Appendiceal Carcinoid Tumors: Is There a Survival Advantage to Colectomy over Appendectomy?

BACKGROUND: Guidelines recommend colectomy for appendiceal carcinoid tumors larger than 2 cm, but physicians debate whether colectomy would be beneficial in treating smaller tumors. We sought to determine when colectomy confers a survival advantage over appendectomy. METHODS: Appendiceal carcinoid patients in the US Surveillance, Epidemiology, and End Results (SEER) database (1988-2011) were stratified by age group, gender, TNM stage, tumor grade, and race. Kaplan-Meier and logistic regression analyses relating grade, stage, and receipt of colectomy to overall and cancer-specific survival were performed. RESULTS: Of 817 patients who underwent surgical extirpation of an appendiceal carcinoid, 338 (41%) had appendectomy alone and 479 (59%) had additional colectomy. Surprisingly, patients who underwent colectomy had worse cancer-specific survival (HR 1.98, 95% CI 1.32-2.98, p = 0.001) than those who underwent appendectomy, and colectomy did not confer a survival advantage over appendectomy in any subset analysis including low-grade or high-grade tumors, smaller or larger than 2 cm, or node-positive, non-metastatic tumors. Even when accounting for stage and grade, colectomy was not associated with significantly better survival rates. Furthermore, as colectomy frequency has increased over the last decade, the 5-year survival rate has trended down. The main predictors of cancer-specific mortality in carcinoid patients were high-grade (grades 3-4) and high-stage (node positive or metastatic) tumors. CONCLUSIONS: Survival in patients with carcinoid tumor of the appendix is primarily determined by tumor grade and stage. Our study found no survival advantage to colectomy over appendectomy in a large cohort of patients with the disease. Further investigation is necessary prior to recommending change of practice for patients with appendiceal carcinoid tumors.

Trends in lymph node excision and impact of positive lymph node ratio in patients with colectomy for primary colon adenocarcinoma: Population based study 1988 to 2011.

BACKGROUND: Studies suggest increased lymph node excision in patients with colon cancer portends improved survival. Guidelines recommend excising 12 or more lymph nodes during colectomy. There is an inverse correlation between the positive lymph node ratio and survival in patients of these patients. OBJECTIVE: We sought to determine whether colon cancer patients have adequate lymph node excision and whether positive lymph node ratio can be used as a guiding factor for their treatment plan. DESIGN: Retrospective, Observational. SETTINGS: United States, 1988-2011. PATIENTS: Utilizing the Surveillance, Epidemiology, and End Results registry, we identified 318,323 patients who underwent colectomy for colonic adenocarcinoma. Patients were stratified by age, tumor stage, tumor grade, race, ratio of positive nodes, and year of diagnosis. MAIN OUTCOME MEASURES: We determined the percentage of patients undergoing lymph node excision and mean number of nodes excised by year of diagnosis. In patients with adequate lymph node excision, positive lymph node ratio versus overall and cancer-specific survival was evaluated. RESULTS: 302,620 patients (95%) had at least 1 lymph node excised and 164,583 patients (52%) had 12 or more lymph nodes excised. This correlates to an increase from approximately 30% in 1988 to 80% by 2011. The mean number of nodes excised doubled from 9 to 18 in the entire cohort over the timeframe studied. On multivariate analysis, the 4 year cluster of diagnosis was the largest predictor of receipt of adequate lymph node excision with a 1.68 times higher odds per 4-year increase from 1988 (95% CI 1.67-1.69, p < 0.001). Higher positive lymph node ratio correlated with significantly worse overall and cancer-specific survival in those who had 12 or more lymph nodes excised. At a positive lymph node ratio of 0.16, there is a 15.7% increased rate of cancer specific mortality. CONCLUSIONS: Despite improvement in the performance of lymph node excision in patients undergoing colectomy for colon adenocarcinoma since 1988, only 80% of patients had adequate lymph node excision in 2011. Increasing positive lymph node ratio predicts significantly worse cancer-specific survival and a ratio of 0.16 may be considered an indication for a more aggressive therapeutic plan. CATEGORY: Colorectal/Anal Neoplasia.

Postendoscopic Zenker esophagodiverticulostomy leaks associated with a specific stapler cartridge.

OBJECTIVE: To determine the cause of postoperative leaks in 2 patients with Zenker diverticula treated with endoscopic staple-assisted esophagodiverticulostomy. DESIGN: Medical chart review and simulated surgery. SETTING: Teaching hospital. PATIENTS AND METHODS: Two case reports of postoperative leaks in patients treated with endoscopic staple-assisted esophagodiverticulostomy and experimental simulated surgery to investigate the possible cause of this complication. Use of a TR45B, 3.5-mm cartridge for an Endopath ETS Flex45 Endoscopic Articulation Linear Cutter stapler was associated with complications, whereas use of a TR45W, 2.5-mm cartridge in the same stapler was not. RESULTS: In a simulated surgery model, the 3.5-mm cartridge staple line leaked from the incision apex with pressure of less than 20 cm H(2)O, whereas the apex remained dry when using the 2.5-mm cartridge. When pressure was increased to 30 cm H(2)O, the staple line of the 2.5-mm cartridge had diffuse weeping of fluid but no focal, apical leak. CONCLUSIONS: Endoscopic staple-assisted esophagodiverticulostomy continues to be a relatively safe procedure; however, to provide maximum safety at the apex, the surgeon needs to be aware of stapler cartridge differences.