5-year outcome after complete mesocolic excision for right-sided colon cancer: a population-based cohort study.

BACKGROUND: The benefits of extensive lymph node dissection as performed in complete mesocolic excision are still debated, although recent studies have shown an association with improved long-term outcomes. However, none of these studies had an intention-to-treat design or aimed to show a causal effect; therefore in this study, we aimed to estimate the causal oncological treatment effects of complete mesocolic excision on right-sided colon cancer. METHODS: We did a population-based cohort study involving prospective data collected from four hospitals in Denmark. We compared the oncological outcome data of patients at one centre performing central lymph node dissection and vascular division after almost complete exposure of the proximal part of the superior mesenteric vein (ie, the complete mesocolic excision group) with three other centres performing conventional resections with unstandardised and limited lymph node dissection (ie, non-complete mesocolic excision; control group). We included data for all patients in the Capital Region of Denmark undergoing elective curative-intent right-sided colon resections for stages I-III colon cancer, as categorised by the Union for International Cancer Control (UICC; 5th edition), from June 1, 2008, to Dec 31, 2013. Patients were followed-up for 5·2 years after surgery. The primary outcome was the cumulative incidence of recurrence after 5·2 years of surgery. Inverse probability of treatment weighting and competing risk analyses were used to estimate the possible causal effects of complete mesocolic excision. This study is registered with ClinicalTrials.gov, number NCT03754075. FINDINGS: 1069 patients (813 in the control group and 256 in the complete mesocolic excision group) underwent curative-intent elective surgery for right-sided colon cancer during the study period. None of the patients were lost to follow-up regarding survival or recurrence status, and consequently no patient was censored in the analyses. The 5·2-year cumulative incidence of recurrence was 9·7% (95% CI 6·3-13·1) in the complete mesocolic excision group compared with 17·9% (15·3-20·5) in the control group, and the absolute risk reduction of complete mesocolic excision after 5·2 years was 8·2% (95% CI 4·0-12·4; p=0·00015). In the control group, 145 (18%) of 813 patients were diagnosed with a recurrence and 281 (35%) died during follow-up, whereas in the complete mesocolic excision group 25 (10%) of 256 patients were diagnosed with a recurrence and 75 (29%) died during follow-up. INTERPRETATION: This study shows a causal treatment effect of central mesocolic lymph node excision on risk of recurrence after resection for right-sided colon adenocarcinoma. Complete mesocolic excision has the potential to reduce the risk of recurrence and improve long-term outcome after resection for all UICC stages I-III of right-sided colon adenocarcinomas. FUNDING: The Tvergaard Fund, Helen Rude Fund, Krista and Viggo Petersen Fund, Olga Bryde Nielsen Fund, and Else and Mogens Wedell-Wedellsborg Fund.

Lymph node metastases in the gastrocolic ligament in patients with colon cancer.

BACKGROUND: Long-term survival after colorectal cancer may be improved by more extensive resection of the primary tumor and lymph nodes. Resection of the gastroepiploic and infrapyloric lymph nodes in the gastrocolic ligament has been proposed as a standard procedure when resecting tumors located in the proximity of the flexures or in the transverse colon. OBJECTIVE: The purpose of this work was to present our findings of metastases in the gastrocolic ligament in a consecutive series of patients. DESIGN: This was a single-center retrospective study. SETTINGS: The study was conducted in a colorectal cancer center. PATIENTS: All of the colon adenocarcinoma resections with relevant tumor location from June 1, 2008, to December 31, 2012 were included in this study. MAIN OUTCOME MEASURES: The presence of lymph node metastases in the gastrocolic ligament in colon adenocarcinomas located in the proximity of the flexures or in the transverse colon was measured. RESULTS: Gastrocolic resection was performed in 130 patients. Thirty-two patients were excluded because of a lack of information about gastrocolic lymph node status in the pathology reports. Median age of the remaining 98 patients was 70 years (range, 30-90 years), and 57% were men. Gastrocolic lymph nodes were found in 86 specimens (88%) with a median number of 4 lymph nodes (range, 0-16 lymph nodes). Thirty-four patients (35%) had mesocolic lymph node metastases. Gastrocolic lymph node metastases were found in 4 (12%) of these 34 patients and in 4% of all 98 included patients. Gastrocolic lymph node metastases were related to perineural invasion (p > 0.001). LIMITATIONS: Limitations of this study include the retrospective design, size of material, and lack of gastrocolic ligament lymph node status in the pathology report in some patients. CONCLUSIONS: Metastases in the gastroepiploic or infrapyloric lymph nodes can be found in patients with tumors located in the proximity of the flexures or in the transverse colon. Further studies are needed to reveal the clinical relevance of this finding, with special focus on recurrence risk and long-term survival.

Primary and repeated stapled hemorrhoidopexy for prolapsing hemorrhoids: follow-up to five years.

PURPOSE: Treating hemorrhoids by stapled hemorrhoidopexy has become increasingly common, because the procedure results in less pain and allows the patient to return to work earlier than with open hemorrhoidectomy. However, the durability of stapled hemorrhoidopexy has not been evaluated. This study was designed to assess initial results, analyze complications and failures, and document both the need for repeated procedures and the outcomes of follow-up to five years. METHODS: From 1998 to 2004, 258 patients underwent modified stapled hemorrhoidopexy. The appearance of the anus was scored preoperatively, immediately after the procedure, at three months, and at one to five years postoperatively. The anatomy score ranged from 1 (normal anus) to 7 (worst prolapse). We also evaluated operation time, analgesia, staple line position, postoperative pain score, technical failures, postoperative complications, need for repeated procedures, and patient satisfaction. Statistical analyses were used to identify correlations and differences, and the variables were analyzed in relation to the final outcome. RESULTS: The patients were observed for a median of 34 (range, 18-78) months. The median postoperative pain score was 4 (Visual Analog Scale 1-10) on the day of stapled hemorrhoidopexy; additional external procedures resulted in significantly higher pain (P<0.05). Stapled hemorrhoidopexy was repeated in 31 patients (12 percent), and 38 patients (14.7 percent) had subsequent excisions. Technical failures occurred in 18 of 258 patients (7 percent). The median anatomy score decreased from 6 (range, 3-7) preoperatively to 1 (range, 1-6) at last follow-up, irrespective of one or a repeated stapled hemorrhoidopexy, surgical excision, or technical failure. The risk of reintervention was greatest during the first year after a stapled hemorrhoidopexy. Overall, patient satisfaction was high and correlated significantly with the anatomy score (r=0.46, P<0.05). CONCLUSIONS: The pain after stapled hemorrhoidopexy was low, recovery was rapid, complications were few, and patient satisfaction was high. A recurrent (or persistent) prolapse was alleviated by a repeated stapled hemorrhoidopexy for cure. However, there was a high risk of reintervention after a stapled hemorrhoidopexy, and this should be further evaluated.