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Persistent High Rate of Positive Margins and Postoperative Complications After Surgery for cT4 Rectal Cancer at a National Level. Dis Colon Rectum 2021; 64:389-398. [PMID: 33651005 DOI: 10.1097/dcr.0000000000001855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND A more extensive resection is often required in locally advanced rectal cancer, depending on preoperative neoadjuvant treatment response. OBJECTIVE Circumferential margin involvement and postoperative outcomes after total mesorectal excision and multivisceral resection were assessed in patients with clinical locally advanced (cT4) rectal cancer at a national level. DESIGN This is a population-based study. SETTINGS Data were retrieved from the Dutch Colorectal Audit. PATIENTS A total of 2242 of 2881 patients with cT4 rectal cancer between January 2009 and December 2017 were selected. MAIN OUTCOME MEASURES Main outcomes were resection margins, postoperative complications, and mortality. RESULTS Multivisceral resection was performed in 936 of 2242 patients, of whom 629 underwent extended multivisceral resection. Positive circumferential margin rate was higher after multivisceral resection than after total mesorectal excision: 21.2% vs 13.9% (p < 0.001). More postoperative complications occurred after limited and extended multivisceral resections than after total mesorectal excision (44.1% and 53.8% vs 37.6%, p < 0.001). Incidence of 30-day mortality was similarly low in both groups (1.5% vs 2.2%, p = 0.20). Independent predictors of postoperative complications were age ≥70 years (OR, 1.28 [95% CI, 1.04-1.56]; p = 0.02), male sex (OR, 1.68 [95% CI, 1.38-2.04]; p< 0.001), mucinous tumors (OR, 1.55 [95% CI, 1.06-2.27]; p = 0.02), extended multivisceral resection (OR, 1.98 [95% CI, 1.56-2.52]; p< 0.001), Hartmann procedure (OR, 1.42 [95% CI, 1.07-1.90]; p = 0.02), and abdominoperineal resection (OR, 1.56 [95% CI, 1.25-1.96]; p < 0.001). LIMITATIONS Data specifying the extent of multivisceral resections and Clavien Dindo I to II complications were not available. CONCLUSIONS This population-based study revealed relatively high circumferential margin positivity and postoperative complication rates in patients with cT4 rectal cancer, especially after multivisceral resections, but low mortality rates. See Video Abstract at http://links.lww.com/DCR/B457. ALTA TASA PERSISTENTE DE MRGENES POSITIVOS Y COMPLICACIONES POSTOPERATORIAS DESPUS DE LA CIRUGA DE CNCER RECTAL CTA NIVEL NACIONAL ANTECEDENTES:A menudo se requiere una resección más extensa en el cáncer de recto localmente avanzado, según la respuesta al tratamiento neoadyuvante preoperatorio.OBJETIVO:Se evaluó la afectación del margen circunferencial y los resultados postoperatorios después de la escisión mesorrectal total y la resección multivisceral en pacientes con cáncer rectal clínico localmente avanzado (cT4) a nivel nacional.DISEÑO:Este es un estudio poblacional.ENTORNO CLINICO:Los datos se recuperaron de la Auditoría colorrectal holandesa.PACIENTES:Se seleccionaron un total de 2242 de 2881 pacientes con cáncer de recto cT4 entre enero de 2009 y diciembre de 2017.PRINCIPALES MEDIDAS DE VALORACION:Los principales resultados fueron los márgenes de resección, las complicaciones postoperatorias y la mortalidad.RESULTADOS:Se realizó resección multivisceral en 936 de 2242 pacientes, de los cuales 629 fueron sometidos a resección multivisceral extendida. La tasa de margen circunferencial positivo fue mayor después de la resección multivisceral que después de la escisión mesorrectal total: 21,2% versus a 13,9% (p <0,001). Se produjeron más complicaciones postoperatorias después de resecciones multiviscerales limitadas y extendidas en comparación con la escisión mesorrectal total (44,1% y 53,8% versus a 37,6%, p <0,001). La incidencia de mortalidad a 30 días fue igualmente baja en ambos grupos (1,5% versus a 2,2%, p = 0,20). Los predictores independientes de complicaciones posoperatorias fueron la edad ≥70 años (OR = 1,28, IC del 95% [1,04 a 1,56], p = 0,02), hombres (OR = 1,68, IC del 95% [1,38 a 2,04], p <0,001), tumores mucinosos (OR = 1,55, IC del 95% [1,06 a 2,27], p = 0,02), resección multivisceral extendida (OR = 1,98, IC del 95% [1,56 a 2,52], p <0,001), Hartmann (OR = 1,42, 95% Cl [1,07 a 1,90], p = 0,02) y resección abdominoperineal (OR 1,56, Cl 95% [1,25 a 1,96], p <0,001).LIMITACIONES:No se disponía de datos que especificaran el alcance de las resecciones multiviscerales y las complicaciones de Clavien Dindo I-II.CONCLUSIONES:Este estudio poblacional reveló tasas de complicaciones postoperatorias y positividad del margen circunferencial relativamente altas en pacientes con cáncer de recto cT4, especialmente después de resecciones multiviscerales, pero tasas de mortalidad bajas. Consulte Video Resumen en http://links.lww.com/DCR/B457.
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Ng KS, Lee PJM. Pelvic exenteration: Pre-, intra-, and post-operative considerations. Surg Oncol 2021; 37:101546. [PMID: 33799076 DOI: 10.1016/j.suronc.2021.101546] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/02/2021] [Indexed: 01/18/2023]
Abstract
This review outlines the role of pelvic exenteration (PE) in the management of certain locally-advanced primary and recurrent rectal cancers. PE has undergone significant evolution over the past decades. Advances in pre-, intra-, and post-operative care have been directed towards achieving the 'holy grail' of an R0 resection, which remains the most important predictor of survival, quality of life, morbidity, and cost effectiveness following PE. Patient selection for surgery is largely determined by assessment of resectability. Pelvic magnetic resonance imaging determines the extent of local disease, while positron emission tomography remains the most accurate tool for exclusion of distant metastases. PE in the setting of metastatic disease or with palliative intent remains controversial. The intra-operative approach is based on the anatomical division of the pelvis into five compartments (anterior, central, posterior, and two lateral). Within each compartment are various possible dissection planes which are elected depending on the extent of tumour involvement. Innovations in surgical technique have allowed 'higher and wider' dissection planes with resultant en bloc excision of major vessels, major nerves, and bone. Evidence of improved R0 resection and survival rates with these techniques justifies the radicality of these novel approaches. Post-operative care for PE patients is technically demanding with a substantial hospital resource burden. Unique considerations for PE patients include the 'empty pelvis syndrome', urological complications, and management of post-operative malnutrition. While undeniably a morbid procedure, quality of life largely returns to baseline at six months, and for long-term survivors is sustained for up to five years.
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Affiliation(s)
- Kheng-Seong Ng
- Royal Prince Alfred Hospital, Department of Colorectal Surgery, Sydney, Australia; Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter J M Lee
- Royal Prince Alfred Hospital, Department of Colorectal Surgery, Sydney, Australia; Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, Australia.
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Kazi M, Rohila J, Kumar NA, Bankar S, Engineer R, Desouza A, Saklani A. Urinary reconstruction following total pelvic exenteration for locally advanced rectal cancer: complications and factors affecting outcomes. Langenbecks Arch Surg 2021; 406:329-337. [PMID: 33527204 DOI: 10.1007/s00423-021-02086-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/10/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Total pelvic exenteration (TPE) for rectal cancers is associated with significant morbidity. We evaluated the complications related to urinary reconstruction following TPE and factors predicting urologic morbidity. METHODS Retrospective analysis of TPE patients with incontinent urinary diversions between August 2013 and January 2020. RESULTS One hundred TPE were performed with 96 ileal conduits (IC). Early complications occurred in 10 patients that included uretero-ileal leaks (5%), conduit-related complications (3%), and acute pyelonephritis (3%). Late complications were seen in 26% of patients with uretero-intestinal strictures in 11%. Mortality attributable to urinary complications was seen in 2%. No single factor, including prior radiation, recurrent disease, type of anastomosis, or blood loss, predicted development of urinary morbidity. CONCLUSION Conduit urinary diversion following TPE is associated with high urinary morbidity rate but low mortality. It can be safely performed even after previous surgeries and radiation by a dedicated colorectal team.
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Affiliation(s)
- Mufaddal Kazi
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi, Bhabha National Institute (HBNI), Dr Ernest Borges, Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Jitender Rohila
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi, Bhabha National Institute (HBNI), Dr Ernest Borges, Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Naveena An Kumar
- Department of Surgical Oncology, Manipal Comprehensive Cancer Care Center, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, 576401, India
| | - Sanket Bankar
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi, Bhabha National Institute (HBNI), Dr Ernest Borges, Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Centre, Homi, Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Ashwin Desouza
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi, Bhabha National Institute (HBNI), Dr Ernest Borges, Marg, Parel, Mumbai, Maharashtra, 400012, India
| | - Avanish Saklani
- Department of Colorectal Surgical Oncology, Tata Memorial Centre, Homi, Bhabha National Institute (HBNI), Dr Ernest Borges, Marg, Parel, Mumbai, Maharashtra, 400012, India.
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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] [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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Brown KGM, Ansari N, Solomon MJ, Austin KKS, Hamilton AER, Young CJ. Pelvic exenteration combined with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for advanced primary or recurrent colorectal cancer with peritoneal metastases. Colorectal Dis 2021; 23:186-191. [PMID: 32978813 DOI: 10.1111/codi.15378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 07/25/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023]
Abstract
AIM The aim was to report early outcomes of six patients who underwent combined pelvic exenteration (PE), cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for advanced or recurrent colorectal cancer with colorectal peritoneal metastases at a single centre. The literature contains limited data on the safety and oncological outcomes of patients who undergo this combined procedure. METHODS Six patients who underwent combined PE, CRS and HIPEC at Royal Prince Alfred Hospital, Sydney, between January 2017 and February 2020 were identified and included. Data were extracted from prospectively maintained databases. RESULTS Three patients underwent surgery for advanced primary rectal cancer, while two patients had recurrent sigmoid cancer and one had recurrent rectal cancer. All patients had synchronous peritoneal metastases. Two patients required total PE and two patients had a central (bladder-sparing) PE. The median peritoneal carcinomatosis index was 6 (range 3-12) and all patients underwent a complete cytoreduction. The median operating time was 702 min (range 485-900) and the median blood loss was 1650 ml (range 700-12,000). The median length of intensive care unit and hospital stay was 4.5 and 25 days, respectively. There was no inpatient, 30-day or 90-day mortality. Three patients (50%) experienced a major (Clavien-Dindo III/IV) complication. At a median follow-up of 11.5 months (range 2-18 months), two patients died with recurrent disease, one patient was alive with recurrence, while three patients remain alive and disease-free. Of the three patients who developed recurrent disease, one had isolated pelvic recurrence, one had pelvic and peritoneal recurrences and one had bone metastases. CONCLUSION Early results from this initial experience with simultaneous PE, CRS and HIPEC suggest that this combined procedure is safe and feasible; however, the long-term oncological and quality of life outcomes require further investigation.
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Affiliation(s)
- Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Nabila Ansari
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Auerilius E R Hamilton
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher J Young
- The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
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106
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Predicting outcomes of pelvic exenteration using machine learning. Colorectal Dis 2020; 22:1933-1940. [PMID: 32627312 DOI: 10.1111/codi.15235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/19/2020] [Indexed: 12/13/2022]
Abstract
AIM We aim to compare machine learning with neural network performance in predicting R0 resection (R0), length of stay > 14 days (LOS), major complication rates at 30 days postoperatively (COMP) and survival greater than 1 year (SURV) for patients having pelvic exenteration for locally advanced and recurrent rectal cancer. METHOD A deep learning computer was built and the programming environment was established. The PelvEx Collaborative database was used which contains anonymized data on patients who underwent pelvic exenteration for locally advanced or locally recurrent colorectal cancer between 2004 and 2014. Logistic regression, a support vector machine and an artificial neural network (ANN) were trained. Twenty per cent of the data were used as a test set for calculating prediction accuracy for R0, LOS, COMP and SURV. Model performance was measured by plotting receiver operating characteristic (ROC) curves and calculating the area under the ROC curve (AUROC). RESULTS Machine learning models and ANNs were trained on 1147 cases. The AUROC for all outcome predictions ranged from 0.608 to 0.793 indicating modest to moderate predictive ability. The models performed best at predicting LOS > 14 days with an AUROC of 0.793 using preoperative and operative data. Visualized logistic regression model weights indicate a varying impact of variables on the outcome in question. CONCLUSION This paper highlights the potential for predictive modelling of large international databases. Current data allow moderate predictive ability of both complex ANNs and more classic methods.
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Bankar S, Desouza A, Paliwal V, Pandey D, Gori J, Sukumar V, Rohila J, Saklani A. Novel use of the Bakri balloon to minimize empty pelvis syndrome following laparoscopic total pelvic exenteration. Colorectal Dis 2020; 22:2322-2325. [PMID: 32810348 DOI: 10.1111/codi.15319] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/11/2020] [Indexed: 12/21/2022]
Abstract
AIM Pelvic exenteration is the only surgical option for locally advanced pelvic malignancies infiltrating the surrounding organs. The resultant pelvic void after the procedure is responsible for a number of complications, collectively termed empty pelvis syndrome (EPS). We aim to show how EPS can be minimized by presenting a case series demonstrating the surgical technique of laparoscopic total pelvic exenteration with bilateral pelvic node dissection along with a novel use of the Bakri balloon. METHOD This is a case series of three successive patients undergoing laparoscopic total pelvic exenteration for locally advanced primary, nonmetastatic rectal adenocarcinoma over a period of 1 month in a specialized colorectal unit at a tertiary cancer centre. The Bakri balloon was deployed in all three patients and retained for variable time intervals postoperatively. Features of EPS were prospectively documented. RESULTS In the first patient, the Bakri balloon was completely deflated and removed on postoperative day (POD) 5. The patient developed subacute intestinal obstruction which resolved with conservative management by POD 12. In the second and third patients, the Bakri balloon was deflated in a sequential manner, beginning on POD 8, until it was finally removed on POD 11. Neither of these patients had any abdominal complaints. A postoperative CT scan of both these patients showed the small bowel loops clearly above the pelvic inlet. CONCLUSIONS The Bakri balloon is a simple, safe and cost-effective method to reduce the complications of EPS following laparoscopic total pelvic exenteration. A prospective study is ongoing to objectively quantify the benefits of this technique.
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Affiliation(s)
- S Bankar
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - A Desouza
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - V Paliwal
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - D Pandey
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - J Gori
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - V Sukumar
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - J Rohila
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
| | - A Saklani
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute (HBNI), Mumbai, India
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Liao YT, Liang JT. Applicability of minimally invasive surgery for clinically T4 colorectal cancer. Sci Rep 2020; 10:20347. [PMID: 33230168 PMCID: PMC7683557 DOI: 10.1038/s41598-020-77317-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/10/2020] [Indexed: 01/02/2023] Open
Abstract
The role of minimally invasive surgery (MIS) to treat clinically T4 (cT4) colorectal cancer (CRC) remains uncertain and deserves further investigation. A retrospective cohort study was conducted between September 2006 and March 2019 recruiting patients diagnosed as cT4 CRC and undergoing MIS at a university hospital and its branch. Patients’ demography, clinicopathology, surgical and oncological outcomes, and radicality were analyzed. A total of 128 patients were recruited with an average follow-up period of 33.8 months. The median time to soft diet was 6 days, and the median postoperative hospitalization periods was 11 days. The conversion and complication (Clavien–Dindo classification ≥ II) rates were 7.8% and 27.3%, respectively. The 30-day mortality was 0.78%. R0 resection rate was 92.2% for cT4M0 and 88.6% for pT4M0 patients. For cT4 CRC patients, the disease-free survival and 3-year overall survival were 86.1% and 86.8% for stage II, 54.1% and 57.9% for stage III, and 10.8% and 17.8% for stage IV. With acceptable conversion, complication and mortality rate, MIS may achieve satisfactory R0 resection rate and thus lead to good oncological outcomes for selected patients with cT4 CRC.
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Affiliation(s)
- Yu-Tso Liao
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC.,Division of Colorectal Surgery, Department of Surgery, Biomedical Park Hospital, National Taiwan University Hospital, Hsinchu, Taiwan, ROC
| | - Jin-Tung Liang
- Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan, ROC.
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Vigneswaran HT, Schwarzman LS, Madueke IC, David SM, Nordenstam J, Moreira D, Abern MR. Morbidity and Mortality of Total Pelvic Exenteration for Malignancy in the US. Ann Surg Oncol 2020; 28:2790-2800. [PMID: 33105501 DOI: 10.1245/s10434-020-09247-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/27/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Total pelvic exenterations (TPEs) for malignancies are complex operations often performed by multidisciplinary teams. The differences among primary cancer for TPE and multicentered results are not well described. We aimed to describe TPE outcomes for different malignant origins in a national multicentered sample. METHODS Patients from the National Surgical Quality Improvement Program (NSQIP) database who underwent TPE between 2005 and 2016 for all malignant indications (colorectal, gynecologic, urologic, or other) were included. Chi square and Kruskal-Wallis tests were used to compare patient characteristics by primary malignancy. Multivariate logistic and linear regression models were used to determine factors associated with any 30-day Clavien-Dindo grade 3 or higher complication, length of hospital stay (LOS; days), 30-day wound infection, and 30-day mortality. RESULTS Overall, 2305 patients underwent TPE. Indications for surgery included 33% (749) colorectal, 15% (335) gynecologic, 9% (196) other, and 45% (1025) urologic malignancies. Median LOS decreased from 10 to 8 days during the study period (p < 0.001), 36% were males, and 50% required blood transfusion. High-grade complications occurred in 15% of patients and were associated with bowel diversion [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.1-2.4], disseminated cancer (OR 1.8, 95% CI 1.4-2.3), and gynecologic cancers (OR 2.9, 95% CI 1.8-4.7). Mortality was 2% and was associated with disseminated cancer (OR 2.2, 95% CI 1.1-4.3) and male sex (OR 2.4, 95% CI 1.3-4.4). CONCLUSIONS TPE is associated with high rates of complications, however mortality rates remain low. Preoperative and perioperative outcomes differ depending on the origin of the primary malignancy.
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Affiliation(s)
- Hari T Vigneswaran
- Department of Urology, University of Illinois at Chicago, Chicago, IL, USA.
| | - Logan S Schwarzman
- Department of Urology, University of Illinois at Chicago, Chicago, IL, USA
| | - Ikenna C Madueke
- Department of Urology, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Johan Nordenstam
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Daniel Moreira
- Department of Urology, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael R Abern
- Department of Urology, University of Illinois at Chicago, Chicago, IL, USA
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van Ramshorst G. Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative. Colorectal Dis 2020; 22:1216. [PMID: 33099877 DOI: 10.1111/codi.15077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Kelly ME, Aalbers AGJ, Abdul Aziz N, Abecasis N, Abraham‐Nordling M, Akiyoshi T, Alberda W, Albert M, Andric M, Angenete E, Antoniou A, Auer R, Austin KK, Aziz O, Baker RP, Bali M, Baseckas G, Bebington B, Bednarski BK, Beets GL, Berg PL, Beynon J, Biondo S, Boyle K, Bordeianou L, 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, Chan KKL, Chang GJ, Chew MH, Chong PC, Christensen HK, Clouston H, Codd M, Collins D, Colquhoun A, Corr A, Coscia M, Coyne PE, Creavin B, Croner RS, Damjanovic L, Daniels IR, Davies M, Davies RJ, Delaney CP, Denost Q, Deutsch C, Dietz D, Domingo S, Dozois EJ, Duff M, Eglinton T, Enrique‐Navascues JM, Espin‐Basany E, Evans MD, Fearnhead NS, Flatmark K, Fleming F, Frizelle FA, Gallego MA, Garcia‐Granero E, Garcia‐Sabrido JL, Gentilini L, George ML, Ghouti L, Giner F, Ginther N, Glynn R, Golda T, Griffiths B, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helewa RM, Heriot AG, Hochman D, Hohenberger W, Holm T, Hompes R, Jenkins JT, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kelley SR, Keller DS, Khan MS, Kiran RP, Kim H, Kim HJ, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kristensen HØ, Kroon HM, Kusters M, Lago V, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Lydrup ML, Lyons A, Lynch AC, Mantyh C, Mathis KL, Margues CFS, Martling A, Meijerink WJHJ, Merkel S, Mehta AM, McArthur DR, McDermott FD, McGrath JS, Malde S, Mirnezami A, Monson JRT, Morton JR, Mullaney TG, Negoi I, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, O’Connell PR, O’Dwyer ST, Palmer G, Pappou E, Park J, Patsouras D, Pellino G, Peterson AC, Poggioli G, Proud D, Quinn M, Quyn A, Radwan RW, van Ramshorst GH, Rasheed S, Rasmussen PC, Regenbogen SE, Renehan A, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Ryan ÉJ, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu V, Selvasekar C, Shaikh I, Hellawell G, Shida D, Simpson A, Smart NJ, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Sumrien H, Sutton PA, Swartking T, Taylor C, Tekkis PP, Teras J, Thurairaja R, Toh EL, Tsarkov P, Tsukada Y, Tsukamoto S, Tuech JJ, Turner WH, Tuynman JB, Vasquez‐Jimenez W, Verhoef C, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weber K, Weiser MR, Wheeler JMD, Wild J, Wilson M, de Wilt JHW, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, van Zoggel D, Winter DC. Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative. Colorectal Dis 2020; 22:1258-1262. [PMID: 32294308 DOI: 10.1111/codi.15064] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/24/2020] [Indexed: 02/08/2023]
Abstract
AIM At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection. METHOD Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival. RESULTS Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006). CONCLUSION Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.
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Mirnezami R, Mirnezami A. Multivisceral Resection of Advanced Pelvic Tumors: From Planning to Implementation. Clin Colon Rectal Surg 2020; 33:268-278. [PMID: 32968362 DOI: 10.1055/s-0040-1713744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pelvic exenteration involves radical multivisceral resection for locally advanced and recurrent pelvic tumors. Advances in tumor staging, oncological therapies, preoperative patient optimization, surgical techniques, and critical care medicine have permitted the safe expansion of pelvic exenterative surgery at specialist units. It is now understood that in carefully selected patients, 5-year survival can exceed 60% following pelvic exenteration, and that very low mortality figures and an optimum postexenteration quality of life are possible. In the present review, we provide a contemporary summary of the current state of the art in pelvic exenterative surgery following all key phases of the treatment pipeline from patient staging and tumor assessment, to treatment planning and surgery.
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Affiliation(s)
- R Mirnezami
- Department of Colorectal Surgery, Royal Free Hospital, Hampstead, London
| | - A Mirnezami
- Division of Cancer Sciences, Cancer Research UK Centre, University of Southampton, Southampton, United Kingdom.,Southampton Complex Cancer and Exenterative Unit, University Hospital Southampton, Southampton, United Kingdom
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Konstantinidis IT, Lee B, Trisal V, Paz I, Melstrom K, Sentovich S, Lai L, Raoof M. National postoperative and oncologic outcomes after pelvic exenteration for T4b rectal cancer. J Surg Oncol 2020; 122:739-744. [PMID: 32516469 DOI: 10.1002/jso.26058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/08/2020] [Accepted: 05/22/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Studies reporting outcomes after pelvic exenteration for rectal cancer are limited. The objective of this study was to evaluate early postoperative and oncologic outcomes in a national multi-institutional cohort. METHODS Using the National Cancer Database (NCDB), which collects data from over 1500 commission on cancer (CoC)-accredited hospitals, we analyzed patients undergoing pelvic exenteration for T4b rectal adenocarcinoma. RESULTS There were 1367 pelvic exenterations performed in 552 hospitals. Median age was 60 years, the majority of patients (n = 831; 60.8%) were female. Neoadjuvant radiation was used only in 57%; 24.3% of resections had positive margins. Following exenteration, 30-day mortality rate, 90-day mortality rate, and readmission rates were: 1.8%, 4.4%, and 7.4%. Age ≥ 60 years and higher Charlson-Deyo comorbidity index were independently associated with increased 90-day mortality (P < .001). Overall survival (OS) was 50 months. After adjustment of significant covariates, negative margin status (adjusted HR, 0.6, 95% CI, 0.5-0.8; P < .001) and receipt of perioperative radiation or chemoradiation (adjusted HR, 0.5; 95% CI, 0.4-0.6; P < .001) were significantly associated with decreased risk of death. Only 71% of the patients received perioperative radiation. CONCLUSIONS Pelvic exenterations are being performed safely in Coc-accredited hospitals. However, up to one fourth of patients undergo resections with positive margins or are subject to underutilization of perioperative radiation therapy. Increased use of radiation may increase negative margin resections and improve patient outcomes.
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Affiliation(s)
| | - Byrne Lee
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Vijay Trisal
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Issac Paz
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Kurt Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Stephen Sentovich
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Lily Lai
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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Management strategies for patients with advanced rectal cancer and liver metastases using modified Delphi methodology: results from the PelvEx Collaborative. Colorectal Dis 2020; 22:1184-1188. [PMID: 32043753 DOI: 10.1111/codi.15007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 01/22/2020] [Indexed: 12/13/2022]
Abstract
AIM A total of 15-20% of patients with rectal cancer have liver metastases on presentation. The management of these patients is controversial. Heterogeneity in management strategies is considerable, with management often being dependent on local resources and available expertise. METHOD Members of the PelvEx Collaborative were invited to participate in the generation of a consensus statement on the optimal management of patients with advanced rectal cancer with liver involvement. Fifteen statements were created for topical discussion on diagnostic and management issues. Panellists were asked to vote on statements and anonymous feedback was given. A collaborative meeting was used to discuss any nuances and clarify any obscurity. Consensus was considered when > 85% agreement on a statement was achieved. RESULTS A total of 135 participants were involved in the final round of the Delphi questionnaire. Nine of the 15 statements reached consensus regarding the management of patients with advanced rectal cancer and oligometastatic liver disease. Routine use of liver MRI was not recommended for patients with locally advanced rectal cancer, unless there was concern for metastatic disease on initial computed tomography staging scan. Induction chemotherapy was advocated as first-line treatment in those with synchronous liver metastases in locally advanced rectal cancer. In the presence of symptomatic primary disease, a diverting stoma may be required to facilitate induction chemotherapy. Overall, only one-quarter of the panellists would consider simultaneous pelvic exenteration and liver resection. CONCLUSION This Delphi process highlights the diverse treatment of advanced rectal cancer with liver metastases and provides recommendations from an experienced international group regarding the multidisciplinary management approach.
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The global cost of pelvic exenteration: in-hospital perioperative costs. Br J Surg 2020; 107:e470-e471. [PMID: 33460051 DOI: 10.1002/bjs.11924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 01/03/2023]
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Robotic multivisceral pelvic resection: experience from an exenteration unit. Tech Coloproctol 2020; 24:1145-1153. [PMID: 32662050 DOI: 10.1007/s10151-020-02290-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pelvic exenteration remains a viable and effective treatment option for the management of locally advanced or recurrent pelvic malignancy. The aim of this study was to present an early experience of robotic multivisceral resection of pelvic malignancy, and to compare this experience with similar series through a systematic review of the literature. METHODS A retrospective study was performed on patients who had robotic-assisted multi-visceral resection for pelvic malignancy at a single Colorectal Surgical unit based between two tertiary academic hospitals. Primary outcomes observed included operation type, operation time, perioperative complications, and hospital length of stay. Secondary outcomes included R0 resection status, lymph node harvest, and rate of recurrence at clinical follow-up. RESULTS Eight cases of robotic multivisceral resection were performed for primary locally advanced pelvic malignancy involving a rectal resection as part of their operative management. The median age of patients undergoing resection was 56 years (range 29-83 years). The male:female ratio was 6:2. The mean total operating time was 8.3 h (range 6-10 h). Perioperative blood transfusion requirements were minimal. Mean hospital length of stay was 15 days (range 7-26 days). No patients experienced any serious postoperative morbidity or mortality. All patients had clear margins on histological assessment and no patients have recurrence at 12-month follow-up. CONCLUSIONS Robotic multivisceral resection for malignant disease of the pelvis is a safe and feasible minimally invasive approach in highly selected cases.
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Khan O, Patsouras D, Ravindraanandan M, Abrar MM, Schizas A, George M, Malde S, Thurairaja R, Khan MS, Sahai A. Total Pelvic Exenteration for Locally Advanced and Recurrent Rectal Cancer: Urological Outcomes and Adverse Events. Eur Urol Focus 2020; 7:638-643. [PMID: 32622667 DOI: 10.1016/j.euf.2020.06.008] [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: 04/08/2020] [Revised: 05/25/2020] [Accepted: 06/12/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Little has been reported on urological complications of total pelvic exenteration (TPE) for locally advanced or recurrent rectal cancer. OBJECTIVE To assess urological reconstructive outcomes and adverse events in this setting. DESIGN, SETTING, AND PARTICIPANTS A total of 104 patients underwent TPE from 2004 to 2016 in this single-centre, retrospective study. Electronic and paper records were evaluated for data extraction. Mean follow-up was 36.5 mo. INTERVENTION TPE. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Urological complications were analysed using two-tailed t and chi-square tests, binary logistic regression analysis. RESULTS AND LIMITATIONS Sixty-three (61%) patients received radiotherapy prior to TPE. Incontinent diversions included ileal conduit (n = 95), colonic conduits (n = 4), wet colostomy (n = 1), and cutaneous ureterostomy (n = 1). Three patients had a continent diversion. The overall urological complication rate was 54%. According to Clavien-Dindo classification, 30 patients, five patients, and one patient had grade III, IV, and V complications, respectively. The commonest complication was urinary tract infection (in 32 [31%] patients). Anastomotic leaks were seen in 14 (13%) cases, of which eight (8%) were urinary leaks. Fistulas were seen in three (3%) patients, involving the urinary system. A return to theatre was required in 12 (12%) patients. Ureteroenteric strictures were seen in seven (7%). No differences were seen in urological outcomes in patients with primary or recurrent rectal cancer (p = 0.69), or by radiation status (p = 0.24). The main limitation is the retrospective nature of the study. CONCLUSIONS TPE is complex with recognised high risk of morbidity. In this cohort, there was no significant difference in outcomes between primary and recurrent disease, and surgery after radiation. PATIENT SUMMARY In this study, we assessed urological complications following total pelvic exenteration. Urinary complications affected more than half of patients. Urinary tract infection is the commonest risk. Approximately one-third of patients required surgical, radiological, or endoscopic intervention ± intensive care admission. Radiation prior to the operation did not affect urinary complications.
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Affiliation(s)
- Omeair Khan
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dimitrios Patsouras
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | | - Alexis Schizas
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mark George
- Department of Colorectal Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sachin Malde
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ramesh Thurairaja
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mohammed S Khan
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Arun Sahai
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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Hagemans J, Voogt E, Rothbarth J, Nieuwenhuijzen G, Kirkels W, Boormans J, Koldewijn E, Richardson R, Verhoef C, Rutten H, Burger J. Outcomes of urinary diversion after surgery for locally advanced or locally recurrent rectal cancer with complete cystectomy; ileal and colon conduit. Eur J Surg Oncol 2020; 46:1160-1166. [DOI: 10.1016/j.ejso.2020.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 10/25/2022] Open
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A Comparison of the Short-term Outcomes of Three Flap Reconstruction Techniques Used After Beyond Total Mesorectal Excision Surgery for Anorectal Cancer. Dis Colon Rectum 2020; 63:461-468. [PMID: 31977583 DOI: 10.1097/dcr.0000000000001585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgery for advanced or recurrent pelvic malignancy can result in perineal defects that cannot be closed by wound edge approximation. Myocutaneous flaps can fill the defect and accelerate healing. No reconstruction has been proven to be superior to the others. OBJECTIVE This study aimed to compare 3 flap procedures after beyond total mesorectal excision surgery. DESIGN This is a retrospective analysis of a prospective database, according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. SETTINGS This study was performed at a tertiary hospital. PATIENTS Consecutive series of patients who required flap reconstruction after beyond total mesorectal excision surgery between 2007 and 2016 were included. MAIN OUTCOME MEASURES Short-term outcomes after oblique rectus abdominis flap vs vertical rectus abdominis flap vs inferior gluteal artery perforator flap reconstruction were evaluated. RESULTS Included are 65 (59%) oblique rectus abdominis flap, 30 (27.3%) vertical rectus abdominis flap, and 15 (13.7%) inferior gluteal artery perforator flap outcomes. Sacrectomy was performed in 12 (18.5%), 10 (33.3%), and 8 (53.3%) patients (p = 0.016). Preoperative radiotherapy was used in 60 (92.3%), 26 (86.7%), and 11 (73.3%) patients (p = 0.11). Flap infection and dehiscence occurred in 7 (10.8%), 1 (3.3%), and 4 (26.7%) patients. There was an increased risk of flap complication with inferior gluteal artery perforator flap vs vertical rectus abdominis flap (p = 0.036). Inferior gluteal artery perforator flap (OR, 6.26; p = 0.02) and obesity (OR, 4.96; p = 0.02) were associated with flap complications. Only complications of the oblique rectus abdominis flap decreased significantly over time (p = 0.03). The length of stay and complete (R0) resection rate were not different between the groups. LIMITATIONS This study was limited because of its retrospective nature and because it was conducted at a single center. CONCLUSIONS The techniques appear comparable. The approaches should be considered complementary, and the choice should be individualized. See Video Abstract at http://links.lww.com/DCR/B141. COMPARACIÓN DE RESULTADOS A CORTO PLAZO DE TRES TÉCNICAS DE RECONSTRUCCIÓN CON COLGAJO UTILIZADAS DESPUÉS DE LA CIRUGÍA DE ESCISIÓN MESORRECTAL TOTAL EXTENDIDA PARA EL CÁNCER ANORRECTAL: La cirugía para malignidad pélvica avanzada o recurrente puede provocar defectos perineales, que no pueden cerrarse por aproximación de los bordes de la herida. Los colgajos miocutáneos pueden llenar el defecto y acelerar la curación. Ninguna reconstrucción ha demostrado ser superior a las demás.Comparar tres procedimientos de colgajo después de una cirugía de escisión mesorrectal total extendida.Análisis retrospectivo de una base de datos prospectiva, de acuerdo con la Declaración de Fortalecimiento de los informes de estudios observacionales en epidemiología.Hospital de tercer nivel.Series consecutivas de pacientes que requirieron reconstrucción con colgajo después de una cirugía de escisión mesorrectal total extendida entre 2007 y 2016.Resultados a corto plazo después del colgajo oblicuo recto abdominal versus colgajo vertical recto abdominal versus reconstrucción del colgajo perforador de la arteria glútea inferior.Se incluyen 65 (59%) colgajo oblicuo recto abdominal oblicuo, 30 (27.3%) colgajo vertical recto abdominal y 15 (13.7%) colgajo perforador de la arteria glútea inferior. Sacrectomía se realizó en 12 (18.5%), 10 (33.3%) y 8 (53.3%) pacientes respectivamente (p = 0.016). La radioterapia preoperatoria se utilizó en 60 (92.3%), 26 (86.7%) y 11 (73.3%) (p = 0,11). La infección del colgajo y la dehiscencia ocurrieron en 7 (10.8%), 1 (3.3%) y 4 (26.7%). Hubo un mayor riesgo de complicación con el colgajo perforador de la arteria glútea inferior en comparación al colgajo vertical del recto abdominal (p = 0.036). El colgajo perforador de la arteria glútea inferior (OR 6.26, p = 0.02) y la obesidad (OR 4.96, p = 0.02) se asociaron con complicaciones del colgajo. Solo las complicaciones del colgajo oblicuo recto abdominal disminuyeron significativamente con el tiempo (p = 0.03). La duración de la estancia hospitalaria y la tasa de resección completa (R0) no fue diferente entre los grupos.Estudio retrospectivo en centro único.Las técnicas parecen comparables. Los enfoques deben considerarse complementarios y la elección individualizada. Consulte Video Resumen en http://links.lww.com/DCR/B141.
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Voogt ELK, van Zoggel DMGI, Kusters M, Nieuwenhuijzen GAP, Bloemen JG, Peulen HMU, Creemers GJM, van Lijnschoten G, Nederend J, Roef MJ, Burger JWA, Rutten HJT. Improved Outcomes for Responders After Treatment with Induction Chemotherapy and Chemo(re)irradiation for Locally Recurrent Rectal Cancer. Ann Surg Oncol 2020; 27:3503-3513. [PMID: 32193717 DOI: 10.1245/s10434-020-08362-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite improvements in the multimodality treatment for patients with locally recurrent rectal cancer (LRRC), oncological outcomes remain poor. This study evaluated the effect of induction chemotherapy and subsequent chemo(re)irradiation on the pathologic response and the rate of resections with clear margins (R0 resection) in relation to long-term oncological outcomes. METHODS All consecutive patients with LRRC treated in the Catharina Hospital Eindhoven who underwent a resection after treatment with induction chemotherapy and subsequent chemo(re)irradiation between January 2010 and December 2018 were retrospectively reviewed. Induction chemotherapy consisted of CAPOX/FOLFOX. Endpoints were pathologic response, resection margin and overall survival (OS), disease free survival (DFS), local recurrence free survival (LRFS), and metastasis free survival (MFS). RESULTS A pathologic complete response was observed in 22 patients (17%), a "good" response (Mandard 2-3) in 74 patients (56%), and a "poor" response (Mandard 4-5) in 36 patients (27%). An R0 resection was obtained in 83 patients (63%). The degree of pathologic response was linearly correlated with the R0 resection rate (p = 0.026). In patients without synchronous metastases, pathologic response was an independent predictor for LRFS, MFS, and DFS (p = 0.004, p = 0.003, and p = 0.024, respectively), whereas R0 resection was an independent predictor for LRFS and OS (p = 0.020 and p = 0.028, respectively). CONCLUSIONS Induction chemotherapy in addition to neoadjuvant chemo(re)irradiation is a promising treatment strategy for patients with LRRC with high pathologic response rates that translate into improved oncological outcomes, especially when an R0 resection has been achieved.
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Affiliation(s)
- E L K Voogt
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.
| | | | - M Kusters
- Department of Surgery, Amsterdam University Medical Centres, Location VUmc, Amsterdam, The Netherlands
| | | | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - H M U Peulen
- Department of Radiotherapy, Catharina Hospital, Eindhoven, The Netherlands
| | - G J M Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - G van Lijnschoten
- Pathology Department, PAMM Laboratory for Pathology and Medical Microbiology, Eindhoven, The Netherlands
| | - J Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | - M J Roef
- Department of Nuclear Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
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Safety and Feasibility of Laparoscopic Pelvic Exenteration for Locally Advanced or Recurrent Colorectal Cancer. Surg Laparosc Endosc Percutan Tech 2020; 29:389-392. [PMID: 31335481 DOI: 10.1097/sle.0000000000000699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Pelvic exenteration (PE) for locally advanced or recurrent colorectal cancer is often used to secure negative resection margins. The aim of this study was to evaluate the feasibility of laparoscopic PE. MATERIALS AND METHODS The clinical records of 24 patients (9, open; 15, laparoscopic) who underwent total or posterior PE for locally advanced or recurrent colorectal cancer between July 2012 and April 2016 at Osaka National Hospital were retrospectively reviewed. Operative factors were compared between the 2 groups. RESULTS The R0 resection rate was 100% in the laparoscopic group and 89% in the open group. The operative time and the incidence of postoperative complications were not significantly different between the 2 groups. The laparoscopic group showed less intraoperative blood loss (P=0.019), a lower C-reactive protein elevation on postoperative day 7 (P=0.025), and a shorter postoperative hospital stay (P=0.0009). CONCLUSIONS Laparoscopic PE is a safe and feasible procedure to reduce postoperative stress.
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Garcia-Granero A, Pellino G, Giner F, Frasson M, Fletcher-Sanfeliu D, Romaguera VP, Flor-Lorente B, Gamundi M, Brogi L, Garcia-Calderón D, Gonzalez-Argente FX, Garcia-Granero E. A mathematical 3D-method applied to MRI to evaluate prostatic infiltration in advanced rectal cancer. Tech Coloproctol 2020; 24:605-607. [PMID: 32107687 DOI: 10.1007/s10151-020-02170-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/07/2020] [Indexed: 12/30/2022]
Affiliation(s)
- A Garcia-Granero
- Colorectal Surgery Unit, Hospital Universitario Son Espases, Mallorca, Spain
| | - G Pellino
- Colorectal Surgery Unit, Hospital Vall D'Hebron, Passeig de la Vall d'Hebron 119-129, 08035, Barcelona, Spain. .,Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Naples, Italy.
| | - F Giner
- Department of Pathology Hospital, Universitario y Politéctico la Fe, Valencia, Spain
| | - M Frasson
- Colorectal Surgery Unit, Hospital Universitario y Politéctico la Fe, Valencia, Spain
| | - D Fletcher-Sanfeliu
- Cardiovascular Surgery Department, Hospital, Universitario Son Espases, Mallorca, Spain
| | - V P Romaguera
- Colorectal Surgery Unit, Hospital Universitario y Politéctico la Fe, Valencia, Spain
| | - B Flor-Lorente
- Colorectal Surgery Unit, Hospital Universitario y Politéctico la Fe, Valencia, Spain
| | - M Gamundi
- Colorectal Surgery Unit, Hospital Universitario Son Espases, Mallorca, Spain
| | - L Brogi
- 3D-Reconstruction Unit and Simulation Center, Hospital Universitario Son Espases, Mallorca, Spain
| | | | | | - E Garcia-Granero
- Colorectal Surgery Unit, Hospital Universitario y Politéctico la Fe, Valencia, Spain
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O'Shannassy SJ, Brown KGM, Steffens D, Solomon MJ. Referral patterns and outcomes of a highly specialised pelvic exenteration multidisciplinary team meeting: A retrospective cohort study. Eur J Surg Oncol 2020; 46:1138-1143. [PMID: 32122755 DOI: 10.1016/j.ejso.2020.02.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 01/31/2020] [Accepted: 02/20/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The purpose of this study was to review recommendations made from a specialist pelvic exenteration (PE) multidisciplinary team (MDT) and to provide insights as to the impact of the MDT on patient selection and clinical decision making. MATERIALS & METHODS A retrospective review was conducted at Royal Prince Alfred Hospital's PE MDT between June 2014 and December 2015. Data was collected from the recorded minutes of MDT meetings. Referral information and clinical data was extracted from individual patient files. Additional data including operative dates and surgical resection margins were collected from electronic medical records. RESULTS Of the 183 patients considered for PE during the MDT meeting, 104 (57%) were recommended for surgery. Factors that influenced the recommendation in favour of surgery were referral by a surgeon (P = 0.004), referral from a rural location (P = 0.05) and having locally advanced primary cancer (P < 0.001). Patients who were seen by the unit's surgeon prior to the MDT did not impact on the MDT recommendation nor the decision for or against surgery (P = 0.771). The most common reason for recommendation against PE was unresectable distant metastatic disease (43%). CONCLUSIONS The PE MDT meeting is a critical step in the patient care pathway and facilitates critical decision making. Anatomically-based contraindications to surgery (i.e. involvement of adjacent organs, bone and neurovascular structures) do not appear to influence MDT decision making regarding resectability.
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Affiliation(s)
- Sarah J O'Shannassy
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery (IAS), Sydney, Australia.
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery (IAS), Sydney, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; The University of Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery (IAS), Sydney, Australia; The University of Sydney, New South Wales, Australia
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Smith N, Waters PS, Peacock O, Kong JC, McCormick J, Warrier SK, McNally O, Lynch AC, Heriot AG. Pelvic Exenteration for Anal and Urogenital Squamous Cell Carcinoma: Experience and Outcomes from an Exenteration Unit Over 12 Years. Ann Surg Oncol 2020; 27:2450-2456. [PMID: 31993856 DOI: 10.1245/s10434-020-08229-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pelvic exenteration has increasingly been shown to improve disease-free and overall survival for patients with locally advanced pelvic malignancies. Squamous cell carcinoma (SCC) is the second most common pelvic malignancy requiring exenteration. OBJECTIVE The aim of this study was to report the clinical and oncological outcomes from patients treated with pelvic exenteration for anal and urogenital SCC from a single, high-volume unit. METHODS A review of a prospectively maintained database from 1991 to 2018 at a high-volume specialised institution was performed. Primary endpoints included R0 resection rates, local recurrence and overall survival (OS) rates. RESULTS From January 1999 to July 2018, 361 patients underwent pelvic exenteration of which 31 patients were identified with SCC (15 anal SCC, 16 urogenital SCC). The majority of patients were females (n = 24, 77.4%). Median age was 59 (range 35-81). Twenty-seven patients underwent resection with curative intent with an R0 resection rate of 81.5%. Four patients underwent a palliative procedure [R1 = 3 (8%), R2 = 1 (3.3%)]. Mean hospital length of stay was 32 days (range 8-122 days). Disease-free survival was significantly increased in anal SCC with no significant difference in OS compared to urogenital SCC (p = 0.03, p = 0.447 respectively). Advanced pathological T stage was associated with decreased OS (p = 0.023). In the curative intent group the disease-free survival and OS rate was 59.3% and 70% at 24 months, respectively. CONCLUSION Complete R0 resection is achievable in a high proportion of patients. Urogenital SCC is associated with significantly worse disease-free survival, and advanced T-stage was a significant prognostic factor for OS.
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Affiliation(s)
- Nicholas Smith
- Surgery Oncology Unit, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Peadar S Waters
- Surgery Oncology Unit, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Oliver Peacock
- Surgery Oncology Unit, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Joseph C Kong
- Surgery Oncology Unit, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Jacob McCormick
- Surgery Oncology Unit, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Satish K Warrier
- Surgery Oncology Unit, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Orla McNally
- Surgery Oncology Unit, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Obstetrics and Gynaecology, Royal Women's Hospital, Parkville, Victoria, Australia
| | - Andrew C Lynch
- Surgery Oncology Unit, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Alexander G Heriot
- Surgery Oncology Unit, Peter MacCallum Cancer Centre, Melbourne, Australia. .,Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
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126
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Complications and 5-year survival after radical resections which include urological organs for locally advanced and recurrent pelvic malignancies: analysis of 646 consecutive cases. Tech Coloproctol 2020; 24:181-190. [DOI: 10.1007/s10151-019-02141-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 12/19/2019] [Indexed: 10/25/2022]
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Beck C, Weber K, Brunner M, Agaimy A, Semrau S, Grützmann R, Schellerer V, Merkel S. The influence of postoperative complications on long-term prognosis in patients with colorectal carcinoma. Int J Colorectal Dis 2020; 35:1055-1066. [PMID: 32172320 PMCID: PMC7245593 DOI: 10.1007/s00384-020-03557-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The impact of postoperative complications (POCs) on the long-term prognosis of patients with colorectal carcinoma was analysed with respect to their severity according to the Clavien-Dindo classification (CDC). METHODS The prospectively collected data of 2158 patients who underwent curative resection of a colorectal carcinoma (1168 rectal carcinomas, 990 colon carcinomas) without distant metastases from 1995 to 2014 were analysed. The POCs were documented in a standardized form and graded with the CDC. Patients who died postoperatively (CDC grade V, 1.7%) were excluded. RESULTS In total, 467 patients (21.6%) had POCs: CDC I, 141 (6.5%); CDC II, 162 (7.5%); CDC III, 112 (5.2%); and CDC IV, 52 (2.4%). More POCs and higher CDC grades were found in men, ASA III-IV patients, rectal carcinoma patients, and patients who underwent abdominoperineal excisions or multivisceral resections. The 5-year locoregional recurrence rate was 5.3% in patients without POCs and 6.6% in patients with POCs. It was highest in CDC III patients (12.9%), which was confirmed in multivariate analysis (HR 2.2; p = 0.005). The 5-year distant metastasis rate was 15.9% in CDC 0 patients and 19.5% in CDC I-IV patients. In multivariate analysis, distant metastasis was highest in CDC III patients (HR 1.7; p = 0.020). The 5-year overall survival rate was 83.5% in patients without POCs and 73.5% in patients with POCs. It was worst in CDC IV patients (63.1%), which was confirmed by multivariate analysis (HR 1.9; p = 0.001). CONCLUSION Patients with POCs after colorectal surgery have a poor long-term prognosis. As the CDC grade increases, survival deteriorates.
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Affiliation(s)
- Clemens Beck
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Klaus Weber
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Maximilian Brunner
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Abbas Agaimy
- Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Robert Grützmann
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Vera Schellerer
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Waters PS, Peacock O, Larach T, Lee JD, McCormick JJ, Chander S, Heriot AG, Warrier SK. Utilization of a Transanal TME Platform to Enable a Distal TME Dissection En Bloc with Presacral Fascia and Pelvic Sidewall with Intraoperative Radiotherapy Delivery in a Locally Advanced Rectal Cancer: Advanced Application of taTME. J Laparoendosc Adv Surg Tech A 2019; 30:53-57. [PMID: 31721637 DOI: 10.1089/lap.2019.0576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction: The safe introduction of transanal total mesorectal excision (taTME) has been documented by the Australasian group previously. The most important prognostic indicator for rectal cancer is the ability to achieve a clear resection margin. By utilizing false planes for taTME surgery, the endopelvic fascia and or presacral fascia can be resected en bloc. Technique: This case highlights the utilization of a taTME platform to perform a distal taTME with presacral fascial stripping and a lateral pelvic sidewall transanal-assisted dissection in a 53-year-old otherwise healthy woman with a mid-rectal tumor. Radiologically the tumor was staged as a T3c/T4 rectal cancer with an N1c deposit extending beyond mesorectal fascia abutting the left piriformis muscle. An extramural venous invasion positive tumor was evident with a positive circumferential resection margin at 4 o' clock. In addition, the taTME platform was used to allow transanal intraoperative radiotherapy (IORT) delivery to the sacrum. An R0 resection was achieved and the patient recovered well without incident. Results: Total operative time was 250 minutes with the patient being discharged on day 7 postoperatively without complication. Macroscopic evaluation revealed a grade III mesorectal excision with en bloc removal of presacral fascia. On microscopic evaluation, revealed a T3N1b tumor with 2 of 14 positive lymph nodes (0/5 pelvic sidewall nodes). Conclusion: The case highlights a novel application of taTME and is to the authors' best knowledge the first described use of a transanal platform to deliver intraoperative radiation therapy in the literature.
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Affiliation(s)
- Peadar S Waters
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Oliver Peacock
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tomas Larach
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jordan D Lee
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jacob J McCormick
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Sarat Chander
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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130
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Peacock O, Waters PS, Kong JC, Warrier SK, Wakeman C, Eglinton T, Heriot AG, Frizelle FA, McCormick JJ. Complications After Extended Radical Resections for Locally Advanced and Recurrent Pelvic Malignancies: A 25-Year Experience. Ann Surg Oncol 2019; 27:409-414. [PMID: 31520213 DOI: 10.1245/s10434-019-07816-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND The oncological role of pelvic exenteration for locally advanced and recurrent pelvic malignancies arising from the anorectum, gynaecological, or urological systems is now well-established. Despite this, the surgical community has been slow to accept pelvic exenteration, undoubtedly due to concerns about high morbidity and mortality rates. This study assessed the general major complications and predictors of morbidity following extended radical resections for locally advanced and recurrent pelvic malignancies. METHODS Data were collected from prospective databases at two high-volume institutions specialising in beyond TME surgery for locally advanced and recurrent pelvic malignancies between 1990 and 2015. The primary outcome measures were major complications (Clavien-Dindo 3 or above) and predictors for morbidity. RESULTS A total of 646 consecutive patients required extended surgery for local advanced pelvic malignancies. The median age was 63 (range 19-89) years, and the majority were female (371; 57.4%). One or more major complications were observed in 106 patients (16.4%). The most common major complications were intra-abdominal collection (43.7%; n = 59/135) and wound infection (14.1%; n = 19/135). The overall inpatient mortality rate was 0.46% (n = 3/646). Independent predictors for major morbidity following surgery for locally advanced or recurrent pelvic malignancies were squamous cell carcinoma of anus, sacrectomy, and blood transfusion requirement. CONCLUSIONS This series adds increasing evidence that good outcomes can be achieved for extended radical resections in locally advanced and recurrent pelvic malignancies. A coordinated approach in specialist centres for beyond TME surgery demonstrates that this is a safe and feasible procedure, offering low major complication rates.
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Affiliation(s)
- Oliver Peacock
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
| | - Peadar S Waters
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Joseph C Kong
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Satish K Warrier
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Chris Wakeman
- Colorectal Surgery Unit, Christchurch Hospital, Christchurch, New Zealand
| | - Tim Eglinton
- Colorectal Surgery Unit, Christchurch Hospital, Christchurch, New Zealand
| | - Alexander G Heriot
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Frank A Frizelle
- Colorectal Surgery Unit, Christchurch Hospital, Christchurch, New Zealand
| | - Jacob J McCormick
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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131
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Peacock O, Waters PS, Bressel M, Lynch AC, Wakeman C, Eglinton T, Koh CE, Lee PJ, Austin KK, Warrier SK, Solomon MJ, Frizelle FA, Heriot AG. Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era. Br J Surg 2019; 106:1685-1696. [PMID: 31339561 DOI: 10.1002/bjs.11242] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/31/2019] [Accepted: 04/26/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Despite advances in the rates of total mesorectal excision (TME) for rectal cancer surgery, decreased local recurrence rates and increased 5-year survival, there still exists large variation in the quality of treatment received. Up to 30 per cent of rectal cancers are locally advanced at presentation and approximately 5-10 per cent still breach the mesorectal plane and invade adjacent structures despite neoadjuvant therapy. With the evolution of extended resections for rectal cancers beyond the TME plane, proponents advocate that these resections should be performed only in specialist centres. The aim was to assess the prognostic factors and patterns of failure after beyond TME surgery for T4 rectal cancers. METHODS Data were collected from prospective databases at three high-volume institutions specializing in beyond TME surgery for T4 rectal cancers between 1990 and 2013. The primary outcome measures were overall survival, local recurrence and patterns of first failure. RESULTS Three hundred and sixty patients were identified. The negative resection margin (R0) rate was 82·8 per cent (298 patients) and the local recurrence rate was 12·5 per cent (45 patients). The type of surgical procedure (Hartmann's: hazard ratio (HR) 4·49, 95 per cent c.i. 1·99 to 10·14; P = 0·002) and lymphovascular invasion (HR 2·02, 1·08 to 3·77; P = 0·032) were independent predictors of local recurrence. The 5-year overall survival rate for all patients was 61 (95 per cent c.i. 55 to 67) per cent. The 5-year cumulative incidence of first failure was 8 per cent for local recurrence, 6 per cent for local and distant disease, and 18 per cent for distant disease. CONCLUSION This study has demonstrated that a coordinated approach in specialist centres for beyond TME surgery can offer good oncological and long-term survival in patients with T4 rectal cancers.
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Affiliation(s)
- O Peacock
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - P S Waters
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - M Bressel
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A C Lynch
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - C Wakeman
- Colorectal Surgery Unit, Christchurch Hospital, Christchurch, New Zealand
| | - T Eglinton
- Colorectal Surgery Unit, Christchurch Hospital, Christchurch, New Zealand
| | - C E Koh
- Department of Colorectal Surgery and Royal Prince Alfred Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - P J Lee
- Department of Colorectal Surgery and Royal Prince Alfred Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - K K Austin
- Department of Colorectal Surgery and Royal Prince Alfred Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - S K Warrier
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - M J Solomon
- Department of Colorectal Surgery and Royal Prince Alfred Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Unit, University of Sydney, Sydney, New South Wales, Australia
| | - F A Frizelle
- Colorectal Surgery Unit, Christchurch Hospital, Christchurch, New Zealand
| | - A G Heriot
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Evolution of pelvic exenteration surgery- resectional trends and survival outcomes over three decades. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2019; 45:2325-2333. [PMID: 31303376 DOI: 10.1016/j.ejso.2019.07.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/04/2019] [Accepted: 07/06/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the changes in exenterative surgery over three decades analysing oncological outcomes and whether changes in surgical approach have led to improved patient outcomes. BACKGROUND Advances in surgical technology, perioperative care and pattern of disease recurrence have coincided with an evolutionary change in exenterative surgery. METHODS A review of a prospectively maintained databases of pelvic exenteration surgery from 1988 to 2018 at two high volume specialised institutions. The total cohort was divided into three major time points (1988-2004, 2005-2010 and 2011 to 2018) to allow comparative analysis. Primary endpoints were overall survival in primary and recurrent disease at each time point. Secondary endpoints included anastomotic leak, blood transfusion, ileus, wound infection rates and evolution of case complexity. Data were analysed using R with a p < 0.05 considered significant. RESULTS Six hundred and seventy patients underwent exenterative surgery. In 2011-2018 there was an increase in resection of recurrent malignancy with a continuous increase in GI malignancies resected over each time period(p < 0.001,<0.01) and a reduction in gynaecological malignancy(p < 0.001). A significant increase in sacrectomy, pelvic sidewall resection and ileal conduit reconstruction was observed (p < 0.01,<0.001).In 2005-2010 patients had increased rates of ileus and anastomotic leak(p < 0.05). Patients undergoing resection for primary disease had improved overall survival at time points 1988-2004 and 2011-2018 compared to those with recurrent disease(p = 0.007,<0.001). Overall survival was significantly improved in patients with primary versus recurrent disease(p = 0.022). CONCLUSION There has been a significant improvement in survival in patients undergoing pelvic exenteration surgery from primary disease. Case complexity has increased without significant morbidity.
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Humphries EL, Kroon HM, Dudi-Venkata NN, Thomas ML, Moore JW, Sammour T. Short- and long-term outcomes of selective pelvic exenteration surgery in a low-volume specialized tertiary setting. ANZ J Surg 2019; 89:E226-E230. [PMID: 31067602 DOI: 10.1111/ans.15212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Most published data on pelvic exenteration comes from high-volume quaternary units, with limited data available from outside of this setting. This study reports outcomes of selective pelvic exenteration performed in a low-volume tertiary unit with multidisciplinary support. METHODS A retrospective review of consecutive patients who underwent pelvic exenteration surgery for rectal/anal carcinoma, or gynaecological malignancy at Royal Adelaide Hospital between June 2008 and September 2018. Descriptive statistics and Kaplan-Meier analysis of 5-year disease-free and overall survival for patients treated with curative intent were performed. RESULTS A total of 54 patients who underwent pelvic exenteration were included. Most patients presented with primary rectal adenocarcinoma, and posterior and total pelvic exenterations were the most common operations performed (>90%). Median total operating time was 323 min, median hospital stay was 15 days, and the readmission rate was 14.8%. The overall complication rate (per patient) was 70.4%, and the re-intervention rate was 20.4%. Thirteen percent of patients required intensive care unit-admission, and there was one postoperative death (1.9%). R0 resection margins were achieved in 81.5% of patients, with R1 and R2 margins in 13.0 and 5.6% of patients, respectively. Estimated 5-year disease-free survival was 38.8%, and 5-year overall survival was 65.7%. CONCLUSION Short- and long-term outcomes of selective pelvic exenteration surgery are acceptable in a low-volume specialized tertiary setting with suitable multidisciplinary expertise. If the required expertise is not readily available, then outside referral is recommended.
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Affiliation(s)
- Emily L Humphries
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nagendra N Dudi-Venkata
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michelle L Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - James W Moore
- 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
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Pellino G, Biondo S, Codina Cazador A, Enríquez-Navascues JM, Espín-Basany E, Roig-Vila JV, García-Granero E. Pelvic exenterations for primary rectal cancer: Analysis from a 10-year national prospective database. World J Gastroenterol 2018; 24:5144-5153. [PMID: 30568391 PMCID: PMC6288654 DOI: 10.3748/wjg.v24.i45.5144] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 11/05/2018] [Accepted: 11/16/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To identify short-term and oncologic outcomes of pelvic exenterations (PE) for locally advanced primary rectal cancer (LAPRC) in patients included in a national prospective database. METHODS Few studies report on PE in patients with LAPRC. For this study, we included PE for LAPRC performed between 2006 and 2017, as available, from the Rectal Cancer Registry of the Spanish Association of Surgeons [Asociación Española de Cirujanos (AEC)]. Primary endpoints included procedure-associated complications, 5-year local recurrence (LR), disease-free survival (DFS) and overall survival (OS). A propensity-matched comparison with patients who underwent non-exenterative surgery for low rectal cancers was performed as a secondary endpoint. RESULTS Eight-two patients were included. The mean age was 61.8 ± 11.5 years. More than half of the patients experienced at least one complication. Surgical site infections were the most common complication (abdominal wound 18.3%, perineal closure 19.4%). Thirty-three multivisceral resections were performed, including two hepatectomies and four metastasectomies. The long-term outcomes of the 64 patients operated on before 2013 were assessed. The five-year LR was 15.6%, the distant recurrence rate was 21.9%, and OS was 67.2%, with a mean survival of 43.8 mo. R+ve resection increased LR [hazard ratio (HR) = 5.58, 95%CI: 1.04-30.07, P = 0.04]. The quality of the mesorectum was associated with DFS. Perioperative complications were independent predictors of shorter survival (HR = 3.53, 95%CI: 1.12-10.94, P = 0.03). In the propensity-matched analysis, PE was associated with better quality of the specimen and tended to achieve lower LR with similar OS. CONCLUSION PE is an extensive procedure, justified if disease-free margins can be obtained. Further studies should define indications, accreditation policy, and quality of life in LAPRC.
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Affiliation(s)
- Gianluca Pellino
- Colorectal Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia 46026, Spain
| | - Sebastiano Biondo
- Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona and IDIBELL, L’Hospitalet de Llobregat, Barcelona 08907, Spain
| | - Antonio Codina Cazador
- Department of General and Digestive Surgery--Colorectal Unit, Josep Trueta University Hospital, Girona 17001, Spain
| | | | - Eloy Espín-Basany
- Department of General Surgery, Colorectal Surgery Unit, Hospital Valle de Hebron, Autonomous University of Barcelona, Barcelona 08035, Spain
| | | | - Eduardo García-Granero
- Colorectal Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia 46026, Spain
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Kulu Y, Mehrabi A, Khajeh E, Klose J, Greenwood J, Hackert T, Büchler MW, Ulrich A. Promising Long-Term Outcomes After Pelvic Exenteration. Ann Surg Oncol 2018; 26:1340-1349. [PMID: 30519763 DOI: 10.1245/s10434-018-07090-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pelvic exenteration (PE) is a complex and challenging surgical procedure. The reported results of this procedure for primary and recurrent disease are limited and conflicting. METHODS This study analyzed patient outcomes after all PEs performed in the authors' department between October 2001 and December 2016. Relevant patient data were obtained from a prospective database. Morbidity and mortality were reported for all patients. For patients with malignant disease, differences in perioperative outcomes, prognostic indicators for overall survival, and local and systemic disease recurrence were analyzed using uni- and multivariate analyses. RESULTS The study enrolled 187 patients. Of the 183 patients with malignant disease, 63 (38.2%) had primary locally advanced tumors and 115 (62.5%) had recurrent tumors. The 10-year overall survival rate was 63.5% for the patients with primary tumors that were curatively resected and 20.9% for the patients with recurrent disease (p = 0.02). The 10-year survival rate for the patients with extrapelvic disease who underwent curative resection was 37%. Multivariable analysis identified margin positivity (p < 0.01), surgery lasting longer than 7 h (p = 0.02), and recurrent disease (p < 0.01) as predictors of poor survival. Multivariate analysis of local and systemic disease recurrence showed recurrent disease (p < 0.01) as the only significant prognostic factor. CONCLUSIONS Pelvic exenteration has good long-term results, even for patients with extrapelvic disease. The oncologic outcome for patients with recurrent disease is worse than for patients with primary disease. However, even for these patients, long-time survival is possible.
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Affiliation(s)
- Yakup Kulu
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Johannes Klose
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Johanna Greenwood
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Alexis Ulrich
- Chirurgische Klinik I, Lukaskrankenhaus Neuss, Neuss, Germany
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136
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van Ramshorst GH, O'Shannassy S, Brown WE, Kench JG, Solomon MJ. A qualitative study of the development of a multidisciplinary case conference review methodology to reduce involved margins in pelvic exenteration surgery for recurrent rectal cancer. Colorectal Dis 2018; 20:1004-1013. [PMID: 29920909 DOI: 10.1111/codi.14311] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 05/21/2018] [Indexed: 02/08/2023]
Abstract
AIM Pelvic exenteration surgery remains the only curative option for recurrent rectal cancer. Microscopically involved surgical margins (R1) are associated with a higher risk of local recurrence and decreased survival. Our study aimed to develop a post hoc multidisciplinary case conference review and investigate its potential for identifying areas for improvement. METHOD Patients who underwent pelvic exenteration surgery for recurrent rectal cancer with R1 resections at a tertiary referral centre between April 2014 and January 2016 were retrospectively reviewed from a prospectively maintained database. Patients with non-rectal cancers or who underwent palliative surgery were excluded. Cases, imaging and histopathology were evaluated by a dedicated panel including colorectal surgeons, an abdominal radiologist and a gastrointestinal pathologist. RESULTS R1 resections were reported in 32 of 110 pelvic exenterations. Patients with other tumours were excluded and one patient had a palliative resection. Nine male patients with 11 exenterations were included with a median age of 56 years. All patients had positive soft tissue margins, and one patient also had an involved bony margin. Failures were due to (interdisciplinary) communication problems, specific management of tumour biology (multifocality, spiculated tumours), which can lead to radiological undercalling, and inadequate surgical technical planning. In hindsight, surgery would have been withheld from one patient. CONCLUSION A retrospective multidisciplinary case evaluation of pelvic exenteration patients with involved surgical margins led to a list of recommendations which included the need to plan for wider surgical soft tissue resections and improvement in interdisciplinary communication. Lessons learned may increase clear margin rates in future resections.
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Affiliation(s)
- G H van Ramshorst
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,SOuRCe (Surgical Outcomes Research Centre), Sydney, New South Wales, Australia.,Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Surgery, VU Medical Center, Amsterdam, The Netherlands
| | - S O'Shannassy
- SOuRCe (Surgical Outcomes Research Centre), Sydney, New South Wales, Australia
| | - W E Brown
- Department of Radiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - J G Kench
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - M J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,SOuRCe (Surgical Outcomes Research Centre), Sydney, New South Wales, Australia.,Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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137
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Dickfos M, Tan SBM, Stevenson ARL, Harris CA, Esler R, Peters M, Taylor DG. Development of a pelvic exenteration service at a tertiary referral centre. ANZ J Surg 2018; 88. [PMID: 29510462 DOI: 10.1111/ans.14427] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 01/07/2018] [Accepted: 01/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Over one-third of primary rectal cancers are locally advanced at diagnosis, and local recurrence of rectal cancer occurs at a rate of 3-10% following primary curative resection. Extended resectional surgery, including pelvic exenteration, is the only proven therapy with curative potential in the treatment of these cancers along with many other pelvic malignancies. A microscopically clear resection margin (R0 resection) is the predominant prognostic factor affecting overall and disease-free survival. The extent and complexity of surgery required to achieve an R0 resection is associated with significant risk of morbidity and mortality. The aim of this paper is to show that pelvic exenterations can be performed with acceptable oncological and safe perioperative results in an appropriately resourced specialist centre. METHODS Data was collected retrospectively for 61 consecutive patients treated between June 2012 and February 2017. This included patient demographics, tumour characteristics, operative, clinical and histological data, length of hospital stay, morbidity and mortality data. RESULTS A total of 61 patients underwent surgery. Median age was 57 years (range 27-78 years). Median length of stay was 41 days (range 6-288 days). Median operative time was 624 min (range 239-1035 min); 30-day mortality was 3.3% (n = 2). Resection rates were 91.5% - R0, 6.8% - R1 and 1.7% - R2 resections. Histologically, 86.9% - adenocarcinomas, 3.3% - squamous cell carcinomas and 9.8% - represented by leiomyosarcoma, melanoma, myxoid chondrosarcoma, non-neoplastic processes and undifferentiated carcinoma. CONCLUSION Our experience confirms that radical resectional pelvic surgery can be safely performed with acceptable results during the establishment phase of a dedicated tertiary service.
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Affiliation(s)
- Marilla Dickfos
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Stephanie B M Tan
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Medicine, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Andrew R L Stevenson
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Craig A Harris
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Department of Colorectal Surgery, Mater Hospital, Brisbane, Queensland, Australia
| | - Rachel Esler
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Department of Urology, Wesley Hospital, Brisbane, Queensland, Australia
| | - Matthew Peters
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - David G Taylor
- General Surgery Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Department of Urology, Wesley Hospital, Brisbane, Queensland, Australia
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