Cancer pathways are associated with improved long-term survival.

INTRODUCTION: The impact of cancer patient pathways (CPP) on long-term outcome after surgery for colorectal cancer has not been documented. This study aimed to investigate the effect of CPP on survival in patients who underwent surgery for colorectal cancer. METHODS: This was a retrospective cohort study performed in a single centre on prospectively collected data from a national database, the Danish Colorectal Cancer Group. In total, we reviewed 309 consecutive patients (145 females) with a median age of 70 years (range: 30-92 years), who underwent surgery for colorectal cancer between 2007 and 2009. RESULTS: A total of 148 patients who underwent elective surgery after the introduction of CPP on 1 April 2008 had a decrease in the median number of days from referral to endoscopy (from 8 to 6, p = 0.001, from referral to oncological treatment (from 46.5 to 32 days, p < 0.001) and from referral to surgery (from 28 to 22 days, p = 0.066), but this latest reduction was not significant. Overall survival (OS) was analysed using the Kaplan Meier method; and variables were compared with the log rank test. The 60-month OS was significantly improved from 61.1% in those who were operated before 1 April 2008 (n = 161) to 72.6% in the CPP group operated after 1 April (p = 0.026). Using the Cox regression model, we found that CPP was an independent factor associated with survival (p = 0.032, hazard ratio = 0.661, 95% confidence interval: 0.454-0.964). CONCLUSION: Introduction of CCPs in a single centre was associated with a significant improvement of overall sur-vival, and using Cox regression we found that the CPP was an independent marker for survival. Larger studies are needed to clearly understand the effect of CPP.

Low risk of pelvic sepsis after intersphincteric proctectomy in patients with low rectal cancer.

INTRODUCTION: Pelvic sepsis after Hartmann's procedure for low rectal cancer is a frequent complication. It has been reported at a frequency of 12.2-17.2% and has even reached 33% when the transection level of the rectum is ≤ 2 cm from the anal verge. The aim of this study was to examine whether intersphincteric proctectomy reduces the frequency of pelvic sepsis in patients operated with an extended Hartmann's procedure for rectal cancer. METHODS: Patients undergoing elective extended Hartmann's procedure with an intersphincteric proctectomy from 2010 until 2014 were reviewed retrospectively. Patient characteristics and post-operative complications were obtained and analysed. RESULTS: A total of 50 patients were included in this analysis. Sixteen were female, the median age was 73 years, and the median BMI was 26 kg/m2. Furthermore, the American Society of Anesthesiologists (ASA) scores were as follows: ASA 1 (28%), ASA 2 (60%), and ASA 3 (12%); their tumour-node-metastasis (TNM) staging was TNM: ≤ T2 (30%), T3 (50%), and T4 (20%); and 26% had received neoadjuvant radiotherapy, whereas 40% had received chemotherapy. A total of three patients (6%) developed a post-operative pelvic sepsis. The median length of post-operative hospitalisation was 9.5 days. Overall mortality was 4% (n = 50). The most frequent surgical complication to intersphincteric proctectomy was perineal wound infection, occurring in 20%. DISCUSSION: This study suggests a reduction in the frequency of pelvic sepsis when intersphincteric proctectomy is performed in patients who undergo extended Hartmann's procedure. The frequency is, however, larger than that reported herein when the rectal stump is left long. Intersphincteric proctectomy should therefore primarily be reserved for low cancers with short rectal stumps. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Vacuum with mesh is a feasible temporary closure device after fascial dehiscence.

INTRODUCTION: The open abdomen is a challenging condition and a temporary abdominal closure device is required in order to protect the intra-abdominal viscera. We aimed to evaluate the feasibility of a recent device: vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) after fascial dehiscence focusing on fascial closure rate, mortality and procedure-related complications. MATERIAL AND METHODS: We performed a retrospective study on 18 patients treated with VAWCM after fascial dehiscence who were consecutively admitted to the Department of Surgery, Slagelse Hospital, between October 2008 and October 2012. RESULTS: The 18 patients had a median age of 64 (29-90) years. 80% (12/15) obtained delayed primary abdominal closure. The in-hospital mortality was 17% (3/18). The median treatment period with VAWCM and vacuum-assisted wound closure were 18 (7-34) and 21 (7-53) days, respectively, with a median of six (1-11) tightenings. One patient developed an intra-abdominal abscess. Three patients survived until discharge without having obtained delayed primary closure. In two of these patients, the fascial edges were adapted with a prosthetic mesh and one patient was left with a planned ventral hernia. We performed a retrospective follow-up with a median duration of 21 months 21% developed an incisional hernia. Two patients died within 60 days after closure of the abdomen. CONCLUSION: We found and that VAWCM is a safe and useful technique for delayed primary closure of the open abdomen after fascial dehiscence. We stress the need for more studies on temporary abdominal closure devices in selected groups of patients. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Promising results after endoscopic vacuum treatment of anastomotic leakage following resection of rectal cancer with ileostomy.

INTRODUCTION: In colorectal surgery, the most feared complication is anastomotic leakage (AL), which is associated with a high morbidity and mortality. In this study, we focus on treatment of perianastomotic abscess following AL after low anterior resection (LAR) of rectal cancer. In the literature, conservative irrigation regimes are reported to perdure for months and some even years and to be associated with a poor stoma closure rate. In the present paper, we evaluated endoscopic vacuum treatment of the perianastomotic abscess. MATERIAL AND METHODS: Patients who had LAR due to rectal cancer with total mesorectal excision (TME) performed in Slagelse and Næstved Hospitals in the 2008-2012 (1st February) period were identified in the Danish Colorectal Cancer Group database. We included patients who had AL and who did not require emergency reoperation and were treated with endoscopic vacuum in the study period. Patients who initiated treatment more than one month after the leakage were excluded. All patients had primary ileostomy. RESULTS: A total of 13 patients were included. All patients had successful closure of the perianastomotic abscess for a median of 18 (3-40) days in a median of eight (1-18) sessions. The median length of hospital stay was 25 (7-39) days. Mortality was zero, and the stoma closure rate was 12/13 (97%). CONCLUSION: Our data support the positive findings previously reported by other studies. Endoscopic vacuum treatment seems to be a safe approach for selected patients in the treatment of perianastomotic abscess after LAR with TME of rectal cancer. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Chromogranin A is a sensitive marker of progression or regression in ileo-cecal neuroendocrine tumors.

OBJECTIVE: The correlation between plasma Chromogranin A concentrations and changes in tumor size evaluated by computed tomography (CT) - as a gold standard - was evaluated. MATERIAL AND METHODS: One hundred and sixteen patients with CgA-producing ileo-cecal neuroendocrine tumors were evaluated by events, which were recorded when a CT was followed by another CT 1 - 12 months later. Change in tumor size was defined as regression, progression, or stable disease using RECIST criteria 1.1. Of 426 events, there were 97 with progression, 279 with stable disease, and 50 with regression. Based on the ROC curves a cutoff value of 25% change was selected to discriminate between increased, decreased, or unchanged CgA concentrations in plasma, using a sensitive radioimmunoassay with well-defined epitope specificity. RESULTS: In the 97 events showing tumor progression diagnostic sensitivity and specificity of an increased CgA concentration were 86% and 86%, respectively. The positive and negative predictive values were 64% and 85%, respectively. In the 279 events with unchanged tumor size the diagnostic sensitivity and specificity of an unchanged CgA concentration were 73% and 86%, and the positive and negative predictive values were 91% and 63%, respectively. In the 50 events showing tumor regression, diagnostic sensitivity and specificity of a decrease in CgA concentration were 78% and 91%, the positive and negative predictive values being 55% and 97%. CONCLUSIONS: CgA concentrations in plasma have a high diagnostic accuracy in monitoring patients with ileo-cecal neuroendocrine tumors. In particular, an increase in plasma CgA concentration was useful to indicate tumor progression.