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Press review
Journal of Visceral Surgery (2012) 149, e126—e133
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Press review C. Mariette a,∗, S. Benoist b a
Service de chirurgie digestive et générale, hôpital Claude-Huriez, place de Verdun, 59037 Lille, France b Service de chirurgie digestive, CHU de Le Kremlin-Bicêtre, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
Incidence of adenocarcinoma among patients with Barrett’s esophagus 䊏 Hvid-Jensen F, Pedersen L, Drewes AM, Sørensen HT, Funch-Jensen P. N Engl J Med 2011;365:1375—83. DOI: 10.1056/NEJMoa1103042 Background Accurate population-based data are needed on the incidence of esophageal adenocarcinoma (ADC) and high-grade dysplasia among patients with Barrett’s esophagus (BE). Methods We conducted a nationwide, population-based, cohort study involving all patients with BE in Denmark during the period from 1992 through 2009, using data from the Danish Pathology Registry and the Danish Cancer Registry. We determined the incidence rates (numbers of cases per 1000 person-years) of ADC and high-grade dysplasia. As a measure of relative risk, standardized incidence ratios were calculated with the use of national cancer rates in Denmark during the study period. Results We identified 11,028 patients with BE and analyzed their data for a median of 5.2 years. Within the first year after the index endoscopy, 131 new cases of ADC were diagnosed. During subsequent years, 66 new ADC were detected, yielding an incidence rate for ADC of 1.2 cases per 1000 personyears (95% confidence interval [CI], 0.9—1.5). As compared with the risk in the general population, the relative risk of
∗
Auteur correspondant. E-mail address: [email protected] (C. Mariette).
1878-7886/$ — see front matter doi:10.1016/j.jviscsurg.2012.01.004
ADC among patients with BE was 11.3 (95% CI, 8.8—14.4). The annual risk of esophageal ADC was 0.12% (95% CI, 0.09—0.15). Detection of low-grade dysplasia on the index endoscopy was associated with an incidence rate for ADC of 5.1 cases per 1000 person-years. In contrast, the incidence rate among patients without dysplasia was 1.0 case per 1000 person-years. Risk estimates for patients with high-grade dysplasia were slightly higher. Conclusions BE is a strong risk factor for esophageal ADC, but the absolute annual risk, 0.12%, is much lower than the assumed risk of 0.5%, which is the basis for current surveillance guidelines. Data from the current study call into question the rationale for ongoing surveillance in patients who have BE without dysplasia. Comments 1. Despite large variations in the reported yearly incidence of ADC developing in the setting of BE, two recent reviews have suggested that the incidence of ADC/Barrett is 5.3 to 6.5 cases per 1000 patients/year or 9.1 to 19.2 cases per 1000 patients/year when highgrade dysplasia is combined with ADC. This paper, whose strong point is an overall population analysis, reports a much lower incidence of ADC of 1.2 cases per 1000 patients/year, i.e. four to five times less than previous reports. 2. Of note, more than two thirds of cases of ADC were diagnosed within 1 year of the index endoscopy, perhaps because evaluation was suboptimal at the time of diagnosis, or because of sampling errors during biopsy. 3. While BE screening programs have never been proven to improve survival [1,2], this study seriously questions the
Press review value of systematic surveillance in BE patients without dysplasia when quality of life and medico-economical aspects are considered. References [1] Am J Gastroenterol 1999;94:86—91. [2] Gastroenterology 1990;99:918—22. Risk of recurrence after surgery for chronic radiation enteritis 䊏 Lefevre JH, Amiot A, Joly F, Bretagnol F, Panis Y. Br J Surg. 2011;98:1792—7. DOI: 10.1002/bjs.7655 Background Approximately one-third of patients with chronic radiation enteritis (CRE) require surgery, which is associated with a high morbidity rate and a high risk of reoperation. The aim of this study was to report outcome after surgery for CRE. Methods Patients with CRE who underwent operation with extensive small bowel resection between 1980 and 2009 were included in the study. Postoperative morbidity and mortality reoperation for recurrent enteritis and risk factors for reoperation were analysed. Results Of 107 patients (94 women; 87.8%) with CRE included in the study, the main indication for surgery was symptomatic stricture (82 patients; 76.6%). Forty-nine ileocaecal resections (45.8%) were performed. Overall and surgical morbidity rates were 74.8% (80 patients) and 28.0% (30) respectively. Fourteen patients (13.1%) underwent reoperation for complications. Reoperation rates for CRE at 1 and 3 years of follow-up were 37 and 54% respectively. Risk factors for reoperation for recurrent enteritis were: emergency surgery (odds ratio (OR) 2.72, 95% confidence interval 1.57 to 4.86), anastomotic leakage (OR 2.53, 1.54 to 4.42) and male sex (OR 3.57, 1.82 to 7.29). The only protective factor for reoperation was ileocaecal resection during the first surgical procedure (OR 4.48, 2.52 to 8.31). Conclusion Ileocaecal resection was the only factor that protected against reoperation for recurrent CRE, demonstrating the importance of resecting all damaged tissue in these patients. These results suggest that there is little place for intestinal bypass surgery or adhesiolysis. Comments 1. Five to 55% of patients undergoing radiation therapy develop chronic radiation enteritis (CRE), typically between 18 months and 6 years after treatment [1,2]. The small bowel is most often involved, and CRE is revealed by obstruction in 0.8% to 13% of patients or by a fistula in 0.6% to 4.8% of cases [3]. 2. Besides a recognized morbidity that remains high in this type of surgery, the strong point of this study is to show that ileocecal valve resection is a protective factor for reoperation, probably because it reduces the anastomotic leakage rate. This suggests (i) the necessity to resect the entire portion of involved small bowel and to perform the anastomosis in healthy tissues in the right or transverse colon [4] and (ii) to avoid conservative adhesiolysis or bypass procedures, which do not reduce the complication rates of CRE [5]. References [1] Ann Surg 1969;170:369—84. [2] Aliment Pharmacol Ther 2003;18:987—94. [3] Acta Oncol 2007;46:504—16.
e127 [4] Surgery 1986;99;133—9. [5] Am J Surg 2001;182:237—42.
Self-expanding metallic stents for large bowel obstruction 䊏 Mackay CD, Craig W, Hussey JK, Loudon MA. Br J Surg. 2011;98:1625—9. DOI: 10.1002/bjs.7644 Background Self-expanding metallic stents (SEMS) may relieve colonic obstruction as definitive therapy or as a bridge to elective surgery. Methods This was a retrospective longitudinal cohort study of patients undergoing insertion of SEMS for large bowel obstruction at one institution. Scrutiny of the radiology department’s coding system allowed identification of all patients undergoing colonic stent insertion between 2002 and 2008. Data were extracted from patient case notes and investigation reports. Results Eighty-two patients with a median age of 75 (interquartile range [IQR] 43—94) years underwent stent insertion, 71 for palliation and 11 as a bridge to surgery. Obstruction was due to malignant disease in 67 patients and had a benign cause in 15. Median survival in the palliative setting was 103 (IQR 44—317) days. Complications occurred in 43 patients, of whom 22 underwent unplanned surgery. High-grade obstruction (relative risk [RR] 2.05; P = 0.055) and benign disease (RR 3.45; P < 0.001) were associated with risk of adverse events. Conclusion SEMS should not be used for large bowel obstruction with benign pathology. Comments 1. The center managing these patients is very ‘‘surgically oriented’’. It is likely that the patients in this series represent only 3.5% of all patients with colonic cancer, in other words, without severe disease or comorbidity. 2. The two important messages in this paper are the poor outcome of stents as a bridge to surgery, similar to a recently published French randomized trial [1], and the poor results in benign disease since the prosthesis easily and efficiently dilates the stricture and then migrates. 3. The criticism often advanced by gastroenterologists, that the type of stent might be responsible for the poor results reported, does not hold here because not less than three different types of stents were used in the study. 4. In sum, accumulating evidence has led to the consideration that colonic stents are not the best therapeutic option for benign strictures, and especially that they should not to be used as a bridge to surgery for malignant strictures. References [1] Surg Endosc 2011;25:1814—21. [2] Colorectal Dis 2006;8:102—11.
Predicting risk for serious complications with bariatric surgery: results from the Michigan Bariatric Surgery Collaborative 䊏 Finks JF, Kole KL, Yenumula PR, et al. Ann Surg 2011;254:633—40. DOI: 10.1097/SLA.0b013e318230058c
e128 Objectives To develop a risk prediction model for serious complications after bariatric surgery. Background Despite evidence for improved safety with bariatric surgery, serious complications remain a concern for patients, providers and payers. There is little populationlevel data on which risk factors can be used to identify patients at high risk for major morbidity. Methods The Michigan Bariatric Surgery Collaborative is a statewide consortium of hospitals and surgeons, which maintains an externally-audited prospective clinical registry. We analyzed data from 25,469 patients undergoing bariatric surgery between June 2006 and December 2010. Significant risk factors on univariable analysis were entered into a multivariable logistic regression model to identify factors associated with serious complications (life threatening and/or associated with lasting disability) within 30 days of surgery. Bootstrap resampling was performed to obtain biascorrected confidence intervals and c-statistic. Results Overall, 644 patients (2.5%) experienced a serious complication. Significant risk factors (P < 0.05) included: prior Venous thromboembolic event (VTE) (odds ratio [OR] 1.90, confidence interval [CI] 1.41—2.54); mobility limitations (OR 1.61, CI 1.23—2.13); coronary artery disease (OR 1.53, CI 1.17—2.02); age over 50 (OR 1.38, CI 1.18—1.61); pulmonary disease (OR 1.37, CI 1.15—1.64); male gender (OR 1.26, CI 1.06—1.50); smoking history (OR 1.20, CI 1.02—1.40); and procedure type (reference lap band): duodenal switch (OR 9.68, CI 6.05—15.49); laparoscopic gastric bypass (OR 3.58, CI 2.79—4.64); open gastric bypass (OR 3.51, CI 2.38—5.22); sleeve gastrectomy (OR 2.46, CI 1.73—3.50). The c-statistic was 0.68 (bias-corrected to 0.66) and the model was well-calibrated across deciles of predicted risk. Conclusions We have developed and validated a population-based risk scoring system for serious complications after bariatric surgery. We expect that this scoring system will improve the process of informed consent, facilitate the selection of procedures for high-risk patients, and allow for better risk stratification across studies of bariatric surgery. Comments 1. Although bariatric surgery has been shown to control diabetes, reduce the frequency of cardiovascular accidents and other obesity-related diseases, and even, prolonge life, the 2.5% to 4% risk of severe complications is still not negligible, [1]. This study reports overall morbidity and mortality rates that are quite low, but very variable, depending on the type of operation performed: in decreasing order, duodenal switch, gastric bypass, sleeve gastrectomy and adjustable banding. 2. As these data originate from a registry, the complication rate should be close to accurate. Nonetheless, this assumption needs to be tested in an independent cohort for external validity (reproducible in other populations than that of the state of Michigan) 3. Even though the essential value of this analysis resides in the identification of risk factors upon which action can be taken, the discrimination of the model used herein is of intermediary quality, potentially because (i) patients with severe disease might not have undergone operation; (ii) certain variables such as the volume effect or technique variations were not included in the analysis, and
C. Mariette, S. Benoist (iii) the severe complications are very heterogeneous, each with their specific factors. 4. Of note, the body mass index was not identified as an independent risk factor of severe complications, even though it is related to certain specific complications such as deep venous thrombosis. Reference [1] N Engl J Med 2009;361:445—54.
Prevalence of and risk factors for morbidity after elective left colectomy: cancer versus non-complicated diverticular disease 䊏 Piessen G, Muscari F, Rivkine E, et al. Arch Surg 2011;146:1149—55. DOI: 10.1001/archsurg.2011.231 Hypothesis Independent risk factors for postoperative morbidity after colectomy are most likely linked to disease characteristics. Design Retrospective analysis. Setting Twenty-eight centers of the French Federation for Surgical Research. Patients In total, 1721 patients (1230 with colon cancer [CC] and 491 with diverticular disease [DD]) from a databank of seven prospective, multisite, randomized trials on colorectal resection. Intervention Elective left colectomy via laparotomy. Main outcome measures Preoperative and intraoperative risk factors for postoperative morbidity. Result Overall postoperative morbidity was higher in CC than in DD (32.4% versus 30.3%) but the difference was not statistically significant (P = 0.40). Two independent risk factors for morbidity in CC were antecedent heart failure (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.42—6.32) (P = 0.003) and bothersome intraluminal fecal matter (2.08; 1.42—3.06) (P = 0.001). Three independent risk factors for morbidity in DD were at least 10% weight loss (OR, 2.06; 95% CI, 1.25—3.40) (P = 0.004), body mass index (calculated as weight in kilograms divided by height in meters squared) exceeding 30 (2.05; 1.15—3.66) (P = 0.02), and left hemicolectomy (versus left segmental colectomy) (2.01; 1.19—3.40) (P = 0.009). Conclusions Patients undergoing elective left colectomy for CC or for DD constitute two distinct populations with completely different risk factors for morbidity, which should be addressed differently. Improving colonic cleanliness (by antiseptic enema) may reduce morbidity in CC. In DD, morbidity may be reduced by appropriate preoperative nutritive support (by immunonutrition), even in patients with obesity, and by preference of left segmental colectomy over left hemicolectomy. By decreasing morbidity, mortality should be lowered as well, especially when reoperation becomes necessary. Comments 1. This study identifies morbidity and mortality rates similar to those reported in the literature. Of note, it underscores that, contrary to common opinion, postoperative outcome is related more to the patient and the
Press review underlying disease (these being inter-related) than to the surgical technique itself. 2. The analysis of postoperative mortality factors might have been more useful. The authors justified their analysis of morbidity by the fact that morbidity and mortality are inter-related and that analysis of risk factors for mortality is more difficult because of the rarity of death in colorectal surgery. Even if this seems rational, the authors should have looked at severe morbidity separately, which they did not. 3. Although the statistical methodology is clear and the study is well conducted, the pertinence of the results is suboptimal and there is some debate as to the independent risk factors found. For example, malnutrition is a risk factor for diverticular disease and, paradoxically, not for colonic cancer. The question that arises is whether preoperative fasting is a source of complication due to some degree of malnutrition? On the other hand, the patients undergoing operation for cancer might have been correctly nourished, cancelling the adverse effects of cancer. Another paradox is the fact that both malnutrition and overweight were risk factors in diverticular disease (28.5% des patients). Influence of surgical margins on outcome in patients with intrahepatic cholangiocarcinoma: a multicenter study by the AFC-IHCC-2009 study group 䊏 Farges O, Fuks D, Boleslawski E, et al. Ann Surg 2011;254:824—29. DOI: 10.1097/SLA.0b013e318236c21d Objective Define the optimal surgical margin in patients undergoing surgery for intrahepatic cholangiocarcinoma (IHCC). Background data Surgery is the most effective treatment for IHCC. However, the influence of R1 resection on outcome is controversial and that of margin width has not been evaluated. Methods We studied 212 patients undergoing curative resection of mass-forming-type IHCC. The respective influences on survival of resection status (R0 versus R1), surgical margin width, pTNM stage, and the latter’s components were evaluated. Results Incidence of R1 resection was 24%. Overall, R1 resection was not an independent predictor of survival (odds ratio [OR] 1.2 [0.7—2.1]) in contrast to the pTNM stage (OR 2.10 [1.2—3.5]). In the 78 pN+ patients, survival was similar after R0 and R1 resections (median: 18 versus 13 months, respectively, P = 0.1). In the 134 pN0 patients, R1 resection was an independent predictor of poor survival (OR 9.6 [4.5—20.4]), as was the presence of satellite nodules (OR 1.9 [1.1—3.2]). In the 116 pN0 patients with R0 resections, median survival was correlated with margin width (≤ 1 mm: 15 months; 2—4 mm: 36 months; 5—9 mm: 57 month; ≥ 10 mm: 64 month, P < 0.001) and a margin greater than 5 mm was an independent predictor of survival (OR 2.22 [1.59—3.09]). Conclusion Patients undergoing surgery for IHCC are at high risk of R1 resections. In pN0 patients, R1 resection is the strongest independent predictor of poor outcome and a margin of at least 5 mm should be created. The survival benefits of
e129 resection in pN+ patients and R1 resection in general are very low. Comments 1. While the incidence of intrahepatic cholangiocarcinoma has been increasing, patient survival after resection remains low (between 25% and 35%), lower than that of hepatocellular carcinoma and colorectal liver metastases [1]. While the impact of R1 resection depends on other disease characteristics, and in particular on the pN+ status, R0 resection has impact only on pN0 patients. 2. The second strong message is the demonstration of a linear correlation between survival and the size of the margin, the cut-off being 5 mm. The surgeon must strive to obtain the largest margin possible in pN0 patients, even though, in this series, a margin of greater than 5 mm was achieved in only 31% of patients. 3. For patients who are N+ and/or who are at high risk of an R1 resection, these results suggest that neoadjuvant chemotherapy has value in order to improve survival and select the good candidates for surgery. 4. It might be interesting to evaluate the respective impact of parenchymal, vascular or biliary margins as well as the impact of disease parameters such as the number of involved lymph nodes, the size of the tumor. . . even though the risk of type II errors might be high because of small numbers in the subgroups. Reference [1] Gastroenterol Clin Biol 2010;34:191—9. Routine colonoscopy following acute uncomplicated diverticulitis 䊏 Westwood DA, Eglinton TW, Frizelle FA. Br J Surg 2011;98:1630—34. DOI: 10.1002/bjs.7602 Background The evidence supporting current recommendations that the colon should be evaluated following an initial episode of acute diverticulitis is poor. The aim of this study was to clarify whether acute uncomplicated diverticulitis is a valid indication for subsequent colonoscopy/computed tomography (CT) colonography. Methods This was a retrospective longitudinal study of patients, with an initial presentation of acute uncomplicated diverticulitis on the basis of CT criteria, at a single institution between January 2004 and December 2008. Results A radiological diagnosis of acute uncomplicated diverticulitis was made in 292 patients. Some 205 patients underwent subsequent colonic evaluation or had undergone colonoscopy/CT colonography within the preceding 2 years. Colorectal polyps were present in 50 patients (24.4%). Twenty patients (9.8%) had hyperplastic polyps and 19 (9.3%) had adenomas. Eleven patients (5.4%) had advanced colonic neoplasia, including one (0.5%) with a colorectal cancer. One patient had inflammatory bowel disease (IBD). The patients with colorectal cancer and IBD had clinical indicators that independently warranted colonoscopy. None of the 87 patients who did not undergo colonic evaluation had a diagnosis of colorectal cancer registered with the New Zealand Cancer Registry. Conclusion The yield of advanced colonic neoplasia in this cohort was equivalent to, or less than that detected on screening asymptomatic average-risk individuals. In the absence of
e130 other indications, subsequent evaluation of the colon may not be required to confirm the diagnosis of diverticulitis. Comments 1. In 2007, the French recommendations for treatment of sigmoid diverticular disease by the SFNGE and the SFCD argued against routine colonoscopy after the index flare of diverticulitis. Colonoscopy was recommended only in those patients whose CT scan suggested a high risk of colorectal cancer. 2. It is regrettable that the authors did not give any precisions as to the localization of the lesions that turned out to be cancer: it would have been interesting to know whether these lesions were located in the sigmoid and whether they had any role in the inflammatory flare-up, mimicking diverticulitis. 3. The fact that patients had a colonoscopy 2 years before the flare poses a serious methodological problem: these patients probably had a colonoscopy for other symptoms or in a screening program leading to the diagnosis of non-superinfected lesions, and therefore probably less advanced disease. 4. A 5.4% rate of locally advanced tumors and a 0.5% rate of cancer are probably not sufficient reasons to recommend routine performance of colonoscopy after a non-complicated index flare of diverticulitis, but they are high enough to suggest that colonoscopy should be performed prior to surgery for diverticular disease in order to treat associated lesions at the same time. Reference [1] Dis Colon Rectum 2006;49:933—44. Gastroenterol Clin Biol 2007;31:3S5-3S10 Mortality after colorectal cancer surgery: a French survey of more than 84,000 patients 䊏 Panis Y, Maggiori L, Caranhac G, et al. Ann Surg 2011;254:738—44. DOI: 10.1097/SLA.0b013e31823604ac Objectives This study aimed to identify risk factors of postoperative 30-day mortality (POM) after colorectal cancer resection. Summary Meta-analyses have failed to demonstrate any significant benefit of laparoscopy in terms of postoperative mortality. This could be explained by the lack of a large sample size. Methods All patients who underwent colorectal resection for cancer between 2006 and 2008 in France were included. Data were extracted from the French National Health Service Database. A multivariate analysis evaluating risk factors for POM was performed including the following factors: age, gender, tumor location, associated comorbidities, emergency surgery, synchronous liver metastasis, malnutrition, and surgical approach. Results During the 3-year period, a total of 84,524 colorectal resections for colorectal cancer were performed: 22,359 through laparoscopy (26%) and 62,165 through laparotomy (74%). From 2006 to 2008, laparoscopic approach rate increased from 23% to 29% (P < 0.001). POM was 5.0%: 2% after laparoscopy and 6% after laparotomy (P < 0.001). In multivariate analysis, seven independent factors were significantly associated with a higher POM: age 70 years or more (P < 0.001, odds ratio [OR]: 3.28; [3.00—3.59]), respiratory comorbidity (P < 0.001, OR: 3.16; [2.91—3.37]), vascular
C. Mariette, S. Benoist comorbidity [P < 0.001, OR: 2.66; (2.48—2.85)], neurologic comorbidity (P < 0.001, OR: 1.78; [1.51—2.09]), emergency surgery (P < 0.001, OR: 2.68; [2.48—2.90]), synchronous liver metastasis (P < 0.001, OR: 2.63; [2.41—2.86]), and preoperative malnutrition (OR: 1.33; [1.19—1.50]). Laparoscopic surgery (P < 0.001, OR: 0.59; [0.54—0.65]) was independently associated with a significant decreased POM. Conclusions This all-inclusive national study showed that POM after colorectal cancer surgery is significantly reduced in case of age less than 70 years, elective surgery, and absence of synchronous liver metastasis, malnutrition, respiratory, neurologic, or vascular comorbidity. Furthermore, it is suggested that a laparoscopic surgery is independently associated with a decreased POM. This result, observed at a national level, must be considered when choosing the best surgical approach for colorectal cancer treatment. Comments 1. This cohort study constitutes an excellent snapshot of the outcome of colorectal surgery for cancer in France. It should be a reference against which all surgical teams can compare their results. 2. A 30% rate for laparoscopic surgery may seem small compared to the rates achieved by several teams that consider this the standard approach, especially for left colonic cancer. Nonetheless, 30% is higher than most North American series where the percentage ranges from 1.5 to 4.5% [1,2]. Moreover, it would have been interesting to know the conversion rate in this series. 3. Caution is warranted in drawing conclusions as to whether laparoscopy can decrease the operative mortality. Even though the power of a large cohort study with many patients does not differ much from a randomized trial, it cannot replace the latter, particularly when the principal item tested (i.e., laparoscopic resection) was in fact highly selected. In other terms, even if this multivariable study allows smoothing out of the selection bias, the laparoscopy and open surgical groups were not really comparable, in particular, for the other mortalityrelated risk factors. Indeed 80% of the patients with respiratory, vascular or neurologic history, 84% of undernourished patients, 87% of patients undergoing emergency operation and 83% of patients with synchronous metastases underwent colonic resection by open laparotomy. References [1] Arch Surg 2008;143:832—40. [2] Dis Colon Rectum 2009;52:1695—704. [3] Arch Surg 2005;140:278—83. Reassessing the need for prophylactic surgery in patients with porcelain gallbladder: case series and systematic review of the literature 䊏 Khan ZS, Livingston EH, Huerta S. Arch Surg 2011;146:1143—47. DOI 10.1001/archsurg.2011.257 Objective To evaluate the risk of gallbladder cancer (GBC) in patients with a porcelain gallbladder (PGB). Design Retrospective analysis of our institutional experience and a systematic review of the literature. Setting
Press review Academic teaching facility, Parkland Memorial Hospital, and the Dallas Veterans Affairs Medical Center (all in Dallas, Texas). Patients Medical records of 1200 cholecystectomies performed between 2008 and 2009 at Parkland Memorial Hospital, the University of Texas Southwestern Medical Center, and the Dallas Veterans Affairs Medical Center were reviewed. Patients with radiologic or histologic evidence of PGB or GBC were included. Main outcome measures The risk of GBC in patients with a PGB was assessed by contingency table analysis. Results We identified 13 patients with a PGB among 1200 cholecystectomies (1.1%). Most of these patients had concomitant gallstones (n = 9). None of the patients with a PGB had evidence of carcinoma. We also reviewed the histologic analysis results of 35 cases of GBC operated on between 1997 and 2009; none of these had gallbladder wall calcifications. Most patients underwent a laparoscopic cholecystectomy without any postoperative complications. We reviewed seven published series that included 60,665 cholecystectomies. The overall incidence of PGB was 0.2%, and GBC occurred in 15% of the PGB cases. Most cases of GBC occurring in PGB were found in the older literature; in the contemporary series, there were few reports of GBC associated with a PGB. Conclusions PGB is only weakly associated with GBC. Prophylactic cholecystectomy is not indicated for PGB alone and should be performed only in patients with conventional indications for cholecystectomy. A laparoscopic approach is appropriate for most patients with a PGB. Comments 1. The conclusions of this study confirm those of a preceding study showing that the risk of cancer in patients with PGB did not in itself justify cholecystectomy [1—3]. 2. This study underscores a problem of semantics. The authors’ definition of PGB does not correspond to the historical definition of PGB, i.e., an entirely calcified gallbladder on plain abdominal X-ray. In other terms, it is not the risk of cancer that has varied with time, but the very definition of PGB. It is probable that the risk of cancer in a patient with a completely calcified gallbladder is high whereas the risk is very low when small calcifications are detected in the gallbladder wall only on ultrasound or CT scan. 3. As most asymptomatic patients with gallbladder wall calcifications will only be closely followed in the near future, it would be interesting to evaluate the risk of developing gallbladder cancer over time. References [1] Surgery 2001;129:699—703. [2] Am Surg 2001;67:7—10. [3] Hepatogastroenterology 2009;56:943—5. Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience 䊏 Patel UB, Taylor F, Blomqvist L, et al. J Clin Oncol 2011;29:3753—60. DOI: 10.1200/JCO.2011.34.9068 Purpose To assess magnetic resonance imaging (MRI) and pathologic staging after neoadjuvant therapy for
e131 rectal cancer in a prospectively enrolled, multicenter study. Methods In a prospective cohort study, 111 patients who had rectal cancer treated by neoadjuvant therapy were assessed for response by MRI and pathology staging by T, N and circumferential resection margin (CRM) status. Tumor regression grade (TRG) was also assessed by MRI. Overall survival (OS) was estimated by using the Kaplan-Meier product-limit method, and Cox proportional hazards models were used to determine associations between staging of good and poor responders on MRI or pathology and survival outcomes after controlling for patient characteristics. Results On multivariate analysis, the MRI-assessed TRG (mrTRG) hazard ratios (HRs) were independently significant for survival (HR, 4.40; 95% CI, 1.65—11.7) and disease-free survival (DFS; HR, 3.28; 95% CI, 1.22—8.80). Five-year survival for poor mrTRG was 27% versus 72% (P = 0.001), and DFS for poor mrTRG was 31% versus 64% (P = 0.007). Preoperative MRI-predicted CRM independently predicted local recurrence (LR; HR, 4.25; 95% CI, 1.45—12.51). Five-year survival for poor post-treatment pathologic T stage (ypT) was 39% versus 76% (P = 0.001); DFS for the same was 38% versus 84% (P = 0.001); and LR for the same was 27% versus 6% (P = 0.018). The 5-year survival for involved pCRM was 30% versus 59% (P = 0.001); DFS, 28 versus 62% (P = 0.02); and LR, 56% versus 10% (P = 0.001). Pathology node status did not predict outcomes. Conclusion MRI assessment of TRG and CRM are imaging markers that predict survival outcomes for good and poor responders and provide an opportunity for the multidisciplinary team to offer additional treatment options before planning definitive surgery. Postoperative histopathology assessment of ypT and CRM but not post-treatment N status were important postsurgical predictors of outcome. Comments 1. This study, like most of the studies originating from the MERCURY study group, is well conducted but it remains essentially descriptive. Before concluding that post-treatment MRI can assess long-term carcinologic outcome, several steps are still necessary. First of all, the reproducibility of the investigation must be improved since, even in this study with the direct participation of two highly specialized radiologists, reproducibility of radiologic diagnosis was weak. Moreover, the prognostic criteria of post-treatment MRI have to be validated in an independent cohort. Lastly, it is necessary to verify if these criteria are still valid in patients treated by radiochemotherapy alone since, in this study, patients received only radiation therapy. 2. Diffusion sequences, which have been shown to improve the performance of MRI and have become the standard in 2011, were not performed in this study. [2]. These sequences could be useful to better appreciate the score of tumor regression. 3. If the results of this study are confirmed, this could have a major clinical impact. For example, patients considered to be poor responders by post-treatment MRI findings, might be candidates for intensification of treatment with chemotherapy alone before resorting to surgery. References [1] BMJ 2006;333:779. [2] Ann Surg Oncol 2011;18:2224—31
e132 Predictors of outcome for anal fistula surgery 䊏 Abbas MA, Jackson CH, Haigh PI. Arch Surg 2011;146:1011—16. DOI: 10.1001/archsurg.2011.197 Objectives To review our experience with patients treated for anal fistula secondary to cryptoglandular disease and to determine factors that influence postoperative outcome. Design Retrospective review. Setting A regional tertiary referral center. Patients Adult patients with anal fistula secondary to cryptoglandular disease. Interventions Fistulotomy, advancement flap, and fistula plugging. Main outcome measures Rates of operative failure (persistent fistula), incontinence, and septic complications. We evaluated age, sex, previous operation, fistula type, number of fistula tracts, horseshoe fistula, and intervention type to determine their independent influence on outcomes. Results One hundred and seventy-nine patients (79.3% male) underwent fistula operation from October 1, 2003, through December 31, 2008. Median age was 45 years. Fistulotomy was undertaken in 82.7% of patients, advancement flap in 10.6%, and plugging in 6.7%. The rates of operative failure, postoperative incontinence, and septic complications were 15.6%, 15.6%, and 7.3%, respectively. Plugging carried the highest failure rate (83.3%) compared with fistulotomy (10.1%) (odds ratio [OR], 44.3 [95% confidence interval (CI), 8.9—221.0; P < 0.001]) and was the only independent predictor for failure after adjusting for all variables. Being older than 45 years was associated with a higher postoperative incontinence rate compared with the younger group (adjusted OR, 2.8 [95% CI, 1.0—7.7; P = 0.04]). High transsphincteric and suprasphincteric fistulas were predictors of incontinence compared with subcutaneous fistulas (adjusted OR, 22.9 [95% CI, 2.2—242.0; P = 0.009] and 61.5 [4.5—844.0; P = 0.002], respectively). The only predictor of septic complications was plugging compared with fistulotomy (adjusted OR, 15.1 [95% CI, 2.3—97.7; P = 0.004]). Conclusions Fistulotomy is the preferred operation for anal fistula. Plugging is associated with the highest operative failure and septic complication rates. Incontinence was influenced more by fistula type and age rather than procedure. Comments 1. The conclusion of this study must be interpreted with caution because the groups of patients undergoing the different techniques were not comparable: plug and advancement flaps were performed only in those patients with complex transsphincteric fistulas. It is not at all surprising to see that their outcome was not that good. The only conclusion here is that one-stage fistulotomy provides good results for simple fistula involving less than 50% of the external sphincter. In case of complex fistula, the fistula plug does not seem to be adequate. This confirms preceding studies on the same subject [1,2]. 2. Several techniques were not evaluated such as two-stage fistulotomy after seton placement, the technique most often used in France, and the LIFT technique (suture of
C. Mariette, S. Benoist the orifice), which seems promising in complex fistulas [3]. References [1] Dis Colon Rectum 2009;52:18—22. [2] Br J Surg 2009:96:608—12. [3] Dis Colon Rectum 2010;53:43—6.
The impact of perioperative chemotherapy on survival in patients with gastric signet ring cell adenocarcinoma: a multicenter comparative study 䊏 Messager M, Lefevre JH, Pichot-Delahaye V et al. Ann Surg 2011;254:684—93. DOI: 10.1097/SLA.0b013e3182352647 Objective The aim of this retrospective study was to evaluate the survival impact of perioperative chemotherapy (PCT) in patients with gastric signet ring cell (SRC) adenocarcinoma. Background PCT is a standard treatment for advanced resectable gastric adenocarcinoma (GA). SRC has a worse prognosis compared to non-SRC and the chemosensitivity of SRC is uncertain. Methods Among 3010 patients registered in 19 French centers between January 1997 and January 2010, 1050 (34.9%) were diagnosed with SRC. Of those treated with curative intent (n = 924), 171 (18.5%) received PCT with surgery (PCT group), whereas 753 (81.5%) were treated with primary surgery (S group). PCT was based mainly on a fluorouracil-platinum doublet or triplet regimen. Results The groups were comparable regarding age, gender, American Society of Anesthesiologists (ASA) score, malnutrition, tumor location and cTNM stage. Sixty patients did not undergo resection because of tumor progression (10) or metastases (50) found at operation. The R0 resection rates were 65.9% and 62.3% in the S and PCT groups, respectively (P = 0.308). Fewer patients received adjuvant chemotherapy in the S group than in the PCT group (35.2% versus 66.5%, P < 0.001). At a median follow-up of 31.5 months, the median survival was shorter in the PCT group (12.8 versus 14.0 months, P = 0.043). On multivariate analysis, PCT was found to be an independent predictor of poor survival (HR = 1.4, 95% CI 1.1—1.9, P = 0.042). Conclusions PCT provides no survival benefit in patients with gastric SRC. Clinical Trial.gov record: ADCI001, Clinical Trial.gov identifier NCT01249859. Comments 1. This study confirms once again that signet ring cell gastric adenocarcinoma is a distinct entity with poor prognosis, whatever the management; 5-year survival is less than 5%. 2. The results of this study contradict a flawed argument that is used in medical oncology all too often: the fact that a cancer is severe or has high risk of recurrence does not signify, a priori, that chemotherapy will decrease the severity or the risk of recurrence. 3. The lack of efficacy, or even the deleterious effect of perioperative chemotherapy for signet ring cell adenocarcinoma must now be confirmed by a controlled study. Such a study, including a large number of patients, should be starting soon in France (group PRODIGEFRENCH).
Press review 4. To explain the poorer results of perioperative chemotherapy, the authors suggest that signet ring cell adenocarcinoma probably continues to progress during preoperative chemotherapy. Supporting this hypothesis is the fact that more total gastrectomies (+6%) and extended resections (+13%) were performed in the group receiving chemotherapy. This hypothesis is not certain. In fact, although the tumor stage was not the same in both groups, these tumors had the same pre-therapeutic TNM stage but the number of resections was not lower, and there were fewer R0 resections, more carcinomatosis and more histologically-advanced lesions in the group undergoing chemotherapy. Moreover, the 6% increased rate of total gastrectomy in the group receiving chemotherapy
e133 was probably due to the fact that there were 11% fewer antral cancers in this group and that total gastrectomy was systematically performed. 5. What should be done in case of signet ring cell carcinoma? The authors suggest that surgery should be performed first. The outcome of surgery followed by adjuvant chemotherapy remains mediocre with a median survival of 14 months and 3-year survival of 12%. New drugs or neoadjuvant chemo- or radiochemotherapy remain to be tested. References [1] N Engl J Med 2006;355:11—20. [2] J Clin Oncol 2011;29:1715—21. [3] Ann Surg 2009;250:878—87.
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Press review C. Mariette a,∗, S. Benoist b a
Service de chirurgie digestive et générale, hôpital Claude-Huriez, place de Verdun, 59037 Lille, France b Service de chirurgie digestive, CHU de Le Kremlin-Bicêtre, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
Incidence of adenocarcinoma among patients with Barrett’s esophagus 䊏 Hvid-Jensen F, Pedersen L, Drewes AM, Sørensen HT, Funch-Jensen P. N Engl J Med 2011;365:1375—83. DOI: 10.1056/NEJMoa1103042 Background Accurate population-based data are needed on the incidence of esophageal adenocarcinoma (ADC) and high-grade dysplasia among patients with Barrett’s esophagus (BE). Methods We conducted a nationwide, population-based, cohort study involving all patients with BE in Denmark during the period from 1992 through 2009, using data from the Danish Pathology Registry and the Danish Cancer Registry. We determined the incidence rates (numbers of cases per 1000 person-years) of ADC and high-grade dysplasia. As a measure of relative risk, standardized incidence ratios were calculated with the use of national cancer rates in Denmark during the study period. Results We identified 11,028 patients with BE and analyzed their data for a median of 5.2 years. Within the first year after the index endoscopy, 131 new cases of ADC were diagnosed. During subsequent years, 66 new ADC were detected, yielding an incidence rate for ADC of 1.2 cases per 1000 personyears (95% confidence interval [CI], 0.9—1.5). As compared with the risk in the general population, the relative risk of
∗
Auteur correspondant. E-mail address: [email protected] (C. Mariette).
1878-7886/$ — see front matter doi:10.1016/j.jviscsurg.2012.01.004
ADC among patients with BE was 11.3 (95% CI, 8.8—14.4). The annual risk of esophageal ADC was 0.12% (95% CI, 0.09—0.15). Detection of low-grade dysplasia on the index endoscopy was associated with an incidence rate for ADC of 5.1 cases per 1000 person-years. In contrast, the incidence rate among patients without dysplasia was 1.0 case per 1000 person-years. Risk estimates for patients with high-grade dysplasia were slightly higher. Conclusions BE is a strong risk factor for esophageal ADC, but the absolute annual risk, 0.12%, is much lower than the assumed risk of 0.5%, which is the basis for current surveillance guidelines. Data from the current study call into question the rationale for ongoing surveillance in patients who have BE without dysplasia. Comments 1. Despite large variations in the reported yearly incidence of ADC developing in the setting of BE, two recent reviews have suggested that the incidence of ADC/Barrett is 5.3 to 6.5 cases per 1000 patients/year or 9.1 to 19.2 cases per 1000 patients/year when highgrade dysplasia is combined with ADC. This paper, whose strong point is an overall population analysis, reports a much lower incidence of ADC of 1.2 cases per 1000 patients/year, i.e. four to five times less than previous reports. 2. Of note, more than two thirds of cases of ADC were diagnosed within 1 year of the index endoscopy, perhaps because evaluation was suboptimal at the time of diagnosis, or because of sampling errors during biopsy. 3. While BE screening programs have never been proven to improve survival [1,2], this study seriously questions the
Press review value of systematic surveillance in BE patients without dysplasia when quality of life and medico-economical aspects are considered. References [1] Am J Gastroenterol 1999;94:86—91. [2] Gastroenterology 1990;99:918—22. Risk of recurrence after surgery for chronic radiation enteritis 䊏 Lefevre JH, Amiot A, Joly F, Bretagnol F, Panis Y. Br J Surg. 2011;98:1792—7. DOI: 10.1002/bjs.7655 Background Approximately one-third of patients with chronic radiation enteritis (CRE) require surgery, which is associated with a high morbidity rate and a high risk of reoperation. The aim of this study was to report outcome after surgery for CRE. Methods Patients with CRE who underwent operation with extensive small bowel resection between 1980 and 2009 were included in the study. Postoperative morbidity and mortality reoperation for recurrent enteritis and risk factors for reoperation were analysed. Results Of 107 patients (94 women; 87.8%) with CRE included in the study, the main indication for surgery was symptomatic stricture (82 patients; 76.6%). Forty-nine ileocaecal resections (45.8%) were performed. Overall and surgical morbidity rates were 74.8% (80 patients) and 28.0% (30) respectively. Fourteen patients (13.1%) underwent reoperation for complications. Reoperation rates for CRE at 1 and 3 years of follow-up were 37 and 54% respectively. Risk factors for reoperation for recurrent enteritis were: emergency surgery (odds ratio (OR) 2.72, 95% confidence interval 1.57 to 4.86), anastomotic leakage (OR 2.53, 1.54 to 4.42) and male sex (OR 3.57, 1.82 to 7.29). The only protective factor for reoperation was ileocaecal resection during the first surgical procedure (OR 4.48, 2.52 to 8.31). Conclusion Ileocaecal resection was the only factor that protected against reoperation for recurrent CRE, demonstrating the importance of resecting all damaged tissue in these patients. These results suggest that there is little place for intestinal bypass surgery or adhesiolysis. Comments 1. Five to 55% of patients undergoing radiation therapy develop chronic radiation enteritis (CRE), typically between 18 months and 6 years after treatment [1,2]. The small bowel is most often involved, and CRE is revealed by obstruction in 0.8% to 13% of patients or by a fistula in 0.6% to 4.8% of cases [3]. 2. Besides a recognized morbidity that remains high in this type of surgery, the strong point of this study is to show that ileocecal valve resection is a protective factor for reoperation, probably because it reduces the anastomotic leakage rate. This suggests (i) the necessity to resect the entire portion of involved small bowel and to perform the anastomosis in healthy tissues in the right or transverse colon [4] and (ii) to avoid conservative adhesiolysis or bypass procedures, which do not reduce the complication rates of CRE [5]. References [1] Ann Surg 1969;170:369—84. [2] Aliment Pharmacol Ther 2003;18:987—94. [3] Acta Oncol 2007;46:504—16.
e127 [4] Surgery 1986;99;133—9. [5] Am J Surg 2001;182:237—42.
Self-expanding metallic stents for large bowel obstruction 䊏 Mackay CD, Craig W, Hussey JK, Loudon MA. Br J Surg. 2011;98:1625—9. DOI: 10.1002/bjs.7644 Background Self-expanding metallic stents (SEMS) may relieve colonic obstruction as definitive therapy or as a bridge to elective surgery. Methods This was a retrospective longitudinal cohort study of patients undergoing insertion of SEMS for large bowel obstruction at one institution. Scrutiny of the radiology department’s coding system allowed identification of all patients undergoing colonic stent insertion between 2002 and 2008. Data were extracted from patient case notes and investigation reports. Results Eighty-two patients with a median age of 75 (interquartile range [IQR] 43—94) years underwent stent insertion, 71 for palliation and 11 as a bridge to surgery. Obstruction was due to malignant disease in 67 patients and had a benign cause in 15. Median survival in the palliative setting was 103 (IQR 44—317) days. Complications occurred in 43 patients, of whom 22 underwent unplanned surgery. High-grade obstruction (relative risk [RR] 2.05; P = 0.055) and benign disease (RR 3.45; P < 0.001) were associated with risk of adverse events. Conclusion SEMS should not be used for large bowel obstruction with benign pathology. Comments 1. The center managing these patients is very ‘‘surgically oriented’’. It is likely that the patients in this series represent only 3.5% of all patients with colonic cancer, in other words, without severe disease or comorbidity. 2. The two important messages in this paper are the poor outcome of stents as a bridge to surgery, similar to a recently published French randomized trial [1], and the poor results in benign disease since the prosthesis easily and efficiently dilates the stricture and then migrates. 3. The criticism often advanced by gastroenterologists, that the type of stent might be responsible for the poor results reported, does not hold here because not less than three different types of stents were used in the study. 4. In sum, accumulating evidence has led to the consideration that colonic stents are not the best therapeutic option for benign strictures, and especially that they should not to be used as a bridge to surgery for malignant strictures. References [1] Surg Endosc 2011;25:1814—21. [2] Colorectal Dis 2006;8:102—11.
Predicting risk for serious complications with bariatric surgery: results from the Michigan Bariatric Surgery Collaborative 䊏 Finks JF, Kole KL, Yenumula PR, et al. Ann Surg 2011;254:633—40. DOI: 10.1097/SLA.0b013e318230058c
e128 Objectives To develop a risk prediction model for serious complications after bariatric surgery. Background Despite evidence for improved safety with bariatric surgery, serious complications remain a concern for patients, providers and payers. There is little populationlevel data on which risk factors can be used to identify patients at high risk for major morbidity. Methods The Michigan Bariatric Surgery Collaborative is a statewide consortium of hospitals and surgeons, which maintains an externally-audited prospective clinical registry. We analyzed data from 25,469 patients undergoing bariatric surgery between June 2006 and December 2010. Significant risk factors on univariable analysis were entered into a multivariable logistic regression model to identify factors associated with serious complications (life threatening and/or associated with lasting disability) within 30 days of surgery. Bootstrap resampling was performed to obtain biascorrected confidence intervals and c-statistic. Results Overall, 644 patients (2.5%) experienced a serious complication. Significant risk factors (P < 0.05) included: prior Venous thromboembolic event (VTE) (odds ratio [OR] 1.90, confidence interval [CI] 1.41—2.54); mobility limitations (OR 1.61, CI 1.23—2.13); coronary artery disease (OR 1.53, CI 1.17—2.02); age over 50 (OR 1.38, CI 1.18—1.61); pulmonary disease (OR 1.37, CI 1.15—1.64); male gender (OR 1.26, CI 1.06—1.50); smoking history (OR 1.20, CI 1.02—1.40); and procedure type (reference lap band): duodenal switch (OR 9.68, CI 6.05—15.49); laparoscopic gastric bypass (OR 3.58, CI 2.79—4.64); open gastric bypass (OR 3.51, CI 2.38—5.22); sleeve gastrectomy (OR 2.46, CI 1.73—3.50). The c-statistic was 0.68 (bias-corrected to 0.66) and the model was well-calibrated across deciles of predicted risk. Conclusions We have developed and validated a population-based risk scoring system for serious complications after bariatric surgery. We expect that this scoring system will improve the process of informed consent, facilitate the selection of procedures for high-risk patients, and allow for better risk stratification across studies of bariatric surgery. Comments 1. Although bariatric surgery has been shown to control diabetes, reduce the frequency of cardiovascular accidents and other obesity-related diseases, and even, prolonge life, the 2.5% to 4% risk of severe complications is still not negligible, [1]. This study reports overall morbidity and mortality rates that are quite low, but very variable, depending on the type of operation performed: in decreasing order, duodenal switch, gastric bypass, sleeve gastrectomy and adjustable banding. 2. As these data originate from a registry, the complication rate should be close to accurate. Nonetheless, this assumption needs to be tested in an independent cohort for external validity (reproducible in other populations than that of the state of Michigan) 3. Even though the essential value of this analysis resides in the identification of risk factors upon which action can be taken, the discrimination of the model used herein is of intermediary quality, potentially because (i) patients with severe disease might not have undergone operation; (ii) certain variables such as the volume effect or technique variations were not included in the analysis, and
C. Mariette, S. Benoist (iii) the severe complications are very heterogeneous, each with their specific factors. 4. Of note, the body mass index was not identified as an independent risk factor of severe complications, even though it is related to certain specific complications such as deep venous thrombosis. Reference [1] N Engl J Med 2009;361:445—54.
Prevalence of and risk factors for morbidity after elective left colectomy: cancer versus non-complicated diverticular disease 䊏 Piessen G, Muscari F, Rivkine E, et al. Arch Surg 2011;146:1149—55. DOI: 10.1001/archsurg.2011.231 Hypothesis Independent risk factors for postoperative morbidity after colectomy are most likely linked to disease characteristics. Design Retrospective analysis. Setting Twenty-eight centers of the French Federation for Surgical Research. Patients In total, 1721 patients (1230 with colon cancer [CC] and 491 with diverticular disease [DD]) from a databank of seven prospective, multisite, randomized trials on colorectal resection. Intervention Elective left colectomy via laparotomy. Main outcome measures Preoperative and intraoperative risk factors for postoperative morbidity. Result Overall postoperative morbidity was higher in CC than in DD (32.4% versus 30.3%) but the difference was not statistically significant (P = 0.40). Two independent risk factors for morbidity in CC were antecedent heart failure (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.42—6.32) (P = 0.003) and bothersome intraluminal fecal matter (2.08; 1.42—3.06) (P = 0.001). Three independent risk factors for morbidity in DD were at least 10% weight loss (OR, 2.06; 95% CI, 1.25—3.40) (P = 0.004), body mass index (calculated as weight in kilograms divided by height in meters squared) exceeding 30 (2.05; 1.15—3.66) (P = 0.02), and left hemicolectomy (versus left segmental colectomy) (2.01; 1.19—3.40) (P = 0.009). Conclusions Patients undergoing elective left colectomy for CC or for DD constitute two distinct populations with completely different risk factors for morbidity, which should be addressed differently. Improving colonic cleanliness (by antiseptic enema) may reduce morbidity in CC. In DD, morbidity may be reduced by appropriate preoperative nutritive support (by immunonutrition), even in patients with obesity, and by preference of left segmental colectomy over left hemicolectomy. By decreasing morbidity, mortality should be lowered as well, especially when reoperation becomes necessary. Comments 1. This study identifies morbidity and mortality rates similar to those reported in the literature. Of note, it underscores that, contrary to common opinion, postoperative outcome is related more to the patient and the
Press review underlying disease (these being inter-related) than to the surgical technique itself. 2. The analysis of postoperative mortality factors might have been more useful. The authors justified their analysis of morbidity by the fact that morbidity and mortality are inter-related and that analysis of risk factors for mortality is more difficult because of the rarity of death in colorectal surgery. Even if this seems rational, the authors should have looked at severe morbidity separately, which they did not. 3. Although the statistical methodology is clear and the study is well conducted, the pertinence of the results is suboptimal and there is some debate as to the independent risk factors found. For example, malnutrition is a risk factor for diverticular disease and, paradoxically, not for colonic cancer. The question that arises is whether preoperative fasting is a source of complication due to some degree of malnutrition? On the other hand, the patients undergoing operation for cancer might have been correctly nourished, cancelling the adverse effects of cancer. Another paradox is the fact that both malnutrition and overweight were risk factors in diverticular disease (28.5% des patients). Influence of surgical margins on outcome in patients with intrahepatic cholangiocarcinoma: a multicenter study by the AFC-IHCC-2009 study group 䊏 Farges O, Fuks D, Boleslawski E, et al. Ann Surg 2011;254:824—29. DOI: 10.1097/SLA.0b013e318236c21d Objective Define the optimal surgical margin in patients undergoing surgery for intrahepatic cholangiocarcinoma (IHCC). Background data Surgery is the most effective treatment for IHCC. However, the influence of R1 resection on outcome is controversial and that of margin width has not been evaluated. Methods We studied 212 patients undergoing curative resection of mass-forming-type IHCC. The respective influences on survival of resection status (R0 versus R1), surgical margin width, pTNM stage, and the latter’s components were evaluated. Results Incidence of R1 resection was 24%. Overall, R1 resection was not an independent predictor of survival (odds ratio [OR] 1.2 [0.7—2.1]) in contrast to the pTNM stage (OR 2.10 [1.2—3.5]). In the 78 pN+ patients, survival was similar after R0 and R1 resections (median: 18 versus 13 months, respectively, P = 0.1). In the 134 pN0 patients, R1 resection was an independent predictor of poor survival (OR 9.6 [4.5—20.4]), as was the presence of satellite nodules (OR 1.9 [1.1—3.2]). In the 116 pN0 patients with R0 resections, median survival was correlated with margin width (≤ 1 mm: 15 months; 2—4 mm: 36 months; 5—9 mm: 57 month; ≥ 10 mm: 64 month, P < 0.001) and a margin greater than 5 mm was an independent predictor of survival (OR 2.22 [1.59—3.09]). Conclusion Patients undergoing surgery for IHCC are at high risk of R1 resections. In pN0 patients, R1 resection is the strongest independent predictor of poor outcome and a margin of at least 5 mm should be created. The survival benefits of
e129 resection in pN+ patients and R1 resection in general are very low. Comments 1. While the incidence of intrahepatic cholangiocarcinoma has been increasing, patient survival after resection remains low (between 25% and 35%), lower than that of hepatocellular carcinoma and colorectal liver metastases [1]. While the impact of R1 resection depends on other disease characteristics, and in particular on the pN+ status, R0 resection has impact only on pN0 patients. 2. The second strong message is the demonstration of a linear correlation between survival and the size of the margin, the cut-off being 5 mm. The surgeon must strive to obtain the largest margin possible in pN0 patients, even though, in this series, a margin of greater than 5 mm was achieved in only 31% of patients. 3. For patients who are N+ and/or who are at high risk of an R1 resection, these results suggest that neoadjuvant chemotherapy has value in order to improve survival and select the good candidates for surgery. 4. It might be interesting to evaluate the respective impact of parenchymal, vascular or biliary margins as well as the impact of disease parameters such as the number of involved lymph nodes, the size of the tumor. . . even though the risk of type II errors might be high because of small numbers in the subgroups. Reference [1] Gastroenterol Clin Biol 2010;34:191—9. Routine colonoscopy following acute uncomplicated diverticulitis 䊏 Westwood DA, Eglinton TW, Frizelle FA. Br J Surg 2011;98:1630—34. DOI: 10.1002/bjs.7602 Background The evidence supporting current recommendations that the colon should be evaluated following an initial episode of acute diverticulitis is poor. The aim of this study was to clarify whether acute uncomplicated diverticulitis is a valid indication for subsequent colonoscopy/computed tomography (CT) colonography. Methods This was a retrospective longitudinal study of patients, with an initial presentation of acute uncomplicated diverticulitis on the basis of CT criteria, at a single institution between January 2004 and December 2008. Results A radiological diagnosis of acute uncomplicated diverticulitis was made in 292 patients. Some 205 patients underwent subsequent colonic evaluation or had undergone colonoscopy/CT colonography within the preceding 2 years. Colorectal polyps were present in 50 patients (24.4%). Twenty patients (9.8%) had hyperplastic polyps and 19 (9.3%) had adenomas. Eleven patients (5.4%) had advanced colonic neoplasia, including one (0.5%) with a colorectal cancer. One patient had inflammatory bowel disease (IBD). The patients with colorectal cancer and IBD had clinical indicators that independently warranted colonoscopy. None of the 87 patients who did not undergo colonic evaluation had a diagnosis of colorectal cancer registered with the New Zealand Cancer Registry. Conclusion The yield of advanced colonic neoplasia in this cohort was equivalent to, or less than that detected on screening asymptomatic average-risk individuals. In the absence of
e130 other indications, subsequent evaluation of the colon may not be required to confirm the diagnosis of diverticulitis. Comments 1. In 2007, the French recommendations for treatment of sigmoid diverticular disease by the SFNGE and the SFCD argued against routine colonoscopy after the index flare of diverticulitis. Colonoscopy was recommended only in those patients whose CT scan suggested a high risk of colorectal cancer. 2. It is regrettable that the authors did not give any precisions as to the localization of the lesions that turned out to be cancer: it would have been interesting to know whether these lesions were located in the sigmoid and whether they had any role in the inflammatory flare-up, mimicking diverticulitis. 3. The fact that patients had a colonoscopy 2 years before the flare poses a serious methodological problem: these patients probably had a colonoscopy for other symptoms or in a screening program leading to the diagnosis of non-superinfected lesions, and therefore probably less advanced disease. 4. A 5.4% rate of locally advanced tumors and a 0.5% rate of cancer are probably not sufficient reasons to recommend routine performance of colonoscopy after a non-complicated index flare of diverticulitis, but they are high enough to suggest that colonoscopy should be performed prior to surgery for diverticular disease in order to treat associated lesions at the same time. Reference [1] Dis Colon Rectum 2006;49:933—44. Gastroenterol Clin Biol 2007;31:3S5-3S10 Mortality after colorectal cancer surgery: a French survey of more than 84,000 patients 䊏 Panis Y, Maggiori L, Caranhac G, et al. Ann Surg 2011;254:738—44. DOI: 10.1097/SLA.0b013e31823604ac Objectives This study aimed to identify risk factors of postoperative 30-day mortality (POM) after colorectal cancer resection. Summary Meta-analyses have failed to demonstrate any significant benefit of laparoscopy in terms of postoperative mortality. This could be explained by the lack of a large sample size. Methods All patients who underwent colorectal resection for cancer between 2006 and 2008 in France were included. Data were extracted from the French National Health Service Database. A multivariate analysis evaluating risk factors for POM was performed including the following factors: age, gender, tumor location, associated comorbidities, emergency surgery, synchronous liver metastasis, malnutrition, and surgical approach. Results During the 3-year period, a total of 84,524 colorectal resections for colorectal cancer were performed: 22,359 through laparoscopy (26%) and 62,165 through laparotomy (74%). From 2006 to 2008, laparoscopic approach rate increased from 23% to 29% (P < 0.001). POM was 5.0%: 2% after laparoscopy and 6% after laparotomy (P < 0.001). In multivariate analysis, seven independent factors were significantly associated with a higher POM: age 70 years or more (P < 0.001, odds ratio [OR]: 3.28; [3.00—3.59]), respiratory comorbidity (P < 0.001, OR: 3.16; [2.91—3.37]), vascular
C. Mariette, S. Benoist comorbidity [P < 0.001, OR: 2.66; (2.48—2.85)], neurologic comorbidity (P < 0.001, OR: 1.78; [1.51—2.09]), emergency surgery (P < 0.001, OR: 2.68; [2.48—2.90]), synchronous liver metastasis (P < 0.001, OR: 2.63; [2.41—2.86]), and preoperative malnutrition (OR: 1.33; [1.19—1.50]). Laparoscopic surgery (P < 0.001, OR: 0.59; [0.54—0.65]) was independently associated with a significant decreased POM. Conclusions This all-inclusive national study showed that POM after colorectal cancer surgery is significantly reduced in case of age less than 70 years, elective surgery, and absence of synchronous liver metastasis, malnutrition, respiratory, neurologic, or vascular comorbidity. Furthermore, it is suggested that a laparoscopic surgery is independently associated with a decreased POM. This result, observed at a national level, must be considered when choosing the best surgical approach for colorectal cancer treatment. Comments 1. This cohort study constitutes an excellent snapshot of the outcome of colorectal surgery for cancer in France. It should be a reference against which all surgical teams can compare their results. 2. A 30% rate for laparoscopic surgery may seem small compared to the rates achieved by several teams that consider this the standard approach, especially for left colonic cancer. Nonetheless, 30% is higher than most North American series where the percentage ranges from 1.5 to 4.5% [1,2]. Moreover, it would have been interesting to know the conversion rate in this series. 3. Caution is warranted in drawing conclusions as to whether laparoscopy can decrease the operative mortality. Even though the power of a large cohort study with many patients does not differ much from a randomized trial, it cannot replace the latter, particularly when the principal item tested (i.e., laparoscopic resection) was in fact highly selected. In other terms, even if this multivariable study allows smoothing out of the selection bias, the laparoscopy and open surgical groups were not really comparable, in particular, for the other mortalityrelated risk factors. Indeed 80% of the patients with respiratory, vascular or neurologic history, 84% of undernourished patients, 87% of patients undergoing emergency operation and 83% of patients with synchronous metastases underwent colonic resection by open laparotomy. References [1] Arch Surg 2008;143:832—40. [2] Dis Colon Rectum 2009;52:1695—704. [3] Arch Surg 2005;140:278—83. Reassessing the need for prophylactic surgery in patients with porcelain gallbladder: case series and systematic review of the literature 䊏 Khan ZS, Livingston EH, Huerta S. Arch Surg 2011;146:1143—47. DOI 10.1001/archsurg.2011.257 Objective To evaluate the risk of gallbladder cancer (GBC) in patients with a porcelain gallbladder (PGB). Design Retrospective analysis of our institutional experience and a systematic review of the literature. Setting
Press review Academic teaching facility, Parkland Memorial Hospital, and the Dallas Veterans Affairs Medical Center (all in Dallas, Texas). Patients Medical records of 1200 cholecystectomies performed between 2008 and 2009 at Parkland Memorial Hospital, the University of Texas Southwestern Medical Center, and the Dallas Veterans Affairs Medical Center were reviewed. Patients with radiologic or histologic evidence of PGB or GBC were included. Main outcome measures The risk of GBC in patients with a PGB was assessed by contingency table analysis. Results We identified 13 patients with a PGB among 1200 cholecystectomies (1.1%). Most of these patients had concomitant gallstones (n = 9). None of the patients with a PGB had evidence of carcinoma. We also reviewed the histologic analysis results of 35 cases of GBC operated on between 1997 and 2009; none of these had gallbladder wall calcifications. Most patients underwent a laparoscopic cholecystectomy without any postoperative complications. We reviewed seven published series that included 60,665 cholecystectomies. The overall incidence of PGB was 0.2%, and GBC occurred in 15% of the PGB cases. Most cases of GBC occurring in PGB were found in the older literature; in the contemporary series, there were few reports of GBC associated with a PGB. Conclusions PGB is only weakly associated with GBC. Prophylactic cholecystectomy is not indicated for PGB alone and should be performed only in patients with conventional indications for cholecystectomy. A laparoscopic approach is appropriate for most patients with a PGB. Comments 1. The conclusions of this study confirm those of a preceding study showing that the risk of cancer in patients with PGB did not in itself justify cholecystectomy [1—3]. 2. This study underscores a problem of semantics. The authors’ definition of PGB does not correspond to the historical definition of PGB, i.e., an entirely calcified gallbladder on plain abdominal X-ray. In other terms, it is not the risk of cancer that has varied with time, but the very definition of PGB. It is probable that the risk of cancer in a patient with a completely calcified gallbladder is high whereas the risk is very low when small calcifications are detected in the gallbladder wall only on ultrasound or CT scan. 3. As most asymptomatic patients with gallbladder wall calcifications will only be closely followed in the near future, it would be interesting to evaluate the risk of developing gallbladder cancer over time. References [1] Surgery 2001;129:699—703. [2] Am Surg 2001;67:7—10. [3] Hepatogastroenterology 2009;56:943—5. Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience 䊏 Patel UB, Taylor F, Blomqvist L, et al. J Clin Oncol 2011;29:3753—60. DOI: 10.1200/JCO.2011.34.9068 Purpose To assess magnetic resonance imaging (MRI) and pathologic staging after neoadjuvant therapy for
e131 rectal cancer in a prospectively enrolled, multicenter study. Methods In a prospective cohort study, 111 patients who had rectal cancer treated by neoadjuvant therapy were assessed for response by MRI and pathology staging by T, N and circumferential resection margin (CRM) status. Tumor regression grade (TRG) was also assessed by MRI. Overall survival (OS) was estimated by using the Kaplan-Meier product-limit method, and Cox proportional hazards models were used to determine associations between staging of good and poor responders on MRI or pathology and survival outcomes after controlling for patient characteristics. Results On multivariate analysis, the MRI-assessed TRG (mrTRG) hazard ratios (HRs) were independently significant for survival (HR, 4.40; 95% CI, 1.65—11.7) and disease-free survival (DFS; HR, 3.28; 95% CI, 1.22—8.80). Five-year survival for poor mrTRG was 27% versus 72% (P = 0.001), and DFS for poor mrTRG was 31% versus 64% (P = 0.007). Preoperative MRI-predicted CRM independently predicted local recurrence (LR; HR, 4.25; 95% CI, 1.45—12.51). Five-year survival for poor post-treatment pathologic T stage (ypT) was 39% versus 76% (P = 0.001); DFS for the same was 38% versus 84% (P = 0.001); and LR for the same was 27% versus 6% (P = 0.018). The 5-year survival for involved pCRM was 30% versus 59% (P = 0.001); DFS, 28 versus 62% (P = 0.02); and LR, 56% versus 10% (P = 0.001). Pathology node status did not predict outcomes. Conclusion MRI assessment of TRG and CRM are imaging markers that predict survival outcomes for good and poor responders and provide an opportunity for the multidisciplinary team to offer additional treatment options before planning definitive surgery. Postoperative histopathology assessment of ypT and CRM but not post-treatment N status were important postsurgical predictors of outcome. Comments 1. This study, like most of the studies originating from the MERCURY study group, is well conducted but it remains essentially descriptive. Before concluding that post-treatment MRI can assess long-term carcinologic outcome, several steps are still necessary. First of all, the reproducibility of the investigation must be improved since, even in this study with the direct participation of two highly specialized radiologists, reproducibility of radiologic diagnosis was weak. Moreover, the prognostic criteria of post-treatment MRI have to be validated in an independent cohort. Lastly, it is necessary to verify if these criteria are still valid in patients treated by radiochemotherapy alone since, in this study, patients received only radiation therapy. 2. Diffusion sequences, which have been shown to improve the performance of MRI and have become the standard in 2011, were not performed in this study. [2]. These sequences could be useful to better appreciate the score of tumor regression. 3. If the results of this study are confirmed, this could have a major clinical impact. For example, patients considered to be poor responders by post-treatment MRI findings, might be candidates for intensification of treatment with chemotherapy alone before resorting to surgery. References [1] BMJ 2006;333:779. [2] Ann Surg Oncol 2011;18:2224—31
e132 Predictors of outcome for anal fistula surgery 䊏 Abbas MA, Jackson CH, Haigh PI. Arch Surg 2011;146:1011—16. DOI: 10.1001/archsurg.2011.197 Objectives To review our experience with patients treated for anal fistula secondary to cryptoglandular disease and to determine factors that influence postoperative outcome. Design Retrospective review. Setting A regional tertiary referral center. Patients Adult patients with anal fistula secondary to cryptoglandular disease. Interventions Fistulotomy, advancement flap, and fistula plugging. Main outcome measures Rates of operative failure (persistent fistula), incontinence, and septic complications. We evaluated age, sex, previous operation, fistula type, number of fistula tracts, horseshoe fistula, and intervention type to determine their independent influence on outcomes. Results One hundred and seventy-nine patients (79.3% male) underwent fistula operation from October 1, 2003, through December 31, 2008. Median age was 45 years. Fistulotomy was undertaken in 82.7% of patients, advancement flap in 10.6%, and plugging in 6.7%. The rates of operative failure, postoperative incontinence, and septic complications were 15.6%, 15.6%, and 7.3%, respectively. Plugging carried the highest failure rate (83.3%) compared with fistulotomy (10.1%) (odds ratio [OR], 44.3 [95% confidence interval (CI), 8.9—221.0; P < 0.001]) and was the only independent predictor for failure after adjusting for all variables. Being older than 45 years was associated with a higher postoperative incontinence rate compared with the younger group (adjusted OR, 2.8 [95% CI, 1.0—7.7; P = 0.04]). High transsphincteric and suprasphincteric fistulas were predictors of incontinence compared with subcutaneous fistulas (adjusted OR, 22.9 [95% CI, 2.2—242.0; P = 0.009] and 61.5 [4.5—844.0; P = 0.002], respectively). The only predictor of septic complications was plugging compared with fistulotomy (adjusted OR, 15.1 [95% CI, 2.3—97.7; P = 0.004]). Conclusions Fistulotomy is the preferred operation for anal fistula. Plugging is associated with the highest operative failure and septic complication rates. Incontinence was influenced more by fistula type and age rather than procedure. Comments 1. The conclusion of this study must be interpreted with caution because the groups of patients undergoing the different techniques were not comparable: plug and advancement flaps were performed only in those patients with complex transsphincteric fistulas. It is not at all surprising to see that their outcome was not that good. The only conclusion here is that one-stage fistulotomy provides good results for simple fistula involving less than 50% of the external sphincter. In case of complex fistula, the fistula plug does not seem to be adequate. This confirms preceding studies on the same subject [1,2]. 2. Several techniques were not evaluated such as two-stage fistulotomy after seton placement, the technique most often used in France, and the LIFT technique (suture of
C. Mariette, S. Benoist the orifice), which seems promising in complex fistulas [3]. References [1] Dis Colon Rectum 2009;52:18—22. [2] Br J Surg 2009:96:608—12. [3] Dis Colon Rectum 2010;53:43—6.
The impact of perioperative chemotherapy on survival in patients with gastric signet ring cell adenocarcinoma: a multicenter comparative study 䊏 Messager M, Lefevre JH, Pichot-Delahaye V et al. Ann Surg 2011;254:684—93. DOI: 10.1097/SLA.0b013e3182352647 Objective The aim of this retrospective study was to evaluate the survival impact of perioperative chemotherapy (PCT) in patients with gastric signet ring cell (SRC) adenocarcinoma. Background PCT is a standard treatment for advanced resectable gastric adenocarcinoma (GA). SRC has a worse prognosis compared to non-SRC and the chemosensitivity of SRC is uncertain. Methods Among 3010 patients registered in 19 French centers between January 1997 and January 2010, 1050 (34.9%) were diagnosed with SRC. Of those treated with curative intent (n = 924), 171 (18.5%) received PCT with surgery (PCT group), whereas 753 (81.5%) were treated with primary surgery (S group). PCT was based mainly on a fluorouracil-platinum doublet or triplet regimen. Results The groups were comparable regarding age, gender, American Society of Anesthesiologists (ASA) score, malnutrition, tumor location and cTNM stage. Sixty patients did not undergo resection because of tumor progression (10) or metastases (50) found at operation. The R0 resection rates were 65.9% and 62.3% in the S and PCT groups, respectively (P = 0.308). Fewer patients received adjuvant chemotherapy in the S group than in the PCT group (35.2% versus 66.5%, P < 0.001). At a median follow-up of 31.5 months, the median survival was shorter in the PCT group (12.8 versus 14.0 months, P = 0.043). On multivariate analysis, PCT was found to be an independent predictor of poor survival (HR = 1.4, 95% CI 1.1—1.9, P = 0.042). Conclusions PCT provides no survival benefit in patients with gastric SRC. Clinical Trial.gov record: ADCI001, Clinical Trial.gov identifier NCT01249859. Comments 1. This study confirms once again that signet ring cell gastric adenocarcinoma is a distinct entity with poor prognosis, whatever the management; 5-year survival is less than 5%. 2. The results of this study contradict a flawed argument that is used in medical oncology all too often: the fact that a cancer is severe or has high risk of recurrence does not signify, a priori, that chemotherapy will decrease the severity or the risk of recurrence. 3. The lack of efficacy, or even the deleterious effect of perioperative chemotherapy for signet ring cell adenocarcinoma must now be confirmed by a controlled study. Such a study, including a large number of patients, should be starting soon in France (group PRODIGEFRENCH).
Press review 4. To explain the poorer results of perioperative chemotherapy, the authors suggest that signet ring cell adenocarcinoma probably continues to progress during preoperative chemotherapy. Supporting this hypothesis is the fact that more total gastrectomies (+6%) and extended resections (+13%) were performed in the group receiving chemotherapy. This hypothesis is not certain. In fact, although the tumor stage was not the same in both groups, these tumors had the same pre-therapeutic TNM stage but the number of resections was not lower, and there were fewer R0 resections, more carcinomatosis and more histologically-advanced lesions in the group undergoing chemotherapy. Moreover, the 6% increased rate of total gastrectomy in the group receiving chemotherapy
e133 was probably due to the fact that there were 11% fewer antral cancers in this group and that total gastrectomy was systematically performed. 5. What should be done in case of signet ring cell carcinoma? The authors suggest that surgery should be performed first. The outcome of surgery followed by adjuvant chemotherapy remains mediocre with a median survival of 14 months and 3-year survival of 12%. New drugs or neoadjuvant chemo- or radiochemotherapy remain to be tested. References [1] N Engl J Med 2006;355:11—20. [2] J Clin Oncol 2011;29:1715—21. [3] Ann Surg 2009;250:878—87.