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AIM: Sacral neuromodulation (SNM) has become a standard surgical treatment for faecal incontinence (FI). Prior studies have reported various adverse events of SNM, including suboptimal therapeutic response, infection, pain, haematoma, and potential need for redo SNM. The aim of this study was to identify the risk factors associated with long-term complications of SNM. METHOD: This retrospective cohort reviewed patients who underwent two-stage SNM for FI at our institution between 2011-2021. Preoperative baseline characteristics and follow-up were obtained from the medical record and/or by telephone interview. Management and outcome of each postoperative event were evaluated by univariate and multivariate regression analyses. RESULTS: A total of 291 patients (85.2% female) were included in this study. Postoperative complications were recorded in 219 (75.2%) patients and 154 (52.9%) patients required surgical intervention to treat complications. The most common postoperative event was loss of efficacy (46.4%). Other common adverse events were problems at the implant site (pain, infection, etc.) in 16.5% and pain during stimulation in 11.7%. Previous vaginal delivery (OR 2.74, p = 0.003) and anal surgery (OR = 2.46, p = 0.039) were independent predictors for complications. Previous colorectal (OR = 2.04, p = 0.026) and anal (OR = 1.98, p = 0.022) surgery and history of irritable bowel syndrome (IBS) (OR = 3.49, p = 0.003) were independent predictors for loss of efficacy. CONCLUSION: Postoperative adverse events are frequently recorded after SNM. Loss of efficacy is the most common. Previous colorectal or anal surgery, vaginal delivery, and IBS are independent risk factors for complications.
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Background: Local surgical excision of T1 rectal adenocarcinoma is a well-established approach. Yet, there are still open questions regarding the recurrence rates and its risk factors. Methods: A retrospective multicenter study including all patients who underwent local excision of early rectal cancer with an open or MIS approach and had a T1 lesion from 2010 to 2020 in six academic centers. Data included demographics, preoperative studies, surgical findings, postoperative outcomes, and local and systemic recurrence. A univariable and multivariable logistic regression analysis was performed to identify risk factors for recurrence. Results: Overall, 274 patients underwent local excision of rectal lesions. Of them, 97 (35.4%) patients with a T1 lesion were included in the cohort. The mean age was 69 ± 10.5 years, and 42 (43.3%) were female. The mean distance of the lesions from the anal verge was 7.8 ± 3.2 cm, and the average tumor size was 2.7 ± 1.6 cm. Eighty-two patients (85%) had a full-thickness resection. Eight patients (8%) had postoperative complications. Kikuchi classification of submucosal (SM) involvement was reported in 29 (30%) patients. Twelve patients had SM1, two SM2, and fifteen SM3. Following pathology, 24 patients (24.7%) returned for additional surgery or treatment. The overall recurrence rate was 14.4% (14 patients), with 11 patients having a local recurrence and 6 having a systemic metastatic recurrence, 3 of which had both. The mean time for recurrence was 2.78 ± 2.8 years and the overall mortality rate was 11%. On univariable and multivariable logistic regression analysis of recurrence vs. non-recurrence groups, the strongest and most significant association and possible risk factors for recurrence were larger lesions (4.3 vs. 2.5 cm, p < 0.001) with an OR of 6.67 (CI-1.82-24.36), especially for tumors larger than 3.5 cm, mucinous histology (14.3% vs. 1.2%, p = 0.004, OR of 14.02, CI-1.13-173.85), and involved margins (41.7% vs. 16.2%, p = 0.003, OR of 9.59, CI-2.14-43.07). The open transanal excision (TAE) approach was also identified as a possible significant risk factor in univariant analysis, while SM3 level penetration showed only a trend. Conclusion: Surgical local excision of T1 rectal malignancy is a safe and viable option. Still, one in four patients received additional treatment. There is an almost 15% chance for recurrence, especially in large tumors, mucinous histology, or involved margin cases. These high-risk patients might warrant additional intervention and stricter surveillance protocols.
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Background: We aimed to assess the efficacy and safety of low-pressure pneumoperitoneum (LPP) in minimally invasive colorectal surgery. Methods: A PRISMA-compliant systematic review/meta-analysis was conducted, searching PubMed, Scopus, Google Scholar, and clinicaltrials.gov for randomized-controlled trials assessing outcomes of LPP vs standard-pressure pneumoperitoneum (SPP) in colorectal surgery. Efficacy outcomes [pain score in post-anesthesia care unit (PACU), pain score postoperative day 1 (POD1), operative time, and hospital stay] and safety outcomes (blood loss and postoperative complications) were analyzed. Risk of bias2 tool assessed bias risk. The certainty of evidence was graded using GRADE. Results: Four studies included 537 patients (male 59.8%). LPP was undertaken in 280 (52.1%) patients and associated with lower pain scores in PACU [weighted mean difference: -1.06, 95% confidence interval (CI): -1.65 to -0.47, P = 0.004, I 2 = 0%] and POD1 (weighted mean difference: -0.49, 95% CI: -0.91 to -0.07, P = 0.024, I 2 = 0%). Meta-regression showed that age [standard error (SE): 0.036, P < 0.001], male sex (SE: 0.006, P < 0.001), and operative time (SE: 0.002, P = 0.027) were significantly associated with increased complications with LPP. In addition, 5.9%-14.5% of surgeons using LLP requested pressure increases to equal the SPP group. The grade of evidence was high for pain score in PACU and on POD1 postoperative complications and major complications, and blood loss, moderate for operative time, low for intraoperative complications, and very low for length of stay. Conclusions: LPP was associated with lower pain scores in PACU and on POD1 with similar operative times, length of stay, and safety profile compared with SPP in colorectal surgery. Although LPP was not associated with increased complications, older patients, males, patients undergoing laparoscopic surgery, and those with longer operative times may be at risk of increased complications.
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BACKGROUND: Available platforms for local excision (LE) of early rectal cancer are rigid or flexible [transanal minimally invasive surgery (TAMIS)]. We systematically searched the literature to compare outcomes between platforms. METHODS: PRISMA-compliant search of PubMed and Scopus databases until September 2022 was undertaken in this random-effect meta-analysis. Statistical heterogeneity was assessed using I2 statistic. Studies comparing TAMIS versus rigid platforms for LE for early rectal cancer were included. Main outcome measures were intraoperative and short-term postoperative outcomes and specimen quality. RESULTS: 7 studies were published between 2015 and 2022, including 931 patients (423 females); 402 underwent TAMIS and 529 underwent LE with rigid platforms. Techniques were similar for operative time (WMD 11.1, 95%CI - 2.6 to 25, p = 0.11), percentage of defect closure (OR 0.7, 95%CI 0.06-8.22, p = 0.78), and peritoneal violation (OR 0.41, 95%CI 0.12-1.43, p = 0.16). Rigid platforms had higher rates of short-term complications (19.1% vs 14.2, OR 1.6, 95%CI 1.07-2.4, p = 0.02), although no significant differences were seen for major complications (OR 1.41, 95%CI 0.61-3.23, p = 0.41). Patients in the rigid platforms group were 3-times more likely to be re-admitted within 30 days compared to the TAMIS group (OR 3.1, 95%CI 1.07-9.4, p = 0.03). Rates of positive resection margins (rigid platforms: 7.6% vs TAMIS: 9.34%, OR 0.81, 95%CI 0.42-1.55, p = 0.53) and specimen fragmentation (rigid platforms: 3.3% vs TAMIS: 4.4%, OR 0.74, 95%CI 0.33-1.64, p = 0.46) were similar between the groups. Salvage surgery was required in 5.5% of rigid platform patients and 6.2% of TAMIS patients (OR 0.8, 95%CI 0.4-1.8, p = 0.7). CONCLUSION: TAMIS or rigid platforms for LE seem to have similar operative outcomes and specimen quality. The TAMIS group demonstrated lower readmission and overall complication rates but did not significantly differ for major complications. The choice of platform should be based on availability, cost, and surgeon's preference.
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Neoplasias Retais , Cirurgia Endoscópica Transanal , Humanos , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Cirurgia Endoscópica Transanal/métodos , Cirurgia Endoscópica Transanal/instrumentação , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Duração da Cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Margens de ExcisãoRESUMO
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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Minimally invasive surgery is safe and effective in colorectal cancer. Conversion to open surgery may be associated with adverse effects on treatment outcomes. This study aimed to assess risk factors of conversion from minimally invasive to open colectomy for colon cancer and impact of conversion on short-term and survival outcomes. This case-control study included colon cancer patients undergoing minimally invasive colectomy from the National Cancer Database (2015-2019). Logistic regression analyses were conducted to determine independent predictors of conversion from laparoscopic and robotic colectomy to open surgery. 26,546 patients (mean age: 66.9 ± 13.1 years) were included. Laparoscopic and robotic colectomies were performed in 79.1% and 20.9% of patients, respectively, with a 10.6% conversion rate. Independent predictors of conversion were male sex (OR: 1.19, p = 0.014), left-sided cancer (OR: 1.35, p < 0.001), tumor size (OR: 1, p = 0.047), stage II (OR: 1.25, p = 0.007) and stage III (OR: 1.47, p < 0.001) disease, undifferentiated carcinomas (OR: 1.93, p = 0.002), subtotal (OR: 1.25, p = 0.011) and total (OR: 2.06, p < 0.001) colectomy, resection of contiguous organs (OR: 1.9, p < 0.001), and robotic colectomy (OR: 0.501, p < 0.001). Conversion was associated with higher 30- and 90-day mortality and unplanned readmission, longer hospital stay, and shorter overall survival (59.8 vs 65.3 months, p < 0.001). Male patients, patients with bulky, high-grade, advanced-stage, and left-sided colon cancers, and patients undergoing extended resections are at increased risk of conversion from minimally invasive to open colectomy. The robotic platform was associated with reduced odds of conversion. However, surgeons' technical skills and criteria for conversion could not be assessed.
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BACKGROUND: Ileus is a common complication of major abdominal surgery, including colorectal resection. The present study aimed to assess the predictors of ileus after laparoscopic right colectomy for colon cancer. METHODS: This study was a retrospective case-control analysis of a prospective IRB-approved database of patients who underwent laparoscopic right colectomy at the Department of Colorectal Surgery, Cleveland Clinic Florida. Patients who developed ileus after right colectomy were compared to patients without ileus to determine the risk factors of ileus. RESULTS: The present study included 270 patients with a mean age of 68.7 years. Thirty-six patients (13.3%) experienced ileus after laparoscopic right colectomy. The median duration of ileus was 6 days. Factors associated with ileus were age (71.6 vs 68.2 years, P = .158), emergency colectomy (11.1% vs 3.9%, P = .082), extended hemicolectomy (19.4% vs 6.8%, P = .021), green gastrointestinal anastomosis (GIA) 4.8mm staple height cartridge (19% vs 8.1%, P = .114), and longer operative time (177.9 vs 160.4 minutes, P = .157). The only independent predictor of ileus was extended colectomy (OR: 16.7, P = .003). CONCLUSIONS: Increased age, emergency surgery, green GIA cartridge, and longer operative times were associated with ileus, yet the only independent predictor of ileus was extended right hemicolectomy.
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BACKGROUND: Rectal neuroendocrine tumors are uncommon tumor types. Lymph node metastases may occur in up to 40%, potentially impacting decision-making. We aimed to assess risk factors for lymph node metastases of rectal neuroendocrine tumors and their association with overall and cancer-specific survival. METHODS: This retrospective case-control study involved patients with stage I to III rectal neuroendocrine tumors who underwent radical resection. Data were derived from the Surveillance, Epidemiology, and End Results database (2000-2020). Patients with pathologic evidence of lymph node metastases were compared to those without lymph node metastases for baseline patient and tumor characteristics. The main outcomes were lymph node metastases, overall survival, and cancer-specific survival. RESULTS: In total, 580 patients (50.9% male; mean age: 58.9 years) were included. The lymph node metastases rate was 37.1%. Independent predictors of lymph node metastases were Grade 2 neuroendocrine tumors (odds ratio: 8.06; P = .001), neuroendocrine carcinoma (odds ratio: 2.59, P = .006), large-cell neuroendocrine carcinoma (odds ratio: 4.89; P = .017), T2 tumors (odds ratio: 6.44; P < .001), T3 tumors (odds ratio: 27.5; P < .001), and T4 tumors (odds ratio: 17.3; P < .001). Lymph node metastases were associated with shorter restricted mean overall survival (40.8 vs 52.7 months; P < .001) and cancer-specific survival (41.3 vs 54.8 months; P < .001). When adjusted for other confounders, the nodal status of rectal neuroendocrine tumors was not independently associated with overall (hazard ratio = 1.56; P = .165) or cancer-specific survival (hazard ratio = 1.69; P = .158). Significant factors associated with worse overall survival and cancer-specific survival were age, tumor size, neuroendocrine carcinomas, large-cell neuroendocrine carcinomas, and the number of positive lymph nodes. CONCLUSIONS: Lymph node metastases of rectal neuroendocrine tumors were more likely associated with high-grade, large-sized, and T2 to T4 tumors. The number of involved lymph nodes was an independent predictor of overall and cancer-specific survival. Other independent survival predictors were tumor grade, size, and T stage.
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BACKGROUND: Colon cancer pathological and clinical staging may be disoncordant. This study assessed patients with colon cancer in whom the nodal status was clinically understaged. METHODS: Patients with stage I-III clinical node-negative colon cancer from the National Cancer Database were included. Regression analyses were conducted to elucidate risk factors for clinical nodal understaging and a scoring system was developed to identify high-risk patients. RESULTS: The study included 94,945 patients with 78.4 â% of patients correctly staged and 21.6 â% clinically understaged. The predictors of nodal positivity in clinically understaged patients were age <65 (OR 1.43), left-sided tumors (OR 1.41), elevated CEA (OR 2.03), moderately (OR 1.81) or poorly/undifferentiated tumors (OR 3.76), T1 tumors (OR 1.29), signet-ring cell histology (OR 2.26), and microsatellite-stable tumors (OR 1.4). CONCLUSION: Patients with colon cancer and the above factors are more likely to have their nodal status clinically understaged. A scoring system has been developed to identify high-risk patients.
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BACKGROUND AND OBJECTIVES: Pathological nodal staging is relevant to postoperative decision-making and a prognostic marker of cancer survival. This study aimed to assess the effect of different total neoadjuvant therapy (TNT) regimens on lymph node status following total mesorectal excision (TME) for locally advanced rectal cancer (LARC). METHODS: A retrospective cohort study of patients treated for node-positive clinical stage 3 LARC with TNT between January 2015 and August 2022. Patients were stratified into induction therapy and consolidation therapy groups. Variables collated included patient demographics, clinical and radiological characteristics of the tumor, and pathology of the resected specimen. Primary outcome was total harvested lymph nodes. RESULTS: Ninety-seven patients were included (57 [58.8%] males; mean age of 58.5 ± 11.4 years). The induction therapy group included 85 (87.6%) patients while 12 (12.4%) patients received consolidation therapy. A median interquartile range value of 22.00 (5.00-72.00) harvested lymph nodes was recorded for the induction therapy group in comparison to 16.00 (16.00-47.00) in the consolidation therapy arm (p = 0.487). Overall pathological complete response rate was 34%. CONCLUSION: Total harvested nodes from resected specimens were marginally lower in the consolidation therapy group. Induction therapy may be preferrable to optimize postoperative specimen staging.
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Linfonodos , Terapia Neoadjuvante , Neoplasias Retais , Humanos , Neoplasias Retais/patologia , Neoplasias Retais/terapia , Neoplasias Retais/mortalidade , Neoplasias Retais/cirurgia , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Linfonodos/patologia , Linfonodos/cirurgia , Excisão de Linfonodo , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Metástase Linfática , Seguimentos , Prognóstico , Estadiamento de NeoplasiasRESUMO
AIM: Splenic flexure mobilization (SFM) is commonly performed during left-sided colon and rectal resections. The aim of the present systematic review was to assess the outcomes of SFM in left-sided colon and rectal resections and the risk factors for complications and anastomotic leak (AL). METHOD: This study was a PRISMA-compliant systematic review. PubMed, Scopus and Web of Science were searched for studies that assessed the outcomes of sigmoid and rectal resections with or without SFM. The primary outcomes were AL and total complications, and the secondary outcomes were individual complications, operating time, conversion to open surgery, length of hospital stay (LOS) and pathological and oncological outcomes. RESULTS: Nineteen studies including data on 81 116 patients (49.1% male) were reviewed. SFM was undertaken in 40.7% of patients. SFM was associated with a longer operating time (weighted mean difference 24.50, 95% CI 14.47-34.52, p < 0.0001) and higher odds of AL (OR 1.19, 95% CI 1.06-1.33, p = 0.002). Both groups had similar odds of total complications, splenic injury, anastomotic stricture, conversion to open surgery, (LOS), local recurrence, and overall survival. A secondary analysis of rectal cancer cases only showed similar outcomes for SFM and the control group. CONCLUSIONS: SFM was associated with a longer operating time and higher odds of AL, yet a similar likelihood of total complications, splenic injury, anastomotic stricture, conversion to open surgery, LOS, local recurrence, and overall survival. These conclusions must be cautiously interpreted considering the numerous study limitations. SFM may have only been selectively undertaken in cases in which anastomotic tension was suspected. Therefore, the suboptimal anastomoses may have been the reason for SFM rather than the SFM being causative of the anastomotic insufficiencies.
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Fístula Anastomótica , Colectomia , Colo Transverso , Tempo de Internação , Duração da Cirurgia , Humanos , Fístula Anastomótica/etiologia , Fístula Anastomótica/epidemiologia , Colo Transverso/cirurgia , Fatores de Risco , Colectomia/efeitos adversos , Colectomia/métodos , Tempo de Internação/estatística & dados numéricos , Feminino , Masculino , Protectomia/efeitos adversos , Protectomia/métodos , Reto/cirurgia , Pessoa de Meia-Idade , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Idoso , Neoplasias Retais/cirurgia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologiaRESUMO
BACKGROUND: Incisional hernias (IH) are a significant postoperative complication with profound implications for patient morbidity and healthcare costs. The relationship between IH and perioperative factors in pancreatic surgery, with particular attention to preoperative biliary stents and pancreatic fistulas requires further exploration. METHODS: This retrospective observational study examined adult patients who underwent open pancreatic surgeries via midline incision at a high-volume tertiary hepatopancreatobiliary center from January 2008 to December 2021. The study focused on IH incidence and associated risk factors, with particular attention to preoperative biliary stents and pancreatic fistulas. RESULTS: In a cohort of 620 individuals undergoing pancreatic surgery, 351 had open surgery with at least one-year follow-up. Within a median follow-up of 794 days (IQR 1694-537), the overall incidence of IH was 17.38%. The highest frequency of IH was observed among patients who had a Pancreaticoduodenectomy (PD). Significant predictors for the development of IH within the entire study population in a multivariable analysis included perioperative biliary stenting (OR 2.05; 95% CI 1.06-3.96; p = 0.03), increased age at diagnosis (OR 2.05; 95% CI 1.06-3.96; p = 0.01), and BMI (OR 1.08; 95% CI 1.01-1.15; p = 0.01). In the subset of patients who underwent Pancreaticoduodenectomy (PD), although the presence of biliary stents was associated with a heightened occurrence of SSIs, it did not demonstrate a direct correlation with an increased incidence of incisional hernias (IH). The development of pancreatic fistulas did not show a significant correlation with IH in either the Distal Pancreatectomy with Splenectomy (DPS) or the PD patient groups. CONCLUSIONS: The study underscores a notable association between biliary stent placement and increased IH risk after PD, mediated by elevated SSI incidence. Pancreatic fistulas were not directly correlated with IH in the studied cohorts. Further research is necessary to validate these findings and guide clinical practice.
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Hérnia Incisional , Humanos , Estudos Retrospectivos , Masculino , Feminino , Pessoa de Meia-Idade , Hérnia Incisional/etiologia , Hérnia Incisional/epidemiologia , Fatores de Risco , Incidência , Idoso , Fístula Pancreática/etiologia , Fístula Pancreática/epidemiologia , Pancreatectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Stents , Pancreaticoduodenectomia/efeitos adversos , AdultoRESUMO
BACKGROUND: Treatment of elderly patients with cancer is challenging as they can be overtreated with respect to frailty or undertreated because of advanced age. Maintaining a good quality of life is essential for this population. This study aimed to assess the difference in overall survival and short-term outcomes according to the extent of rectal cancer resection in patients aged ≥80 years. METHODS: In this retrospective cohort study, very elderly patients with stage I-III rectal cancer aged ≥80 years were identified from the National Cancer Database (2004-2019). Patients were divided into 2 groups: radical resection and local excision. The groups were matched using exact matched analysis for clinical T and N stage, tumor size, and neoadjuvant treatment. The main outcome measures were overall survival, hospital stay, 30-day unplanned readmissions, and short-term mortality. RESULTS: A total of 9634 patients were included (local excision = 2710; radical resection = 6924). After matching, 1106 patients were included in each group with a median follow-up of 49.9 and 51.7 months, respectively. The radical resection group had statistically significantly longer overall survival than did the local excision group (60 vs 57.2 months, P = .026). Local excision was associated with shorter length of stay (1 vs 7 days. P < .001), lower 30-day mortality (odds ratio: 0.43; 95% CI: 0.25-0.75, P = .003), lower 90-day mortality (odds ratio: 0.47, 95% CI: 0.32-0.68, P < .001), and lower 30-day readmission (odds ratio: 0.49, 95% CI: 0.33-0.74, P < .001). A subgroup analysis of matched patients with cTis-T2 and N0 tumors who underwent curative surgery revealed similar results. CONCLUSION: Radical resection of rectal cancer in very elderly patients has a modest survival benefit, whereas local excision has lower odds of readmission and short-term mortality.
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Bases de Dados Factuais , Tempo de Internação , Estadiamento de Neoplasias , Neoplasias Retais , Humanos , Neoplasias Retais/cirurgia , Neoplasias Retais/mortalidade , Neoplasias Retais/patologia , Masculino , Feminino , Estudos Retrospectivos , Idoso de 80 Anos ou mais , Tempo de Internação/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Protectomia/métodos , Taxa de Sobrevida , Terapia Neoadjuvante/estatística & dados numéricosRESUMO
SUMMARY: Immunotherapy for the systemic treatment of cancer offers new treatment possibilities for advanced malignancies. Despite promising initial results, evidence on efficacy of immunotherapy for colon cancer is lacking. Thus, we aimed to assess short-term and long-term outcomes of immunotherapy in patients with advanced colon cancer. A US National Cancer Database was searched for patients with stage III-IV colonic adenocarcinoma between 2010 and 2019. Propensity score matching was used to classify the cohort into 2 groups: patients who received immunotherapy and controls. Main outcome measures were primary outcome was overall survival (OS). A total of 23,778 patients with stage III-IV colonic adenocarcinoma were treated with immunotherapy during the study period compared to 114,753 controls. Immunotherapy treated patients were younger (median age 61 vs. 67 y; P<0.001), more often male (57.3% vs. 50.7%, P<0.001), had more private insurance (44.1% vs. 33.7%; P<0.001), had more left-sided tumors (49.5% vs. 39.1%; P<0.001) and liver metastasis (80.2% vs. 61.7%; P<0.001) than controls. Immunotherapy patients received more standard chemotherapy (49.8% vs. 41.6%; P<0.001). After propensity-score matching, mean OS was significantly shorter in the immunotherapy group compared with controls (34.7 vs. 36.2 mo; P=0.008). Cox regression analysis demonstrated that immunotherapy was associated with increased risk for mortality (HR: 1.1; 95% CI: 1.02-1.18; P=0.005). Patients who received immunotherapy had lower 90-day mortality rates compared with controls (2.3% vs. 3.6%; P=0.004), but the groups had equivalent 30-day mortality rates (0.7% vs. 0.8%; P=0.76). Immunotherapy showed no improvement in OS in patients with stage III-IV colon cancer.
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There is controversy in the best management of colorectal cancer liver metastasis (CLM). This study aimed to compare short-term and survival outcomes of simultaneous resection of CLM and primary colon cancer compared to resection of only colon cancer. This retrospective matched cohort study included patients from the National Cancer Database (2015-2019) with stage IV colon adenocarcinoma and synchronous liver metastases who underwent colectomy. Patients were divided into two groups: colectomy-only (resection of primary colon cancer only) and colectomy-plus (simultaneous resection of primary colon cancer and liver metastases). The groups were matched using the propensity score method. The primary outcome was short-term mortality and readmission. Secondary outcomes were conversion, hospital stay, surgical margins, and overall survival. 4082 (37.6%) of 10,862 patients underwent simultaneous resection of primary colon cancer and liver metastases. After matching, 2038 patients were included in each group. There were no significant differences between the groups in 30-days mortality (3.1% vs 3.8%, p = 0.301), 90-days (6.6% vs 7.7%, p = 0.205) mortality, 30-days unplanned readmission (7.2% vs 5.3%, p = 0.020), or conversion to open surgery (15.5% vs. 13.8%, p = 0.298). Patients in the colectomy plus group had a higher rate of lower incidence of positive surgical margins (13.2% vs. 17.2%, p = 0.001) and longer overall survival (median: 41.5 vs 28.4 months, p < 0.001). Synchronous resection of CLM did not increase the rates of short-term mortality, readmission, conversion from minimally invasive to open surgery, or hospital stay and was associated with a lower incidence of positive surgical margins.
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Colectomia , Neoplasias do Colo , Neoplasias Hepáticas , Estadiamento de Neoplasias , Readmissão do Paciente , Pontuação de Propensão , Humanos , Neoplasias do Colo/patologia , Neoplasias do Colo/cirurgia , Neoplasias do Colo/mortalidade , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/mortalidade , Colectomia/métodos , Estudos Retrospectivos , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Resultado do Tratamento , Tempo de Internação/estatística & dados numéricos , Hepatectomia/métodos , Margens de Excisão , Adenocarcinoma/cirurgia , Adenocarcinoma/mortalidade , Adenocarcinoma/secundário , Adenocarcinoma/patologia , Taxa de Sobrevida , Estudos de Coortes , Conversão para Cirurgia Aberta/estatística & dados numéricosRESUMO
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 do Colo , Procedimentos Cirúrgicos Minimamente Invasivos , Estadiamento de Neoplasias , Humanos , Masculino , Neoplasias do Colo/cirurgia , Neoplasias do Colo/patologia , Neoplasias do Colo/mortalidade , Adenocarcinoma/cirurgia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Feminino , Idoso , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Tempo de Internação/estatística & dados numéricos , Estudos Retrospectivos , Colectomia/métodos , Pontuação de Propensão , Resultado do Tratamento , Margens de Excisão , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricosRESUMO
BACKGROUND: It is unclear whether conversion from minimally invasive surgery to laparotomy in patients with colon cancer contributes to worse outcomes compared with those operated by laparotomy. In this study, we aimed to assess the implications of transitioning from minimally invasive surgery to laparotomy in patients with colon cancer compared with patients undergoing upfront laparotomy. METHODS: A retrospective analysis of the National Cancer Database, including patients with stages I to III colon cancer (2010-2019). Patients who underwent either upfront laparotomy (Open Surgery Group) or minimally invasive surgery converted to open surgery (Converted Surgery Group) were included. Groups were balanced using propensity-score matching. Primary outcome was overall survival, and secondary outcomes included 30- and 90-day mortality and 30-day readmission rates. RESULTS: The study included 65,083 operated patients with stage I to III colon cancer; 57,091 patients (87.7%) were included in the Open Surgery group and 7,992 (12.3%) in the Converted Surgery group. 93.5% were converted from laparoscopy, and 6.5% were converted from robotic surgery. After propensity-score matching, 7,058 patients were included in each group. Median overall survival was significantly higher in the Converted Surgery group (107.3 months) than in the Open Surgery group (101.5 months; P = .006). A survival benefit was seen in patients >65 years of age (79.5 vs 71.9 months; P = .001), left-sided disease (129.4 vs 114.5 months; P < .001), and with a high Charlson comorbidity index score (=3; 58.9 vs 42.3 months; P = .03). Positive margin rates were similar between the groups (6.3% vs 5.6%; P = .07). Converted patients had a higher 30-day readmission rate (6.7% vs 5.6%, P = .006) and shorter duration of stay (median, 5 vs 6 days, P < .001) than patients in the Open Surgery group. In addition, 30-day mortality was comparable between the groups (2.9% vs 3.5%; P = .07). CONCLUSION: Conversion to open surgery from minimally invasive surgery was associated with better overall survival compared with upfront open surgery. A survival benefit was mainly seen in patients >65 years of age, with significant comorbidities, and with left-sided tumors. We believe these data suggest that, in the absence of an absolute contraindication to minimally invasive surgery, it should be the preferred approach in patients with colon cancer.
Assuntos
Neoplasias do Colo , Conversão para Cirurgia Aberta , Laparotomia , Humanos , Masculino , Feminino , Neoplasias do Colo/cirurgia , Neoplasias do Colo/mortalidade , Neoplasias do Colo/patologia , Estudos Retrospectivos , Idoso , Pessoa de Meia-Idade , Laparotomia/métodos , Laparotomia/mortalidade , Conversão para Cirurgia Aberta/estatística & dados numéricos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Pontuação de Propensão , Laparoscopia/métodos , Laparoscopia/mortalidade , Resultado do Tratamento , Colectomia/métodos , Colectomia/mortalidade , Estadiamento de Neoplasias , Idoso de 80 Anos ou mais , Readmissão do Paciente/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/mortalidade , Bases de Dados FactuaisRESUMO
BACKGROUND: Microsatellite instability (MSI) is an important prognosticator for colorectal cancer (CRC). The present study aimed to assess the impact of MSI status on the characteristics and outcomes of early-onset compared to late-onset rectal cancer. METHODS: This retrospective cohort study used data from the US National Cancer Database (2004-2019) to assess the baseline characteristics, treatment patterns, short-term outcomes, and overall survival (OS) of early-onset rectal adenocarcinoma affecting patients < 50 years compared to late-onset rectal adenocarcinoma according to the MSI status. RESULTS: The present study included 48,407 patients (59.9% male) with rectal cancer, 17.3% of patients were < 50 years and 6.3% had MSI-H tumors. In the early-onset group, patients with MSI-H tumors had a lower mean age (41.5 vs 43 years, p < 0.001) and presented less often with stage IV disease (22.1% vs 17.7%, p = 0.03) and liver metastasis (9.1% vs 13.5%, p = 0.011) than patients with MSS tumors. In the late-onset group, patients with MSI-H and MSS tumors had similar demographics, disease stage, and metastatic pattern, yet MSI-H patients more often received neoadjuvant radiation therapy (58.9% vs 55.1%, p = 0.009) and neoadjuvant systemic therapy (40% vs 36.2%, p = 0.005). In both age groups, MSI-H tumors were associated with more pathologic T3-4 stage and were more likely mucinous and poorly differentiated carcinomas than MSS tumors. The median OS of MSI-H tumors was similar to MSS tumors (108.09 vs 102.31 months, p = 0.1), whether in the early-onset (139.5 vs 134.2 months, p = 0.821) or late-onset groups (106.1 vs 104.3 months, p = 0.236). CONCLUSIONS: In both age groups, MSI-H rectal cancers were more often mucinous and poorly differentiated carcinomas and had pT3-4 stage more often than MSS cancers. MSI-H rectal cancers tend to present less often with distant metastases and nodal involvement than MSS cancers only in early-onset, but not in late-onset rectal cancers. The association between MSI status and survival was not notable in this study, whether in the early-onset or late-onset groups.
Assuntos
Adenocarcinoma , Carcinoma , Neoplasias Colorretais , Neoplasias Retais , Humanos , Masculino , Adulto , Feminino , Estudos Retrospectivos , Prognóstico , Neoplasias Retais/genética , Neoplasias Retais/terapia , Repetições de Microssatélites , Instabilidade de Microssatélites , Adenocarcinoma/genética , Adenocarcinoma/terapia , Neoplasias Colorretais/patologiaRESUMO
Management of colon cancer has changed over the last few decades. We assessed the trends in management and outcomes using the US National Cancer Database (NCDB). A retrospective analysis of all patients with colonic adenocarcinoma between 2005 and 2019 was conducted. The cohort was divided into three equal time periods: Period 1 (2005-2009), Period 2 (2010-2014), and Period 3 (2015-2019) to examine treatment and outcomes trends. The primary outcome was 5-year overall survival (OS). The study included 923,275 patients. A significant increase in patients with stage IV disease was noted in Period 3 compared to Period 1 (47.9% vs. 27.9%, respectively), whereas a reciprocal reduction was seen in patients with locally advanced disease (stage II: 20.8%-12%; stage III: 14.5%-7.7%). Use of immunotherapy significantly increased from 0.3% to 7.6%. Mean 5-year OS increased (43.6 vs. 42.1 months) despite the increase in metastatic disease and longer time from diagnosis to definitive surgery (7 vs. 14 days). A reduction in 30-day readmission (5.1%-4.2%), 30- (3.9%-2.8%), and 90-day mortality (7.1%-5%) was seen. Laparoscopic and robotic surgery increased from 45.8% to 53.1% and 2.9% to 12.7%, respectively. Median postoperative length of hospital stay decreased by 2 days. Rate of positive resection margins (7.2%-6%) and median number of examined lymph nodes (14-16) also improved. Minimally invasive surgery and immunotherapy for colon cancer significantly increased in recent years. Patient outcomes including OS improved over time.
Assuntos
Neoplasias do Colo , Bases de Dados Factuais , Humanos , Neoplasias do Colo/terapia , Neoplasias do Colo/mortalidade , Neoplasias do Colo/patologia , Neoplasias do Colo/epidemiologia , Estados Unidos/epidemiologia , Masculino , Feminino , Idoso , Estudos Retrospectivos , Pessoa de Meia-Idade , Adenocarcinoma/terapia , Adenocarcinoma/mortalidade , Adenocarcinoma/epidemiologia , Adenocarcinoma/patologia , Estadiamento de Neoplasias , Resultado do Tratamento , Imunoterapia/métodos , Idoso de 80 Anos ou mais , AdultoRESUMO
BACKGROUND: This study assessed trends in treatment and outcomes of anal melanomas over a 17-year period. METHODS: NCDB was searched for patients with anal melanoma (2004-2020). Receiver-operating characteristic curve analysis was used to determine cutoff year marking increased overall survival (OS) of anal melanoma. Characteristics, treatments, and outcomes in consecutive time periods were compared. RESULTS: A total of 815 patients (mean age: 67.2 years; 59.4% female) were included: 354 in Period 1 (2004-2012) and 461 in Period 2 (2013-2020). Period 2 included fewer abdominoperineal resections (18% vs. 28%, p = 0.002), more local tumor excisions (61.1% vs. 55%, p = 0.002), more often immunotherapy (odds ratio [OR]: 3.41, 95% confidence interval [CI]: 2.22-5.22, p < 0.001) and less often chemotherapy (OR: 0.516, 95% CI: 0.352-0.755, p < 0.001) administered and longer median OS (25.2 vs. 19.8 months, p = 0.006). Independent predictors of worse OS were older age (hazard ratio [HR]: 1.02, p = 0.012), higher Charlson score (HR: 2.32, p = 0.02), and greater number of positive lymph nodes (HR: 1.15, p < 0.001); conversely private insurance (HR: 0.385, p = 0.008) was predictive of increased OS. CONCLUSIONS: Anal melanoma patients diagnosed between 2013 and 2020 underwent fewer abdominoperineal resections and more local excisions than patients diagnosed between 2004 and 2013. Increased immunotherapy and longer median OS were noted in period two. Age and private insurance were significant predictors of OS, remaining constant across time periods.