Clinics in Colon and Rectal Surgery最新文献

Surgically resected stage I colon cancer results in the best possible prognosis for patients diagnosed with colorectal cancer. However, there remains some debate about whether formal oncologic resection is necessary for the earliest of tumors-those detected in a polyp. To best understand whether an oncologic resection is "avoidable" in select cases of patients with a malignant polyp, it is necessary to review the contemporary evidence on endoscopic techniques, risks of lymph node metastasis, and nuances of the decision-making between oncologic resection and surveillance.

Hospitals in the United States continue to merge into expanding hospital networks. As the U.S. health care landscape rapidly evolves toward regionalized hospital networks, there is a critical opportunity for these networks to fulfill their clinical potential toward coordination of care, particularly for cancer patients. While regionalization aims broadly to improve care by distributing services optimally, centralization remains the dominant approach. This article explores regionalization and centralization specific to colon cancer care. We examine the benefits and drawbacks of centralization of colon cancer surgery as a strategy to enhance patient outcomes and access to care. Additional methods for optimizing regional care delivery also exist. In this article, we also present additional strategies for improving regional care delivery and clinical integration for colon cancer patients.

Patients have common and personalized questions about expected outcomes after colon cancer treatment. Surgeons and oncologists can use high-quality clinical counseling and patient-reported outcomes to identify what matters most to each patient. This article reviews common patient-centered outcomes and how to elicit personalized outcomes, preferences, and values for patients facing colon cancer.

The traditional, surgery-first approach for colon cancer is increasingly challenged by our evolving understanding of tumor biology and a growing number of measurable tumor features that can help guide contemporary treatment plans. Certain tumor characteristics now make it practical to challenge locally advanced colon cancer with neoadjuvant chemotherapy or immunotherapy, and allow for targeted postoperative therapies. The contemporary data supporting these tailored approaches to integrating systemic therapy before or after resection are summarized in this article.

Colectomy for malignant tumors or unresectable benign tumors requires preoperative planning based on cross-sectional imaging, consideration of neoadjuvant therapy, a decision on the extent of lymphadenectomy, and comprehensive knowledge of the relevant anatomy. Imaging review is critical for determining resectability and noting any aberrant anatomy. Based on the imaging, neoadjuvant therapy should be considered for bulky or locally advanced disease. The anatomical resection of the colon, mesentery, and lymph node basins is performed in accordance with the concept of complete mesocolic excision (CME), entailing the resection of the mesentery with visceral peritoneum intact, appropriate proximal and distal margins taken en bloc, and high ligation of the primary feeding vessels along which the lymph nodes are positioned. High ligation of the colic arteries is part of a standard lymphadenectomy and is intended to address possible micrometastatic nodal disease and proper staging for adjuvant therapy. Extended lymphadenectomy in the form of CME with central vascular ligation is indicated for patients with advanced T stage or clinical lymphadenopathy. Whether extended lymphadenectomy should be performed routinely is subject to debate. In this article, we review the indications and operative strategies for management of colon cancer in various locations in the colon, as well as key considerations for minimally invasive colectomy and advanced techniques such as CME with central vascular ligation.

Multiple randomized controlled trials have demonstrated the short-term recovery benefits of laparoscopic colectomy for colon cancer while maintaining noninferior long-term oncologic outcomes relative to open surgery. These short- and long-term results have been validated in large observational trials with the widespread adoption of laparoscopic colectomy for colon cancer. Subsequent advances in minimally invasive technique including robotic colectomy, intracorporeal anastomosis, and natural orifice extraction may preserve or augment the benefits of minimally invasive surgical treatment for colon cancer although data in these areas are less robust.

Lynch's syndrome is a common cause of hereditary colorectal cancer (CRC), resulting in higher risk of CRC and development of subsequent, metachronous CRC (mCRC). Beyond treating the primary cancer, surgeons and patients must decide on whether performing an extended colectomy, to reduce the risk of mCRC, is worth the change in function that comes with the larger operation. Considerations include likelihood for mCRC, morbidity and quality of life after resection, impact of pathogenic variant, and certain other cancer risk reduction options. The contemporary evidence to guide these decisions is reviewed herein.

Malignant bowel obstruction (MBO) is a complex problem in patients with advanced malignancies, one that poses difficult decision-making involving a patient's clinical status, extent of disease, and overall goals of care. This article will present common clinical presentations of MBO, initial resuscitation efforts, and helpful diagnostic tools. It will also review the contemporary data on medical, endoscopic, and surgical interventions used for the management of MBO. Our goal is to delineate benefits, common pitfalls, and limiting factors for these interventions while taking into consideration quality of life, patient wishes, and palliative care to support decision-making for clinicians treating patients with MBO.

While advances in treatment and diagnostics have improved prognosis in colorectal cancer (CRC), room for advancement remains, highlighting the importance of improving tools for early detection and treatment guidance. Current national guidelines rely on stage-based treatment recommendations but fail to identify patients with lower stage disease who have a higher likelihood of recurrence or those for whom additional therapy may not be beneficial. Circulating tumor DNA (ctDNA) is an emerging noninvasive blood-based assay, which can inform cancer status as a single time point and/or longitudinal biomarker. ctDNA can be used for the diagnosis of cancer, detection of minimal/molecular residual disease, molecular profiling, and assessing treatment response. In patients for whom operative management is indicated, detectable ctDNA is associated with worse survival outcomes. This review highlights the expanding field of ctDNA in CRC, underlining pivotal data and areas with the need for more research that are key for colorectal surgeons to understand.