Jesse Moore

Staging error does not explain the relationship between the number of lymph nodes in a colon cancer specimen and survival

BACKGROUND Survival in colon cancer is greater in those patients who have more lymph nodes identified at resection and may be due to stage migration, confounding by treatment, social, or clinical characteristics. Identifying factor(s) responsible for the effect may represent an opportunity to improve quality of care for patients with colon cancer by increasing node counts in specimens. METHODS Cox proportional hazards models were created to analyze survival of 11,399 patients with stage I-III colon cancer from the Surveillance, Epidemiology and End Results (SEER)-Medicare database. The primary predictor variable was the number of lymph nodes identified. The models allowed adjustment for patient factors, use of chemotherapy, surgical specialty, and the average number of nodes identified by surgeon and hospital pathologist. RESULTS The number of nodes identified was related to survival. Compared to those with less than 7 nodes, patients with 7 to 11 nodes had a 13% lesser risk of death (hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.76-0.99; P = .037). Patients with more than 12 nodes had a 17% lesser risk (HR, 0.83; 95% CI, 0.73-0.95; P = .005). Adjusting for selected patient demographic characteristics, receipt of chemotherapy, surgical specialty, and the average number of nodes identified per specimen by the surgeon or hospital did not significantly alter the relationship between number of nodes and survival. CONCLUSION These findings argue against understaging or confounding as the explanation for the inferior survival observed in patients with fewer nodes identified. National initiatives to increase the number of nodes identified in colon cancer specimens may not improve substantially the cancer-specific outcomes.

1038 Staging Error Does Not Explain the Relationship Between the Number of Nodes in a Colon Cancer Specimen and Survival

Background. Survival in colon cancer is greater in those patients who have more lymph nodes identified at resection and may be due to stage migration, confounding by treatment, social, or clinical characteristics. Identifying factor(s) responsible for the effect may represent an opportunity to improve quality of care for patients with colon cancer by increasing node counts in specimens. Methods. Cox proportional hazards models were created to analyze survival of 11,399 patients with stage I-III colon cancer from the Surveillance, Epidemiology and End Results (SEER)-Medicare database. The primary predictor variable was the number of lymph nodes identified. The models allowed adjustment for patient factors, use of chemotherapy, surgical specialty, and the average number of nodes identified by surgeon and hospital pathologist. Results. The number of nodes identified was related to survival. Compared to those with less than 7 nodes, patients with 7 to 11 nodes had a 13% lesser risk of death (hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.76--0.99; P = .037). Patients with more than 12 nodes had a 17% lesser risk (HR, 0.83; 95% CI, 0.73--0.95; P = .005). Adjusting for selected patient demographic characteristics, receipt of chemotherapy, surgical specialty, and the average number of nodes identified per specimen by the surgeon or hospital did not significantly alter the relationship between number of nodes and survival. Conclusion. These findings argue against understaging or confounding as the explanation for the inferior survival observed in patients with fewer nodes identified. National initiatives to increase the number of nodes identified in colon cancer specimens may not improve substantially the cancer-specific outcomes. (Surgery 2010;147:358-65.)

Transanal Endoscopic Microsurgery for Early Rectal Cancer: A Single-Center Experience.

BACKGROUND: There is debate regarding the appropriate use of transanal endoscopic microsurgery for rectal cancer. OBJECTIVE: This study analyzed our single-center experience with transanal endoscopic microsurgery for early rectal cancer. DESIGN: Medical charts of patients who underwent transanal endoscopic microsurgery were reviewed to determine lesion characteristics, as well as operative and treatment characteristics. Complications and recurrences were recorded. SETTINGS: The study was conducted at a single academic medical center. PATIENTS: Patients with early stage cancer (T1 or T2, N0, and M0) of the rectum were included. MAIN OUTCOME MEASURES: Local and overall recurrence and disease-specific survival were measured. RESULTS: A total of 92 patients were analyzed. Median follow-up was 4.6 years. Negative margins were obtained in 98.9%. Length of stay was 1 day for 95.4% of patients. The complication rate was 10.9% (n = 10), including urinary retention at 4.3% (n = 4) and postoperative bleeding at 4.3% (n = 4). Preoperative staging included 54 at T1 (58.7%) and 38 at T2 (41.3%). Adjuvant therapy was recommended for all of the T2 and select T1 lesions with adverse features on histology. The final pathologic stages of tumors were ypT0 at 8.7% (n = 8), pT1 at 58.7% (n = 54), pT2 at 23.9% (n = 22), and ypT2 at 8.7% (n = 8). The 3-year local recurrence risk was 2.4% (SE = 1.7), and overall recurrence was 6.7% (SE = 2.9). There were no recurrences among patients with complete pathologic response to neoadjuvant therapy. Mean time to recurrence was 2.5 years (SD = 1.43). A total of 89.2% of patients with very low tumors underwent curative resection without a permanent stoma (33/37). The 3-year disease-specific survival rate was 98.6% (95% CI, 90.4%–99.8%), and overall survival rate was 89.4% (95% CI, 79.9%–94.6%). LIMITATIONS: The study was limited by its single-center retrospective experience. CONCLUSIONS: Transanal endoscopic microsurgery provides comparable oncologic outcomes to radical resection in properly selected patients with early rectal cancer. Sphincter preservation rates approach 90% even in patients with very distal rectal cancer.

Laparoscopic Colectomy and the General Surgeon.

BackgroundLaparoscopic colectomy has a shorter length of stay and less analgesic requirements than its open counterpart. Studies have suggested a learning curve of 30 cases. It is uncertain whether surgeons in rural settings have the case volume to acquire and maintain the necessary skill set. The aim of this study was to analyze the volume of colon resections performed by surgeons in rural practice.MethodsWe performed a retrospective cohort study of the laparoscopic and open partial colectomy case volumes of rural general surgeons seeking American Board of Surgery recertification in 2012. Results were stratified by large and small rural area.ResultsOne hundred ninety-seven surgeons were classified as practicing in a rural setting (large rural—150, small rural—47). The median open partial colectomy frequency for large rural surgeons was 7 cases and 4 for small rural surgeons. Median annual partial laparoscopic colectomy volume was 1.0 for large rural surgeons and 0.0 for small rural surgeons. Approximately half of surgeons in both groups did not perform a laparoscopic partial colectomy.ConclusionsIndustry and financial pressures to promote laparoscopic colectomy may not promote optimal patient outcomes in rural settings, as safety concerns may outweigh the modest benefits of the procedure. Although referral to remote high-volume centers could be advocated, the need for rural general surgeons to perform urgent colectomy for acute indications and the desire of many patients to have care close to home must also be considered.

Management of the Unhealed Perineal Wound After Proctectomy

Abdominoperineal resection is the surgical standard for low rectal cancers when sphincter salvage is not possible, and has proven to be a life-saving procedure for patients who need it. Otherindications for abdominoperineal resection include inflammatory bowel disease (IBD), and salvage surgery for persistent or recurrentanal cancer [1]. An unhealed perineal wound after oncologic surgery was first described by Miles in 1908 and it remains an ongoing issue for patients to this day [2]. As surgical approaches have become more aggressive, i.e., extralevator abdominoperineal excision of the rectum to reduce positive circumferential margins, patients have become more susceptible to wound complications. The increased use of perioperative chemoradiation further impairs local healing. For these reasons the unhealed perineal wound is a common complication following proctectomy [3]. The presence of an unhealed perineal wound can delay adjuvant chemotherapy or radiation therapy. It can also result in severely diminished quality of life following the operation owing to frequent outpatient visits, prolonged hospital stays, frequent dressing changes, further operations, and increased healthcare costs [1, 4].

Surgery clerkship orientation: evaluating temporal changes in student orientation needs

BACKGROUND Surgery clerkship students at our institution receive a standardized orientation covering objectives, requirements, grading, and expectations. Limited data exist regarding the student perceptions of this approach. METHODS Surveys were provided to students to rate the importance of orientation topics and their satisfaction with topic conclusion. Scores between student groupings over the clerkship year were analyzed with Student t tests and analysis of variance with Scheffe adjustments. RESULTS Significant differences in the mean importance rating between topics exists (P < .0001) as well as among satisfaction scores for topics (P < .0005). Early clerkship students value course expectations higher than later students (P = .03). Early clerkship students want more time devoted to hospital tours and expectations compared with later students (31% vs 8%). CONCLUSIONS Orientation needs for students change over the clerkship year. Beginning students prefer basic direction for time spent on the ward. Later students prefer information regarding shelf preparation. Surgery course directors can adapt the orientation based on the experience of clerkship students.

Die transanale endoskopische Mikrochirurgie ist bei der Resektion rektaler Tumoren effektiver als die traditionelle transanale Exzision

ZusammenfassungFragestellung und Hintergrund:Die von Buess in den 80er Jahren des vorigen Jahrhunderts entwickelte transanale endoskopische Mikrochirurgie erfreut sich in den letzten Jahren zunehmender Beliebtheit. Bisher gibt es noch keine größere Studie zum Vergleich der Effektivität der transanalen endoskopischen Mikrochirurgie und der traditionellen transanalen Exzision.Patienten und Methodik:Zwischen 1990 und 2005 unterzogen sich 171 Patienten wegen rektaler Neoplasien einer traditionellen transanalen Exzision (n = 89) oder einem transanalen endoskopischen mikrochirurgischen Eingriff (n = 82). Die Krankenakten wurden ausgewertet, um Art der Operation, Resektionsränder, Präparatfragmentation, Komplikationen, Rezidive, Tumortyp, Krankheitsstadium und Größe zu bestimmen.Ergebnisse:Die Gruppen waren hinsichtlich Alter, Geschlecht, Tumortyp, Krankheitsstadium und Größe vergleichbar. Das mittlere Follow-up betrug 37 Monate. Es fand sich kein Unterschied bei der Komplikationsrate zwischen den Gruppen (transanale endoskopische Mikrochirurgie 15% vs. traditionelle transanale Exzision 17%; p = 0,69). Die transanale endoskopische Mikrochirurgie erbrachte im Vergleich zur transanalen Exzision mit höherer Wahrscheinlichkeit tumorfreie Ränder (90% vs. 71%; p = 0,001) sowie ein nicht fragmentiertes Präparat (94% vs. 65%, p < 0,001). Nach der transanalen endoskopischen Mikrochirurgie traten weniger häufig Rezidive auf als nach einer traditionellen transanalen Exzision (5% vs. 27%; p = 0,004).Schlussfolgerung:Die transanale endoskopische Mikrochirurgie ist die Methode der Wahl bei der lokalen Exzision rektaler Neoplasien.AbstractPurpose:Transanal endoscopic microsurgery, developed by Buess in the 1980s, has become increasingly popular in recent years. No large studies have compared the effectiveness of transanal endoscopic microsurgery with traditional transanal excision.Methods:Between 1990 and 2005, 171 patients underwent traditional transanal excision (n = 89) or transanal endoscopic microsurgery (n = 82) for rectal neoplasms. Medical records were reviewed to determine type of surgery, resection margins, specimen fragmentation, complications, recurrence, lesion type, stage, and size.Results:The groups were similar with respect to age, sex, lesion type, stage, and size. Mean follow-up was 37 months. There was no difference in the complication rate between the groups (transanal endoscopic microsurgery 15% vs. traditional transanal excision 17%; p = 0.69). Transanal endoscopic microsurgery was more likely to yield clear margins (90% vs. 71%; p = 0.001) and a nonfragmented specimen (94% vs. 65%; p < 0.001) compared with transanal excision. Recurrence was less frequent after transanal endoscopic microsurgery than after traditional transanal excision (5% vs. 27%; p = 0.004).Conclusions:Transanal endoscopic microsurgery is the technique of choice for local excision of rectal neoplasms.