p = 0.004). The median disease-free survival was 32.9 months for patients with an LNR of 0, 30.4 for an LNR of 0.19 or less and 17.8 for an LNR greater than 0.19 (p = 0.002).

Conclusion

Our results suggest that LNR should be considered an additional prognostic factor in patients with locally advanced rectal cancer.     

Should We Pursue Patients Who Fail to Attend Colorectal Clinics? A 9-Year Study

INTRODUCTION

No uniform protocol exists on how to deal with patients who fail to attend colorectal clinics. Our aim was to identify whether the tendency to ‘failure to attend’ (FTA) in the colorectal clinic was associated with FTA in other clinics and also whether FTA patients have serious pathology.

PATIENTS AND METHODS

This was a retrospective study of a prospectively recorded list of FTA patients, in colorectal urgent or two-week wait clinics from 1996–2004.

RESULTS

A total of 151 patients, who failed to attend their first appointment, were included in the study. Of these, 61 (40.4%) were colorectal referrals, 76 (50.3%) were general surgical referrals, and for 14 (9.3%) case notes were not available. There were 59 FTA episodes in 61 colorectal patients associated with 59 FTA episodes in other clinics (Pearson correlation: r = 0.411; P = 0.01, two-tailed, SPSS v.12). Of 58 colorectal outcomes, five (8.6%) colorectal cancers (CRC) were diagnosed, 23 (39.6%) were persistent non-attendees, 16 (27.5%) had benign colorectal pathology, two (3.4%) benign non-colorectal outcomes and 12 (20.6%) normal outcomes.

CONCLUSIONS

Tendency to FTA is habitual. Care needs to be exercised in the management of FTAs to avoid delayed presentation of colorectal cancer.     

FIRST BRAZILIAN CONSENSUS ON MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 1: PRE-TREATMENT EVALUATION

Background

: Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients with these tumors.

Aim

: In this module, was contextualized the clinical situations and parameterized epidemiological data and results of the various treatment modalities established.

Method:

Was realized deep discussion on detecting and staging metastatic colorectal cancer, as well as employment of imaging methods in the evaluation of response to instituted systemic therapy.

Results

: The next step was based on the definition of which patients would have their metastases considered resectable and how to expand the amount of patients elegible for modalities with curative intent.

Conclusion

: Were presented clinical, pathological and molecular prognostic factors, validated to be taken into account in clinical practice.     

Rett syndrome with colon cancer presented with sigmoid volvulus: Report of a case

INTRODUCTION

Rett syndrome is a progressive neurodevelopment disorder in which MECP gene mutations are responsible and might be related to cancer.

PRESENTATION OF CASE

A 22 year-old girl with Rett syndrome was hospitalized for abdominal distention and shock. Abdominal tenderness and distention were revealed in physical examination. Radiological investigations revealed sigmoid volvulus and colonic obstruction. Sigmoid volvulus, sigmoid colon perforation due to sigmoid cancer with liver metastasis were observed at laparotomy. Hartman procedure performed. The patient died on the second postoperative day.

DISCUSSION

Rett syndrome has several gastrointestinal pathologies related with inadequate parasympathetic control. Genetic mutations in methyl-CpG-binding protein 2 (MECP2) which has role in several cancer mechanisms is the reason of Rett syndrome. Colon cancer with the underlying gastrointestinal pathologies complicated our case.

CONCLUSION

Rett syndrome patients need a high level of concern for gastrointestinal emergencies with cancer risk.     

Choroidal metastasis from early rectal cancer: Case report and literature review

INTRODUCTION

Choroidal metastasis from colorectal cancer is rare, and there have been no reported cases of such metastasis from early colorectal cancer. We report a case of choroidal metastasis from early rectal cancer.

PRESENTATION OF CASE

A 61 year-old-man experienced myodesopsia in the left eye 2 years and 6 months after primary rectal surgery for early cancer, and was diagnosed with left choroidal metastasis and multiple lung metastases. Radiotherapy was initiated for the left eye and systemic chemotherapy is initiated for the multiple lung metastases. The patient is living 2 years and 3 months after the diagnosis of choroidal metastasis without signs of recurrence in the left eye, and continues to receive systemic chemotherapy for multiple lung metastases.

DISCUSSION

Current literatures have few recommendations regarding the appropriate treatment of choroidal metastasis from colorectal cancer, but an aggressive multi-disciplinary approach may be effective in local regression.

CONCLUSION

This is the first report of choroidal metastasis from early rectal cancer. We consider it important to enforce systemic chemotherapy in addition to radiotherapy for choroidal metastasis from colorectal cancer.     

Long-term survival after hepatic cryosurgery versus surgical resection for metastatic colorectal carcinoma: a critical review of the literature

Objective

To critically assess the evidence for long-term survival after hepatic resection and hepatic cryosurgery for metastatic colorectal cancer. The purpose of this review is to determine if a randomized controlled trial comparing these two treatment modalities is justified.

Data sources

A review of the medical literature from 1973 to 1995 using the MEDLINE and CAN-CERLIT databases. References were also retrieved from the bibliographies of identified articles and from experts in the field of hepatobiliary and pancreatic surgery.

Study selection

One hundred and seventy-eight studies were reviewed. Studies presenting original data on the results of hepatic resection or cryotherapy for colorectal liver metastases were selected. Studies were excluded if they did not present survival data longer than 2 years. Studies pertaining to resection for fewer than 60 patients with colorectal metastases to the liver were excluded.

Data extraction

Data forms were designed before studies were examined in detail. All studies that met the inclusion and exclusion criteria were reviewed and the identified data extracted and tabulated.

Data synthesis

No controlled studies were identified, only case series. Four reports on hepatic cryosurgery and 9 on hepatic resection met the study criteria. The cryosurgery studies were methodologically poor; the resection studies were larger and more methodologically sound. The median follow-up for cryosurgery ranged from 12 to 28.8 months, that for resection 21 to 69 months. There is clear evidence that hepatic cryosurgery has a role in the management of selected patients with colorectal metastases to the liver. However, valid conclusions cannot be made about the 5-year survival rate. The results of the studies on hepatic resection in patients with colorectal metastases to the liver have greater validity and consistency, with 5-year survival rates of 20% to 40%.

Conclusions

Although hepatic cryosurgery offers some unequivocal and other potential advantages over surgical resection for colorectal metastases to the liver, the published data do not support its use in patients with resectable disease outside a clinical trial, and do not yet justify a randomized trial. A study that collects prospective data on 2 groups of patients (resectable v. unresectable) who differ only in the anatomic location of their metastases within the liver is needed.     

22-year longitudinal study of repetitive colonoscopy in patients with a family history of colorectal cancer

Introduction

We report the outcomes of a long-term surveillance programme for individuals with a family history of colorectal cancer.

Methods

The details of patients undergoing a colonoscopy having been referred on the basis of family history of colorectal cancer were entered prospectively into a database. Further colonoscopy was arranged on the basis of the findings. The outcomes assessed included incidence of cancer and adenoma identification at initial and subsequent colonoscopy.

Results

The records of 2,293 patients (917 men; median patient age: 51 years) were entered over 22 years, giving data on 3,982 colonoscopies. Eight adverse events (0.2%) were recorded. Twenty-seven cancers were found at first colonoscopy and thirteen developed during the follow-up period. There were significantly more cancers identified in those with more than one first-degree relative with cancer than in other groups (p=0.01). The number of adenomas identified at subsequent surveillance colonoscopies remained constant with between 9.3% and 12.0% of patients having adenomas that were removed. Two-thirds (68%) of patients with cancer and three-quarters (77%) with adenomas fell outside the British Society of Gastroenterology (BSG) 2006 guidelines.

Conclusions

Repeated colonoscopy continues to yield significant pathology including new cancers. These continue to occur despite removal of adenomas at prior colonoscopies. The majority of patients with cancers and adenomas fell outside the BSG 2006 guidelines; more would have fallen outside the 2010 guidelines.     

Prophylactic mesh placement of permanent stomas at index operation for colorectal cancer

INTRODUCTION

Parastomal herniation occurs in 30–50% of colostomy formations. The aim of this study was to radiologically evaluate the mechanical defects at stoma sites in patients who had previously undergone a permanent colostomy with or without mesh at the index operation for colorectal cancer.

METHODS

A study was performed of all colorectal cancer patients (n=41) having an end colostomy between 2002 and 2010, with or without Prolene® mesh plication, with blinded evaluation of the annual follow-up staging computed tomography (CT) for stomal characteristics. The presence of parastomal hernias, volume, dimensions, grade of the parastomal hernia and abdominal wall defect size were measured by two independent radiologists, and compared with demographic and operative variables.

RESULTS

In those patients with radiological evidence of a parastomal hernia, Prolene® mesh plication significantly reduced the incidence of bowel containing parastomal hernias at one year following the procedure (p<0.05) and also reduced the diameter of the abdominal wall defect (p=0.006).

CONCLUSIONS

Prophylactic mesh placement at the time of the index procedure reduces the diameter of abdominal wall aperture and the incidence of parastomal hernias containing bowel. Future studies should use both objective radiological as well as clinical endpoints when assessing parastomal hernia development with and without prophylactic mesh.     

Facilitating Intracorporeal Colorectal Anastomoses

Background and Objectives:

An experimental study was undertaken to evaluate whether a previously described technique for laparoscopic sigmoid resection with intracorporeal resection-anastomosis and specimen removal via a suprapubic incision could be facilitated and applied to the rectum.

Methods:

Ten domestic pigs (median weight 41 kg) underwent low anterior resection of the rectum, which was transected with an articulating endoscopic stapler. Pursestring sutures were fashioned intracorporeally with a laparoscopic pursestring clamp. The anvil of a circular stapler was inserted through a 33 mm port into the colon and pursestring tied intracorporeally. A circular gun with a spike fixed to its shaft was introduced per anum and a double-stapled anastomosis performed.

Results:

Complete doughnuts were obtained in all cases and anastomoses were all methylene blue tight. All porcine subjects had an uneventful 5-week postoperative course. The median anastomotic level from the anal verge was 5.2 cm. Histology of colorectal anastomoses revealed healing mucosa.

Conclusions:

The use of articulating endoscopic stapler, laparoscopic pursestring clamp, and circular stapler with a spike fixed to its shaft seems to facilitate a previously described intracorporeal approach to sigmoid resection which was safely applied to the rectum in a porcine model.     

ASSOCIATION BETWEEN HUMAN PAPILLOMAVIRUS AND COLORECTAL ADENOCARCINOMA AND ITS INFLUENCE ON TUMOR STAGING AND DEGREE OF CELL DIFFERENTIATION

Background

Colorectal cancer is one of the most common types of neoplasia among the worldwide adult population. Among neoplasms of the gastrointestinal tract, it is ranked second in relation to prevalence and mortality, but its etiology is only known in around 5% of the cases. It is believed that 15% of malignant diseases are related to viral oncogenesis.

Aim

To correlate the presence of HPV with the staging and degree of cell differentiation among patients with colorectal adenocarcinoma.

Methods

A retrospective case-control study was conducted on 144 patients divided between a test group of 79 cases of colorectal cancer and a control group to analyze 144 patients aged 25 to 85 years (mean, 57.85 years; standard deviation, 15.27 years and median, 58 years). Eighty-six patients (59.7%) were male. For both groups, tissue samples from paraffin blocks were subjected to DNA extraction followed by the polymerase chain reaction using generic and specific primers for HPV 16 and 18. Dot blot hybridization was also performed with the aim of identifying HPV DNA.

Results

The groups were shown to be homogenous regarding sex, age and site of HPV findings in the samples analyzed. Out of the 41 patients with HPV, 36 (45.6%) were in the cases and five (7.7%) were in the control group (p<0.001). All the HPV cases observed comprised HPV 16, and HPV 18 was not shown in any of the cases studied. There were no significant differences in comparisons of sex, age and site regarding the presence of HPV in either of the groups. It was not observe any significant difference in relation to staging or degree of cell differentiation among the patients with colorectal cancer.

Conclusion

Human papillomavirus type 16 is present in individuals with colorectal carcinoma. However, its presence was unrelated to staging or degree of differentiation.     

Impact of laparoscopic right hemicolectomy for colon cancer

INTRODUCTION

This study specifically examined right colonic cancer resection, a common operation for colorectal surgeons starting laparoscopic resection, to assess the impact of commencing laparoscopy.

PATIENTS AND METHODS

A total of 56 patients undergoing open (n = 34) and attempted laparoscopic (n = 22) elective right hemicolectomy for colorectal cancer between November 2003 and March 2007 were compared. Postoperative stay was the primary outcome. Secondary outcomes included analgesic requirements, bowel recovery, morbidity and mortality. Frequency of laparoscopic versus open surgery over time was also examined.

RESULTS

Resections attempted laparoscopically increased from 9.1% to 75% in the first and last quarters of the study period, respectively (P = 0.0002). Uptake of ‘enhanced recovery’ was mainly in the laparoscopic group. Conversion was required in two of 22 patients. Attempted laparoscopic cases had a shorter median postoperative stay (6 vs 10 days; P < 0.0001), duration of parenteral or epidural analgesia (48 vs 72 h; P < 0.0001) and time to first bowel action (3 vs 4 days; P = 0.001) compared with open cases. Demography, tumour characteristics, morbidity and mortality were comparable between groups. Multivariate analysis identified decreased age, attempted laparoscopic surgery, use of enhanced recovery and absence of complications as independently shortening postoperative stay.

CONCLUSIONS

Advantages of laparoscopic surgery and enhanced recovery, even early in a surgeon''s experience, suggest this is the preferred mode for elective right colon cancer resection.