Second look in colorectal surgery

Follow-up should identify metachronous colonic neoplasms and precancers, suture line recurrences, and isolated liver or pulmonary metastases. For some sites of failure the surgical re-resection and multimodal approaches increase disease-free survival and quality of life. The aim of our study was to evaluate the role of the different follow-up plans and the carcinoembryonic antigen directed second-look surgery.

One hundred-sixty patients radically resected for Dukes B or C colorectal cancer were evaluated by a follow-up plan (plasma carcinoembryonic antigen every 2 months; echography every 6 months; chest x-ray every 12 months; and colonoscopy at 1 year and then every 3-5 years).

Eighty-nine recurrences were detected (55.6 percent). In 72 recurrences plasma carcinoembryonic antigen elevation was present. Eight carcinoembryonic antigen directed second-look surgeries were performed: in four patients surgical evidence of recurrence was found (two isolated liver metastases were radically resected); two patients with no surgical evidence of recurrence developed a surrenalic isolated metastases and pelvic and hepatic recurrences; two patients had a five-year disease-free survival. In the 17 symptomatic patients with no carcinoembryonic antigen elevation diffuse disease was present, not resectable for cure. Four solitary liver metastases, one metachronous colonic neoplasm, and one suture line recurrence presented a five-year survival.

The authors emphasize that carcinoembryonic antigen-directed second-look surgery is not acceptable for elevated costs. Intensive follow-up plans are superflous, while the monitoring of the carcinoembryonic antigen and instrumental restaging as an indicator of solitary liver metastases and mucosal lesions are very useful.