- Is Laparoscopic Complete Mesocolic Excision and Central Vascular Ligation Really Necessary for All Patients With Right-Sided Colon Cancer?
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Gyung Mo Son, In Young Lee, Yoon Suk Lee, Bong-Hyeon Kye, Hyeon-Min Cho, Je-Ho Jang, Chang-Nam Kim, Kil Yeon Lee, Suk-Hwan Lee, Jun-Gi Kim
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Ann Coloproctol. 2021;37(6):434-444. Published online December 8, 2021
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- Influence of Colonic Mesenteric Area on the Number of Lymph Node Retrieval for Colon Cancer: A Prospective Cohort Study
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Nadir Adnan Hacım, Ahmet Akbaş, Yigit Ulgen, Talar Vartanoglu Aktokmakyan, Serhat Meric, Merve Tokocin, Onder Karabay, Yuksel Altinel
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Received June 5, 2021 Accepted July 31, 2021
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Purpose
The minimum harvested 12 lymph nodes (LNs) is regarded as the limit for accurate staging of nodal status in colorectal cancer patients. Besides the association of the lengths of resected intestinal segments and vascular pedicles, the mesocolic mesenteric area’s impact on LN count has not been studied. We aimed to evaluate the associations between metric variables, including the mesocolic mesentery area on the nodal harvest.
Methods
All consecutive patients who underwent elective colectomy with a curative intention for colon adenocarcinoma were prospectively included. The metric variables included the lengths of resected intestinal segments, vascular pedicle, and colonic mesenteric area. The variables influencing the LN count and the correlation between the total LN count and the specimens’ relevant metric measurements were analyzed.
Results
There were 46 patients with a median age of 64 years. The median count for total LNs was 22, and the LN positivity was 59.2%. There was an inadequate LN yield (<12) in 3 patients (6.1%). No significant associations were found between the adequacy of nodal harvest and the demographic, clinical, and tumoral features (P>0.05). There were significant positive correlations between total LN number and length of vascular pedicle and mesenteric area (r=0.576, P<0.001 and r=0.566, P<0.001).
Conclusion
The length of the vascular pedicle and mesenteric area were significantly correlated with total LN counts. Although there was no significant impact on the length of resected segments, the colonic mesenteric area can be used alone as a measure for the assessment of the nodal yield in colon cancer.
- Upregulation of Prostaglandin E2 by Inducible Microsomal Prostaglandin E Synthase-1 in Colon Cancer
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Young Hun Kim, Kyung Jong Kim
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Received May 24, 2021 Accepted July 20, 2021
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Purpose
Prostaglandin E2 (PGE2) is known to promote carcinogenesis and cancer progression in colon cancer. Enzymes involved in the metabolism of PGE2 include cyclooxygenase (COX)-2, microsomal prostaglandin E synthase-1 (mPGES-1), and 15-prostaglandin dehydrogenase (15-PGDH). The current study aims to determine how PGE2 is expressed by examining patients with colorectal cancer and evaluating colon cancer cells to gain insight into changes in relevant enzymes upon induction of PGE2.
Methods
The concentration of PGE2 was measured in tumor tissues and adjacent normal mucosal tissues of 26 patients with colon cancer. The expression of COX-1, COX-2, mPGES-1, and 15-PGDH proteins was measured. The concentration of PGE2 in FET colon cancer cells was measured both in the initial status and after stimulation by tumor necrosis factor (TNF)-α. The expression levels of PGE2-related enzymes were measured as well.
Results
There was no significant difference in the average concentration of PGE2, which was measured at 453.1 pg/mL in cancer tissues and 401.2 pg/mL in normal mucosa. Among PGE2-related enzymes, 15-PGDH was expressed at a lower level in tumor cells than in normal mucosa. In colon cancer cells, PGE2 was found to be upregulated upon stimulation by TNF-α, which led to strong induction of mPGES-1 without any change in the expression of COX-2 among the PGE2-related enzymes.
Conclusion
These results demonstrated that PGE2 can be induced by stimuli such as TNF-α, and suggest that activation of mPGES-1 is more closely related than that of COX-2 in the induction of PGE2 on colon cancer.
- The Impact of Variations in Care and Complications Within a Colorectal Enhanced Recovery After Surgery Program on Length of Stay
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James Wei Tatt Toh, Jack Cecire, Kerry Hitos, Karen Shedden, Fiona Gavegan, Nimalan Pathmanathan, Toufic El Khoury, Angelina Di Re, Annelise Cocco, Alex Limmer, Tom Liang, Kar Yin Fok, James Rogers, Edgardo Solis, Grahame Ctercteko
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Received September 8, 2020 Accepted November 23, 2020
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Abstract Full text PubReader ePub Crossref - TDM PDF
Supplementary Material
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Purpose
Enhanced Recovery After Surgery (ERAS) has become standard of care in colorectal surgery. However, there is not a universally accepted colorectal ERAS protocol and significant variations in care exist between institutions. The aim of this study was to examine the impact of variations in ERAS interventions and complications on length of stay (LOS).
Methods
This study was a single-center review of the first 200 consecutive patients recruited into our prospectively collected ERAS database. The primary outcome of this study was to examine the rate of compliance to ERAS interventions and the impact of these interventions on LOS. The secondary outcome was to assess the impact of complications (anastomotic leak, ileus, and surgical site infections) on LOS. ERAS interventions, rate of adherence, LOS, readmissions, morbidity, and mortality were recorded, and statistical analysis was performed.
Results
ERAS variations and complications significantly influenced patient LOS on both univariate and multivariate analysis. ERAS interventions identified as the most important strategies in reducing LOS included laparoscopic surgery, mobilization twice daily postoperative day (POD) 0 to 1, discontinuation of intravenous fluids on POD 0 to 1, upgrading to solid diet by POD 0 to 2, removal of indwelling catheter by POD 0 to 2, avoiding nasogastric tube reinsertion and removing drains early. Both major and minor complications increased LOS. Anastomotic leak and ileus were associated with the greatest increase in LOS.
Conclusion
Seven high-yield ERAS interventions reduced LOS. Major and minor complications increased LOS. Reducing variations in care and complications can improve outcomes following colorectal surgery.
- The Impact of Primary Tumor Resection on Survival in Asymptomatic Colorectal Cancer Patients With Unresectable Metastases
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Ki Yoon Doah, Ui Sup Shin, Byong Ho Jeon, Sang Sik Cho, Sun Mi Moon
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Ann Coloproctol. 2021;37(2):94-100. Published online April 30, 2021
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Purpose
This study was conducted to evaluate the effectiveness of primary tumor resection (PTR) in asymptomatic colorectal cancer (CRC) patients with unresectable metastases using the inverse probability of treatment weighting (IPTW) method to minimize selection bias.
Methods
We selected 146 patients diagnosed with stage IV CRC with unresectable metastasis between 2001 and 2018 from our institutional database. In a multivariate logistic regression model using the patients’ baseline covariates associated with PTR, we applied the IPTW method based on a propensity score and performed a weighted Cox proportional regression analysis to estimate survival according to PTR.
Results
Upfront PTR was performed in 98 patients, and no significant differences in baseline factors were detected. The upweighted median survival of the PTR group was 18 months and that of the non-PTR group was 15 months (P = 0.15). After applying the IPTW, the PTR was still insignificant in the univariate Cox regression (hazard ratio [HR], 0.26; 95% confidence interval [CI], 0.5–1.21). However, in the multivariate weighted Cox regression with adjustment for other covariates, the PTR showed a significantly decreased risk of cancer-related death (HR, 0.61; 95% CI, 0.40–0.94).
Conclusion
In this study, we showed that asymptomatic CRC patients with unresectable metastases could gain a survival benefit from upfront PTR by analysis with the IPTW method. However, randomized controlled trials are mandatory.
- Comparison of Short-term Results after Laparoscopic Complete Mesocolic Excision and Standard Colectomy for Right-Sided Colon Cancer: Analysis of a Western Center Cohort
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Cristian Conti, Corrado Pedrazzani, Giulia Turri, Eduardo Fernandes, Enrico Lazzarini, Raffaele De Luca, Alessandro Valdegamberi, Andrea Ruzzenente, Alfredo Guglielmi
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Ann Coloproctol. 2021;37(3):166-173. Published online April 22, 2021
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Abstract Full text PubReader ePub Crossref - TDM PDF
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Purpose
Laparoscopic complete mesocolic excision (CME) right colectomy is a technically demanding procedure infrequently employed in Western centers. This retrospective cohort study aims to analyze the safety of laparoscopic CME colectomy compared to standard colectomy for right-sided colon cancer in a Western series.
Methods
Prospectively collected data from 60 patients who underwent laparoscopic CME right colectomy were compared to the ones of 55 patients who underwent laparoscopic standard right colectomy.
Results
No differences in clinical characteristics were observed between the CME and standard right colectomy groups. No differences were demonstrated in terms of blood loss (P = 0.060), intraoperative complications (P = 1), conversion rate (P = 0.102), and operative time (P = 0.473). No deaths were observed in either group, while complication rate was 40.0% in the CME and 49.1% in the standard group (P = 0.353). Severe complications occurred in 10.0% vs. 9.1% (P = 0.842), redo surgery in 5.0% vs. 7.3% (P = 0.708), and unplanned readmission in 5.0% vs. 5.5% (P = 1) after CME and standard colectomy, respectively. A significant difference in favor of CME was observed in the total length of specimen (P < 0.001), proximal (P = 0.018), and distal margins (P = 0.037). The number of lymph nodes harvested was significantly higher in the CME group (27 vs. 22, P = 0.037).
Conclusion
In Western series, where patients have less favorable clinical characteristics, laparoscopic CME allows to obtain better quality surgical specimens and comparable short-term outcomes compared to standard right colectomy.
- Surgical Risk and Pathological Results of Emergency Resection in the Treatment of Acutely Obstructing Colorectal Cancers: A Retrospective Cohort Study
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Giovanni Domenico Tebala, Andrea Mingoli, Andrea Natili, Abdul Qayyum Khan, Gioia Brachini
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Ann Coloproctol. 2021;37(1):21-28. Published online March 16, 2020
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Abstract Full text PubReader ePub Crossref - TDM PDF
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Purpose
The treatment of acutely obstructing colorectal cancers is still a matter of debate. The prevailing opinion is that an immediate resection should be performed whenever possible. This study sought to determine whether immediate resection is safe and oncologically valid.
Methods
We completed a retrospective 2-center cohort study using the medical records of patients admitted for acutely obstructing colorectal cancer under the care of the Colorectal Team, Noble’s Hospital, Isle of Man, and the Emergency Surgery Unit, Umberto I University Hospital, Rome, from March 2013 to May 2017. The primary endpoints were 90-day mortality and morbidity, reoperation rate, and length of stay. The secondary endpoints were status of margins, number of lymph nodes retrieved, and the rate of adequate nodal harvest.
Results
Sixty-three patients were retrospectively enrolled in the study. Mortality was associated with age > 80 years and Dukes B tumors. The length of hospital stay was shorter in patients who had their resection less than 24 hours from their admission, in those who had laparoscopic resection and in those with distal tumors. The number of lymph nodes retrieved and rate of R0 resections were similar to those reported in elective colorectal surgery and were greater in laparoscopic resections and in patients operated on within 24 hours, respectively.
Conclusion
Immediate resection is a safe and reliable option in patients with acutely obstructing colorectal cancer.
- Identification of Risk Factors Associated With Stage III Disease in Nonmetastatic Colon Cancer: Results From a Prospective National Cohort Study
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Jakob Lykke, Ole Roikjaer, Per Jess, Jacob Rosenberg
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Ann Coloproctol. 2020;36(5):316-322. Published online February 18, 2020
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Abstract Full text PubReader ePub Crossref - TDM PDF
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Purpose
This study aimed to identify possible patient- and tumor-related factors associated with risk of TNM stage III disease in nonmetastatic colon cancer.
Methods
The associations between stage III disease and age, sex, lymph node yield, pathological tumor (pT) stage, tumor subsite, type of surgery, and priority of surgery were assessed in a nationwide cohort of 13,766 patients treated with curative resection of colon cancer. Each level of age, lymph node yield, and pT stage was compared to the preceding level.
Results
Age, lymph node yield, pT stage, tumor subsite, and priority of surgery were associated with stage III disease. Odds ratios (95% confidence interval [CI]) were as follows: age < 65/65–75 years: 1.28 (95% CI, 1.15–1.43) and 65–75/ > 75 years: 1.22 (95% CI, 1.13–1.32); lymph node yield 0–5/6–11: 0.60 (95% CI, 0.50–0.72), lymph node yield 6–11/12–17: 0.84 (95% CI, 0.76–0.93), and lymph node yield 12–17/ ≥ 18: 0.97 (95% CI, 0.89–1.05); pT1/pT2: 0.74 (95% CI, 0.57–0.95), pT2/pT3: 0.35 (95% CI, 0.30–0.40), and pT3/pT4: 0.49 (95% CI, 0.47–0.54). Only tumors of the transverse colon were independently associated with lower risk of stage III disease than tumors in the sigmoid colon (sigmoid colon: 1, transverse colon: 0.84 [95% CI, 0.73–0.96]; elective surgery: 1, acute surgery: 1.43 [95% CI, 1.29–1.60]).
Conclusion
In this study, stage III disease in colon cancer was significantly associated with age, lymph node yield, pT stage, tumor subsite, and priority of surgery but was not associated with right-sided location compared with stage I and II cancers.
- Indication for and Effect of Adjuvant Chemotherapy for Stage IIa (T3N0M0) Colon Cancer
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Chul-Hyo Jeon, Min Ki Kim, In Kyu Lee
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Ann Coloproctol. 2019;35(5):254-261. Published online October 31, 2019
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Abstract Full text PubReader ePub Crossref - TDM PDF
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Purpose
The efficacy of adjuvant chemotherapy (AC) in stage IIa colon cancer is controversial. This study aimed to investigate the factors influencing survival in patients with stage IIa colon cancer, the role of AC, and the indications for AC utilization by surgical oncologists.
Methods
Between January 2004 and December 2010, 736 patients with stage IIa colon cancer underwent curative resection in 1 of 6 participating hospitals. Factors related to survival were identified and analyzed according to whether AC was administered or not. After high- and low-risk groups were identified, their respective results were analyzed.
Results
The 5-year overall survival (OS) of stage IIa colon cancer was 90.3%. With the exception of poorly differentiated histology, indications for AC did not include typical high-risk factors. The indications for AC were significantly younger patients, higher body mass index (BMI), lower American Society of Anesthesiologists (ASA) physical status classification, and higher histologic grade. BMI, preoperative carcinoembryonic antigen, and harvested lymph node (LN) count were significant factors for disease-free survival, while BMI and ASA physical status classification were significant factors for OS in the chemotherapy group. In the high-risk group, AC was associated with increased OS in univariate analysis. BMI and harvested LN count were statistically significant in multivariate analysis.
Conclusion
Surgical oncologists consider the patient’s condition and postoperative course rather than high-risk factors to determine use of AC. Regardless of AC use, both the extent of surgery and the patient’s subsequent status affected the survival rate in the high-risk group. None of the factors identified influenced survival rate in the low-risk group.
- Does the Different Locations of Colon Cancer Affect the Oncologic Outcome? A Propensity-Score Matched Analysis
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Kwan Mo Yang, In Ja Park, Jong Lyul Lee, Yong Sik Yoon, Chan Wook Kim, Seok-Byung Lim, Na Young Kim, Shinae Hong, Chang Sik Yu, Jin Cheon Kim
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Ann Coloproctol. 2019;35(1):15-23. Published online February 28, 2019
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Abstract Full text PubReader ePub Crossref - TDM PDF
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Purpose
We evaluate the prognostic value of primary tumor location for oncologic outcomes in patients with colon cancer (CC).
Methods
CC patients treated with curative surgery between 2009 and 2012 were classified into 2 groups: right-sided colon cancer (RCC) and left-sided colon cancer (LCC). Recurrence-free survival (RFS) and overall survival (OS) were examined based on tumor stage. Propensity scores were created using eight variables (age, sex, T stage, N stage, histologic grade, presence of lymphovascular invasion/perineural invasion, and microsatellite instability status).
Results
Overall, 2,329 patients were identified. The 5-year RFSs for RCC and LCC patients were 89.7% and 88.4% (P = 0.328), respectively, and their 5-year OSs were 90.9% and 93.4% (P = 0.062). Multivariate survival analyses were carried out by using the Cox regression proportional hazard model. In the unadjusted analysis, a marginal increase in overall mortality was seen in RCC patients (hazard ratio [HR], 1.297; 95% confidence interval [CI], 0.987–1.704, P = 0.062); however, after multivariable adjustment, similar OSs were observed in those patients (HR, 1.219; 95% CI, 0.91–1.633; P = 0.183). After propensity-score matching with a total of 1,560 patients, no significant difference was identified (P = 0.183). A slightly worse OS was seen for stage III RCC patients (HR, 1.561; 95% CI, 0.967–2.522; P = 0.068) than for stage III LCC patients. The 5-year OSs for patients with stage III RCC and stage III LCC were 85.5% and 90.5%, respectively (P = 0.133).
Conclusion
Although the results are inconclusive, tumor location tended to be associated with OS in CC patients with lymph node metastasis, but it was not related to oncologic outcome.
