Acute diverticulitis: old challenge, current trends, open questions.

Acute diverticulitis (AD) is an increasing issue for health systems worldwide. As accuracy of clinical symptoms and laboratory examinations is poor, a pivotal role in preoperative diagnosis and severity assessment is played by CT scan. Several new classifications trying to adapt the intraoperative Hinchey's classification to preoperative CT findings have been proposed, but none really entered clinical practice. Treatment of early AD is mostly conservative (antibiotics) and may be administered in outpatients in selected cases. Larger abscesses (exceeding 3 to 5 cm) need percutaneous drainage, while management of stages 3 (purulent peritonitis) and 4 (fecal peritonitis) is difficult to standardize, as various approaches are nowadays suggested. Three situations are identified: situation A, stage 3 in stable/healthy patients, where various options are available, including conservative management, lavage/drainage and primary resection/anastomosis w/without protective stoma; situation B, stage 3 in unstable and/or unhealthy patients, and stage 4 in stable/healthy patients, where stoma-protected primary resection/anastomosis or Hartmann procedure should be performed; situation C, stage 4 in unstable and/or unhealthy patients, where Hartmann procedure or damage control surgery (resection without any anastomosis/stoma) are suggested. Late, elective sigmoid resection is less and less performed, as a new trend towards a patient-tailored management is spreading.

"Is CT Scan more Accurate than Endoscopy in Identifying Distance from the Anal Verge for Left Sided Colon Cancer? A Comparative Cohort Analysis".

Purposes: Accurately localizing colorectal cancer during surgery may be challenging due to intraoperative limitations. In the present study, localization of left-sided colon cancer (LCC) by CT scan is compared to colonoscopy. Material and methods: Consecutive patients with LCC located by colonoscopy and CT scan and undergoing left-hemicolectomy were included. Tumor distance from the anal verge (TDAV) was calculated by both CT-scan and colonoscopy, and then compared, using as reference TDAV measured intraoperatively. Statistical analysis was performed including (1) comparison of means between all three TDAVs, (2) comparison of mean differences between all three TDAVs, (3) comparison of number of patients with a difference between endoscopic TDAV and intraoperative TDAV ≤5 cm and the number of patients with a difference between CT scan TDAV and intraoperative TDAV ≤5 cm (4) statistical relationship between either CT scan and endoscopic and intraoperative TDAVs. Results: Both CT scan and endoscopy overestimate TDAV (25.8 ± 12.5 cm and 24.6 ± 10.6 cm vs. 21.5 ± 7.4 cm, p = 0.005), but CT scan TDAV resulted as being different from intraoperative TDAV (p < 0.01). Regression analysis reported an increasing divergence of measurements with increasing values of intraoperative TDAV, which resulted greater for CT. Tumors within 5 cm of intraoperative TDAV were 22/28 (78.6%) for endoscopy, and 17/28 (60.7%) for CT (p = 0.2448). Conclusions: Accuracy of both examinations seems poor, with a mean overestimation >3 cm and a significant number of tumors found at >5 cm from preoperative evaluation. Preoperative examinations' bias increase proportionally with TDAV length, decreasing their interest especially for tumors located at a greater distance from anal verge.

Partial splenectomy: Who, when and how. A systematic review of the 2130 published cases.

BACKGROUND/PURPOSE: In order to avoid consequences of total splenectomy (including severe postsplenectomy sepsis), partial splenectomy (PS) is increasingly reported. Without guidelines and indications concerning a rarely-indicated procedure, a review of literature should be an asset. METHODS: A systematic review of all PSs from 1960 to December 2017 was performed, with special focus on surgical indications, sites of resection, approaches and techniques of vascular dissection and parenchymal section/hemostasis of the spleen, perioperative morbidity/mortality, including complications compelling to perform total splenectomy. RESULTS: Among 2130 PSs, indications for resection were hematological disease in 1013 cases and nonhematological conditions in 1078, including various tumors in 142 and trauma in 184. Parenchymal transection was performed using several techniques through the years, most frequently after having induced partial ischemia by splenic hilum vascular dissection/ligation. 371 laparoscopic/robotic PSs were reported. Rescue total splenectomy was required in 75 patients. CONCLUSIONS: Although good results are probably overestimated by such a retrospective review, PS should be considered as a procedure associated with a low morbidity/mortality. Nevertheless, severe complications are also reported, and the need of total splenectomy should not to be minimized. Laparoscopic/robotic procedures are increasingly performed, with good results and rare conversions. TYPE OF STUDY: Systematic review. LEVEL OF EVIDENCE: IV.

Applications of indocyanine green-enhanced fluorescence in laparoscopic colorectal resections.

Recently, Indocyanine Green (ICG)-enhanced fluorescence has been introduced in laparoscopic colorectal surgery to provide detailed anatomical informations. The aim of our study is the application of ICG imaging during laparoscopic colorectal resections: to assess anastomotic perfusion to reduce the risk of anastomotic leak, to facilitate vascular dissection when vascular anatomy of tumor site is unclear, and to identify ureter to prevent iatrogenic injury. After the transection, 5 ml of ICG solution is intravenously injected. A Full HD IMAGE1S camera, switching to NIR mode, in few seconds provides a real-time angiography of colonic perfusion. After anastomosis, another bolus is injected to confirm the anastomotic perfusion. When the tumor is localized in difficult site, the fluorescence provides a real-time angiography of tumor area vascularization to perform the vascular dissection. When the tumor is tightly attached to the ureter, the ICG solution injection through the catheter allows ureter identification. From November 2016, 38 patients were enrolled: ten left colectomies, 22 right colectomies, three transverse resections, and three splenic flexure resections. In five cases, intraoperative angiography led to the identification of vascular anatomy. In one case the surgical strategy was changed. In one procedure, ureter identification allowed to prevent injury. Three postoperative complications that required surgical reoperation occured, of which one anastomotic leak, due to a mechanical problem. ICG-enhanced fluorescence imaging is a safe, cheap and effective tool to increase visualization during surgery. It can be employed also in small hospitals without learning curve. It is recommended to obtain additional information on anatomy and perfusion in colorectal surgery.

De Garengeot hernia: laparoscopic treatment in emergency.

INTRODUCTION: De Garengeot Hernia is described as the presence of an appendix within a femoral hernia. CASE REPORT: We report the case of an elderly woman, who presented with incarcerated femoral hernia without signs of bowel obstruction. CT showed a femoral hernia with appendix in the femoral canal with signs of strangulation. the patient underwent emergency surgery. Diagnostic laparoscopy revelead a non-reducible appendix in the femoral canal, in the absence of signs of peritonitis. An infrainguinal incision was performed. An gangrenous appendix within the sac was revealed, detached from the sac and reintroduced into the abdomen through the femoral canal. The laparoscopic appendectomy was then performed. The hernia repair was performed by suturing the iliopubic tract to Cooper's ligament. Patient had a regular course. DISCUSSION: De Garengeot's hernia is a rare occurrence. After the year 2000 a total of 32articles, wich presented 34 cases of de Garengeot's hernia have been published. Due to the rarity of this disease there is not standard procedure; laparoscopy may be a valid technique for determining the condition of the hernia, but due to the difficulty of preoperative diagnosis it is unlikely to be the first choice for the surgical approach. The use of CT can therefore be decisive to help the surgeon in the choice of the approach. CONCLUSION: De Garengeot's hernia can be approached in urgent laparoscopy even in the complicated forms of appendicular inflammation. (www.actabiomedica.it).

Delayed, diffuse acute peritonitis secondary to misplacement of a cystogastrostomic "pigtail" drain in an outpatient after discharge.

BACKGROUND AND AIM OF THE WORK: Pancreatic pseudocyst endoscopic drainage by pancreatogastrostomy "pigtail" drain placement is spreading worldwide, with high success-rate and low morbidity, and is increasingly performed as outpatient procedure. The paper reports an unusual very early complication of this procedure and discusses the peculiar aspects of this event in an outpatient setting. METHODS: The first case of a 56-year-old outpatient developing a postoperative diffused acute peritonitis by gastric juice spilling caused by the  misplacement of the distal end of two transgastric drains not reaching the pseudocyst is reported. As the case was programmed as outpatient and acute peritonitis symptoms occurred eight hours postoperatively, the patient was discharged and rehospitalized. A review of the literature of rare perforative complications of pancreatogastrostomy is performed. RESULTS: CT scan allowed the prompt diagnosis, as it showed massive pneumoperitoneum, free fluid collection, and pigtail drain misplacement. Emergency laparoscopy allowed the removal of the two misplaced drains and gastric reparation. The procedure lasted 65 minutes, mostly needed for lavage. The patient was discharged 5 days later and outcomes are unremarkable 7 months after the procedure. CONCLUSION: The indication to endoscopic pancreatogastrostomy and its outpatient management should be carefully pondered. Pancreogastrostomy drain misplacement may cause a life-threatening acute peritonitis associated with early aspecific symptoms, resulting in a challenging situation, especially in an outpatient setting. CT-scan may allow prompt diagnosis and effective management by minimally invasive surgery.

Effectiveness and risk of biliary drainage prior to pancreatoduodenectomy: review of current status.

Preoperative biliary drainage (PBD) prior to pancreatoduodenectomy (PD) has gained popularity as bridge management to resolve jaundice, but its role is being challenged as it is thought to increase morbidity. To clarify the current recommendations for PBD prior to PD, we reviewed the literature, including all relevant articles published in English up until December, 2015. There is increasing evidence that PBD causes bile infection, which is related to the morbidity of infectious complications. Results of transhepatic drainage are poorer than those of endoscopic stenting, especially in an oncologic setting, although it is still unclear whether metallic stents are superior to nasobiliary drainage. PBD should be avoided whenever possible and performed only in selected cases, such as the emergency setting, an inevitable long delay (>4 weeks) before PD, and jaundice-related anorexia. Seemingly, transhepatic drainage should be reserved for refractory cases if endoscopic drainage is not possible. Further studies comparing endoscopic drainage techniques, such as metallic stents and nasobiliary drainage, are required to assess the most effective technique of PBD. Bile infection should be prevented by adequate antibiotic prophylaxis and treated even in the absence of symptoms, and bile status should be assessed systematically.

Poor Results of Pancreatoduodenectomy in High-Risk Patients with Endoscopic Stent and Bile Colonization are Associated with E. coli, Diabetes and Advanced Age.

BACKGROUND: Endoscopic stenting has spread as bridge management before pancreatoduedenectomy (PD) to resolve jaundice, but its role is nowadays challenged as it is reported to increase morbidity. Although bile sampling is increasingly performed, its clinical role is unclear. The objective of the study is to assess bile colonization's impact on outcome. METHODS: Results of pancreatoduodenectomy after endoscopic stenting are analyzed in 61 high-risk patients presenting bacterial bile colonization. The impact of 11 demographic, clinical, infectious, and laboratory parameters and outcome, including pancreatic leakage, morbidity, and mortality, is analyzed. RESULTS: All stented patients present bacterial bile colonization and PD mortality approaches 10 %. The presence of E. coli in the bile is significantly related to poor outcome, including 23.5 % mortality (p = 0.034), whereas age (≥70 years) and diabetes present borderline results (p < 0.070 and p < 0.066, respectively). E. coli (p = 0.002) and age (p = 0.017) are also related to grade C pancreatic fistula. CONCLUSIONS: In high-risk patients undergoing PD, bile colonization inevitably occurs after endoscopic stenting and is a major risk factor of poor outcome, reaching its maximum in the case of E. coli colonization and elderly patients, where the indication to stent and/or to perform PD should be accurately evaluated. E. coli-targeted antibiotic prophylaxis should be administered.

Anastomotic recurrence of colon cancer: Genetic analysis challenges the widely held theories of cancerous cells' intraluminal implantation and metachronous carcinogenesis.

BACKGROUND AND OBJECTIVES: Anastomotic recurrence (AR), whose etiopathogenesis is attributed to intraluminal implantation of cancerous cells or metachronous carcinogenesis, is a major issue for patients undergoing colon cancer (CC) resection. The objective of the study is to throw some light on AR etiopathogenesis and to identify risk factors of AR in selecting patients to undergo early endoscopy. METHODS: An analysis of clinical and histopathological parameters, including MSI and LOH of seven sites (Myc-L, BAT26, BAT40, D5S346, D18S452, D18S64, D16S402) was performed in primary CC and AR of 18 patients. They were then compared to 36 controls not developing AR. RESULTS: A genetic instability was present in 16/18 patients, with distinct genetic patterns between primaries and ARs. LOH at 5q21 and/or 18p11.23 were found in both primary and AR in >50% of cases, but this rate was no different from control population. CEA resulted as associated with AR (P = 0.03), whereas N status presented a borderline result (P = 0.08). CONCLUSIONS: Our findings challenge present theories about AR development. No "genetic marker" has been found. CEA and, to a lesser extent, N status, appear associated with AR. Rectal washout is seemingly meaningless. Iterative resection should be recommended since a long survival may be expected. J. Surg. Oncol. 2016;114:228-236. © 2016 Wiley Periodicals, Inc.

Spleen hydatidosis treated by hemi-splenectomy: A low-morbidity, cost-effective management by a recently improved surgical technique.

BACKGROUND: Splenic hydatidosis is a rare condition and is usually managed by total splenectomy, which is associated to various complications, including overwhelming post-splenectomy sepsis and thrombosis. Probably due to supposed technical difficulties, the partial splenectomy is rarely performed being often unknown to physicians, infectious disease specialists and surgeons. METHODS: Demographic, clinical and surgical data were collected of four consecutive patients undergoing partial (or hemi-) splenectomy using an original, recently improved technique as a treatment for polar splenic hydatid cyst. The procedure implies a selective vascular ligation, a mechanical stapler-assisted section and haemostatic agents (Surgicel(®)) application on the cutting surface. Three patients were treated by laparotomy (including one affected by both liver and spleen localizations) whereas the last one was approached laparoscopically. RESULTS: Partial splenectomy operative time reached 74 min (range: 60-94 min) and blood loss was 8 ml (range: 5-10 ml). Hospital stay was 5.6 days (range: 5-7 days). At a mean follow-up of 20 months (range: 12-36 months), outcomes were uneventful. CONCLUSIONS: Partial splenectomy for hydatidosis is effective and safe. Physicians and surgeons should be aware of such an easy-to-catch option when dealing with benign splenic conditions, such as parasitic cysts. Cost-effectiveness, low morbidity and the possible prevention of splenectomy-related infectious complications should plead in favor of this technique in developing countries, where hydatidosis is endemic and post-splenectomy drugs and vaccines may be lacking.

Lymph node ratio improves TNM and Astler-Coller's assessment of colorectal cancer prognosis: an analysis of 761 node positive cases.

BACKGROUND: Prognosis assessment of node-positive colorectal cancer patients by Astler-Coller (AC) and TNM classifications is suboptimal. Recently, several versions of lymph node ratio (LNR; ratio metastatic/examined nodes) have been proposed but are still mostly unused. METHODS: The prognostic value of several criteria, including LNR (two classes-LNR1 and LNR2-identified by a 15% cut-off) was studied in 761 consecutive patients, from 2000 through 2010. The relationships between total examined nodes, N, T and LNR were also analysed. LNR1 and LNR2 patients' survival was analysed within AC and TNM subgroups, and then coupled with them. RESULTS: Age, tumour location and LNR are independent factors predicting survival. The relationships between LNR, N stage and T stage with examined nodes suggest confusing factors. LNR allows for identification of subgroups with different survival within AC and TNM classifications (p < 0.0001). Patients with LNR class discordant from AC stage (LNR1-C2 and LNR2-C1) have a similar 5-year survival (54 and 57%, respectively). LNR2 and TNM stage IIIC define a poor 5-year prognosis (33%). CONCLUSIONS: LNR is a powerful prognosis predictor, easily integrated with TNM and AC classifications to improve prognosis assessment and facilitate clinical use. Possible confusing factors should be considered in future studies.

Palliative care and end-stage colorectal cancer management: the surgeon meets the oncologist.

Colorectal cancer (CRC) is a common neoplasia in the Western countries, with considerable morbidity and mortality. Every fifth patient with CRC presents with metastatic disease, which is not curable with radical intent in roughly 80% of cases. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV CRC patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy (CHT). This latter have allowed for a dramatic increase in survival, whereas the role of colonic and liver surgery is nowadays matter of debate. Although any generalization is difficult, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases. In asymptomatic patients, new CHT regimens allow today long survival in selected patients, also exceeding two years. The role of colonic resection in this group has been challenged in recent years, as it is not clear whether the resection of primary CRC may imply a further increase in survival, thus justifying surgery-related morbidity/mortality in such a class of short-living patients. Secondary surgery of liver metastasis is gaining acceptance since, under new generation CHT regimens, an increasing amount of patients with distant metastasis initially considered non resectable become resectable, with a significant increase in long term survival. The management of CRC emergency patients still represents a major issue in Western countries, and is associated to high morbidity/mortality. Obstruction is traditionally approached surgically by colonic resection, stoma or internal by-pass, although nowadays CRC stenting is a feasible option. Nevertheless, CRC stent has peculiar contraindications and complications, and its long-term cost-effectiveness is questionable, especially in the light of recently increased survival. Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma. Bleeding and other CRC-related symptoms (pain, tenesmus, etc.) may be managed by several mini-invasive approaches, including radiotherapy, laser therapy and other transanal procedures.

Pure pancreaticocutaneous fistula shunted into the urinary bladder. Lesson learned by an incomplete, original attempt.

Because pancreaticocystostomy is a method of exocrine secretion management in pancreas transplantation, a legitimate question is whether a pure pancreatic fistula could be shunted into the bladder. After duodenopancreatectomy for cancer, a pancreaticojejunostomy leakage was treated by pancreas-saving anastomosis disconnection. The resulting pure pancreaticocutaneous fistula was later diverted into the bladder using a Denver valved-pump device. Technical problems necessitated redoing the shunt using a modified technique and device. Although the system did work, catheter displacement outside the bladder finally caused device takedown and external fistula restoration. Our attempt did not succeed mostly because of our inexperience in dealing with an altogether novel issue without appropriate technology. Supposing its feasibility, a pancreatic-bladder shunt might have a role in treating pure pancreatic fistulas or creating an external fistula whenever the pancreatic remnant is unreliable for an anastomosis, or when a leaked anastomosis' disconnection is preferable to completion pancreatectomy.

Volume-outcome relationship in colon cancer surgery: another biased logical short cut towards questionable centralization policies.

The association between hospital high volumes and good outcomes after complex surgery has given rise to a worldwide controversial debate. Important and unsolved questions have followed, both theoretical and practical, which could have repercussions on health care and health economic policies, such as the centralization/regionalization of major surgical procedures.We read a recent study on the impact of surgery volumes on short-term outcomes after colon cancer resection in Emilia Romagna, Italy, the same geographic area where we operate. Ten issues were submitted to critical analysis and many sources of planning and methodology bias were identified, which, in our opinion, paradigmatically led to unreliable results, inadequate statistical analysis and deceptive conclusions. Despite the authors' admitted awareness of their study's limits, their conclusive message was, surprisingly, that centralization of colon cancer surgery should be substantially encouraged.Unrecognized, systemic biases may easily turn into cognitive biases, into logical short cuts which could confuse healthcare policy-makers. The volume-outcome relationship, in which a direct causal link has never been demonstrated, should not be used as a reliable measure of quality, rather  than less implementable process indicators, to address centralization policies.A disregarded negative consequence of centralization could be that non-high-volume centres, after a further progressive workload decrease and depletion in resources and surgical skills, will have to cope with patients in bad general condition and at high risk, who must be treated in emergency or cannot anyway afford the move for age, indigence or severe co-morbidities. Thus, centralization policies might disadvantage the weak segments of the population, thereby moving towards an iniquitous health service.

A rare case of appendicitis-like syndrome: prompt laparoscopic diagnosis and management.

BACKGROUND: Hyperpyrexia associated with right iliac fossa pain and tenderness in a young patient is a common finding in an Emergency Department, and is frequently caused by acute appendicitis or genitourinary affliction. Especially in the case of young males, it is debated whether the patient should undergo immediate surgery or be referred for imagery, and, when surgery is finally planned, whether an open incision of the iliac fossa or a laparoscopic approach is preferred. OBJECTIVE: We describe a case of a patient with a twisted, ischemic ileal hemangioma mimicking an acute appendicitis, which was diagnosed and managed laparoscopically. CASE REPORT: A 16-year-old boy was admitted to the Emergency Department with a 2-day history of hyperpyrexia, nausea, right iliac fossa pain, and tenderness. Perioperative computed tomography scan showed a 3-cm image that was interpreted as a periappendicular abscess. At laparoscopy, a twisted ischemic mass adherent to the surrounding ileum was located and removed. The patient's outcome was uneventful. Pathology showed a benign hemangioma of the ileal mesentery. To our knowledge, this is the first case treated by laparoscopic resection. CONCLUSIONS: Rare conditions, such as peduncolated tumors, can mimic common conditions like acute appencitis. Also, due to the aspecificity of symptoms and difficult interpretation of imagery, diagnosis can be difficult to achieve preoperatively and surgery can be challenging. Laparoscopy can allow a diagnosis to be made and the appropriate treatment to be performed without the need for laparotomy. Rare causes of appendicitis-like syndrome represent an argument in favor of a laparoscopic approach, even in the case of young male patients.

Hemoperitoneum caused by a ruptured GIST located in the posterior gastric wall managed by endoscopic diagnosis and laparoscopic treatment: case report and literature review.

A case of hemoperitoneum caused by a ruptured gastrointestinal stromal tumor (GIST) of the posterior gastric wall is presented. An otherwise healthy 81-year-old man presented with abdominal pain/tenderness and anemia (hemoglobin: 7.4 g/dL). Computed tomography scan showed hemoperitoneum and a gastric mass of uncertain nature. As the patient was hemodynamically stable, a mini-invasive approach was decided. Esophagogastroscopy revealed an umbilicated mass of the posterior gastric wall, therefore allowing for a correct preoperative diagnosis of GIST and its appropriate treatment by laparoscopic atypical gastrectomy. Laparoscopically, a longitudinal resection of gastric fundus including the tumor was performed in a sleeve gastrectomy fashion, 25 minutes after the induction of pneumoperitoneum. The outcome was uneventful. Pathologic examination confirmed a benign 4 × 3-cm gastric GIST with <1 mitosis per 50 high power field, staining positive for CD117 (C-KIT) and negative for S-100 protein and smooth muscle actin. To our knowledge, it is the first case of a successful laparoscopic resection of an endoscopically diagnosed gastric GIST in an emergency setting. Hemoperitoneum is a rare, potentially severe complication of GIST. As bleeding is rarely severe, most patients may benefit from a mini-invasive approach, even if the tumor is located in the posterior gastric wall.

Repeated anastomotic recurrence of colorectal tumors: genetic analysis of two cases.

AIM: To investigate genetics of two cases of colorectal tumor local recurrence and throw some light on the etiopathogenesis of anastomotic recurrence. METHODS: Two cases are presented: a 65-year-old female receiving two colonic resections for primary anastomotic recurrences within 21 mo, and a 57-year-old female undergoing two local excisions of recurrent anastomotic adenomas within 26 mo. A loss of heterozygosity (LOH) study of 25 microsatellite markers and a mutational analysis of genes BRAF, K-RAS and APC were performed in samples of neoplastic and normal colonic mucosa collected over the years. RESULTS: A diffuse genetic instability was present in all samples, including neoplastic and normal colonic mucosa. Two different patterns of genetic alterations (LOH at 5q21 and 18p11.23 in the first case, and LOH at 1p34 and 3p14 in the second) were found to be associated with carcinogenesis over the years. A role for the genes MYC-L (mapping at 1p34) and FIHT (mapping at 3p14.2) is suggested, whereas a role for APC (mapping at 5q21) is not shown. CONCLUSION: The study challenges the most credited intraluminal implantation and metachronous carcinogenesis theories, and suggests a persistent, patient-specific alteration as the trigger of colorectal cancer anastomotic recurrence.

Elective palliative resection of incurable stage IV colorectal cancer: who really benefits from it?

PURPOSE: Despite the encouraging results of chemotherapy in patients affected by incurable colorectal cancer (CRC), surgical resection of a primitive tumor is still a common approach worldwide. The identification of prognostic factors related to short survival (<6 months) may allow excluding from resective surgery those who may not benefit from it. METHODS: A retrospective analysis was performed of 15 variables in a population of 71 patients undergoing nonemergency palliative primary resections of incurable CRC, including patients' demographics and clinical/histopathological characteristics of the tumor. RESULTS: No variables were related to perioperative mortality (8.5% overall). A multivariate analysis revealed that older age (≥80 years) and metastasis to more than 25% of the lymph nodes were associated with survival (4 and 6 months, respectively). Mucoid adenocarcinoma therefore tends to be associated with the prognosis (P = 0.070). CONCLUSIONS: An elderly age tends to be a contraindication to an elective primary tumor resection in patients affected by incurable CRC. Massive lymph node involvement and mucoid adenocarcinoma should also be considered before planning major colonic surgery.