E. L. Bokey

Postoperative morbidity and mortality following resection of the colon and rectum for cancer

PURPOSE: The aim of this study was to report the prevalence of postoperative complications and mortality of patients with colorectal cancer when treated by conventional surgery. METHODS: Morbidity and mortality following open resection for colorectal cancer were analyzed in 1,846 patients whose clinical, operative, and pathology data were prospectively documented over a 20-year period. RESULTS: Mortality following elective resection of the left and right colon was low, whereas overall morbidity was high (37.2 percent). Respiratory and cardiac complications were especially common. Incidence of clinically significant leakage was similar following right (0.5 percent) or left (1.1 percent) hemicolectomy. Incidence of anastomotic leakage was significantly higher after emergency right hemicolectomy (4.3 percent). Overall morbidity following excision of the rectum was high (40.2 percent). Respiratory and cardiac complications predominated. Incidence of clinically significant anastomotic leakage following anterior resection was low (2.9 percent). Over the years, there has been a decline in the number of patients with tumor demonstrated histologically in a line of resection, suggesting an improved local surgical clearance. CONCLUSIONS: These results following conventional surgery may be useful when evaluating new techniques.

Anastomotic leakage after curative anterior resection results in a higher prevalence of local recurrence

The aim of this study was to determine whether leakage from a colorectal anastomosis following potentially curative anterior resection for rectal cancer is an independent risk factor for local recurrence.

Factors affecting survival after excision of the rectum for cancer: a multivariate analysis.

PURPOSE: The aim of this study was to identify and categorize the independent prognostic effects of patient, clinical, operative, and pathology variables on long-term survival after anterior resection or abdominoperineal excision of the rectum for cancer. METHODS: Proportional hazards regression analysis was used to analyze prospective data from 709 patients who underwent surgery at Concord Hospital during a 23-year period. No patient received adjuvant therapy. RESULTS AND CONCLUSIONS: After adjusting for age and clinicopathologic stage, significantly poorer survival was experienced by males, patients with extensive tumor adherent to other organ(s), those with a high-grade tumor or a tumor showing venous invasion, those who had a postoperative cardiovascular or respiratory complication, and those who did not undergo surgery by a colorectal surgeon specialist. The nature of the operation performed had no independent effect on survival.

Morbidity and mortality following laparoscopic-assisted right hemicolectomy for cancer

PURPOSE: This study was undertaken to compare morbidity, mortality, and pathology after laparoscopically assisted right hemicolectomy (LARHC) or open right hemicolectomy (ORHC) for cancer of the right colon. METHODS: Patients undergoing either LARHC or ORHC for invasive carcinoma of the right colon during a 30-month period were studied. Data were collected from two sources. All morbidity, mortality, and pathology data were collected prospectively in a form suitable for computer storage and analysis as part of the ongoing Concord Hospital Colorectal Cancer Registry. Data concerning in hospital course were obtained by casenote review. RESULTS: Twenty-eight patients underwent LARHC, and 33 had an ORHC during the study period. The two groups were well matched with respect to age, sex, weight, associated comorbidities, and tumor stage. Mean operating room use time was significantly higher for LARHC (LARHC=261 minutes; ORHC=203 minutes;P<0.001). Mean hospital stay from date of resection was the same in both groups (LARHC=12 days; ORHC=12.2 days). There was no significant difference between procedures with respect to postoperative complications, return of gastrointestinal function, or narcotic analgesic requirements. There was a significant shorter distal margin of resection in the LARHC group (ORHC=13.4 cm; LARHC=10 cm;P=0.03.). Total cost was significantly greater for LARHC (

Are special investigations of value in the management of patients with fecal incontinence

9,064vs.

Promoter methylation of the mutated in colorectal cancer gene is a frequent early event in colorectal cancer

7,881 (Australian);P<0.001). Median follow-up was 23.4 months for the LARHC group and 23.9 months for the ORHC group. To date, there have been no local or port site recurrences. CONCLUSION: Although there is no difference in morbidity and mortality following LARHC or ORHC, there is no apparent benefit for LARHC.

Low level microsatellite instability may be associated with reduced cancer specific survival in sporadic stage C colorectal carcinoma

PURPOSE: The aim of this study was to determine whether special investigations significantly alter either the diagnosis or the management plan of patients with fecal incontinence assessed on the basis of a structured history and physical examination alone. METHODS: Fifty consecutive patients with fecal incontinence were prospectively studied in a tertiary referral clinic. Each patient was assessed by two clinicians who independently formulated a diagnosis and treatment plan based on the history and physical examination. The resulting 100 patient assessments were then compared with the final diagnosis and treatment plan formulated on completion of endoanal ultrasound, anal manometry, external sphincter electromyography, and defecating proctography. RESULTS: In the assessment of fecal incontinence, the addition of special investigations altered the diagnosis of the cause of incontinence based on history and examination alone in 19 percent of cases. The management plan was altered in 16 percent of cases. Special investigations were most useful in separating neuropathy from rectal wall disorders and in demonstrating the unexpected presence of internal sphincter defects and neuropathy. CONCLUSIONS: Even experienced colorectal surgeons will misdiagnose up to one-fifth of patients presenting with fecal incontinence if assessment is based on the history and physical examination alone. However surgically correctable causes of incontinence are rarely missed on clinical assessment.

Anastomotic leakage after resection of colorectal cancer generates prodigious use of hospital resources.

The mutated in colorectal cancer (MCC) gene is in close linkage with the adenomatous polyposis coli (APC) gene on chromosome 5, in a region of frequent loss of heterozygosity in colorectal cancer. The role of MCC in carcinogenesis, however, has not been extensively analysed, and functional studies are emerging, which implicate it as a candidate tumor suppressor gene. The aim of this study was to examine loss of MCC expression due to promoter hypermethylation and its clinicopathologic significance in colorectal cancer. Correspondence of MCC methylation with gene silencing was demonstrated using bisulfite sequencing, reverse transcription–polymerase chain reaction and Western blotting. MCC methylation was detected in 45–52% of 187 primary colorectal cancers. There was a striking association with CDKN2A methylation (P<0.0001), the CpG island methylator phenotype (P<0.0001) and the BRAF V600E mutation (P<0.0001). MCC methylation was also more common (P=0.0084) in serrated polyps than in adenomas. In contrast, there was no association with APC methylation or KRAS mutations. This study demonstrates for the first time that MCC methylation is a frequent change during colorectal carcinogenesis. Furthermore, MCC methylation is significantly associated with a distinct spectrum of precursor lesions, which are suggested to give rise to cancers via the serrated neoplasia pathway.

Adverse histopathological findings as a guide to patient management after curative resection of node-positive colonic cancer.

Background: Colorectal cancers (CRCs) may be categorised according to the degree of microsatellite instability (MSI) exhibited, as MSI-high (MSI-H), MSI-low (MSI-L), or microsatellite stable (MSS). MSI-H status confers a survival advantage to patients with sporadic CRC. Aims: To determine if low levels of MSI are related to the clinicopathological features and prognosis of sporadic stage C CRC. Patients: A total of 255 patients who underwent resection for sporadic stage C CRC were studied. No patient received chemotherapy. Minimum follow up was five years. Methods: DNA extracted from archival malignant and non-malignant tissue was amplified by polymerase chain reaction using a panel of 11 microsatellites. MSI-H was defined as instability at ⩾40% of markers, MSS as no instability, and MSI-L as instability at >0% but <40% of markers. Patients with MSI-H CRC were excluded from analysis as they have previously been shown to have better survival. Results: Thirty three MSI-L and 176 MSS CRCs were identified. There was no difference in biological characteristics or overall survival of MSI-L compared with MSS CRC but MSI-L was associated with poorer cancer specific survival (hazard ratio 2.0 (95% confidence interval 1.1–3.6)). Conclusions: Sporadic MSI-L and MSS CRCs have comparable clinicopathological features. Further studies are required to assess the impact of MSI-L on prognosis.

Effect of supervised surgical training on outcomes after resection of colorectal cancer

Objective  The aim of this study was to determine the demand for hospital resources generated by anastomotic leakage, including surgical, medical, imaging, pathology, and other allied health consultations or services and length of postoperative hospital stay.