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BACKGROUND The aim of this study was to describe temporal trends in presentation, surgical management and immediate postoperative outcomes in patients recorded in a registry of colorectal cancer resections that was initiated at Concord Hospital, Sydney, Australia, in 1971. A companion paper describes tumour pathology and long-term recurrence and survival. METHODS This report is based on 5217 consecutive resections up to 2013, with no exclusions. Categories in variables examined were expressed as percentages over annual totals of relevant patients or annual mean values. The statistical significance of trends was examined by least squares regression. RESULTS The percentage of asymptomatic patients increased over time, whereas urgent presentations declined. Tumour size declined. The percentage of rectal cancers fell but the percentage of low rectal tumours rose. Initially, restorative rectal resections increased rapidly but later remained stable. There was no trend in medical complications, whereas surgical complications declined. Anastomotic leakage after restorative rectal resections declined but it was low and stable for colonic tumours. The rate of early reoperation remained stable, whereas 30-day mortality declined. Neoadjuvant radiotherapy for rectal cancer and adjuvant chemotherapy for stages B and C were introduced in 1992 and applied increasingly thereafter. CONCLUSION Our findings, based on a 43-year prospective study, indicate sustained trends towards the earlier diagnosis of colorectal cancer and favourable short-term outcomes following bowel resection.

BACKGROUND The aim of this study was to describe temporal trends in tumour pathology and long-term outcomes in 5217 patients recorded in a registry of colorectal cancer resections initiated at Concord Hospital, Sydney, Australia, in 1971. METHODS This report is based on consecutive resections up to December 2013, with no exclusions. Categories in variables examined were expressed as percentages over annual totals of relevant patients or annual mean values. The statistical significance of temporal trends was examined by least squares regression. RESULTS The percentages of patients with local spread beyond the muscularis propria, nodal metastasis, distant metastasis and tumour in a line of resection all declined significantly. In consequence, the percentage of stage D patients fell, whereas the percentage in stage A rose. Other tumour variables that increased significantly were polypoid morphology, contiguous adenoma and invasion of a free serosal surface. Tumours in which an adherent adjacent structure was partly or completely removed also increased. There were significant declines in high-grade malignancy, venous invasion and tumour size. The recurrence rate for rectal cancers declined significantly, whereas for rectal and colonic cancers combined, both the overall 5-year survival rate and the 5-year cancer-specific survival rate increased markedly. CONCLUSION These results show a reduction in adverse pathology findings and favourable trends in recurrence and survival after colorectal cancer resections in a high-incidence country over a period of 43 years.

Two recent reviews reached opposing conclusions regarding the apparent detrimental effect of peri-operative blood transfusion on patient survival after resection of colorectal cancer. However, both studies agree that the influence of confounding variables has not been controlled adequately in most studies. The present study is based on 433 patients who had a curative resection for colorectal cancer between 1984 and 1989 and whose details and follow-up information were recorded in the Concord Hospital Colorectal Cancer Registry, Sydney. The association between peri-operative transfusion and patient survival after resection of colorectal cancer was examined taking into account 20 other prognostic variables. A proportional hazards regression model showed that transfusion did not have a statistically significant independent effect on survival after controlling for the patients' poor general condition, the complexity of the surgery and the occurrence of postoperative complications.

Today, a standardized method of staging that is internationally accepted is urgently needed for the management of patients with colorectal cancer. The use of a uniform, sensitive staging system would greatly improve case selection and avoid unnecessary bias when entering patients into adjuvant therapy trials. This would allow a more accurate evaluation of new treatment protocols and assist in the development of more effective follow-up programmes.

Comparison of 122 patients who have had an abdominoperineal excision of the rectum with 118 patients treated by conventional anterior resection showed no significant difference in patient survival. The grounds were comparable in respect of age, sex, tumour level and pathology. This suggests that conventional restorative resection for rectal cancer may be undertaken without adversely affecting survival.

Between 1971 and 1980, 346 patients had a carcinoma of the colon resected. Seventy-seven patients had an urgent operation with a hospital mortality of 13.3%; 269 patients had an elective operation with a mortality of 3.8%. Three patients died as a result of anastomotic leakage. Other complications were thromboembolism (2%) and wound infection (14.5%). The overall median survival was 28.4 months and 57 months following curative resection. The clinicopathological staging system used identified 28% of patients as incurable at the time of resection.

Out of 338 patients undergoing laparotomy and resection of a primary colorectal carcinoma, 49 (14.5%) were found to have liver metastases. The average age was 70 years. The median period of survival was 11.4 months. The histological grade of malignancy of the primary tumour did not appear to influence the survival rate. Compared with similar tumours in patients without hepatic metastases, the primary growth showed a significantly increased incidence of venous invasion, a higher grade of malignancy, and a more frequent origin from the right colon. When the local spread of the primary tumours was investigated it was found that one-third of them had not progressed beyond Stage Dukes A or B.

Twenty patients (10%) developed a local recurrence following 200 consecutive curative resections for colorectal carcinoma. Analysis of the pathology of the primary tumours suggests that invasion of adjacent tissues, and lymph node involvement, were more important predisposing factors for the development of local recurrence than the margin of resection on the mucosa. The average time interval between resection and diagnosis of local recurrence was 17 months. The average survival time following diagnosis was 10 months. Nineteen out of 20 of these patients developed evidence of disseminated disease subsequent to the diagnosis of local recurrence. The most effective palliation occurred in patients in whom the local recurrence could be resected.

The cases of 13 patients suffering from chronic phlegmonous diverticulitis have been studied. Histological examination of the resected specimens revealed the classical features of diverticular disease, but in addition, a chronic fibroblastic inflammatory reaction surrounding the diverticula in the subserosal fat was observed. Eight patients developed an inflammatory tumour insidiously, with no previous history of diverticular disease. Resection is indicated for diagnostic reasons, as well as for potentially lethal complications. Resection and primary anastomosis with a covering transverse colostomy are the recommended surgical management.