Surgical Treatment Of Colorectal Cancer Research Articles

Diagnostic value of serial measurement of C-reactive protein in serum and matrix metalloproteinase-9 in drainage fluid in the detection of infectious complications and anastomotic leakage in patients with colorectal resection.

Postoperative infectious complications are one of the most important problems in surgical treatment of colorectal cancer (CRC), being present in up to 40% of patients. The aim of this paper was to establish the significance of serial measurement of C-reactive protein (CRP) in serum and matrix metalloproteinase-9 (MMP-9) in drainage fluid for the detection of infectious complications and anastomotic leakage (AL) in patients with colorectal resection. CRP and MMP-9 values in serum and drainage fluid, respectively, were measured on the first, third, fifth, and seventh postoperative day (POD) in 150 patients with colorectal resection and primary anastomosis. The values obtained were compared between the patients without complicatons and those with surgical site and remote infections and AL. Surgical site infections (SSIs) were observed in 41 (27.3%), and remote infections in 10 (6.7%) patients. Clinically evident AL was observed in 15 (10/6) patients. In 82% of the patients with SSIs, serum CRP value on POD 5 exceeded 82 mg/L, with 81% specificity. AL was reported in 85% and 92% of the patients on PODs 5 and 7, respectively, with CRP values of 77 mg/L and 90 mg/L, respectively. The specificity was 77% for POD 5 and 88% for POD 7. All the patients with CRP values exceeding 139 mg/L on POD 5 had some of SSIs and/or AL. The mean values of MMP-9 were not statistically different between the group without complications (n = 99) and the group with AL (n = 15). Serial measurement of CRP is recommended for screening of infectious complications of colorectal resection. Patients with CRP values above 139 mg/L on POD 5 cannot be discharged from hospital, and require an intensive search for infectious complications, particularly AL. MMP-9 measurement in drainage fluid is not relevant in the detection of AL in patients with colorectal resection.

Measurement of Indoleamine 2, 3 Dioxygenase Activity in Colorectal Cancer: A Controlled Group Study

Background: Indoleamine 2,3-dioxygenase (IDO), the rate-limiting enzyme that converts tryptophan (Trp) to kynurenine (Kyn), suppresses antitumor immune responses via depletion of Trp and accumulation of Kyn. We hypothesized that, in colorectal cancer (CRC), IDO activity may serve as a biomarker and thus we compared the IDO activity between patients with CRC and those without CRC. We further assessed the effect of surgical treatment of CRC on IDO activity.Methods: Serum concentrations of Trp and Kyn were measured by high performance liquid chromatography in the sera of 68 patients with CRC (CRC group) and 38 without CRC (Control group) prior surgery (D0) and 7 days after surgery (D7). The IDO activity was estimated by the serum Kyn-to-Trp ratio (Kyn/Trp ratio).Results: At Day 0, serum Kyn concentration was higher in the CRC group than in Control group (1.7 [1.4;2.1] μM vs 1.25 [0.9;1.78] μM, respectively; p=0.004) while no difference in serum concentration of Trp was observed between the two groups. Kyn/Trp ratio (IDO activity) was significantly higher in the CRC group than in Control group. At Day 7 serum concentrations of Trp, Kyn and the Kyn/Trp ratio were not statistically different between the two groups.Conclusion: This study indicates that IDO activity is higher in patients with CRC compared with those without CRC. Surgical treatment impacts the IDO activity with a similar Kyn/Trp ratio in both groups. This study is the first step to larger studies to establish the Kyn/Trp ratio as a reliable serum marker of CRC.

Minorities and High Volume Hospitals: Factors Influencing Underutilization of Surgical Treatment for Colorectal Cancer

Minorities and High Volume Hospitals: Factors Influencing Underutilization of Surgical Treatment for Colorectal Cancer

Laparoscopic surgery for colon cancer: quality requirements for (extended) right hemicolectomy

The current S3 guidelines on the surgical treatment of colorectal cancer note that with a suitable patient selection and expertise of the surgeon the same oncological results can be achieved laparoscopically as with the open procedure. This requires that the same quality requirements have to be provided for both methods. The most important quality parameters of right sided (extended) hemicolectomy are central ligation of the supplying arteries (ileocolic artery, right branch of the middle colic artery and middle colic artery) flush to the central origin of the vessel (superior mesenteric artery or middle colic artery) and the sharp dissection of the mesocolon without any preparation tears. The photographic documentation of the fresh surgical specimens for categorizing the preparation quality as well as to determine the pedicle of the vessel can capture this quality well and is also currently the best surrogate parameter to evaluate the oncological quality of the operation. At present, there are still considerable widespread deficits not only with the laparoscopic approach but also in open surgery which must be urgently fixed.

Analysis of the Quality of Care in Surgical Treatment of Colorectal Cancer: National Study. Follow-up Results

ObjectivesUsing the cases included in the study on the quality of care in colorectal cancer conducted by the Spanish Association of Surgeons in 2008, we present follow-up data. MethodMulticenter, descriptive, longitudinal and prospective study of patients operated on a scheduled basis for colorectal cancer. 35 hospitals have contributed data on 334 patients. Follow-up data included: survival, recurrence and complications. ResultsMean follow-up was 28.61±11.32 months. Follow-up by the surgeon was 69.2%, tumor recurrence was 23.6%, in 83.3% it was systemic; and 28.2% underwent salvage surgery. Overall survival was 76.6%, disease-free survival 65.6% (26.49±11.90 months). Tumor related mortality was 12.6%. Percentage of ventral hernias was 5.8% and intestinal obstruction was 3.5%. ConclusionsQuality and results of follow-up of patients operated on for CRC in Spain are similar to those reported in the scientific literature. Areas for improvement included: follow-up, earlier diagnosis, increased adjuvant and neoadjuvant treatments and total mesorectal excision as standard surgery for rectal cancer.

Risk analysis for the surgical treatment of colorectal cancer in elderly patients undergoing scheduled and urgent interventions.

Due to recorded growth both in living standards and latest researches in medicine, proportion of people in old age has significantly improved all over the world. Although old age people are several percent of the entire society, number of surgeries within the group does not exceed 40%. Also risk of malignant neoplasms among old age people, significantly grows. Malignant neoplasm of colon appears to be most visible problem in group of people in age over 75 years old. The aim of the study was a retrospective analysis of results in treatment of the sick over 75 years old, suffering from Malignant neoplasm of colon. Therapy was performed in the I Unit of General Surgery and Surgical Oncology in Provinical Hospital in Jelenia Góra. Subject to analysis were 63 patients that went under operations in years from 2006 to 2010 due to the colorectal cancer, who have been divided now into two groups. First group included 49 patients treated as per schedule, and the second stood for 14, who required urgent treatment. Reference group has involved 20 younger patients, treated in urgent and scheduled courses, due to the colon cancer. There are no contradictions to emergencies and scheduled surgeries for patients in advanced years, suffering from colon cancer. Complications after colon cancer emergencies are far more frequent than in case of scheduled surgeries. Death rates among patients over 75 years old are far more frequent after emergencies than after scheduled surgeries. Concomitant diseases occur the same frequent during emergenices as during scheduled operations. During emergencies, it was left side of the colon that occured to be infected with cancer more frequent. There is no significant diversity in hospitalization time frames after emergencies and scheduled surgeries. Dangerous surgical complications within group of older patients, those after emergencies and scheduled surgeries too, are far more frequent in comparison to the reference group.

The assessment of the probability for the surgical treatment of colorectal cancer with concomitant liver cirrhosis

The assessment of the probability for the surgical treatment of colorectal cancer with concomitant liver cirrhosis

Endoscopic Detection and Surgical Treatment of Colorectal Cancer in Octogenarians

Background: Colorectal Cancer (CRC) in the elderly is being diagnosed and treated more frequently, as a consequence of longer life expectancy. However, patients aged over 80 years are diagnosed late and surgical treatment is often difficult or aimed to palliate symptoms. Aim of the present study was to report on the characteristics of elderly patients referred to the endoscopy of our surgical Unit and outcomes of surgical treatment compared with younger patients. Materials and Methods: We prospectively gathered data of all patients referred to our Unit between January 2011 and January 2013 for suspicion of CRC, confirmed during endoscopy. We collected baseline characteristics, management, survival and quality of life (QoL). Patients who received radical surgery were compared with a sex- and disease cohort of younger patients undergoing surgery for CRC in the same period. Presentation and outcomes were compared, as well as survival and QoL. QoL was evaluated in all patients 3 months after endoscopy by means of EORTC QLQ-C30. Results: Twenty patients aged over 80 years received CRC diagnosis during endoscopy. Most patients were referred to endoscopy because of rectal bleeding (35%). Cancers were mainly located below the splenic flexure (75%), but the rate of right localizations was not negligible. Three (15%) patients received palliative surgery while 4 (20%) refused to undergo surgery or did not meet surgical criteria. At a mean follow-up of 14 ± 6 months survival rate was significantly higher in patients receiving radical surgery (p=0.04). Thirty patients aged < 80 years served as controls. No differences were observed in terms of cancer localization and stage, although elderly patients were more often found with node-positive CRC. Elderly patients more frequently suffered from minor perioperative complications (46.1 vs 6.7% p=0.006), but perioperative mortality and overall survival did not differ between groups. Concerning QoL, radical surgery conferred optimal results when compared with palliative/no surgery, irrespective of age. Conclusions: Referral of elderly patients to endoscopic examination is often delayed, and may result in suboptimal treatment. Pancolonoscopy and radical surgery should be encouraged, as a timely approach offers excellent results in terms of survival and QoL.

Significant Changes in the Intestinal Environment After Surgery in Patients with Colorectal Cancer

BackgroundThere have been very few detailed reports of the intestinal environment after surgical treatment for colorectal cancer (CRC). We analysed faecal microbiota, organic acids and pH to investigate the influence of colorectal surgery on the intestinal environment. MethodsFaecal samples from 81 CRC patients were collected before the start of pre-operative preparation the day before surgery, as well as 7 days or more after surgery. Thirteen groups of intestinal microbiota, eight types of organic acids, and pH were measured using 16S rRNA-targeted reverse transcription-quantitative PCR, high-performance liquid chromatography and a pH meter, respectively. ResultsTotal bacterial counts (10.3±0.6 vs. 9.4±1.2 log10 cells/g; p < 0.001) and the numbers of 6 groups of obligate anaerobes were significantly decreased after surgery. In contrast, the populations of Enterobacteriaceae, Enterococcus, Staphylococcus and Pseudomonas were significantly increased. Post-operatively, the concentration of total organic acids was lower (77.9±40.1 vs. 50.1±37.0 μmol/g; p < 0.001) than the pre-operative concentration, and a significant reduction in short-chain fatty acids (SCFAs) was observed. ConclusionSignificant changes in the intestinal environment, including marked decreases in obligate anaerobes, increases in pathogenic bacteria, and reductions in SCFAs, were detected after surgery for CRC.

Innovations and developments in surgical coloproctology

The field of coloproctology covers the treatment of both benign and cancerous disease of the colon, rectum and anus. Significant recent developments in the surgical treatment of colorectal cancer include the development of minimally invasive techniques for colorectal resections and the use of stenting for obstructed patients. The introduction of widespread screening aims to diagnose the disease at an earlier stage. Developments in chemotherapy and radiotherapy have also complimented surgical advances towards this disease. There have also been changes in the treatment of benign disease such as diverticular disease, haemorrhoids and anal fissures with a trend towards less invasive surgical techniques.

The Pattern of Colorectal Cancer Surgery in Lithuania in 2005: Do Results Meet Expectations?

The aim of this study was to expose the pattern of the surgical treatment of colorectal cancer in Lithuania in 2005. A retrospective analysis of 590 patients treated for colorectal cancer in the surgical departments of the Hospital of Lithuanian University of Health Sciences, the Institute of Oncology of Vilnius University, and Vilnius University Hospital Santariškių Klinikos in 2005 was performed. Demographic data, preoperative evaluation, postoperative complications assessed according to the Clavien-Dindo classification, the quality of pathological examination, and survival rates were analyzed. A total of 590 patients, 269 women (45.6%) and 321 men (54.4%), were included in this study; the mean age was 68.3 years (SD, 11.2). Tumors were found in the colon of 274 patients (46.4%) and in the rectum of 316 patients (53.6%). An abdominal ultrasound scan was preoperatively performed in 516 patients (87.5%) and a chest x-ray in 316 patients (53.6%); 35 patients (5.9%) underwent abdominal computed tomography. Endorectal ultrasound was done in 99 (31.7%) cases. Neoadjuvant radiotherapy for T3 and T4 rectal tumors was applied in 42 cases (18.1%). Besides, 211 patients (35.8%) developed postoperative complications with an anastomotic leak emerging in 20 cases (3.4%). Death occurred in 7 patients (1.18%). On the average, 11.15 lymph nodes (SD, 6.02) were found in pathological specimens. Circumferential resection margins were assessed in 58 cases (18.4%). The overall 5-year survival rate was 52.06%. The preoperative evaluation and the treatment of patients with colorectal cancer were not sufficiently consistent in Lithuania in 2005. In order to improve the treatment of colorectal cancer, standardization or the national database of colorectal cancer is necessary.

Factors that influence lymph node retrieval in the surgical treatment of colorectal cancer: a comparison of the laparoscopic versus open approach

BackgroundThe purpose of this study was to determine whether surgical approach and patient demographics are important factors that influence lymph node retrieval. MethodsThis was a retrospective review of patients receiving surgical treatment for colorectal cancer at a single institution. ResultsTwo hundred three patients underwent resection for colorectal cancer. The total number of lymph nodes recovered and the number of lymph nodes involved were similar in both the laparoscopic group and the open group. Patients who had right-sided colon resection had a higher total number of lymph nodes recovered. There was no effect of age, sex, race, or body mass index (BMI) on the total number of lymph nodes harvested or on the number of positive lymph nodes. ConclusionsAdequate regional lymphadenectomy for colorectal cancer can be successfully performed using a laparoscopic approach. Patient demographics did not make a difference in the number of total or positive lymph nodes recovered.

Five‐year results of surgical colorectal cancer treatment in rural Australia

The incidence of colorectal cancer in Australia is among the highest worldwide. We investigate whether similar treatment results for colorectal cancer can be achieved in rural surgery as reported from metropolitan centres. Retrospective analysis of prospectively collected follow-up data in a rural surgical centre in South Australia has been carried out. Results of all patients undergoing surgical treatment for colorectal cancer are analysed, and all cancer stages and interventions over a 5-year period are included. Five-year survival of all patients (n = 194) treated for colorectal cancer independent of stage and cause of death was 56%, cancer-specific 5-year survival was 64%. Perioperative mortality was 1.7%. Overall survival was 96% in stage 1, 92% in stage 2, 58% in stage 3 and 0% for patients with metastatic disease at the time of diagnosis. Cancer-specific survival ranged from 100% in stage 1 to 0% for patients with metastatic disease. Assessment of overall and cancer-specific survival of all patients undergoing surgery for colorectal cancer over a 5-year time period in a rural South Australian centre shows that good long-term results can be achieved with low perioperative mortality. These findings compare well with the results of other groups.

Surgical treatment of colorectal cancer associated with ulcerative colitis

Surgical treatment of colorectal cancer associated with ulcerative colitis

Outcomes in Laparoscopic Colectomy for Colorectal Cancer in the Obese

Background: Although laparoscopic resection is widely accepted for the surgical treatment of colorectal cancer (CRC), the impact of obesity on the potential short-term benefits of laparoscopy seems unclear since oncological outcomes must be preserved. Objectives: This review aimed to examine the published data supporting laparoscopic surgery in obese patients with localized CRC. Methods: We reviewed the relevant literature (PUBMED, EMBASE and the Cochrane databases) from 2005 to 2013 for obese patients with CRC who underwent laparoscopic surgery. Results: A total of 18 studies were included. Conversion to open surgery was higher in the obese population, without affecting oncologic long-term outcome. The harvested lymph nodes, specimen length, or resection margins were not affected by obesity. One study reported no differences in disease-free (p=0.6) and overall survival (p=0.5) between obese and non-obese patients. The anastomotic leak was similar in both groups; only one study reported a higher incidence of anastomotic leak in obese patients, but only in the mid to lower rectum. No studies reported any statistically significant differences between obese and nonobese patients in terms of mortality and time to resumption of intestinal function or oral intake. The incidence of wound infection had variable results among the studies. Conclusion: Laparoscopic surgery for localized CRC can be safe in obese patients, including preservation of oncological outcome.

Is limited surgery justified in the treatment of T1 colorectal cancer?

Surgical treatment of colorectal cancer (CRC) should be aimed primarily at achieving a combination of surgical-oncologic radicalness and the highest possible quality of life. In recent years, surgical therapy for T1 CRC has tended toward less radical interventions. The question regarding changes in survival and recurrence rates still is unanswered. A retrospective medical chart review of patients surgically treated in our department for T1 CRC from January 1990 to December 2010 (n = 223) was performed. Charts were reviewed for tumor-specific parameters, local recurrence, distant metastasis, and patient survival. The different treatment options used were strictly separated for a more detailed workup. Radical resection (RR) was performed for 57.1 %, local resection (LR) for 14.8 %, and an endoscopic approach (EA) for 28.1 % of the study population. After receipt of the histology report, 35.7 % of the patients initially resected nonradically underwent reoperation, mostly using RR. Seven patients experienced a local recurrence over time (3.6 %): one after initial RR, three after LR, and three after EA. Systemic recurrence occurred for nine patients (4.6 %) over time, six of whom had undergone initial RR. High-risk criteria were shown for 20 T1 CRCs. For 60 % (12/20) of the patients, initial RR was performed. Radical reoperation was performed for 75 % of the nonradically treated high-risk tumors. One high-risk patient without reoperation experienced metastatic disease over time. The 5-year overall survival rate was 87.2 %, itemized for the defined subgroups as follows: 83.9 % for RR, 82.8 % for LR, and 58.2 % for EA. Patients with T1 CRC had a distinctly higher incidence of local recurrence after EA or LR. Explicit workup in terms of risk classification is crucial to reducing the risk of local and systemic recurrence. A nonradical approach should be only a second option for patients with T1 CRC, namely, those solely in clearly low-risk situations or those with distinct comorbidities.

367. Early Outcome of Surgical Treatment of Colorectal Cancer in Patients up to 75 Years and Older

367. Early Outcome of Surgical Treatment of Colorectal Cancer in Patients up to 75 Years and Older

Surgical treatment of colorectal cancer in patients aged over 80 years

The aim of this study was to identify the clinical factors and tumour characteristics that predict the outcome in patients older than 80 years with colorectal cancer. One hundred and four patients with colorectal cancer aged over 80 years were identified from a computer database, and their clinical variables were analysed by both univariate and multivariate analyses. All 104 patients underwent resective surgery, 87% radical and 13% palliative resection. Postoperative mortality was 5%, being associated with a number of coexisting diseases and the presence of postoperative complications, especially anastomotic leakage. The cumulative 5-year survival was 33%, the median survival was 31 months and the cancer-specific 5-year survival was 36%. The recurrence rate after radical surgery was 30%, being 13%, 25%, 44% and 100% in the Union for International Cancer Control stages I, II, III and IV. Kaplan-Meier estimates indicated that age, number of underlying diseases, radicality of operation, Dukes' staging, size of tumour, number of lymph node metastasis, metastasised disease, venous invasion and recurrent disease were significant predictors of survival, but in the Cox regression model, only venous invasion was an independent prognostic factor of survival. Low mortality and acceptable survival can be achieved even in very elderly patients with colorectal cancer. Venous invasion is an independent predictor of survival.

Surgical treatment of colorectal cancer hepatic metastasis.

Colorectal cancer (CRC) is the fourth most common cancer in the United States, with approximately 140,000 new cases this year. Unfortunately, it will kill almost 50,000 people this year. Far and away, the most common site of hematogenous spread is the liver. Nearly 50% of patients with CRC will eventually develop hepatic metastasis as part of their disease process. Two decades ago, the outlook for patients with metastatic CRC was indeed bleak. Two relatively ineffective systemic chemotherapy agents (5-fluorouracil and leucovorin) were used for the majority of treatment, and surgical metastasectomy was an undeveloped field in which operative mortality was almost as high as the chance for cure. Fortunately, that has changed. Now, there are many effective systemic chemotherapy agents for the treatment of colorectal cancer, and these significantly improve survival in various combinations in both the adjuvant and the metastatic setting. In addition, the field of surgical metastasectomy has matured significantly. This is especially true for resection of hepatic metastasis. Because of important improvements in patient selection, preoperative imaging, perioperative management, surgical techniques, and adjunctive methods, surgical treatment of colorectal cancer hepatic metastasis is now safe, reliable, and effective. For properly selected patients with liver metastasis, the combination of surgical metastasectomy with effective systemic therapy by experienced multidisciplinary teams can result in very low morbidity and mortality, along with long-term cure rates approaching 50%. This issue is dedicated to the surgical treatment of colorectal cancer hepatic metastasis. Experts in the field offer their perspectives about the important concepts, techniques, details, and practical “pearls” that make surgical resection of hepatic metastasis an important part of the armamentarium of the colorectal cancer disease management team. In the first two articles, teams from the Memorial Sloan-Kettering Cancer Center will discuss two important parts of preoperative planning in preparation for hepatic resection: patient selection and preoperative imaging. In the first article, Mike D’Angelica leads us through a discussion of ways to decide whether a given patient is a good candidate for surgical resection (1). In the second article, a team led by Bill Jarnagin presents the all-important topic of preoperative imaging, and how this can be used to not only select patients, but to also plan the surgical procedure (2). In the next three articles, groups from Emory University and Loma Linda University take us through the actual events surrounding surgery. In the third article, David Kooby talks about important perioperative considerations that make hepatic resection safe and reliable (3). Next, Naveen Solomon discusses the actual surgical techniques that are used in surgical resection, weighing the risks and benefits of each (4). In the fifth article, Magi Senthil walks us through the important points of postoperative management of liver resection patients (5). In the last three articles, teams from Methodist Hospital, Johns Hopkins University, and Roger Williams Medical Center discuss additional topics of more complex presentations of hepatic metastasis. Bridget Fahy presents the issues and treatment options for the synchronous presentation of hepatic metastasis with the colorectal primary (6). Next, Tim Pawlik discusses the treatment approaches for patients with extrahepatic metastasis, including which patients with hepatic metastasis and limited extrahepatic disease should be considered for surgical resection (7). Finally, Joe Espat presents the topic of thermal ablation for hepatic metastasis, including how it can be used to extend options for surgical resection and its role in unresectable disease (8). In summary, CRC with liver metastasis is a challenging problem. However, there are now safe and effective surgical options that are an important part of a multidisciplinary treatment approach that can result in long-term survival and cure.

The effects of early rehabilitation in patients with surgically treated colorectal cancer

Colorectal cancer is one of the most common cancer. Caught early, it is often curable. The important role in functional recovery of these patients, have enhanced recovery after surgery (ERAS) clinical care protocol and early rehabilitation. The goal of this research is the objective evaluation of the effects of early rehabilitation in patients after surgical treatment of colorectal cancer, respecting their functional recovery and quality of life, before and after rehabilitation. Tis study was made as experimental, randomized, controlled clinical trial, opened type.The examination included 58 patients (39 males and 19 females), age from 36 to 85 years, average 63.3, with surgically treated colorectal cancer. All patients had appropriate early multimodal accelerated rehabilitation program.The mean value of this program was 7,24 days. As observing parameter was used short form, 36 items health related questionnaire (SF-36), with two summary measures-Physical component summary (PCS) and Mental component summary (MCS), for the evaluation of quality of life, before and after treatment. For the statistical analysis of the aquired data, before and after therapy, was used Student's t-test. Afer therapy, the quality of life of patients was significantly improved, physical health (p< 0.01), as well as mental health (p<0,01). SF36 score after rehabilitation, show important improvement of quality of life in early treated patients. These results show exellent therapeutic possibilities of enhaced recovery clinical care protocol and early rehabilitation procedures. Acording to the results of this study, it can be concluded that early rehabilitation accelerated program is very effective in treatment of patients with surgically treated colorectal cancer.