Rectal washout with cytotoxic solution can be extended to the whole colon

Intraoperative esophageal washout reduces free intraluminal tumor cells during resection of carcinomas of the esophagus and cardia

OBJECTIVE

Intraluminally shed viable tumor cells might contribute to anastomotic recurrence in cancer of the esophagus and the cardia. The study aimed to establish a method of esophageal washout and, hence, to reduce intraluminal cancer cells before esophageal anastomosis.

METHODS

Forty-eight consecutive patients with esophago-gastric resection for histologically proven cancer of the esophagus or the cardia were included in a prospective, interventional study. Before transection, the esophagus was clamped proximally to the tumor and rinsed with 1:10 diluted povidone-iodine-solution (10 × 30 ml) applied by a transorally inserted 24F-Foley catheter. The first, fifth and tenth portion of the lavage fluid were sent to cytological examination.

RESULTS

Intraoperative frozen sections confirmed clear proximal resection margins of the esophagus. The cytological examination of the fluid recovered from the esophageal washout revealed malignant cells in 13/48 patients (27%). The presence of malignant cells was significantly less likely in patients with neoadjuvant treatment than in patients without neoadjuvant treatment: 2/23 (9%) vs. 11/25 (44%) (p = 0.009). Repetitive washout reduced the probability of detectable malignant cells from 13 to 8 (62%) patients after 5, and further to 4 patients (30%) after 10 washout maneuvers.

CONCLUSIONS

Free malignant cells may be present in the esophageal lumen following intraoperative manipulation of cancers of the esophagus or cardia. Transoral washout of the esophagus is novel, feasible and enables reduction or even elimination of these tumor cells. The reliability of this procedure raises with increasing washout volume. Esophageal washout might be especially worthwhile in patients who do not receive neoadjuvant therapy.

Extent of intraluminal exfoliated malignant cells during surgery for colon cancer: Differences in cell abundance ratio between laparoscopic and open surgery

INTRODUCTION

Laparoscopic colectomy with intracorporeal anastomosis is a minimally invasive surgical procedure for patients with colon cancer. However, there are often concerns about the presence of intraluminal exfoliated malignant cells in the intracorporeal anastomosis. This study investigated the relationship between colon cancer surgery and the incidence of intraluminal exfoliated malignant cells and several factors.

METHODS

Eighty-nine consecutive patients who underwent either laparoscopic or open colectomy were prospectively studied in our department between 2007 and 2011. Before anastomosis, the proximal and distal lumens were irrigated with normal saline and subjected to cytological examination.

RESULTS

In 27 patients (30.3%), exfoliated cancer cells were detected. On the distal side, the frequency of positive cytology findings of exfoliated malignant cells was significantly lower in the laparoscopic colectomy group than in the open colectomy group (P = 0.01). In the laparoscopic colectomy group, there were no cases of positive cytology findings for exfoliated malignant cells more than 100 mm from the primary tumor. The incidence of positive cytology more than 100 mm from the primary tumor was significantly lower than the incidence of positive cytology less than 100 mm from the primary tumor (P = 0.04).

CONCLUSIONS

Exfoliated malignant cells were detected at anastomosis sites in patients with colon cancer. On the distal side, laparoscopic colectomy may prevent the development of exfoliated malignant cells.

Peritoneal lavage with povidone-iodine solution in colorectal cancer-induced rats

BACKGROUND

Although peritoneal lavage with povidone-iodine (PVPI) is frequently performed after surgery on the gastrointestinal tract, the effects of PVPI on the intestinal epithelial barrier are unknown. The purpose of this study was to investigate the effects of abdominal irrigation with PVPI on the intestinal epithelial barrier in a colorectal cancer (CRC)-induced rat model.

MATERIALS AND METHODS

The CRC model was induced in rats with azoxymethane and dextran sodium sulfate. Next, a total of 24 male CRC-induced rats were randomly divided into three groups (n = 8): (1) a sham-operated group, (2) an NS group (peritoneal lavage 0.9% NaCl), and (3) a PVPI group (peritoneal lavage with 0.45%-0.55% PVPI). The mean arterial pressure was continuously monitored throughout the experiment. The levels of plasma endotoxin and D-lactate, blood gases, and protein concentration were measured. The ultrastructural changes of the epithelial tight junctions were observed by transmission electron microscopy.

RESULTS

The mean arterial pressure after peritoneal lavage was lower in the PVPI group than that in the NS group. The protein concentration and levels of endotoxin and D-lactate were higher in the PVPI group than they were in the PVPI group. In addition, PVPI treatment resulted in a markedly severe metabolic acidosis and intestinal mucosal injury compared with NS rats.

CONCLUSIONS

Peritoneal lavage with PVPI dramatically compromises the integrity of the intestinal mucosa barrier and causes endotoxin shock in CRC rats. It is unsafe for clinical applications to include peritoneal lavage with PVPI in colorectal operations.

Anastomotic recurrence of colon cancer: Genetic analysis challenges the widely held theories of cancerous cells' intraluminal implantation and metachronous carcinogenesis

BACKGROUND AND OBJECTIVES

Anastomotic recurrence (AR), whose etiopathogenesis is attributed to intraluminal implantation of cancerous cells or metachronous carcinogenesis, is a major issue for patients undergoing colon cancer (CC) resection. The objective of the study is to throw some light on AR etiopathogenesis and to identify risk factors of AR in selecting patients to undergo early endoscopy.

METHODS

An analysis of clinical and histopathological parameters, including MSI and LOH of seven sites (Myc-L, BAT26, BAT40, D5S346, D18S452, D18S64, D16S402) was performed in primary CC and AR of 18 patients. They were then compared to 36 controls not developing AR.

RESULTS

A genetic instability was present in 16/18 patients, with distinct genetic patterns between primaries and ARs. LOH at 5q21 and/or 18p11.23 were found in both primary and AR in >50% of cases, but this rate was no different from control population. CEA resulted as associated with AR (P = 0.03), whereas N status presented a borderline result (P = 0.08).

CONCLUSIONS

Our findings challenge present theories about AR development. No "genetic marker" has been found. CEA and, to a lesser extent, N status, appear associated with AR. Rectal washout is seemingly meaningless. Iterative resection should be recommended since a long survival may be expected. J. Surg. Oncol. 2016;114:228-236. © 2016 Wiley Periodicals, Inc.

Isolated repeated anastomotic recurrence after sigmoidectomy

Repeated anastomotic recurrence (AR) of colonic cancer is uncommon. We report a case of a double-isolated AR after sigmoidectomy. In 2003, a 60-year-old woman underwent stapled sigmoid resection for a moderately differentiated adenocarcinoma. Further rectal bleeding occurred after six months, and colonoscopy detected an AR. Thus, an additional stapled colorectal anastomosis was performed. Ten months later, a colonoscopy detected a circumferential AR that prompted the completion of a second colorectal resection, with a double-stapled colorectal anastomosis. Twenty-four hours after surgery, a massive pulmonary embolism occurred, and the patient died within a few hours. At present, only six cases of repeated isolated AR have been described. Repeated segmental colorectal resections are generally associated with a favourable prognosis, with a median survival rate of 45 mo (range, 13-132 mo). Repeated isolated ARs are rare, and segmental colorectal resections are generally associated with long-term disease-free survival.

Benefits of the povidone-iodine: simultaneously decrease risk of infection and tumor seeding after percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is a well-established enteral feeding modality in patients with oropharyngeal/esophageal cancer; however, these patients are at risk for two possible PEG-related complications. First, oropharyngeal organisms may be transported to the PEG stoma and thus increase the risk of peristomal infection. Second, oropharyngeal/esophageal cancer cells may adhere to the PEG tube and thus increase the risk of tumor seeding along the PEG tract. Because of its microbicidal and tumoricidal effects, povidone-iodine pretreatment of the PEG tube may decrease the risk of peristomal infection and tumor seeding associated with PEG insertion in patients with oropharyngeal/esophageal cancer. To test this hypothesis, we brushed povidone-iodine onto the outer surface of PEG tubes prior to insertion.

Evaluation of the presence of intraluminal cancer cells following rectal washout in rectal cancer surgery

BACKGROUND

The presence of intraluminal tumour cells in colorectal cancer is known, as is their ability to implant in colorectal anastomoses, causing perianastomotic tumour growth. There is no consensus as to the volume and agent to use for rectal washout. The purpose of this study was to assess the efficacy of our current routine for rectal washout in eliminating intraluminal tumour cells.

METHODS

Sixty consecutive patients undergoing low anterior resection or low Hartmann's procedure for rectal cancer at our unit were included. After the pelvic dissection was completed, the bowel was cross-clamped distal to the tumour and the prewashout sample (no. 1), was obtained by instilling 50 ml of saline and collecting the return fluid. A rectal washout followed using 500 ml of sterile water, 2 × 500 ml of 70 % ethanol and 500 ml of sterile water (sample no. 2-4) and the postwashout sample (no. 5) was obtained by using 50 ml of saline. The samples were examined and categorized as non-malignant or malignant at the Department of Pathology. The usual pathology report information was also assessed.

RESULTS

In 33 of the 60 patients, cancer cells were identified in the prewashout sample. The rectal washout eliminated intraluminal cancer cells in 30 of the 33 patients. All of the remaining 3 had a higher blood loss (p = 0.026) and a tendency towards more polypoidal tumours (p = 0.053).

CONCLUSIONS

A rectal washout volume larger than 2,000 ml might be necessary to eliminate all intraluminal tumour cells in total mesorectal excision for rectal cancer.

The effect of intraoperative rectal washout on local recurrence after rectal cancer surgery: a meta-analysis

BACKGROUND

Implantation of exfoliated cancer cells has been suggested as a possible mechanism of local recurrence at the site of colorectal anastomosis. Intraoperative rectal washout has been suggested to eliminate free cancer cells; however, there is no conclusive evidence of a beneficial effect of intraoperative rectal washout on local recurrence after anterior resection of rectal cancer.

METHODS

Studies published through February 2012 evaluating the impact of intraoperative rectal washout for local recurrence or positive cytology from donuts wash were identified by an electronic literature search. A meta-analysis was performed using the DerSimonian-Laird random-effects models to compute risk ratio (RR) along with 95% confidence intervals (CI).

RESULTS

Nine studies met the inclusion criteria, yielding a total of 5,395 patients. Eight studies evaluated overall local recurrence, including anastomotic recurrence, and five of the eight studies evaluated anastomotic recurrence separately. Two studies evaluated positive cytology from donuts wash. Local recurrence rate was 5.79% in the washout group and 10.05% in the no washout group-a difference that was statistically significant (RR = 0.57; 95% CI = 0.46-0.71; P < 0.00001). Rectal washout significantly reduced the risk of anastomotic recurrence (RR = 0.3; 95% CI = 0.12-0.71; P = 0.007). No influence of rectal washout was observed on positive cytology from donuts wash.

CONCLUSIONS

From the results of this meta-analysis, it may be justified to recommend intraoperative rectal washout to prevent local recurrence in rectal cancer surgery.

Colonic treatments and targets: issues and opportunities

The colon provides a plethora of therapeutic opportunities. There are multiple disease targets, drug molecules, and colon-specific delivery systems to be explored. Clinical studies highlight the potential for systemic delivery via the colon, and the emerging data on the levels of cell membrane transporters and metabolic enzymes along the gut could prove advantageous for this. Often efflux transporters and metabolic enzyme levels are lower in the colon, suggesting a potential for improved bioavailability of drug substrates at this site. The locoregional distribution of multiple metabolic enzymes (including cytochromes), efflux transporters (including P-glycoprotein and breast cancer resistance proteins), and influx transporters (including the solute carrier family) along the intestine is summarized. Local delivery to the colonic mucosa remains a valuable therapeutic option. New therapies that target inflammatory mediators could improve the treatment of inflammatory bowel disease, and old and new anticancer molecules could, when delivered topically, prove to be beneficial adjuncts to the current systemic or surgical treatments. New issues such as pharmacogenomics, chronotherapeutics, and the delivery of prebiotics and probiotics are also discussed in this review. Targeting drugs to the colon utilizes various strategies, each with their advantages and flaws. The most promising systems are considered in the light of the physiological data which influence their in vivo behavior.

Clinicopathological features of anastomotic recurrence after an anterior resection for rectal cancer

PURPOSE

Anastomotic recurrence after an anterior resection for rectal cancer has not been analyzed in detail in the era of total mesorectal excision. This study tried to clarify the characteristics of patients with anastomotic recurrence when compared to the pelvic recurrence.

METHODS

This study compared the clinicopathological data of 21 isolated recurrent patients that were treated between 1998 and 2007, including eight with anastomotic recurrence and 13 with pelvic recurrence.

RESULTS

The rate of positive serum carcinoembryonic antigen level at the time of recurrence is 0% in the anastomotic recurrence group and 85% in the pelvic recurrence group (p < 0.001). The clinical symptoms presented in 13% in the anastomotic recurrence group, in comparison to 69% in the pelvic recurrence group (p = 0.024). The median time from the initial resection until recurrence was 14 months in the anastomotic recurrence group, whereas it was 12 months in the pelvic recurrence group (p = 0.992). The survival rate of patients with anastomotic recurrence was higher than those with pelvic recurrence (p = 0.005).

CONCLUSION

A difference was observed in the serum carcinoembryonic antigen, clinical symptom, and survival between patients with anastomotic and pelvic recurrence. Furthermore, according to these results, we should pay attention to these clinical features in the follow-up period.

Benefits of povidone-iodine solution in colorectal operations: science or legend

Povidone-iodine solution (Betadine) has long been accepted as an effective topical broad spectrum antiseptic, disinfectant, and tumoricidal agent. In colorectal operations, this solution generally has been used for the purpose of minimizing postoperative septic complications and reducing cancer recurrence, although the optimal application, advantages, and undesirable side effects have been debated. With limited prospective, randomized, controlled trials and insufficient data available, this article examines the safe and effective clinical applications of this solution for colorectal operations.

Efeitos da injeção de solução bicarbonatada de ácido acetilsalicílico em mucosa colorretal de coelhos, com vistas a aplicação no preparo pré-operatório do cólon

INTRODUÇÃO: A recidiva local no câncer colorretal tem como principal causa o implante de células tumorais nas anastomoses. 11-15 Dessa maneira, lavagem química do lúmen intestinal é preconizada para evitar tanto o implante quanto à recidiva local. 11-28 Em estudos prévios constatamos que a solução bicarbonatada de ácido acetilsalicílico tem efeitos citolíticos e anti-tumorais in-vitro.31 OBJETIVOS: Avaliar a toxicidade da solução de aspirina na mucosa colônica de coelhos com o objetivo de usá-la no preparo intestinal de portadores de câncer colorretal. MATERIAIS E MÉTODOS: Foram utilizados 20 coelhos. Um clampe vascular foi colocado acima do cólon sigmóide. Os animais foram submetidos a um enema com 50 ml da solução de aspirina ou soro fisiológico de acordo com o grupo. Os animais foram sacrificados ao término do procedimento ou tardiamente de acordo com o grupo. RESULTADOS: A solução de aspirina não altera a mucosa colônica de coelhos. CONCLUSÃO: O uso da solução bicarbonatada de ácido acetilsalicílico no preparo intestinal de portadores de câncer colorretal é clinicamente possível.

Recurrence of colonic cancer twice at the site of stapled colorectal anastomosis

Recurrence at the site of a stapled anastomosis is generally believed to result from the luminal implantation of viable cancer cells during stapling. We report a case in which colon cancer recurred twice at the site of a stapled anastomosis, despite povidone iodine (PVP-I) lavage consisting of an enema with 5% PVP-I solution before the operation and intraoperative lavage of the rectal remnant and the descending colon with a 10% PVP-I solution. Three months after sigmoidectomy to resect a carcinoma of the sigmoid colon, a circular anastomotic recurrence was found at the suture line after anastomosis with a stapler. However, 11 months after the subsequent resection and reanastomosis to remove the first anastomotic recurrence, another anastomotic recurrence was found. We performed abdominoperineal resection for the second recurrence at the site of the stapled anastomosis. Suture-line recurrence could not be prevented in the present case despite lavage with a PVP-I solution for prophylaxis.

Surgical treatment of rectal cancer: radical resection

Currently, surgery is the only potentially curative treatment modality for rectal cancer. The major goals of surgery for rectal cancer are to optimize oncologic outcome and maintain anorectal and genitourinary function. This article reviews the surgical management of primary rectal cancer and discusses major surgical considerations in the treatment of this disease.

Efeito do uso de povidine-iodine na cicatrização de anastomoses de cólon direito de ratos

RACIONAL: Dados da literatura sugerem que, possivelmente, a lavagem intraluminar de segmentos do tubo digestivo com povidona-iodine antes da execução de uma anastomose poderia favorecer a cicatrização dessas anastomoses e prevenir a formação de aderências perianastomóticas, podendo ser útil se empregada em pacientes submetidos cirurgias do trato digestivo. OBJETIVO: Avaliar a eficácia da lavagem das bordas entéricas com povidona-iodine a 5% sobre a cicatrização do cólon direito de ratos. MATERIAL E MÉTODOS: Estudaram-se 20 ratos Wistar divididos nos seguintes grupos: A (n = 10), limpeza das bordas da ferida colônica com solução salina a 0,9%; B (n = 10), limpeza das bordas da ferida colônica com solução de povidona-iodine a 5%. Os animais foram submetidos a laparotomia, secção de 75% da circunferência do cólon, preservando 25% da borda mesentérica e tratamento das bordas a serem anastomosadas segundo o grupo descrito acima. Após a realização das anastomoses, os animais foram observados durante 7 dias e, no 7º dia pós-operatório, mortos. Foram coletadas amostras de sangue para dosagem da albumina sérica e feita análise macroscópica das anastomoses, observando-se presença de fístula, aderências e dilatação acima da anastomose. O segmento contendo a anastomose colônica foi retirado com 3 cm de cólon intacto em torno da anastomose e feita medida da pressão de ruptura. RESULTADOS: Não se observou presença de fístula em nenhum animal dos grupos estudados. Não houve diferença significativa em relação à presença de estenose da anastomose, aderências ou no valor da pressão de ruptura quando comparados os dois grupos. CONCLUSÃO: O emprego da povidona-iodine não resultou em aumento da resistência tênsil das anastomoses do cólon direito de ratos.