Long-term oncological outcomes after local excision of T1 rectal cancer.

BACKGROUND: A growing proportion of patients with early rectal cancer is treated by local excision only. The aim of this study was to evaluate long-term oncological outcomes and the impact of local recurrence on overall survival for surgical local excision in pT1 rectal cancer. METHODS: Patients who only underwent local excision for pT1 rectal cancer between 1997 and 2014 in two Dutch tertiary referral hospitals were included in this retrospective cohort study. The primary outcome was the local recurrence rate. Secondary outcomes were distant recurrence, overall survival and the impact of local recurrence on overall survival. RESULTS: A total of 150 patients (mean age 68.5 ± 10.7 years, 57.3% males) were included in the study. Median length of follow-up was 58.9 months (range 6-176 months). Local recurrence occurred in 22.7% (n = 34) of the patients, with a median time to local recurrence of 11.1 months (range 2.3-82.6 months). The vast majority of local recurrences were located in the lumen. Five-year overall survival was 82.0%, and landmark analyses showed that local recurrence significantly impacted overall survival at 6 and 36 months of follow-up (6 months, p = 0.034, 36 months, p = 0.036). CONCLUSIONS: Local recurrence rates after local excision of early rectal cancer can be substantial and may impact overall survival. Therefore, clinical decision-making should be based on patient- and tumour characteristics and should incorporate patient preferences.

Outcomes on diverting ostomy formation and reversal after low anterior resection in the older more advanced rectal cancer patient.

BACKGROUND: To decrease morbidity caused by anastomotic leakages after a low anterior resection (LAR) with primary anastomosis, a diverting ostomy is often created. Reversal of a diverting ostomy is associated with morbidity, which may result in non-reversal, particularly in the elderly. This study aimed to describe the diverting ostomy-related outcomes in elderly patients with more advanced rectal cancer after LAR. MATERIALS AND METHODS: All rectosigmoid and rectal cancer patients ≥70 years who underwent LAR with primary anastomosis between 2006 and 2019 in the Catharina Hospital (Eindhoven, The Netherlands) were included for analyses. Reversal rates, ostomy-related complications, morbidity and mortality after ostomy reversal, and definitive ostomy rates were evaluated. RESULTS: In total 164 patients were included, of which 150 (91.5%) underwent primary or secondary ostomy creation. Ostomy-related complications were reported in 34.7% (95%-CI 27.1-42.9%). In total, 72.5% (95%-CI 64.2-79.7%) reversed their diverting ostomy. Non-reversal was mostly due to relapsing disease (52.6%). Median time to ostomy reversal was 3.2 months (IQR 2.3-5.0). No or minor complications after ostomy reversal were observed in 84.0% (95%-CI 75.3-90.6%). Over time, ostomy recreation was performed in 15.0% (95%-CI 8.6-23.5%), and ultimately 65.8% (95%-CI 57.8-73.2%) were ostomy-free after the median follow-up of 3.8 years. CONCLUSION: Although most elderly successfully reversed their diverting ostomy after LAR with limited morbidity, attention should be paid for the risk of non-reversal and ostomy recreation over time. Preoperative patient counselling is important in every individual to be able to decide if LAR with primary anastomosis or a permanent end colostomy is preferred.

Yield of Adding chest CT to Abdominal CT to Detect COVID-19 in Patients Presenting With Acute Gastrointestinal Symptoms (SCOUT-3): Multicenter Study.

OBJECTIVE: To determine the incremental yield of standardized addition of chest CT to abdominal CT to detect COVID-19 in patients presenting with primarily acute gastrointestinal symptoms requiring abdominal imaging. Summary Background Data: Around 20% of patients with COVID-19 present with gastrointestinal symptoms. COVID-19 might be neglected in these patients, as the focus could be on finding abdominal pathology. During the COVID-19 pandemic, several centers have routinely added chest CT to abdominal CT to detect possible COVID-19 in patients presenting with gastrointestinal symptoms. However, the incremental yield of this strategy is unknown. METHODS: This multicenter study in 6 Dutch centers included consecutive adult patients presenting with acute nontraumatic gastrointestinal symptoms, who underwent standardized combined abdominal and chest CT between March 15, 2020 and April 30, 2020. All CT scans were read for signs of COVID-19 related pulmonary sequelae using the СО-RADS score. The primary outcome was the yield of high COVID-19 suspicion (СО-RADS 4-5) based on chest CT. RESULTS: A total of 392 patients were included. Radiologic suspicion for COVID-19 (СО-RADS 4-5) was present in 17 (4.3%) patients, eleven of which were diagnosed with COVID-19. Only 5 patients with СО-RADS 4-5 presented without any respiratory symptoms and were diagnosed with COVID-19. No relation with community prevalence could be detected. CONCLUSION: The yield of adding chest CT to abdominal CT to detect COVID-19 in patients presenting with acute gastrointestinal symptoms is extremely low with an additional detection rate of around 1%.

Age-related differences in morbidity and mortality after surgery for primary clinical T4 and locally recurrent rectal cancer.

AIM: Outcomes in elderly patients (≥75 years) with non-advanced colorectal cancer have improved. It is unclear whether this is also true for elderly patients with clinical T4 rectal cancer (cT4RC) or locally recurrent rectal cancer (LRRC). We aimed to compare age-related differences in morbidity and mortality after curative treatment for cT4RC and LRRC. METHODS: All cT4RC and LRRC patients without distant metastasis who underwent curative surgery between 2005 and 2017 in the Catharina Hospital (Eindhoven, The Netherlands) were included. Morbidity and mortality were evaluated based on age (<75 and ≥75 years) and date of surgery (2005-2011 and 2012-2017). RESULTS: Overall, 72 of 474 (15.2%) cT4RC and 53 of 293 (18.1%) LRRC patients were ≥75 years. No significant differences in the incidence of Clavien-Dindo I-IV complications were observed between age groups. However, in elderly cT4RC patients, cerebrovascular accidents occurred more frequently (4.2% vs. 0.5%, P = 0.03). Between 2005-2011 and 2012-2017, 30-day mortality improved from 7.5% to 3.1% and from 10.0% to 0.0% in elderly cT4RC and LRRC patients, respectively. The 1-year mortality during 2012-2017 was worse in elderly than in younger patients (28.1% vs. 6.2%, P = 0.001 for cT4RC and 27.3% vs. 13.8%, P = 0.06 for LRRC). In elderly cT4RC and LRRC patients, 44.4% and 46.2% died due to non-cancer-related causes, while only 27.8% and 23.1% died due to disease recurrence, respectively. CONCLUSION: Although the 30-day mortality in elderly cT4RC and LRRC patients improved after curative treatment, the 1-year mortality in elderly patients continued to be high, which requires more awareness for the elderly after hospitalization.

When and how should surgery be performed in senior colorectal cancer patients?

Older studies reported high rates of postoperative morbidity and mortality in the senior population, which lead to a tendency to withhold curative surgery in the older population. However, more recent studies showed impressing developments in postoperative outcomes in seniors. Probably, these improvements are due to enhancements in both surgical and non-surgical aspects in the pre-, peri- and postoperative period, such as minimally invasive techniques and anesthesiological insights. The postoperative survival gap seen earlier between younger and older patients is fading. For optimal treatment in the older population, special awareness and care on several aspects is needed. As only a minority of the seniors are frail, a quick frailty assessment is crucial to distinguish the fit from the frail in the decision-making process. In addition, it could be valuable to improve the lacks in physical condition in the preoperative period with the use of prehabilitation programs. Furthermore, it is important to evolve an emergency to an elective setting by postponing emergency surgery to prevent any high-risk situation. In conclusion, based on modern insights, surgery is a valid option in the curative treatment of colorectal cancer in seniors, however individual attention and care is required.

Significant improvement in postoperative and 1-year mortality after colorectal cancer surgery in recent years.

BACKGROUND: In earlier studies an association between older patients and higher morbidity and mortality after colorectal surgery is shown, especially in the first postoperative year. We conducted this study to investigate if there is improvement in postoperative morbidity and mortality in senior CRC patients over time. MATERIALS AND METHODS: All patients, except those with distant metastasis, who received curative CRC surgery between 2006 and 2017 in the Catharina Hospital (Eindhoven, the Netherlands) were selected retrospectively. Differences in mortality and relative survival between different age groups (<75 and ≥ 75 years), period of surgery (2006-2012 and 2013-2017) and type of tumor (colon and rectum) were investigated. RESULTS: In total 2018 patients, of whom 57.4% is male, were selected (n = 1037 colon and n = 981 rectum). 615 (30.5%) patients were ≥75 years old. For electively treated CRC patients aged ≥75 years 30- and 90-day mortality improved from 5.8% to 1.2% (p = 0.004) and 9.1% to 4.6% (p = 0.043) respectively, in favour of the latest time period. Relative one-year survival rates of all electively treated CRC patients were not significantly different between younger and older patients in the latest time period (95.5% vs. 94.3%, p = n.s.). CONCLUSIONS: This study shows significant improvement in postoperative morbidity and mortality over time for both age and treatment groups. Relative survival rates improved especially for older patients and no significant differences were seen between both age groups. Senior CRC patients should not be withheld curative treatment based on age or comorbidities alone.

Stoma placement in obstructive rectal cancer prior to neo-adjuvant treatment and definitive surgery: A practical guideline.

INTRODUCTION: Mechanical bowel obstruction in rectal cancer is a common problem, requiring stoma placement to decompress the colon and permit neo-adjuvant treatment. The majority of patients operated on in our hospital are referred; after stoma placement at the referring centre without overseeing final type of surgery. Stoma malpositioning and its effects on rectal cancer care are described. METHODS: All patients who underwent surgery for locally advanced or locally recurrent rectal cancer between 2000 and 2013 in our tertiary referral centre were reviewed and included if they received a stoma before curative surgery. Patients with recurrent rectal cancer were only included if the stomas from the primary surgery had been restored. The main outcome measures are stoma malpositioning, postoperative and stoma-related complications. RESULTS: A total of 726 patients were included; of these, 156 patients (21%) had a stoma before curative surgery. In the majority of patients, acute or pending large bowel obstruction was the main indication for emergent stoma creation; some of the patients had tumour-related fistulae. In 53 patients (34%), the stoma required revision during definitive surgery. No significant differences were found regarding postoperative complications. CONCLUSION: One-third of the previously placed emergency stomas were considered to be located inappropriately and required revision. We were able to avoid increased complication rates in patients with a malpositioned stoma, however unnecessary surgery for an inappropriately placed stoma should be avoided to decrease patient inconvenience and risks. An algorithm is proposed for the placement of a suitable stoma.

Anastomotic leakage and presacral abscess formation after locally advanced rectal cancer surgery: Incidence, risk factors and treatment.

PURPOSE OF THE STUDY: Anastomotic leakage (AL) and presacral abscess (PA) after rectal cancer surgery are a major concern for the colorectal surgeon. In this study, incidence, prognosis and treatment was assessed. METHODS: Patients operated on in our institute, between 1994 and 2011, for locally advanced rectal cancer (LARC, T3+/T4M0) were included. Morbidity was scored using the Clavien-Dindo classification. Prognostic factors were analysed using binary logistic regression. RESULTS: 517 patients were included after a low anterior resection (n = 219) or abdominoperineal resection (n = 232). AL occurred in 25 patients (11.4%); 50 patients (9.7%) developed a PA. We identified intraoperative blood loss ≥4500 cc (p = 0.038) and the era of surgery; patients operated on before the year 2006 (p = 0.042); as risk factors for AL. The time between last day of neo-adjuvant treatment and surgery, <8 weeks is significantly associated with the development of PA (p = 0.010). CONCLUSIONS: In our population of LARC patients we found an incidence of 9.7% PA and 11.4% AL, with a 12% mortality rate for AL, which is comparable to surgery in general colorectal cancer. Increased intraoperative blood loss and surgery prior to 2006 are associated with AL. Increased intraoperative blood loss and a timing interval <8 weeks increases the risk of PA formation.

Large variation between hospitals in follow-up for colorectal cancer in southern Netherlands.

PURPOSE: The aims of the study were to describe the follow-up of colorectal cancer (CRC) patients in southern Netherlands and examine their overall and disease-free survival. METHODS: Patients newly diagnosed with CRC in 2003-2005 and 2008 with a survival of at least 1 year after diagnosis and recorded in the retrospective Eindhoven Cancer Registry were included (n = 579). Follow-up was defined as at least one liver imaging and at least two carcinoembryonic antigen (CEA) measurements. Logistic regression analyses were conducted to assess determinants of follow-up. Proportions of patients undergoing colonoscopy, CEA measurements and liver and chest imaging were calculated. Overall and disease-free survival were calculated. RESULTS: Patients ≥75 years (odds ratio (OR) 0.5 (95% confidence interval (CI) 0.3-0.7)) were less likely to receive follow-up, contrasting patients <50 years (OR 3.1 (95% CI 1.3-7.4)). In 2008, follow-up intensity increased (OR 2.3 (95% CI 1.2-4.3)), especially for liver imaging and CEA measurements. There were large differences in follow-up intensity and activities between hospitals, which were unaffected by comorbidity: ranges for colonoscopy 15-73 %, CEA measurement 46-91 % and imaging of the liver 22-70 % between hospitals. No effect of follow-up intensity was found on 5-year disease-free survival for patients aged <75 years (64 vs. 68 %; p = 0.6). Similarly, no effect of follow-up intensity on 5-year overall survival was found in these patients (77 vs. 82 %; p = 0.07). CONCLUSION: Large variation in follow-up was found for patients with CRC, mainly declining with age and hospital of follow-up. Over time, follow-up became more intensive, especially with respect to liver imaging and CEA measurements. However, follow-up consisting of at least one liver imaging and at least two CEA measurements did not improve overall and disease-free survival.

Quality of life of older rectal cancer patients is not impaired by a permanent stoma.

BACKGROUND: The current study was undertaken to investigate the impact of a stoma on the HRQL with a special focus on age. MATERIALS AND METHODS: Using the Eindhoven Cancer Registry, rectal cancer patients diagnosed between 1998 and 2007 in 4 hospitals were identified. All patients underwent TME surgery. Survivors were approached to complete the SF-36 and EORTC QLQ-C38 questionnaires. HRQL scores of the four groups, stratified by stoma status (stoma/no stoma) and age at operation (<70 and ≥ 70), were compared. The SF-36 and the QLQ-CR38 sexuality subscale scores of the survivors were compared with an age- and sex-matched Dutch norm population. RESULTS: Median follow-up of 143 patients was 3.4 years. Elderly had significantly worse physical function (p = 0.0003) compared to younger patients. Elderly (p = 0.005) and patients without a stoma (p = 0.009) had worse sexual functioning compared to younger patients and patients with a stoma. Older males showed more sexual dysfunction (p = 0.01) when compared to younger males. In comparison with the normative population, elderly with a stoma had worse physical function (p < 0.01), but slightly better mental health (p < 0.05). Elderly without a stoma had better emotional role function (p < 0.01), and younger patients had worse sexual functioning and enjoyment (both p < 0.0001). CONCLUSIONS: Older patients with a stoma have comparable HRQL to older patients without a stoma or the normative population, indicating the feasibility of a permanent stoma for elderly patients with a low situated rectal carcinoma. The negative impact of treatment on sexual functioning as found in the current study calls for further attention to alleviate this problem in sexually active patients.