Surgical quality surrogates do not predict colon cancer survival in the setting of technical credentialing: a report from the prospective COST trial.

OBJECTIVE: We tested the hypothesis that the 12 lymph node (LN) count and other surgical variables would not predict survival in a setting where surgical techniques were standardized and surgeons were credentialed and audited. BACKGROUND: The National Quality Forum has adopted the 12-node minimum as a surgical quality metric due to the strong association between node count and survival. METHODS: We performed a secondary analysis of data from the Clinical Outcomes of Surgical Therapy (COST) multicenter randomized trial testing laparoscopic versus open colectomy. Surgeons were credentialed and video-audited for adherence to technical standards. Patients with noninvasive and stage IV disease were excluded, leaving 787 subjects (267 stage I, 284 stage II, and 236 stage III). Median age was 70 years and 50% were male. The overall 5-year survival was 77.2%. RESULTS: Five-year overall and disease-free survival was not influenced by LN count (< 12 vs ≥ 12), sex, tumor location (right vs left vs sigmoid), surgical technique (laparoscopic vs open), total bowel length, proximal margin, distal margin, radial margin, or mesenteric length (P > 0.05 for all). Univariate predictors of survival included age and cancer stage, and these remained significant in the multivariate model. Across all stages of disease, after adjusting for age and stage, LN count did not predict overall or disease-free survival (P = 0.60). CONCLUSIONS: Despite the known association between LN count and survival, we could not confirm an association between surgical surrogates and cancer outcomes. We postulate that standardization, credentialing, and monitoring may be more important than traditional surgical quality surrogates.

Adoption of laparoscopic colectomy: results and implications of ASCRS hands-on course participation.

INTRODUCTION: Beginning in 2003, the American Society of Colon and Rectal Surgeons has annually sponsored a laparoscopic colon and rectal surgery instructional course using a cadaver model. This study reports the adoption rate and postcourse practice patterns of participants. METHODS: All prior participants of hands-on courses from 2003 to 2005 were asked to participate in a 25-question survey. Questions probed practice setting, prior laparoscopic experience, motivation for course participation, time to, indication for, and type of first laparoscopic colectomy, experience prior to cancer resection, factors facilitating skill acquisition, and impact on practice from course completion. RESULTS: A total of 43 of 63 participants completed the survey and 53% had performed at least 1 laparoscopic colon resection prior to the course. A laparoscopic colon resection was performed within 1 week of the course by 52% of participants and within 1 month by 90%. Laparoscopic colectomy was performed frequently postcourse with 42% performing between 1 and 5 laparoscopic colectomies/month and 42% between 5 and 10. Hand-assisted technologies lowered the threshold for performance of first laparoscopic colectomy for 62% of participants. Cancer resection was the first procedure for 31% and 36% performed between 5 and 10 colectomies prior to cancer resection. Most important factor in particular course selection was a cadaver model (77%). A majority of the participants would require course completion prior to granting hospital privileges (73%) and would recommend the course to other surgeons (97%). CONCLUSIONS: Cadaver course completion enables rapid integration of laparoscopic colon resection into clinical practice. Experience prior to laparoscopic resection of cancer is modest. Hand-assisted technologies promote technique acquisition.

Reoperation following minimally invasive surgery: are the "rules" different?

This article discusses various indications for reoperation and how employing laparoscopy at primary operation might affect the incidence, presentation, and treatment of common complications. The abdomen is likely to be far less hostile after laparoscopic surgery than after laparotomy. Adhesions to the anterior abdominal wall are minimal or absent. As a result, relaparoscopy is a reasonable diagnostic and often successful treatment modality in patients suspected of having intra-abdominal complications following laparoscopic operation. Laparoscopic success in dealing with acute bowel obstruction after laparoscopic surgery is related to the paucity of adhesions and unique mechanisms of obstruction that are localized and amenable to minimal dissection. The same mechanisms are also responsible for the increased risk of bowel necrosis associated with bowel obstruction after laparoscopic surgery. Limited experience with successful laparoscopic management of bleeding and anastomotic leak has been reported with the caveat that if the bleeding or contamination is excessive, cannot be identified and controlled quickly, or is unresponsive to a reasonable and brief effort using laparoscopy, a prompt laparotomy is indicated. Based on the current literature, it is reasonable to conclude that laparoscopic approaches to primary Crohn's disease and relaparoscopy for recurrence are an appropriate (perhaps the most appropriate) management strategy. Also, laparoscopic restorative proctocolectomy and ileal pouch-anal anastomosis after laparoscopic subtotal colectomy is the preferred treatment for toxic ulcerative colitis. We conclude that laparoscopic reoperative surgery is feasible for the treatment of many complications following laparoscopic major abdominal surgery and bowel resection.

Screening methods for high-grade dysplasia in patients with anal condyloma.

UNLABELLED: Human papilloma virus (HPV) is one of the most common sexually transmitted diseases in the United States. HPV infection can cause anal condylomas and is a risk factor for dysplasia. High-grade dysplasia may progress to squamous cell carcinoma. Currently, biopsy and histological examination are required to grade dysplasia. The purpose of this study is to determine whether anal cytology, morphological characteristics, and/or the presence of high-risk oncogenic HPV-types are effective noninvasive methods to detect high-risk anal condylomas. PATIENTS AND METHODS: From November 2003 to June 2004, all patients with anal condyloma were prospectively evaluated for anal cytology, high-risk oncogenic HPV-types, and tissue biopsies. The Bethesda classification system was used to classify cytologic findings and histological examination, which were grouped as high-risk (HRL) and low-risk (LRL) lesions. Histology results served as true disease for all comparisons. RESULTS: Forty-seven patients with anal condyloma were studied; 43 (91.5%) were men, and the mean age was 39 +/- 11 years. Histology showed 19 (40.5%) patients with HRL, and 28 (59.5%) patients with LRL. Cytology correctly identified 8 patients with HRL and 27 patients with LRL (sensitivity 42% and specificity 96%). High-risk oncogenic HPV-types were found in 84.2% of HRL and 39.3% of LRL (P = 0.0029). Combining cytology with oncogenic HPV-testing, the sensitivity of detecting HRL increased to 89%, and specificity decreased to 42%. CONCLUSION: Anal cytology alone is not accurate for detecting HRL in patients with anal condylomas. Combining oncogenic HPV-testing with cytology is more sensitive in detecting HRL in patients with anal condyloma, and therefore, a more effective screening tool.

Outcome of HIV-infected patients with invasive squamous-cell carcinoma of the anal canal in the era of highly active antiretroviral therapy.

PURPOSE: Before the development of highly active antiretroviral therapy for the treatment of HIV infection, HIV patients diagnosed with invasive squamous-cell carcinoma of the anal canal carried a very poor prognosis. This study was designed to determine the outcome in a similar group of patients in the era of highly active antiretroviral therapy. METHODS: HIV-positive patients treated for invasive squamous-cell carcinoma of the anal canal at the University of Texas Medical Center affiliated hospitals from 1980 to 2001 were identified from operative data and cancer registries. We reviewed these records and collected data regarding age, CD4 count, highly active antiretroviral therapy, cancer treatment, complications, and survival. The patients were divided into two groups based on the presence or absence of highly active antiretroviral therapy and compared using a Kaplan-Meier approach. RESULTS: Fourteen patients with HIV and invasive squamous-cell carcinoma of the anal canal were identified. Six were in the prehighly active antiretroviral therapy group and eight in the highly active antiretroviral therapy group. All were considered for treatment with chemotherapy and radiation. In the prehighly active antiretroviral therapy group, one patient refused therapy and three were unable to complete the squamous-cell carcinoma therapy as planned because of complications. Four of eight highly active antiretroviral therapy patients were unable to complete the squamous-cell carcinoma therapy as planned. The prehighly active antiretroviral therapy patients had a mean age of 40 years and a mean CD4 count of 190 at the time of diagnosis. The highly active antiretroviral therapy patients had a mean age of 44 years and a mean CD4 count of 255 at the time of diagnosis. The 24-month survival was 17 percent in the prehighly active antiretroviral therapy group and 67 percent in the highly active antiretroviral therapy group (P = 0.0524). All six patients in the prehighly active antiretroviral therapy group died with active squamous-cell carcinoma vs. two in the highly active antiretroviral therapy group. Four of the remaining six patients had no evidence of active squamous-cell carcinoma at the last follow-up visit. CONCLUSIONS: A review of patients with HIV and invasive squamous-cell carcinoma of the anal canal suggests a trend toward a higher CD4 count at the time of diagnosis and improved survival in patients receiving highly active antiretroviral therapy. In this new era, HIV-positive patients should be on highly active antiretroviral therapy. If not, highly active antiretroviral therapy should be initiated, and standard multimodality therapies for invasive squamous-cell carcinoma of the anal canal are recommended.

Diverticular disease.

Diverticular disease is a common finding in Western countries with an increasing prevalence with age. Many patients with the disorder remain asymptomatic. However, up to 30% of those affected may show clinical signs including pain, bleeding, obstruction, abscess, fistulae and perforation. The purpose of this chapter is to review the epidemiology, pathogenesis, clinical presentation, diagnostic regimens and treatment options for this disorder.