Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient.

BACKGROUND: This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS: Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS: Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS: These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care.

BACKGROUND: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS: Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS: Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS: These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Short and long-term oncologic outcomes of patients with colon cancer of the splenic flexure.

BACKGROUND: There is currently no consensus on surgical management of splenic flexure adenocarcinoma (SFA). METHODS: Patients undergoing surgical resection for SFA between 1993 and 2015 were identified. Postoperative outcomes were compared between patients who underwent segmental (SR) vs. anatomical resection (AR). RESULTS: One-hundred and thirteen patients underwent SR and 89 underwent AR. More patients in the SR group had open resections, but there were otherwise no differences in demographics or surgical characteristics between the two groups. There were no differences in overall (p = 0.29) or recurrence-free(p = 0.37) survival. On multivariable analysis, increased age (HR 1.04, 1.01-1.07, p = 0.005), higher American Society of Anesthesiology classification (HR 3.1, 1.7-5.71, p < 0.001), and higher tumor stage (HR 8.84, 3.76-20.82, p < 0.001) were predictive of mortality. CONCLUSIONS: Short and long-term outcomes after SR and AR for SFA are not different, making SR a viable option for SFA surgical management.

Management of Acute Diverticulitis in Immunocompromised Patients-The Mayo Clinic Experience.

BACKGROUND: Acute diverticulitis in immunocompromised patients is associated with high morbidity and mortality rates with either medical or surgical treatment. Thus, management approach is controversial, especially for patients presenting with nonperforated disease. OBJECTIVE: This study aimed to report the Mayo clinic experience of acute diverticulitis management in immunocompromised patients. DESIGN: This design is based on a retrospective cohort study. SETTING: This study was conducted with institutional data composed from 3 tertiary referral centers. PATIENTS: Immunocompromised patients presenting with acute diverticulitis at 3 Mayo clinic sites between 2016 and 2020 were included. MAIN OUTCOME MEASURES: The main outcome measures were the management algorithm and short-term outcomes. RESULTS: Immunocompromised patients presenting with acute uncomplicated diverticulitis (86) were all managed nonoperatively at presentation with a success rate of 93% (80/86). Two patients (2.3%, 2/86) required surgery during the same admission, and 4 patients (4.8%, 4/84) had 30-day readmission. Complicated diverticulitis patients with abscess (22) were all managed nonoperatively first with a success rate of 95.4% (21/22). One patient (4.6%, 1/22) required surgery during the same admission. All the patients who presented with obstruction (2), fistula (1), or free perforation (11) underwent surgery except one who chose hospice. Overall, the major complication rate was 50% (8/16) and mortality rate was 18.8% (3/16) among patients who underwent surgery during the same admission. For patients who presented with perforated diverticulitis, the mortality rate was 27.3% (3/11), compared with 0% (0/111) for patients who presented with nonperforated disease. LIMITATIONS: This cohort was limited by its retrospective nature and heterogeneity of the patient population. CONCLUSIONS: Nonoperative management was safe and feasible for immunocompromised patients with colonic diverticulitis without perforation at our center. Perforated colonic diverticulitis in immunocompromised patients was associated with high morbidity and mortality rate. See Video Abstract at http://links.lww.com/DCR/B988 .MANEJO DE LA DIVERTICULITIS AGUDA EN PACIENTES INMUNOCOMPROMETIDOS: EXPERIENCIA DE LA CLINICA MAYOANTECEDENTES:La diverticulitis aguda en pacientes inmunocomprometidos se asocia con una alta tasa de morbilidad y mortalidad con el tratamiento médico o quirúrgico. Por lo tanto, el enfoque de manejo es controvertido, especialmente para pacientes que presentan enfermedad no perforada.OBJETIVO:El propósito fue informar la experiencia de la clínica Mayo en el manejo de la diverticulitis aguda en pacientes inmunocomprometidos.DISEÑO:Este es un estudio de cohorte retrospectivoENTORNO CLÍNICO:Este estudio se realizó con datos institucionales compuestos de tres centros de referencia terciarios.PACIENTES:Se incluyeron pacientes inmunocomprometidos que presentaron diverticulitis aguda en tres sitios de la clínica Mayo entre 2016 y 2020.RESULTADO PRINCIPAL:Algoritmo de gestión y resultados a corto plazo.RESULTADOS:Los pacientes inmunocomprometidos que presentaban diverticulitis aguda no complicada (86) fueron tratados de forma no quirúrgica en la presentación inicial con una tasa de éxito del 93 % (80/86). Dos pacientes (2,3%, 2/86) requirieron cirugía durante el mismo ingreso y cuatro pacientes (4,8%, 4/84) tuvieron reingreso a los 30 días. Todos los pacientes con diverticulitis complicada con absceso (22) fueron tratados primero de forma no quirúrgica con una tasa de éxito del 95,4 % (21/22). Un paciente (4,6%, 1/22) requirió cirugía durante el mismo ingreso. Todos los pacientes que presentaron obstrucción (2), fístula (1) o perforación libre (11) fueron intervenidos excepto uno que optó por hospicio. La tasa global de complicaciones mayores fue del 50 % (8/16) y la tasa de mortalidad fue del 18,8 % (3/16) entre los pacientes que se sometieron a cirugía durante el mismo ingreso. Para los pacientes que presentaban diverticulitis perforada, la tasa de mortalidad fue del 27,3 % (3/11), en comparación con el 0 % (0/111) de los pacientes que presentaban enfermedad no perforada.LIMITACIONES:Esta cohorte estuvo limitada por su naturaleza retrospectiva y la heterogeneidad de la población de pacientes. CONCLUSINES: El manejo no quirúrgico fue seguro y factible para pacientes inmunocomprometidos con diverticulitis colónica sin perforación en nuestro centro. La diverticulitis colónica perforada en pacientes inmunocomprometidos se asoció con una alta tasa de morbilidad y mortalidad. Consulte Video Resumen en http://links.lww.com/DCR/B988 . (Traducción- Dr. Ingrid Melo ).

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS: Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS: Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Same-Day Discharge After Mastectomy: Breast Cancer Surgery in the Era of ERAS®.

BACKGROUND: Enhanced recovery after surgery (ERAS®) principles have been beneficial in major abdominal surgery. ERAS® was instituted in our breast surgery practice in 2017. The goal of this study was to evaluate the feasibility of outpatient mastectomies before and after ERAS®. METHODS: A retrospective review of all mastectomies between 1/2013 and 6/2018 was performed. Patients receiving autologous flap reconstruction were excluded. The institution-specific ERAS® pathway began on February 1, 2017. Patient characteristics, operative intervention, and postoperative outcomes were compared between pre-ERAS® and post-ERAS® groups and between outpatient and inpatient subgroups. Continuous and categorical variables were compared using Wilcoxon rank-sum and Chi-square analyses. RESULTS: A total of 487 patients were analyzed. Three hundred and forty-seven (71%) were prior to ERAS® and 140 after (29%). The two groups were not significantly different in background characteristics. Same-day discharge occurred in 58.6% of post-ERAS® patients versus 7.2% of pre-ERAS® patients (p < 0.001). Liposomal bupivacaine block was used for pain control more in the post-ERAS® group, 62.1% versus 6.1% (p < 0.001). Reconstruction type differed with 45.7% of the post-ERAS® group undergoing direct-to-implant reconstruction versus 34.3% of pre-ERAS® patients (p < 0.001) and with higher rates of submuscular implant and tissue expander placement in the pre-ERAS® versus post-ERAS® group (p < 0.001). Complications rates were lower in the post-ERAS® group versus pre-ERAS® group, 32.9% versus 52.4% (p < 0.001). The outpatient subgroup had higher rates of liposomal bupivacaine administration 74.4% versus 44.8% (p < 0.001). Baseline characteristics and complication rates did not differ between outpatient and admitted subgroups. CONCLUSION: ERAS® principles can be applied to breast cancer patients and allow for outpatient mastectomies with no increase in postoperative morbidity.

Implementation of an Enhanced Recovery After Surgery (ERAS) Program is Associated with Improved Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with increased postoperative complications and a prolonged length of stay (LOS). We report on our experience following implementation of an Enhanced Recovery After Surgery (ERAS) program for CRS and HIPEC. METHODS: Patients were divided into pre- and post-ERAS groups. Modifications in the ERAS group included routine use of transversus abdominis plane blocks, intra- and postoperative fluid restriction, and minimizing the use of narcotics, drains, and nasogastric tubes. RESULTS: Of a total of 130 procedures, 49 (38%) were in the pre-ERAS group and 81 (62%) were in the ERAS group. Mean LOS was reduced from 10.3 ± 8.9 days to 6.9 ± 5.0 days (p = 0.007) and the rate of grade III/IV complications was reduced from 24 to 15% (p = 0.243) following ERAS implementation. The ERAS group received less intravenous fluid during hospitalization (19.2 ± 18.7 L vs. 32.8 ± 32.5 L, p = 0.003) and used less opioids than the pre-ERAS group (median of 159.7 mg of oral morphine equivalents vs. 272.6 mg). There were no significant changes in the rates of 30-day readmission or acute kidney injury between the two groups (p = non-significant). On multivariable analyses, ERAS was significantly associated with a reduction in LOS (- 2.89 days, 95% CI - 4.84 to - 0.94) and complication rates (odds ratio 0.22, 95% CI 0.08-0.57). CONCLUSIONS: Implementation of an ERAS program for CRS and HIPEC is associated with a reduction in overall intravenous fluids, postoperative narcotic use, complication rates, and LOS.

Enhanced recovery program implementation: an evidence-based review of the art and the science.

BACKGROUND: The benefits of enhanced recovery program (ERP) implementation include patient engagement, improved patient outcomes and satisfaction, better team relationships, lower per episode costs of care, lower public consumption of narcotic prescription pills, and the promise of greater access to quality surgical care. Despite these positive attributes, vast numbers of surgical patients are not treated on ERPs, and many of those considered "on pathway" are unlikely to be exposed to a majority of recommended ERP elements. METHODS: To explain the gap between ERP knowledge and action, this manuscript reviewed formal implementation strategies, proposed a novel change adoption model and focused on common barriers (and corollary solutions) that are encountered during the journey to a fully implemented and successful ERP. Given the nature of this review, IRB approval was not required/obtained. RESULTS: The information reviewed indicates that implementation of best practice is both a science and an art. What many surgeons have learned is that the "soft" skills of emotional intelligence, leadership, team dynamics, culture, buy-in, motivation, and sustainability are central to a successful ERP implementation. CONCLUSIONS: To lead teams toward achievement of pervasive and sustained adherence to best practices, surgeons need to learn new strategies, techniques, and skills.

Chronic constipation.

Chronic constipation is a prevalent condition that severely impacts the quality of life of those affected. Several types of primary chronic constipation, which show substantial overlap, have been described, including normal-transit constipation, rectal evacuation disorders and slow-transit constipation. Diagnosis of primary chronic constipation involves a multistep process initiated by the exclusion of 'alarm' features (for example, unintentional weight loss or rectal bleeding) that might indicate organic diseases (such as polyps or tumours) and a therapeutic trial with first-line treatments such as dietary changes, lifestyle modifications and over-the-counter laxatives. If symptoms do not improve, investigations to diagnose rectal evacuation disorders and slow-transit constipation are performed, such as digital rectal examination, anorectal structure and function testing (including the balloon expulsion test, anorectal manometry or defecography) or colonic transit tests (such as the radiopaque marker test, wireless motility capsule test, scintigraphy or colonic manometry). The mainstays of treatment are diet and lifestyle interventions, pharmacological therapy and, rarely, surgery. This Primer provides an introduction to the epidemiology, pathophysiological mechanisms, diagnosis, management and quality of life associated with the commonly encountered clinical problem of chronic constipation in adults unrelated to opioid abuse.

The History of Enhanced Recovery After Surgery and the ERAS Society.

This short historical overview explains the development of enhanced recovery from a small group of surgeons in European academic centers to the establishment of ERAS®Society, a not-for-profit multiprofessional multidisciplinary medical-academic society, reaching all major continents and involving a wide range of surgical and anesthesia disciplines.

Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference.

BACKGROUND: The last 30 years have witnessed a significant increase in the diagnosis of early-stage rectal cancer and the development of new strategies to reduce the treatment-related morbidity. Currently, there is no consensus on the definition of early rectal cancer (ERC), and the best management of ERC has not been yet defined. The European Association for Endoscopic Surgery in collaboration with the European Society of Coloproctology developed this consensus conference to provide recommendations on ERC diagnosis, staging and treatment based on the available evidence. METHODS: A multidisciplinary group of experts selected on their clinical and scientific expertise was invited to critically review the literature and to formulate evidence-based recommendations by the Delphi method. Recommendations were discussed at the plenary session of the 14th World Congress of Endoscopic Surgery, Paris, 26 June 2014, and then posted on the EAES website for open discussion. RESULTS: Tumour biopsy has a low accuracy. Digital rectal examination plays a key role in the pre-operative work-up. Magnification chromoendoscopy, endoscopic ultrasound and magnetic resonance imaging are complementary staging modalities. Endoscopic submucosal dissection and transanal endoscopic microsurgery are the two established approaches for local excision (LE) of selected ERC. The role of all organ-sparing approaches including neoadjuvant therapies followed by LE should be formally assessed by randomized controlled trials. Rectal resection and total mesorectal excision is indicated in the presence of unfavourable features at the pathological evaluation of the LE specimen. The laparoscopic approach has better short-term outcomes and similar oncologic results when compared with open surgery. CONCLUSIONS: The management of ERC should always be based on a multidisciplinary approach, aiming to increase the rate of organ-preserving procedures without jeopardizing survival.

Portomesenteric venous thrombosis following major colon and rectal surgery: incidence and risk factors.

BACKGROUND: Portomesenteric venous thrombosis (PMVT) is an uncommon complication of abdominal surgery. The objective of this study was to assess PMVT risk factor profiles and patient outcomes after colorectal surgery. METHODS: A single center retrospective review of patients undergoing colorectal surgery was performed (2007-2012). PMVT was defined as thrombus within the portal, splenic, or superior mesenteric vein on computed tomography (CT). Inferior mesenteric vein thrombosis was excluded. Independent samples t test was used to compare data variables between PMVT and non-PMVT patients. Univariate and multivariate logistic regression analyses were used to assess PMVT risk factors. RESULTS: There were 1,224 patients included (mean age 62 years, male = 566). Elective bowel resection was performed for colon carcinoma (n = 302), rectal carcinoma (n = 112), ulcerative colitis (n = 125), Crohn's disease (n = 78), polyps (n = 117), and diverticulitis (n = 215). Patients undergoing gynecological resections and emergent laparotomies were included (n = 275). Thirty-six patients (3%) were diagnosed with PMVT by CT: 17/36 on initial presentation and 19/36 by expert radiologist review. Patients with PMVT were younger (53 vs. 62 years, p = 0.001) with higher BMI (30.5 vs. 26.7, p < 0.001) and thrombocytosis (464 vs. 306, p < 0.001) compared to patients without PMVT. Univariate logistic regression identified younger age (p < 0.001), obesity (p < 0.001), ulcerative colitis (p < 0.001), thrombocytosis, (p < 0.001) and proctocolectomy as significant predictors of PMVT. Stepwise multivariate logistic regression identified that obesity (p < 0.001), thrombocytosis, (p < 0.001) and restorative proctocolectomy (p = 0.001) were still significant predictors. No patients in the PMVT group suffered bowel infarction and no related mortalities occurred. Thirty-day readmission rates were higher in the PMVT group (53% vs. 17%, p < 0.01). CONCLUSION: BMI ≥ 30 kg/m(2), thrombocytosis, and restorative proctocolectomy were significant predictors of PMVT. Initial diagnostic studies showed a PMVT rate of 1.4%; however, after expert focused radiologic review, the actual rate was 3%. Thus, the diagnosis of PMVT is difficult and readmission after colorectal surgery should prompt its consideration.

Dysplasia in ulcerative colitis as a predictor of unsuspected synchronous colorectal cancer.

BACKGROUND: Endoscopic surveillance of patients with ulcerative colitis aims to prevent cancer-related morbidity through the detection and treatment of dysplasia. The literature to date varies widely with regard to the importance of dysplasia as a marker for colorectal cancer at the time of colectomy. OBJECTIVE: The aim of this study was to accurately characterize the extent to which the preoperative detection of dysplasia is associated with undetected cancer in patients with ulcerative colitis. DESIGN/PATIENTS/SETTING: A retrospective chart review was conducted of patients undergoing surgery for colitis within the Mayo Clinic Health System between August 1993 and July 2012. MAIN OUTCOME MEASURES: Patient demographics and pre- and postoperative dysplasia were tabulated. The relationship between pre- and postoperative dysplasia/cancer in surgical pathology specimens was assessed. RESULTS: A total of 2130 patients underwent abdominal colectomy or proctocolectomy; 329 patients were identified (15%) as having at least 1 focus of dysplasia preoperatively. Of these 329 patients, the majority were male (69%) with a mean age of 49.7 years. Unsuspected cancer was found in 6 surgical specimens. Indeterminate dysplasia was not associated with cancer (0/50). Preoperative low-grade dysplasia was associated with a 2% (3/141) risk of undetected cancer when present in random surveillance biopsies and a 3% (2/79) risk if detected in endoscopically visible lesions. Similarly, 3% (1/33) of patients identified preoperatively with random surveillance biopsy high-grade dysplasia harbored undetected cancer. Unsuspected dysplasia was found in 62/1801 (3%) cases without preoperative dysplasia. LIMITATIONS: This study is limited by its retrospective nature and by its lack of evaluation of the natural history of dysplastic lesions that progress to cancer. CONCLUSIONS: The presence of dysplasia was associated with a low risk of unsuspected cancer at the time of colectomy. These findings will help inform the decision-making process for patients with ulcerative colitis who are considering intensive surveillance vs surgical intervention after a diagnosis of dysplasia.

Patient survival after surgical treatment of rectal cancer: impact of surgeon and hospital characteristics.

BACKGROUND: Surgeon and hospital factors are associated with the survival of patients treated for rectal cancer. The relative contribution of each of these factors toward determining outcomes is poorly understood. METHODS: We used data from the Surveillance, Epidemiology, and End Results-Medicare database to analyze the outcomes of patients aged 65 years and older undergoing operative treatment for nonmetastatic rectal cancer, diagnosed in the United States between 1998 and 2007. These data were linked to a registry to identify whether the treating surgeon was a board-certified colorectal surgeon versus a noncolorectal surgeon. Hospital volume and hospital certification as a National Cancer Institute-designated Comprehensive Cancer Centers were also analyzed. The primary outcome of interest was long-term survival. RESULTS: Our data source yielded 6432 patients. Initial analysis demonstrated improved long-term survival in patients treated by higher-volume colorectal surgeons, higher-volume hospitals, teaching hospitals, and National Cancer Institute (NCI)-designated Comprehensive Cancer Centers. Based on an iterative approach to modeling the interactions between these various factors, we found a robust effect of surgeon subspecialty status, hospital volume, and NCI designation. Surgeon volume was not distinctly associated with long-term survival. CONCLUSIONS: Patients treated for rectal cancer by board-certified colorectal surgeons in centers that are higher volume and/or NCI-designated Comprehensive Cancer Centers experience better overall survival. These differences persist after adjustment for a broad range of patient and contextual risk factors, including surgeon volume. Patients and payers can use these results to identify surgeons and hospitals where outcomes are most favorable.

Extended lymphadenectomy in colon cancer is debatable.

Extended lymphadenectomy has gained considerable attention as an adjunct to conventional colon cancer surgery with the hope that it may potentially decrease local recurrence rates and improve cancer-specific outcome measures. Despite the enthusiasm surrounding these techniques, it is difficult to establish any additional survival benefit associated with more comprehensive lymphadenectomy strategies when these are performed in addition to conventional colon cancer surgery. Furthermore, these techniques remain unproven by large randomized clinical trials. The appropriate indications for performing extended lymphadenectomy also remain unclear, and there is a lack of standardization with regard to surgical technique. Moreover, there are a number of confounding factors that frequently receive little attention when oncological outcome measures are reported following extended lymphadenectomy in the setting of colon cancer. The purpose of this review is to outline these confounding issues and discuss their impact on reports describing cancer-specific outcome measures following the use of extended lymphadenectomy techniques. Furthermore, this review proposes that in light of the available published evidence, the role of radical lymphadenectomy is currently unproven, with large randomized clinical trials required in the future to determine whether there is a survival benefit for colon cancer patients.