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Minimally invasive surgery for maximally invasive tumors: pelvic exenterations for rectal cancers. JOURNAL OF MINIMALLY INVASIVE SURGERY 2022; 25:131-138. [PMID: 36601490 PMCID: PMC9763485 DOI: 10.7602/jmis.2022.25.4.131] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 12/23/2022]
Abstract
Purpose Trials comparing minimally invasive rectal surgery have uniformly excluded T4 tumors. The present study aimed to determine the safety of minimally invasive surgery (MIS) for locally-advanced rectal cancers requiring pelvic exenterations based on benchmarked outcomes from the international PelvEx database. Methods Consecutive patients of T4 rectal cancers with urogenital organ invasion that underwent MIS exenterations between November 2015 and June 2022 were analyzed from a single center. A safety threshold was set at 20% for R1 resections and 40% for major complications (≥grade IIIA) for the upper limit of the 95% confidence interval (CI). Results The study included 124 MIS exenterations. A majority had a total pelvic exenteration (74 patients, 59.7%). Laparoscopic surgery was performed in 95 (76.6%) and 29 (23.4%) had the robotic operation. Major complications were observed in 35 patients (28.2%; 95% CI, 20.5%-37.0%). R1 resections were found pathologically in nine patients (7.3%; 95% CI, 3.4%-13.4%). The set safety thresholds were not crossed. At a median follow-up of 15 months, 44 patients (35.5%) recurred with 8.1% local recurrence rate. The 2-year overall and disease-free survivals were 85.2% and 53.7%, respectively. Conclusion MIS exenterations for locally-advanced rectal cancers demonstrated acceptable morbidity and safety in term of R0 resections at experienced centers. Longer follow-up is required to demonstrate cancer survival outcomes.
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Minimum radial margin in pelvic exenteration for locally advanced or recurrent rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2502-2508. [PMID: 35768314 DOI: 10.1016/j.ejso.2022.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/27/2022] [Accepted: 06/13/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study was to clarify the suitable radial margin (RM) for favourable outcomes after pelvic exenteration (PE), focusing on the discrepancy between the concepts of circumferential resection margin (CRM) and traditional R status. METHODS Seventy-three patients with locally advanced (LARC, n = 24) or locally recurrent rectal cancer (LRRC, n = 49) who underwent PE between 2006 and 2018 were retrospectively analysed. Patients were histologically classified into the following 3 groups; wide RM (≥1 mm, n = 45), narrow RM (0-1 mm, n = 10), and exposed RM (n = 18). The analysis was performed not only in the entire cohort but also in each disease group separately. RESULTS The rates of traditional R0 (RM > 0 mm) and wide RM were 75.3% and 61.6%, respectively, resulting in the discrepancy rate of 13.7% between the two concepts. Preoperative radiotherapy was given in 12.3%. In the entire cohort, the local recurrence and overall survival (OS) rates for narrow RMs were significantly worse than those for wide RMs (p < 0.001 and p = 0.002), but were similar to those for exposed RMs. In both LARC and LRRC, RM < 1 mm resulted in significantly worse local recurrence and OS rates compared to the wide RMs. Multivariate analysis showed that RM < 1 mm was an independent risk factor for local recurrence in both LARC (HR 15.850, p = 0.015) and LRRC (HR 4.874, p = 0.005). CONCLUSIONS Narrow and exposed RMs had an almost equal impact on local recurrence and poor OS after PE. Preoperative radiotherapy might have a key role to ensure a wide RM.
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Sutton PA, Brown KGM, Ebrahimi N, Solomon MJ, Austin KKS, Lee PJ. Long-term surgical complications following pelvic exenteration: Operative management of the empty pelvis syndrome. Colorectal Dis 2022; 24:1491-1497. [PMID: 35766998 DOI: 10.1111/codi.16238] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 01/07/2023]
Abstract
AIM Pelvic exenteration (PE) has become the standard of care for locally advanced and recurrent rectal cancer. The high short-term morbidity reported from this procedure is well established; however, longer term complications of such radical surgery and their management have not been fully addressed. This study aimed to investigate the incidence, indications and outcomes of long-term (more than 90-day) reoperative surgery in this group of patients, with a focus on the empty pelvis syndrome (EPS). METHODS Clinical data were extracted from a prospectively maintained database, with additional data pertaining to indications, operative details and outcomes of reoperative surgery obtained from electronic medical records. Patients were excluded if reoperative surgery was endoscopic or radiologically guided, was for the investigation or treatment of recurrent disease, or was clearly unrelated to previous surgery. RESULTS Of 716 patients who underwent PE, 75 (11%) required 101 reoperative abdominal or perineal procedures, 52 (51%) of which were in 40 (6%) patients for complications of EPS. This group were more likely to have undergone a total PE (65% vs. 43%; P < 0.01) with either major bony (70% vs. 50%; P < 0.01) and/or nerve (40% vs. 25%; P = 0.03) resections at index exenteration. The patho-anatomy, surgical management and outcomes of these patients are described herein, considering separately complications of entero-cutaneous fistula, entero-perineal fistula, small bowel obstruction and local management of perineal wound complications. CONCLUSION Six per cent of PE patients will require re-intervention for the management of EPS. Reliable strategies for preventing EPS remain elusive; however, surgical management is feasible with acceptable short-term outcomes with the optimum strategy to be selected on an individual patient basis.
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Affiliation(s)
- Paul A Sutton
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Colorectal and Peritoneal Oncology Centre, The Christie Hospital, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Nargus Ebrahimi
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia
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Apte SS, Cohen LCL, Larach JT, Mohan HM, Snow HA, Wagner T, McCormick JJ, Warrier SK, Gyorki DE, Waters PS, Heriot AG. Major vascular reconstruction in colorectal adenocarcinoma and retroperitoneal sarcoma: A retrospective study of safety and margins in a tertiary referral centre. Surg Oncol 2022; 45:101871. [DOI: 10.1016/j.suronc.2022.101871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/18/2022] [Accepted: 10/03/2022] [Indexed: 12/03/2022]
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Fahy MR, Kelly ME, Aalbers AGJ, Abdul Aziz N, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alberda W, Albert M, Andric M, Angeles MA, Angenete E, Antoniou A, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Beynon J, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelan W, Chan KKL, Chang GJ, Chang M, Chew MH, Chok AY, Chong P, Clouston H, Codd M, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovich L, Daniels IR, Davies M, Delaney CP, de Wilt JHW, Denost Q, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Eglinton T, Enriquez-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fearnhead NS, Ferron G, Flatmark K, Fleming FJ, Flor B, Folkesson J, Frizelle FA, Funder J, Gallego MA, Gargiulo M, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther DN, Glyn T, Glynn R, Golda T, Griffiths B, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kazi M, Kelley SR, Keller DS, Ketelaers SHJ, Khan MS, Kiran RP, Kim H, Kim HJ, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kristensen HØ, Kroon HM, Kumar S, Kusters M, Lago V, Lampe B, Lakkis Z, Larach JT, Larkin JO, Larsen SG, Larson DW, Law WL, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Maciel J, Manfredelli S, Mann C, Mantyh C, Mathis KL, Marques CFS, Martinez A, Martling A, Mehigan BJ, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, Mikalauskas S, McArthur DR, McCormick JJ, McCormick P, McDermott FD, McGrath JS, Malde S, Mirnezami A, Monson JRT, Navarro AS, Negoi I, Neto JWM, Ng JL, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, Nugent T, Oliver A, O’Dwyer ST, O’Sullivan NJ, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock O, Pellino G, Peterson AC, Pinson J, Poggioli G, Proud D, Quinn M, Quyn A, Rajendran N, Radwan RW, Rajendran N, Rao C, Rasheed S, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Selvasekar C, Shaikh I, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Sorrentino L, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Spasojevic M, Sumrien H, Sutton PA, Swartking T, Takala H, Tan EJ, Taylor C, Tekin A, Tekkis PP, Teras J, Thaysen HV, Thurairaja R, Thorgersen EB, Toh EL, Tsarkov P, Tsukada Y, Tsukamoto S, Tuech JJ, Turner WH, Tuynman JB, Valente M, van Ramshorst GH, van Zoggel D, Vasquez-Jimenez W, Vather R, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Urrejola G, Wakeman C, Warrier SK, Wasmuth HH, Waters PS, Weber K, Weiser MR, Wheeler JMD, Wild J, Williams A, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline. Br J Surg 2022; 109:1251-1263. [PMID: 36170347 DOI: 10.1093/bjs/znac317] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/18/2022] [Accepted: 08/18/2022] [Indexed: 12/31/2022]
Abstract
This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.
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Kazi M, Desouza A, Bankar S, Jajoo B, Dohale S, Vadodaria D, Ghadi A, Ghandade N, Vasudevan L, Nashikkar C, Saklani A. The use of an obstetric balloon as a pelvic spacer in preventing empty pelvis syndrome after total pelvic exenteration in rectal cancers - A prospective safety and efficacy study for the Bakri balloon. Colorectal Dis 2022; 25:616-623. [PMID: 36408669 DOI: 10.1111/codi.16424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/22/2022]
Abstract
AIM Empty pelvis syndrome (EPS) is a source of considerable morbidity following total pelvic exenteration. None of the available methods have been universally successful in mitigating this problem. The aim of this work was to evaluate the safety and efficacy of the obstetric Bakri balloon in preventing empty pelvis syndrome. METHOD This study was a combined prospective and retrospective study of all total pelvic exenterations for rectal cancers from a single institution performed between October 2013 and May 2022. Since December 2019 the Bakri balloon was used in all patients who provided consent. EPS within 90 days was the primary end point, and included bowel obstruction, pelvic collection and entero-perineal fistula. Comparison with those patients who did not have a Bakri balloon was performed. RESULTS Seventy-five patients with a Bakri balloon were compared with 96 patients without a balloon placed after pelvic exenteration. No patient experienced an untoward complication from balloon deployment. The incidence of EPS was 13.3% and 22.9% in the Bakri and no Bakri cohorts, respectively (p = 0.110). Every component of EPS was proportionally lower, without statistical significance. Based on point estimates, the number needed to treat to prevent EPS using the Bakri balloon was 10. CONCLUSIONS Use of the Bakri balloon was safe without serious adverse events. The incidence of EPS after total pelvic exenteration was not statistically different with the use of the Bakri balloon despite a 9.6% reduction. A larger comparative study is needed to evaluate the efficacy of the balloon.
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Affiliation(s)
- Mufaddal Kazi
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Ashwin Desouza
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Sanket Bankar
- Department of Surgical Oncology, Dr D. Y. Patil Medical College Hospital and Research Centre, Pimpri, Pune, India.,Dr D. Y. Patil Vidyapeeth, Pune, India
| | - Bhushan Jajoo
- Division of Surgical Oncology, SGM Cancer Hospital, Swangi, Wardha, India
| | - Sayali Dohale
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, India
| | - Divya Vadodaria
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, India
| | - Aayushi Ghadi
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, India
| | - Netra Ghandade
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, India
| | | | | | - Avanish Saklani
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
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Fahy MR, Hayes C, Kelly ME, Winter DC. Updated systematic review of the approach to pelvic exenteration for locally advanced primary rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2284-2291. [PMID: 35031157 DOI: 10.1016/j.ejso.2021.12.471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/23/2021] [Accepted: 12/29/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To review the evidence regarding surgical advances in the management of primary locally advanced rectal cancer. BACKGROUND The management of rectal cancer has evolved significantly in recent decades, with improved (neo)adjuvant treatment strategies and enhanced perioperative protocols. Centralization of care for complex, advanced cases has enabled surgeons in these units to undertake more ambitious surgical procedures. METHODS A Pubmed, Ovid, Embase and Cochrane database search was conducted according to the predetermined search strategy. The review protocol was prospectively registered with PROSPERO (CRD42021245582). RESULTS 14 studies were identified which reported on the outcomes of 3,188 patients who underwent pelvic exenteration (PE) for primary rectal cancer. 50% of patients had neoadjuvant radiotherapy. 24.2% underwent flap reconstruction, 9.4% required a bony resection and 34 patients underwent a major vascular excision. 73.9% achieved R0 resection, with 33.1% experiencing a major complication. Median length of hospital stay ranged from 13 to 19 days. 1.6% of patients died within 30 days of their operation. Five-year overall survival (OS) rates ranged 29%-78%. LIMITATIONS The studies included in our review were mostly single-centre observational studies published prior to the introduction of modern neoadjuvant treatment regimens. It was not possible to perform a meta-analysis on the basis that most were non-randomized, non-comparative studies. CONCLUSIONS Pelvic exenteration offers patients with locally advanced rectal cancer the chance of long-term survival with acceptable levels of morbidity. Increased experience facilitates more radical procedures, with the introduction of new platforms and/or reconstructive options.
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Affiliation(s)
- Matthew R Fahy
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland.
| | - Cathal Hayes
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
| | - Michael E Kelly
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
| | - Desmond C Winter
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
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van Kessel CS, Solomon MJ. Understanding the Philosophy, Anatomy, and Surgery of the Extra-TME Plane of Locally Advanced and Locally Recurrent Rectal Cancer; Single Institution Experience with International Benchmarking. Cancers (Basel) 2022; 14:cancers14205058. [PMID: 36291842 PMCID: PMC9600029 DOI: 10.3390/cancers14205058] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/04/2022] [Accepted: 10/13/2022] [Indexed: 12/01/2022] Open
Abstract
Simple Summary Worldwide there is still unwarranted variation in peri-operative management and subsequently oncological outcome following pelvic exenteration for locally advanced and recurrent rectal cancer. The major contributing factor seems to be a difference in treatment strategy with many centres aiming for more neoadjuvant treatment and less radical surgery. However, a radical resection with clear operative margins remains the single most important prognostic factor for survival and therefore an aggressive, radical approach is justified for an optimal oncological outcome and remains the gold standard of care. Abstract Pelvic exenteration surgery has become a widely accepted procedure for treatment of locally advanced (LARC) and locally recurrent rectal cancer (LRRC). However, there is still unwarranted variation in peri-operative management and subsequently oncological outcome after this procedure. In this article we will elaborate on the various reasons for the observed differences based on benchmarking results of our own data to the data from the PelvEx collaborative as well as findings from 2 other benchmarking studies. Our main observation was a significant difference in extent of resection between exenteration units, with our unit performing more complete soft tissue exenterations, sacrectomies and extended lateral compartment resections than most other units, resulting in a higher R0 rate and longer overall survival. Secondly, current literature shows there is a tendency to use more neoadjuvant treatment such as re-irradiation and total neoadjuvant treatment and perform less radical surgery. However, peri-operative chemotherapy or radiotherapy should not be a substitute for adequate radical surgery and an R0 resection remains the gold standard. Finally, we describe our experiences with standardizing our surgical approaches to the various compartments and the achieved oncological and functional outcomes.
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Affiliation(s)
- Charlotte S. van Kessel
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown 2050, Sydney, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown 2050, Sydney, Australia
| | - Michael J. Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown 2050, Sydney, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown 2050, Sydney, Australia
- Institute of Academic Surgery at RPA, Camperdown 2050, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown 2006, Sydney, Australia
- Correspondence:
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Traeger L, Bedrikovetski S, Oehler MK, Cho J, Wagstaff M, Harbison J, Lewis M, Vather R, Sammour T. Short-term outcomes following development of a dedicated pelvic exenteration service in a tertiary centre. ANZ J Surg 2022; 92:2620-2627. [PMID: 35866328 PMCID: PMC9795898 DOI: 10.1111/ans.17921] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/05/2022] [Accepted: 07/08/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pelvic exenteration surgery (PE) offers potentially curative resection for locally advanced malignancy but is associated with significant complexity and morbidity. Specialised teams are recommended to achieve optimal patient outcomes. This study aims to analyse short-term outcomes at a tertiary setting before and after creating a dedicated PE service. METHODS Patients undergoing PE between 2008 and October 2021 at the Royal Adelaide Hospital and St. Andrews Hospital in South Australia were included, with prospective data collection since June 2017. Patients operated on prior and post the creation of the PE service were compared via univariate analyses. RESULTS In total, 113 patients were included, with a significant increase in volume of cases post creation of the PE service, (n = 46 pre versus n = 67 post). There were significant differences in the type of neoadjuvant therapy and patient co-morbidity, with more advanced disease stage and a higher likelihood of bone involvement (P < 0.05) in the latter period. An increased proportion of patients had flap reconstruction (40.3 versus 33.9%, P = 0.010) as well as lateral lymph node dissection (13.4 versus 2.2%, P = 0.046). Despite this, peri-operative outcomes such as urosepsis (11.9 versus 28.3%, P = 0.028) and Clavien-Dindo grade of complications grade improved. R0 resections were achieved in 93.9% of curative cases (93.9 versus 84.2%, P = 0.171). CONCLUSION The development of a PE service significantly improved short term patient outcomes, despite the inclusion of patients with more advanced disease and comorbidity.
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Affiliation(s)
- Luke Traeger
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Martin K. Oehler
- Department of Gynaecological OncologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Jonathan Cho
- Urology Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Marcus Wagstaff
- Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia,Department of Plastic and Reconstructive SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Jack Harbison
- Department of Plastic and Reconstructive SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Mark Lewis
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Ryash Vather
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Tarik Sammour
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
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Fernandez B, Fleming CA, Marichez A, Mauriac P, Denost Q. Advances in pelvic exenteration surgery can support clear margin resection for metastatic non-pelvic primary malignancies. Br J Surg 2022; 109:1023-1024. [DOI: 10.1093/bjs/znac289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Arthur Marichez
- Department of Colorectal Surgery, CHU Bordeaux , Bordeaux , France
| | - Paul Mauriac
- Department of Colorectal Surgery, CHU Bordeaux , Bordeaux , France
| | - Quentin Denost
- Department of Colorectal Surgery, CHU Bordeaux , Bordeaux , France
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van den Berg K, Schaap DP, Voogt ELK, Buffart TE, Verheul HMW, de Groot JWB, Verhoef C, Melenhorst J, Roodhart JML, de Wilt JHW, van Westreenen HL, Aalbers AGJ, van 't Veer M, Marijnen CAM, Vincent J, Simkens LHJ, Peters NAJB, Berbée M, Werter IM, Snaebjornsson P, Peulen HMU, van Lijnschoten IG, Roef MJ, Nieuwenhuijzen GAP, Bloemen JG, Willems JMWE, Creemers GJM, Nederend J, Rutten HJT, Burger JWA. Neoadjuvant FOLFOXIRI prior to chemoradiotherapy for high-risk ("ugly") locally advanced rectal cancer: study protocol of a single-arm, multicentre, open-label, phase II trial (MEND-IT). BMC Cancer 2022; 22:957. [PMID: 36068495 PMCID: PMC9446695 DOI: 10.1186/s12885-022-09947-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/29/2022] [Indexed: 11/14/2022] Open
Abstract
Background The presence of mesorectal fascia (MRF) invasion, grade 4 extramural venous invasion (EMVI), tumour deposits (TD) or extensive or bilateral extramesorectal (lateral) lymph nodes (LLN) on MRI has been suggested to identify patients with indisputable, extensive locally advanced rectal cancer (LARC), at high risk of treatment failure. The aim of this study is to evaluate whether or not intensified chemotherapy prior to neoadjuvant chemoradiotherapy improves the complete response (CR) rate in these patients. Methods This multicentre, single-arm, open-label, phase II trial will include 128 patients with non-metastatic high-risk LARC (hr-LARC), fit for triplet chemotherapy. To ensure a study population with indisputable, unfavourable prognostic characteristics, hr-LARC is defined as LARC with on baseline MRI at least one of the following characteristics; MRF invasion, EMVI grade 4, enlarged bilateral or extensive LLN at high risk of an incomplete resection, or TD. Exclusion criteria are the presence of a homozygous DPD deficiency, distant metastases, any chemotherapy within the past 6 months, previous radiotherapy within the pelvic area precluding standard chemoradiotherapy, and any contraindication for the planned treatment. All patients will be planned for six two-weekly cycles of FOLFOXIRI (5-fluorouracil, leucovorin, oxaliplatin and irinotecan) prior to chemoradiotherapy (25 × 2 Gy or 28 × 1.8 Gy with concomitant capecitabine). A resection will be performed following radiological confirmation of resectable disease after the completion of chemoradiotherapy. A watch and wait strategy is allowed in case of a clinical complete response. The primary endpoint is the CR rate, described as a pathological CR or a sustained clinical CR one year after chemoradiotherapy. The main secondary objectives are long-term oncological outcomes, radiological and pathological response, the number of resections with clear margins, treatment-related toxicity, perioperative complications, health-related costs, and quality of life. Discussion This trial protocol describes the MEND-IT study. The MEND-IT study aims to evaluate the CR rate after intensified chemotherapy prior to concomitant chemoradiotherapy in a homogeneous group of patients with locally advanced rectal cancer and indisputably unfavourable characteristics, defined as hr-LARC, in order to improve their prognosis. Trial registration Clinicaltrials.gov: NCT04838496, registered on 02–04-2021 Netherlands Trial Register: NL9790. Protocol version Version 3 dd 11–4-2022.
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Affiliation(s)
- K van den Berg
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands.,Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - D P Schaap
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - E L K Voogt
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - T E Buffart
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Medical Oncology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - H M W Verheul
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - J W B de Groot
- Department of Medical Oncology, Isala Oncology Centre, Zwolle, the Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - J Melenhorst
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - J M L Roodhart
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - A G J Aalbers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - M van 't Veer
- Department of Research and Education, Catharina Hospital, Eindhoven, the Netherlands
| | - C A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Vincent
- Department of Medical Oncology, Elkerliek Hospital, Helmond, the Netherlands
| | - L H J Simkens
- Department of Medical Oncology, Maxima Medical Centre, Veldhoven, the Netherlands
| | - N A J B Peters
- Department of Medical Oncology, St. Jans Hospital, Weert, the Netherlands
| | - M Berbée
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - I M Werter
- Department of Medical Oncology, Rijnstate Hospital, Arnhem, the Netherlands
| | - P Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - H M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - I G van Lijnschoten
- Department of Pathology, PAMM Laboratory for Pathology and Medical Microbiology, Eindhoven, the Netherlands
| | - M J Roef
- Department of Nuclear Medicine, Catharina Hospital, Eindhoven, the Netherlands
| | | | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - J M W E Willems
- Department of Medical Oncology, Anna Hospital, Geldrop, the Netherlands
| | - G J M Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.,GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
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Harji DP, Houston F, Cutforth I, Hawthornthwaite E, McKigney N, Sharpe A, Coyne P, Griffiths B. The impact of multidisciplinary team decision-making in locally advanced and recurrent rectal cancer. Ann R Coll Surg Engl 2022; 104:611-617. [PMID: 35639482 PMCID: PMC9680687 DOI: 10.1308/rcsann.2022.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Appropriate patient selection within the context of a multidisciplinary team (MDT) is key to good clinical outcomes. The current evidence base for factors that guide the decision-making process in locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) is limited to anatomical factors. METHODS A registry-based, prospective cohort study was undertaken of patients referred to our specialist MDT between 2015 and 2019. Data were collected on patients and disease characteristics including performance status, Charlson Comorbidity Index, the English Index of Multiple Deprivation quintiles and MDT treatment decision. Curative treatment was defined as neoadjuvant treatment and surgical resection that would achieve a R0 resection, and/or complete treatment of distant metastatic disease. Palliative treatment was defined as non-surgical treatment. RESULTS In total, 325 patients were identified; 72.7% of patients with LARC and 63.6% of patients with LRRC were offered treatment with curative intent (p = 0.08). Patients with poor performance status (PS > 2; p < 0.001), severe comorbidity (p < 0.001), socio-economic deprivation (p = 0.004), a positive predictive circumferential resection margin (p = 0.005) and metastatic disease (p < 0.001) were associated with palliative treatment. Overall survival in the curative cohort was 49 months (95% confidence interval [CI] 32.4-65.5) compared with 12 months (95% CI 9.1-14.9) in the palliative cohort (p < 0.001). The presence of metastatic disease was identified as a prognostic factor for patients undergoing curative treatment (p = 0.05). The only prognostic factor identified in patients treated palliatively was performance status (p < 0.001). CONCLUSIONS Our study identifies a number of preoperative, prognostic factors that affect MDT decision-making and overall survival.
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Affiliation(s)
| | | | | | | | | | - A Sharpe
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - P Coyne
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - B Griffiths
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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63
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Javed MA, Kohler A, Tiernan J, Quyn A, Sagar P. Evaluating potential delays and outcomes of patients undergoing surgical resection for locally advanced and recurrent colorectal cancer during a pandemic. Ann R Coll Surg Engl 2022; 104:624-631. [PMID: 35132892 PMCID: PMC9433197 DOI: 10.1308/rcsann.2021.0274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 09/03/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic resulted in a significant disruption of colorectal cancer (CRC) care pathways. This study evaluates the management and outcomes of patients with primary locally advanced or recurrent CRC during the pandemic in a single tertiary referral centre. METHODS Patients undergoing elective surgery for advanced or recurrent CRC with curative intent between March 2020 and March 2021 were identified. Following first multidisciplinary team discussion patients were broadly classified into two groups: straight to surgery (n=22, 45%) or neoadjuvant therapy followed by surgery (n=27, 55%). Primary outcome was COVID-19-related complication rate. RESULTS Forty-nine patients with a median age of 66 years (interquartile range: 54-73) were included. No patients developed a COVID-19 infection or related complication during hospital admission. Significant delays were identified in the treatment pathway of patients in the straight to surgery group, mostly due to delays in referral from external centres. Nine of 22 patients in the straight to surgery group had evidence of tumour progression compared with 3 of 27 in the neoadjuvant group (p=0.015839). Seven of 27 patients in the neoadjuvant group showed evidence of tumour regression. During the study, surgical waiting times were reduced, and more operations were performed during the second wave of COVID-19. CONCLUSION This study suggests that it is possible to mitigate the risks of COVID-19-related complications in patients undergoing complex surgery for locally advanced and recurrent CRC. Delay in surgical intervention is associated with tumour progression, particularly in patients who may not have neoadjuvant therapy. Efforts should be made to prioritise resources for patients requiring time-sensitive surgery for advanced and recurrent CRC.
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Harji DP, Williams A, McKigney N, Boissieras L, Denost Q, Fearnhead NS, Jenkins JT, Griffiths B. Utilising quality of life outcome trajectories to aid patient decision making in pelvic exenteration. Eur J Surg Oncol 2022; 48:2238-2249. [PMID: 36030134 DOI: 10.1016/j.ejso.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/01/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Shared decision-making in pelvic exenteration is a complex and detailed process, which must balance clinical, oncological and patient-reported outcomes (PROs), whilst addressing and valuing the patient priorities. Communicating patient-centred information on quality of life (QoL) and functional outcomes is an essential component of this. The aim of this systematic review was to understand the impact of pelvic exenteration on QoL PROs over a longitudinal period and to develop QoL trajectories to support decision-making in this context. METHODS MEDLINE, Embase and Web of Science databases were searched between 1st January 2000 and 20th December 2021 Studies reporting on PROs, including QoL, in adults undergoing pelvic exenteration were included. Risk of bias was assessed using the ROBINS-I assessment tool. Data from studies reporting QoL using the same outcome measure at the same candidate timepoint were extracted and synthesised to develop a longitudinal QoL trajectory. RESULTS Fourteen studies consisting of 1370 patients were included in this review. QoL trajectories were constructed in the domains of physical function, psychological function, role function, sexual function, body image and general and specific symptoms. Decision-making was only assessed by one study, with satisfaction with decision-making reported to be high. There is an initial decline in QoL scores in the domains of physical function, role function, sexual function, body image and general health and symptoms deteriorating during the first 3-6 months post-operatively. Psychological function is the only QoL domain that remains stable throughout the post-operative period. CONCLUSION Mapping QoL trajectories provides a visual representation of post-operative progress, highlighting the enduring impact of pelvic exenteration on patients and can be used to inform pre-operative shared decision-making.
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Affiliation(s)
- Deena P Harji
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK.
| | | | - Niamh McKigney
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Lara Boissieras
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Quentin Denost
- Department of Digestive Surgery, Colorectal Unit, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Nicola S Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospitals, Cambridge, UK
| | - John T Jenkins
- Department of Surgery, St Mark's Hospital, Watford Road, Harrow, UK
| | - Ben Griffiths
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
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Casey L, Larach JT, Waters PS, Kong JCH, McCormick JJ, Heriot AG, Warrier SK. Application of minimally invasive approaches to pelvic exenteration for locally advanced and locally recurrent pelvic malignancy - A narrative review of outcomes in an evolving field. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2330-2337. [DOI: 10.1016/j.ejso.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 07/26/2022] [Accepted: 08/05/2022] [Indexed: 11/28/2022]
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Desouza A, Kazi M, Bankar S, Pandey D, Janesh M, Saklani A. Minimally invasive, 'en-bloc' seminal vesicle excision for locally advanced rectal adenocarcinoma: surgical technique and short-term outcomes. ANZ J Surg 2022; 92:2595-2599. [PMID: 35762325 DOI: 10.1111/ans.17888] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/18/2022] [Accepted: 06/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Isolated seminal vesicle invasion is a rare occurrence in patients with locally advanced rectal cancers. This study describes the surgical technique and the perioperative outcomes of minimally invasive 'en-bloc' seminal vesicle excision, preserving the bladder and the prostate. METHODS A retrospective review of 23 consecutive patients who underwent minimally invasive, en-bloc resection of seminal vesicles for locally advanced, non-metastatic rectal adenocarcinoma between May 2016 and November 2021. Perioperative outcomes and short-term oncological outcomes were defined. RESULTS Eighteen patients underwent a laparoscopic procedure while five received a robotic resection. All patients received preoperative radiation with or without consolidation chemotherapy. The median age was 42 years (range 20-64 years) and the median hospital stay was 8 days (range 3-19 days), respectively. Serious complications (Clavien-Dindo ≥ IIIb) were seen in six patients (26.1%). Two patients (8.7%) had an involved circumferential resection margin. At a median follow up of 19 months (range 2-52 months), four patients developed recurrences. The 2-year overall and disease-free survival was 84.4% and 73.6%, respectively. CONCLUSION Minimally invasive, en-bloc resection of one or both seminal vesicles for locally advanced rectal adenocarcinoma, is feasible in a select group of patients with acceptable morbidity and short-term outcomes.
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Affiliation(s)
- Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,HBNI, Homi Bhabha National Institute, Mumbai, India
| | - Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,HBNI, Homi Bhabha National Institute, Mumbai, India
| | - Sanket Bankar
- Division of Surgical Oncology, D.Y. Patil Medical College Hospital and Research Centre, Pune, India
| | - Diwakar Pandey
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,HBNI, Homi Bhabha National Institute, Mumbai, India
| | - Murugan Janesh
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,HBNI, Homi Bhabha National Institute, Mumbai, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,HBNI, Homi Bhabha National Institute, Mumbai, India
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Kitakaze M, Uemura M, Kobayashi Y, Paku M, Miyo M, Takahashi Y, Miyake M, Kato T, Ikeda M, Fujino S, Ogino T, Miyoshi N, Takahashi H, Yamamoto H, Mizushima T, Sekimoto M, Doki Y, Eguchi H. Postoperative pain management after concomitant sacrectomy for locally recurrent rectal cancer. Surg Today 2022; 52:1599-1606. [PMID: 35661260 DOI: 10.1007/s00595-022-02522-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/22/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess pain management in patients post-sacrectomy, focusing on opioid use, and to identify the factors associated with postoperative pain. METHODS Patients who underwent resection of locally recurrent rectal cancer (LRRC) with concomitant sacrectomy at one of two hospitals between 2007 and 2020 were reviewed retrospectively. We examined the use of opioids preoperatively and postoperatively. Patients were classified into high and low sacrectomy groups based on the sacral bone resection level passing through the S3 vertebra. RESULTS Sixty-four patients were enrolled. Opioid use was significantly higher in the high sacrectomy group than in the low sacrectomy group at all times assessed: on postoperative days 7, 14, 30, 90, 180, and 365. Opioid use 3 months after locally recurrent rectal cancer surgery was significantly higher in patients with local re-recurrence of the tumor than in those without re-recurrence (p < 0.05), and the median morphine-equivalent opioid use 3 months postoperatively was significantly higher in the high sacrectomy group (30 vs. 0 mg/day; p < 0.05). CONCLUSIONS Opioid use after concomitant sacrectomy for LRRC was higher in the high sacrectomy group. Prolonged postoperative pain or increasing pain was associated with local recurrence.
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Affiliation(s)
- Masatoshi Kitakaze
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Mamoru Uemura
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan.
| | - Yuta Kobayashi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Masakatsu Paku
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Masaaki Miyo
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Yusuke Takahashi
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Masakazu Miyake
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Takeshi Kato
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Masataka Ikeda
- Division of Lower GI Surgery, Department of Surgery, Hyogo College of Medicine, Hyogo, 6638501, Japan
| | - Shiki Fujino
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Takayuki Ogino
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Norikatsu Miyoshi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Hirofumi Yamamoto
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, Osaka, 5731010, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
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Ng KS, Lee PJ. Pelvic exenteration: Pre-, intra-, and post-operative considerations. Surg Oncol 2022. [DOI: 10.1016/j.suronc.2022.101787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Lindenberg M, Kramer A, Kok E, Retèl V, Beets G, Ruers T, van Harten W. Image-guided navigation for locally advanced primary and locally recurrent rectal cancer: evaluation of its early cost-effectiveness. BMC Cancer 2022; 22:504. [PMID: 35524234 PMCID: PMC9074374 DOI: 10.1186/s12885-022-09561-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 04/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A first pilot study showed that an image-guided navigation system could improve resection margin rates in locally advanced (LARC) and locally recurrent rectal cancer (LRRC) patients. Incremental surgical innovation is often implemented without reimbursement consequences, health economic aspects should however also be taken into account. This study evaluates the early cost-effectiveness of navigated surgery compared to standard surgery in LARC and LRRC. METHODS A Markov decision model was constructed to estimate the expected costs and outcomes for navigated and standard surgery. The input parameters were based on pilot data from a prospective (navigation cohort n = 33) and retrospective (control group n = 142) data. Utility values were measured in a comparable group (n = 63) through the EQ5D-5L. Additionally, sensitivity and value of information analyses were performed. RESULTS Based on this early evaluation, navigated surgery showed incremental costs of €3141 and €2896 in LARC and LRRC. In LARC, navigated surgery resulted in 2.05 Quality-Adjusted Life Years (QALYs) vs 2.02 QALYs for standard surgery. For LRRC, we found 1.73 vs 1.67 QALYs respectively. This showed an Incremental Cost-Effectiveness Ratio (ICER) of €136.604 for LARC and €52.510 for LRRC per QALY gained. In scenario analyses, optimal utilization rates of the navigation technology lowered the ICER to €61.817 and €21.334 for LARC and LRRC. The ICERs of both indications were most sensitive to uncertainty surrounding the risk of progression in the first year after surgery, the risk of having a positive surgical margin, and the costs of the navigation system. CONCLUSION Adding navigation system use is expected to be cost-effective in LRRC and has the potential to become cost-effective in LARC. To increase the probability of being cost-effective, it is crucial to optimize efficient use of both the hybrid OR and the navigation system and identify subgroups where navigation is expected to show higher effectiveness.
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Affiliation(s)
- Melanie Lindenberg
- Health Technology and Services Research, University of Twente, Enschede, The Netherlands
- Division of Psychosocial Research and Epidemiology Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Astrid Kramer
- Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Esther Kok
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Valesca Retèl
- Health Technology and Services Research, University of Twente, Enschede, The Netherlands
- Division of Psychosocial Research and Epidemiology Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Geerard Beets
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Theo Ruers
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Faculty TNW, Group Nanobiophysics, Twente University, Enschede, The Netherlands
| | - Wim van Harten
- Health Technology and Services Research, University of Twente, Enschede, The Netherlands.
- Division of Psychosocial Research and Epidemiology Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
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Dinger TL, Kroon HM, Traeger L, Bedrikovetski S, Hunter A, Sammour T. Regional variance in treatment and outcomes of locally invasive (T4) rectal cancer in Australia and New Zealand: analysis of the Bi-National Colorectal Cancer Audit. ANZ J Surg 2022; 92:1772-1780. [PMID: 35502647 PMCID: PMC9541368 DOI: 10.1111/ans.17699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/05/2022] [Accepted: 03/30/2022] [Indexed: 12/09/2022]
Abstract
Backgrounds Locally invasive T4 rectal cancer often requires neoadjuvant treatment followed by multi‐visceral surgery to achieve a radical resection (R0), and referral to a specialized exenteration quaternary centre is typically recommended. The aim of this study was to explore regional variance in treatment and outcomes of patients with locally advanced rectal cancer in Australia and New Zealand (ANZ). Methods Data were collected from the Bi‐National Colorectal Cancer Audit (BCCA) database. Rectal cancer patients treated between 2007 and 2019 were divided into six groups based on region (state/country) using patient postcode. A subset analysis of patients with T4 cancer was performed. Primary outcomes were positive circumferential resection margin (CRM+), and positive circumferential and/or distal resection margin (CRM/DRM+). Results A total of 9385 patients with rectal cancer were identified, with an overall CRM+ rate of 6.4% and CRM/DRM+ rate of 8.6%. There were 1350 patients with T4 rectal cancer (14.4%). For these patients, CRM+ rate was 18.5%, and CRM/DRM+ rate was 24.1%. Significant regional variation in CRM+ (range 13.4–26.0%; p = 0.025) and CRM/DRM+ rates (range 16.1–29.3%; p = 0.005) was identified. In addition, regions with higher CRM+ and CRM/DRM+ rates reported lower rates of multi‐visceral resections: range 24.3–26.8%, versus 32.6–37.3% for regions with lower CRM+ and CRM/DRM+ rates (p < 0.0001). Conclusion Positive resection margins and rates of multi‐visceral resection vary between the different regions of ANZ. A small subset of patients with T4 rectal cancer are particularly at risk, further supporting the concept of referral to specialized exenteration centres for potentially curative multi‐visceral resection.
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Affiliation(s)
- Tessa L Dinger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Medical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Luke Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Hunter
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Wang J, Prabhakaran S, Larach T, Warrier SK, Bednarski BK, Ngan SY, Leong T, Rodriguez-Bigas M, Peacock O, Chang G, Heriot AG, Kong JCH. Treatment strategies for locally recurrent rectal cancer. Eur J Surg Oncol 2022; 48:2292-2298. [DOI: 10.1016/j.ejso.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 05/03/2022] [Accepted: 05/13/2022] [Indexed: 10/18/2022] Open
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Shine RJ, Glyn T, Frizelle F. Pelvic exenteration: a review of current issues/controversies. ANZ J Surg 2022; 92:2822-2828. [PMID: 35490337 DOI: 10.1111/ans.17734] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/09/2022] [Accepted: 04/01/2022] [Indexed: 11/28/2022]
Abstract
Management of advanced or recurrent pelvic cancer has evolved dramatically over the past few decades. Patients who were previously considered inoperable are now candidates for potentially curative surgery and avoid suffering with intractable symptoms. Up to 10% of primary rectal cancers present with isolated advanced local disease and between 10% and 15% of patients develop localized recurrence following proctectomy. Advances in surgical technique, reconstruction and multidisciplinary involvement have led to a reduction in mortality and morbidity and culminated in higher R0 resection rates with superior longer-term survival outcomes. Recent studies boast over 50% 5-year survival for rectal with an R0 resection. Exenteration has cemented itself as an important treatment option for advanced primary/recurrent pelvic tumours, however, there are still a few controversies. This review will discuss some of these issues, including: limitations of resection and the approach to high/wide tumours; the role of acute exenteration; re-exenteration; exenteration in the setting of metastatic disease and palliation; the role of radiotherapy (including intra-operative and re-irradiation); management of the empty pelvis; and the impact on quality of life and function.
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Affiliation(s)
- Rebecca J Shine
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Tamara Glyn
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand.,Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Frank Frizelle
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand.,Department of Surgery, University of Otago, Christchurch, New Zealand
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Robotic Surgery in Rectal Cancer: Potential, Challenges, and Opportunities. Curr Treat Options Oncol 2022; 23:961-979. [PMID: 35438444 PMCID: PMC9174118 DOI: 10.1007/s11864-022-00984-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 12/09/2022]
Abstract
The current standard treatment for locally advanced rectal cancer is based on a multimodal comprehensive treatment combined with preoperative neoadjuvant chemoradiation and complete surgical resection of the entire mesorectal cancer. For ultra-low cases and cases with lateral lymph node metastasis, due to limitations in laparoscopic technology, the difficulties of operation and incidence of intraoperative complications are always difficult to overcome. Robotic surgery for the treatment of rectal cancer is an emerging technique that can overcome some of the technical drawbacks posed by conventional laparoscopic approaches, improving the scope and effect of radical operations. However, evidence from the literature regarding its oncological safety and clinical outcomes is still lacking. This brief review summarized the current status of robotic technology in rectal cancer therapy from the perspective of several mainstream surgical methods, including robotic total mesorectal excision (TME), robotic transanal TME, robotic lateral lymph node dissection, and artificial intelligence, focusing on the developmental direction of robotic approach in the field of minimally invasive surgery for rectal cancer in the future.
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74
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Denys A, van Nieuwenhove Y, Van de Putte D, Pape E, Pattyn P, Ceelen W, van Ramshorst GH. Patient-reported outcomes after pelvic exenteration for colorectal cancer: A systematic review. Colorectal Dis 2022; 24:353-368. [PMID: 34941002 DOI: 10.1111/codi.16028] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/15/2021] [Accepted: 12/14/2021] [Indexed: 12/15/2022]
Abstract
AIM Pelvic exenteration (PE) carries high morbidity. Our aim was to analyse the use of patient-reported outcome measures (PROMs) in PE patients. METHOD Search strategies were protocolized and registered in PROSPERO. PubMed, Embase, Cochrane Library, Google Scholar, Web of Science and ClinicalTrials.gov were searched with the terms 'patient reported outcomes', 'pelvic exenteration' and 'colorectal cancer'. Studies published after 1980 reporting on PROMs for at least 10 PE patients were considered. Study selection, data extraction, rating of certainty of evidence (GRADE) and risk of bias (ROBINS-I) were performed independently by two reviewers. RESULTS Nineteen of 173 studies were included (13 retrospective, six prospective). All studies were low to very low quality, with an overall moderate/serious risk of bias. Studies included data on 878 patients with locally advanced rectal cancer (n = 344), recurrent rectal cancer (n = 411) or cancer of unknown type (n = 123). Thirteen studies used validated questionnaires, four used non-validated measures and two used both. Questionnaires included the Functional Assessment of Cancer Therapy-Colorectal questionnaire (n = 6), Short Form Health Survey (n = 6), European Organization for Research and Treatment for Cancer (EORTC) Quality of Life Questionnaire C30 (n = 6), EORTC-CR38 (n = 4), EORTC-BLM30 (n = 1), Brief Pain Inventory (n = 2), Short Form 12 (n = 1), Assessment of Quality of Life (n = 1), Short Form Six-Dimension (n = 1), the Memorial Sloan Kettering Cancer Center Sphincter Function Scale (n = 1), the Cleveland Global Quality of Life (n = 1) or other (n = 4). Timing varied between studies. CONCLUSIONS Whilst the use of validated questionnaires increased over time, this study shows that there is a need for uniform use and timing of PROMs to enable multicentre studies.
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Affiliation(s)
- Andreas Denys
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Yves van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Dirk Van de Putte
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Eva Pape
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
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75
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Robinson M, O'Cathail S, Duffton A, Aitken K, Muirhead R. Potential for Isotoxic Re-irradiation Stereotactic Ablative Body Radiotherapy in Locally Recurrent Rectal Cancer. Clin Oncol (R Coll Radiol) 2022; 34:571-577. [DOI: 10.1016/j.clon.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 12/17/2021] [Accepted: 04/13/2022] [Indexed: 12/25/2022]
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Omarov N, Uymaz DS, Bugra D. Different uses of the breast implant to prevent empty pelvic complications following pelvic exenteration. BMJ Case Rep 2022; 15:e245630. [PMID: 35351741 PMCID: PMC8966538 DOI: 10.1136/bcr-2021-245630] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/04/2022] Open
Abstract
Pelvic exenteration surgery is used as a standard procedure in recurrent pelvic cancers. Total pelvic exenteration (TPE) includes resection of the uterus, prostate, ureters, bladder and rectosigmoid colon from pelvic space. Empty pelvis syndrome is a complication of the TPE procedure. Following TPE, complications such as haematoma, abscess leading to permanent pus discharge and chronic infections can occur. Herein, we present the case of a man in his 50s who was referred for pelvic pain, foul-smelling discharge and non-functioning colostomy, and operated for distal rectal cancer 1.5 years ago and underwent low anterior resection. In this case, we performed TPE for the recurrent tumour. To prevent TPE complications, we used a breast implant for filling the pelvic cavity. The early and late postoperative course was uneventful.
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Affiliation(s)
- Nail Omarov
- General Surgery, Koç University Hospital, Istanbul, Turkey
| | | | - Dursun Bugra
- School of Medicine, Koç University, Istanbul, Turkey
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77
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Retrograde ureteric stenting and ileus tube insertion for a safer reoperation after pelvic exenteration: a case report. Clin J Gastroenterol 2022; 15:582-585. [PMID: 35258847 DOI: 10.1007/s12328-022-01609-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/09/2022] [Indexed: 10/18/2022]
Abstract
A 64-year-old male had undergone open pelvic exenteration and urinary tract reconstruction with an ileal conduit for locally advanced rectal cancer. Six years later, he developed a late-onset perineal intestinal fistula and was scheduled for surgical treatment. Before reoperation, a transnasal ileus tube was inserted toward the ileal fistula, and ureteric stents were placed by endoscopy into the bilateral ureters via an ileal conduit. After laparotomy, ureteric stents and an ileus tube were palpable in the ileal conduit and jejunum to the proximal ileum. Ileal transection and ileo-transverse bypass were safely performed. The patient showed satisfactory progress and was discharged from the hospital on postoperative day 14. Retrograde ureteric stenting and ileus tube insertion seems to present a less-invasive and effective method for a safer reoperation after pelvic exenteration.
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Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative. Cancers (Basel) 2022; 14:cancers14051161. [PMID: 35267469 PMCID: PMC8909015 DOI: 10.3390/cancers14051161] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 12/12/2022] Open
Abstract
Pelvic exenteration is a complex operation performed for locally advanced and recurrent pelvic cancers. The goal of surgery is to achieve clear margins, therefore identifying adjacent or involved organs, bone, muscle, nerves and/or vascular structures that may need resection. While these extensive resections are potentially curative, they can be associated with substantial morbidity. Recently, there has been a move to centralize care to specialized units, as this facilitates better multidisciplinary care input. Advancements in pelvic oncology and surgical innovation have redefined the boundaries of pelvic exenterative surgery. Combined with improved neoadjuvant therapies, advances in diagnostics, and better reconstructive techniques have provided quicker recovery and better quality of life outcomes, with improved survival This article provides highlights of the current management of advanced pelvic cancers in terms of surgical strategy and potential future developments.
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79
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S. Al Ghamdi S, Leeds I, Fang S, Ngamruengphong S. Minimally Invasive Endoscopic and Surgical Management of Rectal Neoplasia. Cancers (Basel) 2022; 14:cancers14040948. [PMID: 35205695 PMCID: PMC8869910 DOI: 10.3390/cancers14040948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 12/10/2022] Open
Abstract
Rectal cancer demonstrates a characteristic natural history in which benign rectal neoplasia precedes malignancy. The worldwide burden of rectal cancer is significant, with rectal cancer accounting for one-third of colorectal cancer cases annually. The importance of early detection and successful management is essential in decreasing its clinical burden. Minimally invasive treatment of rectal neoplasia has evolved over the past several decades, which has led to reduced local recurrence rates and improved survival outcomes. The approach to diagnosis, staging, and selection of appropriate treatment modalities is a multidisciplinary effort combining interventional endoscopy, surgery, and radiology tools. This review examines the currently available minimally invasive endoscopic and surgical management options of rectal neoplasia.
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Affiliation(s)
- Sarah S. Al Ghamdi
- Division of Gastroenterology and Hepatology, Department of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
| | - Ira Leeds
- Division of Colon and Rectal Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06510, USA;
| | - Sandy Fang
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21224, USA;
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD 21224, USA
- Correspondence:
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80
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Williams A, Cunningham A, Hutchings H, Harris DA, Evans MD, Harji D. Quality of internet information to aid patient decision making in locally advanced and recurrent rectal cancer. Surgeon 2022; 20:e382-e391. [PMID: 35033455 DOI: 10.1016/j.surge.2021.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/25/2021] [Accepted: 12/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND To review whether online decision aids are available for patients contemplating pelvic exenteration (PE) for locally advanced and recurrent rectal cancer (LARC and LRRC). METHODS A grey literature review was carried out using the Google Search™ engine undertaken using a predefined search strategy (PROSPERO database CRD42019122933). Written health information was assessed using the DISCERN criteria and International Patient Decision Aids Standards (IPDAS) with readability content assessed using the Flesch-Kincaid reading ease test and Flesch-Kincaid grade level score. RESULTS Google search yielded 27, 782, 200 results for the predefined search criteria. 131 sources were screened resulting in the analysis of 6 sources. No sources were identified as a decision aid according to the IPDAS criteria. All sources provided an acceptable quality of written health information, scoring a global score of 3 for the DISCERN written assessment. The median Flesch-Kincaid reading ease was 50.85 (32.5-80.8) equating to a reading age of 15-18 years and the median Flesch-Kincaid grade level score was 7.65 (range 3-9.7), which equates to a reading age of 13-14. CONCLUSIONS This study has found that there is a paucity of online information for patients contemplating PE. Sources that are available are aimed at a high health literate patient. Given the considerable morbidity associated with PE surgery there is a need for high quality relevant information in this area. A PDA should be developed to improve decision making and ultimately improve patient experience.
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Affiliation(s)
- A Williams
- Department of Surgery, Swansea Bay University Health Board, Singleton Hospital, Swansea, SA2 8QA, UK; Swansea University Medical School, Institute of Life Science 2, Swansea, SA2 8QA, UK.
| | - A Cunningham
- Department of Surgery, Swansea Bay University Health Board, Singleton Hospital, Swansea, SA2 8QA, UK; Swansea University Medical School, Institute of Life Science 2, Swansea, SA2 8QA, UK.
| | - H Hutchings
- Swansea University Medical School, Institute of Life Science 2, Swansea, SA2 8QA, UK.
| | - D A Harris
- Department of Surgery, Swansea Bay University Health Board, Singleton Hospital, Swansea, SA2 8QA, UK.
| | - M D Evans
- Department of Surgery, Swansea Bay University Health Board, Singleton Hospital, Swansea, SA2 8QA, UK.
| | - D Harji
- Population Health Sciences, University of Newcastle, Australia.
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Johnson YL, West MA, Gould LE, Drami I, Behrenbruch C, Burns EM, Mirnezami AH, Jenkins JT. Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications. Colorectal Dis 2022; 24:16-26. [PMID: 34653292 DOI: 10.1111/codi.15956] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/12/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
AIM Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is no consensus on the best approach. We evaluated and compared the complications associated with each reconstruction technique with the aim of determining which is associated with the lowest incidence of complications related to the empty pelvis. METHOD The systematic review protocol was prospectively registered with PROSPERO (CRD42021239307). PRISMA-P guidelines were used to present the literature. PubMed and MEDLINE were systematically searched up to 1 February 2021. A dataset containing predetermined primary and secondary outcomes was extracted. RESULTS Eighteen studies fulfilled our criteria; these included 375 patients with mainly rectal and gynaecological cancer. Only three studies had a follow-up greater than 2 years. Six surgical interventions were identified. Mesh reconstruction and breast prosthesis were associated with low rates of small bowel obstruction (SBO), entero-cutaneous fistulas and perineal hernia. Findings for myocutaneous flaps were similar; however, they were associated with high rates of perineal wound complications. Omentoplasty was found to have a high perineal wound infection rate (40%). Obstetric balloons were found to have the highest rates of perineal wound dehiscence and SBO. Silicone expanders effectively kept small bowel out of the pelvis, although rates of pelvic collections remained high (20%). CONCLUSION The morbidity associated with an empty pelvis remains considerable. Given the low quality of the evidence with small patient numbers, strong conclusions in favour of a certain technique and comparison of these interventions remains challenging.
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Affiliation(s)
- Yanika L Johnson
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
| | - Malcolm A West
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
- Complex Cancer Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
- Complex Cancer Clinic, St Mark's Hospital, London, UK
| | - Laura E Gould
- Complex Cancer Clinic, St Mark's Hospital, London, UK
| | - Ioanna Drami
- Complex Cancer Clinic, St Mark's Hospital, London, UK
| | | | | | - Alexander H Mirnezami
- Faculty of Medicine, School of Cancer Sciences, University of Southampton, Southampton, UK
- Complex Cancer Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
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Sanzharov AE, Gallyamov EA, Sergeev VP, Biktimirov RG, Aminova LN, Kochkin AD, Meshchankin IV, Agapov MA, Gololobov GY. [Results of laparoscopic pelvic exenterations]. Khirurgiia (Mosk) 2022:45-57. [PMID: 35775844 DOI: 10.17116/hirurgia202207145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To analyze clinical outcomes after pelvic exenteration for advanced primary or recurrent pelvic cancer. MATERIAL AND METHODS We analyzed the outcomes in 35 patients after pelvic exenteration for advanced primary or recurrent pelvic cancer (gynecological cancer, urologic cancers, colon cancer). There were 3 (8.57%) men and 32 (91.43%) women. Mean BMI was 26 kg/m2. RESULTS Total exenteration was performed in 10 (28.57%) patients, anterior exenteration - 18 (51.43%) patients, posterior exenteration - 7 (20.0%) patients. Intraoperative complications (damage to the common iliac vessels) occurred in 1 (2.86%) patient. Mean surgery time was 280 minutes (range 180-600), mean intraoperative blood loss - 400 ml (range 100-2000). Mean postoperative ICU-stay was 24 hours. Major postoperative complications Clavien-Dindo grade 3-4 were detected in 3 (8.57%) patients. One (2.86%) patient died in 84 days after surgery from multiple organ failure due to progression of disease (Clavien-Dindo grade 5). There were 4 (11.43%) patients with complications Clavien-Dindo grade ≥3. Negative resection margin (R0) was achieved in 32 (91.43%) cases. The follow-up period ranged from 2 to 70 months (median 16.5 months). Overall survival was assessed in 25 patients. Other 10 patients or their relatives did not get in touch and therefore did not participate in assessment of survival. Overall 2-year survival assessed in 6 patients with cervical cancer was 24%. Overall 2-year survival estimated in 8 patients with bladder cancer was 100%. A patient with colon cancer lived for 23 months. Among 2 patients with vulvar cancer, 1 patient died in 25 months after surgery, the second one was followed-up for 11 months. Patients with primary multiple tumors were followed-up for 10-21 months. Overall 1-year survival was 100%. One patient died after 21 months. CONCLUSION Analyzing own findings and world literature data, we can conclude that laparoscopic technique ensures better intra- and postoperative results compared to standard laparotomy. However, there are insufficient data to confirm superiority of laparoscopic approach regarding oncological results.
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Affiliation(s)
- A E Sanzharov
- Federal Scientific and Clinical Center for Specialized Methods of Medical Care and Medical Technologies, Moscow, Russia
| | - E A Gallyamov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - V P Sergeev
- State Research Center of the Russian Federation - Burnazyan Federal Medical Biophysical Center, Moscow, Russia
| | - R G Biktimirov
- Federal Clinical Center of High Medical Technologies of the Federal Medical and Biological Agency, Moscow, Russia
| | | | - A D Kochkin
- Road Clinical Hospital, Nizhny Novgorod, Russia
| | - I V Meshchankin
- MEDSI Clinical Hospital on Pyatnitskoe highway, Moscow, Russia
| | - M A Agapov
- Lomonosov Moscow State University, Moscow, Russia
| | - G Yu Gololobov
- Sechenov First Moscow State Medical University, Moscow, Russia
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83
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Persson P, Chong P, Steele C, Quinn M. Prevention and management of complications in pelvic exenteration. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2277-2283. [DOI: 10.1016/j.ejso.2021.12.470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/29/2021] [Indexed: 11/17/2022]
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Lampe B, Luengas-Würzinger V, Weitz J, Roth S, Rawert F, Schuler E, Classen-von Spee S, Fix N, Baransi S, Dizdar A, Mallmann P, Schaser KD, Bogner A. Opportunities and Limitations of Pelvic Exenteration Surgery. Cancers (Basel) 2021; 13:6162. [PMID: 34944783 PMCID: PMC8699210 DOI: 10.3390/cancers13246162] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/26/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The practice of exenterative surgery is sometimes controversial and has garnered a certain scepticism. Surgical studies are difficult to conduct due to insufficient data. The aim of this review is to present the current standing of pelvic exenteration from a surgical, gynaecological and urological point of view. METHODS This review is based upon a literature review (MEDLINE (PubMed), CENTRAL (Cochrane) and EMBASE (Elsevier)) of retrospective studies on exenterative surgery from 1993-2020. Using MeSH (Medical Subject Headings) search terms, 1572 publications were found. These were evaluated and screened with respect to their eligibility using algorithms and well-defined inclusion and exclusion criteria. Therefore, the guidelines for systematic reviews (PRISMA) were used. RESULTS A complete tumour resection (R0) often represents the only curative option for advanced pelvic carcinomas and their recurrences. A recent systematic review showed significant symptom relief in 80% of palliative patients after pelvic exenteration. Surgical limitations (distant metastases, involvement of the pelvic wall, etc.) are diminished by adequate surgical expertise and close interdisciplinary cooperation. While the mortality rate is low (2-5%), the still relatively high morbidity rate (32-84%) can be minimized by optimizing the perioperative setting. Following exenterations, roughly 79-82% of patients report satisfying results according to PROs (patient-reported outcomes). CONCLUSION Due to multimodality treatment strategies combined with extended surgical expertise and patients' preferences, pelvic exenteration can be offered nowadays with low mortality and acceptable postoperative quality of life. The possibilities of surgical treatment are often underestimated. A multi-centre database (PelvEx Collaborative) was established to collect data and experiences to optimize the research in this field.
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Affiliation(s)
- Björn Lampe
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Verónica Luengas-Würzinger
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (J.W.); (A.B.)
| | - Stephan Roth
- Department of Urology and Pediatric Urology, Helios Faculty of Medicine Wuppertal, Universität Witten/Herdecke, Heusnerstraße 40, 42283 Wuppertal, Germany;
| | - Friederike Rawert
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Esther Schuler
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Sabrina Classen-von Spee
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Nando Fix
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Saher Baransi
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Anca Dizdar
- Department of Gynecology & Obstetrics, Florence Nightingale Hospital, Kreuzbergstr. 79, 40489 Düsseldorf, Germany; (B.L.); (F.R.); (E.S.); (S.C.-v.S.); (N.F.); (S.B.); (A.D.)
| | - Peter Mallmann
- Department of Obstetrics and Gynecology, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany;
| | - Klaus-Dieter Schaser
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Andreas Bogner
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany; (J.W.); (A.B.)
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Drami I, Lord AC, Sarmah P, Baker RP, Daniels IR, Boyle K, Griffiths B, Mohan HM, Jenkins JT. Preoperative assessment and optimisation for pelvic exenteration in locally advanced and recurrent rectal cancer: A review. Eur J Surg Oncol 2021; 48:2250-2257. [PMID: 34922810 DOI: 10.1016/j.ejso.2021.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 01/06/2023] Open
Abstract
The pre-operative phase in planning a pelvic exenteration or extended resections is critical to optimising patient outcomes. This review summarises the key components of preoperative assessment and planning in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LLRC) being considered for potential curative resection. The preoperative period can be considered in 5 key phases: 1) Multidisciplinary meeting (MDT) review and recommendation for neoadjuvant therapy and surgery, 2) Anaesthetic preoperative assessment of fitness for surgery and quantification of risk, 3) Shared decision making with the patient and the process of informed consent, 4) Prehabilitation and physiological optimisation 5) Technical aspects of surgical planning. This review will focus on patients who have been recommended for surgery by the MDT and have completed neoadjuvant therapy. Other important considerations beyond the scope of this review are the various neoadjuvant strategies employed which in this patient group include Total Neo-adjuvant Therapy and reirradiation. Critical to improving perioperative outcomes is the dual aim of achieving a negative resection margin in a patient fit enough for extended surgery. Advanced, realistic communication is required pre-operatively and should be maintained throughout recovery. Optimising patient's physiological and psychological reserve with a preoperative prehabilitation programme is important, with physiotherapy, psychological and nutritional input. From a surgical perspective, image based technical preoperative planning is important to identify risk points and ensure correct surgical strategy. Careful attention to the entire patient journey through these 5 preoperative phases can optimise outcomes with the accumulation of marginal gains at multiple timepoints.
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Affiliation(s)
- I Drami
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK.
| | - A C Lord
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P Sarmah
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - R P Baker
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - I R Daniels
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - K Boyle
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - B Griffiths
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - H M Mohan
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - J T Jenkins
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
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86
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de Nes LCF, van der Heijden JAG, Verstegen MG, Drager L, Tanis PJ, Verhoeven RHA, de Wilt JHW. Predictors of undergoing multivisceral resection, margin status and survival in Dutch patients with locally advanced colorectal cancer. Eur J Surg Oncol 2021; 48:1144-1152. [PMID: 34810058 DOI: 10.1016/j.ejso.2021.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 11/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The aim of this nationwide observational study was to evaluate factors associated with multivisceral resection (MVR), margin status and overall survival in locally advanced colorectal cancer (CRC). MATERIAL AND METHODS Patients with (y)pT4, cM0 CRC between 2006 and 2017 were selected from the Netherlands Cancer Registry. Cox-proportional hazards modelling was used for survival analysis, stratified for T4a and T4b. Annual hospital volume cut-off was 75 for colon and 40 for rectal resections. RESULTS A total of 11.930 patients were included and 2410 patients (20.2%) underwent MVR. Factors associated with MVR for colon and rectal cancer besides cT4 category were more recent diagnosis (OR 3.61, CI 95% 3.06-4.25 (colon) and OR 2.72, CI 95% 1.82-4.08 (rectum)) and high hospital volume (OR 1.20, CI 95% 1.05-1.38 (colon) and OR 2.17, CI 95% 1.55-3.04 (rectum)). Patients ≥70 year were less likely to undergo MVR for colon cancer (OR 0.80, 95% CI 0.70-0.90). Risk factors for incomplete resection were cT4 (OR 3.08, CI 95% 2.35-4.04 (colon) and OR 1.82, CI 95% 1.13-2.94 (rectum)) and poor/undifferentiated tumors (OR 1.41, CI 95% 1.14-1.72 (colon) and OR 1.69, CI 95% 1.05-2.74 (rectum)). More recent diagnosis was independently associated with less incomplete resections in colon cancer (OR 0.58, CI 95% 0.40-0.76). Independent predictors of survival were age, resection margin, nodal status and adjuvant chemotherapy, but not MVR. CONCLUSION Treatment of locally advanced CRC with MVR at population level was influenced by year of diagnosis and hospital volume. Margin status in colon cancer improved substantially over time.
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Affiliation(s)
- L C F de Nes
- Maasziekenhuis Pantein, Department of Surgery, Beugen, the Netherlands; Radboud University Medical Centre, Department of Surgery, Nijmegen, the Netherlands.
| | | | - M G Verstegen
- Radboud University Medical Centre, Department of Surgery, Nijmegen, the Netherlands
| | - L Drager
- Ziekenhuis Gelderse Vallei Department of Surgery, Ede, the Netherlands
| | - P J Tanis
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - R H A Verhoeven
- Netherlands Comprehensive Cancer Organisation, Department of Research & Development, Utrecht, the Netherlands
| | - J H W de Wilt
- Radboud University Medical Centre, Department of Surgery, Nijmegen, the Netherlands
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87
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Assi H, Persson A, Palmquist I, Öberg M, Buchwald P, Lydrup ML. Short-term outcomes following beyond total mesorectal excision and reconstruction using myocutaneous flaps: A retrospective cohort study. Eur J Surg Oncol 2021; 48:1161-1166. [PMID: 34794841 DOI: 10.1016/j.ejso.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/15/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Beyond total mesorectal excision (bTME) offers long-term survival in patients with advanced pelvic malignancy. At Skåne University Hospital (SUS) Malmö in Sweden, the vertical rectus abdominis musculocutaneous (VRAM) and gluteal maximus (GM) flap have been used for perineal reconstruction to promote healing and functional outcomes after significant tissue loss. This study aims to examine 90-day overall and flap-specific complications in patients with advanced pelvic cancer treated with bTME and perineal flap reconstruction. METHOD This retrospective study conducted at SUS included patients undergoing surgery between January 01, 2010 and August 01, 2016. Patients' data were gathered through medical chart reviews. The Clavien-Dindo (CD) classification system was used to classify surgical and medical postoperative complications. Flap-specific complications were evaluated regardless of CD classification. RESULTS One hundred five patients (51 men, 54 women) underwent bTME surgery with perineal reconstruction, with VRAM flaps used in 27 (26%) patients, GM flaps in 51 (49%) patients and GM flaps with vaginal reconstruction in 27 (26%) patients. The 90-day mortality rate was one (1%), despite surgical CD ≥ III and/or medical CD ≥ II complications affecting 51 (48%) patients. Partial perineal dehiscence was noted in 45 (43%) patients, mostly treated conservatively. At the first outpatient postoperative visit (median, 42 days), flap healing was complete in 47 (45%) patients. CONCLUSION bTME surgery in pelvic cancer patients with perineal flap reconstruction using VRAM or GM flaps results in high overall and flap complication rates, but low mortality. Most complications can be conservatively treated.
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Affiliation(s)
- Hanin Assi
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden.
| | - Anna Persson
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Ingrid Palmquist
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Martin Öberg
- Department of Plastic Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Pamela Buchwald
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Skåne University Hospital, Malmö, Lund University, Sweden
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88
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Gallyamov EA, Sanzharov AE, Agapov MA, Prokhorenko KA, Gololobov GY, Doronchyk DN, Daynego VG. LAPOROSCOPIC PELVIC EXENTERATION FOR TREATMENT OF PRIMARY MULTIPLE CANCER. CASE REPORT. SURGICAL PRACTICE 2021. [DOI: 10.38181//2223-2427-2021-3-31-39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This clinical case represents the experience of surgical treatment of a patient with multiple primary metachronous cancer: 1. Sigmoid cancer рТ4NxM0. Resection of sigmoid colon (16.12.2013). Three courses of adjuvant chemotherapy (XELOX). Recurrence (2015). Laparotomy, Colproctectomy with D3 paraaortic lymph dissection. Ileostomy (2015). One course of chemotherapy (XELOX). 2. Upper tract urothelial carcinoma (right ureter) pT2N0M0R0. Right nephroureterectomy with the resection of the bladder and right testicular cord, cystostomy (19.02.2015). Recurrence. Nephrostomy drainage of the left kidney. Adhesive disease. Rectovesical fistula. Taking into account the history and comorbid status of the patient, it was decided to perform laparoscopic supralevator pelvic exenteration, ureterectomy on the left. The duration of the operation was 280 minutes, intraoperative blood loss was 200 ml. The period of stay in intensive care is 24 hours, the patient was discharged on the 7th day after the operation, the resection margin was negative (R0). After 12 months, there is no data for the disease progressed.
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Affiliation(s)
- E. A. Gallyamov
- Sechenov University; Federal Scientific and Clinical Center for Specialized Methods of Medical Aid and Medical Technologies FMBA; Federal State Budget Educational Institution of Higher Education M.V. Lomonosov Moscow State University (Lomonosov MSU)
| | - A. E. Sanzharov
- Federal Scientific and Clinical Center for Specialized Methods of Medical Aid and Medical Technologies FMBA
| | - M. A. Agapov
- Federal State Budget Educational Institution of Higher Education M.V. Lomonosov Moscow State University (Lomonosov MSU)
| | - K. A. Prokhorenko
- Federal Scientific and Clinical Center for Specialized Methods of Medical Aid and Medical Technologies FMBA
| | - G. Yu. Gololobov
- Sechenov University; City Clinical Hospital named S.I. Spasokykockiy DHM
| | - D. N. Doronchyk
- Federal Scientific and Clinical Center for Specialized Methods of Medical Aid and Medical Technologies FMBA
| | - V. G. Daynego
- Federal Scientific and Clinical Center for Specialized Methods of Medical Aid and Medical Technologies FMBA
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89
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Guiney N, Larach JT, Soucisse ML, Waters PS, Warrier SK, Wagner T, Heriot AG, McCormick JJ. Pre-emptive femoral-femoral crossover and subsequent resection of locally recurrent colon cancer with multiorgan involvement including the common iliac vessels. ANZ J Surg 2021; 92:1226-1228. [PMID: 34550634 DOI: 10.1111/ans.17232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/12/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Natalie Guiney
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - José Tomás Larach
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,Faculty of Medicine, dentistry and health sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Mikael L Soucisse
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Peadar S Waters
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,Faculty of Medicine, dentistry and health sciences, University of Melbourne, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Timothy Wagner
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,Department of Vascular Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,Faculty of Medicine, dentistry and health sciences, University of Melbourne, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Jacob J McCormick
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
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90
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Pérez Lara FJ, Hebrero Jimenez ML, Moya Donoso FJ, Hernández Gonzalez JM, Pitarch Martinez M, Prieto-Puga Arjona T. Review of incomplete macroscopic resections (R2) in rectal cancer: Treatment, prognosis and future perspectives. World J Gastrointest Oncol 2021; 13:1062-1072. [PMID: 34616512 PMCID: PMC8465452 DOI: 10.4251/wjgo.v13.i9.1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/28/2021] [Accepted: 07/23/2021] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer is one of the most prevalent tumours, but with improved treatment and early detection, its prognosis has greatly improved in recent years. However, when the tumour is locally advanced at diagnosis or if there is local recurrence, it is more difficult to perform a complete tumour resection, and there may be a residual macroscopic tumour. In this paper, we review the literature on residual macroscopic tumour resections, concerning both locally advanced primary tumours and recurrences, evaluating the main problems encountered, the treatments applied, the prognosis and future perspectives in this field.
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91
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van Rees JM, Visser E, van Vugt JLA, Rothbarth J, Verhoef C, van Verschuer VMT. Impact of nutritional status and body composition on postoperative outcomes after pelvic exenteration for locally advanced and locally recurrent rectal cancer. BJS Open 2021; 5:6406859. [PMID: 34672343 PMCID: PMC8529522 DOI: 10.1093/bjsopen/zrab096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/22/2021] [Indexed: 12/29/2022] Open
Abstract
Background Pelvic exenteration for locally advanced rectal cancer (LARC) and locally recurrent (LRRC) rectal cancer provides radical resection and local control, but is associated with considerable morbidity. The aim of this study was to determine risk factors, including nutritional status and body composition, for postoperative morbidity and survival after pelvic exenteration in patients with LARC or LRRC. Methods Patients with LARC or LRRC who underwent total or posterior pelvic exenteration in a tertiary referral centre from 2003 to 2018 were analysed retrospectively. Nutritional status was assessed using the Malnutrition Universal Screening Tool (MUST). Body composition was estimated using standard-of-care preoperative CT of the abdomen. Logistic regression analyses were performed to identify risk factors for complications with a Clavien–Dindo grade of III or higher. Risk factors for impaired overall survival were calculated using Cox proportional hazards analysis. Results In total, 227 patients who underwent total (111) or posterior (116) pelvic exenteration were analysed. Major complications (Clavien–Dindo grade at least III) occurred in 82 patients (36.1 per cent). High risk of malnutrition (MUST score 2 or higher) was the only risk factor for major complications (odds ratio 3.99, 95 per cent c.i. 1.76 to 9.02) in multivariable analysis. Mean follow-up was 44.6 months. LRRC (hazard ratio (HR) 1.61, 95 per cent c.i. 1.04 to 2.48) and lymphovascular invasion (HR 2.20, 1.38 to 3.51) were independent risk factors for impaired overall survival. Conclusion A high risk of malnutrition according to the MUST is a strong risk factor for major complications in patients with LARC or LRRC undergoing exenteration surgery.
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Affiliation(s)
- Jan M van Rees
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Eva Visser
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jeroen L A van Vugt
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - Joost Rothbarth
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Victorien M T van Verschuer
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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Kazi M, Kumar NAN, Rohila J, Sukumar V, Engineer R, Ankathi S, Desouza A, Saklani A. Minimally invasive versus open pelvic exenterations for rectal cancer: a comparative analysis of perioperative and 3-year oncological outcomes. BJS Open 2021; 5:6369779. [PMID: 34518872 PMCID: PMC8438253 DOI: 10.1093/bjsopen/zrab074] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 07/13/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND This study compared the surgical and oncological outcomes of open and minimally invasive pelvic exenteration. METHODS Patients who underwent pelvic exenterations for primary locally advanced rectal cancers with invasion of the urogenital organs (central and anterior disease) between August 2013 and September 2020 were reviewed retrospectively. Patients were categorized as undergoing open or minimally invasive surgery (MIS) and these groups were compared for perioperative outcomes and 3-year survival (overall, recurrence-free and local relapse-free survival). Multivariable Cox regression analysis was performed to assess the independent influence of approach of surgery and cancer features on recurrence-free survival (RFS). RESULTS Of the 158 patients who underwent pelvic exenteration, 97 (61.4 per cent) had open exenterations and 61 (38.6 per cent) patients had an MIS resection (44 patients (72 per cent) using laparoscopy and 17 (28 per cent) using robotic surgery). There were 96 (60.8 per cent) total pelvic exenterations and 62 (39.2 per cent) posterior pelvic exenterations. MIS exenterations had significantly longer operative times (MIS versus open: 640 mins versus 450 mins; P < 0.001) but reduced blood loss (MIS versus open: 900 ml versus 1600 ml; P < 0.001) and abdominal wound infections (MIS versus open: 8.2 versus 17.5 per cent; P = 0.020) without a difference in hospital stay (MIS versus open: 11 versus 12 days; P = 0.620). R0 resection rates and involvement of circumferential resection margins were similar (MIS versus open: 88.5 versus 91.8 per cent, P = 0.490 and 13.1 versus 8.2 per cent, P = 0.342 respectively). At a median follow-up of 29 months, there were no differences in 3-year overall survival (MIS versus open: 79.4 versus 60.2 per cent; P = 0.251), RFS (MIS versus open: 51.9 versus 47.8 per cent; P = 0.922) or local relapse-free survival (MIS versus open: 89.7 versus 75.2 per cent; P = 0.491. On multivariable analysis, approach to surgery had no bearing on RFS, and only known distant metastasis, aggressive histology and inadequate response to neoadjuvant radiation (pathological tumour regression grade greater than 3) predicted worse RFS. CONCLUSION MIS exenterations documented longer procedures but resulted in less blood loss and fewer wound infections compared with open surgeries. In the setting of an experienced centre, the hospital stay, R0 resection rates and oncological outcomes at 3 years were similar to those of open exenterations.
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Affiliation(s)
- M Kazi
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - N A N Kumar
- Department of Surgical Oncology, Manipal Comprehensive Cancer Care Centre, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - J Rohila
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - V Sukumar
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - R Engineer
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - S Ankathi
- Department of Radiology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - A Desouza
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - A Saklani
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
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93
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Koëter T, Stijns RCH, van Koeverden S, Hugen N, van der Heijden JAG, Nederend J, van Zwam PH, Nagtegaal ID, Verheij M, Rutten HJT, de Wilt JHW. Poor response at restaging MRI and high incomplete resection rates of locally advanced mucinous rectal cancer after chemoradiation therapy. Colorectal Dis 2021; 23:2341-2347. [PMID: 34051043 PMCID: PMC8519080 DOI: 10.1111/codi.15760] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/09/2021] [Accepted: 05/19/2021] [Indexed: 02/08/2023]
Abstract
AIM Mucinous carcinoma is a histological subtype of rectal cancer and has been associated with a poor response to neoadjuvant chemoradiotherapy (CRT). The primary aim of this study was to analyse the response on MRI of mucinous locally advanced rectal cancer (LARC) after CRT compared to regular adenocarcinoma. METHOD Patients with LARC (defined as cT4 and/or cN2), who underwent CRT followed by restaging MRI and surgery in two tertiary referral hospitals were retrospectively included in the study. Pre- and post-treatment MRI was reviewed by an experienced abdominal radiologist. RESULTS A total of 102 patients, of whom 29 were diagnosed with mucinous carcinoma, were included for analysis. At restaging MRI, adenocarcinoma patients demonstrated significantly less clinical involvement of the mesorectal fascia (37% vs. 62%, P = 0.003) while this was not demonstrated in mucinous carcinoma patients (86% vs. 97%, P = 0.16). Significant downstaging after CRT in adenocarcinoma patients (P = 0.01) was seen while, in mucinous carcinoma patients, no downstaging after CRT (P = 0.89) was seen. Pathology revealed significantly higher rates of an involved circumferential resection margin in mucinous carcinoma versus adenocarcinoma patients (27.6% vs. 1.4%; P < 0.001). After multivariate regression analysis, mucinous carcinoma remained an independent prognostic factor for local recurrence (hazard ratio 3.6; 95% CI 1.1-12.4), although no differences in overall or disease-free survival were observed. CONCLUSION Mucinous rectal carcinoma is associated with a poor clinical response at restaging MRI after CRT, leading to relatively higher rates of involved circumferential resection margins at pathology. In this cohort, mucinous carcinoma seems to be a prognostic factor for increased risk of local recurrence, without an effect on overall survival.
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Affiliation(s)
- Tijmen Koëter
- Department of SurgeryRadboud University Medical CentreNijmegenThe Netherlands
| | - Rutger C. H. Stijns
- Department of SurgeryRadboud University Medical CentreNijmegenThe Netherlands
| | - Sebastiaan van Koeverden
- Department of Radiology and Nuclear MedicineRadboud University Medical CentreNijmegenThe Netherlands
| | - Niek Hugen
- Department of SurgeryRadboud University Medical CentreNijmegenThe Netherlands
| | | | - Joost Nederend
- Department of RadiologyCatharina HospitalEindhovenThe Netherlands
| | - Peter H. van Zwam
- Department of PathologyPAMM Laboratory for Pathology and Medical MicrobiologyEindhovenThe Netherlands
| | - Iris D. Nagtegaal
- Department of PathologyRadboud University Medical CentreNijmegenThe Netherlands
| | - Marcel Verheij
- Department of Radiation OncologyRadboud University Medical CentreNijmegenThe Netherlands
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Johnstone P, Okonta L, Aitken K, Holmes J, Harrison M, Harji D, O'Cathail SM, Taylor C, Tsang Y, Wing M, Muirhead R. A multicentre retrospective review of SABR reirradiation in rectal cancer recurrence. Radiother Oncol 2021; 162:1-6. [PMID: 34182013 DOI: 10.1016/j.radonc.2021.06.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/17/2021] [Accepted: 06/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE Locally recurrent rectal cancer (LRRC) is associated with considerable morbidity, poor quality of life and an overall survival of 9 months. The non-operative treatment of LRRC is an understudied area, there is no consensus on management in this setting. We aim to perform a retrospective, multicentre analysis of patients treated with SABR reirradiation. MATERIALS AND METHODS All patients were identified who received SABR re-irradiation for LRRC, at 3 UK centres, between August 2015 and September 2020. Eligible patients had pelvic recurrence and were either not suitable/opted not for surgery, or margin positive after exenturative surgery. Patients were treated with 30 Gy in 5 fractions and followed up with clinical review and CT scan at 3, 6, 12, 18 and 24 months. RESULTS 69 patients with 81 lesions were identified and median follow up was 28 months. Median progression free survival (PFS) and overall survival (OS) were 12.1 months (10.4, 17.7) and 38.7 months (28.9,-) respectively. 2-year OS was 0.77 (0.66, 0.89). 58.3% of deaths were as a result of consequences of local relapse. 42.6% of patients had local relapse at death or last follow up. CONCLUSION Our outcomes are encouraging for a population who had R1 resections, refused or were refused surgery; as they are similar to those in surgical series. Prospective data including details of survival, local relapse and QOL; with an optimised SABR technique, is required to establish SABR as an alternative to surgery.
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Affiliation(s)
| | | | | | - Jane Holmes
- Centre for Statistics in Medicine, University of Oxford, UK
| | - Mark Harrison
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, UK
| | | | | | | | - Yat Tsang
- Mount Vernon Cancer Centre, Mount Vernon Hospital, Northwood, UK
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95
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Kazi M, Sukumar V, Desouza A, Saklani A. State-of-the-art surgery for recurrent and locally advanced rectal cancers. Langenbecks Arch Surg 2021; 406:1763-1774. [PMID: 34341869 DOI: 10.1007/s00423-021-02285-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023]
Abstract
Extended and beyond total mesorectal excisions (TME) for advanced and recurrent rectal cancers are increasingly performed with acceptable oncological and functional outcomes. These are undoubtedly due to better understanding of tumor biology and improved patient selection rather than surgical valor and technical refinements alone. In the present review, we attempt to present the current surgical standards for advanced and recurrent cancers requiring surgery outside the TME planes based on involved pelvic compartments. The available procedures, their indications, and extent of resection and reconstruction are highlighted. Emphasis is on formation of dedicated exenteration teams, structured training, and referral systems that increase hospital and surgeon volume to improve patient outcomes and reduce morbidity. Areas of deficiencies in literature were recognized with regards to factors influencing recurrences, patient selection, and quality of life. Finally, the most appropriate preoperative therapy for these tumors is unclear in both the primary and recurrent settings.
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Affiliation(s)
- Mufaddal Kazi
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Vivek Sukumar
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Ashwin Desouza
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Avanish Saklani
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India.
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96
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Fahy MR, Kelly ME, Power Foley M, Nugent TS, Shields CJ, Winter DC. The role of intraoperative radiotherapy in advanced rectal cancer: a meta-analysis. Colorectal Dis 2021; 23:1998-2006. [PMID: 33905599 DOI: 10.1111/codi.15698] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 12/12/2022]
Abstract
AIM Patients with locally advanced and locally recurrent rectal cancer (LARC/LRRC) experience higher rates of local recurrence (LR) and poorer overall survival than patients with primary rectal cancer restricted to the mesorectum despite improved neoadjuvant treatment regimens and radical surgical procedures. Intraoperative radiotherapy (IORT) has been suggested as an adjunctive tool in the surgical management of these challenging cases. However, clear evidence regarding the oncological benefit of IORT is sparse. The aim of this review was to update this evidence in the era of standardized neoadjuvant radiotherapy administration. METHOD A systematic review of patients who received IORT as part of multimodal treatment for advanced rectal cancer from 2000 to 2020 and an analysis of IORT and surgery/external beam radiotherapy (EBRT) groups was performed. The primary endpoint was the rate of LR between the two groups. RESULTS Seven papers met the predefined criteria. LR was reduced by the addition of IORT when compared with the surgery/EBRT alone group (14.7% vs. 21.4%; OR 0.55, 95% CI 0.27-1.14; p = 0.11). There was no increase in reported genitourinary morbidity, wound issues, pelvic collections or anastomotic leak in those patients who received IORT. Notably, there was no survival difference between the two groups. CONCLUSION The addition of IORT to current treatment strategies in the management of patients with LARC/LRRC is associated with a lower rate of locoregional recurrence without increased morbidity. However, this marks a highly selective group of patients, with heterogeneity regarding indications, prior neoadjuvant treatments and/or IORT dosing.
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Affiliation(s)
- Matthew R Fahy
- University College Dublin, Belfield, Dublin 4, Ireland.,Centre for Colorectal Disease, St Vincent's Hospital, Dublin, Ireland
| | - Michael E Kelly
- University College Dublin, Belfield, Dublin 4, Ireland.,Centre for Colorectal Disease, St Vincent's Hospital, Dublin, Ireland
| | | | - Timothy S Nugent
- Department of Surgery, Trinity College Dublin, College Green, Dublin, Ireland
| | | | - Des C Winter
- University College Dublin, Belfield, Dublin 4, Ireland.,Centre for Colorectal Disease, St Vincent's Hospital, Dublin, Ireland
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97
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Tominaga T, Nonaka T, Fukuda A, Shiraisi T, Hashimoto S, Araki M, Sumida Y, Sawai T, Nagayasu T. Combined transabdominal and transperineal endoscopic pelvic exenteration for colorectal cancer: feasibility and safety of a two-team approach. Ann Surg Treat Res 2021; 101:102-110. [PMID: 34386459 PMCID: PMC8331559 DOI: 10.4174/astr.2021.101.2.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/16/2020] [Accepted: 01/15/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Pelvic exenteration (PE) is a highly invasive procedure with high morbidity and mortality rates. Promising options to reduce this invasiveness have included laparoscopic and transperineal approaches. The aim of this study was to identify the safety of combined transabdominal and transperineal endoscopic PE for colorectal malignancies. Methods Fourteen patients who underwent combined transabdominal and transperineal PE (T group: 2-team approach, n = 7; O group: 1-team approach, n = 7) for colorectal malignancies between April 2016 and March 2020 in our institutions were included in this study. Clinicopathological features and perioperative outcomes were compared between groups. Results All patients successfully underwent R0 resection. Operation time tended to be shorter in the T group (463 minutes) than in the O group (636 minutes, P = 0.080). Time to specimen removal was significantly shorter (258 minutes vs. 423 minutes, P = 0.006), blood loss was lower (343 mL vs. 867 mL, P = 0.042), and volume of blood transfusion was less (0 mL vs. 560 mL, P = 0.063) in the T group, respectively. Postoperative complications were similar between groups. Conclusion Combined transabdominal and transperineal PE under a synchronous 2-team approach was feasible and safe, with the potential to reduce operation time, blood loss, and surgeon stress.
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Affiliation(s)
- Tetsuro Tominaga
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Takashi Nonaka
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Akiko Fukuda
- Department of Surgery, Sasebo City General Hospital, Nagasaki, Japan
| | - Toshio Shiraisi
- Department of Surgery, Sasebo City General Hospital, Nagasaki, Japan
| | | | - Masato Araki
- Department of Surgery, Sasebo City General Hospital, Nagasaki, Japan
| | - Yorihisa Sumida
- Department of Surgery, Sasebo City General Hospital, Nagasaki, Japan
| | - Terumitsu Sawai
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
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98
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A prospective investigation of pain and fatigue following pelvic exenteration. Eur J Surg Oncol 2021; 47:3137-3143. [PMID: 34366173 DOI: 10.1016/j.ejso.2021.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 07/01/2021] [Accepted: 07/25/2021] [Indexed: 11/23/2022] Open
Abstract
AIM To describe the long-term course of pain and fatigue in patients undergoing pelvic exenteration and to evaluate potential prognostic factors for these outcomes. DESIGN Prospective cohort study. SETTINGS Royal Prince Alfred Hospital, Sydney, Australia. PATIENTS Consecutive patients undergoing pelvic exenteration surgery between July 2008 and December 2017. MAIN OUTCOME MEASURES Pain and fatigue scores collected via SF-36v2 Health surveys pre-operatively and at eight time-points post-operatively for a period of 5-years. The course of pain and fatigue were described according to the following prognostic factors; bone resection (yes/no), cancer type (primary/recurrent), margin status (R0/R1-2) and extent of exenteration (complete/partial). RESULTS 345 of 459 eligible patients (75 %) consented to the study. The course of pain and fatigue over the 5 year follow-up was favourable. Patients undergoing pelvic exenteration with an R0 resection margin or without bone resection presented lower pain levels throughout the follow-up period. Bone resection, positive surgical margin (R1/R2) and type of cancer did not influence fatigue trajectories. Patients undergoing complete pelvic exenteration were more likely to report a higher level of pain and fatigue in the initial follow-up period, however this difference was not observed in the longer-term. CONCLUSIONS Patients undergoing PE (Austin and Solomon, 2015) [1] can expect improvement but an incomplete recovery in the levels of pain and fatigue postoperatively over the 5-year follow-up period. Bone resection as part of exenteration demonstrated higher levels of pain and fatigue.
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99
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Harji D, Mauriac P, Bouyer B, Berard X, Gille O, Salut C, Rullier E, Celerier B, Robert G, Denost Q. The feasibility of implementing an enhanced recovery programme in patients undergoing pelvic exenteration. Eur J Surg Oncol 2021; 47:3194-3201. [PMID: 34736803 DOI: 10.1016/j.ejso.2021.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pelvic exenteration (PE) is a complex operative procedure, reserved for patients with locally advanced and recurrent pelvic malignancies. PE is associated with a high index of post-operative morbidity. Enhanced Recovery After Surgery (ERAS) programmes have been successful in improving postoperative outcomes, however, its application in PE has not been studied. The aim of our study is to assess the feasibility and short-term impact of ERAS on PE. METHODS A dedicated PE ERAS programme was developed reflecting the complexity of differing subtypes of PE. A prospective cohort study was undertaken to evaluate the feasibility of implementing our PE ERAS between 2016 and 2020. The primary endpoint of this study was overall compliance with the ERAS programme. RESULTS 145 patients were enrolled into our PE ERAS programme, with 86 (56.2%) patients undergoing a soft tissue PE, 27 (17.6%) a vascular PE and 32 (20.9%) a bony PE. The median overall compliance to the PE ERAS programme was 70% (IQR 55.5-88.8). There were no observed differences between overall compliance to the PE ERAS programme between different subtypes of PE (p = 0.60). Patients with higher compliance with the PE ERAS programme had a shorter LoS (p < 0.001), less post-operative morbidity (p < 0.001), reduced severity of Clavien-Dindo grade of morbidity (p < 0.001) and fewer readmissions (p = 0.03). CONCLUSIONS The principles of ERAS can be readily applied to patients undergoing PE, with high adherence to the ERAS programme associated with improved clinical outcomes.
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Affiliation(s)
- Deena Harji
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France
| | - Paul Mauriac
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
| | - Benjamin Bouyer
- Département de Chirurgie Rachidienne, Hôpital Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, CHU Bordeaux, France.
| | - Xavier Berard
- Département de Chirurgie Vasculaire, Hôpital Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, CHU Bordeaux, France
| | - Olivier Gille
- Département de Chirurgie Rachidienne, Hôpital Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, CHU Bordeaux, France.
| | - Cécile Salut
- Département D'imagerie Diagnostique et Interventionnelle, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
| | - Eric Rullier
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
| | - Bertrand Celerier
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
| | - Grégoire Robert
- Département D'urologie, Hôpital Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, CHU Bordeaux, France.
| | - Quentin Denost
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
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100
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Voogt ELK, van Rees JM, Hagemans JAW, Rothbarth J, Nieuwenhuijzen GAP, Cnossen JS, Peulen HMU, Dries WJF, Nuyttens J, Kolkman-Deurloo IK, Verhoef C, Rutten HJT, Burger JWA. Intraoperative Electron Beam Radiation Therapy (IOERT) Versus High-Dose-Rate Intraoperative Brachytherapy (HDR-IORT) in Patients With an R1 Resection for Locally Advanced or Locally Recurrent Rectal Cancer. Int J Radiat Oncol Biol Phys 2021; 110:1032-1043. [PMID: 33567303 DOI: 10.1016/j.ijrobp.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/18/2020] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Intraoperative radiation therapy (IORT), delivered by intraoperative electron beam radiation therapy (IOERT) or high-dose-rate intraoperative brachytherapy (HDR-IORT), may reduce the local recurrence rate in patients with locally advanced and locally recurrent rectal cancer (LARC and LRRC, respectively). The aim of this study was to compare the oncological outcomes between both IORT modalities in patients with LARC or LRRC who underwent a microscopic irradical (R1) resection. METHODS All consecutive patients who received IORT because of an R1 resection of LARC or LRRC between 2000 and 2016 in two tertiary referral centers were included. In LARC, a resection margin of ≤2 mm was considered R1. A resection margin of 0 mm was considered R1 in LRRC. RESULTS In total, 215 patients with LARC were included, of whom 151 (70%) received IOERT and 64 (30%) received HDR-IORT; in addition, 158 patients with LRRC were included, of whom 112 (71%) received IOERT and 46 (29%) received HDR-IORT. After multivariable analyses, the overall survival was not significantly different between the two IORT modalities. The local recurrence-free survival was significantly longer in patients treated with HDR-IORT, both in LARC (hazard ratio [HR], 0.496; 95% CI, 0.253-0.973; P = .041) and LRRC (HR, 0.567; 95% CI, 0.349-0.920; P = .021). In patients with LARC, major postoperative complications were similar for both IORT modalities (IOERT, 30%; HDR-IORT, 27%), whereas in patients with LRRC, the incidence of major postoperative complications was higher after HDR-IORT (IOERT, 26%; HDR-IORT, 46%). CONCLUSIONS This study showed a significantly better local recurrence-free survival in favor of HDR-IORT in patients with an R1 resection for LARC or LRRC. Optimization of the IOERT technique seems warranted.
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Affiliation(s)
- Eva L K Voogt
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.
| | - Jan M van Rees
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jan A W Hagemans
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Joost Rothbarth
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Jeltsje S Cnossen
- Department of Radiation Oncology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Heike M U Peulen
- Department of Radiation Oncology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Wim J F Dries
- Department of Radiation Oncology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Joost Nuyttens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Jacobus W A Burger
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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