Diseases of the Colon & Rectum (DIS COLON RECTUM )

Publisher: American Society of Colon and Rectal Surgeons; American Proctologic Society, Springer Verlag


Diseases of the Colon and Rectum is published monthly for the American Society of Colon and Rectal Surgeons. It is designed for the publication of original papers that constitute significant contributions to the advancement of knowledge within the special field designated by the name of this journal. Discontinued in 2004.

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    Diseases of the colon & rectum, Diseases of the colon and rectum
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Publications in this journal

  • [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVES: The aim of this study is to evaluate the effectiveness and complications associated with combined topical diltiazem cream and botulinum toxin A injection versus partial lateral internal sphincterotomy in chronic anal fissure. DESIGN: This study is a parallel, randomized controlled trial (using the block randomization method). SETTING: This study was performed at a university hospital in Iran. PARTICIPANTS: Ninety-nine patients who had chronic anal fissures were included. INTERVENTION: A total of 99 patients were randomly assigned to 2 groups; the first group received combined topical diltiazem ointment (for 6 weeks) and botulinum toxin A injection (once) (n = 49), and the second group received partial lateral internal sphincterotomy (n = 50). All the patients were followed up for 1 year. MAIN OUTCOME MEASURES: The primary outcomes measured were the healing of the anal fissure and the development of incontinence as the major adverse event during the 1-year follow-up period. RESULTS: The overall healing rate was 65% and 94% in the botulinum toxin A–diltiazem and partial lateral internal sphincterotomy groups (p < 0.001). The patients in the partial lateral internal sphincterotomy group experienced significantly higher incontinence scores (p = 0.04) according to the Cleveland Clinic Florida-Fecal Incontinence scoring system. In patients who had chronic anal fissure for ≤12 months, no statistical difference was observed in the healing rate between the botulinum toxin A–diltiazem and partial lateral internal sphincterotomy groups (100% vs 100%). However, in the patients with longer chronic fissures, the healing rate was significantly higher in the partial lateral internal sphincterotomy group (86% [18/21] vs 23% [5/21], p < 0.001). LIMITATIONS: The 1-year follow-up period, subjective definitions of itching, and lack of anorectal manometry examinations and data regarding the effect of each treatment on anal sphincter pressure at rest and contraction are the key limitations of this study. CONCLUSION: Combined botulinum toxin A injection with a topical application of diltiazem could be as effective as partial lateral internal sphincterotomy in the treatment of chronic anal fissure in patients who have chronic anal fissure for ≤12 months. However, in chronic anal fissures of longer duration, partial lateral internal sphincterotomy is associated with a significantly higher cure rate.
    Diseases of the Colon & Rectum 02/2015;
  • Diseases of the Colon & Rectum 01/2015; 58(1):1-2.
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    ABSTRACT: Anterior sagittal anorectoplasty is a standardized operative treatment for females with congenital rectoperineal or vestibular fistula. The controlled, long-term outcomes require characterization. The aim of this study was to define the bowel functional outcomes following anterior sagittal anorectoplasty in relation to age- and sex-matched controls. This cross-sectional study was conducted at a single institution. All females treated for congenital perineal or vestibular fistula with anterior sagittal anorectoplasty between 1983 and 2006 were invited to answer a detailed, previously validated questionnaire on bowel function. Each patient was matched to 3 controls who had answered identical questionnaires. Ethical approval was obtained. Social continence was defined as soiling or fecal accidents <1/week and no requirement for changes of underwear or protective aids. This study was conducted at the Hospital for Children and Adolescents, University of Helsinki, Finland. No interventions were performed. The primary outcomes measured were the prevalence of problems with rectal sensation, voluntary bowel control, soiling, fecal accidents, constipation, and social problems. Bowel function score (out of 20 items) was considered, as well as the age at completion of toilet training for stool. Of 34 respondents (79%; median age, 13 (4-28) years), all had voluntary bowel movements. Problems withholding defecation, soiling, and fecal accidents were significantly more common among patients than controls (p ≤ 0.001). Eighty-five percent of patients and 100% of controls (p = 0.001) were socially continent; 41% of patients and 76% of controls were totally continent (p = 0.0003). Constipation tended to decline with age (from 59% to 25%; p = 0.16). The bowel functional outcome was good in 68% of patients, satisfactory in 26% of patients, and poor in 6% of patients. Diapers for stool had been discontinued at the same median age as controls. Number of patients in comparative analysis of symptoms by age group. After anterior sagittal anorectoplasty for perineal or vestibular fistula, 2 of 3 of patients are likely to achieve bowel control comparable to normal in the long term, and the vast majority will be socially continent. The effective treatment of constipation is essential.
    Diseases of the Colon & Rectum 01/2015; 58(1):97-103.
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    ABSTRACT: Radiotherapy reduces local recurrence rates but is also capable of short- and long-term toxicity. It may also render treatment of local recurrence more challenging if it develops despite previous radiotherapy. This study examined the impact of radiotherapy for the primary rectal cancer on outcomes after pelvic exenteration for local recurrence. We conducted a retrospective review of exenteration databases. The study took place at a quaternary referral center that specializes in pelvic exenteration. Patients referred for pelvic exenteration from October 1994 to November 2012 were reviewed. Patients who did and did not receive radiotherapy as part of their primary rectal cancer treatment were compared. The main outcomes of interest were resection margins, overall survival, disease-free survival, and surgical morbidities. There were 108 patients, of which 87 were eligible for analysis. Patients who received radiotherapy for their primary rectal cancer (n = 41) required more radical exenterations (68% vs 44%; p = 0.020), had lower rates of clear resection margins (63% vs 87%; p = 0.010), had increased rates of surgical complications per patient (p = 0.014), and had a lower disease-free survival (p = 0.022). Overall survival and disease-free survival in patients with clear margins were also lower in the primary irradiated patients (p = 0.049 and p < 0.0001). This difference in survival persisted in multivariate analysis that corrected for T and N stages of the primary tumor. This study is limited by its retrospective nature and heterogeneous radiotherapy regimes among radiotherapy patients. Patients who previously received radiotherapy for primary rectal cancer treatment have worse oncologic outcomes than those who had not received radiotherapy after pelvic exenteration for locally recurrent rectal cancer.
    Diseases of the Colon & Rectum 01/2015; 58(1):65-73.
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    ABSTRACT: We performed a prospective pilot study of robotic-assisted laparoscopic transanal proctectomy with total mesorectal excision for the surgical treatment of rectal cancer. This study was to assess the feasibility and safety of robotic-assisted laparoscopic transanal total mesorectal excision. All patients underwent robotic-assisted laparoscopic left colon mobilization, robotic-assisted laparoscopic transanal total mesorectal excision, ultralow mechanical colorectal or handsewn coloanal anastomosis, and a diverting loop ileostomy. Four patients with stage III disease received long-course preoperative chemoradiation before surgery. Primary and secondary end points included the assessment of pathological examination and postoperative morbidity. Between August 2013 and January 2014, 4 men and 1 woman underwent robotic-assisted laparoscopic transanal total mesorectal excision. Patient age and BMI were 57 ± 13.9 years and 25.8 ± 2,7 kg/m. Tumors were located an average of 5 ± 1 cm from the anal verge and were preoperatively staged as T2N0M0 (1 patient) and T2N1M0 (4 patients). Mean operative time was 398 ± 88 minutes with no intraoperative complications. Mean length of hospital stay was 6 ± 1 days. A Clavien II, grade B anastomotic leakage developed in 1 patient postoperatively. In all cases, pathological examination of the total mesorectal excision specimens showed complete mesorectal excision with negative proximal, distal, and circumferential margins. All patients were disease-free at their initial 3-month follow-up. Robotic-assisted laparoscopic transanal total mesorectal excision is a feasible and safe option for the surgical management of early-stage rectal cancers. Robotic technology with endowristed instruments and 3-dimensional high-definition imaging are of great help in overcoming the limitations of traditional laparoscopic transanal surgery. Long-term functional and oncological assessments of outcome are needed.
    Diseases of the Colon & Rectum 01/2015; 58(1):145-53.
  • Diseases of the Colon & Rectum 01/2015; 58(1):143-4.
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    ABSTRACT: Surgical site infections are a potentially preventable patient harm. Emerging evidence suggests that the implementation of evidence-based process measures for infection reduction is highly variable. The purpose of this work was to develop an auditing tool to assess compliance with infection-related process measures and establish a system for identifying and addressing defects in measure implementation. This was a retrospective cohort study using electronic medical records. We used the auditing tool to assess compliance with 10 process measures in a sample of colorectal surgery patients with and without postoperative infections at an academic medical center (January 2012 to March 2013). We investigated 59 patients with surgical site infections and 49 patients without surgical site infections. First, overall compliance rates for the 10 process measures were compared between patients with infection vs patients without infection to assess if compliance was lower among patients with surgical site infections. Then, because of the burden of data collection, the tool was used exclusively to evaluate quarterly compliance rates among patients with infection. The results were reviewed, and the key factors contributing to noncompliance were identified and addressed. Ninety percent of process measures had lower compliance rates among patients with infection. Detailed review of infection cases identified many defects that improved following the implementation of system-level changes: correct cefotetan redosing (education of anesthesia personnel), temperature at surgical incision >36.0°C (flags used to identify patients for preoperative warming), and the use of preoperative mechanical bowel preparation with oral antibiotics (laxative solutions and antibiotics distributed in clinic before surgery). Quarterly compliance improved for 80% of process measures by the end of the study period. This study was conducted on a small surgical cohort within a select subspecialty. The infection auditing tool is a useful strategy for identifying defects and guiding quality improvement interventions. This is an iterative process requiring dedicated resources and continuous patient and frontline provider engagement.
    Diseases of the Colon & Rectum 01/2015; 58(1):83-90.
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    ABSTRACT: The American Joint Committee on Cancer and the College of American Pathologists provide guidelines for reporting pathologic response to neoadjuvant treatment of rectal cancer. The clinical relevance of these tumor regression grading guidelines is undefined. This study evaluates the prognostic significance of the American Joint Committee on Cancer/College of American Pathologists regression grading. This is a retrospective cohort study based on data from a prospectively maintained colorectal cancer database. The cohorts were defined by American Joint Committee on Cancer/College of American Pathologists tumor regression grade. This study was performed at a single tertiary referral center. Five hundred thirty-eight patients with primary rectal adenocarcinoma who underwent neoadjuvant therapy between 1992 and 2012 were identified. The primary outcome measures were overall and disease-free survival, cancer-specific mortality, and cumulative recurrence rate. Five hundred thirty-eight patients were included, 105 of whom (19.5%) were American Joint Committee on Cancer/College of American Pathologists grade 0, 153 patients (28.4%) were grade 1, 181 patients (33.6%) were grade 2, and 99 (18.4%) were grade 3. Kaplan-Meier analysis revealed that American Joint Committee on Cancer/College of American Pathologists grade was associated with significant differences in overall survival (p < 0.001), disease-free survival (p < 0.001), and cumulative recurrence (p < 0.001). No local recurrences were observed in American Joint Committee on Cancer/College of American Pathologists grade 0 patients. Five-year overall survival rates were 89%, 74%, 63%, and 40% (p < 0.001); 5-year disease-free survival rates were 85%, 64%, 54%, and 33% (p < 0.001); and 5-year recurrence rates were 7%, 18%, 25%, and 33% (p <0.001) for American Joint Committee on Cancer/College of American Pathologists grades 0, 1, 2, and 3. After adjusting for significant covariates, including pathologic stage, American Joint Committee on Cancer/College of American Pathologists grade remained an independent predictor of overall survival (p < 0.001), disease-free survival (p < 0.001), and cumulative recurrence (p < 0.001) in Cox regression analyses. This was a retrospective study. There was a low local recurrence rate in our population, limiting the sensitivity of recurrence analyses. This is the first study to delineate American Joint Committee on Cancer/College of American Pathologists regression grade as an independent oncologic prognostic factor. This information can be used in discussions with patients who have rectal cancer.
    Diseases of the Colon & Rectum 01/2015; 58(1):32-44.
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    ABSTRACT: Dynamic graciloplasty has been proposed for anal reconstruction, but this method has 2 major drawbacks. First, an electrical device is required for control of the gracilis. The anastomosis with the pudendal nerve will provide more physiological control. Second, the limitation in the mobility of the muscle flap results in wrapping the anal canal with the muscle's distal portion, which is tendonlike and inelastic. Enhancing the mobility of the muscle flap will enable wrapping with the proximal, muscle-like, and extensible portion, possibly providing better sphincteric function. However, the basis for such an operative method is lacking. The aim of this study is to provide the basis for the refined method of anal sphincter reconstruction by dynamic graciloplasty with pudendal nerve anastomosis and to verify the feasibility of lengthening the nerve to the gracilis muscle flap by dissecting into the muscle belly, detaching the gracilis muscle from its origin, and enhancing the mobility of the muscle flap. This is a retrospective, descriptive study. The results from the anatomical study on 9 cadavers are reported. Tension-free anastomosis of the pudendal nerve and nerve to the gracilis was successfully performed in all the 9 cases: in 2 cases, by lengthening the nerve. The detachment of the muscle origin improved the mobility of the muscle flap, and the more proximal portion could be used for wrapping the anal canal, as confirmed in 4 cases. The limited number of cases was a shortcoming of this study. By lengthening the nerve to the muscle, the gracilis can be used for anal sphincter reconstruction with pudendal nerve anastomosis, negating the need for an electrical device. By detaching the origin of the gracilis muscle, its proximal portion can be used to wrap the anal canal, possibly enabling a longer functional canal with stronger constricting force and better vascularity. These modifications to past methods may improve fecal continence after the operation.
    Diseases of the Colon & Rectum 01/2015; 58(1):104-8.
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    ABSTRACT: Radiochemotherapy without surgical resection has become the treatment of choice for anal squamous-cell carcinoma. The optimal treatment for rectal squamous-cell carcinoma is not well established. The purpose of this work was to assess the efficacy of nonoperative strategies in the management of primary rectal squamous-cell carcinoma. We retrospectively reviewed data from all of the patients with documented rectal squamous-cell carcinoma who were treated with conservative strategies in a single institution. Concomitant radiochemotherapy was proposed to all except 1 patient. The remaining patient was treated by radiotherapy alone given his impaired functional status. All of the patients were treated with conformal or intensity-modulated radiation therapy. Surgical resection was reserved for persistent disease or relapse. This study was conducted in a single tertiary institution. After a mean follow-up of 56 months, 2 patients experienced relapse and no patients died. Eleven patients were included in the series. The clinical response to radiotherapy was complete for 7 patients. The remaining 4 patients underwent salvage surgery. The pathologic response was incomplete for 2 of the 4 patients. One recurrence occurred outside the field of radiotherapy and was successfully treated by radiotherapy. The second was a local recurrence, which occurred on a patient who was treated with radiotherapy alone. The number of patients included in this retrospective series was limited because of the rarity of the disease. Patients were treated with nonhomogeneous conservative strategies because of modification in the therapeutic strategy for anal squamous-cell carcinoma and of the adaptation of the treatment to patient comorbidities and functional status. This series demonstrates that good results can be obtained by using a rectum-conserving strategy. Close follow-up should be maintained, with the use of salvage surgery reserved only for persistent disease or relapse (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A155).
    Diseases of the Colon & Rectum 01/2015; 58(1):60-4.
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    ABSTRACT: We practice in an era of evidence-based medicine. In 1993, Solomon and McLeod published an article examining study designs in 3 surgical journals from 1980 and 1990. The purpose of this study was to evaluate subsequent 30-year trends in the quality of selected literature. All of the articles from Diseases of the Colon & Rectum, Surgery, and the British Journal of Surgery during 2000 and 2010 were classified by study design. Nonclinical studies were substratified by animal/laboratory, surgical technique, editorial/review, or miscellaneous articles. Clinical articles were categorized as case or comparative studies, further categorized by study design, and rated on a 10-point scale to determine strength. We compared interobserver reliability using a random sample. This study was conducted at 3 North American medical centers. Patients described in the scope of the literature were included in this study. Frequency, type, and strength of study design were measured. We evaluated 1911 articles (967 clinical; 17% comparative). There was a significant increase in multicenter clinical studies (from 12% to 27%; p < 0.0001) and mean study population (from 326 to 6775; p < 0.05). Studies using administrative data increased from 14% to 43% (p < 0.0001). Case reports decreased from 16% to 7% of all clinical studies (p < 0.001), whereas the percentage of comparative studies increased from 14% to 21% (p = 0.001). The percentage of randomized controlled trials did not increase significantly (8.5% in 2000; 10.0% in 2010; p = 0.44). The mean 10-point score for comparative studies was 6.7 for both years (p = 0.50). There was good interobserver agreement in the classification of studies (κ = 0.70) and moderate agreement in scoring comparative studies (κ = 0.47). This descriptive study cannot fully account for the reasons behind the identified differences. Comparative and multicenter studies, mean study population, and the use of administrative data increased from 2000 to 2010. This suggests that increased use of administrative databases has allowed larger populations of patients from more institutions to be studied and may be more generalizable. Researchers should strive toward improving the level of evidence (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A167).
    Diseases of the Colon & Rectum 01/2015; 58(1):115-21.
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    ABSTRACT: Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection. The aim of this study was to compare local with radical resection in terms of oncologic control (survival and local recurrence), postoperative complications, and the need for a permanent stoma in adult patients with T1N0M0 rectal adenocarcinoma. Data were retrieved from Medline, Embase, Central, www.clinicaltrials.gov, and conference proceedings. Two reviewers independently screened studies and assessed the risk of bias. Local resection (transanal procedures, excluding endoscopic polypectomy) versus radical resection were considered. The primary outcomes measured were overall survival, major postoperative complications, and the 'need for permanent stoma.' : One randomized controlled trial and 12 observational studies contributed 2855 patients for analysis. The randomized controlled trial was inadequately powered. Observational study meta-analysis showed that local resection was associated with significantly lower 5-year overall survival (72 more deaths per 1000 patients; 95%CI 30-120). However, the transanal endoscopic microsurgery subgroup did not yield significantly lower overall survival than radical resection. Local resection was associated with higher local recurrence but with lower perioperative mortality (relative risk 0.31, 95% CI 0.14-0.71), major postoperative complications (relative risk 0.20, 95% CI 0.10-0.41), and need for a permanent stoma (relative risk 0.17, 95% CI 0.09-0.30). Findings were robust to sensitivity analyses. Meta-regression suggests that the higher overall survival associated with radical resection may be explained by increased use of local resection on tumors in the lower third of the rectum, which have poorer prognosis. This systematic review of nonrandomized studies had inherent biases that may persist despite our rigorous use of systematic review methodology and sensitivity analyses. Local resection does not offer oncologic control comparable to radical surgery. However, this finding may be driven by the higher prevalence of cancers with poorer prognosis in local resection groups. Local resection is associated with lower postoperative complications, mortality, and the need for a permanent stoma. Local resection with transanal endoscopic microsurgery appears to offer oncologic control similar to that of radical resection while offering all the benefits of local resection.
    Diseases of the Colon & Rectum 01/2015; 58(1):122-40.
  • Diseases of the Colon & Rectum 01/2015; 58(1):e1.
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    ABSTRACT: Fecal incontinence is a common, distressing condition with limited surgical options. This study examines the results of magnetic sphincter augmentation in patients with severe fecal incontinence. This was a single-center, prospective, nonrandomized investigation. This study was conducted in a private colorectal practice. The cohort included all of the patients implanted with magnetic sphincter augmentation between January 2012 and October 2013. Magnetic sphincter augmentation was studied. Adverse events, symptom severity, quality of life, bowel diary, and manometry data were collected. Eighteen patients (15 women), with mean age of 69 years (range, 31-91 years), were implanted with magnetic sphincter augmentation. Follow-up ranged from 353 to 738 days. Previous treatment consisted of peripheral nerve evaluation test in 10 patients (56%), 2 patients (11%) with previous permanent sacral nerve stimulation, and 1 patient (6%) with previous implantation of an artificial bowel sphincter. Implantation was successful in 17 (94%) of 18 patients. Five patients (29%) had postoperative pain, and 5 patients (29%) had temporary swelling and erythema in both gluteal regions after the implantation. No devices were explanted during the follow-up. Cleveland Clinic Incontinence Score decreased from a mean of 17.5 (range, 14.0-20.0) to 7.3 (range, 0-12.0), and Fecal Incontinence Quality of Life scores improved in all of the domains. Bowel diary results showed that 76% of the patients with implants experienced a ≥50% reduction in the number of fecal incontinence episodes per week. Manometry at 6 months after implantation showed increased mean resting and squeeze pressures. This study does not allow for comparison between surgical treatments and involves a limited number of patients. Magnetic sphincter augmentation shows consistent results for the treatment of severe fecal incontinence in this patient group. The surgical procedure is straightforward as compared with other implantable devices. The safety profile is acceptable. Magnetic sphincter augmentation is a promising new treatment with the potential to become a first-line surgical therapy for patients with severe fecal incontinence.
    Diseases of the Colon & Rectum 01/2015; 58(1):109-14.
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    ABSTRACT: High-resolution anoscopy has been shown to improve identification of anal intraepithelial neoplasia but a reduction in progression to anal squamous-cell cancer has not been substantiated when serial high-resolution anoscopy is compared with traditional expectant management. The aim of this study was to compare high-resolution anoscopy versus expectant management for the surveillance of anal intraepithelial neoplasia and the prevention of anal cancer. This is a retrospective review of all patients who presented with anal squamous dysplasia, positive anal Pap smears, or anal squamous-cell cancer from 2007 to 2013. This study was performed in the colorectal department of a university-affiliated, tertiary care hospital. Included patients had biopsy-proven anal intraepithelial neoplasia from 2007 to 2013. Patients were treated with high-resolution anoscopy with ablation or standard anoscopy with ablation. Both groups were treated with imiquimod and followed every 6 months indefinitely. The incidence of anal squamous-cell cancer in each group was the primary end point. From 2007 to 2013, 424 patients with anal squamous dysplasia were seen in the clinic (high-resolution anoscopy, 220; expectant management, 204). Three patients (high-resolution anoscopy, 1; expectant management, 2) progressed to anal squamous-cell cancer; 2 were noncompliant with follow-up and with HIV treatment, and the third was allergic to imiquimod and refused to take topical 5-fluorouracil. The 5-year progression rate was 6.0% (95% CI, 1.5-24.6) for expectant management and 4.5% (95% CI, 0.7-30.8) for high-resolution anoscopy (p = 0.37). This was a retrospective review. There is potential for selection and referral bias. Because of the rarity of the outcome, the study may be underpowered. Patients with squamous-cell dysplasia followed with expectant management or high-resolution anoscopy rarely develop squamous-cell cancer if they are compliant with the protocol. The cost, morbidity, and value of high-resolution anoscopy should be further evaluated in lieu of these findings.
    Diseases of the Colon & Rectum 01/2015; 58(1):53-9.
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    ABSTRACT: Laparoscopic surgical treatment of T4 cancers remains a concern that is mostly associated with technical feasibility, high conversion rate, inadequate oncologic clearance, and surgical outcome. The purpose of this work was to evaluate the short- and long-term clinical and oncologic outcomes after laparoscopic and open surgeries for T4 colon cancers. This was a retrospective study of patients with T4 colon cancer without metastasis (M0) who had laparoscopic or open surgery from 2003 to 2011. The study was conducted at a single institution. A total of 83 patients with pT4 colon cancer were included. R0 resection rate, morbidity and mortality within 30 postoperative days, overall survival, and disease-free survival were measured. Laparoscopic surgery was performed on 61 and open surgery on 22 patients. The groups were similar in overall staging (p = 0.461), with 35 (42%) of the patients at stage 2 and 48 (58%) at stage 3. A complete R0 resection was achieved in 61 (100%) of the patients who underwent laparoscopic surgery and in 21 (96%) of the patients who underwent open surgery (p = 0.265). The average number of lymph nodes harvested was 21 in the laparoscopic group and 24 in the open group (p = 0.202). Thirty-day morbidity rate was similar between the groups (p = 0.467), and the mortality rate was 0. The length of hospital and postsurgical stay was significantly shorter in the laparoscopic group (p = 0.002 and p = 0.008). The 3-year overall survival rates between the groups were 82% (range, 71%-93%) for patients who underwent laparoscopic surgery and 81% (range, 61%-100%) for those who underwent open surgery (p = 0.525), and disease-free survival was 67% (range, 54%-79%) for laparoscopic surgery and 64% (range, 43%-86%) for open surgery (p = 0.848). The follow-up time was 40 ± 25 in months in the laparoscopic group and 34 ± 26 months in the open surgery group (p = 0.325). This was a retrospective study at a single institution. The study shows that laparoscopic surgery is feasible in T4 colon cancers. With comparable clinical and oncologic outcomes, this study suggests that laparoscopy may be considered as an alternative approach for T4 colon cancers with the advantage of faster recovery (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A156).
    Diseases of the Colon & Rectum 01/2015; 58(1):25-31.
  • Diseases of the Colon & Rectum 01/2015; 58(1):e1.
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    ABSTRACT: Perioperative allogeneic red blood cell transfusion has been conclusively shown to be associated with adverse oncologic outcomes after resection of nonmetastatic colorectal adenocarcinoma. The aim of the study was to identify risk factors for a perioperative transfusion and to assess the effects of transfusion on survival after curative-intended resection of hepatic metastases in patients featuring stage IV colorectal cancer. This was an observational study with a retrospective analysis of a prospective data collection. The study was conducted at a tertiary care center. A total of 292 patients undergoing curative-intended liver resection for colorectal liver metastases were included in the study. Univariate and multivariate analyses were performed identifying factors influencing transfusion, recurrence-free survival, and overall survival. A total of 106 patients (36%) received allogeneic red blood cells. Female sex (p = 0.00004), preoperative anemia (p = 0.001), major intraoperative blood loss (p < 0.00001), and major postoperative complications (p = 0.02) were independently associated with the necessity of transfusion. Median recurrence-free and overall survival were 58 months. Allogeneic red blood cell transfusion was significantly associated with reduced recurrence-free survival (32 vs 72 months; p = 0.008). It was reduced further by administration of >2 units (27 months; p = 0.02). Overall survival was not significantly influenced by transfusion (48 vs 63 months; p = 0.08). When multivariately adjusted for major intraoperative blood loss and factors univariately associated, namely comorbidities, tumor load, and positive resection margins, transfusion was an independent predictor for reduced recurrence-free survival (p = 0.03). These include the retrospective and observational design, as well as the impossibility to prove causality of the association between transfusion and poor outcome. In patients undergoing liver resection for colorectal liver metastases, perioperative transfusion is independently associated with earlier disease recurrence. This emphasizes appropriate blood management measures, including the conservative correction of preoperative anemia, the use of low transfusion triggers, and the minimization of intraoperative blood loss.
    Diseases of the Colon & Rectum 01/2015; 58(1):74-82.
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    ABSTRACT: The treatment of slow-transit constipation combined with outlet obstruction is controversial. Subtotal colectomy with colorectal anastomosis is regarded as a safe and effective surgical option for refractory constipation. The clinical and morphologic outcomes of patients who underwent subtotal colectomy with colorectal anastomosis for refractory mixed constipation were prospectively evaluated. This study is a nonrandomized, prospective review of gathered data. This investigation was conducted at a tertiary-care GI surgical center in China. The study prospectively included 42 consecutive patients with refractory constipation who were diagnosed with obstructed defecation syndrome combined with slow colon transit. The primary outcomes measured were the Longo obstructive defecation syndrome score and the Wexner constipation scale. The pelvic morphologic changes were determined with defecography before surgery and at 6 and 24 months after surgery. A significant reduction in the Wexner constipation score was observed between baseline (median 24) and 6 months (median 10), which was maintained until 24 months (median 8, compared with baseline, p < 0.01). Improvement in the constipation score was matched by an overall improvement in the Longo obstructive defecation syndrome score at the 6- and 24-month follow-up times (compared with baseline, p < 0.01). In 17 of 21 patients, preexisting intussusception was no longer visible during defecography. Rectoceles were significantly reduced in depth, from 36 mm to 8 mm (p < 0.01), whereas the number of detectable rectoceles was also significantly decreased, from 29 to 7 (p < 0.01). Incomplete evacuation disappeared in 28 of 38 patients. No stenosis was observed at the colorectal posterior side-to-side anastomosis. Most complications were managed conservatively without significant events. This study was performed in selected patients with constipation and did not include a comparison group. Subtotal colectomy with colorectal anastomosis can correct pelvic anatomical disorders in patients with mixed refractory constipation. The clinical improvement of obstructed defecation syndrome after subtotal colectomy with colorectal anastomosis is highly correlated with the morphologic correction of the rectal redundancy.
    Diseases of the Colon & Rectum 01/2015; 58(1):91-6.
  • Diseases of the Colon & Rectum 01/2015; 58(1):3-5.