The number of high-risk factors is related to outcome in stage II colonic cancer patients.

BACKGROUND: A subgroup of stage II colonic cancer patients are considered to be at high-risk for recurrent/metastatic disease based on 1) tumour obstruction/perforation 2) <10 lymph nodes 3) T4 lesions and 4) lymphangio-invasion. Their prognosis is regarded as comparable to stage III (T1-4N+M0) colonic cancer and it is therefore strongly advised to treat them with adjuvant chemotherapy. The purpose of this study was i) to determine the magnitude of prognostic significance of the conventional high-risk factors and ii) to determine whether the number of high-risk factors influences outcome. METHODS: We retrospectively analyzed 212 stage II colonic cancer patients undergoing surgery between January 2002 and December 2008. No adjuvant chemotherapy was given. Survival analyses were performed. RESULTS: 154/212 (73%) patients were considered to be high-risk patients based on conventional high-risk factors. 58 patients did not meet any high-risk factor, 125 patients met 1 high-risk factor and 29 patients met ≥2 high-risk factors. Median follow up was 40 months. Multivariate analysis identified four independent risk factors for recurrent/metastatic disease: age, obstruction, perforation and lymphangio-invasion. The three-year-DFS-rates for the low-risk group, the high-risk group with 1 high-risk factor and the high-risk group with ≥2 high-risk criteria are 90.4%, 87.6% and 75.9% respectively. Patients meeting ≥2 conventional high-risk criteria had a significantly worse three-year disease free survival (p < 0.002). CONCLUSIONS: Four independent high-risk factors were identified. The number of high-risk factors does influence outcome. More attention should be given to the definition and treatment of high-risk stage II colonic cancer patients.

Percutaneous cholecystostomy in critically ill patients with a cholecystitis: a safe option.

BACKGROUND: Cholecystectomy is the standard procedure in patients with acute cholecystitis. However, some patients might not be able to undergo immediate surgery because of severe sepsis or underlying comorbid conditions. Percutaneous cholecystostomy is a minimally invasive radiological procedure under local anesthesia which seems to be an effective alternative to conservative treatment or immediate laparoscopic/open cholecystectomy. METHODS: We retrospectively analyzed 35 patients who underwent percutaneous cholecystostomy between 2003 and 2009. RESULTS: Percutaneous cholecystostomy was technically successful in all patients. Symptoms resolved within 3 days in 33/35 patients. Two patients needed an emergency laparotomy. The catheter dislodged in 5 patients and was replaced in 2/5. The 30-day mortality rate was 3/35 (8.7%) due to gallbladder necrosis, myocardial infarction and multiorgan failure. Median length of hospital stay was 17 days and median drainage time was 28 days. 23 patients (66%) underwent open or laparoscopic cholecystectomy after a median interval of 44 days. CONCLUSION: Percutaneous cholecystostomy is an effective procedure and a good alternative for patients unfit to undergo immediate surgery because of severe sepsis or underlying comorbid conditions, preferably followed by interval cholecystectomy to prevent recurrent cholecystitis.

Transanal endoscopic microsurgery for local excision of rectal lesions: is there a learning curve?

BACKGROUND: Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for the local resection of benign and stage T1 rectal lesions in selected patients, associated with lower morbidity and mortality rates than open surgery. We present our initial results and assess whether experience influences outcome after TEM. METHODS: This was a prospective descriptive survey. All patients undergoing TEM for tubulovillous adenoma or carcinoma between 2002 and 2007 were included. RESULTS: A total of 105 patients were included. Median age was 68 years. Median distance of the lesion from the anal verge was 7.0 cm; median operating time was 90 min. In 10 patients, the peritoneum was opened. Six procedures were converted to (low) anterior resections. Postoperative staging revealed 77 tubulovillous adenomas, 22 stage T1, 5 stage T2 and 1 stage T3 carcinomas; tumor resection was radical in 86%. The postoperative complication rate was 7.6%. Length of hospital stay, operating time and complications significantly diminished over time. After a median follow-up of 27 months, 8 recurrences occurred (7.6%). CONCLUSION: TEM is a safe technique with low morbidity and recurrence rates. Over time, experience leads to a reduction in operation time, length of patients' hospital stay and complication rate. TEM remains the treatment of choice for benign lesions and stage T1 rectal carcinomas in selected patients.