The risk of lymph node metastasis in T1 colorectal cancer: new parameters to assess the degree of submucosal invasion.

PURPOSE: In T1 colorectal cancer, the depth is the main factor assessing the degree of submucosal invasion (DSI) to predict the risk of lymph node metastasis (LNM). The width (WSI) and the area of submucosal invasion (ASI) have been suggested as additional parameters to assess the risk of LNM. A review of the literature was undertaken on the correlation between WSI and ASI parameters and the incidence of LNM. METHODS: A Medline, PubMed, and Cochrane Library search was performed to retrieve all studies reporting correlation between WSI/ASI and risk of LNM in T1 colorectal cancer. RESULTS: Eight studies including 1727 patients were identified. All considered the degree of WSI and its influence on LNM: seven assessed different width cut-off of submucosal invasion, and one study the mean width of submucosal invasion in patients having or not involved lymph nodes. The WSI was significantly a prognostic factor for LNM (p < 0.05) in four studies. Both 2 and 3 mm seem to be the most discriminatory cut-off values of submucosal width invasion in defining the risk difference of LNM above and below the cut-off (2 mm, OR = infinite; 3 mm, OR = 6.9). Patients having a cut-off ≤ 5 mm of WSI showed a low risk (5.6%) of LNM rendering radical surgery unnecessary. Four studies assessed the risk of LNM according to the involved submucosal area (width × depth). In two of these, the ASI was a significant prognostic factor for LNM (p < 0.05). CONCLUSION: The WSI and ASI seem to be reliable prognostic factors for LNM in T1 colorectal cancer. There is no agreement on ideal cut-off value.

Hostile pelvis: how to avoid permanent stoma.

The aim was to report our experience with delayed colo-anal anastomosis (DCA) to avoid permanent stoma for complex rectal cases evaluating short- and long-term outcomes. Nine patients who underwent DCA from 2011 to 2016 were collected and analysed case by case. We considered medical history and surgical outcomes. Long-term bowel function was evaluated using the Wexner and low anterior resection syndrome (LARS) score at 6, 12 and 24 months. The range from previous surgery and salvage procedure was 337 days. All cases were performed with a full laparoscopic approach. The median length of hospital stay was 15 days. The median follow-up was 970.5 days. There was no peri-operative mortality. Two patients developed a post-operative pelvic abscess that required redo surgery. Long-term post-operative complications were mucosal prolapsed, anastomosis retraction and anastomotic stricture. The average values of LARS and Wexner scores were, respectively, at 6 months 33.7 and 16.2, at 12 months 28.5 and 11.7, at 24 months 21.1 and 6.7. Colo-anal sleeve delayed anastomosis appears a real answer to avoid permanent stoma in selected patients. The laparoscopic procedure is safe and feasible for skilful mini-invasive surgeons. Our experience describes the complexity of clinical history of these patients underlying a slow, but progressive improvement in continence after restoration of bowel continuity.