Polyp surveillance after surgery for colorectal cancer

Purpose

Although it is known that those patients who have developed colorectal cancer (CRC) are at a higher risk to develop metachronous adenoma or CRC, no study has been performed to analyze the relationship between the risk factors and the time course for the formation of postoperative adenoma using survival analysis.

Methods

One hundred seventy-six patients with CRC, who had received surgical resection, were endoscopically followed-up to detect the development of metachronous adenoma or adenocarcinoama. The association between the risk factors such as age, synchronous adenomas with index CRC or other clinicopathological variables and the formation of postoperative adenoma was assessed using the logrank test and the Cox proportional hazard model.

Results

Age over 60, synchronous lesions at the time of surgery for primary CRCs and presence of diabetes mellitus (DM) as the associated disease were positively related to the formation of postoperative adenoma. Among those patients with the three risk factors, only 27.8% remained adenoma-free during 5?years after operation, whereas in the group without any risk factor, it was 90.4%.

Conclusions

From our data, age over 60, synchronous adenomas or CRCs and DM were the potential risk factors for the postoperative formation of adenoma or CRC, and they should be taken into consideration when defining the appropriate interval of postoperative colonoscopy.     

Colon surveillance after colorectal cancer surgery

PURPOSE: This study was performed to determine costeffective colonoscopy guidelines for patients with prior colorectal adenocarcinoma. METHOD: A retrospective review was performed of patients who had been treated for colorectal adenocarcinoma and later underwent follow-up colonoscopy from 1984 to 1994. RESULTS: During this study period, 389 patients previously treated for colorectal adenocarcinoma underwent follow-up colonoscopy. All patients had perioperative colon evaluation for other neoplasms. Ages ranged from 26 to 89 (mean, 65.8) years, and 46.8 percent were female. Recurrent or metachronous cancer or a neoplastic polyp constituted a positive examination. Results of 389 first follow-up colonoscopies were compared with 259 second (66.6 percent), 165 third (42.4 percent), and 83 fourth (21.3 percent) follow-up examinations. Median interval between all colonoscopies was 13 months. Positive examination rates for the first two yearly examinations were 18.3 and 18.5 percent, respectively. Slightly lower, third-year and fourth-year positive examination rates were 16.4 and 14.5 percent, respectively. Fouryear examinations yielded the following: first year-1 carcinoid, 1 new adenocarcinoma, and 100 polyps; second year-1 anastomotic recurrence and 68 polyps; third year-55 polyps; and fourth year-1 recurrent cancer and 17 polyps. CONCLUSIONS: These data suggest that 1) annual follow-up colonoscopy for two years after colorectal cancer surgery is beneficial for detecting recurrent and metachronous neoplasms and 2) the interval between subsequent examinations may be increased depending on the result of the most recent examination.Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

大肠癌术后患者结肠镜随访检查的意义

目的 通过大肠镜检查在临床的广泛应用,防止和降低多原发大肠癌的发生.方法 分析1986年6月至2007年6月大肠癌外科术后进行无症状定期结肠镜随访2762例患者的资料,随访方法为术后3～6个月内首次肠镜检查,以后每年1次,连续3年.并与1981年9月至1986年5月大肠癌术后有症状者结肠镜复查的218例资料进行对比.结果 2762例中发现多原发癌48例,其中同时多原发癌39例(1.4%),异时多原发癌9例(0.3%);TNM分类Ⅰ期癌6例,Ⅱ期癌31例,Ⅲ期癌11例.发现腺瘤583例(21.1%),病理检查证实17例(3.2%)为浸润性早期癌,58例(9.9%)为高级别上皮内瘤变.218例有症状检查者共发现多原发癌27例(12.4%),明确Ⅰ期癌4例,Ⅱ期癌6例,Ⅲ期癌16例.发现腺瘤29例(13.3%).结论 无症状定期结肠镜随访检查发现多原发癌明显低于有症状者,发现的早期癌、腺瘤比例高,说明无症状定期检查,能防止和降低多原发大肠癌的发生.     

Predictive factors by multivariate analysis for colorectal cancer in Malaysian patients undergoing colonoscopy

BACKGROUND: The majority of colorectal cancers are still diagnosed in patients who present with symptoms especially in countries where colorectal screening programs are not practised. The aim of our study was to determine the predictive factors for colorectal cancer in patients referred for colonoscopy. METHODS: A prospective study of 485 consecutive patients who underwent colonoscopy during a 22-month period was performed. All patients answered a detailed questionnaire. Indications for colonoscopy and the findings were recorded. RESULTS: The mean age of the study population was 55.7 +/- 14.7 years. There were 221 (45.6%) males and 264 (54.4%) females. Sixty-five (13.4%) were Malays, 298 (61.4%) were Chinese and 112 (23.1%) were Indians. Multiple backward stepwise regression analysis revealed that independent predictors for colorectal cancer (odds ratio [95% CI]) were the presence of rectal bleeding (4.3 [4.0-8.0]) and iron deficiency anemia (4.0 [3.6-10.2]). In those aged 50 and over, male gender (4.5 [2.2-9.3]) and abdominal pain (3.1 [1.4-6.7]) were also significant positive predictors of cancer. CONCLUSIONS: With the ever-increasing demand for gastrointestinal endoscopy, the appropriate utilization of colonoscopy is essential to afford prompt patient evaluation. Our study supports the need to prioritize the use of colonoscopy in patients with rectal bleeding and iron deficiency anemia. In the older patient where the background prevalence of colorectal cancer is higher, referral for colonoscopy is also justified.     

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery

Every colorectal surgeon during his or her career is faced with anastomotic leakage(AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.     

Colorectal cancer after surveillance colonoscopy

PURPOSE: Colonoscopy is the preferred method for colorectal cancer surveillance of high-risk patients. Despite its high sensitivity, polyps or cancers may be undetected by colonoscopy and later attributed to an accelerated adenoma-carcinoma sequence. This study assesses how the characteristics of colorectal cancers found at intervals between surveillance relate to the adenoma-carcinoma sequence and its prevention. METHODS: The records of 557 patients with colorectal cancer that were diagnosed from January 1, 1990, to December 31, 1996, were reviewed to identify those patients who had prior colonoscopic surveillance within 60 months of their diagnosis. RESULTS: There were 29 (5.2 percent) patients who had one or more colonoscopies before diagnosis of their colorectal cancer. Mean interval between diagnosis and prior colonoscopy was 23 (range, 4–59) months. The distribution of cancers included nine cecum, two ascending, three hepatic flexure, five transverse, one splenic flexure, three descending, two sigmoid, three rectum, and one anal canal. The mean tumor size was 4.4 cm for the cecum and 2.4 cm for all other locations. There were 7 Tis, 6 T1, 4 T2, and 12 T3 lesions. Six patients with T3 lesions had prior colonoscopies within 24 months of the diagnosis. Three of four patients with lymphatic metastases had tumors in the cecum. Twenty tumors (69 percent) were well or moderately differentiated. Mean follow-up was 41 (range, 7–95) months with two local recurrences and two unrelated deaths. CONCLUSIONS: Size, differentiation, and stage of colorectal cancer in addition to the interval to diagnosis suggest that the majority of cancers found during surveillance colonoscopy followed prior false-negative examinations. Because cecal landmarks are most constant, prior photographic documentation may help to prove or disprove fast growth of cancers found in the cecum during surveillance colonoscopy.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Value of postoperative surveillance after radical surgery for colorectal cancer

PURPOSE: Early detection of recurrence after curative resection for primary colorectal cancer should improve patients' prognosis. However, the usefulness of postoperative surveillance programs has not been clarified yet. The present cohort study was aimed at assessing the effectiveness of systematic follow-up in patients with colorectal cancer who were operated on for cure, regarding both rate of tumor recurrence amenable to curative-intent surgery and rate of survival. METHODS: One hundred ninety-nine colorectal cancer patients who underwent radical primary surgery were followed according a well-defined postoperative surveillance program, which consisted of laboratory studies (including serum carcinoembryonic antigen assay) every three months, physical examination and abdominal ultrasound or computed tomography every six months, and chest radiograph and total colonoscopy once per year. Cohorts were defined according to patients' compliance with the proposed follow-up program. A multivariate regression model was constructed to predict survival. RESULTS: One hundred forty patients were considered to be compliant with the surveillance program, whereas the remaining 59 patients occasionally attended follow-up investigations or did not comply at all. Although there were no differences in the overall recurrence rate (38vs. 41 percent;P=0.52), curative-intent reoperation was possible in 18 patients (34 percent) of those with tumor recurrence in the compliant cohort but in only 3 patients (12 percent) in the noncompliant cohort (P=0.05). Similarly, the probability of survival was higher in the compliant cohort, both regarding overall (63vs. 37 percent at 5 years;P<0.001) and cancer-related (69vs. 49 percent at 5 years;P<0.02) rates. Cox regression analysis disclosed that only a more advanced TNM stage (odds ratio, 8.17; 95 percent confidence interval, 1.13–59.29) and noncompliance with the postoperative surveillance program (odds ratio, 2.32; 95 percent confidence interval, 1.50–3.60) had an independent negative impact on survival. CONCLUSION: Systematic postoperative surveillance in patients with colorectal cancer who were operated on for cure increases both the rate of tumor recurrence amenable to curative-intent surgery and rate of survival.Supported in part by grants from the Agència d'Avaluació de Tecnologia Mèdica de la Generalitat de Catalunya (2/6/96), the Fondo de Investigaciones Sanitarias de la Seguridad Social (96/0240), and the Marató TV3-Càncer (95/3008).Presented in part at the meeting of the American Gastroenterological Association, Washington, D.C., May 11 to 14, 1997.     

Predictive factors for conversion in laparoscopic colorectal surgery

BACKGROUND: Although laparoscopic colon and rectal surgery can be safely performed in the hands of well-trained surgeons, criteria for patient selection should be further developed in order to decrease the conversion rate. The main objective of this study was to identify predictive factors for conversion of laparoscopic colorectal surgery to an open procedure based on statistical analysis. METHODS: A retrospective survey was performed using data collected from 400 patients who underwent laparoscopic colorectal surgery between March 2000 and December 2006. As potential predictive factors for conversion, we considered demographic characteristics, surgery-related variables and disease-related variables. Univariable analysis was performed to identify individual predictive risk factors for conversion. Factors with p values below 0.05 were included in a regression model. RESULTS: Conversion to open surgery was required in 51 patients (12.7%). Age (>65 years) was the only independent predictive demographic factor (OR=2.3; 95% CI, 1.25-4.46). Low anterior resection (OR=3.9; 95% CI, 1.64-9-18) and complicated diverticulitis (OR=3.9; 95% CI, 1.64-9.18) were also predictive factors. The only predictive factor evidenced in the multivariate analysis was complicated diverticulitis (OR=159.99; 95% CI, 41.02-624.02). Indications for conversion were: adhesions in 53% of the patients, technical problems in 18%, bleeding in 1%, and other indications for the remaining 28%. CONCLUSION: Complicated diverticulitis or cancer of the rectum treated by low anterior resection have higher probabilities of conversion.     

Haemoccult does not reduce the need for colonoscopy in surveillance after curative resection for colorectal cancer.

Patients who had undergone curative resection for colorectal cancer were studied to compare the efficacy of faecal occult blood detection (Haemoccult test) with colonoscopy in the detection of metachronous tumours. Fifty nine patients were studied and both Haemoccult testing and colonoscopy were successfully completed in 54 patients. In 37 patients, both tests were negative. One patient with a positive Haemoccult test had no colonoscopic abnormality and remains alive and well two years later. There were, however, 16 patients with negative Haemoccult tests in whom an abnormality was found on colonoscopy. In four patients, one Dukes's A cancer and seven tubulovillous adenomas were found--all neoplastic lesions that would have been missed if surveillance had been by Haemoccult alone.     

Chromoendoscopic colonoscopy for detecting preneoplastic lesions in hereditary nonpolyposis colorectal cancer syndrome.

BACKGROUND & AIMS: In hereditary nonpolyposis colorectal cancer (HNPCC) syndrome, flat and small adenomas are particularly prone to malignant transformation but might be missed by standard colonoscopy. We prospectively studied the diagnostic yield of high-resolution colonoscopy coupled with chromoendoscopy for preneoplastic and neoplastic colorectal lesions in patients with HNPCC syndrome. METHODS: Thirty-six consecutive asymptomatic patients (mean age, 42 years) belonging to HNPCC families and receiving genetic counseling were enrolled in this prospective study. Colonoscopy was performed in 2 steps. Conventional colonoscopy was performed first, followed by a second colonoscopy with chromoendoscopy with indigo carmine (.4%) dye sprayed onto the entire proximal colon. RESULTS: Conventional colonoscopy identified 25 lesions (mean size, 4 +/- 3 mm) in 13 patients. Seven lesions, detected in 5 patients, were adenomas, 3 of which were located in the proximal colon. Chromoendoscopy identified additional 45 lesions (mean size, 3 +/- 1 mm) in 20 patients; most of these lesions were flat and hyperplastic. Eleven additional adenomas were detected in the proximal colon of 8 patients, and 8 of these 11 lesions were flat. The use of chromoendoscopy significantly increased the detection rate of adenomas in the proximal colon, from 3 of 33 patients to 10 of 33 patients (P = .045). CONCLUSION: Relative to conventional colonoscopy, high-resolution colonoscopy with chromoendoscopy markedly improves the detection of adenomas in patients with HNPCC syndrome and might help to prevent colorectal carcinoma in these patients with a very high risk of colorectal cancer.     

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.     

Predictive factors for response to chemotherapy in colorectal cancer patients

Colorectal cancer represents a major health problem in the western world. A lot of drugs have been employed in treatment of this disease, but only few data are available about predictive factors for response to anticancer treatments in colorectal cancer. Aim of this paper is to review the main data about this investigation field. Using a Medline database search (1966-2003) we reviewed all the relevant papers that investigate clinical and molecular predictors for response to the main drugs used in the treatment of colorectal cancer patients, both in adjuvant and in advanced setting. Moreover we comprehensively reviewed all the data published in abstract form during the most significant international meetings. Our review put in evidence the most important predictive factors for response in colorectal cancer patients treated with anticancer chemotherapy both in adjuvant and in advanced setting. The predictive factors are clustered on the basis of the different anticancer drugs. The results of this review provide the rationale basis for personalizing anticancer treatment in colorectal cancer patients by molecular and clinical features, aiming to improve response rate and reduce toxicities.     

Survival of elderly persons undergoing colonoscopy: implications for colorectal cancer screening and surveillance

BACKGROUND: In the elderly, the increased prevalence of colorectal neoplasia and the protective effect of colonoscopy may be offset by advancing age and comorbidity. OBJECTIVE: To describe and quantify the endoscopic findings, survival, and predictors of mortality of elderly persons after colonoscopy. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of persons aged>or=75 years who underwent colonoscopy in 1999 and 2000 at a U.S. Veterans Affairs facility and urban county hospital. MAIN OUTCOME MEASURES: Advanced neoplasms were defined as colorectal cancer (CRC), polyp with high-grade dysplasia, villous histologic features, or tubular adenoma>or=1 cm. Comorbidity was measured with the Charlson comorbidity index. Subjects were followed until death or study closure. RESULTS: Of 469 eligible subjects, 65 were excluded and 404 were included in the study. Fifty-nine of 404 (15%) had an advanced neoplasm, including 8 (2%) with CRC. There were 167 deaths (41%); the mean overall survival was 4.1+/-0.1 years (median 5.95 years). A symptomatic indication for colonoscopy was not predictive of death. Mortality was predicted by age (hazard ratio 1.16 for each year increase beyond age 75 years, 95% CI 1.07-1.3, P=.0003) and Charlson score (hazard ratio 8.3 for each point increase, 95% CI 1.4-48.5, P=.02). The median survival of patients aged 75 to 79 years was >5 years if the Charlson score was or=80 years, the median survival was <5 years regardless of Charlson score. LIMITATIONS: Retrospective design. CONCLUSIONS: In this cohort of elders, age and comorbidity were predictors of death. The protective effect of younger age lessens as comorbidity increases. These findings may have important implications for CRC screening and surveillance in elders.