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Lymph node size affects lymph node retrieval in surgical specimen and is used as criterion for pre-operative radiological estimation of metastatic disease. However, factors determining lymph node size remain to be established. Therefore, the association between lymph node size and presence of metastatic cancer deposits as well as different primary tumor characteristics was analyzed in a prospective cross-sectional study. Visible and palpable nodes were harvested, and conventional histology, immunohistochemistry, and molecular analysis were performed. The study cohort comprised 148 patients (median age 69 years, range 36-92). Lymph node dissection rendered 4167 nodes. Mean lymph node count was 28 (median 26, range 9-67). Metastatic disease was detected in 320 (8%) nodes and was associated with lymph node size (P0.001). Positive nodes measuring ≤2 mm caused upstaging within the N category in one third of cases, but did not identify patients as node-positive as all patients also had positive larger nodes. Large tumor size (P=0.001), right tumor location (P0.001), and deep tumor penetration (P=0.024) were all independently associated with lymph node size, whereas high lymphocytic antitumor reaction just missed statistical significance (P=0.053) in multivariable analysis. Microsatellite instability had no influence on lymph node size when analysis was restricted to right-sided tumors. In conclusion, analysis of small lymph nodes may lead to upstaging within the N category, but they do not identify a patient as node-positive and do therefore not influence clinical decision-making in the adjuvant setting. The majority of enlarged lymph nodes, including those measuring1 cm, are not involved by cancer. Different tumor characteristics, such as large primary tumor size, right tumor location, and deep tumor penetration are independently associated with lymph node size and need to be considered when interpreting enlarged nodes detected by radiological imaging.

Background This study sought to determine whether a protective diverting ileostomy improves short-term outcomes in patients with rectal resection and colonic J-pouch reconstruction for low anastomoses. Criteria for the use of a proximal stoma in rectal resections with colonic J-pouch reconstruction have not been defined sufficiently. Methods In a multicenter prospective study, rectal cancer patients with anastomoses below 8 cm treated with low anterior resection and colonic J-pouch were randomized to a defunctioning loop ileostomy or no ileostomy. The primary study endpoint was the rate of anastomotic leakage, and the secondary endpoints were surgical complications related to primary surgery, stoma, or stoma closure. Results From 2004 to 2014, a total of 166 patients were randomized to 1 of the 2 study groups. In the intention-to-treat analysis, the overall leakage rate was 5.8% in the stoma group and 16.3% in the no stoma group ( P = .0441). However, some patients were not treated according to randomization and only 70% of our patients with low anastomoses received a pouch. Therefore, we performed a second analysis as to actual treatment. In this analysis, as well, leakage rates ( P = .044) and reoperation rates for leakage ( P = .021) were significantly higher in patients without a stoma. In multivariate analysis, male gender ( P = .0267) and the absence of a stoma ( P = .0092) were significantly associated with anastomotic leakage. Conclusion Defunctioning loop ileostomy should be fashioned in rectal cancer patients with anastomoses below 6 cm, particularly in male patients, even if reconstruction was done with a J-pouch.

Purpose We previously described the prognostic impact of tumor regression grading (TRG) on the outcome of patients with rectal carcinoma treated with preoperative chemoradiotherapy (CRT) in the CAO/ARO/AIO-94 trial. Here we report long-term results after a median follow-up of 132 months. Patients and Methods TRG after preoperative CRT was determined in 386 surgical specimens by the amount of viable tumor cells versus fibrosis, ranging from TRG 4 (no viable tumor cells) to TRG 0 (no signs of regression). Clinicopathologic parameters and TRG were correlated to the cumulative incidence of local recurrence, distant metastasis, and disease-free survival (DFS). Results Ten-year cumulative incidence of distant metastasis and DFS were 10.5% and 89.5% for patients with TRG 4 (complete regression), 29.3% and 73.6% for TRG 2 and 3 (intermediate regression), and 39.6% and 63% for TRG 0 and 1 (poor regression), respectively (P = .005 and P = .008, respectively). On multivariable analysis, residual lymph node metastasis (ypN+) and TRG were the only independent prognostic factors for cumulative incidence of distant metastasis (P < .001 and P = .035, respectively) and DFS (P < .001 and P = .039, respectively), whereas local recurrence was significantly affected by ypN status (P < .001) and lymphatic invasion (P = .026). Conclusion Complete and intermediate tumor regressions were associated with improved long-term outcome in patients with rectal carcinoma after preoperative CRT independent of clinicopathologic parameters. This classification system needs to be prospectively tested in multiple data sets to validate its reproducibility in a wider setting.

OBJECTIVES The influence of obesity on postoperative complications after various surgical interventions remains controversial. The aim of this study was to evaluate the impact of overweight and obesity on the occurrence of postoperative complications for patients undergoing elective resection for rectal carcinoma. METHODS We conducted a retrospective data analysis of 676 patients undergoing surgical treatment for rectal carcinoma. Depending on their body mass index (BMI), patients were grouped as follows: group I, patients up to BMI 24.9 kg/m; group II patients, with a BMI between 25 and 29.9 kg/m; and group III, all patients with a BMI >30 kg/m. Complications were classified as minor and major with regard to severity grades (1-5). Statistical analysis was performed to evaluate the difference in complication rates between the different BMI groups. RESULTS A total of 444 patients were included for analysis. Overall, 300 (67.6%) of the 444 patients did not develop postoperative complications, 82 (18.4%) patients had minor complications (grade 1 + 2), and 56 patients (12.6%) had major (grade 3 + 4) complications. Six (1.4%) patients died (grade 5). The Fisher exact test indicated no statistically significant difference of complication rates between the different BMI groups (P = 0.3716). CONCLUSIONS Compared with nonobese or normal-weight patients, obese patients do not have a statistically significant higher risk of developing postoperative complications after rectal resection for carcinoma.

Aim Low and ultralow anterior resection for rectal cancer with colorectal or coloanal anastomosis does not compromise oncological results compared with abdominoperineal excision. Although avoidance of a permanent colostomy is regarded as beneficial for a patient’s quality of life (QoL), patients undergoing sphincter-sparing surgery may develop a number of functional problems. A colonic pouch significantly improves functional outcome after rectal resection and low anastomosis and may positively influence QoL. The aim of this study was to compare QoL in long-term survivors who underwent ultralow anterior resection with total mesorectal excision and colonic J-pouch anastomosis (CPA) with patients treated with abdominoperineal excision (APE) and end colostomy for rectal cancer. Method The medical records from our institution’s prospectively maintained rectal cancer database of 151 patients who underwent surgery for ultralow rectal cancer from 2001 to 2007 were analysed. QoL in 59 eligible patients was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 core and Colorectal Cancer 29. Results were compared for patients with CPA and APE. Results The median follow-up in the 59 patients was 74 (37–119) months. QoL was good in all patients, but it was better in CPA than in APE patients. Global health status (P = 0.009), physical functioning (P = 0.0002), role functioning (P = 0.03), cognitive functioning (P = 0.046), social functioning (P = 0.002), body image (P = 0.053), embarrassment (P = 0.002) and urinary frequency (P = 0.003) were significantly improved for patients with CPA. Conclusion QoL after rectal resection and CPA was better than after APE in several respects. However, QoL should not be regarded as an isolated concept but rather as one of several possible clinical outcomes of interest.

BACKGROUND: To avoid abdominal colostomy and improve quality of life, several types of anorectal reconstruction following abdominoperineal resection have been proposed. The aim of this study was to assess functional results and the quality of life of patients with very low rectal cancer after abdominoperineal resection and neosphincter reconstruction by perineal colostomy with a colonic muscular cuff. PATIENTS AND METHODS: Twenty-seven patients who had undergone neosphincter reconstruction with a perineal spiral cuff plasty after abdominoperineal resection were included in a retrospective study to evaluate long-term outcome. The functional results were analyzed using anal manometry and the continence score. The quality of life was measured with the global and disease-specific questionnaires European Organization for Research and Treatment of Cancer QLQ-C30 and C38. RESULTS: Median follow-up time was 105 months (range, 18-185 mo). The median Holschneider continence score of the study sample was 13 (continent), with a range of 10 (partially continent) to 16 (continent), thus demonstrating satisfactory functional results. The functional assessment was completed by neosphincter manometry which revealed a median resting vs compression pressure of 40 vs 96 cmH 2 O with a range of 5 to 81 cmH 2 O vs 49 to 364 cmH 2 O. The quality-of-life analyses showed an above-average score for both global health and disease-specific status. CONCLUSION: Spiral cuff colostomy with reconstruction after abdominoperineal resection of very low distal rectal cancer offers a surgical option for a selective group of patients with reasonable functional long-term results and an improved quality of life.

Introduction: There is no clear consensus about the optimal postoperative pain management in morbidly obese patients undergoing bariatric surgery. The aim of this study was to evaluate the effects of Patient-Controlled- Epidural-Analgesia (PCEA) compared to Intravenous-Patient-Controlled-Analgesia (IV-PCA) in patients undergoing laparoscopic gastric bypass surgery. Methods: Between January 2013 and December 2014, 154 obese patients underwent laparoscopic gastric bypass surgery. Included in our analyses were all patients receiving either IV-PCA or PCEA in their postoperative course. Group comparison with respect to patient demographics, co-morbidities, details of surgical procedure, details of postoperative course, NRS-scores at rest, and medical follow-ups were performed. Results: Overall 63 (44.4%) patients were treated by PCEA, 79 (55.6%) patients by IV-PCA. We observed no differences across the groups with respect to sex, age, ASA-score, co-morbidities, postoperative BMI, body height, pre- and postoperative weight, ideal weight, weight loss, duration of surgery and postoperative ward. Patient´s BMI (p=0.025) and excess weight before surgery (p=0.029) were significantly higher in the IV-PCA-group. Surgical complications occurred significantly more often in the IV-PCA group (p=0.045). Concerning the postoperative pain management there was no statistically significant difference between different NRS-scores throughout the study period. However, individuals in the IV-PCA-group received significantly more paracetamol (p

Renal cell carcinoma (RCC) represents a rare tumor entity accounting for approximately 3 % of all malignancies in the adult population. Approximately 30 % of all patients suffering from RCC develop metastases after nephrectomy and another 30 % of patients suffer from synchronous metastases at the date of diagnosis. Gallbladder metastases represent an extremely rare clinical condition and up to date there are only 35 published cases of gallbladder metastasis from RCC. Surgical resection should be the treatment of choice in any case based on the reported data in literature. In spite of the small series of cases, survival can be improved even in patients suffering from additional sites of metastases.

Background & Aims: Therapies for perianal fistulas in patients with Crohn's disease are often ineffective in producing long-term healing. We performed a randomized placebo-controlled trial to determine the long-term efficacy and safety of a single local administration of allogeneic expanded adipose-derived stem cells (Cx601) in patients with Crohn's disease and perianal fistulas. Methods: We performed a double-blind study at 49 hospitals in Europe and Israel, comprising 212 patients with Crohn's disease and treatment-refractory, draining, complex perianal fistulas. Patients were randomly assigned (1:1) to groups given a single local injection of 120 million Cx601 cells or placebo (control), in addition to the standard of care. Efficacy endpoints evaluated in the modified intention-to-treat population (randomly assigned, treated, and with 1 or more post-baseline efficacy assessment) at week 52 included combined remission (closure of all treated external openings draining at baseline with absence of collections >2 cm, confirmed by magnetic resonance imaging) and clinical remission (absence of draining fistulas). Results: The study's primary endpoint, at week 24, was previously reported (combined remission in 51.5% of patients given Cx601 vs 35.6% of controls, for a difference of 15.8 percentage points; 97.5% confidence interval [CI] 0.5–31.2; P =.021). At week 52, a significantly greater proportion of patients given Cx601 achieved combined remission (56.3%) vs controls (38.6%) (a difference of 17.7 percentage points; 95% CI 4.2–31.2; P =.010), and clinical remission (59.2% vs 41.6% of controls, for a difference of 17.6 percentage points; 95% CI 4.1–31.1; P =.013). Safety was maintained throughout week 52; adverse events occurred in 76.7% of patients in the Cx601 group and 72.5% of patients in the control group. Conclusion: In a phase 3 trial of patients with Crohn's disease and treatment-refractory complex perianal fistulas, we found Cx601 to be safe and effective in closing external openings, compared with placebo, after 1 year. ClinicalTrials.gov no: NCT01541579.

Background The relevance of type and severity of postoperative complications after curative resection for rectal cancer on survival and recurrence rates is a matter of controversy. Objective The aim of this study was to investigate the impact of postoperative complications on long-term outcome after resection for rectal cancer. Design This study is a retrospective analysis of prospectively collected data. Settings The study was conducted at a university teaching hospital by a specialized colorectal team. Patients Between January 1984 and October 2008, 811 patients with rectal cancer underwent curative resection. Patients who experienced postoperative complications were divided into a minor complication group (grades I and II) and a major complications group (grades III and IV) according to the Clavien classification. Main outcome measures The influence of several pathological and clinical factors, including complications in terms of overall and disease-free survival, was tested and compared in univariate and multivariate analyses. Results Curative resection was performed in 811 patients; median age was 65 years. The Kaplan-Meier estimates (± SE) for 5- and 10-year overall cumulative survival were 70.3% ± 1.8% and 54.5% ± 2.4%; Kaplan-Meier estimates for 5- and 10-year disease-free survival were 64.0% ± 1.8% and 50.9% ± 2.3%. One hundred sixty-five patients (20.3%) had minor complications, and 103 patients (12.7%) had major complications. Twelve patients (1.48%) died within 30 days after surgery. There was no significant difference between patients with no complications, patients with minor complications, and patients with major complications in terms of overall (p = 0.41) or disease-free survival (p = 0.32). Limitations A possible limitation of our study is that the data represent a cohort study from a single center. Conclusion Following resection for rectal cancer, the severity of postoperative complications (minor or major) according to a standardized classification system does not demonstrate a statistically significant effect on either overall or disease-free survival.

Natural orifice endoscopic surgery (NOTES) is an emerging technique that has been postulated as a promising alternative to laparoscopy in the field of minimal invasive surgery. Until now appropriate indications, safe access routes and general feasibility of this approach have not been defined exactly in surgical oncology.A total of 474 patients undergoing cancer surgery were analyzed regarding possible applications of transluminal endoscopic surgery. Patient with potential indications underwent intraoperative endoscopy to evaluate technical aspects, indications and intraoperative feasibility.A potential indication for transluminal surgery was found in 54 of 474 patients (11%) undergoing abdominal cancer surgery. Staging of gastrointestinal tumors was considered the main indication (45%) followed by splenectomy (11%) and diagnostic excision (11%). As a potential access route the transgastric approach was considered in 42 patients (66%) and the transcolonic approach in 18 patients (28 %). Of these 42 patients, 19 (30%) presented with significant intra-abdominal adhesions which would have resulted in a more complicated procedure. Accurate transluminal orientation was considered impossible in 13 cases (20%).Although some indications for NOTES procedures in surgical oncology have been identified in this study these techniques have to be assessed cautiously. Implementation of NOTES in surgical oncology is currently difficult because of technical problems, lack of intraoperative orientation and abdominal adhesions.

Objective Evaluate whether depth of infiltration within T3 colorectal tumors influences long-term oncologic outcome. Patients and methods Patients with stage pT3 colon and rectal tumors were divided into four subgroups according to the depth of infiltration. The influence on overall and disease-free survival was tested for each subgroup and compared in univariate and multivariate analyses. Results A total of 368 patients were evaluated, with a median follow-up time of 92.5 months. In 181 patients with colon cancer 5- and 10-year overall survival rates were 82.7% and 65.0%, respectively, and 5- and 10-year disease-free survival rates were 80.9% and 64.4%, respectively. For 187 patients, rectal cancer 5- and 10-year overall survival rates were 69.0% and 50.5%, respectively, and disease-free survival rates were 61.3% and 47.5%, respectively. In either colon or rectal cancer, different pT3 categories showed neither a statistically significant influence on survival nor the occurrence of local or distant recurrence in univariate and multivariate analyses; however, higher pT3 subgroups had a significant influence on lymph node involvement and vessel invasion in patients with rectal cancer. Conclusions Subdivision of pT3 tumors in colon cancer based on depth of infiltration does not provide additional information about prognosis. In rectal cancer, T3 substages were associated with lymph node involvement; however, we could not demonstrate an impact on recurrence or survival.

The case of a 75-year-old female suffering from recurrent abdominal pain and nausea is presented. Ultrasound showed gallstones without inflammation of the gallbladder. The patient underwent laparoscopic cholecystectomy and her symptoms resolved. Histological examination of the operation specimen disclosed heterotopic pancreatic tissue within the cystic duct. An accurate clinical diagnosis of pancreatic heterotopia is difficult. The deep submucosal or intramural location of the lesion may hamper retrieval of representative biopsy material. Indications for surgery or endoscopic resection include symptomatic lesions as well as cases of unclear histological examination in order to distinguish pancreatic heterotopia from other tumors.

Background Despite surgical advances, anastomotic leaks remain a major complication after rectal resection. Endoscopic techniques are increasingly used as an alternative or in addition to conventional operative therapy of anastomotic leakage. We have analyzed the impact of endoscopic treatment on the outcome of patients with leaks after resection of rectal cancer. Methods From January 2000 to December 2005, rectal resection was performed in 274 patients with rectal cancer. Anastomotic leakage was observed in 29 patients (11%). Nine of these patients received a protective ileostomy. The remaining 20 patients underwent either conventional operative or endoscopic treatment. Both groups were analyzed regarding complications, necessity of operative reintervention, hospitalization, anastomotic healing time, and stoma reversal rate. Results The endoscopic group included 13 patients who underwent endoscopic debridement in combination with stenting, endoluminal vacuum therapy, or fibrin injection. The remaining 7 patients underwent reoperation—secondary ileostomy creation ( n = 4), Hartmann procedure ( n = 2), or anastomotic repair ( n = 1). Stoma creation was necessary in 7 of 13 patients (54%) in the endoscopic group and in 6 of 7 patients (86%) in the operative group. There were no significant differences regarding postoperative septicemia (39 vs 43%), duration of intensive care (13 vs 11 days), or time of hospitalization (25 vs 26 days) for endoscopic and conventional therapies. Mean healing time of the anastomotic leak in the endoscopic and conventional group was 105 and 173 days, respectively. The stoma reversal rate was similar in both groups (50 vs 57%), but the overall rate of patients without colostomy was higher in the endoscopic group (77 vs 57%). Conclusion Endoscopic therapy in combination with effective operative drainage may support healing of anastomotic leaks after rectal resection. However, the majority of patients require operative reintervention with bowel diversion despite endoscopic treatment.

To the editor: Obesity surgery recently published an interesting review entitled “An Evidence-Based Algorithm for the Management of Marginal Ulcers following Roux-en-Y Gastric Bypass” by Carr et al. [1]. I absolutely agree with their recommendations concerning the therapeutical management of MU following gastric bypass surgery based on 47 relevant articles including large case series and case control studies. Following their proposed algorithm for the management of MU, patients treated by NSAID and smokers are seen as a high risk group to develop MU and lifelong PPI prophylaxis is recommended. In my opinion, also patients with hyperacidity in their gastric pouch have to be seen as high risk patients and PPI prophylaxis should be performed. Hedberg et al. found that the proximal pouch of patients suffering fromMU is significantly more exposed to acid compared to asymptomatic RYGBP patients. In their study, the median percentage of time with pH