National differences in implementation of minimally invasive surgery for colorectal cancer and the influence on short-term outcomes.

BACKGROUND: The timing and degree of implementation of minimally invasive surgery (MIS) for colorectal cancer vary among countries. Insights in national differences regarding implementation of new surgical techniques and the effect on postoperative outcomes are important for quality assurance, can show potential areas for country-specific improvement, and might be illustrative and supportive for similar implementation programs in other countries. Therefore, this study aimed to evaluate differences in patient selection, applied techniques, and results of minimal invasive surgery for colorectal cancer between the Netherlands and Sweden. METHODS: Patients who underwent elective minimally invasive surgery for T1-3 colon or rectal cancer (2012-2018) registered in the Dutch ColoRectal Audit or Swedish ColoRectal Cancer Registry were included. Time trends in the application of MIS were determined. Outcomes were compared for time periods with a similar level of MIS implementation (Netherlands 2012-2013 versus Sweden 2017-2018). Multilevel analyses were performed to identify factors associated with adverse short-term outcomes. RESULTS: A total of 46,095 Dutch and 8,819 Swedish patients undergoing MIS for colorectal cancer were included. In Sweden, MIS implementation was approximately 5 years later than in the Netherlands, with more robotic surgery and lower volumes per hospital. Although conversion rates were higher in Sweden, oncological and surgical outcomes were comparable. MIS in the Netherlands for the years 2012-2013 resulted in a higher reoperation rate for colon cancer and a higher readmission rate but lower non-surgical complication rates for rectal cancer if compared with MIS in Sweden during 2017-2018. CONCLUSION: This study showed that the implementation of MIS for colorectal cancer occurred later in Sweden than the Netherlands, with comparable outcomes despite lower volumes. Our study demonstrates that new surgical techniques can be implemented at a national level in a controlled and safe way, with thorough quality assurance.

Preoperative multidisciplinary team assessment is associated with improved survival in patients with locally advanced colon cancer; a nationwide cohort study in 3157 patients.

INTRODUCTION: Multidisciplinary team (MDT) assessment is associated with improved survival in locally advanced rectal cancer, but the effect of an MDT assessment on survival in locally advanced colon cancer has not been reported. The aim of this national population-based cohort study was to establish if preoperative MDT assessment affects prognosis in patients with primary locally advanced colon cancer. MATERIAL AND METHODS: All patients in Sweden with locally advanced colon cancer, without metastatic disease, who underwent an elective colon resection between 2010 and 2017 were identified through the Swedish Colorectal Cancer Registry (SCRCR), and the cohort was linked to national registers. Data on patient characteristics, preoperative staging, surgical procedures, recurrence and survival were collected from SCRCR. The association between MDT assessment and colon cancer-specific survival was evaluated using Kaplan-Meier survival curves and Cox proportional hazards models. The multivariable analysis was adjusted for sex, age, ASA grade, CCI, time period, pN, region and preoperative MDT. RESULTS: MDT assessment was performed in 2663 patients (84.4%) of 3157 eligible patients. The 3-year colon cancer-specific survival was higher following MDT, compared with no MDT assessment (80% versus 68%). MDT assessment was independently associated with reduced colon cancer-specific mortality (HR 0.70, 0.57-0.84 95% CI). CONCLUSION: Preoperative MDT assessment is associated with an improved long-term survival in patients with locally advanced colon cancer and should be mandatory in patients with suspected locally advanced colon cancer.

Improvement of the experience of colorectal cancer patients in Sweden with a regional cancer plan.

AIM: The Stockholm-Gotland Regional Cancer Plan was launched in 2012 to improve cancer care. A personal contact nurse (CN), an individual written care plan (IWCP) and a standardized care pathway (SCP) were introduced. The aim of the current study was to evaluate whether these efforts have resulted in an improved experience for patients treated for colorectal cancer. METHOD: Patients treated with bowel resection for colorectal cancer in the Stockholm-Gotland region between 1 January 2013 and 31 December 2017 were identified through the Swedish Colorectal Cancer Registry. Six to eight months postoperatively, the patients received a patient-reported experience questionnaire. Patients were classified as 'satisfied' or 'not satisfied'. RESULTS: The questionnaire was sent to 4465 patients, and 3154 (70.64%) responded. The proportion of patients assigned a CN increased over time (79.84%-88.44%) and so did the proportion of patients receiving an IWCP (39.36%-70.00%). The waiting times were significantly shortened during the study period. In multivariable analysis, access to a CN and an IWCP was independently associated with increased patient satisfaction (OR 3.03, 95% CI 2.28-4.02 and OR 1.64, 95% CI 1.38-1.94). Patients with a long waiting time were significantly less satisfied than patients with a short waiting time (OR 0.72, 95% CI 0.60-0.88). CONCLUSION: Implementation of a CN, IWCP and SCP has been successful, measured by a higher proportion of patients gaining access to these assets and shortened waiting times. This has led to an improved patient experience in patients treated for colorectal cancer in the Stockholm-Gotland region.

Anastomotic leak after surgery for colon cancer and effect on long-term survival.

AIM: An anastomotic leak after surgery for colon cancer is a recognized complication but how it may adversely affect long-term survival is less clear because data are scarce. The aim of the study was to investigate the long-term impact of Grade C anastomotic leak in a large, population-based cohort. METHOD: Data on patients undergoing resection for Stage I-III colon cancer between 2008 and 2012 were collected from the Swedish, Norwegian and Danish Colorectal Cancer Registries. Overall relative survival and conditional 5-year relative survival, under the condition of surviving 1 year, were calculated for all patients and stratified by stage of disease. RESULTS: A total of 22 985 patients were analysed. Anastomotic leak occurred in 849 patients (3.7%). Five-year relative survival in patients with anastomotic leak was 64.7% compared with 87.0% for patients with no leak (P < 0.001). Five-year relative survival among the patients who survived the first year was 88.6% vs 81.3% (P = 0.003). Stratification by cancer stage showed that anastomotic leak was significantly associated with decreased relative survival in patients with Stage III disease (P = 0.001), but not in patients with Stage I or II (P = 0.950 and 0.247, respectively). CONCLUSION: Anastomotic leak after surgery for Stage III colon cancer was associated with significantly decreased long-term relative survival.

Low anterior resection syndrome after right- and left-sided resections for colonic cancer.

Background: This population-based cohort study aimed to evaluate occurrence of low anterior resection syndrome (LARS) and correlate this to health-related quality of life in patients who had undergone segmental colonic resection for colonic cancer in the Stockholm-Gotland region. The hypothesis was that there is a difference in occurrence of LARS depending on whether a right- or a left-sided resection was performed. Methods: Patients who underwent segmental colonic resection for colonic cancer stages I-III in the Stockholm-Gotland region in 2013-2015 received EORTC QLQ-C30, QLQ-CR29 and LARS score questionnaires 1 year after surgery. Clinical patient and tumour data were collected from the Swedish ColoRectal Cancer Registry. Patient-reported outcome measures were analysed in relation to type of colonic resection. Results: Questionnaires were sent to 866 patients and complete responses were provided by 517 (59·7 per cent). After right-sided resection 20·6 per cent reported major LARS. After left-sided resection the proportion with major LARS was 15·6 per cent. The odds ratio (OR) for major LARS after right-sided resection was 1·45 (95 per cent c.i. 1·02 to 2·06; P = 0·037) compared with left-sided resection. After adjustment for age and sex, an increase in the risk of major LARS after right- versus left-sided resection remained (OR 1·48, 1·03 to 2·13; P = 0·035). Major LARS correlated with impaired quality of life. Conclusion: Major LARS was more frequent after right-sided than following left-sided colonic resection. Major LARS reflected impaired quality of life.

Complete mesocolic excision in right-sided colon cancer does not increase severe short-term postoperative adverse events.

AIM: The aim was to assess whether complete mesocolic excision (CME) in patients with right-sided colon cancer is related to short-term mortality or postoperative adverse events requiring reoperation. The complete mobilization of an integral mesocolon and central ligation of blood vessels are essential steps in CME surgery. The resultant specimen, with an intact mesocolic fascia and a high number of harvested lymph nodes, is believed to be oncologically favourable. However, it has been suggested that CME surgery may increase the risk of intra-operative severe adverse events, due to exposure of vital retroperitoneal organs and large blood vessels. METHOD: In a population-based, nested case-control study, all residents in the Stockholm County operated for right-sided colon cancer from 2004 until 2012 were identified from the Swedish Colorectal Cancer Registry. Patients who died within 90 days after surgery or were reoperated within 30 days after surgery, or during the index hospital stay, were defined as cases. Two controls per case were randomly sampled and individually matched for age, sex, TNM stage and emergency vs elective surgery. Exposure status (CME surgery) was assessed from original surgical reports. RESULTS: The estimated proportion of CME surgery was 14.8% (35 of 236) for cases and 19.5% (92 of 473) for controls. The unadjusted OR for short-term mortality or reoperation after CME surgery was 0.72 (95% CI: 0.47-1.10; P = 0.15). The ORs were lower in the late part of the study (0.51; 95% CI: 0.26-1.01) and in high volume hospitals (0.61, 95% CI: 0.35-1.06). CONCLUSIONS: The present study does not indicate that CME surgery is associated with an increased risk of severe adverse events such as 90-day mortality or reoperation.

Accuracy of preoperative T and N staging in colon cancer--a national population-based study.

AIM: To select patients for neoadjuvant therapy in colon cancer, there is a need to improve pre-therapeutic locoregional staging. There are now data showing that the TN stage can be adequately assessed by preoperative CT in dedicated centres. In Sweden the use of preoperative CT of the abdomen for staging of the primary tumour is increasing. The aim of this study was to determine to what extent the preoperatively reported radiological TN stage correlates with the histopathological TN stage in an entire population. METHOD: Data were collected on the preoperative cTN stage according to the radiologist and postoperative pTN stage according to the pathologist on all patients operated on for colon cancer in Sweden 2007-2010. The correlation between cTN stage and pTN stage was calculated using kappa statistics. RESULTS: T stage was compared in 4373 patients with cT and pT stage. The correlation coefficient was 0.44, indicating fair agreement. The cN and pN correlation coefficient was 0.28, indicating a slight correlation. There was no difference in correlation related to age, gender, tumour location, body mass index or emergent vs elective surgery. A slight difference was seen between different geographical regions. CONCLUSION: Preoperative CT in an unselected population does not result in an accurate cTN staging as previously reported from dedicated centres. To achieve adequate preoperative cTN staging nationally, the education of radiologists and optimization of the radiological method will be necessary.

Improved survival after an educational project on colon cancer management in the county of Stockholm--a population based cohort study.

INTRODUCTION: Outcomes in rectal cancer have improved dramatically after the introduction of total mesorectal excision (TME). Recently, the TME concept has been transformed into that of complete mesocolic excision (CME) in an attempt to improve prognosis for patients with colon cancer. PATIENTS AND METHODS: Multidisciplinary team (MDT) workshops including the CME concept were held annually between 2004 and 2008 at the Karolinska University Hospital. The workshops focused on preoperative staging, surgery and histopathology and included lectures and live surgery sessions. To compare survival before and after the "Stockholm Colon Cancer Project" all patients diagnosed with a right sided colon cancer between January 1, 2001 and December 31, 2003 (Group 1) and from January 1, 2006 until December 31, 2008 (Group 2) in Stockholm were identified from the Swedish ColoRectal Cancer Registry (SCRCR). RESULTS: The proportion of patients having a tumour resection and the proportion having emergency surgery was higher in Group 1. There were more early tumours and more R0 resections in Group 2. Overall survival in all diagnosed patients and disease free survival after tumour resection was improved in the second time period. DISCUSSION: Surgical teaching programmes may have an impact on the management and outcome in colon cancer. The exact impact from the "Stockholm Colon Cancer Project" cannot be established, however it is likely that it contributed to the improved survival.

Management of colon cancer in the elderly: a population-based study.

AIM: Although the median age of patients diagnosed with colon cancer is over 70 years, little is known about specific characteristics and management in the elderly. The aim of this study was to define the characteristics of colon cancer in elderly patients and compare the quality of preoperative assessment and surgery with that of younger patients undergoing surgery for colon cancer. METHOD: Data on 15,255 patients diagnosed with colon cancer between 2007 and 2010 were retrieved from the Swedish National Colon Cancer Register. Of these, 12,959 underwent surgical resection: 6141 were 75 years or older while 6818 were younger. The χ(2) test, Mann-Whitney U-test and univariable and multivariable logistic regression analyses were used for between-group comparison. RESULTS: Older patients were more likely to be female (54% older/48% younger) and have right-sided cancer (60% older/49% younger). Among patients who underwent resection, the elderly were less often evaluated regarding tumour stage prior to surgery (59% older/65% younger) and they were less often evaluated at a multidisciplinary team conference (26% older/34% younger). Elderly patients more frequently underwent emergency surgery (22% older/19% younger) despite having an earlier cancer stage. When adjusted for stage, fewer elderly patients underwent a radical curative procedure (OR for noncurative resection 1.19; 95% CI 1.06-1.33). CONCLUSION: Routine management of patients with colon cancer is age-dependent. Patients aged 75 years and older are less often completely staged and less often evaluated at a multidisciplinary team conference prior to surgery. Adjusted for stage, fewer elderly patients undergo curative resection.

Pretreatment staging of colon cancer in the Swedish population.

AIM: Preoperative staging of colon cancer according to Swedish national guidelines implies imaging evaluation of the primary tumour, liver and lungs. Failure to adhere to these guidelines results in negative scorings in the national registration system. In the present study we report the extent of compliance with these guidelines. METHOD: Since 2007 clinical data on all patients diagnosed with colon cancer in Sweden have been collected in a national database. This includes information on pretherapeutic diagnostic imaging performed, pretherapeutic TNM stage and data on treatment and follow-up. All patients diagnosed with colon cancer in Sweden between 2007 and 2010 were included. RESULTS: Nine thousand and eight-three patients (i.e. 60.5% of all patients) had a complete pretherapeutic radiological evaluation; 65.2% had a CT or MRI of the primary tumour, whereas over 80% had examinations of the liver and lungs. There were no difference related to sex, but more patients under 75 years had a complete evaluation. There were large differences between different regions; one region performed a complete evaluation of 78.3% of all patients. The proportion of patients examined increased from 53.9 to 65.0% during the study period. Elective cases were more frequently evaluated before treatment than those with an emergency presentation. CONCLUSION: Most patients in Sweden had a complete pretreatment imaging evaluation of the colon cancer with geographical and time-dependent variations. Knowledge of the importance of these variations and correlation of pre- and postoperative TNM stage is warranted, and such studies are ongoing.

Population-based data from the Swedish Colon Cancer Registry.

BACKGROUND: Evaluating the external validity of clinical trials requires knowledge not only of the study population but also of a relevant reference population. The main aim of this study was to present data from a large, contemporary, population-based cohort of patients with colonic cancer. METHODS: Data on patients diagnosed between 2007 and 2011 were extracted from the Swedish Colon Cancer Registry. The data, registered prospectively in a national population of almost 10 million, included over 99 per cent of all diagnosed adenocarcinomas of the colon. RESULTS: This analysis included 18,889 patients with 19,526 tumours (3·0 per cent had synchronous tumours). The sex distribution was fairly equal, and the median age was 74·1 (interquartile range 65-81) years. The overall and relative (cancer-specific) survival rates after 3 years were 62·7 and 71·4 per cent respectively. Some 88·0 per cent of the patients were operated on, and 83·8 per cent had tumours resected. Median blood loss during bowel resection was 200 (mean 311) ml, and the median operating time was 160 min; 5·6 per cent of the procedures were laparoscopic. Preoperative chemotherapy was administered to 2·1 per cent of patients; postoperative chemotherapy was planned in 90·1 per cent of fit patients aged less than 75 years with stage III disease. In patients operated on in an emergency setting (21·5 per cent), the preoperative evaluation was less extensive, the proportion of R0 resections was lower, and the outcomes were poorer, in both the short and long term. CONCLUSION: These population-based data represent good-quality reference points.

Increased lymph node harvest in patients operated on for right-sided colon cancer: a population-based study.

AIM: In recent decades, the focus has been on the treatment of rectal cancer with improved surgical techniques. This has resulted in improved results for patients with rectal cancer. Recently, the focus has shifted to colon cancer surgery with the introduction of preoperative staging, new surgical techniques, quality control and enhanced recovery programmes. The change in operative techniques has been most pronounced for patients with tumours on the right side of the colon, with more extensive resections and proximal ligations of the vessels. The aim of this study was to assess the number of analysed lymph nodes and the metastatic index (MI) in patients operated on for right-sided colon cancer in the Stockholm area between 1996 and 2009. METHOD: All patients operated on for cancer of the right colon between January 1996 and December 2009 were divided into three groups based on the year in which they were operated (period 1, 1996-1999; period 2, 2000-2004; and period 3, 2005-2009). The number of lymph nodes and lymph node status were analysed. RESULTS: In total, 3536 patients were operated on for right-sided colon cancer during the study period. There was a significantly lower proportion of emergency operations in the third time period. The mean number of lymph nodes examined increased significantly during the overall study period (seven in period 1, 11 in period 2 and 18 in period 3; P < 0.001). A significant drop in MI was seen during the third time period (0.25, compared with 0.40 in period 1 and 0.40 in period 2; P < 0.001). CONCLUSION: During the study period there was an increase in the number of analysed lymph nodes and a decrease in MI after right-sided hemicolectomies. Further investigations are needed to evaluate the potential impact on short-term and long-term outcome.

Epidemiology and prognosis of ovarian metastases in colorectal cancer.

BACKGROUND: National guidelines for prophylactic oophorectomy in women with colorectal cancer are lacking. The aim of this population-based cohort study was to report on the prevalence, incidence and prognosis of ovarian metastases from colorectal cancer, providing information relevant to the discussion of prophylactic oophorectomy. METHODS: All 4566 women with colorectal cancer in Stockholm County during 1995-2006 were included and followed until 2008. Prospectively collected data regarding clinical characteristics, treatment and outcome were obtained from the Regional Quality Registry. RESULTS: The prevalence of ovarian metastases at the time of diagnosis of colorectal cancer was 1.1 per cent (34 of 3172) among women with colonic cancer and 0.6 per cent (8 of 1394) among those with rectal cancer (P = 0.105). After radical resection of stage I-III colorectal cancer, metachronous ovarian metastases were found during follow-up in 1.1 per cent (22 of 1971) with colonic cancer and 0.1 per cent (1 of 881) with rectal cancer (P = 0.006). Survival in patients with ovarian metastases was poor. CONCLUSION: Ovarian metastases from colorectal cancer are uncommon.

Colon cancer management and outcome in relation to individual hospitals in a defined population.

BACKGROUND: The Stockholm and Gotland region in Sweden has a common management protocol for the treatment of colon cancer. The aim of this study was to assess the management and treatment of colon cancer in the region and to try to identify ways to improve the outcome further. METHODS: Clinical data on all patients diagnosed with colon cancer in the region's nine hospitals between January 1996 and December 2000 were prospectively collected. Patients were followed until December 2004, and their management and outcome analysed. RESULTS: Colon cancer was diagnosed in 2775 patients. An elective operation was performed in 2116 (76.3 per cent) patients and an emergency procedure in 590 (21.3 per cent). Emergency surgery was an independent risk factor for death. The crude overall cumulative 5-year survival was 46.2 per cent. A multivariable analysis of risk of dying and risk of local recurrence showed significant differences between hospitals. The number of lymph nodes examined in the specimens also differed between hospitals. CONCLUSION: Differences in the management and outcome of colon cancer in the nine hospitals, despite a common management protocol, indicate a need for improving collaboration between hospitals and multidisciplinary management.

The potential for improved outcome in patients with hepatic metastases from colon cancer: a population-based study.

AIMS: Reports from specialized centres suggest that 20-25% of patients with hepatic metastases from colorectal cancer have resectable disease, with 5-year survival rates of 30-40%, and that an additional 13-38% may become resectable after chemotherapy. The purpose of this study was to assess the potential for improvement in outcome for patients with hepatic metastases from colon cancer in an unselected population. PATIENTS AND METHODS: All patients diagnosed with colon cancer in the Stockholm/Gotland region between 1 January 1996 and 31 December 1999 were identified and followed until 31 December 2002. Treatment and outcome in patients with hepatic metastases was analyzed and CT-scans and MR images of the liver were reviewed to re-evaluate resectability. RESULTS: In 2280 patients with colon cancer, hepatic metastases were diagnosed in 537 patients. Only 21 of these patients underwent a hepatic resection. Retrospective evaluation of liver images indicated that 10% of the patients had potentially resectable hepatic disease. CONCLUSION: The rate of potentially resectable liver metastases from colon cancer in a population is lower than suggested from hospital-based series. With structured management programs including follow-up routines and multidisciplinary treatment protocols the proportion of patients amenable for liver resection may be increased. In this study preoperative chemotherapy might have increased the resectability rate to at the most 17%. To significantly improve prognosis for patients with hepatic metastases from colon cancer more effective treatment modalities are needed.

Blunt abdominal trauma in children: risks of nonoperative treatment.

This retrospective study includes 203 children who had intraabdominal injuries after blunt trauma, mainly bicycle accidents and falls. Of 145 patients with splenic injury, seven underwent surgery. There was a 100% splenic salvage rate. Twenty-nine children had hepatic injury and four underwent laparotomy. One patient who was initially treated conservatively had a complicated clinical course with rebleeding that led to two laparotomies. Three of 10 pancreatic injuries were operated on; one of them 4 weeks after the trauma because of a pseudocyst. Nineteen patients had gastrointestinal tract injuries. Of seven intramural hematomas, five were treated nonoperatively. Twelve patients had gastrointestinal perforations. Seven underwent laparotomy without delay. Three patients underwent surgery 24 hours after admission because of severe abdominal rigidity or pneumoperitoneum. There was one case of severe in-hospital delay in which splenic and hepatic injuries were thought to account for the physical findings. At laparotomy 36 hours after admission, a jejunal rupture and necrosis of the transverse colon were found. Nonoperative management of blunt abdominal trauma has been very successful regarding splenic ruptures. Conservative management of hepatic injuries is more hazardous, and treatment of pancreatic injuries is a matter of controversy. Gastrointestinal-tract perforations are difficult to diagnose and important to bear in mind while keeping a conservative attitude toward abdominal trauma.

A mild form of mucolipidosis type III in four Baluch siblings.

Four Baluch siblings with mucolipidosis type III (pseudo-Hurler polydystrophy) are described. The patients had features commonly found in mucolipidosis III, including claw hands, joint stiffness, aortic valve involvement and radiological dysostosis multiplex. However, intelligence was normal, there were no eye abnormalities on slit-lamp examination and skin elasticity was normal. Many lysosomal enzymes were elevated in serum and diminished in cultured fibroblasts, although the findings for beta-galactosidase were atypical. Assays for the two enzymes involved in formation of the phosphomannose recognition marker revealed normal activity of the phosphotransferase with alpha-methylmannoside as an acceptor, and normal activity of the phosphodiester glycosidase. Metabolic labelling of fibroblasts with 32P followed by immunoprecipitation of cathepsin D, electrophoresis and fluorography showed that this enzyme was not labelled in the patients' cells, although some label was detected in the secreted precursor polypeptide. The data are consistent with the assumption that activity of the phosphotransferase is low towards lysosomal enzymes as substrates, and that the patients belong to complementation group C.