Πέμπτη, 24 Οκτωβρίου 2019

Is colonoscopic surveillance necessary after curative resection of colorectal cancer in elderly patients?
Suat Chin Ng, Joseph Kong, Douglas Stupart, David Watters

World Journal of Colorectal Surgery 2019 8(3):65-68

Background: Surveillance colonoscopy is routinely offered to patients who have undergone curative resections for colorectal cancer (CRC). The purpose of this study is to investigate the early detection of metachronous tumors or anastomotic recurrences. Few studies have investigated the utility of surveillance scopes in the elderly population. Objective: To investigate the incidence of metachronous cancer or anastomotic recurrence in patients over the age of 80 years who underwent resection of CRC with curative intent. Design: This is a retrospective study of a prospectively maintained database. Setting: University Hospital Geelong. Patients and Methods: All patients ≥80 years of age who underwent resection of CRC with curative intent at University Hospital Geelong between January 2002 and December 2014 were studied. Demographic information, comorbidities (Charlson score), types of surgery, postoperative complications (Clavien–Dindo), tumor staging, and details regarding postoperative colonoscopies were recorded. Patients were followed up for life whenever possible. The mean length of hospital stay and follow-up were determined. Survival analysis was done using the Kaplan–Meier method. The incidence of metachronous and locally recurrent CRC was calculated. Main Outcome Measures: Incidence of metachronous or locally recurrent CRC. Sample Size: One hundred and eighty-three patients. Results: Ninety-nine patients (54%) were female and 147 (80%) had elective resections. Seventy-one (39%) patients had moderate-to-severe comorbidities (Charlson Comorbidity Index ≥3). There were 139 patients who had had colon cancer and 44 with rectal cancer who had been resected with curative intent. Stages I, II, and III cancers comprised 16%, 47%, and 37%, respectively. The mean length of hospital stay was 13.3 days. The mean duration of follow-up was 3.43 years. Median survival after surgery by stage was 93 months (Stage I), 92 months (Stage II), and 72 months (Stage III). A total of 26 surveillance colonoscopies were performed on 24 patients. After a total of 627.21 patient-years of follow up, one metachronous CRC was detected, but no local recurrences were observed. Conclusion: It is extremely uncommon to detect clinically significant metachronous tumors in patients aged over 80. Limitation: Small cohort size. Conflict of Interest: None.

The influence of neoadjuvant chemoradiotherapy on muscle mass in patients with rectal cancer
Gregory Simpson, Thomas Marks, Sarah Blacker, Conor Magee, Jeremy Wilson

World Journal of Colorectal Surgery 2019 8(3):69-73

Background: The psoas major muscle accurately represents overall skeletal muscle mass. The skeletal muscle mass volume is related to outcomes in multiple surgical procedures including colorectal cancer. However, neoadjuvant chemoradiotherapy for rectal cancer may adversely affect muscle mass. Objective: Assess the effect of neoadjuvant chemoradiotherapy on muscle mass in rectal cancer patients as well as on outcomes. Design: Retrospective study. Setting: A large UK District General Hospital. Patients and Methods: Analysis of all rectal cancer patients between 2014 and 2017. Psoas major was measured at the L3 level using pre- and post-neoadjuvant chemoradiotherapy images. Psoas major to L3 cross-sectional area (PML3) was calculated for each patient. Main Outcome Measures: 30-day and 90-day mortality, inpatient stay, and postoperative complications. Sample Size: One hundred and twenty-one rectal cancer patients. Results: Median age was 72 years (IQR: 64–78 years). Male:Female ratio was 82:39. 30-day mortality was 0%, and 90-day mortality was 0.83%. Sixty-one patients underwent neoadjuvant chemoradiotherapy (50.4%). Thirty-one patients underwent abdominoperineal excision of the rectum (APER) (25.6%), 1 underwent proctocolectomy (0.83%), 1 underwent completion proctectomy (0.83%), and 88 patients underwent anterior resection (72.7%). Significant muscle loss occurred during neoadjuvant therapy (median loss: 25.9%, IQR: 12.6–36.8%) (P < 0.0001). No correlation was observed between PML3 and inpatient stay. Patients with PML3 in the lowest quartile had a chest infection rate of 11.1% and a complication rate of 37.1% rather than 6.2% and 26.8%, respectively, for those in the upper quartiles. Anastomotic leak rate in the PML3 lowest quartile was 23.5% compared to 11.4% in patients in the upper quartiles. Conclusion: Patients who received neoadjuvant chemoradiotherapy had a significant reduction in muscle mass. Muscle mass loss can be overcome with a prehabilitation program that may reduce muscle loss and improve outcomes. Limitations: Due to a low event-rate of anastomotic leak, it is difficult to show statistical significance with a patient cohort of this size. Conflict of Interest: None.

Long-term outcomes of locally advanced rectal cancer after neoadjuvant chemoradiotherapy: A bi-national colorectal cancer audit study
Joseph C Kong, Glen R Guerra, Angus Lee, Satish K Warrier, A Craig Lynch, Alexander G Heriot

World Journal of Colorectal Surgery 2019 8(3):74-78

Background: There is a great interest in predicting the pathological complete response (pCR) to facilitate patient selection for a “watch and wait” protocol, sparing locally advanced rectal cancer patients from surgical related morbidity and mortality. However, there is a high risk of tumor regrowth with the current assessment of clinical complete response, highlighting the need for a better predictive marker of pCR. Objective: The aim of this study was to assess the short- and long-term outcomes according to tumor response after neoadjuvant chemoradiotherapy for locally advanced rectal cancer. Design: Retrospective analysis of a prospectively maintained bi-national database. Settings: Multicenter bi-national database. Patients and Methods: This was a retrospective study of a prospectively maintained bi-national colorectal cancer audit database. Inclusion criteria were T3-4 and/or N1-2 rectal cancer patients receiving long course chemoradiotherapy followed by surgery. The primary outcome measure was pathological tumor response. Main Outcome Measures: The primary outcome measure was rate of pathological response and associated local and distant recurrence. Sample Size: There were 929 consecutive locally advanced rectal cancer patients identified within the database. Results: A total of 929 patients were included, with a pCR rate of 29.6% (275 patients). Non-responding tumors had a higher circumferential resection margin positive rate of 20% (33 of 165 patients) compared to partial responding tumors of 5.1% (24 of 475 patients). Local recurrence rates in accordance to tumor regression grade (pCR, partial and no response) were 2.2%, 4.4%, and 4.7% (P = 0.254) respectively, with distant recurrence rates of 2.9%, 4.1%, and 8.1% (P = 0.03) respectively. Independent predictors of pCR were early stage disease on pre-treatment imaging (OR 2.12 95% CI 1.24–3.63, P = 0.005), a rural setting (OR 3.15 [95%] CI 1.63–6.06, P < 0.001) and private insurance (OR 2.06 [95%] CI 1.45–2.93, P < 0.001), with an inverse association to metastatic disease (OR 0.22 [95%] CI 0.1-0.5, P < 0.001). Conclusions: Early-stage tumors had the greatest likelihood of attaining a pCR with a lower risk of local and distant recurrence than partial or non-responding tumors. Limitations: This study is limited by the retrospective nature of the analysis and the lack of data auditing to ensure accuracy of data is maintained. Conflict of Interest: None.

Anorectal melanoma surgical management: A tertiary cancer centre analysis
Ravi Arjunan, C Ramach, Pavan Kumar Jonnada, Uday Karjol

World Journal of Colorectal Surgery 2019 8(3):79-83

Background: Primary rectal malignant melanoma is an exceptionally rare neoplasm associated with an extremely poor prognosis despite aggressive treatment. The described management options for localized disease are abdominoperineal resection (APR) and wide local excision (WLE) with or without radiation. Objective: To assess the surgical outcomes of the patients with anorectal melanoma. Design and Setting: Retrospective study. Patients and Methods: This retrospective study describes the experience in surgical management of 18 cases of anorectal melanoma treated surgically at our center, between 2010 and 2015. Main Outcome Measures: To assess the median survival and recurrence rates of anorectal melanoma patients who underwent surgery. Sample size: Eighteen cases. Results: This is a retrospective study of 18 cases of anorectal melanoma. APR was performed in 77.8%, wide excision (WLE) in 16.7%, and posterior exenteration in 5.6%. The median survival of patients undergoing APR was 14.66 months and median survival of patients undergoing WLE was 18 months. No significant difference in median survival was observed in the patients undergoing abdominoperineal resection (APR) or wide local excision (P = 0.168). A significant difference in median survival between the node negative group and node positive group was observed (17 months vs 13.4 months P = 0.019). The median survival of patients with stage I, II, and III cancers were 17.28 months, 16 months, and 13.4 months, respectively. A statistically significant difference in median survival was found between patients with lympho-vascular invasive and noninvasive cancer (13.37 months vs 16.7 months P = 0.029). There was no significant difference in the recurrence rate between APR and WLE groups (86% vs 66% P = 0.893).Conclusion: Anorectal melanoma is an aggressive disease which require timely diagnosis. Nodal status is an important factor that impact median survival. There is no significant difference in survival when WLE compared to APR. Node positivity and lympho-vascular invasion confer poor prognosis. Recurrence rates are identical regardless of the surgical approach. Limitations: It is a retrospective series based on case records. A major drawback of this investigation is the limited detail available for each case. Not all patients who underwent local excision received radiotherapy. Conflict of Interest: None.

Case-matched comparison of intersphincteric proctectomy versus proctectomy with stapled coloanal anastomosis for low rectal cancer
Lameese Tabaja, Yasir Akmal, Zoltan Lackberg, Maher A Abbas

World Journal of Colorectal Surgery 2019 8(3):84-88

Background: The role of intersphincteric proctectomy in low rectal cancer remains controversial. Objective: To compare the perioperative and oncologic outcomes of intersphincteric proctectomy to proctectomy with stapled coloanal anastomosis. Design: A retrospective case-matched review. Setting: A tertiary colorectal surgery unit. Patients and Methods: All intersphincteric proctectomy cases conducted by one surgeon over a 7-year period were matched for gender, race, age, and comorbidities with patients who underwent proctectomy with stapled coloanal anastomosis. Main Outcome Measures: Operative time, blood loss, postoperative complications, length of stay, margin status, lymph node harvest, and local recurrence rate. Sample Size: Thirty-four patients. Results: Group A (intersphincteric) 17 and Group B (stapled) 17 were compared. Mean age was 57.2 years (12 males and 5 females in each group). All patients received neoadjuvant chemoradiation and underwent diverting ileostomy. Estimated blood loss was higher in Group A (771 ml vs. 327 ml, P < 0.05). Similarly, operative time was longer in Group A (295 vs. 235 min, P < 0.05). No difference was noted in postoperative complication rate between Group A and B (29.4% vs. 17.6%, P = 0.688). Length of stay was similar in both groups (6.9 vs. 6.3 days, P = 0.565). There was no difference in radial or distal margin positivity (0%, both groups) or lymph node harvest. Distal margin was longer in Group B (3.7 vs. 1.6 cm, P = 0.007). During a mean follow-up of 22 months, the local recurrence rate was 0%. Conclusions: Intersphincteric proctectomy was associated with higher blood loss and longer operative time compared to stapled coloanal anastomosis. Immediate and long-term oncologic outcomes were comparable. Limitations: A single surgeon experience, retrospective study, and small number of patients. Conflict of Interest: None.

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