Impact of imaging magnification on colorectal surgery: a matched analysis of a single tertiary center F. Puccetti, L. Cinelli, M. Molteni, L. Gozzini, U. Casiraghi, L. A. Barbieri, E. Treppiedi, A. Cossu, R. Rosati, U. Elmore Techniques in Coloproctology.2023; 27(11): 1057. CrossRef
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The aim of this review is to evaluate the outcomes after an intersphincteric resection (ISR) for patients with low-lying rectal cancer. Reports published in the literature regarding surgical, oncological, and functional outcomes of an ISR were reviewed. The morbidity after an ISR was 7.7%–32%, and anastomotic leakage was the most common adverse event. Local recurrence rates ranged from 0% to 12%, 5-year overall survival rates ranged from 62% to 92%, and rates of major incontinence ranged from 0% to 25.8% after an ISR. An ISR is a safe procedure for sphincter-saving rectal surgery in patients with very low rectal cancer; it does not compromise the oncological outcomes of the resection and is a valuable alternative to an abdominoperineal resection. While the functional outcomes after an ISR were found to be acceptable, the long-term functional outcome and quality of life still require careful investigation. ISRs have been performed with surgical and oncologic safety on patients with low-lying rectal cancer. However, patients must be selected very carefully for an ISR, considering the associated functional derangement and the limited extent of the resection.
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Purpose Obstructive ileocolitis is an ulcero-inflammatory condition which typically occurs in the ileum or colon proximal to an obstructing colorectal lesion. If left unresolved, it often leads to intestinal perforation. We present a matched case control study of patients with obstructive ileocolitis caused by colorectal cancer to determine if any factors can predict this condition.
Methods This is a retrospective review of 21 patients with obstructive colorectal cancer and histologically proven obstructive ileocolitis from 2005 to 2015 matched for age and sex with 21 controls with obstructing colorectal cancer without obstructive ileocolitis.
Results The 21 patients with obstructive ileocolitis had a median age of 71 years (range, 52–86 years). The most common presenting symptom was abdominal pain (n = 16, 76.2%), followed by vomiting/nausea (n = 14, 66.7%) and abdominal distension (n = 12, 57.1%). Interestingly, the radiological feature of pneumatosis intestinalis was noted in only 1 case. No significant differences were observed in baseline comorbidities, clinical presentations, or tumor characteristics between the 2 groups. Patients with obstructive ileocolitis were found to have a significantly higher total leucocyte count (17.1 ± 9.4×109/L vs. 12.0 ± 6.8×109/L, P = 0.016), lower pCO2 (32.3 ± 8.2 mmHg vs. 34.8 ± 4.9 mmHg, P = 0.013), lower HCO3 (18.8 ± 4.5 mmol/L vs. 23.6 ± 2.7 mmol/L, P < 0.001), lower base excess (-6.53 ± 5.32 mmol/L vs. -0.57 ± 2.99 mmol/L, P < 0.001) and higher serum lactate levels (3.14 ± 2.19 mmol/L vs. 1.19 ± 0.91 mmol/L, P = 0.007) compared to controls. No radiological features were predictive of obstructive ileocolitis.
Conclusion Patients with obstructive ileocolitis tend to present with metabolic acidosis with respiratory compensation, raised lactate, and worse leucocytosis. Radiological features are not useful for predicting this condition.
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Purpose Revolutions have occurred over the last 3 decades in the management of patients with colorectal cancer. Most advances were in rectal cancer surgery, especially after the introduction of the total mesorectal excision (TME) by Heald. However, no parallel advances regarding colon cancer surgeries have occurred. In 2009, Hohenberger introduced a new concept trying to translate the survival advantages of TME to patients with colon cancer. This relatively new concept of a complete mesocolic excision (CME) with central vascular ligation (CVL) in the management of patients with colon cancer represents an evolution in operative technique. We performed a comparative study between CME with CVL and conventional surgery for patients with colon cancer at Italian and Egyptian cancer centers, considering surgical quality and clinical outcome.
Methods Seventy-nine Egyptian patients underwent conventional surgery (non-CME group) while 52 Italian patients underwent CME with sharp dissection between the embryological planes and CVL of the supplying vessels (CME group).
Results Significantly better results were observed in terms of lymph node yield (CME group: 22.5 vs. non-CME group: 12; P < 0.0001) and lymph node ratio (CME group: 0.03 vs. non-CME group: 0.22; P < 0.0001). Regarding surgical morbidity, no significant difference was noted (CME group: 2 vs. non-CME group: 5; P < 0.702).
Conclusion CME appears to be a safe procedure when performed by experienced hands through proper embryological planes. It also provides a superior specimen, with a higher lymph node yield, which consequently affects the lymph node ratio. Eventually, CME with CVL should be increasingly adopted and studied more deeply.
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Purpose Along the invasive margin, colorectal cancer may show distinctive morphologic changes characterized by an asymmetrically attenuating tumor gland with loss of polarity. The author coined the term ‘gland attenuation (GA)’ for these peculiar changes. The aims of this study were to compare the immunoreactivity of the epithelial-mesenchymal transition (EMT) markers E-cadherin and β-catenin and thus determine whether EMTs occurs at tumor budding (TB) or GA sites and to assess the association of TB and/or GA levels with clinicopathological parameters and prognosis.
Methods Expression patterns of E-cadherin and β-catenin in the tumor centers at GA and TB sites were examined in 101 patients with well or moderately differentiated CRCs, and the prognostic significance of TB and/or GA was statistically evaluated.
Results GA foci, as well as TB foci, revealed loss of membranous and cytoplasmic E-cadherin expressions and aberrant β-catenin expression with reduced membranous expression and increased localization to the nucleus, suggesting that EMTs occur in GA as well as in TB. The high-TB and the TB-dominant groups were significantly correlated with advanced invasion depth, presence of lymph node metastasis, advanced pathologic staging and presence of lymphovascular invasion. The high-TB and the TB-dominant groups showed poor overall survival (OS) and recurrence-free survival (RFS), and high TB was an independent prognostic factor in the multivariate analyses for OS and RFS.
Conclusion This study showed evidence that EMTs occurs at GA sites as well as TB foci. TB is a strong and independent prognostic factor, and TB-dominance may be an indicator of adverse clinical outcome.
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Purpose The quality of bowel preparation is a major determinant of the quality of colonoscopy. This study evaluated lifestyle factors, including usual dietary style, associated with bowel preparation.
Methods This retrospective study evaluated 1,079 consecutive subjects who underwent complete colonoscopy from December 2012 to April 2014 at National Cancer Center of Korea. Questionnaires on bowel preparation were completed by the subjects, with the quality of bowel preparation categorized as optimal (excellent or good) or suboptimal (fair, poor or inadequate). Lifestyle factors associated with bowel preparation were analyzed.
Results The 1,079 subjects included 680 male (63.0%) and 399 female patietns (37.0%), with a mean age of 49.6 ± 8.32 years. Bowel preparation was categorized as optimal in 657 subjects (60.9%) and as suboptimal in 422 (39.1%). Univariate analyses showed no differences between groups in lifestyle factors, such as regular exercise, alcohol intake, smoking, and dietary factor. Body mass index (BMI) > 25 kg/m2 was the only factor associated with suboptimal bowel preparation on both the univariate (P = 0.007) and the multivariate (odds ratio, 1.437; 95% confidence interval, 1.104–1.871; P = 0.007) analyses.
Conclusion Most lifestyle factors, including dietary patterns, exercise, alcohol intake and smoking, were not associated with suboptimal bowel preparation in Koreans. However, BMI > 25 kg/m2 was independently associated with suboptimal bowel preparation. More intense preparation regimens before colonoscopy can be helpful in subjects with BMI > 25 kg/m2.
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Purpose The aim of the present study was to evaluate the usefulness of indocyanine green (ICG) as a preoperative marking dye for laparoscopic colorectal surgery.
Methods Between March 2013 and March 2015, 174 patients underwent preoperative colonoscopic tattooing using 1.0 to 1.5 mL of ICG and saline solution before laparoscopic colorectal surgery. Patients’ medical records and operation videos were retrospectively assessed to evaluate the visibility, duration, and adverse effects of tattooing.
Results The mean age of the patients was 65 years (range, 34–82 years), and 63.2% of the patients were male. The median interval between tattooing and operation was 1.0 day (range, 0–14 days). Tattoos placed within 2 days of surgery were visualized intraoperatively more frequently than those placed at an earlier date (95% vs. 40%, respectively, P < 0.001). For tattoos placed within 2 days before surgery, the visualization rates by tattoo site were 98.6% (134 of 136) from the ascending colon to the sigmoid colon. The visualization rates at the rectosigmoid colon and rectum were 84% (21 of 25) and 81.3% (13 of 16), respectively (P < 0.001). No complications related to preoperative ICG tattooing occurred.
Conclusion Endoscopic ICG tattooing is more useful for the preoperative localization of colonic lesions than it is for rectal lesions and should be performed within 2 days before laparoscopic surgery.
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Purpose The incidence of colorectal cancer (CRC) in Korea has increased remarkably during the past few decades. The present study investigated the characteristics and survival of patients with CRC in Korea as a function of time, tumor distribution, stage, sex, and age.
Methods We retrieved clinical data on 326,712 CRC patients diagnosed between 1996 and 2015 from the Korea Central Cancer Registry. The incidence and the 5-year relative survival rates were compared across time period, tumor distribution, stage, sex, and age group.
Results The percentage of patients with colon cancer increased from 49.5% in 1996–2000 to 66.4% in 2011–2015 while the percentage of patients with rectal cancer decreased from 50.5% to 33.6%. The 5-year relative survival rates for all CRCs improved from 58.7% in 1996–2000 to 75.0% in 2011–2015. For 1996–2000, survival rates were highest for patients with left-sided colon cancers, followed by those with right-sided, transverse, rectal, rectosigmoid cancers. For 2011–2015, the survival rates for patients with left-sided cancers were highest, followed by those with rectosigmoid, rectal, transverse, and right-sided colon cancers. Patients with local and regional, but not distant, SEER (Surveillance, Epidemiology, and End Results) stage tumors experienced significantly increased survival rates for 2006–2010 and 2011–2015. The proportion of CRC patients by age decreased in the order ≥70, 60–69, 50–59, 40–49, ≤39 years whereas survival rates decreased in the order 50–59, 60–69, 40–49, ≤39, ≥70 years.
Conclusion Korean CRC has some distinct characteristics and survival patterns in terms of tumor distribution, stage, sex, and age. With time, survival outcomes have improved for both local and regional, but not distant, stage tumors.
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Colorectal large-cell neuroendocrine carcinomas (NECs) are extremely rare and have very poor prognosis compared to adenocarcinomas. A 74-year-old man presented with abdominal pain, diarrhea and hematochezia. The histopathologic report of colonoscopic biopsy performed at a local clinic was a poorly differentiated carcinoma. An abdominopelvic computed scan revealed irregularly enhanced wall thickening at the sigmoid colon with regional fat stranding and lymphnode enlargement. He underwent a laparoscopic high anterior resection with selective peritonectomy for peritoneal carcinomatosis, intraoperative peritoneal irrigation chemotherapy, and early postoperative intraperitoneal chemotherapy for 5 days. The tumor had a high proliferation rate (mitotic count > 50/10 HPFs and 90% of the Ki-67 index) and lymph-node metastases had occurred. On immunohistochemistry, the tumor cells expressed CD56 and synaptophysin. Large-cell NEC was confirmed. Systemic chemotherapy with cisplatin/etoposide was done. The patient is still alive after 3 years with no evidence of recurrence.
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