Suboptimal surgery and omission of neoadjuvant therapy for upper rectal cancer is associated with a high risk of local recurrence.

AIM: The aim of the present study was to estimate the risk of local recurrence in an audited cohort of patients, with a particular focus on patients with upper rectal cancer treated by partial mesorectal excision without neoadjuvant therapy. METHOD: Perioperative clinical data on all patients who underwent mesorectal excision for primary adenocarcinoma of the rectum in the period from 2007 to 2010 were prospectively collected and follow-up data on oncological outcome were retrieved from patient records. Three-year actuarial local recurrence rates were estimated using Kaplan-Meier methods. RESULTS: Local recurrence was diagnosed in 17 of 247 patients treated with curative intent. The 3-year actuarial local recurrence rate was 7.0% (95% CI 4.0-11.8). The risk of local recurrence was negatively associated with tumour stage (P = 0.015), an involved circumferential resection margin (P = 0.007) and tumour height (P = 0.044). The local recurrence rate at 3 years was 13.5% after partial mesorectal excision, 2.9% following total mesorectal excision and 5.7% after extralevator abdominoperineal excision (P = 0.032). CONCLUSION: Tumour stage and an involved circumferential resection margin were the most important predictors of local recurrence. For cancer of the upper rectum, partial mesorectal excision was associated with a high risk of local recurrence.

Cost-effectiveness of computed tomographic colonography: a prospective comparison with colonoscopy.

PURPOSE: To estimate the cost-effectiveness of detecting colorectal polyps with computed tomographic colonography (CTC) and subsequent polypectomy with primary colonoscopy (CC), using CC as the alternative strategy. MATERIAL AND METHODS: A marginal analysis was performed regarding 103 patients who had had CTC prior to same-day CC at two hospitals, H-I (n = 53) and H-II (n = 50). The patients were randomly chosen from surveillance and symptomatic study populations (148 at H-I and 231 at H-II). Populations, organizations, and procedures were compared. Cost data on time consumption, medication, and minor equipment were collected prospectively, while data on salaries and major equipment were collected retrospectively. The effect was the (previously published) sensitivities of CTC and CC for detection of colorectal polyps > or = 6 mm (H-I, n = 148) or > or = 5 mm (H-II, n = 231). RESULTS: Thirteen patients at each center had at least one colorectal polyp > or = 6 mm or > or = 5 mm. CTC was the cost-effective alternative at H-I (euro187 vs. euro211), while CC was the cost-effective alternative at H-II (euro239 vs. euro192). The cost-effectiveness (costs per finding) mainly depended on the sensitivity of CTC and CC, but the depreciation of equipment and the staff's use of time were highly influential as well. CONCLUSION: Detection of colorectal polyps > or = 6 mm or > or = 5 mm with CTC, followed by polypectomy by CC, can be performed cost-effectively at some institutions with the appropriate hardware and organization.

Extracolonic findings at computed tomography colonography are a challenge.

AIM: Our aim was to perform a prospective evaluation of the frequency and diagnostic consequences of extracolonic findings at multidetector array computed tomography colonography (MDCTC) in asymptomatic patients undergoing surveillance for former colorectal polyps or cancer. PATIENTS AND METHODS: Seventy five consecutive patients undergoing surveillance for former colorectal cancer (CRC) or large bowel adenoma were examined with MDCTC. Two independent observers evaluated the images with regard to extracolonic findings. Patient records and radiological information systems were reviewed to determine the results and consequences of the workup derived from MDCTC. RESULTS: Sixty five per cent (95% confidence interval (CI) 55-73%) of patients had extracolonic abnormalities and in 12% (CI 7-18%) of patients additional workup was indicated. Two patients (3% (CI 1-6%)) underwent surgery because of the findings (one) or because of complications of the workup (one). CONCLUSION: MDCTC identifies a large number of extracolonic findings. Approximately 12% of asymptomatic patients undergo additional workup, of benefit to only a few. The high prevalence of extracolonic findings may make MDCTC a problematic colorectal screening tool for both ethical and economic reasons.

Colonoscopy and multidetector-array computed-tomographic colonography: detection rates and feasibility.

BACKGROUND AND STUDY AIMS: Computed-tomographic (CT) colonography has been introduced as a minimally invasive colon examination for the detection of colorectal neoplasms. The aim of this study was to compare the performance characteristics of multidetector-array CT colonography (MDCTC) and conventional colonoscopy in a prospective, blinded design. PATIENTS AND METHODS: Sixty-six symptomatic patients, 75 patients undergoing polyp and cancer surveillance, and seven patients undergoing preoperative colonoscopy due to colorectal cancer (CRC) were examined with MDCTC and subsequent colonoscopy. The gold standard was colonoscopy. If MDCTC was positive and the first-pass colonoscopy was negative, a second-pass colonoscopy served as the gold standard. RESULTS: Complete colonoscopy was achieved in 91% of the patients, while technically satisfying MDCTC was obtained in 76% of the patients (P < 0.01), insufficient air distension in the sigmoid colon being the main problem. MDCTC and colonoscopy both detected all 11 carcinomas. Overall detection rates for polypoid lesions 6 mm or larger in size were 81% (95% CI, 70% to 90%) for MDCTC and 87% (95% CI, 77% to 94%) for colonoscopy (P = 0.52), with a significant difference with regard to the detection of polyps 6-9 mm in size in favor of colonoscopy (P = 0.008). The specificity of MDCTC at a 6-mm level was 97% (95% CI, 92% to 99%). CONCLUSIONS: MDCTC and colonoscopy show equal overall sensitivity for the detection of polypoid lesions 6 mm or larger in size, but more patients are inadequately examined when MDCTC is used.

Bowel cleansing methods prior to CT colonography.

PURPOSE: To compare the cleansing effect, ease of preparation and side-effects of two cleansing regimens containing either polyethylene glycol solution (PEG) or phospho-soda (Na-P) solution prior to CT colonography in a prospective, randomized, radiologist-blinded design. MATERIAL AND METHODS: Fifty persons were randomized to receive either a PEG preparation or a Na-P preparation prior to CT colonography. On axial 2D images, the rectum, the sigmoid, the descending, the transverse and the cecum/ascending colon were scored semiquantitatively as to cleanness by two radiologists blinded to the bowel preparation regimen. Quality scores in the two groups were compared. Ease of preparation and side-effects were assessed by a questionnaire. RESULTS: The overall quality of the bowel preparation with the Na-P preparation was better than with the PEG preparation with significantly better cleansing scores for the rectum, the sigmoid, the descending and the transverse colon. The Na-P preparation was significantly better tolerated than the PEG preparation with significantly less nausea and significantly less fecal incontinence. CONCLUSION: The quality of the bowel preparation was better with the Na-P preparation than with the PEG preparation prior to CT colonography. Moreover, the Na-P preparation was better tolerated and with fewer side-effects.