Effect of no touch isolation on survival and recurrence in curative resections for colorectal cancer.

BACKGROUND: Curative resections for colorectal cancer were studied to determine the effects of the application of bowel ligatures and the sequence of mesenteric ligation on survival and recurrence as part of the no touch isolation technique. METHODS: Records documenting the application of bowel ligatures in 2015 consecutive curative resections for colorectal cancer and the sequence of mesenteric vessel ligation in 1863 of these cases were reviewed. RESULTS: Bowel ligatures applied before tumor mobilization in curative resections for colorectal cancer consistently reduced cancer-related deaths and the incidence of distant, local, and suture line recurrences. Their impact on survival began to approach statistical significance in Dukes C colon cancers and in the overall group of colon cancers (P = .019). Early application of bowel ligatures decreased the incidence of subsequent liver metastases from 15.3% to 9.5% and systemic metastases from 18.0% to 13.0% (P <.0001). Local recurrence was reduced from 18.3% to 10.8% in Dukes B and from 28.6% to 19.3% in Dukes C cases (P = .002). The incidence of suture line recurrence was reduced from 6.8% to 0.9% in Dukes B and from 12.2% to 3.2% in Dukes C cases (P = .001). Ligating the mesenteric vessels before mobilizing the tumor did not significantly affect survival, but did increase the incidence of distant systemic metastases and of local and suture line recurrences. With early vessel ligation, systemic metastases developed in 24.5% of 813 curative resections, compared to 15.7% of 1050 cases in which vessel ligation followed tumor mobilization (P <.001). Early vessel ligation in Dukes C cancers was associated with an increase in local recurrence from 22.5% to 34.2% and in suture line recurrence from 6.9% to 18.8% (P = .0003). The correlation became greater as the stage of the cancer became more advanced. CONCLUSION: By controlling lymphatic and intraluminal dissemination of malignant cells as well as minimizing tumor manipulation, bowel ligatures help to reduce cancer-related deaths and the incidence of distant, local, and suture line recurrences. The sequence in which the mesenteric vessels were ligated did not affect survival, but did change the distribution of distant metastases and the incidence of local and suture line recurrences.

Effect of high and intermediate ligation on survival and recurrence rates following curative resection of colorectal cancer.

PURPOSE: How wide excision of the regional mesenteric lymphatic drainage influences survival and recurrence rates following curative resection of colorectal cancers needs to be more clearly defined. METHODS: A series of 2,409 consecutive patients undergoing curative resections with detailed descriptions of the operative procedure and the lymphatic drainage in the surgical specimens provided a unique database to provide meaningful comparisons between high and intermediate level ligation. RESULTS: High ligation made a statistically significant difference in the death rate from recurrent cancer in patients with Dukes B, AC, and C1 cancers. Based on cancer-related deaths, the probability of five-year survival rate increased with high ligation from 73.9 to 84 percent in patients with Dukes B colon cancers and from 49.0 to 58.6 percent in patients with Dukes C1 colon cancers. In patients with Dukes AC cancers, high ligation increased the five-year survival rate from 64.9 to 80.4 percent. In patients with Dukes C cancers with involved middle level lymph nodes, the five-year survival rate increased from 20.5 to 33 percent and the death rate from recurrent cancer fell from 77 to 59 percent with high ligation. In patients with Dukes AC cancers with four or less involved nodes, the five-year survival rate was increased by high ligation from 50 to 78.6 percent in the colon and from 40 to 71.4 percent in the rectum. When more than four lymph nodes were involved, the survival rate was unaffected by the level of ligation. Although high ligation reduced distant recurrences, its greatest effect was observed in the incidence of local and suture line recurrence. The five-year local recurrence rate in patients with Dukes B who were managed by high ligation was 11.4 percent compared with 18.7 percent with intermediate ligation. In patients with Dukes C cancer, the local recurrence rate was 20.8 percent five years following high ligation compared with 30.7 percent for intermediate ligation. In patients with Dukes B cancer who were undergoing curative resections, the incidence of suture line recurrence was 3.9 percent following high ligation compared with 5.5 percent following intermediate ligation. In patients with Dukes C cancer, the incidence of suture line recurrence was 6.9 percent with high ligation and 11.4 percent with intermediate ligation. CONCLUSION: In certain stages of colorectal cancer, the more extensive resection of mesenteric lymphatic drainage associated with high ligation appears to increase the survival rate and reduce the recurrence rate following curative resections.

The effect of inadvertent intraoperative perforation on survival and recurrence in colorectal cancer.

Inadvertent perforation of the bowel during curative resection for colorectal cancer has serious consequences. In 174 curative resections with spillage, five-year survival was 29 per cent. In 67 patients where the cancer itself was disrupted during dissection, five-year survival fell to 14 per cent in the colon and to 9.3 per cent in the rectum. Local recurrence developed in 65 per cent of spillage cases. In Dukes' C tumors that were perforated during surgery, local recurrence occurred in 87 per cent. As surgeons, our efforts must be directed toward preventing injury to the bowel during definitive resection of colorectal cancers. The instillation of tumoricidal solutions within the bowel lumen and the application of bowel ligatures prior to dissection may help toward preventing recurrence, should inadvertent perforation and spillage occur.

Autologous anticancer antigen preparation for specific immunotherapy in advanced cancer patients. A phase I clinical trial.

A phase I clinical trial was performed to detect adverse reactions in far advanced cancer patients treated with a unique specific cancer immunotherapy. The vaccines consisted of autologous tumor cell membranes and manganese phosphate gel. From 133 patients admitted into the trial, 95 vaccine batches were made. No batch was toxic in animals. One batch was bacteriologically contaminated. Sufficient patients survived or complied to receive 32 complete and 23 partial courses for a total of 707 SC and ID injections. Minor swelling and occasional minimal pain occurred at injection sites. There were two possible vaccine-related systemic reactions but no evidence of tumor transplantation, tumor acceleration, sepsis or autoimmune disease. Subjective and objective improvement occurred in a number of patients. The vaccines are safe. Their efficacy must be determined. The value of ID vaccine skin testing and the unexpectedly little bacteriological contamination require further study.