Overuse and Limited Benefit of Chemotherapy for Stage II Colon Cancer in Young Patients.

BACKGROUND: Few studies have confirmed a benefit for adjuvant chemotherapy (aCTX) in stage II colon cancer. We used the National Cancer Database to explore the use and efficacy of aCTX in patients with both normal-risk (NR) and high-risk (HR) young stage II colon cancer. PATIENTS AND METHODS: We identified patients with stage II colon cancer who underwent colectomy between 2010 and 2015. HR patients included at least: lymphovascular or perineural invasion, < 12 lymph nodes, poor/un-differentiation, T4, or positive margins. Rates of aCTX by age and risk were calculated, and adjusted factors associated with aCTX were identified. Overall survival was estimated using the Kaplan-Meier method and Cox multivariable analyses for patients < 50 years. RESULTS: Among the 81,066 stage II patients who underwent colectomy, 6093 (7.5%) were < 50 years old. Of these, 2669 patients were HR. Thirty percent of NR and almost 60% of HR patients < 50 years received aCTX, compared with 8% and 23% of patients > 50 years (P < .001). In NR patients < 50 years, 35.3% with microsatellite-stable tumors and 18% with microsatellite unstable tumors received aCTX (P < .001), whereas 63.6% and 43.2%, respectively, of HR patients did (P < .001). The most significant multivariable predictors of aCTX were risk status and age. On univariate analysis, there was no survival benefit associated with aCTX in patients < 50 years. Multivariate analysis failed to demonstrate a survival benefit for aCTX for either group (HR, 0.97; P = .84; NR, 0.1.03; P = .90). CONCLUSION: Young patients with HR and NR colon cancer received aCXT more frequently than older patients with no demonstrable survival benefit. This bears further evaluation to avoid the real risks of over-treatment in this increasing population.

Ostomy-Related Complications.

Ileostomy or colostomy formation is an important component of many surgical procedures performed for a wide range of disorders of the gastrointestinal tract. Despite the frequency with which intestinal stomas are created, stoma-related complications remain common and are associated with significant morbidity as well as cost. Some of the most prevalent complications of stoma formation which will be detailed in this article include peristomal skin complications, retraction, stomal necrosis, stomal stenosis, prolapse, bleeding, dehydration from high ostomy output, and parastomal hernia. The authors will review these common complications, detail means to avoid or prevent them, and outline recommendations for management.

Elective colon resection without curative intent in stage IV colon cancer.

BACKGROUND: Evidence suggests that elective primary colon resection (ePCR) in patients with asymptomatic colon tumors and unresectable metastases is not required and may expose patients to unnecessary operative risk. METHODS: Stage IV colon cancer patients with liver metastases from 2000 to 2011 were identified with SEER-Medicare data. Liver-based therapy or urgent/emergent colectomies were excluded. Chemotherapy alone was compared to ePCR ±â€¯chemotherapy. Univariate and multivariate analyses were used to identify predictors of ePCR. Multivariate Cox regression compared survival. RESULTS: 5139 patients were identified. The ePCR rate decreased over time; 84% underwent ePCR in 2000, compared to 52% in 2011 (p < 0.001). In multivariate analysis, older patients were more likely to undergo ePCR, as were patients from rural areas (OR 1.65, p < 0.001). The odds of PCR in high poverty areas (>10%) were almost 25% higher than those in low poverty areas (OR 1.23, p = 0.03). African-Americana were less likely to undergo PCR than Caucasians (OR 0.76, p = 0.01). In multivariate survival analysis, PCR was associated with a significant survival benefit (HR 0.59, p < 0.001). CONCLUSIONS: Although ePCR is not recommended with unresectable metastases and the rate has decreased significantly, over 50% of patients with untreated hepatic metastases underwent ePCR in 2011. Disparities exist in use of ePCR that are likely multifactorial and deserve further study.

Anal and Perineal Injuries.

With increased use of explosive devices in warfare, anal trauma is often seen coupled with more complex pelviperineal injury. While the associated mortality is high, casualties that survive are often left with disabling fecal incontinence from damage to the anosphincteric complex. After resolution of the acute insult, the initial evaluation mandates a thorough physical exam, including endoscopic evaluation with rigid proctoscopy and flexible sigmoidoscopy, as well as adjunctive testing, specifically anal manometry and endoanal ultrasound. First-line therapy favors bulking agents and antidiarrheals, in conjunction with biofeedback, due to a minimal risk profile. Surgical options range from direct sphincter repairs to complex anosphincteric reconstruction with widely variable results. Most recently, burgeoning therapies in the treatment of fecal incontinence, including sacral nerve stimulation and magnetic anal sphincters, offer excellent alternatives with promising long-term outcomes. In summation, the goal of all interventions is the re-establishment of bowel continence, but, in its absence, permanent fecal diversion for devastating fecal incontinence is a reasonable option with excellent patient satisfaction scores.

Transanal Minimally Invasive Surgery.

Transanal endoscopic surgery (TES) techniques encompass a variety of approaches, including transanal endoscopic microsurgery and transanal minimally invasive surgery. These allow a surgeon to perform local excision of rectal lesions with minimal morbidity and the potential to spare the need for proctectomy. As understanding of the long-term outcomes from these procedures has evolved, so have the indications for TES. In this study, we review the development of TES, its early results, and the evolution of new surgical techniques. In addition, we evaluate the most recent research on indications and outcomes in rectal cancer.

Colorectal Specialization Increases Lymph Node Yield: Evidence from a National Database.

BACKGROUND: Current guidelines recommend the evaluation of at least 12 lymph nodes (LNs) in the pathologic specimen following surgery for colorectal cancer (CRC). We sought to examine the role of colorectal specialization on nodal identification. METHODS: We conducted a retrospective cohort study using SEER-Medicare data to examine the association between colorectal specialization and LN identification following surgery for colon and rectal adenocarcinoma between 2001 and 2009. Our dataset included patients >65 years who underwent surgical resection for CRC. We excluded patients with rectal cancer who had received neoadjuvant therapy. The primary outcome measure was the number of LNs identified in the pathologic specimen following surgery for CRC. Multivariate analysis was used to identify the association between surgical specialization and LN identification in the pathologic specimen. RESULTS: In multivariate analysis, odds of an adequate lymphadenectomy following surgery with a colorectal specialist were 1.32 and 1.41 times greater for colon and rectal cancer, respectively, than following surgery by a general surgeon (p < 0.001). These odds increased to 1.36 and 1.58, respectively, when analysis was limited to board-certified colorectal surgeons. Hospital factors associated with ≥12 LNs identified included high-volume CRC surgery (colon OR 1.84, p < 0.001; rectal OR 1.78, p < 0.001) and NCI-designated Cancer Centers (colon OR 1.75, p < 0.001; rectal OR 1.64; p = 0.007). CONCLUSIONS: Colorectal specialization and, in particular, board-certification in colorectal surgery, is significantly associated with increased LN identification following surgery for colon and rectal adenocarcinoma since the adoption of the 12-LN guideline in 2001.

Social media is a necessary component of surgery practice.

Social media is a necessary component of the practice of surgery. Each surgeon must embrace the power and potential of social media and serve as a guide or content expert for patients and other health care providers to facilitate and share responsible use of the various media available. Social media facilitates rapid communication of information not only across providers but also between patients and providers. The power of social media has the potential to improve consultation and collaboration, facilitate patient education, and expand research efforts; moreover, by harnessing its potential, the appropriate use of many of the avenues of social media also can be used to disseminate campaigns to increase disease awareness and communicate new research findings and best-practice guidelines. Because its reach is so broad within as well as outside the censorship of medical experts, professional oversight and engagement is required to maximize responsible use. Staying consistent with our history of surgery, rich in innovation and technologic advancement, surgeons must get to the front of this evolving field and direct the path of social media as it applies to the practice of surgery rather than take a passive role.