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AIM Clinical presentation with large bowel obstruction has been proposed as a predictor of poor long-term oncological outcomes after resection for colorectal cancer. This study examines the association between obstruction and recurrence and cancer-specific death after resection for colon cancer. METHOD Consecutive patients who underwent resection for colon cancer between 1995 and 2014 were drawn from a prospectively recorded hospital database with all surviving patients followed for at least 5 years. The outcomes of tumour recurrence and colon cancer-specific death were assessed by competing risks multivariable techniques with adjustment for potential clinical and pathological confounding variables. RESULTS Recurrence occurred in 271 of 1485 patients who had a potentially curative resection. In bivariate analysis, obstruction was significantly associated with recurrence [hazard ratio (HR) 2.23, CI 1.52-3.26, p

Objective To examine the independent prognostic value of ALN status in patients with stage III CRC. Summary of background data Early CRC staging classified nodal involvement by level of involved nodes in the operative specimen, including both locoregional and apical node status, in contrast to the American Joint Committee on Cancer/tumor nodes metastasis (TNM) system where tumors are classified by the number of nodes involved. Whether ALN status has independent prognostic value remains controversial. Methods Consecutive patients who underwent curative resection for Stage III CRC from 1995 to 2012 at Concord Hospital, Sydney, Australia were studied. ALN status was classified as: (i) ALN absent, (ii) ALN present but not histologically involved, (iii) ALN present and involved. Outcomes were the competing risks incidence of CRC recurrence and CRC-specific death. Associations between these outcomes and ALN status were compared with TNM N status results. Results In 706 patients, 69 (9.8%) had an involved ALN, 398 (56.4%) had an uninvolved ALN and 239 (33.9%) had no ALN identified. ALN status was not associated with tumor recurrence [adjusted hazard ratio (HR) 1.02, 95% confidence interval (CI) 0.84-1.26] or CRC-specific death (HR 1.14, CI 0.91-1.43). However, associations persisted between TNM N-status and both recurrence (HR 1.58, CI 1.21-2.06) and CRC-specific death (HR 1.59, CI 1.19-2.12). Conclusions No further prognostic information was conferred by ALN status in patients with stage III CRC beyond that provided by TNM N status. ALN status is not considered to be a useful additional component in routine TNM staging of CRC.

BACKGROUND While most colorectal cancer (CRC) recurrences reportedly occur within 3 years following curative treatment, many studies are limited by short-term follow-up. This study examines the time to recurrence of CRC in a large Australian cohort with a long follow-up period and assesses whether time to recurrence has changed over time. METHODS A comprehensive prospective database of patients undergoing resection for CRC is maintained at Concord Hospital, Sydney. Demographic and time to recurrence data were extracted for patients who developed a recurrence following potentially curative resection for colon cancer from 1995 to 2010 and rectal cancer from 1971 to 2010. Non-deceased patients had a minimum of 5 years follow-up. RESULTS Between 1995 and 2010, 2575 patients with CRC underwent surgery. After exclusions, 386 had recurrence following potentially curative resection, ranging from 1 to 172.5 months (median 20.3) after treatment. Within 1 year, 27.5% recurred, 57.5% by 2 years, 74.6% by 3 years, 85.5% by 4 years and 89.6% by 5 years. There was no difference in time to recurrence between colon and rectal cancers (P = 0.674). Among patients having a potentially curative resection for rectal cancer between 1971 and 2010, 386 recurred. There was no difference in time to recurrence by decade (P = 0.863). CONCLUSION The majority of recurrences occurred within 3 years of curative treatment. Had surveillance been limited to 5 years, detection of more than 10% of recurrences would have been delayed. Time to recurrence for rectal cancer has not changed in over 40 years, despite treatment advances.

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.

Aim Complete mesocolic excision (CME) has been advocated as likely to improve the long-term oncological outcome of colon cancer resection, although there is a paucity of long-term results in the literature. The aim of this study was to supplement our previously published results on colon cancer resection based on a standardized technique of precise dissection along anatomical planes with high vascular ligation and to compare our long-term results with those of recent European studies of CME. Method Data were drawn from a prospective hospital registry of consecutive resections for colon cancer between 1996 and 2007, including follow-up to the end of 2012. The principal outcomes from potentially curative resections were 5-year Kaplan–Meier rates of local recurrence, systemic recurrence, overall survival and cancer-specific survival. Secondary outcomes for all resections were postoperative complications, number of lymph nodes retrieved and R0 status. Results For 779 potentially curative resections the local recurrence rate was 2.1% (95% CI 1.3–3.4), the systemic recurrence rate was 10.2% (95% CI 8.1–12.7), the 5-year overall survival rate was 76.2% (95% CI 73.0–79.0) and the cancer-specific survival rate was 89.8% (95% CI 87.3–91.9). For all 905 resections, rates of 14 surgical complications were low and not dissimilar to those in a comparable study. The median lymph node count was 15 (range 0–113). R0 status was confirmed in 883/905 patients (97.6%; 95% CI 96.4–98.5). Conclusion For colon cancer, meticulous dissection along anatomical planes together with high vascular ligation results in few complications, a high R0 rate, low recurrence and high survival.

Purpose The REMARK guidelines give authors comprehensive and specific advice on the complete and transparent reporting of studies of prognostic tumor markers. The aim of this study was to use the REMARK guidelines to evaluate the quality of reporting in a sample of studies assessing tissue-based protein markers for survival after resection of colorectal cancer. Experimental design Eighty pertinent articles were scored according to their conformity to 26 items derived from the REMARK criteria. Results Overall, on a scale of adequacy of reporting that potentially ranged from 26 to 78, the median for these studies was 60 (interquartile range 54–64) and several criteria were adequately covered in a large proportion of studies. However, others were either not dealt with or inadequately covered, including description of the study design (35%), definition of survival endpoints (48%), adjuvant therapy (54%), follow-up procedures and time (59%), neoadjuvant therapy (63%), inclusion/exclusion criteria (73%), multivariable modeling methods and results (74%), and discussion of study limitations (85%). Conclusions and clinical relevance Inadequacies in presentation militate against comparability among protein marker studies and undermine the generalizability of their findings. The quality of reporting could be improved if journal editors were to require authors to ensure that their work satisfied the REMARK criteria.

Background To our knowledge, immediate post-operative complication rates after resection of colorectal cancer (CRC) have not been compared between public and private hospitals in the Australian health care system. We compared the frequency of surgical and medical complications between a public tertiary referral hospital and a private hospital. Methods Data were drawn from a prospective registry of all patients having a resection for CRC between 2000 and 2010 performed by members of the Concord Hospital colorectal surgical unit, either at this hospital or at a single private hospital with which they were affiliated. Complication rates were compared after adjustment for preoperative and perioperative features by logistic regression. Results Among the 16 surgical complications, the only significant difference after adjustment for other features was a higher rate of septicaemia in the public hospital (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.1–4.6). Among the seven medical complications, the only significant differences were a higher risk of cardiac complications in patients with cardiac co-morbidity (OR 1.8, 95% CI 1.1–3.0) and of respiratory complications in patients without respiratory co-morbidity (OR 3.1, 95% CI 2.2–5.9) in the public hospital. Conclusion In this study, where the same group of surgeons performed all reported CRC resections in the two hospitals, no independent effect of the type of hospital was found on 15 of 16 surgical complications and 5 of 7 medical complications. Type of hospital had no impact on rates of specific complications apart from septicaemia and cardiorespiratory complications, which were higher in the public hospital.

OBJECTIVE: Prolonged ileus-the failure of postoperative ileus to resolve within a few days after major abdominal surgery-leads to significant medical consequences for the patient and costs to the hospital system. The aim of this retrospective analysis of prospectively collected data was to identify independent preoperative and intraoperative risk factors for prolonged ileus in a large consecutive series of patients who had undergone resection for colorectal cancer. METHODS: Patients were drawn from a hospital registry of 2400 consecutive resections over the period 1995-2009. Thirty-four potential predictors of prolonged ileus were analyzed by logistic regression. RESULTS: Prolonged ileus occurred in 14.0% of patients. Statistically significant independent predictors of prolonged ileus were male sex (OR: 1.7, P < 0.001), peripheral vascular disease (OR: 1.8, P < 0.001), respiratory comorbidity (OR: 1.6, P < 0.001), resection at urgent operation (OR: 2.2, P < 0.001), perioperative transfusion (OR: 1.6, P < 0.010), stoma constructed (OR: 1.4, P < 0.001), and operation lasting ≥3 hours (OR: 1.6, P < 0.001). CONCLUSIONS: These features can be used to alert medical and nursing staff to patients likely to experience prolonged ileus after bowel resection so that they can be monitored closely in the postoperative period and available treatments targeted toward them. These features may also be useful in the research context to facilitate the more efficient selection of high-risk patients as subjects in clinical trials of prevention or treatment.

Background Despite an extensive literature suggesting that high microsatellite instability (MSI-H) enhances survival and protects against recurrence after colorectal cancer resection, such effects remain controversial as many studies show only a weak bivariate association or no multivariable association with outcome. This study examined the relationship between MSI status and colorectal cancer outcomes with adjustment for death from other causes as a competing risk. Methods A hospital database of patients following colorectal cancer resection was interrogated for clinical, operative, pathology, adjuvant therapy and follow-up information. MSI-H status was determined by immunohistochemistry for mismatch repair protein deficiency. The cumulative incidence of recurrence and colorectal cancer-specific death was evaluated by competing risks methods. Results Among 1009 patients who had a resection between August 2002 and December 2008, and were followed to at least December 2013, there were 114 (11·3 per cent) with MSI-H (72·8 per cent aged at least 70 years; 63·2 per cent women). After potentially curative resection, with adjustment for non-colorectal cancer death as a competing risk and adjustment for 22 clinical, operative and pathological variables, there was no association between MSI-H and recurrence (hazard ratio (HR) 0·81, 95 per cent c.i. 0·42 to 1·57) or colorectal cancer-specific death (HR 0·73, 0·39 to 1·35) in this patient population. For palliative resections, there was no association between MSI-H and colorectal cancer-specific death (HR 0·65, 0·21 to 2·04). MSI-H was associated with non-colorectal cancer death after both curative (HR 1·55, 1·04 to 2·30) and palliative (HR 3·80, 1·32 to 11·00) resections. Conclusion Microsatellite instability status was not an independent prognostic variable in these patients.

Aim The study aimed to compare recent reports on standard and alternative methods of abdominoperineal excision for low rectal cancer regarding the rates of circumferential resection margin involvement and intra-operative bowel perforation. Method Data on rates of margin involvement and perforation were obtained from eight recently published reports and also from a prospective registry of resections at Concord Hospital. Rates of these outcomes and their 95% confidence intervals were evaluated. Results There was no evidence that extralevator abdominoperineal excision yielded significantly lower rates of resection margin involvement or intra-operative bowel perforation compared with standard abdominoperineal excision in six independent hospital- and population-based patient series. Abdominosacral resection of the rectum, on the other hand, did show significantly lower rates of these endpoints, albeit in selected patients. Conclusion The role of extralevator abdominoperineal excision and abdominosacral resection of the rectum should be investigated further in randomized controlled trials.

Aim Several recent studies have attempted to evaluate the accuracy of preoperative magnetic resonance imaging (MRI) in predicting the likelihood of tumour involvement of the postoperative circumferential resection margin (CRM) in rectal cancer with the intention of selecting patients who might benefit from neoadjuvant therapy and as a guide to surgery. The aim of this study was to assess whether such studies can provide a valid answer as to whether preoperative MRI can accurately predict CRM involvement by tumour. Method The study design and methodology of studies on this topic were critically examined. Results Features identified as affecting the efficacy of these studies were: representativeness of patients, definition of the margin assessed by MRI and by histology, lack of blinding of surgeons and pathologists to MRI results, effect of neoadjuvant treatment, and number of patients studied. Conclusion Because of methodological inadequacies in studies completed to date, there is insufficient evidence of the ability of a positive MRI result to predict an involved CRM. Although MRI may be able to identify a tumour that has extended to the mesorectal fascia and/or intersphincteric plane, logically, it cannot indicate where the surgical boundary of the resection will ultimately lie, and therefore cannot validly predict an involved CRM and should not be relied upon for this purpose.

The aim of this study was to determine whether the previously noted poorer survival of men after resection of colorectal cancer varied among clinicopathological tumor stages.The question of whether sex is independently associated with prognosis after resection of colorectal cancer has been examined in numerous studies over the past 2 decades, but with conflicting results.Data on 3,301 patients were drawn from a comprehensive, prospective hospital registry of all resections for colorectal cancer performed between January 1971 and December 2005. Statistical analysis employed Kaplan Meier estimation and relative survival analysis to adjust for differential male/female life expectancy in the general population.The relative survival of males was significantly less than that of females (P = 0.004) only in stage B. This was not accounted for by other negative pathology features and cause of death did not differ significantly between males and females. However, men with stage B tumor were more likely than women to experience postoperative morbidity, particularly a respiratory complication or a surgical complication requiring urgent reoperation. The sex difference in relative survival persisted among patients who had either a respiratory complication or an urgent reoperation (P = 0.003) but disappeared among those who had neither (P = 0.193).The poorer survival of men with stage B tumor was attributable to their greater postoperative morbidity which led to the earlier death of some due to causes unrelated to their colorectal cancer.

Background: The aim of this study was to determine the extent to which pathology reporting of colorectal cancers notified to the New South Wales Central Cancer Registry during 2000 conformed to guidelines promulgated by the National Health and Medical Research Council. Methods: De-identified reports for 2233 resected specimens of primary invasive colorectal carcinoma were coded according to a standardized system to compile information on 28 clinical and pathology features. An overall score for each report was calculated by computing the number out of 13 essential features specified in the guidelines for which data had been recorded explicitly and unambiguously in the report. Results: The overall score ranged from 3 to 13 features with a mean of 9. No more than 7 features were reported explicitly in just less than one quarter of the reports and no more than 10 in three quarters. There were only 110 reports (4.9%) that included all features. Information on direct spread and nodal metastasis was well reported; resection margins less so. Many reports lacked information on metastases beyond the operative field, the involvement of deep or circumferential resection margins and tumour stage. Conclusion: In some respects pathology reports of resected colorectal cancer specimens displayed a high level of completeness. Some important features, however, were poorly described. Reporting could be improved if surgeons were to use a standardized form to convey clinical information to the pathologist and if pathologists were to report in a structured or synoptic format, explicitly recording the presence or absence of each feature in a standard list.

Objective To determine whether the presence of tumour at a free serosal surface was independently associated with pelvic recurrence or survival in patients who had a resection for clinicopathological stage B or stage C rectal cancer and who had not received adjuvant therapy. Method Data were drawn from a comprehensive, prospective hospital registry of all resections for rectal cancer from January 1971 to December 1998 with follow up to December 2003. Statistical analysis employed the χ2 test or Fisher's exact probability, Kaplan–Meier estimation and proportional hazards regression, with a significance level of ≤0.05 and 95% confidence intervals (CI). Results In 665 patients with stages B or C tumour, 35 (5.3%; CI 3.7–7.2%) had tumour at a free serosal surface. These comprised 6/332 (1.8%; CI 0.8–3.7%) patients with stage B tumour and 29/333 (8.7%; CI 6.1–12.2%) with stage C tumour. After adjustment for other relevant variables, involvement of a free serosal surface was significantly associated with pelvic recurrence [hazard ratio (HR) 2.7; CI 1.3–5.5] and diminished survival (HR 1.6; CI 1.1–2.4) but not with systemic (only) recurrence. Conclusion This study has confirmed that direct tumour spread to a free serosal surface independently predicts pelvic recurrence and diminished survival after resection of clinicopathological stage B and C rectal cancer. This feature should always be sought by the pathologist and reported when present, and noted by the surgeon and oncologist. Serosal involvement should be evaluated further for its utility in selecting patients for adjuvant therapy.

Objective: To investigate predictors of evidence-based surgical care in a populationbased sample of patients with newly diagnosed colorectal cancer. Design, patients and setting: Prospective audit of all new patients with colorectal cancer reported to the New South Wales Central Cancer Registry between 1 February 2000 and 31 January 2001. Main outcome measures: Concordance with seven guidelines from the 1999 Australian evidence-based guidelines for colorectal cancer; predictors of guideline concordance; the mean proportion of relevant guidelines followed for individual patients. Results: Questionnaires were received for 3095 patients (91.6%). Between 0 and 100% of relevant guidelines were followed for individual patients (median, 67%). Concordance with individual guidelines varied considerably. Patient age independently predicted nonconcordance with guidelines for adjuvant therapy and preoperative radiotherapy. Adjuvant chemotherapy was more likely if a patient with node-positive colon cancer was treated in a metropolitan hospital or by a general surgeon. Surgeons with a high caseload or specialty in colorectal cancer were more likely to perform colonic pouch reconstruction, prescribe thromboembolism or antibiotic prophylaxis, and were less likely to refer patients with high-risk rectal cancer for adjuvant radiotherapy. Bowel preparation was less likely among older patients and in high-caseload hospitals. Conclusion: Effective strategies to fully implement national colorectal cancer guidelines are needed. In particular, increasing the use of appropriate adjuvant therapy should be a

Objective Circumferential resection margin involvement (CRMI) after resection of rectal cancer is regarded as a risk factor for local recurrence. We have been able to identify only nine peer-reviewed English-language publications which focus primarily on this association, and they report widely differing rates of local recurrence. The aims of this study were to review possible reasons for this variability and to assess the evidence for the micrometrically measured threshold defining CRMI. Method Methodological and statistical evaluation of relevant literature. Results Several factors which could account for this variability are discussed including the nature of the patient series, surgical technique, curative vs palliative resections, pathology technique, the definition of CRMI, adjuvant therapy, tumour stage, definition and ascertainment of local recurrence, length of follow-up and method of analysis. The objective evidence for the conventional definition of CRMI as tumour 1 mm or less from a circumferential margin is considered along with the evidence supporting a recent proposal that the margin be extended to 2 mm or less. The evidence is numerically weak in both cases and we believe that neither definition should be set in concrete at this stage. Conclusion Pending further research, we recommend that routine pathology reports should record frank tumour transection, if present, or otherwise report the histological width of the margin between the tumour and the nearest circumferential line of resection in millimetres. The definition of CRMI should be simply histological evidence of tumour in a line of resection, that is, a margin of 0 mm. The definition of CRMI as a margin of 1 mm should not be adopted as a basis for assessing the quality of surgery.

Approximately 50% of patients with colorectal cancer (CRC) will eventually die of metastatic disease. Effective palliative management can be used within a shared care model in CRC to provide optimum symptom control, psychological well-being and maintenance of quality of life for patients, their families and carers, including bereavement support. Maintenance of realistic hope and early goal setting are equally important in end-of-life discussions with patients and families. Palliative care should be incorporated early in the course of the illness, concurrent with disease-modifying therapies. Within shared care, the palliative medicine specialist, surgeon and other members of the multidisciplinary team can each bring their own expertise to provide a patient-centred approach. A case is presented that incorporates some of these principles and exemplifies the benefits of contemporary palliative care for patients with advanced CRC.

Background Mobilization of rectal cancer can be difficult if the tumour is located anteriorly and may result in a higher incidence of local recurrence. The aim of this study was to determine whether local recurrence and survival following curative resection of rectal cancer were associated with the position of the tumour. Methods Data were drawn from a comprehensive, prospective hospital registry of all resections for rectal cancer from January 1990 to December 1998, with follow-up to December 2003. Results The 5-year local recurrence rate was 15·9 (95 per cent confidence interval (c.i.) 11·0 to 22·8) per cent in 176 patients with tumours that had an anterior component compared with 5·8 (95 per cent c.i. 2·8 to 11·9) per cent in 132 patients with tumours without an anterior component (P = 0·009). This association persisted after adjustment for other factors linked to local recurrence (hazard ratio (HR) 2·4 (95 per cent c.i. 1·1 to 5·4)). Similarly, anterior position had a significant negative independent association with survival (HR 1·4 (95 per cent c.i. 1·0 to 2·00)). Conclusion Anterior position is an independent negative prognostic factor for both local recurrence and survival after curative resection of rectal cancer.

Background The process of training surgeons in technique for resection of colorectal cancer should not compromise patient care or outcomes. The aim of this study was to compare morbidity, mortality and survival rates after resection performed by trainees with those for a consultant surgeon. Methods Outcomes for 150 patients operated on by a single colorectal surgeon at a private hospital were compared with those of 344 patients admitted under the same surgeon and operated on by closely supervised trainee surgeons in a public teaching hospital between 1995 and 2002. Results Co-morbidity was significantly more common in patients operated on by trainees; their American Society of Anesthesiologists grades were higher and tumours were more advanced. Of 16 postoperative complications evaluated, only respiratory and cardiac problems were significantly more common in patients operated on by trainees. There was no difference in operative mortality, local recurrence or 2-year survival rate after adjustment for age and tumour stage. Conclusion Outcomes after resection for colorectal cancer did not differ between the consultant and trainees in the context of a closely supervised training programme.

The aim of this study was to determine whether anastomotic leakage has an independent association with overall survival and cancer-specific survival.There are many known prognostic indicators following surgery for colorectal cancer (CRC). However, the impact of anastomotic leakage has not been adequately assessed.Consecutive patients undergoing resection between 1971 and 1999 were recorded prospectively in the Concord Hospital CRC database. Total anastomotic leakage was defined as any leak, whether local, general, or radiologically diagnosed. Patients were followed until death or to December 31, 2002. The association between anastomotic leakage and both overall survival and cancer-specific survival was examined by proportional hazards regression with adjustment for other patient and tumor characteristics influencing survival. Confidence intervals (CI) were set at the 95% level.From an initial 2980 patients, 1722 remained after exclusions. The total leak rate was 5.1% (CI 4.1-6.2%). In patients with a leak, the 5-year overall survival rate was 44.3% (CI 33.5-54.6%) compared to 64.0% (CI 61.5-66.3%) in those without leak. In proportional hazards regression-after adjustment for age, gender, urgent resection, site, size, stage, grade, venous invasion, apical node metastasis and serosal surface involvement-anastomotic leakage had an independent negative association with overall survival (hazard ratio [HR] 1.6, CI 1.2-2.0) and cancer-specific survival (HR 1.8, CI 1.2-2.6).Apart from its immediate clinical consequences, anastomotic leakage also has an independent negative association with survival.

Background: The aim of this study was to identify independent background and perioperative risk factors for prolonged postoperative hospital stay among patients having a resection for colorectal cancer. Methods: Data from 1095 consecutive resections performed by specialist colorectal surgeons between 1995 and 2001 were examined by multiple least squares regression. Each putative risk factor was coded 0 if absent and 1 if present and postoperative stay was measured in days, so that the unstandardized partial regression coefficients (B) represent days of additional stay if the factor was present. Confidence intervals are at the 95% level. Results: Of 35 factors examined, the following 11 had a significant independent association with postoperative stay: urgent operation (B = 4.2, CI 2.2−6.2); preoperative stay>5 days (B = 4.2, CI 2.7−5.7); perioperative transfusion (B = 3.1, CI 2.2−4.2); adjacent organ or structure involved (B = 3.0, CI 1.2−4.9); stoma constructed (B = 2.6, CI 1.8−3.5); peripheral vascular disease (B = 2.3, CI 0.4−4.1); age ≥75 years (B = 2.2, CI 1.2−3.1); respiratory disease (B = 1.7, CI 0.5−2.8); American Society of Anesthetists’ (ASA) classification>Class 2 (B = 1.5, CI 0.4−2.5); splenic flexure mobilized (B = 1.4, CI 0.5−2.3); private hospital (B = 1.4, CI 0.3−2.5). Conclusions: Together these factors accounted for only a fifth of the variability in length of stay and few, except possibly ASA, were susceptible of interventions that might reduce stay. Postoperative morbidity, which is largely unpredictable, remains the major cause of prolonged hospital stay.

Background The aim of this study was to identify patient and tumour characteristics that might assist in developing an improved approach to patient selection for chemotherapy after resection of clinicopathological stage C colonic cancer. Methods Clinical, pathological and follow-up data have been collected prospectively for all patients undergoing resection for colorectal cancer at Concord Hospital since 1971. From an initial 2980 patients, after exclusions 378 remained who had a potentially curative operation for colonic cancer with nodal metastases and did not receive adjuvant chemotherapy. Associations between several pathological features and survival were examined by proportional hazards regression. Results In a multivariate model, both overall and colonic cancer-specific survival rates were negatively associated with serosal surface involvement, apical node metastasis, high histological grade and venous invasion. The survival of patients with stage C disease who had none of these adverse features was not significantly different from that of patients with stage B lesions. However, survival diminished significantly when one or more of the adverse features were present. Conclusion Patients with a stage C tumour but with none of the identified adverse features experience relatively good survival and are unlikely to benefit from adjuvant chemotherapy. In this series such patients accounted for 40·5 per cent of patients with stage C disease.

Introduction: Colorectal cancer is common. At presentation 25% of patients have established hepatic metastases and overall at least half will develop hepatic metastases. Many different therapeutic options have been proposed. This study evaluates the current resources available and patterns of care for patients with hepatic colorectal metastases in the Sydney metropolitan area. Methods: Prospective data were collated describing all patients presenting to any one of nine hospitals within the Sydney metropolitan area in a 12-month period, diagnosed with hepatic metastases. The data included patient demographics and background, treatment of the primary tumour, diagnosis and treatment of the hepatic metastases and histopathology both of the primary and of the hepatic metastases. Results: There were 194 patients in the study. Most when diagnosed with hepatic colorectal metastases were independent, active, retired and usually had existing social supports. The majority had had their primary colorectal cancer resected and were later treated with systemic chemotherapy. Conclusions: This study highlights the need for a comprehensive multicentre, prospective data collection of patients with hepatic metastatic disease. This would clarify the effectiveness or otherwise of the health system caring for such patients and provide additional information for the development and implementation of guidelines.

Background: In the palliative treatment of patients with advanced, inoperable rectal cancer, combined endoscopic laser and radiotherapy have been claimed to be more effective than laser therapy alone. The number of laser treatments, laser energy used, relapse rate, treatment of relapse, morbidity and survival in consecutive patients who were treated either by laser therapy alone or laser plus radiotherapy was compared. Methods: Prospective data were analysed with regard to number of treatments, laser energy used, relapse rate, morbidity and survival for 56 consecutive patients. Results: The crude relapse rate was significantly higher in the laser only group than in the laser plus radiotherapy group (58 and 15%, respectively; P = 0.002). There was no difference between the groups in the median total number of laser treatments or the mean total laser energy used. In patients experiencing a relapse, there was no difference in the median number of relapses, the number of laser treatments post-relapse or the total energy used post-relapse. Survival did not differ between the groups and there were no treatment-related deaths. Conclusions: These findings demonstrate a clear reduction in relapse after using combined laser and radiotherapy to palliate patients with advanced rectal cancer with no appreciable additional morbidity and have encouraged continuing use of this treatment.

Background Widely varying rates have been reported in the extensive literature published in the English language on local recurrence after curative excision of rectal carcinoma. These variations may be attributable to differences in the case mix of pathological factors influencing recurrence, differences in surgical technique or expertise, differences in the administration of adjuvant therapy and various combinations of these. They may also arise from methodological differences among studies. Methods This paper reviews the adequacy of methodology and reporting in 21 recent studies of local recurrence after curative resection of rectal cancer. Results Many flaws in reporting and apparent inadequacies in methodology were identified. On an index of 26 criteria examined, eight studies scored no more than 8 and only three studies scored more than 11. Conclusion To date, the value of reports of local recurrence rates following curative excision of rectal cancer has been limited by inadequacies in documentation and methodology. Suggestions are made for preferred procedures to be followed in the reporting of future studies.

Background and Aims: Clinical practice is determined by many different factors, but with the advent of evidence-based medicine, there may be a tendency to concentrate upon the scientific facts when decision-making rather than focusing on the patient. Furthermore, individual clinician opinion or bias may potentially influence patient management. This study outlines clinician opinion with regard to management of patients with hepatic colorectal metastases, and compares it to present practice in the Sydney metropolitan area. Methods: Clinician opinion was assessed by using a questionnaire and compared to results from a prospective multicenter study looking at patterns of care of patients with hepatic colorectal metastases. Results: Clinicians participating in the present study had a good knowledge of the current evidence concerning hepatic colorectal metastases and its treatment. However, there was a discrepancy between clinician knowledge that matched scientific evidence and actual clinical practice. Conclusions: This study suggests that clinician bias/opinion does influence patterns of care for patients with hepatic colorectal metastases.

Background: A fibrous stricture may develop at the site of a colorectal anastomosis or as a complication following abdominal aortic surgery. A major resection may be necessary if the stricture cannot be released. The authors’ experience with endoscopic stricturotomy using neodymium:yttrium–aluminium–garnet laser, together with balloon dilatation, as a conservative method of treating such strictures, is reported here. Methods: The case notes of all patients referred for laser treatment of benign distal large bowel strictures at Concord Hospital were reviewed. Results: Ten patients had endoscopic laser treatment combined with endoscopic balloon dilatation between October 1991 and July 1999. An anastomotic stricture had developed in eight patients and two patients had a fibrous stricture of the upper rectum after abdominal aortic aneurysm surgery. Nine of the 10 patients had their stricture treated successfully without complication or recurrence (median follow up 82 months; range: 14–104 months). The remaining patient re-presented with a large bowel obstruction at the site of his stricture 6 years following initial treatment. Conclusion: A protocol combining laser stricturotomy with balloon dilatation appears to be a safe and effective treatment of such strictures.

Purpose: The purpose of this study was to analyse preliminary experience and outcomes with the Cook Surgisis AFP™ anal fistula plug (Cook Medical, Bloomington, IN, USA) with respect to the treatment of complex anal fistulae in a specialist colorectal unit. Methods: Data on all patients who were treated with the Surgisis AFP™ between October 2006 and January 2009 were retrospectively reviewed. The plug was placed in accordance with the Cook guidelines. Successful closure of the anal fistula was defined as absence of drainage at final follow-up with no subsequent abscess formation or further intervention required. Results: Thirty-two patients underwent a total of 35 anal fistula plug insertion procedures. No patients were lost to follow-up. The median follow-up was 15 months (2–29 months). The overall success rate was 13 out of 35 (37%). For those in the subgroups of Crohn's disease and cryptoglandular disease, the success rate was 1 out of 3 (33%) and 11 out of 31 (35%), respectively. Conclusion: This series demonstrates a success rate for the Cook Surgisis AFP™ of 37%. These results in patients managed in a specialist unit confirm that the Surgisis AFP™ is a useful option in the management of complex fistulae.

Background Colorectal cancers exhibiting microsatellite instability (MSI) appear to have unique biological behaviour. This study analyses the association between extensive MSI (MSI-H), clinicopathological features and survival in an unselected group of patients with sporadic Australian Clinico-Pathological Stage (ACPS) C (tumour node metastasis stage III) colorectal cancer. Methods Some 255 patients who underwent resection for sporadic ACPS C colorectal cancer between 1986 and 1992 were studied. No patient had received chemotherapy. Minimum follow-up for all patients was 5 years. Archival normal and tumour DNA was extracted and amplified by polymerase chain reaction using a radioactive labelling technique. MSI-H was defined as instability in 40 per cent or more of seven markers. Results Twenty-one patients showed MSI-H. No association was found between MSI and age or sex. Tumours exhibiting MSI-H were more commonly right sided (P < 0·00001), larger (P = 0·002) and more likely to be high grade (P = 0·049). After adjustment for age, sex and other pathological variables, patients whose cancers exhibited MSI-H had improved survival (P = 0·015). Conclusion Recognition of MSI-H in sporadic ACPS C tumours identifies a subset of cancers with improved prognosis. Such stratification should be considered in trials of adjuvant therapy and may be relevant to therapeutic decision making.

Aim The prevalence of obesity in Australia is high and increasing, with associated serious negative effects on health. The technical complexity of rectal cancer surgery is exacerbated in obese patients, which may compromise outcomes. The aim of this study was to examine the association between obesity and complications after resection of rectal cancer. Method Data were drawn from a comprehensive prospective registry of rectal cancer resections performed from 2007 to 2011 by members of the colorectal surgical unit in a tertiary referral hospital and in a single private hospital with which they were affiliated. Results Of 255 patients who had a resection for rectal cancer during the study period, 95 (37%) were classified as obese on the basis of a body mass index (BMI) ≥ 30 kg/m2. Among 24 postoperative complications the only significant differences for obese patients were higher rates of wound complications (16% vs 8%, P = 0.038), small bowel obstruction (4% vs 0%, P = 0.019) and prolonged ileus (18% vs 8%, P = 0.011). The total number of complications did not differ significantly between obese and nonobese patients, and there was no difference between obese and nonobese patients in the rates of reoperation and postoperative death. Conclusion This study did not support an association between obesity and early postoperative complications after resection of rectal cancer.

Background Laparoscopically-assisted resection for large bowel cancer is technically feasible. Sixty-six patients who had resection of the colon or rectum for cancer have been audited prospectively. Methods Clinical and pathological data were collected prospectively as part of the ongoing Concord Hospital colorectal cancer project. Patients were followed up for a median of 29 months. Results In 57 of 66 patients in whom laparoscopic resection was attempted the operation was completed laparoscopically. Three patients died from perioperative myocardial infarction. The median postoperative stay was 14 days. There was a high incidence of postoperative respiratory and cardiac complications. One patient developed a port-site metastasis. Conclusion There was no obvious benefit from laparoscopically-assisted resection of large bowel cancer in these patients.

The aim of this study was to estimate and compare the costs of open right hemicolectomy (ORHC) versus laparoscopically assisted right hemicolectomy (LARHC) performed for cancer. A retrospective cost analysis of 61 consecutive patients operated on between January 1992 and August 1994 for right-sided colonic cancer by either LARHC (n = 28) or ORHC (n = 33) was performed. The analysis focused on the cost (in Australian dollars) incurred from the date of operation to the date of discharge. LARHC was significantly more expensive than ORHC (total cost LARHC $9064, ORHC $7881; p < 0.001). LARHC was associated with a significantly longer operating room utilization time (LARHC 261 minutes, ORHC 203 minutes; p < 0.001) and a greater cost of disposables (LARHC $854, ORHC $189; p < 0.001). This study demonstrates no cost benefit for LARHC compared to ORHC when performed for cancer.

PURPOSE: The aim of this study was to identify and categorize the independent prognostic effects of patient, clinical, operative, and pathology variables on long-term survival after anterior resection or abdominoperineal excision of the rectum for cancer. METHODS: Proportional hazards regression analysis was used to analyze prospective data from 709 patients who underwent surgery at Concord Hospital during a 23-year period. No patient received adjuvant therapy. RESULTS AND CONCLUSIONS: After adjusting for age and clinicopathologic stage, significantly poorer survival was experienced by males, patients with extensive tumor adherent to other organ(s), those with a high-grade tumor or a tumor showing venous invasion, those who had a postoperative cardiovascular or respiratory complication, and those who did not undergo surgery by a colorectal surgeon specialist. The nature of the operation performed had no independent effect on survival.

Background The preoperative ratio of neutrophils to lymphocytes (NLR) has been proposed as a marker of poor outcome in patients having a resection for colorectal cancer (CRC). This study investigated the association between NLR and overall survival, cancer-specific survival and recurrent cancer in patients who had a potentially curative resection for node-positive CRC. Methods Data on 322 patients were drawn from a prospectively recorded registry operated on between 1999 and 2007. Analyses of survival involved the Kaplan-Meier method, Cox regression and competing risks Cox regression. Results Increasing NLR as a continuous variable was independently though weakly associated with diminishing overall survival after adjustment for other prognostic variables (HR 1.06, 95% CI 1.01-1.11, p = 0.013). Receiver operating characteristic analysis to dichotomize NLR as a predictor of overall survival yielded relatively poor sensitivity (55%), specificity (66%) and positive predictive value (56%, CI 47%-64%). Competing risks regression also showed that NLR was not independently associated with recurrence at any site (HR 1.04, CI 0.97-1.11, p = 0.241) or CRC-specific mortality (HR 1.02, CI 0.92-1.12, p = 0.782) but was associated with non-CRC mortality (HR 1.09, CI 1.03-1.15, p = 0.004). Conclusion In patients with stage C tumor the weak link between NLR and overall mortality was not specific to CRC but apparently arose because patients with an elevated inflammatory status preoperatively were likely to progress to earlier death but not necessarily because of their cancer.

Backgrounds and Methods: This study reviews the clinical features and reports the preliminary results of treatment of 34 consecutive patients with clinically significant bleeding from chronic, radiation-induced proctitis, using a combination of endoscopic YAG Laser and the application of topical formalin dressings to the rectal rnucosa. Results: Bleeding ceased in 25 patients (74%); bleeding continued but occurred only slightly and occasionally in five patients (15%); and three patients required operation to control the bleeding (9%). One patient relapsed after treatment and died while receiving a further transfusion. Conclusions: This experience has been used to develop a management protocol for patients with this serious complication.

Background: Epidemiologic evidence of associations between the high intake of fat and low intake of dietary fiber, beta carotene, and other dietary constituents and the risk of colorectal neoplasia has been inconsistent and has not provided a sufficient basis for recommendations concerning the dietary prevention of large-bowel cancer in humans. Purpose: We conducted a clinical trial to assess the effects on the incidence of adenomas of reducing dietary fat to 25% of total calories and supplementing the diet with 25 g of wheat bran daily and a capsule of beta carotene (20 mg daily). Methods: We performed a randomized, partially double-blinded, placebo-controlled factorial trial in which half the patients were assigned to each intervention, resulting in seven intervention groups and one control group. Eligibility criteria included histologic confirmation of at least one colorectal adenoma and confidence expressed by the colonoscopist that all polyps had been removed. Dietary changes were individually initiated and monitored by dietitians and research nurses. At surveillance colonoscopy, the size and location of all polyps were recorded, and their histology was later centrally reviewed. Among 424 patients who were randomly assigned in the trial, 13 were found to be ineligible upon histologic review. Among the remaining 411, complete outcome data were collected from 390 at 24 months and from 306 at 48 months. All P values are from two-sided tests of statistical significance. Results: There was no statistically significant prevention of total new adenomas with any of the interventions. We found a statistically nonsignificant reduced risk of large adenomas (≥10 mm) with the low-fat intervention: At 24 months, the odds ratio (OR) adjusted for potential confounders = 0.4 and 95% confidence interval (CI) = 0.1-1.1; at 48 months, OR = 0.3 and 95% CI = 0.1-1.0. Less and statistically nonsignificant reductions in the risk of large adenomas were found with wheat bran: At 24 months, OR = 0.8 and 95% CI = OJ-2.2; at 48 months, OR = 0.8 and 95% CI = 0.3-2.5. Patients on the combined intervention of low fat and added wheat bran had zero large adenomas at both 24 and 48 months, a statistically significant finding (P =.03). Conclusions: Because only small numbers of patients were studied, our finding that the combination of fat reduction and a supplement of wheat bran reduced the incidence of large adenomas in this randomized, controlled trial must be treated with caution. The results do suggest, however, that these interventions may reduce the transition from smaller to larger adenomas, a step that may critically define those adenomas most likely to progress to malignancy.

Background. Approximately half of all patients treated for colorectal carcinoma by bowel resection have neither lymph node metastases nor known residual tumor (clinicopathologic Stages A and B). The aim of this study was to compare the survival of these patients with that of the general population and to explain any significant difference. Methods. Prospectively collected data recorded for 910 patients from one institution during a period of 21.5 years were used in the analysis. Patient follow-up ranged from 6 months to 21.5 years. The “Survival” procedure, developed by the Finnish Cancer Registry, was used to compare the observed survival of patients with their expected survival, based on age- and sex-matched data from the population of New South Wales. Survival analysis was performed by the Kaplan-Meier method. Multivariate models were examined using Cox proportional hazards regression. Results. Males with tumor spread beyond the muscularis propria (Stage B) was the only group with significantly poorer survival than expected. The reduced survival in this group was due to the effects of four clinical variables (cardiovascular complication, permanent stoma, urgent operation, respiratory complication) and one pathologic variable (direct spread involving a free serosal surface) acting independently. Conclusion. The survival of patients with clinicopathologic Stages A or B tumors closely matched their expected survival as predicted from the general population. Males with Stage B tumors were the only exception and their significantly reduced survival was largely due to clinical, as distinct from pathologic factors. These findings suggest that the risk of occult metastases is low for patients with Stages A and B tumors using this classification. Cancer 1995; 76:564–71.

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.