L. Peter Fielding

Prediction of outcome after curative resection for large bowel cancer.

Prospectively collected information on 2524 patients who had undergone curative resection for colorectal cancer was analysed to establish the rank-order of importance of both clinical and pathological factors affecting outcome. The patients were divided into two groups. In the first, a statistical weighting was established for each prognostic factor and those that influenced long-term survival were, in order of importance, lymph node status, tumour mobility, number of lymph nodes positive for tumour, presence of bowel obstruction, and depth of primary tumour penetration. Factors that influenced in-hospital mortality were cardiopulmonary complications, intraabdominal sepsis (without anastomotic leak), presence of bowel obstruction, and age. In the second group these mathematical weightings were applied, and the predicted and observed outcomes were in close agreement. Statistical techniques of this kind will be of value in prognosis and in analysis of the results of new treatment regimens.

FACTORS INFLUENCING MORTALITY AFTER CURATIVE RESECTION FOR LARGE BOWEL CANCER IN ELDERLY PATIENTS

Mortality rates from the Large Bowel Cancer Project are presented with special reference to patients older than 70 years. The in-hospital mortality rate among those who underwent curative resection for colorectal carcinoma was 7%. Unlike long-term prognosis, which is influenced by pathological features, in-hospital mortality is influenced largely by clinical factors. Age was an adverse factor (78% of deaths occurred among those aged over 70, who formed 46% of the study population), as was obstruction or perforation. 55% of deaths were due to cardiopulmonary complications. Educating patients to seek treatment early, careful preoperative assessment and postoperative monitoring of cardiopulmonary function, and, in selected patients, use of local treatments rather than wide resections may help to reduce mortality in elderly patients.

Primary resection and anastomosis for treatment of acute diverticulitis

The patterns of presentation and associated treatments of 65 patients with acute perforated diverticulitis of the left colon have been reviewed. Four types of operations were identified: primary resection with anastomosis (group I, N=29), primary resection with anastomosis and protective colostomy (group II, N=5), primary resection with Hartmann procedure (group III, N=26), and delayed resection three-staged procedure (group IV, N=5). The severity of disease was also classified (stages I to IV). Postoperative mortality rates in the first two groups were lower than that of the Hartmann group (3.4 vs. 15.3 percent). The mean length of initial hospitalization was 16±1.2 days for group I, 18.2±4.4 days for group II, 19.4±2 days for group III, 26.4±4.4 days for group IV (P<.05,t-test group IVvs. groups I, II, and III). Complications in the Hartmann group were high with a 23 percent wound infection rate and mortality after closure of colostomy and bowel reconstruction was 3.8 percent. These data demonstrate that primary resection with anastomosis is a satisfactory operation for the majority of patients with perforated diverticulitis (stages I to III), and there appears to be no clinical indication to use the three-staged operation.

Local tumor recurrence after curative resection for rectal cancer

Local tumor recurrence rates after curative rectal cancer surgery with the end-to-end anastomosis stapler (EEA®) are reportedly high. Therefore, a retrospective review in ten Yale-affiliated hospitals was undertaken to establish the outcome of surgical resection for rectal cancer in this patient population.Of those 373 patients who had had curative resections, 192 (52 percent) were abdominoperineal resections (APR); 105 patients (28 percent) had restorative resections with sutured anastomoses, and the EEA stapler was used in 76 patients (20 percent). There was an equal distribution of tumors in the various Dukes stages in all three procedures. Local tumor recurrence was: APR 19 percent, SUT 17 percent, and EEA 24 percent, but local tumor recurrence was more frequent after EEA than APR for tumors 7 to 10 cm from the anal verge (32 vs. 13 percent, respectively,P<0.05), and the time to recurrence was least in EEA patients.It is concluded that local tumor recurrence is higher than expected for all three procedures and that the EEA stapler was associated with a greater risk of local tumor recurrence. These findings are attributed to surgeon-related technical operative factors rather than to the nature of the tumors themselves.

Multiple prognostic factors and outcome analysis in patients with cancer. Communication from the American joint committee on cancer

The authors report the establishment of a new Committee of the American Joint Committee on Cancer that has two objectives as follows: (1) to review the methods available to estimate outcome and (2) to study certain tumors to determine whether an expanded list of prognostic factors can be formulated into new prognostic systems that will have scientific value and clinical utility for treatment selection and staging.

Clinical-pathologic staging of large-bowel cancer

After surgical treatment in patients with large-bowel cancer, a prediction about the likelihood for cure remains uncertain despite the availability of several different types of staging systems. A committee of the American Society of Colon and Rectal Surgeons has reviewed the available data and concludes that future assessments of prognosis should be based on a combination of clinical and pathologic prognostic factors, using multivariate statistical techniques for the analysis. Although many important prognostic factors are known, there is much to learn about these and other items before a confident prediction of long-term outcome can be made. An extension of these methods should be possible to assist in prospective clinical decision making based on clinical and investigational data. Such a system would be of particular value for patients with rectal cancer for whom cost-benefit relationships of alternative treatments can be so controversial. It is concluded that an accepted, standard nomenclature is required to reach both these objectives using large multicenter studies.

Risks of surgery for upper gastrointestinal hemorrhage: 1972 versus 1982.

A retrospective comparison was undertaken to determine if the risks of undergoing surgery for nonvariceal upper gastrointestinal hemorrhage had changed between 1972 and 1982. In 1982, patients were on the average 9 years older, there was a significant decrease in bleeding from duodenal ulcers compared with 1972 data, gastric ulcer rates remained unchanged, and diffuse gastritis occurred more frequently in 1982. Mortality and morbidity rates showed no significant differences; however, the patient population did change with the emergence of older patients, in whom bleeding developed after hospitalization for other reasons. These patients comprised 30 percent of the 1982 study population. If further improvements in surgical treatment of upper gastrointestinal hemorrhage are to occur, these patients must be identified and aggressively managed.