A prospective study of outcomes of emergency and elective surgeries for complicated colonic cancer

BACKGROUND: Although a significantly decreased long-term survival has been observed in patients undergoing surgery for complicated colorectal tumors compared with uncomplicated ones, the role of radical oncologic surgery on emergency colonic cancer is not defined clearly. The aim of this study was to analyze the efficacy of a curative emergency surgery in terms of tumor recurrence and cancer-related survival compared with elective colonic surgery. METHODS: Between January 1996 and December 1998, all patients with colonic cancer deemed to have undergone a curative resection were considered for inclusion in this prospective study. Patients were classified into 2 groups: group 1, after emergency surgery for complicated colonic cancer, and group 2, patients undergoing elective surgery. The main end points were cancer-related survival and the probability of being free from recurrence at 3 years. RESULTS: Of the 266 patients included in the study, 59 patients (22.2%) were in group 1 and 207 patients (77.8%) were in group 2. Postoperative mortality was higher in group 1 (P=.0004). After patients were stratified by the tumor node metastasis system, differences between the groups with respect to overall survival of stage II tumors (P=.0728), the probability of being free from recurrence (P=.0827), and cancer-related survival (P=.1071) of stage III cancers did not reach statistical significance. Differences were observed for the overall survival in stage III tumors (P=.0007), and for the probability of being free from recurrence (P=.0011) and cancer-related survival (P=.0029) in stage II cancers. When patients with elective stage II tumors presenting 1 or more negative prognostic factor were compared with emergency patients affected by a stage II colonic cancer, no differences were observed. CONCLUSION: Curative surgeries for complicated colonic cancer are acceptable in emergency conditions. Cancer-related survival and recurrence in patients with complicated colonic cancers may approach that of elective surgery if a surgical treatment with radical oncologic criteria is performed.     

Elective colonic surgery for cancer in the elderly: an investigation into postoperative mortality in English NHS hospitals between 1996 and 2007

Background This study was primarily aimed to quantify perioperative mortality risk in elderly patients undergoing elective colonic resectional surgery. In addition, the safety of minimally invasive colonic surgery in this patient group was evaluated. Methods All patients aged > 75 undergoing elective colonic resection for colorectal malignancy between 1996 and 2007 in English NHS hospitals were included from the Hospital Episode Statistics (HES) dataset. Results Between the study dates, 28 746 patients > 75 years underwent elective colonic resection. The national annual number of colonic excisions carried out amongst elderly patients increased from 2188 patients in 1996/7 to 3240 patients in 2006/7. Following adjustment for gender, comorbidity and surgical approach, advancing age was an independent predictor for 30‐day mortality (OR 2.47 for patients aged 85–89 vs 75–79, P < 0.001). Use of laparoscopy was a significant predictor of reduced perioperative mortality (OR 0.56, P = 0.003) once adjusted for advancing age, gender and comorbidity. Comparison of 30‐day and 1‐year postoperative mortality following elective colonic resection in patients aged 90 revealed a large excess of patients dying outside of the immediate perioperative period (10.1% and 26.2% for proximal cancers, respectively; 12.9% and 36.1% for distal colonic resections, respectively). Conclusions Advancing age is an independent risk factor for postoperative death in elderly patients undergoing elective colonic resection for cancer. The risk of death in the elderly is extremely high and surgical decision‐making should incorporate the mortality risk that occurs outside the immediate perioperative period. In this national series, patients selected for a laparoscopic procedure were at lower risk of perioperative death than those undergoing the conventional approach.     

Colorectal cancer in nonagenarians

Aim The aim of the study was to analyze the short‐term and long‐term outcomes of nonagenarians treated for colorectal cancer. Method A retrospective analysis was performed of 74 patients, ≥ 90 years of age, diagnosed with colorectal cancer during the period 1986–2009. Comorbidity, American Society of Anesthesiology (ASA) grade, symptoms, diagnosis, treatment, mortality, morbidity and survival were analyzed. Results Of the 74 patients, 48 (65%) were women. Twenty‐two patients were classified as ASA grade I–II, 26 as ASA grade III and 26 as ASA grade IV–V. Thirty‐one (42%) had intestinal obstruction at the time of diagnosis. Twenty‐two (30%) patients were diagnosed during the period 1986–2000 and 52 (70%) were diagnosed between 2001 and 2009. Forty‐four (59%) patients underwent surgery, of whom 19 (49%) were treated as an emergency. Eleven (25%) patients died postoperatively, with mortality rates of 12% (3/25) for elective surgery and 42% (8/19) for emergency surgery. Surgical mortality for ASA grade I and grade II patients was 5% (1/20) and their 5‐year survival rate (postoperative mortality excluded) was 44%, whereas 5‐year survival for ASA grade III patients who underwent surgery was 12.5% and surgical mortality was 25% (4/16). There were no survivors beyond 36 months among patients who did not receive surgery. Conclusion Our results indicate that elective and emergency colorectal surgery can be performed with acceptable rates of mortality and morbidity on nonagenarian patients in good general condition with low perioperative risk. The 5‐year survival rate was related to ASA grade and to the use of surgery.     

Short‐ and long‐term impact of body mass index on laparoscopic rectal cancer surgery

Aim Obesity is associated with increased technical difficulty in laparoscopic surgery. However, its impact has been measured mainly for colectomy but not specifically for rectal excision. The aim of the study was to assess the impact of body mass index (BMI) on technical feasibility and oncological outcome of laparoscopic rectal excision for cancer. Method A total of 490 patients treated by laparoscopic rectal excision for rectal cancer from January 1999 to June 2010 were included. Seventy per cent had had preoperative radiochemotherapy. Patients were separated into four groups according to BMI (kg/m²): < 20, 20–25, 25–30 and ≥ 30. The impact of BMI on conversion, surgical morbidity, quality of excision (Quirke mesorectal grade and circumferential resection margin) and long‐term oncological outcome was determined. Results Among the 490 patients BMI was < 20 in 43, 20–25 in 223, 25–30 in 177 and ≥ 30 in 47. Mortality (overall 1%) and morbidity (overall 19%) were similar between the groups. Conversion in the four groups was 5%, 14%, 23% and 32% (P = 0.001). The quality of mesorectal excision and circumferential margins did not differ between the groups. The 5‐year local recurrence rates (0%, 4.6%, 5.3% and 5.9% respectively; P = 0.823) and the overall and disease‐free survival were not significantly influenced by BMI. Conclusion In laparoscopic surgery for rectal cancer, BMI influenced the risk of conversion but not surgical morbidity, quality of surgery and survival. This suggests that all patients, including obese patients, are suitable for laparoscopic surgery.     

Hospital stay amongst patients undergoing major elective colorectal surgery: predicting prolonged stay and readmissions in NHS hospitals

Aim Reduced hospital stay confers clinical and economic benefits for patients and healthcare providers. This article examines the length of stay and consequent bed resource usage of patients undergoing elective excisional colorectal surgery in English NHS trusts. Method All patients undergoing elective colorectal resections for malignancy between 1996 and 2006 in English NHS trusts were included from the Hospital Episode Statistics data set. Unifactorial and multifactorial analyses were performed to identify independent predictors of prolonged stay and 28‐day readmission. Results Over the 10‐year period, 186 013 patients underwent elective colorectal procedures in 181 NHS trusts. About 2.893 million bed days were utilized for elective colorectal surgery. Admission stay was shorter following colonic surgery than following rectal surgery (median 11 vs 13 days, P < 0.001). A 2‐day decrease in median stay was observed over the 10‐year period for both colonic and rectal procedures. Readmissions within 28 days of discharge were higher following rectal excision than following colonic surgery (9.4 vs 7.6%, P < 0.001). Multiple logistic regression analyses revealed the following independent predictors of prolonged hospital stay: distal (vs proximal) bowel resection, benign pathology, open technique, increasing age, comorbidity, social deprivation and low provider volume status. Independent predictors of 28‐day readmission included distal bowel resection, benign diagnosis, young age, social deprivation and high provider volume status. Conclusion Patients of advanced age, with associated comorbidities, and those living in areas of social deprivation are at increased risk of prolonged stay. Targeted pre‐emptive discharge planning and enhanced use of laparoscopic surgery could improve bed resource utilization.     

Oncological outcome of T1 rectal cancer undergoing standard resection and local excision

Aim We studied the outcome and prognostic factors for T1 rectal cancer patients undergoing standard resection or transanal excision. Method One hundred and twenty‐four patients with T1 rectal cancer were included in the study, of whom 66 (53.2%) underwent standard resection and 58 (46.8%) underwent transanal excision. Survival analysis was performed to compare the outcome. Results The 5‐year local recurrence rate was 11.0% in the transanal excision group versus 1.6% in the standard resection group (P = 0.031) but the 5‐year disease‐free survival and overall survival rates were not significantly different between the two groups. Multivariate analysis suggested that a high tumour grade and perineural or lymphovascular invasion were independent risk factors for local recurrence and recurrence‐free survival. For high‐risk patients (with at least one of the above risk factors), the 5‐year local recurrence and 10‐year recurrence‐free survival rates were 21.2% and 74.5%, versus 1.2% and 92.0% in low‐risk patients (P = 0.00003 and P = 0.003). In patients undergoing transanal excision, none in the low‐risk group had local recurrence during follow up, while 40% (6 of 15) of patients in the high‐risk group developed local recurrence within 5 years after surgery. The 5‐year local recurrence rate was 45.0%. Conclusion Transanal excision in T1 rectal cancer may result in a high rate of local failure for patients with a high‐grade tumour, or perineural or lymphovascular invasion. Local excision should be avoided as a curative treatment in high‐risk patients.     

Colon cancer incidence,presentation, treatment and outcomes over 25 years

Aim The aim of this study was to evaluate changes in the incidence, presentation, treatment and outcome of colon cancer in a complete cohort of patients treated at a single institution over a 25‐year period. Method All 869 patients at Levanger Hospital, Norway with colon cancer during 1980–2004 were included in the study. Results The incidence of colon cancer increased by 2.1% per year. During the later years, patients presented with less advanced stages, and fewer patients had emergency presentation with obstruction. The rate of operations performed by a colorectal specialist attending increased from 56 to 98%. Postoperative mortality after resection with curative intent decreased from 6.3 to 3.2%, and the presence of a colorectal specialist during the operation was an independent factor that reduced the risk of postoperative death. The local recurrence rate after curative surgery was 10.9% (19 of 174) in 1980–1989, 5.9% (14 of 239) in 1990–1999 and 0.6% (1 of 154) in 2000–2004 (P < 0.001). The 5‐year relative survival after resection with curative intent was 71, 81 and 85% in the three periods 1980–1989, 1990–1999 and 2000–2004, respectively. Conclusion The outcome of colon cancer improved from 1980 to 2004. Patients presented at earlier stages, and fewer had emergency presentation. The local recurrence and postoperative mortality rates were reduced, and relative survival improved.     

Emergency surgery for colonic cancer in a defined population

BACKGROUND: The aim of this study was to identify risk factors in emergency surgery for colonic cancer in a large population and to investigate the economic impact of such surgery. METHODS: Data from the colonic cancer registry (1997-2001) of the Uppsala/Orebro Regional Oncological Centre were analysed and classified by hospital category. Some 3259 patients were included; 806 had an emergency and 2453 an elective procedure. Data for calculating effects on health economy were derived from a national case-costing register. RESULTS: Patients who had emergency surgery had more advanced tumours and a lower survival rate than those who had an elective procedure (5-year survival rate 29.8 versus 52.4 per cent; P < 0.001). There was a stage-specific difference in survival, with poorer survival both for patients with stage I and II tumours and for those with stage III tumours after emergency compared with elective surgery (P < 0.001). Emergency surgery was associated with a longer hospital stay (mean 18.0 versus 10.0 days; P < 0.001) and higher costs (relative cost 1.5 (95 per cent confidence interval 1.4 to 1.6)) compared with elective surgery. The duration of hospital stay was the strongest determinant of cost (r(2) = 0.52, P < 0.001). CONCLUSION: Emergency surgery for colonic cancer is associated with a stage-specific increase in mortality rate.     

Survival of patients with pseudomyxoma peritonei treated by serial debulking

Aim We evaluated the outcome of patients with pseudomyxoma peritonei (PMP) after traditional debulking. PMP is a clinical condition characterized by disseminated intraperitoneal mucinous tumours often accompanied by mucinous ascites derived usually from an appendiceal neoplasm. Patients with PMP have traditionally been treated by serial debulking, but aggressive cytoreduction followed by hyperthermic intraperitoneal chemotherapy is now advocated as standard treatment in PMP. Method The analysis included 33 consecutive patients with PMP who underwent traditional debulking surgery between June 1984 and August 2008. The patient characteristics and details of the treatment were analysed retrospectively. The primary end‐point was survival. Results The overall 5‐ and 10‐year survival rates were 67% and 31% respectively. The patients underwent an average of 3.2 ± 0.4 operations (range 1–10). Of 33 patients, 23 (70%) underwent only 1–3 operations. The 30‐day operative mortality rate was 2.7%. However, four patients (12%) seemed to have achieved long‐term disease‐free survival of more than 5 years. Conclusions The 5‐year survival is comparable with results achieved in patients receiving a combination of cytoreductive surgery and intraperitoneal chemotherapy, but in the long term, the latter seems superior.     

Trends in colorectal cancer survival in northern Denmark: 1985–2004

Objective The prognosis for colorectal cancer (CRC) is less favourable in Denmark than in neighbouring countries. To improve cancer treatment in Denmark, a National Cancer Plan was proposed in 2000. We conducted this population‐based study to monitor recent trends in CRC survival and mortality in four Danish counties. Method We used hospital discharge registry data for the period January 1985–March 2004 in the counties of north Jutland, Ringkjøbing, Viborg and Aarhus. We computed crude survival and used Cox proportional hazards regression analysis to compare mortality over time, adjusted for age and gender. A total of 19 515 CRC patients were identified and linked with the Central Office of Civil Registration to ascertain survival through January 2005. Results From 1985 to 2004, 1‐year and 5‐year survival improved both for patients with colon and rectal cancer. From 1995–1999 to 2000–2004, overall 1‐year survival of 65% for colon cancer did not improve, and some age groups experienced a decreasing 1‐year survival probability. For rectal cancer, overall 1‐year survival increased from 71% in 1995–1999 to 74% in 2000–2004. Using 1985–1989 as reference period, 30‐day mortality did not decrease after implementation of the National Cancer Plan in 2000, neither for patients with colon nor rectal cancer. However, 1‐year mortality for patients with rectal cancer did decline after its implementation. Conclusion Survival and mortality from colon and rectal cancer improved before the National Cancer Plan was proposed; after its implementation, however, improvement has been observed for rectal cancer only.     

Improvement in outcomes of breast cancer patient treatment in Poland in the 21st century

Breast cancer accounts for 22%‐25% of all female cancers diagnosed worldwide. The aim of study was to compare the 5‐year relative survival rates for breast cancer patients treated in the years 2008‐2010, 2000‐2002, and 2005‐2007, and to determine their relationships with the methods and costs of treatment. Data were collected from the National Cancer Registry and the Narodowy Fundusz Zdrowia (National Health Fund) data bases. An increase in the 5‐year survival rate was observed. The results show the impact of some factors on the survival and treatment costs. It is necessary to create data bases being a platform for further comprehensive analyses.     

Intra‐operative perforation is an important predictor of local recurrence and impaired survival after abdominoperineal resection for rectal cancer

Aim Abdominoperineal resection for rectal cancer is associated with higher rates of local recurrence and poorer survival than anterior resection. The aim of this study was to evaluate the outcome of conventional abdominoperineal resection in a large national series. Method The study was based on the Danish National Colorectal Cancer Database and included patients treated with abdominoperineal resection between 1 May 2001 and 31 December 2006. Follow up in the departments was supplemented with vital status in the Civil Registration System. The analysis included actuarial local and distant recurrence, and overall and cancer‐specific survival. Risk factors for local recurrence, distant metastases, overall survival and cancer‐specific survival were identified using multivariate analyses. Results A total of 1125 patients were followed up for a median of 57 (25–93) months. Intra‐operative perforation was reported in 108 (10%) patients. The cumulative 5‐year local recurrence rate was 11% [95% confidence interval (CI), 7–13)], overall survival was 56% (95% CI, 53–60) and cancer‐specific survival was 68% (95% CI, 65–71). Multivariate analysis showed that perforation, tumour stage and nonradical surgery were independent risk factors for local recurrence; tumour fixation to other organs, perforation and tumour stage were independent risk factors for distant metastases; and risk factors for impaired overall survival and cancer‐specific survival were age, tumour perforation, tumour stage, lymph node metastases and nonradical surgery. Conclusion Intra‐operative perforation is a major risk factor for local and distant recurrence and survival and therefore should be avoided.     

Outcome of right‐ and left‐sided colonic and rectal cancer following surgical resection

Aim To determine the outcome of surgery for colorectal cancer from a single region and to see whether location of the primary cancer influences prognosis. Method Patients with colorectal cancer diagnosed from January 2002 to December 2006, entered into a prospective database were followed until death or to December 2008. Right‐sided (caecum to transverse colon) and left‐sided (splenic flexure to rectosigmoid junction) colonic cancers and rectal cancers (distal to rectosigmoid junction to the anus) were identified. Statistical analysis was performed using Pearson’s chi‐square test, Kaplan–Meier (log‐rank statistic) and Cox regression analysis with a P‐value < 0.05 denoting significance. Results Of 841 patients with solitary colorectal cancers identified (median age 72 [30–101] years; 53% male), 283 (33.7%) were right‐sided colonic, 330 (39.2%) were left‐sided colonic and 228 (27.1%) were rectal. Respective resection rates were 82.7%, 77.9% and 91.6%, and curative resection rates were 79.9%, 82.9.0% and 85.7%, respectively. There was no significant difference in recurrence rates between right‐ (16.1%), left‐sided (23.0%) colonic and rectal (20.7%) cancers (P = 0.207). Respective mean survival rates were 54.4, 59.8 and 63.6 months (P = 0.007). Conclusion Right‐sided colorectal cancers had a worse prognosis than left‐sided and rectal cancers, possibly because of more advanced staging and fewer curative resections.     

Laparoscopic total mesorectal excision can be performed on a nonselective basis in patients with rectal cancer with excellent medium‐term results

Aim Concerns exist regarding laparoscopic rectal cancer surgery due to increased rates of open conversion, complications and circumferential resection margin positivity. This study reports medium‐term results from consecutive unselected cases in a single surgeon series. Method The results of laparoscopic total mesorectal excision (TME) for rectal cancer over a 9‐year period within the context of an evolving ‘enhanced recovery protocol’ (ERP) were reviewed from analysis of a prospectively maintained database. Results One hundred and fifty patients (91 male, median age 69 years, median BMI 26) underwent laparoscopic TME over 9 years. Median follow up was 28.5 months (range 0–88). Sixteen (10.6%) patients underwent neoadjuvant radiotherapy. Six (4.0%) required open conversion and 13 (9.0%) had an anastomotic leakage. The proportion of Dukes stages were: A, 33.3%; B, 30.7%; C, 31.3%; D, 4.7%. Five (3.3%) patients had an R1 and one an R2 resection. Median length of postoperative stay was 6 days. Three (2.0%) patients died within 30 days. Four (2.7%) developed local recurrence and 14 (9.3%) developed distant metastases. Predicted 5‐year disease‐free and overall survival rates by Kaplan–Meier analysis were 85.8% and 78.7%, respectively. Conclusion Laparoscopic TME surgery can safely be offered to unselected patients with rectal cancer with excellent medium‐term results.     

Influences on length of stay in an enhanced recovery programme after colonic surgery

Aim Enhanced recovery after surgery (ERAS) programmes have been shown to accelerate and enhance functional recovery after colonic surgery. We analysed prospectively collected data to investigate potentially modifiable factors that may influence the length of stay (LOS) in the ERAS setting at a single institution. Method Between October 2005 and November 2008, prospective data were collected on consecutive patients who underwent elective colonic surgery without a stoma. Patients with rectal cancer, those unable to participate in preoperative ERAS components because of their inability to communicate effectively in English, those with cognitive impairment and those with an American Society of Anesthesiologists (ASA) grade of ≥4 were excluded. Statistical analyses were performed using the Mann–Whitney U‐test and Cox regression modelling. Results A total of 100 (79 malignancies) patients underwent elective colon resection during the study period. There were 57 right‐sided, 41 left‐sided and two total colectomies. The median age of the patients was 67.5 (range 31–92) years and the median day stay was 4 (range 3–46) days. Factors with significant correlations for reduced LOS were female gender, the surgeon, operative severity, high‐dependency unit (HDU) admission and incision type favouring laparoscopic and transverse approaches. Age, operation site, indication for surgery and body mass index were not significant predictors of hospital stay. Gender, operative severity, HDU admission and surgeon did not have any independent correlation with LOS; in contrast to the ASA score and the type of incision, which did. Conclusion Lower ASA score, transverse incision laparotomy and laparoscopy correlated independently with reduced postoperative LOS within the ERAS setting.     

Adjuvant chemotherapy for stage C colonic cancer in a multidisciplinary setting

Background: In this study of patients undergoing adjuvant chemotherapy for clinicopathological stage C colonic cancer after optimal surgery, the aims were: to describe their immediate experience of chemotherapy, to assess disease‐free survival, to compare overall survival with that of a matched untreated historical control group, and to evaluate the associations between previously identified adverse risk factors and survival. Methods: Data were drawn from a comprehensive, prospective hospital registry of resections for colorectal cancer between 1971 and 2004, with retrospective data on adjuvant chemotherapy. The main end point was overall survival. Statistical analysis employed the chi‐squared test, Kaplan–Meier estimation and proportional hazards regression. Results: From May 1992 to December 2004, there were 104 patients who received adjuvant chemotherapy. Duration of treatment, withdrawal from treatment, toxicity and other immediate treatment outcomes were similar to those in other equivalent studies. There were no toxicity‐associated deaths. Overall survival was significantly longer in the treated patients than in the control group (3‐year rates 81% and 66%, respectively, P = 0.009). A significant protective effect of adjuvant therapy was found (hazard ratio 0.5, 95% confidence interval 0.3–0.8, P = 0.001) after adjustment for histopathology features previously shown to be negatively associated with survival (high grade, venous invasion, apical node metastasis, free serosal surface involvement). Conclusions: For patients who have had a curative resection for lymph node positive colonic cancer in a specialist colorectal surgical unit and been managed by a multidisciplinary team, post‐operative adjuvant chemotherapy is safe and provides the same survival advantage as seen in randomized trials.     

Extending the horizons of restorative rectal surgery: intersphincteric resection for low rectal cancer

Objective Radical resection of tumours of the distal rectum has generally entailed an abdominoperineal excision, but the recognition of shorter safe distal resection margins, neoadjuvant chemoradiotherapy and the application of the technique of intersphincteric resection (ISR) have led to the prospect of restorative surgery for patients with distally situated tumours. The present study examines the indications, techniques and outcomes following ISR. Method A literature search was performed to identify studies reporting outcomes following ISR for low rectal cancer. The outcomes of interest included short‐term adverse events, functional and manometric results, postoperative quality of life and oncologic outcomes. Results Twenty‐one studies reflecting the experience of 13 units and 612 patients were included. Operative mortality following ISR was 1.6% (inter‐unit range 0–5%) and anastomotic leak rate 10.5% (inter‐unit range 0–48.4%). The pooled rate of local recurrence was 9.5% (range 0–31% between units) with an average 5‐year survival of 81.5%. Most studies recorded a significant reduction in resting anal pressure but not squeeze pressure following surgery, but urgency was reported in up to 58.8% of patients. Functional outcomes and quality of life may be improved using colonic j‐pouch reconstruction. The use of chemoradiotherapy can offer benefits in terms of oncologic result, but at the cost of worse functional outcomes. Conclusion Careful case selection and counselling is required if satisfactory results are to be achieved following ISR for low rectal cancers. In selected patients, however, the technique offers sphincter preserving surgery with acceptable oncologic and functional results.     

Can the Kattan nomogram still accurately predict prognosis in renal cell carcinoma using the revised 2010 tumor–nodes–metastasis reclassification?

The Kattan nomogram has been used in renal cell cancer to predict progression‐free survival after nephrectomy. Tumor–nodes–metastasis staging is essential for the calculation of this score. The effect of the recent 2010 revision to the tumor–nodes–metastasis classification on the predictive ability of the Kattan nomogram was studied. All patients having radical nephrectomy for renal cell cancer in the 5‐year period of 2004–2008 at a tertiary referral center were included. Pathological and radiological records were reviewed to identify tumor–nodes–metastasis stage (2002 and 2010 classifications). Kattan scores were calculated for the 2002 and 2010 tumor–nodes–metastasis stages, and the effect on survival predictions were compared with actual outcomes. A total of 291 patients with non‐metastatic renal cell cancer were identified. Revision of the tumor–nodes–metastasis staging from the 2002 to 2010 classification resulted in an increase in the number of patients with stage pT3a (from 30 to 75), a reduction in the patients with stage pT3b (from 57 to 10) and a small increase in stage pT4 cases (1 to 3). This altered the proportion of patients in the Kattan prognostic of “good” (from 61% to 69%), “intermediate” (from 29% to 22%) and “poor” (from 10% to 8%). The overall median predicted 5‐year progression‐free survival was 79.8% with 2002 tumor–nodes–metastasis, and 81.8% with 2010 tumor–nodes–metastasis. Actual 5‐year progression‐free survival was 83.0%, which was not significantly different from that predicted using either tumor–nodes–metastasis classification (P = 0.66). On comparing the new 2010 and old 2002 tumor–nodes–metastasis classification in our cohort, we showed the predictive ability of the Kattan nomogram remained unaltered.     

Impact of laparoscopic surgery on the long‐term outcomes for patients with rectal cancer

Background: This 20‐year retrospective study compared the results of laparoscopic surgery with open surgery for patients with rectal cancer to evaluate the impact of laparoscopic surgery on long‐term oncological outcomes for rectal cancer. Methods: We analysed survival data collected over 20 years for patients with rectal cancer (n= 407) according to surgical methods and tumour stage between those treated with laparoscopic surgery (n= 272) and those with open surgery (n= 135). Clinical factors were analysed to ascertain possible risk factors that might have been associated with survival from and recurrence of rectal cancer. A multivariate analysis was applied by using Cox's regression model to determine the impact of laparoscopic surgery on long‐term oncological outcomes. Results: Overall survival, disease‐specific survival and disease‐free survival rates were statistically higher in the laparoscopic group than in the open‐surgery group. The incidence of local recurrence in the laparoscopic group (7.9%; 95% confidence intervals (CI), 4.2–11.5) was significantly lower than that for the open‐surgery group (30.2%; 95% CI, 21.0–39.3; P < 0.001). By using a multivariate analysis, laparoscopic surgery for rectal cancer appeared not to be an independent factor for disease‐specific survival or disease‐free survival. However, the laparoscopic surgery was an independent factor associated with reduced local recurrence (Hazard ratio (HR), 3.408; 95% CI, 1.890–6.149; P < 0.001). Conclusion: Laparoscopic surgery did not adversely affect the long‐term oncological outcome for patients with rectal cancer.     

Can the quality of colonic surgery be improved by standardization of surgical technique with complete mesocolic excision?

Aim we analysed the influence of standardization of colon cancer surgery with complete mesocolic excision (CME) on the quality of surgery measured by the pathological end‐points of number of harvested lymph nodes, high tie of supplying vessels, plane of mesocolic resection and rate of R0 resection. Method One hundred and ninety‐eight patients with colonic carcinoma who underwent radical surgery between September 2007 and February 2009 were divided into two groups, including those undergoing surgery before (93) or after (105) 1 June 2008, when complete mesocolic excision (CME) was introduced as standard in our hospital. Results The overall mean high tie increased from 7.1 (CI, 6.5–7.6) to 9.6 (8.9–10.3) cm (P < 0.0001) and the mean number of harvested lymph nodes from 24.5 (22.8–26.2) to 26.7 (24.6–28.8) (P = 0.0095). There were no significant increases in these end‐points in open right hemicolectomy, and in laparoscopic sigmoid resection the number of lymph nodes did not increase significantly. The plane of mesocolic resection, the rate of R0 resection and the risk of complications did not change significantly. The median (range) length of hospital stay increased from 4 (2–62) to 5 (2–71) days (P = 0.04). Conclusion Standardization of colonic cancer surgery with CME seems to improve the quality of surgery without increasing the risk of complications.