Trends in management and outcomes of colon cancer in the United States over 15 years: Analysis of the National Cancer Database.

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.

Outcomes of Early Versus Standard Closure of Diverting Ileostomy After Proctectomy: Meta-analysis and Meta-regression Analysis of Randomized Controlled Trials.

OBJECTIVE: We aimed to compare outcomes of early and standard closure of diverting loop ileostomy (DLI) after proctectomy and determine risk factors for anastomotic leak (AL) and complications. BACKGROUND: Formation of DLI has been a routine practice after proctectomy to decrease the incidence and potential adverse sequela of AL. METHODS: PubMed, Scopus, and Web of Science were searched for randomized controlled trials (RCTs) that compared outcomes of early versus standard closure of DLI after proctectomy. Main outcome measures were postoperative complications, AL, ileus, surgical site infection, reoperation, readmission, and hospital stay following DLI closure. RESULTS: Eleven RCTs (932 patients; 57% male) were included. Early closure group included 474 patients and standard closure 458 patients. Early closure was associated with higher odds of AL [odds ratio (OR): 2.315, P =0.013] and similar odds of complications (OR: 1.103, P =0.667), ileus (OR: 1.307, P =0.438), surgical site infection (OR: 1.668, P =0.079), reoperation (OR: 1.896, P =0.062), and readmission (OR: 3.431, P =0.206). Hospital stay was similar (weighted mean difference: 1.054, P =0.237). Early closure had higher odds of AL than standard closure when early closure was done ≤2 weeks (OR: 2.12, P =0.047) but not within 3 to 4 weeks (OR: 2.98, P =0.107). Factors significantly associated with complications after early closure were diabetes mellitus, smoking, and closure of DLI ≤2 weeks, whereas factors associated with AL were ≥ American Society of Anesthesiologists II classification and diabetes mellitus. CONCLUSIONS: Early closure of DLI after proctectomy has a higher risk of AL, particularly within 2 weeks of DLI formation. On the basis of this study, routine early ileostomy closure cannot be recommended.

A national database analysis of the evolution of outcomes of surgery for anal melanoma.

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.

Effect of neoadjuvant therapy regimens on lymph nodes yield in rectal cancer.

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.

Association between microsatellite status and characteristics and outcomes of early-onset compared to late-onset rectal cancer.

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.

Splenic flexure mobilization in left-sided colonic and rectal resections: A meta-analysis and meta-regression of factors associated with anastomotic leak and complications.

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.

Risk factors for complications following sacral neuromodulation for faecal incontinence: Long-term follow-up.

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.

Stapler size independently predicts postoperative complications following stapled ileocolic anastomosis: A retrospective cohort study.

AIM: Staplers used in ileocolic anastomosis construction differ in length and height. We assessed the impact of stapler type in creating ileocolic anastomoses on postoperative outcomes. METHODS: This retrospective cohort study of an Institutional Review Board approved database included patients who underwent laparoscopic right colectomy for cancer between January 2011 and August 2021. All patients had construction of extracorporeal antiperistaltic stapled ileocolic anastomosis using a linear cutting stapler. Main outcome measures were short-term (<30 day) morbidity and mortality. RESULTS: In all, 270 patients (136 men; median age 70.2 years) were included. A 75 mm stapler was used in 49 (18.1%) patients, 80 mm in 97 (35.9%) and 100 mm in 124 (45.9%). Blue cartridge (stapler height 3.5 mm) was used in 175 (64.5%) and green cartridge (4.8 mm) in 18 (7%) patients; this information was unavailable in 77 (28.5%) cases. Apical enterotomy closure was performed by linear stapler in 54% and linear cutting stapler in 46%. Apical staple line reinforcement or imbrication suturing was used in 26.3%. The overall postoperative complication rate was 28.9%. The anastomotic leak rate was 2.6%. Independent predictors of complications after laparoscopic right colectomy were older age (OR 1.03, 95%CI 1-1.06; P = 0.01), extended colectomy (OR 2.76, 95%CI 1.07-7.08; P = 0.035) and emergency surgery (OR 4.5, 95%CI 1.3-14.9; P = 0.014). A 100-mm linear cutting stapler was an independent protective factor against postoperative complications (OR 0.3, 95%CI 0.18-0.85; P = 0.019). Stapler height and closure technique of apical enterotomy did not affect postoperative complications. CONCLUSION: Independent predictors of complications after laparoscopic right colectomy were older age, extended colectomy and emergency surgery. Using a 100 mm stapler was an independent protective factor against postoperative complications.

Trans­anal minimally invasive surgery (TAMIS) versus rigid platforms for local excision of early rectal cancer: a systematic review and meta-analysis of the literature.

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.

Meta-analysis of Randomized Clinical Trials on Long-term Outcomes of Surgical Treatment of Perforated Diverticulitis.

OBJECTIVE: To assess long-term outcomes of patients with perforated diverticulitis treated with resection or laparoscopic lavage (LL). BACKGROUND: Surgical treatment of perforated diverticulitis has changed in the last few decades. LL and increasing evidence that primary anastomosis (PRA) is feasible in certain patients have broadened surgical options. However, debate about the optimal surgical strategy lingers. METHODS: PubMed, Scopus, and Web of Science were searched for randomized clinical trials (RCT) on surgical treatment of perforated diverticulitis from inception to October 2022. Long-term reports of RCT comparing surgical interventions for the treatment of perforated diverticulitis were selected. The main outcome measures were long-term ostomy, long-term complications, recurrence, and reintervention rates. RESULTS: After screening 2431 studies, 5 long-term follow-up studies of RCT comprising 499 patients were included. Three studies, excluding patients with fecal peritonitis, compared LL and colonic resection, and 2 compared PRA and Hartmann procedures. LL had lower odds of long-term ostomy [odds ratio (OR) = 0.133, 95% CI: 0.278-0.579; P < 0.001] and reoperation (OR = 0.585, 95% CI: 0.365-0.937; P = 0.02) compared with colonic resection but higher odds of diverticular disease recurrence (OR = 5.8, 95% CI: 2.33-14.42; P < 0.001). Colonic resection with PRA had lower odds of long-term ostomy (OR = 0.02, 95% CI: 0.003-0.195; P < 0.001), long-term complications (OR = 0.195, 95% CI: 0.113-0.335; P < 0.001), reoperation (OR = 0.2, 95% CI: 0.108-0.384; P < 0.001), and incisional hernia (OR = 0.184, 95% CI: 0.102-0.333; P < 0.001). There was no significant difference in odds of mortality among the procedures. CONCLUSIONS: Long-term follow-up of patients who underwent emergency surgery for perforated diverticulitis showed that LL had lower odds of long-term ostomy and reoperation, but more risk for disease recurrence when compared with resection in purulent peritonitis. Colonic resection with PRA had better long-term outcomes than the Hartmann procedure for fecal peritonitis.

Robotic and laparoscopic colectomy: propensity score-matched outcomes from a national cancer database.

BACKGROUND: Laparoscopic and robotic approaches to colonic cancer surgery appear to provide similar outcomes. The present study aimed to compare short-term and survival outcomes of laparoscopic and robotic colectomy for colonic cancer. METHODS: This retrospective review of patients with stage I-III colonic cancer who underwent laparoscopic or robotic colonic resection was undertaken using data from the National Cancer Database (2013-2019). Patients were matched using the propensity score matching method. The primary outcome was 5-year overall survival. Secondary outcomes included conversion to open surgery, duration of hospital stay, 30- and 90-day mortality, unplanned readmission, and positive resection margins. RESULTS: The original cohort included 40 457 patients with stage I-III colonic adenocarcinoma, with a mean(s.d.) age of 67.4(12.9) years. Some 33 860 (83.7 per cent) and 6597 (17.3 per cent) patients underwent laparoscopic and robotic colectomy respectively. After matching, 6210 patients were included in each group. Robotic colectomy was associated with marginally longer overall survival for women, and patients with a Charlson score of 0, stage II-III disease or left-sided tumours. The robotic group had a significantly lower rate of conversion (6.6 versus 11 per cent; P < 0.001) and shorter hospital stay (median 3 versus 4 days) than the laparoscopic group. The two groups had similar rates of 30-day mortality (1.3 versus 1 per cent for laparoscopic and robotic procedures respectively), 90-day mortality (2.1 versus 1.8 per cent), 30-day unplanned readmission (3.7 versus 3.8 per cent), and positive resection margins (2.8 versus 2.5 per cent). CONCLUSION: In this study population, robotic colectomy was associated with less conversion to open surgery and a shorter hospital stay compared with laparoscopic colectomy.

Outcomes of laparoscopic versus robotic-assisted resection of T4 rectal cancer: propensity score-matched analysis of a national cancer database.

BACKGROUND: T4 rectal cancer is a challenging condition owing to the highly invasive nature of the tumour that may compromise R0 resection. The present study aimed to assess the outcomes of laparoscopic versus robotic-assisted resection of non-metastatic T4 rectal adenocarcinoma. METHODS: This was a retrospective propensity score-matched analysis using the National Cancer Database between 2010 and 2019. Patients with pathological T4 non-metastatic rectal adenocarcinoma who underwent laparoscopic or robotic-assisted resection were compared and a propensity score-matched analysis was performed in a 1:1 manner. The main outcome measures were conversion to open surgery, mortality, readmission, resection margins, and overall survival. RESULTS: After propensity score matching, 235 patients were included in each group. There were 260 (55.3 per cent) men and 210 (44.7 per cent) women, with a mean (s.d.) age of 61 (13.2) years. Patients in the robotic group had a statistically significantly lower conversion rate (8.9 per cent versus 17.9 per cent; P = 0.006), shorter median duration of hospital stay (5 versus 6 days; P = 0.007), higher overall survival rate (56.2 per cent versus 43.4 per cent; P = 0.007), and a longer median survival (60.8 versus 43.2; P = 0.025). There were no significant differences between the two groups with regard to positive resection margins, examined lymph nodes, 30-day and 90-day mortality rates, and 30-day readmission rate. CONCLUSIONS: Robotic resections of T4 rectal cancer were associated with a significantly lower conversion rate and shorter duration of hospital stay than laparoscopic resections. The two approaches were comparable with regard to positive resection margins, short-term mortality, and readmission.

Does Completeness of the Mesorectal Excision Still Correlate With Local Recurrence?

BACKGROUND: Total mesorectal excision is the standard surgical procedure for rectal cancer treatment. Several studies have shown a close correlation between the prognosis of patients with rectal cancer and the completeness of the mesorectal specimen. OBJECTIVE: To assess the correlation between macroscopic assessment of mesorectal excision and long-term oncological outcomes. DESIGN: Retrospective analysis of an Institutional Review Board-approved database. SETTINGS: Tertiary referral center. PATIENTS: Patients with rectal cancer who were operated on between March 2016 and October 2019 were classified into 3 groups based on the mesorectal specimen quality: complete, near complete, and incomplete. Only patients with a follow-up of ≥2 years and without signs of preoperative distant disease were included. MAIN OUTCOME MEASURES: Relationship between total mesorectal excision and local and distant recurrence rates in patients with rectal cancer. RESULTS: A total of 124 patients (35.5% females) were included in the analysis, with a mean age of 58.1 (SD 12) years and a mean BMI of 26.4 (SD 4.59) kg/m². Neoadjuvant chemoradiation was administered to 71% of patients, whereas 13.7% received total neoadjuvant therapy. Restorative procedures were performed in 107 patients (86.3%), whereas 17 patients (13.7%) underwent abdominoperineal resection. The majority of mesorectal excision specimens (87.09%) were complete or near complete. Local recurrence rates were 6.3% (1/16) in the incomplete and 7.4% (8/108) in the complete/near complete group ( p = 0.86). Metachronous distant metastases occurred in 6 patients (37.5%) in the incomplete group and in 24 patients (22.2%) in the complete/near complete group (p = 0.18). Thus, specimen quality did not appear to impact disease-free survival. LIMITATIONS: Retrospective, single-center study with relatively short follow-up. CONCLUSIONS: In the era of a multidisciplinary approach and extensive use of neoadjuvant therapy, macroscopic completeness of total mesorectal excision may not be as valuable a prognosticator as in the past. Larger studies with longer follow-ups are needed to clarify these preliminary findings. See Video Abstract at http://links.lww.com/DCR/C129. LA INTEGRIDAD DE LA ESCISIN MESORRECTAL TODAVA SE CORRELACIONA CON LA RECURRENCIA LOCAL: ANTECEDENTES:La escisión total desl mesorrecto es el estándar de oro para el tratamiento del cáncer de recto. Varios estudios han demostrado una estrecha correlación entre el pronóstico de los pacientes con cáncer de recto y la integridad espécimen mesorrectal.OBJETIVO:Evaluar la correlación entre la evaluación macroscópica de la escisión mesorrectal y los resultados oncológicos a largo plazo en pacientes con cáncer de recto.DISEÑO:Análisis retrospectivo de una base de datos aprobada por el IRB.ENTORNO CLINICO:El estudio se realizó en un centro de referencia terciario de una sola institución.PACIENTES:Todos los pacientes con cáncer de recto operados entre 3/2016-10/2019. Los pacientes se clasificaron en 3 grupos, según la calidad del espécimen mesorrectal: completo, casi completo e incompleto. Solo se incluyeron pacientes con seguimiento >2 años y sin signos de enfermedad a distancia preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Identificar la relación entre la escisión mesorrectal total y las tasas de recurrencia local y a distancia en pacientes con cáncer de recto.RESULTADOS:Se incluyeron 124 pacientes (35,5% mujeres) con una edad media de 58,1 años (DE 12) y un índice de masa corporal medio de 26,4 (DE 4,59). Se administró quimiorradiación neoadyuvante al 71% de los pacientes, mientras que el 13,7% recibió terapia neoadyuvante total. Se realizaron procedimientos de restauración en 107 pacientes (86,3%), mientras que 17 pacientes (13,7%) se sometieron a resección abdominoperineal. La mayoría (87,09%) de los especímenes de escisión mesorrectal fueron completas o casi completas. Las tasas de recurrencia local fueron 1/16 (6,3%) en el grupo incompleto y 8/108 (7,4%) en el grupo completo/casi completo ( p = 0,86). Se produjeron metástasis a distancia metacrónicas en 6 pacientes (37,5%) en el grupo incompleto y 24 (22,2%) en el grupo completo/casi completo ( p = 0,18). Por lo tanto, la calidad del espécimen no pareció afectar la supervivencia libre de enfermedad.LIMITACIONES:Estudio retrospectivo de un solo centro con pequeño número de casos y seguimiento relativamente corto.CONCLUSIÓN:En la era de un enfoque multidisciplinario y el uso extensivo de la terapia neoadyuvante, la integridad macroscópica de la escisión total del mesorrecto, puede no ser un pronóstico tan valioso como en el pasado. Se necesitan estudios más amplios con períodos de seguimiento más prolongados para aclarar estos hallazgos preliminares. Consulte Video Resumen en http://links.lww.com/DCR/C129 . (Traducción-Dr. Fidel Ruiz Healy ).

Propensity-score matched analysis of the pathologic outcomes and survival benefits of neoadjuvant therapy in stage II-III anal adenocarcinoma.

BACKGROUND: Anal adenocarcinomas are a rare condition which account for less than 10% of anal cancers. The present study aimed to assess the impact of neoadjuvant therapy on the clinical and pathologic outcomes and overall survival (OS) of patients with stage II-III anal adenocarcinomas after abdominoperineal resection (APR). METHODS: A retrospective cohort study of patients with anal adenocarcinoma in the US National Cancer Database (NCDB) (2010-2020) was conducted. Propensity-score matching was used to compare patients who received neoadjuvant therapy (neoadjuvant therapy group) to the no-neoadjuvant group. The primary outcome was 5-year OS whereas secondary outcomes included conversion to open surgery, hospital stay, surgical margins, 30-day mortality, 90-day mortality, and 30-day readmission. RESULTS: A total of 742 patients (56% male) with a mean age of 63.6 ± 12.4 years were included. A total of 214 patients in the neoadjuvant group were matched with 107 in the no-neoadjuvant group. The mean OS was similar between the two groups (47.5 vs. 44.8 months, p = 0.253). Patients who received neoadjuvant therapy had a longer median time between diagnosis and surgery (151 vs. 54 days, p < 0.001), lower 90-day mortality (1.9% vs. 6.7%, p = 0.046), more pT0 tumors (15.7% vs. 0%), less pT3-4 tumors (28.4% vs. 36.4%, p = 0.001), less pN1-2 tumors (22.9% vs. 34.7%, p < 0.001), and less lymphovascular invasion (16.2% vs. 40%, p < 0.001) than the no-neoadjuvant group. Both groups had similar conversion rates, hospital stay, 30-day mortality, 30-day readmission, and positive surgical margins. CONCLUSIONS: Neoadjuvant therapy before APR was associated with significant downstaging of anal adenocarcinomas and lower 90-day mortality, yet similar OS to patients who were surgically treated without neoadjuvant treatment.

Predictors and survival outcomes of having less than 12 harvested lymph nodes in proctectomy for rectal cancer.

BACKGROUND: Current recommendations suggest that a minimum of 12 lymph nodes (LNs) should be harvested during curative rectal cancer resection. We aimed to assess predictors and survival outcomes of harvesting < 12 lymph nodes in rectal cancer surgery. METHODS: A retrospective case-control analysis of factors associated with harvesting < 12 LNs in rectal cancer surgery was conducted. Data were derived from the National Cancer Database 2010-2019. Univariate and multivariate binary logistic regression analyses were performed to determine predictors of harvesting < 12 LNs. Association between harvesting < 12 LNs and 5-year overall survival (OS) was assessed using Cox regression and Kaplan Meier statistics. RESULTS: 67,529 patients (60.8% male; mean age: 61.2 ± 12.5 years) were included. Median number of harvested LNs was 15 (IQR: 11-20); 27.1% of patients had < 12 harvested LNs. Independent predictors of harvesting < 12 LNs were older age (OR: 1.016;p < 0.001), neoadjuvant systemic treatment (OR: 1.522;p < 0.001), neoadjuvant radiation treatment (OR: 1.367;p < 0.001), longer duration of radiation therapy (OR: 1.003;p < 0.001) and abdominoperineal resection (OR: 1.071;p = 0.017). Higher clinical TNM stage and tumor grade, pull-through coloanal anastomosis, and minimally invasive surgery were independently associated with ≥ 12 harvested LNs. < 12 harvested LNs was independently associated with lower 5-year OS (HR: 1.24;p < 0.001) and shorter mean OS (96.7 vs 102.8 months;p < 0.001) than ≥ 12 harvested LNs. CONCLUSIONS: Older age, open resection, and neoadjuvant therapy were independent predictors of < 12 harvested LNs. Conversely, higher clinical TNM stage and tumor grade, coloanal anastomosis, and minimally invasive surgery were predictive of ≥ 12 harvested LNs. < 12 LNs harvested was associated with lower OS.

Immunotherapy in rectal cancer patients-a propensity score matched analysis of the National Cancer Database.

BACKGROUND: Rectal cancer patients with microsatellite instability (MSI-H) are candidates for immunotherapy. However, there is little evidence on its effect on overall survival (OS). METHODS: Retrospective analysis of stage II-IV rectal adenocarcinoma patients in the National Cancer Database (NCDB) between 2010 and 2019. Propensity score matching was adjusted for baseline and treatment confounders. The cohort was divided into patients who received immunotherapy and matched controls. The primary outcome was OS. RESULTS: 5175/206,615 (2.5%) patients with rectal adenocarcinoma underwent immunotherapy. These patients were younger (58 vs 62 years; p < 0.001), more often male (64.4% vs 61.7%; p < 0.001), were more likely to have private insurance (50.8% vs 43.4%; p < 0.001), more metastatic disease at presentation (clinical TNM stage IV-80.8% vs 23.3%; p < 0.001), presented with larger tumors (median: 5 cm vs. 4.2 cm; p < 0.001) and less often underwent surgery (33.7% vs. 69.9%; p < 0.001), radiation therapy (21.5% vs 57.4%; p < 0.001), and standard chemotherapy (38.1% vs 61%; p < 0.001) than controls. After matching, 488 patients were in each group. OS was significantly shorter in the immunotherapy group (mean survival: 56.4 months (95% CI: -53.03-59.86)) compared to controls (mean survival: 70.5 months (95% CI: -66.15-74.92) (p = 0.004)). Cox regression analysis of factors associated with OS demonstrated that immunotherapy was associated with increased mortality (HR 2.16; 95% CI: 2.09-2.24; p < 0.001). After clinical staging stratification, immunotherapy was associated with improved OS in stage IV (HR 0.91, 95% CI: 0.88-0.95; p < 0.001) but lower survival in stage II (HR 2.38; 95% CI: 2.05-2.77; p < 0.001) and stage III (HR 2.43; 95% CI: 2.18-2.7; p < 0.001) patients. CONCLUSION: Immunotherapy showed modest increase in OS in stage IV metastatic rectal cancer. OS was significantly lower in stage II-III disease treated with immunotherapy.

Surgical treatment of stomal prolapse: A systematic review and meta-analysis of the literature.

AIM: This study aimed to assess success, recurrence, and overall complication rates among different surgical procedures for stomal prolapse. METHODS: This study was a PRISMA-compliant systematic review. PubMed, Scopus, and Google Scholar were searched until March 2022. Studies that assessed surgical treatments of stomal prolapse in adults were included. The primary outcome was recurrence of stomal prolapse and the secondary outcome was 30-day complications. A random-effect meta-analysis was used to estimate the weighted mean rates of recurrence. RESULTS: Six studies published (111 patients; 103 males) were included. 52 (46.8%) patients had end colostomies, 35 (31.5%) had loop colostomies. Seven procedures were assessed and included local stoma reconstruction (40%), stapled local repair (27%), modified Altemeier technique (10%), mesh strip repair (9%), stoma relocation (6%) redo laparotomy repair (5%), and colectomy and end ileostomy (3%). The weighted mean recurrence rate after local stoma reconstruction was 37.2% (95% CI: -1.8 to 76.3), higher than that after the stapled local repair technique (14.9%; 95% CI: 1.7-28.2). The crude recurrence rate of the modified Altemeier technique was 20%, and of stoma relocation was 66.6%. No recurrence was detected after the mesh strip technique (n = 10). The median follow-up ranged between 7 months and 2.5 years. CONCLUSION: Several surgical techniques are available to treat stomal prolapse. Local stoma reconstruction may be associated with high rates of recurrence while the stapled local repair and modified Altemeier procedure has relatively low recurrence. Further larger studies are needed to compare the efficacy of these techniques.

Can preoperative CT/MR enterography preclude the development of Crohn's disease-like pouch complications in ulcerative colitis patients undergoing J pouch surgery?

AIM: We aimed to determine whether ulcerative colitis patients with preoperative negative computed tomography or magnetic resonance enterography (CTE/MRE) were less likely to develop Crohn's disease-like pouch complications (CDLPC) and establish risk factors and predictors for developing CDLPC. METHODS: This was a single centre retrospective analysis of patients with ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBDU) who underwent total proctocolectomy with ileal J-pouch between January 2010 and December 2020. The study group comprised patients with negative preoperative CTE/MRE and the control group included patients operated without preoperative CTE/MRE. RESULTS: A total of 131 patients were divided into the negative CTE/MRE study group (76 [58%] patients) and control group (55 [42%] patients). There were no significant differences in incidence rates (21% vs. 23.6%, p = 0.83), time to developing CDLPC from ileostomy closure (22.3 vs. 23.8 months; p = 0.81), pouchitis rates (23.6% vs. 27.2%; p = 0.68), or pouch failure rates (5.2 vs. 7.2; p = 0.71). Multivariate Cox regression analysis showed backwash ileitis (HR 4.1; p = 0.03, CI: 1.1-15.1), severe pouchitis (HR 3.4; p = 0.039, CI: 1.0-10.9), and history of perianal disease (HR 3.4; p = 0.017, CI: 1.4-39.6) were independent predictors for CDLPC. CONCLUSIONS: Negative findings on MRE/CTE prior to J-pouch surgery in ulcerative colitis should be interpreted with caution as it is does not reliably exclude or predict development of CDLPC. These patients should be preoperatively counselled concerning the possibility of developing CDLPC regardless of lack of positive findings on preoperative CTE/MRE. Patients with backwash ileitis with a previous history of perianal disease should be informed of the potentially increased risk of developing such complications.

Gracilis muscle interposition for complex perineal fistulas: A systematic review and meta-analysis of the literature.

AIM: Complex perineal fistulas (CPFs) are among the most challenging problems in colorectal practice. Various procedures have been used to treat CPFs, with none being a panacea. Our study aimed to assess the overall success and complication rates after gracilis muscle interposition in patients with CPF. METHOD: PubMed, Scopus and Google Scholar databases were systematically searched until January 2022 according to PRISMA 2020 guidelines. Studies including children <18 years or <10 patients were excluded, as well as reviews, duplicate or animal studies, studies with poor documentation (no report of success rate) and non-English text. An open-source, cross-platform software for advanced meta-analysis openMeta [Analyst]™ version 12.11.14 and Cochrane Review Manager 5.4® were used to conduct the meta-analysis of data. RESULTS: Twenty-five studies published between 2002 and 2021 were identified. The studies included 658 patients (409 women). Most patients had rectovaginal (50.7%) or rectourethral fistulas (33.7%). The most common causes of CPF were pelvic surgery (29.4%) and inflammatory bowel disease (25.2%). A history of radiotherapy was reported in approximately 18% of the patients. 498 (75.7%) patients with CPF achieved complete healing after gracilis muscle interposition. The weighted mean rate of success of the gracilis interposition procedure was 79.4% (95% CI 73.8%-85%, I2  = 75.3%), the weighted mean short-term complication rate was 25.7% (95% CI 18.1-33.2, I2  = 84.1%) and the weighted mean rate for 30-day reoperation was 3.6% (95% CI 1.6-5.6, I2  = 42%). The weighted mean rate of fistula recurrence was 16.7% (95% CI 11%-22.3%, I2  = 61%). CONCLUSION: The gracilis muscle interposition technique is a viable treatment option for CPF. Surgeons should be familiar with indications and techniques to offer it as an option for patients. Given the relatively infrequent use of the operation, referral rather than performance of graciloplasty is an acceptable option.

How reliable is restaging MRI after neoadjuvant therapy in rectal cancer?

BACKGROUND: Despite the pivotal role of magnetic resonance imaging (MRI) in rectal cancer staging and evaluation, the reliability of restaging MRI after neoadjuvant therapy is still debatable. This study aimed to assess the accuracy of restaging MRI by comparing post-neoadjuvant MRI findings with those of the final pathology. METHODS: This study was a retrospective review of the medical records of adult rectal cancer patients who had restaging MRI following neoadjuvant therapy and prior to rectal cancer resection in a NAPRC-certified rectal cancer centre between 2016 and 2021. The study compared findings of preoperative, post-neoadjuvant MRI with final pathology relative to T stage, N stage, tumour size, and circumferential resection margin (CRM) status. RESULTS: A total of 126 patients were included in the study. We found fair concordance (kappa -0.316) for T stage between restaging MRI and pathology report, and slight concordance for N stage and CRM status (kappa -0.11, kappa = 0.089, respectively). Concordance rates were lower for patients following total neoadjuvant treatment (TNT) or with a low rectal tumour. In total, 73% of patients with positive N pathology status had negative N status in the restaging MRI. Sensitivity and specificity regarding positive CRM in post-neoadjuvant treatment MRI were 45.45% and 70.4%, respectively. CONCLUSION: We found low concordance levels between restaging MRI and pathology regarding TN stage and CRM status. Concordance levels were even lower for patients after TNT regimen and with a low rectal tumour. In the era of TNT and watch-and-wait approach, we should not rely solely on restaging MRI to make post-neoadjuvant treatment decisions.