H. Ptok

Impact of anastomotic leakage on oncological outcome after rectal cancer resection

Anastomotic leakage has a major impact on morbidity and mortality in rectal cancer surgery. Its relevance to oncological outcome is controversial. This observational study investigated the influence of anastomotic leakage on oncological outcome.

Palliative stent implantation in the treatment of malignant colorectal obstruction

BackgroundPalliative surgical interventions for the management of colonic obstruction in cases of metastasized or locally irresectable colorectal carcinoma show remarkable morbidity and mortality rates for mostly older and multimorbid patients. For manifest obstruction, placement of a self-expanding metal stent (SEMS) is considered to be a suitable minimally invasive therapeutic option. This study aimed to investigate the efficacy of stent-based treatment for malignant large bowel obstruction.MethodsFrom January 1999 to June 2005, consecutive patients who had undergone placement of a SEMS for malignant colorectal obstruction were enrolled and monitored. Manifest incontinence and rectum carcinoma within 5 cm above the anocutaneous line were contraindications for SEMS implantation. For all further locations of tumor-induced stenosis, a stent was implanted using endoscopy and fluoroscopy. This case series was characterized in terms of age, carcinoma localization, complications, morbidity and mortality, and the necessity for further interventions.ResultsFor 44 of 48 patients (92%), stents were placed successfully and obstruction was abolished. The four remaining patients experienced stent dislocation. The median of age of the patients was 77.7 years (range, 47–96 years). The distribution of malignant stenoses was as follows: rectum (n = 16, 33.3%), sigmoideal colon (n = 21, 43.8%), descending colon (n = 4, 8.3%), splenic flexure (n = 2, 4.2%), transversal colon (n = 3, 6.2%), hepatic flexure (n = 1, 2.1%), and ascending colon (n = 1, 2.1%). There was no peri-interventional morbidity or mortality. The median in situ time for the stents was 251 days (mean, 422 days), with 13 of 44 patients treated with palliative therapy showing complications (29.5%). Six patients were treated endoscopically, and three individuals underwent surgical intervention. For four patients, no further intervention was required. Overall, there was no treatment-related mortality.ConclusionsFor palliative treatment of malignancy-induced colorectal obstruction, SEMS is an efficient tool associated with low morbidity and minimal mortality. From a technical point of view, all tumor locations are accessible.

Conversion from laparoscopic to open colonic cancer resection – Associated factors and their influence on long-term oncological outcome

PURPOSE Comparisons of open and laparoscopic colon cancer resection have shown that laparoscopy offers an oncologically safe option. However, there are no data on long-term influence of converted resection, despite conversion rates of up to 30% and the general observation that short-term outcome is significantly worsened. The aim was to compare the long-term results of primary open resection (OR), purely laparoscopic resection (LR-p) and converted resection (LR-c). METHODS In a prospective study at 282 German hospitals demographic, tumor- and treatment-related data and disease-free survival were compared in the three groups. RESULTS 8015 of 8307 patients with OR, 280 of 290 patients with LR-p and 55 of 56 patients with LR-c were followed for 39.5 months (median). Overall, no statistically significant differences were seen for five-year DFS (74.8%, 81.3% and 65.6%). However, for patients in stage II with conversion, the five-year DFS was significantly poorer (43.3%) than for OR (80.5%; p=0.003) and LR-p patients (92.5%; p=0.001). For stages I and III no differences were observed. CONCLUSION Conversion of laparoscopic colon cancer resection worsens DFS in locally advanced stage II carcinoma. There is a need to reduce the conversion rate by adequate patient selection for laparoscopic resection by experienced surgeons.

[Long-term oncological results after laparoscopic, converted and primary open procedures for rectal carcinoma. Results of a multicenter observational study].

ZusammenfassungHintergrundDie laparoskopische Rektumkarzinomresektionen hat eine den offenen Verfahren vergleichbare Morbidität und onkologische Sicherheit bei jedoch deutlich höherer Morbidität nach Konversion. Zu den onkologischen Langzeitergebnisse nach Konversion liegen keine Daten vor.MethodeVom 01.01.2000–31.12.2002 in einer Beobachtungsstudie erfasste Patienten mit kurativ reseziertem Rektumkarzinom wurden hinsichtlich der postoperativen Morbidität, Letalität, des tumor- und lokalrezidivfreien Überlebens nach laparoskopischer vs. konvertierter vs. offener Resektion verglichen.ErgebnisseVon 7189 Patienten wurden 237 (3,3%) laparoskopisch (ITT) reseziert. Diese Patienten hatten signifikant häufiger T1/2-Tumore (p<0,001) in früheren UICC-Stadien (p<0,001) als die offen resezierten. Die Konversionsrate betrug 14,8% (n=35). Die Konversionsgruppe hatte signifikant mehr intraoperative (p<0,001) und allgemeine postoperative Komplikationen (p=0,003) sowie die höchste Gesamtmorbidität (p=0,031) im Vergleich zur laparoskopischen und offenen Resektion. Nach einem medianen Follow-up von 30.1 Monaten zeigten die konvertierten Patienten die höchste 5-J-Lokalrezidivrate (16.0%). Nach laparoskopischer sowie offener Resektion betrug diese 3.3% resp. 12.4% (p=0.082). Die tumorfreie 5-J-Üerlebensrate war vergleichbar (p=0.585).Schlussfolgerungen Die laparoskopische Rektumkarzinomresektion bietet gegenüber der offenen Resektion vergleichbare onkologische Ergebnisse, jedoch ist nach Konversion das frühpostoperative und das onkologische Langzeit-Outcome schlechter. Bei Konversionsraten um 15% ist eine strenge Patientenselektion und Durchführung der laparoskopischen Resektion an Zentren zu fordern.AbstractBackgroundThe laparoscopic resection of rectal cancer shows morbidity and oncological safety comparable to the open approach, but morbidity increases after conversion to open resection. No oncological long-term results are available for the latter patients.MethodsFrom 01/01/2000–31/12/2002, patients with curatively resected rectal cancer enrolled in a observational study were evaluated for morbidity, mortality, tumor- and local recurrence rate, paying attention to patients with conversion from laparoscopic to open resection.Results237 (3.3%) of 7,189 patients underwent laparoscopic resection (ITT). These patients showed significantly more T1/2 tumors (P<0.001) in earlier UICC stages (P<0.001) than open resected patients. 35 (14.8%) of 237 laparoscopic procedures were converted. Compared with patients receiving complete laparoscopic or open resection, these patients showed significantly higher frequencies of intraoperative (P<0.001) and general postoperative complications (P=0.003) as well as the highest overall morbidity (P=0.031). After a median follow-up of 30.1 months, the highest 5-year local recurrence rate was found in the converted group (16.0%). The laparoscopically resected patients showed a local recurrence rate of 3.3%, patients with open resection of 12.4% (P=0.082). The disease-free survival rate did not differ between the groups (P=0.585).ConclusionLaparoscopic resection of rectal cancer provides oncological results similar to open resection. After conversion, the short and oncological long-term outcomes were worse. Considering a conversion rate of 15%, only a strict indication for the laparoscopic approach can be allowed, and laparoscopic resection should be performed at centers.

Operative Behandlung von Rektumkarzinomen im Vergleich

ZusammenfassungHintergrundDie laparoskopische Rektumkarzinomresektionen hat eine den offenen Verfahren vergleichbare Morbidität und onkologische Sicherheit bei jedoch deutlich höherer Morbidität nach Konversion. Zu den onkologischen Langzeitergebnisse nach Konversion liegen keine Daten vor.MethodeVom 01.01.2000–31.12.2002 in einer Beobachtungsstudie erfasste Patienten mit kurativ reseziertem Rektumkarzinom wurden hinsichtlich der postoperativen Morbidität, Letalität, des tumor- und lokalrezidivfreien Überlebens nach laparoskopischer vs. konvertierter vs. offener Resektion verglichen.ErgebnisseVon 7189 Patienten wurden 237 (3,3%) laparoskopisch (ITT) reseziert. Diese Patienten hatten signifikant häufiger T1/2-Tumore (p<0,001) in früheren UICC-Stadien (p<0,001) als die offen resezierten. Die Konversionsrate betrug 14,8% (n=35). Die Konversionsgruppe hatte signifikant mehr intraoperative (p<0,001) und allgemeine postoperative Komplikationen (p=0,003) sowie die höchste Gesamtmorbidität (p=0,031) im Vergleich zur laparoskopischen und offenen Resektion. Nach einem medianen Follow-up von 30.1 Monaten zeigten die konvertierten Patienten die höchste 5-J-Lokalrezidivrate (16.0%). Nach laparoskopischer sowie offener Resektion betrug diese 3.3% resp. 12.4% (p=0.082). Die tumorfreie 5-J-Üerlebensrate war vergleichbar (p=0.585).Schlussfolgerungen Die laparoskopische Rektumkarzinomresektion bietet gegenüber der offenen Resektion vergleichbare onkologische Ergebnisse, jedoch ist nach Konversion das frühpostoperative und das onkologische Langzeit-Outcome schlechter. Bei Konversionsraten um 15% ist eine strenge Patientenselektion und Durchführung der laparoskopischen Resektion an Zentren zu fordern.AbstractBackgroundThe laparoscopic resection of rectal cancer shows morbidity and oncological safety comparable to the open approach, but morbidity increases after conversion to open resection. No oncological long-term results are available for the latter patients.MethodsFrom 01/01/2000–31/12/2002, patients with curatively resected rectal cancer enrolled in a observational study were evaluated for morbidity, mortality, tumor- and local recurrence rate, paying attention to patients with conversion from laparoscopic to open resection.Results237 (3.3%) of 7,189 patients underwent laparoscopic resection (ITT). These patients showed significantly more T1/2 tumors (P<0.001) in earlier UICC stages (P<0.001) than open resected patients. 35 (14.8%) of 237 laparoscopic procedures were converted. Compared with patients receiving complete laparoscopic or open resection, these patients showed significantly higher frequencies of intraoperative (P<0.001) and general postoperative complications (P=0.003) as well as the highest overall morbidity (P=0.031). After a median follow-up of 30.1 months, the highest 5-year local recurrence rate was found in the converted group (16.0%). The laparoscopically resected patients showed a local recurrence rate of 3.3%, patients with open resection of 12.4% (P=0.082). The disease-free survival rate did not differ between the groups (P=0.585).ConclusionLaparoscopic resection of rectal cancer provides oncological results similar to open resection. After conversion, the short and oncological long-term outcomes were worse. Considering a conversion rate of 15%, only a strict indication for the laparoscopic approach can be allowed, and laparoscopic resection should be performed at centers.

Surgical practices for malignant left colonic obstruction in Germany

AIM Data from the multicentric observation study Kolon/Rektum-Karzinome (Primärtumor) (primary colorectal carcinoma) are adduced to assess the status of surgical treatment of this condition in Germany and to compare different operative approaches in the emergency treatment of obstructive left-sided colon cancer, especially diversion (Hartmanns procedure) and primary anastomosis. PATIENTS AND METHODS Out of 15,911 patients with cancer of the left colon, recorded between 01.01.2000 and 31.12.2004, a total of 743 patients underwent emergency surgery for an obstructive tumour, performed as a radical resection. These patients were compared in respect of their risk profile and postoperative result. RESULTS In 57.9% (n=430) a one-stage operation (Group I), in 11.7% (n=87) a primary anastomosis with protective stoma (Group II), and in 30.4% (n=226), Hartmanns procedure (Group III) was performed. In Group III more patients were male, overweight and multimorbid, and more had advanced-stage tumours. The morbidity and hospital mortality (overall hospital mortality, 7.7%; n=57) did not differ significantly between the groups. The insertion of a protective stoma did not affect the rate of anastomotic insufficiency (Group I, 7%; Group II, 8.0%). CONCLUSIONS Primary anastomosis for emergency left colon carcinoma obstruction should only be regarded as indicated in cases where the risk profile is favourable. Our results suggest that in advanced obstruction and in high-risk cases Hartmanns procedure should be used. A protective stoma did not appear to confer any advantage.

Neoadjuvant chemoradiotherapy for rectal carcinoma: effects on anastomotic leak rate and postoperative bladder dysfunction after non-emergency sphincter-preserving anterior rectal resection

IntroductionRandomized trials have demonstrated a reduction in local recurrence rate in rectal cancer patients treated with preoperative chemoradiotherapy and total mesorectal excision (TME) compared to patients undergoing TME alone. Accordingly, preoperative chemoradiotherapy in all UICC stages II and III rectal cancers has been recommended in the German treatment guidelines as of 2004. However, this policy has been questioned in recent years, partly due to concern regarding an increase in postoperative complications through preoperative therapy. Studies on this issue are sparse; most have been conducted in specialized centers, included relatively few patients, and yielded partly contradicting results. It was the aim of our analysis to investigate the influence of preoperative chemoradiotherapy on anastomotic leak rate and postoperative bladder dysfunction in rectal cancer patients using a representative data set from the Quality Assurance in Rectal Cancer Surgery multicenter observational trial.MethodThis is a retrospective analysis of data from the Quality Assurance in Rectal Cancer Surgery prospective multicenter observational trial. Data of all patients undergoing curatively intended sphincter-preserving resection for UICC stage I through III rectal carcinoma between 01 Jan 2005 and 31 Dec 2007 with or without preoperative chemoradiotherapy (groups A and B, respectively) were included. Multivariate statistical analysis using propensity score analysis was carried out regarding outcome parameters total anastomotic leak rate, rate of anastomotic leaks requiring reoperation, and postoperative bladder dysfunction.ResultsA total of 2,085 patients were included (group A, n = 676, group B, n = 1,409). Significant differences were present between groups regarding age, sex, distance of the tumor from the anal verge, pT-stage, UICC stage, hepatic risk factors, and use of protective enterostomy by univariate analysis. Multivariate logistic regression including these parameters was used to calculate the propensity score (likelihood to be assigned to group A or B as a consequence of the individual profile of these factors) for each patient. When outcome parameters were compared between groups A and B after stratification for propensity score, no significant differences regarding postoperative bladder dysfunction (p = 0.12), total anastomotic leak rate (p = 0.56), and anastomotic leaks requiring reoperation (p = 0.56) could be demonstrated.ConclusionNeoadjuvant chemoradiotherapy for rectal carcinoma does not increase the risk for anastomotic leakage or postoperative bladder dysfunction after curatively intended sphincter-preserving rectal resection.

Factors influencing the quality of total mesorectal excision

Total mesorectal excision (TME) has become the standard of care for rectal cancer. Incomplete TME may lead to local recurrence.

No prognostic impact of isolated lymphovascular invasion after radical resection of rectal cancer—results of a multicenter observational study

BackgroundThe prognostic impact of isolated lymphovascular invasion (LVI) after radical resection of rectal cancer is controversially discussed. However, it could be relevant to decide for an adjuvant treatment.AimThe aim of the analysis was, based on the data of an observational study, to determine the prognostic relevance of the isolated LVI.Materials and methodsPatients after radical resection of rectal cancer with no hemangioinvasion were subdivided in three groups: I—no LVI, no lymph node metastases (LNM); II—positive LVI, no LNM; III—positive LNM. Five-year local recurrence rate, distant metastases-free and disease-free survival were determined uni- and multivariate.ResultsPatients, n = 846, were studied (I, n = 471; II, n = 75; III, n = 300). The univariate comparison between the groups revealed the following 5-year results: local recurrence rate: 9.4 vs 10.0 vs 14.0%; distant metastases-free survival: 84.1 vs 82.5 vs 49.3%; disease-free survival: 83.2 vs 80.7 vs 45.5%. The differences between groups I and III were significant, but not between groups I and II. The determined higher disease-free survival rate in group II vs group III was significant (P = 0.041), but the differences in local recurrence rate and rate of distant metastases did not reach statistical significance. The multivariate analysis revealed no impact of the isolated LVI on the oncological outcome.ConclusionThe isolated LVI has no independent prognostic impact on the local recurrence rate and long-term survival after radical resection of rectal cancer. Based on this finding, no indication for an adjuvant treatment in these patients can be derived.

Low‐volume centre vs high‐volume: the role of a quality assurance programme in colon cancer surgery

Aim  The study aimed to determine whether hospitals within a quality assurance programme have outcomes of colon cancer surgery related to volume.