Performance Of Colectomy Research Articles

Outpatient colectomy within an enhanced recovery program

The application of a fast-track recovery program after surgery can decrease the physiological impact of surgery and reduce the duration of hospitalisation compared to conventional care. This program has permitted us to consider the performance of colectomy on an outpatient basis. After analyzing the recommendations for fast-track recovery, we developed and validated a specific protocol. Drawing on extensive experience in ambulatory surgery (inguinal hernia, cholecystectomy, adjustable gastric-banding), we formalized a protocol for outpatient colectomy. Patient selection criteria were the absence of serious or decompensated comorbidity, very good general condition, and full patient understanding of the procedure. Discharge was authorized if the patient met the exit criteria according to the Chung score. Postoperative surveillance was provided by regular home visits of a nurse trained in enhanced recovery, every afternoon until day 10. Five patients underwent this management strategy (4 men and 1 woman, mean age 64 years, range: 59-69), for indications including cancer of the rectosigmoid junction (1 case), sigmoid diverticulitis (3 cases), and volvulus. The postoperative course was simple and uncomplicated except for two patients who had dysuria and an incisional hematoma, respectively. To our knowledge, these are the first cases of colectomy performed strictly on an outpatient basis (i.e., stay<12h). We demonstrated the feasibility of outpatient colectomy when integrated into a protocol of enhanced recovery for selected patients provided that at-home monitoring was available.

Thresholds and combined quality control in the multimodal treatment of colorectal cancer

Solid accumulating evidence proves that comprehensive surgical and adjuvant treatment quality and pathohistologic examination of specimens drive the outcomes for patients with colorectal cancer (CRC). More simply, whether a patient with CRC will be cured or die of cancer recurrence depends, beyond tumor staging and aggressiveness, on the level of medical care provided. Recently, efforts have been made to establish criteria and quality control measurements to rank hospitals according to the level of care provided for patients with CRC. This is very important for physicians and patients aiming to select the hospital, surgeon, and oncologist that can provide a high level of treatment quality. Therapeutic decisions have become very complex given the rapid advances in surgical practice including minimally invasive interventions, systemic adjuvant treatment including targeted therapy for selected patients, and the timing of chemotherapy before or after surgery. These decision have an impact not only survival but also on quality of life (QOL). A recent example of quality control measurement involves the number of lymph nodes resected by surgeon and examined by the pathologist. The total number of lymph nodes examined (TNODS) has been proposed as a quality control measurement in the treatment of CRC. However, surgeons, pathologists, and oncologists are debating. Some surgeons and pathologists propose harvesting at least 12 to 20 or more lymph nodes, whereas oncologists question the number of evaluated nodes required for accurate staging and correct adjuvant treatment decision making. El-Gazzaz et al. [1] highlight this topic in a recent issue of Surgical Endoscopy. These authors investigated whether a difference existed between laparoscopic and open surgery in the number of nodes harvested after the operation. In the current study, 243 patients underwent laparoscopic surgery and 486 patients had open procedures with curative intent. The mean number of lymph nodes retrieved and examined was high (24.8 ± 20.6 per patient, with no significant difference between laparoscopic and open surgery). The high TNODS in this study reflects an adequate standardized lymphadenectomy by the surgeon as well as appropriate lymph node harvesting and examination by the pathologists. But long-term follow-up evaluation was not in the scope of this study, so no conclusion about the impact of TNODS on survival can be drawn. Does the number of lymph nodes examined affect oncologic outcomes? Can a high TNODS result in improved disease-free and overall survival? Many retrospective studies have shown better locoregional tumor control, more accurate nodal staging, more appropriate adjuvant treatment decision making, and higher overall survival rates when a large number of lymph nodes have been evaluated. Based on these and other studies, the American College of Surgeons (ACS), the National Quality Forum (NQF), the National Comprehensive Cancer Network (NCCN), and the American Society for Clinical Oncology (ASCO) have reached the consensus that a minimum of 12 lymph nodes is the standard for hospitalbased performance of colectomy for colon cancer patients [2–4]. In contrast to this recommendation, Wong et al. [5] concluded that ‘‘efforts by payers and professional organizations to increase node examination rates may have limited value as a public health intervention.’’ These authors came to this conclusion based on a retrospective D. H. Roukos (&) G. Baltogiannis C. G. Katsios Surgical Department, University of Ioannina, Ioannina, Greece e-mail: droukos@cc.uoi.gr