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Sadien ID, Ari K, Fernandes M, Paddock S, Sington J, Kapur S, Hernon J, Stearns AT, Shaikh IA. Circumferential resection margin positivity due to direct or indirect tumour involvement in rectal cancer - a call for better stratification. ANZ J Surg 2024; 94:931-937. [PMID: 38156719 DOI: 10.1111/ans.18851] [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: 10/16/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND A positive circumferential resection margin (CRM) after rectal cancer surgery, which can be the result of direct or indirect tumour involvement, has consistently been associated with increased local recurrence and poorer survival. However, little is known of the differential impact of the mode of tumour involvement on outcomes. METHODS 1460 consecutive patients undergoing rectal cancer resection between 2003 and 2018 were retrospectively assessed. Histopathology reports for patients with a positive CRM were reviewed to determine cases of direct (R1-tumour) or indirect tumour involvement (R1-other). Disease-free survival (DFS) and overall survival (OS) were assessed by Kaplan-Meier analysis. The role of the mode of CRM positivity was examined by univariate and multivariate Cox proportional hazards models. RESULTS Eighty-five patients had an R1 resection due to CRM involvement (5.8%). Of those, 69 were due to direct tumour involvement, while 16 were from indirect causes. Kaplan-Meier analysis revealed that R1-other was associated with increased OS (hazard ratio 0.40, log-rank P = 0.006) and DFS (P = 0.043). Multivariate regression confirmed that the mode of CRM positivity was an independent predictor of OS. More interestingly, the patterns of recurrence were different between the two groups, with R1-tumour leading to significantly more local recurrence (P = 0.04). CONCLUSIONS Our data strongly suggests that direct tumour involvement of the CRM confers worse prognosis after rectal cancer surgery. Importantly, differences in the site and frequency of recurrences make a case for better stratification of patients with a positive CRM to guide treatment decisions.
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Affiliation(s)
- Iannish D Sadien
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospital Trust, Norwich, UK
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Kaso Ari
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospital Trust, Norwich, UK
| | - Megan Fernandes
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospital Trust, Norwich, UK
| | - Sophie Paddock
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospital Trust, Norwich, UK
| | - James Sington
- Department of Pathology, Norfolk and Norwich University Hospital Trust, Norwich, UK
| | - Sandeep Kapur
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospital Trust, Norwich, UK
| | - James Hernon
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospital Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Adam T Stearns
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospital Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Irshad A Shaikh
- Sir Thomas Browne Academic Colorectal Unit, Norfolk and Norwich University Hospital Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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Mirnezami AH, Drami I, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Denys A, Pape E, van Ramshorst GH, Baker D, Bignall E, Blair I, Davis P, Edwards T, Jackson K, Leendertse PG, Love-Mott E, MacKenzie L, Martens F, Meredith D, Nettleton SE, Trotman MP, van Hecke JJM, Weemaes AMJ, Abecasis N, Angenete E, Aziz O, Bacalbasa N, Barton D, Baseckas G, Beggs A, Brown K, Buchwald P, Burling D, Burns E, Caycedo-Marulanda A, Chang GJ, Coyne PE, Croner RS, Daniels IR, Denost QD, Drozdov E, Eglinton T, Espín-Basany E, Evans MD, Flatmark K, Folkesson J, Frizelle FA, Gallego MA, Gil-Moreno A, Goffredo P, Griffiths B, Gwenaël F, Harris DA, Iversen LH, Kandaswamy GV, Kazi M, Kelly ME, Kokelaar R, Kusters M, Langheinrich MC, Larach T, Lydrup ML, Lyons A, Mann C, McDermott FD, Monson JRT, Neeff H, Negoi I, Ng JL, Nicolaou M, Palmer G, Parnaby C, Pellino G, Peterson AC, Quyn A, Rogers A, Rothbarth J, Abu Saadeh F, Saklani A, Sammour T, Sayyed R, Smart NJ, Smith T, Sorrentino L, Steele SR, Stitzenberg K, Taylor C, Teras J, Thanapal MR, Thorgersen E, Vasquez-Jimenez W, Waller J, Weber K, Wolthuis A, Winter DC, Brangan G, Vimalachandran D, Aalbers AGJ, Abdul Aziz N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Baker RP, Bali M, Baransi S, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Bui A, Burgess A, Burger JWA, Campain N, Carvalhal S, Castro L, Ceelen W, Chan KKL, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Damjanovic L, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Deutsch C, Dietz D, Domingo S, Dozois EJ, Duff M, Egger E, Enrique-Navascues JM, Espín-Basany E, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Fleming F, Flor B, Foskett K, Funder J, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Giner F, Ginther N, Glover T, Golda T, Gomez CM, Harris C, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Jenkins JT, Jourand K, Kaffenberger S, Kapur S, Kanemitsu Y, Kaufman M, Kelley SR, Keller DS, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Lago V, Lakkis Z, Lampe B, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lynch AC, Mackintosh M, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Morton JR, Mullaney TG, Navarro AS, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Pappou E, Park J, Patsouras D, Peacock O, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steffens D, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor D, Tejedor P, Tekin A, Tekkis PP, Thaysen HV, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Yano H, Yip B, Yip J, Yoo RN, Zappa MA. The empty pelvis syndrome: a core data set from the PelvEx collaborative. Br J Surg 2024; 111:znae042. [PMID: 38456677 PMCID: PMC10921833 DOI: 10.1093/bjs/znae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/15/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored. METHOD Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition. RESULTS One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed. CONCLUSIONS EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.
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Thorgersen EB, Solbakken AM, Strøm TK, Goscinski M, Spasojevic M, Larsen SG, Flatmark K. Short-term results after robot-assisted surgery for primary rectal cancers requiring beyond total mesorectal excision in multiple compartments. Scand J Surg 2024; 113:3-12. [PMID: 37787437 DOI: 10.1177/14574969231200654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
AIM Rectal cancers requiring beyond total mesorectal excision (bTME) are traditionally operated using an open approach, but the use of minimally invasive robot-assisted procedures is increasing. Introduction of minimal invasive surgery for complex cancer cases could be associated with compromised surgical margins or increased complication rates. Therefore, reporting results both clinical and oncological in large series is important. Since bTME procedure reports are heterogeneous, comparing results is often difficult. In this study, a magnetic resonance imaging (MRI) classification system was used to describe the bTME surgery according to pelvic compartments. METHODS Consecutive patients with primary rectal cancer operated with laparoscopic robot-assisted bTME were prospectively included for 2 years. All patients had tumors that threatened the mesorectal fascia, invaded adjacent organs, and/or involved metastatic pelvic lateral lymph nodes. Short-term clinical outcomes and oncological specimen quality were registered. Surgery was classified according to pelvic compartments resected. RESULTS Clear resection margins (R0 resection) were achieved in 95 out of 105 patients (90.5%). About 26% had Accordion Severity Grading System of Surgical Complications grade 3-4 complications and 15% required re-operations. About 7% were converted to open surgery. The number of compartments resected ranged from one to the maximum seven, with 83% having two or three compartments resected. All 10 R1 resections occurred in the lateral and posterior compartments. CONCLUSIONS The short-term clinical outcomes and oncological specimen quality after robot-assisted bTME surgery were comparable to previously published open bTME surgery. The description of surgical procedures using the Royal Marsden MRI compartment classification was feasible.
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Affiliation(s)
- Ebbe B Thorgersen
- Department of Gastroenterological Surgery Oslo University Hospital The Radium Hospital Pb 4950 Nydalen 0424 Oslo Norway
| | - Arne M Solbakken
- Department of Gastroenterological Surgery, Oslo University Hospital, The Radium Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Tumor Biology, Oslo University Hospital, The Radium Hospital, Oslo, Norway
| | - Tuva K Strøm
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Mariusz Goscinski
- Department of Gastroenterological Surgery, Oslo University Hospital, The Radium Hospital, Oslo, Norway
| | - Milan Spasojevic
- Department of Gastroenterological Surgery, Oslo University Hospital, The Radium Hospital, Oslo, Norway
| | - Stein G Larsen
- Department of Gastroenterological Surgery, Oslo University Hospital, The Radium Hospital, Oslo, Norway
| | - Kjersti Flatmark
- Department of Gastroenterological Surgery, Oslo University Hospital, The Radium Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Tumor Biology, Oslo University Hospital, The Radium Hospital, Oslo, Norway
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4
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Ralston C, Hainsworth A, de Naurois J, Schizas A, George M. Is an uncomplicated postoperative recovery following total pelvic exenteration a more important prognostic factor than achieving R0 in the first 2 years? Colorectal Dis 2024; 26:73-80. [PMID: 38071402 DOI: 10.1111/codi.16817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/30/2023] [Accepted: 10/18/2023] [Indexed: 01/28/2024]
Abstract
AIM Total pelvic exenteration (TPE) can achieve an R0 resection in locally advanced and recurrent rectal cancer (LARC and RRC) and remains the only curative option. The resultant high morbidity creates prolonged complex recoveries, rendering patients unfit for adjuvant chemotherapy. This study aims to evaluate the impact of this on overall survival (OS) and disease-free survival (DFS) as it has not been studied previously. METHOD This is a retrospective single-centre study from 2017 to 2021 evaluating patients with LARC or RRC who underwent a curative TPE. Demographics, oncological history, perioperative data [using Clavien-Dindo (CD) scoring], disease recurrence and mortality were analysed using multivariate Cox regression to assess the impact of variables on DFS and OS. RESULTS A total of 120 patients were included with a median follow-up of 3 years. 28% of patients received adjuvant chemotherapy, 27.5% had surgical follow-up and 44% missed systemic treatment. Missed treatment was predominantly due to prolonged recovery or poor performance status (59%). Patients who missed adjuvant chemotherapy experienced significantly higher CD scores (p = 0.0031), reintervention rates (p=0.0056) and further related surgeriesp (p = 0.0314). Missing adjuvant chemotherpy is a significant factor for poorer survival, with almost a three times higher mortality (p=0.0096, hazard ratio 2.7). R status was not a significant factor for OS following multivariate analysis (p = 0.336), indicating that another factor has an impact on survival within the first 2 years. CONCLUSIONS In the initial 2 years after exenteration, an uncomplicated postoperative recovery allows for the delivery of adjuvant chemotherapy, prolonging survival. R0/R1 status was not the main prognostic factor. Longer follow-up and further multivariate analysis may influence decisions about aggressive R0 resection balanced against the patient being fit for chemotherapy postoperatively.
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Affiliation(s)
| | | | | | | | - Mark George
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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5
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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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Kojima D, Fujikawa T, Kajitani R, Matsumoto Y, Hasegawa S. Trans-anal Minimally Invasive Surgery Combined With a Robotic Anterior Approach for Sleeve Resection of a Huge Rectal Gastrointestinal Stromal Tumor. Cureus 2023; 15:e46288. [PMID: 37915880 PMCID: PMC10617749 DOI: 10.7759/cureus.46288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2023] [Indexed: 11/03/2023] Open
Abstract
Due to anatomical complexity, large rectal gastrointestinal stromal tumors (GISTs) in the pelvis at the anterior aspect often require extended abdominal surgery to obtain clear surgical margins. Here, we show our trans-anal minimally invasive surgery combined with a robotic anterior approach for a huge low rectal GIST that was widely in contact with the prostate and urethra. By performing lateral dissection first, we can identify the orientation of critical organs such as the prostate, urethra, and neurovascular bundles, facilitating anterior anorectal dissection without urethral injury. Although the combination with a transabdominal robotic approach was required because of firm inflammatory adhesion between the tumor and prostate, the preceding trans-anal dissection plane facilitated the robotic anterior dissection and contributed to achieving complete dissection with negative resection margins.
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Affiliation(s)
- Daibo Kojima
- Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka, JPN
- Surgery, Kokura Memorial Hospital, Kitakyushu, JPN
| | | | - Ryuji Kajitani
- Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka, JPN
| | - Yoshiko Matsumoto
- Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka, JPN
| | - Suguru Hasegawa
- Gastroenterological Surgery, Fukuoka University Hospital, Fukuoka, JPN
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Sun JX, Xu JZ, An Y, Ma SY, Liu CQ, Zhang SH, Luan Y, Wang SG, Xia QD. Future in precise surgery: Fluorescence-guided surgery using EVs derived fluorescence contrast agent. J Control Release 2023; 353:832-841. [PMID: 36496053 DOI: 10.1016/j.jconrel.2022.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022]
Abstract
Surgery is the only cure for many solid tumors, but positive resection margins, damage to vital nerves, vessels and organs during surgery, and the range and extent of lymph node dissection are significant concerns which hinder the development of surgery. The emergence of fluorescence-guided surgery (FGS) means a farewell to the era when surgeons relied only on visual and tactile feedback, and it gives surgeons another eye to distinguish tumors from normal tissues for precise resection and helps to find a balance between complete tumor lesions removal and maximal organ function conservation. However, the existing synthetic fluorescence contrast agent has flaws in safety, specificity and biocompatibility to various extents. Extracellular vesicles (EVs) are a group of heterogeneous types of cell-derived membranous structures present in all biological fluids. EVs, especially engineered targeting EVs, play an increasingly important role in drug delivery because of their good biocompatibility, validated safety and targeting ability. Nevertheless, few studies have employed EVs loaded with fluorophores to construct fluorescence contrast agents and used them in FGS. Here, we systematically reviewed the current state of knowledge regarding FGS, fundamental characteristics of EVs, and the development of engineered targeting EVs, and put forward a novel strategy and procedures to produce EVs-based fluorescence contrast agent used in fluorescence-guided surgery.
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Affiliation(s)
- Jian-Xuan Sun
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, 430030 Wuhan, China
| | - Jin-Zhou Xu
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, 430030 Wuhan, China
| | - Ye An
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, 430030 Wuhan, China
| | - Si-Yang Ma
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, 430030 Wuhan, China
| | - Chen-Qian Liu
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, 430030 Wuhan, China
| | - Si-Han Zhang
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, 430030 Wuhan, China
| | - Yang Luan
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, 430030 Wuhan, China.
| | - Shao-Gang Wang
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, 430030 Wuhan, China.
| | - Qi-Dong Xia
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, 430030 Wuhan, China.
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Sturgess GR, Garner JP, Slater R. Abdominoperineal Resection in the United Kingdom: a Case against Centralisation. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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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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10
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Ng KS, Lee PJ. Pelvic exenteration: Pre-, intra-, and post-operative considerations. Surg Oncol 2022. [DOI: 10.1016/j.suronc.2022.101787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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11
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Boaz E, Freund MR, Harbi A, Dagan A, Gilshtein H, Reissman P, Yellinek S. Anorectal Malignancies Presenting as a Perianal Abscess or Fistula. Am Surg 2022:31348221101481. [PMID: 35621130 DOI: 10.1177/00031348221101481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acute anorectal abscess and fistula are common conditions that usually presents as a painful lump close to the anal margin. Tumors in the distal rectum and in the perianal region may mimic the symptoms and signs of anorectal sepsis, thereby leading to a delay in diagnosis and management. The purpose of this study was to describe patients presenting with acute perianal abscess or fistula who were subsequently diagnosed with anorectal cancer. METHODS We performed a retrospective, review of all cases presenting with acute perianal abscess or fistula who were subsequently found to have anorectal carcinoma on biopsy in two tertiary centers. We analyzed the data focusing on the clinical features, laboratory values, clinical staging of the tumors, the subsequent management, the pathological staging, and the outcome of each patient. RESULTS Overall, 3219 patients presenting with anorectal abscess or fistula were reviewed. Cancer was diagnosed in 16 (.5%) patients, 12 with adenocarcinoma of the rectum and 4 with squamous cell carcinoma of the anus. In 5 patients (31.2%), cancer was diagnosed in the setting of chronic perianal fistula, 4 of them had Crohn's disease. In 10 patients (62.5%), cancer was not diagnosed during the initial evaluation of the acute symptoms. CONCLUSIONS A high index of suspicion is required to make the diagnosis of perianal tumors when assessing patients presenting with perianal sepsis, particularly those with Crohn's disease, a long history of persistent perianal disease, and an advanced age. In most cases, proper drainage followed by proximal diversion are the surgical treatment of choice in the acute setting.
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Affiliation(s)
- Elad Boaz
- Department of General Surgery, 26743Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Michael R Freund
- Department of General Surgery, 26743Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Asaf Harbi
- Colorectal Unit, Department of General Surgery, 574334Rambam Health Care Campus, The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Amir Dagan
- Department of General Surgery, 26743Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Hayim Gilshtein
- Colorectal Unit, Department of General Surgery, 574334Rambam Health Care Campus, The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Petachia Reissman
- Department of General Surgery, 26743Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Shlomo Yellinek
- Department of General Surgery, 26743Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
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12
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Wang J, Prabhakaran S, Larach T, Warrier SK, Bednarski BK, Ngan SY, Leong T, Rodriguez-Bigas M, Peacock O, Chang G, Heriot AG, Kong JCH. Treatment strategies for locally recurrent rectal cancer. Eur J Surg Oncol 2022; 48:2292-2298. [DOI: 10.1016/j.ejso.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 05/03/2022] [Accepted: 05/13/2022] [Indexed: 10/18/2022] Open
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13
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Uematsu D, Sugihara T. Transperineal abdominoperineal resection in the prone jackknife position in male patients with low rectal cancer. Asian J Endosc Surg 2022; 15:453-457. [PMID: 34655173 DOI: 10.1111/ases.13001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/12/2021] [Accepted: 10/03/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In male patients with low rectal cancer undergoing abdominoperineal resection (APR), successful dissection of the anterior anorectum is key to reducing the risk of circumferential resection margin involvement, intraoperative bowel perforation, and local recurrence, but it is challenging. To overcome difficulties dissecting the anterior anorectum, we present a safe and feasible procedure using a transperineal endoscopic approach during APR (TpAPR). MATERIALS AND SURGICAL TECHNIQUE The male patient is placed in the prone jackknife position. TpAPR precedes the procedure from an abdominal approach. We use some pelvic tissues as clear anatomical landmarks to dissect the anterior anorectum. The key steps of this procedure are shown in the video. DISCUSSION The identification of a clear anatomical dissection plane of the anterior anorectum is difficult because of the complex surgical anatomy of the region. Clear anatomical landmarks for dissection of the anterior anorectum are necessary for safe implementation of this procedure. Therefore, TpAPR in the prone jackknife position can be performed to obtain better visualization of each anatomical landmark at a glance.
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Affiliation(s)
- Dai Uematsu
- Department of Surgery, Saku Central Hospital Nagano Prefectural Federation of Agricultural Cooperatives for Health and Welfare, Saku, Japan
| | - Takehiko Sugihara
- Department of Colorectal Surgery, Saku Central Hospital Advanced Care Center, Saku, Japan
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14
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Exenteraţia pelviană – între istorie şi viitor. ONCOLOG-HEMATOLOG.RO 2022. [DOI: 10.26416/onhe.60.3.2022.7151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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15
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The role of surgery in the palliation of advanced pelvic malignancy. Eur J Surg Oncol 2022; 48:2323-2329. [DOI: 10.1016/j.ejso.2022.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/23/2021] [Accepted: 01/18/2022] [Indexed: 11/20/2022] Open
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16
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Opportunities and Limitations of Pelvic Exenteration Surgery. Cancers (Basel) 2021; 13:cancers13246162. [PMID: 34944783 PMCID: PMC8699210 DOI: 10.3390/cancers13246162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/26/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The practice of exenterative surgery is sometimes controversial and has garnered a certain scepticism. Surgical studies are difficult to conduct due to insufficient data. The aim of this review is to present the current standing of pelvic exenteration from a surgical, gynaecological and urological point of view. METHODS This review is based upon a literature review (MEDLINE (PubMed), CENTRAL (Cochrane) and EMBASE (Elsevier)) of retrospective studies on exenterative surgery from 1993-2020. Using MeSH (Medical Subject Headings) search terms, 1572 publications were found. These were evaluated and screened with respect to their eligibility using algorithms and well-defined inclusion and exclusion criteria. Therefore, the guidelines for systematic reviews (PRISMA) were used. RESULTS A complete tumour resection (R0) often represents the only curative option for advanced pelvic carcinomas and their recurrences. A recent systematic review showed significant symptom relief in 80% of palliative patients after pelvic exenteration. Surgical limitations (distant metastases, involvement of the pelvic wall, etc.) are diminished by adequate surgical expertise and close interdisciplinary cooperation. While the mortality rate is low (2-5%), the still relatively high morbidity rate (32-84%) can be minimized by optimizing the perioperative setting. Following exenterations, roughly 79-82% of patients report satisfying results according to PROs (patient-reported outcomes). CONCLUSION Due to multimodality treatment strategies combined with extended surgical expertise and patients' preferences, pelvic exenteration can be offered nowadays with low mortality and acceptable postoperative quality of life. The possibilities of surgical treatment are often underestimated. A multi-centre database (PelvEx Collaborative) was established to collect data and experiences to optimize the research in this field.
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17
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Mei F, Yang X, Na L, Yang L. Anal preservation on the psychology and quality of life of low rectal cancer. J Surg Oncol 2021; 125:484-492. [PMID: 34750821 DOI: 10.1002/jso.26741] [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: 07/22/2021] [Revised: 10/08/2021] [Accepted: 10/31/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The aims of this study are to evaluate depression and quality of life (QOL) after laparoscopic abdominoperineal resection (LAPR) or transanal total mesorectal excision (TaTME) surgery in low rectal cancer (RC) patients. METHODS This is a prospective observational cohort study. Patients were divided into two groups: either TaTME surgery or LAPR. Psychosocial distress and QOL were assessed using a questionnaire before surgery, at 6 months postsurgery, and 12 months postsurgery. The Hospital Anxiety and Depression Scale was used to assess symptoms of anxiety and depression. The European Organization for Research and Treatment of Cancer-QOL questionnaire core was used to estimate the QOL. RESULTS In the TaTME group, the scores of psychosocial distress and QOL showed an obvious tendency to decrease and then recover. Meanwhile, in the LAPR group, these scores deteriorated significantly at 6 and 12 months, and the recovery was less pronounced. Multivariable analysis suggested that surgical options and tumor stage were significantly associated with psychosocial distress and QOL. CONCLUSION For low RC, TaTME could significantly improve patients' QOL and reduce psychological distress as compared to patients with LAPR at 12 months after surgery.
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Affiliation(s)
- Feng Mei
- Department of Medical Psychology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xin Yang
- Department of Medical Psychology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lina Na
- Department of Medical Psychology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Liu Yang
- Department of Colorectal Surgery, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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18
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Stearns GL, Tin AL, Benfante NE, Sjoberg DD, Sandhu JS. Outcomes of Ureteroneocystostomy in Patients With Cancer. Urology 2021; 158:131-134. [PMID: 34499968 DOI: 10.1016/j.urology.2021.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the durability of ureteroneocystostomy as well as pre- or post-operative factors that may be associated with failure to provide appropriate renal drainage. METHODS A total of 290 patients who underwent ureteral reimplantation to native bladder between 2003 and 2015 were identified. After excluding pediatric patients and those without any follow-up, 255 patients, 3 of whom had a subsequent contralateral reimplantation were included, for 258 observations. Kaplan-Meier method and univariate Cox models were used to assess whether factors such as radiation, prior abdominal surgery, age at re-implantation, gender and BMI are associated with re-implantation failure. RESULTS Among 258 observations, there were 27 failures. Median follow-up time was 1.1 years from re-implantation surgery among patients without a failure.1 and 5-year ureteral re-implantation failure is 7% (95% CI 4%, 12%) and 22% (95% CI 15%, 33%), respectively. On univariate analysis, post-operative radiation was found to be strongly associated with poorer ureteral re-implantation survival (HR: 6.62; CI 2.40, 18.29; P = .0003) No significant association between re-implantation failure-free survival and age at reimplantation, gender, BMI, previous abdominal surgery, preoperative radiation and adjuvant radiation was noted (all P > .4). CONCLUSIONS Ureteroneocystotomy in the malignant setting has reasonable success rates through five years. No preoperative factors were associated with re-implantation failure. While all patients need to be followed due to increasing rates of failure with time, patients receiving palliative or salvage radiation therapy appear to be more prone to failure requiring further intervention.
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Affiliation(s)
| | - Amy L Tin
- Memorial Sloan Kettering Cancer, New York, NY
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19
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Bong JW, Lee JA, Ju Y, Seo J, Kang SH, Lee SI, Min BW. Treatment outcomes of patients with involved resection margin after rectal cancer surgery: A nationwide population-based cohort study in South Korea. Asia Pac J Clin Oncol 2021; 18:378-387. [PMID: 34310853 DOI: 10.1111/ajco.13608] [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: 04/01/2021] [Accepted: 04/27/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The involvement of resection margins after rectal cancer surgery by malignant tumors is a negative prognostic factor. Therefore, it is important to analyze treatment outcomes and establish adjuvant therapy. METHODS The Health Insurance Review and Assessment Service collects data from medical institutions in South Korea. We reviewed the database of this prospectively collected cohort for patients who underwent curative resection for rectal cancer. RESULTS Of the 5,620 patients, 113 (2.0%) were diagnosed with resection margin involvement after surgery. The resection margins of patients with mid-rectal cancer, pathologic stage III, mucinous/signet ring cell carcinoma, and undergoing emergency surgery were more frequently involved. Neoadjuvant chemoradiotherapy was a significant preventive factor for resection margin involvement (odds ratio = 0.53; 95% confidence interval [CI], 0.32-0.87; p = 0.012). The OS of patients with adjuvant treatment was better than that of patients without adjuvant treatment (5-year overall survival [OS]: 62.8% vs. 46.3%, p = 0.02). The administration of chemoradiotherapy was also significantly associated with better OS (hazard ratio = 0.36; 95% CI, 0.17-0.77; p = 0.009). CONCLUSION Efforts to acquire wider resection margins are necessary for patients with mid-rectal cancer, pathologic stage III, mucinous/signet ring cell carcinoma, and emergency surgery. Neoadjuvant chemoradiotherapy was a significant preventive factor for involved resection margin. Patients with resection margin involvement showed better OS after adjuvant treatment than those without adjuvant treatment. The adjuvant chemoradiotherapy was helpful to prevent the worse prognosis of these patients.
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Affiliation(s)
- Jun Woo Bong
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jung Ae Lee
- Department of Radiation Oncology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yeonuk Ju
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jihyun Seo
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sang Hee Kang
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sun Il Lee
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung Wook Min
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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20
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Yigit B, Kabul Gurbulak E, Ton Eryilmaz O. Usefulness of Endoscopic Tattooing Before Neoadjuvant Therapy in Patients with Clinical Complete Response in Locally Advanced Rectal Cancer for Providing a Safe Distal Surgical Margin. J Laparoendosc Adv Surg Tech A 2021; 32:506-514. [PMID: 34232787 DOI: 10.1089/lap.2021.0382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Endoscopic tattooing of colorectal tumors enables tumor localization and determination of appropriate surgical margins. It becomes very difficult to detect the distal surgical margins (DSMs) of rectal tumors in patients who obtain clinical complete response (cCR) after neoadjuvant therapy. In this study, our aim is to examine the benefits of endoscopic tattooing of the tumor before neoadjuvant therapy in patients with locally advanced rectal cancer in accurate localization of the previous tumor and in providing appropriate DSMs in cases with cCR. Patients and Methods: The patients who were diagnosed with locally advanced rectal cancer, received neoadjuvant therapy and subsequently achieved cCR, and underwent surgery between January 2015 and October 2020 were included in the study. The patients were divided into two groups according to whether they were endoscopically tattooed before neoadjuvant chemoradiotherapy. Results: A total of 49 cases were included in the study. Significantly better DSMs were observed especially in female gender in the tattooed group. DSMs were found to be closer to the resection margins in the nontattooed group. It was found that endoscopic tattooing had a significant effect on the DSM in the regression analysis (P = .06, R2 = 0.47). It was determined that laparoscopy or open surgery alone did not differ in terms of DSMs but open surgery together with tattooing was found to be strongly effective in providing larger DSMs. Conclusion: In locally advanced rectal cancer, endoscopic tattooing of the distal margin of the tumor before neoadjuvant therapy is a reliable and effective method for obtaining a safe DSM and not leaving the residual tumor at the lower end of anastomosis, especially in cases of cCR.
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Affiliation(s)
- Banu Yigit
- Department of General Surgery, Sisli Hamidiye Etfal Medical Practice and Research Center, University of Health Sciences, Istanbul, Turkey
| | - Esin Kabul Gurbulak
- Department of General Surgery, Sisli Hamidiye Etfal Medical Practice and Research Center, University of Health Sciences, Istanbul, Turkey
| | - Ozlem Ton Eryilmaz
- Department of Pathology, Sisli Hamidiye Etfal Medical Practice and Research Center, University of Health Sciences, Istanbul, Turkey
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21
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Gao Z, Gu J. Surgical treatment of locally recurrent rectal cancer: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1026. [PMID: 34277826 PMCID: PMC8267292 DOI: 10.21037/atm-21-2298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/02/2021] [Indexed: 12/12/2022]
Abstract
Objective To summarize the recent literature on surgical treatment of locally recurrent rectal cancer (LRRC). Background LRRC is a heterogeneous disease that requires a multidisciplinary treatment approach. The treatment and prognosis depend on the site and type of recurrence. Radical resection remains the primary method for achieving long-term survival and improving symptom control. Preoperative chemoradiotherapy can reduce tumor volume and improve the R0 resection rate. Surgeons must clearly understand pelvic anatomy, develop a detailed preoperative plan, adopt a multidisciplinary approach for the surgical resection of the tumor as well as any invaded soft tissues, vessels, and bones, and ensure proper reconstruction. However, extended radical surgery often leads to a higher risk of postoperative complications and a low quality of life. Methods We searched English-language articles with keywords “locally recurrent rectal cancer”, “surgery” and “multidisciplinary team” in PubMed published between January 2000 to October 2020. Conclusions LRRC is a complex problem. Long-term survival is not impossible following multidisciplinary treatment in appropriately selected LRRC patients. The management of LRRC relies on a specialist team that determines the biological behavior of the tumor and evaluates treatment options through multidisciplinary discussions, thereby balancing the surgical costs and benefits, alleviating postoperative complications, and improving patients’ quality of life.
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Affiliation(s)
- Zhaoya Gao
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China
| | - Jin Gu
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing, China.,Department of Gastrointestinal Surgery III, Peking University Cancer Hospital, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing, China
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22
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Fukuhara S, Yoshimitsu M, Yano T, Oshita K, Bekku K, Okamoto H, Toi Y, Ichimura K, Okamoto W, Okajima M. Radical surgery for anal canal neuroendocrine carcinoma with pagetoid spread: a case report. J Surg Case Rep 2021; 2021:rjab111. [PMID: 34025964 PMCID: PMC8130878 DOI: 10.1093/jscr/rjab111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/05/2021] [Indexed: 01/17/2023] Open
Abstract
Anal canal neuroendocrine carcinoma (NEC) with pagetoid spread (PS) is a rare disease, and its treatment strategy remains unclear. The prognosis of anal canal NEC with PS is poor. Resection margin status is very important for anorectal carcinoma because it affects survival. When accompanied by PS, the defect of the resulting perineal wound following radical surgical intervention may be necessarily enlarged to ensure the appropriate margin status. This case report discusses the treatment of a patient with advanced anal canal NEC with PS, inguinal lymph node metastasis and sphincter infiltration in which total pelvic exenteration with plastic surgery was successfully performed. The plastic surgery incorporated a gracilis muscle flap that was useful for the reconstruction of the enlarged perineal defect.
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Affiliation(s)
- Sotaro Fukuhara
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33, Motomachi, Naka-ku, Hiroshima 730-8518, Japan
| | - Masanori Yoshimitsu
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33, Motomachi, Naka-ku, Hiroshima 730-8518, Japan
| | - Takuya Yano
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33, Motomachi, Naka-ku, Hiroshima 730-8518, Japan
| | - Ko Oshita
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33, Motomachi, Naka-ku, Hiroshima 730-8518, Japan
| | - Kensuke Bekku
- Department of Urology, Hiroshima City Hiroshima Citizens Hospital, 7-33, Motomachi, Naka-ku, Hiroshima 730-8518 Japan
| | - Hitoshi Okamoto
- Department of Plastic Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33, Motomachi, Naka-ku, Hiroshima 730-8518, Japan
| | - Yoichiro Toi
- Department of Dermatology, Hiroshima City Hiroshima Citizens Hospital, 7-33, Motomachi, Naka-ku, Hiroshima 730-8518, Japan
| | - Koichi Ichimura
- Department of Pathology, Hiroshima City Hiroshima Citizens Hospital, 7-33, Motomachi, Naka-ku, Hiroshima 730-8518, Japan
| | - Wataru Okamoto
- Cancer Treatment Center, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - Masazumi Okajima
- Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 7-33, Motomachi, Naka-ku, Hiroshima 730-8518, Japan
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23
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Heidkamp J, Scholte M, Rosman C, Manohar S, Fütterer JJ, Rovers MM. Novel imaging techniques for intraoperative margin assessment in surgical oncology: A systematic review. Int J Cancer 2021; 149:635-645. [PMID: 33739453 PMCID: PMC8252509 DOI: 10.1002/ijc.33570] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 12/08/2020] [Accepted: 03/01/2021] [Indexed: 12/25/2022]
Abstract
Inadequate margins continue to occur frequently in patients who undergo surgical resection of a tumor, suggesting that current intraoperative methods are not sufficiently reliable in determining the margin status. This clinical demand has inspired the development of many novel imaging techniques that could help surgeons with intraoperative margin assessment. This systematic review provides an overview of novel imaging techniques for intraoperative margin assessment in surgical oncology, and reports on their technical properties, feasibility in clinical practice and diagnostic accuracy. PubMed, Embase, Web of Science and the Cochrane library were systematically searched (2013‐2018) for studies reporting on imaging techniques for intraoperative margin assessment. Patient and study characteristics, technical properties, feasibility characteristics and diagnostic accuracy were extracted. This systematic review identified 134 studies that investigated and developed 16 groups of techniques for intraoperative margin assessment: fluorescence, advanced microscopy, ultrasound, specimen radiography, optical coherence tomography, magnetic resonance imaging, elastic scattering spectroscopy, bio‐impedance, X‐ray computed tomography, mass spectrometry, Raman spectroscopy, nuclear medicine imaging, terahertz imaging, photoacoustic imaging, hyperspectral imaging and pH measurement. Most studies were in early developmental stages (IDEAL 1 or 2a, n = 98); high‐quality stage 2b and 3 studies were rare. None of the techniques was found to be clearly superior in demonstrating high feasibility as well as high diagnostic accuracy. In conclusion, the field of imaging techniques for intraoperative margin assessment is highly evolving. This review provides a unique overview of the opportunities and limitations of the currently available imaging techniques.
What's new?
While surgical resection is critical in the treatment of primary solid tumors, resection at tumor margins remains problematic, with inadequately resected margins facilitating tumor recurrence. In this systematic review, the authors collected information on novel imaging techniques applied to the intraoperative assessment of tumor margins across cancer types. A total of 16 groups of techniques were identified, with many in early stages of clinical application. Following comparison, no single technique was clearly superior in clinical feasibility or diagnostic accuracy. The review highlights the evolving nature of imaging techniques for intraoperative margin assessment and identifies opportunities and limitations in the field.
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Affiliation(s)
- Jan Heidkamp
- Department of Radiology and Nuclear Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mirre Scholte
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Srirang Manohar
- Multi-Modality Medical Imaging group, Technical Medical Center, University of Twente, Enschede, The Netherlands
| | - Jurgen J Fütterer
- Department of Radiology and Nuclear Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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24
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Ng KS, Lee PJM. Pelvic exenteration: Pre-, intra-, and post-operative considerations. Surg Oncol 2021; 37:101546. [PMID: 33799076 DOI: 10.1016/j.suronc.2021.101546] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/02/2021] [Indexed: 01/18/2023]
Abstract
This review outlines the role of pelvic exenteration (PE) in the management of certain locally-advanced primary and recurrent rectal cancers. PE has undergone significant evolution over the past decades. Advances in pre-, intra-, and post-operative care have been directed towards achieving the 'holy grail' of an R0 resection, which remains the most important predictor of survival, quality of life, morbidity, and cost effectiveness following PE. Patient selection for surgery is largely determined by assessment of resectability. Pelvic magnetic resonance imaging determines the extent of local disease, while positron emission tomography remains the most accurate tool for exclusion of distant metastases. PE in the setting of metastatic disease or with palliative intent remains controversial. The intra-operative approach is based on the anatomical division of the pelvis into five compartments (anterior, central, posterior, and two lateral). Within each compartment are various possible dissection planes which are elected depending on the extent of tumour involvement. Innovations in surgical technique have allowed 'higher and wider' dissection planes with resultant en bloc excision of major vessels, major nerves, and bone. Evidence of improved R0 resection and survival rates with these techniques justifies the radicality of these novel approaches. Post-operative care for PE patients is technically demanding with a substantial hospital resource burden. Unique considerations for PE patients include the 'empty pelvis syndrome', urological complications, and management of post-operative malnutrition. While undeniably a morbid procedure, quality of life largely returns to baseline at six months, and for long-term survivors is sustained for up to five years.
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Affiliation(s)
- Kheng-Seong Ng
- Royal Prince Alfred Hospital, Department of Colorectal Surgery, Sydney, Australia; Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter J M Lee
- Royal Prince Alfred Hospital, Department of Colorectal Surgery, Sydney, Australia; Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, Australia.
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25
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Alahmadi R, Steffens D, Solomon MJ, Lee PJ, Austin KKS, Koh CE. Elderly Patients Have Better Quality of Life but Worse Survival Following Pelvic Exenteration: A 25-Year Single-Center Experience. Ann Surg Oncol 2021; 28:5226-5235. [PMID: 33751294 DOI: 10.1245/s10434-021-09685-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/22/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To describe quality of life (QOL) and survival outcomes following pelvic exenteration (PE) in old and young patients. BACKGROUND PE is a management option for complete resection in locally advanced pelvic cancers. Few studies have examined the impact of age on the outcome in elderly patients following PE. PATIENTS AND METHODS Prospective cohort of consecutive patients undergoing partial and complete PE between 1994 and 2019. Patients were divided into a younger (< 65 years) or older cohort (≥ 65 years) based on their age. QoL was assessed using the SF-36 and FACT-C questionnaires and survival estimated using the Kaplan-Meier method. RESULTS For 710 patients who underwent PE during the study period, FACT-C total score was significantly better in the elderly during the whole follow-up period of 5 years. Mental component score (SF-36) was significantly better at baseline (p = 0.008) and at 24 months postoperatively (p = 0.042), in the elderly group. Median overall survival was 75 months in the younger cohort and 53 months in the older cohort (p = 0.004). In subgroup analysis, older patients with recurrent or primary rectal cancer had a median survival of 37 and 70 months, respectively. Postoperative cardiovascular complications were greater in the elderly cohort (p < 0.001). CONCLUSIONS Elderly patients had better overall QoL but lower survival that is probably related to cardiovascular complications rather than to cancer as both groups had similar R0 resection rate. Hence, the elderly population should be considered equally for PE.
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Affiliation(s)
- Raha Alahmadi
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, University of Sydney, Sydney Local Health District, New South Wales, Australia.,Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia. .,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, University of Sydney, Sydney Local Health District, New South Wales, Australia. .,Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia. .,RPA Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia.
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, University of Sydney, Sydney Local Health District, New South Wales, Australia.,RPA Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, University of Sydney, Sydney Local Health District, New South Wales, Australia
| | - Cherry E Koh
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, University of Sydney, Sydney Local Health District, New South Wales, Australia.,Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia.,RPA Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
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Pandit N, Deo KB, Gautam S, Yadav TN, Kafle A, Singh SK, Awale L. Extended Total Mesorectal Excision (e-TME) for Locally Advanced Rectal Cancer. J Gastrointest Cancer 2021; 53:253-258. [PMID: 33417198 DOI: 10.1007/s12029-020-00562-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Locally advanced rectal cancer (LARC) can involve surrounding pelvic organs requiring multivisceral resection. Extended total mesorectal excision (e-TME) or multivisceral resection is a complex procedure associated with high morbidity, mortality, and R1 resection rates. However, e-TME in LARC with surrounding organ involvement is the only potential option for cure. The study aims to assess the clinical outcome of patients requiring e-TME for LARC. METHODS The study is a retrospective review of all patients with LARC requiring multivisceral resection (2013 to 2019). The database includes clinic-demographic profile, pelvic organ involved, operative details, resection margin status, morbidity, mortality, and survival. RESULTS Seven consecutive patients (9.2%) out of 76 LARC (median age 46 years; 5 females) required multivisceral resection. The organs involved were bladder (4); posterior wall of vagina (2); and uterus (1). The en bloc resection included total cystoprostatectomy - 1; partial cystectomy - 3; posterior vaginectomy - 2; and hysterectomy - 1. Additionally, four required abdominoperineal resection. All were adenocarcinoma: stage III, with R0 resection - 76%. The overall complications were seen in 60% of patients, majority being wound related. There was no operative mortality. The median survival was 32.2 months in the entire series, while one died with the disease at a 28-month follow-up. CONCLUSION e-TME with curative intent, though a complex procedure, is associated with high wound-related morbidity, R1 resection, but improved median survival benefit.
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Affiliation(s)
- Narendra Pandit
- Division of Surgical Gastroenterology, Department of Surgery, B P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal.
| | - Kunal Bikram Deo
- Division of Surgical Gastroenterology, Department of Surgery, B P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
| | - Sujan Gautam
- Division of Surgical Gastroenterology, Department of Surgery, B P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
| | - Tek Narayan Yadav
- Division of Surgical Gastroenterology, Department of Surgery, B P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
| | - Awaj Kafle
- Division of Urology, Department of Surgery, B P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
| | - Sudhir Kumar Singh
- Division of Urology, Department of Surgery, B P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
| | - Laligen Awale
- Division of Surgical Gastroenterology, Department of Surgery, B P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
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Shao W, Wang H, Chen Q, Zhao W, Gu Y, Feng G. Enhanced recovery after surgery nursing program, a protective factor for stoma-related complications in patients with low rectal cancer. BMC Surg 2020; 20:316. [PMID: 33276751 PMCID: PMC7716511 DOI: 10.1186/s12893-020-00978-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/22/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND This study aimed to investigate the association between enhanced recovery after surgery (ERAS) nursing program and stoma-related complications (SRCs) and prognosis in patients with low rectal cancer (LRC) undergoing abdominoperineal resection with sigmoidostomy. METHODS LRC patients who underwent elective abdominoperineal resection with sigmoidostomy between May 2016 and May 2019 were retrospectively enrolled. The occurrence of early major or minor SRCs (within postoperative 30 days) was set as the primary end-point. Clinicopathological variables and laboratory tests were compared between patients with or without SRCs. The univariate and multivariate logistic regression analyses were performed to investigate risk factors for SRCs. Hospitalization satisfaction-related and prognosis-related variables were compared between LRC patients with or without ERAS nursing program. RESULTS A total of 288 patients were enrolled and the incidence of SRCs was 26.7% (77/288). ERAS nursing program was the only independent risk factor for SRCs in LRC patients (OR 2.04, 95%CI 1.31-3.12, P = 0.016) by the multivariate logistic regression analysis. Moreover, ERAS nursing program was associated with higher hospitalization satisfaction rate, faster bowel function recovery, better psychological status, and higher quality of life. CONCLUSIONS ERAS nursing program was a protective factor for SRCs and associated with improved prognosis in LRC patients undergoing elective abdominoperineal resection with sigmoidostomy.
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Affiliation(s)
- Weiling Shao
- Department of General Surgery, Taizhou People's Hospital, Taizhou, China
| | - Honggang Wang
- Department of General Surgery, Taizhou People's Hospital, Taizhou, China
| | - Qun Chen
- Department of General Surgery, Taizhou People's Hospital, Taizhou, China
| | - Wen Zhao
- Department of General Surgery, Taizhou People's Hospital, Taizhou, China
| | - Yulian Gu
- Department of General Surgery, Taizhou People's Hospital, Taizhou, China
| | - Guoqin Feng
- Department of Nursing, Taizhou People's Hospital, No. 366 Taihu Road, Taizhou, 225300, Jiangsu Province, China.
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Vigneswaran HT, Schwarzman LS, Madueke IC, David SM, Nordenstam J, Moreira D, Abern MR. Morbidity and Mortality of Total Pelvic Exenteration for Malignancy in the US. Ann Surg Oncol 2020; 28:2790-2800. [PMID: 33105501 DOI: 10.1245/s10434-020-09247-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/27/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Total pelvic exenterations (TPEs) for malignancies are complex operations often performed by multidisciplinary teams. The differences among primary cancer for TPE and multicentered results are not well described. We aimed to describe TPE outcomes for different malignant origins in a national multicentered sample. METHODS Patients from the National Surgical Quality Improvement Program (NSQIP) database who underwent TPE between 2005 and 2016 for all malignant indications (colorectal, gynecologic, urologic, or other) were included. Chi square and Kruskal-Wallis tests were used to compare patient characteristics by primary malignancy. Multivariate logistic and linear regression models were used to determine factors associated with any 30-day Clavien-Dindo grade 3 or higher complication, length of hospital stay (LOS; days), 30-day wound infection, and 30-day mortality. RESULTS Overall, 2305 patients underwent TPE. Indications for surgery included 33% (749) colorectal, 15% (335) gynecologic, 9% (196) other, and 45% (1025) urologic malignancies. Median LOS decreased from 10 to 8 days during the study period (p < 0.001), 36% were males, and 50% required blood transfusion. High-grade complications occurred in 15% of patients and were associated with bowel diversion [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.1-2.4], disseminated cancer (OR 1.8, 95% CI 1.4-2.3), and gynecologic cancers (OR 2.9, 95% CI 1.8-4.7). Mortality was 2% and was associated with disseminated cancer (OR 2.2, 95% CI 1.1-4.3) and male sex (OR 2.4, 95% CI 1.3-4.4). CONCLUSIONS TPE is associated with high rates of complications, however mortality rates remain low. Preoperative and perioperative outcomes differ depending on the origin of the primary malignancy.
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Affiliation(s)
- Hari T Vigneswaran
- Department of Urology, University of Illinois at Chicago, Chicago, IL, USA.
| | - Logan S Schwarzman
- Department of Urology, University of Illinois at Chicago, Chicago, IL, USA
| | - Ikenna C Madueke
- Department of Urology, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Johan Nordenstam
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Daniel Moreira
- Department of Urology, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael R Abern
- Department of Urology, University of Illinois at Chicago, Chicago, IL, USA
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Hasegawa S, Kajitani R, Munechika T, Matsumoto Y, Nagano H, Taketomi H, Komono A, Aisu N, Yoshimatsu G, Morimoto M, Yoshida Y. Avoiding urethral and rectal injury during transperineal abdominoperineal resection in male patients with anorectal cancer. Surg Endosc 2020; 34:4679-4682. [PMID: 32430530 DOI: 10.1007/s00464-020-07655-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 05/14/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND In abdominoperineal resection (APR) in male patients with rectal cancer, high margin involvement and urethral injury have been reported to result from difficulty in dissecting the anterior anorectum. Recently, the efficacy of an endoscopic down-to-up rectal dissection was reported. Here, we present a safe and simple technique for anterior dissection using a simultaneous laparoscopic and transperineal endoscopic approach. METHODS We perform transperineal APR (TpAPR) using both the laparoscopic and transperineal approach (a 2-team approach). Anterior dissection commences just behind the superficial transverse perineal muscle. Next, the striated muscle complex surrounding the rectum (levator ani and puborectalis muscle) is divided. At this point, it is difficult to identify the dissection plane between the membranous urethra and anterior rectum; thus, dissection along the lateral aspect of neurovascular bundle from the lateral to anterior side with the assistance of the laparoscopic team is helpful in identifying the posterior surface of the prostate. Once the prostate is identified, it is relatively easy to divide the rectourethralis muscles. The key steps of our procedure are shown in the video. RESULTS Between April 2016 and July 2019, we performed 14 TpAPR procedures in male patients with rectal cancer without distant metastasis. Extended surgery was performed in 8 patients, including pelvic sidewall dissection and combined resection of adjacent organs. Median operative time was 453 min and median blood loss was 46 g. There was 1 (7.1%) circumferential-positive case, but no cases of urethral injury or rectal perforation. CONCLUSIONS The 2-team TpAPR procedure is beneficial for appropriate dissection of the anterior side during APR surgery.
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Affiliation(s)
- Suguru Hasegawa
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.
| | - Ryuji Kajitani
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Taro Munechika
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshiko Matsumoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hideki Nagano
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hirotaka Taketomi
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Akira Komono
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Naoya Aisu
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Gumpei Yoshimatsu
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Mitsuaki Morimoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoichiro Yoshida
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Yoon HM, Kim H, Sohn DK, Park SC, Chang HJ, Oh JH, Dasari RR, So PTC, Kang JW. Dual modal spectroscopic tissue scanner for colorectal cancer diagnosis. Surg Endosc 2020; 35:4363-4370. [PMID: 32875410 DOI: 10.1007/s00464-020-07929-2] [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: 07/15/2019] [Accepted: 08/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Margin status is an important prognostic factor for treating colorectal cancer. This study aimed to investigate the usefulness of a multimodal spectroscopic tissue scanner for real-time cancer diagnosis without tissue staining. PATIENTS AND METHODS Diffuse reflectance spectra (DRS) and fluorescence spectra (FS) of < 1-mm-sized paired cancer and normal mucosa tissue were acquired using custom-built spectroscopic tissue scanners. For FS, we analyzed wavelengths and intensities at peaks and highest intensities near (± 1.25 nm) the known fluorescence spectral peaks of collagen (380 nm), reduced nicotinamide adenine dinucleotide (NADH, 460 nm), and flavin adenine dinucleotide (FAD, 550 nm). For DRS, we performed a similar analysis near the peaks of strong absorbers, oxyhemoglobin (oxyHb; 414 nm, 540 nm, and 576 nm) and deoxyhemoglobin (deoxyHb; 432 nm and 556 nm). Logistic regression analysis for these parameters was performed in the testing set. RESULTS We acquired 17,735 spectra of cancer tissues and 9438 of normal tissues from 30 patients. Intensity peaks of representative normal spectra for FS and DRS were higher than those of representative cancer spectra. Logistic regression analysis showed wavelength and intensity at peaks, and the intensities of the peak wavelength of NADH, FAD, deoxyHb, and oxyHb had significant coefficients. The area under the receiver operating characteristic curve was 0.927. The scanner had 100%, 64.3%, and 85.3% sensitivity, specificity, and accuracy, respectively. CONCLUSIONS The spectroscopic tissue scanner has high sensitivity and accuracy and provides real-time intraoperative resection margin assessments and should be further investigated as an alternative to frozen section.
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Affiliation(s)
- Hong Man Yoon
- Division of Convergence Technology, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hongrae Kim
- Division of Convergence Technology, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Kyung Sohn
- Division of Convergence Technology, Research Institute and Hospital, National Cancer Center, Goyang, Korea.
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, 10408, Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, 10408, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, 10408, Korea
| | - Ramachandra R Dasari
- Laser Biomedical Research Center, G. R. Harrison Spectroscopy Laboratory, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA, 02139, USA
| | - Peter T C So
- Laser Biomedical Research Center, G. R. Harrison Spectroscopy Laboratory, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA, 02139, USA
| | - Jeon Woong Kang
- Laser Biomedical Research Center, G. R. Harrison Spectroscopy Laboratory, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, MA, 02139, USA.
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Konstantinidis IT, Lee B, Trisal V, Paz I, Melstrom K, Sentovich S, Lai L, Raoof M. National postoperative and oncologic outcomes after pelvic exenteration for T4b rectal cancer. J Surg Oncol 2020; 122:739-744. [PMID: 32516469 DOI: 10.1002/jso.26058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/08/2020] [Accepted: 05/22/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Studies reporting outcomes after pelvic exenteration for rectal cancer are limited. The objective of this study was to evaluate early postoperative and oncologic outcomes in a national multi-institutional cohort. METHODS Using the National Cancer Database (NCDB), which collects data from over 1500 commission on cancer (CoC)-accredited hospitals, we analyzed patients undergoing pelvic exenteration for T4b rectal adenocarcinoma. RESULTS There were 1367 pelvic exenterations performed in 552 hospitals. Median age was 60 years, the majority of patients (n = 831; 60.8%) were female. Neoadjuvant radiation was used only in 57%; 24.3% of resections had positive margins. Following exenteration, 30-day mortality rate, 90-day mortality rate, and readmission rates were: 1.8%, 4.4%, and 7.4%. Age ≥ 60 years and higher Charlson-Deyo comorbidity index were independently associated with increased 90-day mortality (P < .001). Overall survival (OS) was 50 months. After adjustment of significant covariates, negative margin status (adjusted HR, 0.6, 95% CI, 0.5-0.8; P < .001) and receipt of perioperative radiation or chemoradiation (adjusted HR, 0.5; 95% CI, 0.4-0.6; P < .001) were significantly associated with decreased risk of death. Only 71% of the patients received perioperative radiation. CONCLUSIONS Pelvic exenterations are being performed safely in Coc-accredited hospitals. However, up to one fourth of patients undergo resections with positive margins or are subject to underutilization of perioperative radiation therapy. Increased use of radiation may increase negative margin resections and improve patient outcomes.
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Affiliation(s)
| | - Byrne Lee
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Vijay Trisal
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Issac Paz
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Kurt Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Stephen Sentovich
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Lily Lai
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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Baird DLH, Kontovounisios C, Simillis C, Pellino G, Rasheed S, Tekkis PP. Factors associated with metachronous metastases and survival in locally advanced and recurrent rectal cancer. BJS Open 2020; 4:1172-1179. [PMID: 32856767 PMCID: PMC7709378 DOI: 10.1002/bjs5.50341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 07/15/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Better understanding of the impact of metachronous metastases in locally advanced and recurrent rectal cancer may improve decision-making. The aim of this study was to investigate factors influencing metachronous metastasis and its impact on survival in patients who have a beyond total mesorectal excision (bTME) operation. METHODS This was a retrospective study of consecutive patients who had bTME surgery for locally advanced and recurrent rectal cancer at a tertiary referral centre between January 2006 and December 2016. The primary outcome was overall survival. Cox proportional hazards regression analyses were performed. The influence of metachronous metastases on survival was investigated. RESULTS Of 220 included patients, 171 were treated for locally advanced primary tumours and 49 for recurrent rectal cancer. Some 90·0 per cent had a complete resection with negative margins. Median follow-up was 26·0 (range 1·5-119·6) months. The 5-year overall survival rate was 71·1 per cent. Local recurrence and metachronous metastasis rates were 11·8 and 22·2 per cent respectively. Patients with metachronous metastases had a worse overall survival than patients without metastases (median 52·9 months versus estimated mean 109·4 months respectively; hazard ratio (HR) 6·73, 95 per cent c.i. 3·23 to 14·00). Advancing pT category (HR 2·01, 1·35 to 2·98), pN category (HR 2·43, 1·65 to 3·59), vascular invasion (HR 2·20, 1·22 to 3·97) and increasing numbers of positive lymph nodes (HR 1·19, 1·07 to 1·16) increased the risk of metachronous metastasis. Nine of 17 patients (53 per cent) with curatively treated synchronous metastases at presentation developed metachronous metastases, compared with 40 of 203 (19·7 per cent) without synchronous metastases (P = 0·002). Corresponding median length of disease-free survival was 17·5 versus 90·8 months (P < 0·001). CONCLUSION As metachronous metastases impact negatively on survival after bTME surgery, factors associated with metachronous metastases may serve as selection tools when determining suitability for treatment with curative intent.
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Affiliation(s)
- D. L. H. Baird
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
| | - C. Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
- Department of Colorectal SurgeryChelsea and Westminster HospitalLondonUK
| | - C. Simillis
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
| | - G. Pellino
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
| | - S. Rasheed
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
- Department of Colorectal SurgeryChelsea and Westminster HospitalLondonUK
| | - P. P. Tekkis
- Department of Colorectal Surgery, The Royal Marsden HospitalLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
- Department of Colorectal SurgeryChelsea and Westminster HospitalLondonUK
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Quicker, deeper and stronger imaging: A review of tumor-targeted, near-infrared fluorescent dyes for fluorescence guided surgery in the preclinical and clinical stages. Eur J Pharm Biopharm 2020; 152:123-143. [PMID: 32437752 DOI: 10.1016/j.ejpb.2020.05.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 05/03/2020] [Accepted: 05/03/2020] [Indexed: 12/12/2022]
Abstract
Cancer is a public health problem and the main cause of human mortality and morbidity worldwide. Complete removal of tumors and metastatic lymph nodes in surgery is significantly beneficial for the prognosis of patients. Tumor-targeted, near-infrared fluorescent (NIRF) imaging is an emerging field of real-time intraoperative cancer imaging based on tumor-targeted NIRF dyes. Targeted NIRF dyes contain NIRF fluorophores and specific binding ligands such as antibodies, peptides and small molecules. The present article reviews recently updated tumor-targeted NIRF dyes for the molecular imaging of malignant tumors in the preclinical stage and clinical trials. The strengths and challenges of NIRF agents with tumor-targeting ability are also summarized. Smaller ligands, near infrared II dyes, dual-modality dyes and activatable dyes may contribute to quicker, deeper, stronger imaging in the nearest future. In this review, we highlighted tumor-targeted NIRF dyes for fluorescence-guided surgery and their potential clinical translation.
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Proctor MJ, Westwood DA, Donahoe S, Chauhan A, Lynch AC, Heriot AG, Sent-Doux K, Creagh T, Frizelle FA, Wakeman CJ. Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery. Colorectal Dis 2020; 22:562-568. [PMID: 31713965 DOI: 10.1111/codi.14909] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 10/29/2019] [Indexed: 02/08/2023]
Abstract
AIM Patients who undergo radical pelvic surgery often have problems with perineal wound healing and pelvic collections. While there is recognition of the perineal morbidity, there also remains uncertainty around the benefit of vertical rectus abdominus myocutaneous (VRAM) flaps due to the balance between primary healing and the complications associated with this form of reconstruction. This study aimed to evaluate factors associated with significant flap and donor site related complications following VRAM flap reconstruction for radical pelvic surgery. METHOD A retrospective analysis of VRAM flap related complications was undertaken from prospectively maintained databases for all patients undergoing radical pelvic surgery (2001- 2017) in two cancer centres. RESULTS In all, 154 patients were identified [median age 62 years (range 26-89 years), 80 (52%) men]. Thirty-three (21%) patients experienced significant donor or flap related complications. Major complications (Clavien-Dindo ≥ 3) related to the abdominal donor site occurred in nine (6%) patients, while those related to the flap or perineal site occurred in 28 (18%) patients. Only smoking (P = 0.003) and neoadjuvant radiotherapy (P = 0.047) were associated with the development of significant flap related complications on univariate analysis. Flap related complications resulted in a significantly longer hospital stay (P < 0.001). CONCLUSION Careful patient selection is required to balance the risks vs the benefits of VRAM flap reconstruction. Immediate VRAM reconstruction in patients undergoing radical pelvic surgery can achieve early healing and stable perineal closure; it has a low but significant morbidity. Major flap related complications are significantly associated with smoking status and neoadjuvant radiotherapy and result in a prolonged length of hospital stay.
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Affiliation(s)
- M J Proctor
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - D A Westwood
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - S Donahoe
- Division of Cancer Surgery, Peter MacCullam Cancer Centre, Melbourne, Vic, Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic, Australia
| | - A Chauhan
- Division of Cancer Surgery, Peter MacCullam Cancer Centre, Melbourne, Vic, Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic, Australia
| | - A C Lynch
- Division of Cancer Surgery, Peter MacCullam Cancer Centre, Melbourne, Vic, Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic, Australia
| | - A G Heriot
- Division of Cancer Surgery, Peter MacCullam Cancer Centre, Melbourne, Vic, Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic, Australia
| | - K Sent-Doux
- Department of Plastic and Reconstructive Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - T Creagh
- Department of Plastic and Reconstructive Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - F A Frizelle
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand.,University Department of Surgery, University of Otago, Christchurch, New Zealand
| | - C J Wakeman
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand.,University Department of Surgery, University of Otago, Christchurch, New Zealand
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35
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Heah NH, Wong KY. Feasibility of robotic assisted bladder sparing pelvic exenteration for locally advanced rectal cancer: A single institution case series. World J Gastrointest Surg 2020; 12:190-196. [PMID: 32426098 PMCID: PMC7215973 DOI: 10.4240/wjgs.v12.i4.190] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/12/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pelvic exenteration for locally advanced rectal cancer involving prostate has been performed via open surgery. Robotic pelvic exenteration offers benefits of better pelvic visualisation and dissection for bladder preserving prostatectomy with vesicourethral anastomosis, while achieving clear margins.
AIM To determine the feasibility of robotic assisted bladder sparing pelvic exenteration.
METHODS We describe robotic assisted pelvic exenteration in three cases of locally advanced rectal cancer involving prostate and seminal vesicles (SV). The da Vinci S robotic system was used. Robotic console was docked at left oblique position for abdominal phase and redocked to between the patient’s legs for pelvic phase. All three cases were performed fully robotically at Tan Tock Seng Hospital by colorectal and urological teams.
RESULTS Case 1: 67-year-old with low rectal tumour 3cm from anal verge involving the prostate. He underwent neo-adjuvant chemoradiotherapy and robotic abdominoperineal resection with en-bloc prostatectomy. Case 2: 66-year-old with low rectal tumour 3cm from anal verge involving prostate and bilateral SV. He underwent neo-adjuvant chemoradiotherapy and robot assisted ultra-low anterior resection with coloanal anastomosis and en-bloc prostatectomy. Case 3: 57-year-old with metachronous rectal tumour in the rectovesical pouch inseparable from the anterior mid rectum, prostate and bilateral SV. He underwent robot assisted ultra-low anterior resection with en-bloc prostatectomy. Bladder neck margin revealed cauterized tumour cells, and he underwent total cystectomy and ileal conduit creation. Histology revealed no residual tumour. All patients are currently disease free
CONCLUSION Robot assisted bladder sparing pelvic exenteration can be safely performed in locally advanced rectal cancer with acceptable surgical outcome while preserving benefits of minimally invasive surgery.
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Affiliation(s)
- Nathaniel H Heah
- Department of Urology, 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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36
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Safety and Feasibility of Laparoscopic Pelvic Exenteration for Locally Advanced or Recurrent Colorectal Cancer. Surg Laparosc Endosc Percutan Tech 2020; 29:389-392. [PMID: 31335481 DOI: 10.1097/sle.0000000000000699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Pelvic exenteration (PE) for locally advanced or recurrent colorectal cancer is often used to secure negative resection margins. The aim of this study was to evaluate the feasibility of laparoscopic PE. MATERIALS AND METHODS The clinical records of 24 patients (9, open; 15, laparoscopic) who underwent total or posterior PE for locally advanced or recurrent colorectal cancer between July 2012 and April 2016 at Osaka National Hospital were retrospectively reviewed. Operative factors were compared between the 2 groups. RESULTS The R0 resection rate was 100% in the laparoscopic group and 89% in the open group. The operative time and the incidence of postoperative complications were not significantly different between the 2 groups. The laparoscopic group showed less intraoperative blood loss (P=0.019), a lower C-reactive protein elevation on postoperative day 7 (P=0.025), and a shorter postoperative hospital stay (P=0.0009). CONCLUSIONS Laparoscopic PE is a safe and feasible procedure to reduce postoperative stress.
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37
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What Constitutes a Clear Margin in Patients With Locally Recurrent Rectal Cancer Undergoing Pelvic Exenteration? Ann Surg 2020; 275:157-165. [DOI: 10.1097/sla.0000000000003834] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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38
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Baltussen EJM, Brouwer de Koning SG, Sanders J, Aalbers AGJ, Kok NFM, Beets GL, Hendriks BHW, Sterenborg HJCM, Kuhlmann KFD, Ruers TJM. Using Diffuse Reflectance Spectroscopy to Distinguish Tumor Tissue From Fibrosis in Rectal Cancer Patients as a Guide to Surgery. Lasers Surg Med 2019; 52:604-611. [PMID: 31793012 DOI: 10.1002/lsm.23196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES In patients with rectal cancer who received neoadjuvant (chemo)radiotherapy, fibrosis is induced in and around the tumor area. As tumors and fibrosis have similar visual and tactile feedback, they are hard to distinguish during surgery. To prevent positive resection margins during surgery and spare healthy tissue, it would be of great benefit to have a real-time tissue classification technology that can be used in vivo. STUDY DESIGN/MATERIALS AND METHODS In this study diffuse reflectance spectroscopy (DRS) was evaluated for real-time tissue classification of tumor and fibrosis. DRS spectra of fibrosis and tumor were obtained on excised rectal specimens. After normalization using the area under the curve, a support vector machine was trained using a 10-fold cross-validation. RESULTS Using spectra of pure tumor tissue and pure fibrosis tissue, we obtained a mean accuracy of 0.88. This decreased to a mean accuracy of 0.61 when tumor measurements were used in which a layer of healthy tissue, mainly fibrosis, was present between the tumor and the measurement surface. CONCLUSION It is possible to distinguish pure fibrosis from pure tumor. However, when the measurements on tumor also involve fibrotic tissue, the classification accuracy decreases. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Elisabeth J M Baltussen
- Department of Surgery, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, 1066 CX, The Netherlands
| | - Susan G Brouwer de Koning
- Department of Surgery, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, 1066 CX, The Netherlands
| | - Joyce Sanders
- Department of Pathology, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, 1066 CX, The Netherlands
| | - Arend G J Aalbers
- Department of Surgery, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, 1066 CX, The Netherlands
| | - Niels F M Kok
- Department of Surgery, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, 1066 CX, The Netherlands
| | - Geerard L Beets
- Department of Surgery, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, 1066 CX, The Netherlands
| | - Benno H W Hendriks
- Department of In-body Systems, Philips Research, Eindhoven, 5656 AE, The Netherlands.,Department of Biomechanical Engineering, Delft University of Technology, Delft, 2600 AA, The Netherlands
| | - Henricus J C M Sterenborg
- Department of Surgery, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, 1066 CX, The Netherlands.,Department of Biomedical Engineering and Physics, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, 1105 AZ, The Netherlands
| | - Koert F D Kuhlmann
- Department of Surgery, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, 1066 CX, The Netherlands
| | - Theo J M Ruers
- Department of Surgery, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, 1066 CX, The Netherlands.,Faculty TNW, Group Nanobiophysics, Twente University, Enschede, 7522 NB, The Netherlands
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Lau YC, Brown KGM, Lee P. Pelvic exenteration for locally advanced and recurrent rectal cancer-how much more? J Gastrointest Oncol 2019; 10:1207-1214. [PMID: 31949941 DOI: 10.21037/jgo.2019.01.21] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
There have been significant advances in the surgical management of locally advanced and recurrent rectal cancer in recent decades. Patient with advanced pelvic tumours involving adjacent organs and neurovascular structures, beyond the traditional mesorectal planes, who would have traditionally been considered irresectable at many centres, now undergo surgery routinely at specialised units. While high rates of morbidity and mortality were reported by the pioneers of pelvic exenteration (PE) in early literature, this is now considered historical data. In 2019, patients who undergo PE for advanced or recurrent rectal cancer can expect reasonable rates of long-term survival (up to 60% at 5 years) and acceptable morbidity and quality of life. This article describes the surgical techniques that have been developed for radical multivisceral pelvic resections and reviews contemporary outcomes.
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Affiliation(s)
- Yee Chen Lau
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
| | - Peter Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
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41
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de Jongh SJ, Tjalma JJJ, Koller M, Linssen MD, Vonk J, Dobosz M, Jorritsma-Smit A, Kleibeuker JH, Hospers GAP, Havenga K, Hemmer PHJ, Karrenbeld A, van Dam GM, van Etten B, Nagengast WB. Back-Table Fluorescence-Guided Imaging for Circumferential Resection Margin Evaluation Using Bevacizumab-800CW in Patients with Locally Advanced Rectal Cancer. J Nucl Med 2019; 61:655-661. [PMID: 31628218 DOI: 10.2967/jnumed.119.232355] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/20/2019] [Indexed: 12/20/2022] Open
Abstract
Negative circumferential resection margins (CRM) are the cornerstone for the curative treatment of locally advanced rectal cancer (LARC). However, in up to 18.6% of patients, tumor-positive resection margins are detected on histopathology. In this proof-of-concept study, we investigated the feasibility of optical molecular imaging as a tool for evaluating the CRM directly after surgical resection to improve tumor-negative CRM rates. Methods: LARC patients treated with neoadjuvant chemoradiotherapy received an intravenous bolus injection of 4.5 mg of bevacizumab-800CW, a fluorescent tracer targeting vascular endothelial growth factor A, 2-3 d before surgery (ClinicalTrials.gov identifier: NCT01972373). First, for evaluation of the CRM status, back-table fluorescence-guided imaging (FGI) of the fresh surgical resection specimens (n = 8) was performed. These results were correlated with histopathology results. Second, for determination of the sensitivity and specificity of bevacizumab-800CW for tumor detection, a mean fluorescence intensity cutoff value was determined from the formalin-fixed tissue slices (n = 42; 17 patients). Local bevacizumab-800CW accumulation was evaluated by fluorescence microscopy. Results: Back-table FGI correctly identified a tumor-positive CRM by high fluorescence intensities in 1 of 2 patients (50%) with a tumor-positive CRM. For the other patient, low fluorescence intensities were shown, although (sub)millimeter tumor deposits were present less than 1 mm from the CRM. FGI correctly identified 5 of 6 tumor-negative CRM (83%). The 1 patient with false-positive findings had a marginal negative CRM of only 1.4 mm. Receiver operating characteristic curve analysis of the fluorescence intensities of formalin-fixed tissue slices yielded an optimal mean fluorescence intensity cutoff value for tumor detection of 5,775 (sensitivity of 96.19% and specificity of 80.39%). Bevacizumab-800CW enabled a clear differentiation between tumor and normal tissue up to a microscopic level, with a tumor-to-background ratio of 4.7 ± 2.5 (mean ± SD). Conclusion: In this proof-of-concept study, we showed the potential of back-table FGI for evaluating the CRM status in LARC patients. Optimization of this technique with adaptation of standard operating procedures could change perioperative decision making with regard to extending resections or applying intraoperative radiation therapy in the case of positive CRM.
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Affiliation(s)
- Steven J de Jongh
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jolien J J Tjalma
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjory Koller
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Matthijs D Linssen
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jasper Vonk
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michael Dobosz
- Discovery Oncology, Pharmaceutical Research and Early Development, Roche Innovation Center Munich, Penzberg, Germany
| | - Annelies Jorritsma-Smit
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan H Kleibeuker
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Klaas Havenga
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Patrick H J Hemmer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Arend Karrenbeld
- Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; and
| | - Gooitzen M van Dam
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Boudewijn van Etten
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Pasch JA, MacDermid E, Pasch LB, Premaratne C, Fok KY, Kotecha K, El Khoury T, Barto W. Clinicopathological factors associated with positive circumferential margins in rectal cancers. ANZ J Surg 2019; 89:1636-1641. [DOI: 10.1111/ans.15418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/06/2019] [Accepted: 07/28/2019] [Indexed: 12/20/2022]
Affiliation(s)
- James A. Pasch
- Department of SurgeryNepean Hospital Sydney New South Wales Australia
| | - Ewan MacDermid
- Department of Colorectal SurgeryRoyal North Shore Hospital Sydney New South Wales Australia
| | - Lachlan B. Pasch
- Department of Nursing, School of Nursing and MidwiferyWestern Sydney University Sydney New South Wales Australia
| | - Chatika Premaratne
- Department of Colorectal SurgeryRoyal Devon and Exeter Hospital Exeter UK
| | - Kar Yin Fok
- Department of Colorectal SurgeryRoyal Devon and Exeter Hospital Exeter UK
| | - Krishna Kotecha
- Department of Colorectal SurgeryRoyal North Shore Hospital Sydney New South Wales Australia
| | - Toufic El Khoury
- Department of Colorectal SurgeryWestmead Hospital Sydney New South Wales Australia
- Department of SurgeryUniversity of Notre Dame Medical School Sydney New South Wales Australia
| | - Walid Barto
- Department of SurgeryNepean Hospital Sydney New South Wales Australia
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Liccardo F, Baird DLH, Pellino G, Rasheed S, Kontovounisios C, Tekkis PP. Predictors of short-term readmission after beyond total mesorectal excision for primary locally advanced and recurrent rectal cancer. Updates Surg 2019; 71:477-484. [PMID: 31250396 PMCID: PMC6686032 DOI: 10.1007/s13304-019-00669-6] [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: 03/02/2019] [Accepted: 06/22/2019] [Indexed: 11/24/2022]
Abstract
Unplanned readmissions heavily affect the cost of health care and are used as an indicator of performance. No clear data are available regarding beyond-total mesorectal excision (bTME) procedure. Aim of the study is to identify patient-related and surgery-related factors influencing the 30-day readmissions after bTME. Retrospective data were collected from 220 patients who underwent bTME procedures at single centre between 2006 and 2016. Patient-related and operative factors were assessed, including body mass index (BMI), age, gender, American Society of Anaesthesiologists’ (ASA) score, preoperative stage, neo-adjuvant therapy, primary tumour vs recurrence, the extent of surgery. The readmission rate was 8.18%. No statistically significant association was found with BMI, ASA score, length of stay and stay in the intensive care unit, primary vs recurrent tumour or blood transfusions. Not quite statistically significant was the association with pelvic side wall dissection (OR 3.32, p = 0.054). Statistically significant factors included preoperative stage > IIIb (OR: 4.77, p = 0.002), neo-adjuvant therapy (OR: 0.13, p = 0.0006), age over 65 years (OR: 5.96, p = 0.0005), any re-intervention during the first admission (OR: 7.4, p = 0.0001), and any post-operative complication (OR: 9.01, p = 0.004). The readmission rate after beyond-TME procedure is influenced by patient-related factors as well as post-operative morbidity.
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Affiliation(s)
- Filomena Liccardo
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Daniel L H Baird
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK
| | - Gianluca Pellino
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Advanced Medical and Surgical Sciences, Universitá della Campania "Luigi Vanvitelli, Naples, Italy
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK. .,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK. .,Department of Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK.
| | - Paris P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK.,Department of Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
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44
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Ito E, Yoshida M, Ohdaira H, Kitajima M, Suzuki Y. Case series of in situ pelvic floor reconstruction combining levator ani suture and negative pressure wound therapy for abdominoperineal resection. Ann Med Surg (Lond) 2019; 43:64-67. [PMID: 31198553 PMCID: PMC6556482 DOI: 10.1016/j.amsu.2019.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/18/2019] [Accepted: 05/27/2019] [Indexed: 11/27/2022] Open
Abstract
Background Abdominoperineal resection (APR) is a standard surgical technique for low rectum cancer with a low recurrence rate. There are some problems associated with APR such as perineal hernia and perineal surgical site infection. Recently, the prophylactic efficacy of negative pressure wound therapy (NPWT) for surgical site infection has been reported. Herein, we analyzed the efficacy of in situ pelvic floor reconstruction combining levator ani suture and NPWT after APR for perineal hernia and perineal surgical site infection. Methods We analyzed six patients treated by laparoscopic APR with NPWT combined with levator ani suture retrospectively. The primary endpoints were surgical site infection within 30 days and perineal hernia within 1 year after surgery. The day following surgery, we performed NPWT for the perineal wound using the VAC® abdominal wound management system (KCI, San Antonio, TX, USA). Results There were four male and two female patients ranging in age from 69 to 86 years (mean: 76 years). The mean NPTW duration was 17 days (13–20 days). The length of the postoperative hospital stay was 14–22 days (median: 18 days). There was no patient with surgical site infection within 30 days or with perineal hernia within 1 year after surgery. Conclusion We experienced the in situ pelvic floor reconstruction combining levator ani suture and NPWT after laparoscopic APR for perineal hernia and perineal surgical site infection. This combination treatment was safe and may be effective for preventing surgical site infection and perineal hernia. Although APR has some unresolved problems such as perineal hernia and perineal surgical site infection. NPWT decreased perineal wound infection after APR but not reduced deep wound infection rates. Our procedure was able to reconstruct without foreign materials and provided sufficient separation from internal organs to perform safe NPWT. The in situ pelvic floor reconstruction combining levator ani suture and NPWT after laparoscopic APR was safe and may be effective for preventing surgical site infection and perineal hernia.
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Affiliation(s)
- Eisaku Ito
- Department of Surgery, International University of Health and Welfare Hospital, Japan
| | - Masashi Yoshida
- Department of Surgery, International University of Health and Welfare Hospital, Japan
| | - Hironori Ohdaira
- Department of Surgery, International University of Health and Welfare Hospital, Japan
| | - Masaki Kitajima
- Department of Surgery, International University of Health and Welfare Hospital, Japan
| | - Yutaka Suzuki
- Department of Surgery, International University of Health and Welfare Hospital, Japan
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Baird DLH, Simillis C, Pellino G, Kontovounisios C, Rasheed S, Tekkis PP. The obesity paradox in beyond total mesorectal excision surgery for locally advanced and recurrent rectal cancer. Updates Surg 2019; 71:313-321. [PMID: 30790208 PMCID: PMC6647851 DOI: 10.1007/s13304-019-00631-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/11/2019] [Indexed: 12/18/2022]
Abstract
The objective is to investigate preoperative body mass index (BMI) in patients receiving beyond total mesorectal excision (bTME) surgery. The primary end point is length of postoperative stay. Secondary end points are length of intensive care stay, postoperative morbidity and overall survival. BMI is the most commonly used anthropometric measurement of nutrition and studies have shown that overweight and obese patients can have improved surgical outcomes. Patients who underwent a bTME operation for locally advanced or recurrent rectal cancer were put into three BMI (kg/m2) groups of normal weight (18.5-24.9), overweight (25-29.9) and obese (≥ 30) for analysis. Included are 220 consecutive patients from a single centre. The overall length of stay, in days ± standard deviation (range), for normal weight, overweight and obese patients was 21.14 ± 16.4 (6-99), 15.24 ± 4.3 (7-32) and 19.10 ± 9.8 (8-62) respectively (p = 0.002). The mean ICU length of stay was 5.40 ± 9.1 (1-69), 3.37 ± 2.4 (0-19) and 3.60 ± 2.4 (1-14), respectively (p = 0.030). There was no significant difference between the three groups in terms of postoperative morbidity or overall survival. Patients with a normal weight BMI in this cohort have a significantly longer length of stay in ICU and in hospital than overweight or obese patients. This is seen with no significant difference in morbidity or overall survival.
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Affiliation(s)
- Daniel L H Baird
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster and the Royal Marsden Campus, London, UK
| | | | - Gianluca Pellino
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster and the Royal Marsden Campus, London, UK.
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK.
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster and the Royal Marsden Campus, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - Paris P Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster and the Royal Marsden Campus, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
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Hasegawa S, Yoshida Y, Morimoto M, Kojima D, Komono A, Aisu N, Taketomi H, Nagano H, Matsumoto Y, Munechika T, Kajitani R. Transanal TME: new standard or fad? JOURNAL OF THE ANUS RECTUM AND COLON 2019; 3:1-9. [PMID: 31559361 PMCID: PMC6752130 DOI: 10.23922/jarc.2018-030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 11/19/2018] [Indexed: 12/27/2022]
Abstract
Transanal total mesorectal excision (taTME) has been developed to overcome the difficulty of laparoscopic dissection and transection in the deep pelvis. TaTME has several clinical benefits over laparoscopic surgery, such as better exposure of the distal rectum and direct determination of distal resection margin. Although evidence demonstrating the true benefits of taTME over laparoscopic TME (LapTME) is still insufficient, accumulating data have revealed that, as compared with LapTME, taTME is associated with shorter operative time and a lower conversion rate without jeopardizing other short-term outcomes. However, taTME is a technically demanding procedure with specific complications such as urethral injury, and so sufficient experience of LapTME and step-by-step acquisition of the skills needed for this procedure are requisite. The role of transanal endoscopic surgery is expected to change, along with the recent progress in the treatment of rectal cancer, such as robotic surgery and the watch-and-wait strategy. Optimization of treatment will be needed in the future in terms not only of oncological but also of functional outcomes.
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Affiliation(s)
- Suguru Hasegawa
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoichiro Yoshida
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Mitsuaki Morimoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Daibo Kojima
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Akira Komono
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Naoya Aisu
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hirotaka Taketomi
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hideki Nagano
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshiko Matsumoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Taro Munechika
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Ryuji Kajitani
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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47
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Kojima D, Hasegawa S, Komono A, Sakamoto R, Matsumoto Y, Takeshita I, Yoshida Y. Transperineal abdominoperineal resection synchronously assisted by laparoscopic approach for low rectal cancer directly invading the posterior wall of the vagina. Tech Coloproctol 2019; 23:65-66. [DOI: 10.1007/s10151-018-1912-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 12/13/2018] [Indexed: 11/28/2022]
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Pellino G, Biondo S, Codina Cazador A, Enríquez-Navascues JM, Espín-Basany E, Roig-Vila JV, García-Granero E. Pelvic exenterations for primary rectal cancer: Analysis from a 10-year national prospective database. World J Gastroenterol 2018; 24:5144-5153. [PMID: 30568391 PMCID: PMC6288654 DOI: 10.3748/wjg.v24.i45.5144] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 11/05/2018] [Accepted: 11/16/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To identify short-term and oncologic outcomes of pelvic exenterations (PE) for locally advanced primary rectal cancer (LAPRC) in patients included in a national prospective database. METHODS Few studies report on PE in patients with LAPRC. For this study, we included PE for LAPRC performed between 2006 and 2017, as available, from the Rectal Cancer Registry of the Spanish Association of Surgeons [Asociación Española de Cirujanos (AEC)]. Primary endpoints included procedure-associated complications, 5-year local recurrence (LR), disease-free survival (DFS) and overall survival (OS). A propensity-matched comparison with patients who underwent non-exenterative surgery for low rectal cancers was performed as a secondary endpoint. RESULTS Eight-two patients were included. The mean age was 61.8 ± 11.5 years. More than half of the patients experienced at least one complication. Surgical site infections were the most common complication (abdominal wound 18.3%, perineal closure 19.4%). Thirty-three multivisceral resections were performed, including two hepatectomies and four metastasectomies. The long-term outcomes of the 64 patients operated on before 2013 were assessed. The five-year LR was 15.6%, the distant recurrence rate was 21.9%, and OS was 67.2%, with a mean survival of 43.8 mo. R+ve resection increased LR [hazard ratio (HR) = 5.58, 95%CI: 1.04-30.07, P = 0.04]. The quality of the mesorectum was associated with DFS. Perioperative complications were independent predictors of shorter survival (HR = 3.53, 95%CI: 1.12-10.94, P = 0.03). In the propensity-matched analysis, PE was associated with better quality of the specimen and tended to achieve lower LR with similar OS. CONCLUSION PE is an extensive procedure, justified if disease-free margins can be obtained. Further studies should define indications, accreditation policy, and quality of life in LAPRC.
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Affiliation(s)
- Gianluca Pellino
- Colorectal Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia 46026, Spain
| | - Sebastiano Biondo
- Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona and IDIBELL, L’Hospitalet de Llobregat, Barcelona 08907, Spain
| | - Antonio Codina Cazador
- Department of General and Digestive Surgery--Colorectal Unit, Josep Trueta University Hospital, Girona 17001, Spain
| | | | - Eloy Espín-Basany
- Department of General Surgery, Colorectal Surgery Unit, Hospital Valle de Hebron, Autonomous University of Barcelona, Barcelona 08035, Spain
| | | | - Eduardo García-Granero
- Colorectal Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia 46026, Spain
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Kitz J, Fokas E, Beissbarth T, Ströbel P, Wittekind C, Hartmann A, Rüschoff J, Papadopoulos T, Rösler E, Ortloff-Kittredge P, Kania U, Schlitt H, Link KH, Bechstein W, Raab HR, Staib L, Germer CT, Liersch T, Sauer R, Rödel C, Ghadimi M, Hohenberger W. Association of Plane of Total Mesorectal Excision With Prognosis of Rectal Cancer: Secondary Analysis of the CAO/ARO/AIO-04 Phase 3 Randomized Clinical Trial. JAMA Surg 2018; 153:e181607. [PMID: 29874375 DOI: 10.1001/jamasurg.2018.1607] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Previous retrospective studies have shown that surgical quality affects local control in rectal cancer.. Objective In this secondary end point analysis, we evaluated the prognostic effect of the total mesorectal excision (TME) plane in the CAO/ARO/AIO-04 phase 3 randomized clinical trial. Design, Setting, and Participants The CAO/ARO/AIO-04 trial enrolled 1236 patients with cT3-4 and/or node-positive rectal adenocarcinoma from 88 centers in Germany between July 25, 2006, and February 26, 2010. Interventions Patients were randomized to receive treatment with standard fluorouracil-based preoperative chemoradiotherapy (CRT) alone (control arm) or oxaliplatin (experimental arm) followed by TME and adjuvant chemotherapy. Main Outcomes and Measures The TME quality (mesorectal, intramesorectal, and muscularis propria plane) was prospectively assessed in 1152 operation specimens. An assessment was performed independently by pathologists and surgeons. The results were correlated with clinicopathologic data and the clinical outcome was tested, including multivariable analysis with the Cox regression model. Results Of 1152 German Caucasian participants, 332 (28.8) were women and the mean age was 63 years. The plane of TME was mesorectal in 930 patients (80.7%), intramesorectal in 169 (14.7%), and muscularis propria in 53 (4.6%). In a univariable analysis, the TME plane was significantly associated with 3-year disease-free survival (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 73.1-78.8 vs 61.6-76.0 vs 55.6-81.3, respectively; P = .01), cumulative incidence of local and distant recurrences (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 2.0-4.5 vs 1.2-8.1 vs 2.5-20.5, respectively; P < .001; and mesorectal vs intramesorectal vs muscularis propria, 95% CI, 17.0-22.4 vs 18.3-32.0 vs 14.2-39.0, respectively; P = .03, respectively), and overall survival (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 88.3-92.3 vs 79.7-91.0 vs 81.6-98.7, respectively; P = .02). In contrast to the pathologist-based evaluation, the assessment of TME plane by the operating surgeon failed to demonstrate prognostic significance for any of these clinical end points. In a multivariable analysis, the plane of surgery (mesorectal vs muscularis propria TME) constituted an independent factor for local recurrence (P = .002). Conclusions and Relevance This phase 3 randomized clinical trial confirms the long-term clinical effect of TME plane quality on local recurrence, as initially reported in the MRC CR07 study. The data highlight the key role of pathologists and surgeons in the multidisciplinary management of rectal cancer. Trial Registration ClinicalTrials.gov Identifier: NCT00349076.
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Affiliation(s)
- Julia Kitz
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - Emmanouil Fokas
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
| | - Tim Beissbarth
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Philipp Ströbel
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Arndt Hartmann
- Institute of Pathology, University Medical Center Erlangen, Erlangen, Germany
| | | | | | | | | | - Ulrich Kania
- Department of General and Visceral Surgery, Krankenhaus Maria Hilf, Mönchengladbach, Germany
| | - Hans Schlitt
- Department of Visceral Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl-Heinrich Link
- Department of Visceral Surgery, Asklepios Paulinen Klinik Wiesbaden, Wiesbaden, Germany
| | - Wolf Bechstein
- Department of General and Visceral Surgery, University Medical Center Frankfurt, Frankfurt, Germany
| | - Hans-Rudolf Raab
- Department of General and Visceral Surgery, University Medical Center Oldenburg, Oldenburg, Germany
| | - Ludger Staib
- Department of General and Visceral Surgery, Klinikum Esslingen, Esslingen, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Würzburg, Germany
| | - Torsten Liersch
- Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Rolf Sauer
- Department of Radiation Therapy, University of Erlangen, Erlangen, Germany
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany
| | - Michael Ghadimi
- Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Werner Hohenberger
- Department of General and Visceral Surgery, University of Erlangen, Erlangen, Germany
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Trans-perineal minimally invasive surgery during laparoscopic abdominoperineal resection for low rectal cancer. Surg Endosc 2018; 33:437-447. [PMID: 29987569 DOI: 10.1007/s00464-018-6316-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 06/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic abdominoperineal resection (APR) for low rectal cancer (LRC) is performed worldwide. However, APR involves technical difficulties and often causes intractable perineal complications. Therefore, a novel and secure technique during APR is required to overcome these critical issues. Although the usefulness of the endoscopic trans-anal approach has been documented, no series of the endoscopic trans-perineal approach during laparoscopic APR for LRC has been reported. METHODS Trans-perineal minimally invasive surgery (TpMIS) has been used during laparoscopic APR in our institution since April 2014. TpMIS is defined as an endoscopic trans-perineal approach using a single-port device and laparoscopic instruments. In this study, we retrospectively evaluated 50 consecutive patients with LRC who underwent laparoscopic APR at our institution from February 2011 to June 2017 and compared the outcomes of the patients who underwent TpMIS [trans-perineal APR (TpAPR) group, n = 21] versus the conventional trans-perineal approach (conventional group, n = 29). We investigated our experiences with TpMIS in detail and evaluated the safety and utility of TpMIS for patients with LRC. Moreover, major features and difficulties of TpMIS were examined from a surgical viewpoint. RESULTS Intraoperative blood loss (median (range) 55 (10-600) vs. 120 (20-1650) ml) and severe perineal wound infection (Clavien-Dindo grade 3, 0 vs. 5 cases) were significantly lower in the TpAPR than conventional group. TpMIS led to a shortened hospital stay (median (range), 14 (10-74) vs. 23 (10-84) days), and neither mortality nor conversion to open surgery occurred in the TpAPR group. CONCLUSIONS Magnified visualization via endoscopy provided more accurate dissection and less blood loss during surgery. Minimal skin incisions enabled a reduction in postoperative perineal complications, and consequently shortened the hospital stay. TpMIS during laparoscopic APR is safe and beneficial for patients with LRC.
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