Surgical treatment of colon and rectal cancer

There are many indications for surgical intervention in the current treatment of cancer of the colon and rectum. The hallmark of surgical therapy remains en bloc resection of the primary tumor, accompanied by removal of the mesenteric lymph nodes. Surgical resection is also the principal and most successful treatment for local recurrences and isolated metastases. Although the application of minimally invasive techniques is growing in all aspects of surgery and is accepted in the treatment of benign lesions of the colon, laparoscopic resection for colorectal cancer cannot be recommended apart from randomized, controlled trials. Similarly, the role of sentinel lymph node biopsy in the surgical treatment of colorectal cancer remains to be defined. Various surgical modalities have been developed for the treatment of unresectable colorectal cancer metastatic to the liver. Further studies should help to elucidate the exact role of these therapies in the treatment of this common clinical problem. In summary, surgical treatment plays an important role in multiple aspects of the care of the patient with colorectal cancer.     

结直肠癌肝转移瘤局部介入治疗应用进展

结直肠癌是世界上死亡率排名前5位的恶性肿瘤,其主要死因是肝转移。结直肠癌发生肝转移多是晚期,其治疗效果较差,生存期较短,严重影响结直肠癌的预后。目前,根治性手术切除是结直肠癌肝转移(Colorectal liver metastasis,CRLM)的一线治疗方法,然而,绝大多数病人在被确诊时已失去手术治疗的机会。国家综合癌症网络(National Comprehensive Cancer Network,NCCN)建议将局部治疗(Locoregional therapy,LRT)用于无法行根治性手术切除且对化疗不敏感或无效的CRLM患者,它主要包括经导管动脉内治疗和消融治疗。本文就局部介入治疗CRLM的应用进展做一综述。     

Current Concepts in the Surgical Management of Non-melanoma Skin Cancers

The surgical management of non-melanoma skin cancers has seen some significant changes over the past 20 years, as a result of developments in three equally important and overlapping specialties that deal with this specific pathology: plastic and reconstructive surgery, surgical oncology and dermatological surgery. Better understanding of vascular and particularly microvascular anatomy, coupled with technological advances in operating microscopes, microsurgical instrumentation and preoperative planning via advanced imaging, allows functional and aesthetic restoration of any radical oncological skin and soft-tissue surgery defect from head to toe. As reconstruction has practically lost its technical boundaries, resectional surgery can be executed without compromising on surgical margins, thus reducing rates of local recurrences and metastatic spread. The increasing use of Mohs surgery and its several advantages for difficult high-risk non-melanoma skin cancer in facial sites especially, offers optimal cure rates while reducing functional impairment and optimising cosmetic outcomes. Advances in preoperative planning utilising computed tomography and magnetic resonance imaging scans can help to predict the degree of resectability and tailor further treatments, including radiotherapy, accordingly. From the reconstructive point of view, these techniques provide a roadmap to select the best blood supply for the transplanted flap, thereby reducing complications and increasing success rates. The focus of skin cancer surgery has therefore shifted from pure cancer clearance and flap survival, to a high degree of functional and aesthetic reconstruction.     

Complete mesocolic excision: Techniques and outcomes

Complete mesocolic excision (CME) for the treatment of colon cancer was first introduced in the West in 2008. The first aim of this procedure is to remove the afflicted colon and its accessory lymphovascular supply by resecting the colon and mesocolon in an intact envelope of visceral peritoneum, which holds potentially involved lymph nodes. The second component of CME is a central vascular tie to remove completely all lymph nodes in the central (vertical) direction. In its original iteration, CME was performed via laparotomy, although many centers preferentially perform laparoscopic surgery, with its associated benefits and similar oncological outcomes, as the standard treatment for colonic cancer. Here, we present the surgical techniques for CME in open and laparoscopic surgery, as well as the surgical, pathological and oncological outcomes of the procedure that are available to date. Because there are no randomized control trials comparing CME to “standard” colon surgery, the principles underlying CME seem anatomical and logical, and the results published from the Far East, reporting an 80% 5-year survival rate for Stage III cancer, should guide us.     

结直肠癌合并糖尿病患者围手术期治疗32例报告

目的探讨结直肠癌合并糖尿病患者的围手术期治疗方法。方法回顾性分析32例结直肠癌合并糖尿病患者的临床资料。结果32例患者均行手术治疗,其中根治性手术30例、结肠造瘘手术2例。术前空腹血糖控制在6．0～8．0mmol／L,餐后血糖≤11．1mmol／L,术后血糖维持在6．0～10．0mmol／L。术后并发肺部感染4例,吻合1：3瘘1例,切口裂开2例,切口液化感染3例,心功能衰竭2例,结肠残端糜烂出血1例,其中2例切口裂开、1例心功能衰竭均合并肺部感染,所有病例均顺利度过围手术期。结论合理使用胰岛素,严格监测、控制血糖,完善妥当地处理结直肠癌合并糖尿病患者,能够安全度过围手术期。     

结直肠癌根治术后长期随访结果分析

我院1964年4月～1976年12月根治性切除结直肠癌363例,且随访满10年以上,随访率为97.2％。本组包括结肠癌140例,直肠癌223例。根据Dukes分期法,A期1.7％,B期63.1％,C期35.2％。全部病例均施行根治性切除术,手术死亡率为0.8％(3例)。根治术后5年,10年,15年和20年生存率分别为61.5％,51.9％,48.6％和38.9％。本文对363例结直肠癌进行了临床分析,并将术后生存10年以上的180例和10年内死亡的183例进行比较,以求发现影响术后长期生存的关键因素。结果表明患者年龄、癌瘤部位、病期和淋巴结转移是影响远期疗效最重要的因素。此外,作者通过对治疗失败的原因分析,提出几点提高疗效的措施。     

复发转移性结直肠癌的外科治疗及预后分析

背景与目的:结直肠癌是常见恶性肿瘤之一,其发病率有逐渐增高的趋势.其主要的治疗方法是根治性手术,手术后的复发及转移是导致患者死亡的主要原因.目前复发性结直肠癌的再手术是提高患者生存率和生存质量的主要方法.本文探讨结直肠癌术后复发的原因、诊断和外科治疗方法.方法:回顾性分析2003-2006年35例复发与转移性结直肠癌的外科治疗及预后.结果:手术后1年内复发者9例 (26%),3年内复发者26例(74 %).本组35例复发或转移性结直肠癌均行再次手术,7例复发性直肠癌再切除4例,造瘘3例,28例复发性结肠癌中,根治性切除8例(包括5例肝转移灶切除),姑息性切除10例,盲肠或横结肠造瘘10例.总切除率为63 %(22/35),其中根治性切除率为55%(12/22),姑息性切除45%(10/22).术后随访6～36个月,2例失访,12例根治性切除组中,9例无瘤生存,1例肺转移,2例肝转移;23例姑息治疗组中,5例死亡,4例肝转移,其余14例带瘤生存.结论:结肠癌的手术治疗,应根据其生物学特点,采取规范的手术方式、彻底清除原发灶、转移的肠系膜及淋巴结,术中注意无瘤操作,术后酌情辅以化疗或放疗,定期随访,是预防结直肠癌术后复发的主要措施.而对复发和转移病例,应根据其部位、临床特征,选择以手术为主的综合治疗方案,酌情达到根治或姑息治疗的目的.     

The impact on nodal staging of lymphatic mapping in carcinoma of the colon and rectum

Although the majority of individuals undergoing apparently curative resection for carcinoma of the colon rectum who are found to be without evidence of metastatic disease in the regional lymph nodes will remain free of disease, approximately 20% to 30% of these individuals will develop recurrent disease and die. This may, in part, be due to understaging of the disease. For this reason, there has been increasing interest in approaches to improving staging of all solid tumors, including carcinoma of the colon and rectum. Lymphatic mapping has revolutionized the management of patients with cutaneous melanoma and breast cancer and has been demonstrated to more accurately stage patients with solid tumors. Our investigations as well as others have taken a number of strategies to improving the staging of individuals of colorectal cancer patients with apparently node-negative disease, including the development of a novel ex vivo lymphatic mapping technique. This article summarizes our and other investigations into improved staging of colorectal cancer with an emphasis on the impact of lymphatic mapping on improving the accuracy of staging of apparently node-negative colorectal cancer patients.     

80岁以上合并肠梗阻的结直肠癌患者的外科治疗

目的 探讨80岁以上合并肠梗阻的结直肠癌患者的外科治疗策略。方法 回顾性分析中国医学科学院结直肠外科2007年1月—2018年12月行结直肠癌手术且术前合并肠梗阻的77例80岁以上患者的临床病理资料,按照手术方式分为根治组（n=58）与非根治组（n=19）,比较两组患者临床病理特征、围手术期相关指标和预后。采用Kaplan-Meier法进行生存分析,Log rank检验进行生存时间比较;应用Cox比例风险模型进行多因素分析,对影响预后的因素进行分析。结果 根治组TNM分期为Ⅳ期患者的比例明显低于非根治组（8.6% vs. 57.9%, P<0.001）。根治组患者的5年生存率明显高于非根治组（65.5% vs. 26.3%, P<0.001）。单因素分析显示TNM分期和是否行根治性手术与合并肠梗阻的老年结直肠癌患者预后相关。多因素分析表明是否行根治性手术是影响80岁以上合并肠梗阻的结直肠癌患者预后的独立因素。结论 是否行根治性手术是影响80岁以上合并肠梗阻的结直肠癌患者预后的独立因素。     

Lymphatic vessel invasion is an independent prognostic factor for survival in colorectal cancer

To assess whether lymphatic vessel invasion (LVI) is an independent prognostic factor in colorectal cancer, we retrospectively reviewed the records of 462 patients who underwent potentially curative surgery for carcinoma of the colon and rectosigmoid/rectum (rs/rectum) at the New England Deaconess Hospital from 1965-1978. Sixty-one patients were identified as having tumors with lymphatic vessel invasion (LVI+), and they were compared with the remaining group of 401 patients who had tumors without lymphatic vessel invasion (LVI-). The incidence of lymphatic vessel invasion was significantly increased in tumors with blood vessel invasion (24% vs. 5%, p = 0.000001). Patients with LVI+ tumors also had a significantly increased incidence of positive nodes (59% vs. 25%, p = 0.0004), the average number of positive nodes (4.8 vs. 2.2, p = 0.0003), and a lower 5-year survival rate (colon: 57% vs. 84%, p = 0.0001; rs/rectum: 38% vs. 71%, p = 0.004). There was a significant (p less than or equal to 0.05) increase in local (16% vs. 7%), abdominal (33% vs. 9%), and distant (13% vs. 4%) failure as a component of component of failure in patients with LVI+ colon cancer and a significant increase in abdominal (33% vs. 11%) and distant (13% vs. 8%) failure as a component of failure in patients with LVI+ rectosigmoid/rectal cancer. Proportional hazards analysis demonstrated that lymphatic vessel invasion was an independent prognostic factor for survival.     

Evidence for the existence of different types of large bowel tumor: suggestions from the clinical data of a population-based registry

The clinical findings of a population-based colorectal tumor registry have been analyzed to determine elements of supporting or not supporting the existence of different types of large bowel cancer. Age-specific incidence rate of the 409 registered patients rose sharply with increasing age in all segments of the large bowel; however, regarding left colon and rectum, the male: female ratio showed a marked male preponderance, more evident in the more advanced age groups. Histopathology, studied in 87% of patients, revealed adenocarcinoma as the most frequent feature; however, adenocarcinoma with concomitant adenoma (i.e., presumably arising in adenoma) was observed in 14.3% of cancers of the left colon, in 17.7% of rectal tumors, but in only 5.7% of neoplasms of the proximal colon (P less than 0.05 and P less than 0.01, respectively, vs. left colon and rectum). Some histological features (carcinoid and mucinous carcinoma) were observed in right-side tumors only. Analysis of the familial occurrence of cancer showed that a significantly larger proportion of patients with neoplasms located in proximal colonic segments had three or more first-degree relatives affected by (or deceased from) cancer of all sites. Similarly, colorectal tumors among relatives were more frequent in patients with right-side cancer. The location of the 793 polyps observed during 3 years of registration showed that more than 70% of adenomas were located beyond the splenic flexure, overlapping the distribution of cancers. In conclusion, the differences of sex ratio at different colonic subsites, the higher fraction of adenocarcinomas with adenomas in cancer of the more distal tracts of the large bowel, and the more marked familial occurrence of colorectal cancer in patients with right-side neoplasms tend to support the view that cancer of the proximal colon, cancer of the distal colon, and cancer of the rectum may actually be three different types of tumors.     

A study of the histochemical changes in mucus from patients with benign and malignant pathological conditions of the colon and rectum

This study has shown the presence of an abnormal mucus pattern in premalignant and malignant conditions of the colon and rectum. This abnormal mucus pattern extended as a field change around colorectal tumors into the adjacent apparently normal mucosa. Presence of this premalignant field in patients undergoing apparently curative surgery was associated with an increased risk of local tumor recurrence or metachronous primary tumors.     

Mouse model of colonic adenoma-carcinoma progression based on somatic Apc inactivation

Mutations in the adenomatous polyposis coli (APC) gene are pivotal in colorectal tumorigenesis. Existing mouse intestinal tumor models display mainly small intestinal lesions and carcinomas are rare. We defined human CDX2 sequences conferring colon epithelium-preferential transgene expression in the adult mouse. Mice carrying a CDX2P-NLS Cre recombinase transgene and a loxP-targeted Apc allele developed mainly colorectal tumors, with carcinomas seen in 6 of 36 (17%) of mice followed for 300 days. Like human colorectal lesions, the mouse tumors showed biallelic Apc inactivation, beta-catenin dysregulation, global DNA hypomethylation, and aneuploidy. The predominantly distal colon and rectal distribution of tumors seen in mice where one Apc allele was inactivated in epithelial cells from distal ileum to rectum suggests that regional differences in the intestinal tract in the frequency and nature of secondary genetic and epigenetic events associated with adenoma outgrowth have a contributing role in determining where adenomas develop. The presence of large numbers of small intestine tumors seemed to inhibit colorectal tumor development in the mouse, and gender-specific effects on tumor multiplicity in the distal mouse colon and rectum mimic the situation in humans where males have a larger number of advanced adenomas and carcinomas in the distal colon and rectum than females. The mouse model of colon-preferential gene targeting described here should facilitate efforts to define novel factors and mechanisms contributing to human colon tumor pathogenesis, as well as work on tumor-promoting environmental factors and agents and strategies for cancer prevention and treatment.     

Screening sigmoidoscopy and colorectal cancer mortality.

BACKGROUND: Sigmoidoscopy may reduce colorectal cancer mortality by identifying both cancers and precursor lesions (including polyps) for treatment; however, evidence regarding the efficacy of this technique as a screening procedure is extremely limited. PURPOSE: In the absence of data from randomized controlled trials, we performed a retrospective case-control study to determine if sigmoidoscopy screening is associated with a reduction in colorectal cancer mortality. METHODS: The medical records of 66 members of the Greater Marshfield Community Health Plan (GMCHP) who died of large-bowel cancer from 1979 to 1988 were reviewed for history of screening for colorectal cancer (case subjects). For comparison, the records of 196 GMCHP members of similar gender, age, and enrollment duration were randomly selected for review (control subjects). RESULTS: History of screening sigmoidoscopy was much less common among case subjects (10%) than among control subjects (30%). Risk for death from colorectal cancer was reduced among individuals having had a single examination by screening sigmoidoscopy (odds ratio = 0.21; 95% confidence interval = 0.08-0.52), compared with the risk for those who never had one. The reduction in risk appeared to be limited to tumors in the rectum and distal colon. Neither fecal occult blood testing nor digital rectal examination was associated with a reduction in colorectal cancer mortality. CONCLUSIONS: These results suggest that screening sigmoidoscopy can substantially reduce mortality from cancers of the rectum and distal colon.     

Combined laparoscopic and transperineal endoscopic total pelvic exenteration for the vaginal stump recurrence of cervical cancer

Total pelvic exenteration (TPE) is sometimes required for radical treatment of locally advanced or recurrent gynecologic cancer [1]. However, TPE with a transabdominal approach requires highly advanced techniques in the case of repeated surgery due to the effects of primary surgery and/or chemoradiotherapy, especially when a transabdominal approach is used. Recent technical advances in transanal/transperineal endoscopic surgery have proved beneficial for complicated surgery in the deep pelvis [2]. Here we introduce our surgical procedure for combined laparoscopic and transperineal endoscopic TPE (TpTPE) for pelvic recurrence of cervical cancer. A 42-year-old woman was diagnosed with vaginal stump recurrence of cervical cancer involving the rectum, bladder, and ureters following hysterectomy and pelvic lymph node dissection as primary surgery and chemotherapy/chemoradiotherapy for previous recurrences. We decided to perform TpTPE with a combined laparoscopic approach. The GelPOINT advanced access platform was fixed through a perineal skin incision around the tightly closed anus, external urethral orifice, and vagina. With sufficient pneumopelvic pressure (12 mmHg), TpTPE was performed under a good surgical view without any effect of the primary surgery. A ureterostomy and sigmoid colostomy were created and a right gracilis muscle flap was used to reconstruct the pelvic defect. The total operative time and estimated blood loss were 887 minutes and 497 mL, respectively. Histopathological examination revealed recurrent cervical cancer invading the rectum, bladder, and bilateral ureters with negative surgical margins. The postoperative course was uneventful except for paralytic ileus. The patient was discharged on postoperative day 18. TpTPE is a technically feasible and effective approach for locally advanced pelvic tumors.     

The natural killer blood count in patients with breast, colon and rectal cancers

Blood level of large granular cells was assayed in patients suffering cancer of the breast (30), colon (13) and rectum (34) at various stages of the disease. This level in cancer patients was half as much that in healthy controls. Procedures employed for treatment of the above pathologies were shown to contribute to inhibition of peripheral blood spontaneous cytotoxicity. This makes the case for immunocorrection. The cytologic method of identification of large granular lymphocytes may be used to monitor cell-mediated antitumor immunity in breast and colorectal cancer patients in the course and after treatment and, therefore, serve the diagnosis of recurrence and metastasis.     

Intramucosal colorectal carcinomas treated by surgical resection

Stage 0 colorectal cancer was found only in the innermost lining of the colon and rectum. Treatments for an early stage colorectal cancer were available including endoscopic polypectomy, endoscopic mucosal resection (EMR) and trans-anal or -sacral local excision, laparoscopy-assisted colectomy and open colectomy. Our study indicated that endoscopic therapy for the early stage colorectal cancer was more advantageous than the conventional operative treatment. Although EMR should be applied for intramucosal carcinomas, 11 intramucosal carcinomas were treated by a surgical resection due to several limitations at our institution.     

Difference in prognostic value between sialyl Lewis(a) and sialyl lewis(x) antigens in blood samples obtained from the drainage veins of the colorectal tumors

Subtraction values, (i.e. values obtained by subtracting the serum titer of sialyl Lewis(a) (CA19-9) and sialyl Lewis(x) (SLX) antigens in peripheral venous blood from the serum titer of the same antigen in the tumor's drainage venous blood) were determined in order to clarify whether or not such values for these specific antigens (d-CA19-9 and d-SLX) are prognostic factors after resection for colorectal cancer. The blood samples were obtained from 144 colorectal cancer patients during surgical excisions of the tumors. Univariate and multivariate analyses revealed that d-SLX level was an independent prognostic factor, separate from stage, while d-CA19-9 level did not have any additional prognostic value. In conclusion, a high d-SLX level is a predictor of poor outcome after surgery.     

ERAS protocol in laparoscopic surgery for colonic versus rectal carcinoma: are there differences in short-term outcomes?

Most of the studies concerning enhanced recovery after surgery (ERAS) protocols in colorectal surgery include heterogeneous groups of patients undergoing open or laparoscopic surgery, both due to colonic and rectal cancer, thus creating a potential bias. The data investigating the differences between patients operated for either colonic or rectal cancer are sparse. The aim of the study was to compare short-term outcomes of laparoscopic surgery for colonic and rectal cancer with ERAS protocol. The analysis included consecutive prospectively registered patients operated for a colorectal cancer between January 2012 and September 2015. Patients were divided into two groups (colon vs. rectum). The measured outcomes were: length of stay (LOS), complication rate, readmission rate, compliance with ERAS protocol elements and recovery parameters (tolerance of early oral diet, mobilization and time to first flatus). Group 1 (colon) consisted of 150 patients and Group 2 (rectum) of 82 patients. Patients in Group 1 (150 patients) were discharged home earlier than in Group 2 (82 patients)—median LOS 4 versus 5 days, respectively. There was no statistical difference in complication rate (27.3 vs. 36.6 %) and readmissions (7.3 vs. 6.1 %). Compliance with the protocol was 86.9 and 82.6 %, respectively. However, in Group 1, the following procedures were used less frequently: bowel preparation (24 vs. 78.3 %) and postoperative drainage (23.3 vs. 71.0 %). There were no differences in recovery parameters between the groups. Univariate logistic regression showed that the type of surgery, drainage and stoma creation significantly prolonged LOS. In a multivariate logistic regression model, only a bowel preparation and drainage were shown to be significant. Although functional recovery and high compliance with ERAS protocol are possible irrespective of the type of surgery, laparoscopic rectal resections are associated with a longer LOS.