Optimizing Adjuvant Therapy for Localized Colon Cancer and Treatment Selection in Advanced Colorectal Cancer.

Results from the pivotal IDEA trial, which evaluated 3 versus 6 months of adjuvant oxaliplatin-based chemotherapy, are incorporated into the NCCN Guidelines for Colon Cancer. The guidelines recommend that for patients with low-risk stage III disease, the preferred regimen is CAPEOX for 3 months or FOLFOX for 3 to 6 months. For patients with high-risk stage III disease, the preferred regimen is CAPEOX for 3 to 6 months or FOLFOX for 6 months. In metastatic disease, tumor sidedness should be a consideration when choosing a biologic. For BRAF-mutated disease, several triplets are now recommended options. Importantly, for a subset of patients with metastatic disease, new to the NCCN Guidelines is the incorporation of nivolumab and pembrolizumab as subsequent therapy for those with microsatellite instability-high or mismatch repair-deficient tumors.

Prediction of the adequacy of lymph node retrieval in colon cancer by hospital type.

BACKGROUND: Examination of 12 or more regional lymph nodes (LNs) is the accepted minimum for nodal staging in colon cancer and serves as a surrogate for adequate resection. OBJECTIVE: To determine the contributing role of the hospital in the number of LNs retrieved. Design/ SETTING: We retrospectively reviewed colon resections in 83 patients by 2 surgical oncologists at a National Comprehensive Cancer Network (NCCN) hospital or at community-based hospitals from January 1, 2002, through December 31, 2007. PATIENTS: We included all patients undergoing colectomy for primary colon cancer and excluded patients with recurrence, rectal cancer, or preoperative chemotherapy. MAIN OUTCOME MEASURES: Total number of LNs retrieved. We also analyzed clinical factors accounting for differences. RESULTS: The median number of LNs examined at the NCCN hospital (42 patients) vs the community hospitals (41 patients) were 17.8 vs 7.0 (P < .001), and the frequency of an inadequate number of LNs examined (<12) was 11 of 42 cases (26%) vs 35 of 41 cases (85%) (P < .001). Potential predictive factors for LNs retrieved were grouped into modifiable (hospital type, surgeon, and surgical approach [laparoscopic vs open]) and nonmodifiable (age, sex, and tumor location). On multivariate analysis of the factors, hospital type was the only modifiable factor predictive of LNs reported (P < .001). CONCLUSIONS: Our study is the first, to our knowledge, to demonstrate that the number of LNs removed in colectomies performed by the same 2 surgeons depends on the hospital type (NCCN vs community) in which the resection occurred. We postulate that the number of LNs retrieved may be related to the institution's pathological review in addition to the extent of surgical resection.

Megasigmoid: a source of pseudoincontinence in children with repaired anorectal malformations.

Three children with a history of anorectal malformation repairs were referred to the authors for evaluation and management of fecal incontinence. Their ages ranged from 5 to 7 years. On examination, all the children had fecal impaction and localized dilatation of the rectosigmoid colon. Medical treatment was tried but failed to control the symptoms, and the patients frequently had to be hospitalized for disimpaction. To correct this problem, the authors resected the dilated sigmoid colon, anastomosing the nondilated descending colon to the rectal ampulla, which was preserved to serve as a reservoir. Postoperatively, constipation was cured in all patients. In addition the patients became fecally continent postoperatively, which was an unexpected bonus. The authors believe that localized dilatation of the rectosigmoid should always be considered whenever a child is having intractable constipation after repair of an anorectal malformation and that sigmoid resection may be considered as a therapeutic alternative. Segmental dilatation of the sigmoid colon may be a source of fecal pseudoincontinence and, therefore, should be ruled out when the surgeon is evaluating patients with fecal incontinence.

[Sigmoid diverticular diseases: surgical treatment]. / Les sigmoïdites diverticulaires: traitement chirurgical.

From 1966 to 1990, 226 consecutive patients were operated on electively for diverticular disease of the sigmoid colon. The indications for surgery were colovesical fistula or suspicion of residual abscess, existence of two or more previous attacks of acute inflammation, existence of chronic symptoms and suspicion of colonic carcinoma. Colonic resection with primary anastomosis was performed in 217 patients with a covering colostomy in 1 case only. The Hartmann procedure was performed in 9 patients with extension of the lesions to the rectum and/or high operative risk. One or more abscesses were found by the surgeon or the pathologist in 50 p. cent of the patients. There were no postoperative deaths, no clinical anastomotic leakages. Long-term results were evaluated for the patients operated on before 1987, with a follow-up from 2 to 22 years. 85 p. cent of the patients had no more symptoms, 11 p. cent complained of persistent symptoms and 3% had recurrent attacks of pain and fever. Colonic barium enema is the best examination for diverticulitis and chronic abscesses. Surgical treatment is easier for abscesses located within the colonic wall and mesentery, than for extracolic abscesses with local peritonitis. Correlations between preoperative symptoms and operative findings are often not good. The good results obtained in 82 p. cent of the patients operated on for chronic symptoms suggest that chronic symptoms should be part of the indications for elective surgery. The low incidence (3 p. cent) of recurrent attacks of pain and fever is in favour of a resection limited to the sigmoid colon even when diffuse colonic diverticula are present.(ABSTRACT TRUNCATED AT 250 WORDS)

Subtotal colectomy as a last resort for unrelenting, unlocalized, lower gastrointestinal hemorrhage: experience with 12 cases.

A 7-year experience involving 12 cases of massive, unrelenting lower gastrointestinal hemorrhage is presented. In these patients, the bleeding could not be localized by multiple diagnostic modalities and was managed by blind subtotal colectomy. While the procedure was efficacious in arresting bleeding in all cases, a resultant mortality of four cases (33%) ensued. Morbidity among the survivors was significant. Only three patients (25%) survived without complications, which enabled an early discharge from the hospital. Diverticulosis was the most common cause (83%) of uncontrollable and preoperatively undiagnosed bleeding in this group of patients. These 12 cases of blind subtotal colectomy for massive lower gastrointestinal bleeding represent one of the larger series in the literature. These data are consistent with more recent reports that indicate that subtotal colectomy for lower gastrointestinal bleeding is an effective but a formidable procedure. This is contrary to the earlier published results.

One-stage repair of colovaginal fistula complicating acute diverticulitis.

Fourteen patients with colovaginal fistula secondary to sigmoid diverticulitis were seen between 1964 and 1988. Thirteen had undergone prior hysterectomy. Three different operative approaches were used. Three patients were treated with colostomy alone; one died and the fistula persisted in one. Five patients underwent staged procedures. One patient died of complications after the second stage of a planned three-stage procedure. Four patients underwent a two-stage procedure (fistula takedown, colectomy with colostomy and colostomy closure), all with good results. Six patients were treated with one-stage fistula takedown, colectomy and primary anastomosis, without major complication. We advocate this as the procedure of choice and emphasize the following principles of epidemiology and management: 1) colovaginal fistula complicates diverticulitis in elderly women usually following hysterectomy; this association may be a factor in etiology; 2) vaginography is useful in diagnosis; and 3) planned one-stage repair is the best surgical approach.