Current treatment of pT1 rectal cancers in Denmark: A retrospective national cohort study.

AIM: Organ preservation strategies for patients with rectal cancer are increasingly common. In appropriately selected patients, local excision (LE) of pT1 cancers can reduce morbidity without compromising cancer-related outcomes. However, determining the need for completion surgery after LE can be challenging, and it is unknown if prior LE compromises subsequent total mesorectal excision (TME). The aim of this study is to describe the current management of patients with pT1 rectal cancers. METHOD: This is a retrospective national cohort study of the Danish Colorectal Cancer Group database, including patients with newly diagnosed pT1 cancers between 2016 and 2020. Patients were stratified according to treatment into LE alone, completion TME after LE or upfront TME. The treatment and outcomes of these groups were compared. RESULTS: A total of 1056 patients were included. Initial LE was performed in 715 patients (67.7%), of whom 194 underwent completion TME (27.1%). The remaining 341 patients underwent upfront TME (32.3%). Patients undergoing LE alone were more likely to be male with low rectal cancers and greater comorbidity. No differences in specimen quality or perioperative outcomes were noted between patients undergoing completion or upfront TME. Eighty-five patients (15.9%) had lymph node metastases (LNM). Pathological risk factors poorly discriminated between patients with and without LNM, with similar rates seen in patients with zero (14.1%), one (12.0%) or two (14.4%) risk factors. CONCLUSION: LE is a key component of the treatment of pT1 rectal cancer and does not appear to affect the outcomes of completion TME. Patient selection for completion TME remains a major challenge, with current stratification methods appearing to be inadequate.

European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula.

AIM: The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology. METHODS: Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG. RESULTS: In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations. CONCLUSION: This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

Fistula development after anal abscess drainage-a multicentre retrospective cohort study.

PURPOSE: Anal abscesses are common and, despite correct treatment with surgical drainage, carry the risk of developing fistulas. Studies identifying risk factors for the development of anal fistulas are sparse. This study aimed to identify the risk factors for anal fistulas after anal abscess surgery. METHODS: This was a multicentre, retrospective cohort study of patients undergoing acute surgery for anal abscesses in the Capital Region of Denmark between 2018 and 2019. The patients were identified using ICD-10 codes for anal abscesses. Predefined clinicopathological factors and postoperative courses were extracted from patient records. RESULTS: A total of 475 patients were included. At a median follow-up time of 1108 days (IQR 946-1320 days) following surgery, 164 (33.7%) patients were diagnosed with an anal fistula. Risk factors for developing fistulas were low intersphincteric (OR 2.77, 95CI 1.50-5.06) and ischioanal (OR 2.48, 95CI 1.36-4.47) abscesses, Crohn's disease (OR 5.96, 95CI 2.33-17.2), a history of recurrent anal abscesses (OR 4.14, 95CI 2.47-7.01) or repeat surgery (OR 5.96, 95CI 2.33-17.2), E. coli-positive pus cultures (OR 4.06, 1.56-11.4) or preoperative C-reactive protein (CRP) of more than 100 mg/L (OR 3.21, 95CI 1.57-6.71). CONCLUSION: Several significant clinical risk factors were associated with fistula development following anal abscess surgery. These findings are clinically relevant and could influence the selection of patients for specialised follow-up, facilitate expedited diagnosis, and potentially prevent unnecessarily long treatment courses.

Robot-assisted TAMIS: a systematic review of feasibility and outcomes.

BACKGROUND: In the advancement of transanal local excision, robot-assisted transanal minimal invasive surgery is the newest development. In the confined area of the rectum, robot-assisted surgery should, theoretically, be superior due to articulated utensils, video enhancement, and tremor reduction, however, this has not yet been investigated. The aim of this study was to review the evidence reported to-date on experience of using robot-assisted transanal minimal invasive surgery for treatment of rectal neoplasms. METHODS: A comprehensive literature search of Embase and PubMed from May to August 2021were performed. Studies including patients diagnosed with rectal neoplasia or benign polyps who underwent robot-assisted transanal minimal invasive surgery were included. All studies were assessed for risk of bias through assessment tools. Main outcome measures were feasibility, excision quality, and complications. RESULTS: Twenty-five studies with a total of 322 local excisions were included. The studies included were all retrospective, primarily case-reports, -series, and cohort studies. The median distance from the anal verge ranged from 3.5 to 10 cm and the median size was between 2.5 and 5.3 cm. Overall, 4.6% of the resections had a positive resection margin. The overall complication rate was at 9.5% with severe complications (Clavien-Dindo score III) at 0.9%. CONCLUSION: Based on limited, retrospective data, with a high risk of bias, robot-assisted transanal minimal invasive surgery seems feasible and safe for local excisions in the rectum.

Effectiveness of infliximab treatment of complex idiopathic anal fistulas.

OBJECTIVES: To investigate the effects of infliximab treatment in patients with complex idiopathic anal fistulas refractory to standard surgical treatment. MATERIALS AND METHODS: We retrospectively evaluated the effects ofinfliximab treatmentin patients with complex idiopathic anal fistulas refractory to standard surgical intervention. The primary outcome was achievement of substantial clinical improvement defined as sustained, reduced inflammatory activity at perioperativeevaluation, i.e., only minimal-to-moderate secretion and induration and a reduction of fistula size of a magnitude that would make it possible to perform a lay-open or sphincter-sparring closure procedure. Secondary outcomes weresymptom improvement, adverse treatment events and fistula healing after the surgical procedure in those achieving the primary outcome. RESULTS: Twenty-two patients were included (18 high transsphincteric, 3complex low transsphincteric, 1 suprasphincteric fistula). Fistulas had been present for a median of 24 [interquartile range, IQR: 12-33] months. In total, 16 patients (73%) achieved the primary outcome of substantial clinical improvement. Median time from infliximab initiation to patients achieved the primary outcome was 11 [IQR: 8-22] months. Sixteen of the patients responding to infliximab received subsequent lay-open or sphincter-sparring closure procedure surgery. Of these, ten (63%) achieved fistula healing. No serious infectious complications to infliximab treatment were seen. One patient developed a new abscess. One patient developed psoriasis (pustolosispalmoplantaris). CONCLUSIONS: Infliximab treatment may be considered a supplement to repeated curettage and setondrainage in the management of selected, complex idiopathic anal fistulas. Such combined treatment may make otherwise refractory fistulas amenable to definitive closure attempts.

Fistula Laser Closure (FiLaC™) for fistula-in-ano-yet another technique with 50% healing rates?

PURPOSE: Treatment of ano-cutaneous fistulas remains a therapeutic challenge. Fistula Laser Closure (FiLaC™) is a relatively new technique for the treatment of ano-cutaneous fistulas. This study aimed to determine the success rate of fistula closure using FiLaC™. Secondary endpoints included adverse events and patient characteristics associated with treatment success. METHODS: This was a retrospective cohort study of consecutive patients subjected to FiLaC™ at Digestive Disease Center, Bispebjerg University Hospital, Copenhagen, between March 2017 and July 2019. All patients had a one-track fistula not suitable for fistulotomy. All were treated with a draining seton for at least 8 weeks prior to laser closure. Fistulas were ablated with a 360-degree emitting 12-watt 1470 nm laser probe. The inner fistula opening was closed with absorbable suture. All patients were followed with clinical examination including MRI or EAUS 1 year after the procedure. RESULTS: In total, 66 patients with 68 fistulas were included. Two patients had a high intersphincteric, 20 had low transsphincteric, 41 high transsphincteric and 5 had suprasphincteric fistulas. Fistula aetiology was cryptoglandular in 83.8%, whereas the rest were due to Crohn's disease. Thirty-one (45.6%) were subjected to a second FiLaC™ procedure. Follow-up was median 19 months (12-26 months). Ultimately, 30 of 68 (44.1%) of the fistulas healed. No cases of incontinence following FiLaC™ were observed, but a single patient developed an abscess. CONCLUSION: Fistula closure with FiLaC™ had success rates comparable to that of other sphincter-sparing techniques. The technique seems safe with respect to adverse events and risk of incontinence.

Treatment of chronic anal fissure: a feasibility study on Levorag® Emulgel versus Diltiazem gel 2.

PURPOSE: To compare the standard treatment, diltiazem gel 2%, with Levorag® Emulgel for chronic anal fissures. METHODS: This was a single-blinded, randomised, controlled, clinical trial with a non-inferiority design. Patients with a chronic anal fissure were randomised to treatment with diltiazem or Levorag® Emulgel twice daily for 8 weeks. Primary endpoint was complete healing of the anal fissure after 12 weeks. Secondary endpoints included incidence of adverse events and efficacy on pain relief. RESULTS: In total, 55 patients were included. Inclusion was terminated prematurely due to a slow inclusion rate. Complete fissure healing at 12 weeks follow-up was overall achieved in 31 of 55 (56%) patients, 18 of 29 (62%) in the diltiazem group compared with 13 of 26 (50%) in the Levorag® Emulgel group (P = 0.424). Pain relief was significantly better at day seven in patients treated with diltiazem (P = 0.040) compared with Levorag® Emulgel, whereas there were no differences in early (3 days) or late (12 weeks) pain relief. Three patients (10.3%) developed severe perianal exanthema during diltiazem treatment, whereas no side effects were observed in the Levorag® Emulgel group. CONCLUSION: The study demonstrated statistical non-inferiority of Levorag® Emulgel compared with diltiazem in the treatment of chronic anal fissure. Diltiazem resulted in a more prompt pain relief and also in a substantial number of local allergic reactions. Levorag® Emulgel may therefore be an alternative in these patients. TRIAL REGISTRATION: Clinicaltrials.gov no. NCT02158013.

Incidence of Incisional Hernia Repair After Laparoscopic Compared to Open Resection of Colonic Cancer: A Nationwide Analysis of 17,717 Patients.

BACKGROUND: It remains unknown whether laparoscopic compared to open surgery translates into fewer incisional hernia repairs (IHR). The objectives of the current study were to compare the long-term incidence of IHR and the size of repaired hernias between patients subjected to laparoscopic or open resection of colonic cancer. METHODS: This was a nationwide cohort study comprised of patients undergoing resection for colonic cancer between January 2007 and March 2016 according to the Danish Colorectal Cancer Group database. Patients who subsequently underwent IHR were identified in the Danish Ventral Hernia Database, from which information about the priority of the hernia repair and the size of the fascial defect was retrieved. RESULTS: The study included 17,717 patients, of whom 482 (2.7%) underwent subsequent IHR during a median follow-up of 4.7 (interquartile range 2.8-6.9) years. There was no significant difference in the 5-year cumulative incidence of hernia repair after laparoscopic compared to open colonic resection (3.9%, CI 3.3-4.4% vs 4.1%, CI 3.5-4.6%). After adjustment for confounders, laparoscopic approach was associated with an increased rate of emergency IHR (HR 2.37, 95% CI 1.03-5.46, P = 0.042) as opposed to elective IHR (HR 0.91, 95% CI 0.73-1.14, P = 0.442). Laparoscopic surgery was significantly associated with a decreased fascial defect area compared to open surgery (mean difference -16.0 cm2, 95% CI -29.4 to -2.5, P = 0.020). CONCLUSIONS: There was no difference in the incidence of IHR after open compared to laparoscopic resection. Compared to the open approach, laparoscopic resection increased the rate of subsequent emergency IHR, suggesting that a more aggressive therapeutic approach may be warranted in this patient group upon diagnosis of an incisional hernia.

Increased Leak Rates Following Stapled Versus Handsewn Ileocolic Anastomosis in Patients with Right-Sided Colon Cancer: A Nationwide Cohort Study.

BACKGROUND: Data on anastomotic leak rates after stapled versus handsewn ileocolic anastomosis are conflicting. In a Cochrane review, the combined estimate favored the stapled technique, but recent cohort studies demonstrated a 2-fold increase in anastomotic leak with the stapled approach. OBJECTIVE: The purpose of this study was to investigate anastomotic leak rates following stapled versus handsewn ileocolic anastomosis. DESIGN: This was a nationwide, retrospective cohort study. SETTING: Data were obtained from the Danish Colorectal Cancer Group and National Patient Registry databases. PATIENTS: Danish patients, ≥18 years of age, undergoing right hemicolectomy for a first-time diagnosis of adenocarcinoma in the right colon with primary anastomosis between October 2014 and December 2015 were included. MAIN OUTCOME MEASURES: The primary outcome was anastomotic leak rate. Secondary outcomes included 30-day mortality. Covariates included demographics, comorbidity, tumor stage, and surgical variables. Multivariable logistic regression and propensity score matching were used to adjust for confounding. RESULTS: The 1414 patients included 391 (28%) in the stapled group and 1023 (72%) in the handsewn group. Forty-five patients (3.2%) developed anastomotic leak: 21 of 391 (5.4%) and 24 of 1023 (2.4%) in the stapled and handsewn group (p = 0.004). This difference was confirmed in multivariable analysis (adjusted OR, 2.91; 95% CI, 1.53-5.53; p < 0.001), and after propensity score matching (OR, 2.41; 95% CI, 1.24-4.67; p = 0.009). Thirty-day mortality was 15.6% (7/45) and 2.1% (29/1369) in patients with and without anastomotic leak (p < 0.001), with no difference between the stapled and handsewn approach. LIMITATIONS: The study's design was retrospective, with no information on allocation to the stapled or handsewn approach. CONCLUSIONS: The present study demonstrated a 2-fold increase in anastomotic leak after stapled versus handsewn ileocolic anastomoses. Previous opinions on the optimal anastomosis technique for colon cancer should be scrutinized given the devastating short-term outcome of anastomotic leak. See Video Abstract at http://links.lww.com/DCR/A819.

Quality of life, performance status, and work capacity after post-endoscopic retrograde cholangiopancreatography pancreatitis.

OBJECTIVES: This study evaluated the long-term consequences of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) on health related quality of life (HRQOL), performance status, and work capacity. MATERIALS AND METHODS: A follow-up study with prospective outcome measurements on patients with previous PEP and matched controls from a Danish cohort of 772 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). HRQOL was evaluated by the short form 36 health surveys, performance status by the Zubrod score, and work capacity by employment status. Multivariable models were applied to adjust for potential confounders. RESULTS: Twenty-nine cases and 49 controls were included. Twelve (41%), eight (28%), and nine (31%) patients had mild, moderate, and severe PEP, respectively. Mean follow-up time was 4.8 ± 1.7 years. PEP was associated with long-term reduced mental HRQOL (-13.0 role-emotional score points, 95% CI: -25.4; -0.52). An increased Zubrod score representing reduced performance status was present in 12 of the 29 cases (41.4%) and in nine of the 49 controls (18.4%), p = .002. Reduced work capacity was present in 14 of the 29 cases (48.2%) and in 12 of the 49 controls (24.4%), p = .023. CONCLUSIONS: This study indicates that PEP has a detrimental effect on long-term HRQOL, performance score, and work capacity.

Oncological outcome following laparoscopic versus open surgery for cancer in the transverse colon: a nationwide cohort study.

BACKGROUND: The literature on transverse colonic cancer resection is sparse. The optimal surgical approach for this disease is thus unknown. This study aimed to examine laparoscopic versus open surgery for transverse colonic cancer. METHODS: This study was a nationwide, retrospective cohort study of all patients registered with a transverse colonic cancer in Denmark between 2010 and 2013. Data were obtained from the Danish Colorectal Cancer Group, the Danish Pathology Registry, Danish National Patient Registry, and patients' records. Main outcome measures were surgical resection plane, lymph node yield, and long-term cancer recurrence and survival. RESULTS: In total, 357 patients were included. Non-mesocolic resection was more frequent with laparoscopic compared with open resection (adjusted odds ratio 2.44, 95% CI 1.29-4.60, P = 0.006). Median number of harvested lymph nodes was higher after open compared with laparoscopic resection (22 versus 19, P = 0.03). Non-mesocolic resection (adjusted hazard ratio 2.45, 95% CI 1.25-4.79, P = 0.01) and increasing tumor stage (P < 0.001) were factors associated with recurrence. Cancer recurrence was significantly associated with an increased risk of mortality (adjusted hazard ratio 4.32, 95% CI 2.75-6.79, P < 0.001). Overall mortality was, however, not associated with the surgical approach or surgical plane. CONCLUSIONS: Although associated with a lower rate of mesocolic resection plane and fewer lymph nodes harvested, laparoscopic surgery for transverse colonic cancers led to similar long-term results compared with open resection.

Treatment of Complex Fistula-in-Ano With a Nitinol Proctology Clip.

BACKGROUND: The treatment of complex anocutaneous fistulas remains a major therapeutic challenge balancing the risk of incontinence against the chance of permanent closure. OBJECTIVE: The purpose of this study was to investigate the efficacy of a nitinol proctology clip for closure of complex anocutaneous fistulas. DESIGN: This is a single-center cohort study with retrospective analysis of all of the treated patients. SETTINGS: Data were obtained from patient records and MRI reports, as well as follow-up telephone calls and clinical follow-up with endoanal ultrasonography. PATIENTS: All of the patients were treated for high transsphincteric and suprasphincteric anocutaneous fistulas at the Digestive Disease Center, Bispebjerg Hospital, between May 2013 and February 2015. INTERVENTIONS: All of the patients were treated with the nitinol proctology clip. MAIN OUTCOME MEASURES: Primary outcome was fistula healing after proctology clip placement, as evaluated through clinical examination, endoanal ultrasonography, and MRI. RESULTS: The fistula healing rate 1 year after the clip procedure was 54.3% (19 of 35 included patients). At the end of follow-up, 17 (49%) of 35 patients had persistent closure of the fistula tracks. No impairment of continence function was observed. Treatment outcome was not found to be statistically associated with any clinicopathological characteristics. LIMITATIONS: The study is limited by its retrospective and nonrandomized design. Selection bias may have occurred, because treatment options other than the clip were available during the study period. The small number of patients means that there is a nonnegligible risk of type II error in the conclusion, and the follow-up may be too short to have detected all of the failures. CONCLUSIONS: Healing rates were comparable with those of other noninvasive, sphincter-sparing techniques for high-complex anocutaneous fistulas, with no risk of incontinence. Predictive parameters for fistula healing using this technique remain uncertain. See Video Abstract at http://links.lww.com/DCR/A347.

Differential Impact of Anastomotic Leak in Patients With Stage IV Colonic or Rectal Cancer: A Nationwide Cohort Study.

BACKGROUND: Anastomotic leak has a negative impact on the prognosis of patients who undergo colorectal cancer resection. However, data on anastomotic leak are limited for stage IV colorectal cancers. OBJECTIVE: The purpose of this study was to investigate the impact of anastomotic leak on survival and the decision to administer chemotherapy and/or metastasectomy after elective surgery for stage IV colorectal cancer. DESIGN: This was a nationwide, retrospective cohort study. SETTINGS: Data were obtained from the Danish Colorectal Cancer Group, the Danish Pathology Registry, and the National Patient Registry. PATIENTS: Patients who were diagnosed with stage IV colorectal cancer between 2009 and 2013 and underwent elective resection of their primary tumors were included. MAIN OUTCOME MEASURES: The primary outcome was all-cause mortality depending on the occurrence of anastomotic leak. Secondary outcomes were the administration of and time to adjuvant chemotherapy, metastasectomy rate, and risk factors for leak. RESULTS: Of the 774 patients with stage IV colorectal cancer who were included, 71 (9.2%) developed anastomotic leaks. Anastomotic leak had a significant impact on the long-term survival of patients with colon cancer (p = 0.04) but not on those with rectal cancer (p = 0.91). Anastomotic leak was followed by the decreased administration of adjuvant chemotherapy in patients with colon cancer (p = 0.007) but not in patients with rectal cancer (p = 0.47). Finally, anastomotic leak had a detrimental impact on metastasectomy rates after colon cancer but not on resection rates of rectal cancer. LIMITATIONS: Retrospective data on the selection criteria for primary tumor resection and metastatic tumor load were unavailable. CONCLUSIONS: The impact of anastomotic leak on patients differed between stage IV colon and rectal cancers. Survival and eligibility to receive chemotherapy and metastasectomy differed between patients with colon and rectal cancers. When planning for primary tumor resection, these factors should be considered.

Effect of body weight on fixed dose of diclofenac for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis.

OBJECTIVE: The aim of this study was to assess the influence of patient body weight on the clinical effect of 100 mg diclofenac administered as a single dose for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). MATERIALS AND METHODS: All patients subjected to endoscopic retrograde cholangiopancreatography (ERCP) from 2009 to 2014 were evaluated for inclusion. In total, 772 patients were included of whom 378 (49%) received diclofenac prophylaxis. RESULTS: In the diclofenac prophylaxis group, body weight was higher in patients with PEP (mean ± SD: 82 ± 18 kg) than in patients without PEP (74 ± 18 kg) (p = 0.029). In patients not receiving prophylaxis, body weight was not associated with the occurrence of PEP (mean ± SD: 77 ± 18 vs 75 ± 18 kg, respectively, p = 0.450). In an adjusted analysis, higher patient body weight was inversely associated with the clinical effect of 100 mg diclofenac for the prophylaxis of PEP. CONCLUSIONS: High patient body weight was associated with a reduced effect of 100 mg diclofenac for prophylaxis of PEP.

Mismatch repair status and synchronous metastases in colorectal cancer: A nationwide cohort study.

The causality between the metastatic potential, mismatch repair status (MMR) and survival in colorectal cancer (CRC) is complex. This study aimed to investigate the impact of MMR in CRC on the occurrence of synchronous metastases (SCCM) and survival in patients with SCCM on a national basis. A nationwide cohort study of 6,692 patients diagnosed with CRC between 2010 and 2012 was conducted. Data were prospectively entered into the Danish Colorectal Cancer Group's database and merged with data from the Danish Pathology Registry and the National Patient Registry. Multivariable and multinomial logistic- and Cox-regression and proportional excess hazards analyses were used for confounder adjustment and to adjust for the general population mortality. In total, 983 of 6,692 patients (14.7%) had dMMR and 935 (14.0%) had SCCM. dMMR was associated with a decreased risk of SCCM, adjusted Odds Ratio (aOR) = 0.54 (95% confidence interval (CI):0.40-0.70, p < 0.001). The association only applied to confined hepatic metastases (aOR = 0.30, 95%CI: 0.18-0.49, p < 0.001), whereas the presence of confined pulmonary metastases (aOR = 0.71, 95% CI: 0.39-1.29, p = 0.258) or synchronous hepatic and pulmonary metastases (aOR = 0.69, 95% CI:0.26-1.29, p = 0.436) were unaffected by MMR. MMR in patients with SCCM had no impact on survival (Cox: adjusted Hazard Ratio (aHR) = 0.76, 95% CI: 0.54-1.06, p = 0.101; Proportional excess hazards: aHR = 0.73, 95% CI: 0.50-1.07, p = 0.111) when adjusting for other prognostic factors. The metastatic pattern varied according to MMR status. MMR had no impact on survival in patients with UICC Stage IV CRC. These findings may be important for the understanding of the metastatic processes and thus for optimizing staging and treatment in CRC patients.

Indeterminate pulmonary nodules in colorectal-cancer: do radiologists agree?

BACKGROUND: The clinical significance of indeterminate pulmonary nodules (IPN) at staging computed tomography (CT) for colorectal cancer (CRC), and the optimal diagnostic approach, are debated. This study aimed to analyse variability in radiologists' detection of IPN at staging CT for CRC. METHODS: All patients with CRC referred to our center between 2006 and 2011 were included. Primary staging CT scans were re-evaluated by an experienced thoracic radiologist whose findings were entered into a dedicated database and merged with data from the Danish Colorectal Cancer Group database, the National Patient Registry, the Danish Pathology Registry, and the primary CT evaluation. Inter-reader agreement was calculated by Kappa statistics, and associations between variables and malignancy of pulmonary nodules were analyzed with χ (2) and Mann-Whitney-Wilcoxon tests. Multivariable logistic regression analyses were used to adjust for potential confounding variables. RESULTS: In total, 841 patients were included. The primary CT assessment reported IPN in 9.8 % of patients and pulmonary metastases in 5.1 % of patients compared with 5.6 and 7.0 %, respectively, reported by the experienced thoracic radiologist. Kappa for agreement between the primary assessor and the thoracic radiologist on IPN was 0.31 and 0.65 for pulmonary metastases. Synchronous liver metastases were predictive of malignancy of IPN (adjusted odds ratio 20.1; 95 % confidence interval 2.64-437.66; p = 0.012), whereas no other investigated radiological characteristics or clinicopathological factors were significantly associated with malignancy of IPN. CONCLUSION: The characterization of pulmonary findings on staging CT for CRC varied greatly between the radiologists, and double-reading of scans with IPN is recommended prior to further diagnostic work-up.

Association of Comorbidity with Anastomotic Leak, 30-day Mortality, and Length of Stay in Elective Surgery for Colonic Cancer: A Nationwide Cohort Study.

BACKGROUND: Comorbidity has a negative influence on the long-term prognosis in patients with colorectal cancer, whereas its impact on the postoperative course is less clear. OBJECTIVES: The aim of this study was to investigate the influence of comorbidity on anastomotic leak and short-term outcomes after resection for colonic cancer. DESIGN: This is a retrospective nationwide cohort study SETTING: : Data were obtained from the Danish Colorectal Cancer Group and the National Patient Registry. PATIENTS: Patients with colonic cancer undergoing elective resection between 2001 and 2008 were selected. MAIN OUTCOME MEASURES: The primary outcome was the ability of comorbidity to predict anastomotic leak. Secondary outcomes were 30-day mortality and length of stay. Comorbidity was assessed by the Charlson Comorbidity Index. Multivariable logistic regression and receiver operating characteristics curves were used to adjust for confounding. RESULTS: The rate of anastomotic leak was 535/8597 (6.2%). The mean (95% CI) Charlson score was 0.83 (0.72-0.94) and 0.63 (0.61-0.66) for patients with and without anastomotic leak, p < 0.001. The Charlson score, as assessed in the multivariable analysis (adjusted OR, 1.07; 95% CI, 0.99-1.15; p = 0.077) and by receiver operating characteristics curves (area under the curve = 0.548), failed to predict anastomotic leak. Thirty-day mortality was 425/8587 (4.9%). In patients with anastomotic leakage, a Charlson score of ≥ 2 was associated with increased mortality in comparison with a Charlson score of <2 (adjusted HR, 1.58; 95% CI, 1.00-2.51; p = 0.047). Mean length of stay was 8.7 days (95% CI, 8.4-9.2 days) for patients without an anastomotic leak in comparison with 23.3 days (95% CI, 21.5-25.1 days) for patients with anastomotic leak and 25.5 days (95% CI, 21.7-29.3 days) in patients with anastomotic leak and a Charlson score of >2, p < 0.001. LIMITATIONS: This study is limited by the accuracy of the coding used to generate the Charlson Comorbidity Index and the retrospective study design. CONCLUSION: Comorbidity failed to predict anastomotic leak, but it was associated with an inferior short-term outcome in patients with this surgical complication.

Anastomotic leak increases distant recurrence and long-term mortality after curative resection for colonic cancer: a nationwide cohort study.

OBJECTIVE: To investigate the impact of anastomotic leak (AL) on disease recurrence and long-term mortality in patients alive 120 days after curative resection for colonic cancer. BACKGROUND: There is no solid data as to whether AL after colonic cancer surgery increases the risk of disease recurrence. METHODS: This was a nationwide cohort study of 9333 patients, prospectively registered in the database of the Danish Colorectal Cancer Group and merged with data from the Danish Pathology Registry and the National Patient Registry. Multivariable Cox regression analysis was used to adjust for confounding. RESULTS: The incidence of AL was 6.4%, 744 patients died within 120 days. Of the remaining 8589 patients, 861 (10.0%) developed local recurrence with no association to AL [adjusted hazard ratio (HR) = 0.78; 95% confidence interval (CI): 0.55-1.12; P = 0.184]. Distant recurrence developed in 1281 (14.9%) patients and more frequently after AL (adjusted HR = 1.42; 95% CI: 1.13-1.78; P = 0.003). AL was also associated with increased long-term mortality (adjusted HR = 1.20; 95% CI: 1.01-1.44; P = 0.042). In 2841 patients with stage III cancer, AL was associated with both decreased likelihood of receiving adjuvant chemotherapy (adjusted HR = 0.58; 95% CI: 0.45-0.74; P < 0.001) and a delay to initial administration (16 days; 95% CI: 12-20 days; P < 0.001). CONCLUSIONS: AL was significantly associated with increased rates of distant recurrence and long-term all-cause mortality. Cancelled or delayed administration of adjuvant chemotherapy may partly account for these findings.