Citations

AbstractAimThe Cleveland Clinic has proposed a prognostic model of preoperative risk factors for failure of restorative proctocolectomy (RPC) with ileal pouch–anal anastomosis. The model incorporates four predictive variables: completion proctectomy, handsewn anastomosis, diabetes mellitus and Crohn's disease. The aim of the present study was to perform an external validation of this model in a new cohort of patients who had RPC.MethodValidation was performed in a multicentre cohort of 747 consecutive patients who had an RPC between 1990 and 2015 in three tertiary‐care facilities, using a Kaplan–Meier survival analysis and Cox regression analysis. The performance of the model was expressed using the Harrell concordance error rate. The primary outcome measure was pouch survival with maintenance of anal function.ResultsDuring the study period, 45 (6.0%) patients experienced failure at a median interval of 31 months (interquartile range 9–82 months) from the original RPC. Multivariable analysis showed handsewn anastomosis to be the only significant independent predictor. The Harrell concordance error rate was 0.42, indicating poor performance. Anastomotic leakage and Crohn's disease of the pouch were strong postoperative predictors for pouch failure and showed a significant difference in pouch survival after 10 years (P < 0.001).ConclusionThe poor performance of the Cleveland Clinic prognostic model makes it unsuitable for daily clinical practice. Handsewn anastomosis was associated with pouch failure in our cohort with relatively few events. A prediction model for anastomotic leakage or Crohn's disease of the pouch may be a better solution since these variables are strongly associated with pouch failure.

AbstractAimSurgery aims to prevent cancer‐related morbidity for patients with ulcerative colitis (UC) associated dysplasia. The literature varies widely regarding the likelihood of dysplastic progression to higher grades of dysplasia or cancer. The aim of this study was to characterize the likelihood of the development of colorectal cancer (CRC) of patients with UC‐associated dysplasia who chose to defer surgery.MethodA retrospective review was carried out of patients undergoing surgery for UC at the Mayo Clinic, who were diagnosed to have dysplasia between August 1993 and July 2012. The relationships between grade of dysplasia, time to surgery and the detection of unsuspected carcinoma were investigated.ResultsIn all, 175 patients underwent surgery at a median of 4.9 (interquartile range 2.5–8.9) months after a diagnosis of dysplasia. Their median age was 52 (interquartile range 43−59) years. An initial diagnosis of indeterminate dysplasia was not associated with CRC [0/23; 17.7 (8.1−29.6) months]. Thirty‐six patients who had an initial diagnosis of dysplasia progressed from indeterminate to low‐grade dysplasia [24.2 (11.0−30.4) months]. Low‐grade dysplasia was associated with a 2% (1/56; T2N0M0) risk of CRC when present in random surveillance biopsies and a 3% (2/61; T1N0M0, T4N0M0) risk if detected in endoscopically visible lesions [7.4 (5.2−33.3) months]. Eighteen patients progressed from indeterminate to high‐grade dysplasia [19.1 (9.2−133.9) months]. Seventeen patients progressed from low to high‐grade dysplasia [11.0 (5.8−30.1) months]. None of the patients with high‐grade dysplasia (0/35) progressed to CRC [4.5 (1.7−9.9) months].ConclusionDysplasia was associated with a low incidence of node negative CRC if surgery was deferred for up to 5 years. These findings may help inform the decision‐making process for asymptomatic patients who are having to decide between intensive surveillance or surgery for UC‐associated dysplasia.

BACKGROUNDSurgeon and hospital factors are associated with the survival of patients treated for rectal cancer. The relative contribution of each of these factors toward determining outcomes is poorly understood.METHODSWe used data from the Surveillance, Epidemiology, and End Results–Medicare database to analyze the outcomes of patients aged 65 years and older undergoing operative treatment for nonmetastatic rectal cancer, diagnosed in the United States between 1998 and 2007. These data were linked to a registry to identify whether the treating surgeon was a board‐certified colorectal surgeon versus a noncolorectal surgeon. Hospital volume and hospital certification as a National Cancer Institute–designated Comprehensive Cancer Centers were also analyzed. The primary outcome of interest was long‐term survival.RESULTSOur data source yielded 6432 patients. Initial analysis demonstrated improved long‐term survival in patients treated by higher‐volume colorectal surgeons, higher‐volume hospitals, teaching hospitals, and National Cancer Institute (NCI)–designated Comprehensive Cancer Centers. Based on an iterative approach to modeling the interactions between these various factors, we found a robust effect of surgeon subspecialty status, hospital volume, and NCI designation. Surgeon volume was not distinctly associated with long‐term survival.CONCLUSIONSPatients treated for rectal cancer by board‐certified colorectal surgeons in centers that are higher volume and/or NCI‐designated Comprehensive Cancer Centers experience better overall survival. These differences persist after adjustment for a broad range of patient and contextual risk factors, including surgeon volume. Patients and payers can use these results to identify surgeons and hospitals where outcomes are most favorable. Cancer 2014;120:2472–2481. © 2014 American Cancer Society.

AbstractExtended lymphadenectomy has gained considerable attention as an adjunct to conventional colon cancer surgery with the hope that it may potentially decrease local recurrence rates and improve cancer‐specific outcome measures. Despite the enthusiasm surrounding these techniques, it is difficult to establish any additional survival benefit associated with more comprehensive lymphadenectomy strategies when these are performed in addition to conventional colon cancer surgery. Furthermore, these techniques remain unproven by large randomized clinical trials. The appropriate indications for performing extended lymphadenectomy also remain unclear, and there is a lack of standardization with regard to surgical technique. Moreover, there are a number of confounding factors that frequently receive little attention when oncological outcome measures are reported following extended lymphadenectomy in the setting of colon cancer. The purpose of this review is to outline these confounding issues and discuss their impact on reports describing cancer‐specific outcome measures following the use of extended lymphadenectomy techniques. Furthermore, this review proposes that in light of the available published evidence, the role of radical lymphadenectomy is currently unproven, with large randomized clinical trials required in the future to determine whether there is a survival benefit for colon cancer patients.

AbstractMinimally invasive techniques have had a marked impact on colorectal surgery despite the limited adoption of such techniques. Patients stay in the hospital a shorter time, experience less pain, and have less chance of developing a wound infection, an incisional hernia, a bowel obstruction, or difficulty becoming pregnant. Training courses have undergone metamorphosis from ad hoc animate courses to highly defined educational opportunities, and fellowships have had to respond to the educational demands of trainees demanding to be exposed to minimally invasive techniques.

Background Data collection and review were identified as major contributors to the cost of randomized clinical trials (RCTs). Purpose We proposed and assessed a novel alternative for long-term clinical trial follow-up based on the data captured through an accredited Cancer Registry (CR) that is part of the National Cancer Database (NCDB). Methods Patients from Mayo Clinic, Rochester, enrolled in the North Central Cancer Treatment Group N934653 (COST) trial (98 patients) and the American College of Surgeons Oncology Group Z0030 trial (55 patients) were included in the study. Demographic, treatment, and long-term outcome data were compared between the hospital-based CR and the RCTs’ databases. Concordances were used to estimate the agreement between two databases. Kaplan—Meier curves were plotted to examine the consistency of time-to-event long-term outcomes of the CR and RCT databases. Results High concordances (>95%) were observed for most demographic and treatment variables between the CR data and RCT data. The vital status concordances were 100% and 94.5% between the CR and COST and Z0030 databases, respectively. Three discrepant death dates were observed, one in the COST trial and two in the Z0030 trial. The concordances of disease-free status between the CR and RCT databases were 99.0% and 87.3%, and 15 discrepant disease recurrence cases were identified: 4 for COST and 11 for Z0030. Limitations The analysis has been focused on patients from a single site, Mayo Clinic, Rochester, enrolled in two large RCT evaluating surgical treatments. The findings herein need to be confirmed in a broader setting, such as multi-center, multi-registry including nonsurgical trials. Conclusions CR data were nearly identical to data from two randomized phase III trials in different disease types and conducted by two different cooperative groups. The NCDB Cancer Registries represent a feasible alternative for obtaining long-term follow-up data for large clinical trials. Clinical Trials 2010; 7: 686—695. http:// ctj.sagepub.com

AbstractBackgroundThe aim of the present study was to examine the early outcome in patients undergoing intestinal resection for Crohn’s disease (CD) while they are receiving perioperative immunosuppressive medication.MethodsWe reviewed patients with CD undergoing intestinal surgery from 1999 to 2007. Demographics and relevant perioperative information, including medication, were extracted from patient charts. Statistical analysis was performed using Fisher’s exact test.ResultsDuring the course of the study period 112 with Crohn’s disease underwent intestinal resection, and 69 of them were receiving perioperative medication (47, corticosteroids; 39, immunomodulators; and 17, anti‐tumor necrosis factor‐α antibodies). There were no deaths. Median blood loss was 137 ml. Twenty‐two of the patients using perioperative medication (32%) experienced complications, 10 of which were major. The major complications occurred in 3 of the 43 patients (7%) who were not receiving perioperative medications, in 5 of 38 patients (13%) who were receiving one drug, 4 of 28 patients (14%) receiving two drugs, and 1 of 3 patients (33%) receiving three drugs. Thus the occurrence of major complications was not significantly greater in patients receiving perioperative medication. Risk factors for a major complication were intraoperative blood loss >400 ml (P < 0.003) and emergency surgery (P < 0.005).ConclusionsThe occurrence of complications in Crohn’s disease patients undergoing intestinal resection was not associated with the use of immunosuppressive medication. However, emergency surgery and blood loss were risk factors, and reflect the difficulty of surgery in this group of patients.

Sacral neuromodulation is a therapeutic option for women with detrusor overactivity and more recently has been used in patients with fecal incontinence and slow-transit constipation. A 47-year-old woman presented with chronic constipation since childhood. She used multiple laxatives, fiber supplements, and enemas, all without success, and defecated only once per week. Extensive investigations, including barium enema, colonoscopy, defecating proctography, pelvic magnetic resonance imaging, and anorectal manometry all were normal. A transit study showed delayed small-bowel emptying. Colonic transit could not be accurately interpreted because of the marked delayed in proximal transit. An ileostomy was being considered to defunction the colon after the patient become desperate for a better quality of life. She also complained of severe urinary frequency and incomplete emptying. A cystoscopy was normal, and a temporary sacral neuromodulation device was inserted as a staged procedure to improve her urinary symptoms. From the day of device placement and thereafter, the patient defecated without difficulty and has also been free of bladder symptoms. Repeat colonic transit has shown normalization of the stomach, small bowel, and colon.