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ACS: Loop ileostomy may give IBD colitis patients an alternative to urgent colectomy
CHICAGO – Diverting loop ileostomy may be a better option than urgent colectomy as the first surgical step for medically refractory severe ulcerative colitis and Crohn’s disease.
Investigators from the University of California, Los Angeles, have found that ileostomy gives patients a chance to recover from their acute illness – and their colons a chance to heal – so they’re in better shape for definitive surgery further down the road, if it’s even needed (J Am Coll Surg. 2015 Oct;221[4]:S37-S38).
“Urgent colectomy is standard practice for medically refractory severe ulcerative and Crohn’s colitis. However, immunosuppression and malnutrition can result in significant morbidity. This change in management strategy does not eliminate the potential need for definitive surgery, but it does allow for the more extensive procedure to be performed in an elective setting under optimized conditions, thereby improving clinical outcomes,” said the investigators, led by Dr. Amy Lightner, formerly of UCLA but now a colorectal surgery fellow at the Mayo Clinic in Rochester, Minn.
There were just eight patients in the series, so the results are tentative. Six had ulcerative colitis (UC) and two had Crohn’s disease (CD). On presentation, the patients were tachycardic, febrile, malnourished, and anemic, with severe mucosal disease confirmed by endoscopy. Steroids, immunomodulators, and biologics no longer helped. Overall, the patients were too sick to go home, but not quite sick enough for the ICU. Their average age was 29 years.
They underwent a single-incision, laparoscopic diverting loop ileostomy, which took about 45 minutes. The technique, and perhaps the thinking behind it, are similar to one gaining popularity for Clostridium difficile colitis, but without the colonic lavage.
Within 24-48 hours postop, tachycardia and fevers resolved, and patients tolerated oral intake. Narcotic use dropped, and bloody stools became less frequent, and then ceased in all but one patient. Within a month, the average hemoglobin level had climbed from a baseline of 9 g/dL to 11.5 g/dL, and average albumin from 2.5 g/dL to 4 g/dL. Within 2 months, patients’ bowels looked pink and healthy on repeat endoscopy.
“It was a remarkable turnaround. Within 48 hours, they looked markedly different. We are having very good results with this, and it’s much better for patients” than is colectomy during acute illness. “It’s a good change in management,” Dr. Lightner said.
After months of follow-up, two patients, one with UC and one with CD, haven’t needed a colectomy and are maintained on biologics. The other UC patients have had ileal pouch-anal anastomosis. The other CD patient had a subsequent ileorectal anastomosis. Patients were able to undergo those procedures laparoscopically and “have done really well,” Dr. Lightner said.
It’s unclear why loop ileostomy seems so helpful. Perhaps it has something to do with shifts in bacterial populations or decompression of the colon. Maybe it’s just about giving the colon a rest, she said.
The investigators will continue to study the approach. Since the initial report, 8 more patients have joined the series, for a current total of 16. “We are still seeing good results,” Dr. Lightner said.
Dr. Lightner has no disclosures, and there was no outside funding for the work.
These patients are challenging. Often, they are on multiple immunomodulators and are malnourished and anemic, with systemic manifestations of inflammatory disease. The abdomen may be hostile. None of these are favorable factors for doing a total abdominal colectomy, but that remains the standard even today.
This is truly a feasibility or pilot study, and as such, it’s difficult to draw definitive conclusions. Cost-effectiveness is unclear, and some patients are maintained on biologics when, in fact, they may have had a curative procedure with surgery. The follow-up isn’t long enough to look at recurrence of colitis. Nevertheless, it certainly is an intriguing and perhaps revolutionary approach to treating these patients.
Dr. Sean C. Glasgow is a colorectal surgeon and assistant professor of surgery at Washington University in St. Louis. He was not involved with the study.
These patients are challenging. Often, they are on multiple immunomodulators and are malnourished and anemic, with systemic manifestations of inflammatory disease. The abdomen may be hostile. None of these are favorable factors for doing a total abdominal colectomy, but that remains the standard even today.
This is truly a feasibility or pilot study, and as such, it’s difficult to draw definitive conclusions. Cost-effectiveness is unclear, and some patients are maintained on biologics when, in fact, they may have had a curative procedure with surgery. The follow-up isn’t long enough to look at recurrence of colitis. Nevertheless, it certainly is an intriguing and perhaps revolutionary approach to treating these patients.
Dr. Sean C. Glasgow is a colorectal surgeon and assistant professor of surgery at Washington University in St. Louis. He was not involved with the study.
These patients are challenging. Often, they are on multiple immunomodulators and are malnourished and anemic, with systemic manifestations of inflammatory disease. The abdomen may be hostile. None of these are favorable factors for doing a total abdominal colectomy, but that remains the standard even today.
This is truly a feasibility or pilot study, and as such, it’s difficult to draw definitive conclusions. Cost-effectiveness is unclear, and some patients are maintained on biologics when, in fact, they may have had a curative procedure with surgery. The follow-up isn’t long enough to look at recurrence of colitis. Nevertheless, it certainly is an intriguing and perhaps revolutionary approach to treating these patients.
Dr. Sean C. Glasgow is a colorectal surgeon and assistant professor of surgery at Washington University in St. Louis. He was not involved with the study.
CHICAGO – Diverting loop ileostomy may be a better option than urgent colectomy as the first surgical step for medically refractory severe ulcerative colitis and Crohn’s disease.
Investigators from the University of California, Los Angeles, have found that ileostomy gives patients a chance to recover from their acute illness – and their colons a chance to heal – so they’re in better shape for definitive surgery further down the road, if it’s even needed (J Am Coll Surg. 2015 Oct;221[4]:S37-S38).
“Urgent colectomy is standard practice for medically refractory severe ulcerative and Crohn’s colitis. However, immunosuppression and malnutrition can result in significant morbidity. This change in management strategy does not eliminate the potential need for definitive surgery, but it does allow for the more extensive procedure to be performed in an elective setting under optimized conditions, thereby improving clinical outcomes,” said the investigators, led by Dr. Amy Lightner, formerly of UCLA but now a colorectal surgery fellow at the Mayo Clinic in Rochester, Minn.
There were just eight patients in the series, so the results are tentative. Six had ulcerative colitis (UC) and two had Crohn’s disease (CD). On presentation, the patients were tachycardic, febrile, malnourished, and anemic, with severe mucosal disease confirmed by endoscopy. Steroids, immunomodulators, and biologics no longer helped. Overall, the patients were too sick to go home, but not quite sick enough for the ICU. Their average age was 29 years.
They underwent a single-incision, laparoscopic diverting loop ileostomy, which took about 45 minutes. The technique, and perhaps the thinking behind it, are similar to one gaining popularity for Clostridium difficile colitis, but without the colonic lavage.
Within 24-48 hours postop, tachycardia and fevers resolved, and patients tolerated oral intake. Narcotic use dropped, and bloody stools became less frequent, and then ceased in all but one patient. Within a month, the average hemoglobin level had climbed from a baseline of 9 g/dL to 11.5 g/dL, and average albumin from 2.5 g/dL to 4 g/dL. Within 2 months, patients’ bowels looked pink and healthy on repeat endoscopy.
“It was a remarkable turnaround. Within 48 hours, they looked markedly different. We are having very good results with this, and it’s much better for patients” than is colectomy during acute illness. “It’s a good change in management,” Dr. Lightner said.
After months of follow-up, two patients, one with UC and one with CD, haven’t needed a colectomy and are maintained on biologics. The other UC patients have had ileal pouch-anal anastomosis. The other CD patient had a subsequent ileorectal anastomosis. Patients were able to undergo those procedures laparoscopically and “have done really well,” Dr. Lightner said.
It’s unclear why loop ileostomy seems so helpful. Perhaps it has something to do with shifts in bacterial populations or decompression of the colon. Maybe it’s just about giving the colon a rest, she said.
The investigators will continue to study the approach. Since the initial report, 8 more patients have joined the series, for a current total of 16. “We are still seeing good results,” Dr. Lightner said.
Dr. Lightner has no disclosures, and there was no outside funding for the work.
CHICAGO – Diverting loop ileostomy may be a better option than urgent colectomy as the first surgical step for medically refractory severe ulcerative colitis and Crohn’s disease.
Investigators from the University of California, Los Angeles, have found that ileostomy gives patients a chance to recover from their acute illness – and their colons a chance to heal – so they’re in better shape for definitive surgery further down the road, if it’s even needed (J Am Coll Surg. 2015 Oct;221[4]:S37-S38).
“Urgent colectomy is standard practice for medically refractory severe ulcerative and Crohn’s colitis. However, immunosuppression and malnutrition can result in significant morbidity. This change in management strategy does not eliminate the potential need for definitive surgery, but it does allow for the more extensive procedure to be performed in an elective setting under optimized conditions, thereby improving clinical outcomes,” said the investigators, led by Dr. Amy Lightner, formerly of UCLA but now a colorectal surgery fellow at the Mayo Clinic in Rochester, Minn.
There were just eight patients in the series, so the results are tentative. Six had ulcerative colitis (UC) and two had Crohn’s disease (CD). On presentation, the patients were tachycardic, febrile, malnourished, and anemic, with severe mucosal disease confirmed by endoscopy. Steroids, immunomodulators, and biologics no longer helped. Overall, the patients were too sick to go home, but not quite sick enough for the ICU. Their average age was 29 years.
They underwent a single-incision, laparoscopic diverting loop ileostomy, which took about 45 minutes. The technique, and perhaps the thinking behind it, are similar to one gaining popularity for Clostridium difficile colitis, but without the colonic lavage.
Within 24-48 hours postop, tachycardia and fevers resolved, and patients tolerated oral intake. Narcotic use dropped, and bloody stools became less frequent, and then ceased in all but one patient. Within a month, the average hemoglobin level had climbed from a baseline of 9 g/dL to 11.5 g/dL, and average albumin from 2.5 g/dL to 4 g/dL. Within 2 months, patients’ bowels looked pink and healthy on repeat endoscopy.
“It was a remarkable turnaround. Within 48 hours, they looked markedly different. We are having very good results with this, and it’s much better for patients” than is colectomy during acute illness. “It’s a good change in management,” Dr. Lightner said.
After months of follow-up, two patients, one with UC and one with CD, haven’t needed a colectomy and are maintained on biologics. The other UC patients have had ileal pouch-anal anastomosis. The other CD patient had a subsequent ileorectal anastomosis. Patients were able to undergo those procedures laparoscopically and “have done really well,” Dr. Lightner said.
It’s unclear why loop ileostomy seems so helpful. Perhaps it has something to do with shifts in bacterial populations or decompression of the colon. Maybe it’s just about giving the colon a rest, she said.
The investigators will continue to study the approach. Since the initial report, 8 more patients have joined the series, for a current total of 16. “We are still seeing good results,” Dr. Lightner said.
Dr. Lightner has no disclosures, and there was no outside funding for the work.
AT THE ACS CLINICAL CONGRESS
Key clinical point: Patients with refractory inflammatory bowel disease may benefit from loop ileostomy in lieu of urgent colectomy as a first surgical step.
Major finding: Within 24-48 hours after diverting loop ileostomy, tachycardia and fevers resolved, and patients tolerated oral intake. Narcotic use dropped, and bloody stools became less frequent, then ceased.
Data source: Pilot study in eight patients with refractory inflammatory bowel disease
Disclosures: The lead investigator has no disclosures, and there was no outside funding for the work.
VIDEO: A better option for C. difficile toxic megacolon
CHICAGO – Last-minute colectomy isn’t the way to go for Clostridium difficile–induced toxic megacolon; outcomes are better with a timely loop ileostomy and colonic lavage.
University of Pittsburgh surgery professor Dr. Brian Zuckerbraun, a pioneer of the technique, explained the procedure and its benefits in an interview at the annual Clinical Congress of the American College of Surgeons.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
CHICAGO – Last-minute colectomy isn’t the way to go for Clostridium difficile–induced toxic megacolon; outcomes are better with a timely loop ileostomy and colonic lavage.
University of Pittsburgh surgery professor Dr. Brian Zuckerbraun, a pioneer of the technique, explained the procedure and its benefits in an interview at the annual Clinical Congress of the American College of Surgeons.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
CHICAGO – Last-minute colectomy isn’t the way to go for Clostridium difficile–induced toxic megacolon; outcomes are better with a timely loop ileostomy and colonic lavage.
University of Pittsburgh surgery professor Dr. Brian Zuckerbraun, a pioneer of the technique, explained the procedure and its benefits in an interview at the annual Clinical Congress of the American College of Surgeons.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
EXPERT ANALYSIS FROM THE ACS CLINICAL CONGRESS
VIDEO: Dialysis-dependent patients face rocky road after colorectal surgery
CHICAGO – The odds of emergency surgery were sevenfold higher in dialysis-dependent patients undergoing colorectal surgery than patients with renal insufficiency not on dialysis or those with normal renal function.
Dialysis patients were also far less likely to undergo laparoscopic surgery and to be rescued from death if they experienced a complication.
These are just some of the results of a retrospective study involving 156,645 elective colorectal surgery cases selected as a poster of exceptional merit here at the annual clinical congress of the American College of Surgeons.
Dialysis patients are known to be at high risk for postoperative complications, but few studies have evaluated outcomes after colorectal surgery in these patients or distinguished them from patients with non–dialysis dependent renal insufficiency (NDDRI) or normal renal function (NRF), observed study author Dr. Isibor Arhuidese of Johns Hopkins University in Baltimore.
Indeed, when the researchers compared these three groups, perioperative mortality and morbidity after elective colorectal surgery was the worst in dialysis patients.
Absolute perioperative mortality was highest for dialysis patients vs. NDDRI and NRF patients after open (13.4% vs. 4.8% vs. 2%; P less than .001) and laparoscopic (8% vs. 2% vs. 0.6%; P less than .001) surgery.
Three complications were significantly associated with death in dialysis patients: myocardial infarction (adjusted odds ratio, 48.6; P = .027), bleeding (aOR, 14.5; P = .025), and sepsis or septic shock (aOR, 8.7; P = .001).
It is not enough to simply identify dialysis dependence as a predictor of poor outcomes, but one must identify targets for improvement in surgical care, Dr. Arhuidese stressed.
Dr. Arhuidese reported having no relevant conflicts of interest.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @pwendl
CHICAGO – The odds of emergency surgery were sevenfold higher in dialysis-dependent patients undergoing colorectal surgery than patients with renal insufficiency not on dialysis or those with normal renal function.
Dialysis patients were also far less likely to undergo laparoscopic surgery and to be rescued from death if they experienced a complication.
These are just some of the results of a retrospective study involving 156,645 elective colorectal surgery cases selected as a poster of exceptional merit here at the annual clinical congress of the American College of Surgeons.
Dialysis patients are known to be at high risk for postoperative complications, but few studies have evaluated outcomes after colorectal surgery in these patients or distinguished them from patients with non–dialysis dependent renal insufficiency (NDDRI) or normal renal function (NRF), observed study author Dr. Isibor Arhuidese of Johns Hopkins University in Baltimore.
Indeed, when the researchers compared these three groups, perioperative mortality and morbidity after elective colorectal surgery was the worst in dialysis patients.
Absolute perioperative mortality was highest for dialysis patients vs. NDDRI and NRF patients after open (13.4% vs. 4.8% vs. 2%; P less than .001) and laparoscopic (8% vs. 2% vs. 0.6%; P less than .001) surgery.
Three complications were significantly associated with death in dialysis patients: myocardial infarction (adjusted odds ratio, 48.6; P = .027), bleeding (aOR, 14.5; P = .025), and sepsis or septic shock (aOR, 8.7; P = .001).
It is not enough to simply identify dialysis dependence as a predictor of poor outcomes, but one must identify targets for improvement in surgical care, Dr. Arhuidese stressed.
Dr. Arhuidese reported having no relevant conflicts of interest.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @pwendl
CHICAGO – The odds of emergency surgery were sevenfold higher in dialysis-dependent patients undergoing colorectal surgery than patients with renal insufficiency not on dialysis or those with normal renal function.
Dialysis patients were also far less likely to undergo laparoscopic surgery and to be rescued from death if they experienced a complication.
These are just some of the results of a retrospective study involving 156,645 elective colorectal surgery cases selected as a poster of exceptional merit here at the annual clinical congress of the American College of Surgeons.
Dialysis patients are known to be at high risk for postoperative complications, but few studies have evaluated outcomes after colorectal surgery in these patients or distinguished them from patients with non–dialysis dependent renal insufficiency (NDDRI) or normal renal function (NRF), observed study author Dr. Isibor Arhuidese of Johns Hopkins University in Baltimore.
Indeed, when the researchers compared these three groups, perioperative mortality and morbidity after elective colorectal surgery was the worst in dialysis patients.
Absolute perioperative mortality was highest for dialysis patients vs. NDDRI and NRF patients after open (13.4% vs. 4.8% vs. 2%; P less than .001) and laparoscopic (8% vs. 2% vs. 0.6%; P less than .001) surgery.
Three complications were significantly associated with death in dialysis patients: myocardial infarction (adjusted odds ratio, 48.6; P = .027), bleeding (aOR, 14.5; P = .025), and sepsis or septic shock (aOR, 8.7; P = .001).
It is not enough to simply identify dialysis dependence as a predictor of poor outcomes, but one must identify targets for improvement in surgical care, Dr. Arhuidese stressed.
Dr. Arhuidese reported having no relevant conflicts of interest.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @pwendl
AT THE ACS CLINICAL CONGRESS
Lavage does not reduce severe complications in perforated diverticulitis
Patients needing emergency surgery for perforated diverticulitis saw no decrease in serious complications when treated with laparoscopic lavage, a minimally invasive procedure, than with primary resection of the colon, according to results from a randomized multicenter trial in Scandinavia.
Likelihood of reoperation also was significantly higher among patients undergoing laparoscopic lavage, and more sigmoid carcinomas were missed.
For their research, published Oct. 6 in JAMA (2015;314:1364-75), a group led by Dr. Johannes Kurt Schultz of the Akershus University Hospital in Lørenskog, Norway, and the University of Oslo sought to eliminate the selection bias that may have contributed to more favorable outcomes associated with laparoscopic lavage in observational studies.
Dr. Schultz and colleagues randomized patients with suspected perforated diverticulitis from 21 centers in Sweden and Norway to laparoscopic peritoneal lavage (n = 101) or colon resection (n = 98), with the choice of open or laparoscopic approach used for resection, as well as the option of colorectal anastomosis, left to the surgeon.
The study did not use laparoscopic Hinchey staging to classify the severity of the perforation prior to treatment assignment as a way of reducing the selection bias that may have occurred in observational studies.
The preoperative randomization resulted in both groups having similar rates of feculent peritonitis and incorrect preoperative diagnoses. Patients assigned to laparoscopic lavage were treated instead with resection if they were found to have fecal peritonitis. Also, patients in both groups whose pathology required additional treatment were treated at surgeon discretion. This left 74 patients randomized to lavage who received it as assigned and 70 patients undergoing resection per assigned protocol. In the intention-to-treat analysis, 31% of patients in the lavage group and 26% of patients in the resection group saw severe postoperative complications within 90 days, a difference of 4.7% that did not reach statistical significance (95% confidence interval, −7.9% to 17%; P = .53). Severe postoperative complications were defined as any complications resulting in a reintervention requiring general anesthesia, a life-threatening organ dysfunction, or death.
Of the patients treated as assigned with lavage, about 20% (n = 15) required reoperation, compared with 6% (n = 4) in the resection arm, a difference of about 14.6% (95% CI, 3.5% to 25.6%; P =.01).
The main reasons for reoperation were secondary peritonitis in the lavage group and wound rupture in the resection group. Intra-abdominal infections were more frequent in the laparoscopic lavage group, Dr. Schultz and colleagues found.
Also in the lavage group, four carcinomas were missed, compared with two in the resection group. “Because of the relatively high rate of missed colon carcinomas in the lavage group, it was essential to perform a colonoscopy after a patient recovered from the perforation,” the researchers wrote in their analysis.
Although patients in the laparoscopic lavage group had significantly shorter operating times, less blood loss, and lower incidence of stoma at 3 months, the researchers concluded that, based on these results, laparoscopic lavage could not be supported in perforated diverticulitis.
Dr. Schultz and colleagues had planned to enroll about half of eligible patients at the study sites. They noted as a limitation of their study that those not enrolled had more severe disease and worse postoperative outcomes, raising the possibility that the results “may not pertain to patients with perforated diverticulitis who are very ill.”
The study was funded by the South-Eastern Norway Regional Health Authority and Akershus University Hospital. None of its authors reported conflicts of interest.
Dr. Schultz and associates detail findings from a randomized, multicenter clinical trial conducted in Scandinavia designed to assess the superiority of laparoscopic lavage plus drainage, compared with laparoscopic or open resection with or without anastomosis for diverticulitis (Hinchey grades I-III) requiring urgent surgery.
The primary outcome was the incidence of severe complications (Clavien-Dindo classification IIIb-V). Of 144 patients, 74 were randomized to receive laparoscopic lavage and 70 to resection. The two groups were similar in characteristics, although significantly fewer of the lavage procedures were performed by a specialty-trained surgeon. Severe complications occurred in 25.7% of patients in the lavage group and 14.3% in the resection group (difference, 11.4%; 95% CI, −1.8 to 24.1), and significantly more patients in the lavage group developed secondary peritonitis (12% vs. 0%) or returned to the operating room (20% vs. 6%). The hospital mortality rates and follow-up quality-of-life scores were comparable between the groups (3% vs. 4% and 0.75 vs. 0.73, respectively). Somewhat worrisome is that four colon cancers were initially missed in patients treated by laparoscopic lavage alone.
Performing laparoscopic lavage is more difficult than merely irrigating the abdomen and placing drains within the pelvis. Surgeons vary in their attitudes related to concomitant adhesiolysis or debridement, and consensus about these procedures is lacking. Furthermore, subjective signs and objective criteria that identify patients at risk for secondary peritonitis or reoperation must be studied, and risk models should be validated to determine which patients are best suited for this less invasive approach. The utility of less intrusive strategies and minimally invasive approaches will undoubtedly expand as technologies evolve, but they must be responsibly incorporated into surgical practice based on evidence rather than subjective reasons.
Dr. Scott A. Strong and Dr. Nathaniel J. Soper are with Northwestern University, Chicago. These comments were taken from an accompanying editorial (JAMA 2015;314[13]:1343-5). They declared no conflicts of interest.
Dr. Schultz and associates detail findings from a randomized, multicenter clinical trial conducted in Scandinavia designed to assess the superiority of laparoscopic lavage plus drainage, compared with laparoscopic or open resection with or without anastomosis for diverticulitis (Hinchey grades I-III) requiring urgent surgery.
The primary outcome was the incidence of severe complications (Clavien-Dindo classification IIIb-V). Of 144 patients, 74 were randomized to receive laparoscopic lavage and 70 to resection. The two groups were similar in characteristics, although significantly fewer of the lavage procedures were performed by a specialty-trained surgeon. Severe complications occurred in 25.7% of patients in the lavage group and 14.3% in the resection group (difference, 11.4%; 95% CI, −1.8 to 24.1), and significantly more patients in the lavage group developed secondary peritonitis (12% vs. 0%) or returned to the operating room (20% vs. 6%). The hospital mortality rates and follow-up quality-of-life scores were comparable between the groups (3% vs. 4% and 0.75 vs. 0.73, respectively). Somewhat worrisome is that four colon cancers were initially missed in patients treated by laparoscopic lavage alone.
Performing laparoscopic lavage is more difficult than merely irrigating the abdomen and placing drains within the pelvis. Surgeons vary in their attitudes related to concomitant adhesiolysis or debridement, and consensus about these procedures is lacking. Furthermore, subjective signs and objective criteria that identify patients at risk for secondary peritonitis or reoperation must be studied, and risk models should be validated to determine which patients are best suited for this less invasive approach. The utility of less intrusive strategies and minimally invasive approaches will undoubtedly expand as technologies evolve, but they must be responsibly incorporated into surgical practice based on evidence rather than subjective reasons.
Dr. Scott A. Strong and Dr. Nathaniel J. Soper are with Northwestern University, Chicago. These comments were taken from an accompanying editorial (JAMA 2015;314[13]:1343-5). They declared no conflicts of interest.
Dr. Schultz and associates detail findings from a randomized, multicenter clinical trial conducted in Scandinavia designed to assess the superiority of laparoscopic lavage plus drainage, compared with laparoscopic or open resection with or without anastomosis for diverticulitis (Hinchey grades I-III) requiring urgent surgery.
The primary outcome was the incidence of severe complications (Clavien-Dindo classification IIIb-V). Of 144 patients, 74 were randomized to receive laparoscopic lavage and 70 to resection. The two groups were similar in characteristics, although significantly fewer of the lavage procedures were performed by a specialty-trained surgeon. Severe complications occurred in 25.7% of patients in the lavage group and 14.3% in the resection group (difference, 11.4%; 95% CI, −1.8 to 24.1), and significantly more patients in the lavage group developed secondary peritonitis (12% vs. 0%) or returned to the operating room (20% vs. 6%). The hospital mortality rates and follow-up quality-of-life scores were comparable between the groups (3% vs. 4% and 0.75 vs. 0.73, respectively). Somewhat worrisome is that four colon cancers were initially missed in patients treated by laparoscopic lavage alone.
Performing laparoscopic lavage is more difficult than merely irrigating the abdomen and placing drains within the pelvis. Surgeons vary in their attitudes related to concomitant adhesiolysis or debridement, and consensus about these procedures is lacking. Furthermore, subjective signs and objective criteria that identify patients at risk for secondary peritonitis or reoperation must be studied, and risk models should be validated to determine which patients are best suited for this less invasive approach. The utility of less intrusive strategies and minimally invasive approaches will undoubtedly expand as technologies evolve, but they must be responsibly incorporated into surgical practice based on evidence rather than subjective reasons.
Dr. Scott A. Strong and Dr. Nathaniel J. Soper are with Northwestern University, Chicago. These comments were taken from an accompanying editorial (JAMA 2015;314[13]:1343-5). They declared no conflicts of interest.
Patients needing emergency surgery for perforated diverticulitis saw no decrease in serious complications when treated with laparoscopic lavage, a minimally invasive procedure, than with primary resection of the colon, according to results from a randomized multicenter trial in Scandinavia.
Likelihood of reoperation also was significantly higher among patients undergoing laparoscopic lavage, and more sigmoid carcinomas were missed.
For their research, published Oct. 6 in JAMA (2015;314:1364-75), a group led by Dr. Johannes Kurt Schultz of the Akershus University Hospital in Lørenskog, Norway, and the University of Oslo sought to eliminate the selection bias that may have contributed to more favorable outcomes associated with laparoscopic lavage in observational studies.
Dr. Schultz and colleagues randomized patients with suspected perforated diverticulitis from 21 centers in Sweden and Norway to laparoscopic peritoneal lavage (n = 101) or colon resection (n = 98), with the choice of open or laparoscopic approach used for resection, as well as the option of colorectal anastomosis, left to the surgeon.
The study did not use laparoscopic Hinchey staging to classify the severity of the perforation prior to treatment assignment as a way of reducing the selection bias that may have occurred in observational studies.
The preoperative randomization resulted in both groups having similar rates of feculent peritonitis and incorrect preoperative diagnoses. Patients assigned to laparoscopic lavage were treated instead with resection if they were found to have fecal peritonitis. Also, patients in both groups whose pathology required additional treatment were treated at surgeon discretion. This left 74 patients randomized to lavage who received it as assigned and 70 patients undergoing resection per assigned protocol. In the intention-to-treat analysis, 31% of patients in the lavage group and 26% of patients in the resection group saw severe postoperative complications within 90 days, a difference of 4.7% that did not reach statistical significance (95% confidence interval, −7.9% to 17%; P = .53). Severe postoperative complications were defined as any complications resulting in a reintervention requiring general anesthesia, a life-threatening organ dysfunction, or death.
Of the patients treated as assigned with lavage, about 20% (n = 15) required reoperation, compared with 6% (n = 4) in the resection arm, a difference of about 14.6% (95% CI, 3.5% to 25.6%; P =.01).
The main reasons for reoperation were secondary peritonitis in the lavage group and wound rupture in the resection group. Intra-abdominal infections were more frequent in the laparoscopic lavage group, Dr. Schultz and colleagues found.
Also in the lavage group, four carcinomas were missed, compared with two in the resection group. “Because of the relatively high rate of missed colon carcinomas in the lavage group, it was essential to perform a colonoscopy after a patient recovered from the perforation,” the researchers wrote in their analysis.
Although patients in the laparoscopic lavage group had significantly shorter operating times, less blood loss, and lower incidence of stoma at 3 months, the researchers concluded that, based on these results, laparoscopic lavage could not be supported in perforated diverticulitis.
Dr. Schultz and colleagues had planned to enroll about half of eligible patients at the study sites. They noted as a limitation of their study that those not enrolled had more severe disease and worse postoperative outcomes, raising the possibility that the results “may not pertain to patients with perforated diverticulitis who are very ill.”
The study was funded by the South-Eastern Norway Regional Health Authority and Akershus University Hospital. None of its authors reported conflicts of interest.
Patients needing emergency surgery for perforated diverticulitis saw no decrease in serious complications when treated with laparoscopic lavage, a minimally invasive procedure, than with primary resection of the colon, according to results from a randomized multicenter trial in Scandinavia.
Likelihood of reoperation also was significantly higher among patients undergoing laparoscopic lavage, and more sigmoid carcinomas were missed.
For their research, published Oct. 6 in JAMA (2015;314:1364-75), a group led by Dr. Johannes Kurt Schultz of the Akershus University Hospital in Lørenskog, Norway, and the University of Oslo sought to eliminate the selection bias that may have contributed to more favorable outcomes associated with laparoscopic lavage in observational studies.
Dr. Schultz and colleagues randomized patients with suspected perforated diverticulitis from 21 centers in Sweden and Norway to laparoscopic peritoneal lavage (n = 101) or colon resection (n = 98), with the choice of open or laparoscopic approach used for resection, as well as the option of colorectal anastomosis, left to the surgeon.
The study did not use laparoscopic Hinchey staging to classify the severity of the perforation prior to treatment assignment as a way of reducing the selection bias that may have occurred in observational studies.
The preoperative randomization resulted in both groups having similar rates of feculent peritonitis and incorrect preoperative diagnoses. Patients assigned to laparoscopic lavage were treated instead with resection if they were found to have fecal peritonitis. Also, patients in both groups whose pathology required additional treatment were treated at surgeon discretion. This left 74 patients randomized to lavage who received it as assigned and 70 patients undergoing resection per assigned protocol. In the intention-to-treat analysis, 31% of patients in the lavage group and 26% of patients in the resection group saw severe postoperative complications within 90 days, a difference of 4.7% that did not reach statistical significance (95% confidence interval, −7.9% to 17%; P = .53). Severe postoperative complications were defined as any complications resulting in a reintervention requiring general anesthesia, a life-threatening organ dysfunction, or death.
Of the patients treated as assigned with lavage, about 20% (n = 15) required reoperation, compared with 6% (n = 4) in the resection arm, a difference of about 14.6% (95% CI, 3.5% to 25.6%; P =.01).
The main reasons for reoperation were secondary peritonitis in the lavage group and wound rupture in the resection group. Intra-abdominal infections were more frequent in the laparoscopic lavage group, Dr. Schultz and colleagues found.
Also in the lavage group, four carcinomas were missed, compared with two in the resection group. “Because of the relatively high rate of missed colon carcinomas in the lavage group, it was essential to perform a colonoscopy after a patient recovered from the perforation,” the researchers wrote in their analysis.
Although patients in the laparoscopic lavage group had significantly shorter operating times, less blood loss, and lower incidence of stoma at 3 months, the researchers concluded that, based on these results, laparoscopic lavage could not be supported in perforated diverticulitis.
Dr. Schultz and colleagues had planned to enroll about half of eligible patients at the study sites. They noted as a limitation of their study that those not enrolled had more severe disease and worse postoperative outcomes, raising the possibility that the results “may not pertain to patients with perforated diverticulitis who are very ill.”
The study was funded by the South-Eastern Norway Regional Health Authority and Akershus University Hospital. None of its authors reported conflicts of interest.
FROM JAMA
Key clinical point: Laparoscopic lavage carries risks of severe postoperative complications similar to colon resection in people presenting with suspected perforated diverticulitis requiring emergency surgery.
Major finding: Mortality and severe complications did not differ significantly at 90 days postoperation between intention-to-treat groups, while reoperation was significantly higher among patients treated with lavage (5.7% for resection vs. 20.3% for lavage, P < .01).
Data source: A multicenter, open-label randomized trial in which patients presenting with likely perforated diverticulitis were randomized to lavage (n = 74) or resection (n = 70).
Disclosures: The study was sponsored by investigator institutions and Norwegian regional government grants. No conflicts of interest were reported.
High death rates for IBD patients who underwent emergency resections
Patients with inflammatory bowel disease (IBD) were about five to eight times more likely to die after emergency intestinal resection as opposed to elective surgery, a large meta-analysis found.
Overall mortality rates after emergency intestinal resection were 5.3% for patients with ulcerative colitis (UC) and 3.6% for patients with Crohn’s disease (CD), said Dr. Sunny Singh and his associates at the University of Calgary in Alberta, Canada. In contrast, only 0.6%-0.7% of patients died after elective resection, the researchers reported in the October issue of Gastroenterology (2015 Jun 5. doi: 10.1053/j.gastro.2015.06.001).
Source: American Gastroenterological AssociationClinicians should optimize medical management to avoid emergency resection, seek ways to reduce associated mortality, and use the data when counseling patients and weighing medical and surgical management options, they added.
Intestinal resection is less common among patients with IBD than in decades past, but almost half of CD patients undergo the surgery within 10 years of diagnosis, as do 16% of UC patients, according to another meta-analysis (Gastroenterology 2013;145:996-1006). Past studies have reported divergent rates of death after these surgeries, the researchers noted. To better understand mortality rates and relevant risk factors, they reviewed 18 original research articles and three abstracts published between 1990 and 2015, all of which were indexed in Medline, EMBASE, or PubMed. The studies included 67,057 UC patients and 75,971 CD patients from 15 countries.
Rates of mortality after elective resection were significantly lower than after emergency resection, whether patients had CD (elective, 0.6%; 95% confidence interval, 0.2%-1.7%; emergency, 3.6%; 1.8%-6.9%) or UC (elective, 0.7%; 0.6%-0.9%; emergency, 5.3%; 3.8%-7.3%), the researchers found. Death rates did not significantly differ based on disease type. Postoperative mortality dropped significantly after the 1990s among CD patients only, perhaps because emergency surgery has become less common in Calgary since 1997, the researchers said. However, they were unable to compare changes in death rates over time by surgery type, they said.
Several factors could explain the high fatality rates after emergency intestinal resection, the researchers said. Patients tended to have worse disease activity and higher rates of intestinal obstruction, intra-abdominal abscess, toxic megacolon, preoperative clostridial diarrhea, venous thromboembolism, malnourishment, or prolonged treatment with intravenous corticosteroids, they said. General surgeons are more likely to perform emergency resections than elective cases, which are typically handled by more experienced colorectal surgeons, they added. Emergency resections also are less likely to be performed laparoscopically than are elective resections, they noted. “The low risk of death associated with elective intestinal resections for CD and UC could be used as a quality assurance benchmark to compare outcomes between hospitals and surgeons,” they added.
The research was funded by the Canadian Institute of Health Research, Alberta-Innovates Health-Solutions, the Alberta IBD Consortium. Dr. Singh reported no conflicts of interest. Senior author Dr. Gilaad Kaplan and four coauthors disclosed speaker, advisory board, and funding relationships with a number of pharmaceutical companies.
Patients with inflammatory bowel disease (IBD) were about five to eight times more likely to die after emergency intestinal resection as opposed to elective surgery, a large meta-analysis found.
Overall mortality rates after emergency intestinal resection were 5.3% for patients with ulcerative colitis (UC) and 3.6% for patients with Crohn’s disease (CD), said Dr. Sunny Singh and his associates at the University of Calgary in Alberta, Canada. In contrast, only 0.6%-0.7% of patients died after elective resection, the researchers reported in the October issue of Gastroenterology (2015 Jun 5. doi: 10.1053/j.gastro.2015.06.001).
Source: American Gastroenterological AssociationClinicians should optimize medical management to avoid emergency resection, seek ways to reduce associated mortality, and use the data when counseling patients and weighing medical and surgical management options, they added.
Intestinal resection is less common among patients with IBD than in decades past, but almost half of CD patients undergo the surgery within 10 years of diagnosis, as do 16% of UC patients, according to another meta-analysis (Gastroenterology 2013;145:996-1006). Past studies have reported divergent rates of death after these surgeries, the researchers noted. To better understand mortality rates and relevant risk factors, they reviewed 18 original research articles and three abstracts published between 1990 and 2015, all of which were indexed in Medline, EMBASE, or PubMed. The studies included 67,057 UC patients and 75,971 CD patients from 15 countries.
Rates of mortality after elective resection were significantly lower than after emergency resection, whether patients had CD (elective, 0.6%; 95% confidence interval, 0.2%-1.7%; emergency, 3.6%; 1.8%-6.9%) or UC (elective, 0.7%; 0.6%-0.9%; emergency, 5.3%; 3.8%-7.3%), the researchers found. Death rates did not significantly differ based on disease type. Postoperative mortality dropped significantly after the 1990s among CD patients only, perhaps because emergency surgery has become less common in Calgary since 1997, the researchers said. However, they were unable to compare changes in death rates over time by surgery type, they said.
Several factors could explain the high fatality rates after emergency intestinal resection, the researchers said. Patients tended to have worse disease activity and higher rates of intestinal obstruction, intra-abdominal abscess, toxic megacolon, preoperative clostridial diarrhea, venous thromboembolism, malnourishment, or prolonged treatment with intravenous corticosteroids, they said. General surgeons are more likely to perform emergency resections than elective cases, which are typically handled by more experienced colorectal surgeons, they added. Emergency resections also are less likely to be performed laparoscopically than are elective resections, they noted. “The low risk of death associated with elective intestinal resections for CD and UC could be used as a quality assurance benchmark to compare outcomes between hospitals and surgeons,” they added.
The research was funded by the Canadian Institute of Health Research, Alberta-Innovates Health-Solutions, the Alberta IBD Consortium. Dr. Singh reported no conflicts of interest. Senior author Dr. Gilaad Kaplan and four coauthors disclosed speaker, advisory board, and funding relationships with a number of pharmaceutical companies.
Patients with inflammatory bowel disease (IBD) were about five to eight times more likely to die after emergency intestinal resection as opposed to elective surgery, a large meta-analysis found.
Overall mortality rates after emergency intestinal resection were 5.3% for patients with ulcerative colitis (UC) and 3.6% for patients with Crohn’s disease (CD), said Dr. Sunny Singh and his associates at the University of Calgary in Alberta, Canada. In contrast, only 0.6%-0.7% of patients died after elective resection, the researchers reported in the October issue of Gastroenterology (2015 Jun 5. doi: 10.1053/j.gastro.2015.06.001).
Source: American Gastroenterological AssociationClinicians should optimize medical management to avoid emergency resection, seek ways to reduce associated mortality, and use the data when counseling patients and weighing medical and surgical management options, they added.
Intestinal resection is less common among patients with IBD than in decades past, but almost half of CD patients undergo the surgery within 10 years of diagnosis, as do 16% of UC patients, according to another meta-analysis (Gastroenterology 2013;145:996-1006). Past studies have reported divergent rates of death after these surgeries, the researchers noted. To better understand mortality rates and relevant risk factors, they reviewed 18 original research articles and three abstracts published between 1990 and 2015, all of which were indexed in Medline, EMBASE, or PubMed. The studies included 67,057 UC patients and 75,971 CD patients from 15 countries.
Rates of mortality after elective resection were significantly lower than after emergency resection, whether patients had CD (elective, 0.6%; 95% confidence interval, 0.2%-1.7%; emergency, 3.6%; 1.8%-6.9%) or UC (elective, 0.7%; 0.6%-0.9%; emergency, 5.3%; 3.8%-7.3%), the researchers found. Death rates did not significantly differ based on disease type. Postoperative mortality dropped significantly after the 1990s among CD patients only, perhaps because emergency surgery has become less common in Calgary since 1997, the researchers said. However, they were unable to compare changes in death rates over time by surgery type, they said.
Several factors could explain the high fatality rates after emergency intestinal resection, the researchers said. Patients tended to have worse disease activity and higher rates of intestinal obstruction, intra-abdominal abscess, toxic megacolon, preoperative clostridial diarrhea, venous thromboembolism, malnourishment, or prolonged treatment with intravenous corticosteroids, they said. General surgeons are more likely to perform emergency resections than elective cases, which are typically handled by more experienced colorectal surgeons, they added. Emergency resections also are less likely to be performed laparoscopically than are elective resections, they noted. “The low risk of death associated with elective intestinal resections for CD and UC could be used as a quality assurance benchmark to compare outcomes between hospitals and surgeons,” they added.
The research was funded by the Canadian Institute of Health Research, Alberta-Innovates Health-Solutions, the Alberta IBD Consortium. Dr. Singh reported no conflicts of interest. Senior author Dr. Gilaad Kaplan and four coauthors disclosed speaker, advisory board, and funding relationships with a number of pharmaceutical companies.
FROM GASTROENTEROLOGY
Key clinical point: Patients with IBD were about five to eight times more likely to die after emergency intestinal resection as opposed to elective surgery.
Major finding: Overall mortality rates after emergency intestinal resection were 5.3% for patients with ulcerative colitis and 3.6% for Crohn’s disease; mortality rates after elective surgery were 0.7% and 0.6%, respectively.
Data source: Meta-analysis of 18 original research studies and three abstracts published between 1990 and 2015.
Disclosures: The research was funded by the Canadian Institute of Health Research, Alberta-Innovates Health-Solutions, the Alberta IBD Consortium. Dr. Singh reported no conflicts of interest. Senior author Dr. Gilaad Kaplan and four coauthors disclosed speaker, advisory board, and funding relationships with a number of pharmaceutical companies.
Patterns in the Use of Neoadjuvant and Adjuvant Therapy in Stage II/III Rectal Cancer and Associated Survival
Background: A 2004 German study found preoperative chemoradiotherapy followed by postoperative chemotherapy provided increased local control and reduced toxicity over postoperative chemoradiotherapy in stage II/III rectal cancer, though a statistically significant advantage in overall survival was not observed. We examined similar survival differences and the utilization of appropriate therapy on a larger scale.
Methods: This study retrospectively examined patients diagnosed with stage II/III rectal cancer from 2006 to 2011 using a participant user file from the National Cancer Database, a data registry jointly sponsored by the American College of Surgeons and the American Cancer Society capturing approximately 70% of newly diagnosed cancer cases nationwide. Overall survival differences between treatment modalities were assessed using life tables and pairwise comparisons, and changes in the utilization of these treatments were examined.
Results: Of 40,546 patients diagnosed with stage II/III rectal cancer, 27,014 (66.6%) received therapy consisting of surgery, chemotherapy, and radiation. Those administered preoperative chemoradiotherapy followed by postoperative chemotherapy had the highest 5-year survival rate (stage II 81.4%, stage III 71.2%), but the difference was not significant against postoperative chemoradiotherapy in stage III disease (69.9%) after the Bonferroni correction was applied. Five-year survival was higher in postoperative (stage II 76.0%, stage III 69.9%) than that in preoperative (stage II 72.5%, stage III: 65.8%) chemoradiotherapy in both stages. Preoperative chemoradiotherapy remains the most commonly administered (60.6% in stage II and 46.0% in stage III), but preoperative chemoradio-therapy followed by postoperative chemotherapy has been steadily rising (2006: 12.2% in stage II, 16.5% in stage III vs 2011: 22.8% in stage II, 28.0% in stage III).
Conclusions: A survival benefit of preoperative chemoradiotherapy followed by postoperative chemotherapy in stage II disease was observed, along with a nonsignificant advantage in stage III disease. The utilization of preoperative chemoradiotherapy followed by postoperative chemotherapy increased, but preoperative chemoradiotherapy remained most prevalent despite its lesser overall survival. Cox regression will be performed prior to the AVAHO annual meeting to evaluate the impact of other characteristics such as age, insurance, income, and comorbidities on survival.
Background: A 2004 German study found preoperative chemoradiotherapy followed by postoperative chemotherapy provided increased local control and reduced toxicity over postoperative chemoradiotherapy in stage II/III rectal cancer, though a statistically significant advantage in overall survival was not observed. We examined similar survival differences and the utilization of appropriate therapy on a larger scale.
Methods: This study retrospectively examined patients diagnosed with stage II/III rectal cancer from 2006 to 2011 using a participant user file from the National Cancer Database, a data registry jointly sponsored by the American College of Surgeons and the American Cancer Society capturing approximately 70% of newly diagnosed cancer cases nationwide. Overall survival differences between treatment modalities were assessed using life tables and pairwise comparisons, and changes in the utilization of these treatments were examined.
Results: Of 40,546 patients diagnosed with stage II/III rectal cancer, 27,014 (66.6%) received therapy consisting of surgery, chemotherapy, and radiation. Those administered preoperative chemoradiotherapy followed by postoperative chemotherapy had the highest 5-year survival rate (stage II 81.4%, stage III 71.2%), but the difference was not significant against postoperative chemoradiotherapy in stage III disease (69.9%) after the Bonferroni correction was applied. Five-year survival was higher in postoperative (stage II 76.0%, stage III 69.9%) than that in preoperative (stage II 72.5%, stage III: 65.8%) chemoradiotherapy in both stages. Preoperative chemoradiotherapy remains the most commonly administered (60.6% in stage II and 46.0% in stage III), but preoperative chemoradio-therapy followed by postoperative chemotherapy has been steadily rising (2006: 12.2% in stage II, 16.5% in stage III vs 2011: 22.8% in stage II, 28.0% in stage III).
Conclusions: A survival benefit of preoperative chemoradiotherapy followed by postoperative chemotherapy in stage II disease was observed, along with a nonsignificant advantage in stage III disease. The utilization of preoperative chemoradiotherapy followed by postoperative chemotherapy increased, but preoperative chemoradiotherapy remained most prevalent despite its lesser overall survival. Cox regression will be performed prior to the AVAHO annual meeting to evaluate the impact of other characteristics such as age, insurance, income, and comorbidities on survival.
Background: A 2004 German study found preoperative chemoradiotherapy followed by postoperative chemotherapy provided increased local control and reduced toxicity over postoperative chemoradiotherapy in stage II/III rectal cancer, though a statistically significant advantage in overall survival was not observed. We examined similar survival differences and the utilization of appropriate therapy on a larger scale.
Methods: This study retrospectively examined patients diagnosed with stage II/III rectal cancer from 2006 to 2011 using a participant user file from the National Cancer Database, a data registry jointly sponsored by the American College of Surgeons and the American Cancer Society capturing approximately 70% of newly diagnosed cancer cases nationwide. Overall survival differences between treatment modalities were assessed using life tables and pairwise comparisons, and changes in the utilization of these treatments were examined.
Results: Of 40,546 patients diagnosed with stage II/III rectal cancer, 27,014 (66.6%) received therapy consisting of surgery, chemotherapy, and radiation. Those administered preoperative chemoradiotherapy followed by postoperative chemotherapy had the highest 5-year survival rate (stage II 81.4%, stage III 71.2%), but the difference was not significant against postoperative chemoradiotherapy in stage III disease (69.9%) after the Bonferroni correction was applied. Five-year survival was higher in postoperative (stage II 76.0%, stage III 69.9%) than that in preoperative (stage II 72.5%, stage III: 65.8%) chemoradiotherapy in both stages. Preoperative chemoradiotherapy remains the most commonly administered (60.6% in stage II and 46.0% in stage III), but preoperative chemoradio-therapy followed by postoperative chemotherapy has been steadily rising (2006: 12.2% in stage II, 16.5% in stage III vs 2011: 22.8% in stage II, 28.0% in stage III).
Conclusions: A survival benefit of preoperative chemoradiotherapy followed by postoperative chemotherapy in stage II disease was observed, along with a nonsignificant advantage in stage III disease. The utilization of preoperative chemoradiotherapy followed by postoperative chemotherapy increased, but preoperative chemoradiotherapy remained most prevalent despite its lesser overall survival. Cox regression will be performed prior to the AVAHO annual meeting to evaluate the impact of other characteristics such as age, insurance, income, and comorbidities on survival.
Stage IV Rectal Cancer Trends by Year: A Review of the National Cancer Database, 1998 to 2009
Background: The arrival of novel surgical techniques and chemotherapeutic agents has changed the range of available treatments and improved outcomes for stage IV rectal cancers. This is the largest study on stage IV rectal cancer to evaluate the change in treatment strategy and corresponding mortality from 1998 to 2009.
Methods: A population-based study was conducted using the National Cancer Database (1998-2009), which contains 70% of all cancer diagnoses in the U.S. After exclusion criteria were met, 25,046 stage IV rectal cancer patients were analyzed. Treatment modalities were compared by year of diagnosis between 1998 and 2009. Life tables were used to determine mortality by year. All statistics were run on SPSS Version 22 (IBM, Armonk, NY).
Results: Overall survival in stage IV rectal cancer has increased from 1998 to 2009 for 1-year survival (50% vs 61%) and 5-year survival (7% vs 12%). Analysis by treatment revealed that chemotherapy with radiation was most prevalent (20.6%) in 1998, but chemotherapy alone became the predominant treatment (25%) in 2009. Surgery as a planned first course of treatment decreased from 51.5% in 1998 to 27.2% in 2009, with a concordant increase in chemotherapy from 8.4% to 25% in that time frame. The largest 5-year survival increase across these years included surgery only (6% to 15%), surgery and chemotherapy (8% to 23%), and trimodal therapy (15% to 27%).
Conclusions: The outcomes for stage IV rectal cancer have meaningfully improved from 1998 to 2009, as evidenced by the significant improvement in 1- and 5-year survival. There has been a general trend to treat with chemotherapy and avoid surgery as a planned first course of treatment, despite improvement in mortality for both. Survival rates remain highest with trimodal therapy, but 5-year survival for surgery with chemotherapy and surgery only has also significantly improved from 1998 to 2009. Prior to the AVAHO annual meeting, we will conduct a multivariate analysis to evaluate other influences on survival such as age, comorbidities, insurance, education, and income.
Background: The arrival of novel surgical techniques and chemotherapeutic agents has changed the range of available treatments and improved outcomes for stage IV rectal cancers. This is the largest study on stage IV rectal cancer to evaluate the change in treatment strategy and corresponding mortality from 1998 to 2009.
Methods: A population-based study was conducted using the National Cancer Database (1998-2009), which contains 70% of all cancer diagnoses in the U.S. After exclusion criteria were met, 25,046 stage IV rectal cancer patients were analyzed. Treatment modalities were compared by year of diagnosis between 1998 and 2009. Life tables were used to determine mortality by year. All statistics were run on SPSS Version 22 (IBM, Armonk, NY).
Results: Overall survival in stage IV rectal cancer has increased from 1998 to 2009 for 1-year survival (50% vs 61%) and 5-year survival (7% vs 12%). Analysis by treatment revealed that chemotherapy with radiation was most prevalent (20.6%) in 1998, but chemotherapy alone became the predominant treatment (25%) in 2009. Surgery as a planned first course of treatment decreased from 51.5% in 1998 to 27.2% in 2009, with a concordant increase in chemotherapy from 8.4% to 25% in that time frame. The largest 5-year survival increase across these years included surgery only (6% to 15%), surgery and chemotherapy (8% to 23%), and trimodal therapy (15% to 27%).
Conclusions: The outcomes for stage IV rectal cancer have meaningfully improved from 1998 to 2009, as evidenced by the significant improvement in 1- and 5-year survival. There has been a general trend to treat with chemotherapy and avoid surgery as a planned first course of treatment, despite improvement in mortality for both. Survival rates remain highest with trimodal therapy, but 5-year survival for surgery with chemotherapy and surgery only has also significantly improved from 1998 to 2009. Prior to the AVAHO annual meeting, we will conduct a multivariate analysis to evaluate other influences on survival such as age, comorbidities, insurance, education, and income.
Background: The arrival of novel surgical techniques and chemotherapeutic agents has changed the range of available treatments and improved outcomes for stage IV rectal cancers. This is the largest study on stage IV rectal cancer to evaluate the change in treatment strategy and corresponding mortality from 1998 to 2009.
Methods: A population-based study was conducted using the National Cancer Database (1998-2009), which contains 70% of all cancer diagnoses in the U.S. After exclusion criteria were met, 25,046 stage IV rectal cancer patients were analyzed. Treatment modalities were compared by year of diagnosis between 1998 and 2009. Life tables were used to determine mortality by year. All statistics were run on SPSS Version 22 (IBM, Armonk, NY).
Results: Overall survival in stage IV rectal cancer has increased from 1998 to 2009 for 1-year survival (50% vs 61%) and 5-year survival (7% vs 12%). Analysis by treatment revealed that chemotherapy with radiation was most prevalent (20.6%) in 1998, but chemotherapy alone became the predominant treatment (25%) in 2009. Surgery as a planned first course of treatment decreased from 51.5% in 1998 to 27.2% in 2009, with a concordant increase in chemotherapy from 8.4% to 25% in that time frame. The largest 5-year survival increase across these years included surgery only (6% to 15%), surgery and chemotherapy (8% to 23%), and trimodal therapy (15% to 27%).
Conclusions: The outcomes for stage IV rectal cancer have meaningfully improved from 1998 to 2009, as evidenced by the significant improvement in 1- and 5-year survival. There has been a general trend to treat with chemotherapy and avoid surgery as a planned first course of treatment, despite improvement in mortality for both. Survival rates remain highest with trimodal therapy, but 5-year survival for surgery with chemotherapy and surgery only has also significantly improved from 1998 to 2009. Prior to the AVAHO annual meeting, we will conduct a multivariate analysis to evaluate other influences on survival such as age, comorbidities, insurance, education, and income.
Damage control laparotomy an option for nontrauma secondary peritonitis
LAS VEGAS – Damage control laparotomy is a safe and reliable approach to the surgical management of patients with severe nontrauma secondary peritonitis who require bowel resection, according a review of 182 cases.
For example, the deferred ostomy rate was 16.7% among 72 patients who underwent damage control laparotomy (DCL), which was significantly lower than the primary ostomy rate of 53.6% in 110 patients who underwent a definitive surgical procedure (DSP), Dr. Maria P. Garcia-Garcia reported at the annual meeting of the American Association for the Surgery of Trauma.
Further, the fistula rate was lower among 60 DCL patients who underwent delayed anastomosis, compared with 51 DSP patients who underwent primary anastomosis (26.7% vs. 37.2%), and the mortality rate was lower in the DCL vs. DSP patients (16.7% vs. 24.5%). These differences did not meet statistical significance due to the sample size. Deaths in the DCL group all occurred in those who underwent delayed anastomosis; deaths in the DSP group occurred in 14 ostomy patients and 13 anastomosis patients, said Dr. Garcia-Garcia of Fundacion Valle del Lili, Cali, Colombia.
Disease severity, as measured by APACHE II scores, was similar in the two groups (mean of about 17 for each group). Septic shock was present in 37% at the time of admission. Mean hospital length of stay and mean intensive care unit length of stay did not differ significantly between the groups, nor did the systemic complication rate, or the rates of multiple organ failure and acute respiratory distress syndrome.
Small-bowel perforation occurred in 77 (42.3%), and colon perforation occurred in 105 (57.7%).
The patients included teens and adults aged 16 years or older (mean of 60.3 years) with severe nontrauma secondary peritonitis (NSPT) who were undergoing bowel resection after enteric perforations between 2003 and 2013. The DSP patients underwent either primary anastomosis or primary ostomy, and the DCL patients underwent segmental bowel resection, temporary abdominal closure, and subsequent delayed anastomosis or deferred ostomy.
DCL is a recognized strategy for managing bowel injuries in trauma patients. It was developed in response to the poor outcomes associated with attempting definitive repair, but evidence regarding the role and timing of anastomosis in DCL in NTSP – a condition associated with high morbidity and a 30% in-hospital mortality rate – is lacking, Dr. Garcia-Garcia said, noting that the current findings suggest it is the preferred approach.
“When a definite surgical repair is chosen, there is a 50/50 chance of performing anastomosis or ostomy. However, when a damage control abbreviated laparotomy is performed, there is a high bowel reconstruction success rate of about 80%. Therefore, damage control abbreviated laparotomy is a reliable and safe option in critically ill nontrauma secondary peritonitis patients. At the end of the day it’s your choice: Would you rather leave your patient with an ostomy or tube, or would you give your patient a chance of successful reconstruction without an ostomy?” she said.
Dr. Garcia-Garcia reported having no disclosures.
LAS VEGAS – Damage control laparotomy is a safe and reliable approach to the surgical management of patients with severe nontrauma secondary peritonitis who require bowel resection, according a review of 182 cases.
For example, the deferred ostomy rate was 16.7% among 72 patients who underwent damage control laparotomy (DCL), which was significantly lower than the primary ostomy rate of 53.6% in 110 patients who underwent a definitive surgical procedure (DSP), Dr. Maria P. Garcia-Garcia reported at the annual meeting of the American Association for the Surgery of Trauma.
Further, the fistula rate was lower among 60 DCL patients who underwent delayed anastomosis, compared with 51 DSP patients who underwent primary anastomosis (26.7% vs. 37.2%), and the mortality rate was lower in the DCL vs. DSP patients (16.7% vs. 24.5%). These differences did not meet statistical significance due to the sample size. Deaths in the DCL group all occurred in those who underwent delayed anastomosis; deaths in the DSP group occurred in 14 ostomy patients and 13 anastomosis patients, said Dr. Garcia-Garcia of Fundacion Valle del Lili, Cali, Colombia.
Disease severity, as measured by APACHE II scores, was similar in the two groups (mean of about 17 for each group). Septic shock was present in 37% at the time of admission. Mean hospital length of stay and mean intensive care unit length of stay did not differ significantly between the groups, nor did the systemic complication rate, or the rates of multiple organ failure and acute respiratory distress syndrome.
Small-bowel perforation occurred in 77 (42.3%), and colon perforation occurred in 105 (57.7%).
The patients included teens and adults aged 16 years or older (mean of 60.3 years) with severe nontrauma secondary peritonitis (NSPT) who were undergoing bowel resection after enteric perforations between 2003 and 2013. The DSP patients underwent either primary anastomosis or primary ostomy, and the DCL patients underwent segmental bowel resection, temporary abdominal closure, and subsequent delayed anastomosis or deferred ostomy.
DCL is a recognized strategy for managing bowel injuries in trauma patients. It was developed in response to the poor outcomes associated with attempting definitive repair, but evidence regarding the role and timing of anastomosis in DCL in NTSP – a condition associated with high morbidity and a 30% in-hospital mortality rate – is lacking, Dr. Garcia-Garcia said, noting that the current findings suggest it is the preferred approach.
“When a definite surgical repair is chosen, there is a 50/50 chance of performing anastomosis or ostomy. However, when a damage control abbreviated laparotomy is performed, there is a high bowel reconstruction success rate of about 80%. Therefore, damage control abbreviated laparotomy is a reliable and safe option in critically ill nontrauma secondary peritonitis patients. At the end of the day it’s your choice: Would you rather leave your patient with an ostomy or tube, or would you give your patient a chance of successful reconstruction without an ostomy?” she said.
Dr. Garcia-Garcia reported having no disclosures.
LAS VEGAS – Damage control laparotomy is a safe and reliable approach to the surgical management of patients with severe nontrauma secondary peritonitis who require bowel resection, according a review of 182 cases.
For example, the deferred ostomy rate was 16.7% among 72 patients who underwent damage control laparotomy (DCL), which was significantly lower than the primary ostomy rate of 53.6% in 110 patients who underwent a definitive surgical procedure (DSP), Dr. Maria P. Garcia-Garcia reported at the annual meeting of the American Association for the Surgery of Trauma.
Further, the fistula rate was lower among 60 DCL patients who underwent delayed anastomosis, compared with 51 DSP patients who underwent primary anastomosis (26.7% vs. 37.2%), and the mortality rate was lower in the DCL vs. DSP patients (16.7% vs. 24.5%). These differences did not meet statistical significance due to the sample size. Deaths in the DCL group all occurred in those who underwent delayed anastomosis; deaths in the DSP group occurred in 14 ostomy patients and 13 anastomosis patients, said Dr. Garcia-Garcia of Fundacion Valle del Lili, Cali, Colombia.
Disease severity, as measured by APACHE II scores, was similar in the two groups (mean of about 17 for each group). Septic shock was present in 37% at the time of admission. Mean hospital length of stay and mean intensive care unit length of stay did not differ significantly between the groups, nor did the systemic complication rate, or the rates of multiple organ failure and acute respiratory distress syndrome.
Small-bowel perforation occurred in 77 (42.3%), and colon perforation occurred in 105 (57.7%).
The patients included teens and adults aged 16 years or older (mean of 60.3 years) with severe nontrauma secondary peritonitis (NSPT) who were undergoing bowel resection after enteric perforations between 2003 and 2013. The DSP patients underwent either primary anastomosis or primary ostomy, and the DCL patients underwent segmental bowel resection, temporary abdominal closure, and subsequent delayed anastomosis or deferred ostomy.
DCL is a recognized strategy for managing bowel injuries in trauma patients. It was developed in response to the poor outcomes associated with attempting definitive repair, but evidence regarding the role and timing of anastomosis in DCL in NTSP – a condition associated with high morbidity and a 30% in-hospital mortality rate – is lacking, Dr. Garcia-Garcia said, noting that the current findings suggest it is the preferred approach.
“When a definite surgical repair is chosen, there is a 50/50 chance of performing anastomosis or ostomy. However, when a damage control abbreviated laparotomy is performed, there is a high bowel reconstruction success rate of about 80%. Therefore, damage control abbreviated laparotomy is a reliable and safe option in critically ill nontrauma secondary peritonitis patients. At the end of the day it’s your choice: Would you rather leave your patient with an ostomy or tube, or would you give your patient a chance of successful reconstruction without an ostomy?” she said.
Dr. Garcia-Garcia reported having no disclosures.
AT THE AAST ANNUAL MEETING
Key clinical point: Damage control laparotomy is a safe and reliable approach to the surgical management of patients with severe nontrauma secondary peritonitis who require bowel resection, according a review of 182 cases.
Major finding: The ostomy rate was 16.7% vs. 53.6% with DCL vs. DSP.
Data source: A review of 182 cases.
Disclosures: Dr. Garcia-Garcia reported having no disclosures.
Utilization of Fusion PET/CT in Mapping Surgical/Medical Treatment Algorithms: Individualizing Patient Care for Suspicious Colorectal Masses
Purpose: Determine the utility of fusion positron emission tomography/computed tomography (PET/CT) in mapping surgical procedures for suspicious colorectal masses in the era of minimally invasive surgery—laparoscopy/robotics where haptic feedback is absent.
Background: The National Comprehensive Cancer Network (NCCN) guidelines recommend using CT of the chest, abdomen, and pelvis for colorectal cancer staging. This is largely because PET/CT is not widely available, thus limiting access. Colonoscopy is used to locate/diagnose colorectal masses. Gastroenterologists often “guestimate” the location of the lesion either by anatomical landmarks or by measurement on the colonoscope itself. These are often inaccurate. It is the standard of care to ink the location of the lesion as well. This is not always done or easy to identify. It is often necessary to perform an intraoperative colonoscopy to locate the lesion in question and then make incisions or dock the robot accordingly.
Methods: Retrospective data from a colorectal surgeon were reviewed. Surgeries performed at the Raymond G. Murphy VAMC from March 2012 to June 2015 were included. Data were reviewed for these patients to evaluate for the efficacy of fusion PET/CT studies in identifying the lesion in question regardless of benign or cancerous lesion, mapping of the planned procedure, and how it affected planned treatment algorithms.
Results: Fifty patients were referred for evaluation and treatment of a suspicious colorectal mass, and 45 patients underwent PET/CT for staging. The lesion was not PET avid in 9 patients, and 36 patients had positive findings on the study. Thirty-two of those patients had findings fairly consistent with the colonoscopy site identifiers. In 5 patients, the PET/ CT results changed the planned surgery or delayed surgery for neoadjuvant chemoradiotherapy. The nonvisualized patients were either mucinous or no residual tumor remained.
Conclusions: Although PET/CT is not the recommended staging study by NCCN guidelines for colorectal cancers, it is readily available at our VAMC and proves useful in differentiating scar from tumor when compared with CT alone. Our experience showed that PET/CT is often positive in suspicious colorectal masses, helps to map the surgery, and acts as a baseline for ongoing surveillance. It ultimately can change the entire treatment algorithm for our individual patients.
Purpose: Determine the utility of fusion positron emission tomography/computed tomography (PET/CT) in mapping surgical procedures for suspicious colorectal masses in the era of minimally invasive surgery—laparoscopy/robotics where haptic feedback is absent.
Background: The National Comprehensive Cancer Network (NCCN) guidelines recommend using CT of the chest, abdomen, and pelvis for colorectal cancer staging. This is largely because PET/CT is not widely available, thus limiting access. Colonoscopy is used to locate/diagnose colorectal masses. Gastroenterologists often “guestimate” the location of the lesion either by anatomical landmarks or by measurement on the colonoscope itself. These are often inaccurate. It is the standard of care to ink the location of the lesion as well. This is not always done or easy to identify. It is often necessary to perform an intraoperative colonoscopy to locate the lesion in question and then make incisions or dock the robot accordingly.
Methods: Retrospective data from a colorectal surgeon were reviewed. Surgeries performed at the Raymond G. Murphy VAMC from March 2012 to June 2015 were included. Data were reviewed for these patients to evaluate for the efficacy of fusion PET/CT studies in identifying the lesion in question regardless of benign or cancerous lesion, mapping of the planned procedure, and how it affected planned treatment algorithms.
Results: Fifty patients were referred for evaluation and treatment of a suspicious colorectal mass, and 45 patients underwent PET/CT for staging. The lesion was not PET avid in 9 patients, and 36 patients had positive findings on the study. Thirty-two of those patients had findings fairly consistent with the colonoscopy site identifiers. In 5 patients, the PET/ CT results changed the planned surgery or delayed surgery for neoadjuvant chemoradiotherapy. The nonvisualized patients were either mucinous or no residual tumor remained.
Conclusions: Although PET/CT is not the recommended staging study by NCCN guidelines for colorectal cancers, it is readily available at our VAMC and proves useful in differentiating scar from tumor when compared with CT alone. Our experience showed that PET/CT is often positive in suspicious colorectal masses, helps to map the surgery, and acts as a baseline for ongoing surveillance. It ultimately can change the entire treatment algorithm for our individual patients.
Purpose: Determine the utility of fusion positron emission tomography/computed tomography (PET/CT) in mapping surgical procedures for suspicious colorectal masses in the era of minimally invasive surgery—laparoscopy/robotics where haptic feedback is absent.
Background: The National Comprehensive Cancer Network (NCCN) guidelines recommend using CT of the chest, abdomen, and pelvis for colorectal cancer staging. This is largely because PET/CT is not widely available, thus limiting access. Colonoscopy is used to locate/diagnose colorectal masses. Gastroenterologists often “guestimate” the location of the lesion either by anatomical landmarks or by measurement on the colonoscope itself. These are often inaccurate. It is the standard of care to ink the location of the lesion as well. This is not always done or easy to identify. It is often necessary to perform an intraoperative colonoscopy to locate the lesion in question and then make incisions or dock the robot accordingly.
Methods: Retrospective data from a colorectal surgeon were reviewed. Surgeries performed at the Raymond G. Murphy VAMC from March 2012 to June 2015 were included. Data were reviewed for these patients to evaluate for the efficacy of fusion PET/CT studies in identifying the lesion in question regardless of benign or cancerous lesion, mapping of the planned procedure, and how it affected planned treatment algorithms.
Results: Fifty patients were referred for evaluation and treatment of a suspicious colorectal mass, and 45 patients underwent PET/CT for staging. The lesion was not PET avid in 9 patients, and 36 patients had positive findings on the study. Thirty-two of those patients had findings fairly consistent with the colonoscopy site identifiers. In 5 patients, the PET/ CT results changed the planned surgery or delayed surgery for neoadjuvant chemoradiotherapy. The nonvisualized patients were either mucinous or no residual tumor remained.
Conclusions: Although PET/CT is not the recommended staging study by NCCN guidelines for colorectal cancers, it is readily available at our VAMC and proves useful in differentiating scar from tumor when compared with CT alone. Our experience showed that PET/CT is often positive in suspicious colorectal masses, helps to map the surgery, and acts as a baseline for ongoing surveillance. It ultimately can change the entire treatment algorithm for our individual patients.
Colorectal Cancer Statistics Among Patients Reported in the Veterans Affairs Central Cancer Registry
Purpose: On average, VA patients are older and sicker than is the general population. Our objectives were to provide an overview of VA colorectal (CRC) incidence and make comparisons with the Surveillance, Epidemiology, and End Results (SEER) data, which provides U.S. cancer statistics.
Background: About 3,400 incidents of CRC are reported in the Veterans Affairs Central Cancer Registry (VACCR) annually. This equates to nearly 9% of VA cancers.
Methods/Data Analysis: Data were obtained from VACCR for incident CRC diagnosed/treated in VA from fiscal year (FY) 2009 to 2012. Using VHA Support Service Center information about the distribution of VA health care system enrollees for corresponding years, we made age and gender adjustments for the underlying VA population. Colorectal incidence among VA patients was descriptively compared with projected national 2014 CRC-specific SEER and supporting data sources.
Results: From FY 2009 to 2012, we identified 15,205 VA patients nationwide. For analysis, there were 12,551 patients (n = 322, 2.6% women; n = 12,229, 97.4% men). Among patients in the VACCR, the most common tumor location was proximal colon (n = 4,830, 38%), followed by rectum (n = 3,907, 31%), distal colon (n = 3,240, 26%), and other colon (n = 574, 5%). These percentages are comparable with those of SEER, in which proximal colon and rectum are most common. Among patients in the VACCR, SEER summary stage distribution was 44% (n = 5,517) local, 36% (n = 4,488) regional, 17% (n = 2,091) distant, and 4% (n = 455) unknown. These percentages also align with those of SEER, in which about 40% of CRC cases are diagnosed locally. Mirroring SEER, among the VACCR, overall CRC incidence rate decreased from 0.22 to 0.16 cases per 1,000 veterans in FYs 2009 and 2012, respectively.
Implications: VACCR data indicate that incident CRC in FY 2009 to 2012 approximated SEER projections during a similar time frame. National VA CRC incidence, location, and stage distribution are also similar. This suggests that despite VA patients being more complex than their general population counterparts, VA patients are generally diagnosed with comparable CRC locations and stages. This analysis also suggests that, like SEER, the VACCR may have utility for epidemiologic tracking and research.
Purpose: On average, VA patients are older and sicker than is the general population. Our objectives were to provide an overview of VA colorectal (CRC) incidence and make comparisons with the Surveillance, Epidemiology, and End Results (SEER) data, which provides U.S. cancer statistics.
Background: About 3,400 incidents of CRC are reported in the Veterans Affairs Central Cancer Registry (VACCR) annually. This equates to nearly 9% of VA cancers.
Methods/Data Analysis: Data were obtained from VACCR for incident CRC diagnosed/treated in VA from fiscal year (FY) 2009 to 2012. Using VHA Support Service Center information about the distribution of VA health care system enrollees for corresponding years, we made age and gender adjustments for the underlying VA population. Colorectal incidence among VA patients was descriptively compared with projected national 2014 CRC-specific SEER and supporting data sources.
Results: From FY 2009 to 2012, we identified 15,205 VA patients nationwide. For analysis, there were 12,551 patients (n = 322, 2.6% women; n = 12,229, 97.4% men). Among patients in the VACCR, the most common tumor location was proximal colon (n = 4,830, 38%), followed by rectum (n = 3,907, 31%), distal colon (n = 3,240, 26%), and other colon (n = 574, 5%). These percentages are comparable with those of SEER, in which proximal colon and rectum are most common. Among patients in the VACCR, SEER summary stage distribution was 44% (n = 5,517) local, 36% (n = 4,488) regional, 17% (n = 2,091) distant, and 4% (n = 455) unknown. These percentages also align with those of SEER, in which about 40% of CRC cases are diagnosed locally. Mirroring SEER, among the VACCR, overall CRC incidence rate decreased from 0.22 to 0.16 cases per 1,000 veterans in FYs 2009 and 2012, respectively.
Implications: VACCR data indicate that incident CRC in FY 2009 to 2012 approximated SEER projections during a similar time frame. National VA CRC incidence, location, and stage distribution are also similar. This suggests that despite VA patients being more complex than their general population counterparts, VA patients are generally diagnosed with comparable CRC locations and stages. This analysis also suggests that, like SEER, the VACCR may have utility for epidemiologic tracking and research.
Purpose: On average, VA patients are older and sicker than is the general population. Our objectives were to provide an overview of VA colorectal (CRC) incidence and make comparisons with the Surveillance, Epidemiology, and End Results (SEER) data, which provides U.S. cancer statistics.
Background: About 3,400 incidents of CRC are reported in the Veterans Affairs Central Cancer Registry (VACCR) annually. This equates to nearly 9% of VA cancers.
Methods/Data Analysis: Data were obtained from VACCR for incident CRC diagnosed/treated in VA from fiscal year (FY) 2009 to 2012. Using VHA Support Service Center information about the distribution of VA health care system enrollees for corresponding years, we made age and gender adjustments for the underlying VA population. Colorectal incidence among VA patients was descriptively compared with projected national 2014 CRC-specific SEER and supporting data sources.
Results: From FY 2009 to 2012, we identified 15,205 VA patients nationwide. For analysis, there were 12,551 patients (n = 322, 2.6% women; n = 12,229, 97.4% men). Among patients in the VACCR, the most common tumor location was proximal colon (n = 4,830, 38%), followed by rectum (n = 3,907, 31%), distal colon (n = 3,240, 26%), and other colon (n = 574, 5%). These percentages are comparable with those of SEER, in which proximal colon and rectum are most common. Among patients in the VACCR, SEER summary stage distribution was 44% (n = 5,517) local, 36% (n = 4,488) regional, 17% (n = 2,091) distant, and 4% (n = 455) unknown. These percentages also align with those of SEER, in which about 40% of CRC cases are diagnosed locally. Mirroring SEER, among the VACCR, overall CRC incidence rate decreased from 0.22 to 0.16 cases per 1,000 veterans in FYs 2009 and 2012, respectively.
Implications: VACCR data indicate that incident CRC in FY 2009 to 2012 approximated SEER projections during a similar time frame. National VA CRC incidence, location, and stage distribution are also similar. This suggests that despite VA patients being more complex than their general population counterparts, VA patients are generally diagnosed with comparable CRC locations and stages. This analysis also suggests that, like SEER, the VACCR may have utility for epidemiologic tracking and research.