Extent Of Colon Resection Research Articles

The role of sentinel lymph node mapping in colon cancer: detection of micro-metastasis, effect on survival, and driver of a paradigm shift in extent of colon resection.

Unlike in breast cancer and melanoma, sentinel lymph node mapping in colon cancer is primarily used as an aid to the pathologist for accurate nodal staging. The study was undertaken to review the incidence of micro-metastasis and its impact on survival when treated with chemotherapy. The study was also undertaken to see if SLNM could guide limited colon resection in early T stage tumor as a paradigm shift. SLNM was done by subserosal injection of a blue dye. SLNs were ultra-staged by multilevel sectioning and remaining Specimen was then examined by conventional method. For the last 245 patients the specimen was divied ex vivo into two segments as segment A containing the tumor bearing portion of the colon and SLNs with attached mesentery, while segment B include distal part of the colon with attached mesentery. Nodal staging was separately examined. Of the 354 Pts, SLNM was successful in 99.9% of Pts with an average no of SLN/ Pt = 2.8 and total nodes 17.8/pt. Survival was directly related negatively with stage and nodal status. Pts with +ve LN did much better with chemotherapy than without chemotherapy. With 245 Pts, specimen A Vs B, no Pts had +ve node in specimen B with -ve LN in specimen A. SLNM results in more node/Pt, more positive node/Pt ,and more micro-metastasis who when treated with chemotherapy survive longer. Limited segmental resection in early T stage is possible when done with guidance by SLNM without compromising biology.

Laparoscopic segmental left colectomy for splenic flexure carcinoma: a single institution experience.

There is ongoing debate regarding surgical treatment of splenic flexure cancer. The main points of controversy include the appropriate extent of colon resection, either to the right or to the left, and the appropriate extent of lymph-node dissection. The aim of this study was to review our experience in laparoscopic treatment of splenic flexure cancer cases and to compare our data to the recent literature. Consecutive patients, operated on for splenic flexure colon carcinoma at a single institution between April 2005 and January 2013, were included in the study. Exclusion criteria were a previous history of colorectal cancer, recurrent colonic cancer, emergency cases with an obstructive tumor or a perforated tumor with peritonitis, synchronous cancer, palliative surgery, and a past history of colorectal resection. Patients underwent laparoscopic segmental left colectomy with ligation of the left branch of the middle colic and of the left colic artery.Patient characteristics, operative and postoperative outcomes, and long-term technical, functional, and oncological results from a prospectively maintained database were retrospectively analyzed. After hospital discharge, standardized follow-up was performed at 1month postoperatively, then every 3months during the first 2years, and every 6months thereafter, for a total of 5years. A total of 28 consecutive patients (16 males) with a median age of 71.8years (range 42.5-88.8years) were included. Ninety-day mortality was 3.5% and surgical morbidity was 21.5%with anastomotic leak rate of 10.7%. All survivors experienced good or very good functional results. During a median follow-up period of 50.9months, eight patients (28.5%) presented with a recurrence. The 5-year overall and disease-free survival rates were 46.3% and 39.2%, respectively. Segmental left colectomy for splenic flexure carcinoma is associated with reasonably low morbidity and very good functional results. However, survival rates are low.

Barriers to Lynch Syndrome Testing and Preoperative Result Availability in Early-onset Colorectal Cancer: A National Physician SurveyStudy.

ObjectiveAlthough widely recommended, Lynch syndrome (LS) testing with tumor microsatellite instability (MSI) and/or immunohistochemistry (IHC) is infrequently performed in early-onset colorectal cancer (CRC), and CRC generally. Reasons are poorly understood. Hence, we conducted a national survey focusing on gastroenterologists, as they are frequently first to diagnose CRC, assessing testing barriers and which specialist is felt responsible for ordering MSI/IHC. Additionally, we assessed factors influencing timing of MSI/IHC ordering; testing on colonoscopy biopsy, opposed to post-operative surgical specimens, assists decisions on preoperative germline genetic testing and extent of colonic resection (ECR).MethodsA 21-question web-based survey was distributed through an American College of Gastroenterology email listing.ResultsIn total 509 completed the survey. 442 confirmed gastroenterologists were analyzed. Only 33.4% felt gastroenterologists were responsible for MSI/IHC ordering; pathologists were believed most responsible (38.6%). Cost, unfamiliarity interpreting results and unavailable genetic counseling most commonly prevented routine ordering (33.3%, 29.2%, 24.9%, respectively). In multivariable analysis, non-academic and rural settings were associated with cost and genetic counseling barriers. Only 46.1% felt MSI/IHC should always be performed on colonoscopy biopsy. Guideline familiarity predicted whether respondents felt surgical resection should be delayed until results returned given potential effect on ECR decisions.ConclusionInconsistencies in who is felt should order MSI/IHC may lead to diffusion of responsibility, preventing consistent testing, including preoperatively. Assuring institutional universal testing protocols are in place, with focus on timing of testing, can optimize care. Strategies addressing cost barriers and genomic service availability in rural and non-academic settings can enhance testing. Greater emphasis on guideline familiarity is required.

Lynch Syndrome Screening: A Nationwide Physician Survey Focusing on Factors Influencing Microsatellite Instability Testing Decisions and Early Onset Colorectal Cancer

Introduction: Prior studies demonstrated that Lynch syndrome (LS) screening by tumor microsatellite instability (MSI) and/or immunohistochemistry (IHC) is not routinely performed in early-onset (< age 50) colorectal cancer (CRC), and CRC generally. As there are no studies assessing factors influencing test ordering decisions and who physicians feel is most responsible for testing, we conducted a national web-based survey. Additionally, we sought to determine variables influencing timing of MSI/IHC result availability as preoperative availability, through colonoscopy biopsy as opposed to surgical resection specimen testing, can assist with decisions on germline genetic testing and extent of colonic resection (ECR).Table: No Caption available.Methods: A 21 question web-based survey was distributed twice to physicians through an American College of Gastroenterology email listing. Results: 4,491 confirmed initial survey receipt. 3,508 confirmed the 2nd. 509 (6.4%) completed the survey with analysis eligibility in 474 (see table 1 with footnote). 97% were gastroenterologists. Table 2 outlines factors preventing MSI/IHC ordering in early-onset CRC. Lack of familiarity interpreting results and cost were most common. Table 3 outlines who is felt to be responsible for ordering MSI/IHC. Only 32.7% felt that gastroenterologists are responsible. In early-onset CRC, 47.2% felt that MSI/IHC should always be performed on colonoscopy, as opposed to surgical resection specimens. Only 30.4% felt if MSI/IHC was ordered on colonoscopy biopsy, surgery should be delayed until results became available. 44.2% were familiar with guidelines for this scenario. Guideline familiarity predicted whether respondents felt surgical resection should be delayed until results returned as this could affect decisions regarding ECR (P=0.0016). Regression analysis demonstrated urban practice location (P=0.026) and GI oncology specialization (P=0.006) were associated with guideline familiarity.Table: No Caption available.Table: No Caption available.Conclusion: Cost and lack of familiarity in interpreting MSI/IHC were the most common factors preventing testing. Importantly, inconsistencies in who is responsible for ordering MSI/IHC may prevent reliable test performance. Lack of guideline familiarity can impede preoperative result availability, thus affecting decisions regarding germline testing and ECR, which may leave patients susceptible to developing a 2nd CRC if not enough colon is removed. Greater attention to guidelines and defined institutional protocols on responsibility and timing of testing are needed.

Restoration of intestinal continuity after colectomy for non-occlusive ischemic colitis

Non-occlusive ischemic colitis (IC) is a rare and life-threatening abdominal disease associated with high rates of postoperative mortality. When surgery is performed, in patients with IC, either a Hartmann's procedure (HP) or a total colectomy and ileostomy is required. The possibility of restoration of intestinal continuity in surviving patients is an important issue. The aim of the present study was to report the outcome of surgically managed IC patients and to identify predictive factors for restoration of intestinal continuity and to assess the results of this procedure. Between January 1997 and May 2011, 96 IC patients underwent total colectomy and 68 underwent left colectomy. IC was spontaneous in 62 patients and occurred after prior surgery in 102. Eighty patients died during the postoperative period and nine died during the follow-up from an unrelated disease. Fifteen patients were lost to follow-up. The remaining 60 surviving patients were our study population. There were 44 men and 16 women with a mean age of 67 years ± 12 SD. Restoration of bowel continuity was performed in 24 patients (40%). There were no predictive factors for restoration of intestinal continuity in terms of sex, age, IC etiology, and the extent of colon resection at primary surgery. The median interval between first surgery and restoration of bowel continuity was 7.9 months (range 0.2-35 months). There were no postoperative deaths and the overall morbidity rate was 45% (11/24). No patients developed anastomotic leak or underwent unplanned reoperation. Reversal of HP after IC is feasible in 40% of surviving patients with acceptable mortality and morbidity rates. This restoration of intestinal continuity should therefore be discussed for every surviving IC patient.

Surgical management of cancer of the colon

BACKGROUND: The incidence of colon carcinoma has increased during the last years, but novel diagnostic tools have also been developed. METHODS: Review on colon carcinoma. RESULTS: The only chance in the cure of colonic carcinoma is achieved by radical surgery (R0-resection). Prognosis of advanced carcinomas may improve with chemotherapy, although the efficiency of neoadjuvant designs has not yet been confirmed. Taking into account the intramural microscopic tumor spread, a safety margin of 5 cm seems to be sufficient for circumferentially growing tumors. The extent of colonic resection is defined by the resection of the blood vessels as well as its lymphovascular excision. Prognosis of colonic cancer depends on the tumor stage at the time of diagnosis as well as on the experience of the operating surgeon. In addition, TNM stage and tumor grading are very important factors, too, regarding prognosis. The impact of molecular markers of tumor tissue and serum are still being discussed. CONCLUSIONS: Radical surgical resection can yield good results in the treatment of colon carcinoma.

Anastomotic leak after double-stapled low colorectal resection.

Anastomotic leaks after double-stapled low anterior resection were associated with a number of factors related to patient condition, level of anastomosis, and variety of surgery-related and antitumor therapy-related factors. This retrospective analysis of a group of patients with consistent length of rectal stump was undertaken to determine the risk factors of anastomotic leak after low colorectal resection related to surgery and to intraperitoneal chemotherapy. A group of 165 patients treated with surgery only, surgery with early postoperative intraperitoneal chemotherapy, and surgery with hyperthermic intraoperative and early postoperative intraperitoneal chemotherapy. All patients underwent surgery that used the double-stapled technique with transection of the rectum through its middle third. In univariate and multivariate analysis, the relationship between anastomotic leak rate and extent of colon resection, length of residual colon, presence of left colon, and type of applied treatment was studied. With a full length of residual colon, leak rate was 1 percent but increased progressively with the extent of proximal colon resection. Removal of the left colon was associated with the 2.7 odds ratio for anastomotic disruption. Leak rate after surgery only was 6 percent; surgery with normothermic intraperitoneal chemotherapy was 5 percent; and surgery with heated intraperitoneal chemotherapy was 20 percent. In this group of patients with consistent length of residual rectum, the incidence of anastomotic disruption was related to extent of proximal colon resection. Anastomotic integrity was not compromised by normothermic intraperitoneal chemotherapy. Hyperthermic intraperitoneal chemotherapy was associated with high leak rate only when extensive resection of the colon was performed. Variables other than extent of rectal excision are important in causing a leak of colorectal anastomosis.

Neuronal intestinal dysplasia

Findings in 23 children with neuronal intestinal dysplasia (NID) are presented. Twelve children had Hirschsprung's disease that masked the existence of proximal NID. In all cases the diagnosis was established by histological-histochemical examination. Amelioration of symptoms by conservative treatment alone was achieved in 4 children; in 13 cases colostomy was necessary. In 6 patients colon resection was performed: 2 suffered from both colitis and obstruction; the other 4 were treated for obstruction, multiple perforations, persistant adynamia of the left colon, and fistulation. In 9 patients the colostomy was closed. Four of 6 children who did not have sonographic confirmation of motility had complications due to colon dysmotility after closure of their normally functioning colostomy. Therapeutic measures are based exclusively on clinical and functional parameters. The clinical picture dictates the emergency measures (colostomy, colon resection, and colectomy). Normal colostomy function is not a sufficient criterion of normal colon motility. Functional sonography of the colon is included in the planning of further therapy. Indications, timing, and extent of colon resection can be reliably determined using the sonographic method.

Appraisal of the 14C-glycocholate acid test with special reference to the measurement of faecal 14C excretion

The (14)C-glycocholate test, including the measurement of marker corrected faecal (14)C, has been assessed in the following groups of subjects: normal controls (18), patients with diarrhoea not attributable to altered bile acid metabolism (21), patients with diverticula of the small intestine (12), patients with previous resection of ileum and often proximal colon (34), and established ileostomists (10). Patients with diverticular disease had increased breath (14)CO(2) excretion, but normal faecal excretion of (14)C, and this test was more frequently abnormal than the Schilling test. Ileostomists excreted increased amounts of faecal (14)C, even when the ileum was intact and apparently normal. The pattern after resection was complex. Breath (14)C output was normal if the ileal resection was less than 25 cm in length, although some of these patients had increased faecal (14)C excretion if, in addition, at least 15 cm of proximal colon had been resected or by-passed. Longer ileal resections were associated with increased breath and/or faecal (14)C excretion, depending in part on the length of colon resected or by-passed and the 24 hour faecal volume. Fewer than half these patients had both increased breath and faecal excretion of isotope and faecal (14)C alone was occasionally normal with an ileal resection of 50 cm of more. The (14)C-glycocholate test was more frequently abnormal than the Schilling test in this group. The use of faecal marker correction had only a minor impact on the results. These data suggest that, in patients with ileal resection, faecal (14)C, like faecal weight, is determined by the extent of colonic resection as well as by the amount of ileum resected.

An Evaluation of the ‘Breath Test’ in Crohn’s Disease

The 1-(14C)-glycine-glycocholic-acid breath test was evaluated in 10 normal subjects and in 38 patients with Crohn's disease. Twelve patients were non-operated and 26 had been subjected to ileal resection (10-180 cm). In addition, coecal resection or right-sided hemicolectomy was performed on 20 patients and subtotal colectomy on six. The 14C-excretion in breath was abnormally elevated in only 16 of the 38 patients with Crohn's disease. Combining 14C-excretion in both breath and faeces, the test was found to be correlated with the activity of the disease in non-operated cases, whereas all resected patients were found to have bile acid malabsorption. It is concluded that the breath test is useless in Crohn's disease without concomitant measurement of the radioactivity in stools. The faecal 14C-excretion was correlated with the extent of ileal resection and with the extent of colonic resection, whereas the 14C-excretion in breath was independent of the type of operation performed. The breath test was found to be a more sensitive assay for ileal dysfunction than the duodenal bile acid concentration and the vitamin B12 absorption. No correlation with an elevated G/T-ratio and an abnormal bacterial growth was found.