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BACKGROUND: This study aimed to assess concordance between clinical and pathologic assessment of colon cancer. PATIENTS AND METHODS: A retrospective cohort analysis of patients with stage I-III colon cancer in the National Cancer Database (2010-2019) was conducted. Concordance between clinical and pathologic assessment of colon cancer was calculated using Kappa coefficients and 95% confidence intervals (CIs). RESULTS: A total of 125,473 patients (51.2% female; mean age 68.2 years) were included. There was moderate concordance between clinical and pathologic T stage (Kappa = 0.606, 95%CI: 0.602-0.609) and between clinical and pathologic N stage (Kappa = 0.506, 95%CI: 0.501-0.511). For right-sided colon cancer, there was moderate agreement between clinical and pathologic T stage (Kappa = 0.594, 95%CI: 0.589-0.599) and N stage (Kappa = 0.530, 95%CI: 0.523-0.537). For left-sided colon cancer, there was substantial agreement between clinical and pathologic T stage (Kappa = 0.624, 95%CI: 0.619-0.630) and moderate agreement between N stage (Kappa 0.472, 95%CI: 0.463-0.480). Sensitivity of clinical assessment of T and N stage ranged from 64.3% to 77.2% and 41.6% to 54.5%, respectively. Specificity ranged from 96.7% to 97.7% for T stage and 95.7% to 97.3% for N stage. CONCLUSIONS: Clinical assessment of T and N stages of colon cancer had good diagnostic accuracy with moderate concordance with the final pathologic stage. While clinical assessment was highly specific with < 3% of patients being over-staged, it had modest sensitivity, especially for detection of nodal involvement. Diagnostic accuracy of clinical assessment of right and left colon cancers was similar, except for higher sensitivity and accuracy of assessment of nodal involvement in right than left colon cancers.
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Laparoscopía , Reoperación , Cirugía Endoscópica Transanal , Humanos , Laparoscopía/métodos , Reoperación/métodos , Cirugía Endoscópica Transanal/métodos , Reservorios Cólicos/efectos adversos , Proctocolectomía Restauradora/métodos , Proctocolectomía Restauradora/efectos adversos , Femenino , Masculino , Colitis Ulcerosa/cirugíaAsunto(s)
Anastomosis Quirúrgica , Íleon , Recto , Humanos , Recto/cirugía , Anastomosis Quirúrgica/métodos , Íleon/cirugía , MasculinoRESUMEN
BACKGROUND: Colon cancer prognosis is primarily dependent on the stage at diagnosis, but tumor size and location may also impact prognosis. This study aimed to assess the characteristics and outcomes of patients with ≥5 cm colonic adenocarcinomas and compare outcomes of open and minimally invasive surgery for stage I to III large colonic adenocarcinomas. METHODS: The National Cancer Database (2010-2019) was searched for patients with colonic adenocarcinomas ≥5 cm. Outcomes of patients who underwent minimally invasive surgery or open surgery were compared after propensity-score matching. The primary outcome was 5-year overall survival and, secondarily, hospital stay, surgical margins, and short-term mortality. RESULTS: A total of 126,959 patients were included (22.1% of all diagnosed adenocarcinomas). 56% of tumors were right-sided, 32.6% were left-sided, and 11.4% were in the transverse colon. Stage IV disease was recorded in 34.6% of patients. Lymphovascular invasion, perineural invasion, and Kirsten rat sarcoma viral oncogene homolog mutations were recorded in 35.7%, 14.9%, and 41.6% of patients. The rate of positive surgical margins was 9.8%. Median hospital stay was 6 (interquartile range: 4-8) days. 30- and 90-day mortality rates were 4.1% and 7.5%, respectively. After matching, 15,228 patients in the open surgery group were matched to a similar number in the minimally invasive surgery group. The minimally invasive surgery group was associated with significantly lower rates of 30- and 90-day mortality, positive surgical margins, shorter hospital stay, and longer median overall survival (110.6 vs 86.6 months, P < .001) than did open surgery. CONCLUSION: Large colonic adenocarcinomas are mostly right-sided or transverse and present at a more advanced stage with adverse pathologic features. Minimally invasive surgery was associated with better overall survival and short-term benefits when compared with open surgery.
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Adenocarcinoma , Neoplasias del Colon , Procedimientos Quirúrgicos Mínimamente Invasivos , Estadificación de Neoplasias , Humanos , Masculino , Neoplasias del Colon/cirugía , Neoplasias del Colon/patología , Neoplasias del Colon/mortalidad , Adenocarcinoma/cirugía , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Femenino , Anciano , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Tiempo de Internación/estadística & datos numéricos , Estudios Retrospectivos , Colectomía/métodos , Puntaje de Propensión , Resultado del Tratamiento , Márgenes de Escisión , Laparoscopía/métodos , Laparoscopía/estadística & datos numéricosRESUMEN
PURPOSE: Recent studies have suggested that extended mesenteric excision (ME) may reduce surgical reintervention in Crohn's Disease (CD), but there remains clinical concerns regarding potential peri-operative morbidity. This retrospective study compares 30-day perioperative morbidity between limited and extended ME in segmental colectomies for CD. METHODS: Using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) colectomy-specific database, all patients with CD undergoing segmental colectomy for non-malignant indications between 2014-2019 were included. A lymph node harvest of 12 or more nodes was used as a surrogate for extended ME. The primary outcome was NSQIP major morbidity. Secondary outcomes included abdominal complications and perioperative bleeding. RESULTS: Of 3,709 patients included from the ACS-NSQIP database, 3,087 underwent limited ME and 622 underwent extended ME. On univariate analysis, those with limited mesenteric excision were less likely to be anemic (46.1% vs 55.0%, p < 0.001) and have undergone an open surgery (44.7% vs 34.7%, p < 0.001). On univariate comparison of limited and extended ME, there was no significant difference in major morbidity. On multiple logistic regression, controlling for age, sex, BMI, smoking, preoperative sepsis, preoperative anemia, surgical approach, emergency surgery, stoma creation, bowel preparation, and immunosuppression, the extent of ME was not an independent predictor of NSQIP major morbidity (OR 1.1, 95% CI 0.84-1.44). Likewise, the extent of ME was not associated with an increase in abdominal complications (OR 0.95, 95% CI 0.76-1.19) or post-operative bleeding (OR 1.89, 95% CI 0.75-1.53). CONCLUSION: Extended ME for CD was not associated with an increase in 30-day perioperative major morbidity.
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Enfermedad de Crohn , Humanos , Enfermedad de Crohn/cirugía , Enfermedad de Crohn/complicaciones , Estudios Retrospectivos , Mejoramiento de la Calidad , Colectomía/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugíaRESUMEN
BACKGROUND: Preoperative administration of oral antibiotic bowel preparation (OABP) alone has been shown to reduce infectious outcomes in patients undergoing elective colectomy. However, it remains unclear if these benefits extend to the emergency setting. This is a retrospective, propensity-score matched study comparing 30-day perioperative morbidity between those who received OABP alone versus no preparation prior to urgent colectomy. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, adults undergoing urgent colectomy from 2012 to 2019 were included. Those who were clinically obstructed or who received mechanical bowel preparation were excluded. Outcomes of interest included: surgical site infection (SSI), leak, ileus, and major morbidity. RESULTS: Of 24,559 patients meeting inclusion criteria, 878 (3.6%) received OABP prior to urgent colectomy. Prior to matching, those receiving no preparation were more likely to have higher ASA class, diabetes, hypertension, preoperative sepsis, open procedures, and a dirty wound classification. After matching, 1756 patients, remained with 878 in each arm. Preoperative characteristics were balanced on univariate analysis. Postoperatively, patients receiving OABP experienced decreased organ space SSI (11.2% vs. 15.5%, p = 0.009) and ileus (30.3% vs. 35.3%, p = 0.029), with no difference in leak rates (3.3% vs 3.3%, p = 1.000) or NSQIP major morbidity (47.4% vs. 49.9%, p = 0.316). On multivariate logistic regression, including propensity score, the reduction in organ space SSI associated with OABP persisted (OR 0.684, 95% CI 0.516-0.903). CONCLUSION: OABP prior to select urgent colectomies was associated with fewer organ space SSIs and may be considered when feasible.
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Ileus , Infección de la Herida Quirúrgica , Administración Oral , Adulto , Antibacterianos/uso terapéutico , Profilaxis Antibiótica , Catárticos/uso terapéutico , Colectomía/efectos adversos , Colectomía/métodos , Humanos , Ileus/tratamiento farmacológico , Ileus/etiología , Ileus/prevención & control , Cuidados Preoperatorios/métodos , Puntaje de Propensión , Estudios Retrospectivos , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/prevención & controlRESUMEN
This article reviews the oncological principles of rectal cancer surgery, beginning with an overview of the pertinent rectal and pelvic anatomy, followed by a discussion of the historical evolution in surgical management. Evidence supporting current practices with respect to proximal, distal, and circumferential margins are reviewed. Finally, operative approaches to restorative proctectomies and abdominoperineal resections are highlighted.
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Neoplasias del Recto , Humanos , Márgenes de Escisión , Perineo/anatomía & histología , Perineo/cirugía , Neoplasias del Recto/cirugía , Recto/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: The purpose of this study was to determine if observational therapy is noninferior to antibiotics for acute uncomplicated diverticulitis according to clinically relevant margins. METHODS: MEDLINE, EMBASE, and Cochrane were systematically searched by 2 independent reviewers to identify comparative studies of observational therapy versus antibiotics for acute uncomplicated diverticulitis. Non-inferiority margins (ΔNI) for each outcome were based on Delphi consensus including 50 patients and 55 physicians: persistent diverticulitis (ΔNI = 4.0%), progression to complicated diverticulitis (ΔNI = 3.0%), and time to recovery (ΔNI = 5 days). Risk differences and mean differences were pooled using random-effects meta-analysis. One-sided 90% confidence intervals and Z-tests were used to determine non-inferiority. A sensitivity analysis was performed, excluding patients post hoc determined to have complicated diverticulitis. RESULTS: Nine studies (3 randomized controlled trials, 6 observational studies) met inclusion criteria: observational therapy (n = 2,011) versus antibiotics (n = 1,144). Observational therapy was noninferior to antibiotics regarding the risk of persistent diverticulitis (pooled risk differences: -0.39%, 90% CI -3.22 to 2.44%, ΔNI: 4.0%, PNI < 0.001; I2 = 66%) and progression to complicated diverticulitis (pooled risk differences: -0.030%, 90% CI -0.99 to 0.92%, ΔNI: 3.0%, PNI < 0.001; I2 = 0%). On sensitivity analysis, observational therapy remained noninferior for both outcomes. When stratified by study design, observational therapy also remained noninferior for both outcomes among randomized controlled trials only. Only 1 study reported on time to recovery as a continuous outcome, with no statistical difference between antibiotics and observational therapy. CONCLUSION: According to clinically relevant ΔNIs, observational therapy was noninferior to antibiotics for the treatment of acute uncomplicated diverticulitis with regard to persistent diverticulitis and progression to complicated diverticulitis.
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Antibacterianos/uso terapéutico , Diverticulitis del Colon/tratamiento farmacológico , Espera Vigilante , Enfermedad Aguda , Técnica Delphi , Progresión de la Enfermedad , Estudios de Equivalencia como Asunto , Humanos , Resultado del TratamientoRESUMEN
BACKGROUND: The purpose of this study was to develop and validate a prediction model and clinical risk score for Intensive Care Resource Utilization after colon cancer surgery. METHODS: Adult (≥ 18 years old) patients from the 2012 to 2018 ACS-NSQIP colectomy-targeted database who underwent elective colon cancer surgery were identified. A prediction model for 30-day postoperative Intensive Care Resource Utilization was developed and transformed into a clinical risk score based on the regression coefficients. Model performance was assessed using the area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow goodness-of-fit test. The model was validated in a separate test set of similar patients. RESULTS: In total, 54,893 patients underwent an elective colon cancer resection, of which 1224 (2.2%) required postoperative Intensive Care Resource Utilization. The final prediction model retained six variables: age (≥ 70; OR 1.90, 95% CI 1.68-2.14), sex (male; OR 1.73, 95% CI 1.54-1.95), American Society of Anesthesiologists score (III/IV; OR 2.52, 95% CI 2.15-2.95), cardiorespiratory disease (yes; OR 2.22, 95% CI 1.94-2.53), functional status (dependent; OR 2.81, 95% CI 2.22-3.56), and operative approach (open surgery; OR 1.70, 95% CI 1.51-1.93). The model demonstrated good discrimination (AUC = 0.73). A clinical risk score was developed, and the risk of requiring postoperative Intensive Care Resource Utilization ranged from 0.03 (0 points) to 19.0% (8 points). The model performed well on test set validation (AUC = 0.73). CONCLUSION: A prediction model and clinical risk score for postoperative Intensive Care Resource Utilization after colon cancer surgery was developed and validated.
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COVID-19 , Colectomía , Neoplasias del Colon/cirugía , Cuidados Críticos/estadística & datos numéricos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Selección de Paciente , Complicaciones Posoperatorias/epidemiología , Adulto , Factores de Edad , Anciano , Reglas de Decisión Clínica , Neoplasias del Colon/patología , Comorbilidad , Bases de Datos Factuales , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante , Complicaciones Posoperatorias/terapia , Prueba de Estudio Conceptual , Curva ROC , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , SARS-CoV-2 , Factores SexualesRESUMEN
BACKGROUND: Rates of colectomy for ulcerative colitis have been decreasing, particularly since the advent of biologics, but the subsequent impact of reduced colectomy rates on the development of neoplasms in chronically treated ulcerative colitis colons is unknown. PURPOSE: To determine trends in colectomy for colorectal neoplasms in adult patients with ulcerative colitis. METHODS: Adult admissions with ulcerative colitis were identified from the National Inpatient Sample from 1993 to 2015. The rate of colectomy with concurrent colorectal neoplasm served as the primary outcome and was evaluated using time trend linear and multivariable regression. RESULTS: There were 366,286 admissions with ulcerative colitis including 16,556 (4.5%) total colectomies. Of those undergoing colectomy, 2018 (12.2%) had a concurrent diagnosis of colorectal neoplasm. The proportion of colectomies for ulcerative colitis with concurrent colorectal neoplasm increased from 10.3 to 12.5% (pTrend = 0.004). Specifically, the proportion of colectomies performed for dysplasia/benign neoplasm and rectal cancer increased from 3.5 to 5.6% (pTrend < 0.001) and from 2.6 to 3.0% (pTrend = 0.028) respectively, and those for colon cancer remained stable (4.5 to 3.9%, pTrend = 0.423). On multivariate regression, year of colectomy was a significant predictor of colectomy for colorectal neoplasm (OR = 1.044, 95% CI = 1.025-1.062). DISCUSSION: Operative management of ulcerative colitis appears to be slowly increasing in oncological indications. The rising proportions of colectomies performed for colorectal neoplasms suggest the need for continued screening in these patients, including rectal surveillance.