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Background The optimal management of colorectal cancer with synchronous liver metastases has not yet been elucidated. The aim of the present study was systematically to review current evidence concerning the timing and sequence of surgical interventions: colon first, liver first or simultaneous. Methods A systematic literature review was performed of clinical studies comparing the timing and sequence of surgical interventions in patients with synchronous liver metastases. Retrospective studies were included but case reports and small case series were excluded. Preoperative and intraoperative data, length of hospital stay, perioperative mortality and morbidity, and 1-, 3- and 5-year survival rates were compared. The studies were evaluated according to a modification of the methodological index for non-randomized studies ( MINORS) criteria. Results Eighteen papers were included and 21 entries analysed. Five entries favoured the simultaneous approach regarding duration of procedure, whereas three showed no difference; five entries favoured simultaneous treatment in terms of blood loss, whereas in four there was no difference; and all studies comparing length of hospital stay favoured the simultaneous approach. Five studies favoured the simultaneous approach in terms of morbidity and eight found no difference, and no study demonstrated a difference in perioperative mortality. One study suggested a better 5-year survival rate after staged procedures, and another suggested worse 1-year but better 3- and 5-year survival rates following the simultaneous approach. The median MINORS score was 10, with incomplete follow-up and outcome reporting accounting primarily for low scores. Conclusion None of the three surgical strategies for synchronous colorectal liver metastases appeared inferior to the others. [ABSTRACT FROM AUTHOR]

Background The routine collection of large amounts of clinical data, 'big data', is becoming more common, as are research studies that make use of these data source. The aim of this paper is to provide an overview of the uses of data from large multi-institution clinical databases for research. Methods This article considers the potential benefits, the types of data source, and the use to which the data is put. Additionally, the main challenges associated with using these data sources for research purposes are considered. Results Common uses of the data include: providing population characteristics; identifying risk factors and developing prediction (diagnostic or prognostic) models; observational studies comparing different interventions; exploring variation between healthcare providers; and as a supplementary source of data for another study. The main advantages of using such big data sources are their comprehensive nature, the relatively large number of patients they comprise, and the ability to compare healthcare providers. The main challenges are demonstrating data quality and confidently applying a causal interpretation to the study findings. Conclusion Large clinical database research studies are becoming ubiquitous and offer a number of potential benefits. However, the limitations of such data sources must not be overlooked; each research study needs to be considered carefully in its own right, together with the justification for using the data for that specific purpose. [ABSTRACT FROM AUTHOR]

Background: Optical techniques using previously unexploited properties of light interaction with tissue may be valuable in the detection, diagnosis and staging of colorectal neoplasia. Methods: A Medline search (1990 to present) was conducted on optical diagnostics in the detection of colorectal neoplasia. The reference list of each identified article was reviewed for further relevant papers. Results and conclusion: Chromoendoscopy is the only optical adjunct to colonoscopy that has been tested in large randomized clinical trials. It improves the detection of small and flat colorectal adenomas, and of neoplasia in chronic ulcerative colitis and hereditary non-polyposis colorectal cancer. All other techniques are the subject of ongoing research and the practicality of population screening with any of the methods has yet to be established. Optical techniques may, however, permit immediate clinical diagnosis, removing the need for histological analysis. They may also improve the diagnosis of early colonic neoplasia. Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background and method: This paper reviews the current status of radiofrequency ablation in the treatment of colorectal liver metastases. Relevant studies with at least ten patients that reported rates of complete tumour ablation, local recurrence, or survival from 1 to 5 years after treatment were included in the review. Results and conclusion: Only six studies that reported at least 3-year survival were identified, with results ranging from 37 to 58 per cent. Some of these figures are promising, given that the patients were considered to have unresectable disease. However, available evidence is limited and hepatic resection remains the standard of care when feasible; radiofrequency ablation cannot be considered an equivalent. Radiofrequency ablation does, however, appear to have a role in treating unresectable disease, and may also be used in conjunction with resection to extend its limits. [ABSTRACT FROM AUTHOR]

Background: Cyclo-oxygenase inhibition for the treatment of colorectal neoplasia has been studied with renewed interest since the discovery of cyclo-oxygenase (Cox) 2 and the introduction of specific Cox-2 inhibitors. These drugs have implications for both the prevention of colorectal carcinoma and the potential treatment of the disease. Methods and results: A Medline database search was performed for articles using the keywords 'colonic, colon or rectal and neoplasia or cancer' and 'cyclo-oxygenase or Cox-2.' Cross-references of relevant historical papers were also included. There is substantial evidence that Cox-2 plays a role in the development and progression of colorectal cancer. The specific inhibition of this enzyme has been shown to inhibit cancer growth in in vitro and in vivo models. The mechanisms of action for these effects are poorly understood and potential clinical applications at present remain under investigation. Conclusion: Cox-2 inhibitors have great promise as useful additions to current cancer treatments. There is a need for randomized clinical trials to define a role for these drugs in chemoprevention, recurrence prophylaxis, and adjuvant therapy for colorectal and other solid tumours. [ABSTRACT FROM AUTHOR]

Background: Hereditary non-polyposis colorectal cancer (HNPCC) is an inherited genetic condition associated with microsatellite instability; it accounts for around 5 per cent of all cases of colorectal cancer. This review examines recent data on management strategies for this condition. Methods: A Medline-based literature search was performed using the keywords 'HNPCC' and 'microsatellite instability'. Additional original papers were obtained from citations in articles identified by the initial search. Results and conclusion: The Amsterdam criteria identify patients in whom the presence of an inherited mutation should be investigated. Those with a mutation should be offered counselling and screening. The role of prophylactic surgery has been superseded by regular colonoscopy, which dramatically reduces the risk of colorectal cancer. Screening for extracolonic malignancy is also advocated, but the benefits are uncertain. Chemoprevention may be of value in lowering the incidence of bowel cancer in affected patients, but further studies are required. [ABSTRACT FROM AUTHOR]

Background: This paper reports a 7-year experience of cryoablation for colorectal and non-colorectal liver metastases. Methods: A retrospective review was undertaken of patients treated in two adjacent UK centres in the north-west of England. Results: Over a 7-year period (1993-2000), 57 patients underwent cryotherapy for malignant hepatic tumours (41 colorectal, 16 non-colorectal). In the patients with colorectal metastases, preoperative carcinoembryonic antigen (CEA) levels fell significantly, from a mean of 444.1 to 6.22 μg/1 (P = 0.002). One patient died, two developed cryoshock and six had cardiorespiratory complications. All patients with colorectal metastases subsequently received 5-fluorouracil-based chemotherapy. The remaining 16 patients with non-colorectal tumours (seven neuroendocrine metastases, five hepatocellular carcinomas, three sarcomas, one cholangiocarcinoma) all received cryotherapy alone, with no major complications. The median survival for patients with non-colorectal metastases was 37 months, compared with 22 months for those with colorectal metastases (P = 0.005). Conclusion: Hepatic cryotherapy is effective and safe, as demonstrated by the significant reduction in postoperative CEA concentration and the low risk of complications. However, this initial short-term success was not reflected in 5-year survival rates. Cryotherapy for non-colorectal metastases had a greater long-term survival benefit and is a useful means of controlling symptoms. [ABSTRACT FROM AUTHOR]

Background: It is widely accepted that the adenoma–carcinoma sequence represents the process by which most, if not all, colorectal cancers arise. The evidence supporting this hypothesis has increased rapidly in recent years and the purpose of this article is to review this evidence critically and highlight its clinical significance. Methods: Medline searches were used to identify recent key articles relating to the adenoma–carcinoma sequence. Further pertinent articles were obtained by manual scanning of the reference lists of identified papers. Results: The evidence supporting the adenoma–carcinoma sequence can be classified as epidemiological, clinicopathological and genetic. The most recent and largest body of data relates to molecular genetic events and their cellular effects; however, many other approaches, such as cytogenetics, molecular cytogenetics and cytometry, have also yielded valuable information. Conclusion: Recent work continues to support the adenoma–carcinoma sequence, but there is a paucity of data on the interrelationship between different genetic mutations and on the relationship between molecular and other types of genetic abnormalities. The clinical utility of the observations described has yet to be fully realized and global genetic analysis of colorectal tumours may prove to be central in rational adenoma management. [ABSTRACT FROM AUTHOR]

Background Advances in molecular pathology have enabled a number of colorectal cancer antigens to be identified and characterized. The commonest investigated include 17-1A, 791Tgp72 and carcinoembryonic antigen. Vaccines have been developed that stimulate the immune system to target these antigens. This paper reviews current areas of research in this field. Methods and Results Relevant articles were obtained on vaccines for colorectal cancer from Medline and the Bath Information Data System. A number of approaches are currently being evaluated in Phase I, II and III trials. These include anti-idiotypic antibody immunization, DNA vaccines, mucin and heat shock protein-based vaccines, oncogenes and viral vectors. Conclusion Evidence is accumulating to suggest that immune responses may be generated against colorectal cancer using these approaches. While the concept of vaccination against this malignancy is essentially experimental, surgeons should be aware of current advances. [ABSTRACT FROM AUTHOR]

The article discusses a study which examines the medical prognosis after resection and ablation of colorectal liver metastases (CLMs). The study shows that poorer overall and disease-free survival in patients is the result of the radical treatment of more than three CLMs and that the number of lesions should not be the basis to exclude patients from surgery. It is stated that the number of CLMs must not be used as reason for excluding patients from radical treatment.

Presents several letters to the editor in response to previous articles related to surgery that was previously published in the "British Journal of Surgery." "Fast-track Surgery," which tackles the adoption of fast-tracking patients undergoing colorectal cancer; "Risk Factors for Anastomotic Failure After Total Mesorectal Excision of Rectal Cancer," which discusses the possibility for the placement of one or more pelvic drains after total mesorectal excision to limit the consequence of anastomotic failure; "Randomized Clinical Trial of Laparoscopic Versus Open Appendicectomy for Confirmed Appendicitis," which discusses the outcomes associated with standard open and laparoscopic appendicectomy.

Adequate lymph node dissection is just one part of oncologic surgery; plane preservation and multivisceral en bloc resections are the two other important objectives. 2 West NP, Hohenberger W, Weber K, Perrakis A, Finan PJ, Quirke P. Complete mesocolic excision with central vascular ligation produces an oncologically superior specimen compared with standard surgery for carcinoma of the colon. Understanding optimal colonic cancer surgery: comparison of Japanese D3 resection and European complete mesocolic excision with central vascular ligation. [Extracted from the article]

Copyright of British Journal of Surgery is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of British Journal of Surgery is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Patients with non‐resectable colorectal metastases are currently treated with chemotherapy. However, liver transplantation can increase the 5‐year survival rate from 9 to 56 per cent if the cancer is confined to the liver. The aim of this study was to estimate the cost‐effectiveness of liver transplantation for colorectal liver metastases. Methods: A Markov model with a lifetime perspective was developed to estimate the life‐years, quality‐adjusted life‐years (QALYs), direct healthcare costs and cost‐effectiveness for patients with non‐resectable colorectal liver metastases who received liver transplantation or chemotherapy alone. Results: In non‐selected cohorts, liver transplantation increased patients' life expectancy by 3·12 life‐years (2·47 QALYs), at an additional cost of €209 143, giving an incremental cost‐effectiveness ratio (ICER) of €67 140 per life‐year (€84 667 per QALY) gained. In selected cohorts (selection based on tumour diameter, time since primary cancer, carcinoembryonic antigen levels and response to chemotherapy), the effect of liver transplantation increased to 4·23 life‐years (3·41 QALYs), at a higher additional cost (€230 282), and the ICER decreased to €54 467 per life‐year (€67 509 per QALY) gained. Given a willingness to pay of €70 500, the likelihood of transplantation being cost‐effective was 0·66 and 0·94 (0·23 and 0·67 QALYs) for non‐selected and selected cohorts respectively. Conclusion: Liver transplantation was cost‐effective but only for highly selected patients. This might be possible in countries with good access to grafts and low waiting list mortality. Not cost effective for everyone [ABSTRACT FROM AUTHOR]

Background: Obesity increases the risk of several types of cancer. Whether bariatric surgery influences the risk of obesity‐related cancer is not clear. This study aimed to uncover the risk of hormone‐related (breast, endometrial and prostate), colorectal and oesophageal cancers following obesity surgery. Methods: This national population‐based cohort study used data from the Hospital Episode Statistics database in England collected between 1997 and 2012. Propensity matching on sex, age, co‐morbidity and duration of follow‐up was used to compare cancer risk among obese individuals undergoing bariatric surgery (gastric bypass, gastric banding or sleeve gastrectomy) and obese individuals not undergoing such surgery. Conditional logistic regression provided odds ratios (ORs) with 95 per cent confidence intervals. Results: In the study period, from a cohort of 716 960 patients diagnosed with obesity, 8794 patients who underwent bariatric surgery were matched exactly with 8794 obese patients who did not have surgery. Compared with the no‐surgery group, patients who had bariatric surgery exhibited a decreased risk of hormone‐related cancers (OR 0·23, 95 per cent c.i. 0·18 to 0·30). This decrease was consistent for breast (OR 0·25, 0·19 to 0·33), endometrium (OR 0·21, 0·13 to 0·35) and prostate (OR 0·37, 0·17 to 0·76) cancer. Gastric bypass resulted in the largest risk reduction for hormone‐related cancers (OR 0·16, 0·11 to 0·24). Gastric bypass, but not gastric banding or sleeve gastrectomy, was associated with an increased risk of colorectal cancer (OR 2·63, 1·17 to 5·95). Longer follow‐up after bariatric surgery strengthened these diverging associations. Conclusion: Bariatric surgery is associated with decreased risk of hormone‐related cancers, whereas gastric bypass might increase the risk of colorectal cancer. Obesity affects cancer risk [ABSTRACT FROM AUTHOR]

Background: Despite a 5-year overall survival rate of 58 per cent after liver resection for colorectal liver metastases (CLMs),more than half of patients develop recurrence, highlighting the need for accurate risk stratification and prognostication.Traditional prognostic factors have been superseded by newer outcome predictors, including those defined by the molecular origin of the primary tumour. Methods: This review synthesized findings in the literature using the PubMed database of articles in the English language published between 1998 and 2017 on prognostic and predictive biomarkers in patients undergoing resection of CLMs. Results: Responses to preoperative chemotherapy define prognosis in patients undergoing CLM resection. There are differences by embryological origin too. Somatic mutations in the proto-oncogenes KRAS and NRAS are associated with positive surgical margins and tumour regrowth after ablation. Other mutations (such as BRAF) and co-occurring mutations in RAS/TP53 and APC/PIK3CA have emerged as important biomarkers that determine an individual patient's tumour biology and may be used to predict outcome after CLM resection. Conclusion: Knowledge of somaticmutations can guide the use of preoperative therapy, extent of surgical margin and selection for ablation alone. [ABSTRACT FROM AUTHOR]

The author comments on the article "Surgical Management of Disappearing Colorectal Liver Metastases" published in this issue of the journal. He notes the effect of the personalization trend in patients with unresectable colorectal metastases. He says the article has described a modern approach to assessing resectability potential. He points out the unpredictable relationship between disappearing liver metastases and complete pathological responses.

Background New Zealand has among the highest rates of colorectal cancer in the world and is an unscreened population. The aim of this study was to determine the trends in incidence and tumour location in the New Zealand population before the introduction of national colorectal cancer screening. Methods Data were obtained from the national cancer registry and linked to population data from 1995 to 2012. Incidence rates for colorectal cancer by sex, age (less than 50 years, 50-79 years, 80 years or more) and location (proximal colon, distal colon and rectum) were assessed by linear regression. Results Among patients aged under 50 years, the incidence of distal colonic cancer in men increased by 14 per cent per decade (incidence rate ratio ( IRR 1·14), 95 per cent c.i. 1·00 to 1·30; P = 0·042); the incidence of rectal cancer in men increased by 18 per cent ( IRR 1·18, 1·06 to 1·32; P = 0·002) and that in women by 13 per cent ( IRR 1·13, 1·02 to 1·26; P = 0·023). In those aged 50-79 years, there was a reduction in incidence per decade of proximal, distal and rectal cancers in both sexes. In the group aged 80 years and over, proximal cancer incidence per decade increased by 19 per cent in women ( IRR 1·19, 1·13 to 1·26; P < 0·001) and by 25 per cent in men ( IRR 1·25, 1·18 to 1·32; P < 0·001); among women, the incidence of distal colonic cancer decreased by 8 per cent ( IRR 0·92, 0·86 to 0·98); P = 0·012), as did that of rectal cancer ( IRR 0·92, 0·86 to 0·97; P = 0·005). Conclusion The increasing incidence of rectal cancer among younger patients needs to be considered when implementing screening strategies. [ABSTRACT FROM AUTHOR]

Background Ulcerative colitis ( UC) promotes cancer, and can be ameliorated by early appendicectomy for appendicitis. The aim of the study was to explore the effect of appendicectomy on colitis and colonic neoplasia in an animal model of colitis and a cohort of patients with UC. Methods Five-week old IL10/ Nox1DKO mice with nascent colitis and 8-week-old IL10/ Nox1DKO mice with established colitis underwent appendicectomy (for experimental appendicitis or no appendicitis) or sham laparotomy. The severity and extent of colitis was assessed by histopathological examination, and a clinical disease activity score was given. From a cohort of consecutive patients with UC who underwent colectomy, the prevalence of appendicectomy and pathological findings were collected from two institutional databases. Results Appendicectomy for appendicitis ameliorated experimental colitis in the mice; the effect was more pronounced in the 5-week-old animals. Appendicectomy in the no-appendicitis group was associated with an increased rate of colonic high-grade dysplasia ( HGD) or cancer compared with rates in sham and appendicitis groups (13 of 20 versus 0 of 20 and 0 of 20 respectively; P < 0·001). Fifteen of 232 patients who underwent colectomy for UC had previously had an appendicectomy, and nine of these had colonic cancer or HGD. Thirty (13·8 per cent) of 217 patients with the appendix in situ had colonic neoplastic lesions. Multivariable analysis showed that previous appendicectomy was associated with colorectal neoplasia (odds ratio 16·88, 95 per cent c.i. 3·32 to 112·69). Conclusion Appendicectomy for experimental appendicitis ameliorated colitis. The risk of colorectal neoplasia appeared to increase following appendicectomy without induced appendicitis in a mouse model of colitis, and in patients with UC who had undergone appendicectomy. [ABSTRACT FROM AUTHOR]

Background After potentially curative resection of primary colorectal cancer, patients may be monitored by measurement of carcinoembryonic antigen and/or CT to detect asymptomatic metastatic disease earlier. Methods A systematic review and meta-analysis was conducted to find evidence for the clinical effectiveness of monitoring in advancing the diagnosis of recurrence and its effect on survival. MEDLINE (Ovid), Embase, the Cochrane Library, Web of Science and other databases were searched for randomized comparisons of increased intensity monitoring compared with a contemporary standard policy after resection of primary colorectal cancer. Results There were 16 randomized comparisons, 11 with published survival data. More intensive monitoring advanced the diagnosis of recurrence by a median of 10 (i.q.r. 5-24) months. In ten of 11 studies the authors reported no demonstrable difference in overall survival. Seven RCTs, published from 1995 to 2016, randomly assigned 3325 patients to a monitoring protocol made more intensive by introducing new methods or increasing the frequency of existing follow-up protocols versus less invasive monitoring. No detectable difference in overall survival was associated with more intensive monitoring protocols (hazard ratio 0·98, 95 per cent c.i. 0·87 to 1·11). Conclusion Based on pooled data from randomized trials published from 1995 to 2016, the anticipated survival benefit from surgical treatment resulting from earlier detection of metastases has not been achieved. [ABSTRACT FROM AUTHOR]

Background The most common sites of metastasis from colorectal cancer ( CRC) are hepatic and pulmonary; they can present simultaneously (hepatic and pulmonary metastases) or sequentially (hepatic then pulmonary metastases, or vice versa). Simultaneous disease may be aggressive, and thus may be approached with caution by the clinician. The aim of this study was to determine the outcomes following hepatic and pulmonary resection for simultaneously presenting metastatic CRC. Methods A retrospective review was undertaken of a prospectively maintained database to identify patients presenting with simultaneous hepatopulmonary disease who underwent hepatic resection. Patients' electronic records were used to identify clinicopathological variables. The log rank test was used to determine survival, and χ2 analysis to determine predictors of failure of intended treatment. Results Fifty-nine patients were identified and underwent hepatic resection; median survival was 45·4 months and the 5-year survival rate 38 per cent. Twenty-two patients (37 per cent) did not have the intended pulmonary intervention owing to progression or recurrence of disease. Thirty-seven patients who progressed to hepatopulmonary resection had a median survival of 54·2 months (5-year survival rate 43 per cent). Those who had hepatic resection alone had a median survival of 24·0 months (5-year survival rate 30 per cent). Failure to progress to pulmonary resection was predicted by heavy nodal burden of primary colorectal disease and bilobar hepatic metastases. Redo pulmonary surgery following pulmonary recurrence did not confer a survival benefit. Conclusion Selected patients with simultaneous hepatopulmonary CRC metastases should be considered for attempted curative resection, but some patients may not receive the intended treatment owing to progression of pulmonary disease after hepatic resection. [ABSTRACT FROM AUTHOR]

Background The aim was to establish the feasibility of using a tissue stabilization gel ( Allprotect™) as an alternative to liquid nitrogen to facilitate collection of clinical samples for translational research. Methods Tumour samples from patients undergoing surgery for primary or metastatic colorectal cancer were either snap-frozen in liquid nitrogen or stored in Allprotect™ under a number of different conditions. Sample integrity was compared across different storage conditions by assessing biomolecule stability and function. DNA quality was assessed spectrophotometrically and by KRas genotyping by pyrosequencing. Total RNA retrieval was determined by nanodrop indices/ RNA integrity numbers, and quality assessed by reverse transcription- PCR for two representative genes (high-mobility group box 1, HMGB1; carboxylesterase 1, CES1) and two microRNAs ( miR122 and let7d). Western blot analysis of HMGB1 and CES1 was used to confirm protein expression, and the metabolic conversion of irinotecan to its active metabolite, SN-38, was used to assess function. Results Under short-term storage conditions (up to 1 week) there was no apparent difference in quality between samples stored in Allprotect™ and those snap-frozen in liquid nitrogen. Some RNA degradation became apparent in tissue archived in Allprotect™ after 1 week, and protein degradation after 2 weeks. Conclusion In hospitals that do not have access to liquid nitrogen and -80°C freezers, Allprotect™ provides a suitable alternative for the acquisition and stabilization of clinical samples. Storage proved satisfactory for up to 1 week, allowing transfer of samples without the need for specialized facilities. [ABSTRACT FROM AUTHOR]

Background Small studies have examined the effect of faecal occult blood test ( FOBT) screening on the proportion of hospital admissions for colorectal cancer ( CRC) classed as an emergency. This study aimed to examine this and short-term outcomes in persons invited for screening compared with a control group not invited. Methods The invited group comprised all individuals invited between 1 April 2000 and 31 July 2007 in the Scottish arm of the UK demonstration pilot of FOBT, and subsequently diagnosed with CRC aged 50-72 years between 1 May 2000 and 31 July 2009. The controls comprised all remaining individuals in Scotland not invited for FOBT but diagnosed with CRC aged 50-72 years in the same period. Results There were 2981 people diagnosed with CRC in the group invited for screening (58·3 per cent participated) and 9842 in the control group. Multivariable regression adjusted for sex, age, deprivation, co-morbidities, tumour site and Dukes' stage showed no difference between the groups for emergency admissions (odds ratio ( OR) 0·89, 95 per cent confidence interval (c.i.) 0·77 to 1·02; P = 0·084) or length of hospital stay ( LOS) (β coefficient −1·02 (95 per cent c.i. -1·05 to 1·01) days; P = 0·226). Comparing participants with controls, there were fewer emergency admissions ( OR 0·59, 0·49 to 0·71; P < 0·001) and shorter LOS (β coefficient −1·06 (−1·10 to −1·02) days; P = 0·001). Short-term mortality was lower in the screened than the non-screened population (1·1 versus 2·8 per cent; P = 0·001). Conclusion People who participated in FOBT screening had fewer emergency admissions and a shorter LOS. Deprivation was associated negatively with participation, but the impact of FOBT participation on emergency admissions was independent of deprivation level. The reduction in LOS has potential to reduce financial costs. [ABSTRACT FROM AUTHOR]

Background: Clinical guidelines recommend that, where clinically appropriate, laparoscopic tumour resections should be available for patients with colorectal cancer. This study aimed to examine the introduction of laparoscopic surgery in the English National Health Service. Methods: Data were extracted from the National Cancer Data Repository on all patients who underwent major resection for a primary colorectal cancer diagnosed between 2006 and 2008. Laparoscopic procedures were identified from codes in the Hospital Episode Statistics and National Bowel Cancer Audit Project data in the resource. Trends in the use of laparoscopic surgery and its influence on outcomes were examined. Results: Of 58 135 resections undertaken over the study period, 10 955 (18·8 per cent) were attempted laparoscopically. This increased from 10·0 (95 per cent confidence interval (c.i.) 8·1 to 12·0) per cent in 2006 to 28·4 (25·4 to 31·4) per cent in 2008. Laparoscopic surgery was used less in patients with advanced disease (modified Dukes' stage 'D' versus A: odds ratio (OR) 0·45, 95 per cent c.i. 0·40 to 0·50), rectal tumours (OR 0·71, 0·67 to 0·75), those with more co-morbidity (Charlson score 3 or more versus 0: OR 0·69, 0·58 to 0·82) or presenting as an emergency (OR 0·15, 0·13 to 0·17). A total of 1652 laparoscopic procedures (15·1 per cent) were converted to open surgery. Conversion was more likely in advanced disease (modified Dukes' stage 'D' versus A: OR 1·56, 1·20 to 2·03), rectal tumours (OR 1·29, 1·14 to 1·46) and emergencies (OR 2·06, 1·54 to 2·76). Length of hospital stay (OR 0·65, 0·64 to 0·66), 30-day postoperative mortality (OR 0·55, 0·48 to 0·64) and risk of death within 1 year (hazard ratio 0·60, 0·55 to 0·65) were reduced in the laparoscopic group. Conclusion: Laparoscopic surgery was used more frequently in low-risk patients. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Short-term outcomes with intrathecal versus epidural analgesia in laparoscopic colorectal surgery," by V. Ratnalikar et al.

A letter to the editor is presented in response to the article "Predictive Value of Common Symptom Combinations in Diagnosing Colorectal Cancer," by M. R. Thompson in a 2007 issue.

A response by M. R. Thompson to a letter to the editor about his article "Predictive Value of Common Symptom Combinations in Diagnosing Colorectal Cancer," in a 2007 issue is presented.

Background: Some 75-80 per cent of patients undergoing liver resection for colorectal liver metastases develop intrahepatic recurrence. A significant number of these can be considered for repeat liver surgery. This study examined the outcomes of repeat liver resection for the treatment of recurrent colorectal metastases confined to the liver. Methods: Patients who underwent repeat liver resection in a single tertiary referral hepatobiliary centre were identified from a database. Clinicopathological variables were analysed to assess factors predictive of survival. Results: A total of 195 patients underwent repeat resection between 1993 and 2010. Median age was 63 years, and the median interval between first and repeat resection was 13·8 months. Thirty-three patients (16·9 per cent) underwent completion hemihepatectomy or extended hemihepatectomy and the remainder had non-anatomical or segmental resection. The 30-day mortality rate was 1·5 per cent, and the overall 30-day morbidity rate was 20·0 per cent. Overall 1-, 3- and 5-year survival rates were 91·2, 44·3 and 29·4 per cent respectively. Tumour size 5 cm or greater was the only independent predictor of overall survival (relative risk 1·71, 95 per cent confidence interval 1·08 to 2·70; P = 0·021). Neoadjuvant chemotherapy before resection, perioperative blood transfusion, bilobar disease, R1 resection margin and multiple metastases were among factors that did not significantly influence survival. Conclusion: Repeat hepatic resection remains the only curative option for patients presenting with recurrent colorectal liver metastases. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Intraoperative ultrasonography (IOUS) is considered the standard for the identification of liver metastases. Use of lipid-stabilized perfluorobutane microbubbles as an ultrasound contrast agent may improve this. The value of contrast-enhanced IOUS (CE-IOUS) in enumerating colorectal liver metastases was studied here. Methods: CE-IOUS was performed in consecutive resections for colorectal liver metastases in 2007-2010. All patients underwent preoperative computed tomography. Magnetic resonance imaging was not carried out routinely. Conventional intraoperative examination including IOUS, and CE-IOUS with peripherally injected contrast were performed. The histopathological findings and 6-month follow-up images were used as the reference standard. Results: The study group of 102 patients had a total of 315 lesions identified on preoperative imaging (2·4 lesions per operation; 129 operations). Conventional intraoperative examination including IOUS identified 350 lesions (2·7 per operation). CE-IOUS identified 370 lesions (2·9 per operation). The sensitivity, specificity and accuracy of CE-IOUS were 97·1, 59·1 and 93·2 per cent respectively. The CE-IOUS findings altered the surgical plan in 19 operations (14·7 per cent). Conclusion: CE-IOUS provided additional information to that obtained using contemporary preoperative imaging and conventional intraoperative examinations. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: One hundred and ten patients were treated with palliative chemotherapy, of whom 53 had liver-only disease and had not been reviewed by a specialist liver surgeon. One scan was excluded as all reviewers felt it to be of insufficient quality to assess. Improved surgical technique and better chemotherapeutic manipulation of metastatic disease has increased the number of patients eligible for potentially curative resection of colorectal liver metastases. The rapid evolution in this field suggests that non-specialist decision-making may lead to inappropriate management. This study aimed to assess the management of colorectal liver metastases by non-liver surgeons. Methods: All patients who underwent chemotherapy with palliative intent for metastatic colorectal cancer at a regional oncology centre between 1 January and 31 December 2009 were identified from a prospectively maintained local database. Six resectional liver surgeons blinded to patient management and outcome reviewed pretreatment imaging and assigned each scan a score based on their own management choice. A consensus decision was reached on the appropriateness of palliative chemotherapy. Results: Tumours in 33 patients (63 per cent) were considered potentially resectable, with a high level of interobserver agreement (κ = 0·577). When individual approach to management was considered, interobserver agreement was less marked (κ = 0·378). Conclusion: Management of patients with colorectal liver metastases without the involvement of a specialist liver multidisciplinary team can lead to patients being denied potentially curative treatments. Management of these patients must involve a specialist liver surgeon to ensure appropriate management. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: With the implementation of multimodal analgesia regimens in fast-track surgery programmes, non-steroidal anti-inflammatory drugs (NSAIDs) are being prescribed routinely. However, doubts have been raised concerning the safety of NSAIDs in terms of anastomotic healing. Methods: Data on patients who had undergone primary colorectal anastomosis at two teaching hospitals between January 2008 and December 2010 were analysed retrospectively. Exact use of NSAIDs was recorded. Rates of anastomotic leakage were compared between groups and corrected for known risk factors in both univariable and multivariable analyses. Results: A total of 795 patients were divided into four groups according to NSAID use: no NSAIDs (471 patients), use of non-selective NSAIDs (201), use of selective cyclo-oxygenase (COX) 2 inhibitors (79), and use of both selective and non-selective NSAIDs (44). The overall leak rate was 9·9 per cent (10·0 per cent for right colonic, 8·7 per cent for left colonic and 12·4 per cent for rectal anastomoses). Known risk factors such as smoking and use of steroids were not significantly associated with anastomotic leakage. Stapled anastomosis was identified as an independent predictor of leakage in multivariable analysis (odds ratio (OR) 2·22, 95 per cent confidence interval 1·30 to 3·80; P = 0·003). Patients on NSAIDs had higher anastomotic leakage rates than those not on NSAIDs (13·2 versus 7·6 per cent; OR 1·84, 1·13 to 2·98; P = 0·010). This effect was mainly due to non-selective NSAIDs (14·5 per cent; OR 2·13, 1·24 to 3·65; P = 0·006), not selective COX-2 inhibitors (9 per cent; OR 1·16, 0·49 to 2·75; P = 0·741). The overall mortality rate was 4·2 per cent, with no significant difference between groups ( P = 0·438). Conclusion: Non-selective NSAIDs may be associated with anastomotic leakage. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: This was a population-based cohort study to determine the incidence, prevalence and risk factors for peritoneal carcinomatosis (PC) from colorectal cancer. Methods: Prospectively collected data were obtained from the Regional Quality Registry. The Cox proportional hazards regression model was used for multivariable analysis of clinicopathological factors to determine independent predictors of PC. Results: All 11 124 patients with colorectal cancer in Stockholm County during 1995-2007 were included and followed until 2010. In total, 924 patients (8·3 per cent) had synchronous or metachronous PC. PC was the first and only localization of metastases in 535 patients (4·8 per cent). The prevalence of synchronous PC was 4·3 per cent (477 of 11 124). The cumulative incidence of metachronous PC was 4·2 per cent (447 of 10 646). Independent predictors for metachronous PC were colonic cancer (hazard ratio (HR) 1·77, 95 per cent confidence interval 1·31 to 2·39; P = 0·002 for right-sided colonic cancer), advanced tumour (T) status (HR 9·98, 3·10 to 32·11; P < 0·001 for T4), advanced node (N) status (HR 7·41, 4·78 to 11·51; P < 0·001 for N2 with fewer than 12 lymph nodes examined), emergency surgery (HR 2·11, 1·66 to 2·69; P < 0·001) and non-radical resection of the primary tumour (HR 2·75, 2·10 to 3·61; P < 0·001 for R2 resection). Patients aged > 70 years had a decreased risk of metachronous PC (HR 0·69, 0·55 to 0·87; P = 0·003). Conclusion: PC is common in patients with colorectal cancer and is associated with identifiable risk factors. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Radiofrequency ablation (RFA) is a common procedure for the management of colorectal liver metastases. RFA-generated lesions are surrounded by a rim of hypoxia that is associated with aggressive outgrowth of intrahepatic micrometastases. Hypoxia-activated prodrugs such as tirapazamine are designed selectively to induce apoptosis in tumour cells under hypoxic conditions. Therefore, it was hypothesized that tirapazamine may have therapeutic value in limiting hypoxia-associated tumour outgrowth following RFA. Methods: Murine C26 and MC38 colorectal cancer cells were grown under hypoxia and normal oxygenation in vitro, and treated with different concentrations of tirapazamine. Apoptosis and cell cycle distribution were assessed by western blot and fluorescence-activated cell sorting analysis. Proliferative capacity was tested by means of colony-formation assays. Mice harbouring microscopic colorectal liver metastases were treated with RFA, followed by a single injection of tirapazamine (60 mg/kg) or saline. Tumour load was assessed morphometrically 7 days later. Results: Tirapazamine induced apoptosis of colorectal tumour cells under hypoxia in vitro. Under normal oxygenation, tirapazamine caused a G2 cell cycle arrest from which cells recovered partly. This reduced, but did not abolish, colony-forming capacity. A single dose of tirapazamine largely prevented accelerated outgrowth of hypoxic micrometastases following RFA. Tirapazamine administration was associated with minimal toxicity. Conclusion: Tirapazamine induced apoptosis in colorectal cancer cells in a hypoxia-dependent manner and potently suppressed hypoxia-associated outgrowth of liver metastases with limited toxicity. This warrants further study to assess the potential value of tirapazamine, or other hypoxia-activated prodrugs, as adjuvant therapeutics following RFA treatment of colorectal liver metastases. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: The evidence surrounding optimal follow-up after liver resection for colorectal metastases remains unclear. A significant proportion of recurrences occur in the early postoperative period, and some groups advocate more intensive review at this time. Methods: A systematic review of literature published between January 2003 and May 2010 was performed. Studies that described potentially curative primary resection of colorectal liver metastases that involved a defined follow-up protocol and long-term survival data were included. For meta-analysis, studies were grouped into intensive (more frequent review in the first 5 years after resection) and uniform (same throughout) follow-up. Results: Thirty-five studies were identified that met the inclusion criteria, involving 7330 patients. Only five specifically addressed follow-up. Patients undergoing intensive early follow-up had a median survival of 39·8 (95 per cent confidence interval 34·3 to 45·3) months with a 5-year overall survival rate of 41·9 (34·4 to 49·4) per cent. Patients undergoing routine follow-up had a median survival of 40·2 (33·4 to 47·0) months, with a 5-year overall survival rate of 38·4 (32·6 to 44·3) months. Conclusion: Evidence regarding follow-up after liver resection is poor. Meta-analysis failed to identify a survival advantage for intensive early follow-up. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Despite neoadjuvant chemotherapy, few patients with colorectal cancer liver metastases (CRLM) are eligible for liver resection. The aim of the present study was to investigate the efficacy of intraoperative radiofrequency ablation (IRFA) in the treatment of unresectable CRLM. Methods: Patients with unresectable metastases confined to the liver were eligible for this prospective, multicentre phase II study conducted between 2003 and 2008. They received IRFA treatment either with or without parenchymal resection, and underwent clinical and pathological examinations. The primary endpoint was complete hepatic response at 3 months. Overall, event-free and local progression-free survival, morbidity and quality of life were also examined. Results: Fifty-two patients were included, all of whom received neoadjuvant chemotherapy. They had a median of 5 (range 1-13) metastases, mostly bilateral or recurrent. A complete hepatic response was observed in 39 patients (75 (95 per cent confidence interval (c.i.) 61 to 86) per cent). Of ten patients with hepatic recurrence at 3 months, two relapses were at the site of ablation. Median follow-up was 2·9 (95 per cent c.i. 2·5 to 3·6) years. The 1-year local progression-free survival rate was 46 (95 per cent c.i. 32 to 59) per cent, the 3-year event-free survival rate was 10 (95 per cent c.i. 4 to 21) per cent and the 5-year overall survival rate was 43 (95 per cent c.i. 21 to 64) per cent. Twenty patients had postoperative complications, including one death. Quality of life increased over time for patients without disease progression. Conclusion: IRFA, either with or without resection, is a promising treatment option for patients with unresectable CRLM. Registration number: NTC00210106 (). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Tumour necrosis is a marker of poor prognosis in some tumours but the mechanism is unclear. This study examined the prognostic value of tumour necrosis and host inflammatory responses in colorectal cancer. Methods: This was a retrospective study of patients undergoing potentially curative resection of colorectal cancer at a single surgical institution over a 10-year period. Patients who underwent preoperative radiotherapy were excluded. The systemic and local inflammatory responses were assessed using the modified Glasgow Prognostic Score and Klintrup-Makinen criteria respectively. Original tumour sections were retrieved and necrosis graded as absent, focal, moderate or extensive. Associations between necrosis and clinicopathological variables were examined, and multivariable survival analyses carried out. Results: A total of 343 patients were included between 1997 and 2007. Tumour necrosis was graded as absent in 32 (9·3 per cent), focal in 166 (48·4 per cent), moderate in 101 (29·4 per cent) and extensive in 44 (12·8 per cent). There were significant associations between tumour necrosis and anaemia ( P = 0·022), white cell count ( P = 0·006), systemic inflammatory response ( P < 0·001), local inflammatory cell infiltrate ( P = 0·004), tumour node metastasis (TNM) stage ( P = 0·015) and Petersen Index ( P = 0·003). On univariable survival analysis, tumour necrosis was associated with cancer-specific survival ( P < 0·001). On multivariable survival analysis, age (hazard ratio (HR) 1·29, 95 per cent confidence interval 1·00 to 1·66), systemic inflammatory response (HR 1·74, 1·27 to 2·39), low-grade local inflammatory cell infiltrate (HR 2·65, 1·52 to 4·63), TNM stage (HR 1·55, 1·02 to 2·35) and high-risk Petersen Index (HR 3·50, 2·21 to 5·55) were associated with reduced cancer-specific survival. Conclusion: The impact of tumour necrosis on colorectal cancer survival may be due to close associations with the host systemic and local inflammatory responses. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

A response by J. A. Basco and M. M. Reza to a letter to the editor about their article "Systematic review of laparoscopic versus open surgery for colorectal cancer" in a 2006 issue is presented.

A letter to the editor is presented in response to the article "Systematic review of laparoscopic versus open surgery for colorectal cancer" in a 2006 issue.

Background: Up to 5 per cent of liver resections for colorectal cancer metastases involve the caudate lobe, with cancer-involved resection margins of over 50 per cent being reported following caudate lobe resection. Methods: Outcomes of consecutive liver resections for colorectal metastases involving the caudate lobe between 1996 and 2009 were reviewed retrospectively, and compared with those after liver surgery without caudate resection. Results: Twenty-five patients underwent caudate and 432 non-caudate liver resection. Caudate resection was commonly performed as part of extended resection. There were no differences in operative complications (24 versus 21·1 per cent; P = 0·727) or blood loss (median 300 versus 250 ml; P = 0·234). The operating time was longer for caudate resection (median 283 versus 227 min; P = 0·024). Tumour size was larger in the caudate group (median 40 versus 27 mm; P = 0·018). Resection margins were smaller when the caudate lobe was involved by tumour, than in resections including tumour-free caudate or non-caudate resection; however, there was no difference in the proportion of completely excised tumours between caudate and non-caudate resections (96 versus 96·1 per cent; P = 0·990). One-year overall survival rates were 90 and 89·3 per cent respectively ( P = 0·960), with 1-year recurrence-free survival rates of 62 and 71·2 per cent ( P = 0·340). Conclusion: Caudate lobe surgery for colorectal cancer liver metastases does not increase the incidence of resection margin involvement, although when the caudate lobe contains metastases the margins are significantly closer than in other resections. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: As surgical resection of colorectal liver metastases (CLM) remains the only treatment for cure, efforts to extend the surgical indications to include patients with multiple bilobar CLM have been made. This study evaluated the long-term outcome, safety and efficacy of two-stage hepatectomy (TSH) for CLM in a large cohort of patients. Methods: Patients undergoing surgery between December 1996 and December 2009 were reviewed. The early postoperative and long-term outcomes as well as the patterns of failure to complete TSH and its clinical implications were analysed. Results: Eighty patients were scheduled to undergo TSH. Sixty-one patients had completion of TSH combined with (58 patients), or without (3) portal vein embolization/ligation (PVE/PVL). Five patients were excluded after first-stage hepatectomy and 14 after PVE/PVL. The 5-year overall survival rate and median survival in patients who completed TSH were 32 per cent and 39·6 months respectively, and corresponding recurrence-free values were 11 per cent and 9·4 months respectively. Six patients were alive beyond 5 years after TSH. Multivariable logistic regression analysis showed that failure to complete TSH was driven by two independent prognostic scenarios: three or more CLM in the future remnant liver (FRL) combined with age over 70 years predicted tumour progression after first-stage hepatectomy, and three or more CLM in the FRL combined with carcinomatosis at the time of first-stage hepatectomy predicted the development of additional FRL metastases after PVE/PVL. Conclusion: A therapeutic strategy using TSH provided acceptable long-term survival with no postoperative mortality. Further efforts are needed to increase the number of patients who undergo TSH successfully. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

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The following abstracts will be presented at the 98th Annual Congress of the Swiss Society of Surgery, held in Geneva 25-27 May 2011. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: The aim of the study was to determine the association between short- and long-term outcomes and deprivation for patients undergoing operative treatment for colorectal cancer in the Northern Region of England. Methods: This was a retrospective analytical study based on the Northern Region Colorectal Cancer Audit Group database for the period 1998-2002. The Index of Multiple Deprivation 2004, an area-based measure, was recalibrated and used to quantify deprivation. Patients were ranked based on their postcode of residence and grouped into five categories. Results: Of 8159 patients in total, 7352 (90.1 per cent) had surgery; 6953 (94.6 per cent) of the 7352 patients underwent tumour resection and 4935 (67.7 per cent) of 7294 had a margin-negative (R0) resection. Deprivation was not associated with age, sex, tumour site, stage or other tumour-related factors. Compared with the most affluent group, the most deprived patients had fewer elective operations (72.9 versus 76.4 per cent; P = 0.014), more adverse co-morbidity (P < 0.001) and fewer curative resections (65.5 versus 71.2 per cent; P < 0.001). In multivariable analysis, deprivation was not an independent predictor of postoperative death (odds ratio (OR) 0.72, 95 per cent confidence interval 0.48 to 1.06; P = 0.101) but it was a predictor of curative resection (OR 1.24, 1.01 to 1.52; P = 0.042),overall survival (HR 0.83, 0.73 to 0.95; P = 0.006) and relative survival (HR 0.74, 0.58 to 0.95; P = 0.023). Conclusion: Deprivation, both independently and by influencing other surgical predictors, impacts on short- and long-term outcomes of patients with colorectal cancer. [ABSTRACT FROM AUTHOR]

Background: Meta-analyses have indicated that preoperative mechanical bowel preparation (MBP) confers no clear benefit and may indeed be harmful for patients with colorectal cancer. The effects of bowel preparation on longer-term outcomes have not been reported. The aim was to compare long-term survival and surgical complications in patients who did or did not receive MBP before surgery for colonic cancer. Methods: This was a retrospective cohort study of all patients undergoing potentially curative surgery for colonic cancer after routine hospital admission in the West of Scotland between January 2000 and December 2005. Clinical audit data were linked to cancer registrations and death certificates. Kaplan-Meier and Cox proportional hazards models were used to explore determinants of survival. Results: A total of 1730 patients underwent potentially curative surgery for colonic cancer, of whom 886 (51.2 per cent) were men. The mean(s.d.) age was 69.7(10.6) years. Some 1460 patients (84.4 per cent) received MBP. Median follow-up was 3.5 (range 0.1-6.7) years. There were no statistically significant differences in 30-day postoperative complication rates between groups. The unadjusted hazard ratio (HR) for death from all causes for patients treated with MBP (versus no MBP) was 0.72 (95 per cent confidence interval 0.57 to 0.91). Multivariable analysis with adjustment for age, sex, socioeconomic circumstances, disease stage and presentation for surgery showed that MBP had no independent effect on all-cause mortality (HR 0.85, 0.67 to 1.10). Conclusion: Neither postoperative complications nor long-term survival are improved by MBP before colonic cancer surgery. [ABSTRACT FROM AUTHOR]