The lymph node ratio optimises staging in patients with node positive colon cancer with implications for adjuvant chemotherapy.

PURPOSE: The ratio of positive lymph nodes to total retrieved lymph nodes (lymph node ratio, LNR) has been proposed to be the superior prognostic score in colon cancer. This study aimed to validate LNR in a large, multi-centred population, focusing on patients that have undergone adjuvant chemotherapy. METHODS: Analysis of a prospectively collected database (The West of Scotland Colorectal Cancer Managed Clinical Network) with 1,514 patients with colonic cancer identified that had undergone elective curative surgical resection in the 12 hospitals in the West of Scotland from 2000-2004. Variables recorded were as follows: demographics, adjuvant chemotherapy, number of lymph nodes retrieved, lymph node retrieval ≥12, number of positive lymph nodes and LNR. Follow up continued until June 2009. Univariate and multivariate analyses were performed to determine the influence of LNR on overall survival. RESULTS: In 673 patients (44.5%), ≥12 lymph nodes were retrieved. Patients had a poorer long-term prognosis with increasing age, T stage and N stage. Retrieval of <12 lymph nodes and increasing LNR were both found to be significantly associated with poorer long-term survival, but on multivariable analysis, LNR was the only independently significant variable. In patients that had received adjuvant chemotherapy, only patients staged in the second lowest LNR group (0.05-0.19) had a significant improvement in long-term survival. CONCLUSION: Lymph node ratio is the optimal method of assessing lymph node status and highlights the heterogeneity of patients with node positive disease, altering patient stratification with implications for adjuvant chemotherapy.

Deprivation and colorectal cancer surgery: longer-term survival inequalities are due to differential postoperative mortality between socioeconomic groups.

BACKGROUND: Deprivation is associated with poorer survival after surgery for colorectal cancer, but determinants of this socioeconomic inequality are poorly understood. METHODS: A total of 4,296 patients undergoing surgery for colorectal cancer in 16 hospitals in the West of Scotland between 2001 and 2004 were identified from a prospectively maintained regional audit database. Postoperative mortality (<30 days) and 5-year relative survival by socioeconomic circumstances, measured by the area-based Scottish Index of Multiple Deprivation 2006, were examined. RESULTS: There was no difference in age, gender, or tumor characteristics between socioeconomic groups. Compared with the most affluent group, patients from the most deprived group were more likely to present as an emergency (23.5 vs 19.5 %; p = .033), undergo palliative surgery (20.0 vs 14.5 %; p < .001), have higher levels of comorbidity (p = .03), have <12 lymph nodes examined (56.7 vs 53.1 %; p = .016) but were more likely to receive surgery under the care of a specialist surgeon (76.3 vs 72.0 %; p = .001). In multivariate analysis, deprivation was independently associated with increased postoperative mortality [adjusted odds ratio 2.26 (95 % CI, 1.45-3.53; p < .001)], and poorer 5-year relative survival [adjusted relative excess risk (RER) 1.25 (95 % CI, 1.03-1.51; p = .024)] but not after exclusion of postoperative deaths [adjusted RER 1.08 (95 %, CI .87-1.34; p = .472)]. CONCLUSIONS: The observed socioeconomic gradient in long-term survival after surgery for colorectal cancer was due to higher early postoperative mortality among more deprived groups.

Evaluation of autofluorescence colonoscopy for the detection and diagnosis of colonic polyps.

BACKGROUND: Colorectal cancer is the second most common cause of death in the United Kingdom. Most cancers are believed to arise within preexisting adenomas. Although colorectal adenomas have a clear neoplastic potential, hyperplastic polyps do not. It, therefore, would be helpful to be able to differentiate between different polyps at a colonoscopy. Autofluorescence (AF) endoscopy has been developed to enhance conventional white light (WL) endoscopy in the diagnosis of GI lesions. OBJECTIVE: The aim of the present study was to evaluate whether AF colonoscopy can facilitate endoscopic detection and differentiation of colorectal polyps. DESIGN: Patients were invited to attend for colonic assessment with both AF and WL endoscopy. AF readings, pictures, and biopsy specimens were taken of any visible pathology and of any high AF areas. SETTING: Gartnavel General Hospital, Glasgow, U.K. PATIENTS: A total of 107 patients were assessed. INTERVENTION: Each patient was assessed with AF and WL colonoscopy. MAIN OUTCOME MEASUREMENTS: An AF intensity ratio (AIR) was calculated for each polyp (ratio of direct polyp AF reading/background rectal AF activity). RESULTS: A total of 75 polyps were detected: 54 adenomatous and 21 hyperplastic polyps. Colorectal adenomas had a significantly higher AIR compared with hyperplastic polyps (median, interquartile range): adenoma (3.54, 2.54-5.00] versus hyperplastic (1.60, 1.30-2.24); P = .0001). When using an AIR with the empirically cutoff value of 2.3, AF endoscopy had a sensitivity of 85% and a specificity of 81% at distinguishing adenomatous polyps from hyperplastic polyps. CONCLUSIONS: AF colonoscopy may be a valuable tool for the visual distinction between adenomatous and hyperplastic polyps.

Laparoscopic colorectal resection does not reduce incisional hernia rates when compared with open colorectal resection.

BACKGROUND: Laparoscopic colorectal surgery has been reported to have some advantages compared with open surgery. The purpose of this study was to evaluate the incidence of incisional hernias after elective open colorectal resection versus laparoscopic colorectal resection. METHODS: The study group consisted of 104 patients who underwent elective colorectal resection or reversal of a Hartmann's procedure between November 2003 and March 2005. Baseline data were prospectively recorded on all patients. All were examined by an independent observer for evidence of incisional hernia after they had reached a minimum follow up of one year. RESULTS: At a median follow up of 22 (17-26) months, nine patients had died and 95 were reviewed. Of these, 32 underwent laparoscopic resection while 63 had open surgery. Patients were well matched for all baseline characteristics. The median length of the wound in the laparoscopic group was 9 cm (IQR: 8-11 cm) while in the open group it was 20.8 cm (IQR: 17-24 cm). There was no significant difference in incisional hernia rates between the groups (3 vs. 10, p = 0.52) or in those who had symptoms from their hernia (p = 0.773). CONCLUSIONS: Laparoscopic colorectal resection does not appear to reduce incisional hernia rates when compared with open surgery. Large randomised trials are required to confirm these findings.

Prospective, five-year follow-up study of patients with symptomatic uncomplicated diverticular disease.

PURPOSE: The natural history of diverticular disease is largely unknown. Most studies are retrospective and treatment recommendations are derived from outdated literature. This study was a prospective, long-term assessment of the development of complications in patients with symptomatic diverticular disease. METHODS: All patients with a confirmed diagnosis of symptomatic diverticular disease between August 1999 and April 2001 were followed up prospectively for an average of five years. Hospital computerized discharges were assessed for any subsequent elective or emergency admission for diverticular disease-related complications, including surgical intervention. A telephone questionnaire was conducted on all patients and/or their family physician looking specifically for symptoms, complications, and surgical intervention. RESULTS: A total of 163 patients (106 females) were identified (median age, 74 (interquartile range, 64-80) years). The diagnosis was confirmed through colonoscopy (n = 106), flexible sigmoidoscopy (n = 57), and barium enema (n = 31). Nineteen were lost to follow-up and a further 19 died from unrelated causes. Twenty-five were excluded. After the initial diagnosis, two patients (1.7 percent) subsequently presented with an episode of diverticulitis, which was treated conservatively. A single patient (0.8 percent) required surgery for chronic symptoms. One hundred sixteen patients (97 percent) had no or mild symptoms after a median follow-up of 66 months. CONCLUSIONS: In this prospective long-term study, symptomatic uncomplicated diverticular disease seems to run a long-term benign course with a very low incidence of subsequent complications. Symptomatic disease, acute diverticulitis, and complicated diverticular disease seem to constitute distinct clinical entities with little crossover between groups.