Right colon cancer: Left behind.

INTRODUCTION: Prognosis of colon cancer (CC) has steadily improved during the past three decades. This trend, however, may vary according to proximal (right) or distal (left) tumor location. We studied if improvement in survival was greater for left than for right CC. METHODS: We included all CC recorded at the Geneva population-based registry between 1980 and 2006. We compared patients, tumor and treatment characteristics between left and right CC by logistic regression and compared CC specific survival by Cox models taking into account putative confounders. We also compared changes in survival between CC location in early and late years of observation. RESULTS: Among the 3396 CC patients, 1334 (39%) had right-sided and 2062 (61%) left-sided tumors. In the early 1980s, 5-year specific survival was identical for right and left CCs (49% vs. 48%). During the study period, a dramatic improvement in survival was observed for patients with left-sided cancers (Hazard ratio [HR]: 0.42, 95% confidence interval [CI]: 0.29-0.62, p < 0.001) but not for right CC patients (HR: 0.76, 95% CI: 0.50-1.14, p = 0.69). As a consequence, patients with distal CC have a better outcome than patients with proximal CC (HR for left vs. right CC: 0.81, 95% CI: 0.72-0.90, p < 0.001). CONCLUSION: Our data indicate that, contrary to left CC, survival of patients with right CC did not improve since 1980. Of all colon cancer patients, those with right-sided lesions have by far the worse prognosis. Change of strategic management in this subgroup is warranted.

Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines.

The mission of the Italian Society of Colorectal Surgery (SICCR) is to optimize patient care. Providing evidence-based practice guidelines is therefore of key importance. About the present report it concernes the SICCR practice guidelines for the diagnosis and treatment of diverticular disease of the colon. The guidelines are not intended to define the sole standard of care but to provide evidence-based recommendations regarding the available therapeutic options.

CT scan-based modelling of anastomotic leak risk after colorectal surgery.

AIM: Prolonged ileus, low-grade fever and abdominal discomfort are common during the first week after colonic resection. Undiagnosed anastomotic leak carries a poor outcome and computed tomography (CT) scan is the best imaging tool for assessing postoperative abdominal complications. We used a CT scan-based model to quantify the risk of anastomotic leak after colorectal surgery. METHOD: A case-control analysis of 74 patients who underwent clinico-radiological evaluation after colorectal surgery for suspicion of anastomotic leak was undertaken and a multivariable analysis of risk factors for leak was performed. A logistic regression model was used to identify determinant variables and construct a predictive score. RESULTS: Out of 74 patients with a clinical suspicion of anastomotic leak, 17 (23%) had this complication confirmed following repeat laparotomy. In multivariate analysis, three variables were associated with anastomotic leak: (1) white blood cells count > 9 × 10(9) /l (OR = 14.8); (2) presence of ≥ 500 cm(3) of intra- abdominal fluid (OR = 13.4); and (3) pneumoperitoneum at the site of anastomosis (OR = 9.9). Each of these three parameters contributed one point to the risk score. The observed risk of leak was 0, 6, 31 and 100%, respectively, for patients with scores of 0, 1, 2 and 3. The area under the receiver operating characteristic curve for the score was 0.83 (0.72-0.94). CONCLUSION: This CT scan-based model seems clinically promising for objective quantification of the risk of a leak after colorectal surgery.

Assessment of recurrence and complications following uncomplicated diverticulitis.

BACKGROUND: The natural history of sigmoid diverticulitis has been inferred from population-based or retrospective studies. This study assessed the risk of a recurrent attack following the first episode of uncomplicated diverticulitis. METHODS: Patients admitted between January 2007 and December 2011 with a first episode of uncomplicated sigmoid diverticulitis confirmed on computed tomography were enrolled in this prospective study. After successful medical management of the first episode, follow-up was conducted through yearly telephone interviews. Cox proportional hazards regression was performed to model the impact of various parameters on eventual recurrences and complications. RESULTS: During a median follow-up of 24 (range 3-63) months, 46 (16·4 per cent) of 280 patients experienced a second episode of diverticulitis. Six patients (2·1 per cent) subsequently developed complicated diverticulitis and four (1·4 per cent) underwent emergency surgery for peritonitis. In multivariable analysis, a raised serum level of C-reactive protein (over 240 mg/l) during the first attack was associated with early recurrence (hazard ratio 1·75, 95 per cent confidence interval 1·04 to 2·94; P = 0·035). CONCLUSION: Uncomplicated sigmoid diverticulitis follows a benign course with few recurrences and little need for emergency surgery. REGISTRATION NUMBER: NCT01015378 (http://www.clinicaltrials.gov).

Sigmoid diverticulitis in 2011: many questions; few answers.

AIM: Patients were studied after a first episode of acute left-colonic diverticulitis for the initial and later evolution of the disease with the aim of defining evidence-based indications for elective surgery. METHOD: Relevant data from prospective studies were retrieved from a MEDLINE search of English language articles. RESULTS: Young male patients (≤ 50 years of age) had a higher risk of CT-graded severe diverticulitis. After medical treatment of the first episode, the incidence of complications was highest for young patients with CT-graded severe diverticulitis and lowest for older patients with CT-graded moderate diverticulitis. Recurrence in the form of diffuse peritonitis was rare. CT grading of initial diverticulitis seemed to be a predictor of recurrence, whereas the role of age was less clear. A family history of diverticulitis might be predictive of recurrence. CONCLUSION: CT grading of acute diverticulitis helps to predict poor outcome after medical treatment of a first episode. Elective surgical resection should be proposed to patients with residual symptoms who do not respond to conservative treatment. Additional research is needed to clarify the role of a genetic predisposition in the development of diverticulitis in young adults.

Scoring system to predict the risk of surgical-site infection after colorectal resection.

BACKGROUND: There is no dedicated scoring system for predicting the risk of surgical-site infection (SSI) after resection of the colon or rectum. Generic scores, such as the National Nosocomial Infections Surveillance index, are not used by colorectal surgeons. METHODS: Multivariable analysis of risk factors for SSI was performed in patients who underwent resection of the colon or rectum, and were followed during the first month after operation. A logistic regression model was used to identify determinant variables and construct a predictive score. RESULTS: There were 534 patients of whom 114 (21·3 per cent) developed SSI. In multivariable analysis, four parameters correlated with an increased risk of SSI: obesity (odds ratio (OR) 2·93, 95 per cent confidence interval 1·71 to 5·03), contamination class 3-4 (OR 3·33, 2·08 to 5·32), American Society of Anesthesiologists grade III-IV (OR 1·82, 1·14 to 2·90) and open surgery (OR 2·22, 1·01 to 4·88). Each of these contributed 1 point to the risk score. The observed risk of SSI was 5 per cent for a score of 0, 12·0 per cent for a score of 1 point, 18·7 per cent for 2 points, 44 per cent for 3 points and 68 per cent for 4 points. The area under the receiver operating characteristic curve for the score was 0·729. CONCLUSION: A simple clinical score based on four preoperative variables was clinically useful in predicting the risk of SSI in patients undergoing colorectal surgery.

A clinical and radiological comparison of sigmoid diverticulitis episodes 1 and 2.

AIM: After an initial uncomplicated attack, sigmoid diverticulitis may recur, but the morphological characteristics of recurrent diverticulitis have not been investigated. We compared the clinical and radiological severity, the respective location and clinical outcome of the first two episodes of sigmoid diverticulitis. METHOD: We reviewed the charts of 60 patients [median age 61 (range 31-90) years] who were admitted initially for a first episode of uncomplicated left colonic diverticulitis, and who were eventually readmitted for a second episode, both being documented by abdominal computed tomography (CT) scan. RESULTS: The median delay between the two episodes was 19 (3-97) months. Six (10%) patients developed a second complicated episode of diverticulitis [Hinchey II (n = 2), CT-guided percutaneous drainage; Hinchey III (n = 3), emergency Hartmann's operation; colovesical fistula (n = 1), elective sigmoid resection]. Fifty-four (90%) patients were admitted for a second episode of uncomplicated diverticulitis. In this group, the duration of hospital stay [11 (4-22) vs 10 (1-39) days, P = 0.28], serum levels of C-reactive protein [131 (31-350) vs 112 (22-333) mm, P = 0.62] and CT scan-based severity score [3 (1-6) vs 3 (0-7) points, P = 0.07] were similar between the two episodes. In 19 out of 54 (35%) patients with simple recurrent diverticulitis, although disease severity was similar, the disease topography differed and recurrence involved another segment of the left colon. CONCLUSION: The majority of patients who develop recurrence do so in a similar mode and location. However, 10% develop complicated diverticulitis and in 35% of patients recurrent diverticulitis occurs at a different location.

[Acute small bowel obstruction: conservative or surgical treatment?]. / Occlusion grêle aiguë: traitement conservateur ou chirurgical?

Small bowel obstruction (SBO) is a common clinical syndrome caused mainly by postoperative adhesions. In complement to clinical and biological evaluations, CT scan has emerged as a valuable imaging modality and may provide reliable information. The early recognition of signs suggesting bowel ischemia is essential for urgent operation. However appropriate management of SBO remains a common clinical challenge. Although a conservative approach can be successful in a substantial percentage of selected patients, regular and close re-assessement is mandatory. Any persistance or progression of the critical symptoms and signs should indeed lead to surgical exploration. Here we review the principles of adhesive SBO management and suggest a decision procedure for conservative versus surgical treatment.

Clinicoradiological score for predicting the risk of strangulated small bowel obstruction.

BACKGROUND: Intestinal ischaemia as a result of small bowel obstruction (SBO) requires prompt recognition and early intervention. A clinicoradiological score was sought to predict the risk of ischaemia in patients with SBO. METHODS: A clinico-radiological protocol for the assessment of patients presenting with SBO was used. A logistic regression model was applied to identify determinant variables and construct a clinical score that would predict ischaemia requiring resection. RESULTS: Of 233 consecutive patients with SBO, 138 required laparotomy of whom 45 underwent intestinal resection. In multivariable analysis, six variables correlated with small bowel resection and were given one point each towards the clinical score: history of pain lasting 4 days or more, guarding, C-reactive protein level at least 75 mg/l, leucocyte count 10 x 10(9)/l or greater, free intraperitoneal fluid volume at least 500 ml on computed tomography (CT) and reduction of CT small bowel wall contrast enhancement. The risk of intestinal ischaemia was 6 per cent in patients with a score of 1 or less, whereas 21 of 29 patients with a score of 3 or more underwent small bowel resection. A positive score of 3 or more had a sensitivity of 67.7 per cent and specificity 90.8 per cent; the area under the receiver operating characteristic curve was 0.87 (95 per cent confidence interval 0.79 to 0.95). CONCLUSION: By combining clinical, laboratory and radiological parameters, the clinical score allowed early identification of strangulated SBO.

[Really so far from fast-track colorectal surgery in senior patients?]. / Vraiment si loin d'une approche fast-track chez les seniors après chirurgie colorectale?

Senior population (> or = 70 y) represents approximately 17% of Western population and account for 2/3 of all solids cancers of which > 50% are colorectal. Their treatment would request major abdominal surgery, often not offered because of senior age or fear of prohibitive morbidity. Fast-track programs reduce postoperative morbidity and hospital stay after elective colorectal surgery. According to few studies, this approach seems to be safe and feasible in senior patients. In our institution, mortality/morbidity rates were 0% and 37% after elective colorectal surgery in senior patients with standard care, with a median hospital stay of 13 days. Elective colorectal surgery should be offered to senior patients. However the relative high morbidity rate with standard care prompts us to initiate a specifically designed fast-track protocol in senior patients.

[Management of sigmoid diverticulitis]. / Traitement de la diverticulite sigmoïdienne.

While a majority of patients with diverticular disease remain asymptomatic, a subset will develop complications such as diverticulitis or bleeding. Simple diverticulitis is successfully managed with oral or intravenous antibiotics. Complicated diverticulitis is defined by the presence of abscess, fistula, stenosis or peritonitis. The severity of infectious complications is assessed by the Hinchey classification. Hinchey I stage is a small (<4 cm) pericolic abscess and is treated with intravenous antibiotics. Hinchey II stage is a larger (<4 cm) pelvic abscess, which usually requires percutaneous CT scan-guided drainage in addition to antibiotics. Hinchey III stage refers to purulent peritonitis and Hinchey IV to fecal peritonitis. Both stages require an emergent laparotomy. Indications for an elective sigmoidectomy are: a) two or more previous episodes of simple diverticulitis; and b) one episode of complicated diverticulitis.

Surgical management of gastrointestinal stromal tumours.

BACKGROUND: Over the past decade, gastrointestinal stromal tumours (GISTs) have served as a model for the application of tyrosine kinase inhibitors in the treatment of solid neoplasms. Operative and medical management of GISTs is rapidly evolving, but current guidelines appear restricted to basic non-organ-specific recommendations. METHODS: A PubMed search was made of the English literature from 1998 to 2008 for references containing the terms 'gastrointestinal stromal tumours' and 'surgery'. This paper reviews the various operative strategies so far reported for GISTs within the digestive tract. RESULTS: Many original procedures tailored to the specific characteristics of these rare sarcomas have been reported. GISTs exhibit distinct features, in particular an absence of metastases within locoregional lymph nodes. Operations requiring extended lymph node dissection, typically designed for adenocarcinomas, such as gastrectomy with extended lymph node dissection, Whipple's procedure and total mesorectum excision, are inappropriate for treating GISTs originating from the stomach, duodenum and rectum respectively. CONCLUSION: GISTs allow the possibility of performing oncologically adequate but limited (wedge; segmental) resections. Such surgery can be carried out in a variety of ways, such as open, laparoscopic, trans-sacral or endoscopic.

Risk factors for mortality-morbidity after emergency-urgent colorectal surgery.

BACKGROUND: The aim of this study was to assess the risk factors associated with mortality and morbidity following emergency or urgent colorectal surgery. MATERIALS AND METHODS: All data regarding the 462 patients who underwent emergency colonic resection in our institution between November 2002 and December 2007 were prospectively entered into a computerized database. RESULTS: The median age of patients was 73 (range 17-98) years. The most common indications for surgery were: 171 adenocarcinomas (37%), 129 complicated diverticulitis (28%), and 35 colonic ischemia (7.5%). Overall mortality and morbidity rates were 14% and 36%, respectively. In multivariate analysis, the only parameter significantly associated with postoperative mortality was blood loss >500 cm(3) (odds ratio (OR) = 3.33, 95% confidence interval (CI) 1.63-6.82, p = 0.001). There were three parameters which correlated with postoperative morbidity: ASA score > or =3 (OR = 2.9, 95% CI 1.9-4.5, p < 0.001), colonic ischemia (OR = 3.4, 95% CI 1.4-7.7, p = 0.006), and stoma creation (OR = 2.2, 95% CI 1.4-3.4, p = 0.0003). CONCLUSIONS: The main risk factors for postoperative morbidity and mortality following emergency colorectal surgery are related to: (1) patients' ASA score, (2) colonic ischemia, and (3) perioperative bleeding. These variables should be considered in the elaboration of future scoring systems to predict outcome of emergency colorectal surgery.

Trans-sacral (Kraske) approach for gastrointestinal stromal tumour of the lower rectum: old procedure for a new disease.

Gastrointestinal stromal tumours (GISTs) of the lower rectum are rare cancers from mesenchymatous origin, which are characterized by; 1) the absence of metastases in loco-regional lymph nodes; and 2) a tendency to grow opposite to the intestinal lumen. Thus, the two preferred surgical approaches for rectal adenocarcinomas (i.e. abdominal and transanal) are inappropriate for GISTs, due to: 1) the uselessness of total mesorectal excision; and 2) to the difficulty to locate the tumour with a transanal approach. We report here a case of a large GIST of the lower rectum which was successfully treated with a posterior trans-sacral approach. Lower rectum GISTs are good indications for the Kraske procedure, and this relatively new disease entity may contribute to the reintroduction of an old procedure into the armamentarium of 21(st) century colorectal surgeons.

Long-term quality of life after endoscopic dilation of strictured colorectal or colocolonic anastomoses.

BACKGROUND: Endoscopic balloon dilation is the first-line treatment for benign colorectal anastomotic strictures. We aimed to objectively assess its long-term results. METHODS: Gastrointestinal symptoms and health-related quality of life (HRQoL) were assessed at long-term after balloon dilation of anastomotic strictures in 31 consecutive patients (excluding those with inflammatory bowel disease) as well as and controls, using the validated Gastrointestinal Quality of Life Index (GIQLI). Most colectomies had been performed for benign diseases, with anastomoses located at the colorectal junction. RESULTS: Completed surveys were collected from 81 subjects, including 27 study patients (response rate 87%), 27 surgical controls matched for age, gender, and indication of colectomy, and 27 healthy subjects. At a mean of 3.9 +/- 2.3 years after the first endoscopic balloon-dilation, study patients self-reported significantly more gastrointestinal symptoms than controls; these included frequent and urgent bowel movements, bloating, food restriction (p < or = 0.001, all comparisons), diarrhea, excessive passage of gas through the anus (p < 0.01, all comparisons), constipation, and abdominal pain (p < 0.05, all comparisons). Health-related quality of life was significantly impaired in study patients versus surgical controls and healthy subjects (GIQLI scores, 104 +/- 20, 119 +/- 24, and 121 +/- 16, respectively; p = 0.005). Impaired HRQoL subdimensions included gastrointestinal symptoms (p < 0.001), stress by treatment (p < 0.05), and emotional status (p = 0.08). HRQoL was independent of the delay between stricture dilation and the survey. Follow-up endoscopy (performed in 21/27 [78%] study patients, including the 7 patients with the lowest HRQoL, and 19 [70%] surgical controls) disclosed anastomoses larger than 13 mm in all cases. CONCLUSIONS: Health-related quality of life is significantly impaired at long-term after standard balloon-dilation of benign anastomotic colorectal strictures as a result of gastrointestinal symptoms and stress by treatment. This impairment might be related to the fact that an anastomotic diameter > or = 13 mm, although commonly used to define successful endoscopic treatment, is insufficient to provide long-term symptom relief in some patients, or to other, yet to be identified, factors.

Treatment strategies for the management of advanced colorectal liver metastases detected synchronously with the primary tumour.

The review summarises the contributions of chemotherapy, interventional radiology and surgery to the improved survival observed in patients with colorectal liver metastases. The rationale in favour of modern neoadjuvant chemotherapy regimens, of pro-generative manoeuvres to increase the volume of the future remnant liver, and of resection techniques that preserve its function is discussed. For advanced synchronous colorectal metastases, the arguments in favour of a reversed approach with systemic chemotherapy, liver surgery and colon surgery in that order, as opposed to the traditional approach of colon surgery first, or to a simultaneous liver and large bowel resection, are presented.

[Vacuum-assisted abdominal closure: its role in the treatment of complex abdominal and perineal wounds. Experience in 48 patients]. / Le Vacuum Assisted Closure: utilité dans le traitement des plaies abdomino-périnéales complexes. Expérience sur 48 patients.

INTRODUCTION: Vacuum-assisted closure (VAC) is a promising approach for the management of complex abdominal and perineal wounds. This paper summarizes our experience with this therapeutic modality and demonstrates its efficacity in difficult situations. PATIENTS AND METHODS: From January 2003 until December 2005, 48 patients (age 30-89) were treated with VAC therapy for open abdomen, infected laparotomy wounds, or tissue loss due to debridement of Fournier's gangrene. Wound dressings were changed every 2-3 days. RESULTS: Thirty-eight patients (79%) had major co-morbid conditions liable to impact negatively on wound healing. The treatment duration with VAC varied from 20-30 days with an average of eleven dressing changes (minimum 3-maximum 18). Treatment was effective in all patients. Spontaneous closure was achieved in 36 cases (75%); nine patients (19%) required a split-thickness skin graft, and three (6%) underwent delayed secondary closure. CONCLUSION: In our institution, VAC has become the treatment of choice for complex abdominal and perineal wounds. It is a safe, simple, and effective technique to speed wound healing and it has reduced the duration of hospital treatment in difficult clinical situations and in patients whose general condition is often severely compromised.