Is there no need to discuss adjuvant chemotherapy in stage II colon cancer patients with high tumor budding and lymphovascular invasion?

PURPOSE: The aim of this study is to evaluate the clinicopathologic associations of tumor budding (Bd) as well as other potential prognosticators including lymphovascular invasion (LVI) in T3/4aN0 colon cancer patients and to investigate their impact on the outcome. METHODS: The patients were enrolled in three groups according to the number of budding as Bd1 (0-4 buds), Bd2 (5-9 buds), and Bd3 (> 10 buds). These groups were retrospectively compared in terms of demographic features, other tumor characteristics, operative outcomes, recurrences, and survival. The mean follow-up time was 58 ± 22 months. RESULTS: A total of 194 patients were divided as follows: 97 in Bd1, 41 in Bd2, and 56 in Bd3 groups. The Bd3 group was associated with significantly higher LVI and larger tumor size. The rate of recurrence increased progressively from 5.2% in Bd1 to 9.8% in Bd2 and to 17.9% in Bd3 group (p = 0.03). More importantly, the 5-year overall survival (OS: Bd1 = 92.3% vs. Bd2 = 88% vs. Bd3 = 69.5%, p = 0.03) and disease-free survival (DFS: Bd1 = 87.9% vs. Bd2 = 75.3% vs. Bd3 = 66%, p = 0.02) were significantly worse in Bd3 group. In addition, in the subgroup of patients with the presence of Bd3 and LVI together, the 5-year OS (60% vs. 92%, p = 0.001) and DFS (56.1% vs. 85.4%, p = 0.001) were significantly worse. In multivariate analysis, Bd3+LVI was significantly associated with poor OS and DFS (p < 0.001). CONCLUSION: In patients with T3/4aN0 colon cancer, high tumor budding negatively affects long-term oncological outcomes. These findings strongly suggest that adjuvant chemotherapy be considered for the patients with Bd3 and LVI together.

Mid-transverse Location in Primary Colon Tumor: A Poor Prognostic Factor?

BACKGROUND: The location of colonic tumors has been linked to different clinical and oncologic outcomes. Transverse colon cancers are generally included as right colon cancers. Furthermore, hepatic and splenic flexure tumors are usually included as components of the transverse colon. OBJECTIVE: This study was aimed at comparing the clinicopathologic characteristics and long-term outcomes between mid-transverse and right and left colon cancers and determining the prognostic impact of the primary tumor location in the mid-transverse colon. DESIGN: This was a retrospective study. SETTINGS: Two specialized colorectal centers were included. PATIENTS: Patients who underwent curative surgery for colon cancer were analyzed. Tumors located in the transverse colon, excluding the flexures, were defined as mid-transverse colon cancers. MAIN OUTCOME MEASURES: Demographic characteristics, operative outcomes, pathologic results, and long-term outcomes were the primary outcome measures. RESULTS: Of the 487 patients, 41 (8.4%) had mid-transverse, 191 (39.2%) had right, and 255 (52.4%) had left colon cancers. For mid-transverse colon cancers, the mean length of hospital stay, mean length of the resected specimen, and the mean number of harvested lymph nodes were significantly higher. For patients with stage I to III cancer, the 5-year overall and disease-free survival rates were significantly worse in the mid-transverse colon cancers than in the right and left colon cancers (overall survival: 55.5% vs 82.8% vs 85.9%, p = 0.004, and disease-free survival; 47.7% vs 72.4% vs 79.5%, p = 0.003). After adjustment for other clinicopathologic factors, mid-transverse colon cancers were significantly associated with a poor prognosis (HR = 2.19 [95% CI, 1.25-3.83]; p = 0.006). LIMITATIONS: Molecular and genetic information were unavailable in this retrospective study. CONCLUSIONS: In our case series, colon cancers located in the mid-transverse colon showed poorer prognosis than cancers in other locations. The impact of tumor location in the mid-transverse colon on prognosis, including molecular and genetic markers, should be investigated further in prospective studies. See Video Abstract at http://links.lww.com/DCR/B631. LOCALIZACIN TRANSVERSA MEDIA EN EL TUMOR DE COLON PRIMARIO UN FACTOR DE MAL PRONSTICO: ANTECEDENTES:La ubicación de los tumores de colon se ha relacionado con diferentes resultados clínicos y oncológicos. Los cánceres de colon transverso se incluyen generalmente como cánceres de colon derecho. Además, los tumores del ángulo hepático y esplénico suelen incluirse como un componente del colon transverso.OBJETIVO:Este estudio tuvo como objetivo comparar las características clínico-patológicas y los resultados a largo plazo entre los cánceres de colon transverso medio y derecho e izquierdo y determinar el impacto pronóstico de la ubicación del tumor primario en el colon transverso medio.DISEÑO:Este fue un estudio retrospectivo.AJUSTE ENTORNO CLINICO:Se incluyeron dos centros colorrectales especializados.PACIENTES:Se analizaron los pacientes que fueron sometidos a cirugía curativa por cáncer de colon. Los tumores ubicados en el colon transverso, excluidos los ángulos, se definieron como "cánceres de colon transverso medio".PRINCIPALES MEDIDAS DE RESULTADO VOLARACION:Las características demográficas, los resultados quirúrgicos, los resultados patológicos y los resultados a largo plazo fueron las principales medidas de resultado valoracion.RESULTADOS:De los 487 pacientes, 41 (8,4%) tenían cáncer de colon transverso medio, 191 (39,2%) derecho y 255 (52,4%) cáncer de colon izquierdo. Para los cánceres de colon transverso medio, la duración media de la estancia hospitalaria, la duración de la muestra resecada y el número medio de ganglios linfáticos extraídos fueron significativamente mayores. Para los pacientes en estadio I-III, las tasas de supervivencia general y sin enfermedad a 5 años fueron significativamente peores en los cánceres de colon transverso medio que en los cánceres de colon derecho e izquierdo (supervivencia general: 55,5% frente versus a 82,8% frente versus a 85,9%, p = 0,004 y supervivencia libre de enfermedad; 47,7% frente a 72,4% frente a 79,5%, p = 0,003, respectivamente). Después del ajuste por otros factores clínico-patológicos, los cánceres de colon transverso medio se asociaron significativamente con un pronóstico desfavorable (Razón de riesgo: 2,19; intervalo de confianza del 95%: 1,25-3,83; p = 0,006).LIMITACIONES:La información molecular y genética no estuvo disponible en este estudio retrospectivo.CONCLUSIONES:En nuestra serie de casos, los cánceres de colon localizados en el colon transverso medio mostraron un peor pronóstico que los cánceres en otras localizaciones. El impacto de la ubicación del tumor en el colon transverso medio sobre el pronóstico, incluidos los marcadores moleculares y genéticos, debe investigarse más a fondo en estudios prospectivos. Consulte Video Resumen en http://links.lww.com/DCR/B631. (Traducción-Dr Adrián Ortega).

Comparative study between ghost ileostomy and defunctioning ileostomy in terms of morbidity and cost-effectiveness in low anterior resection for rectal cancer.

PURPOSE: The aim of this study was to compare ghost ileostomy (GI) and defunctioning ileostomy (DI) in patients who underwent low anterior resection (LAR) for rectal cancer in terms of postoperative morbidity, rehospitalization rates, and total costs. METHODS: Patients with an anastomosis level between 5 and 10 cm from the anal verge after LAR were analyzed retrospectively. Clinical characteristics, operative outcomes, postoperative morbidity, rehospitalization rates, and total costs were compared. RESULTS: A total of 123 patients were enrolled as follows: 42 patients in the GI group and 81 patients in the DI group. Anastomotic leakage (AL) was identified in three patients who underwent GI, and in all of them, GI was easily converted to DI. There were 96.3% of the patients with DI rehospitalized at least one time because of surgery-related and/or stoma-related complications or stoma closure. When we did not take into account the patients who were rehospitalized for stoma closure, the rates of rehospitalization were 4.7% and 22.2% in the GI and DI groups, respectively (P= 0.01). The mean total costs calculated by removing additional surgical procedures and adding all of the rehospitalization costs were 25,767 USD and 41,875 USD in the GI and DI groups, respectively (P= 0.0001). CONCLUSION: GI may be a safe and cost-effective method in patients who underwent LAR with low or medium risk factors for AL. It is possible to avoid unnecessary ileostomy and reduce unwanted outcomes due to it, such as postoperative complications, rehospitalizations, and increased total costs by performing GI.

A new technique of doppler dearterialization for hemorrhoidal disease: arterial detection ligation (ADL).

PURPOSE: We describe the arterial detection ligation (ADL) technique, designed to find arteries at time-appropriate depth for ligating, and report our preliminary results of using this technique to treat patients with the hemorrhoidal disease (HD). METHODS: The subjects of this retrospective analysis were patients with symptomatic grades 2 or 3 HD. We analyzed the clinical characteristics, postoperative complications, recurrence, and patient satisfaction of the patients treated with ADL. RESULTS: A total of 75 patients were included in the study (male/female ratio 1.88; mean age 48 ± 19 years; mean BMI 24 ± 3 kg/m2). Thirty-nine patients (52%) did not require hospitalization and were discharged from the day clinic approximately 4 h postoperatively. Four patients (5.3%) suffered tenesmus for about 1 week postoperatively and two (2.7%) suffered temporary rectal bleeding. The mean VAS scores 1 day postoperatively, then at 1 week, 1 month and 1 year were 2.9, 1.5, 0.4, and 0, respectively. At the 1-month follow-up, there was no sign of recurrence and the satisfaction rate was 78.6% (n = 59). At the 1-year follow-up, three patients (4%) had a recurrence and the satisfaction rate was 86.7% (n = 65). CONCLUSION: Based on our preliminary findings, ADL is an effective technique for treating HD, generally as an outpatient procedure, without serious morbidity. We anticipate that the incidence of tenesmus, which is encountered frequently after other dearterialization methods, will be lower after the ADL technique, which avoids both mass ligation of hemorrhoidal arteries deeper than 12 mm and running a long mucopexy suture line.

Clinicopathologic features and prognosis of histologic subtypes in the right-sided colon cancer.

PURPOSE: Differentiation of the histopathologic subtypes can be clinically important as it can affect the course of treatment and the prognosis. The aim of this study was to investigate both the clinicopathological features and prognosis of histologic subtypes in right-sided colon cancer. METHODS: This study included 138 patients who underwent surgery for right-sided colon cancer. The patients were divided into three groups according to histopathological subtypes as follows: medullary carcinoma (MC, n=11), mucinous adenocarcinoma (MAC, n=29), and classic adenocarcinoma (AC, n=98). The groups were compared in terms of demographic characteristics, type of surgery, pathological outcomes and survival. RESULTS: The rate of laparoscopic surgery was significantly lower in the MC group compared with MAC and AC groups (45.4% vs 54.5% vs 35.7%, respectively, p=0.001). In MC group, T4 stage was significantly higher than in other groups (90.0% vs 34.5% vs 35.7%, respectively, p=0.001). While patients with MAC had no distant metastasis, 18.2% and 15.3% of patients with MC and AC respectively, had distant metastasis (p=0.07). MAC vs MC, p=0.01, MAC vs AC, p=0.03). Tumor size, tumor volume, and the rate of microsatellite instability were found significantly higher in the MC group (p<0.05). The 5-year overall (OS) and disease-free survival (DFS) were better in the MAC group compared with MC and AC groups, but these differences did not reach statistical significance (OS: 92.8% vs 72.7% and 68.7%, p=0.16 and DFS 87.3% vs 58.2% and 64%, p=0.10, respectively). CONCLUSION: MC is associated with more advanced tumor size and T stages, and therefore entails reduced rate of minimally invasive procedures. In our series, the absence of distant metastasis in the patients of MAC also had a positive effect on survival.

Surgical site infections after pancreaticoduodenectomy: Preoperative biliary system interventions and antimicrobial prophylaxis.

BACKGROUND: The rate of surgical site infection (SSI) after pancreaticoduodenectomy (PD) is high and insertion of preoperative bile duct catheterization (PBDC) predispose a high risk of SSI with multidrug resistant (MDR) microorganisms. AIM: To describe the effects of PBDC and the prophylaxis in development of SSI. METHODS: We conducted a retrospective study between January 01, 2010 and December 2018 including the patients with PD and total pancreatectomy. FINDINGS: In total 214 consecutive patients were included. The PBDC was inserted to 63 (29%) patients. The rate of intraoperative bile fluid culture positivity was higher among the patients with PBDC (84% vs. 17% respectively, p<0.001). The SSI was detected in 52 patients (24%). In multivariate analysis, the rate of SSI was found to be higher among the patients with PBDC (OR: 2.33, 95% Cl: 1.14-4.76, p=0.02). As the etiologic agents of SSI, Pseudomonas spp. and MDR pathogens were mainly detected in PBDC group. The resistance to ampicillin-sulbactam was significantly higher in the PBDC group (87.5% vs. 25%, p=0.012). The similar bacterial species both in bile fluid and the surgical site were detected in 11 (21%) patients with SSI. Among 8 patients (15%), antimicrobial susceptibility was the same. Only in five out of 52 (10%) patients, the SSI pathogens was susceptible to the agent that was used for surgical prophylaxis. CONCLUSION: Unnecessary catheterizations should be avoided. By considering the increasing prevalence of resistant bacteria as the cause of SSI, the clinicians should closely follow-up their patients for choosing the proper antimicrobials.

A descriptive survey study to evaluate the relationship between socio-demographic factors and quality of life in patients with a permanent colostomy.

The impact of having a stoma on quality of life is increasingly recognized and studied. A descriptive survey study was conducted between January 2006 and December 2011 among 44 patients (18 women, 26 men) with a permanent stoma receiving care at the Kartal Training and Research Hospital, Istanbul, Turkey, to evaluate socio-demographic factors that may affect the quality of life in Turkish Muslim patients with an enteral stoma. A socio-demographic questionnaire, a 10- item Religious Orientation Scale (Modified Allport-Ross ROS), and the Medical Outcomes Study Short Form 36 Quality of Life survey were administered by a stoma therapy nurse at least 6 months after completion of all surgical and oncological treatments. The mean follow-up period was 15.3 ± 9.7 (range 6-44) months since completion of all treatments. Data were collected using paper/pencil instruments and entered for data analysis using Student's t-tests or one-way ANOVA univariate and multivariate analyses. No significant differences were observed for income, education level, surgical history, or religion score. Gender, geographic region, and household status were found independently related to quality of life in stoma patients. Female patients had significantly lower scores than males in general health perception (P = 0.049), role emotion (P = 0.02), mental health perception (P = 0.026), and mental component (P = 0.007). Patients living in a village (four) had significantly lower scores than patients living in a big city (33) in all scales (P <0.05 for all comparisons). Village-dwelling patents also had significantly lower scores than patients living in a town (seven) in physical function (P = 0.001), vitality (P = 0.012), social function (P = 0.003), and mental component scores (P = 0.021). Patients living alone (seven) had significantly lower scores than patients living with a partner (11) in three of eight scales (physical functioning [P <0.001], role-physical [P = 0.047], and bodily pain [P = 0.015]) and physical component scores (P <0.001); they also had significantly lower scores than patients living with their families (26) in four of eight scales (physical functioning [P <0.001], role-physical [P = 0.032], bodily pain [P = 0.02], and general health perception [P=0.036]) and physical component scores (P <0.001). Although these findings provide evidence for the relationship between some socio-demographic factors on quality of life of patients with a stoma, the results of the study should be interpreted with caution; multicenter, prospective, controlled studies are needed to substantiate and clarify the relationships among these variables.