Asymptomatic Colorectal Cancer with Un-Resectable Liver Metastases: Immediate Colorectal Resection or Up-Front Systemic Chemotherapy?

Background About 20% of patients with colorectal cancer have synchronous un-resectable liver metastases. Resection of colorectal cancer in patients with moderate-severe symptoms is mandatory before starting chemotherapy. Surgical treatment of asymptomatic colorectal cancers is still a matter of discussion. Methods From January 2000 to December 2004, we prospectively collected data on 35 consecutive patients who were treated straightaway by chemotherapy without primary tumor resection. All patients underwent FOLFOX6 as first-line chemotherapy. The aim of the study was to evaluate the rate of surgical complications related to un-resected colorectal tumor. Results The mean interval between diagnosis and start of chemotherapy was 23.1 days (95% CI: 17.3–28.8). Fifteen of the 35 patients (42.9%) were down-staged to surgery; the mean interval between chemotherapy start and colon-rectum cancer resection was 6.5 months (95% CI: 5.5–7.5). None of them developed complications related to the primary tumor during chemotherapy. Of the other 20 patients who did not undergo any curative surgery, 16 received a second line chemotherapy and 10 a third line: six patients are alive and without intestinal symptoms (mean follow up 22.5 months, 95% CI: 11.2–33.9). Only one patient (2.8%) developed clinical signs of intestinal occlusion 5.6 months from the start of chemotherapy and required urgent colostomy. Conclusions The rate of complications related to the non-resected colorectal tumor is very low using oxaliplatin as first line chemotherapy. Non-operative management of asymptomatic colorectal cancers with un-resectable liver metastases is a safe approach.     

Colorectal cancer risk in hamartomatous polyposis syndromes

Colorectal cancer(CRC) is a major cause of morbidity and mortality around the world, and approximately 5% of them develop in a context of inherited mutations leading to some form of familial colon cancer syndromes. Recognition and characterization of these patients have contributed to elucidate the genetic basis of CRC. Polyposis Syndromes may be categorized by the predominant histological structure found within the polyps. The aim of the present paper is to review the most important clinical features of the Hamartomatous Polyposis Syndromes, a rare group of genetic disorders formed by the peutz-Jeghers syndrome, juvenil polyposis syndrome and PTEN Hamartoma Tumor Syndrome(Bannayan-Riley-Ruvalacaba and Cowden Syndromes). A literature search was performed in order to retrieve the most recent and important papers(articles, reviews, clinical cases and clinical guidelines) regarding the studied subject. We searched for terms such as “hamartomatous polyposis syndromes”, “Peutz-Jeghers syndrome”, “juvenile polyposis syndrome”, “juvenile polyp”, and “PTEN hamartoma tumour syndrome”(Cowden syndrome, Bananyan-Riley-Ruvalcaba). The present article reports the wide spectrum of disease severity and extraintestinal manifestations, with a special focus on their potential to develop colorectal and other neoplasia. In the literature, the reported colorectal cancer risk for Juvenile Polyposis, Peutz-Jeghers and PTEN Hamartoma Tumor Syndromes are 39%-68%, 39%-57% and 18%, respectively. A review regarding cancer surveillance recommendations is also presented.     

Obesity,Regardless of Comorbidity,Influences Outcomes After Colorectal Surgery—Time to Rethink the Pay-for-Performance Metrics?

An elevated body mass index (BMI) is associated with increased morbidity and mortality after colorectal surgery. While coexistent comorbid conditions are captured in some determinations of case-severity, BMI itself is not factored into pay for performance (P4P) initiatives. From the National Surgical Quality Improvement Program database 2006–2011, obese (BMI ≥30 kg/m²) and nonobese (BMI <30 kg/m²) patients with and without comorbidity undergoing colorectal resection were identified. Pre- and intraoperative factors as well as postoperative outcomes were compared. Of 130,415 patients, 31.3 % were obese. 80.4 % of obese and 72.9 % of nonobese patients had comorbid conditions. Among obese patients, overall rates of surgical site infection (SSI), wound dehiscence, and various medical complications were significantly higher for those with comorbidity compared to those without (p?相似文献   

Colorectal polyps: when should we tattoo?

Background

Current guidelines recommend tattooing of suspicious-looking lesions at colonoscopy without a reference to the size of the polyp. However, the endoscopist has to make a judgement as to which lesion may be malignant and require future localisation based on the appearance and size of the polyp. The aim of this study was to determine the relationship between endoscopic polyp size and invasive colorectal cancer so as to inform tattooing practice for patients taking part in the national bowel cancer screening programme (BCSP).

Methods

Data of BCSP patients who had undergone a polypectomy between October 2008 and October 2010 were collected from a prospectively maintained hospital endoscopic database. Histology data were obtained from electronic patient records.

Results

A total of 165 patients had undergone 269 polypectomies. Their median age was 66?years and 66?% were men. The mean endoscopic polyp size was 10.7?mm (SD?=?±8?mm). Histologically, 81?% were neoplastic with 95?% showing low-grade and 5?% high-grade dysplasia. Eight patients were found to have invasive malignancy within their polyp. The risk of invasive malignancy within a polyp was 0.7?% (1/143) when the endoscopic polyp size was <10?mm; the risk increased to 2.4?% (2/83) when the polyp size was 10–19?mm and 13?% (5/40) when the polyp was >20?mm. This trend was statistically significant (p?=?0.001). About 23?% of the patients had the site of their polyp tattooed; the mean size of the tattooed polyps was 21?mm (range?=?15–50?mm). Consequently, 25?% of malignant polyps and 63?% of polyps with high-grade dysplasia were not tattooed.

Conclusion

The risk of polyp cancer among BCSP patients increases significantly when the endoscopic polyp size is ≥10?mm. We recommend that all polyps ≥10?mm be tattooed.     

Do We Really Know Why Colorectal Anastomoses Leak?

Introduction

Colorectal anastomotic leak, a feared complication, results in significantly increased patient morbidity, mortality, and hospital resource utilization. The overall incidence of colorectal anastomotic leak is approximately 11 % with increasing rate the closer the anastomosis is to the anal verge. Because surgeons are unable to reliably predict which anastomosis would fail, most will construct a diverting ileostomy for low colorectal anastomosis to circumvent the devastating complications of anastomotic failure. Despite extensive investigations on technical considerations of anastomosis construction, anastomotic leaks continue to occur at an unacceptably high rate.

Discussion

In this review, we examine the major known risk factors and technical considerations that have been implicated as factors in leakage. Although surgical technique has evolved over the past several decades with the advent of newer surgical staplers, laparoscopy, and robotics, we have not witnessed a decrease in the incidence of colorectal anastomotic leaks suggesting that the fundamental pathogenesis of anastomotic leak remains unknown. Among the factors contributing to anastomotic healing, intestinal bacteria remains largely overlooked even though compelling evidence exist that intraluminal microbes could play a major role in pathogenesis of anastomotic leak. Further investigation focusing on intestinal microbes could be one such avenue for uncovering the elusive cause of colorectal anastomotic leak.     

Colorectal surgeons’ learning curve of transanal endoscopic microsurgery

Background

Transanal endoscopic microsurgery (TEM) is a technically demanding key technique in minimally invasive rectal surgery. We investigated the learning curve of colorectal surgeons commencing with TEM.

Methods

All TEM procedures of four colorectal surgeons were analyzed. Procedures were ranked chronologically per surgeon. Outcomes included conversion, postoperative complications, procedure time, and recurrence. Backward multivariable regression analysis identified learning curve effects and other predictors.

Results

Four surgeons resected 693 rectal lesions [69.9 % adenoma/25.5 % carcinoma; median size 20 cm²; interquartile range (IQR) 11–35; 7 ± 4 cm ab ano]. A total of 555 resections (80.1 %) were histopathologically radical (R0). Conversion (4.3 %) was influenced by a learning curve [odds ratio (OR) 0.991 per additional procedure; 95 % confidence interval (CI) 0.984–0.998] and by lesion size. Postoperative complications depended only on the individual surgeon and lesion size in benign lesions (10.4 % complications). A learning curve (OR 0.99; 95 % CI 0.988–0.998) and peritoneal entrance affected complications in malignant lesions (13.3 %). Procedure time [median 55 min (IQR 30–90)] was influenced by a learning curve [B ?0.11 (95 % CI ?0.14 to ?0.09)], individual surgeon, single-piece resection, peritoneal entrance, lesion size, and rectal quadrant. Recurrence of benign lesions (4.5 %) depended on lesion size, R0 resection, and prior resection attempts. Recurrence of malignant lesions (8.9 %) depended on 3D stereoscopic view, lesion size, full-thickness resection, and length of follow-up. Recurrence-free survival of patients operated during the 36th through 80th procedure per surgeon was significantly shorter than in patients operated during procedures 1–35 and 81 onwards.

Conclusions

A surgical learning curve affected conversion rate, procedure time, and complication rate. It did not influence recurrence rates, possibly due to evolving patient populations. This first insight into the learning curve of TEM stresses the importance of quality monitoring and centralisation of care.     

Respiratory Complications After Colorectal Surgery: Avoidable or Fate?

Background

The prevention of post-operative pulmonary complications (PPC) is targeted by several enhanced recovery (ERAS) items including early mobilisation, prevention of fluid overload and omission of routine nasogastric tubes. The aim of the present study was to assess the impact of ERAS on PPC.

Methods

This was a retrospective analysis of an institutional database including consecutive colorectal ERAS procedures from May 2011 until May 2017. Multiple logistic regressions were performed to identify risk factors for PPC among demographic, surgical characteristics and items related to the ERAS protocol.

Results

In total, 1298 patients were included; among them 120 (9.2%) had one or more PPC. Multivariable analysis retained minimally invasive surgery [odds ratio (OR) 0.26; 95% confidence interval (CI) 0.15–0.46] and compliance to the ERAS protocol of?≥?70% (OR 0.53; CI 0.30–0.94) as protective factors. Emergency surgery (OR 2.70; CI 1.20–6.01), blood loss of?≥?200 mL (OR 2.06; CI 1.20–3.53) and ASA score of?≥?3 (OR 2.00; CI 1.12–3.57) were independent risk factors. Median length of hospital stay was significantly longer in patients who experienced respiratory complications (21 [4–183] vs. 6 [1–95] days, p?≤?0.001).

Conclusions

Minimally invasive surgery and high compliance with the ERAS protocol can help to prevent PPC.

     

Colorectal cancer surgery in the elderly: acceptable morbidity?

BACKGROUND: Because of the increase in the geriatric population, an increasing number of elderly patients are being treated for colorectal cancer. The purpose of this study was to evaluate perioperative morbidity and mortality in this population. METHODS: A retrospective chart review was performed for patients 80 years of age or older who underwent surgery for colorectal cancer (1993-2006). RESULTS: Ninety patients were identified, with a median age of 84 years. More than 90% presented with symptoms; the remaining were diagnosed by screening colonoscopy. Emergent surgery was required in 10%. The morbidity rate was 21% and the overall 30-day mortality rate was 1.1%. Morbidity was higher in patients who required surgery emergently. CONCLUSIONS: Despite advanced age, the majority of patients in this study did well. Postoperative morbidity was higher than in the general population, but we believe it was acceptably low in most patients. Colorectal surgery appears to be safe in most elderly patients.     

Improving Nodal Harvest in Colorectal Cancer: So What?

Background  

Adequate nodal harvest (≥12 lymph nodes) in colorectal cancer has been shown to optimize staging and has been proposed as a quality indicator of colorectal cancer care. We previously demonstrated a population-based improvement in adequate nodal harvest over time, particularly with the use of an audit and feedback strategy. The goal of this current study is to evaluate the impact of improved adequate nodal harvest on 3 relevant clinical outcomes: node positivity rate, use of adjuvant chemotherapy, and survival.     

Colorectal cancer in the elderly: which surgical approach?

Single-operator case studies of 135 patients undergoing surgery for colon rectal carcinoma (CRC) between June 2004 and April 2008 in our Institute. Patients were divided into two groups (A: < 70 years old, n = 44, - = 27 U = 17, B: ≥ 70 years old, n = 91, - = 49 U = 42) and were compared clinical, pathological and surgical data. In particular, were analyzed age range and average age, ASA score, post-operative complications (major and minor), mortality at 30 days. Surgical procedure with radical intent (R0) was achieved in 41 (93%) and 76 (83%) patients respectively in group A and B; Given the more than double the number in group B than in group A is easy to imagine that for equal numbers in both groups might have observed an almost equal R0 resections in both groups; Despite the uneven number of groups A and B, it was noted that age is not a factor in determining the surgical therapeutic strategy in the CRC, as well as the clinical conditions of patients.     

Liver Surgery for Colorectal Metastases: Results after 10 Years of Follow-Up. Long-Term Survivors,Late Recurrences,and Prognostic Role of Morbidity

Background  Liver surgery is the gold-standard treatment of colorectal liver metastases. Five-year survival rates may be inadequate to evaluate surgical outcomes because some patients are alive with recurrence and late recurrences are possible. The aim of this study was to analyze 10-year survival outcome in terms of late recurrence rate and prognostic factors of survival. Methods  One hundred twenty-five patients underwent liver resection for colorectal liver metastases between 1985 and 1996. Four patients who experienced postoperative mortality were excluded. The analysis was performed on 121 patients. Results  Five- and 10-year survival rates were 23.1% and 15.7%, respectively. Nineteen patients were alive 10 years after liver resection and 17 were disease-free (5 after re-resection). Five- and 10-year disease-free survival rates were 17.4% and 14.8%, respectively. In patients with recurrence, re-resection significantly improved survival (P < 0.001); 98% of recurrences occurred within the first 5 years, but 15% of patients disease-free at 5 years developed later recurrence. Multivariate analysis evidenced five independent negative prognostic factors of survival: male sex (P = 0.029), synchronous metastases (P = 0.011), >3 metastases (P < 0.001), metastatic infiltration of nearby structures (P < 0.001), and postoperative morbidity (P < 0.001). In 17 patients without negative prognostic factors the 10-year survival rate was 35.3%. Conclusion  Liver resection for colorectal liver metastases may be curative in more than one-third of patients without negative prognostic factors. Postoperative morbidity significantly worsens long-term outcomes. The risk of recurrence after liver resection is high even after 5 years of follow-up, but re-resection can improve the outcome.