Mechanical bowel preparation before elective colorectal surgery: is it necessary?

Aim

To present the worldwide accepted guidelines concerning the use of mechanical bowel preparation (MBP) before elective colorectal surgery (ECS).

Patients and methods

We conducted a retrospective review of the Pubmed Databases for randomized controlled trials (RCTs) and meta-analyses, which included adult patients who underwent elective colorectal surgery. We compared the patients who had a preoperative MBP with those who did not. Significant factors that were taken into account were postoperative septic complications and anastomotic dehiscence.

Results

Our search revealed 5 RCTs and 2 meta-analyses that met our criteria. Patients who underwent emergency colorectal surgery were excluded from the study. We identified the recommendations for 6 different types of elective colorectal surgery.

Conclusion

MBP has been for many years a standard clinical procedure for patients undergoing elective colorectal surgery. However, many recent researches suggest the omission of MBP, since there are no significant differences regarding postoperative infectious complications, such as anastomotic dehiscence and superficial surgical site infections. Furthermore, MBP is a time-consuming, expensive procedure and causes severe discomfort to the patient. More importantly, the application of MBP has been associated with serious complications in both healthy patients and patients with existing cardiac or renal disease, such as electrolyte and volume disturbances.

     

The role of oral antibiotics prophylaxis in prevention of surgical site infection in colorectal surgery

Background

Surgical site infection (SSI) continues to be a challenge in colorectal surgery. Over the years, various modalities have been used in an attempt to reduce SSI risk in elective colorectal surgery, which include mechanical bowel preparation before surgery, oral antibiotics and intravenous antibiotic prophylaxis at induction of surgery. Even though IV antibiotics have become standard practice, there has been a debate on the exact role of oral antibiotics.

Aim

The primary aim was to identify the role of oral antibiotics in reduction of SSI in elective colorectal surgery. The secondary aim was to explore any potential benefit in the use of mechanical bowel preparation (MBP) in relation to SSI in elective colorectal surgery.

Methods

Medline, Embase and the Cochrane Library were searched. Any randomised controlled trials (RCTs) or cohort studies after 1980, which investigated the effectiveness of oral antibiotic prophylaxis and/or MBP in preventing SSIs in elective colorectal surgery were included.

Results

Twenty-three RCTs and eight cohorts were included. The results indicate a statistically significant advantage in preventing SSIs with the combined usage of oral and systemic antibiotic prophylaxis. Furthermore, our analysis of the cohort studies shows no benefits in the use of MBP in prevention of SSIs.

Conclusions

The addition of oral antibiotics to systemic antibiotics could potentially reduce the risk of SSIs in elective colorectal surgery. Additionally, MBP does not seem to provide a clear benefit with regard to SSI prevention.

     

Metachronous colorectal cancer

Aim

In this study, we present our patients with metachronous colorectal cancer.

Patients and methods

In the period between 1990 and 2009, 670 patients with colorectal cancer were treated.

Results

Metachronous cancer was developed in 4 (0.6%) patients. The time interval between index and metachronous cancer was 28 months to 22 years (mean 146 months).

Conclusion

Metachronous colorectal cancer is a potential risk that proves the necessity of postoperative colonoscopic control of all patients with colorectal cancer.

     

An outcome analysis of laparoscopic management of diverticulitis

Background

All operative procedures for simple or complicated diverticulitis, including primary resection and anastomosis (PRA) with or without a diverting stoma, Hartmann procedure (HP), or stoma reversal, whether done in an elective setting or as an emergency, can be performed laparoscopically. However, owing to low incidence of the disease and complexity of the procedure, there are very few studies on outcomes of laparoscopic surgery for sigmoid diverticulitis from India.

Aim

The present study was undertaken to evaluate outcomes of laparoscopically treated patients of sigmoid diverticulitis.

Methods

Prospective observational study enrolled 37 patients with sigmoid diverticulitis managed laparoscopically from March 2015 to March 2017. Demographic, clinical, operative, postoperative, and complication data were entered into a patient proforma and analyzed.

Results

Eleven simple and 26 complicated diverticulitis patients were operated laparoscopically, 22 in emergency setting and 15 in elective setting. Only three patients required conversion to open surgery—two due to dense adhesions and one due to chronic obstructive pulmonary disease (COPD). No patients had ureteric or bowel injury. Eighteen patients underwent laparoscopic PRA without stoma, 11 patients had PRA with stoma, 6 had HP, and 2 had laparoscopic lavage. Results showed lesser blood loss, shorter hospital stay, and fewer complications in the elective group and simple diverticulitis patients. None of the patients had anastomosis-related complications. Two patients had stoma-related complications.

Conclusion

Laparoscopic management of diverticulitis is feasible, safe, provides the benefits of less wound-related complications, and shorter hospital stay and should be the surgical procedure of choice in elective or emergency setting for simple/complicated diverticulitis.

     

Enhanced recovery care after colorectal surgery in elderly patients. Compliance and outcomes of a multicenter study from the Spanish working group on ERAS

Purpose

ERAS (enhanced recovery after surgery) programs have proven to reduce morbidity and hospital stay in colorectal surgery. However, the feasibility of these programs in elderly patients has been questioned. The aim of this study is to assess the implementation and outcomes of an ERAS program for colorectal cancer in elderly patients.

Methods

This is a multicenter observational study of a cohort of elderly patients undergoing colorectal surgery within an ERAS program. A total of 188 consecutive patients over 70 years who underwent elective colorectal surgery within an ERAS program at three institutions during a 2-year period were included. The compliance with the ERAS protocol interventions was measure. Complications were evaluated according to Clavien-Dindo classification. Data on length of stay and readmission rates were analyzed.

Results

Early intake and early mobilization were the most successfully carried out interventions. There was a global compliance rate of 56 % of patients for whom compliance was achieved with all measured interventions. The median hospital length of stay was 6 days. Almost 60 % of patients had no complications, 24 % had minor complications while 13 % had major complications; of them, 8 % patients were reoperated. The readmission rate was 6.4 %.

Conclusions

ERAS after colorectal surgery in elderly patients presents as safe and feasible based on good reported outcomes of compliance rates, complications, readmissions, and needs for reoperation.

     

Is preoperative physical activity related to post-surgery recovery?—a cohort study of colorectal cancer patients

Introduction

An increasing interest is seen in the role of preoperative physical activity (PA) in enhancing postoperative recovery. The short-term effect of preoperative PA on recovery after colorectal cancer is unknown. The aim of this study was to evaluate the association of the preoperative level of PA with postoperative recovery after surgery due to colorectal cancer disease.

Methods

This is a prospective observational cohort study, with 115 patients scheduled to undergo elective colorectal surgery. The self-reported level of preoperative PA was compared to measures of recovery.

Results

Regular self-reported preoperative PA was associated with a higher chance of feeling highly physically recovered 3 weeks after surgery (relative chance 3.3, p?=?0.038), compared to physical inactivity. No statistically significant associations were seen with length of hospital stay, self-assessed mental recovery, re-admittances or with re-operations.

Discussion

In clinical practice, evaluating the patients’ level of PA is feasible and may potentially be used as a prognostic tool for patients undergoing colorectal cancer surgery. Given the study design, the results from this study cannot prove causality.

Conclusion

The present study found that the preoperative level of PA was associated with a faster self-assessed physical recovery after colorectal cancer surgery. PA did not show any associations with the primary outcome measure length of hospital stay or any of the other secondary outcome measures. Assessment of PA level preoperatively could be used for prognostic reasons. If systematic preoperative/postoperative physical training will enhance recovery, this remains to be studied in a randomized controlled study.

Highlights

• We examined preoperative physical activity and the recovery after colorectal cancer surgery.
• Physically active individuals had faster self-assessed physical recovery.
• Assessment of preoperative physical activity may provide prognostic clinical information.

     

Emergency surgery for colorectal cancer does not affect nodal harvest comparing elective procedures: a propensity score-matched analysis

Purpose

About 30% of colorectal cancers (CRCs) present with acute symptoms. The adequacy of oncologic resections is a matter of concern since few authors reported that emergency surgery in these patients results in a lower lymph node harvest (LNH). In addition, emergency resections have been reported with a longer hospital stay and higher morbidity rate. We thus conducted a propensity score-matched analysis with the aim of investigating LNH in emergency specimens comparing with elective ones. Secondary aim was the comparison of morbidity and hospital stay.

Methods

Eighty-seven consecutive R0 emergency surgical procedures were matched with elective CRCs using the propensity score method and the following covariates: age, sex, stage, and localization. Groups were compared using univariate and multivariate analyses. Outcome measures were LNH, nodal ratio, Clavien’s morbidity grades, and hospital stay.

Results

Emergency patients presented more metastatic nodes compared with elective ones (p 0.017); however, both presented a comparable mean LNH. Multivariate analysis documented that a T stage ≥3 was the only variable correlated with a nodal positivity (OR 6.3). On univariate analysis, emergency CRCs had a longer mean hospital stay compared with elective resections (p 0.006) and a higher rate of Clavien ≥4 events (p 0.0173). Finally, emergency resection and an age >66 years were variables independently correlated with a mean hospital stay >10 days (OR, respectively, 3.7 and 3.5).

Conclusions

Emergency CRC resections were equivalent to the elective procedures with respect to LNH. However, emergency surgery correlated with a longer mean hospital stay.

Open image in new window

Graphical abstract Emergency and Elective resections for CRC provide similar LNH.

     

Effects of a Video on Organ Donation Consent Among Primary Care Patients: A Randomized Controlled Trial

BACKGROUND

Low organ donation rates remain a major barrier to organ transplantation.

OBJECTIVE

We aimed to determine the effect of a video and patient cueing on organ donation consent among patients meeting with their primary care provider.

DESIGN

This was a randomized controlled trial between February 2013 and May 2014.

SETTING

The waiting rooms of 18 primary care clinics of a medical system in Cuyahoga County, Ohio.

PATIENTS

The study included 915 patients over 15.5 years of age who had not previously consented to organ donation.

INTERVENTIONS

Just prior to their clinical encounter, intervention patients (n?=?456) watched a 5-minute organ donation video on iPads and then choose a question regarding organ donation to ask their provider. Control patients (n?=?459) visited their provider per usual routine.

MAIN MEASURES

The primary outcome was the proportion of patients who consented for organ donation. Secondary outcomes included the proportion of patients who discussed organ donation with their provider and the proportion who were satisfied with the time spent with their provider during the clinical encounter.

KEY RESULTS

Intervention patients were more likely than control patients to consent to donate organs (22 % vs. 15 %, OR 1.50, 95%CI 1.10–2.13). Intervention patients were also more likely to have donation discussions with their provider (77 % vs. 18 %, OR 15.1, 95%CI 11.1–20.6). Intervention and control patients were similarly satisfied with the time they spent with their provider (83 % vs. 86 %, OR 0.87, 95%CI 0.61–1.25).

LIMITATION

How the observed increases in organ donation consent might translate into a greater organ supply is unclear.

CONCLUSION

Watching a brief video regarding organ donation and being cued to ask a primary care provider a question about donation resulted in more organ donation discussions and an increase in organ donation consent. Satisfaction with the time spent during the clinical encounter was not affected.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01697137

     

Effect of immunonutrition on colorectal cancer patients undergoing surgery: a meta-analysis

Purpose

Immunonutrition has been used to prevent the complications after colorectal elective surgery. This systematic review aimed to analyze and assess the effect of immunonutrition on colorectal cancer patients who received elective surgery.

Methods

Three electronic databases (Medline, Embase, Cochrane) were used to search the latent studies which investigated the effects of enteral immunonutrition (EIN) compared with standard enteral nutrition (EN) or parenteral immunonutrition (PIN) compared with standard parenteral nutrition (PN) on colorectal cancer patients who are undergoing surgery until 21st of April, 2017. Meta-analysis was conducted to calculate odd risk (OR), mean difference (MD), or standard mean difference (SMD) with 95% confidence interval (CI), and heterogeneity was tested by Q test.

Results

Nine publications were included. The meta-analysis results presented that EIN improved the length of hospital stay (pooled MD, 2.53; 95% CI, 1.29–3.41), infectious complications (pooled OR, 0.33; 95% CI, 0.21–0.53) which contains the Surgical Site Infections (pooled OR, 0.25; 95% CI, 0.22–0.58) and Superficial/Deep incisional infections (pooled OR, 0.27; 95% CI, 0.12–0.64); meanwhile, PIN improved the length of hospital stay (pooled MD, 2.66; 95% CI, 0.62–4.76), IL-6 (pooled MD, ??6.09; 95% CI, ??10.11 to ??2.07), CD3 (pooled MD, 7.50; 95% CI, 3.57–11.43), CD4 (pooled MD, 5.47; 95% CI, 2.54–8.40), and CD4/CD8 (pooled MD, 0.50; 95% CI, 0.22–0.78); the level of CD8 was lower (pooled MD, ??4.32; 95% CI, ??7.09 to ??1.55) in PIN.

Conclusion

Immunonutrition could be an effective approach to enhance the immune function of colorectal cancer patients undergoing elective surgery and to improve the clinical and laboratory outcomes.

     

A Model for Interprofessional Health Disparities Education: Student-Led Curriculum on Chronic Hepatitis B Infection

BACKGROUND

Although health disparities are commonly addressed in preclinical didactic curricula, direct patient care activities with affected communities are more limited.

PURPOSE

To address this problem, health professional students designed a preclinical service-learning curriculum on hepatitis B viral (HBV) infection, a major health disparity affecting the Asian/Pacific Islander (API) population, integrating lectures, skills training, and direct patient care at student-run clinics.

SETTING

An urban health professions campus.

METHODS

Medical and other health professional students at University of California, San Francisco, organized a preclinical didactic and experiential elective, and established two monthly clinics offering HBV screening, vaccination, and education to the community.

RESULTS

Between 2004 and 2009, 477 students enrolled in the student-led HBV curriculum. Since the clinics’ inception in 2007, 804 patients have been screened for chronic HBV; 87% were API immigrants, 63% had limited English proficiency, and 46% were uninsured. Serologically, 10% were found to be chronic HBV carriers, 44% were susceptible to HBV, and 46% were immune.

DISCUSSION

Our student-led didactic and experiential elective can serve as an interprofessional curricular model for learning about specific health disparities while providing important services to the local community.

     

Delay of surgery after stent placement for resectable malignant colorectal obstruction is associated with higher risk of recurrence

Background

Self-expanding metal stents can be used as bridge to elective surgery for acute malignant colonic obstruction. However, the impact on long-term oncological outcome and the optimal timing of surgery are still unknown.

Method

This was a retrospective multicenter study performed at four colorectal centers. Patients undergoing stent placement as bridge to surgery, between January 2010 and December 2013, were included in the study. Primary outcomes were survival and recurrence rates along with location of the metastases. Additionally, we recorded time from stent placement to elective surgery. Secondary outcomes were postoperative complication rates. Complications were classified according to the Clavien-Dindo classification score. A logistic regression model was used to describe impact of delayed stent removal on risk of recurrence.

Results

This study included 112 patients, with a median follow-up of 43 months. Survival rate was 70%. We found a recurrence rate of 37%, primarily local recurrences (17%). Procedure-related complications at the stent placement were seen in 18%, and complications after subsequent elective surgery were seen in 39%. A significantly higher risk of recurrence with increased time from stent placement to elective surgery (OR 5.1 [1.6–15.8], p = 0.005) was found.

Conclusion

Delay of elective surgery after stent placement may have a negative influence on long-term oncologic outcomes.

     

Influence of hospital type on survival in stage IV colorectal cancer

Purpose

Hospital factors along with various patient and surgeon factors are considered to affect the prognosis of colorectal cancer. Hospital volume is well known, but little is known regarding other hospital factors.

Methods

We reviewed data on 853 patients with stage IV colorectal cancer who underwent elective palliative primary tumor resection between January 2006 and December 2007. To detect the hospital factors that could influence the prognosis of incurable colorectal cancer, the relationships between patient/hospital factors and overall survival were analyzed. Among hospital factors, hospital type (Group A: university hospital or cancer center; Group B: community hospital), hospital volume, and number of colorectal surgeons were examined.

Results

In univariate analysis, Group A hospitals showed significantly better prognosis than Group B hospitals (p?=?0.034), while hospital volume and number of colorectal surgeons were not associated with overall survival. After adjustment for patient factors in multivariate analysis, hospital type was significantly associated with overall survival (hazard ratio: 1.31; 95 % confidence interval: 1.05–1.63; p?=?0.016). However, there was no significant difference in short-term outcomes between hospital types.

Conclusions

Hospital type was identified as a hospital factor that possibly affects the prognosis of stage IV colorectal cancer patients.

     

Postoperative recurrence and risk factors of colorectal cancer perforation

Purpose

The common causes of colorectal perforation are benign. However, perforated colorectal cancer confers a risk of recurrence in the long term because of the malignant nature of the disease. In addition, the recurrence rate can also increase because of dissemination of cancer cells, reduced extent of lymph node dissection to prioritize saving life, and other reasons.

Methods

We evaluated the clinical features and postoperative recurrence in patients with perforated colorectal cancer who developed general peritonitis and underwent emergency surgery during a 7-year period between April 2007 and March 2014.

Results

During the study period, 44 patients had colorectal cancer perforation. The cancer sites were the ascending colon in 6 patients, transverse colon in 1, descending colon in 4, sigmoid colon in 15, and rectum in 18. The disease stage was stage II in 18 patients, stage III in 15, and stage IV in 7. Among 22 patients who could be followed up, 8 had postoperative recurrence. The recurrence rates were 18.2% for stage II cancer and 54.5% for stage III. Postoperative recurrence was more likely to occur in the patients positive for lymph node metastasis, those with poorly differentiated adenocarcinoma, those with T4 cancer, and those who did not receive postoperative adjuvant chemotherapy.

Conclusion

The recurrence rate was higher in the patients with perforated colorectal cancer than in those who underwent surgery for common colorectal cancer. The prognosis can be expected to improve by performing standard surgical procedures, to the maximum extent possible, followed by postoperative adjuvant chemotherapy.

     

Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding

Background

Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines.

Objective

To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations.

Design

Cross-sectional study using explicit chart abstraction methods.

Participants

Three hundred adults, 40–80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016.

Main Measures

1) The frequency at which colorectal cancer risk factors were documented in patients’ charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations.

Key Results

Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50–64 years of age than in those aged 40–50 years (OR?=?2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR?=?4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR?=?0.85, 95% CI: 0.75, 0.96).

Conclusions

Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients’ other concurrent medical problems.

     

Association of Structured Virtual Visits for Hypertension Follow-Up in Primary Care with Blood Pressure Control and Use of Clinical Services

Background

Optimal management of hypertension requires frequent monitoring and follow-up. Novel, pragmatic interventions have the potential to engage patients, maintain blood pressure control, and enhance access to busy primary care practices. “Virtual visits” are structured asynchronous online interactions between a patient and a clinician to extend medical care beyond the initial office visit.

Objective

To compare blood pressure control and healthcare utilization between patients who received virtual visits compared to usual hypertension care.

Design

Propensity score-matched, retrospective cohort study with adjustment by difference-in-differences.

Participants

Primary care patients with hypertension.

Exposure

Patient participation in at least one virtual visit for hypertension. Usual care patients did not use a virtual visit but were seen in-person for hypertension.

Main measures

Adjusted difference in mean systolic blood pressure, primary care office visits, specialist office visits, emergency department visits, and inpatient admissions in the 180 days before and 180 days after the in-person visit.

Key results

Of the 1051 virtual visit patients and 24,848 usual care patients, we propensity score-matched 893 patients from each group. Both groups were approximately 61 years old, 44% female, 85% White, had about five chronic conditions, and about 20% had a mean pre-visit systolic blood pressure of 140–160 mmHg. Compared to usual care, virtual visit patients had an adjusted 0.8 (95% CI, 0.3 to 1.2) fewer primary care office visits. There was no significant adjusted difference in systolic blood pressure control (0.6 mmHg [95% CI, ??2.0 to 3.1]), specialist visits (0.0 more visits [95% CI, ??0.3 to 0.3]), emergency department visits (0.0 more visits [95% CI, 0.0 to 0.01]), or inpatient admissions (0.0 more admissions [95% CI, 0.0 to 0.1]).

Conclusions

Among patients with reasonably well-controlled hypertension, virtual visit participation was associated with equivalent blood pressure control and reduced in-office primary care utilization.

     

Predictive factors for extraction site hernia after laparoscopic right colectomy

Purpose

Incisional hernia at the extraction site (ESIH) is a common complication after laparoscopic colorectal resections. The aim of this study was to evaluate the prevalence and potential risk factors for ESIH in a large cohort study having standardized technique.

Methods

A cross-sectional study was performed including all patients who underwent elective laparoscopic right or extended right colectomy for cancer from November 2006 to October 2013 using a standard technique. All patients have been followed up for a minimum of 1 year with abdominal CT scan.

Results

A total of 292 patients were included with a median follow-up of 42 months. Twenty patients (6.8 %) developed ESIH. Obesity (odds ratio (OR) = 3.76, 95 % confidence interval (CI) 1.39–10.15; p = 0.009) and incision length (OR 2.86, 95 % CI 1.077–7.60; p = 0.035) significantly predisposed to the development of ESIH.

Conclusion

This study identified that the risk of ESIH is significant after colonic resections and there are several risk factors responsible for the development of ESIH.

     

Three steps and a join: a simple guide to right- and left-sided medial to lateral laparoscopic colorectal surgery

Background

To provide a standardised ‘medial to lateral’ approach to laparoscopic colorectal surgery.

Methods

Both right- and left- sided laparoscopic colorectal procedures were simplified into three well-defined steps and a join. An instructional video and procedural guide provides the important pearls and pitfalls in performing laparoscopic colorectal surgery.

Results

During a 10-year period (2006–2016) at a single institution, 20 senior colorectal trainee surgeons and 20 general surgery registrars were trained in the ‘three steps and a join’ technique. Five hundred and sixty-eight laparoscopic anterior resections using this technique were performed. There were 5 (0.9%) leaks. Five hundred and forty-three laparoscopic right-sided resections were performed. There were 3 (0.6%) anastomotic leaks requiring reoperation and loop ileostomy.

Conclusions

This step-by-step instructional video and procedural guide provides a simple and standardised approach which may be incorporated into a training pathway for laparoscopic right- and left-sided colorectal surgery.

     

Treatment with daclatasvir and sofosbuvir for 24 weeks without ribavirin in cirrhotic patients who failed first-generation protease inhibitors

Background

Treatment of patients with chronic hepatitis C who failed the triple therapy with first generation of protease inhibitors is not still defined. The combined use of sofosbuvir (SOF) and daclatasvir (DCV) seems to be promising due to higher genetic barrier, good tolerance and effectiveness.

Methods

We described the treatment with this drug combination in a real-life cohort of 20 cirrhotic patients with genotype 1 who failed the triple therapy.

Results

18 of them (90%) with Child–Pugh A, 11 (55%) with genotype 1a, 17 (85%) with more than 1 and 8 (40%) with more than 2 previous failed treatment; all patients had at baseline NS3 resistance-associated variants related to triple therapy failure. RBV was not administered due to anemia in previous treatments. The sustained virological response was 100%.

Conclusion

Treatment with SOF + DCV without RBV for 24 weeks is safe and effective in cirrhotic patients who failed triple therapy with the first generation of protease inhibitors.

     

Interdisziplinäre Therapie kolorektaler Lebermetastasen

Background

Liver metastases occur in every second patient with colorectal carcinoma.

Objectives

Therapeutic options for patients with hepatic metastases from colorectal cancer (CRC), specific indications, and interdisciplinary concepts are presented.

Methods

Based on the current literature and guidelines, novel study results and expert opinions are discussed.

Results

Surgical resection of primarily resectable liver metastases from CRC is standard and allows long-term control or healing in up to 36?% of cases. Adjuvant chemotherapy after resection can be performed, but the current study data are insufficient to generally recommend perioperative chemotherapy in this setting. Secondary resectability of primarily irresectable metastases can be reached by interventional induction of liver hypertrophy or neoadjuvant chemotherapy (conversion therapy). New study results suggested a benefit for more intensive combination chemotherapies, but possible side effects have to be considered. Finally, locoregional ablative therapies have gained increasing importance in the multimodal treatment of hepatic CRC metastases, and current clinical trials suggest a possible benefit of combination strategies together with chemotherapy and surgery even in early therapy lines.

Conclusions

Liver metastases from CRC require an multidisciplinary approach. Therefore, patients should be presented to a multidisciplinary tumor board not only at the beginning, but also along different therapy lines.

     

Elektive Operationsindikationen bei Sigmadivertikulitis

Background

A paradigm shift in therapeutic management of sigmoid diverticulitis has occurred with increasing reluctance regarding surgical treatment. While there is still a clear surgical indication in cases of complications such as strictures, fistulas, perforations or persistent bleeding, an elective indication for sigmoid resection is not clearly defined, especially in chronic-recurrent courses.

Objectives

The main aspects of elective surgery for sigmoid diverticulitis are discussed.

Materials and methods

Relevant studies were selected and the reference lists from those studies were also searched.

Results

An uncomplicated form of acute diverticulitis (Classification of Diverticular Disease [CDD] type 1a/b) is not an indication for surgery (exception: immunosuppressed patients). In acute complicated diverticulitis (except free perforation), elective surgery should only be recommended in case of a macroabscess (CDD type 2b). In chronic recurrent, uncomplicated diverticulitis (CDD typ 3a/b), indication for surgery should be individualized. However, indications for elective surgery are complications such as strictures or fistulas (CDD type 3c). Recent data show that patients with type 2b and 3 diverticulitis benefit from elective surgery, especially in terms of quality of life.

Conclusions

Although the majority of patients with diverticulitis can be treated conservatively, elective surgery should also be considered in terms of better quality of life compared to conservative therapy.