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Zanatto RM, Mucci S, Pinheiro RN, de Oliveira JC, Nicolau UR, Domezi JP, Silva DLE, Pracucho EM, Zanatto DO, Saad SS. Quality of life following pelvic exenteration in neoplasms. J Surg Oncol 2024. [PMID: 39076008 DOI: 10.1002/jso.27760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/25/2024] [Accepted: 06/02/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Pelvic exenteration (PE) is an extensive surgical treatment reserved for advanced or recurrent pelvic neoplasms, with potential impacts on patients' quality of life (QoL) poorly referenced in the literature. OBJECTIVES This study aimed to evaluate QoL outcomes among three types of PE. METHODS A cross-sectional study assessed 106 patients divided into anterior PE (APE), posterior PE (PPE), or total PE (TPE) groups. QoL was measured using e short form 36 version 2 (SF-36) and the European Organization for Research and Treatment of Cancer QoL Quality of Life Questionnaire Core 30 (QLQ-C30) QoL questionnaires. Descriptive and inferential analyses compared questionnaire scores. RESULTS The findings unveiled a balance among the three groups concerning demographic variables and comorbidities, with the exception of a male predominance in the APE and TPE cohorts. Notably, the APE group exhibited elevated scores in overall health (assessed via SF-36) and social functioning and diarrhea domains (assessed via QLQ-C30). Moreover, in terms of the fatigue and nausea/vomiting domains (assessed via QLQ-C30), the APE group demonstrated superior QoL compared to the PPE group. Conversely, the PPE group manifested a notably lower QoL in the constipation domain (assessed via QLQ-C30) compared to the other two groups. Additionally, disease recurrence was significantly associated with diminished QoL across multiple domains. CONCLUSION APE patients exhibited better QoL than PPE and TPE groups, with disease recurrence adversely affecting QoL.
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Affiliation(s)
- Renato Morato Zanatto
- Department of Surgical Oncology, Amaral Carvalho Cancer Hospital, Jaú, Brazil
- Interdisciplinary Surgical Science Postgraduate Program, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Samantha Mucci
- Department of Psychiatry, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Rodrigo N Pinheiro
- Department of Surgical Oncology, Federal District Base Hospital, Brasília, Brazil
| | | | | | - João Paulo Domezi
- Department of Surgical Oncology, Amaral Carvalho Cancer Hospital, Jaú, Brazil
| | - Dárcia Lima E Silva
- Department of Surgical Oncology, Amaral Carvalho Cancer Hospital, Jaú, Brazil
| | | | | | - Sarhan Sydney Saad
- Interdisciplinary Surgical Science Postgraduate Program, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
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Yatabe Y, Hanaoka M, Hanazawa R, Hirakawa A, Mukai T, Kimura K, Yamanoi K, Kono J, Yokota M, Takahashi H, Kobayashi A, Kobayashi K, Ichikawa N, Yasui M, Nakane K, Yamamoto M, Takenaka A, Nakamura Y, Takemasa I, Yabusaki N, Akamoto S, Tatarano S, Murata K, Manabe T, Fujimura T, Kawamura M, Egi H, Yamaguchi S, Terai Y, Inoue S, Ito A, Kinugasa Y. Robotic versus open and laparoscopic pelvic exenterations for pelvic cancer: a multicenter propensity-matched analysis in Japan. Surg Endosc 2024:10.1007/s00464-024-10966-w. [PMID: 38886231 DOI: 10.1007/s00464-024-10966-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 05/26/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors. METHODS Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias. RESULTS In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408 mL vs. 2385 ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002). CONCLUSION This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.
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Affiliation(s)
- Yusuke Yatabe
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Marie Hanaoka
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Ryoichi Hanazawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Toshiki Mukai
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kei Kimura
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Hyogo, Japan
| | - Koji Yamanoi
- Department of Gynecology and Obstetrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Jin Kono
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mitsuru Yokota
- Department of General Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Hiroki Takahashi
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | - Kenji Kobayashi
- Department of Gastroenterological Surgery, Kariya Toyota General Hospital, Aichi, Japan
| | - Nobuki Ichikawa
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Masayoshi Yasui
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Keita Nakane
- Department of Urology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Manabu Yamamoto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Atsushi Takenaka
- Division of Urology, Department of Surgery, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yuya Nakamura
- Department of Surgery, National Hospital Organization, Himeji Medical Center, Hyogo, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Hokkaido, Japan
| | | | | | - Shuichi Tatarano
- Department of Urology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kohei Murata
- Department of Surgery, Kansai Rosai Hospital, Hyogo, Japan
| | - Tatsuya Manabe
- Department of Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | | | - Mikio Kawamura
- Department of Gastrointestinal and Pediatric Surgery, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroyuki Egi
- Department of Gastrointestinal Surgery and Surgical Oncology, Ehime University Hospital, Ehime, Japan
| | - Shigeki Yamaguchi
- Division of Colorectal Surgery, Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshito Terai
- Department of Obstetrics and Gynecology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Shigetaka Inoue
- Department of Surgery, Fukuoka Red Cross Hospital, Fukuoka, Japan
| | - Akihiro Ito
- Department of Urology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yusuke Kinugasa
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45, Yushima, Bunkyo-ku, Tokyo, Japan.
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Abe S, Nozawa H, Sasaki K, Murono K, Emoto S, Yokoyama Y, Matsuzaki H, Nagai Y, Shinagawa T, Sonoda H, Ishihara S. Minimally invasive versus open multivisceral resection for rectal cancer clinically invading adjacent organs: a propensity score-matched analysis. Surg Endosc 2024; 38:3263-3272. [PMID: 38658387 PMCID: PMC11133092 DOI: 10.1007/s00464-024-10844-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Minimally invasive surgery (MIS), such as laparoscopic and robotic surgery for rectal cancer, is performed worldwide. However, limited information is available on the advantages of MIS over open surgery for multivisceral resection for cases clinically invading adjacent organs. PATIENTS AND METHODS This was a retrospective propensity score-matching study of consecutive clinical T4b rectal cancer patients who underwent curative intent surgery between 2006 and 2021 at the University of Tokyo Hospital. RESULTS Sixty-nine patients who underwent multivisceral resection were analyzed. Thirty-three patients underwent MIS (the MIS group), while 36 underwent open surgery (the open group). Twenty-three patients were matched to each group. Conversion was required in 2 patients who underwent MIS (8.7%). R0 resection was achieved in 87.0% and 91.3% of patients in the MIS and open groups, respectively. The MIS group had significantly less blood loss (170 vs. 1130 mL; p < 0.0001), fewer Clavien-Dindo grade ≥ 2 postoperative complications (30.4% vs. 65.2%; p = 0.0170), and a shorter postoperative hospital stay (20 vs. 26 days; p = 0.0269) than the open group. The 3-year cancer-specific survival rate, relapse-free survival rate, and cumulative incidence of local recurrence were 75.7, 35.9, and 13.9%, respectively, in the MIS group and 84.5, 45.4, and 27.1%, respectively, in the open group, which were not significantly different (p = 0.8462, 0.4344, and 0.2976, respectively). CONCLUSION MIS had several short-term advantages over open surgery, such as lower complication rates, faster recovery, and a shorter hospital stay, in rectal cancer patients who underwent multivisceral resection.
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Affiliation(s)
- Shinya Abe
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan.
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
| | - Koji Murono
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
| | - Yuichiro Yokoyama
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
| | - Hiroyuki Matsuzaki
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
| | - Yuzo Nagai
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
| | - Takahide Shinagawa
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
| | - Hirofumi Sonoda
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
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Li Y, Zhuang M, Hu G, Zhang J, Qiu W, Mei S, Tang J. A novel classification of posterior pelvic exenteration to assess prognosis in female patients with locally advanced primary rectal cancer: a retrospective cohort study from China PelvEx collaborative. Int J Colorectal Dis 2024; 39:59. [PMID: 38664256 PMCID: PMC11045567 DOI: 10.1007/s00384-024-04632-9] [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: 04/16/2024] [Indexed: 04/28/2024]
Abstract
PURPOSE Surgical techniques and the prognosis of posterior pelvic exenteration for locally advanced primary rectal cancer in female patients pose challenges that need to be addressed. Therefore, we investigated the short-term and survival outcomes of posterior pelvic exenteration in female patients using a novel Peking classification. METHODS We retrospectively analysed a prospective database from China PelvEx Collaborative across three tertiary referral centres. A total of 172 patients who underwent combined resection for locally advanced primary rectal cancer were classified based on four subtypes (PPE-I [64/172], PPE-II [68/172], PPE-III [21/172], and PPE-IV [19/172]) according to the Peking classification; perioperative characteristics and short-term and oncological outcomes were analysed. RESULTS Differences were significant among the four groups regarding colorectal reconstruction (p < 0.001), perineal reconstruction (p < 0.001), in-hospital complications (p < 0.05), and urinary retention (p < 0.05). The R0 resection rates for PPE-I, PPE-II, PPE-III, and PPE-IV were 90.6%, 89.7%, 90.5%, and 89.5%, respectively. The 5-year overall survival rates of the PPE-I, PPE-II, PPE-III, and PPE-IV groups were 73.4%, 68.8%, 54.7%, and 37.3%, respectively. Correspondingly, their 5-year disease-free survival rates were 76.0%, 62.5%, 57.7%, and 43.1%, respectively. Notably, the PPE-IV group demonstrated the lowest 5-year overall survival rate (p < 0.001) and 5-year disease-free survival rate (p < 0.001). CONCLUSION The Peking classification can aid in determining suitable surgical techniques and conducting prognostic assessments in female patients with locally advanced primary rectal cancer.
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Affiliation(s)
- Yuegang Li
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Meng Zhuang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Gang Hu
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jinzhu Zhang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Wenlong Qiu
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Shiwen Mei
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jianqiang Tang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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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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Kamei J, Fujimura T. Current status of robot-assisted total pelvic exenteration focusing on the field of urology: a clinical practice review. Transl Cancer Res 2024; 13:453-461. [PMID: 38410226 PMCID: PMC10894324 DOI: 10.21037/tcr-23-1039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 12/08/2023] [Indexed: 02/28/2024]
Abstract
Total pelvic exenteration (TPE) is a highly invasive surgery associated with high rates of perioperative morbidity and mortality and is commonly performed for several types of locally advanced or recurrent pelvic cancers. It involves multivisceral resection, including the rectum, sigmoid colon, bladder, prostate, uterus, vagina, or ovaries, and urologists normally perform radical cystectomy or radical prostatectomy and urinary diversion in collaboration with colorectal surgeons and gynecologists. In the urological field, robot-assisted surgeries have been widely performed as one of the main minimally invasive procedures because of their superior perioperative or oncological outcomes compared to open or laparoscopic surgeries. In pelvic exenteration (PE) surgery, laparoscopic surgeries have shown superior rates of mortality, morbidity, and R0 resection compared to open surgeries. Robot-assisted TPE for the treatment of locally advanced rectal cancer was first reported in 2014, and reports of its safety and usefulness have gradually increased. Robot-assisted PE, in which multivisceral resection in a narrow pelvic space is easier, will eventually be a standard minimally invasive procedure, although evidence has been limited to date. This clinical practice review summarizes the indications for surgery, perioperative complications, and oncological outcomes of robot-assisted TPE and highlights the current status of robot-assisted TPE for patients with urological malignancies and its surgical technique, focusing on the manipulation of urological organs.
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Affiliation(s)
- Jun Kamei
- Department of Urology, Jichi Medical University, Tochigi, Japan
- Department of Urology, The University of Tokyo Hospital, Tokyo, Japan
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Mukai T, Nagasaki T, Akiyoshi T, Hiyoshi Y, Yamaguchi T, Kawachi H, Fukunaga Y. The impact of staple transection of the dorsal venous complex and urethra on intraoperative blood loss in cooperative laparoscopic and transperineal endoscopic pelvic exenteration. Surg Today 2024; 54:23-30. [PMID: 37127776 DOI: 10.1007/s00595-023-02693-x] [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: 12/04/2022] [Accepted: 04/06/2023] [Indexed: 05/03/2023]
Abstract
PURPOSE While laparoscopic pelvic exenteration reduces intraoperative blood loss, dorsal venous complex bleeding during this procedure causes issues. We previously introduced a method to transect the dorsal venous complex and urethra using a linear stapler during cooperative laparoscopic and transperineal endoscopic (two-team) pelvic exenteration. The present study assessed its effectiveness in reducing intraoperative blood loss by comparing it with conventional laparoscopic pelvic exenteration. METHODS This retrospective cohort study was conducted at a Japanese tertiary referral center. Eleven cases of two-team laparoscopic pelvic exenteration with staple transection of the dorsal venous complex (T-PE group) were compared to 25 cases of conventional laparoscopic pelvic exenteration (C-PE group). The primary outcome measure was intraoperative blood loss. RESULTS There were no significant between-group differences in patient background. The mean intraoperative blood loss was significantly lower in the T-PE group than in the C-PE group (200 vs. 850 mL, p = 0.01). The respective mean operation time, postoperative complication rate, and R0 resection rate were similar between the T-PE and C-PE groups (636 min vs. 688 min, p = 0.36; 36% vs. 44%, p = 0.65; 100% vs. 100%, p = 1.00). CONCLUSIONS Two-team laparoscopic pelvic exenteration with staple transection of the dorsal venous complex reduced intraoperative blood loss from the dorsal venous complex in a technically safe and oncologically feasible manner.
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Affiliation(s)
- Toshiki Mukai
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan.
| | - Toshiya Nagasaki
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Takashi Akiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Yukiharu Hiyoshi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Tomohiro Yamaguchi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Hiroshi Kawachi
- Department of Pathology, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Yosuke Fukunaga
- Department of Gastroenterological Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
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8
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Saklani A, Kazi M, Desouza A, Sharma A, Engineer R, Krishnatry R, Gudi S, Ostwal V, Ramaswamy A, Dhanwat A, Bhargava P, Mehta S, Sundaram S, Kale A, Goel M, Patkar S, Vartey G, Kulkarni S, Baheti A, Ankathi S, Haria P, Katdare A, Choudhari A, Ramadwar M, Menon M, Patil P. Tata Memorial Centre Evidence Based Management of Colorectal cancer. Indian J Cancer 2024; 61:S29-S51. [PMID: 38424681 DOI: 10.4103/ijc.ijc_66_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 03/02/2024]
Abstract
ABSTRACT This review article examines the evidence-based management of colorectal cancers, focusing on topics characterized by ongoing debates and evolving evidence. To contribute to the scientific discourse, we intentionally exclude subjects with established guidelines, concentrating instead on areas where the current understanding is dynamic. Our analysis encompasses a thorough exploration of critical themes, including the evidence surrounding complete mesocolic excision and D3 lymphadenectomy in colon cancers. Additionally, we delve into the evolving landscape of perioperative chemotherapy in both colon and rectal cancers, considering its nuanced role in the context of contemporary treatment strategies. Advancements in surgical techniques are a pivotal aspect of our discussion, with an emphasis on the utilization of minimally invasive approaches such as laparoscopy and robotic surgery in both colon and rectal cancers, including advanced rectal cases. Moving beyond conventional radical procedures, we scrutinize the feasibility and implications of endoscopic resections for small tumors, explore the paradigm of organ preservation in locally advanced rectal cancers, and assess the utility of total neoadjuvant therapy in the current treatment landscape. Our final segment reviews pivotal trials that have significantly influenced the management of colorectal liver and peritoneal metastasis.
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Affiliation(s)
- Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
- Department of Surgical Oncology, Advanced Centre of the Treatment, Research, and Education in Cancer, Kharghar, Navi Mumbai, India
| | - Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Ankit Sharma
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
- Department of Surgical Oncology, Advanced Centre of the Treatment, Research, and Education in Cancer, Kharghar, Navi Mumbai, India
| | - Reena Engineer
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Rahul Krishnatry
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shivkumar Gudi
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Vikas Ostwal
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Anant Ramaswamy
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Aditya Dhanwat
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Prabhat Bhargava
- Homi Bhabha National Institute, Mumbai, India
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shaesta Mehta
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Sridhar Sundaram
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Aditya Kale
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
| | - Mahesh Goel
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Shraddha Patkar
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Gurudutt Vartey
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Suyash Kulkarni
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Akshay Baheti
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Suman Ankathi
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Purvi Haria
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Aparna Katdare
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Amit Choudhari
- Homi Bhabha National Institute, Mumbai, India
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
| | - Mukta Ramadwar
- Homi Bhabha National Institute, Mumbai, India
- Department of Pathology, Tata Memorial Hospital, Mumbai, India
| | - Munita Menon
- Homi Bhabha National Institute, Mumbai, India
- Department of Pathology, Tata Memorial Hospital, Mumbai, India
| | - Prachi Patil
- Homi Bhabha National Institute, Mumbai, India
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, India
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9
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Zhuang M, Chen H, Li Y, Mei S, Liu J, Du B, Wang X, Wang X, Tang J. Laparoscopic posterior pelvic exenteration is safe and feasible for locally advanced primary rectal cancer in female patients: a comparative study from China PelvEx collaborative. Tech Coloproctol 2023; 27:1109-1117. [PMID: 37243857 DOI: 10.1007/s10151-023-02824-z] [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: 02/02/2023] [Accepted: 05/08/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE Posterior pelvic exenteration (PPE) for locally advanced rectal cancer is a technical and challenging procedure. The safety and feasibility of laparoscopic PPE remain to be determined. This study aims to compare short-term and survival outcomes of laparoscopic PPE (LPPE) with open PPE (OPPE) in female patients. METHOD From January 2015 to December 2020, data from 105 female patients who underwent PPE at three institutions were retrospectively analyzed. The short-term and oncological outcomes between LPPE and OPPE were compared. RESULTS A total of 54 cases with LPPE and 51 cases with OPPE were enrolled. The operative time (240 vs. 295 min, p = 0.009), blood loss (100 vs. 300 ml, p < 0.001), surgical site infection (SSI) rate (20.4% vs. 58.8%, p = 0.003), urinary retention rate (3.7% vs. 17.6%, p = 0.020), and postoperative hospital stay (10 vs. 13 days, p = 0.009) were significantly lower in the LPPE group. The two groups showed no significant differences in the local recurrence rate (p = 0.296), 3-year overall survival (p = 0.129), or 3-year disease-free survival (p = 0.082). A higher CEA level (HR 1.02, p = 0.002), poor tumor differentiation (HR 3.05, p = 0.004), and (y)pT4b stage (HR 2.35, p = 0.035) were independent risk factors for disease-free survival. CONCLUSION LPPE is safe and feasible for locally advanced rectal cancers and shows lower operative time and blood loss, fewer SSI complications, and better preservation of bladder function without compromising oncological outcomes.
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Affiliation(s)
- M Zhuang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - H Chen
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, 300450, China
| | - Y Li
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - S Mei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - J Liu
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - B Du
- Department of Colorectal Surgery, Gansu Provincial Hospital, Lanzhou, 730000, China
| | - X Wang
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
| | - J Tang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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10
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Haney CM, Kowalewski KF, Schmidt MW, Lang F, Bintintan V, Fan C, Wehrtmann F, Studier-Fischer A, Felinska EA, Müller-Stich BP, Nickel F. Robotic-assisted versus laparoscopic bowel anastomoses: randomized crossover in vivo experimental study. Surg Endosc 2023; 37:5894-5901. [PMID: 37072638 PMCID: PMC10338398 DOI: 10.1007/s00464-023-10044-7] [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: 01/08/2023] [Accepted: 03/25/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Initial learning curves are potentially shorter in robotic-assisted surgery (RAS) than in conventional laparoscopic surgery (LS). There is little evidence to support this claim. Furthermore, there is limited evidence how skills from LS transfer to RAS. METHODS A randomized controlled, assessor blinded crossover study to compare how RAS naïve surgeons (n = 40) performed linear-stapled side-to-side bowel anastomoses in an in vivo porcine model with LS and RAS. Technique was rated using the validated anastomosis objective structured assessment of skills (A-OSATS) score and the conventional OSATS score. Skill transfer from LS to RAS was measured by comparing the RAS performance of LS novices and LS experienced surgeons. Mental and physical workload was measured with the NASA-task load index (NASA-Tlx) and the Borg-scale. OUTCOMES In the overall cohort, there were no differences between RAS and LS for surgical performance (A-OSATS, time, OSATS). Surgeons that were naïve in both LS and RAS had significantly higher A-OSATS scores in RAS (Mean (Standard deviation (SD)): LS: 48.0 ± 12.1; RAS: 52.0 ± 7.5); p = 0.044) mainly deriving from better bowel positioning (LS: 8.7 ± 1.4; RAS: 9.3 ± 1.0; p = 0.045) and closure of enterotomy (LS: 12.8 ± 5.5; RAS: 15.6 ± 4.7; p = 0.010). There was no statistically significant difference in how LS novices and LS experienced surgeons performed in RAS [Mean (SD): novices: 48.9 ± 9.0; experienced surgeons: 55.9 ± 11.0; p = 0.540]. Mental and physical demand was significantly higher after LS. CONCLUSION The initial performance was improved for RAS versus LS for linear stapled bowel anastomosis, whereas workload was higher for LS. There was limited transfer of skills from LS to RAS.
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Affiliation(s)
- Caelán Max Haney
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- Department of Urology, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Karl-Friedrich Kowalewski
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- Department of Urology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Mona Wanda Schmidt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Franziska Lang
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Vasile Bintintan
- Department of Surgery, University Hospital Cluj Napoca, Cluj-Napoca, Romania
| | - Carolyn Fan
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Fabian Wehrtmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Alexander Studier-Fischer
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Eleni Amelia Felinska
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Beat Peter Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- Department of Surgery, Clarunis University Center for Gastrointestinal and Liver Disease, University Hospital and St. Clara Hospital Basel, Basel, Switzerland
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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11
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Ryan OK, Doogan KL, Ryan ÉJ, Donnelly M, Reynolds IS, Creavin B, Davey MG, Kelly ME, Kennelly R, Hanly A, Martin ST, Winter DC. Comparing minimally invasive surgical and open approaches to pelvic exenteration for locally advanced or recurrent pelvic malignancies - Systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1362-1373. [PMID: 37087374 DOI: 10.1016/j.ejso.2023.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/30/2023] [Accepted: 04/05/2023] [Indexed: 04/24/2023]
Abstract
INTRODUCTION Pelvic exenteration (PE) is a complex multivisceral surgical procedure indicated for locally advanced or recurrent pelvic malignancies. It poses significant technical challenges which account for the high risk of morbidity and mortality associated with the procedure. Developments in minimally invasive surgical (MIS) approaches and enhanced peri-operative care have facilitated improved long term outcomes. However, the optimum approach to PE remains controversial. METHODS A systematic literature search was conducted in accordance with PRISMA guidelines to identify studies comparing MIS (robotic or laparoscopic) approaches for PE versus the open approach for patients with locally advanced or recurrent pelvic malignancies. The methodological quality of the included studies was assessed systematically and a meta-analysis was conducted. RESULTS 11 studies were identified, including 2009 patients, of whom 264 (13.1%) underwent MIS PE approaches. The MIS group displayed comparable R0 resections (Risk Ratio [RR] 1.02, 95% Confidence Interval [95% CI] 0.98, 1.07, p = 0.35)) and Lymph node yield (Weighted Mean Difference [WMD] 1.42, 95% CI -0.58, 3.43, p = 0.16), and although MIS had a trend towards improved towards improved survival and recurrence outcomes, this did not reach statistical significance. MIS was associated with prolonged operating times (WMD 67.93, 95% CI 4.43, 131.42, p < 0.00001) however, this correlated with less intra-operative blood loss, and a shorter length of post-operative stay (WMD -3.89, 955 CI -6.53, -1.25, p < 0.00001). Readmission rates were higher with MIS (RR 2.11, 95% CI 1.11, 4.02, p = 0.02), however, rates of pelvic abscess/sepsis were decreased (RR 0.45, 95% CI 0.21, 0.95, p = 0.04), and there was no difference in overall, major, or specific morbidity and mortality. CONCLUSION MIS approaches are a safe and feasible option for PE, with no differences in survival or recurrence outcomes compared to the open approach. MIS also reduced the length of post-operative stay and decreased blood loss, offset by increased operating time.
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Affiliation(s)
- Odhrán K Ryan
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Katie L Doogan
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Éanna J Ryan
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland.
| | - Mark Donnelly
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Ian S Reynolds
- Department of Surgery, Royal College of Surgeons in Ireland, 123. St. Stephen's Green, Dublin 2, Ireland
| | - Ben Creavin
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Matthew G Davey
- Department of Surgery, Royal College of Surgeons in Ireland, 123. St. Stephen's Green, Dublin 2, Ireland
| | - Michael E Kelly
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Rory Kennelly
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland; Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ann Hanly
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland; Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Seán T Martin
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland; Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland; Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland; School of Medicine, University College, Dublin, Dublin 4, Ireland
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12
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Saravanabavan S, Kazi M, Murugan J, Vispute T, Vijayakumaran P, Desouza A, Saklani A. Outcomes of extended total mesorectal excision in patients with locally advanced rectal cancer. Colorectal Dis 2023. [PMID: 37246309 DOI: 10.1111/codi.16606] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 04/09/2023] [Accepted: 04/25/2023] [Indexed: 05/30/2023]
Abstract
AIM Extended total mesorectal excision (eTME) is a complex procedure involving en bloc resection of the structures surrounding the various quadrants of the rectum. This study, presenting the largest series so far of patients undergoing eTME, aimed to assess the surgical and survival outcomes of patients following treatment with eTME and to compare these outcomes with historical data on pelvic exenteration. METHOD The study is a retrospective review of all patients with locally advanced rectal cancer requiring an eTME (2014-2020). The database includes the demographic profile, operative details, histopathological features and follow-up. RESULTS One hundred and sixty three patients who underwent eTME were analysed. The overall Clavien-Dindo complication rate of > IIIa was 21.1%. The anterior quadrant was the most common anatomical site resected (68.5%). The R1 resection rate was 10.4%. After a median follow-up of 28 months, there were 51 recurrences in the study and twenty two deaths were recorded. The local recurrence rate was 7.3% among the study population. The disease-free survival (DFS) and overall survival were 66.7% and 80.4%, respectively, at 3 years. The majority of the recurrences were distant metastasis (84.3%). In univariate analysis, the quadrant involved did not affect survival. In multivariate analysis, signet ring histology, metastatic presentation, inadequate tumour response and R1 resection affected DFS. CONCLUSION The recurrence pattern, R1 resection rate and survival outcomes of patients in the present study were comparable with those for patients undergoing an exenteration. Therefore, eTME is probably a safe alternative to pelvic exenterations when R0 resection is achievable and when the procedure is performed in high-volume specialist tertiary care centres.
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Affiliation(s)
- Srivishnu Saravanabavan
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Janesh Murugan
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Tejas Vispute
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Preeti Vijayakumaran
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
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13
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Kazi M, Desouza A, Saklani A. What are the preoperative predictors of a futile pelvic exenteration in rectal cancers? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:633-640. [PMID: 36357296 DOI: 10.1016/j.ejso.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/06/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Early recurrences and deaths after a morbid procedure like pelvic exenteration are devastating events. The present study aimed at determining the incidence and predictors of futile pelvic exenterations. METHODS Consecutive pelvic exenterations for advanced and recurrent rectal adenocarcinomas operated between January 2013 and January 2021 were included with a minimum of six months follow-up. Futility of exenteration was defined as recurrence or death within six months of operation. Multivariate logistic regression was used to define predictors of futility. RESULTS Two-hundred eighty-five patients were included and 61 patients (21.4%) had a futile resection. Poorly differentiated (or signet) histology, presence of lateral pelvic nodes, M1 disease, and the need for pelvic bone resections predicted a futile resection. The probability of futility was 10%, 20%, 35-40%, 55-60%, and >75% when none, one, two, three, and all four of the predictors were present. The model was able to correctly predict futility in 70% of the cases suggesting moderate discrimination, and showed good calibration. CONCLUSIONS Futile pelvic exenterations were observed in one-fifth of patients. Four strong predictors of futility were identified. The risk of early failures was additive when combination of these adverse features was present, and can be used for patient selection and prognostication.
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Affiliation(s)
- Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, India; Homi Bhabha National Institute, Mumbai, 400012, India
| | - Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, India; Homi Bhabha National Institute, Mumbai, 400012, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, India; Homi Bhabha National Institute, Mumbai, 400012, India.
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14
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Kazi M, Patkar S, Patel P, Kunte A, Desouza A, Saklani A, Goel M. Simultaneous resection of synchronous colorectal liver metastasis: Feasibility and development of a prediction model. Ann Hepatobiliary Pancreat Surg 2023; 27:40-48. [PMID: 36168272 PMCID: PMC9947373 DOI: 10.14701/ahbps.22-043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/13/2022] [Accepted: 07/21/2022] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Timing of resection for synchronous colorectal liver metastasis (CRLM) has been debated for decades. The aim of the present study was to assess the feasibility of simultaneous resection of CRLM in terms of major complications and develop a prediction model for safe resections. Methods A retrospective single-center study of synchronous, resectable CRLM, operated between 2013 and 2021 was conducted. Upper limit of 95% confidence interval (CI) of major complications (≥ grade IIIA) was set at 40% as the safety threshold. Logistic regression was used to determine predictors of morbidity. Prediction model was internally validated by bootstrap estimates, Harrell's C-index, and correlation of predicted and observed estimates. Results Ninety-two patients were operated. Of them, 41.3% had rectal cancers. Major hepatectomy (≥ 4 segments) was performed for 25 patients (27.2%). Major complications occurred in 20 patients (21.7%, 95% CI: 13.8%-31.5%). Predictors of complications were the presence of comorbidities and major hepatectomy (area under the ROC curve: 0.692). Unacceptable level of morbidity (≥ 40%) was encountered in patients with comorbidities who underwent major hepatectomy. Conclusions Simultaneous bowel and CRLM resection appear to be safe. However, caution should be exercised when combining major liver resections with bowel resection in patients with comorbid conditions.
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Affiliation(s)
- Mufaddal Kazi
- Division of Gastrointestinal and Hepatopancreaticobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India,Homi Bhabha National Institute, Mumbai, India
| | - Shraddha Patkar
- Division of Gastrointestinal and Hepatopancreaticobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India,Homi Bhabha National Institute, Mumbai, India,Corresponding author: Shraddha Patkar, MS, MCh Division of Gastrointestinal and Hepatopancreaticobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai 400012, India Tel: +91-2224177000, E-mail: ORCID: https://orcid.org/0000-0001-8489-6825
| | - Prerak Patel
- Division of Gastrointestinal and Hepatopancreaticobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India,Homi Bhabha National Institute, Mumbai, India
| | - Aditya Kunte
- Division of Gastrointestinal and Hepatopancreaticobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India,Homi Bhabha National Institute, Mumbai, India
| | - Ashwin Desouza
- Division of Gastrointestinal and Hepatopancreaticobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India,Homi Bhabha National Institute, Mumbai, India
| | - Avanish Saklani
- Division of Gastrointestinal and Hepatopancreaticobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India,Homi Bhabha National Institute, Mumbai, India
| | - Mahesh Goel
- Division of Gastrointestinal and Hepatopancreaticobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India,Homi Bhabha National Institute, Mumbai, India
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15
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Bizzarri N, Chiantera V, Loverro M, Sozzi G, Perrone E, Gueli Alletti S, Costantini B, Gallotta V, Tortorella L, Fagotti A, Fanfani F, Ercoli A, Scambia G, Vizzielli G. Minimally invasive versus open pelvic exenteration in gynecological malignancies: a propensity-matched survival analysis. Int J Gynecol Cancer 2023; 33:190-197. [PMID: 36593063 DOI: 10.1136/ijgc-2022-003954] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE The primary endpoint of this study was to compare the disease-free survival of patients undergoing open versus minimally invasive pelvic exenteration. The secondary endpoints were cancer-specific survival and peri-operative morbidity. METHODS A multi-center, retrospective, observational cohort study was undertaken. Patients undergoing curative and palliative anterior or total pelvic exenteration for gynecological cancer by a minimally invasive approach and an open approach between June 2010 and May 2021 were included. Patients with distant metastases were excluded. A 1:2 propensity match analysis between patients undergoing minimally invasive and open pelvic exenteration was performed to equalized baseline characteristics. RESULTS After propensity match analysis a total of 117 patients were included, 78 (66.7%) and 39 (33.3%) in the open and minimally invasive group, respectively. No significant difference in intra-operative (23.4% vs 10.3%, p=0.13) and major post-operative complications (24.4% vs 17.9%, p=0.49) was evident between the open and minimally invasive approach. Patients undergoing open pelvic exenteration received higher rates of intra-operative transfusions (41.0% vs 17.9%, p=0.013). Median disease-free survival was 17.0 months for both the open and minimally invasive groups (p=0.63). Median cancer-specific survival was 30.0 months and 26.0 months in the open and minimally invasive groups, respectively (p=0.80). Positivity of surgical margins at final histology was the only significant factor influencing the risk of recurrence (hazard ratio (HR) 2.38, 95% CI 1.31 to 4.31) (p=0.004), while tumor diameter ≥50 mm at the time of pelvic exenteration was the only significant factor influencing the risk of death (HR 1.83, 95% CI 1.08 to 3.11) (p=0.025). CONCLUSION In this retrospective study no survival difference was evident when minimally invasive pelvic exenteration was compared with open pelvic exenteration in patients with gynecological cancer. There was no difference in peri-operative complications, but a higher intra-operative transfusion rate was seen in the open group.
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Affiliation(s)
- Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, ARNAS "Civico - Di Cristina - Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Matteo Loverro
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Giulio Sozzi
- Department of Gynecologic Oncology, ARNAS "Civico - Di Cristina - Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Emanuele Perrone
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Salvatore Gueli Alletti
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Barbara Costantini
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Valerio Gallotta
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Lucia Tortorella
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Anna Fagotti
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Fanfani
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Alfredo Ercoli
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Giuseppe Vizzielli
- Department of Medical Area (DAME), University of Udine, Udine, Friuli-Venezia Giulia, Italy.,Clinic of Obstetrics and Gynecology - "Santa Maria della Misericordia" University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
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16
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Kawada K, Hanada K, Yokoyama D, Akamatsu S, Goto T, Obama K. Combined laparoscopic and transperineal total pelvic exenteration for recurrent rectal cancer-a video vignette. Colorectal Dis 2023; 25:333-334. [PMID: 36000801 DOI: 10.1111/codi.16308] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/02/2022] [Accepted: 08/08/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Kenji Kawada
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Keita Hanada
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Daiju Yokoyama
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shusuke Akamatsu
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takayuki Goto
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazutaka Obama
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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17
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Gori JJ, Sukumar V, Kazi MK, Desouza AL, Saklani AP. Laparoscopic Abdominoperineal Resection With Bilateral Seminal Vesicle Excision: Video Presentation. Dis Colon Rectum 2023; 66:e49. [PMID: 36538679 DOI: 10.1097/dcr.0000000000002449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Jayesh J Gori
- Division of Colorectal Surgery, Tata Memorial Hospital, Mumbai, Homibhabha National Institute, Mumbai, Maharashtra, India
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18
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Minimally invasive surgery for maximally invasive tumors: pelvic exenterations for rectal cancers. JOURNAL OF MINIMALLY INVASIVE SURGERY 2022; 25:131-138. [PMID: 36601490 PMCID: PMC9763485 DOI: 10.7602/jmis.2022.25.4.131] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 12/23/2022]
Abstract
Purpose Trials comparing minimally invasive rectal surgery have uniformly excluded T4 tumors. The present study aimed to determine the safety of minimally invasive surgery (MIS) for locally-advanced rectal cancers requiring pelvic exenterations based on benchmarked outcomes from the international PelvEx database. Methods Consecutive patients of T4 rectal cancers with urogenital organ invasion that underwent MIS exenterations between November 2015 and June 2022 were analyzed from a single center. A safety threshold was set at 20% for R1 resections and 40% for major complications (≥grade IIIA) for the upper limit of the 95% confidence interval (CI). Results The study included 124 MIS exenterations. A majority had a total pelvic exenteration (74 patients, 59.7%). Laparoscopic surgery was performed in 95 (76.6%) and 29 (23.4%) had the robotic operation. Major complications were observed in 35 patients (28.2%; 95% CI, 20.5%-37.0%). R1 resections were found pathologically in nine patients (7.3%; 95% CI, 3.4%-13.4%). The set safety thresholds were not crossed. At a median follow-up of 15 months, 44 patients (35.5%) recurred with 8.1% local recurrence rate. The 2-year overall and disease-free survivals were 85.2% and 53.7%, respectively. Conclusion MIS exenterations for locally-advanced rectal cancers demonstrated acceptable morbidity and safety in term of R0 resections at experienced centers. Longer follow-up is required to demonstrate cancer survival outcomes.
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19
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Kazi M, Sukumar V, Bankar S, Kapadia R, Desouza A, Saklani A. Learning curves for minimally invasive total mesorectal excision beyond the competency phase - a risk-adjusted cumulative sum analysis of 1000 rectal resections. Colorectal Dis 2022; 24:1516-1525. [PMID: 35839321 DOI: 10.1111/codi.16266] [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: 05/19/2022] [Revised: 06/08/2022] [Accepted: 07/07/2022] [Indexed: 01/07/2023]
Abstract
AIM The learning curve of total mesorectal excision (TME) by minimally invasive surgery (MIS) beyond the competency phase has not been adequately reported with large numbers or using a statistical control limit. The aim of this work was to study the learning curve of MIS TME in the proficiency phase. METHOD Risk-adjusted (RA) cumulative sum (CUSUM) and RA Bernoulli CUSUM charts were plotted for sequential MIS TME performed by a surgical team over 1000 cases. Surgical failure, a composite endpoint of conversions, complications of grade IIIA or above, R1 resections and inadequate nodal yield were used to monitor the performance. RESULTS The RA CUSUM detected an inflection point around the 600th operation. Two peaks were identified that could be traced back to probable causes of surgical failure. Similar inflection points were detected at the 450th case for laparoscopic TME and the 367th case for sphincter preservation. No single definite threshold point was noticed for robotic or abdominoperineal operations. At no point did the curves cross the safety threshold. The probability of surgical failure reduced with increasing experience in the multivariate regression (OR 0.899, p = 0.000). This association persisted irrespective of the surgical approach (laparoscopic versus robotic) or the type of operation (sphincter preservation versus abdominoperineal resection). CONCLUSION The learning curves for MIS TME did not cross the safety threshold beyond the competency phase. However, a 10% reduction of relative risk in surgical failure was observed for every 100 cases operated on.
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Affiliation(s)
- Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Parel, Mumbai, India
| | - Vivek Sukumar
- Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Parel, Mumbai, India
| | - Sanket Bankar
- Dr D.Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, India.,Dr D. Y. Patil Vidyapeeth, Pune, India
| | - Raj Kapadia
- Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Parel, Mumbai, India
| | - Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Parel, Mumbai, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Parel, Mumbai, India
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20
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Mathew J, Kazi M, DeSouza A, Saklani A. Utility of the da Vinci Xi platform in extended resections for locally advanced rectal cancer: A video vignette. Colorectal Dis 2022; 25:1051-1052. [PMID: 36416148 DOI: 10.1111/codi.16430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 10/24/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Joseph Mathew
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Mufaddal Kazi
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Ashwin DeSouza
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Avanish Saklani
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
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21
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Kazi M, Desouza A, Bankar S, Jajoo B, Dohale S, Vadodaria D, Ghadi A, Ghandade N, Vasudevan L, Nashikkar C, Saklani A. The use of an obstetric balloon as a pelvic spacer in preventing empty pelvis syndrome after total pelvic exenteration in rectal cancers - A prospective safety and efficacy study for the Bakri balloon. Colorectal Dis 2022; 25:616-623. [PMID: 36408669 DOI: 10.1111/codi.16424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/22/2022]
Abstract
AIM Empty pelvis syndrome (EPS) is a source of considerable morbidity following total pelvic exenteration. None of the available methods have been universally successful in mitigating this problem. The aim of this work was to evaluate the safety and efficacy of the obstetric Bakri balloon in preventing empty pelvis syndrome. METHOD This study was a combined prospective and retrospective study of all total pelvic exenterations for rectal cancers from a single institution performed between October 2013 and May 2022. Since December 2019 the Bakri balloon was used in all patients who provided consent. EPS within 90 days was the primary end point, and included bowel obstruction, pelvic collection and entero-perineal fistula. Comparison with those patients who did not have a Bakri balloon was performed. RESULTS Seventy-five patients with a Bakri balloon were compared with 96 patients without a balloon placed after pelvic exenteration. No patient experienced an untoward complication from balloon deployment. The incidence of EPS was 13.3% and 22.9% in the Bakri and no Bakri cohorts, respectively (p = 0.110). Every component of EPS was proportionally lower, without statistical significance. Based on point estimates, the number needed to treat to prevent EPS using the Bakri balloon was 10. CONCLUSIONS Use of the Bakri balloon was safe without serious adverse events. The incidence of EPS after total pelvic exenteration was not statistically different with the use of the Bakri balloon despite a 9.6% reduction. A larger comparative study is needed to evaluate the efficacy of the balloon.
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Affiliation(s)
- Mufaddal Kazi
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Ashwin Desouza
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Sanket Bankar
- Department of Surgical Oncology, Dr D. Y. Patil Medical College Hospital and Research Centre, Pimpri, Pune, India.,Dr D. Y. Patil Vidyapeeth, Pune, India
| | - Bhushan Jajoo
- Division of Surgical Oncology, SGM Cancer Hospital, Swangi, Wardha, India
| | - Sayali Dohale
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, India
| | - Divya Vadodaria
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, India
| | - Aayushi Ghadi
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, India
| | - Netra Ghandade
- Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, India
| | | | | | - Avanish Saklani
- Division of Colorectal Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
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22
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Gould LE, Pring ET, Drami I, Moorghen M, Naghibi M, Jenkins JT, Steele CW, Roxburgh CS. A systematic review of the pathological determinants of outcome following resection by pelvic exenteration of locally advanced and locally recurrent rectal cancer. Int J Surg 2022; 104:106738. [PMID: 35781038 DOI: 10.1016/j.ijsu.2022.106738] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/07/2022] [Accepted: 06/16/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Despite multimodal therapy 5-15% of patients who undergo resection for advanced rectal cancer (LARC) will develop local recurrence. Management of locally recurrent rectal cancer (LRRC) presents a significant therapeutic challenge and even with modern exenterative surgery, 5-year survival rates are poor at 25-50%. High rates of local and systemic recurrence in this cohort are reflective of the likely biological aggressiveness of these tumour types. This review aims to appraise the current literature identifying pathological factors associated with survival and tumour recurrence in patients undergoing exenterative surgery. METHODS A systematic review was carried out searching MEDLINE, EMBASE and COCHRANE Trials database for all studies assessing pathological factors influencing survival following pelvic exenteration for LARC or LRRC from 2010 to July 2021 following PRISMA guidelines. Risk of bias was assessed using QUIPS tool. RESULTS Nine cohort studies met inclusion criteria, reporting outcomes for 2864 patients. Meta-analysis was not possible due to significant heterogeneity of reported outcomes. Resection margin status and nodal disease were the most commonly reported factors. A positive resection margin was demonstrated to be a negative prognostic marker in six studies. Involved lymph nodes and lymphovascular invasion also appear to be negative prognostic markers with tumour stage to be of lesser importance. No studies assessed other adverse tumour features that would not otherwise be included in a standard histopathology report. CONCLUSION Pathological resection margin status is widely demonstrated to influence disease free and overall survival following pelvic exenteration for rectal cancer. With increasing R0 rates, other adverse tumour features must be explored to help elucidate differences in survival and potentially guide tailored oncological treatment.
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Affiliation(s)
- Laura E Gould
- University of Glasgow College of Medical Veterinary and Life Sciences, Academic Unit of Surgery, School of Medicine, United Kingdom; St Mark's Academic Institute, St Mark's Hospital, United Kingdom.
| | - Edward T Pring
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom; Imperial College London, United Kingdom
| | - Ioanna Drami
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom; Imperial College London, United Kingdom
| | - Morgan Moorghen
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom
| | - Mani Naghibi
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom
| | - John T Jenkins
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom; Imperial College London, United Kingdom
| | - Colin W Steele
- University of Glasgow College of Medical Veterinary and Life Sciences, Academic Unit of Surgery, School of Medicine, United Kingdom
| | - Campbell Sd Roxburgh
- University of Glasgow College of Medical Veterinary and Life Sciences, Academic Unit of Surgery, School of Medicine, United Kingdom
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23
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Desouza A, Kazi M, Bankar S, Pandey D, Janesh M, Saklani A. Minimally invasive, 'en-bloc' seminal vesicle excision for locally advanced rectal adenocarcinoma: surgical technique and short-term outcomes. ANZ J Surg 2022; 92:2595-2599. [PMID: 35762325 DOI: 10.1111/ans.17888] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/18/2022] [Accepted: 06/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Isolated seminal vesicle invasion is a rare occurrence in patients with locally advanced rectal cancers. This study describes the surgical technique and the perioperative outcomes of minimally invasive 'en-bloc' seminal vesicle excision, preserving the bladder and the prostate. METHODS A retrospective review of 23 consecutive patients who underwent minimally invasive, en-bloc resection of seminal vesicles for locally advanced, non-metastatic rectal adenocarcinoma between May 2016 and November 2021. Perioperative outcomes and short-term oncological outcomes were defined. RESULTS Eighteen patients underwent a laparoscopic procedure while five received a robotic resection. All patients received preoperative radiation with or without consolidation chemotherapy. The median age was 42 years (range 20-64 years) and the median hospital stay was 8 days (range 3-19 days), respectively. Serious complications (Clavien-Dindo ≥ IIIb) were seen in six patients (26.1%). Two patients (8.7%) had an involved circumferential resection margin. At a median follow up of 19 months (range 2-52 months), four patients developed recurrences. The 2-year overall and disease-free survival was 84.4% and 73.6%, respectively. CONCLUSION Minimally invasive, en-bloc resection of one or both seminal vesicles for locally advanced rectal adenocarcinoma, is feasible in a select group of patients with acceptable morbidity and short-term outcomes.
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Affiliation(s)
- Ashwin Desouza
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,HBNI, Homi Bhabha National Institute, Mumbai, India
| | - Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,HBNI, Homi Bhabha National Institute, Mumbai, India
| | - Sanket Bankar
- Division of Surgical Oncology, D.Y. Patil Medical College Hospital and Research Centre, Pune, India
| | - Diwakar Pandey
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,HBNI, Homi Bhabha National Institute, Mumbai, India
| | - Murugan Janesh
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,HBNI, Homi Bhabha National Institute, Mumbai, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,HBNI, Homi Bhabha National Institute, Mumbai, India
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24
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Kazi M, Gori J, Sasi S, Srivastava N, Khan AM, Mukherjee S, Garg V, Singh L, Mundhada R, Patil P, Desouza A, Saklani A. Prognostic Nutritional Index Prior to Rectal Cancer Resection Predicts Overall Survival. Nutr Cancer 2022; 74:3228-3235. [PMID: 35533003 DOI: 10.1080/01635581.2022.2072906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Prognostic nutritional index (PNI) correlates with postoperative complications and survival in colorectal cancers. Separate studies for rectal cancers are not available where the majority have preoperative radiation, operated by minimally invasive approaches and have diverting ostomies.Consecutive rectal resections between October 2014 and December 2017 from a single center were included. PNI was calculated as 10 x (serum Albumin) + 0.005 x TLC (per mm3) before operation. Multivariate cox regression was used with overall survival (OS) as the dependent variable. Interaction terms of PNI with neoadjuvant therapy, surgical approach and postoperative complications were used to assess specific subgroups.Three-hundred forty elective rectal resections were included with a mean PNI of 46.711 (SD - 6.692), and a median follow up of 44 mo. In multivariable regression, PNI predicted OS (HR - 0.943; p-0.001). Interaction of PNI with preoperative radiation or surgical approach (open, laparoscopic, or robotic) did not change its influence on survival. PNI predicted survival with similar hazard even in patients without major postoperative complicationsDespite routine diversion after rectal resections, PNI predicted OS with an absolute survival benefit of 1.2% at 3-year for every unit increase in PNI irrespective of preoperative therapy or surgical approach.
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Affiliation(s)
- Mufaddal Kazi
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jayesh Gori
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sajith Sasi
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Nishit Srivastava
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Afreen Mohsin Khan
- Department of Digestive Disease and Clinical Nutrition, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Soumi Mukherjee
- Department of Digestive Disease and Clinical Nutrition, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vidur Garg
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Lovedeep Singh
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rohit Mundhada
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Prachi Patil
- Department of Digestive Disease and Clinical Nutrition, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Ashwin Desouza
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Avanish Saklani
- Department of Colorectal Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute, Mumbai, Maharashtra, India
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