Helen R Dorrance

Effect of surgeon specialty interest on patient outcome after potentially curative colorectal cancer surgery

OBJECTIVE: There are significant differences in patient outcome after potentially curative surgery for colorectal cancer that relate to the surgeon performing the procedure. The reasons for these differences remain obscure. The aim of this study was to examine the effect of the surgeons specialty on patient outcome after potentially curative colorectal cancer surgery and to identify factors that may help explain differences in outcome among specialty groups. METHODS: Between 1990 and 1993, 378 patients underwent potentially curative surgery for colorectal cancer by surgeons with different specialty interests, vascular or transplant, general, and colorectal surgeons, in a large teaching hospital. Information on operative details, including the length of the resection specimen, resection margins, whether the tumor was removed withen bloc resection of adjacent clinically involved organs, number of lymph nodes removed, and stage was collected. Factors affecting both local and overall recurrence rates were analyzed using logistic regression analysis at both univariate and multivariate levels. RESULTS: At a median follow-up of 45 months the only factors associated with a significantly reduced local recurrence rate were the length of the resection specimen (odds ratio, 0.56; 95 percent confidence interval, 0.31–0.99) and colorectal specialty (P=0.04). Patients operated on by a general surgeon were 3.42 times (95 percent confidence interval, 1.32–8.9) more likely to develop a local recurrence than those operated on by a colorectal surgeon. For overall recurrence, early stage disease (P<0.0001), absence of vascular invasion (0.005), and colorectal specialty (0.025) were the only factors associated with significantly improved outcome at multivariate analysis. CONCLUSIONS: These data show that surgeons with an interest in colorectal cancer achieve lower local and overall recurrence rates compared with vascular or transplant or general surgeons. Differences in local recurrence rates seem to be predominantly related to the extent of resection performed and demonstrate the need to remove an adequate specimen when performing potentially curative colorectal cancer surgery.

Acquired abnormalities of the biliary tract from chronic gallstone disease.

BACKGROUND Acquired abnormalities of the biliary tract from chronic gallstone disease are rare. The aim of this study was to examine the frequency with which these abnormalities occur and to assess the probability of encountering such an abnormality at laparoscopic cholecystectomy. STUDY DESIGN We conducted a prospective study of all patients undergoing elective and emergency cholecystectomy under the care of one surgeon between January 1991 and December 1997. RESULTS Biliary tract abnormalities from chronic gallstone disease were encountered in 10 (2%) of 486 patients undergoing cholecystectomy. Four were observed in patients undergoing elective laparoscopy cholecystectomy, and the remainder were observed at open cholecystectomy. Five had a cholecystocholedochal fistula (Mirizzi Syndrome Type II), and one had a stone impacted at the cystic duct-bile duct junction (Mirizzi Syndrome Type I). Two had cholecystoduodenal fistulas and two had an absent cystic duct with a normal bile duct. Both instances of an absent cystic duct were encountered at laparoscopic cholecystectomy; in one the bile duct was mistaken for the cystic duct and a 2-cm segment was excised at operation, and in the other the abnormality was recognized and confirmed by cholangiography. CONCLUSIONS This study demonstrates a similar incidence of acquired abnormalities of the biliary tract from chronic gallstone disease to that already reported. But acquired absence of the cystic duct may occur more frequently than previously suspected. Patients with this condition are at high risk for bile duct injury during laparoscopic cholecystectomy. Clinical awareness of this problem with strict adherence to the principles taught at open cholecystectomy may prevent or reduce the severity of bile duct injury in these patients.

Bile carcinoembryonic antigen levels and occult hepatic metastases from colorectal cancer

PURPOSE: Up to 30 percent of patients will have occult hepatic metastases at the time of curative surgery for colorectal cancer. The ability to predict this group of patients would allow better targeting of appropriate therapy. It has been shown previously that patients with overt hepatic metastases have significantly high levels of carcinoembryonic antigen in gallbladder bile compared with serum levels. The aim of this study was to assess the accuracy of bile carcinoembryonic antigen levels taken at the time of operation in predicting patients with occult hepatic metastases. METHODS: Bile and serum carcinoembryonic antigen samples were collected from 37 patients undergoing surgery for colorectal cancer, 26 of whose procedures were deemed curative and who were followed up for a median of 63.5 months. RESULTS: Twelve patients were alive with no evidence of recurrent disease, and two had recurrent disease, whereas 12 died of disease. The median (interquartile range) serum carcinoembryonic antigen in the disease-free group was 2.8 (1.1–6.1) ng/ml, and in the recurrent group it was 6.35 (4.3–30) ng/ml (P=0.006), whereas bile carcinoembryonic antigen in the disease-free group was 7 (5–39) ng/ml as compared with 31 (5–383.7) ng/ml in the recurrent group (P=0.210). The accuracy of serum carcinoembryonic antigen in predicting occult hepatic metastases was 77 percent compared with 72 percent for bile carcinoembryonic antigen. CONCLUSION: Intraoperative bile carcinoembryonic antigen levels are no more accurate than serum carcinoembryonic antigen levels in predicting occult hepatic metastases in patients undergoing potentially curative colorectal cancer surgery.