Colorectal cancer with non-resectable synchronous metastases: should the primary tumor be resected?

OBJECTIVES: In asymptomatic patients presenting with non-resectable synchronous metastatic disease from colorectal adenocarcinoma, the beneficial effect of resecting the primary tumor remains to be documented. The aim of this study was to compare survival of patients with metastatic colorectal cancer who underwent elective resection of the primary tumor to those who did not. METHODS: A retrospective analysis of patients with metastatic colo-rectal cancer treated between June, 1996 and December, 1999 was performed. Overall survival was compared between patients who underwent first-line resection of the primary colorectal tumor (group 1) or those who did not undergo elective resection of the primary (group 2). The probability of surgical resection of the primary tumor for gastrointestinal complications in group 2 was evaluated. RESULTS: Thirty-one and 23 patients were included in groups 1 and 2 respectively. Five patients (21.7%, 95% confidence interval CI95% 4.9-38.5%) in group 2 required surgical treatment for intestinal obstruction due to the primary tumor. Two clinical characteristics were significantly different between groups 1 and 2: rectal localization (9.7% versus 34.7%; P=0.03) and presence of fewer than three metastases (29.0% versus 4.3%; P=0.03). Survival curves were not significantly different (logrank). Median duration of survival was 21 and 14 Months, respectively (P=0.718). CONCLUSION: In patients with non-resectable synchronous metastatic disease, non-surgical management of the primary tumor is a rational alternative if asymptomatic. A prospective randomized trial integrating the quality-of-life factor should be organized.     

Primary tumour resection in metastatic nonfunctioning pancreatic endocrine carcinomas

BackgroundThe role of debulking surgery in metastatic nonfunctioning pancreatic endocrine carcinomas (M-NF-PECs) with resectable primary tumour and unresectable liver metastases is debated.AimAim of the study is to evaluate whether the resection of the primary tumour in metastatic nonfunctioning pancreatic endocrine carcinoma improves survival.Patients and methodsFifty-one metastatic nonfunctioning pancreatic endocrine carcinoma patients with unresectable liver metastases were enrolled from 1990 to 2004 at the time of diagnosis. Nineteen patients underwent complete resection of the primary tumour whilst 32 were judged unresectable. All cases were classified according to the WHO 2000 classification. All clinico-pathological parameters, including grade of differentiation and the Ki-67 proliferation index were considered in univariate and multivariate models.ResultsOf the 19 resected patients, 14 (73.7%) underwent left-pancreatectomy and 5 (26.3%) pancreaticoduodenectomy. In the unresected group of 32 patients, 9 (28.1%) underwent surgical biliary and/or gastric by-pass. There was no postoperative mortality and the median survival was 54.3 months (95% CI: 25.7–82.9). No difference in survival was observed between the two groups [resected: median 54.3 months (95% CI: 25–83.6), unresected: median 39.5 months (95% CI: 5.4–73.6); p = 0.74]. Upon multivariate analysis poor differentiation (HR 3.01; 95% CI 1.08–8.4; p = 0.035) and a Ki-67 index ≥10% (HR 4.4; 95% CI 1.2–16.1; p = 0.023) were significant predictors of survival.ConclusionsResection of the primary pancreatic tumour in metastatic nonfunctioning pancreatic endocrine carcinoma patients with unresectable liver metastases does not significantly improve survival. Resection can be considered as symptomatic palliative therapy in patients with well-differentiated endocrine carcinomas and a proliferative index lower than 10%.     

Preoperative systemic 5-fluorouracil does not increase the risk of liver resection

BACKGROUND/AIMS: The majority of patients who underwent surgery for colorectal liver metastases have been previously treated with 5-FU either as adjuvant chemotherapy or as a primary treatment. We have performed a retrospective study to assess whether this chemotherapy increases the risk of liver resection. METHODOLOGY: Mortality, morbidity and histology of the resected liver of two groups of patients having colorectal liver metastases who underwent major resection were studied. The first group included 17 patients who had received at least 2 courses of 5-FU chemotherapy within 3 months prior to liver resection. The second group included 18 patients who had received no chemotherapy and who were used as controls. RESULTS: Perioperative mortality was nil. Intraoperative blood loss during liver resection (1 +/- 2.5 vs. 1.2 +/- 2 units) was similar in the two groups. Changes of liver function tests on days 2 and 5 were similar in the two groups. Morbidity rate was similar in the two groups (29 vs. 22%) with a mean duration of postoperative hospital stay of 19 +/- 9 days in the 5-FU group and 16 +/- 6 days in the control group. Although 7 (41%) patients in the 5-FU group had an abnormal parenchyma consistency as compared to only 3 (17%) in the control group, the pathological findings within the resected specimen were not different. CONCLUSIONS: 5-FU based systemic chemotherapy does not increase the risk of liver resections.     

Missing metastases as a model to challenge current therapeutic algorithms in colorectal liver metastases

In oncosurgical approach to colorectal liver metastases, surgery remains considered as the only potentially curative option, while chemotherapy alone represents a strictly palliative treatment. However, missing metastases, defined as metastases disappearing after chemotherapy, represent a unique model to evaluate the curative potential of chemotherapy and to challenge current therapeutic algorithms. We reviewed recent series on missing colorectal liver metastases to evaluate incidence of this phenomenon, predictive factors and rates of cure defined by complete pathologic response in resected missing metastases and sustained clinical response when they were left unresected. According to the progresses in the efficacy of chemotherapeutic regimen, the incidence of missing liver metastases regularly increases these last years. Main predictive factors are small tumor size, low marker level, duration of chemotherapy, and use of intra-arterial chemotherapy. Initial series showed low rates of complete pathologic response in resected missing metastases and high recurrence rates when unresected. However, recent reports describe complete pathologic responses and sustained clinical responses reaching 50%, suggesting that chemotherapy could be curative in some cases. Accordingly, in case of missing colorectal liver metastases, the classical recommendation to resect initial tumor sites might have become partially obsolete. Furthermore, the curative effect of chemotherapy in selected cases could lead to a change of paradigm in patients with unresectable liver-only metastases, using intensive first-line chemotherapy to intentionally induce missing metastases, followed by adjuvant surgery on remnant chemoresistant tumors and close surveillance of initial sites that have been left unresected.     

Simultaneous surgery for primary colorectal cancer and metastatic lesions?

Approximately 20-25% of patients with colorectal cancer present with liver metastases at the time of diagnosis. Traditionally, resection of the primary tumor has been advocated in order to prevent complications of the primary tumor colorectal cancer in patients with synchronous liver metastases. The published data concerning long-term prognosis in this group of patients are discordant. Although some of the reports show survival benefits from resection of the primary tumor, these studies are retrospective with small number of patients and using single drug chemotherapy. For patients with resectable liver metastases, new studies indicate that progression-free survival is best in patients receiving perioperative chemotherapy. In patients with synchronous nonresectable liver metastases and colorectal cancer, there is no published prospective randomized study comparing initial surgery of the primary tumor with neoadjuvant chemotherapy. However, recent publications show that in patients receiving chemotherapy based on oxaliplatin or irinotecan combined with targeted treatments, the complications associated with the primary tumor are less than 10%. The conclusion should be that today prophylactic surgery of asymptomatic primary colorectal cancer in patients with liver metastases cannot be recommended.     

Preoperative systemic chemotherapy does not modify strategy of liver resection

BACKGROUND/AIMS: Most patients who undergo surgical resection of colorectal liver metastases have been previously treated with chemotherapy as adjuvant therapy or as a primary treatment. The aim of this retrospective study was to compare morbidity, mortality, liver function and histology of the liver specimens in patients undergoing colorectal liver metastases (CRLM) resection with and without a history of previous chemotherapy. METHODOLOGY: Records of 210 patients who underwent CRLM resection in our institution between January 1996 and March 2003 were retrospectively reviewed. We selected for further analysis medical charts of 40 patients who didn't receive a combined treatment concurrently to liver resection. Group I included 25 patients who did not receive adjuvant chemotherapy. Group II included 15 patients who received chemotherapy in the 3 months before liver resection. RESULTS: Postoperative mortality was 0% and 0.7% in group I and II respectively. Specific liver complications and pulmonary complications were similar in the two groups: 20% and 32% us. 33% respectively. The mean length of stay in the hospital was similar in the two groups (19 +/- 14 vs. 14 +/- 8). Changes of liver function test were similar in the two groups. Pathologic examination of liver specimens was not different in the two groups. CONCLUSIONS: Preoperative systemic chemotherapy didn't increase the risk of liver resection.     

Mortality and follow-up colonoscopy after colorectal cancer

OBJECTIVE: There have been no studies that demonstrate surveillance colonoscopy decreases mortality in patients with a history of colorectal cancer. The purpose of this study was to compare the mortality of patients with colorectal cancer who received at least one colonoscopy after their diagnosis with patients who had no further procedures after adjusting for age, race, chemotherapy, radiation therapy, and comorbidity using the national Veterans Affairs (VA) databases. METHODS: We studied a cohort of 3546 patients within the VA national databases with a new diagnosis of colorectal cancer during fiscal year 1995-1996. Patients with inflammatory bowel disease, metastatic disease at presentation, or who died within 1 yr of initial diagnosis were excluded. We collected data for demographics, comorbidities, colonoscopies, chemotherapy, and radiation therapy. The primary outcome was adjusted 5-yr mortality. RESULTS: In the adjusted analysis, the risk of death was decreased by 43% (hazard ratio = 0.57, 95% CI = 0.51-0.64) in the group who had at least one follow-up colonoscopy compared with patients who had no follow-up colonoscopies. CONCLUSIONS: This study strongly supports a mortality benefit for follow-up colonoscopy in patients with a history of nonmetastatic colorectal cancer.     

Prior radiation and/or chemotherapy has no effect on the outcome of metal stent placement for oesophagogastric carcinoma

OBJECTIVE: It is still unclear whether prior radiation and/or chemotherapy (RTCT) increases the risk of complications after the placement of self-expanding metal stents in patients with inoperable oesophagogastric carcinoma. We evaluated the influence of prior RTCT on the outcome of stent placement in a large group of patients. METHODS: From October 1994 to December 2000, 200 patients underwent placement of self-expanding metal stents for malignant dysphagia, and were followed prospectively. Forty-nine of these patients had received prior RTCT (chemotherapy n = 35, radiation therapy n = 8, or both n = 6). RESULTS: At 4 weeks after stenting, the dysphagia score had improved similarly in patients with or without prior RTCT, from a median of 3 to 0 (P < 0.001). The occurrence of major complications (bleeding, perforation, fistula formation, fever and severe pain) was not different between patients with or without prior RTCT (29% vs 21%; relative risk (RR) = 1.15 (95% CI 0.54-2.46; P = 0.72)), as was the occurrence of recurrent dysphagia due to tumour overgrowth, stent migration, or impaction of a food bolus (35% vs 27%; RR = 1.49 (95% CI 0.71-3.13; P = 0.29)). Median survival of both patient groups after stent placement was similar (110 vs 93 days; RR = 0.90 (95% CI 0.60-1.34; P = 0.60) for prior RTCT versus no prior treatment). Only minor complications (mainly mild retrosternal pain) occurred more frequently in patients with prior RTCT (41% vs 15%; RR = 2.12 (95% CI 1.06-4.25; P = 0.035)). CONCLUSIONS: Both the incidence of life-threatening complications and survival after placement of self-expanding metal stents for oesophagogastric carcinoma are not affected by prior RTCT, but retrosternal pain occurs more frequently in patients who had previously undergone RTCT.     

Neoadjuvant therapy for patients with borderline resectable pancreatic cancer: A systematic review and meta-analysis of response and resection percentages

BackgroundWe systematically reviewed and performed a meta-analysis of the available data regarding neoadjuvant chemo- and/or radiotherapy with special emphasis on tumor response/progression rates, toxicities, and clinical benefit, i.e. resection probabilities and survival estimates.Methods and findingsTrials were identified by searching PUBMED, MEDLINE, and the Cochrane Central Register of Controlled Trials from 1966 to Feb 2015. A total of 18 studies (n = 959) were analyzed. the estimated fraction of patients with complete response was 2.8% (CI 0.8–4.7%) and with partial response 28.7% (CI 18.9%–38.5%). Stable disease was averaged to 45.9% (CI 32.9%–58.9%) in all patients and tumor progression under therapy occurred by estimation in 16.9% (CI 10.2%–23.6%) of the patients. The weighted frequency of those who underwent resection was 65.3% (CI 54.2%–76.5%), and the proportion of R0 resection amounted to 57.4% (CI 48.2%–66.5%). The weighted mean of median survival amounted to 17.9 months (range: 14.7–21.2 months) for the overall cohort of patients, 25.9 months (range: 21.1–30.7 months) for those who were resected, and 11.9 months (range: 10.4–13.5 months) for unresected patients.ConclusionsThe resection and R0 resection rates in the group of borderline resectable tumor patients after neoadjuvant therapy are similar to the resectable tumor patients, much higher than those in unresectable tumor patients. The survival estimates of borderline resectable tumor patients after neoadjuvant therapy were similar to resectable tumor patients. Patients with borderline resectable pancreatic cancer should be included in neoadjuvant protocols and subsequently be reevaluated for resection. How to find chemo-responsiveness before neoadjuvant chemotherapy so as to give individualized treatment is still an important issue.     

Synchronous resection of colorectal cancer primary and liver metastases: an outcomes analysis

BackgroundConcurrent resection of the primary cancer and synchronous colorectal cancer liver metastases (CRCLM) was evaluated for differences in outcomes following stratification of both the liver and colorectal resection.MethodsConsecutive cases of synchronous resection of both the CRC primary and CRCLM were reviewed retrospectively at a single, high-volume institution over a 17-year period (2000–2017).Results273 patients underwent simultaneous resection of CRCLM. The distribution of the primary lesion was similar between the colon (52.4%) and rectum (47.6%), while 46.9% of patients had bilobar liver disease. Major liver/major colorectal resection (n = 24) were significantly more likely to experience colorectal specific morbidity (OR 3.98, 95% CI 1.56–10.15, p = 0.004), liver specific morbidity (OR 7.4, 95% CI 2.22–24.71, p = 0.001), total morbidity (OR 2.91, 95% CI 1.18–7.18, p = 0.020) and 90-day mortality (OR 5.50, 95% CI 1.27–23.81, p = 0.023). Failure to receive adjuvant chemotherapy secondary to postoperative morbidity was associated with significantly worsened survival (HR for death 5.91, 95% CI 1.59–22.01, p = 0.008).ConclusionsPostoperative morbidity precluding the administration of adjuvant chemotherapy is associated with an increase in mortality. Combining a major liver with major colorectal resection is associated with a significant increase in major morbidity and 90-day mortality, and should be avoided.     

Chemotherapy alone versus surgery followed by chemotherapy for stage I/IIE large-cell lymphoma of the stomach

The optimal treatment of localized large-cell lymphoma of the stomach remains controversial. In particular, the role of surgical resection of the primary tumor needs to be clearly defined. We have reviewed all patients with a diagnosis of gastric lymphoma and treated in our institutions between 1988 and 1998. Patients fulfilling the following criteria were included in this study: (1) histologically proven large-cell lymphoma of the stomach; (2) adequate pathological materials and complete clinical information for analysis; (3) clinical stage I/II disease according to the Musshoff modification of Ann Arbor system; and (4) received primary chemotherapy alone with anthracycline- or anthracenedione-containing regimens (group A) or curative surgery followed by adjuvant chemotherapy (group B). There were 38 and 21 patients in group A and group B, respectively. All pertinent clinicopathologic features were similar between the two groups of patients, except that patients of group A had significantly more stage II-2 disease (P = 0.004). Of group A, among 36 patients who could be evaluated for response to chemotherapy, there were 29 complete and 1 partial responses, with an overall response rate of 83.3% (95% CI, 71.1-95.5%). The projected 5-year relapse-free survival (RFS) and overall survival (OS) were 86.0% (95% CI, 73.3-98.7%) and 72.6% (95% CI, 57.0-88.2%), respectively. On the other hand, the projected 5-year RFS and OS of group B were 77.9% (95% CI, 58.0-97.8%) and 77.8% (95% CI, 57.9-97. 7%), respectively, not significantly different from that of group A. Our data suggest that systemic chemotherapy alone may be a reasonable alternative treatment for stage I/II large-cell lymphoma of the stomach. Resection of the primary tumor before systemic chemotherapy does not appear to improve the cure rate of this group of patients.     

洛铂用于结直肠癌术中腹腔灌洗化疗的近期疗效分析

目的探讨洛铂用于结直肠癌术中腹腔灌洗化疗的安全性和可行性。 方法选取中国医学科学院肿瘤医院结直肠外科在2016年11月1日至2017年11月1日行结直肠癌根治术的患者160例,采用随机数余数分组法前瞻性随机分为洛铂灌洗化疗组（研究组）80例和无腹腔化疗组（对照组）80例,研究组术中行洛铂腹腔灌洗化疗,对照组不行腹腔化疗。分析两组术后肠道功能恢复、血液和肝肾功能毒性以及术后并发症等近期疗效的差异。 结果研究组和对照组术后总并发症发生率相似,分别为11.2%和12.5%（χ²=0.060,P=0.807）。两组患者术后肠道功能恢复状况、白细胞和血小板水平以及术后出现肝肾功能异常、消化道反应患者数量之间差异也均无统计学意义（均P>0.05）。 结论洛铂术中腹腔灌洗化疗并不增加结直肠癌患者毒副反应及术后并发症,具有良好的安全性和可行性。     

结直肠癌同时性肝转移患者原发灶切除的预后分析

目的 原发灶切除能否使结直肠癌肝转移患者生存获益,目前仍有争议.本研究探讨接受原发灶切除结直肠癌肝转移患者的生存状况及预后的影响因素.方法 回顾性分析2010年1月～2018年2月在国家癌症中心/中国医学科学院肿瘤医院治疗的371例结直肠癌同时性肝转移患者的病例资料.根据治疗方式分为单纯化疗组和原发灶切除组,分析两组患...     

Meta-analysis and systematic review of colorectal endoscopic mucosal resection

AIM： To evaluate the proportion of successful complete cure en-bloc resections of large colorectal polyps achieved by endoscopic mucosal resection （EMR）. METHODS： Studies using the EMR technique to resect large colorectal polyps were selected. Successful complete cure en-bloc resection was defined as one piece margin-free polyp resection. Articles were searched for in Medline, Pubmed, and the Cochrane Control Trial Registry, among other sources. RESULTS： An initial search identified 2620 reference articles, from which 429 relevant articles were selected and reviewed. Data was extracted from 25 studies （n = 5221） which met the inclusion criteria. All the studies used snares to perform EMR. Pooled proportion of en-bloc resections using a random effect model was 62.85% （95% CI： 51.50-73.52）. The pooled proportion for complete cure en-bloc resections using a random effect model was 58.66% （95% CI： 47.14-69.71）. With higher patient load （〉 200 patients）, this complete cure en-bloc resection rate improves from 44.19% （95% CI： 24.31-65.09） to 69.17% （95% CI： 51.11-84.61）. CONCLUSION： EMR is an effective technique for the resection of large colorectal polyps and offers an alternative to surgery.     

Storage time of transfused blood and disease recurrence after colorectal cancer surgery

BACKGROUND: Perioperative blood transfusion and subsequent development of postoperative infectious complications may lead to poor prognosis of patients with colorectal cancer. It has been suggested that the development of postoperative infectious complications may be related to the storage time of the transfused blood. Therefore, we studied the relationship between blood storage time and the development of disease recurrence and long-term survival after colorectal cancer surgery. METHODS: Preoperative and postoperative data were prospectively recorded in 740 patients undergoing elective resection for primary colorectal cancer. None of the patients received preoperative or postoperative chemotherapy or radiation therapy. Endpoints were overall survival and disease recurrence in the subgroup of patients operated on with curative intention who also survived the first 30 days after operation. Storage of buffy-coat-depleted red cells suspended in saline, adenine, glucose, and mannitol blood for 21 days was used as cut-off point. RESULTS: Median follow-up was 6.8 years (range, 5.4 years to 7.9 years), and median overall survival was 4.6 years for 288 nontransfused patients and 3.0 years for 452 transfused patients (P = 0.004). The survival of patients receiving blood exclusively stored < 21 days was 2.5 years. For patients receiving any blood stored > or = 21 days, survival was 3.7 years (P = 0.12). Among patients with curative resection (n = 532), the hazard ratio of disease recurrence was 1.5 (95 percent CI; 1.1 to 2.2) and 1.0 (95 percent CI; 0.7 to 1.4) in the two transfused groups, respectively, compared with the nontransfused group after multivariable correction for patient age, gender, colonic/rectal tumor localization, Dukes classification, blood loss, and postoperative infectious complications. CONCLUSION: Transfusion of buffy-coat-depleted red cells suspended in saline, adenine, glucose, and mannitol blood stored for < 21 days may be an independent risk factor for development of recurrence after elective colorectal cancer surgery.     

Factores de riesgo y tratamiento endoscópico para estenosis de anastomosis posterior a resección en pacientes con cáncer colorrectal

IntroductionBenign strictures are frequent complications following colorectal surgery, with an incidence of up to 20%. Endoscopic treatment is safe and effective but there is not enough evidence for establishing stricture management at that anatomic level.AimTo determine the risk factors associated with the development of stricture in patients with colorectal cancer and describe endoscopic treatment in those patients.Materials and methodsA retrospective study was conducted on patients with colorectal cancer that underwent surgery and anastomosis, evaluated through colonoscopy, within the time frame of 2014 to 2019.ResultsOf the 213 patients included in the study, 18.3% presented with stricture that was associated with the type of surgery. Intersphincteric resection was a risk factor (OR = 18.81, 95% CI: 3.31-189.40, p < .001). A total of 69.2% patients with stricture had a stoma, identifying it as a risk factor for stricture (OR = 7.07, 95% CI: 3.10-16.57, p < .001). Mechanical anastomotic stapling was performed in 87.4% of the patients that did not present with stricture, identifying it as a protective factor (OR = 0.41, 95% CI: 0.16-1.1, p = .04). Endoscopic treatment was required in 69.2% of the patients and provided favorable results in 83.3%. Only 2.6% of the patients had recurrence. No complications were reported.ConclusionIntersphincteric resection and the presence of a stoma were independent risk factors for stricture, and mechanical anastomosis was a protective factor against stricture development. Endoscopic treatment was safe and effective.     

Recurrence after microwave ablation of liver malignancies: a single institution experience

BackgroundMicrowave ablation (MWA) is increasingly used to achieve local control for liver tumours. This study sought to examine a monocentric experience with MWA, with a primary hypothesis that primary tumour histology was a significant predictor of early recurrence.MethodsRetrospective single‐institution review identified consecutive patients with liver tumours treated by MWA. Cox proportional hazards models assessed significance of prognostic variables.ResultsSeventy‐two patients (43 female, 60%) underwent 83 MWA procedures for 157 tumours. Tumour histologies included hepatocellular cancer (10 operations), colorectal metastases (39), metastatic carcinoid (20) and other (14). The median tumour size was 2.0 cm. A concomitant liver resection was performed in 50 cases (60%). Crude peri‐operative morbidity and mortality rates were 16% and 1%, respectively. The median follow‐up was 16 months. Ablations were complete for 149 out of 157 tumours (95%). The median overall and recurrence‐free survivals were 36 and 18 months, respectively. There was no difference in time to recurrence between the primary tumour types. In multivariable models, recurrence‐free survival was independently associated with the use of neoadjuvant [hazard ratio (HR): 2.90, 95% confidence interval (CI): 1.09–7.76, P = 0.034] and adjuvant chemotherapy (HR: 0.36, 95% CI: 0.15–0.82, P = 0.016).ConclusionsMWA is a safe and feasible approach for local control of liver tumours. While chemotherapy administration was associated with time to recurrence after MWA, larger studies are needed to corroborate these findings.     

Intestinal perforation in Crohn's disease. Factors predictive of surgical resection

New medical therapeutic options challenge the usual surgical management of Crohn's disease patients with intestinal perforation. OBJECTIVES: To determine factors predictive of surgery for perforation in Crohn's disease and define a group of patients that may benefit from non-surgical treatment. METHODS: One hundred and sixty-two patients (69 males, 93 females, mean age 39) with perforated Crohn's disease (fistula, abscess, inflammatory mass) between January 1995 and September 2003 were studied retrospectively. RESULTS: One hundred and fifty-one patients (93%) underwent surgery: 70 had planned surgery and 81 had surgery for symptomatic deterioration. At two years, the cumulative probability of intestinal resection was 0.89 +/- 0.03, and the cumulative probability of unplanned intestinal resection was 0.72 +/- 0.05. Predictive factors of unplanned surgery were elevated platelet count (adjusted hazard ratio 3.15; 95% CI 2.21-4.50) and absence of fistula (adjusted hazard ratio 3.14; 95% CI 2.48-3.99). The rate of postoperative complications, the need for a stoma, and the length of bowel resection were not significantly different whether the surgery was planned or not. CONCLUSION: A significant proportion of patients with intestinal perforation complicating Crohn's disease, particularly those with a fistula, might benefit from non-surgical treatment.     

Mini-invasive vs open resection of colorectal cancer and liver metastases: A meta-analysis

BACKGROUND The safety and feasibility of the simultaneous resection of primary colorectal cancer (CRC) and synchronous colorectal liver metastases (SCRLM) have been demonstrated in some studies. Combined resection is expected to be the optimal strategy for patients with CRC and SCRLM. However, traditional laparotomy is traumatic, and the treatment outcome of minimally invasive surgery (MIS) is still obscure. AIM To compare the treatment outcomes of MIS and open surgery (OS) for the simultaneous resection of CRC and SCRLM. METHODS A systematic search through December 22, 2018 was conducted in electronic databases (PubMed, EMBASE, Web of Science, and Cochrane Library). All studies comparing the clinical outcomes of MIS and OS for patients with CRC and SCRLM were included by eligibility criteria. The meta-analysis was performed using Review Manager Software. The quality of the pooled study was assessed using the Newcastle-Ottawa scale. The publication bias was evaluated by a funnel plot and the Begg’s and Egger’s tests. Fixed- and random-effects models were applied according to heterogeneity. RESULTS Ten retrospective cohort studies involving 502 patients (216 patients in the MIS group and 286 patients in the OS group) were included in this study. MIS was associated with less intraoperative blood loss [weighted mean difference (WMD)=-130.09, 95% confidence interval (CI):-210.95 to -49.23, P = 0.002] and blood transfusion [odds ratio (OR)= 0.53, 95%CI: 0.29 to 0.95, P = 0.03], faster recovery of intestinal function (WMD =-0.88 d, 95%CI:-1.58 to -0.19, P = 0.01) and diet (WMD =-1.54 d, 95%CI:-2.30 to -0.78, P < 0.0001), shorter length of postoperative hospital stay (WMD =-4.06 d, 95%CI:-5.95 to -2.18, P < 0.0001), and lower rates of surgical complications (OR = 0.60, 95%CI: 0.37 to 0.99, P = 0.04). However, the operation time, rates and severity of overall complications, and rates of general complications showed no significant differences between the MIS and OS groups. Moreover, the overall survival and disease-free survival after MIS were equivalent to those after OS. CONCLUSION Considering the studies included in this meta-analysis, MIS is a safe and effective alternative technique for the simultaneous resection of CRC and SCRLM. Compared with OS, MIS has less intraoperative blood loss and blood transfusion and quicker postoperative recovery. Furthermore, the two groups show equivalent long-term outcomes.     

Effect of successful late reperfusion by primary coronary angioplasty on mechanical complications of acute myocardial infarction

It has been suggested that early treatment decreases, but late treatment increases, the risk of mechanical complications for a thrombolytic strategy. However, few studies have evaluated whether late reperfusion by primary coronary angioplasty decreases the risk of mechanical complications. A total of 2,209 patients with acute myocardial infarction treated with primary coronary angioplasty within 24 hr after the onset of symptoms were divided into three groups: early reperfusion (ER; <- 12 hr, n = 1,647), late reperfusion (LR; > 12 hr, n = 219), and failed reperfusion (RF; n = 343). We evaluated the incidence, risk ratio, and predictors of mechanical complication. The overall incidence of mechanical complications was 2.0%. The incidence of mechanical complications was highest in the FR group (ER 1.4%, LR 1.8%, FR 5.0%, p <0.01). After adjusting for clinical variables, the risk ratio for mechanical complications increased in the FR group compared with LR group [risk ratio 7.34, 95% confidence interval (CI) 1.02 - 52.80, p = 0.04]. Predictors of an increased risk of mechanical complications by multivariate analysis were age >- 70 years (odds ratio 3.68, 95% CI 1.56-8.64, p < 0.01), Killip class >- II (odds ratio 3.73, 95% CI 1.52-9.12, p >- 0.01), absence of collateral vessels (odds ratio 4.09, 95% CI 1.17-14.26, p = 0.03), and FR (odds ratio 2.68, 95% CI 1.01-6.61, p = 0.03). In conclusion, successful late reperfusion by primary coronary angioplasty is associated with the reduced risk of mechanical complications in patients with acute myocardial infarction.