Acuity and survival in colon cancer surgery

Prognostic Factors of Postoperative Mortality in Patients with Complicated Right Colon Cancer

The incidence of right colon cancer presenting in a stage with complications is significant. There are major differences in therapeutic approach between elective colon cancer surgery and emergency surgery. Complications such as hemorrhage, obstruction, and perforation require careful evaluation of prognostic factors, with morbidity and mortality rates being much higher compared to elective colon surgery. We retrospectively analyzed a group of 95 patients admitted in an emergency to the County Emergency Hospital St. Apostol Apostol Andrei Galati with complicated tumors of the right colon-occlusive, perforated, or hemorrhagic. A series of clinical and biological parameters were followed in order to identify the prognostic factors in the occurrence of death. We analyzed the specialized literature, comparing our study with other similar research from the most important databases. The postoperative death rate in patients with complicated right colon cancer was high. Most complications were occlusive, followed by hemorrhagic and perforative.

Exploring rural-urban differences in the receipt of nonelective cancer-specific gastrointestinal surgery using a multilevel mixed-effects approach

BACKGROUND

Rural communities constitute a populace marked by various social challenges influencing health outcomes. As such, nonelective surgeries for cancer may have a disproportionate impact on rural populations. We explored patient and county-level factors contributing to differences in the receipt of nonelective cancer-specific surgery between rural and urban residents.

METHODS

This retrospective study included adult patients captured in the Surveillance, Epidemiology, and End Results-Medicare data between January 2008 and December 2015 with an incident stage I to IV cancer of the stomach, liver/intrahepatic bile duct, pancreas, gallbladder/other biliary origin, or small intestine who underwent a cancer-specific surgery. The primary outcome was a nonelective cancer-directed surgery among rural vs urban residents. We conducted a multivariable mixed-effects logistic regression model to adjust for confounders while accounting for county-level clustering.

RESULTS

The sample included 10,136 patients who underwent a surgical intervention; 2941 (29%) were nonelective. The incidence of nonelective surgery was lower among rural than urban patients (351 [27%] and 2590 [29%]; P = .05). There was no statistically significant difference in the unadjusted and adjusted odds of nonelective surgery between rural and urban residents (odds ratio, 0.88; 95% CI, 0.76-1.03; P = .11; adjusted odds ratio [aOR], 0.86; 95% CI, 0.72-1.02; P = .080). In addition, high social vulnerability index (SVI) counties or Black race was significantly associated with increase odds of nonelective surgery (aOR, 1.33; 95% CI, 1.07-1.65; P = .009; aOR, 1.49; 95% CI, 1.26-1.77; P < .0001, respectively).

CONCLUSION

This study found no difference in the odds of receiving nonelective surgery for gastrointestinal foregut cancers between rural and urban populations. However, Black race and high SVI were associated with higher odds of the receipt of nonelective surgery. Further research is warranted to explore whether disparities in clinical outcomes exist despite the comparable likelihood of receiving nonelective surgery between rural and urban communities.

Self-expandable metallic stent as bridge to surgery vs. emergency resection in obstructive right-sided colon cancer: a systematic review and meta-analysis

BACKGROUND

Emergency resection is common for malignant right-sided obstructive colon cancer. As there is evidence showing a potential benefit of self-expandable metal stents as a bridge to surgery, a new debate has been initiated.

OBJECTIVE

The aim of this study was to compare self-expandable metal stents with emergency resection in right-sided obstructive colon cancer.

DATA SOURCE

A systematic search was conducted accessing Medline/PubMed, Scopus, Embase, and the Cochrane Database of Systematic Reviews.

STUDY SELECTION

Studies reporting either emergency surgery or stent placement in right-sided obstructive colon cancer were included.

INTERVENTION

Stent or emergency resection in right-sided obstructive colon cancer.

MAIN OUTCOME MEASURES

Morbidity rate, mortality rate, stoma rate, laparoscopic resection rate, anastomotic insufficiency rate, success rate of stent.

RESULTS

A total of 6343 patients from 16 publications were analyzed. The stent success rate was 0.92 (95% CI, 0.87 to 0.95) with perforation of 0.03 (95% CI, 0.01 to 0.06). Emergency resection was performed laparoscopically at a rate of 0.15 (95% CI, 0.09 to 0.24). Primary anastomosis rate in emergency resection was 0.95 (95% CI, 0.91 to 0.97) with an anastomotic insufficiency rate of 0.07 (95% CI, 0.04 to 0.11). The mortality rate after emergency resection was 0.05 (95% CI, 0.02 to 0.09). Primary anastomosis and anastomotic insufficiency rate were similar between the two groups (RR: 1.02; 95% CI, 0.95 to 1.1; p = 0.56 and RR: 0.53; 95% CI, 0.14 to 1.93; p = 0.33). The mortality rate in emergency resection was higher compared to stent (RR: 0.51, 95% CI 0.30 to 10.89, p = 0.016).

LIMITATION

No randomized controlled trials are available.

CONCLUSION

Stent is a safe and successful alternative to emergency resection and may increase the rate of minimally invasive surgery. Emergency resection, however, remains safe and did not result in higher rate of anastomotic insufficiency. Further high-quality comparative studies are warranted to assess long-term outcomes.

Short- and long-term outcomes following bridge to surgery and emergency resection in acute malignant large bowel obstruction

AIM

Bridge to surgery (BtS) aims to decrease perioperative morbidity and mortality in emergency resection (ER) of the colon. Previous results are inconsistent, and long-term comparisons are scarce. The aim of this study was to compare the short- and long-term outcomes of BtS and ER.

METHOD

This retrospective study examined data from the Swedish Colorectal Cancer Registry for patients treated for acute malignant large bowel obstruction from 2007 to 2009. Patients were grouped by treatment strategy: BtS (using a self-expanding metallic stent or diverting stoma) or ER. Medical records were scrutinized for all patients in the BtS group. The primary endpoints were 5-year overall survival (OS) and 3-year recurrence-free survival (RFS). The secondary endpoints were postoperative mortality and morbidity rates and stoma permanence.

RESULTS

Overall, 143 patients were treated using BtS versus 1302 patients treated with ER. The 5-year OS was higher in the BtS group than in the ER group (53.8% vs. 37.4%; p < 0.05). No difference was noted in the 3-year RFS (75.7% vs. 75.0%; p = 0.38). The postoperative mortality rate was lower in the BtS group than in the ER group (0.7% vs. 7.3%; p < 0.05). Complications occurred in 46.9% of patients in the BtS group (both procedures) versus 35.9% of patients in the ER group (p < 0.05); the rate of severe complications was 23.1% and 16.9%, respectively (p = 0.07).

CONCLUSION

This retrospective population-based registry study showed higher long-term survival and lower postoperative mortality rates among patients treated with BtS versus ER for acute malignant large bowel obstruction.

Emergency resection or diverting stoma followed by elective resection in patients with colonic obstruction due to locally advanced cancer: a national cohort study

AIM

The aim was to assess long-term prognosis after emergency resection versus primary diverting stoma followed by elective tumour resection.

METHOD

A national-register-based cohort study with retrospective analysis of prospectively collected data was performed. All Swedish patients with non-metastatic obstructive locally advanced colon cancer treated with emergency resection or diverting stoma, followed by an elective resection, between 2007 and 2017 were included. The Kaplan-Meier method and Cox proportional hazards model were used to compare all-cause mortality between patients with emergency resection and elective right- and left-sided resection. The multivariable model was adjusted for year of diagnosis, age at diagnosis, sex, Charlson Comorbidity Index, American Society of Anesthesiologists class, tumour location and pN stage.

RESULTS

In all, 751 patients with a tumour in the right colon and 700 patients with a tumour in the left colon were included. Emergency resection was more common in patients with right-sided colon tumours (681/751) than in patients with left-sided colon tumours (483/700). The 5-year overall survival in patients with right-sided tumours was 25% after emergency resection and 46% after diverting stoma followed by elective resection (log-rank test P = 0.001). The corresponding numbers for patients with left-sided colon tumours were 40% and 64% (P < 0.001). Emergency resection was independently associated with increased all-cause mortality in patients with left-sided tumour (hazard ratio 1.63, 95% CI 1.21-2.19) but not in patients with right-sided tumour (hazard ratio 1.21, 95% CI 0.80-1.81).

CONCLUSION

Diverting stoma followed by elective resection is associated with improved survival compared with emergency resection in patients with left-sided colonic obstruction due to locally advanced tumours.

Urgent Inpatient Colectomy Carries a Higher Morbidity and Mortality than Elective Surgery

BACKGROUND

Emergency colorectal surgery confers a higher risk of adverse outcomes compared to elective surgery. Few studies have examined the outcomes after urgent colectomies, typically defined as those performed at the index admission, but not performed at admission in an emergency fashion. The aim of this study is to evaluate the risk of adverse outcomes following urgent inpatient colorectal surgery.

MATERIALS AND METHODS

All adult patients undergoing colectomy between 2013 and 2017 in the ACS NSQIP were included in the analysis. Patients were grouped into Elective, Urgent and Emergency groups. The Urgent group was further stratified by time from admission to surgery. Baseline characteristics and 30 day outcomes were compared between the Elective, Urgent and Emergency groups using univariable and multivariable analyses.

RESULTS

104,486 patients underwent elective colorectal resection. 23,179 underwent urgent while 22,241 had emergency resections. Patients undergoing urgent colectomy presented with increased comorbidities, and experienced higher mortality (2.5-4.1%, AOR 2.3 (1.9 - 2.8)) compared to elective surgery (0.4%). Urgent colectomy was an independent risk factor for the majority of short term complications documented in NSQIP. Moreover, patients undergoing urgent colectomy more than a week following admission had an increased risk of bleeding, deep venous thrombosis, pulmonary embolism, urinary tract infection, and prolonged hospitalization.

CONCLUSION

Urgent colectomies are associated with a greater risk of adverse outcomes compared to elective surgery. Urgent status is an independent risk factor for post operative mortality and morbidity. Further characterization of this patient population and their specific challenges may help ameliorate these adverse events.

A Systematic Review Comparing Emergency Resection and Staged Treatment for Curable Obstructing Right-Sided Colon Cancer

BACKGROUND

Treatment for obstructing colon cancer (OCC) is controversial because the outcome of acute resection is less favorable than for patients without obstruction. Few studies have investigated curable right-sided OCC, and patients with OCC usually undergo acute resection. This study aimed to better understand the outcome and best management of potentially curable right-sided OCC.

METHODS

A systematic review of studies was performed with a focus on differences in mortality and morbidity between emergency resection and staged treatment for patients with potentially curable right-sided OCC. In March 2019, the study searched Embase, Medline, Web of Science, Cochrane, and Google scholar databases according to PRISMA guidelines using search terms related to "colon tumour," "stenosis or obstruction and surgery," and "decompression or stents." All English-language studies reporting emergency or staged treatment for potentially curable right-sided OCC were included in the review. Emergency resection and staged resection were compared for mortality, morbidity, complications, and survival.

RESULTS

Nine studies were found to be eligible and comprised 600 patients treated with curative intent for their right-sided OCC by emergency resection or staged resection. The mean overall complication rate was 42% (range 19-54%) after emergency resection, and 30% (range 7-44%) after staged treatment. The average mortality rate was 7.2% (range 0-14.5%) after emergency resection and 1.2% (range 0-6.3%) after staged treatment. The 5-year disease-free and overall survival rates were comparable for the two treatments.

CONCLUSIONS

The patients who received staged treatment for right-sided OCC had lower mortality rates, fewer complications, and fewer anastomotic leaks and stoma creations than the patients who had emergency resection.

The effects of the Affordable Care Act on access and outcomes of colon surgery

BACKGROUND

Insurance status has been strongly associated with both access to and outcomes of colon resection (CRS). Under the Affordable Care Act (ACA), individual states opted to participate in Medicaid expansion (ME) and adopt essential health benefits (EHB).

METHODS

We performed a quasi-experimental difference-in-differences (DID) analysis of 2012-2017 state-level inpatient claims with risk adjustment. We examined frequency of emergent presentation and in-hospital death. Subset analyses were performed by insurance type.

RESULTS

Among the 73,961 CRS patients, 49.6% were in a state with both ME and EHB, 34.7% presented emergently, and 2.0% died. Adoption of ME and EHB was associated with a significant, 24%, reduction in the likelihood of in-hospital mortality, and no significant change in emergent presentation for CRS.

CONCLUSIONS

The ACA's ME was strongly associated with a decrease in mortality following colon resection among Medicaid beneficiaries. These findings support the adoption of healthcare policies that improve access to insurance.

Time-dependent Estimates of Recurrence and Survival in Colon Cancer: Clinical Decision Support System Tool Development for Adjuvant Therapy and Oncological Outcome Assessment

Unanswered questions remain in determining which high-risk node-negative colon cancer (CC) cohorts benefit from adjuvant therapy and how it may differ in an equal access population. Machine-learned Bayesian Belief Networks (ml-BBNs) accurately estimate outcomes in CC, providing clinicians with Clinical Decision Support System (CDSS) tools to facilitate treatment planning. We evaluated ml-BBNs ability to estimate survival and recurrence in CC. We performed a retrospective analysis of registry data of patients with CC to train–test–crossvalidate ml-BBNs using the Department of Defense Automated Central Tumor Registry (January 1993 to December 2004). Cases with events or follow-up that passed quality control were stratified into 1-, 2-, 3-, and 5-year survival cohorts. ml-BBNs were trained using machine-learning algorithms and k-fold crossvalidation and receiver operating characteristic curve analysis used for validation. BBNs were comprised of 5301 patients and areas under the curve ranged from 0.85 to 0.90. Positive predictive values for recurrence and mortality ranged from 78 to 84 per cent and negative predictive values from 74 to 90 per cent by survival cohort. In the 12-month model alone, 1,132,462,080 unique rule sets allow physicians to predict individual recurrence/mortality estimates. Patients with Stage II (N0M0) CC benefit from chemotherapy at different rates. At one year, all patients older than 73 years of age with T2–4 tumors and abnormal carcinoembryonic antigen levels benefited, whereas at five years, all had relative reduction in mortality with the largest benefit amongst elderly, highest T-stage patients. ml-BBN can readily predict which high-risk patients benefit from adjuvant therapy. CDSS tools yield individualized, clinically relevant estimates of outcomes to assist clinicians in treatment planning.

How Soon Should Patients With Colon Cancer Undergo Definitive Resection?

BACKGROUND

Timing of surgery has been shown to affect outcomes in many forms of cancer, but definitive national data do not exist to determine the effect of time to surgery on survival in colon cancer.

OBJECTIVE

This study aimed to determine whether a delay in definitive surgery in colon cancer significantly affects survival.

DATA SOURCES

A retrospective cohort study using 2 independent population-based databases, The Surveillance, Epidemiology, and End Results Medicare-linked database and the National Cancer Database, was performed.

STUDY SELECTION

All patients had American Joint Committee on Cancer stage 1 through 3 colon cancer. Patients were more than 18 years of age in the National Cancer Database cohort and older than 66 years of age in the Medicare cohort. Patients had a minimum of 3 years of follow-up.

MAIN OUTCOME MEASURES

The main outcome was overall survival as a function of time between diagnosis and surgery in 4 intervals (1-2, 3-4, 5-6, >6 weeks).

RESULTS

The Medicare cohort demonstrated an adjusted 5-year survival of 8% to 14% higher in patients with a surgical delay between 3 and 6 weeks, with significantly lower hazard ratios in that interval. The National Cancer Database cohort demonstrated an adjusted 5-year survival of 9% to 16% higher in patients with surgery 3 to 6 weeks after diagnosis, with comparatively similar improvements in survival hazard.

LIMITATIONS

Because this was a retrospective study of administrative databases, with Medicare data limited to billing data, the causality of outcomes must be interpreted with caution.

CONCLUSIONS

The ideal timing of definitive resection in colon cancer is between 3 and 6 weeks after initial diagnosis. All efforts should be made for patients to obtain definitive surgery within this interval to achieve a modest but significant improvement in overall survival. See Video Abstract at http://links.lww.com/DCR/B76. ¿CUÁNDO DEBEN SOMETERSE LOS PACIENTES CON CÁNCER DE COLON A UNA RESECCIÓN DEFINITIVA?: Se ha demostrado que el momento de la cirugía afecta los resultados en muchas formas de cáncer, pero no existen datos nacionales definitivos para determinar el efecto del tiempo hasta la cirugía en la supervivencia en el cáncer de colon.Determinar si un retraso en la cirugía definitiva en el cáncer de colon afecta significativamente la supervivencia.Un estudio de cohorte retrospectivo que utiliza dos bases de datos independientes basadas en la población; Se realizó la base de datos vinculada a la vigilancia, la epidemiología y los resultados finales y la base de datos nacional del cáncer.Pacientes con cáncer de colon en estadíos 1 a 3 del Comité Estadounidense Conjunto sobre el Cáncer. Los pacientes tenían más de 18 años en la cohorte de la National Cancer Database y más de 66 años en la cohorte de Medicare. Los pacientes tuvieron un mínimo de 3 años de seguimiento.El resultado principal fue la supervivencia general en función del tiempo entre el diagnóstico y la cirugía en 4 intervalos (1-2, 3-4, 5-6, y mas de 6 semanas).La cohorte de Medicare demostró una supervivencia ajustada de 5 años de 8 a 14% más en pacientes con un retraso quirúrgico entre 3 a 6 semanas, con razones de riesgo significativamente más bajas en ese intervalo. La cohorte de la National Cancer Database demostró una supervivencia ajustada a 5 años de 9 a 16% más en pacientes con cirugía de 3 a 6 semanas después del diagnóstico, con mejoras comparativamente similares en el riesgo de supervivencia.Dado que este fue un estudio retrospectivo de bases de datos administrativas, con datos de Medicare limitados a datos de facturación, la causalidad de los resultados debe interpretarse con precaución.El momento ideal para la resección definitiva en el cáncer de colon es entre tres y seis semanas después del diagnóstico inicial. Se deben hacer todos los esfuerzos para que los pacientes obtengan una cirugía definitiva dentro de este intervalo para lograr una mejora modesta pero significativa en la supervivencia general. Consulte Video Resumen en http://links.lww.com/DCR/B76.

A nomogram for predicting bowel obstruction in preoperative colorectal cancer patients with clinical characteristics

BACKGROUND

Bowel obstruction (BO) is a complication that commonly affects patients with colorectal cancer (CRC). BO causes severe outcomes, and its treatment leads to a dilemma for many surgeons. Moreover, the factors correlated to BO in preoperative CRC patients remain unclear. The objectives of this study were to investigate the clinical characteristics of BO to identify risk predictors and to construct a BO prediction model with preoperative CRC patients.

METHODS

A large-scale, retrospective cohort, population-based study analyzed the data of 11,814 patients obtained from the Surveillance, Epidemiology, and End Results and Medicare claims-linked databases (SEER-M database). Patients aged ≥ 66 years and primarily diagnosed with CRC from 1992 to 2009 were divided into BO and non-BO groups. Cox proportional hazards regression models were used to determine predictors, and then, a nomogram was constructed by those predictors.

RESULTS

A total of 11,814 patients (5293 men and 6251 women) were identified. In multivariate analysis, 14 factors were found to be associated with BO including age, race, marital status, residence location, T category, M category, primary tumor site, histologic type, histologic grade, tumor size, history of alcoholism, chemotherapy, radiotherapy, abdominal pain, and anemia. A nomogram predicting the 90- and 180-day rates of BO was built for the preoperative CRC patients with a C-index of 0.795.

CONCLUSIONS

This study identified 14 BO-related factors, and a statistical model was constructed to predict the onset of BO in preoperative CRC patients. The obtained data may guide decision-making for the intervention of patients at risk for BO.

Ileus caused by obstructing colorectal cancer-impact on long-term survival

PURPOSE

It is unclear whether obstructing colorectal cancer (CRC) has a worse prognosis than non-obstructing CRC. Of CRC patients, 10-28% present with symptoms of acute obstruction. Previous studies regarding obstruction have been primarily based on short-term outcomes, risk factors and treatment modalities. With this study, we want to determine the long-term survival of patients presenting with acute obstructive CRC.

METHODS

This single-centre observational retrospective cohort study includes all CRC patients who underwent surgery between December 2004 and 2010. Patients were divided into two groups: ileus and no ileus. Survival analyses were performed for both groups. Additional survival analyses were performed in patients with and without synchronous metastases. The primary outcome was survival in months.

RESULTS

A total of 1236 patients were included in the analyses. Ileus occurred in 178 patients (14.4%). The 5-year survival for patients with an ileus was 32% and without 60% (P < 0.01). In patients without synchronous metastases, survival with and without an ileus was 40.9 and 68.4%, respectively (P < 0.01). If ileus presentation was complicated by a colon blowout, 5-year survival decreased to 29%. No significant difference was found in patients with synchronous metastases. Survival at 5 years in this subgroup was 10 and 12% for patients with and without an ileus, respectively (P = 0.705).

CONCLUSIONS

Patients with obstructive CRC have a reduced short-term overall survival. Also, long-term overall survival is impaired in patients who present with acute obstructive CRC compared to patients without obstruction.

Systematic review of the influence of socioeconomic deprivation on mortality after colorectal surgery

Background

Socioeconomic deprivation is a potentially important factor influencing surgical outcomes. This systematic review aimed to summarize the evidence for any association between socioeconomic group and mortality after colorectal surgery, and to report the definitions of deprivation used and the approaches taken to adjust for co-morbidity in this patient population.

Methods

MEDLINE, Embase, the Cochrane Library and Web of Science were searched for studies up to November 2016 on adult patients undergoing major colorectal surgery, which reported on mortality according to socioeconomic group. Risk of bias and study quality were assessed by extracting data relating to study size, and variations in inclusion and exclusion criteria. Quality was assessed using a modification of a previously described assessment tool.

Results

The literature search identified 59 studies published between 1993 and 2016, reporting on 2 698 403 patients from eight countries. Overall findings showed evidence for higher mortality in more deprived socioeconomic groups, both in the perioperative period and in the longer term. Studies differed in how they defined socioeconomic groups, but the most common approach was to use one of a selection of multifactorial indices based on small geographical areas. There was no consistent approach to adjusting for co-morbidity but, where this was considered, the Charlson Co-morbidity Index was most frequently used.

Conclusion

This systematic review suggests that socioeconomic deprivation influences mortality after colorectal surgery.

Nonelective colon cancer resection: A continued public health concern

BACKGROUND

Little is known regarding recent trends in the rate of nonelective colon cancer resection in the United States and its impact on both short-term and long-term outcomes.

METHODS

The New York State Cancer Registry and Statewide Planning & Research Cooperative System identified stage I-III colon cancer resections from 2004-2011. Propensity-matched analyses assessed differences in short-term adverse outcomes and 5-year disease-specific and overall survival between elective and nonelective colon cancer operations. Further analyses assessed the association among patient, surgeon, and hospital-level factors and outcomes within the nonelective operation group.

RESULTS

Among 26,420 patients, 26.5% underwent nonelective operations. There was no significant change in the rate of nonelective resection from 2004-2011 (P = .25). Nonelective operations were independently associated with greater odds of 30-day mortality (odds ratio [OR] = 3.42, 95% confidence interval [CI] = 2.87-4.06), stoma creation (OR = 4.49, 95% CI = 3.95-5.09), intensive care unit admission (OR = 1.68, 95% CI = 1.53-1.84), complications (OR = 2.34, 95% CI = 2.18-2.52), and discharge to another health care facility (OR = 2.46, 95% CI = 2.26-2.68), longer duration of stay (incidence rate ratio = 1.79, 95% CI = 1.76-1.83), and worse disease-specific (hazard ratio = 1.74, 95% CI = 1.61-1.88) and overall survival (hazard ratio = 1.64, 95% CI = 1.55-1.75). Other than an association among high-volume surgeons, adequate lymph node yield, and receipt of adjuvant chemotherapy and lower mortality, no other potentially modifiable factors were associated with survival after nonelective operations.

CONCLUSION

Nonelective colon cancer resection remains a concerning public health issue with >25% of cases being performed on a nonelective basis and an independent association with poor short-term and long-term survival compared with elective operations. Given that few potentially modifiable factors appear to have an impact on survival after nonelective operations, these findings highlight the importance of adherence to colon cancer screening guidelines to limit the number of nonelective colon cancer resections.

Reviewing the Management of Obstructive Left Colon Cancer: Assessing the Feasibility of the One-stage Resection and Anastomosis After Intraoperative Colonic Irrigation

BACKGROUND

The management of obstructive left colon cancer (OLCC) remains debatable with the single-stage procedure of primary colonic anastomosis after cancer resection and on-table intracolonic lavage now being supported.

PATIENTS AND METHODS

Patients with acute OLCC who were admitted between January 2008 and January 2015 were distributed into 5 different groups. Group ICI underwent emergency laparotomy for primary anastomosis following colonic resection and intraoperative colonic lavage; Group HP underwent emergency Hartmann's Procedure; Group CON consisted of patients treated by conservative management with subsequent elective open cancer resection; Group COL were colostomy patients; and Group INT consisted of patients who had interventional radiology followed by open elective colon cancer resection. The demographics of the patients and comorbidity, intraoperative data, and postoperative data were collected, with P < .05 as significant.

RESULTS

There were 4 deaths in 138 cases (2.90%). There was only 1 patient who had anastomotic leakage (5.56%) in Group ICI, compared with none in Group HP and Group COL, 1 case in Group INT (7.69%), and 2 cases in Group CON (6.06%) (P > .05). Group INT and Group CON, when compared to the three surgical groups, Groups ICI, Group COL, and Group HP, individually, were statistically significant for the duration of surgery (P < .05).

CONCLUSIONS

Primary anastomosis following colonic resection after irrigation can be safely performed in selected patients, with the necessary surgical expertise, with no increased risk in mortality, anastomotic leakage, and other postoperative complications.

Effect of Social Deprivation on the Stage and Mode of Presentation of Colorectal Cancer

Purpose

Based in a hospital serving one of the most deprived areas in the United Kingdom (UK), we aimed to investigate, using the Indices of Deprivation 2010, the hypothesis that deprivation affects the stage and mode of presentation of colorectal cancer.

Methods

All newly diagnosed patients with colorectal cancer presenting to a District General Hospital in the UK between January 2010 and December 2014 were included. Data were collected from the Somerset National Cancer Database. The effect of social deprivation, measured using the Index of Multiple Deprivation Score, on the stage and mode of presentation was evaluated utilizing Microsoft Excel and IBM SPSS ver. 22.0.

Results

A total of 701 patients (54.5% male; mean age, 76 years) were included; 534 (76.2%) underwent a surgical procedure, and 497 (70.9%) underwent a colorectal resection. Of the patients undergoing a colorectal resection, 86 (17.3%) had an emergency surgical resection. Social deprivation was associated with Duke staging (P = 0.09). The 90-day mortality in patients undergoing emergency surgery was 12.8% compared to 6.8% in patients undergoing elective surgery (P = 0.06). No association was found between deprivation and emergency presentation (P = 0.97). A logistic regression analysis showed no increase in the probability of metastasis amongst deprived patients.

Conclusion

This study suggests an association between deprivation and the stage of presentation of colorectal cancer. Patients undergoing emergency surgery tend to have a higher 90-day mortality rate, although this was not related to deprivation. This study highlights the need to develop an individual measure to assess social deprivation.

Missed opportunities: racial and neighborhood socioeconomic disparities in emergency colorectal cancer diagnosis and surgery

BACKGROUND

Disparities by race and neighborhood socioeconomic status exist for many colorectal cancer (CRC) outcomes, including screening use and mortality. We used population-based data to determine if disparities also exist for emergency CRC diagnosis and surgery.

METHODS

We examined two emergency CRC outcomes using 1992-2005 population-based U.S. SEER-Medicare data. Among CRC patients aged ≥66 years, we examined racial (African American vs. white) and neighborhood poverty disparities in two emergency outcomes defined as: 1) newly diagnosed CRC or 2) CRC surgery associated with: obstruction, perforation, or emergency inpatient admission. Multilevel logistic regression (patients nested in census tracts) analyses adjusted for sociodemographic, tumor, and clinical covariates.

RESULTS

Of 83,330 CRC patients, 29.1% were diagnosed emergently. Of 55,046 undergoing surgery, 26.0% had emergency surgery. For both outcomes, race and neighborhood poverty disparities were evident. A significant race by poverty interaction (p < .001) was noted: poverty rate was associated with both outcomes among African Americans, but not whites. Compared to whites in low poverty (<10%) neighborhoods, African Americans in high poverty (≥20%) neighborhoods had increased odds of emergency diagnosis (AOR: 1.50, 95% CI: 1.38-1.63) and surgery (AOR: 1.63, 95% CI: 1.47-1.81).

CONCLUSIONS

Emergency CRC outcomes are associated with high poverty residence among African Americans in this population-based study, potentially contributing to observed disparities in CRC morbidity and mortality. Targeted efforts to increase CRC screening among African Americans living in high poverty neighborhoods could reduce preventable disparities.

Survival after elective surgery for colonic cancer in Denmark

AIM

Total mesorectal excision (TME) has been shown to improve the outcome for patients with rectal cancer. In contrast, there are fewer data on complete mesocolic excision (CME) for colonic cancer.

METHOD

Data from the National Colorectal Cancer Database were analysed. This includes about 95% of all patients with colorectal cancer in Denmark. Only patients having elective surgery for colonic cancer in the period 2001-2008 were included. Overall and relative survival analyses were carried out. The study period was divided into the periods 2001-2004 and 2005-2008.

RESULTS

9149 patients were included for the final analysis. The overall 5-year survival rates were 0.65 in 2001-2004 and 0.66 in 2005-2008. The relative 5-year survival rates were also within 1% of each other. None of these comparisons was statistically significant.

CONCLUSION

Survival following elective colon cancer surgery has been almost unchanged since 2001.

Emergency management of acute colonic cancer obstruction

Emergency management of obstructing colonic cancer depends on both tumor location and stage, general condition of the patient and surgeon's experience. Right sided or transverse colon obstructing cancers are usually treated by right hemicolectomy-extended if necessary to the transverse colon-with primary anastomosis. For left-sided obstructing cancer, in patients with low surgical risk, primary resection and anastomosis associated with on-table irrigation or manual decompression can be performed. It prevents the confection of a loop colostomy but presents the risk of anastomotic leakage. Subtotal or total colectomy allows the surgeon to encompass distended and fecal-loaded colon, and to perform one-stage resection and anastomosis. Its disadvantage is an increased daily frequency of stools. It must be performed only in cases of diastatic colon perforation or synchronous right colonic cancer. In patients with high surgical risk, Hartmann procedure must be preferred. It allows the treatment of both obstruction and cancer, and prevents anastomotic leakage but needs a second operation to reverse the colostomy. Colonic stenting is clinically successful in up to 90% in specialized groups. It is used as palliation in patients with disseminated disease or bridge to surgery in the others. If stent insertion is not possible, loop colostomy is still indicated in patients at high surgical risk.