ASCRS Annual Meeting

PHOENIX – A new model based on clinical, hospital, and operative factors predicted the risk of ureteral injury among patients undergoing colorectal surgery.

Using data from the Nationwide Inpatient Sample, which includes more than 2 million patients in the United States, researchers retrospectively studied patients undergoing surgery in the United States between 2001 and 2010 for colorectal cancer, polyps, diverticular disease, or inflammatory bowel disease.

Less than 1% of patients sustained a ureteral injury, but the incidence rose significantly during the study period and injured patients had sharply higher rates of complications, researchers reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Eight factors were independently associated with the risk of ureteral injury. A predictive model incorporating these factors had an area under the receiver operating characteristic curve of 0.73. The model-predicted probability of injury ranged from 0.1% to 1.65%, depending on hospital factors, disease type, and procedure type, said Dr. Wissam J. Halabi, a research fellow at the University of California-Irvine, Orange.

Patients had higher adjusted odds of ureteral injury if they had rectal cancer (odds ratio, 1.85), adhesions (OR, 1.83), and metastatic cancer (OR, 1.76); if they had lost weight (OR, 1.08); and if they underwent surgery at a teaching hospital (OR, 1.05). On the other hand, patients had lower odds of injury if they had a laparoscopic procedure (OR, 0.91), a transverse colectomy (OR, 0.90), or a right hemicolectomy (OR, 0.43).

With the new predictive model incorporating these factors, the probability of injury ranged from 0.1% for patients undergoing laparoscopic right hemicolectomy to 1.65% for patients having all five adverse risk factors.

"Diverticulitis did not appear as a predictor in our model," Dr. Halabi said. "As for radiation, one of our predictors was metastatic cancer. So this goes for any cancer at advanced stage that has spread to lymph nodes or distant organ metastasis. In the case of rectal cancer, those are most likely to have received radiation therapy. So part of this effect of radiation therapy was apparent in the metastatic cancer group predictor."

Analyses were based on 2,165,848 colorectal surgery procedures. The overall rate of ureteral injury was 0.28%, he reported.

There was a significant 24% increase in the rate during the study period, from 2.5 per 1,000 cases in 2001-2005 to 3.1 per 1,000 cases in 2006-2010.

On average, the patients sustaining injury were younger and were more likely to be female and to have metastatic cancer, to be immunosuppressed, and to have had weight loss. They were less likely to have certain major comorbidities, such as diabetes and hypertension.

"Interestingly, obesity was similar in the two groups," Dr. Halabi commented.

Patients who sustained ureteral injuries had longer hospital stays and higher rates of a variety of postoperative complications, such as anastomotic leak and acute renal failure, but in-hospital mortality was statistically indistinguishable.

In adjusted analysis, patients with ureteral injury were significantly more likely to die (OR, 1.45) and to experience complications (OR, 1.66), and they had a longer hospital stay (+3.65 days) and total hospital charges (+$31,497).

Ureteral injuries "affect a relatively younger and healthier population. However, they have a significant and dramatic impact on outcomes," he added. "This predictive model can be used for risk stratification and counseling."

Dr. Halabi disclosed no relevant conflicts of interest.

PHOENIX – A new model based on clinical, hospital, and operative factors predicted the risk of ureteral injury among patients undergoing colorectal surgery.

Using data from the Nationwide Inpatient Sample, which includes more than 2 million patients in the United States, researchers retrospectively studied patients undergoing surgery in the United States between 2001 and 2010 for colorectal cancer, polyps, diverticular disease, or inflammatory bowel disease.

Less than 1% of patients sustained a ureteral injury, but the incidence rose significantly during the study period and injured patients had sharply higher rates of complications, researchers reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Eight factors were independently associated with the risk of ureteral injury. A predictive model incorporating these factors had an area under the receiver operating characteristic curve of 0.73. The model-predicted probability of injury ranged from 0.1% to 1.65%, depending on hospital factors, disease type, and procedure type, said Dr. Wissam J. Halabi, a research fellow at the University of California-Irvine, Orange.

Patients had higher adjusted odds of ureteral injury if they had rectal cancer (odds ratio, 1.85), adhesions (OR, 1.83), and metastatic cancer (OR, 1.76); if they had lost weight (OR, 1.08); and if they underwent surgery at a teaching hospital (OR, 1.05). On the other hand, patients had lower odds of injury if they had a laparoscopic procedure (OR, 0.91), a transverse colectomy (OR, 0.90), or a right hemicolectomy (OR, 0.43).

With the new predictive model incorporating these factors, the probability of injury ranged from 0.1% for patients undergoing laparoscopic right hemicolectomy to 1.65% for patients having all five adverse risk factors.

"Diverticulitis did not appear as a predictor in our model," Dr. Halabi said. "As for radiation, one of our predictors was metastatic cancer. So this goes for any cancer at advanced stage that has spread to lymph nodes or distant organ metastasis. In the case of rectal cancer, those are most likely to have received radiation therapy. So part of this effect of radiation therapy was apparent in the metastatic cancer group predictor."

Analyses were based on 2,165,848 colorectal surgery procedures. The overall rate of ureteral injury was 0.28%, he reported.

There was a significant 24% increase in the rate during the study period, from 2.5 per 1,000 cases in 2001-2005 to 3.1 per 1,000 cases in 2006-2010.

On average, the patients sustaining injury were younger and were more likely to be female and to have metastatic cancer, to be immunosuppressed, and to have had weight loss. They were less likely to have certain major comorbidities, such as diabetes and hypertension.

"Interestingly, obesity was similar in the two groups," Dr. Halabi commented.

Patients who sustained ureteral injuries had longer hospital stays and higher rates of a variety of postoperative complications, such as anastomotic leak and acute renal failure, but in-hospital mortality was statistically indistinguishable.

In adjusted analysis, patients with ureteral injury were significantly more likely to die (OR, 1.45) and to experience complications (OR, 1.66), and they had a longer hospital stay (+3.65 days) and total hospital charges (+$31,497).

Ureteral injuries "affect a relatively younger and healthier population. However, they have a significant and dramatic impact on outcomes," he added. "This predictive model can be used for risk stratification and counseling."

Dr. Halabi disclosed no relevant conflicts of interest.

PHOENIX – A new model based on clinical, hospital, and operative factors predicted the risk of ureteral injury among patients undergoing colorectal surgery.

Using data from the Nationwide Inpatient Sample, which includes more than 2 million patients in the United States, researchers retrospectively studied patients undergoing surgery in the United States between 2001 and 2010 for colorectal cancer, polyps, diverticular disease, or inflammatory bowel disease.

Less than 1% of patients sustained a ureteral injury, but the incidence rose significantly during the study period and injured patients had sharply higher rates of complications, researchers reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Eight factors were independently associated with the risk of ureteral injury. A predictive model incorporating these factors had an area under the receiver operating characteristic curve of 0.73. The model-predicted probability of injury ranged from 0.1% to 1.65%, depending on hospital factors, disease type, and procedure type, said Dr. Wissam J. Halabi, a research fellow at the University of California-Irvine, Orange.

Patients had higher adjusted odds of ureteral injury if they had rectal cancer (odds ratio, 1.85), adhesions (OR, 1.83), and metastatic cancer (OR, 1.76); if they had lost weight (OR, 1.08); and if they underwent surgery at a teaching hospital (OR, 1.05). On the other hand, patients had lower odds of injury if they had a laparoscopic procedure (OR, 0.91), a transverse colectomy (OR, 0.90), or a right hemicolectomy (OR, 0.43).

With the new predictive model incorporating these factors, the probability of injury ranged from 0.1% for patients undergoing laparoscopic right hemicolectomy to 1.65% for patients having all five adverse risk factors.

"Diverticulitis did not appear as a predictor in our model," Dr. Halabi said. "As for radiation, one of our predictors was metastatic cancer. So this goes for any cancer at advanced stage that has spread to lymph nodes or distant organ metastasis. In the case of rectal cancer, those are most likely to have received radiation therapy. So part of this effect of radiation therapy was apparent in the metastatic cancer group predictor."

Analyses were based on 2,165,848 colorectal surgery procedures. The overall rate of ureteral injury was 0.28%, he reported.

There was a significant 24% increase in the rate during the study period, from 2.5 per 1,000 cases in 2001-2005 to 3.1 per 1,000 cases in 2006-2010.

On average, the patients sustaining injury were younger and were more likely to be female and to have metastatic cancer, to be immunosuppressed, and to have had weight loss. They were less likely to have certain major comorbidities, such as diabetes and hypertension.

"Interestingly, obesity was similar in the two groups," Dr. Halabi commented.

Patients who sustained ureteral injuries had longer hospital stays and higher rates of a variety of postoperative complications, such as anastomotic leak and acute renal failure, but in-hospital mortality was statistically indistinguishable.

In adjusted analysis, patients with ureteral injury were significantly more likely to die (OR, 1.45) and to experience complications (OR, 1.66), and they had a longer hospital stay (+3.65 days) and total hospital charges (+$31,497).

Ureteral injuries "affect a relatively younger and healthier population. However, they have a significant and dramatic impact on outcomes," he added. "This predictive model can be used for risk stratification and counseling."

Dr. Halabi disclosed no relevant conflicts of interest.

PHOENIX – Applying continuous negative pressure to the incisional wound sharply reduces the incidence of surgical site infection after open colorectal surgery, according to results from a retrospective study.

A team led by Dr. Allison M. Bonds, a general surgery resident at the University of Texas Southwestern Medical Center at Dallas, studied 254 patients who underwent open colorectal surgery, whether planned or converted from a laparoscopic procedure.

In 13% of the patients, surgeons used incisional negative-pressure wound therapy, which entails standard wound closure followed by placement of a wound vacuum device over the completed stapled skin closure.

Study results, reported at the annual meeting of the American Society of Colon and Rectal Surgeons, showed that relative to the group receiving usual wound care, patients receiving incisional negative-pressure wound therapy were two-thirds less likely to develop a surgical site infection.

"Our study, although a retrospective chart review, does seem to show that the use of incisional negative-pressure wound therapy is associated with a decreased risk of surgical site infection," Dr. Bonds asserted. "This finding is significant enough that we feel it further needs a randomized controlled trial to see if there is actually a significant effect in the colorectal population."

Several attendees wondered about the cost of the negative-pressure wound therapy and how that was covered in the study population.

"We didn’t do an official cost analysis," Dr. Bonds replied. "Normally, the device that we used is associated with about $200 extra initially and then ... another $500 a day to use. So it is a fairly expensive addition to the care of the patients." She said she did not have data on how this cost was covered.

Dr. Jason Hall of the Lahey Clinic in Burlington, Mass., asked, "What was the indication to use the vac in those 32 patients?" and further wondered whether the patients receiving this therapy differed in ways that may have confounded the results.

"Placement of the vacuum wound device was left to the discretion of the surgeons," Dr. Bonds replied. "It’s hard to know exactly which patients would have been chosen for the study. There is some chance that the surgeons would have chosen the patients that they didn’t think would have a high rate of infection risk. But from our talking with the surgeons who use this, we believe that most of the vacuum devices were placed on patients who they had a high suspicion were going to get surgical site infections."

She agreed that there might have been selection bias at play, despite the study’s use of multivariate analysis. "That’s exactly why we believe that a randomized controlled trial is really the only way to show whether this is going to be a good technique to use or not," she said.

Cost of the therapy and its coverage will be major issues going forward, according to session comoderator Dr. Mark Welton of Stanford (Calif.) University. "Any time you are talking about downstream benefit to the insurer, they really need to see robust data before they are going to start to pay for that. So, especially in today’s health care environment, it’s going to come back to the patient paying for it. If you could talk about driving the cost associated with the wound infection down significantly, then the insurance companies would pay for it."

"Interestingly, there are companies coming out producing less expensive and less cumbersome devices. So I think it’s actually a very exciting idea, it’s intriguing. But we have a long way to go, and we do get to this cost-benefit question, and who’s going to pay for it," he said in an interview.

Dr. Kim Rhoads, the other session comoderator, also of Stanford University, said that "it’s an interesting concept," but she would like to see a standardized protocol detailing, for example, whether the vacuum and dressing are changed at some point and how long it has to be used for benefit; additionally, the indication for use should be worked out.

Also, "what we didn’t hear is how much fluid actually comes out ... because if nothing is coming out, you have to ask, what’s happening here and would that patient not have otherwise been wound infection free," she said. "We don’t know."

Incisional negative-pressure wound therapy has been used in orthopedic surgery for several years, according to Dr. Bonds. "At UT Southwestern, we began using this in 2010 [in colorectal surgery], and anecdotally saw that it seemed to be decreasing the rate of infections in our patients, so we thought that this warranted further study," she explained.

With this therapy, surgeons close the incision with standard staples, apply a strip of bridge dressing (GranuFoam, made by KCI), and cover the area with clear occlusion tape. The vacuum device (V.A.C. Therapy, made by KCI) is then applied at 75 mm Hg of continuous suction; in patients having a stoma, the stoma is returned after the device is in place.

In the study, the vacuum device was left on until postoperative day 5 or 7, and was removed before patients were discharged, according to Dr. Bonds.

Overall, 27.2% of the patients developed a surgical site infection. The rate was 12.5% in the group given incisional negative-pressure wound therapy, compared with 29.3% in the group given standard care.

In a multivariate analysis, patients in the negative-pressure wound therapy group were 68% less likely to develop a surgical site infection (odds ratio, 0.32; P = .04).

The only other independent predictor of this outcome was diabetes mellitus, which was associated with roughly a doubling of risk (OR, 1.98; P = .03).

"There are several proposed mechanisms for why this therapy would work," Dr. Bonds noted. The device prevents the incision from coming into contact with the surrounding environment, and decreases patient mobility and shear forces on the wound.

"In addition, the continuous suction seems to remove infectious material and the interstitial fluid, thereby decreasing the wound edema. Studies have also shown that the wound vacuum device increases vascularity to the wound, which would seem to help it heal as well," she said.

Dr. Bonds disclosed no relevant conflicts of interest. One coinvestigator has an affiliation with KCI.

PHOENIX – Applying continuous negative pressure to the incisional wound sharply reduces the incidence of surgical site infection after open colorectal surgery, according to results from a retrospective study.

A team led by Dr. Allison M. Bonds, a general surgery resident at the University of Texas Southwestern Medical Center at Dallas, studied 254 patients who underwent open colorectal surgery, whether planned or converted from a laparoscopic procedure.

In 13% of the patients, surgeons used incisional negative-pressure wound therapy, which entails standard wound closure followed by placement of a wound vacuum device over the completed stapled skin closure.

Study results, reported at the annual meeting of the American Society of Colon and Rectal Surgeons, showed that relative to the group receiving usual wound care, patients receiving incisional negative-pressure wound therapy were two-thirds less likely to develop a surgical site infection.

"Our study, although a retrospective chart review, does seem to show that the use of incisional negative-pressure wound therapy is associated with a decreased risk of surgical site infection," Dr. Bonds asserted. "This finding is significant enough that we feel it further needs a randomized controlled trial to see if there is actually a significant effect in the colorectal population."

Several attendees wondered about the cost of the negative-pressure wound therapy and how that was covered in the study population.

"We didn’t do an official cost analysis," Dr. Bonds replied. "Normally, the device that we used is associated with about $200 extra initially and then ... another $500 a day to use. So it is a fairly expensive addition to the care of the patients." She said she did not have data on how this cost was covered.

Dr. Jason Hall of the Lahey Clinic in Burlington, Mass., asked, "What was the indication to use the vac in those 32 patients?" and further wondered whether the patients receiving this therapy differed in ways that may have confounded the results.

"Placement of the vacuum wound device was left to the discretion of the surgeons," Dr. Bonds replied. "It’s hard to know exactly which patients would have been chosen for the study. There is some chance that the surgeons would have chosen the patients that they didn’t think would have a high rate of infection risk. But from our talking with the surgeons who use this, we believe that most of the vacuum devices were placed on patients who they had a high suspicion were going to get surgical site infections."

She agreed that there might have been selection bias at play, despite the study’s use of multivariate analysis. "That’s exactly why we believe that a randomized controlled trial is really the only way to show whether this is going to be a good technique to use or not," she said.

Cost of the therapy and its coverage will be major issues going forward, according to session comoderator Dr. Mark Welton of Stanford (Calif.) University. "Any time you are talking about downstream benefit to the insurer, they really need to see robust data before they are going to start to pay for that. So, especially in today’s health care environment, it’s going to come back to the patient paying for it. If you could talk about driving the cost associated with the wound infection down significantly, then the insurance companies would pay for it."

"Interestingly, there are companies coming out producing less expensive and less cumbersome devices. So I think it’s actually a very exciting idea, it’s intriguing. But we have a long way to go, and we do get to this cost-benefit question, and who’s going to pay for it," he said in an interview.

Dr. Kim Rhoads, the other session comoderator, also of Stanford University, said that "it’s an interesting concept," but she would like to see a standardized protocol detailing, for example, whether the vacuum and dressing are changed at some point and how long it has to be used for benefit; additionally, the indication for use should be worked out.

Also, "what we didn’t hear is how much fluid actually comes out ... because if nothing is coming out, you have to ask, what’s happening here and would that patient not have otherwise been wound infection free," she said. "We don’t know."

Incisional negative-pressure wound therapy has been used in orthopedic surgery for several years, according to Dr. Bonds. "At UT Southwestern, we began using this in 2010 [in colorectal surgery], and anecdotally saw that it seemed to be decreasing the rate of infections in our patients, so we thought that this warranted further study," she explained.

With this therapy, surgeons close the incision with standard staples, apply a strip of bridge dressing (GranuFoam, made by KCI), and cover the area with clear occlusion tape. The vacuum device (V.A.C. Therapy, made by KCI) is then applied at 75 mm Hg of continuous suction; in patients having a stoma, the stoma is returned after the device is in place.

In the study, the vacuum device was left on until postoperative day 5 or 7, and was removed before patients were discharged, according to Dr. Bonds.

Overall, 27.2% of the patients developed a surgical site infection. The rate was 12.5% in the group given incisional negative-pressure wound therapy, compared with 29.3% in the group given standard care.

In a multivariate analysis, patients in the negative-pressure wound therapy group were 68% less likely to develop a surgical site infection (odds ratio, 0.32; P = .04).

The only other independent predictor of this outcome was diabetes mellitus, which was associated with roughly a doubling of risk (OR, 1.98; P = .03).

"There are several proposed mechanisms for why this therapy would work," Dr. Bonds noted. The device prevents the incision from coming into contact with the surrounding environment, and decreases patient mobility and shear forces on the wound.

"In addition, the continuous suction seems to remove infectious material and the interstitial fluid, thereby decreasing the wound edema. Studies have also shown that the wound vacuum device increases vascularity to the wound, which would seem to help it heal as well," she said.

Dr. Bonds disclosed no relevant conflicts of interest. One coinvestigator has an affiliation with KCI.

PHOENIX – Applying continuous negative pressure to the incisional wound sharply reduces the incidence of surgical site infection after open colorectal surgery, according to results from a retrospective study.

A team led by Dr. Allison M. Bonds, a general surgery resident at the University of Texas Southwestern Medical Center at Dallas, studied 254 patients who underwent open colorectal surgery, whether planned or converted from a laparoscopic procedure.

In 13% of the patients, surgeons used incisional negative-pressure wound therapy, which entails standard wound closure followed by placement of a wound vacuum device over the completed stapled skin closure.

Study results, reported at the annual meeting of the American Society of Colon and Rectal Surgeons, showed that relative to the group receiving usual wound care, patients receiving incisional negative-pressure wound therapy were two-thirds less likely to develop a surgical site infection.

"Our study, although a retrospective chart review, does seem to show that the use of incisional negative-pressure wound therapy is associated with a decreased risk of surgical site infection," Dr. Bonds asserted. "This finding is significant enough that we feel it further needs a randomized controlled trial to see if there is actually a significant effect in the colorectal population."

Several attendees wondered about the cost of the negative-pressure wound therapy and how that was covered in the study population.

"We didn’t do an official cost analysis," Dr. Bonds replied. "Normally, the device that we used is associated with about $200 extra initially and then ... another $500 a day to use. So it is a fairly expensive addition to the care of the patients." She said she did not have data on how this cost was covered.

Dr. Jason Hall of the Lahey Clinic in Burlington, Mass., asked, "What was the indication to use the vac in those 32 patients?" and further wondered whether the patients receiving this therapy differed in ways that may have confounded the results.

"Placement of the vacuum wound device was left to the discretion of the surgeons," Dr. Bonds replied. "It’s hard to know exactly which patients would have been chosen for the study. There is some chance that the surgeons would have chosen the patients that they didn’t think would have a high rate of infection risk. But from our talking with the surgeons who use this, we believe that most of the vacuum devices were placed on patients who they had a high suspicion were going to get surgical site infections."

She agreed that there might have been selection bias at play, despite the study’s use of multivariate analysis. "That’s exactly why we believe that a randomized controlled trial is really the only way to show whether this is going to be a good technique to use or not," she said.

Cost of the therapy and its coverage will be major issues going forward, according to session comoderator Dr. Mark Welton of Stanford (Calif.) University. "Any time you are talking about downstream benefit to the insurer, they really need to see robust data before they are going to start to pay for that. So, especially in today’s health care environment, it’s going to come back to the patient paying for it. If you could talk about driving the cost associated with the wound infection down significantly, then the insurance companies would pay for it."

"Interestingly, there are companies coming out producing less expensive and less cumbersome devices. So I think it’s actually a very exciting idea, it’s intriguing. But we have a long way to go, and we do get to this cost-benefit question, and who’s going to pay for it," he said in an interview.

Dr. Kim Rhoads, the other session comoderator, also of Stanford University, said that "it’s an interesting concept," but she would like to see a standardized protocol detailing, for example, whether the vacuum and dressing are changed at some point and how long it has to be used for benefit; additionally, the indication for use should be worked out.

Also, "what we didn’t hear is how much fluid actually comes out ... because if nothing is coming out, you have to ask, what’s happening here and would that patient not have otherwise been wound infection free," she said. "We don’t know."

Incisional negative-pressure wound therapy has been used in orthopedic surgery for several years, according to Dr. Bonds. "At UT Southwestern, we began using this in 2010 [in colorectal surgery], and anecdotally saw that it seemed to be decreasing the rate of infections in our patients, so we thought that this warranted further study," she explained.

With this therapy, surgeons close the incision with standard staples, apply a strip of bridge dressing (GranuFoam, made by KCI), and cover the area with clear occlusion tape. The vacuum device (V.A.C. Therapy, made by KCI) is then applied at 75 mm Hg of continuous suction; in patients having a stoma, the stoma is returned after the device is in place.

In the study, the vacuum device was left on until postoperative day 5 or 7, and was removed before patients were discharged, according to Dr. Bonds.

Overall, 27.2% of the patients developed a surgical site infection. The rate was 12.5% in the group given incisional negative-pressure wound therapy, compared with 29.3% in the group given standard care.

In a multivariate analysis, patients in the negative-pressure wound therapy group were 68% less likely to develop a surgical site infection (odds ratio, 0.32; P = .04).

The only other independent predictor of this outcome was diabetes mellitus, which was associated with roughly a doubling of risk (OR, 1.98; P = .03).

"There are several proposed mechanisms for why this therapy would work," Dr. Bonds noted. The device prevents the incision from coming into contact with the surrounding environment, and decreases patient mobility and shear forces on the wound.

"In addition, the continuous suction seems to remove infectious material and the interstitial fluid, thereby decreasing the wound edema. Studies have also shown that the wound vacuum device increases vascularity to the wound, which would seem to help it heal as well," she said.

Dr. Bonds disclosed no relevant conflicts of interest. One coinvestigator has an affiliation with KCI.

PHOENIX – Two differing surgical approaches for early rectal cancer – radical resection and local resection—appear to be essentially equivalent treatment options, finds a systematic review and meta-analysis.

The conclusion is based on an analysis of morbidity and mortality data from 13 studies with a total of 2,855 patients with stage T1N0M0 rectal adenocarcinoma. All of the studies were published after 1979, when total mesorectal excision and modern local resection techniques were being used.

There are "improved results with the newer techniques of TEMS [transanal endoscopic microsurgery] and TAMIS [transanal minimally invasive surgery], as well as comparable outcomes when we adjust for the fact that there is a bit of a selection bias in the literature for lower-third lesions to be performed by local resection," lead investigator Dr. Sami A. Chadi reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

"We know that quality of life data is better with local resection," he commented. Relative to radical resection, local resection was associated with an 87% lower risk of postoperative complications, a 69% lower risk of perioperative mortality, and an 83% lower risk of permanent ostomy.

On the other hand, local resection also was associated with a 46% higher likelihood of death at 5 years. Survival no longer differed significantly, however, when analyses took into account the greater use of local resection for cancers located in the lower third of the rectum.

"The implication is that we have established clinical equipoise between groups with T1N0M0 adenocarcinoma of the rectum, thus prompting the need for a prospective randomized, controlled trial on these two procedures," he maintained. "We do need further data to assess whether or not there is a role for neoadjuvant or adjuvant therapy in these groups." Ongoing studies are assessing the role of therapy, as well as the potential for local resection to be performed for T2 lesions.

Dr. Chadi, a surgeon with the University of Western Ontario in London, and his colleagues analyzed data from 12 observational studies and one randomized, controlled trial among patients with T1N0M0 cancer.

The 5-year rate of overall survival was poorer with local resection (relative risk, 1.46), with the difference between groups corresponding to 72 more deaths per 1,000 patients in the local resection group, according to Dr. Chadi, who disclosed no conflicts of interest related to the research.

However, this difference was largely driven by transanal excision (TAE) local procedures. There was no significant difference in this outcome for TEMS local procedures as compared with radical resection.

The researchers also repeated the survival analysis with an adjustment for cancers in the lower third of the rectum. In these patients, the surgical choice is more often local resection, potentially leading to selection bias.

When the ratio of lower-third cancers was equal in both the radical and local resection groups, there was no longer a significant difference in 5-year overall survival.

Compared with radical resection, local resection yielded a lower risk of postoperative complications (rate ratio, 0.13), with the difference corresponding to 129 fewer complications per 1,000 patients in the local resection group. The difference was significant for both TAE and TEMS individually as compared with radical resection.

Local resection also was associated with a lower risk of perioperative mortality (rate ratio, 0.31), with the difference corresponding to 11 fewer deaths per 1,000 patients in the local resection group, and a lower risk of permanent ostomy (risk ratio, 0.17), with the difference corresponding to 225 fewer permanent ostomies per 1,000 patients in the local resection group.

PHOENIX – Two differing surgical approaches for early rectal cancer – radical resection and local resection—appear to be essentially equivalent treatment options, finds a systematic review and meta-analysis.

The conclusion is based on an analysis of morbidity and mortality data from 13 studies with a total of 2,855 patients with stage T1N0M0 rectal adenocarcinoma. All of the studies were published after 1979, when total mesorectal excision and modern local resection techniques were being used.

There are "improved results with the newer techniques of TEMS [transanal endoscopic microsurgery] and TAMIS [transanal minimally invasive surgery], as well as comparable outcomes when we adjust for the fact that there is a bit of a selection bias in the literature for lower-third lesions to be performed by local resection," lead investigator Dr. Sami A. Chadi reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

"We know that quality of life data is better with local resection," he commented. Relative to radical resection, local resection was associated with an 87% lower risk of postoperative complications, a 69% lower risk of perioperative mortality, and an 83% lower risk of permanent ostomy.

On the other hand, local resection also was associated with a 46% higher likelihood of death at 5 years. Survival no longer differed significantly, however, when analyses took into account the greater use of local resection for cancers located in the lower third of the rectum.

"The implication is that we have established clinical equipoise between groups with T1N0M0 adenocarcinoma of the rectum, thus prompting the need for a prospective randomized, controlled trial on these two procedures," he maintained. "We do need further data to assess whether or not there is a role for neoadjuvant or adjuvant therapy in these groups." Ongoing studies are assessing the role of therapy, as well as the potential for local resection to be performed for T2 lesions.

Dr. Chadi, a surgeon with the University of Western Ontario in London, and his colleagues analyzed data from 12 observational studies and one randomized, controlled trial among patients with T1N0M0 cancer.

The 5-year rate of overall survival was poorer with local resection (relative risk, 1.46), with the difference between groups corresponding to 72 more deaths per 1,000 patients in the local resection group, according to Dr. Chadi, who disclosed no conflicts of interest related to the research.

However, this difference was largely driven by transanal excision (TAE) local procedures. There was no significant difference in this outcome for TEMS local procedures as compared with radical resection.

The researchers also repeated the survival analysis with an adjustment for cancers in the lower third of the rectum. In these patients, the surgical choice is more often local resection, potentially leading to selection bias.

When the ratio of lower-third cancers was equal in both the radical and local resection groups, there was no longer a significant difference in 5-year overall survival.

Compared with radical resection, local resection yielded a lower risk of postoperative complications (rate ratio, 0.13), with the difference corresponding to 129 fewer complications per 1,000 patients in the local resection group. The difference was significant for both TAE and TEMS individually as compared with radical resection.

Local resection also was associated with a lower risk of perioperative mortality (rate ratio, 0.31), with the difference corresponding to 11 fewer deaths per 1,000 patients in the local resection group, and a lower risk of permanent ostomy (risk ratio, 0.17), with the difference corresponding to 225 fewer permanent ostomies per 1,000 patients in the local resection group.

PHOENIX – Two differing surgical approaches for early rectal cancer – radical resection and local resection—appear to be essentially equivalent treatment options, finds a systematic review and meta-analysis.

The conclusion is based on an analysis of morbidity and mortality data from 13 studies with a total of 2,855 patients with stage T1N0M0 rectal adenocarcinoma. All of the studies were published after 1979, when total mesorectal excision and modern local resection techniques were being used.

There are "improved results with the newer techniques of TEMS [transanal endoscopic microsurgery] and TAMIS [transanal minimally invasive surgery], as well as comparable outcomes when we adjust for the fact that there is a bit of a selection bias in the literature for lower-third lesions to be performed by local resection," lead investigator Dr. Sami A. Chadi reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

"We know that quality of life data is better with local resection," he commented. Relative to radical resection, local resection was associated with an 87% lower risk of postoperative complications, a 69% lower risk of perioperative mortality, and an 83% lower risk of permanent ostomy.

On the other hand, local resection also was associated with a 46% higher likelihood of death at 5 years. Survival no longer differed significantly, however, when analyses took into account the greater use of local resection for cancers located in the lower third of the rectum.

"The implication is that we have established clinical equipoise between groups with T1N0M0 adenocarcinoma of the rectum, thus prompting the need for a prospective randomized, controlled trial on these two procedures," he maintained. "We do need further data to assess whether or not there is a role for neoadjuvant or adjuvant therapy in these groups." Ongoing studies are assessing the role of therapy, as well as the potential for local resection to be performed for T2 lesions.

Dr. Chadi, a surgeon with the University of Western Ontario in London, and his colleagues analyzed data from 12 observational studies and one randomized, controlled trial among patients with T1N0M0 cancer.

The 5-year rate of overall survival was poorer with local resection (relative risk, 1.46), with the difference between groups corresponding to 72 more deaths per 1,000 patients in the local resection group, according to Dr. Chadi, who disclosed no conflicts of interest related to the research.

However, this difference was largely driven by transanal excision (TAE) local procedures. There was no significant difference in this outcome for TEMS local procedures as compared with radical resection.

The researchers also repeated the survival analysis with an adjustment for cancers in the lower third of the rectum. In these patients, the surgical choice is more often local resection, potentially leading to selection bias.

When the ratio of lower-third cancers was equal in both the radical and local resection groups, there was no longer a significant difference in 5-year overall survival.

Compared with radical resection, local resection yielded a lower risk of postoperative complications (rate ratio, 0.13), with the difference corresponding to 129 fewer complications per 1,000 patients in the local resection group. The difference was significant for both TAE and TEMS individually as compared with radical resection.

Local resection also was associated with a lower risk of perioperative mortality (rate ratio, 0.31), with the difference corresponding to 11 fewer deaths per 1,000 patients in the local resection group, and a lower risk of permanent ostomy (risk ratio, 0.17), with the difference corresponding to 225 fewer permanent ostomies per 1,000 patients in the local resection group.

PHOENIX – Patients with inflammatory bowel disease undergoing major abdominal surgery have a persistent elevation of the risk of blood clots postoperatively that warrants extended prophylaxis similar to that recommended for patients with colorectal cancer, new data suggest.

Investigators led by Dr. Molly Gross, a colorectal surgeon at the University of Utah in Salt Lake City, retrospectively analyzed data from the National Surgical Quality Improvement Program (NSQIP) database, assessing rates of venous thromboembolism (VTE) among nearly 46,000 patients with inflammatory bowel disease (IBD) or colorectal cancer who had major abdominal surgery.

Study results, reported at the annual meeting of the American Society of Colon and Rectal Surgeons, showed that the IBD group had a 35% higher adjusted risk of VTE at 30 days relative to the colorectal cancer group. Also, the majority of the events in the IBD group occurred a week or more after surgery, by which time most patients would have been leaving the hospital or already home.

"The National Comprehensive Cancer Network (NCCN) currently recommends that colorectal cancer patients undergoing major abdominal surgery receive up to 4 weeks of postoperative out-of-hospital prophylaxis with either subcutaneous heparin or Lovenox [enoxaparin]," Dr. Gross commented. "There are currently no such recommendations for IBD patients undergoing similar operations."

Taken together, the study’s findings "lead to our conclusion that postdischarge VTE prophylaxis recommendations for IBD patients should mirror those for colorectal cancer patients," she maintained. "This would suggest a change in clinical practice to extend out-of-hospital VTE prophylaxis in IBD patients."

"You have done excellent work, and I congratulate you on the statistical rigor that’s quite evident in your study," said Dr. Justin Lee, of St. Elizabeth’s Medical Center in Brighton, Mass., who was invited to discuss the study.

However, he questioned the low absolute 30-day rates of VTE seen in the study – 2.7% in the IBD group and 2.1% in the colorectal cancer group – as compared with those reported in other studies.

The NCCN guidelines for patients with colorectal cancer "are based on large prospective studies considered to be closer to real-time data than NSQIP. If you look at those studies, they show anywhere from a 7% to 12% 30-day rate of deep vein thrombosis in colorectal cancer patients. And if you treat them with long-term prophylaxis within 30 days after surgery, it brings the rate down to 4% or 4.5%," he explained – about twice that in the presented study.

"How do you reconcile [these rates]?" Dr. Lee asked. "And should you apply your recommended 30-day postop prophylaxis to all IBD surgical patients when in fact the 2.7% is actually lower than the literature-quoted rate of deep vein thrombosis" in patients with colorectal cancer on anticoagulation?

Dr. Gross speculated that the difference in rates between the cancer studies and the current study was multifactorial in origin, stemming from differing study designs (randomized controlled trial vs. retrospective review), differing surgical populations (patients undergoing open surgery only in an older era vs. patients undergoing open or laparoscopic surgery in the current era), and uncertainty in their study about how many patients with colorectal cancer received extended prophylaxis.

Given the generally low rates of VTE events, "it would be difficult to adequately power a large randomized controlled trial," she added. "So we are kind of making a lot of assumptions that we hope we could decrease morbidity and mortality in IBD patients without significantly causing increased cost or bleeding complications" by using extended prophylaxis.

Dr. John Migaly of the Duke University Medical Center in Durham, N.C., who comoderated the session, noted that the incidence of VTE after surgery showed a sharp drop-off at approximately day 20. "That would be about 2 weeks after discharge. Is there an optimal length, in your opinion, of VTE prophylaxis, instead of just saying 4 weeks is fine?" he asked.

The investigators based that 4-week recommendation on the conclusions of a trial among oncology patients (N. Engl. J. Med. 2002;346:975-80), according to Dr. Gross. "It is probably variable based on patient condition: how much they are ambulating, how much they are back to their regular status, and how active their IBD is. So I think it would be difficult to come up with an ideal for every patient; that [4 weeks] is an arbitrary number created from that study."

For the study, Dr. Gross’ team analyzed data from the NSQIP database for the years 2005 through 2010, restricting analyses to 8,888 patients with IBD and 37,076 patients with colorectal cancer who had major abdominal surgery.

"Previous studies looking at IBD and VTE risk included perineal and benign anorectal procedures, as well as open procedures," Dr. Gross noted. "But we only included open and laparoscopic abdominal procedures that involved resection of bowel."

The 30-day rate of VTE (deep vein thrombosis and/or pulmonary embolism) was significantly higher in the IBD group than in the colorectal cancer group (2.7% vs. 2.1%, P less than .001).

In a multivariate analysis, relative to their peers with colorectal cancer, patients with IBD still had a significantly elevated risk of this outcome (odds ratio, 1.35; P = .005).

"The [temporal] distribution of VTE events in IBD patients mirrors that in colorectal cancer patients," commented Dr. Gross, who disclosed no conflicts of interest related to the research; in both groups, events continued to occur out to 30 days.

In the IBD group, fully 55% of events occurred on day 7 or later. "At this time, most patients will have been discharged or will be discharged soon," she pointed out.

PHOENIX – Patients with inflammatory bowel disease undergoing major abdominal surgery have a persistent elevation of the risk of blood clots postoperatively that warrants extended prophylaxis similar to that recommended for patients with colorectal cancer, new data suggest.

Investigators led by Dr. Molly Gross, a colorectal surgeon at the University of Utah in Salt Lake City, retrospectively analyzed data from the National Surgical Quality Improvement Program (NSQIP) database, assessing rates of venous thromboembolism (VTE) among nearly 46,000 patients with inflammatory bowel disease (IBD) or colorectal cancer who had major abdominal surgery.

Study results, reported at the annual meeting of the American Society of Colon and Rectal Surgeons, showed that the IBD group had a 35% higher adjusted risk of VTE at 30 days relative to the colorectal cancer group. Also, the majority of the events in the IBD group occurred a week or more after surgery, by which time most patients would have been leaving the hospital or already home.

"The National Comprehensive Cancer Network (NCCN) currently recommends that colorectal cancer patients undergoing major abdominal surgery receive up to 4 weeks of postoperative out-of-hospital prophylaxis with either subcutaneous heparin or Lovenox [enoxaparin]," Dr. Gross commented. "There are currently no such recommendations for IBD patients undergoing similar operations."

Taken together, the study’s findings "lead to our conclusion that postdischarge VTE prophylaxis recommendations for IBD patients should mirror those for colorectal cancer patients," she maintained. "This would suggest a change in clinical practice to extend out-of-hospital VTE prophylaxis in IBD patients."

"You have done excellent work, and I congratulate you on the statistical rigor that’s quite evident in your study," said Dr. Justin Lee, of St. Elizabeth’s Medical Center in Brighton, Mass., who was invited to discuss the study.

However, he questioned the low absolute 30-day rates of VTE seen in the study – 2.7% in the IBD group and 2.1% in the colorectal cancer group – as compared with those reported in other studies.

The NCCN guidelines for patients with colorectal cancer "are based on large prospective studies considered to be closer to real-time data than NSQIP. If you look at those studies, they show anywhere from a 7% to 12% 30-day rate of deep vein thrombosis in colorectal cancer patients. And if you treat them with long-term prophylaxis within 30 days after surgery, it brings the rate down to 4% or 4.5%," he explained – about twice that in the presented study.

"How do you reconcile [these rates]?" Dr. Lee asked. "And should you apply your recommended 30-day postop prophylaxis to all IBD surgical patients when in fact the 2.7% is actually lower than the literature-quoted rate of deep vein thrombosis" in patients with colorectal cancer on anticoagulation?

Dr. Gross speculated that the difference in rates between the cancer studies and the current study was multifactorial in origin, stemming from differing study designs (randomized controlled trial vs. retrospective review), differing surgical populations (patients undergoing open surgery only in an older era vs. patients undergoing open or laparoscopic surgery in the current era), and uncertainty in their study about how many patients with colorectal cancer received extended prophylaxis.

Given the generally low rates of VTE events, "it would be difficult to adequately power a large randomized controlled trial," she added. "So we are kind of making a lot of assumptions that we hope we could decrease morbidity and mortality in IBD patients without significantly causing increased cost or bleeding complications" by using extended prophylaxis.

Dr. John Migaly of the Duke University Medical Center in Durham, N.C., who comoderated the session, noted that the incidence of VTE after surgery showed a sharp drop-off at approximately day 20. "That would be about 2 weeks after discharge. Is there an optimal length, in your opinion, of VTE prophylaxis, instead of just saying 4 weeks is fine?" he asked.

The investigators based that 4-week recommendation on the conclusions of a trial among oncology patients (N. Engl. J. Med. 2002;346:975-80), according to Dr. Gross. "It is probably variable based on patient condition: how much they are ambulating, how much they are back to their regular status, and how active their IBD is. So I think it would be difficult to come up with an ideal for every patient; that [4 weeks] is an arbitrary number created from that study."

For the study, Dr. Gross’ team analyzed data from the NSQIP database for the years 2005 through 2010, restricting analyses to 8,888 patients with IBD and 37,076 patients with colorectal cancer who had major abdominal surgery.

"Previous studies looking at IBD and VTE risk included perineal and benign anorectal procedures, as well as open procedures," Dr. Gross noted. "But we only included open and laparoscopic abdominal procedures that involved resection of bowel."

The 30-day rate of VTE (deep vein thrombosis and/or pulmonary embolism) was significantly higher in the IBD group than in the colorectal cancer group (2.7% vs. 2.1%, P less than .001).

In a multivariate analysis, relative to their peers with colorectal cancer, patients with IBD still had a significantly elevated risk of this outcome (odds ratio, 1.35; P = .005).

"The [temporal] distribution of VTE events in IBD patients mirrors that in colorectal cancer patients," commented Dr. Gross, who disclosed no conflicts of interest related to the research; in both groups, events continued to occur out to 30 days.

In the IBD group, fully 55% of events occurred on day 7 or later. "At this time, most patients will have been discharged or will be discharged soon," she pointed out.

PHOENIX – Patients with inflammatory bowel disease undergoing major abdominal surgery have a persistent elevation of the risk of blood clots postoperatively that warrants extended prophylaxis similar to that recommended for patients with colorectal cancer, new data suggest.

Investigators led by Dr. Molly Gross, a colorectal surgeon at the University of Utah in Salt Lake City, retrospectively analyzed data from the National Surgical Quality Improvement Program (NSQIP) database, assessing rates of venous thromboembolism (VTE) among nearly 46,000 patients with inflammatory bowel disease (IBD) or colorectal cancer who had major abdominal surgery.

Study results, reported at the annual meeting of the American Society of Colon and Rectal Surgeons, showed that the IBD group had a 35% higher adjusted risk of VTE at 30 days relative to the colorectal cancer group. Also, the majority of the events in the IBD group occurred a week or more after surgery, by which time most patients would have been leaving the hospital or already home.

"The National Comprehensive Cancer Network (NCCN) currently recommends that colorectal cancer patients undergoing major abdominal surgery receive up to 4 weeks of postoperative out-of-hospital prophylaxis with either subcutaneous heparin or Lovenox [enoxaparin]," Dr. Gross commented. "There are currently no such recommendations for IBD patients undergoing similar operations."

Taken together, the study’s findings "lead to our conclusion that postdischarge VTE prophylaxis recommendations for IBD patients should mirror those for colorectal cancer patients," she maintained. "This would suggest a change in clinical practice to extend out-of-hospital VTE prophylaxis in IBD patients."

"You have done excellent work, and I congratulate you on the statistical rigor that’s quite evident in your study," said Dr. Justin Lee, of St. Elizabeth’s Medical Center in Brighton, Mass., who was invited to discuss the study.

However, he questioned the low absolute 30-day rates of VTE seen in the study – 2.7% in the IBD group and 2.1% in the colorectal cancer group – as compared with those reported in other studies.

The NCCN guidelines for patients with colorectal cancer "are based on large prospective studies considered to be closer to real-time data than NSQIP. If you look at those studies, they show anywhere from a 7% to 12% 30-day rate of deep vein thrombosis in colorectal cancer patients. And if you treat them with long-term prophylaxis within 30 days after surgery, it brings the rate down to 4% or 4.5%," he explained – about twice that in the presented study.

"How do you reconcile [these rates]?" Dr. Lee asked. "And should you apply your recommended 30-day postop prophylaxis to all IBD surgical patients when in fact the 2.7% is actually lower than the literature-quoted rate of deep vein thrombosis" in patients with colorectal cancer on anticoagulation?

Dr. Gross speculated that the difference in rates between the cancer studies and the current study was multifactorial in origin, stemming from differing study designs (randomized controlled trial vs. retrospective review), differing surgical populations (patients undergoing open surgery only in an older era vs. patients undergoing open or laparoscopic surgery in the current era), and uncertainty in their study about how many patients with colorectal cancer received extended prophylaxis.

Given the generally low rates of VTE events, "it would be difficult to adequately power a large randomized controlled trial," she added. "So we are kind of making a lot of assumptions that we hope we could decrease morbidity and mortality in IBD patients without significantly causing increased cost or bleeding complications" by using extended prophylaxis.

Dr. John Migaly of the Duke University Medical Center in Durham, N.C., who comoderated the session, noted that the incidence of VTE after surgery showed a sharp drop-off at approximately day 20. "That would be about 2 weeks after discharge. Is there an optimal length, in your opinion, of VTE prophylaxis, instead of just saying 4 weeks is fine?" he asked.

The investigators based that 4-week recommendation on the conclusions of a trial among oncology patients (N. Engl. J. Med. 2002;346:975-80), according to Dr. Gross. "It is probably variable based on patient condition: how much they are ambulating, how much they are back to their regular status, and how active their IBD is. So I think it would be difficult to come up with an ideal for every patient; that [4 weeks] is an arbitrary number created from that study."

For the study, Dr. Gross’ team analyzed data from the NSQIP database for the years 2005 through 2010, restricting analyses to 8,888 patients with IBD and 37,076 patients with colorectal cancer who had major abdominal surgery.

"Previous studies looking at IBD and VTE risk included perineal and benign anorectal procedures, as well as open procedures," Dr. Gross noted. "But we only included open and laparoscopic abdominal procedures that involved resection of bowel."

The 30-day rate of VTE (deep vein thrombosis and/or pulmonary embolism) was significantly higher in the IBD group than in the colorectal cancer group (2.7% vs. 2.1%, P less than .001).

In a multivariate analysis, relative to their peers with colorectal cancer, patients with IBD still had a significantly elevated risk of this outcome (odds ratio, 1.35; P = .005).

"The [temporal] distribution of VTE events in IBD patients mirrors that in colorectal cancer patients," commented Dr. Gross, who disclosed no conflicts of interest related to the research; in both groups, events continued to occur out to 30 days.

In the IBD group, fully 55% of events occurred on day 7 or later. "At this time, most patients will have been discharged or will be discharged soon," she pointed out.

PHOENIX – The longer a laparoscopic colectomy for cancer takes, the less its advantages over an open colectomy in terms of morbidity and mortality, researchers reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

A team led by Dr. Matthew Bailey, a surgery resident at the University of Kentucky in Lexington, queried the National Surgical Quality Improvement Program (NSQIP) database to identify more than 4,000 patients undergoing right colectomy because of colorectal malignancy.

Results showed that compared with their peers having an open operation lasting 3 hours or less, patients having a laparoscopic operation of this duration were less likely to develop complications and to die. However, when the operations lasted more than 3 hours, there was no longer any significant difference.

Within the laparoscopic group, patients were more likely to have a procedure lasting longer than 3 hours if they had recently received radiation therapy, were morbidly obese, or had peripheral vascular disease.

"We recommend that surgeons consider an open approach if the patient has risk factors for an operative duration greater than 3 hours," Dr. Bailey said. "We also recommend surgeons consider conversion to an open approach when it is anticipated that a laparoscopic right colectomy will exceed 3 hours."

Dr. Walter Peters of Columbia (Mo.) Surgical Associates, who comoderated the session, asked, "Were the laparoscopic procedures lasting more than 3 hours concentrated in a few institutions, or were they spread across the entire NSQIP database?"

The investigators did not assess the institutional distribution, and it may not be possible to tease that information out of NSQIP, Dr. Bailey replied.

Session attendee Dr. Eric Haas, of Colorectal Surgical Associates in Houston asked what percentage of patients had a conversion from laparoscopic to open procedures and whether analyses were conducted according to intention to treat.

"NSQIP unfortunately does not allow you to discern that, there’s no CPT [Current Procedural Terminology] code for conversion," Dr. Bailey said. "We can only assume that cases that were converted laparoscopic to open were most likely ultimately coded as open. So there was no way to perform an intent-to-treat analysis."

Dr. Haas also noted that surgeon experience with laparoscopy may have played a role. "In my own experience, certainly at the beginning of the learning curve phase, I would take 3, maybe 4 hours. And the one risk factor that you can’t put [in analyses] is surgeon," he said. "So were these 3-hour cases because of the learning curve, or were they true 3-hour cases because of the patient factors?"

The NSQIP database captures the surgeon who dictates the operative report and the level of training, the highest-level resident involved, and the specialty of the surgeon (although colorectal surgery is not among the options), according to Dr. Bailey. Still, it is generally not possible to determine who did all or most of the operation.

"We did look at operative time, and it was around 138 minutes, plus-minus, for a laparoscopic right colectomy, with the reported literature being around 187 minutes. So I’m not sure if the reported literature is dated or if, in these over 200 hospitals across the nation, this is realistic of current practice trends," he said.

"The study shows that patients are probably going to have increased complications with longer surgery, whether it’s laparoscopic or open," Dr. Timothy Geiger of Vanderbilt University Medical Center, Nashville, Tenn., the session’s other comoderator, said in an interview. "It was a good study, but it needs a little bit more in-depth look, especially at things like redosing of antibiotics, whether that is done in an appropriate manner. But otherwise, it’s a great kind of intro for us to look at this."

Giving some background to the research, Dr. Bailey noted, "The use of laparoscopy in colon cancer has been shown to be equivalent to open surgery in survival and oncologic outcomes. The question of whether operative time negatively impacts laparoscopic outcomes compared to open surgery outcomes requires further investigation if we are to endorse a laparoscopic approach regardless of procedure length. We postulated that there is an operative duration where the benefits of a laparoscopic approach are negated."

The investigators analyzed data from the NSQIP database for the years 2005 through 2010, identifying patients who had a right colectomy for cancer and excluding those treated on an emergent basis, or having secondary procedures other than enterolysis or mobilization of the splenic flexure.

Analyses were based on 2,141 patients in the laparoscopic group and 2,132 patients in the open group. Procedures lasted longer than 3 hours in 18% of the former and 11% of the latter.

Compared with the open group, the laparoscopic group was younger and had lower American Society of Anesthesiologists scores, higher serum albumin levels, and lower prothrombin time and platelet count.

In unadjusted analysis among patients whose operations lasted 3 hours or less, the laparoscopic group fared better than did the open group in terms of 30-day mortality (1.1% vs 2.6%, P less than .001), cardiopulmonary and cerebrovascular complications (5.4% vs. 8.4%, P less than .001), and infectious complications (9.2% vs. 13.3%, P less than .001).

In contrast, among patients whose operations lasted more than 3 hours, differences in these outcomes were not significant. If anything, there was a trend toward a higher rate of infectious complications with laparoscopy.

To assess the role of preoperative risk factors, the investigators looked at NSQIP estimates of morbidity and mortality for all gastrointestinal and abdominal surgery by operative duration and including 37 preoperative risk factors, and found patterns differing from those in the study cohort.

Specifically, these estimates suggested mortality was consistently lower for procedures lasting more then 3 hours, whether laparoscopic or open. And the risk of infectious complications was constant for each type and less for laparoscopy, regardless of the operative duration.

Thus, "there is something other than preoperative risk factors causing an increase in mortality" with longer operative time for laparoscopic procedures in the study cohort, said Dr. Bailey, who disclosed no conflicts of interest related to the research. Also, "the increased infectious complications that we demonstrated are not related to the morbidity risk."

Patients in the laparoscopic group had a significantly higher risk of surgery lasting more than 3 hours if they had recently received radiation therapy (odds ratio, 6.5), were morbidly obese (3.0), or had peripheral vascular disease (2.5).

Hospital length of stay was consistently shorter with the laparoscopic approach, regardless of how long the operation lasted, according to Dr. Bailey.

PHOENIX – The longer a laparoscopic colectomy for cancer takes, the less its advantages over an open colectomy in terms of morbidity and mortality, researchers reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

A team led by Dr. Matthew Bailey, a surgery resident at the University of Kentucky in Lexington, queried the National Surgical Quality Improvement Program (NSQIP) database to identify more than 4,000 patients undergoing right colectomy because of colorectal malignancy.

Results showed that compared with their peers having an open operation lasting 3 hours or less, patients having a laparoscopic operation of this duration were less likely to develop complications and to die. However, when the operations lasted more than 3 hours, there was no longer any significant difference.

Within the laparoscopic group, patients were more likely to have a procedure lasting longer than 3 hours if they had recently received radiation therapy, were morbidly obese, or had peripheral vascular disease.

"We recommend that surgeons consider an open approach if the patient has risk factors for an operative duration greater than 3 hours," Dr. Bailey said. "We also recommend surgeons consider conversion to an open approach when it is anticipated that a laparoscopic right colectomy will exceed 3 hours."

Dr. Walter Peters of Columbia (Mo.) Surgical Associates, who comoderated the session, asked, "Were the laparoscopic procedures lasting more than 3 hours concentrated in a few institutions, or were they spread across the entire NSQIP database?"

The investigators did not assess the institutional distribution, and it may not be possible to tease that information out of NSQIP, Dr. Bailey replied.

Session attendee Dr. Eric Haas, of Colorectal Surgical Associates in Houston asked what percentage of patients had a conversion from laparoscopic to open procedures and whether analyses were conducted according to intention to treat.

"NSQIP unfortunately does not allow you to discern that, there’s no CPT [Current Procedural Terminology] code for conversion," Dr. Bailey said. "We can only assume that cases that were converted laparoscopic to open were most likely ultimately coded as open. So there was no way to perform an intent-to-treat analysis."

Dr. Haas also noted that surgeon experience with laparoscopy may have played a role. "In my own experience, certainly at the beginning of the learning curve phase, I would take 3, maybe 4 hours. And the one risk factor that you can’t put [in analyses] is surgeon," he said. "So were these 3-hour cases because of the learning curve, or were they true 3-hour cases because of the patient factors?"

The NSQIP database captures the surgeon who dictates the operative report and the level of training, the highest-level resident involved, and the specialty of the surgeon (although colorectal surgery is not among the options), according to Dr. Bailey. Still, it is generally not possible to determine who did all or most of the operation.

"We did look at operative time, and it was around 138 minutes, plus-minus, for a laparoscopic right colectomy, with the reported literature being around 187 minutes. So I’m not sure if the reported literature is dated or if, in these over 200 hospitals across the nation, this is realistic of current practice trends," he said.

"The study shows that patients are probably going to have increased complications with longer surgery, whether it’s laparoscopic or open," Dr. Timothy Geiger of Vanderbilt University Medical Center, Nashville, Tenn., the session’s other comoderator, said in an interview. "It was a good study, but it needs a little bit more in-depth look, especially at things like redosing of antibiotics, whether that is done in an appropriate manner. But otherwise, it’s a great kind of intro for us to look at this."

Giving some background to the research, Dr. Bailey noted, "The use of laparoscopy in colon cancer has been shown to be equivalent to open surgery in survival and oncologic outcomes. The question of whether operative time negatively impacts laparoscopic outcomes compared to open surgery outcomes requires further investigation if we are to endorse a laparoscopic approach regardless of procedure length. We postulated that there is an operative duration where the benefits of a laparoscopic approach are negated."

The investigators analyzed data from the NSQIP database for the years 2005 through 2010, identifying patients who had a right colectomy for cancer and excluding those treated on an emergent basis, or having secondary procedures other than enterolysis or mobilization of the splenic flexure.

Analyses were based on 2,141 patients in the laparoscopic group and 2,132 patients in the open group. Procedures lasted longer than 3 hours in 18% of the former and 11% of the latter.

Compared with the open group, the laparoscopic group was younger and had lower American Society of Anesthesiologists scores, higher serum albumin levels, and lower prothrombin time and platelet count.

In unadjusted analysis among patients whose operations lasted 3 hours or less, the laparoscopic group fared better than did the open group in terms of 30-day mortality (1.1% vs 2.6%, P less than .001), cardiopulmonary and cerebrovascular complications (5.4% vs. 8.4%, P less than .001), and infectious complications (9.2% vs. 13.3%, P less than .001).

In contrast, among patients whose operations lasted more than 3 hours, differences in these outcomes were not significant. If anything, there was a trend toward a higher rate of infectious complications with laparoscopy.

To assess the role of preoperative risk factors, the investigators looked at NSQIP estimates of morbidity and mortality for all gastrointestinal and abdominal surgery by operative duration and including 37 preoperative risk factors, and found patterns differing from those in the study cohort.

Specifically, these estimates suggested mortality was consistently lower for procedures lasting more then 3 hours, whether laparoscopic or open. And the risk of infectious complications was constant for each type and less for laparoscopy, regardless of the operative duration.

Thus, "there is something other than preoperative risk factors causing an increase in mortality" with longer operative time for laparoscopic procedures in the study cohort, said Dr. Bailey, who disclosed no conflicts of interest related to the research. Also, "the increased infectious complications that we demonstrated are not related to the morbidity risk."

Patients in the laparoscopic group had a significantly higher risk of surgery lasting more than 3 hours if they had recently received radiation therapy (odds ratio, 6.5), were morbidly obese (3.0), or had peripheral vascular disease (2.5).

Hospital length of stay was consistently shorter with the laparoscopic approach, regardless of how long the operation lasted, according to Dr. Bailey.

PHOENIX – The longer a laparoscopic colectomy for cancer takes, the less its advantages over an open colectomy in terms of morbidity and mortality, researchers reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

A team led by Dr. Matthew Bailey, a surgery resident at the University of Kentucky in Lexington, queried the National Surgical Quality Improvement Program (NSQIP) database to identify more than 4,000 patients undergoing right colectomy because of colorectal malignancy.

Results showed that compared with their peers having an open operation lasting 3 hours or less, patients having a laparoscopic operation of this duration were less likely to develop complications and to die. However, when the operations lasted more than 3 hours, there was no longer any significant difference.

Within the laparoscopic group, patients were more likely to have a procedure lasting longer than 3 hours if they had recently received radiation therapy, were morbidly obese, or had peripheral vascular disease.

"We recommend that surgeons consider an open approach if the patient has risk factors for an operative duration greater than 3 hours," Dr. Bailey said. "We also recommend surgeons consider conversion to an open approach when it is anticipated that a laparoscopic right colectomy will exceed 3 hours."

Dr. Walter Peters of Columbia (Mo.) Surgical Associates, who comoderated the session, asked, "Were the laparoscopic procedures lasting more than 3 hours concentrated in a few institutions, or were they spread across the entire NSQIP database?"

The investigators did not assess the institutional distribution, and it may not be possible to tease that information out of NSQIP, Dr. Bailey replied.

Session attendee Dr. Eric Haas, of Colorectal Surgical Associates in Houston asked what percentage of patients had a conversion from laparoscopic to open procedures and whether analyses were conducted according to intention to treat.

"NSQIP unfortunately does not allow you to discern that, there’s no CPT [Current Procedural Terminology] code for conversion," Dr. Bailey said. "We can only assume that cases that were converted laparoscopic to open were most likely ultimately coded as open. So there was no way to perform an intent-to-treat analysis."

Dr. Haas also noted that surgeon experience with laparoscopy may have played a role. "In my own experience, certainly at the beginning of the learning curve phase, I would take 3, maybe 4 hours. And the one risk factor that you can’t put [in analyses] is surgeon," he said. "So were these 3-hour cases because of the learning curve, or were they true 3-hour cases because of the patient factors?"

The NSQIP database captures the surgeon who dictates the operative report and the level of training, the highest-level resident involved, and the specialty of the surgeon (although colorectal surgery is not among the options), according to Dr. Bailey. Still, it is generally not possible to determine who did all or most of the operation.

"We did look at operative time, and it was around 138 minutes, plus-minus, for a laparoscopic right colectomy, with the reported literature being around 187 minutes. So I’m not sure if the reported literature is dated or if, in these over 200 hospitals across the nation, this is realistic of current practice trends," he said.

"The study shows that patients are probably going to have increased complications with longer surgery, whether it’s laparoscopic or open," Dr. Timothy Geiger of Vanderbilt University Medical Center, Nashville, Tenn., the session’s other comoderator, said in an interview. "It was a good study, but it needs a little bit more in-depth look, especially at things like redosing of antibiotics, whether that is done in an appropriate manner. But otherwise, it’s a great kind of intro for us to look at this."

Giving some background to the research, Dr. Bailey noted, "The use of laparoscopy in colon cancer has been shown to be equivalent to open surgery in survival and oncologic outcomes. The question of whether operative time negatively impacts laparoscopic outcomes compared to open surgery outcomes requires further investigation if we are to endorse a laparoscopic approach regardless of procedure length. We postulated that there is an operative duration where the benefits of a laparoscopic approach are negated."

The investigators analyzed data from the NSQIP database for the years 2005 through 2010, identifying patients who had a right colectomy for cancer and excluding those treated on an emergent basis, or having secondary procedures other than enterolysis or mobilization of the splenic flexure.

Analyses were based on 2,141 patients in the laparoscopic group and 2,132 patients in the open group. Procedures lasted longer than 3 hours in 18% of the former and 11% of the latter.

Compared with the open group, the laparoscopic group was younger and had lower American Society of Anesthesiologists scores, higher serum albumin levels, and lower prothrombin time and platelet count.

In unadjusted analysis among patients whose operations lasted 3 hours or less, the laparoscopic group fared better than did the open group in terms of 30-day mortality (1.1% vs 2.6%, P less than .001), cardiopulmonary and cerebrovascular complications (5.4% vs. 8.4%, P less than .001), and infectious complications (9.2% vs. 13.3%, P less than .001).

In contrast, among patients whose operations lasted more than 3 hours, differences in these outcomes were not significant. If anything, there was a trend toward a higher rate of infectious complications with laparoscopy.

To assess the role of preoperative risk factors, the investigators looked at NSQIP estimates of morbidity and mortality for all gastrointestinal and abdominal surgery by operative duration and including 37 preoperative risk factors, and found patterns differing from those in the study cohort.

Specifically, these estimates suggested mortality was consistently lower for procedures lasting more then 3 hours, whether laparoscopic or open. And the risk of infectious complications was constant for each type and less for laparoscopy, regardless of the operative duration.

Thus, "there is something other than preoperative risk factors causing an increase in mortality" with longer operative time for laparoscopic procedures in the study cohort, said Dr. Bailey, who disclosed no conflicts of interest related to the research. Also, "the increased infectious complications that we demonstrated are not related to the morbidity risk."

Patients in the laparoscopic group had a significantly higher risk of surgery lasting more than 3 hours if they had recently received radiation therapy (odds ratio, 6.5), were morbidly obese (3.0), or had peripheral vascular disease (2.5).

Hospital length of stay was consistently shorter with the laparoscopic approach, regardless of how long the operation lasted, according to Dr. Bailey.

PHOENIX – Improving cancer-specific survival after resection for colorectal cancer may be as simple as ordering preoperative mechanical bowel preparation, according to an analysis of data from a randomized trial conducted in Sweden and Germany.

Roughly half of the 841 patients studied had such preparation before their operation. The actuarial 5-year rate of cancer-specific survival was about 8% higher in this group, first author Dr. Åsa Collin of Uppsala University reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

An analysis of cancer stage at the time of surgery suggested that the two groups were well matched on this measure. Preparation did not significantly decrease the rate of recurrence or increase the rate of overall survival.

Session attendee Dr. J. Daniel Stanley of University Surgical Associates in Chattanooga, Tenn., questioned whether the patients might have differed on other factors that influenced whether they underwent mechanical bowel preparation.

"Were some of them obstructed, which might indicate a different tumor biology than was reflected in the staging?" he asked.

"These were all elective surgeries, and there was no patient who we actually decided that they shouldn’t have preparation," Dr. Collin replied.

In an interview, session comoderator Dr. David Maron, a colorectal surgeon at the Cleveland Clinic in Weston, Fla., said, "What was interesting was that they didn’t show a significant difference in cancer recurrence, although it was close to significance. So the question remains, is it in fact the mechanical bowel prep, or could there be differences in the postoperative follow-up and even the postoperative treatment of those patients who developed recurrence?"

Guidelines leave preparation up to the treating surgeon, and several studies have found no benefit at least in the short term, he noted. "This is one of the first studies that have shown that perhaps from a long-term standpoint in patients with cancer, that there may be some benefit to preoperative preparation of the bowel, although again, it’s preliminary and there’s a lot of unknowns out there."

Dr. Collin and her colleagues analyzed data from a trial among patients who underwent an elective resection for cancer, adenoma, or diverticular disease of the colon at 21 hospitals in Sweden and Germany between 1999 and 2005.

Earlier results for the entire trial population, previously reported, showed no significant reduction in 30-day rates of complications with mechanical bowel preparation (Br. J. Surg. 2007;94:689-95).

The new, long-term results for just the 841 patients with colorectal cancer – 53% of whom had a mechanical bowel preparation before their surgery – indicated those undergoing this preparation had a higher actuarial 5-year rate of cancer-specific survival (90% vs. 82%; P = .03).

The two groups were similar in terms of the 5-year rate of recurrence (80% vs. 89%, P = .08) and overall survival, Dr. Collin said.

"We looked at tumor stage to see if the explanation for patients having no mechanical bowel preparation having poorer cancer-specific survival was that they had more advanced tumors, and there was no difference in the stages" between groups, she said, with the majority of patients in both groups having stage II or III disease.

Dr. Collin disclosed no conflicts of interest related to the research.

PHOENIX – Improving cancer-specific survival after resection for colorectal cancer may be as simple as ordering preoperative mechanical bowel preparation, according to an analysis of data from a randomized trial conducted in Sweden and Germany.

Roughly half of the 841 patients studied had such preparation before their operation. The actuarial 5-year rate of cancer-specific survival was about 8% higher in this group, first author Dr. Åsa Collin of Uppsala University reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

An analysis of cancer stage at the time of surgery suggested that the two groups were well matched on this measure. Preparation did not significantly decrease the rate of recurrence or increase the rate of overall survival.

Session attendee Dr. J. Daniel Stanley of University Surgical Associates in Chattanooga, Tenn., questioned whether the patients might have differed on other factors that influenced whether they underwent mechanical bowel preparation.

"Were some of them obstructed, which might indicate a different tumor biology than was reflected in the staging?" he asked.

"These were all elective surgeries, and there was no patient who we actually decided that they shouldn’t have preparation," Dr. Collin replied.

In an interview, session comoderator Dr. David Maron, a colorectal surgeon at the Cleveland Clinic in Weston, Fla., said, "What was interesting was that they didn’t show a significant difference in cancer recurrence, although it was close to significance. So the question remains, is it in fact the mechanical bowel prep, or could there be differences in the postoperative follow-up and even the postoperative treatment of those patients who developed recurrence?"

Guidelines leave preparation up to the treating surgeon, and several studies have found no benefit at least in the short term, he noted. "This is one of the first studies that have shown that perhaps from a long-term standpoint in patients with cancer, that there may be some benefit to preoperative preparation of the bowel, although again, it’s preliminary and there’s a lot of unknowns out there."

Dr. Collin and her colleagues analyzed data from a trial among patients who underwent an elective resection for cancer, adenoma, or diverticular disease of the colon at 21 hospitals in Sweden and Germany between 1999 and 2005.

Earlier results for the entire trial population, previously reported, showed no significant reduction in 30-day rates of complications with mechanical bowel preparation (Br. J. Surg. 2007;94:689-95).

The new, long-term results for just the 841 patients with colorectal cancer – 53% of whom had a mechanical bowel preparation before their surgery – indicated those undergoing this preparation had a higher actuarial 5-year rate of cancer-specific survival (90% vs. 82%; P = .03).

The two groups were similar in terms of the 5-year rate of recurrence (80% vs. 89%, P = .08) and overall survival, Dr. Collin said.

"We looked at tumor stage to see if the explanation for patients having no mechanical bowel preparation having poorer cancer-specific survival was that they had more advanced tumors, and there was no difference in the stages" between groups, she said, with the majority of patients in both groups having stage II or III disease.

Dr. Collin disclosed no conflicts of interest related to the research.

PHOENIX – Improving cancer-specific survival after resection for colorectal cancer may be as simple as ordering preoperative mechanical bowel preparation, according to an analysis of data from a randomized trial conducted in Sweden and Germany.

Roughly half of the 841 patients studied had such preparation before their operation. The actuarial 5-year rate of cancer-specific survival was about 8% higher in this group, first author Dr. Åsa Collin of Uppsala University reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

An analysis of cancer stage at the time of surgery suggested that the two groups were well matched on this measure. Preparation did not significantly decrease the rate of recurrence or increase the rate of overall survival.

Session attendee Dr. J. Daniel Stanley of University Surgical Associates in Chattanooga, Tenn., questioned whether the patients might have differed on other factors that influenced whether they underwent mechanical bowel preparation.

"Were some of them obstructed, which might indicate a different tumor biology than was reflected in the staging?" he asked.

"These were all elective surgeries, and there was no patient who we actually decided that they shouldn’t have preparation," Dr. Collin replied.

In an interview, session comoderator Dr. David Maron, a colorectal surgeon at the Cleveland Clinic in Weston, Fla., said, "What was interesting was that they didn’t show a significant difference in cancer recurrence, although it was close to significance. So the question remains, is it in fact the mechanical bowel prep, or could there be differences in the postoperative follow-up and even the postoperative treatment of those patients who developed recurrence?"

Guidelines leave preparation up to the treating surgeon, and several studies have found no benefit at least in the short term, he noted. "This is one of the first studies that have shown that perhaps from a long-term standpoint in patients with cancer, that there may be some benefit to preoperative preparation of the bowel, although again, it’s preliminary and there’s a lot of unknowns out there."

Dr. Collin and her colleagues analyzed data from a trial among patients who underwent an elective resection for cancer, adenoma, or diverticular disease of the colon at 21 hospitals in Sweden and Germany between 1999 and 2005.

Earlier results for the entire trial population, previously reported, showed no significant reduction in 30-day rates of complications with mechanical bowel preparation (Br. J. Surg. 2007;94:689-95).

The new, long-term results for just the 841 patients with colorectal cancer – 53% of whom had a mechanical bowel preparation before their surgery – indicated those undergoing this preparation had a higher actuarial 5-year rate of cancer-specific survival (90% vs. 82%; P = .03).

The two groups were similar in terms of the 5-year rate of recurrence (80% vs. 89%, P = .08) and overall survival, Dr. Collin said.

"We looked at tumor stage to see if the explanation for patients having no mechanical bowel preparation having poorer cancer-specific survival was that they had more advanced tumors, and there was no difference in the stages" between groups, she said, with the majority of patients in both groups having stage II or III disease.

Dr. Collin disclosed no conflicts of interest related to the research.

PHOENIX – The standard sequential approach to treatment of patients with isolated synchronous liver metastases of colorectal cancer, entailing up-front removal of the primary tumor, is associated with growth of the metastases, according to results from a retrospective cohort study.

A team led by Dr. Alistair Slesser, a surgical registrar at the Royal Marsden Hospital in London, studied 114 patients with colorectal cancer who had synchronous liver metastases, meaning ones identified within a year of the cancer diagnosis, and no other metastases.

Results showed that patients whose initial treatment was resection of the colorectal primary tumor had ninefold higher odds of progression of their liver metastases at 3 months, compared with patients whose initial treatment was chemotherapy, he reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Although liver metastases showed regression during 3-6 months of treatment in both groups, the rate was somewhat slower in the primary tumor resection group.

"Our findings suggest that an up-front primary tumor resection is actually an adverse prognostic factor. Indeed, our results have demonstrated that up-front primary tumor resection seemed to negate the effects of the adjuvant therapy on the treatment of the liver metastasis," Dr. Slesser commented.

"How does this apply clinically? We would recommend that patients who have limited metastatic disease, instead of having an up-front primary tumor resection perhaps [they should] be treated with neoadjuvant chemotherapy first. Or perhaps another surgical approach, like a simultaneous resection, should be considered to negate the adverse effects of a primary tumor resection on the metastatic disease," he said.

"When patients have lesions which are suspicious for liver metastases, we would recommend that these patients [be] thoroughly investigated, and if metastatic disease is confirmed, then again, we would recommend that they have chemotherapy prior to any subsequent intervention," he added.

The mechanism leading to growth of liver metastases after primary tumor resection is unknown, according to Dr. Slesser. "There is possibly an association for ... biological reasons. The other reason is that perhaps when a patient has an up-front primary tumor resection, there is a delay in getting chemotherapy, and that can cause the progression that we see."

Session attendee Dr. Gary Dunn, of the University of Oklahoma, Oklahoma City, asked how much time elapsed between up-front resection and receipt of adjuvant chemotherapy in that group, and the variance in this measure, noting, "That will significantly affect your outcome, if some patients started at 6 weeks and some patients started at 12 weeks postop."

"Usually, patients waited 6 weeks before they started chemotherapy postoperatively," Dr. Slesser explained. "The majority of patients who had primary tumor resection had the adjuvant chemotherapy after the postoperative scan; the 3-month scan tends to be the postoperative scan."

Dr. Dunn further wondered about the comparability between groups of the chemotherapy received, asking what agents were used.

"At the Royal Marsden, the chemotherapy regimes tend to be quite uniform," Dr. Slesser replied. "Generally, all patients are on capecitabine [Xeloda] and oxaliplatin, with a monoclonal agent such as bevacizumab [Avastin]. They tend to get that when they have neoadjuvant chemotherapy."

Another attendee said, "Excellent paper, very well presented data, particularly considering there are a lot of retrospective series out there that are showing the up-front resection as a favorable prognostic indicator, which I don’t believe. ... But I would like to see a little more information about how the patients were treated subsequently. Were these patients who they were planning to get to surgery for resection, or were these patients who were treated for palliative intent? Did they have symptomatic primaries?"

"In the majority of these patients, the intent was curative surgery," Dr. Slesser replied. "We tried to exclude patients who were clearly referred for palliative treatment because we really wanted to assess patients who were referred for curative treatment."

Attendee Dr. David Shibata, of the Moffitt Cancer Center in Tampa, commented, "I think a critical question is that you have done a primary tumor resection and the liver tumor has tended to grow, which is not entirely surprising, but then in those cases, how many became unresectable from a liver standpoint?"

"About 60% ended up having hepatectomies," Dr. Slesser said, noting that the data reported looked only at the short-term time frame. "We do have further results, which will be in the paper, pertaining to survival. But the real aim of this study was to look at initial radiological progression of disease, because we thought that the primary tumor resection may be associated with a sudden increase in the size of metastasis."

The finding of a better liver outcome with initial chemotherapy "makes sense," session comoderator Dr. Marylise Boutros, of McGill University in Montreal, said in an interview. "That’s something that we would expect, that you can treat the largest burden of the disease, which is the metastasis – it’s a systemic disease – with chemotherapy up-front."

"But it’s definitely a smaller study, and this needs to be looked at in a larger subset and in a prospective fashion," she added.

Giving some background to the research, Dr. Slesser noted that "the mainstay of surgical treatment for these patients with limited metastatic disease is a sequential resection. Patients tend to have an up-front primary tumor resection, followed by adjuvant chemotherapy, followed by hepatic resection if feasible. On the other hand, patients who have extensive metastatic disease tend to have neoadjuvant chemotherapy prior to a surgical intervention."

He and his coinvestigators studied patients with isolated synchronous colorectal liver metastases who were referred to the Royal Marsden Hospital for treatment between 2005 and 2010 and had imaging done at baseline, 3 months, and 6 months.

The mean age of the cohort was 64 years, and the ratio of men to women was about 2:1. In terms of treatment, 51% of the patients underwent primary tumor resection, while the other 49% received neoadjuvant chemotherapy.

In univariate analysis, the factor most strongly associated with progression of liver metastases – defined as an increase in their cumulative diameter of at least 20% – at 3 months was a primary tumor resection, according to Dr. Slesser.

In a multivariate analysis, relative to their counterparts in the neoadjuvant chemotherapy group, patients undergoing primary tumor resection had dramatically elevated odds of progression of liver metastases (odds ratio, 9.0; P = .001).

Additionally, metastatic burden showed an upward trend between baseline and 6 months in the group undergoing primary tumor resection (from 40 to 51 mm; P = .19), whereas it decreased significantly in the neoadjuvant chemotherapy group (from 96 to 52 mm; P = .001).

Overall, 93% of patients having a primary tumor resection went on to receive adjuvant chemotherapy, according to Dr. Slesser.

Comparing baseline to 3 months versus 3 months to 6 months, liver metastases began regressing in the primary tumor resection group, with the growth rate changing from 4.0 to –3.0 mm/month (P less than .001), reflecting the effect of the adjuvant chemotherapy, he said. Liver metastases in the neoadjuvant chemotherapy group continued to regress, albeit also at a slower pace, with the growth rate changing from –5.6 to –4.0 mm/month (P = .003).

Dr. Slesser disclosed no relevant conflicts of interest.

PHOENIX – The standard sequential approach to treatment of patients with isolated synchronous liver metastases of colorectal cancer, entailing up-front removal of the primary tumor, is associated with growth of the metastases, according to results from a retrospective cohort study.

A team led by Dr. Alistair Slesser, a surgical registrar at the Royal Marsden Hospital in London, studied 114 patients with colorectal cancer who had synchronous liver metastases, meaning ones identified within a year of the cancer diagnosis, and no other metastases.

Results showed that patients whose initial treatment was resection of the colorectal primary tumor had ninefold higher odds of progression of their liver metastases at 3 months, compared with patients whose initial treatment was chemotherapy, he reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Although liver metastases showed regression during 3-6 months of treatment in both groups, the rate was somewhat slower in the primary tumor resection group.

"Our findings suggest that an up-front primary tumor resection is actually an adverse prognostic factor. Indeed, our results have demonstrated that up-front primary tumor resection seemed to negate the effects of the adjuvant therapy on the treatment of the liver metastasis," Dr. Slesser commented.

"How does this apply clinically? We would recommend that patients who have limited metastatic disease, instead of having an up-front primary tumor resection perhaps [they should] be treated with neoadjuvant chemotherapy first. Or perhaps another surgical approach, like a simultaneous resection, should be considered to negate the adverse effects of a primary tumor resection on the metastatic disease," he said.

"When patients have lesions which are suspicious for liver metastases, we would recommend that these patients [be] thoroughly investigated, and if metastatic disease is confirmed, then again, we would recommend that they have chemotherapy prior to any subsequent intervention," he added.

The mechanism leading to growth of liver metastases after primary tumor resection is unknown, according to Dr. Slesser. "There is possibly an association for ... biological reasons. The other reason is that perhaps when a patient has an up-front primary tumor resection, there is a delay in getting chemotherapy, and that can cause the progression that we see."

Session attendee Dr. Gary Dunn, of the University of Oklahoma, Oklahoma City, asked how much time elapsed between up-front resection and receipt of adjuvant chemotherapy in that group, and the variance in this measure, noting, "That will significantly affect your outcome, if some patients started at 6 weeks and some patients started at 12 weeks postop."

"Usually, patients waited 6 weeks before they started chemotherapy postoperatively," Dr. Slesser explained. "The majority of patients who had primary tumor resection had the adjuvant chemotherapy after the postoperative scan; the 3-month scan tends to be the postoperative scan."

Dr. Dunn further wondered about the comparability between groups of the chemotherapy received, asking what agents were used.

"At the Royal Marsden, the chemotherapy regimes tend to be quite uniform," Dr. Slesser replied. "Generally, all patients are on capecitabine [Xeloda] and oxaliplatin, with a monoclonal agent such as bevacizumab [Avastin]. They tend to get that when they have neoadjuvant chemotherapy."

Another attendee said, "Excellent paper, very well presented data, particularly considering there are a lot of retrospective series out there that are showing the up-front resection as a favorable prognostic indicator, which I don’t believe. ... But I would like to see a little more information about how the patients were treated subsequently. Were these patients who they were planning to get to surgery for resection, or were these patients who were treated for palliative intent? Did they have symptomatic primaries?"

"In the majority of these patients, the intent was curative surgery," Dr. Slesser replied. "We tried to exclude patients who were clearly referred for palliative treatment because we really wanted to assess patients who were referred for curative treatment."

Attendee Dr. David Shibata, of the Moffitt Cancer Center in Tampa, commented, "I think a critical question is that you have done a primary tumor resection and the liver tumor has tended to grow, which is not entirely surprising, but then in those cases, how many became unresectable from a liver standpoint?"

"About 60% ended up having hepatectomies," Dr. Slesser said, noting that the data reported looked only at the short-term time frame. "We do have further results, which will be in the paper, pertaining to survival. But the real aim of this study was to look at initial radiological progression of disease, because we thought that the primary tumor resection may be associated with a sudden increase in the size of metastasis."

The finding of a better liver outcome with initial chemotherapy "makes sense," session comoderator Dr. Marylise Boutros, of McGill University in Montreal, said in an interview. "That’s something that we would expect, that you can treat the largest burden of the disease, which is the metastasis – it’s a systemic disease – with chemotherapy up-front."

"But it’s definitely a smaller study, and this needs to be looked at in a larger subset and in a prospective fashion," she added.

Giving some background to the research, Dr. Slesser noted that "the mainstay of surgical treatment for these patients with limited metastatic disease is a sequential resection. Patients tend to have an up-front primary tumor resection, followed by adjuvant chemotherapy, followed by hepatic resection if feasible. On the other hand, patients who have extensive metastatic disease tend to have neoadjuvant chemotherapy prior to a surgical intervention."

He and his coinvestigators studied patients with isolated synchronous colorectal liver metastases who were referred to the Royal Marsden Hospital for treatment between 2005 and 2010 and had imaging done at baseline, 3 months, and 6 months.

The mean age of the cohort was 64 years, and the ratio of men to women was about 2:1. In terms of treatment, 51% of the patients underwent primary tumor resection, while the other 49% received neoadjuvant chemotherapy.

In univariate analysis, the factor most strongly associated with progression of liver metastases – defined as an increase in their cumulative diameter of at least 20% – at 3 months was a primary tumor resection, according to Dr. Slesser.

In a multivariate analysis, relative to their counterparts in the neoadjuvant chemotherapy group, patients undergoing primary tumor resection had dramatically elevated odds of progression of liver metastases (odds ratio, 9.0; P = .001).

Additionally, metastatic burden showed an upward trend between baseline and 6 months in the group undergoing primary tumor resection (from 40 to 51 mm; P = .19), whereas it decreased significantly in the neoadjuvant chemotherapy group (from 96 to 52 mm; P = .001).

Overall, 93% of patients having a primary tumor resection went on to receive adjuvant chemotherapy, according to Dr. Slesser.

Comparing baseline to 3 months versus 3 months to 6 months, liver metastases began regressing in the primary tumor resection group, with the growth rate changing from 4.0 to –3.0 mm/month (P less than .001), reflecting the effect of the adjuvant chemotherapy, he said. Liver metastases in the neoadjuvant chemotherapy group continued to regress, albeit also at a slower pace, with the growth rate changing from –5.6 to –4.0 mm/month (P = .003).

Dr. Slesser disclosed no relevant conflicts of interest.

PHOENIX – The standard sequential approach to treatment of patients with isolated synchronous liver metastases of colorectal cancer, entailing up-front removal of the primary tumor, is associated with growth of the metastases, according to results from a retrospective cohort study.

A team led by Dr. Alistair Slesser, a surgical registrar at the Royal Marsden Hospital in London, studied 114 patients with colorectal cancer who had synchronous liver metastases, meaning ones identified within a year of the cancer diagnosis, and no other metastases.

Results showed that patients whose initial treatment was resection of the colorectal primary tumor had ninefold higher odds of progression of their liver metastases at 3 months, compared with patients whose initial treatment was chemotherapy, he reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Although liver metastases showed regression during 3-6 months of treatment in both groups, the rate was somewhat slower in the primary tumor resection group.

"Our findings suggest that an up-front primary tumor resection is actually an adverse prognostic factor. Indeed, our results have demonstrated that up-front primary tumor resection seemed to negate the effects of the adjuvant therapy on the treatment of the liver metastasis," Dr. Slesser commented.

"How does this apply clinically? We would recommend that patients who have limited metastatic disease, instead of having an up-front primary tumor resection perhaps [they should] be treated with neoadjuvant chemotherapy first. Or perhaps another surgical approach, like a simultaneous resection, should be considered to negate the adverse effects of a primary tumor resection on the metastatic disease," he said.

"When patients have lesions which are suspicious for liver metastases, we would recommend that these patients [be] thoroughly investigated, and if metastatic disease is confirmed, then again, we would recommend that they have chemotherapy prior to any subsequent intervention," he added.

The mechanism leading to growth of liver metastases after primary tumor resection is unknown, according to Dr. Slesser. "There is possibly an association for ... biological reasons. The other reason is that perhaps when a patient has an up-front primary tumor resection, there is a delay in getting chemotherapy, and that can cause the progression that we see."

Session attendee Dr. Gary Dunn, of the University of Oklahoma, Oklahoma City, asked how much time elapsed between up-front resection and receipt of adjuvant chemotherapy in that group, and the variance in this measure, noting, "That will significantly affect your outcome, if some patients started at 6 weeks and some patients started at 12 weeks postop."

"Usually, patients waited 6 weeks before they started chemotherapy postoperatively," Dr. Slesser explained. "The majority of patients who had primary tumor resection had the adjuvant chemotherapy after the postoperative scan; the 3-month scan tends to be the postoperative scan."

Dr. Dunn further wondered about the comparability between groups of the chemotherapy received, asking what agents were used.

"At the Royal Marsden, the chemotherapy regimes tend to be quite uniform," Dr. Slesser replied. "Generally, all patients are on capecitabine [Xeloda] and oxaliplatin, with a monoclonal agent such as bevacizumab [Avastin]. They tend to get that when they have neoadjuvant chemotherapy."

Another attendee said, "Excellent paper, very well presented data, particularly considering there are a lot of retrospective series out there that are showing the up-front resection as a favorable prognostic indicator, which I don’t believe. ... But I would like to see a little more information about how the patients were treated subsequently. Were these patients who they were planning to get to surgery for resection, or were these patients who were treated for palliative intent? Did they have symptomatic primaries?"

"In the majority of these patients, the intent was curative surgery," Dr. Slesser replied. "We tried to exclude patients who were clearly referred for palliative treatment because we really wanted to assess patients who were referred for curative treatment."

Attendee Dr. David Shibata, of the Moffitt Cancer Center in Tampa, commented, "I think a critical question is that you have done a primary tumor resection and the liver tumor has tended to grow, which is not entirely surprising, but then in those cases, how many became unresectable from a liver standpoint?"

"About 60% ended up having hepatectomies," Dr. Slesser said, noting that the data reported looked only at the short-term time frame. "We do have further results, which will be in the paper, pertaining to survival. But the real aim of this study was to look at initial radiological progression of disease, because we thought that the primary tumor resection may be associated with a sudden increase in the size of metastasis."

The finding of a better liver outcome with initial chemotherapy "makes sense," session comoderator Dr. Marylise Boutros, of McGill University in Montreal, said in an interview. "That’s something that we would expect, that you can treat the largest burden of the disease, which is the metastasis – it’s a systemic disease – with chemotherapy up-front."

"But it’s definitely a smaller study, and this needs to be looked at in a larger subset and in a prospective fashion," she added.

Giving some background to the research, Dr. Slesser noted that "the mainstay of surgical treatment for these patients with limited metastatic disease is a sequential resection. Patients tend to have an up-front primary tumor resection, followed by adjuvant chemotherapy, followed by hepatic resection if feasible. On the other hand, patients who have extensive metastatic disease tend to have neoadjuvant chemotherapy prior to a surgical intervention."

He and his coinvestigators studied patients with isolated synchronous colorectal liver metastases who were referred to the Royal Marsden Hospital for treatment between 2005 and 2010 and had imaging done at baseline, 3 months, and 6 months.

The mean age of the cohort was 64 years, and the ratio of men to women was about 2:1. In terms of treatment, 51% of the patients underwent primary tumor resection, while the other 49% received neoadjuvant chemotherapy.

In univariate analysis, the factor most strongly associated with progression of liver metastases – defined as an increase in their cumulative diameter of at least 20% – at 3 months was a primary tumor resection, according to Dr. Slesser.

In a multivariate analysis, relative to their counterparts in the neoadjuvant chemotherapy group, patients undergoing primary tumor resection had dramatically elevated odds of progression of liver metastases (odds ratio, 9.0; P = .001).

Additionally, metastatic burden showed an upward trend between baseline and 6 months in the group undergoing primary tumor resection (from 40 to 51 mm; P = .19), whereas it decreased significantly in the neoadjuvant chemotherapy group (from 96 to 52 mm; P = .001).

Overall, 93% of patients having a primary tumor resection went on to receive adjuvant chemotherapy, according to Dr. Slesser.

Comparing baseline to 3 months versus 3 months to 6 months, liver metastases began regressing in the primary tumor resection group, with the growth rate changing from 4.0 to –3.0 mm/month (P less than .001), reflecting the effect of the adjuvant chemotherapy, he said. Liver metastases in the neoadjuvant chemotherapy group continued to regress, albeit also at a slower pace, with the growth rate changing from –5.6 to –4.0 mm/month (P = .003).

Dr. Slesser disclosed no relevant conflicts of interest.

PHOENIX – When the entire colon cannot be examined during a colonoscopy, physicians should persevere in obtaining a full colonic evaluation because a sizable share of these patients will have an advanced polyp or cancer, a new study shows.

In the study, which used a prospective institutional database, about 1 in every 8 patients having an incomplete initial colonoscopy were subsequently found to have a clinically significant lesion after undergoing some other type of completion exam, lead investigator Dr. Timothy J. Ridolfi reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Patients with a personal history of polyps or cancer accounted for two-thirds of all patients who were found to have lesions on completion studies.

"Complete colonic evaluation in patients with an incomplete colonoscopy is important, and repeat colonoscopy is the most efficient way of achieving that," he commented. "Those with a personal history of polyps or cancer have the highest likelihood of a positive finding on repeat colonoscopy."

Session attendee Dr. Joshua Bleier, of the Hospital of the University of Pennsylvania, Philadelphia, asked, "Since you have this prospective database, was any chart review done to follow up on the patients who didn’t have completion evaluations?"

The investigators have not yet assessed outcomes among patients who were offered a completion study but skipped it, according to Dr. Ridolfi, who is a colorectal surgery fellow at the Cleveland Clinic. He noted that some patients may have had such studies done at outside institutions.

Commenting on the research in an interview, comoderator Dr. H. David Vargas, of the Ochsner Medical Center in New Orleans, said that although the study’s findings are not surprising, they are a good reminder to physicians of the need to follow through in cases where a colonoscopy cannot be completed.

Examining the entire colon "is really incumbent upon us. The onus is on us to complete it," he said. The study "confirms why we need to be thorough, if you will."

The investigators analyzed data from a prospective database that captured information on 25,645 colonoscopies performed by colorectal surgeons at the Cleveland Clinic between 1982 and 2009.

A total of 242 patients were identified as having an incomplete initial colonoscopy. The group had a mean age of 59 years, and 69% were women.

The leading reasons for an incomplete procedure were presence of stool, pain, and tortuosity, with the reason varying according to the anatomic extent of the procedure. Fully 71% of procedures were terminated at the splenic flexure or more distally, he reported.

Overall, 90% of the patients were offered some type of completion study, and 82% of this group complied and underwent the study.

The completion study was most commonly a barium enema (41%) or repeat colonoscopy (40%), and less commonly CT colonography (9%), colonoscopy under general anesthesia (5%), or indicated resection with intraoperative or perioperative colonoscopy (5%).

Some 12% of the patients undergoing a barium enema or CT colonography were found to have new abnormalities, according to Dr. Ridolfi.

In addition, 24% of the patients undergoing repeat colonoscopy were found to have polyps. Of the 32 polyps identified (21 located beyond the extent of the initial incomplete colonoscopy), 9 were advanced adenomas.

And 38% of the patients undergoing indicated resection were found to have some additional lesions on their intraoperative or perioperative colonoscopy.

Patients whose indication for the initial colonoscopy was a personal history of polyps or cancer were more likely than those with other indications – a family history, symptoms, or screening – to have lesions on their completion study. In fact, these patients made up 67% of all patients with positive findings.

Ultimately, 12% of the patients undergoing completion studies were determined to have clinically significant lesions that led to polypectomy or partial colectomy.

Dr. Ridolfi disclosed no relevant conflicts of interest.

PHOENIX – When the entire colon cannot be examined during a colonoscopy, physicians should persevere in obtaining a full colonic evaluation because a sizable share of these patients will have an advanced polyp or cancer, a new study shows.

In the study, which used a prospective institutional database, about 1 in every 8 patients having an incomplete initial colonoscopy were subsequently found to have a clinically significant lesion after undergoing some other type of completion exam, lead investigator Dr. Timothy J. Ridolfi reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Patients with a personal history of polyps or cancer accounted for two-thirds of all patients who were found to have lesions on completion studies.

"Complete colonic evaluation in patients with an incomplete colonoscopy is important, and repeat colonoscopy is the most efficient way of achieving that," he commented. "Those with a personal history of polyps or cancer have the highest likelihood of a positive finding on repeat colonoscopy."

Session attendee Dr. Joshua Bleier, of the Hospital of the University of Pennsylvania, Philadelphia, asked, "Since you have this prospective database, was any chart review done to follow up on the patients who didn’t have completion evaluations?"

The investigators have not yet assessed outcomes among patients who were offered a completion study but skipped it, according to Dr. Ridolfi, who is a colorectal surgery fellow at the Cleveland Clinic. He noted that some patients may have had such studies done at outside institutions.

Commenting on the research in an interview, comoderator Dr. H. David Vargas, of the Ochsner Medical Center in New Orleans, said that although the study’s findings are not surprising, they are a good reminder to physicians of the need to follow through in cases where a colonoscopy cannot be completed.

Examining the entire colon "is really incumbent upon us. The onus is on us to complete it," he said. The study "confirms why we need to be thorough, if you will."

The investigators analyzed data from a prospective database that captured information on 25,645 colonoscopies performed by colorectal surgeons at the Cleveland Clinic between 1982 and 2009.

A total of 242 patients were identified as having an incomplete initial colonoscopy. The group had a mean age of 59 years, and 69% were women.

The leading reasons for an incomplete procedure were presence of stool, pain, and tortuosity, with the reason varying according to the anatomic extent of the procedure. Fully 71% of procedures were terminated at the splenic flexure or more distally, he reported.

Overall, 90% of the patients were offered some type of completion study, and 82% of this group complied and underwent the study.

The completion study was most commonly a barium enema (41%) or repeat colonoscopy (40%), and less commonly CT colonography (9%), colonoscopy under general anesthesia (5%), or indicated resection with intraoperative or perioperative colonoscopy (5%).

Some 12% of the patients undergoing a barium enema or CT colonography were found to have new abnormalities, according to Dr. Ridolfi.

In addition, 24% of the patients undergoing repeat colonoscopy were found to have polyps. Of the 32 polyps identified (21 located beyond the extent of the initial incomplete colonoscopy), 9 were advanced adenomas.

And 38% of the patients undergoing indicated resection were found to have some additional lesions on their intraoperative or perioperative colonoscopy.

Patients whose indication for the initial colonoscopy was a personal history of polyps or cancer were more likely than those with other indications – a family history, symptoms, or screening – to have lesions on their completion study. In fact, these patients made up 67% of all patients with positive findings.

Ultimately, 12% of the patients undergoing completion studies were determined to have clinically significant lesions that led to polypectomy or partial colectomy.

Dr. Ridolfi disclosed no relevant conflicts of interest.

PHOENIX – When the entire colon cannot be examined during a colonoscopy, physicians should persevere in obtaining a full colonic evaluation because a sizable share of these patients will have an advanced polyp or cancer, a new study shows.

In the study, which used a prospective institutional database, about 1 in every 8 patients having an incomplete initial colonoscopy were subsequently found to have a clinically significant lesion after undergoing some other type of completion exam, lead investigator Dr. Timothy J. Ridolfi reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Patients with a personal history of polyps or cancer accounted for two-thirds of all patients who were found to have lesions on completion studies.

"Complete colonic evaluation in patients with an incomplete colonoscopy is important, and repeat colonoscopy is the most efficient way of achieving that," he commented. "Those with a personal history of polyps or cancer have the highest likelihood of a positive finding on repeat colonoscopy."

Session attendee Dr. Joshua Bleier, of the Hospital of the University of Pennsylvania, Philadelphia, asked, "Since you have this prospective database, was any chart review done to follow up on the patients who didn’t have completion evaluations?"

The investigators have not yet assessed outcomes among patients who were offered a completion study but skipped it, according to Dr. Ridolfi, who is a colorectal surgery fellow at the Cleveland Clinic. He noted that some patients may have had such studies done at outside institutions.

Commenting on the research in an interview, comoderator Dr. H. David Vargas, of the Ochsner Medical Center in New Orleans, said that although the study’s findings are not surprising, they are a good reminder to physicians of the need to follow through in cases where a colonoscopy cannot be completed.

Examining the entire colon "is really incumbent upon us. The onus is on us to complete it," he said. The study "confirms why we need to be thorough, if you will."

The investigators analyzed data from a prospective database that captured information on 25,645 colonoscopies performed by colorectal surgeons at the Cleveland Clinic between 1982 and 2009.

A total of 242 patients were identified as having an incomplete initial colonoscopy. The group had a mean age of 59 years, and 69% were women.

The leading reasons for an incomplete procedure were presence of stool, pain, and tortuosity, with the reason varying according to the anatomic extent of the procedure. Fully 71% of procedures were terminated at the splenic flexure or more distally, he reported.

Overall, 90% of the patients were offered some type of completion study, and 82% of this group complied and underwent the study.

The completion study was most commonly a barium enema (41%) or repeat colonoscopy (40%), and less commonly CT colonography (9%), colonoscopy under general anesthesia (5%), or indicated resection with intraoperative or perioperative colonoscopy (5%).

Some 12% of the patients undergoing a barium enema or CT colonography were found to have new abnormalities, according to Dr. Ridolfi.

In addition, 24% of the patients undergoing repeat colonoscopy were found to have polyps. Of the 32 polyps identified (21 located beyond the extent of the initial incomplete colonoscopy), 9 were advanced adenomas.

And 38% of the patients undergoing indicated resection were found to have some additional lesions on their intraoperative or perioperative colonoscopy.

Patients whose indication for the initial colonoscopy was a personal history of polyps or cancer were more likely than those with other indications – a family history, symptoms, or screening – to have lesions on their completion study. In fact, these patients made up 67% of all patients with positive findings.

Ultimately, 12% of the patients undergoing completion studies were determined to have clinically significant lesions that led to polypectomy or partial colectomy.

Dr. Ridolfi disclosed no relevant conflicts of interest.