Influence of caseload and surgical speciality on outcome following surgery for colorectal cancer: a review of evidence. Part 1: short-term outcome

OBJECTIVE: An association between caseload and outcome has been reported for complex surgical procedures. We systematically reviewed recent literature to determine whether caseload and surgical speciality are associated with short-term outcome following colorectal cancer surgery. METHOD: We searched the MEDLINE and Cochrane Library databases for relevant publications starting in 1992. We selected hospital caseload and type, and surgeon's caseload, education and experience as variables of interest. Measures of outcome were postoperative morbidity, in-hospital and 30-day mortality, and for rectal cancer anastomotic leak. We stratified the 35 reviewed studies by tumor location: colonic cancer, rectal cancer, or colorectal cancer and described the studies individually. A meta-analysis was performed only when it was considered appropriate. RESULTS: For colonic cancer, postoperative morbidity was associated with surgeon's caseload and education. Postoperative mortality was strongly associated with hospital caseload (OR 0.64, 95% CI 0.55-0.73), and surgeon's caseload (OR 0.50, 95% CI 0.39-0.64). It was also influenced by surgeon's education and experience. For rectal cancer, we found no evidence of an association between the selected variables and short-term outcome, including frequency of anastomotic leak. For colorectal cancer, there was evidence for an association between postoperative morbidity and hospital caseload. CONCLUSION: Our review offers evidence for a positive association between high hospital caseload, surgeon's caseload, sub-speciality and experience and improved short-term outcome in colonic cancer surgery. We failed to find evidence of a relationship for rectal cancer surgery, possibly owing to methodological artifacts. No study reported an inverse relation.     

The influence of the surgeon's and the hospital's caseload on survival and local recurrence after colorectal cancer surgery

BACKGROUND: Past studies have identified surgeon- and institution- related characteristics as prognostic factors in colorectal cancer surgery. The present work assesses the influence of the surgeon's and the hospital's caseload on long-term results of colorectal cancer surgery. METHODS: The data on 2706 patients from 2, randomized, colorectal cancer trials (Swiss Group for Clinical Cancer Research [SAKK] 40/81, SAKK 40/87) investigating adjuvant intraportal and systemic chemotherapy and 1 concurrent registration study (SAKK 40/88) were reviewed. A first analysis included 1809 eligible, nonmetastatic patients from all 3 studies. A subsequent subgroup analysis included 915 eligible patients from both randomized trials. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) were analyzed in multivariate models taking into account the possible effect of clustering. The main potential covariates were surgeon's annual caseload (>5 operations/year vs < or =5 operations/year), hospital's annual caseload (>26 operations/year vs < or =26 operations/year), tumor site, T stage, and nodal status. RESULTS: Primary analysis of all 3 studies combined found a high surgeon's caseload to be positively associated with OS (P = .025) and marginally with DFS (P = .058). Separate analysis for each trial, however, showed that a high surgeon's caseload was beneficial for outcome in both randomized trials but not in the registration study. A subgroup analysis of 915 patients with 376 rectal and 539 colonic primaries from both randomized trials, therefore, was performed. Neither age, gender, year of operation, adjuvant chemotherapy (intraportal vs systemic vs operation alone), hospital academic status (university vs non-university), training status of the surgeon (certified surgeon vs surgeon-in-training), nor inclusion in 1 of the 2 randomized trials (SAKK 40/81 vs SAKK 40/87) was a significant predictor of outcome. However, both high surgeon's and high hospital's annual caseloads were independent, beneficial prognostic factors for OS (P = .0003, P = .044) and DFS (P = .0008, P = .020), and marginally significant factors for LR (P = .057, P = .055). CONCLUSIONS: High surgeon's and hospital's annual caseloads are strong, independent prognostic factors for extending overall and disease-free survival and reducing the rate of local recurrence in 2 randomized colorectal cancer trials.     

Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery at a national level

BACKGROUND: The purpose of this prospective study was to examine the influence of hospital caseload on long-term outcome following standardization of rectal cancer surgery at a national level. METHODS: Data relating to all 3388 Norwegian patients with rectal cancer treated for cure between November 1993 and December 1999 were recorded in a national database. Treating hospitals were divided into four groups according to their annual caseload: hospitals in group 1 (n = 4) carried out 30 or more procedures, those in group 2 (n = 6) performed 20-29 procedures, group 3 (n = 16) 10-19 procedures and group 4 (n = 28) fewer than ten procedures. RESULTS: The 5-year local recurrence rates were 9.2, 14.7, 12.5 and 17.5 per cent (P = 0.003) and 5-year overall survival rates were 64.4, 64.0, 60.8 and 57.8 per cent (P = 0.105) respectively in the four hospital caseload groups. An annual hospital caseload of less than ten procedures increased the risk of local recurrence compared with that in hospitals where 30 or more procedures were performed each year (hazard ratio 1.9 (95 per cent confidence interval (c.i.) 1.3 to 2.7); P < 0.001). Overall survival was lower for patients treated at hospitals with an annual caseload of less than ten versus hospitals with 30 or more (hazard ratio 1.2 (95 per cent c.i. 1.0 to 1.5); P = 0.023). CONCLUSION: The rate of local recurrence was higher for hospitals with a low annual caseload of less than ten procedures than for hospitals with a high treatment volume of 30 or more. Patients treated in small hospitals also had a shorter long-term survival than those treated in large hospitals.     

Quality of rectal cancer surgery and its relationship to surgeon and hospital caseload: a population‐based study

Aim A population‐based audit of all rectal cancers diagnosed in Ireland in 2007 has shown an inconsistent relationship between surgeon and hospital caseload and a range of quality measures. Better outcome for rectal cancer has been associated with increasing surgeon and hospital caseload, but there is less evidence of how this may relate to quality of care. Our aim was to examine how measures of quality in rectal cancer surgery related to surgeon and hospital workload and to outcome. Method All colorectal surgeons in Ireland participated in an audit of rectal cancer based on an evidence‐based instrument. Data were extracted from medical records by trained coders. Generalized linear mixed models were used to determine the relationship between surgeon or hospital caseload and measures of quality of care. Results Five hundred and eighty‐one (95%) of the 614 rectal cancers diagnosed in Ireland in 2007 were audited; 49 hospitals and 86 surgeons participated. Ten (28%) hospitals treated fewer than five cases and seven fewer than three. A positive relationship between caseload and quality was seen for a few measures, more frequently for hospital than surgeon caseload. The relationship between caseload and quality of care was inconsistent, suggesting these measures do not represent a single dimension of quality. One‐year survival was negatively associated with hospital caseload. There was no statistically significant relationship between survival and measures of quality of care. Discussion Quality of care was inconsistently influenced by surgeon and hospital caseload. Caseload may affect only one aspect of surgical management, such as the quality of preoperative workup, and is not necessarily related to the quality of other hospital care. Simple measures of outcome, such as survival, cannot represent the complexity of this relationship.     

Surgeon and hospital‐related risk factors in colorectal cancer surgery

Aim The aim of this study was to identify surgeon and hospital‐related factors in a well‐defined population‐based cohort; the results of this study could possibly be used to improve outcome in colorectal cancer. Method Data from the colonic (1997–2006) and rectal (1995–2006) cancer registers of the Uppsala/Örebro Regional Oncology Centre were used to assess 1697 patients with rectal and 2692 with colonic cancer. Putative risk factors and their impact on long‐term survival were evaluated using the Cox proportional hazard model. Results The degree of specialization of the operating surgeon had no significant effect on long‐term survival. When comparing the surgeons with the highest degree of specialization, noncolorectal surgeons demonstrated a slightly lower long‐term survival for rectal cancer stage I and II (HR, 2.03; 95% CI, 1.05–3.92). Surgeons with a high case‐load were not associated with better survival in any analysis model. Regional hospitals had a lower survival rate for rectal cancer stage III surgery (HR, 1.47; 95% CI, 1.08–2.00). Conclusion Degree of specialization, surgeon case‐load and hospital category could not be identified as important factors when determining outcome in colorectal cancer surgery in this study.     

Metabolic syndrome is an important factor for the evolution of prognosis of colorectal cancer: survival, recurrence, and liver metastasis

Background

Several studies have shown that metabolic syndrome (MS) was a risk factor for colorectal cancer, but few studies have reported the relationship between MS and the prognosis of colorectal cancer.

Methods

Data were collected from 507 cases of colorectal carcinoma between January 2002 and March 2007 to establish the database. These patients were divided into 2 groups based on the presence of MS. We tested the prognostic value of MS in the patients. The risk of adverse events was examined by Cox proportional hazard modeling.

Results

The rates of liver metastasis and tumor recurrence were higher in the group of patients with colorectal cancer accompanied by MS. Moreover, MS is one of the important elements that independently can influence the survival (colonic carcinoma: hazard ratio [HR], 1.633; 95% confidence interval [CI], 1.039-2.565; rectal carcinoma: HR, 1.939, 95% CI, 1.076-3.494) and liver metastasis (colonic carcinoma: HR, 2.619; 95% CI, 1.288-5.324; rectal carcinoma: HR, 2.814; 95% CI, .962-2.888) of both colonic and rectal carcinoma patients, and MS patients have the highest risk with worse survival and liver metastases compared with other parameters.

Conclusions

The results suggest that MS may be an important prognostic factor for colorectal cancer, decreasing the incidence of MS may improve the therapeutic efficacy of colorectal cancer.     

Risk Factors for Complications After Laparoscopic Surgery in Colorectal Cancer Patients: Experience of 401 Cases at a Single Institution

Background  Laparoscopic surgery is widely used for the treatment of colorectal cancer, but little is known about perioperative risk factors for complications. Methods  Clinical data were reviewed for 401 consecutive unselected colorectal cancer patients who underwent laparoscopic surgery at Kyoto Medical Center between 1998 and 2005. The outcome variable was incidence of postoperative complications. Using logistic regression analysis, 58 background, clinical, preoperative, and intraoperative factors were assessed as potential predictors of complications. Results  The set of independent protective factors that had the greatest influence on the incidence of local complications after colon surgery was as follows: cefmetazole use for prophylaxis (versus oral only; adjusted odds ratio (OR) 0.18, 95% confidence interval (CI) 0.06–0.54), high operative infusion rate (per ml/min; OR 0.82, 95% CI 0.70–0.95), regular laxative use (OR 0.33, 95% CI 0.12–0.79), and double-stapled anastomosis (versus hand-sewn; OR 0.15, 95% CI 0.03–0.83). Independent risk factors for local complications after rectal surgery were abdominoperineal resection (versus low anterior resection, OR 4.84, 95% CI 1.64–14.9), long operative time (per hour, OR 1.55, 95% CI 1.11–2.23), and history of heart disease (OR 5.18, 95% CI 1.34–21.5). The occurrence of complications was not found to be associated with overall survival in this study. Conclusions  We identified intraoperative management such as low operative infusion rate is one of the independent significant risk factors for complications after laparoscopic surgery for colorectal cancer in addition to patient characteristics and surgical procedure. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Correlates and outcomes of tumor adherence in resected colonic and rectal cancers

OBJECTIVES: The aims of this study were to examine the associations between tumor adherence and other operative findings, postoperative complications, recurrence, and survival after resection of colorectal cancer. SUMMARY BACKGROUND DATA: The prognostic importance of tumor adherence to other organs or structures, either by direct invasion (T4) or simply by inflammatory adhesions, is yet to be clearly defined as earlier studies have been limited in size or have not used contemporary multivariable statistical techniques. METHODS: Data were drawn from a comprehensive, prospective hospital registry of all resections for colorectal cancer between January 1971 and December 2000 with follow-up to December 2005. Statistical analysis employed the chi test, Kaplan-Meier estimation, and proportional hazards regression with a significance level of <0.05 and 95% confidence intervals (CI). RESULTS: Tumor adherence was identified in 268 of 2504 resections (10.7%). Adherent tumors were more likely than nonadherent tumors to be spontaneously or surgically perforated or transected, to have nodal metastases and to be poorly differentiated. Venous invasion was more frequent in adherent colonic but not rectal tumors. Adherence was associated with only 5 of 16 medical and surgical complications considered. In rectal cancer, adherence was independently associated with pelvic recurrence (hazard ratio 1.8, 95% CI 1.2-2.7) and diminished survival (hazard ratio 1.6, 95% CI 1.3-2.0) after adjustment for other variables. CONCLUSION: In rectal cancer, tumor adherence indicates a poor prognosis after adjustment for other prognostic factors, regardless of whether actual tumor invasion of the adherent structure has occurred. However, adherence is not associated with survival after resection of colonic cancer.     

Cardiopulmonary resuscitation in pediatric trauma patients: survival and functional outcome.

BACKGROUND: Although injury is the leading cause of cardiac arrests in children older than 1 year, few studies have examined the survival and functional outcome of cardiopulmonary resuscitation (CPR) in pediatric trauma patients. METHODS: A historical cohort of 957 trauma patients younger than 15 years who received CPR at the scene of injury or at the admitting hospital was constructed on the basis of the National Pediatric Trauma Registry. The rate of survival to discharge and factors related to survival were examined. Functional impairments were documented for surviving patients. RESULTS: The overall survival rate was 23.5%. With adjustment for the Injury Severity Score, the risk of fatality after CPR increased for children with systolic blood pressure below 60 mm Hg at admission (odds ratio [OR] 24.5, 95% confidence interval [CI] 8.6-69.3), for those who were comatose at admission (OR, 4.7; 95% CI, 1.9-11.6), for those with penetrating injury (OR, 4.4; 95% CI, 1.5-13.3), and for those with CPR initiated at the hospital (OR, 2.4; 95% CI, 1.5-3.9). Surviving patients stayed in hospitals for an average of 24.3 days; at discharge, 64% had at least one impairment in the functional activities of daily living. CONCLUSIONS: Survival outcome of CPR in pediatric trauma patients appears to be comparable to that reported in adults of mixed arrest causes. Future research needs to identify factors underlying the excess mortality associated with penetrating trauma.     

The Impact of Postoperative Complications on Long-Term Outcomes Following Curative Resection for Colorectal Cancer

Background This study aimed to investigate the impact of postoperative complications on long-term survival and disease recurrence in patients who underwent curative resection for colorectal cancer. Method Patients who underwent radical resection for colorectal cancer with curative intent from January 1996 to December 2004 were included. Operative mortality and morbidity were documented prospectively. Factors that might affect long-term outcome were analyzed with multivariate analysis. Results Curative resection was performed in 1657 patients (943 men), and the median age was 70 years (range: 24–94 years). The 30-day mortality was 2.4%, and the complication rate was 27.3%. Age over 70 years (P < .001, odds ratio: 2.06, 95% CI: 1.63–2.61), male gender (P = .001, odds ratio: 1.49, 95% CI: 1.19–1.88), emergency operation (P < .001, odds ratio: 3.14, 95% CI: 2.26–4.35) and rectal cancer (P < .001, odds ratio: 1.41, 95% CI: 1.25–1.61) were associated with a significantly higher complication rate. With exclusion of patients who died within 30 days, the median follow-up of the surviving patients was 45.3 months. The 5-year overall survival was 64.9%, and the overall recurrence rate was 29.1%. The presence of postoperative complications was an independent factor associated with a worse overall survival (P = .023, hazard ratio: 1.26; 95% CI: 1.03–1.52) and a higher overall recurrence rate (P = .04, hazard ratio: 1.26; 95% CI: 1.01–1.57). Conclusion The presence of postoperative complication not only affects the short-term results of resection of colorectal cancer, but the long-term oncologic outcomes are also adversely affected. Long-term outcomes can be improved with efforts to reduce postoperative complications.     

Long-term oncologic outcome following preoperative combined modality therapy and total mesorectal excision of locally advanced rectal cancer

OBJECTIVE: Our aims were to (1) determine the long-term oncologic outcome for patients with rectal cancer treated with preoperative combined modality therapy (CMT) followed by total mesorectal excision (TME), (2) identify factors predictive of oncologic outcome, and (3) determine the oncologic significance of the extent of pathologic tumor response. SUMMARY BACKGROUND DATA: Locally advanced (T3-4 and/or N1) rectal adenocarcinoma is commonly treated with preoperative CMT and TME. However, the long-term oncologic results of this approach and factors predictive of a durable outcome remain largely unknown. METHODS: Two hundred ninety-seven consecutive patients with locally advanced rectal adenocarcinoma at a median distance of 6 cm from the anal verge (range 0-15 cm) were treated with preoperative CMT (radiation: 5040 centi-Gray (cGy) and 5-fluorouracil (5-FU)-based chemotherapy) followed by TME from 1988 to 2002. A prospectively collected database was queried for long-term oncologic outcome and predictive clinicopathologic factors. RESULTS: With a median follow-up of 44 months, the estimated 10-year overall survival (OS) was 58% and 10 year recurrence-free survival (RFS) was 62%. On multivariate analysis, pathologic response >95%, lymphovascular invasion and/or perineural invasion (PNI), and positive lymph nodes were significantly associated with OS and RFS. Patients with a >95% pathologic response had a significantly improved OS (P = 0.003) and RFS (P = 0.002). CONCLUSIONS: Treatment of locally advanced rectal cancer with preoperative CMT followed by TME can provide for a durable 10-year OS of 58% and RFS of 62%. Patients who achieve a >95% response to preoperative CMT have an improved long-term oncologic outcome, a novel finding that deserves further study.     

Relation of surgeon and hospital volume to processes and outcomes of colorectal cancer surgery

BACKGROUND: Greater hospital volume has been associated with lower mortality after colorectal cancer surgery. The contribution of surgeon volume to processes and outcomes of care is less well understood. We assessed the relation of surgeon and hospital volume to postoperative and overall mortality, colostomy rates, and use of adjuvant radiation therapy. METHODS: From the California Cancer Registry, we studied 28,644 patients who underwent surgical resection of stage I to III colorectal cancer during 1996 to 1999 and were followed up to 6 years after surgery to assess 30-day postoperative mortality, overall long-term mortality, permanent colostomy, and use of adjuvant radiation therapy. RESULTS: Across decreasing quartiles of hospital and surgeon volume, 30-day postoperative mortality ranged from 2.7% to 4.2% (P < 0.001). Adjusting for age, stage, comorbidity, and median income among patients with colorectal cancer who survived at least 30 days, patients in the lowest quartile of surgeon volume had a higher adjusted overall mortality rate than those in the highest quartile (hazard ratio, 1.16; 95% confidence interval, 1.09-1.24), as did patients in the lowest quartile of hospital volume relative to those treated in the highest quartile (hazard ratio, 1.11; 95% confidence interval, 1.05-1.19). For rectal cancer, adjusted colostomy rates were significantly higher for low-volume surgeons, and the use of adjuvant radiation therapy was significantly lower for low-volume hospitals. CONCLUSIONS: Greater surgeon and hospital volumes were associated with improved outcomes for patients undergoing surgery for colorectal cancer. Further study of processes that led to these differences may improve the quality of colorectal cancer care.     

Impact of surgeon volume on outcomes of rectal cancer surgery: A systematic review and meta-analysis

AimTo clarify the relationship between surgeon caseload and patient outcomes for patients undergoing rectal cancer surgery in order to inform debate about organisation of services.MethodsWe searched Medline and Embase for articles published up to March 2010, and included studies examining surgeon caseload and outcomes in rectal cancer patients treated after 1990. Outcomes considered were 30-day mortality, overall survival, anastomotic leak, local recurrence, permanent stoma and abdominoperineal excision rates. We assessed the risk of bias in included studies and performed random effects meta-analyses based on both unadjusted and casemix adjusted data.ResultsEleven included studies enrolled 18,301 rectal cancer patients undergoing resective surgery. Unadjusted meta-analysis showed a statistically significant benefit in favour of high volume surgeons for 30-day postoperative mortality (OR = 0.57, 95% CI: 0.43–0.77; based on three studies, 4809 patients) and overall survival (HR = 0.76, 95% CI 0.63–0.90; based on two studies, 1376 patients), although the former relationship was attenuated and non-significant when based on two studies (9685 patients) that adjusted for casemix (OR = 0.79, 95% CI: 0.59–1.06). Pooling of three studies (2202 patients) showed no significant relationship between surgeon volume and anastomotic leak rate. Permanent stoma formation was less likely for high volume surgeons (adjusted OR = 0.75, 95% CI: 0.64 to 0.88; based on two studies, 9685 patients) and APER rates were lower for high volume surgeons (unadjusted OR = 0.58, 95% CI: 0.45 to 0.76); based on six studies, 3921 participants.ConclusionsThis review gives evidence that higher surgeon volume is associated with better overall survival, lower permanent stoma and APER rates.     

内镜支架减压对比肠造口减压对梗阻性结直肠癌择期手术近远期疗效影响的Meta分析

目的 比较急诊造口减压和内镜支架减压后择期手术切除治疗梗阻性结直肠癌的近远期效果。方法 检索PubMed、Embase、Cochrane Library、中国知网、万方数据库已公开发表的有关造口减压对比内镜支架减压后序贯择期手术切除的梗阻性结直肠癌近远期效果的文献,提取的数据采用RevMan 5.3软件进行Meta分析。结果 共10篇回顾性病例对照研究纳入汇总分析,Newcastle-Ottawa Scale评分范围为6～8分,其中高质量文献6篇。总样本量为1 807例,包括造口组939例,支架组868例。汇总分析结果提示,支架组两次手术间隔时间短于造口组（WMD=13.37,95%CI:7.88～18.86,P<0.000 01）,但造口组择期手术一期吻合率高于支架组（OR=1.58,95%CI:1.10～2.26,P=0.01）,3年总生存率也高于支架组（HR=0.77,95%CI:0.61～0.97,P=0.02）。两组在择期手术入路方式、永久性造口率、总体并发症和围手术期死亡率方面比较,差异均无统计学意义。结论 肠造口减压和内镜支架减压对梗阻性结直肠癌患者后续择期行结直肠...     

Are we undertreating rectal cancer in the elderly? An epidemiologic study

OBJECTIVE: To better understand the reasons for decreased survival rates in elderly patients with rectal cancer by performing an epidemiologic evaluation of age-related differences in treatment and survival. SUMMARY BACKGROUND DATA: The incidence of rectal cancer increases with older age, and localized disease can be curatively treated with stage-appropriate radical surgery. However, older patients have been noted to experience decreased survival. METHODS: Patients with localized rectal adenocarcinoma were identified in the Surveillance, Epidemiology, and End Results database (1991-2002). Cancer-specific survival by age, sex, surgery type, tumor grade, lymph node status, and use of radiation therapy was evaluated using univariate and multivariate regression analysis. RESULTS: We identified 21,390 patients who met the selection criteria. The median age was 68 years. Each half-decade increase in age > or =70 years was associated with a 37% increase in the relative risk (RR) for cancer-related mortality (RR = 1.37; 95% confidence interval [CI], 1.33-1.42); decreased receipt of cancer-directed surgery (odds ratio [OR] = 0.56; 95% CI, 0.36-0.63); more local excision and less radical surgery (OR = 0.76; 95% CI, 0.72-0.81); less radiotherapy (OR = 0.64; 95% CI, 0.61-0.67); and greater likelihood of N0 pathologic stage classification (OR = 1.10; 95% CI, 1.05-1.15) (P < 0.0001 for each factor). The effect of age on cancer-specific mortality persisted in multivariate analysis with each half-decade increase in age > or =70 years resulting in a 31% increase in cancer-specific mortality (RR = 1.31; 95% CI, 1.25-1.36; P < 0.0001). CONCLUSIONS: In elderly patients, rectal cancer is characterized by decreased cancer-related survival rates that are associated with less aggressive treatment overall and decreased disease stages at presentation. Investigation into the reasons for these treatment differences may help to define interventions to improve cancer outcomes.     

Anastomotic leakage after elective right versus left colectomy for cancer: prevalence and independent risk factors

BACKGROUND: Anastomotic leakage in colorectal surgery remains a major challenge because of its early and late consequences. STUDY DESIGN: To determine whether prevalence and risk factors for anastomotic leakage (AL) differed between right and left elective colectomy for cancer, we conducted univariate and multivariate analyses and compared 33 variables (15 preoperative, 18 intraoperative) culled prospectively for 520 right and 1,230 left colectomies, followed by immediate anastomosis in 1,750 adult patients with or without AL. RESULTS: The overall AL rate was 4% (71 of 1,750) and was significantly lower (p < 0.0001) for right (7 of 520=1.35%) than for left colectomy (64 of 1,230=5.20%). Overall mortality was 4.1% (68 of 1,750), and was not statistically different (p=0.50) between right (4.6%, 24 of 520) and left (3.6%, 44 of 1,230)) colectomy. In right colectomy, differences in associated mortality rates with (14.3%, 1 of 7) and without (4.5%, 23 of 513) AL were not statistically significant (p=0.28), but in left colectomy, associated mortality was statistically significantly higher (p < 0.006) with AL (10.9%, 7 of 64) than without it (3.2%, 37 of 1,166). Independent risk factors for AL were preoperative in right colectomy: loss of weight (> 10%), odds ratio (OR)=5.62, with 95% CI 1.06 to 29.8; and intraoperative in left colectomy: palliative resection (OR=2.12; 95% CI 1.06 to 4.23), "poor" colonic cleanliness (OR=2.4; 95% CI 1.34 to 4.28), proximal colorectal anastomosis (OR=1.34; 95% CI 1 to 1.8), and distal colorectal anastomosis (OR=3.91; 95% CI 1.64 to 9.81). CONCLUSIONS: In right colectomy for cancer, preoperative nutritive support leading to regain of lost weight could reduce postoperative morbidity. Concerning left colectomy, if colonic cleanliness is poor, intraoperative colonic lavage should be done. When poor colonic cleanliness is associated with palliative resection and low distal rectal anastomosis, a protective stoma should be considered.     

Multivisceral Resection in Colorectal Cancer: A Systematic Review

Background

The objective of this study was to critically evaluate current literature on outcomes following multivisceral resection (MVR) in colorectal cancer (CRC). Adequate surgical resection with clear margins is imperative in achieving long-term survival in colorectal cancer. Where there is adherence to or invasion of adjacent organs, (MVR) may be needed to achieve complete disease clearance.

Methods

A systematic review of MVR in CRC was performed. Pubmed/Medline and Cochrane databases were searched for English language articles from 1995 to 2012 using a predefined strategy. Retrieved abstracts were independently screened for relevance and data extracted from selected studies by 2 researchers. Results are reported as weighted means.

Results

Included were 22 studies comprising 1575 patients (87.0 % primary colorectal cancer; 13.0 % recurrent, 63.8 % rectal; 36.2 % colon). The most common organs resected were the bladder and reproductive organs. The perioperative mortality was 4.2 % with morbidity of 41.5 % (95 % CI, 40.8–42.2 %). The overall 5-year survival rate was 50.3 % (95 % CI, 49.9–50.8 %). Surgery for recurrence was associated with worse outcomes than primary tumors with 5-year survival 19.5 % (95 % CI, 17.8–21.1 %) for recurrent rectal cancer and primary rectal tumors 5-year overall survival 52.8 % (95 % CI, 52.0–53.8 %). R0 resection was the strongest factor associated with long-term survival.

Conclusions

Multivisceral resection provides the best possibility of long-term survival in locally advanced primary colorectal cancer in which a clear margin has been achieved.     

Robotic-assisted Colorectal Surgery in the United States: A Nationwide Analysis of Trends and Outcomes

Background

While robotic-assisted colorectal surgery (RACS) is becoming increasingly popular, data comparing its outcomes to other established techniques remain limited to small case series. Moreover, there are no large studies evaluating the trends of RACS at the national level.

Methods

The Nationwide Inpatient Sample 2009–2010 was retrospectively reviewed for robotic-assisted and laparoscopic colorectal procedures performed for cancer, benign polyps, and diverticular disease. Trends in different settings, indications, and demographics were analyzed. Multivariate regression analysis was used to compare selected outcomes between RACS and conventional laparoscopic surgery (CLS).

Results

An estimated 128,288 colorectal procedures were performed through minimally invasive techniques over the study period, and RACS was used in 2.78 % of cases. From 2009 to 2010, the use of robotics increased in all hospital settings but was still more common in large, urban, and teaching hospitals. Rectal cancer was the most common indication for RACS, with a tendency toward its selective use in male patients. On multivariate analysis, robotic surgery was associated with higher hospital charges in colonic ($11,601.39; 95 % CI 6,921.82–16,280.97) and rectal cases ($12,964.90; 95 % CI 6,534.79–19,395.01), and higher rates of postoperative bleeding in colonic cases (OR = 2.15; 95 % CI 1.27– 3.65). RACS was similar to CLS with respect to length of hospital stay, morbidity, anastomotic leak, and ileus. Conversion to open surgery was significantly lower in robotic colonic and rectal procedures (0.41; 95 % CI 0.25–0.67) and (0.10; 95 % CI 0.06–0.16), respectively.

Conclusions

The use of RACS is still limited in the United States. However, its use increased over the study period despite higher associated charges and no real advantages over laparoscopy in terms of outcome. The one advantage is lower conversion rates.     

Efforts to improve local control in rectal cancer compromise survival by the potential morbidity of optimal mesorectal excision

BACKGROUND: The technique of total mesorectal excision (TME) increases the risk of anastomotic leakage. The impact of postoperative morbidity of TME on longterm survival has never been described. We retrospectively analyzed factors that might influence survival after TME for rectal cancer, including postoperative morbidity. STUDY DESIGN: From 1994 to 2001, 300 patients (192 men and 108 women; mean age, 64 years) had TME for rectal cancer. Preoperative radiotherapy was given in 202 patients. Age, gender, tumor height, size and circular invasion of the tumor, pathologic tumor and nodal status, distal and circumferential margins, number of lymph nodes analyzed, type of surgery, postoperative pelvic sepsis, preoperative radiotherapy, and adjuvant chemotherapy were examined; their association with overall and disease-free survival was evaluated by the log-rank test in univariate analysis and by multivariable Cox proportional hazards analysis. RESULTS: Postoperative morbidity was 38% (113 of 300 patients) and included 18% (54 of 300 patients) pelvic sepsis. The local recurrence rate was 6% (18 of 300 patients), and the distant metastasis rate was 24% (73 of 300 patients). Recurrence was three times more frequent distally than locally, including patients with pelvic sepsis The 5-year overall and disease-free survival rates were 72% and 60%, respectively. Independent predictors of overall survival were age older than 64 years (odds ration [OR]=2.19, 95% CI 1.32 to 4.17), pelvic sepsis (OR=2.06, 95% CI 1.10 to 3.87), circumferential surgical margin (OR=3.19, 95% CI 1.67 to 6.09), pathologic tumor (OR=2.69, 95% CI1.23 to 5.88), and nodal status (OR=3.18, 95% CI 1.79 to 5.64). Independent predictors of disease-free survival were pelvic sepsis (OR=2.17, 95% CI 1.31 to 3.58), circumferential surgical margin (OR=2.61, 95 CI 1.52 to 4.49), pathologic tumor (OR=1.82, 95% CI 1.04 to 3.20), and nodal status (OR=2.67, 95% CI 1.68 to 4.23). Patients with pelvic sepsis had a 5-year disease-free survival of 39% compared with 65% without pelvic sepsis (p<0.001). CONCLUSIONS: After TME for rectal cancer, pelvic sepsis is a common complication that is associated with increased risk of distant recurrence and decreased longterm survival. Efforts are necessary to decrease postoperative morbidity in surgical treatment of rectal cancer.     

Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes

Background: Total mesorectal excision (TME) offers the lowest reported rates of local recurrence and the best survival results in patients with rectal cancer. However, the laparoscopic approach to resection for colorectal cancer remains controversial due to fears that oncologic principles will be compromised. We assessed the feasibility, safety and long-term outcome of laparoscopic rectal cancer resections following the principles of TME. The aim of this study was to evaluate the perioperative outcome and long-term results of laparoscopic TME. Methods: We reviewed the prospective database of 102 consecutive unselected patients undergoing laparoscopic TME for rectal cancer between November 1991 and December 2000. Follow-up was done through office charts or direct patient contact. Recurrence and survival curves were generated by the Kaplan-Meier method. Results: Laparoscopic TME was completed successfully in 99 patients, whereas conversion to an open approach was required in three cases (3%). The overall morbidity and mortality rates were 27% and 2%, respectively, with an overall anastomotic leak rate of 17%. Of the 102 patients, four were excluded from the oncologic evaluation because final pathology was not confirmatory (two had anal canal squamous cell carcinoma and two had villous adenoma with dysplasia). In 90 of the 98 remaining patients (91.8%), the resection was considered curative. The remainder had a palliative resection due to synchronous metastatic disease or locally advanced disease. Mean follow-up was 36 months (range, 6–96). There were no trocar site recurrences. The local recurrence rate was 6%, and the cancer-specific survival of all curatively resected patients was 75% at 5 years. The overall survival rate of all curatively resected patients was 65% at 5 years; mean survival time was 6.23 years (95% confidence interval [CI], 5.39–7.07). Conclusion: Laparoscopic TME is feasible and safe. The laparoscopic approach to the surgical treatment of operable rectal cancer does not seem to entail any oncologic disadvantages. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), New York, NY, USA, 13–16 March 2002