Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends

BACKGROUND: In adenocarcinoma of the colon and rectum, obstruction and perforation may occur either alone or together at the site of the neoplasm or proximally. Both events carry a poor prognosis. This retrospective study sought to determine whether a correlation exists between perforation and obstruction, and between these conditions and different clinicopathological factors in colorectal adenocarcinoma. METHODS: The medical records of 1950 patients with colorectal adenocarcinoma treated in our hospital during a 7-year period were retrospectively analyzed. One hundred patients (5%) were excluded from this study because of a loss of follow-up. Data on clinicopathological factors including age, sex, tumor location, surgical mortality, pathological type, stage, and long-time cancer-free rate were simultaneously analyzed. Patients were grouped as follows: Group 1, complete colonic obstruction without perforation (n = 120). Group 2, complete obstruction with perforation at the site of the cancer (n = 35); Group 3, complete obstruction with perforation proximal to the cancer (n = 13); and Group 4, nonobstructing, nonperforated cancers (n = 1682). RESULTS: When compared with Group 4, Group 1 had a more advanced Dukes' stage, older age, greater incidence of colonic versus rectal cancers, and a poorer cancer-free survival (P < or = .005). Groups 2 and 3 had a greater incidence of colonic versus rectal cancers (P < or = .004), and Group 3 had a greater operative mortality (P < .001). No significant differences were found between Groups 1, 2, and 3. Multivariate analysis revealed that the independent factors favorable to cancer-free survival (> 5-year survival) were female gender (P = .035), well-differentiated pathology (P < .001), uncomplicated cases (P = .004), colon versus rectal location (P < .001), and early stage (P < .001). CONCLUSIONS: The perioperative mortality rate for perforated colorectal cancer at the site of the cancer was 9%; for obstructive colorectal cancer, 5%. Perioperative mortality was much greater for perforations of the colon and rectum occurring proximal to the cancer (31%). Survival was worse (P < .001) for patients with obstruction (33%) or perforation proximal to the cancer (33%). The site of perforation did not appear to impact the 5-year survival, although the numbers are relatively small.     

Differences between proximal and distal obstructing colonic cancer after curative surgery

Aim To study any possible differences in morbidity, mortality and overall survival rate after curative surgery for obstructive colon cancer according to tumour location. Method From January 1994 to December 2006, patients with colonic cancer presenting as obstruction were analysed. The two groups were defined as proximal and distal according to the tumour location with respect to the splenic flexure. In relation to the surgeon specialization, patients were operated on by a colorectal surgeon and by a general surgeon. Postoperative morbidity and mortality and cancer‐related survival at 3 years were analysed. Results Of the 377 patients included in the study, there were 173 patients (45.9%) in the proximal group and 204 patients (54.1%) in the distal group. The global morbidity was 54.9% without differences in postoperative morbidity except for anastomotic leakage, which was higher in the proximal group (P < 0.014). No differences in postoperative mortality were observed. After patients were stratified by the tumour node metastasis system, the differences between the groups, with respect to 3‐year overall survival, cancer‐related survival and probability of being free from recurrence, did not reach statistical significance. The overall survival after radical surgery for colonic obstruction was 57.6%. Conclusion Mortality and morbidity after emergency surgery for obstructing colon cancer are high. Specialization in colorectal surgery influences postoperative results in terms of lower anastomotic dehiscence rate after emergency proximal colon resection. After radical surgery, tumour location does not appear to influence the prognosis of obstructive colon cancer.     

Acute colonic perforation associated with colorectal cancer

Our purpose was to evaluate long-term outcome in patients presenting with acute colonic perforation in the setting of colorectal cancer. We conducted a retrospective review of 48 consecutive patients presenting with acute colonic perforation associated with colorectal cancer at a single institution. Patients presented either with free air or acute peritonitis. No patients with colonic obstruction were included. Forty-eight patients presented with colon perforation. Thirty-six had perforation at the tumor, 11 proximal to the tumor, and one distal to the primary tumor. Patients who perforated proximal to the tumor were older (74.5 +/- 2 vs 64.7 +/- 3; P < 0.04) and had a longer length of stay (46.8 +/- 17 vs 11.6 +/- 1 P < 0.001). Fourteen patients had stage II disease, 19 stage III, and 15 stage IV. Thirty-day mortality was 14 per cent (n = 7) with nine in-hospital deaths. Of 30-day survivors 29 (60%) had curative resection (21 with local perforation and nine with proximal perforation). Of these 14 received adjuvant chemotherapy. Eleven patients (33%) had either unresectable or metastatic disease on exploration. Mean follow-up was 21.5 months. Ten patients developed metastatic disease after potentially curative resections. Of these nine patients had perforations of the primary tumor. Three patients developed local recurrence and all had local tumor perforations. One-year survival was 55 per cent (n = 16). Five-year disease-free survival was 14 per cent (n = 4). There were no long-term survivors after perforation proximal to the tumor, although disease stage was comparable in both groups. We conclude that perforation proximal to a cancer is associated with a higher perioperative mortality and worse long-term outcome when compared with acute perforations at the site of the tumor. Long-term survival requires both aggressive management of the concomitant sepsis and definitive oncologic surgery.     

Surgery may be curative for patients with a localized perforation of rectal carcinoma

BACKGROUND: Perforation at the time of operation adversely affects the prognosis of rectal cancer. These procedures have been termed 'palliative' or 'non-curative'. The long-term outcome of generalized perforations may be different from that of localized or contained perforations. Although the oncological results may be compromised when the tumour is perforated, results in cases where the perforation is contained may not be as bad as previously thought. An attempt was made to examine the intermediate and long-term results for locally contained perforated rectal cancers. METHODS: Some 848 patients with rectal cancer were operated on between March 1989 and December 1995. Of these, 42 (5 per cent) had a locally contained perforation of the rectum. Median follow-up was 23 (range 12-74) months. RESULTS: The survival of patients with locally contained tumour perforation who underwent resection without macroscopic residual disease (40 per cent at 5 years) was significantly better than that of patients with metastatic disease at the time of surgery (zero at 4 years) (P < 0.01). The survival of patients in whom the tumour was inadvertently perforated during operation was similar to that of patients with locally contained spontaneous tumour perforations. The incidence of local recurrence in these perforated cases was low provided that a wide tumour clearance was achievable at the time of operation. Operative mortality and morbidity rates were not significantly different but the incidence of postoperative wound infection was marginally higher among patients with perforation. CONCLUSION: If clear margins can be obtained at the time of operation the prognosis of locally contained perforated rectal cancers is good and approaches that of a potentially curative resection.     

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.     

Short‐term and long‐term outcomes of patients with malignant large bowel obstruction

Objective: The aim of the present study was to review our experience in the surgical management of patients with obstructing colorectal cancers over an 11‐year period, 1987–1997. Patients and methods: Retrospective review of case records of 275 patients (male: 177; female 98) who had undergone emergency surgery for obstructing colorectal cancers was performed. Tumours proximal to splenic flexure were defined as proximal tumours while those at or below the splenic flexure were defined as distal tumours. Results: The obstruction was caused by proximal tumours in 88 (32%) patients. The resection rate and the primary anastomotic rate were higher for proximal tumours compared with distal tumours (95.5%vs 85.6%, P = 0.014; 92%vs 30.5%, P < 0.001). For distal tumours, stoma rate was found to be influenced by the following factors: preoperative albumin level, duration of observation after admission, operating surgeons’ years of experience, bowel perforation and site of the obstructing tumour. Multivariate analysis disclosed that surgeons’ experience was the only independent factor predicting stoma formation. The in‐hospital mortality and the anastomotic leakage rates were 15.3% and 5.6%, respectively. Tumour stage was the only prognostic factor affecting the disease‐free survival after curative resection. The 5‐year disease‐free survival rates for Dukes’ B and C disease were 66% and 37.2%, respectively. Conclusions: Tumour stage was a significant prognostic factor for patients with obstructing colorectal cancers. Emergency surgery for distal tumours should preferentially be performed by more experienced surgeons in order to achieve a higher anastomotic rate.     

Interpretation of the Randomized EVAR Trials

Purpose : Laparoscopic surgery for colon cancer has been proven safe, but controversy continues over implementation of laparoscopic technique for rectal cancer. The aim of this study was to compare the long-term outcomes of laparoscopically assisted and open surgery for nonmetastatic colorectal cancer.

Material and methods : From January 2001 to December 2006 all patients with nonmetastatic adenocarcinoma of the colon and rectum were considered for inclusion in this prospective non-randomised trial. The primary endpoint was overall survival, disease free survival and recurrence rate. Analysis was by intention to treat.

Results : A total of 365 resections were performed for nonmetastatic adenocarcinoma of the colon and rectum during the study period. Of those resections, 220 were colonic and 145 were rectal. In the patients with colon cancer 119 (54.1%) were operated laparoscopically and 101 (45.9%) by open surgery, in the patients with rectal cancer 75 (51.7%) were treated by laparoscopy and 70 (48.3%) by open technique. No statistically significant difference was found between the laparoscopic and open group regarding 5-year overall survival (p = 0.17 for colon cancer, p = 0.60 for rectal cancer), 5-year disease free survival (p = 0.25 for colon cancer, p = 0.81 for rectal cancer) and overall recurrence (p = 0.78 for colon cancer, p = 0.79 for rectal cancer). With respect to the tumor stage, in rectal cancer the probability of 5-year disease free survival was significantly higher in the laparoscopic group in stage III (p = 0.03).

Conclusion : Laparoscopic surgery for colorectal cancer is an oncologically safe procedure that is associated with a survival and recurrence rate equal to open surgery.     

The effect of a screening programme on the outcome of colorectal cancer

Aim The study aimed to determine whether the introduction of a screening programme for colorectal cancer influenced resection and recurrence rates and prognosis. Method Details of patients with a biopsy‐confirmed diagnosis of colorectal cancer attending from January 2002 to December 2006 were entered into a prospective database. All were followed to death or the end of the study period (December 2008). Patients with a synchronous cancer were excluded from analysis. A comparison was made between screen and non‐screen detected cancers for survival, disease‐free survival, location of the primary tumour, resection and recurrence rates. Results In all, 841 [median age 72 (30–101) years; 53% men] patients with colorectal cancer were identified. Of these 68 were screen detected of whom 63 underwent surgery. Screen detected cancers were significantly less advanced at presentation (P = 0.001). There was no significant difference in primary tumour location between screen and non‐screen detected cancers (P = 0.184). Among curative resections, significantly fewer screened compared with non‐screened cancers developed a recurrence [6/59 (10.2%) vs 105/491 (21.4%), P = 0.043]. The mean disease‐free survival for screen and non‐screen detected cancers was 78.3 and 65.0 months (P = 0.010). Overall mean survival was significantly improved for screened (73.8 months) over non‐screened (57.9 months) detected cancers, P = 0.001. Conclusion Screening for colorectal cancer in this population significantly improved overall cancer‐related and disease‐free survival, possibly as a result of the detection of significantly more early staged cancers.     

Prognostic factors for survival after curative resection of Dukes’ B colonic cancer

Aim Data on the prognostic factors for survival in patients with locally advanced, node‐negative colon cancer are limited. This study aimed to determine which factors might predict survival in patients with Dukes’ B (T3 or T4, N0) colon cancer. Method One hundred and eighty (93 male; median age 75 [range, 38–96] years) consecutive patients who had resection of a primary Dukes’ B (on final histopathological analysis) colonic cancer between 1998 and 2003 were studied. No patient received neoadjuvant chemotherapy. Multivariate Cox regression modelling was used to assess the prognostic value of variables. Median follow up was 85 (60–125) months. Results Thirteen (7%) patients had a perforation at presentation. The median distance from tumour to the nearest longitudinal resection margin was 6 (0.3–27) cm. One hundred and twenty‐four (69%) patients had a lymph node yield of 12 or more nodes. Actual 5‐year survival was 59%. On multivariate regression analysis, tumour perforation (perforation vs no perforation, 5‐year survival, 23%vs 61%; hazard ratio (HR), 3.7; 95% confidence interval (CI), 1.6–8.4; P = 0.002), tumour‐to‐margin distance (< 5 cm vs≥ 5 cm, 48%vs 65%; HR, 1.7; 95% CI, 1.1–2.7; P = 0.039) and older age (≥ 75 years vs < 75 years, 45%vs 72%; HR, 3; 95% CI, 1.8–5; P < 0.001) were independent significant variables. Conclusion A lymph node yield of 12 or more nodes is not a significant prognostic factor for survival after resection of Dukes’ B colonic cancer. Patients with tumour perforation or limited resection have worse prognosis.     

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.     

结肠腹膜内穿孔26例诊治体会

目的总结结肠腹膜内穿孔的诊治经验。方法回顾分析我院2005年1月至2015年10月收治的26例结肠破裂患者临床资料。结果 26例结肠破裂患者中,由于结肠肿瘤性穿孔9例、肠镜检查导致结肠穿孔6例、外伤性结肠穿孔2例、炎性肠病导致穿孔3例、粪性肠穿孔2例、自发性结肠穿孔2例、结肠憩室2例;以急性腹膜炎主要表现的患者为17例、以局限性腹膜炎者7例、以腹部炎性包块者2例;有慢性便秘病史17例、合并糖尿病、动脉硬化合并脑梗塞、冠心病、慢性咳嗽等内科基础病13例;术前摄腹部平片示膈下游离气体12例、通过泛影葡胺灌肠造影确诊4例、手术确诊10例;降结肠穿孔9例、乙状结肠穿孔6例、横结肠穿孔2例、升结肠穿孔8例、盲肠穿孔1例;腹腔穿刺阳性11例。术前误诊8例,包括误诊为上消化道穿孔6例,阑尾穿孔2例。所有患者均行手术治疗,治愈21例,死亡5例。结论结肠穿孔有时术前确诊不易,只要可疑且有手术指征,应及早手术。     

Outcome after emergency surgery for cancer of the large intestine

The data for 77 patients with colorectal cancer who underwent emergency surgery for acute intestinal obstruction (57 patients) or perforation (20 patients) within 24 h of admission were evaluated. The patients were older and had more advanced disease than patients undergoing elective surgery for colorectal cancer. Emergency surgery for carcinoma of the right colon consisted of primary resection in 95 per cent of cases and was followed by a 28 per cent mortality rate. Perforated tumours of the left colon and rectum were managed by primary resection in 82 per cent of cases with a 22 per cent mortality rate. In contrast, obstructing tumours of the left colon and rectum were treated by primary resection in 38 per cent of cases with a 6 per cent mortality rate, and by primary decompression in 62 per cent of cases with a 25 per cent mortality rate. The overall postoperative mortality rate was 23 per cent and increased with advanced tumour disease, perforation and peritonitis. Cardiac decompensation and intraabdominal sepsis were the major causes of death. Although the long-term survival rate following emergency surgery was worse than after elective surgery, improvements in outcome should be achieved by better management of the initial emergency situation.     

One-stage resection without colonic lavage in emergency surgery of the left colon

OBJECTIVE: Intra-operative colonic lavage is a widespread procedure introduced to decompress and clean the colon of its faecal load during emergency surgery of the left colon in order to perform a safe anastomosis. This type of lavage is never performed at our institution. The aim of this study was to evaluate the safety and acceptability of emergency left-sided colectomy without colonic lavage in a consecutive series of patients admitted at our department for perforation and obstruction of the left colon. PATIENTS AND METHODS: All 44 patients (29 with obstruction and 15 with perforation) on whom a one-stage left-sided colon resection was performed without colonic lavage between January 1998 and June 2004 were evaluated in a retrospective review. During this period all patients with acute disease of the left colon underwent a one stage resection without colonic lavage. The only exclusion criteria for anastomosis were: haemodynamic instability, ASA > 3, unresectable tumour. Death, anastomotic leakage and wound infection were main outcome measures. RESULT: The leak rate was 4.5% and mortality 2.3% due to one case of postoperative myocardial infarction. A 16% morbidity rate was recorded due to 4 wound infections and 3 minor complications. CONCLUSION: The procedure is safe. The low morbidity and mortality of one stage resection without colonic lavage can justify future prospective studies enrolling a large number of patients to compare its results with those obtained by one stage resection with colonic lavage.     

Differences in patient postoperative and long-term outcomes between obstructive and perforated colonic cancer

BACKGROUND: The aim of this observational study was to analyze the differences between patients with obstructive and perforated colonic cancer who managed with emergency curative surgery. METHODS: Between January 1994 and December 2000, patients deemed to have undergone curative resection for complicated colonic cancer were considered for inclusion in the study. They were classified into 2 groups: patients with obstructive cancer (OC) and patients with perforated cancer (PC). The main end points were postsurgical outcomes and long-term overall survival, cancer-related survival, and tumor recurrence. RESULTS: Of the 236 patients, surgery was deemed to be radical and performed with intent to cure in 155 patients (65.7%): 117 patients in the OC group and 38 patients in the PC group. No statistical differences were observed between the percentage of radical surgery between the 2 groups (P = .63). The overall postsurgical mortality rate was 12.2%: 14 patients in the OC group and 5 patients in the PC group (P = .839). Overall survival, probability of being free of recurrence, and cancer-related survival of the entire series were 64.57%, 67.72% and 73.03%, respectively. There were no differences between the 2 groups with respect to tumor recurrence, type of recurrence, overall survival, probability of being free of recurrence, and cancer-related survival at 5 years. CONCLUSIONS: In our experience, patients with perforated colonic cancer do not seem to show worse long-term outcomes than those with OC. Studies with larger series are needed for further investigations.     

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.     

Clinical implications of acellular mucin pools in resected rectal cancer with pathological complete response to neoadjuvant chemoradiation1

Aim Approximately 20% of rectal cancers treated with neoadjuvant chemoradiation achieve a pathological complete response (pCR), which is associated with an improved oncological outcome. However, in a proportion of patients with a pCR, acellular pools of mucin are present in the surgical specimen. The aim of this study was to evaluate the clinical implications of acellular mucin pools in patients with rectal adenocarcinoma achieving a pCR after neoadjuvant chemoradiation followed by proctectomy. Method A single‐centre colorectal cancer database was searched for patients with clinical Stage II and Stage III rectal adenocarcinoma who achieved a pCR (i.e. ypT0N0M0) after neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. Patients were categorized according to the presence or absence of acellular mucin pools in the resected specimen, and groups were compared. Patient demographics, tumour and treatment characteristics, and oncological outcomes were recorded. Primary outcomes were 3‐year local and distant recurrences, and disease‐free and overall survivals. Results Two hundred and fifty‐eight patients with clinical Stage II or Stage III rectal adenocarcinoma were treated by neoadjuvant chemoradiation. Fifty‐eight of these patients had a 58 pCR. Eleven of the 58 patients with a pCR had acellular mucin pools in the surgical specimen. The median follow up was 40 months. The groups were statistically similar with respect to demographics, chemoradiation regimens, distance of tumour from the anal verge, clinical stage and surgical procedure. No patient had local recurrence. Patients with acellular mucin pools had increased distant recurrence (21%vs 5%), decreased disease‐free survival (79%vs 95%) and decreased overall survival (83%vs 95%) rates, although none of these differences was statistically significant. Conclusion The presence of acellular mucin pools in a proctectomy specimen with a pCR does not affect local recurrence, but may suggest a more aggressive tumour biology.     

Long term effect of splenectomy on patients operated on for cancer of the left colon: a retrospective study.

OBJECTIVE: To find out if accidental splenectomy during colonic resection influences the survival of patients with colon cancer. DESIGN: Retrospective clinical study. SETTING: University hospital, Greece. SUBJECTS: Twenty-five patients with colonic cancer (13 Dukes' B and 12 Dukes' C) who had accidental splenectomy during resection of the left colon (n = 22) or the sigmoid (n = 3) between 1973 and 1990. Each study patient was matched with control patients for age, sex, Dukes' stage, grade, site of tumour, date, type of operation and number of blood transfusions. MAIN OUTCOME MEASURES: The five year actuarial and disease free survival estimated by the Kaplan-Meier product limit method. RESULTS: There were significantly more infective postoperative complications (6/25 compared with 0/25, p = 0.02) in patients who had a splenectomy. The incidence of metastases (p = 0.07) and the five-year disease free (p = 0.08) and overall survival (p = 0.1) were lower but not significantly so in patients who had a splenectomy compared with controls. CONCLUSIONS: Splenectomy significantly increases the number of infective postoperative complications in patients with colonic cancer. Although there was a trend for shorter disease-free survival after splenectomy, it seems that splenectomy had no impact on survival.     

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.     

Anti tumour necrosis factor as risk factor for free perforations in Crohn’s disease? A case–control study

Aim Although the occurrence of intestinal perforation in Crohn’s disease (CD) is rare, clinical observation has led to the question whether anti tumour necrosis factor (TNF) treatment is a risk factor for free perforation. The aim of this study was to investigate the possible relation between anti‐TNF treatment and occurrence of free perforation, defined as intestinal perforations leading to emergency surgery. Method In this case–control study, all emergency operation reports from the period 1999–2009 of patients diagnosed with CD were checked for the presence of free perforation. These cases were compared with a sixfold larger control group derived from our CD patient database. Cases and controls were matched for age, gender, Montreal classification and surgical stage to ensure equal disease severity. Cases and controls were then compared regarding previous or current exposure to anti‐TNF treatment. Results Thirteen patients underwent emergency surgery for spontaneous free perforation. Eight (62%) had been treated with anti‐TNF within 5 months before the perforation. In the 78 matched controls, 29 (37%) had been or were still treated with anti‐TNF. The odds for a free perforation adjusted for known confounders in two separate regression analyses were significantly higher in anti‐TNF treated CD patients, albeit with a large confidence interval (OR 4.1, 95% CI: 1.1–16.0; and OR 23.0, 95% CI 2.2–238.5). Conclusion This study showed a higher occurrence of free perforations in CD patients with anti‐TNF therapy compared with those without anti‐TNF therapy. Patients with CD and anti‐TNF treatment showing acute abdominal pain must be suspected of this complication.     

Outcome after emergency surgery in gastric cancer patients with free perforation or severe bleeding

BACKGROUND/AIMS: This study was conducted to evaluate the clinicopathologic characteristics and surgical outcome of perforated or bleeding gastric cancer patients. METHODS: Twenty-six gastric cancer patients undergoing emergency surgery for free perforation (n = 13) or severe bleeding (n = 13) were reviewed. RESULTS: In the perforation group, tumors were mainly located in the greater curvature and anterior wall, but in the bleeding group, they were mainly in the lesser curvature. Three (23%) patients in the perforation group and 7 (54%) in the bleeding group received potentially curative resections (p = 0.11). The postoperative morbidity rate and mortality rate were 31 (8/26) and 8% (2/26), respectively. Median survival time after operation was 5.5 months. One patient in the perforation group and 3 patients in the bleeding group who underwent curative resection survived more than 30 months without recurrence. Three factors were found to be associated with improved survival after emergency surgery: potentially curative resection; TNM stage, and the absence of postoperative complications. CONCLUSION: Emergency surgery for gastric cancer patients with perforation or severe bleeding is associated with a low curative resection rate and a high postoperative complication rate. However, long-term survival can be expected in those patients who underwent curative resection with earlier stage gastric cancer.