Challenges and outcome of surgery for bowel obstruction in women with gynaecologic cancer.

INTRODUCTION: Bowel obstruction is associated with a reduction in quality of life and survival among cancer patients, and the entity is traditionally treated by general surgeons without dedication to the different malignancies that cause bowel obstruction or to palliation. This study aims to identify and improve outcome of bowel obstruction in women with a history of a gynaecologic cancer. METHODS: Women operated for bowel obstruction were screened for a history of gynaecologic cancer and their records were reviewed. RESULTS: Bowel obstruction followed cancer treatment by a median of 18.4 months (range 2.3-277) in 59 women. A malignant cause was identified in 53% and recurrence of cancer in 61%. The cause of malignant bowel obstruction was peritoneal carcinomatosis (19%), obstructing tumour and carcinomatosis (31%) and solitary tumour (3%). Ovarian cancer (OR: 6.29, 95% CI 1.95-20.21), residual tumour during initial surgery (R2-stage) (OR: 18.7, 96% CI: 4.35-80.46) and chemotherapy (OR: 7.19, 95% CI: 2.28-22.67) were all associated with malignant bowel obstruction. Surgery solved 84% of malignant bowel obstructions, but median survival was brief (2.5 months, 95% CI: 1.4-3.6) when compared to benign bowel obstruction (95.3 months, 64.7-125.9) (p < 0.001). Readmission for bowel obstruction occurred after a median of 4.3 months (95% CI: 3.1-5.5) in surviving patients with malignant bowel obstruction and after a median of 84.5 months (95% CI: 73.6-95.3) with adhesive obstruction (p < 0.001). CONCLUSIONS: Increased awareness of the aetiology to bowel obstruction may improve treatment strategy in these women. Women with malignant bowel obstruction should be carefully identified and differentiated in order to improve quality of life rather than pursuing emergency surgical procedures.

Outcome after introduction of complete mesocolic excision for colon cancer is similar for open and laparoscopic surgical treatments.

BACKGROUND: Complete mesocolic excision (CME) and a high (apical) vascular tie may improve oncologic outcome after surgery for colon cancer. Our primary aim was to emulate a previous national result of 73.8% overall survival (OS) with both the open and laparoscopic techniques. METHODS: A prospective study of radical colon cancer was initiated in a Norwegian community teaching hospital in 2007 and comprised a consecutive group of 251 patients with TNM stages I-III that had surgery according to the CME principle. Oncological outcome was assessed as OS, disease-free survival (DFS) and cancer-specific survival (CSS), as well as time to recurrence (TTR), using Cox regression analysis. RESULTS: In-hospital mortality was 3.6%, 2.3% for laparoscopic surgery and 4.9% for open management. Significantly more patients in the open CME group developed complications in the short term (p < 0.001). Twelve or more lymph nodes were retrieved from 82.9% (208/251) of the specimens. Overall 3-year OS was 84.5%, DFS 77.4%, CSS 91.5% and TTR 86.8%. The surgical approach was not a significant predictor for any of the survival parameters. CONCLUSIONS: There was no survival difference between open and laparoscopic CME colonic resections, and the present OS improved from a previous OS from 2000.

Pre-operative anaemia in colon cancer patients became normal after more than a year post-operatively but did not influence oncological outcome in the final analysis.

BACKGROUND: Pre-operative anaemia has been related to adverse outcomes after surgical management of colorectal cancer. How various factors may contribute to anaemia and also its post-operative recovery has not been extensively investigated. METHODS: Two hundred and thirty five colon cancer patients treated surgically in a community teaching hospital in Norway between 2007 and 2009 were prospectively examined. RESULTS: Anaemia was detected in 53.8%, which was dependent on tumour location, albumin level and female gender. More than 60% of all patients were overweight or obese. Pre-operative BMI was negatively associated with age and positively associated with albumin level (p = 0.018 for both). Haemoglobin levels slowly returned to normal during the first year in significant incremental steps, coincidental with an increase in BMI. At 6 months post-operative, age, albumin, female gender and TNM stage (p = 0.010; p = 0.020; p < 0.001; p = 0.028, respectively) were significantly connected with anaemia, whereas only age and albumin (p = 0.016; p = 0.004, respectively) were associated with a reduced BMI. Pre-operative anaemia gave a significantly worse overall survival (p = 0.040) in the univariate analysis but was not significant in the multivariate analysis. CONCLUSION: Beside the influence of tumour location, it appeared that pre-operative Hgb had some relation to a reduced nutritional state. The post-operative recovery of anaemia was more closely related to an improved nutritional state. The relation between anaemia and oncological outcome should undergo further studies.

Improved lymph node harvest from resected colon cancer specimens did not cause upstaging from TNM stage II to III.

BACKGROUND: The number of lymph nodes retrieved and examined from a resected colon cancer specimen may be crucial for correct staging. We examined if efforts to increase the lymph node harvest to more than 12 lymph nodes per specimen would upstage some patients from TNM stage II to III. METHODS: Three hospitals compared results from 2000 with those of 2007 in 421 resected patients with stage II and III colon cancer. Hospital A endeavored to improve the surgical procedure while the pathologists enhanced the quality of lymph node sampling. Hospital B did not make any marked changes, while hospital C introduced the GEWF lymph node solvent (glacial acetic acid, ethanol, distilled water, and formaldehyde) in their pathology method. RESULTS: In 2000, 12 or more lymph nodes were harvested in 39.6, 45.0, and 21.1% of the specimens from the three hospitals, while the figures for 2007 were 85.7, 42.0, and 90.3%, respectively. The significant increase in lymph node harvest in two of the hospitals in 2007 compared to 2000 (p < 0.001) did not affect the share of patients with stage III in 2007 (38.7%) compared to 2000 (44.1%) (p = 0.260). The number of positive lymph nodes and the lymph node ratio (LNR) decreased from 2000 to 2007. A lymph node yield of 12 or more was not associated with an increased probability of positive lymph nodes in a multivariable logistic regression analysis. CONCLUSION: More radical surgery and dedicated pathologists and the use of the GEWF solvent significantly increased the lymph node yield but did not upstage patients from TNM stage II to III.

Overall survival after resection for colon cancer in a national cohort study was adversely affected by TNM stage, lymph node ratio, gender, and old age.

BACKGROUND: A national surveillance program of colon cancer treatment was introduced in 2007. We examined prognostic factors for colon cancer operated in 2000 with an aim of improving survival in the new program and a special focus on the merit of lymph node yield. METHODS: A cohort of 269 patients, 152 women (56.5%), with a mean age of 71 years, was operated for colon cancer in 2000 at three teaching hospitals and followed up for 7 years. RESULTS: Overall 5-year survival was 58.0%, and overall hospital mortality was 5.2%, with 4.5% in elective cases and 12.5% after urgent surgery. In only 41.1% of the specimens were 12 or more lymph nodes retrieved, but this did not affect survival in the combined cohort, although one of the hospitals achieved a significantly better result with a harvest of 12 or more lymph nodes. In a multivariate analysis, old age, gender, a high lymph node ratio (LNR) at stage III, and tumor-node-metastasis stage were adverse factors for survival. CONCLUSIONS: The operative mortality was high and should be reassessed. The lymph node count did not have a significant impact on outcome overall, whereas the LNR proved significant for stage III. A prospective protocol using overall lymph node yield as a surrogate measure for more radical surgery, nevertheless, seems warranted to improve the lymph node harvest according to international recommendations.

Short and long-term survival from gastric cancer. A population-based study from a county hospital during 25 years.

The aim of this study was to evaluate the outcome for gastric cancer patients treated at a medium sized Norwegian hospital. The medical journals of all 356 patients with gastric cancer treated at Levanger Hospital from 1980 to 2004 were retrospectively analysed. Follow-up with regard to survival was complete. The Department of Surgery had treated 277 patients (78%). The resection rate of patients admitted to the Department of Surgery was 56% (154/277), and the total resection rate was 43% (154/356). R0 resection was done in 97 patients (27%), R1 resection in 16 (4%), palliative R2 resection in 41 (12%), other palliative procedures in 59 (17%), and only palliative care was given for 143 (40%) patients. The 30-days postoperative mortality was 2.7% (3/113) after R0 and R1 resections, 4.9% (2/41) after R2 resections, and 24% (14/59) after other palliative procedures. After R0 resections, the estimated overall 5-year survival was 39% (95% C.I. 29-49). After R1 and R2 resections, none survived 5 years and the estimated overall 2-year survival was 12% (95% C.I. 0-27%) and 2% (95% C.I. 0-7%), respectively. Estimated overall 5-year survival was closely related to stage: 91% (95% C.I. 74-100) in stage 1A, 64% (95% C.I. 53-74) in stage 1B, 27% (95% C.I. 10-44) in stage II, 18% (95% C.I. 4-32) in stage IIIA, and none in stages IIIB and IV. Dysphagia, fatigue, weight loss, palpable tumour, ascites and anaemia were related to a bad prognosis. Dyspepsia, vomiting and hematemesis were not related to the prognosis. Symptoms duration > 6 months were related to a better prognosis than short duration of symptoms < 2 months. The results from this hospital are in accordance with previous reports from the Western world.