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Challenges and Opportunities in Colorectal Surgery

Challenges and Opportunities in Colorectal Surgery

Cawich, S. O., Wharfe, G., Nimrod, M., Muddeen, A., Mike, K., Ramesh, S., Barrow, M., & Barrow, S. (2022b)

Abstract

Objectives: Opportunistic (ad-hoc) screening for colorectal cancer is practiced in Trinidad & Tobago, but there is no data on the outcomes of opportunistic screening.  We carried out this study to determine the proportion of persons with colorectal ancer who were screen-detected. 

 Methods: We retrospectively audited the records of all patients who underwent colectomies for colorectal cancer at a public hospital over a 10-year period from January 1, 2012 to January 30, 2022. We compared American Joint Committee on Cancer stage based on method of diagnosis (screening vs symptomatic). Descriptive statistical analyses were generated using SPSS version 21.0.

Results: We analyzed 340 patients with colorectal cancer at a mean age of 63.3 years (SD +/- 13.4). There were 52 (15.3%) patients who had diagnoses made at screening and 283 (84.7%) had investigations after developing symptoms. Significantly more screen-detected lesions were early-stage colorectal cancer (73.1% vs 25%; P <0.001). Table 1 compares the cancer stage in both patient groups.

Conclusions: Although significantly more patients with colorectal cancer are diagnosed at early stages by screening, the incidence screen-detected disease in Trinidad & Tobago is low. Most patients present with locally advanced (52%) or metastatic (15%) disease, when the opportunity for curative treatment is reduced. The time has come for policy makers to develop and institute a national screening programme for colorectal cancer in Trinidad & Tobago.

Waddell, O., Frizelle, F., & Keenan, J. I. (2023)

Abstract

Colorectal cancer is the third most diagnosed cancer worldwide with an estimated 1.93 million cases diagnosed in 2020. Over the past few decades there has been a dramatic rise in the incidence of early onset colorectal cancer, defined as colorectal cancer diagnosed in those aged under 50 years. The largest predictor of survival is early stage at diagnosis, therefore ways to improve prompt diagnosis of early onset colorectal cancer at an early stage is an effective way of managing the impact of this rising disease. Diagnosing colorectal cancer in younger patients has unique challenges with patients falling outside the age of most screening programs and early symptoms of colorectal cancer being common, non-specific and initially intermittent.

While colonoscopy remains the gold standard investigation, it is a limited and expensive resource, and current patterns of practice result in large numbers of patients being scoped unnecessarily. The development and use of new and novel non-invasive biomarkers may help (either alone or in combination) identify either symptomatic patients in primary care, or aid with screening asymptomatic patients to focus resources where they are needed most. This review discusses challenges around diagnosing early onset colorectal cancer, with an overview of both current and future methods that might help overcome these challenges. These include increased assessment of familial risk, and the measurement of different biomarkers including faecal haemoglobin, markers of inflammation, gut microbiota, and selected metabolites.

Cawich, S. O. (2024)

Abstract

Although the laparoscopic approach is the gold standard for operative resection of colorectal carcinoma, the skill sets to complete colectomy laparoscopically is not universally available in developing Caribbean nations. We encountered this situation when general surgeons in Jamaica with experience in open colorectal resections encountered a patient who demanded laparoscopic resection of a confirmed carcinoma. The surgeons completed a laparoscopic sigmoid colectomy via remote mentoring. This may be, in select cases, a method to increase the availability of laparoscopic colorectal operations in developing countries.

Li, W., Gonn, M., Von Holst, S., Thutkawkorapin, J., Jiao, X., Björk, J., Backman, A., Lagerstedt‐Robinson, K., & Lindblom, A. (2022)

Abstract

Colorectal cancer (CRC) is a multifactorial disease, where both the environment and genetics play a role. It is estimated that approximately 35% of CRCs have a potentially identifiable genetic cause. Well-known and highly penetrant genetic causes make up less than 5% of all CRC, and leave many families not explained by known predisposing genes/mutations. Low penetrant alleles have also been thought to modify the risk of CRC. Linkage studies have been successful in discovering and localizing highly penetrant genes in CRC and risk loci has become possible to discover performing genome wide association studies (GWAS).

In this study we have analyzed families with CRC where individuals with CRC as well as individuals with premalignant lesions, adenomas, were codes as affected. In total 600 individuals in 121 families were included in the study.

In total three genomic regions were found with suggestive linkage located at 4p16.3, 6p24.3 and 10p14. These regions were further studied using sequencing analysis and association studies using haplotypes.

Amoudi, A. H. B. (2023)

Abstract

In the past three decades, colorectal surgery has embraced a series of technological advancements focusing on precision preoperative planning, the adoption of minimally invasive laparoscopic, robotic, and endoscopic surgical techniques, and the formulation of personalized, patient-centric care. The main evidence-based drivers for such utilities are, reduction in postoperative pain and operative trauma, improvements in disease specific outcomes, the enhancement of patients’ healthcare journey, and the safeguarding of intermediate and long-term quality of life measures1,2.

Incorporation of these developments into mainstream clinical practice has presented several challenges. These include, the concerns related to patient safety, standardization of operative approach, as well as ensuring cost efficiencies and cost containment relating to surgical-care3,4. Furthermore, there are ethical, technical, and financial constraints associated with minimally invasive surgical (MIS) training, which has impacted a significant section of the existing workforce as well as new generations of surgeons5-8.

Griffith, S., Cawich, S. O., Doyle, A., Chase, C., Hefeji, F., Whitehead, R., Ramkissoon, S., & Padmore, G. (2022b)

Abstract

Background: Fast track protocols (FTPs) have triggered considerable improvements in patients’ perioperative care and are accepted as the standardised approach to patient management in developed countries globally. Although the benefits of FTPs have been illustrated for some time, they are not universally used in developing countries. In the Eastern Caribbean, FTPs are implemented in an ad-hoc manner based on the attending surgeons.

Methods: We designed a comprehensive FTP modified for use in Barbados, an island nation in the Eastern Caribbean. After consensus, the FTPs were introduced into clinical practice at a tertiary referral public hospital. We prospectively evaluated clinical outcomes after introduction of FTP protocols for all patients undergoing colorectal operations from January 1, 2018 to February 1, 2019. The study population was divided into three groups: Group I: full adherence (>16 FTP steps completed), Group II: partial adherence (10-15 FTP steps completed), Group III: non-adherence to FTP protocols (<9 FTP steps observed). In each group, we compared morbidity, mortality, return of bowel function, length of post-operative hospital stay and hospital readmission using SPSS version 20 for statistical analyses. 

Results: Over the study period, there were 27 colorectal operations performed. When the outcomes in group 1 and group 3 were compared, there was a statistically significant reduction in post-operative LOS (3 Vs 8.9 days; P<0.05) and overall morbidity (10% vs 50%; P 0.05) in the full FTP adherence groups.

Conclusions: In this Caribbean healthcare system, FTP implementation resulted in significant improvements in post-operative duration of hospitalization and overall morbidity. The main challenge is to achieve universal buy-in from health care providers in the Caribbean. We believe that the way to achieve this is continued medical education and targeted research to acquire local practice data from the Caribbean. We advocate the incorporation of FTP into colorectal surgical practice for Caribbean hospitals.   

Verduin, W. M., Van Den Helder, R., Janssen, T. W. J., & Houdijk, A. P. J. (2023c)

Abstract

Background: Muscle and fat influence outcome after colorectal cancer surgery. Little data exist on mortality. Muscle mass (MM) relating to lower mortality is mostly studied in dichotomous approaches as sarcopenia or skeletal muscle index (SMI) but rarely as a continuous variable. For fat, compartments as visceral, subcutaneous, or intramuscular have different metabolic impact but on mortality little is known. Sex dictates muscle and fat mass that also may differ between colon and rectal cancer patients.


Objective:  To study associations of muscle and fat parameters as continuous variables with mortality in men and women after colon or rectal cancer resection.

Design: Retrospective multicenter cohort study

Setting: This study used data of the Dutch Surgical Colorectal Audit from 2011 through 2014 from 8 Dutch teaching hospitals. Body composition was assessed on pre-operative CT scans.

Patients: 2597 colon and 931 rectal cancer patients

Main outcome measures:  Associations of muscle and fat measures with 5- year MR in male and female colon and rectal cancer patients.

Results: Negative associations of MM and SMI and positive associations of muscle fat (MF) and sarcopenia with mortality were found only in male patients.  The effect of MM and sarcopenia was found in both colon and rectal patients whereas SMI had no effect in rectal patients.  Muscle fat associated with higher mortality only in male colon patients.  The only effect of visceral fat was seen in male rectal cancer patients associating with lower mortality.  

Limitations: The retrospective nature of the study

Conclusion:  The male predominance and differences between colon and rectal cancer patients for associations of muscle and fat parameters with colorectal cancer mortality stress the importance of separating males from females and colon from rectal cancer patients in the analysis of body composition effects on mortality.

Bagus, B. I. (2023b)

Abstract

Starting in 2020 and continuing for 2 years thereafter, the COVID-19 pandemic has greatly affected routine clinical practice, particularly in treating patients with gastrointestinal cancer. Delay, postponement or refusal to continue multimodal treatment have increased the number of emergency cases, and consequently patient morbidity and mortality.

Many recommendations have been announced to guide the adaptation of clinical practice during and after the COVID-19 pandemic. Although early diagnosis and screening should proceed as usual before the pandemic, adjuvant treatment for patients with gastrointestinal cancer should be evaluated in the future. For example, during the pandemic, most recommendations state that adjuvant treatment for patients with colorectal cancer is still required, and many adaptations have been suggested according to local conditions.

In some instances, 6 months of adjuvant chemotherapy has been modified to an optional 3 month duration. A common challenge is that most patients remain unsure about the decreased chemotherapy duration, although many guidelines recommend this modified treatment strategy. Short term follow up has already indicated promising clinical outcomes of this modified adjuvant duration, but the long-term outcomes remain to be evaluated.

Alfred, J., Clifford, R., Dixon, S., & Kalaiselvan, R. (2023b)

Abstract

Introduction: There are over 42,000 new cases of colorectal cancer diagnosed every year in the UK alone, a third of those being rectal in origin. Although there has been significant progress in the treatment of rectal cancer, overall, 5-year survival can still be as low as 17% for those with advanced disease. We aimed to assess the impact on of overall survival and quality of life of primary tumour resection in the palliative setting.

Method: A literature search was performed using Pubmed and Cochrane databases in March 2022. Bias was assessed using the Joanna Briggs institute checklist.

Results: Seven papers were included in the review; all retrospective cohort. A total of 809 patients underwent rectal resection in the presence of metastatic disease +/- adjuvant therapy. The median age was 61years, 59.7% male. 68.6% of patients presented with liver metastasis at the time of diagnosis. The most commonly reported symptoms preoperatively were bleeding and tenesmus. 4-50% of patients in each cohort underwent neoadjuvant therapy. Highest 30-day mortality reported was 7.3%. Both studies comparing resection v none demonstrated a higher overall survival for those undergoing surgery, with one showing 1year overall

survival 65v20%. Quality of life was not addressed across the literature.

Conclusion: Although there is some evidence to show a favourable overall survival for patients undergoing primary tumour resection in the palliative setting, this data is mainly old and across a heterogeneous population. A larger scale prospective study would be required to assess its potential role and impact upon quality of life. 

Guirgis, H. M. (2023b)

Abstract

Background: We previously reported that the 2-year costs of the immune check inhibitors (ICI) were equitable with outcomes. Extended use multiplied costs. Nivolumab neoadjuvant plus chemotherapy improved event-free survival in early resectable lung cancer at low cost. Neoadjuvant is a novel advance in earlier cancer treatment. The targeted therapy Osimertinib is currently utilized as neoadjuvant, adjuvant and in advanced/metastatic lung cancer with cost increasing yearly with further use. We aimed to quantify the cost and savings of ICI and targeted therapy in earlier vs advanced cancer stages in multiple solid tumors.

Methods: Annual 2019-2020 costs of Osimertinib were calculated ad monthly optimal dose x 12. Costs of ICI were calculated as dose x mg/m2 or per 80 kg x price x number of cycles per year.

Results: The 2-year Osimertinib cost in metastatic disease was $496,744, adjuvant 1-year $248,372 and neoadjuvant $31,046. Estimated neoadjuvant cost savings over 1-year were $217,326.

Pembrolizumab $134,796 annual cost was the median of 5- evaluated ICI. It is used as adjuvant at half the 2-year cost. Extended therapy by 6-12 months, beyond the 2-year approval, added an extra $67,398-$134,796.

Durvalumab following chemo-radiation, (Pacific) was approved in unresectable stage III NSCLC x 1-year at $148,007, saving a 2nd year-cost. Adjuvant Atezolizumab 1-year cost in 1st-line was $124,761. Approval was based on improving the disease-free survival using 4 cycles + chemo in resected stage II-IIIA lung (Impower010), Cost was $35,644 cost with $89,117 savings.

In the neoadjuvant space, Nivolumab + chemotherapy improved event-free survival in resectable lung cancer (Forde, 2022) at $31,425, saving $137,423. In early-stage triple negative breast cancer (GeparoNuevo-NCTO2685059), 8-cycle Durvalumab prolonged survival at $45,464. Cemiplimab x 4-cycle in stage II to IV, cutaneous squamous-cell carcinoma resulted in complete pathological response (Gross, 2022) at $35,652 vs 1-year $125,108. In early colorectal cancer (NICHE-2), 2-cycle Nivolumab plus 1- low-dose Ipilimumab followed by surgery resulted in major pathological response at $24,927.

Conclusions: Neoadjuvant Osimertinib and ICI cost a small fraction resulting in significant savings in early-stage lung cancer treatment. Cost advantages in other solid tumors warrant further confirmation.

Hoel, D. G., & Miller, A. R. (2023)

Abstract

It is becoming well understood that low blood levels of 25-hydroxyvitamin D (25(OH)D) are a risk factor for many diseases and other adverse health effects including hypertension, cardiovascular disease, stroke, breast cancer, colorectal cancer, metabolic syndrome, type 2 diabetes, obesity, multiple sclerosis, type 1 diabetes, rheumatoid arthritis, Alzheimer’s disease, autism, schizophrenia, asthma, preterm birth, maternal mortality, myopia and COVID-19.  Levels of serum 25(OH)D are at the same time a measure of vitamin D status and, since 70-90% of this biomolecule is produced by sun exposure, a measure of sun exposure.  There is some disagreement among scientists as to whether vitamin D supplements are an effective substitute for sun exposure for attenuation of these diseases and adverse health effects.  In this paper we review the current state of the science on this subject and conclude that vitamin D supplements are not an adequate substitute for sun exposure for attenuation of most of these diseases and adverse health effects, particularly hypertension and cardiovascular disease, and should not be recommended in lieu of sun exposure to patients presenting with low levels of serum 25(OH)D. Vitamin D supplementation for such patients could even be harmful, because it will raise patients’ serum 25(OH)D levels, thereby giving patients a false sense of security and obscuring the best available metric for insufficient sun exposure. 

Li, W., Gonn, M., Von Holst, S., Thutkawkorapin, J., Jiao, X., Björk, J., Backman, A., Lagerstedt‐Robinson, K., & Lindblom, A. (2022b)

Abstract

Colorectal cancer (CRC) is a multifactorial disease, where both the environment and genetics play a role. It is estimated that approximately 35% of CRCs have a potentially identifiable genetic cause. Well-known and highly penetrant genetic causes make up less than 5% of all CRC, and leave many families not explained by known predisposing genes/mutations. Low penetrant alleles have also been thought to modify the risk of CRC. Linkage studies have been successful in discovering and localizing highly penetrant genes in CRC and risk loci has become possible to discover performing genome wide association studies (GWAS).

In this study we have analyzed families with CRC where individuals with CRC as well as individuals with premalignant lesions, adenomas, were codes as affected. In total 600 individuals in 121 families were included in the study.

In total three genomic regions were found with suggestive linkage located at 4p16.3, 6p24.3 and 10p14. These regions were further studied using sequencing analysis and association studies using haplotypes.

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