Volume-outcome relationship in rectal cancer surgery

Colorectal cancer in ulcerative colitis after liver transplantation for primary sclerosing cholangitis: a systematic review and pooled analysis of oncological outcomes

INTRODUCTION

Patients with ulcerative colitis (UC) receiving liver transplantation (LT) due to primary sclerosing cholangitis (PSC) have higher risk of developing colorectal cancers (CRC). Aim of this systematic review was to define the patients' features, immunosuppressive management, and oncological outcomes of LT recipients with UC-PSC developing CRC.

METHODS

Searches were conducted in PubMed (MEDLINE), Cochrane Library, Web of Science for all English articles published until September 2023. Inclusion criteria were original articles including patients specifying outcomes of interest. Primary endpoints comprised incidence of CRC, disease free survival (DFS), overall survival (OS) and cancer recurrence. Secondary endpoints were patient's and tumor characteristics, graft function, immunosuppressive management and PSC recurrence. PROSPERO CRD42022369190.

RESULTS

Fifteen studies included, 88 patients were identified. Patients (mean age: 50 years) had a long history of UC (20 years), mainly with active colitis (79%), and developed tumor within the first 3 years from LT, while receiving a double or triple immunosuppressive therapy. Cumulative incidence of tumor was 5.5%. At one, two and three years, DFS was 92%, 82% and 75%, while OS was 87%, 81% and 79% respectively. Disease progression rate was 15%. After CRC surgery, 94% of patients maintained a good graft functionality, with no reported cases of PSC recurrence.

CONCLUSIONS

After LT, patients with PSC and UC have an increased risk of CRC, especially in presence of long history of UC and active colitis. Surgical resection guarantees satisfactory mid-term oncological outcomes, but samples are limited, and long-term data are lacking. National and international registry are auspicial to evaluate long-term oncological outcomes and to optimize clinical management.

Is centralization for rectal cancer surgery necessary?

Rectal cancer surgery is complex and more technically challenging than colonic surgery. Over the last 30 years internationally, there has been a growing impetus for centralizing care to improve outcomes for rectal cancer. Centralizing care may potentially reduce variations of care, increase standardization and compliance with clinical practice guidelines. However, there are barriers to implementation at a professional, political, governance and resource allocation level. Centralization may increase inequalities to accessing healthcare, particularly impacting socioeconomically disadvantaged and rural populations with difficulties to commuting longer distances to "centres of excellence". Furthermore, it is unclear if centralization actually improves outcomes. Recent studies demonstrate that individual surgeon volume rather than hospital volume may be more important in achieving optimal outcomes. In this review, we examine the literature to assess the value of centralization for rectal cancer surgery.

Patient management after primary rectal cancer diagnosis. Special focus on surgical treatment for non-metastatic disease

Background: Rectal cancer is a public health priority. Primary objectives of this study were to evaluate the quality of care for non-metastatic rectal cancer using process and outcome indicators. Delay of management, length of stay and readmission rate, sphincter preservation, morbidity, number of examined lymph nodes, mortality, overall and disease-free survivals were evaluated. Secondary objectives were to estimate the relationship between possible predictive parameters for (1) anastomotic leakage (logistic regression), (2) overall or disease-free survivals (cox regression).Methods: We performed a retrospective study on 312 consecutive patients diagnosed with primary rectal cancer between 2016 and 2019. We focused on the 163 patients treated by surgery for non-metastatic cancer.Results: The treatment began within 33 days (range 0-264) after incidence, resection rate was 67%. Digestive continuity rate in lower, middle and upper rectum was 30%, 87% and 96%. Median of 14 lymph nodes (range 1-46) was analyzed. Length of stay and readmission rate were 11 days (range 3-56) and 4%, respectively. Within 90 postoperative days, clinical anastomotic leakage occurred in 9.2% of cases, major morbidity rate was 17%, mortality 1.2%. Multivariate analysis revealed that stoma decreased the risk of anastomotic leakage [hazard ratio: 0.16; 95% confidence intervals: 0.04-0.63; p = 0.008]. The 5-year overall survival after surgery was 85 ± 4%, disease-free survival 83 ± 4%. Patients with major complications, male gender and R1/R2 resection margin had a poorer prognosis.Conclusion: This work showed encouraging results in rectal cancer treatment in our institution, our results were in line with recommendations at the time.

Impact of hospital volume on failure to rescue for complications requiring reoperation after elective colorectal surgery: multicentre propensity score-matched cohort study

BACKGROUND

It has previously been reported that there are similar reoperation rates after elective colorectal surgery but higher failure-to-rescue (FTR) rates in low-volume hospitals (LVHs) versus high-volume hospitals (HVHs). This study assessed the effect of hospital volume on reoperation rate and FTR after reoperation following elective colorectal surgery in a matched cohort.

METHODS

Population-based retrospective multicentre cohort study of adult patients undergoing reoperation for a complication after an elective, non-centralized colorectal operation between 2006 and 2017 in 11 hospitals. Hospitals were divided into either HVHs (3 hospitals, median ≥126 resections per year) or LVHs (8 hospitals, <126 resections per year). Patients were propensity score-matched (PSM) for baseline characteristics as well as indication and type of elective surgery. Primary outcome was FTR.

RESULTS

A total of 6428 and 3020 elective colorectal resections were carried out in HVHs and LVHs, of which 217 (3.4%) and 165 (5.5%) underwent reoperation (P < 0.001), respectively. After PSM, 142 patients undergoing reoperation remained in both HVH and LVH groups for final analyses. FTR rate was 7.7% in HVHs and 10.6% in LVHs (P = 0.410). The median Comprehensive Complication Index was 21.8 in HVHs and 29.6 in LVHs (P = 0.045). There was no difference in median ICU-free days, length of stay, the risk for permanent ostomy or overall survival between the groups.

CONCLUSION

The reoperation rate and postoperative complication burden was higher in LVHs with no significant difference in FTR compared with HVHs.

Ambulatory laparoscopic colectomies: a systematic review

AIM

Ambulatory laparoscopic colectomy (ALC), meaning discharge within 24 h of surgical colonic resection, has recently been proposed in a few, selected patients. This systematic review was performed with the aim of reviewing protocols for ALC and assessing feasibility, safety and outcomes after ALC.

METHOD

A PRISMA-compliant systematic review and pooled analysis was performed searching all English studies published until October 2022 in PubMed, Cochrane Library, Web of Science (PROSPERO, CRD42022334463). Inclusion criteria were original articles including patients undergoing ALC, specifying at least one outcome of interest. Exclusion criteria were articles reporting a robotic-assisted procedure; unable to retrieve patient data from articles; the same patient series included in different studies. Primary outcomes were success, overall complications and readmission rates. Secondary outcomes included mortality and specific complications such us surgical site infection, anastomotic leak, ileus, bleeding, rate of ALC acceptance, and unscheduled consultation and reoperation rate.

RESULTS

Among 1087 studies imported for screening, 11 were included (1296 patients). The success rate was 47% with an overall morbidity of 14%. Readmission and reoperation rates were 5% and 1%, respectively. No mortality was recorded. Protocols of ALC differ significantly among published studies.

CONCLUSIONS

Overall, ALC appears to be safe and feasible in selected cases with an acceptable success rate and a low risk of readmission after hospital discharge. Future studies should evaluate patients' benefits and discharge criteria, as well as uniformity and standardization of eligibility criteria. This systematic review may help inform on ALC adoption in clinical practice.

Trends in the Characteristics, Treatment, and Outcomes of Rectal Adenocarcinoma in the US From 2004 to 2019: A National Cancer Database Analysis

IMPORTANCE

Rectal cancer management has significantly evolved over the last 2 decades.

OBJECTIVE

This study aimed to evaluate trends in the characteristics, treatment, and outcomes of rectal adenocarcinoma across 16 years.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, observational case series study used data from the National Cancer Database (NCDB) to evaluate patients diagnosed with rectal adenocarcinoma from 2004 through 2019. Data analysis was performed from March to May 2022.

EXPOSURES

Trends in the treatment and outcomes of rectal adenocarcinoma in the US between 2004 and 2019 were explored. This period was subdivided into 4 equal periods: 2004-2007, 2008-2011, 2012-2015, and 2016-2019.

MAIN OUTCOMES AND MEASURES

Patient and tumor characteristics, treatments, short-term outcomes, and overall survival.

RESULTS

A total of 318 548 patients diagnosed with rectal adenocarcinoma were included in the analysis, 191 369 (60.1%) of whom were males and 127 179 (39.9%%) were females. The mean (SD) age of the patients was 63.5 (13.4) years, and 46 824 patients (14.8%) were younger than 50 years. Among the patients, 10 859 (3.4%) were of Asian race and ethnicity, 28 464 (8.9%) were Black, and 271 236 (85.1%) were White. The percentage of patients younger than 50 years who were diagnosed with rectal cancer increased by 1.5%, from 13.9% in period 1 to 15.4% in period 4. Patients in the last period (2016-2019) presented more often with stages III (36.2% vs 30.2% vs 25.0% vs 23.4%; P < .001) and IV (21.5% vs 19.3% vs 18.1% vs 18.6%; P < .001) disease compared with those in the remaining 3 periods. The use of chemotherapy (36.8% vs 48.1% vs 49.1% vs 47.0%; P < .001) and immunotherapy (0.4% vs 0.2% vs 3.5% vs 6.5%; P < .001) significantly increased across the 4 periods. Although neoadjuvant radiotherapy was used more often across the periods studied (28.6% in period 1 to 34.3% in period 4), the use of adjuvant radiotherapy was reduced by half (12.9% to 6.0%). The median (IQR) time from diagnosis to definitive surgery increased from 95 (15-126) days in period 1 to 128 (47-158) days in period 4. The rate of use of open surgery decreased by half (60.1% in period 2 to 30.1% in period 4), and the use of robotic surgery significantly increased (5.2% in period 2 to 28.4% in period 4). The conversion rate was significantly reduced (11.2% in period 2 to 7.3% in period 4) and the median (IQR) hospital stay decreased by 2 days, from 6 (3-9) days to 4 (2-7) days. The median (IQR) overall survival significantly increased across the periods (from 83.1 months [95% CI, 81.8-84.6 months] in period 1 to 92.1 months [95% CI, 90.2-93.6 months] in period 3; P < .001).

CONCLUSION AND RELEVANCE

The findings of this case series study suggest a treatment trend of increased use of chemotherapy, immunotherapy, sphincter-saving surgery, and minimally invasive surgery. In addition, the time between diagnosis and definitive surgery increased by a median of 33 days. This treatment trend was associated with a significant improvement in the overall survival, reduction in the conversion rate by 3.9%, and a 2-day shorter hospital stay. These findings have major clinical relevance to the management of rectal cancer. The improvements seen in short-term outcomes and survival of patients diagnosed with rectal cancer can probably be attributed to the treatment trends observed. Continued improvement in outcomes warrant further updates in treatments.

Application and evaluation of transitory protective stoma in ovarian cancer surgery

Ovarian cancer is the most fatal of all female reproductive cancers. The fatality rate of OC is the highest among gynecological malignant tumors, and cytoreductive surgery is a common surgical procedure for patients with advanced ovarian cancer. To achieve satisfactory tumor reduction, intraoperative bowel surgery is often involved. Intestinal anastomosis is the traditional way to restore intestinal continuity, but the higher rate of postoperative complications still cannot be ignored. Transitory protective stoma can reduce the severity of postoperative complications and traumatic stress reaction and provide the opportunity for conservative treatment. But there are also many problems, such as stoma-related complications and the impact on social psychology. Therefore, it is essential to select appropriate patients according to the indications for the transitory protective stoma, and a customized postoperative care plan is needed specifically for the stoma population.

Laparoscopic versus Open Total Gastrectomy for Locally Advanced Gastric Cancer: Short and Long-Term Results

BACKGROUND

Laparoscopic gastrectomy for early gastric cancer is widely accepted and routinely performed. However, it is still debated whether the laparoscopic approach is a valid alternative to open gastrectomy in advanced gastric cancer (AGC). The aim of this study is to compare short-and long-term outcomes of laparoscopic (LG) and open (OG) total gastrectomy with D2 lymphadenectomy in patients with AGC.

METHODS

A retrospective comparative study was conducted on patients who underwent LG and OG for ACG between January 2015 and December 2021. Primary endpoints were the following: recurrence rate, 3-year disease-free survival, 3-year and 5-year overall survival. Univariate and multivariate analysis was conducted to compare variables influencing outcomes and survival.

RESULTS

Ninety-two patients included: fifty-three OG and thirty-nine LG. No difference in morbidity and mortality. LG was associated with lower recurrence rates (OG 22.6% versus LG 12.8%, p = 0.048). No differences in 3-year and 5-year overall survival; 3-year disease-free survival was improved in the LG group on the univariate analysis but not after the multivariate one. LG was associated with longer operative time, lower blood loss and shorter hospital stay. Lymph node yield was higher in LG.

CONCLUSION

LG for AGC seems to provide satisfactory clinical and oncological outcomes in medium volume centers, improved postoperative results and possibly lower recurrence rates.

The impact of age on rectal cancer treatment, complications and survival

BACKGROUND

The number of older patients with rectal cancer is increasing. Treatment outcome discrepancies persist, despite similar treatment guidelines. To offer the oldest patients optimal individually adjusted care, further knowledge is needed regarding treatment strategy and outcome. The present study aimed to evaluate treatment, postoperative complications, and survival in older patients treated for rectal cancer.

METHODS

This retrospective study included all 666 patients (n=255 females, n=411 males) treated for rectal cancer at Levanger Hospital during 1980-2016 (n=193 <65 years, n=329 65-79 years, n=144 ≥80 years). We performed logistic regression to analyse associations between complications, 90-day mortality, and explanatory variables. We performed a relative survival analysis to identify factors associated with short- and long-term survival.

RESULTS

Despite a similar distribution of cancer stages across age-groups, patients aged ≥80 years were treated with a non-curative approach more frequently than younger age groups. Among patients aged ≥80 years, 42% underwent a non-curative treatment approach, compared to 25% of patients aged <65 years, and 25% of patients aged 65-79 years. The 90-day mortality was 15.3% among patients aged ≥80 years, compared to 5.7% among patients aged <65 years, and 9.4% among patients aged 65-79 years. Among 431 (65%) patients treated with a major resection with curative intent, the 90-day mortality was 5.9% among patients aged ≥80 years (n=68), compared to 0.8% among patients aged <65 years (n=126), and 3.8% among patients aged 65-79 years (n=237). The rate of postoperative complications was 47.6%. Pneumonia was the only complication that occurred more frequently in the older patient group. The severity of complications increased with three factors: age, American Society of Anaesthesiologists score, and >400 ml perioperative blood loss. Among patients that survived the first 90 days, the relative long-term survival rates, five-year local recurrence rates, and metastases rates were independent of age.

CONCLUSION

Patients aged ≥80 years were less likely to undergo a major resection with curative intent and experienced more severe complications after surgery than patients aged <80 years. When patients aged ≥80 years were treated with a major resection with curative intent, the long-term survival rate was comparable to that of younger patients.

The effect of anastomotic leak on postoperative pelvic function and quality of life in rectal cancer patients

AIM

The aim of this review was to collect all available literature data analysing the effects of the anastomotic leak (AL) on post-sphincter preserving rectal cancer surgery bowel and urogenital function as well as to quality of life (QoL) dimensions.

METHODS

A literature search of the PubMed and Embase electronic databases was conducted by two independent investigators and all studies using either functional parameters or QoL as a primary or secondary endpoint after a rectal cancer surgery AL were included.

RESULTS

Amongst the 13 identified studies focusing on the post-AL neorecto-anal function, 3 case-matched studies,3 comparative studies and 1 population-based study supported the deleterious effects of the AL on bowel function, with disturbances of the types of high bowel movement frequency, urgency and increased incontinent episodes to predominate. At one case-matched study the Low Anterior Resection Syndrome (LARS) score was inferior in the AL patients. At limited under-powered studies, urinary frequency, reduced male sexual activity and female dyspareunia may be linked to a prior AL. According to two QoL-targeted detailed studies, QoL disturbances, such as physical and emotional function difficulties may persist up to 3 years after the AL occurrence.

CONCLUSIONS

AL may have adverse effects on postoperative pelvic function and QoL in rectal cancer patients. As evidenced by this literature review, the limited reports on this intriguing topic may trigger the initiative for planning and undertaking larger, multicentre studies on rectal cancer patients with varying degrees of AL severity.

Total neoadjuvant therapy for the treatment of locally advanced rectal cancer: a systematic minireview

Colorectal carcinoma is the second leading cause of cancer-related deaths, and indeed, rectal cancer accounting for approximately one third of newly diagnosed patients. Gold standard in the treatment of rectal cancer is a multimodality approach, aiming at a good control of the local disease. Distant recurrences are the major cause of mortality. Currently, Locally Advanced Rectal Cancer (LARC) patients undergo a combined treatment of chemotherapy and radiotherapy, followed by surgery. Eventually, more chemotherapy, namely adjuvant chemotherapy (aCT), may be necessary. Total Neoadjuvant Therapy (TNT) is an emerging approach aimed to reduce distant metastases and improve local control. Several ongoing studies are analyzing whether this new approach could improve oncological outcomes. Published results were encouraging, but the heterogeneity of protocols in use, makes the comparison and interpretation of data rather complex. One of the major concerns regarding TNT administration is related to its effect on larger and more advanced cancers that might not undergo similar down-staging as smaller, early-stage tumors. This minireview, based on a systematic literature search of randomized clinical trials and meta-analysis, summarizes current knowledge on TNT. The aim was to confirm or refute whether or not current practice of TNT is based on relevant evidence, to establish the quality of that evidence, and to address any uncertainty or variation in practice that may be occurring. A tentative grouping of general study characteristics, clinical features and treatments characteristics has been undertaken to evaluate if the reported studies are sufficiently homogeneous in terms of subjects involved, interventions, and outcomes to provide a meaningful idea of which patients are more likely to gain from this treatment.

Programmed death-ligand 1 and mammalian target of rapamycin signaling pathway in locally advanced rectal cancer

PURPOSE

To evaluate the role of programmed death-ligand 1 (PD-L1) and mammalian target of rapamycin (mTOR) signaling pathway in locally advanced rectal cancer (LARC).

METHODS

Between February 2012 and February 2018, 103 patients with LARC treated by neoadjuvant chemoradiotherapy (neoCRT) and total mesorectal excision (TME) were included. PD-L1, mTOR and p-mTOR of pair-matched pre-neoCRT biopsies and post-neoCRT surgical tissue were evaluated by immunohistochemistry.

RESULTS

The mean combined positive score (CPS), tumor proportion score (TPS) and immune cell score (IC) of pre-neoCRT were 2.24 (0-70), 1.87 (0-70) and 0.67 (0-10), respectively. The mean CPS, TPS and IC of post-neoCRT were 2.19 (0-80), 1.38 (0-80) and 1.60 (0-20), respectively. Significant difference was observed in terms of IC between pre-neoCRT and post-neoCRT (p = 0.010). The 5-year disease-free survival (DFS) rate of the whole group was 62.4%. Multivariate analysis by Cox model indicated that pre-neoCRT TPS [hazard ratio (HR) 1.052, 95% confidence interval (CI) 1.020-1.086, p = 0.001] and post-neoCRT CPS (HR 0.733, 95% CI 0.555-0.967, p = 0.028) were associated with DFS. In the 89 patients without pathological complete response, p-mTOR and IC were upregulated after neoCRT.

CONCLUSIONS

For patients with LARC treated by neoCRT and TME, p-mTOR and IC were upregulated after neoCRT. Pre-neoCRT TPS and post-neoCRT CPS were independent prognostic predictors of DFS.