Current screening guidelines overlook a significant number of patients treated for colorectal cancer.

The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer (CRC) in adults, beginning at age 50 years and continuing until age 75 years. Screening has led to a decreased incidence of CRC in this subset of patients. Despite these improvements, there has been a significant increase in the incidence of CRC in patients aged 20 to 49 years and those older than age 75 years. We sought to evaluate the appropriateness of the current screening guidelines as it pertained to our patient demographic at Greenville Health System. We retrospectively reviewed the Greenville Health System tumor registry from January 2005 to December 2010. Age at diagnosis, pathologic stage, tumor location, and demographic information were obtained on patients treated for CRC. Data points were stratified across the three age distributions used by the USPSTF. Greater than one-third (34.7%) of patients diagnosed with CRC fell outside of the recommended screening ages. Fifty-eight per cent of patients younger than 50 years old had advanced disease at diagnosis, Stage III or IV, as compared with other groups. Two hundred eight of the 708 patients (29.3%) were diagnosed on screening colonoscopy, whereas 500 patients (70.7%) were found to have CRC on diagnostic colonoscopy or at the time of operation for related complications. There are a significant number of patients who are ultimately treated for CRC that would fall outside the recommended screening parameters at our institution. Re-evaluation of the current CRC screening guidelines and risk factor assessment is needed to account for the changing trends.

The efficacy and morbidity of different surgical treatment techniques for chronic anal fissure: an academic colorectal experience.

Up to 40 per cent of chronic fissures will fail to heal with medical treatment alone. Open (OLIS) and closed (CLIS) lateral internal sphincterotomies are considered by many to be the treatment of choice for chronic anal fissures (CAF). The aim of this study was to compare the efficacy and clinical outcomes of different surgical techniques for treatment of CAF. We performed a retrospective chart review of 387 patients with CAF who underwent surgical intervention performed by colorectal surgeons between 2006 and 2012 at Greenville Hospital System. Of 387 patients, 199 underwent OLIS, 124 CLIS, and 64 patients underwent fissurectomy alone (FE). We investigated the effect of the surgical technique on time of healing, rate of flatus incontinence, wound infection, recurrence, and the need for additional intervention. There was no statistically significant difference among patients undergoing OLIS, CLIS, and FE in demographic characteristic, time of healing, rate of wound infections, and fecal continence, or recurrence rate. Comparison of a combined lateral internal sphincterotomy (LIS) group with FE showed that there is similar time of healing (P = 0.58), no statistical difference in flatus incontinence rate (P = 0.61), urinary retention (P = 1.0), fissure recurrence (P = 0.11), and prolonged healing (P = 0.2). Patients in FE group more likely required additional treatment to complete wound healing (P = 0.02). LIS is a safe and effective technique for treatment of CAF. Although there was no difference in complications rate and healing time, patients in the FE group required additional surgical or medical treatment more frequently to achieve complete healing.

Differential lymph node retrieval in rectal cancer: associated factors and effect on survival.

BACKGROUND: Recent publications have identified positive associations between numbers of lymph nodes pathologically examined and five-year overall survival (5-yr OS) in colon cancer. However, focused examinations of relationships between survival of rectal cancer and lymph node counts are less common. We conducted a single institution, retrospective review of rectal cancer resections to determine whether lymph node counts correlated with 5-yr OS and to explore the relationship between lymph node counts and various clinical and pathologic factors. METHODS: A retrospective review of our institutional tumor registry identified 159 patients with AJCC Stage 1, 2, or 3 rectal cancers that underwent surgical resection at our institution over eleven years. Univariate analysis was used to explore the relationship between lymph node counts and age, AJCC Stage, time period of diagnosis, preoperative radiotherapy, and performance of TME. Survival analysis was performed by the Kaplan-Meier method and the Cox proportional hazards model. RESULTS: In univariate analysis, there was an association between increased lymph node counts and age <70, higher stage, and diagnosis during the later portion of the study period [all P-values <0.05]. Lymph node counts were not associated with survival in Kaplan-Meier analysis or in multivariate Cox proportional hazards analysis. CONCLUSIONS: Increasing lymph node counts improve survival and the accuracy of colorectal cancer staging. The body of literature recommends identical minimum lymph node counts in both colon and rectal cancer. In our study, which exclusively examined rectal cancer, we could not demonstrate that increased lymph node counts were associated with improved survival.

Neuroendocrine tumors of the rectum: a 10-year review of management.

Neuroendocrine tumors of the rectum constitute approximately 19 per cent of gastrointestinal neuroendocrine tumors (NETs). The histologic characteristics of the tumor seem to be an indicative prognostic factor. Optimal treatment of NETS of the rectum has been widely debated, but more recent studies suggest that treatment depends upon the size. The medical records of 37 patients with NETS of the rectum were retrospectively reviewed. We reviewed their presentation, surgical treatment, pathology, and outcome. All pathological specimens were reviewed. Neuroendocrine tumors of the rectum were classified as either well-differentiated tumors, well-differentiated neuroendocrine carcinoma, or poorly differentiated neuroendocrine carcinoma. Evaluating tumor size, we found 35/37 patients had tumors less than 1 cm, 1 patient had a tumor between 1 and 2 cm, and one had a tumor greater than 2 cm. Pathologic evaluation of the tumors revealed that 35 of the tumors invaded the submucosa only, one invaded the muscularis propria, and one invaded the perirectal adipose tissue. The histopathologic features of the tumors revealed that 34 of the tumors were well-differentiated NETS with benign features, one tumor had invaded the submucosa, with angioinvasion, and two tumors were neuroendocrine carcinoma. Thirty-five patients underwent local excision. Eleven had reexcisions for positive margins. Two patients had local excision for recurrence, and one patient underwent low anterior resection (4 cm). Twelve patients had negative margins, 25 had positive margins. Eleven patients underwent reexcision. Six had no evidence of residual disease, and five had persistent positive margins and were offered no further treatment. Nineteen patients had positive margins and did not have reexcision. They all had tumors < 1 cm. Despite half of the lesions being resected with final pathologic positive margins, we have seen no significant influence on recurrence or overall survival. This raises the question of margin clearance in early lesions.