Multidisciplinary Conference and Clinical Management of Rectal Cancer.

BACKGROUND: Presentation of rectal cancer cases at a colorectal cancer multidisciplinary conference (CRC-MDC) is a required standard for the newly formed National Accreditation Program for Rectal Cancer administered by the Commission on Cancer. The aim of this study was to determine the frequency and manner in which CRC-MDC changed the management of rectal cancer patients at a tertiary academic center. STUDY DESIGN: All rectal cancer cases presented at a weekly CRC-MDC between July 2015 and June 2016 were prospectively included. Patient demographics and clinical information were recorded. The presenting physician completed a uniform written questionnaire outlining any changes in management as a result of the discussion. RESULTS: There were 408 rectal cancer cases included, and survey responses were obtained for 371 (91%). Thirty-nine patients (11%) had stage IV disease and 20 (5%) had locally recurrent cancer. There was a documented change in plan as a result of the CRC-MDC discussion in 97 of 371 (26%) cases surveyed. Changes in management included a change in therapy or change in therapy sequence in 76 cases, and recommendation of additional evaluation in 36 cases. Rates of management change were similar regardless of surgeon experience. Changes occurred in 23%, 28%, and 26% of cases presented by surgeons with <10, 10 to 20, and >20 years of experience, respectively (chi-square p = 0.63). CONCLUSIONS: The CRC-MDC changes clinical management for a significant portion of rectal cancer patients at a tertiary center, independent of the presenting surgeon's years of clinical experience. Our results support the CRC-MDC standard for the National Accreditation Program for Rectal Cancer.

Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy.

OBJECTIVE: The aim of the study was to compare value (outcomes/costs) of proctectomy in patients with rectal cancer by 3 approaches: open, laparoscopic, and robotic. BACKGROUND: The role of minimally invasive proctectomy in rectal cancer is controversial. In the era of value-based medicine, costs must be considered along with outcomes. METHODS: Primary rectal cancer patients undergoing curative intent proctectomy at our institution between 2010 and 2014 were included. Patients were grouped by approach [open surgery, laparoscopic surgery, and robotic surgery (RS)] on an intent-to-treat basis. Groups were compared by direct costs of hospitalization for the primary resection, 30-day readmissions, and ileostomy closure and for short-term outcomes. RESULTS: A total of 488 patients were evaluated; 327 were men (67%), median age was 59 (27-93) years, and restorative procedures were performed in 333 (68.2%). Groups were similar in demographics, tumor characteristics, and treatment details. Significant outcome differences between groups were found in operative and anesthesia times (longer in the RS group), and in estimated blood loss, intraoperative transfusion, length of stay, and postoperative complications (all higher in the open surgery group). No significant differences were found in short-term oncologic outcomes. Direct cost of the hospitalization for primary resection and total direct cost (including readmission/ileostomy closure hospitalizations) were significantly greater in the RS group. CONCLUSIONS: The laparoscopic and open approaches to proctectomy in patients with rectal cancer provide similar value. If robotic proctectomy is to be widely applied in the future, the costs of the procedure must be reduced.

Long-term follow up of ileal pouch anal anastomosis in a large cohort of pediatric and young adult patients with ulcerative colitis.

AIM: The study's aim is to determine long-term outcomes in a large cohort of pediatric and young adult patients who underwent proctocolectomy with ileal pouch anal anastomsis (IPAA) for ulcerative colitis (UC). METHODS: Patients diagnosed with UC in childhood or adolescence (age≤21years) who underwent IPAA in childhood, adolescence, or young adulthood between 1982 and 1997 were contacted to determine pouch history, complications, and quality of life. RESULTS: Data were obtained from 74 patients out of a previously reported cohort. Median age at diagnosis of UC was 15years and at surgery was 18years. Median follow-up was 20years. Complications during follow-up were pouchitis (45%), strictures (16%), fistulae (30%), obstruction (20%), and change of diagnosis to Crohn's (28%). Twenty-three percent reported no complications. Fourteen percent had pouch failure, with Crohn's and fistulae reported to be the most frequent complications. Seventy-nine percent reported being very satisfied at 20years follow-up. CONCLUSION: To our knowledge, this study represents the largest cohort with the longest follow-up of pediatric and young adult patients undergoing IPAA for UC. Change in diagnosis to Crohn's and development of fistulae are risk factors for pouch failure. Despite reported complications, IPAA remains an excellent option for pediatric patients with UC.

Factors associated with the location of local rectal cancer recurrence and predictors of survival.

PURPOSE: The location of locally recurrent rectal cancer (LRRC) may influence survival. This study examines factors affecting the location of LRRC, the effect of LRRC location on survival, and predictive factors for survival in patients with LRRC. METHODS: Patients undergoing initial proctectomy and subsequent management of LRRC at the Cleveland Clinic (1980-2011) were included. Data regarding index surgery, LRRC, and survival were obtained from a prospectively maintained database. RESULTS: One hundred and fifty-seven patients were identified with a mean follow-up 59.8 ± 50.1 months and time to LRRC of 31.7 ± 30.1 months. Sixty patients underwent surgery with curative intent. Anastomotic leak and retrieving less than 12 lymph nodes at index proctectomy were associated with posterior (P = 0.019) and lateral (P = 0.036) recurrences, respectively. Having an axial relative to an anterior, posterior, or lateral recurrence was associated with improved overall survival (P = 0.001). On multivariable analysis, undergoing primarily palliative treatment (OR, 5.2; 95 % confidence interval (CI), 3.2-8.4; P < 0.001), age at LRRC >60 years (OR, 1.9; 95 % CI, 1.3-2.7, P < 0.001), advanced primary tumour stage (OR, 1.5; 95 % CI, 1.1-2.1; P = 0.021), and anastomotic leak at index surgery (OR, 1.8; 95 % CI, 1.2-2.7; P = 0.008) were associated with reduced LRRC 5-year survival. CONCLUSIONS: The current study suggests that features of the primary tumour and technical factors at the time of index proctectomy influence both the location of LRRC and survival.

The Impact of Preoperative Radiation Therapy on Locoregional Recurrence in Patients with Stage IV Rectal Cancer Treated with Definitive Surgical Resection and Contemporary Chemotherapy.

PURPOSE: Definitive resection of primary rectal cancers is frequently incorporated, with or without preoperative radiotherapy and perioperative chemotherapy, in the management of selected patients with metastatic rectal adenocarcinoma. This study reviews the impact of preoperative radiotherapy and perioperative chemotherapy on locoregional recurrence and overall survival in these patients. METHODS AND MATERIALS: This retrospective study with an Institutional Review Board (IRB) waiver included 109 patients with metastatic rectal adenocarcinoma who underwent definitive primary resection between 1998 and 2011. In addition to resection, 64 patients were treated with preoperative radiotherapy and perioperative chemotherapy and 45 patients were treated with perioperative chemotherapy alone. Radiotherapy dose was typically 50.4 Gy. Baseline variables were compared using chi-square and unpaired t tests. Overall survival was calculated using Kaplan-Meier method. Univariate and multivariate analyses were performed using Cox proportional hazards regression. RESULTS: There were no significant baseline differences between the two groups. There was no significant difference in locoregional recurrence (10.9 vs. 11.1%; p = 0.90) or overall survival (34.5 vs. 34.8 months; p = 0.89) for patients treated with preoperative radiotherapy compared to those treated with perioperative chemotherapy alone, respectively. Patients who underwent radiotherapy were less likely to have a positive margin (10.9 vs. 20.0%; p = 0.19), lymphovascular invasion (32.8 vs. 53.3%; p = 0.03), and pathologic stage N2 disease (25.0 vs. 42.2%; p = 0.02). Grade 2 postoperative complications were more common in the preoperative radiotherapy group (32.8 vs. 15.6%; p = 0.04). Multivariate analysis demonstrated that patients with poorly differentiated tumors (HR 2.19; p = 0.009) and those that did not undergo liver-directed therapy (HR 2.20; p = 0.005) had inferior survival. CONCLUSIONS: Locoregional recurrence is modest in patients with metastatic rectal adenocarcinoma receiving definitive primary resection, irrespective of the use of radiotherapy. Preoperative radiotherapy may enhance pathologic downstaging at the expense of increased grade 2 postoperative complications. Its use should be reserved for patients at high risk for locoregional recurrence.

Radiation therapy in patients with inflammatory bowel disease and colorectal cancer: risks and benefits.

PURPOSE: The effects of radiotherapy are debated in inflammatory bowel disease (IBD). We examined IBD patients with colorectal cancer (CRC) and compared those who underwent external beam radiation therapy (EBRT) to those who did not. We then compared those same patients treated with EBRT to similarly treated non-IBD patients to ascertain differences in toxicity and perioperative outcomes. METHODS: Fifty-seven IBD patients with CRC received EBRT, of which 23 had perioperative follow-up and 15 had complete records. The 23 patients were compared to 229 IBD patients with CRC who did not receive EBRT. The 15 patients were matched, 1:2, to similarly treated non-IBD patients with CRC based on age (±5 years), treatment year (±1 year), BMI (±10 kg/m2), and clinical stage. RESULTS: There was significantly more postoperative bleeding (5.3 % vs. 0 %, p < 0.01), wound dehiscence (3.5 % vs. 0 %, p < 0.01), and perineal infection (8.8 % vs. 1.3 %, p < 0.01) in IBD patients with EBRT compared to those without EBRT. IBD patients were significantly more likely to have grade 3 or higher lower GI toxicity (40 % vs. 7 %, p = 0.02) and wound dehiscence (36 % vs. 7 %, p = 0.02) than non-IBD patients, however without significant difference in bleeding, infection, ileus, or survival. CONCLUSION: IBD patients with CRC who received EBRT were more likely than similar patients without EBRT to experience perioperative complications. These patients also experienced more lower GI toxicity than similarly treated non-IBD patients with CRC. The expected decrease in survival in IBD-associated CRC was not observed. Thus, EBRT may contribute to a survival benefit in this group.

Risk and location of cancer in patients with preoperative colitis-associated dysplasia undergoing proctocolectomy.

OBJECTIVE: To evaluate the influence of preoperative dysplasia grade, appearance, and site on risk and location of cancer in patients with colitis. BACKGROUND: The ability to predict the presence and location of cancer in colitis patients with dysplasia is essential to facilitate recommendations regarding the necessity and type of surgery. METHODS: Ulcerative and indeterminate colitis patients who underwent proctocolectomy for dysplasia were retrospectively selected. Patient characteristics and findings at colonoscopic surveillance were associated with findings on the surgical specimen by regression analysis. RESULTS: From 1984 to 2007, 348 proctocolectomy specimens with preoperative dysplasia showed cancer in 51 (15%) and dysplasia in 172 (49%) cases. Patients with preoperative high-grade dysplasia (HGD) had cancer in 29% compared with 3% in low-grade dysplasia (LGD) (P < 0.001). Patients with preoperative dysplasia-associated lesion/mass (DALM) had cancer in 25% compared with 8% in flat dysplasia (P < 0.001). In LGD with DALM, the risk of cancer was not significantly higher than in flat LGD (7% vs 2%, P = 0.3), but risk of cancer or HGD was higher with a threefold increase (29% vs 9%, P = 0.015). On multivariate analysis, HGD, DALM, and disease duration were independent risk factors for postoperative cancer. In patients with isolated colonic dysplasia above the sigmoid level, postoperative rectal involvement was limited. CONCLUSIONS: Risk of cancer for patients with HGD or DALM is substantial. Despite low risk of cancer in patients with flat LGD, threshold for surgery should be low given the high prevalence of postoperative pathologic findings. Only in selected cases, colonoscopic surveillance after discussion of associated risks may be acceptable, provided high patient compliance can be assured. Surgery should be considered in all other cases, because it is the only modality that can eliminate the risk of cancer. The location of preoperative dysplasia may allow for the clarification of the need for proctectomy especially in the poor risk surgical patient.

Perineal wound healing following ileoanal pouch excision.

INTRODUCTION: There is paucity of information relating to perineal wound healing when pouch failure after ileal pouch anal anastomosis necessitates pouch excision (PE). The aim of this study is to evaluate perineal healing and factors associated with the development of persistent perineal sinus (PPS) after PE. METHODS: Perineal wound-related outcomes for patients who underwent PE from 1985-2009 were evaluated by type of closure (extrasphincteric, intersphincteric, and sphincter-preserving (SP)) and other factors (presence of Crohn's disease (CD) and/or perineal fistulae). Primary outcomes were PPS and delayed healing (healing after PPS development). RESULTS: One hundred ten patients (CD 48 %) underwent PE. PPS occurred in 39.8 % patients, 51 % had delayed perineal healing with further procedures, with an overall healing rate of 80.7 %. Closure technique was not associated with PPS (p = 0.37) or eventual healing (p = 0.94). For CD patients, risk of PPS (41 vs. 39 %, p = 0.83) and delayed healing (44 vs. 59 %, p = 0.61) was similar to non-CD patients, but uncomplicated healing took longer (p = 0.04). Four of 15 (26.7 %) patients who underwent SP closure developed PPS; all eventually healed with secondary sphincter excision. CONCLUSIONS: Perineal healing may be prolonged after pouch excision. Since eventual healing can be achieved in most patients, perineal dissection and closure can be tailored to the individual circumstance. Sphincter preservation may be used in non-CD patients if future reconstruction is possible. Extrasphincteric closure is preferable with cancer or perineal sepsis. Sphincter resection allows for complete healing in patients who undergo SP dissection and develop PPS.

Less than 12 nodes in the surgical specimen after total mesorectal excision following neoadjuvant chemoradiation: it means more than you think!

BACKGROUND: A minimum of 12 examined lymph nodes (LN) is recommended to ensure adequate staging and oncologic resection of patients undergoing proctectomy for rectal adenocarcinoma. However, a decreased number of LN is not unusual in patients receiving neoadjuvant chemoradiation. PURPOSE: We hypothesized that a decreased number of LN in the proctectomy specimen of these patients may be an indicator of tumor response and be associated with improved prognosis. METHODS: A single-center colorectal cancer database was queried for c-stage II-III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. Patients were categorized into two groups according to the number of LN retrieved from the proctectomy specimen: <12 LN versus ≥12 LN. Groups were compared with respect to demographics, tumor and treatment characteristics, and the following oncologic outcomes: overall-survival (OS), cancer-specific-mortality (CSM), cancer-free-survival (CFS), distant (DR), and local recurrences (LR). RESULTS: The query returned 237 patients. There were 173 (73 %) males, and the median age was 57 years [interquartile range (IQR) 49-66 years]. The median number of LN retrieved was 15 (IQR 10-23) and 70 (30 %) patients had less than 12 nodes examined. The <12 nodes group was older [60 (IQR 51-71 years) vs. 55 (IQR 48-65 years), p = 0.009] and had more pathologic complete responders (36 vs. 19 %, p = 0.01). No <12 nodes patient experienced a LR, whereas the 5-year LR rate was 11 % in the ≥12 nodes group (p = 0.004). Other oncologic outcomes were not significantly different. CONCLUSIONS: Retrieval of less than 12 nodes in the proctectomy specimen of rectal cancer patients treated with neoadjuvant chemoradiation does not affect OS, CSM, CFS, or DR and may be a marker of higher tumor response and, consequently, decreased LR rate.

Impact of obesity on operation performed, complications, and long-term outcomes in terms of restoration of intestinal continuity for patients with mid and low rectal cancer.

BACKGROUND: The impact of obesity per se on the surgical strategy, ie, sphincter sacrifice (abdominoperineal resection) vs sphincter-preserving resection, outcomes, and long-term maintenance of intestinal continuity has been poorly studied in patients with mid and low rectal cancer. OBJECTIVE: The aim of this study is to compare the outcomes and long-term maintenance of intestinal continuity for obese and nonobese patients treated surgically for mid and low rectal cancers. DESIGN: This is a retrospective cohort study from a prospectively collected database. SETTING: The investigation took place in a high-volume specialized colorectal surgery department. PATIENTS: All patients who underwent curative surgery for mid or low rectal adenocarcinoma at a single institution from 1976 to 2011 were identified. MAIN OUTCOME MEASURES: Obese (BMI ≥ 30 kg/m) and nonobese patients were matched 1:2 for age, sex, ASA class, location, and stage of tumor. Demographics, use of neoadjuvant chemoradiotherapy, operative and perioperative outcomes, pathology, long-term outcomes including oncologic outcomes, and whether restoration of intestinal continuity was obtained were compared. RESULTS: One hundred fifty-seven obese patients and 314 nonobese patients were included in the study. The groups were similar for matched characteristics. The use of neoadjuvant chemoradiotherapy (p = 0.048) and anastomotic leak (p = 0.0003) rates were higher in obese patients. A similar proportion of nonobese and obese patients underwent sphincter-preserving resection (p > 0.99), and postoperative hospital stay (p = 0.23), 30-day postoperative reoperation (p = 0.83), mortality (p > 0.99), and readmissions (p = 0. 13) were similar. The obese and nonobese groups had similar overall (p = 0.61) and disease-free survival (p = 0.74) at a mean follow-up of 5 years for both groups. LIMITATIONS: This study was limited by its retrospective and nonrandomized nature. CONCLUSION: At a high-volume specialized colorectal unit, proctectomy can be performed in obese patients with similar long-term oncologic outcomes and ability to restore intestinal continuity in comparison with nonobese patients. Proctectomy in obese patients, however, is associated with an increased risk of anastomotic leak in comparison with nonobese patients.

Endorectal ultrasound does not reliably identify patients with uT3 rectal cancer who can avoid neoadjuvant chemoradiotherapy.

PURPOSE: Neoadjuvant chemoradiation (NCRT) may be avoided in some patients with T3-staged rectal cancer undergoing radical resection. We aimed to evaluate the accuracy of endorectal ultrasound (ERUS) in the nodal staging of uT3 tumors and hence the decision for administration of NCRT. METHODS: Patients with uT3-staged rectal cancer who underwent proctectomy were retrospectively identified. The accuracy of ERUS for detecting nodal involvement was determined for patients who did not undergo NCRT. In order to evaluate the impact of use of NCRT, oncologic outcomes, functional outcomes, and quality of life (QOL) were compared for patients who received NCRT (group A) and those who did not (group B). RESULTS: For 384 patients who were included, ERUS overstaging rate for nodal involvement was 6.3% while understaging rate was 23.2%. For the 289 patients in group A and 95 in group B, Kaplan-Meier analysis showed similar 5-year local recurrence rates (3.5%), overall survival (76.9 vs 75.6%), and disease-free survival (87.9 vs 88.1%). Node positivity on final pathology was however associated with worse 5-year local recurrence (9.3 vs 4.3%). For patients undergoing restorative resection, NCRT was associated with worse functional outcomes but QOL was similar. CONCLUSIONS: ERUS identification of nodal involvement used as a criterion for NCRT carries a greater risk for undertreatment than overtreatment. Undertreatment adversely affects oncologic outcomes. While there is functional impairment related to NCRT, its effect on QOL is non-significant. The decision for omitting neoadjuvant chemoradiation for uT3 rectal cancer should hence not be based on ERUS nodal staging alone.

Dysplasia associated with Crohn's colitis: segmental colectomy or more extended resection?

BACKGROUND AND OBJECTIVE: There is limited data on the appropriate management of dysplasia in Crohn's colitis. An evidence-based surgical strategy is provided. METHODS: Patients with a pathologic diagnosis of dysplasia in Crohn's colitis from 1987 to 2009 were identified. Patients were classified by dysplasia grade (low grade or LGD, high grade or HGD). Clinical, endoscopic, operative, and pathologic data were retrieved. Factors associated with a final cancer diagnosis were analyzed. Survival data on patients undergoing limited versus radical resection for cancer and HGD was compared. RESULTS: From 1987 to 2009, 50 patients underwent a colectomy for Crohn's colitis-associated dysplasia. The predictive value of HGD for a final HGD or cancer diagnosis was 73%. The predictive value of LGD on biopsy for HGD in the colectomy was 36%. Sixteen patients (44%) who underwent a total proctocolectomy (TPC) or subtotal colectomy (STC) had multifocal dysplasia. Four of 10 (40%) cancer patients had evidence of dysplasia remote from cancer site on pathologic examination. During follow-up, there were 3 cancer-related deaths. One patient died of metachronous cancer after STC. CONCLUSIONS: The findings confirm the risk of cancer in patients with CD dysplasia. Because of the multifocal nature of dysplasia in Crohn's colitis, TPC is recommended in good-risk patients. In specific circumstances, such as poor-risk patients especially in the setting of LGD, close endoscopic surveillance or alternatively segmental or STC with close postoperative endoscopic surveillance, depending upon the individual circumstance, may be discussed.

Influence of neoadjuvant radiotherapy on anastomotic leak after restorative resection for rectal cancer.

PURPOSE: This study was undertaken to determine whether neoadjuvant radiotherapy is associated with an increased risk of anastomotic leak for rectal cancer patients undergoing restorative resection. METHODS: From 1980 to 2010, patients who underwent restorative resection for rectal cancer (tumors within 15 cm of anal verge) were identified from a prospective institutional database and grouped based on whether they received neoadjuvant radiotherapy (+RT) or not (-RT). The main outcome was anastomotic leak documented by imaging (contrast leak), intra-operative or clinical (signs of peritonitis) findings and confirmed by staff surgeon assessment. Using multivariate (MV) analysis risk factors for leak were identified, presented as OR (95 % CI). RESULTS: One thousand eight hundred sixty-two patients were included in the analysis, 28 % in the +RT group. Eighty-six percent of +RT patients received neoadjuvant chemoradiotherapy. The overall leak rate was 6.3 %, with no significant difference in +RT and -RT groups (8 % vs 5.7 %, p = 0.06). The +RT group had a lower mean age at surgery (58 vs 63 year, p < 0.001), more male (75 % vs 62 %, p < 0.001) and more ASA 3/4 (44 % vs 35 %, p < 0.001) patients, greater use of defunctioning ostomy (87 % vs 44 %, p < 0.001) and colo-anal anastomosis (77 % vs 34 %, p < 0.001). Mean tumor distance from the anal verge was lower in +RT group (6.6 vs 9.7 cm, p < 0.001). On MV analysis, male sex (OR 1.64 (1.03-2.62), p = 0.038), ASA 4 (OR 4.70 (2.07-10.7), p < 0.001), tumor distance from anal verge ≤ 5 cm (OR 2.49 (1.37-4.52), p = 0.003), and tumor size at surgery ≥ 4 cm (OR 1.75 (1.15-2.65), p = 0.009) were independently associated with leak. +RT was not independently associated with leak (OR 1.44 (0.85-2.46), p = 0.18), while defunctioning ostomy did not reduce leak occurrence (OR 0.75 (0.44-1.28), p = 0.29). CONCLUSIONS: The findings suggest that neoadjuvant radiotherapy is not independently associated with an anastomotic leak for rectal cancer patients undergoing restorative resection and support a selective policy towards the use of a defunctioning ostomy on a case by case basis based on intra-operative judgment and consideration of tumor location, size, and patient characteristics.

The predictive value of preoperative carcinoembryonic antigen level in the prognosis of colon cancer.

BACKGROUND: We evaluated factors associated with an increased preoperative carcinoembryonic antigen (CEA) level for colon cancer patients undergoing elective curative surgery and assessed whether this was associated with prognosis when accounting for other potential confounders. METHODS: Prospectively accrued data of patients with stage I, II, and III colon cancer undergoing surgery (1980-2008) were retrieved retrospectively. Patients with a preoperative CEA level greater than 5 ng/mL (group B) were compared with those with a CEA level of 5 ng/mL or less (group A). RESULTS: There were 651 patients (379 men) with a median age of 67 years (range, 21-94 y) and a median follow-up period of 5.9 years. Groups A (n = 451) and B (n = 200) had similar ages and tumor locations. Group B had larger tumors; more patients with T3 and N1/N2; and more patients with stage II/III tumors, and hence greater use of chemotherapy (P = .04). On multivariate analysis, patient age, tumor stage, and differentiation were associated with oncologic outcomes. A CEA level greater than 5 ng/mL was not associated independently with recurrence, recurrence-free survival (P = .47), or overall survival (P = .3). CONCLUSIONS: An increased preoperative CEA level is a marker for a more advanced tumor stage. For adequately staged patients, a high preoperative CEA level is not associated independently with oncologic outcomes.

Factors associated with oncologic outcomes after abdominoperineal resection compared with restorative resection for low rectal cancer: patient- and tumor-related or technical factors only?

BACKGROUND: Previous reports suggest that patients with rectal cancer undergoing abdominoperineal resection have worse oncologic outcomes in comparison with those undergoing restorative rectal resection. OBJECTIVE: This study aimed to assess factors influencing oncologic outcomes for patients undergoing surgery for rectal cancer. DESIGN: This study is a retrospective review of prospectively gathered data. SETTING: Data were gathered from a prospective cancer database. PATIENTS: Patients were included who underwent radical resection for mid and lower third rectal cancer (1991-2006). MAIN OUTCOME MEASURES: The primary outcomes measured were the impact of various factors on perioperative outcomes, local recurrence, and disease-free survival for patients undergoing abdominoperineal resection. RESULTS: Four hundred thirteen (29%) patients underwent abdominoperineal resection and 993 (71%) underwent restorative resection for rectal cancer. Patients with abdominoperineal resection were older (p < 0.0001), had a higher mean ASA score (p < 0.001), worse tumor differentiation (p < 0.001), and higher tumor stage (p = 0.0001). Although overall morbidity was lower in the abdominoperineal resection group (p = 0.001), the length of stay was greater (p < 0.001). After a similar period of follow-up (5.2 ± 3.9 vs 5.3 ± 3.4 y, p = 0.58), local recurrence (7% vs 3%, p = 0.02) was higher after abdominoperineal resection, but overall survival (56% vs 71%, p < 0.001) and disease-free survival (54% vs 70%, p < 0.001) were lower. On multivariate analysis, higher stage, poor tumor differentiation, involved margins, and older age were associated with worse survival, whereas higher stage, poor tumor differentiation, and abdominoperineal resection were associated with greater recurrence. These worse oncologic outcomes persisted even when the groups were stratified based on the location of the cancer in mid or distal rectum and for patients with a clear circumferential margin. LIMITATION: This study was limited by its retrospective nature. CONCLUSION: Technical factors alone are unlikely to be responsible for the worse outcomes after abdominoperineal resection in comparison with restorative resection. A combination of patient- and tumor-related factors that may have indicated the choice of the procedure also probably contribute to the worse outcomes. Because patients undergoing abdominoperineal resection represent a high risk for poor outcomes, management strategies need to consider all these factors during treatment.

Is adjuvant chemotherapy really needed after curative surgery for rectal cancer patients who are node-negative after neoadjuvant chemoradiotherapy?

PURPOSE: Adjuvant chemotherapy is currently offered, as standard, after curative resection for patients with rectal cancer who receive neoadjuvant chemoradiation (NCRT). We postulate that adjuvant chemotherapy adds minimal oncologic benefit for patients who undergo total mesorectal excision who are node-negative after neoadjuvant chemoradiation. METHODS: From a prospective, institutional cancer database, rectal cancer patients who completed neoadjuvant chemoradiation and curative surgery (2000-2008) and were node-negative on final pathology were identified. Patient, tumor, treatment characteristics, and oncologic outcomes were compared for patients who completed intended adjuvant chemotherapy (group chemo) or did not receive any chemotherapy (group no-chemo). RESULTS: Chemo (n=58) and no-chemo (n=70) patients had similar age (P=0.13), gender (P=0.67), body mass index (P=0.46), American Society of Anesthesiologists class (P=0.67), preoperative tumor stage (P=0.16), type of surgery (P=0.76), and postoperative complications. The no-chemo group had greater complete pathologic response (n=34, 48.6% vs. n=14, 24.1%). After prolonged follow-up, local recurrence (P=1), disease-free survival (P=0.41), and overall survival (P=0.52) were similar. Oncologic benefits of adjuvant chemotherapy were especially questionable for patients with complete pathologic response (chemo vs. no-chemo, local recurrence at 5 years: 0 vs. 2.9%, P>0.99), disease-free (79.1% vs. 88%, P=0.51), and overall survival (90.9% vs. 95.2%, P=0.41). CONCLUSIONS: These results question the routine use of adjuvant chemotherapy for patients with rectal cancer who undergo curative surgery who have been rendered node-negative by neoadjuvant chemoradiation.

A novel data-driven prognostic model for staging of colorectal cancer.

BACKGROUND: The aim of this study was to develop a novel prognostic model that captures complex interplay among clinical and histologic factors to predict survival of patients with colorectal cancer after a radical potentially curative resection. STUDY DESIGN: Survival data of 2,505 colon cancer and 2,430 rectal cancer patients undergoing radical colorectal resection between 1969 and 2007 were analyzed by random forest technology. The effect of TNM and non-TNM factors such as histologic grade, lymph node ratio (number positive/number resected), type of operation, neoadjuvant and adjuvant treatment, American Society of Anesthesiologists (ASA) class, and age in staging and prognosis were evaluated. A forest of 1,000 random survival trees was grown using log-rank splitting. Competing risk-adjusted random survival forest methods were used to maximize survival prediction and produce importance measures of the predictor variables. RESULTS: Competing risk-adjusted 5-year survival after resection of colon and rectal cancer was dominated by pT stage (ie, tumor infiltration depth) and lymph node ratio. Increased lymph node ratio was associated with worse survival within the same pT stage for both colon and rectal cancer patients. Whereas survival for colon cancer was affected by ASA grade, the type of resection and neoadjuvant therapy had a strong effect on rectal cancer survival. A similar pattern in predicted survival rates was observed for patients with fewer than 12 lymph nodes examined. Our model suggests that lymph node ratio remains a significant predictor of survival in this group. CONCLUSIONS: A novel data-driven methodology predicts the survival times of patients with colorectal cancer and identifies patterns of cancer characteristics. The methods lead to stage groupings that could redefine the composition of TNM in a simple and orderly way. The higher predictive power of lymph node ratio as compared with traditional pN lymph node stage has specific implications and may address the important question of accuracy of staging in patients when fewer than 12 nodes are identified in the resection specimen.

Abdominoperineal resection does not decrease quality of life in patients with low rectal cancer.

PURPOSE: Issues related to body image and a permanent stoma after abdominoperineal resection may decrease quality of life in rectal cancer patients. However, specific problems associated with a low anastomosis may similarly affect quality of life for patients undergoing low anterior resection. The aim of this study was to compare quality of life of low rectal cancer patients after undergoing abdominoperineal resection versus low anterior resection. METHODS: Demographics, tumor and treatment characteristics, and prospectively collected preoperative quality-of-life data for patients undergoing low anterior resection or abdominoperineal resection for low rectal cancer between 1995 and 2009 were compared. Quality of life collected at specific time intervals was compared for the two groups, adjusting for age, body mass index, use of chemoradiation, and 30 days postoperative complications. The short-form-36 questionnaire was used to determine quality of life. RESULTS: The query returned 153 patients (abdominoperineal resection = 68, low anterior resection = 85) with a median follow-up of 24 (3-64) mo. The after abdominoperineal resection group had a higher mean age (63 + 12 vs. 54 + 12, p < 0.001) and more American Society of Anesthesiologists classification 3/4 patients (65 percent vs. 43 percent, p = 0.03) than low anterior resection. Other demographics, tumor stage, use of chemoradiation, overall postoperative complication rates, and quality-of-life follow-up time were not statistically different in both groups. Patients undergoing abdominoperineal resection had a lower baseline short-form-36 mental component score than those undergoing low anterior resection. However, 6 mo after surgery this difference was no longer statistically significant and essentially disappeared at 36 mo after surgery. CONCLUSION: Patients undergoing abdominoperineal resection for low rectal cancer have a similar long-term quality of life as those undergoing low anterior resection. These findings can help clinicians to better counsel patients with low rectal cancer who are being considered for abdominoperineal resection.

Prone or lithotomy positioning during an abdominoperineal resection for rectal cancer results in comparable oncologic outcomes.

BACKGROUND: There is debate whether performing the perineal part of the abdominoperineal resection in a prone position in comparison with a lithotomy position optimizes circumferential resection margins and, subsequently, cancer outcomes. OBJECTIVE: The aim of this study was to compare outcomes of patients undergoing abdominoperineal in a prone vs a lithotomy position. DESIGN: A single-center, prospectively maintained colorectal cancer database was queried for patients with stages I to III rectal cancer undergoing abdominoperineal resection in a prone vs a lithotomy position from 1997 to 2007. Patients were compared with respect to demographics, tumor and treatment characteristics, perioperative morbidity, and oncologic outcomes. Oncologic outcomes were adjusted for age, ASA class, tumor stage, and use of adjuvant treatments. χ², Fisher exact probability test, Wilcoxon rank-sum test, Kaplan-Meier estimates, log-rank sum test, and Cox regression models were used for the analysis. P < .05 was considered significant. RESULTS: The query returned 168 patients (81 prone and 87 lithotomy), with a median age of 63 (interquartile range, 52-74) years and a median follow-up of 42 (interquartile range, 23-69) months. Prone and lithotomy patients were not statistically different regarding demographics, tumor stage, rates of R0 resection, number of harvested nodes, perioperative morbidity, follow-up time, and oncologic outcomes. CONCLUSIONS: Surgical positioning during the perineal part of the abdominoperineal resection does not affect perioperative morbidity or oncologic outcomes and should be left to the surgeon's discretion.

Efficacy and safety of endoscopic treatment of ileal pouch strictures.

BACKGROUND: Endoscopic management of ileal pouch strictures has not been systemically studied. The aim was to evaluate endoscopic balloon therapy of pouch strictures in inflammatory bowel disease (IBD) patients with ileal pouches and to identify risk factors for pouch failure for those patients. METHODS: Consecutive IBD patients with pouches from the Pouchitis Clinic who underwent nonfluoroscopy-guided outpatient endoscopic therapy were studied. The location, number, degree (range 0-3), and length of strictures and balloon size were documented. Efficacy and safety were evaluated with univariate and multivariate analyses. RESULTS: A total of 150 patients with pouch strictures were studied. Stricture locations were at the pouch inlet (n = 96), outlet (n = 73), afferent limb (n = 33), and pouch body (n = 2). A cumulative of 646 strictures were endoscopically dilated, with a total of 406 pouchoscopies. The median stricture score was 1 (interquartile range [IQR] 1-2); the median stricture length was 1 (IQR 0.5-1.25) cm, and the median balloon size was 20 (IQR 18-20) mm. Of 406 therapeutic endoscopies performed, there were two perforations (0.46%) and four transfusion-required bleeding (0.98%). The 5-, 10-, and 25-year pouch retention rates were 97%, 90.6%, and 85.9%, respectively. In a median follow-up of 9.6 (IQR 6-17) years, 131 patients (87.3%) were able to retain their pouches. The number of strictures and underlying diagnosis were independent risk factors for pouch failure in the Cox regression model. CONCLUSIONS: Endoscopic treatment of pouch stricture appears to be efficacious and generally safe to perform in experienced hands. Underlying diagnosis of Crohn's disease of the pouch and surgery-related strictures and multiple strictures were the risk factors for pouch failure.