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Milanko NA, Kelly ME, Turner G, Kong J, Behrenbruch C, Mohan H, Guerra G, Warrier S, McCormick J, Heriot A. Evaluating postoperative hernia incidence and risk factors following pelvic exenteration. Int J Colorectal Dis 2024; 39:70. [PMID: 38717479 PMCID: PMC11078832 DOI: 10.1007/s00384-024-04638-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/12/2024]
Abstract
Pelvic exenteration (PE) is a technically challenging surgical procedure. More recently, quality of life and survivorship following PEs are being increasingly acknowledged as important patient outcomes. This includes evaluating major long-term complications such as hernias, defined as the protrusion of internal organs through a facial defect (The PelvEx Collaborative in Br J Surg 109:1251-1263, 2022), for which there is currently limited literature. The aim of this paper is to ascertain the incidence and risk factors for postoperative hernia formation among our PE cohort managed at a quaternary centre. METHOD A retrospective cohort study examining hernia formation following PE for locally advanced rectal carcinoma and locally recurrent rectal carcinoma between June 2010 and August 2022 at a quaternary cancer centre was performed. Baseline data evaluating patient characteristics, surgical techniques and outcomes was collated among a PE cohort of 243 patients. Postoperative hernia incidence was evaluated via independent radiological screening and clinical examination. RESULTS A total of 79 patients (32.5%) were identified as having developed a hernia. Expectantly, those undergoing flap reconstruction had a lower incidence of postoperative hernias. Of the 79 patients who developed postoperative hernias, 16.5% reported symptoms with the most common symptom reported being pain. Reintervention was required in 18 patients (23%), all of which were operative. CONCLUSION This study found over one-third of PE patients developed a hernia postoperatively. This paper highlights the importance of careful perioperative planning and optimization of patients to minimize morbidity.
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Affiliation(s)
- Nicole Anais Milanko
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia.
| | - Michael Eamon Kelly
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Trinity St James Cancer Institute, Dublin, Ireland
| | - Greg Turner
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Auckland District Health Board, Auckland, New Zealand
| | - Joeseph Kong
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Cori Behrenbruch
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Helen Mohan
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Glen Guerra
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Satish Warrier
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Jacob McCormick
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Department of General Surgery, Royal Melbourne Hospital, Melbourne, Australia
| | - Alexander Heriot
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia.
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Chan KS, Liu B, Tan MNA, How KY, Wong KY. Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer: A 9-year review. World J Gastrointest Surg 2024; 16:777-789. [PMID: 38577068 PMCID: PMC10989345 DOI: 10.4240/wjgs.v16.i3.777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/09/2024] [Accepted: 02/18/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide. About 5%-10% of patients are diagnosed with locally advanced rectal cancer (LARC) on presentation. For LARC invading into other structures (i.e. T4b), multivisceral resection (MVR) and/or pelvic exenteration (PE) remains the only potential curative surgical treatment. MVR and/or PE is a major and complex surgery with high post-operative morbidity. Minimally invasive surgery (MIS) has been shown to improve short-term post-operative outcomes in other gastrointestinal malignancies, but there is little evidence on its use in MVR, especially so for robotic MVR. AIM To assess the feasibility and safety of minimally invasive MVR (miMVR), and compare post-operative outcomes between robotic and laparoscopic MVR. METHODS This is a single-center retrospective cohort study from 1st January 2015 to 31st March 2023. Inclusion criteria were patients diagnosed with cT4b rectal cancer and underwent MVR, or stage 4 disease with resectable systemic metastases. Patients who underwent curative MVR for locally recurrent rectal cancer, or metachronous rectal cancer were also included. Exclusion criteria were patients with systemic metastases with non-resectable disease. All patients planned for elective surgery were enrolled into the standard enhanced recovery after surgery pathway with standard peri-operative management for colorectal surgery. Complex surgery was defined based on technical difficulty of surgery (i.e. total PE, bladder-sparing prostatectomy, pelvic lymph node dissection or need for flap creation). Our primary outcomes were the margin status, and complication rates. Categorical values were described as percentages and analysed by the chi-square test. Continuous variables were expressed as median (range) and analysed by Mann-Whitney U test. Cumulative overall survival (OS) and recurrence-free survival (RFS) were analysed using Kaplan-Meier estimates with life table analysis. Log-rank test was performed to determine statistical significance between cumulative estimates. Statistical significance was defined as P < 0.05. RESULTS A total of 46 patients were included in this study [open MVR (oMVR): 12 (26.1%), miMVR: 36 (73.9%)]. Patients' American Society of Anesthesiologists score, body mass index and co-morbidities were comparable between oMVR and miMVR. There is an increasing trend towards robotic MVR from 2015 to 2023. MiMVR was associated with lower estimated blood loss (EBL) (median 450 vs 1200 mL, P = 0.008), major morbidity (14.7% vs 50.0%, P = 0.014), post-operative intra-abdominal collections (11.8% vs 50.0%, P = 0.006), post-operative ileus (32.4% vs 66.7%, P = 0.04) and surgical site infection (11.8% vs 50.0%, P = 0.006) compared with oMVR. Length of stay was also shorter for miMVR compared with oMVR (median 10 vs 30 d, P = 0.001). Oncological outcomes-R0 resection, recurrence, OS and RFS were comparable between miMVR and oMVR. There was no 30-d mortality. More patients underwent robotic compared with laparoscopic MVR for complex cases (robotic 57.1% vs laparoscopic 7.7%, P = 0.004). The operating time was longer for robotic compared with laparoscopic MVR [robotic: 602 (400-900) min, laparoscopic: Median 455 (275-675) min, P < 0.001]. Incidence of R0 resection was similar (laparoscopic: 84.6% vs robotic: 76.2%, P = 0.555). Overall complication rates, major morbidity rates and 30-d readmission rates were similar between laparoscopic and robotic MVR. Interestingly, 3-year OS (robotic 83.1% vs 58.6%, P = 0.008) and RFS (robotic 72.9% vs 34.3%, P = 0.002) was superior for robotic compared with laparoscopic MVR. CONCLUSION MiMVR had lower post-operative complications compared to oMVR. Robotic MVR was also safe, with acceptable post-operative complication rates. Prospective studies should be conducted to compare short-term and long-term outcomes between robotic vs laparoscopic MVR.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Biquan Liu
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Kwang Yeong How
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Kar Yong Wong
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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Mirnezami AH, Drami I, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Denys A, Pape E, van Ramshorst GH, Baker D, Bignall E, Blair I, Davis P, Edwards T, Jackson K, Leendertse PG, Love-Mott E, MacKenzie L, Martens F, Meredith D, Nettleton SE, Trotman MP, van Hecke JJM, Weemaes AMJ, Abecasis N, Angenete E, Aziz O, Bacalbasa N, Barton D, Baseckas G, Beggs A, Brown K, Buchwald P, Burling D, Burns E, Caycedo-Marulanda A, Chang GJ, Coyne PE, Croner RS, Daniels IR, Denost QD, Drozdov E, Eglinton T, Espín-Basany E, Evans MD, Flatmark K, Folkesson J, Frizelle FA, Gallego MA, Gil-Moreno A, Goffredo P, Griffiths B, Gwenaël F, Harris DA, Iversen LH, Kandaswamy GV, Kazi M, Kelly ME, Kokelaar R, Kusters M, Langheinrich MC, Larach T, Lydrup ML, Lyons A, Mann C, McDermott FD, Monson JRT, Neeff H, Negoi I, Ng JL, Nicolaou M, Palmer G, Parnaby C, Pellino G, Peterson AC, Quyn A, Rogers A, Rothbarth J, Abu Saadeh F, Saklani A, Sammour T, Sayyed R, Smart NJ, Smith T, Sorrentino L, Steele SR, Stitzenberg K, Taylor C, Teras J, Thanapal MR, Thorgersen E, Vasquez-Jimenez W, Waller J, Weber K, Wolthuis A, Winter DC, Brangan G, Vimalachandran D, Aalbers AGJ, Abdul Aziz N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Baker RP, Bali M, Baransi S, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Bui A, Burgess A, Burger JWA, Campain N, Carvalhal S, Castro L, Ceelen W, Chan KKL, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Damjanovic L, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Deutsch C, Dietz D, Domingo S, Dozois EJ, Duff M, Egger E, Enrique-Navascues JM, Espín-Basany E, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Fleming F, Flor B, Foskett K, Funder J, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Giner F, Ginther N, Glover T, Golda T, Gomez CM, Harris C, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Jenkins JT, Jourand K, Kaffenberger S, Kapur S, Kanemitsu Y, Kaufman M, Kelley SR, Keller DS, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Lago V, Lakkis Z, Lampe B, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lynch AC, Mackintosh M, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Morton JR, Mullaney TG, Navarro AS, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Pappou E, Park J, Patsouras D, Peacock O, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steffens D, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor D, Tejedor P, Tekin A, Tekkis PP, Thaysen HV, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Yano H, Yip B, Yip J, Yoo RN, Zappa MA. The empty pelvis syndrome: a core data set from the PelvEx collaborative. Br J Surg 2024; 111:znae042. [PMID: 38456677 PMCID: PMC10921833 DOI: 10.1093/bjs/znae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/15/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored. METHOD Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition. RESULTS One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed. CONCLUSIONS EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.
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Nascimento AQ, Nagata LAR, Almeida MT, da Silva Costa VL, de Marin ABR, Tavares VB, Ishak G, Callegari B, Santos EGR, da Silva Souza G, de Melo Neto JS. Smartphone-based inertial measurements during Chester step test as a predictor of length of hospital stay in abdominopelvic cancer postoperative period: a prospective cohort study. World J Surg Oncol 2024; 22:71. [PMID: 38419082 PMCID: PMC10900612 DOI: 10.1186/s12957-024-03337-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/14/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Objective assessment of pre-operative functional capacity in cancer patients using the smartphone gyroscope during the Chester step (CST) test may allow greater sensitivity of test results. This study has investigated whether the CST is a postoperative hospital permanence predictor in cancer patients undergoing abdominopelvic surgery through work, VO2MAX and gyroscopic movement analysis. METHODS Prospective, quantitative, descriptive and inferential observational cohort study. Fifty-one patients were evaluated using CST in conjunction with a smartphone gyroscope. Multivariate linear regression analysis was used to examine the predictive value of the CST. RESULTS The duration of hospital permanence 30 days after surgery was longer when patients who performed stage 1 showed lower RMS amplitude and higher peak power. The work increased as the test progressed in stage 3. High VO2MAX seemed to be a predictor of hospital permanence in those who completed levels 3 and 4 of the test. CONCLUSION The use of the gyroscope was more accurate in detecting mobility changes, which predicted a less favorable result for those who met at level 1 of the CST. VO2MAX was a predictor of prolonged hospitalization from level 3 of the test. The work was less accurate to determine the patient's true functional capacity.
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Affiliation(s)
| | | | | | | | | | | | - Geraldo Ishak
- Federal University of Pará (UFPA), Belém, PA, Brazil
| | | | | | | | - João Simão de Melo Neto
- Federal University of Pará (UFPA), Belém, PA, Brazil.
- Clinical and Experimental Research Unit of the Urogenital System (UPCEURG), Institute of Health Sciences of Federal University of Pará, Mundurucus street, Guamá, Belém, PA, 4487CEP: 66073-000, Brazil.
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Beating the empty pelvis syndrome: the PelvEx Collaborative core outcome set study protocol. BMJ Open 2024; 14:e076538. [PMID: 38316595 PMCID: PMC10860036 DOI: 10.1136/bmjopen-2023-076538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/20/2023] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION The empty pelvis syndrome is a significant source of morbidity following pelvic exenteration surgery. It remains poorly defined with research in this field being heterogeneous and of low quality. Furthermore, there has been minimal engagement with patient representatives following pelvic exenteration with respect to the empty pelvic syndrome. 'PelvEx-Beating the empty pelvis syndrome' aims to engage both patient representatives and healthcare professionals to achieve an international consensus on a core outcome set, pathophysiology and mitigation of the empty pelvis syndrome. METHODS AND ANALYSIS A modified-Delphi approach will be followed with a three-stage study design. First, statements will be longlisted using a recent systematic review, healthcare professional event, patient and public engagement, and Delphi piloting. Second, statements will be shortlisted using up to three rounds of online modified Delphi. Third, statements will be confirmed and instruments for measurable statements selected using a virtual patient-representative consensus meeting, and finally a face-to-face healthcare professional consensus meeting. ETHICS AND DISSEMINATION The University of Southampton Faculty of Medicine ethics committee has approved this protocol, which is registered as a study with the Core Outcome Measures in Effectiveness Trials Initiative. Publication of this study will increase the potential for comparative research to further understanding and prevent the empty pelvis syndrome. TRIAL REGISTRATION NUMBER NCT05683795.
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Brown KGM, Pisaniello J, Ng KS, Solomon MJ, Sutton PA, Hatcher S, Steffens D. Variation in outcome measurement and reporting in studies of pelvic exenteration for locally advanced and recurrent rectal cancer: a systematic review. Colorectal Dis 2024; 26:272-280. [PMID: 38131647 DOI: 10.1111/codi.16844] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023]
Abstract
AIM There is increasing research interest in pelvic exenteration for locally advanced and recurrent rectal cancer. Heterogeneity in outcome reporting can prevent meaningful interpretation and valid synthesis of pooled data and meta-analyses. The aim of this study was to assess homogeneity in outcome measures in the current pelvic exenteration literature. METHOD MEDLINE, Embase, CENTRAL, CINAHL and Scopus databases were searched from 1990 to 25 April 2023 to identify studies reporting outcomes of pelvic exenteration for locally advanced or recurrent rectal cancer. All reported outcomes were extracted, merged with those of similar meaning and assigned a domain. RESULTS Of 4137 abstracts screened, 156 studies met the inclusion criteria. A total of 2765 outcomes were reported, of which 17% were accompanied by a definition. There were 1157 unique outcomes, merged into 84 standardized outcomes and assigned one of seven domains. The most reported domains were complications (147 studies, 94%), survival (127, 81%) and surgical outcomes (123, 79%). Resection margins were reported in 122 studies (78%): the definition of a clear resection margin was not provided in 45 studies (37%), it was unclear in 11 studies (9%) and not specified beyond microscopically 'clear' or 'negative' in 31 (28%). Measurements of 2, 1, 0.5 mm and any healthy tissue were all used to define R0 margins. CONCLUSION There is significant heterogeneity in outcome measurement and reporting in the current pelvic exenteration literature, raising concerns about the validity of comparative or collaborative studies between centres and meta-analyses. Coordinated international collaboration is required to define core outcome sets and benchmarks.
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Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Jade Pisaniello
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Paul A Sutton
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Sophie Hatcher
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Brown KGM, Solomon MJ. Topical haemostatic agents in surgery. Br J Surg 2024; 111:znad361. [PMID: 38156466 PMCID: PMC10771136 DOI: 10.1093/bjs/znad361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/15/2023] [Indexed: 12/30/2023]
Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
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Pappou E, Ben-Yaakov A, Jiménez-Rodríguez RM, Garcia-Aguilar J. Simultaneous posterior vaginal and perineal reconstruction using gluteal fasciocutaneous flaps following pelvic exenteration with sacrectomy. Br J Surg 2024; 111:znad395. [PMID: 37988590 PMCID: PMC10938539 DOI: 10.1093/bjs/znad395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/27/2023] [Indexed: 11/23/2023]
Affiliation(s)
- Emmanouil Pappou
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Almog Ben-Yaakov
- Department of Surgical Oncology, Chaim Sheba Medical Center, Tel Aviv, Israel
| | - Rosa M Jiménez-Rodríguez
- Department of General and Digestive Surgery, University Hospital Virgen del Rocio, Seville, Spain
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Wang J, Liu H, Li A, Jiang H, Pan Y, Chen X, Yin L, Lin M. A new membrane anatomy-oriented classification of radical surgery for rectal cancer. Gastroenterol Rep (Oxf) 2023; 11:goad069. [PMID: 38145104 PMCID: PMC10739184 DOI: 10.1093/gastro/goad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/08/2023] [Accepted: 11/10/2023] [Indexed: 12/26/2023] Open
Abstract
For patients with different clinical stages of rectal cancer, tailored surgery is urgently needed. Over the past 10 years, our team has conducted numerous anatomical studies and proposed the "four fasciae and three spaces" theory to guide rectal cancer surgery. Enlightened by the anatomical basis of the radical hysterectomy classification system of Querleu and Morrow, we proposed a new classification system of radical surgery for rectal cancer based on membrane anatomy. This system categorizes the surgery into four types (A-D) and incorporates corresponding subtypes based on the preservation of the autonomic nerve. Our surgical classification unifies the pelvic membrane anatomical terminology, validates the feasibility of classifying rectal cancer surgery using the theory of "four fasciae and three spaces," and lays the theoretical groundwork for the future development of unified and standardized classification of radical pelvic tumor surgery.
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Affiliation(s)
- Jiaqi Wang
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Hailong Liu
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Ajian Li
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
| | - Huihong Jiang
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Yun Pan
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Xin Chen
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
| | - Lu Yin
- Department of General Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, P. R. China
| | - Moubin Lin
- Department of General Surgery, Yangpu Hospital, Tongji University School of Medicine, Shanghai, P. R. China
- Institute of Gastrointestinal Surgery and Translational Medicine, Tongji University School of Medicine, Shanghai, P. R. China
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West CT, West MA, Mirnezami AH, Drami I, Denys A, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Pape E, van Ramshorst GH, Aalbers AGJ, Abdul AN, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Angenete E, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brown K, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelen W, Chan KKL, Chang GJ, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovic L, Daniels IR, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Denost QD, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Egger E, Eglinton T, Enrique-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Flatmark K, Fleming F, Flor B, Folkesson J, Foskett K, Frizelle FA, Funder J, Gallego MA, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther N, Glover T, Goffredo P, Golda T, Gomez CM, Griffiths B, Gwenaël F, Harris C, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kaufman M, Kazi M, Kelley SR, Keller DS, Kelly ME, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Kusters M, Lago V, Lakkis Z, Lampe B, Langheinrich MC, Larach T, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Mackintosh M, Mann C, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McDermott FD, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Monson JRT, Morton JR, Mullaney TG, Navarro AS, Neeff H, Negoi I, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock A, Pellino G, Peterson AC, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Quyn A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Smith T, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor C, Taylor D, Tejedor P, Tekin A, Tekkis PP, Teras J, Thanapal MR, Thaysen HV, Thorgersen E, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weber K, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Empty pelvis syndrome: PelvEx Collaborative guideline proposal. Br J Surg 2023; 110:1730-1731. [PMID: 37757457 PMCID: PMC10805575 DOI: 10.1093/bjs/znad301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023]
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Risbey CWG, Brown KGM, Solomon MJ, Koh C, Karunaratne S, Steffens D. Impact of geographical health disparities on outcomes following pelvic exenteration at a centralised quaternary referral centre. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107082. [PMID: 37738872 DOI: 10.1016/j.ejso.2023.107082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/22/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Pelvic exenteration (PE) is an ultra-radical procedure performed for primary or recurrent malignancies confined to the pelvis. Health outcomes for rural Australian populations are generally inferior compared to those from metropolitan centres, however, the effect of geographical location on outcomes following PE is poorly defined. The aim of this study was to investigate how geographical location affects oncological, quality of life (QoL) and survival outcomes following PE. METHODS Consecutive patients undergoing PE between 1994 and 2022 at a single centre were included. Patient post codes were linked with the Australian Statistical Geography Standard Remoteness Structure to stratify patients into five groups based on the geographical location of their residence. Primary outcome measures included patient survival, QoL and oncological outcomes. RESULTS A total of 953 patients were included, of which 626 (65.7%) were from major cities, 227 (23.8%) inner regional, 84 (8.8%) outer regional, 9 (0.9%) remote, and 7 (0.7%) very remote areas. Rural patients were more likely to undergo PE for primary rectal cancer (p = 002) and less likely for recurrent, non-rectal carcinoma (p = 0.027). Rural patients less frequently had health insurance (p < 0.001) but were more likely to have undergone neoadjuvant radiotherapy (p = 0.022). No difference in length-of-admission, in-hospital complication rates, QoL at 36 months or survival was observed between groups. CONCLUSIONS Despite geographical disparities, rural populations undergoing PE achieved equally favourable outcomes as populations from metropolitan areas. Enhancing access to specialised care may facilitate better outcomes of patients residing in regional and remote areas.
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Affiliation(s)
- Charles W G Risbey
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, 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, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, 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, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Cherry Koh
- 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, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Sascha Karunaratne
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia.
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Brown K, Solomon M, Ng KS, Sutton P, Koh C, White K, Steffens D. Development of a risk prediction tool for patients with locally advanced and recurrent rectal cancer undergoing pelvic exenteration: protocol for a mixed-methods study. BMJ Open 2023; 13:e075304. [PMID: 37648387 PMCID: PMC10471871 DOI: 10.1136/bmjopen-2023-075304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Pelvic exenteration (PE) surgery represents the only potentially curative treatment option for patients with locally advanced or recurrent rectal cancer (LARRC). Given the potential morbidity, whether or not PE should be recommended for an individual patient presents a major decisional conflict. This study aims to identify the outcomes of PE for which there is consensus among patients, carers and clinicians regarding their importance in guiding treatment decision-making, and to develop a risk prediction tool which predicts these outcomes. METHODS AND ANALYSIS This study will be conducted at a specialist PE centre, and employ a mixed-methods study design, divided into three distinct phases. In phase 1, outcomes of PE will be identified through a comprehensive systematic review of the literature (phase 1a), followed by exploration of the experiences of individuals who have undergone PE for LARRC and their carers (phase 1b, target sample size 10-20 patients and 5-10 carers). In phase 2, a survey of patients, their carers and clinicians will be conducted using Delphi methodology to explore consensus around the outcomes of highest priority and the level of influence each outcome should have on treatment decision-making. In phase 3 a, risk prediction tool will be developed using data from a single PE referral centre (estimated sample size 500 patients) to predict priority outcomes using multivariate modelling, and externally validated using data from an international PE collaboration. ETHICS AND DISSEMINATION Ethical approval has been granted for phases 1 and 2 (X22-0422 and 2022/ETH02659) and for maintenance of the database used in phase 3 (X13-0283 and HREC/13/RPAH/504). Informed consent will be obtained from participants in phases 1b and 2; a waiver of consent for secondary use of data in phase 3 will be sought. Study results will be submitted for publication in international and/or national peer reviewed journals. PROSPERO REGISTRATION NUMBER CRD42022351909.
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Affiliation(s)
- Kilian Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Paul Sutton
- Colorectal & Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Cherry Koh
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kate White
- Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
- The Daffodil Centre, University of Sydney and Cancer Council NSW, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Stelzner S, Heinze T, Heimke M, Gockel I, Kittner T, Brown G, Mees ST, Wedel T. Beyond Total Mesorectal Excision: Compartment-based Anatomy of the Pelvis Revisited for Exenterative Pelvic Surgery. Ann Surg 2023; 278:e58-e67. [PMID: 36538640 DOI: 10.1097/sla.0000000000005715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Magnetic resonance imaging-based subdivision of the pelvis into 7 compartments has been proposed for pelvic exenteration. The aim of the present anatomical study was to describe the topographic anatomy of these compartments and define relevant landmarks and surgical dissection planes. BACKGROUND Pelvic anatomy as it relates to exenterative surgery is complex. Demonstration of the topographic peculiarities of the pelvis based on the operative situs is hindered by the inaccessibility of the small pelvis and the tumor bulk itself. MATERIALS AND METHODS Thirteen formalin-fixed pelvic specimens were meticulously dissected according to predefined pelvic compartments. Pelvic exenteration was simulated and illustrated in a stepwise manner. Different access routes were used for optimal demonstration of the regions of interest. RESULTS All the 7 compartments (peritoneal reflection, anterior above peritoneal reflection, anterior below peritoneal reflection, central, posterior, lateral, inferior) were investigated systematically. The topography of the pelvic fasciae and ligaments; vessels and nerves of the bladder, prostate, uterus, and vagina; the internal iliac artery and vein; the course of the ureter, somatic (obturator nerve, sacral plexus), and autonomic pelvic nerves (inferior hypogastric plexus); pelvic sidewall and floor, ischioanal fossa; and relevant structures for sacrectomy were demonstrated. CONCLUSIONS A systematic approach to pelvic anatomy according to the 7 magnetic resonance imaging-defined compartments clearly revealed crucial anatomical landmarks and key structures facilitating pelvic exenterative surgery. Compartment-based pelvic anatomy proved to be a sound concept for beyond TME surgery and provides a basis for tailored resection procedures.
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Affiliation(s)
- Sigmar Stelzner
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Tillmann Heinze
- Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Kiel, Germany
| | - Marvin Heimke
- Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Kiel, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Thomas Kittner
- Department of Radiology, Dresden-Friedrichstadt General Hospital, Dresden, Germany
| | - Gina Brown
- Department of Surgery and Cancer, Gastrointestinal Imaging, Imperial College, London, UK
| | - Sören T Mees
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Dresden, Germany
| | - Thilo Wedel
- Institute of Anatomy, Center of Clinical Anatomy, Christian-Albrechts University Kiel, Kiel, Germany
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Prasath V, Naides AI, Weisberger JS, Quinn PL, Ayyala HS, Lee ES, Girard AO, Chokshi RJ. Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis. Surgery 2023; 173:521-528. [PMID: 36418205 DOI: 10.1016/j.surg.2022.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/25/2022] [Accepted: 09/11/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Radical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm. METHODS A decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature. RESULTS Gluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates. CONCLUSION Our data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.
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Affiliation(s)
| | | | - Joseph S Weisberger
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Patrick L Quinn
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Haripriya S Ayyala
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Division of Plastic & Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Edward S Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Alisa O Girard
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Ravi J Chokshi
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.
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Johnstone CSH, Roberts D, Mathieson S, Steffens D, Koh CE, Solomon MJ, McLachlan AJ. Pain, pain management and related outcomes following pelvic exenteration surgery: a systematic review. Colorectal Dis 2022; 25:562-572. [PMID: 36572393 DOI: 10.1111/codi.16462] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/30/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023]
Abstract
AIM Pelvic exenteration surgery can improve survival in people with advanced colorectal cancer. This systematic review aimed to review pain intensity and other outcomes, for example the management of pain, the relationship between pain and the extent of surgery and the impact of pain on short-term outcomes. METHOD Electronic databases were searched from inception to 1 May 2021. We included interventional studies of adults with any indication for pelvic exenteration surgery that also reported pain outcomes. Risk of bias was assessed using ROBINS-1. RESULTS The search found 21 studies that reported pain following pelvic exenteration [n = 1317 patients, mean age 58.4 years (SD 4.8)]. Ten studies were judged to be at moderate risk of bias. Before pelvic exenteration, pain was reported by 19%-100% of patients. Five studies used validated measures of pain intensity. No study measured pain at all three time points in the surgical journey. The presence of pain before surgery predicted postoperative adverse pain outcomes, and pain is more likely to be experienced in those who require wider resections, including bone resection. CONCLUSION Considering that pain following pelvic exenteration is commonly described by patients, the literature suggests that this symptom is not being measured and therefore addressed.
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Affiliation(s)
- Charlotte S H Johnstone
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Roberts
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Hospital Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Hospital Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Hospital Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Camperdown, New South Wales, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
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16
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Johnstone CS, Koh CE, Britton GJ, Solomon MJ, McLachlan AJ. Implementation of a peri-operative pain-management algorithm reduces the use of opioid analgesia following pelvic exenteration surgery. Colorectal Dis 2022; 25:631-639. [PMID: 36461690 DOI: 10.1111/codi.16442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 12/04/2022]
Abstract
AIM This study aimed to investigate the implementation and pain-related outcomes of a peri-operative pain-management regimen for patients undergoing pelvic exenteration surgery at a university teaching hospital. METHOD This is a single-site prospective observational cohort study involving 100 patients who underwent pelvic exenteration surgery between January 2017 and December 2018. A pain-management algorithm regarding the use of opioid-sparing multimodal analgesia was developed between the departments of anaesthesia, pain management and intensive care. The primary outcomes were: compliance with a pain-treatment algorithm compared with a similar retrospective surgical patient cohort in 2013-2014; and requirements for regular doses of opioid analgesia at discharge, measured in oral morphine equivalent daily dose (oMEDD). RESULTS Following the introduction of a pain-management algorithm, regional anaesthesia techniques (spinal anaesthesia, transversus abdominus plane block, preperitoneal catheters or epidural analgesia) were used in 83/98 (84.7%) of the 2017-2018 cohort compared with 13/73 (17.8%) of the 2013-2014 cohort (p < 0.001). There was a reduction in the median dose of opioid analgesics (oMEDD) at time of discharge, from 150 mg (interquartile range [IQR]: 75.0-235.0 mg) in the 2013-2014 cohort to 10 mg (IQR: 0.00-45.0 mg) in the 2017-2018 cohort (p < 0.001). There was no change in pain intensity (assessed using the Verbal Numerical Rating Score) or oMEDD in the first 7 days following surgery. CONCLUSION Since implementation of a novel peri-operative pain-treatment algorithm, the use of opioid-sparing regional techniques and preperitoneal catheters has increased. Additionally, the dose of opioids required at the time of discharge has reduced significantly.
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Affiliation(s)
- Charlotte S Johnstone
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District & University of Sydney, Sydney, New South Wales, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District & University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery. Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Gregory J Britton
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District & University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery. Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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17
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Sutton PA, Brown KGM, Ebrahimi N, Solomon MJ, Austin KKS, Lee PJ. Long-term surgical complications following pelvic exenteration: Operative management of the empty pelvis syndrome. Colorectal Dis 2022; 24:1491-1497. [PMID: 35766998 DOI: 10.1111/codi.16238] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 01/07/2023]
Abstract
AIM Pelvic exenteration (PE) has become the standard of care for locally advanced and recurrent rectal cancer. The high short-term morbidity reported from this procedure is well established; however, longer term complications of such radical surgery and their management have not been fully addressed. This study aimed to investigate the incidence, indications and outcomes of long-term (more than 90-day) reoperative surgery in this group of patients, with a focus on the empty pelvis syndrome (EPS). METHODS Clinical data were extracted from a prospectively maintained database, with additional data pertaining to indications, operative details and outcomes of reoperative surgery obtained from electronic medical records. Patients were excluded if reoperative surgery was endoscopic or radiologically guided, was for the investigation or treatment of recurrent disease, or was clearly unrelated to previous surgery. RESULTS Of 716 patients who underwent PE, 75 (11%) required 101 reoperative abdominal or perineal procedures, 52 (51%) of which were in 40 (6%) patients for complications of EPS. This group were more likely to have undergone a total PE (65% vs. 43%; P < 0.01) with either major bony (70% vs. 50%; P < 0.01) and/or nerve (40% vs. 25%; P = 0.03) resections at index exenteration. The patho-anatomy, surgical management and outcomes of these patients are described herein, considering separately complications of entero-cutaneous fistula, entero-perineal fistula, small bowel obstruction and local management of perineal wound complications. CONCLUSION Six per cent of PE patients will require re-intervention for the management of EPS. Reliable strategies for preventing EPS remain elusive; however, surgical management is feasible with acceptable short-term outcomes with the optimum strategy to be selected on an individual patient basis.
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Affiliation(s)
- Paul A Sutton
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Colorectal and Peritoneal Oncology Centre, The Christie Hospital, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Nargus Ebrahimi
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia
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18
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Fahy MR, Hayes C, Kelly ME, Winter DC. Updated systematic review of the approach to pelvic exenteration for locally advanced primary rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2284-2291. [PMID: 35031157 DOI: 10.1016/j.ejso.2021.12.471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/23/2021] [Accepted: 12/29/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To review the evidence regarding surgical advances in the management of primary locally advanced rectal cancer. BACKGROUND The management of rectal cancer has evolved significantly in recent decades, with improved (neo)adjuvant treatment strategies and enhanced perioperative protocols. Centralization of care for complex, advanced cases has enabled surgeons in these units to undertake more ambitious surgical procedures. METHODS A Pubmed, Ovid, Embase and Cochrane database search was conducted according to the predetermined search strategy. The review protocol was prospectively registered with PROSPERO (CRD42021245582). RESULTS 14 studies were identified which reported on the outcomes of 3,188 patients who underwent pelvic exenteration (PE) for primary rectal cancer. 50% of patients had neoadjuvant radiotherapy. 24.2% underwent flap reconstruction, 9.4% required a bony resection and 34 patients underwent a major vascular excision. 73.9% achieved R0 resection, with 33.1% experiencing a major complication. Median length of hospital stay ranged from 13 to 19 days. 1.6% of patients died within 30 days of their operation. Five-year overall survival (OS) rates ranged 29%-78%. LIMITATIONS The studies included in our review were mostly single-centre observational studies published prior to the introduction of modern neoadjuvant treatment regimens. It was not possible to perform a meta-analysis on the basis that most were non-randomized, non-comparative studies. CONCLUSIONS Pelvic exenteration offers patients with locally advanced rectal cancer the chance of long-term survival with acceptable levels of morbidity. Increased experience facilitates more radical procedures, with the introduction of new platforms and/or reconstructive options.
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Affiliation(s)
- Matthew R Fahy
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland.
| | - Cathal Hayes
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
| | - Michael E Kelly
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
| | - Desmond C Winter
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
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19
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Khaw CW, Ebrahimi N, Lee P, McCarthy ASE, Solomon M. Long-term results of mesh pelvic floor reconstruction to address the empty pelvis syndrome. Colorectal Dis 2022; 24:1211-1215. [PMID: 35652246 DOI: 10.1111/codi.16203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/28/2022] [Accepted: 05/22/2022] [Indexed: 02/08/2023]
Abstract
AIM As the "empty pelvis syndrome" continues to pose challenges in patients undergoing radical pelvic exenteration, there remains an ongoing need to consider solutions to mitigate or avoid its associated morbidity. As such, this study aims to review the long-term outcomes of a proposed strategy of pelvic reconstruction with BioA mesh. METHOD We conducted a retrospective observational cohort study, reviewing cases of pelvic exenteration and/or pelvic bone resection involving BioA mesh pelvic reconstruction between 2017 and 2021 at our quaternary institution, identified from a prospectively collected database. The primary outcome was pelvic complications including perineal fistula, wound breakdown and pelvic collections. RESULTS Over a 4-year period, there were a total of 36 patients who had pelvic exenteration and/or pelvic bone resection with BioA mesh pelvic reconstruction. The overall pelvic complication rate was 36% (n = 13), including 11 symptomatic pelvic collections, two enteroperineal fistulas, and no cases of perineal hernia. Reoperation was required in two patients. There was no perioperative mortality. CONCLUSION Given that pelvic complications post BioA mesh reconstruction are of an acceptable rate and can be considered minor, using this technique is a safe and practical strategy in patients undergoing major pelvic surgery with or without pelvic bone resection.
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Affiliation(s)
- Chern Wern Khaw
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Nargus Ebrahimi
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Peter Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Alexander S E McCarthy
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
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20
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Traeger L, Bedrikovetski S, Oehler MK, Cho J, Wagstaff M, Harbison J, Lewis M, Vather R, Sammour T. Short-term outcomes following development of a dedicated pelvic exenteration service in a tertiary centre. ANZ J Surg 2022; 92:2620-2627. [PMID: 35866328 PMCID: PMC9795898 DOI: 10.1111/ans.17921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/05/2022] [Accepted: 07/08/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pelvic exenteration surgery (PE) offers potentially curative resection for locally advanced malignancy but is associated with significant complexity and morbidity. Specialised teams are recommended to achieve optimal patient outcomes. This study aims to analyse short-term outcomes at a tertiary setting before and after creating a dedicated PE service. METHODS Patients undergoing PE between 2008 and October 2021 at the Royal Adelaide Hospital and St. Andrews Hospital in South Australia were included, with prospective data collection since June 2017. Patients operated on prior and post the creation of the PE service were compared via univariate analyses. RESULTS In total, 113 patients were included, with a significant increase in volume of cases post creation of the PE service, (n = 46 pre versus n = 67 post). There were significant differences in the type of neoadjuvant therapy and patient co-morbidity, with more advanced disease stage and a higher likelihood of bone involvement (P < 0.05) in the latter period. An increased proportion of patients had flap reconstruction (40.3 versus 33.9%, P = 0.010) as well as lateral lymph node dissection (13.4 versus 2.2%, P = 0.046). Despite this, peri-operative outcomes such as urosepsis (11.9 versus 28.3%, P = 0.028) and Clavien-Dindo grade of complications grade improved. R0 resections were achieved in 93.9% of curative cases (93.9 versus 84.2%, P = 0.171). CONCLUSION The development of a PE service significantly improved short term patient outcomes, despite the inclusion of patients with more advanced disease and comorbidity.
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Affiliation(s)
- Luke Traeger
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Martin K. Oehler
- Department of Gynaecological OncologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Jonathan Cho
- Urology Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Marcus Wagstaff
- Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia,Department of Plastic and Reconstructive SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Jack Harbison
- Department of Plastic and Reconstructive SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Mark Lewis
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Ryash Vather
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Tarik Sammour
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
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21
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Ng KS, Lee PJ. Pelvic exenteration: Pre-, intra-, and post-operative considerations. Surg Oncol 2022. [DOI: 10.1016/j.suronc.2022.101787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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22
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Dinger TL, Kroon HM, Traeger L, Bedrikovetski S, Hunter A, Sammour T. Regional variance in treatment and outcomes of locally invasive (T4) rectal cancer in Australia and New Zealand: analysis of the Bi-National Colorectal Cancer Audit. ANZ J Surg 2022; 92:1772-1780. [PMID: 35502647 PMCID: PMC9541368 DOI: 10.1111/ans.17699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/05/2022] [Accepted: 03/30/2022] [Indexed: 12/09/2022]
Abstract
Backgrounds Locally invasive T4 rectal cancer often requires neoadjuvant treatment followed by multi‐visceral surgery to achieve a radical resection (R0), and referral to a specialized exenteration quaternary centre is typically recommended. The aim of this study was to explore regional variance in treatment and outcomes of patients with locally advanced rectal cancer in Australia and New Zealand (ANZ). Methods Data were collected from the Bi‐National Colorectal Cancer Audit (BCCA) database. Rectal cancer patients treated between 2007 and 2019 were divided into six groups based on region (state/country) using patient postcode. A subset analysis of patients with T4 cancer was performed. Primary outcomes were positive circumferential resection margin (CRM+), and positive circumferential and/or distal resection margin (CRM/DRM+). Results A total of 9385 patients with rectal cancer were identified, with an overall CRM+ rate of 6.4% and CRM/DRM+ rate of 8.6%. There were 1350 patients with T4 rectal cancer (14.4%). For these patients, CRM+ rate was 18.5%, and CRM/DRM+ rate was 24.1%. Significant regional variation in CRM+ (range 13.4–26.0%; p = 0.025) and CRM/DRM+ rates (range 16.1–29.3%; p = 0.005) was identified. In addition, regions with higher CRM+ and CRM/DRM+ rates reported lower rates of multi‐visceral resections: range 24.3–26.8%, versus 32.6–37.3% for regions with lower CRM+ and CRM/DRM+ rates (p < 0.0001). Conclusion Positive resection margins and rates of multi‐visceral resection vary between the different regions of ANZ. A small subset of patients with T4 rectal cancer are particularly at risk, further supporting the concept of referral to specialized exenteration centres for potentially curative multi‐visceral resection.
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Affiliation(s)
- Tessa L Dinger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Medical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Luke Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Hunter
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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23
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Steffens D, Young J, Riedel B, Morton R, Denehy L, Heriot A, Koh C, Li Q, Bauman A, Sandroussi C, Ismail H, Dieng M, Ansari N, Pillinger N, O'Shannassy S, McKeown S, Cunningham D, Sheehan K, Iori G, Bartyn J, Solomon M. PRehabIlitatiOn with pReoperatIve exercise and educaTion for patients undergoing major abdominal cancer surgerY: protocol for a multicentre randomised controlled TRIAL (PRIORITY TRIAL). BMC Cancer 2022; 22:443. [PMID: 35459100 PMCID: PMC9026022 DOI: 10.1186/s12885-022-09492-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 04/06/2022] [Indexed: 12/12/2022] Open
Abstract
Background Radical surgery is the mainstream treatment for patients presenting with advanced primary or recurrent gastrointestinal cancers; however, the rate of postoperative complications is exceptionally high. The current evidence suggests that improving patients’ fitness during the preoperative period may enhance postoperative recovery. Thus, the primary aim of this study is to establish the effectiveness of prehabilitation with a progressive, individualised, preoperative exercise and education program compared to usual care alone in reducing the proportion of patients with postoperative in-hospital complications. The secondary aims are to investigate the effectiveness of the preoperative intervention on reducing the length of intensive care unit and hospital stay, improving quality of life and morbidity, and reducing costs. Methods This is a multi-centre, assessor-blinded, pragmatic, comparative, randomised controlled trial. A total of 172 patients undergoing pelvic exenteration, cytoreductive surgery, oesophagectomy, hepatectomy, gastrectomy or pancreatectomy will be recruited. Participants will be randomly allocated to prehabilitation with a preoperative exercise and education program (intervention group), delivered over 4 to 8 weeks before surgery by community physiotherapists/exercise physiologists, or usual care alone (control group). The intervention will comprise 12 to 24 individualised, progressive exercise sessions (including aerobic/anaerobic, resistance, and respiratory exercises), recommendations of home exercises (16 to 32 sessions), and daily incidental physical activity advice. Outcome measures will be collected at baseline, the week prior to surgery, during the hospital stay, and on the day of discharge from hospital, and 1 month and 1 months postoperatively. The primary outcome will be the development of in-hospital complications. Secondary outcomes include the length of intensive care unit and hospital stay, quality of life, postoperative morbidity and costs. Discussion The successful completion of this trial will provide robust and high-quality evidence on the efficacy of a preoperative community- and home-based exercise and education intervention on important postoperative outcomes of patients undergoing major gastrointestinal cancer surgery. Trial registration This trial was registered prospectively with the Australian New Zealand Clinical Trials Registry (ACTRN12621000617864) on 24th May 2021.
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Affiliation(s)
- Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia. .,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.
| | - Jane Young
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre and the Department of Critical Care, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Rachael Morton
- Department of Health Economics & Health Technology Assessment, NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Linda Denehy
- Melbourne School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Qiang Li
- Statistics Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Adrian Bauman
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Charbel Sandroussi
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Hilmy Ismail
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre and the Department of Critical Care, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Mbathio Dieng
- Department of Health Economics & Health Technology Assessment, NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Nabila Ansari
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Neil Pillinger
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Sarah O'Shannassy
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Sam McKeown
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre and the Department of Critical Care, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Kym Sheehan
- Cancer Voices NSW, Sydney, New South Wales, Australia
| | - Gino Iori
- Cancer Voices NSW, Sydney, New South Wales, Australia
| | - Jenna Bartyn
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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24
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Denys A, van Nieuwenhove Y, Van de Putte D, Pape E, Pattyn P, Ceelen W, van Ramshorst GH. Patient-reported outcomes after pelvic exenteration for colorectal cancer: A systematic review. Colorectal Dis 2022; 24:353-368. [PMID: 34941002 DOI: 10.1111/codi.16028] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/15/2021] [Accepted: 12/14/2021] [Indexed: 12/15/2022]
Abstract
AIM Pelvic exenteration (PE) carries high morbidity. Our aim was to analyse the use of patient-reported outcome measures (PROMs) in PE patients. METHOD Search strategies were protocolized and registered in PROSPERO. PubMed, Embase, Cochrane Library, Google Scholar, Web of Science and ClinicalTrials.gov were searched with the terms 'patient reported outcomes', 'pelvic exenteration' and 'colorectal cancer'. Studies published after 1980 reporting on PROMs for at least 10 PE patients were considered. Study selection, data extraction, rating of certainty of evidence (GRADE) and risk of bias (ROBINS-I) were performed independently by two reviewers. RESULTS Nineteen of 173 studies were included (13 retrospective, six prospective). All studies were low to very low quality, with an overall moderate/serious risk of bias. Studies included data on 878 patients with locally advanced rectal cancer (n = 344), recurrent rectal cancer (n = 411) or cancer of unknown type (n = 123). Thirteen studies used validated questionnaires, four used non-validated measures and two used both. Questionnaires included the Functional Assessment of Cancer Therapy-Colorectal questionnaire (n = 6), Short Form Health Survey (n = 6), European Organization for Research and Treatment for Cancer (EORTC) Quality of Life Questionnaire C30 (n = 6), EORTC-CR38 (n = 4), EORTC-BLM30 (n = 1), Brief Pain Inventory (n = 2), Short Form 12 (n = 1), Assessment of Quality of Life (n = 1), Short Form Six-Dimension (n = 1), the Memorial Sloan Kettering Cancer Center Sphincter Function Scale (n = 1), the Cleveland Global Quality of Life (n = 1) or other (n = 4). Timing varied between studies. CONCLUSIONS Whilst the use of validated questionnaires increased over time, this study shows that there is a need for uniform use and timing of PROMs to enable multicentre studies.
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Affiliation(s)
- Andreas Denys
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Yves van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Dirk Van de Putte
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Eva Pape
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
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25
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Akhtanin EA, Markov PV, Goev AA, Struchkov VY, Arutyunov HR, Martirosyan TA, Shukurov KU. External Small Intestine Fistula as a Rare Complication of Total Infralevatory Pelvic Evisceration. JOURNAL OF BIOCHEMICAL TECHNOLOGY 2022. [DOI: 10.51847/5rzzrebp7j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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26
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Pleth Nielsen CK, Sørensen MM, Christensen HK, Funder JA. Complications and survival after total pelvic exenteration. Eur J Surg Oncol 2022; 48:1362-1367. [PMID: 34998633 DOI: 10.1016/j.ejso.2021.12.472] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/26/2021] [Accepted: 12/29/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pelvic exenteration is a procedure with high morbidity despite careful patient selection. This study investigates potential associations between perioperative markers and major postoperative complications including survival. METHODS Retrospectively collected data for 195 consecutive patients who underwent total pelvic exenteration (January 2015-February 2020) at a single tertiary university hospital were analyzed. RESULTS The 30-day mortality was 0.5%, and the rate of major postoperative complications (≥3 Clavien-Dindo) was 34.5%. Low albumin level (p = 0.02) and blood transfusion (p = 0.02) were significantly correlated with a major postoperative complication in univariate analyses. This had no impact on survival. Positive margins (p = 0.003), liver metastasis (p = 0.001) were related to poor survival in multivariate analyses for colorectal patients. A Charlson Comorbidity Index >6 (p < 0.05) was associated with poor survival in all patients. CONCLUSION The occurrence of major postoperative complication does not negatively impact the overall survival. Pelvic exenteration is a potential life-prolonging operation when negative margins can be obtained, despite known risks for complications. Comorbidity is a predictor for inferior outcomes.
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27
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Garipov MR, Moskalenko AN, Cherepanova EV, Ayupov RT, Feoktistov DV, Tarasov NA, Lyadov VK, Galkin VN. [Fast track recovery protocols for extended pelvic surgery]. Khirurgiia (Mosk) 2022:59-65. [PMID: 36562674 DOI: 10.17116/hirurgia202212259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To compare the immediate results of extended pelvic surgery before and after introduction of standardized fast track surgery (FTS) protocol into routine clinical practice. MATERIAL AND METHODS The study included 111 patients with pelvic tumors who underwent extended pelvic surgery. The control group included 59 patients whose perioperative management implied traditional approaches (2018-2019), the main group - 52 patients with FTS protocol (2020-2021). Age, BMI and ECOG status were similar. In the main group, females (90.4% vs. 74.6%; p=0.046), patients with recurrent (46.2% vs. 22.0%; p=0.009) and complicated tumors (26.9% vs. 11.9%; p=0.054) prevailed. Obstructive resection without anastomosis was less common in the main group (28.8% vs. 47.5%; p=0.068). RESULTS Surgery time was higher (319±125 min vs. 236±79 min, p<0.001) in the main group, but blood loss (238±154 ml vs. 282±150 ml, p=0.029) and incidence of blood transfusions (23.1% vs. 42.4%, p=0.043) were lower. Moreover, complications (36.6% vs. 54.3%; p=0.086), mild complications (Clavien-Dindo class I-II) (11.6% vs. 28.8%; p=0.034) and local infectious complications (19.2% vs. 42.4%; p=0.009) were less common in the main group. Two patients died in the control group due to sepsis following colonic anastomosis and bladder suture failure, respectively. Postoperative hospital-stay was similar (14±9.1 days vs. 14.4±9 days; p=0.89). CONCLUSION FTS protocol is possible and safe in patients with locally advanced and recurrent malignant pelvic tumors. This approach reduces blood loss, the number of blood transfusions and risk of postoperative infections.
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Affiliation(s)
- M R Garipov
- City Clinical Oncology Hospital No. 1, Moscow, Russia
| | | | | | - R T Ayupov
- Republican Clinical Oncology Dispensary, Ufa, Russia
| | | | - N A Tarasov
- Republican Clinical Oncology Dispensary, Ufa, Russia
| | - V K Lyadov
- City Clinical Oncology Hospital No. 1, Moscow, Russia
| | - V N Galkin
- City Clinical Oncology Hospital No. 1, Moscow, Russia
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28
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The role of surgery in the palliation of advanced pelvic malignancy. Eur J Surg Oncol 2022; 48:2323-2329. [DOI: 10.1016/j.ejso.2022.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/23/2021] [Accepted: 01/18/2022] [Indexed: 11/20/2022] Open
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29
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Persson P, Chong P, Steele C, Quinn M. Prevention and management of complications in pelvic exenteration. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2277-2283. [DOI: 10.1016/j.ejso.2021.12.470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/29/2021] [Indexed: 11/17/2022]
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30
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Drami I, Lord AC, Sarmah P, Baker RP, Daniels IR, Boyle K, Griffiths B, Mohan HM, Jenkins JT. Preoperative assessment and optimisation for pelvic exenteration in locally advanced and recurrent rectal cancer: A review. Eur J Surg Oncol 2021; 48:2250-2257. [PMID: 34922810 DOI: 10.1016/j.ejso.2021.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 01/06/2023] Open
Abstract
The pre-operative phase in planning a pelvic exenteration or extended resections is critical to optimising patient outcomes. This review summarises the key components of preoperative assessment and planning in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LLRC) being considered for potential curative resection. The preoperative period can be considered in 5 key phases: 1) Multidisciplinary meeting (MDT) review and recommendation for neoadjuvant therapy and surgery, 2) Anaesthetic preoperative assessment of fitness for surgery and quantification of risk, 3) Shared decision making with the patient and the process of informed consent, 4) Prehabilitation and physiological optimisation 5) Technical aspects of surgical planning. This review will focus on patients who have been recommended for surgery by the MDT and have completed neoadjuvant therapy. Other important considerations beyond the scope of this review are the various neoadjuvant strategies employed which in this patient group include Total Neo-adjuvant Therapy and reirradiation. Critical to improving perioperative outcomes is the dual aim of achieving a negative resection margin in a patient fit enough for extended surgery. Advanced, realistic communication is required pre-operatively and should be maintained throughout recovery. Optimising patient's physiological and psychological reserve with a preoperative prehabilitation programme is important, with physiotherapy, psychological and nutritional input. From a surgical perspective, image based technical preoperative planning is important to identify risk points and ensure correct surgical strategy. Careful attention to the entire patient journey through these 5 preoperative phases can optimise outcomes with the accumulation of marginal gains at multiple timepoints.
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Affiliation(s)
- I Drami
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK.
| | - A C Lord
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P Sarmah
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - R P Baker
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - I R Daniels
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - K Boyle
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - B Griffiths
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - H M Mohan
- Dukes' Club, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - J T Jenkins
- Advanced Malignancy Subcommittee, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
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31
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Kazi M, Sukumar V, Desouza A, Saklani A. State-of-the-art surgery for recurrent and locally advanced rectal cancers. Langenbecks Arch Surg 2021; 406:1763-1774. [PMID: 34341869 DOI: 10.1007/s00423-021-02285-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023]
Abstract
Extended and beyond total mesorectal excisions (TME) for advanced and recurrent rectal cancers are increasingly performed with acceptable oncological and functional outcomes. These are undoubtedly due to better understanding of tumor biology and improved patient selection rather than surgical valor and technical refinements alone. In the present review, we attempt to present the current surgical standards for advanced and recurrent cancers requiring surgery outside the TME planes based on involved pelvic compartments. The available procedures, their indications, and extent of resection and reconstruction are highlighted. Emphasis is on formation of dedicated exenteration teams, structured training, and referral systems that increase hospital and surgeon volume to improve patient outcomes and reduce morbidity. Areas of deficiencies in literature were recognized with regards to factors influencing recurrences, patient selection, and quality of life. Finally, the most appropriate preoperative therapy for these tumors is unclear in both the primary and recurrent settings.
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Affiliation(s)
- Mufaddal Kazi
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Vivek Sukumar
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Ashwin Desouza
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Avanish Saklani
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India.
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32
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Solomon MJ, Däster S, Loizides S, Sutton P, Brown KGM, Austin KKS, Lee PJ. Access to the anterior pelvic compartment in pelvic exenteration in women-the interlabial approach: video vignette. Br J Surg 2021; 108:e268-e269. [PMID: 34291281 DOI: 10.1093/bjs/znab127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/21/2021] [Indexed: 02/02/2023]
Affiliation(s)
- M J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney Local Health District, University of Sydney, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - S Däster
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - S Loizides
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - P Sutton
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - K G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - K K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney Local Health District, University of Sydney, Sydney, New South Wales, Australia
| | - P J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney Local Health District, University of Sydney, Sydney, New South Wales, Australia
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33
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Harji D, Mauriac P, Bouyer B, Berard X, Gille O, Salut C, Rullier E, Celerier B, Robert G, Denost Q. The feasibility of implementing an enhanced recovery programme in patients undergoing pelvic exenteration. Eur J Surg Oncol 2021; 47:3194-3201. [PMID: 34736803 DOI: 10.1016/j.ejso.2021.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pelvic exenteration (PE) is a complex operative procedure, reserved for patients with locally advanced and recurrent pelvic malignancies. PE is associated with a high index of post-operative morbidity. Enhanced Recovery After Surgery (ERAS) programmes have been successful in improving postoperative outcomes, however, its application in PE has not been studied. The aim of our study is to assess the feasibility and short-term impact of ERAS on PE. METHODS A dedicated PE ERAS programme was developed reflecting the complexity of differing subtypes of PE. A prospective cohort study was undertaken to evaluate the feasibility of implementing our PE ERAS between 2016 and 2020. The primary endpoint of this study was overall compliance with the ERAS programme. RESULTS 145 patients were enrolled into our PE ERAS programme, with 86 (56.2%) patients undergoing a soft tissue PE, 27 (17.6%) a vascular PE and 32 (20.9%) a bony PE. The median overall compliance to the PE ERAS programme was 70% (IQR 55.5-88.8). There were no observed differences between overall compliance to the PE ERAS programme between different subtypes of PE (p = 0.60). Patients with higher compliance with the PE ERAS programme had a shorter LoS (p < 0.001), less post-operative morbidity (p < 0.001), reduced severity of Clavien-Dindo grade of morbidity (p < 0.001) and fewer readmissions (p = 0.03). CONCLUSIONS The principles of ERAS can be readily applied to patients undergoing PE, with high adherence to the ERAS programme associated with improved clinical outcomes.
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Affiliation(s)
- Deena Harji
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France
| | - Paul Mauriac
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
| | - Benjamin Bouyer
- Département de Chirurgie Rachidienne, Hôpital Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, CHU Bordeaux, France.
| | - Xavier Berard
- Département de Chirurgie Vasculaire, Hôpital Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, CHU Bordeaux, France
| | - Olivier Gille
- Département de Chirurgie Rachidienne, Hôpital Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, CHU Bordeaux, France.
| | - Cécile Salut
- Département D'imagerie Diagnostique et Interventionnelle, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
| | - Eric Rullier
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
| | - Bertrand Celerier
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
| | - Grégoire Robert
- Département D'urologie, Hôpital Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, CHU Bordeaux, France.
| | - Quentin Denost
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
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Gao Z, Gu J. Surgical treatment of locally recurrent rectal cancer: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1026. [PMID: 34277826 PMCID: PMC8267292 DOI: 10.21037/atm-21-2298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/02/2021] [Indexed: 12/12/2022]
Abstract
Objective To summarize the recent literature on surgical treatment of locally recurrent rectal cancer (LRRC). Background LRRC is a heterogeneous disease that requires a multidisciplinary treatment approach. The treatment and prognosis depend on the site and type of recurrence. Radical resection remains the primary method for achieving long-term survival and improving symptom control. Preoperative chemoradiotherapy can reduce tumor volume and improve the R0 resection rate. Surgeons must clearly understand pelvic anatomy, develop a detailed preoperative plan, adopt a multidisciplinary approach for the surgical resection of the tumor as well as any invaded soft tissues, vessels, and bones, and ensure proper reconstruction. However, extended radical surgery often leads to a higher risk of postoperative complications and a low quality of life. Methods We searched English-language articles with keywords “locally recurrent rectal cancer”, “surgery” and “multidisciplinary team” in PubMed published between January 2000 to October 2020. Conclusions LRRC is a complex problem. Long-term survival is not impossible following multidisciplinary treatment in appropriately selected LRRC patients. The management of LRRC relies on a specialist team that determines the biological behavior of the tumor and evaluates treatment options through multidisciplinary discussions, thereby balancing the surgical costs and benefits, alleviating postoperative complications, and improving patients’ quality of life.
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Affiliation(s)
- Zhaoya Gao
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Jin Gu
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China.,Department of Gastrointestinal Surgery III, Peking University Cancer Hospital, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing, China
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35
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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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36
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Solomon MJ. Redefining the boundaries of advanced pelvic oncology surgery. Br J Surg 2021; 108:453-455. [PMID: 33608731 DOI: 10.1093/bjs/znab047] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/20/2021] [Indexed: 12/15/2022]
Affiliation(s)
- M J Solomon
- Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
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37
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Steffens D, Young J, Beckenkamp PR, Ratcliffe J, Rubie F, Ansari N, Pillinger N, Koh C, Munoz PA, Solomon M. Feasibility and acceptability of a preoperative exercise program for patients undergoing major cancer surgery: results from a pilot randomized controlled trial. Pilot Feasibility Stud 2021; 7:27. [PMID: 33441181 PMCID: PMC7805142 DOI: 10.1186/s40814-021-00765-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 01/03/2021] [Indexed: 12/11/2022] Open
Abstract
Objective To establish the feasibility and acceptability of a preoperative exercise program, and to obtain pilot data on the likely difference in key surgical outcomes to inform the sample size calculation for a full-scale trial. Design Pilot randomized controlled trial. Setting Royal Prince Alfred Hospital, Sydney, Australia. Subjects We included patients undergoing elective pelvic exenteration or cytoreductive surgery aged 18 to 80 years, who presented to the participating gastrointestinal surgeon at least 2 weeks prior to surgery. Patients presenting cognitive impairment, co-morbidity preventing participation in exercise, inadequate English language, currently participating in an exercise program or unable to attend the exercise program sessions were excluded. Methods Participants were randomized to a 2–6 weeks preoperative, face-to-face, individualised exercise program or to usual care. Feasibility was assessed with consent rates to the study, and for the intervention group, retention and adherence rates to the preoperative exercise program. Acceptability of the exercise program was assessed with a semi-structured questionnaire exploring the advice received and the amount, duration and intensity of the exercise program. In addition, postoperative complication rates (Clavien-Dindo), length of hospital stay and self-reported measures of health-related quality of life (SF-36v2) were collected at baseline, day before surgery and in-hospital up to discharge from hospital. Results Of 122 patients screened, 26 (21%) were eligible and 22 (85%) accepted to participate in the trial and were randomized to the intervention (11; 50%) or control group (11; 50%). The median age of the include participants was 63 years. Adherence to the preoperative exercise sessions was 92.7%, with all participants either satisfied (33%) or extremely satisfied (67%) with the overall design of the preoperative exercise program. No significant differences in outcomes were found between groups. Conclusions The results of our pilot trial demonstrate that a preoperative exercise program is feasible and acceptable to patients undergoing major abdominal cancer surgery. There is an urgent need for a definite trial investigating the effectiveness of a preoperative exercise program on postoperative outcomes in patients undergoing major abdominal cancer surgery. This could potentially reduce postoperative complication rates, length of hospital stay and subsequently overall health care costs. Trial registration ACTRN12617001129370. Registered on August 1, 2017, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373396&showOriginal=true&isReview=true Supplementary Information The online version contains supplementary material available at 10.1186/s40814-021-00765-8.
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Affiliation(s)
- Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Missenden Road, Camperdown, New South Wales, 2050, Australia. .,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Building 89, Leval 9, Missenden Road, Camperdown, New South Wales, 2006, Australia.
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Missenden Road, Camperdown, New South Wales, 2050, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Building 89, Leval 9, Missenden Road, Camperdown, New South Wales, 2006, Australia.,Institiute of Academic Surgery (IAS), Royal Prince Alfred Hospital, 145-147 Missenden Road, Camperdown, New South Wales, 2050, Australia
| | - Paula R Beckenkamp
- Faculty of Medicine and Health, School of Health Sciences, The University of Sydney, Lidcombe, New South Wales, 2141, Australia
| | - James Ratcliffe
- Department of Physiotherapy, Royal Prince Alfred Hospital, Camperdown, New South Wales, 2006, Australia
| | - Freya Rubie
- Department of Physiotherapy, Royal Prince Alfred Hospital, Camperdown, New South Wales, 2006, Australia
| | - Nabila Ansari
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Missenden Road, Camperdown, New South Wales, 2050, Australia
| | - Neil Pillinger
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Building 89, Leval 9, Missenden Road, Camperdown, New South Wales, 2006, Australia.,Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, 2006, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Missenden Road, Camperdown, New South Wales, 2050, Australia
| | - Phillip A Munoz
- Faculty of Medicine and Health, School of Health Sciences, The University of Sydney, Lidcombe, New South Wales, 2141, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, 2006, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Missenden Road, Camperdown, New South Wales, 2050, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Building 89, Leval 9, Missenden Road, Camperdown, New South Wales, 2006, Australia.,Institiute of Academic Surgery (IAS), Royal Prince Alfred Hospital, 145-147 Missenden Road, Camperdown, New South Wales, 2050, Australia
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Brown KG, Solomon MJ. Decision making, treatment planning and technical considerations in patients undergoing surgery for locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Doussot A, Vernerey D, Rullier E, Lefevre JH, Meillat H, Cotte E, Piessen G, Tuech JJ, Panis Y, Mege D, Meurisse A, De Bari B, Heyd B, Lakkis Z. Surgical Management and Outcomes of Rectal Cancer with Synchronous Prostate Cancer: A Multicenter Experience from the GRECCAR Group. Ann Surg Oncol 2020; 27:4286-4293. [PMID: 32500342 DOI: 10.1245/s10434-020-08683-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Synchronous prostate cancer (PC) and rectal cancer (RC) is a rare clinical situation. While combining curative-intent management for both cancers can be challenging, available data for guiding the multidisciplinary strategy are lacking. METHODS Consecutive patients undergoing rectal resection for a mid-low RC with synchronous PC treated at 9 tertiary-care centers between 2008 and 2018 were included. Management strategy and data on postoperative and long-term outcomes were retrospectively analyzed. RESULTS Overall, 25 patients underwent curative-intent RC resection combined with PC management. Nine (36%), 10 (40%) and 6 (24%) patients had low-, intermediate-, and high-risk PC, respectively. Management mostly consisted of chemoradiotherapy combined in 18 patients (72%) with either TME in 12 patients or pelvic exenteration for resection of both cancers in 6 patients. Most patients underwent RC resection using a laparoscopic approach (n = 16, 64%). Anastomosis was performed in 18 patients (72%) of whom 13 received diverting ileostomy. The complete R0 resection rate was 96% (n = 24). The overall morbidity rate was 64% (n = 16) and 5 patients (20%) experienced severe surgical morbidity of which two died within 90 days of surgery after pelvic exenteration. Among patients with anastomosis, 2 patients (11%) experienced anastomotic leak requiring surgical management. After a median follow-up of 31.2 months, 3-year OS and RFS were 80.2% (CI 95% 58.8-92.2) and 68.6% (CI 95% 42.3-84.8), respectively. CONCLUSIONS This series is the largest to report that simultaneous curative-intent management of synchronous PC and RC is feasible and safe. Pelvic exenteration might be a better option when RC complete resection seems not achievable through TME.
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Affiliation(s)
- Alexandre Doussot
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, Besançon Cedex, France
| | - Dewi Vernerey
- Methodological and Quality of Life Unit in Oncology, University Hospital of Besançon, Besançon, France
| | - Eric Rullier
- Department of Colorectal Surgery, Haut-Lévèque Hospital, Pessac, France
| | - Jérémie H Lefevre
- Department of Digestive Surgery, AP-HP, Hôpital Saint Antoine, Sorbonne Université, Paris, France
| | - Hélène Meillat
- Department of Digestive Surgical Oncology, Department of Mini Invasive Interventions (DIMI), Paoli Calmettes Institute, Marseille, France
| | - Eddy Cotte
- Department of Digestive and Oncological Surgery, Lyon Sud University Hospital, Pierre Bénite, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Clichy, France
| | - Diane Mege
- Department of Digestive and General Surgery, Timone Hospital, Marseille, France
| | - Aurélia Meurisse
- Methodological and Quality of Life Unit in Oncology, University Hospital of Besançon, Besançon, France
| | - Berardino De Bari
- Department of Radiotherapy, University Hospital of Besançon, Besançon, France.,Department of Radiotherapy, University Hospital of Lausanne, Lausanne, Switzerland
| | - Bruno Heyd
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, Besançon Cedex, France
| | - Zaher Lakkis
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, Besançon Cedex, France.
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40
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Solomon MJ, Brown KGM. Extended Radical Resection: The Standard of Care for Patients with Advanced Pelvic Malignancy. Ann Surg Oncol 2020; 27:323-324. [DOI: 10.1245/s10434-019-07817-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Indexed: 08/30/2023]
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