Prognostic Factors

It is interesting to review all factors mentioned (preoperative, operative and post-operative) and establish their influence on post-salvage survival rates.

Patient's age, gender and the initial stage of primary tumour do not appear to change post-resection survival rates [50]. Prior APR, presentation with pain, elevated CEA levels and unresectable disease are adverse factors. Completeness of resection strongly influences survival, which is significantly shorter in R2 than in R0 and R1 cases. R0 resection, of course, correlates with the best results.

Patients with prior APR have a significantly worse prognosis than those with AR. They more frequently present with pain and elevated CEA levels. These patients also experience longer period between primary and salvage operation. This is explained with no possibility for digital examination or sigmoi-doscopy. It's also impossible to observe changes in bowel habits. The reported resectability rate after APR is 60% and after AR is 86% [50]. But on the positive side, in the case of resectable disease, there is no statistically significant difference in post-salvage survival rates between APR and AR, although results after AR tend to be better [47]. As mentioned, the best results in salvage surgery are achieved after local excision when the indication for surgery is an unfavourable pathohistological report. In other cases, the most favourable outcome is achieved with patients who had recurrent disease within the bowel wall [50].

Many attempts have been made to determine the value of prognostic predictors for patients chosen for curative salvage surgery (St. Marks group, Mayo Clinic group). So far, no consensus has been reached. The only predictive factors that appear to be valuable, for now, are a tumour diameter larger than 3 cm and tumour fixation degree 2. However, it can be useful to follow the recommended tests: a CEA level of 9 ng/ml, if reached in non-smoker, laparotomy is indicated even if all other tests are negative [22].

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