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Hanevelt J, Leicher LW, Moons LMG, Vleggaar FP, Huisman JF, van Westreenen HL, de Vos Tot Nederveen Cappel WH. Colonoscopic-assisted laparoscopic wedge resection versus segmental colon resection for benign colonic polyps: a comparative cost analysis. Colorectal Dis 2023; 25:2147-2154. [PMID: 37814456 DOI: 10.1111/codi.16757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/15/2023] [Accepted: 09/05/2023] [Indexed: 10/11/2023]
Abstract
AIM The colonoscopic-assisted laparoscopic wedge resection (CAL-WR) is proven to be an effective and safe alternative to a segmental colon resection (SCR) for large or complex benign colonic polyps that are not eligible for endoscopic removal. This analysis aimed to evaluate the costs of CAL-WR and compare them to the costs of an SCR. METHOD A single-centre 90-day 'in-hospital' comparative cost analysis was performed on patients undergoing CAL-WR or SCR for complex benign polyps between 2016 and 2020. The CAL-WR group consisted of 44 patients who participated in a prospective multicentre study (LIMERIC study). Inclusion criteria were (1) endoscopically unresectable benign polyps; (2) residual or recurrence after previous polypectomy; or (3) irradically resected low risk pT1 colon carcinoma. The comparison group, which was retrospectively identified, included 32 patients who underwent an elective SCR in the same period. RESULTS Colonoscopic-assisted laparoscopic wedge resection was associated with significantly fewer complications (7% in the CAL-WR group vs. 45% in the SCR group, P < 0.001), shorter operation time (50 min in the CAL-WR group vs. 119 min in the SCR group, P < 0.001), shorter length of hospital stay (median length of stay 2 days in the CAL-WR group vs. 4 days in the SCR group, P < 0.001) and less use of surgical resources (reduction in costs of 32% per patient), resulting in a cost savings of €2372 (£2099 GBP) per patient (P < 0.001). CONCLUSION Given the clinical and financial benefits, CAL-WR should be recommended for complex benign polyps that are not eligible for endoscopic resection before major surgery is considered.
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Affiliation(s)
- Julia Hanevelt
- Department of Gastroenterology and Hepatology, Isala, Zwolle, The Netherlands
| | - Laura W Leicher
- Department of Gastroenterology and Hepatology, Isala, Zwolle, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Jelle F Huisman
- Department of Gastroenterology and Hepatology, Isala, Zwolle, The Netherlands
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Colonoscopic-Assisted Laparoscopic Wedge Resection for Colonic Lesions: A Prospective Multicentre Cohort Study (LIMERIC-Study). Ann Surg 2022; 275:933-939. [PMID: 35185125 DOI: 10.1097/sla.0000000000005417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the safety and efficacy of a modified colonoscopic-assisted laparoscopic wedge resection. SUMMARY BACKGROUND DATA The use of segmental colectomy in patients with endoscopically unresectable colonic lesions results in significant morbidity and mortality. CAL-WR is an alternative procedure that may reduce morbidity. METHODS This prospective multicentre study was performed in 13 Dutch hospitals between January 2017 and December 2019. Inclusion criteria were (1) colonic lesions inaccessible using current endoscopic resection techniques (judged by an expert panel), (2) non-lifting residual/recurrent adenomatous tissue after previous polypectomy or (3) an undetermined resection margin after endoscopic removal of a low-risk pT1 colon carcinoma. Thirty-day morbidity, technical success rate and radicality were evaluated. RESULTS Of the 118 patients included (56% male, mean age 66 years, SD ± 8 years), 66 (56%) had complex lesions unsuitable for endoscopic removal, 34 (29%) had non-lifting residual/recurrent adenoma after previous polypectomy and 18 (15%) had uncertain resection margins after polypectomy of a pT1 colon carcinoma. CAL-WR was technically successful in 93% and R0 resection was achieved in 91% of patients. Minor complications (Clavien-Dindo I-II) were noted in 7 patients (6%) and an additional oncologic segmental resection was performed in 12 cases (11%). Residual tissue at the scar was observed in 5% of patients during endoscopic follow-up. CONCLUSIONS CAL-WR is an effective, organ-preserving approach that results in minor complications and circumvents the need for major surgery. CAL-WR therefore deserves consideration when endoscopic excision of circumscribed lesions is impossible or incomplete.
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Marres CCM, Smit MPCM, van der Bilt JDW, Buskens CJ, Mundt MW, Verbeek PCM, Bemelman WA, van de Ven AWH. Laparoscopic wedge resection as an alternative to laparoscopic oncological colon resection for benign endoscopically unresectable colon polyps. Colorectal Dis 2021; 23:2361-2367. [PMID: 34097812 PMCID: PMC8518389 DOI: 10.1111/codi.15769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/10/2021] [Accepted: 05/19/2021] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to investigate, by comparing clinical and histological outcomes, whether laparoscopic (hybrid) wedge resection (LWR) could be a less invasive and safe alternative to laparoscopic oncological colon resection (OCR) for patients with an endoscopically unresectable, suspected benign, colon polyp. METHOD All patients with an endoscopically unresectable colon polyp who were referred for surgery between 2009 and 2018 and without biopsy-proven colon cancer were identified from a prospectively maintained database. Patients with macroscopic features of malignancy during endoscopy were excluded. Clinical and histological results for patients who underwent OCR or LWR were reviewed. RESULTS One hundred-and-twenty-two patients were included. Ninety-seven patients underwent OCR and 25 LWR. Major complications occurred in 16.7% (n = 16) of the OCR group compared with 4.0% (n = 1) of the LWR group (p = 0.06). In the OCR group the anastomotic leakage rate was 6.3% (n = 6) and the mortality rate 3.1% (n = 3). No anastomotic leakage or deaths occurred in the LWR group. The median length of hospital stay after OCR was 5 days [interquartile range (IQR) 5-9 days)] compared with 2 days (IQR 2-4 days) after LWR (p < 0.0001). Definite pathology showed a malignancy rate of 4.2% (n = 4) in the OCR group and 4.0% (n = 1) (without high-risk features) in the LWR group. CONCLUSION This study shows that LWR was associated with significantly lower complication rates and acceptable oncological risks compared with OCR. Therefore we suggest that LWR is a safe alternative treatment, next to other endoscopic options. The treatment that is most suitable for an individual patient should be discussed in a multidisciplinary meeting.
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Affiliation(s)
- Carla Christine Maria Marres
- Department of SurgeryFlevoziekenhuisAlmereThe Netherlands,Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | | | - Jarmila D. W. van der Bilt
- Department of SurgeryFlevoziekenhuisAlmereThe Netherlands,Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | | | - Marco W. Mundt
- Department of Gastroenterology and HepatologyFlevoziekenhuis, AlmereThe Netherlands
| | | | - Willem A. Bemelman
- Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Anthony Willem Hendrik van de Ven
- Department of SurgeryFlevoziekenhuisAlmereThe Netherlands,Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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Liu ZH, Zhang GX, Zhang H, Jiang L, Deng Y, Chan FSY, Fan JKM. Association of body fat distribution and metabolic syndrome with the occurrence of colorectal adenoma: A case-control study. J Dig Dis 2021; 22:222-229. [PMID: 33656773 DOI: 10.1111/1751-2980.12979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/23/2021] [Accepted: 02/28/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Visceral fat is thought to play different roles in the carcinogenesis of the colon with peripheral fat. Our aim was to evaluate the association of body fat distribution measured by bioelectrical impedance analysis (BIA) with the incidence of colorectal adenoma (CRA). METHODS A total of 410 asymptomatic participants who underwent a screening colonoscopy from July 2017 to December 2019 in our center were recruited, including 230 with adenomas and 180 without detected adenomas. The participants' body fat was measured by BIA, including their body fat mass (BFM), body fat percentage (BFP), and waist-to-hip ratio. Parameters of metabolic syndrome (MetS), including waist circumference, blood pressure, fasting blood glucose (FBG), blood level of triglyceride, cholesterol, and high-density lipoprotein were measured as well. RESULTS According to univariate analysis, age, male sex, body mass index, waist circumference, BFM, waist-to-hip ratio, blood pressure, and FBG were higher in the adenoma group than in the adenoma-free group (P < 0.05). On multivariate logistical analysis (adjusted for age, sex, smoking, drinking, and family history of CRC), a high waist-to-hip ratio was associated with a high incidence of CRA (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.09-3.09, P = 0.02). Only a large waist circumference in components of MetS was independently associated with the incidence of CRA (OR 1.90, 95% CI 1.17-3.08, P = 0.01) in the multivariate analysis. CONCLUSION Body fat distribution is associated with CRA, central obesity is a core risk factor for CRA in MetS. Chinese Clinical Trial Registration number: ChiCTR-RRC-17010862.
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Affiliation(s)
- Zhong Hui Liu
- Department of Surgery, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Gui Xi Zhang
- Department of Surgery, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Hao Zhang
- Department of Surgery, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Li Jiang
- Department of Surgery, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Yang Deng
- Department of Surgery, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Fion Siu Yin Chan
- Department of Surgery, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China.,Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Joe King Man Fan
- Department of Surgery, University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China.,Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
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Bosch D, Leicher LW, Vermeer NCA, C M J Peeters K, de Vos Tot Nederveen Cappel WH, van Westreenen HL. Referrals for surgical removal of polyps since the introduction of a colorectal cancer screening programme. Colorectal Dis 2021; 23:672-679. [PMID: 33107210 DOI: 10.1111/codi.15413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/14/2020] [Indexed: 01/19/2023]
Abstract
AIM Implementation of the Dutch national bowel screening programme in 2014 led to an increased rate of detection of polyps. In general, polyps should be removed endoscopically. However, if the size and location of the polyp make endoscopic removal technically difficult, or if there is a suspicion for early (T1) cancer, surgery is the preferred method for removal. An increasing number of these patients are being treated with minimally invasive surgical procedures instead of segmental resection. The aim of this study was to assess the number of referrals for surgery and the type of surgery for polyps since the introduction of the Dutch national bowel screening programme. METHOD A retrospective cohort study was performed. Patients who underwent surgery for colorectal polyps between January 2012 and December 2017 were included. Patients with histologically proven carcinoma prior to surgery were excluded. Primary outcomes were the number and type of surgical procedures for polyps. RESULTS A total of 164 patients were included. An annual increase in procedures for colorectal polyps was observed, from 18 patients in 2012 to 36 patients in 2017. All the procedures before implementation of the screening programme were segmental resections, and 58.8% of the patients underwent organ-preserving surgery after implementation of the screening. The overall complication rate of organ-preserving surgery was 16.3%, compared with 44.3% for segmental resections (P = 0.001). Overall, invasive colorectal cancer was encountered in 23.8% of cases. CONCLUSION The number of referrals for surgical resection of colorectal polyps has doubled since the introduction of the Dutch national bowel screening programme with a substantial shift towards organ-preserving techniques.
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Affiliation(s)
- Dianne Bosch
- Department of Surgery, Isala, Zwolle, The Netherlands
| | - Laura W Leicher
- Department of Gastroenterology and Hepatology, Isala, Zwolle, The Netherlands
| | - Nina C A Vermeer
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Golda T, Lazzara C, Sorribas M, Soriano A, Frago R, Alrasheed A, Kreisler E, Biondo S. Combined endoscopic-laparoscopic surgery (CELS) can avoid segmental colectomy in endoscopically unremovable colonic polyps: a cohort study over 10 years. Surg Endosc 2021; 36:196-205. [PMID: 33439344 DOI: 10.1007/s00464-020-08255-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 12/16/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Combined-Endoscopic-Laparoscopic-Surgery (CELS) was developed for benign colonic polyps, endoscopically unresectable, to avoid segmental colectomy. This observational study aims to compare surgical outcomes of endoscopically unresectable colonic polyps treated laparoscopically before and since the institutional introduction of CELS. Primary endpoint was postoperative morbidity and mortality; secondary endpoints were time of hospitalization and histopathological findings. METHODS Charts of all patients with preoperative diagnosis of benign colonic tumors, treated laparoscopically at our institution from 1/2010 to 2/2020 were reviewed. Patients with polyps (1) affecting ileocecal valve, (2) occupying > 50% of the circumference, (3) ≥ 3 endoscopically unresectable polyps, (4) inflammatory bowel disease, (5) polyps within diverticular area post diverticulitis, (6) rectal polyps (7) foreseen impossibility of laparoscopy (8) preoperatively biopsy proven invasive adenocarcinoma were excluded. Group I consists of all patients potentially treatable by CELS but operated by laparoscopic colonic resection as CELS was not yet institutionally established. Group II includes all patients treated with CELS (since 11/2017). RESULTS One hundred-fifteen consecutive patients were reviewed. Applying exclusion criteria, twenty-three patients form group I and twenty-three group II (female 30.4%, median age 68 years). Groups distributed homogenously for age, BMI (body mass index) and polyps´ localization with most polyps (60.4%) localized in right colon; group II patients had significantly higher American Society of Anesthesiologists (ASA) score. Median operating time, hospital stay and morbidity were significantly less in group II. Postoperative morbidity occurred overall in 14 patients (30.4%), mostly Clavien-Dindo class I-II (26.1%) and significantly less in group II (p = 0.017), Clavien-Dindo III-IV distributed equally (one patient each group) without postoperative mortality. Definitive histopathology showed invasive adenocarcinoma in 8.3% without differences between groups. Two patients with invasive adenocarcinoma after CELS were advised for oncological resection. CONCLUSION CELS is safe and efficient to treat complex, benign colonic polyps by a complete minimal invasive laparoscopic approach. CELS showed better surgical outcomes with less morbidity, no mortality and appropriate pathological results avoiding unnecessary laparoscopic surgery with intestinal anastomosis.
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Affiliation(s)
- Thomas Golda
- Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain.
| | - Claudio Lazzara
- Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | - Maria Sorribas
- Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | - Antonio Soriano
- Department of Gastroenterology, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | - Ricardo Frago
- Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | | | - Esther Kreisler
- Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | - Sebastiano Biondo
- Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
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Paszat LF, Sutradhar R, Luo J, Baxter NN, Tinmouth J, Rabeneck L. Morbidity and mortality after major large bowel resection of non-malignant polyp among participants in a population-based screening program. J Med Screen 2020; 28:261-267. [PMID: 33153368 PMCID: PMC8366188 DOI: 10.1177/0969141320967960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background and aims Colonoscopy following positive fecal occult blood screening may detect non-malignant polyps deemed to require major large bowel resection. We aimed to estimate the major inpatient morbidity and mortality associated with major resection of non-malignant polyps detected at colonoscopy following positive guaiac fecal occult blood screening in Ontario's population-based colorectal screening program. Methods We identified those without a diagnosis of colorectal cancer in the Ontario Cancer Registry ≤24 months following the date of colonoscopy prompted by positive fecal occult blood screening between 2008 and 2017, who underwent a major large bowel resection ≤24 months after the colonoscopy, with a diagnosis code for non-malignant polyp, in the absence of a code for any other large bowel diagnosis. We extracted records of major inpatient complications and readmissions ≤30 days following resection. We computed mortality within 90 days following resection. Results For those undergoing colonoscopy ≤6 months following positive guaiac fecal occult blood screening, 420/127,872 (0.03%) underwent major large bowel resection for a non-malignant polyp. In 50/420 (11.9%), the resection included one or more rectosigmoid or rectal polyps, with or without a colonic polyp. There were one or more major inpatient complications or readmissions within 30 days in 117/420 (27.9%). Death occurred within 90 days in 6/420 (1.4%). Conclusions Serious inpatient complications and readmissions following major large bowel resection for non-malignant colorectal polyps are common, but mortality ≤90 days following resection is low. These outcomes should be considered as unintended adverse consequences of population-based colorectal screening programs.
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Affiliation(s)
- Lawrence F Paszat
- Institute for Health Care Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Rinku Sutradhar
- Institute for Health Care Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jin Luo
- Cancer Program, Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Nancy N Baxter
- Institute for Health Care Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jill Tinmouth
- Institute for Health Care Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Linda Rabeneck
- Institute for Health Care Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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8
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Liu ZH, Jiang L, Chan FSY, Li MKW, Fan JKM. Combined endo-laparoscopic surgery for difficult benign colorectal polyps. J Gastrointest Oncol 2020; 11:475-485. [PMID: 32655925 DOI: 10.21037/jgo.2019.12.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Prevention of colorectal cancer (CRC) depends largely on the detection and removal of colorectal polyps. Despite the advances in endoscopic techniques, there are still a subgroup of polyps that cannot be treated purely by endoscopic approach, which comprise of about 10-15% of all the polyps. These so-called "difficult colorectal polyps" are polyps with large size, morphology, at difficult location, scarring or due to recurrence, which have historically been managed by surgical segmental resection. In treating benign difficult colorectal polyps, we have to balance the operative risks and morbidities associated with surgical segmental resection. Therefore, combined endoscopic and laparoscopic surgery (CELS) has been developed to remove this subgroup of difficult benign polyps. We review the currently use of CELS for difficult benign colorectal polyps which includes laparoscopy-assisted endoscopic polypectomy (LACP), full-thickness laparo-endoscopic excision (FLEX) and colonoscopy-assisted laparoscopic wedge resection (CAL-WR).
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Affiliation(s)
- Zhong-Hui Liu
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China
| | - Li Jiang
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China
| | - Fion Siu-Yin Chan
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China.,Department of Surgery, The University of Hong Kong, Hong Kong, China
| | | | - Joe King-Man Fan
- Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, China.,Department of Surgery, The University of Hong Kong, Hong Kong, China.,Asia-Pacific Endo-Lap Surgery Group (APELS), Hong Kong, China
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9
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Detering R, Saraste D, de Neree tot Babberich MPM, Dekker JWT, Wouters MWJM, van Geloven AAW, Bemelman WA, Tanis PJ, Martling A, Westerterp M. International evaluation of circumferential resection margins after rectal cancer resection: insights from the Swedish and Dutch audits. Colorectal Dis 2020; 22:416-429. [PMID: 31696599 PMCID: PMC7187294 DOI: 10.1111/codi.14903] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 10/18/2019] [Indexed: 12/14/2022]
Abstract
AIM This study aimed to determine predictive factors for the circumferential resection margin (CRM) within two northern European countries with supposed similarity in providing rectal cancer care. METHOD Data for all patients undergoing rectal resection for clinical tumour node metastasis (TNM) stage I-III rectal cancer were extracted from the Swedish ColoRectal Cancer Registry and the Dutch ColoRectal Audit (2011-2015). Separate analyses were performed for cT1-3 and cT4 stage. Predictive factors for the CRM were determined using univariable and multivariable logistic regression analyses. RESULTS A total of 6444 Swedish and 12 089 Dutch patients were analysed. Over time the number of hospitals treating rectal cancer decreased from 52 to 42 in Sweden, and 82 to 79 in the Netherlands. In the Swedish population, proportions of cT4 stage (17% vs 8%), multivisceral resection (14% vs 7%) and abdominoperineal excision (APR) (37% vs 31%) were higher. The overall proportion of patients with a positive CRM (CRM+) was 7.8% in Sweden and 5.4% in the Netherlands. In both populations with cT1-3 stage disease, common independent risk factors for CRM+ were cT3, APR and multivisceral resection. No common risk factors for CRM+ in cT4 stage disease were found. An independent impact of hospital volume on CRM+ could be demonstrated for the cT1-3 Dutch population. CONCLUSION Within two northern European countries with implemented clinical auditing, rectal cancer care might potentially be improved by further optimizing the treatment of distal and locally advanced rectal cancer.
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Affiliation(s)
- R. Detering
- Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands,Scientific bureau of the Dutch Institute of Clinical AuditingLeidenThe Netherlands
| | - D. Saraste
- Department of Molecular Medicine and SurgeryKarolinska Institutet,StockholmSweden
| | - M. P. M. de Neree tot Babberich
- Scientific bureau of the Dutch Institute of Clinical AuditingLeidenThe Netherlands,Department of Gastroenterology and HepatologyAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - J. W. T. Dekker
- Department of SurgeryReinier de Graaf Hospital,DelftThe Netherlands
| | - M. W. J. M. Wouters
- Scientific bureau of the Dutch Institute of Clinical AuditingLeidenThe Netherlands,Department of Surgical OncologyNetherlands Cancer Institute–Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands
| | | | - W. A. Bemelman
- Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - P. J. Tanis
- Department of SurgeryAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - A. Martling
- Department of Molecular Medicine and SurgeryKarolinska Institutet,StockholmSweden
| | - M. Westerterp
- Department of Colorectal SurgeryHaaglanden Medical CenterThe HagueThe Netherlands
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Abstract
BACKGROUND There is a trend toward organ conservation in the management of rectal tumors. However, there is no consensus on standardized investigations to guide treatment. OBJECTIVE We report the value of multimodal endoscopic assessment (white light, magnification chromoendoscopy and narrow band imaging, selected colonoscopic ultrasound) for rectal early neoplastic tumors to inform treatment decisions. DESIGN This was a retrospective study. SETTING The study was conducted in a tertiary referral unit for interventional endoscopy and early colorectal cancer. PATIENTS A total of 296 patients referred with rectal early neoplastic tumors were assessed using standardized multimodal endoscopic assessment and classified according to risk of harboring invasive cancer. MAIN OUTCOME MEASURES Sensitivity, specificity, positive and negative predictive values of multimodal endoscopic assessment, and previous biopsy to predict invasive cancer were calculated and treatment outcomes reported. RESULTS After multimodal endoscopic assessment, lesions were classified as invasive cancer, at least deep submucosal invasion (n = 65); invasive cancer, superficial submucosal invasion or high risk of covert cancer (n = 119); or low risk of covert cancer (n = 112). Sensitivity, specificity, positive predictive values, and negative predictive values of multimodal endoscopic assessment for diagnosing invasive cancer, deep submucosal invasion, were 77%, 98%, 93%, and 93%. The combined classification of all lesions with invasive cancer or high risk of covert cancer had a negative predictive value of 96% for invasive cancer on final histopathology. Sensitivity of previous biopsy was 37%. A total of 47 patients underwent radical surgery and 33 transanal endoscopic microsurgery. No patients without invasive cancer were subjected to radical surgery; 222 patients initially underwent endoscopic resection. Of the 203 without deep submucosal invasion, 95% avoided surgery and were free from recurrence at last follow-up. LIMITATIONS This was a retrospective study from a tertiary referral unit. CONCLUSIONS Standardized multimodal endoscopic assessment guides rational treatment decisions for rectal tumors resulting in organ-conserving treatment for all patients without deep submucosal invasive cancer. See Video Abstract at http://links.lww.com/DCR/B133. LA EVALUACIÓN ENDOSCÓPICA MULTIMODAL COMO GUÍA DE DECISIONES EN EL TRATAMIENTO DE TUMORES RECTALES NEOPLÁSICOS PRECOCES: La tendencia actual es la preservación del órgano en el manejo de los tumores de rectao. Sin embargo, no hay consenso sobre las investigaciones estandar para guiar dicho tratamiento.Presentamos los valores de la evaluación endoscópica multimodal (luz blanca, cromoendoscopia de aumento, imagen de banda estrecha y ecografía colonoscópica seleccionada) para tumores rectales neoplásicos tempranos y así notificar las decisiones sobre el tratamiento.Estudio retrospectivo.El estudio se realizó en una unidad de referencia terciaria para endoscopia intervencionista y cáncer colorrectal temprano.Se evaluaron 296 pacientes referidos con tumores neoplásicos precoces de recto mediante una evaluación endoscópica multimodal estandarizada y se clasificaron de acuerdo al riesgo de albergar un cáncer invasivo.Se calcularon la sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal y la biopsia previa para predecir el cáncer invasivo y se notificaron los resultados para el tratamiento.Después de la evaluación endoscópica multimodal, las lesiones se clasificaron como: cáncer invasive (al menos invasión submucosa profunda n = 65); cáncer invasive (invasión submucosa superficial o alto riesgo de cáncer encubierto n = 119) y finalmente aquellos de bajo riesgo de cáncer encubierto (n = 112). La sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal para el diagnóstico de cáncer invasivo, la invasión submucosa profunda fueron 77%, 98%, 93% y 93% respectivamente. La clasificación combinada de todas las lesiones con cáncer invasivo o de alto riesgo de cáncer encubierto tuvo un VPN del 96% para el cáncer invasivo en la histopatología final. La sensibilidad fué de 37% en todas las biopsias previas. 47 pacientes fueron sometidos a cirugía radical, 33 por microcirugía endoscópica transanal. Ningún paciente sin cáncer invasivo fue sometido a cirugía radical. Inicialmente, 222 pacientes fueron sometidos a resección endoscópica. De los 203 sin invasión submucosa profunda, el 95% evitó la cirugía y no tuvieron recurrencia en el último seguimiento.Estudio retrospectivo de una unidad de referencia terciaria.La evaluación endoscópica multimodal estandarizada guía las decisiones racionales de tratamiento para los tumores rectales que resultan en un tratamiento conservador de órganos para todos los pacientes sin cáncer invasivo submucoso profundo. Consulte Video Resumen en http://links.lww.com/DCR/B133.
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Dolwani S. Significant polyp and early colorectal cancer - decision-making and treatment planning in regional networks and multidisciplinary teams. Colorectal Dis 2019; 21 Suppl 1:16-18. [PMID: 30809917 DOI: 10.1111/codi.14492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/20/2018] [Indexed: 01/14/2023]
Affiliation(s)
- S Dolwani
- Division of Population Medicine, School of Medicine, Cardiff University, University Hospital of Wales, Cardiff, UK
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