Australasian ACPGBI risk prediction model for 30-day mortality after colorectal cancer surgery.

BACKGROUND: Postoperative mortality after colorectal cancer surgery varies across hospitals and countries. The aim of this study was to test the Association of Coloproctologists of Great Britain and Ireland (ACPGBI) models as predictors of 30-day mortality in an Australian cohort. METHODS: Data from patients who underwent surgery in six hospitals between 1996 and 2015 (CRC data set) were reviewed to test ACPGBI models, and patients from 79 hospitals in the Bi-National Colorectal Cancer Audit between 2007 and 2016 (BCCA data set) were analysed to validate model performance. Recalibrated models based on ACPGBI risk models were developed, tested and validated on a data set of Australasian patients. RESULTS: Of 18 752 patients observed during the study, 6727 (CRC data set) and 3814 (BCCA data set) were analysed. The 30-day mortality rate was 1·1 and 3·5 per cent in the CRC and BCCA data sets respectively. Both the original and revised ACPGBI models overestimated 30-day mortality for the CRC data set (observed to expected (O/E) ratio 0·17 and 0·21 respectively). Their ability to correctly predict mortality risk was poor (P < 0·001, Hosmer-Lemeshow test); however, the area under the curve for both models was 0·88 (95 per cent c.i. 0·85 to 0·92) showing good discriminatory power to classify 30-day mortality. The recalibrated original model performed well for calibration and discrimination, whereas the recalibrated revised model performed well for discrimination but not for calibration. Risk prediction was good for both recalibrated models. On external validation using the BCCA data set, the recalibrated models underestimated mortality risk (O/E ratio 3·06 and 2·98 respectively), whereas both original and revised ACPGBI models overestimated the risk (O/E ratio 0·48 and 0·69). All models showed similar good discrimination. CONCLUSION: The original and revised ACPGBI models overpredicted risk of 30-day mortality. The new Australasian calibrated ACPGBI model needs to be tested further in clinical practice.

ANTECEDENTES: La mortalidad postoperatoria tras la cirugía del cancer colorrectal (colorectal cáncer, CRC) varía entre hospitales y países. El objetivo de este estudio era evaluar los modelos de la Asociación de Coloproctólogos de Gran Bretaña e Irlanda (Association of Coloproctologists of Great Britain and Ireland, ACPGBI) como predictores de mortalidad a los 30 días en una cohorte de pacientes de Australia. MÉTODOS: Se revisaron los datos de pacientes sometidos a cirugía en seis hospitales entre 1996-2015 (datos CRC) para evaluar los modelos ACPGBI, mientras que los datos recogidos en 79 hospitales en la auditoría bi-nacional de cáncer colorrectal (Bi-National Colorectal Cancer Audit) entre 2007-2016 (datos BCCA) se analizaron para validar el comportamiento del modelo. Se desarrollaron modelos recalibrados basados en los modelos de riesgo ACPGBI que fueron aplicados y validados en un conjunto de datos multi-institucionales de pacientes australianos. La mortalidad observada y estimada (tasa 0/E) a 30 días se calculó en los modelos ACPGBI original y revisados usando el test de Hosmer-Lemeshow y los análisis de la curva de las características operador-receptor (ROC) para evaluar la calibración y discriminación de los modelos. RESULTADOS: De un total de 18,752 pacientes observados durante el periodo de estudio, se analizaron 6.727 (datos CRC) y 3.814 (datos BCCA). La mortalidad en los pacientes del grupo de datos CRC fue del 1,1% y en los del grupo de datos BCCA del 3,5%. Para el grupo de datos CRC, los modelos ACPGBI sobreestimaron significativamente la mortalidad a los 30 días, tanto en el modelo original como en el modelo revisado (O/E 0,17 y 0,21). La capacidad de los modelos para predecir correctamente el riesgo de mortalidad también fue limitada (test de Hosmer-Lemeshow 23,1 y 22.9); sin embargo, el área bajo la curva ROC de ambos modelos fue de 0,88 (i.c. del 95% 0,85-0,92) con una buena capacidad discriminatoria para clasificar a los pacientes que fallecían durante los primeros 30 días tras la cirugía. El modelo original ACPGBI recalibrado presentó un buen comportamiento para la predicción de riesgo (tasa O/E 1,06), pero no fue así en el caso del modelo revisado ACPGBI recalibrado (tasa O/E 0,99). En la validación externa con los datos BCCA, los modelos recalibrados subestimaron el riesgo de mortalidad a los 30 días (tasa O/E 3,06 y 2,98), mientras que los modelos ACPGBI original y revisado sobreestimaron el riesgo (tasa O/E 0,48 y 0,69, respectivamente). Todos los modelos mostraron una buena discriminación en las curvas ROC. CONCLUSIÓN: Los modelos ACPGBI original y revisado sobreestimaron el riesgo de mortalidad a los 30 días. Se desarrolló un nuevo modelo, denominado modelo ACPGBI calibrado australiano o modelo ACACPGBI, cuya utilidad en la práctica clínica debe ser evaluada.

Role of lymph node yield and lymph node ratio in predicting outcomes in non-metastatic colorectal cancer.

Background: Lymph node yield (LNY) of 12 or more in resection of colorectal cancer is recommended in current international guidelines. Although a low LNY (less than 12) is associated with poorer outcome in some studies, its prognostic value is unclear in patients with early-stage colorectal or rectal cancer with a complete pathological response following neoadjuvant therapy. Lymph node ratio (LNR), which reflects the proportion of positive to total nodes obtained, may be more accurate in predicting outcome in stage III colorectal cancer. This study aimed to identify factors correlating with LNY and evaluate the prognostic role of LNY and LNR in colorectal cancer. Methods: An observational study was performed on patients with colorectal cancer treated at three hospitals in Melbourne, Australia, from January 2010 to March 2016. Association of LNY and LNR with clinical variables was analysed using linear regression. Disease-free (DFS) and overall (OS) survival were investigated with Cox regression and Kaplan-Meier survival analyses. Results: Some 1585 resections were analysed. Median follow-up was 27·1 (range 0·1-71) months. Median LNY was 16 (range 0-86), and was lower for rectal cancers, decreased with increasing age, and increased with increasing stage. High LNY (12 or more) was associated with better DFS in colorectal cancer. Subgroup analysis indicated that low LNY was associated with poorer DFS and OS in stage III colonic cancer, but had no effect on DFS and OS in rectal cancer (stages I-III). Higher LNR was predictive of poorer DFS and OS. Conclusion: Low LNY (less than 12) was predictive of poor DFS in stage III colonic cancer, but was not a factor for stage I or II colonic disease or any rectal cancer. LNR was a predictive factor in DFS and OS in stage III colonic cancer, but influenced DFS only in rectal cancer.

Surgical outcome after standard abdominoperineal resection: A 15-year cohort study from a single cancer centre.

BACKGROUND: Abdominoperineal resection (APR) is associated with a poorer oncological outcome than anterior resection. This may be due to higher rates of intra-operative perforation and circumferential resection margin involvement. The aim of this study was to audit our short and long-term results of abdominoperineal resection performed using conventional techniques and to compare this with other published series. MATERIALS AND METHODS: A retrospective review of all patients who had standard APR between January 2000 and December 2016 in a single institution, Cabrini Hospital, Melbourne, Australia. A total of 163 cases performed by nine different colorectal surgeons for primary rectal adenocarcinoma were identified, with their clinicopathological data analysed. RESULTS: Using standard APR, only six patients (3.7%) were found to have a positive circumferential resection margin (CRM). There were two cases of intra-operative perforation (1.2%). Local recurrence rate was 5.6% of patients, with distant recurrence found in 24.9%. Disease-free survival at five years was 73.1%. Five-year overall survival was 66.7%, 67.9% of all deaths were cancer-related. CONCLUSION: Short and long-term outcomes after standard APR in this study were comparable to previous published studies. The CRM rate of 3.7% compares favourably to published positive CRM rates for standard APR which ranged from 6 to 18%. Standard APR remains a viable technique for the treatment of rectal cancer. Patient selection and adequate training remain important factors.

The first 1000 patients on an internet-based colorectal neoplasia database across private and public medicine in Australia: development of a binational model for the Colorectal Surgical Society of Australia and New Zealand.

BACKGROUND: Collection of multi-institutional data pertaining to the treatment of bowel cancer has been hindered by poor clinician compliance with data entry and the lack of incentive to participate. OBJECTIVE: This study aimed to establish if a novel browser-based model of data collection results in complete data capture. DESIGN: A Web-based data collection interface was custom written, offering automated reporting modules for clinical outcome to participants and an automated reporting system for outstanding data fields, and summary reporting of surgical quality outcomes. The software was combined with a clinical feedback system incorporating fortnightly data review meetings, at the time of clinical multidisciplinary meetings. PATIENTS AND SETTING: Selected were 932 consecutive patients with opt-out consent from 3 hospital sites, including public and private medicine. MAIN OUTCOME MEASURES: The primary outcomes measured were the analysis of data completeness and accuracy and ensuring that the highest-quality data were used for clinical audit of the surgical practices of Australian colorectal surgeons for the purpose of quality assurance. RESULTS: A total of 932 men and women, 22 to 94 years of age, treated for colorectal neoplasia were evaluated. We obtained 100% completion (>27,000 data points) of perioperative data registered by 8 specialist colorectal surgeons and a full-time database manager. CONCLUSIONS: Data completeness and validity are essential for clinical databases to serve the purpose of quality assurance, benchmarking, and research. The results confirm the safety and efficacy of colorectal cancer surgery in both the public and private sector in Australia. The combination of a simple multiuser interface, defined data points, automated result-reporting modules, and data-deficiency reminder module resulted in 100% data compliance in nearly 1000 clinical episodes. The unprecedented success of this model has lead to the Colorectal Surgical Society of Australia and New Zealand adopting this model for data collection for Australia and New Zealand as the binational database.

Serum concentrations of brain-derived neurotrophic factor (BDNF) are decreased in colorectal cancer patients.

OBJECTIVE: To determine the usefulness of brain-derived neurotrophic factor (BDNF) as a diagnostic biomarker for colorectal cancer (CRC). MATERIALS AND METHODS: ELISA immunoassay was used to examine BDNF concentrations in the sera of two different retrospective cohorts consisting of CRC patients and age/gender matched controls. Cohort 1 consisted of 99 controls and 97 CRC patients, whereas cohort 2 consisted of 47 controls and 91 CRC patients. RESULTS: In cohort 1, the median concentration of BDNF was significantly (p< 0.0001) lower in CRC patient samples (18.8 ng/mL, range 4.0-56.5 ng/mL) than control samples (23.4 ng/mL, range 3.0-43.1 ng/mL). This finding was validated in an independent patient cohort (CRC patients: 23.0 ng/mL, range 6.0-45.9 ng/mL; control patients: 32.3 ng/mL, range 14.2-62.4 ng/mL). BDNF concentrations did not differ significantly between Dukes' staging in the patient cohort, however patients with Stages A, B, C and D (p< 0.01 for each stage) tumours had significantly reduced BDNF levels compared to healthy controls. Receiver operating characteristic analysis was performed to determine the ability of BDNF to discriminate between healthy controls and those with CRC. At 95% specificity, BDNF concentrations distinguished CRC patients with 25% and 18% sensitivity, respectively, in cohorts 1 and 2 (cohort 1: AUC=0.79, 95% CI 0.70-0.87; cohort 2: AUC =0.69, 95% CI 0.61-0.76). CONCLUSION: The serum levels of BDNF were significantly lower in colorectal cancer patients when compared to a control population, and this did not differ between different Dukes' stages.

Local recurrence after curative anterior resection with principally blunt dissection for carcinoma of the rectum and rectosigmoid.

PURPOSE: The aim of this study was to determine the incidence of local pelvic recurrence of carcinoma of the rectum and rectosigmoid (tumors where the lower edge is 18 cm or less from the anal verge) in a consecutive series of patients operated on by a single surgeon. All patients underwent curative anterior resection and a formal anatomic dissection of the rectum where mobilization was achieved through a principally careful blunt manual technique along fascial planes, preserving an oncologic package. METHOD: During the period April 1986 to December 1997, 157 consecutive anterior resections for carcinoma of the rectum and rectosigmoid were performed by one surgeon (ALP). One hundred thirty-eight (87.9 percent) were curative, and 19 (12.1 percent) were palliative. The mean follow-up period was 46 +/- 31.6 (range, 2-140) months. Data were retrospectively collated and computer coded by an independent contracted medical research team. Follow-up data were available on all patients. RESULTS: Four (3.1 percent) of the 131 patients undergoing curative anterior resection had local recurrence. Local recurrences occurred between 16 and 38 months from the time of resection, and the cumulative risk of developing local recurrence at five years was 5.2 percent. All tumors in which pelvic recurrence occurred were high grade, and the probability of developing local recurrence at five years for this group was 13.9 percent, which is significantly higher compared with patients who had average or low-grade tumors (P = 0.01). The probability of developing local recurrence at five years for Stage I tumors was 0, Stage II was 5.9 percent, and Stage III was 8.9 percent. In addition, there was a significantly higher incidence of local recurrence in the group of patients undergoing ultralow anterior resection (between 3 and 6 cm from the anal verge) as compared with patients undergoing low or high anterior resection (P = 0.03). Local recurrence developed in 3 of 28 (10.7 percent) patients having ultralow anterior resection, 1 of 57 (1.8 percent) patients having low anterior resection (between 6 and 10 cm from the anal verge), and no patients having high anterior resection (above 10 cm from the anal verge). The clinical anastomotic leak rate for curative anterior resection was 7 of 131 patients (5.3 percent). Thirty-seven of the 131 (28.2 percent) required a proximal defunctioning stoma; 35 (41.2 percent) of these were established for low or ultralow anterior resections and 2 for high anterior resection. The overall five-year cancer-specific survival rate of the entire group of 131 patients was 81.8 percent, and the overall probability of being disease free at five years including both local and distal recurrence was 72.9 percent. Three local recurrences occurred in the 101 patients (77 percent) who did not receive any form of adjuvant therapy. One local recurrence occurred in the 18 patients (13.7 percent) who had adjuvant chemoradiation. No recurrence occurred in the 12 patients (9.2 percent) who had adjuvant chemotherapy alone. CONCLUSION: Curative anterior resection for carcinoma of the rectum and rectosigmoid with principally blunt dissection of the rectum in this study is associated with a 3.1 percent incidence and a 5.2 percent probability at five years of developing local recurrence. Evidence from this study indicates that, as with sharp pelvic dissection, a low incidence and probability of local recurrence can be achieved by a principally blunt mobilization technique through careful attention to preservation of fascial planes in the pelvis and removal of an oncologic package with selective rather than routine adjuvant or neoadjuvant chemoradiation.

Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity.

BACKGROUND: Surgical control of morbid obesity should benefit from a minimally invasive approach and the ability to adjust the degree of gastric restriction. METHODS: The Lap-Band adjustable gastric banding system was evaluated prospectively in a consecutive series of 302 patients, and data on perioperative outcome and weight loss pattern at up to 4 years of follow-up are presented. Some 302 patients (89 per cent women; mean age 39 years, mean weight 124 kg) were entered into the study. Laparoscopic placement was used in 277 patients. Previous gastric stapling surgery was the principal reason for an elective open approach. RESULTS: The incidence of significant early complications was 4 per cent and included two perforations of the stomach after open placement. The mean length of stay after laparoscopic placement was 3.9 days and only one complication (infected reservoir site) occurred in these patients. The principal late complication of prolapse of the stomach through the band occurred in 27 patients (9 per cent). Significant modification of technique and patient care has enabled reduction of this complication in the latter part of the series. Mean(s.d.) excess weight loss was 51.0(17) per cent at 12 months (n = 120), 58.3(20) per cent at 24 months (n = 43), 61.6(2) per cent at 36 months (n = 25) and 682(21) per cent at 48 months (n = 12). CONCLUSION: The Lap-Band is an effective method for achieving good weight loss in the morbidly obese at up to 4 years of follow-up. Laparoscopic placement has been associated with a short length of stay and a low frequency of complications. The ability to adjust the setting of the device to achieve different degrees of gastric restriction has enabled progressive weight loss throughout the period of study.

Liver-directed therapies for gastrointestinal malignancies.

Although surgery remains the treatment of choice for hepatic malignancy, both primary and secondary, the majority of patients presenting with hepatic tumors are unfortunately not candidates for resection. A number of alternative hepatic-directed therapies are assessed for their role in the following settings: as primary treatment modalities; as treatment adjuvants to surgical resection, including neoadjuvant therapy to downstage tumors prior to planned resection; and as a means of palliation when tumors are incurable. Non-surgical hepatic-directed therapies demonstrated to prolong survival include adjuvant portal vein chemotherapy infusion at the time of resection of primary colorectal cancer, and hepatic artery infusion in the setting of established hepatic metastases. Several other therapies are described but remain incompletely evaluated, including transplantation, microwave coagulation, injection of radiolabeled particles, chemoembolization, percutaneous ethanol injection, and cryosurgery. Due to the rarity of these tumors, many studies present results of heterogeneous populations of patients, making meaningful comparison difficult. Finally, it must be said that screening asymptomatic patients after resection of colorectal cancer with a view to application of hepatic-directed therapy in the setting of colorectal metastases is costly.

Thoracoscopic biopsy of a pathological vertebral body.

When computed tomography (CT) guided biopsy of a pathological vertebral body fails, the accepted alternative has been open thoracotomy and biopsy. The authors wish to report the use of a thoracoscopic approach to biopsy of a pathological thoracic vertebra in a child, after an unsuccessful attempt at CT guided percutaneous biopsy.

Early incisional hernia after use of the 12 mm port for laparoscopic surgery.

This paper reports the complication of early incisional hernia occurring in three patients at the site of entry of a 12 mm disposable port during laparoscopic surgery. To avoid this complication, it is recommended that a 12 mm port be introduced through muscle rather than fascia and, following its removal, the defect in the abdominal wall be closed by sutures.