Preoperative assessment and optimisation for pelvic exenteration in locally advanced and recurrent rectal cancer: A review

The pre-operative phase in planning a pelvic exenteration or extended resections is critical to optimising patient outcomes. This review summarises the key components of preoperative assessment and planning in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LLRC) being considered for potential curative resection. The preoperative period can be considered in 5 key phases: 1) Multidisciplinary meeting (MDT) review and recommendation for neoadjuvant therapy and surgery, 2) Anaesthetic preoperative assessment of fitness for surgery and quantification of risk, 3) Shared decision making with the patient and the process of informed consent, 4) Prehabilitation and physiological optimisation 5) Technical aspects of surgical planning. This review will focus on patients who have been recommended for surgery by the MDT and have completed neoadjuvant therapy. Other important considerations beyond the scope of this review are the various neoadjuvant strategies employed which in this patient group include Total Neo-adjuvant Therapy and reirradiation. Critical to improving perioperative outcomes is the dual aim of achieving a negative resection margin in a patient fit enough for extended surgery. Advanced, realistic communication is required pre-operatively and should be maintained throughout recovery. Optimising patient's physiological and psychological reserve with a preoperative prehabilitation programme is important, with physiotherapy, psychological and nutritional input. From a surgical perspective, image based technical preoperative planning is important to identify risk points and ensure correct surgical strategy. Careful attention to the entire patient journey through these 5 preoperative phases can optimise outcomes with the accumulation of marginal gains at multiple timepoints.

Interobserver variation in the classification of tumor deposits in rectal cancer-is the use of histopathological characteristics the way to go?

The focus on lymph node metastases (LNM) as the most important prognostic marker in colorectal cancer (CRC) has been challenged by the finding that other types of locoregional spread, including tumor deposits (TDs), extramural venous invasion (EMVI), and perineural invasion (PNI), also have significant impact. However, there are concerns about interobserver variation when differentiating between these features. Therefore, this study analyzed interobserver agreement between pathologists when assessing routine tumor nodules based on TNM 8. Electronic slides of 50 tumor nodules that were not treated with neoadjuvant therapy were reviewed by 8 gastrointestinal pathologists. They were asked to classify each nodule as TD, LNM, EMVI, or PNI, and to list which histological discriminatory features were present. There was overall agreement of 73.5% (κ 0.38, 95%-CI 0.33–0.43) if a nodal versus non-nodal classification was used, and 52.2% (κ 0.27, 95%-CI 0.23–0.31) if EMVI and PNI were classified separately. The interobserver agreement varied significantly between discriminatory features from κ 0.64 (95%-CI 0.58–0.70) for roundness to κ 0.26 (95%-CI 0.12–0.41) for a lone arteriole sign, and the presence of discriminatory features did not always correlate with the final classification. Since extranodal pathways of spread are prognostically relevant, classification of tumor nodules is important. There is currently no evidence for the prognostic relevance of the origin of TD, and although some histopathological characteristics showed good interobserver agreement, these are often non-specific. To optimize interobserver agreement, we recommend a binary classification of nodal versus extranodal tumor nodules which is based on prognostic evidence and yields good overall agreement.

Ex vivo specimen MRI and pathology confirm a rectosigmoid mesenteric waist at the junction of the mesorectum and mesocolon

AIM

Continuity of the mesentery has recently been established and may provide an anatomical basis for optimal colorectal resectional surgery. Preliminary data from operative specimen measurements suggest there is a tapering in the mesentery of the distal sigmoid. A mesenteric waist in this area may be a risk factor for local recurrence of colorectal cancer. This study aimed to investigate the anatomical characteristics of the mesentery at the colorectal junction.

METHOD

In this cross-sectional study, 20 patients were recruited. After planned colorectal resection, the surgical specimens were scanned in a MRI system and subsequently dissected and photographed as per national pathology guidelines. Mesenteric surface area and linear measurements were compared between MRI and pathology to establish the presence and location of a mesenteric waist.

RESULTS

Specimen analysis confirmed that a narrowing in the mesenteric surface area was consistently apparent at the rectosigmoid junction. Above the anterior peritoneal reflection, the surface area and posterior distance of the mesentery of the upper rectum initially decreased before increasing as the mesentery of the sigmoid colon. These anatomical properties created the appearance of a mesenteric 'waist' at the rectosigmoid junction. Using the anterior reflection as a reference landmark, the rectosigmoid waist occurred at a mean height of 23.6 and 21.7 mm on MRI and pathology, respectively.

CONCLUSION

A rectosigmoid waist occurs at the junction of the mesorectum and mesocolon, and is a mesenteric landmark for the rectum that is present on both radiology and pathology.

Evaluating the Effect of Functional Electrical Stimulation Used for Foot Drop on Aspects of Health-Related Quality of Life in People with Multiple Sclerosis: A Systematic Review

Background

Multiple sclerosis (MS) is a common degenerative neurologic condition resulting in walking difficulties. Foot drop is a common walking impairment in MS that can affect health-related quality of life (HRQOL). Functional electrical stimulation (FES) can improve walking in people with MS, but its effect on HRQOL is not well established. This review investigated the effect of FES used for foot drop on HRQOL in adults with MS.

Methods

A systematic search was performed using CINAHL, MEDLINE, Cochrane Library, PubMed, and PEDro online databases. Inclusion and exclusion criteria were applied to select eligible studies. Data were extracted, and two reviewers independently rated the quality of the studies using the Effective Public Health Practice Project assessment tool.

Results

Eight studies were eligible for review; seven were of moderate-to-strong methodological quality and one was weak. Seven studies demonstrated significant positive effects of FES on different aspects of HRQOL as measured by the 29-item Multiple Sclerosis Impact Scale, 36-item Short Form Health Status Survey, Canadian Occupational Performance Measure, and Psychosocial Impact of Assistive Devices Scale.

Conclusions

This review provides preliminary evidence that FES has a positive effect on aspects of HRQOL in people with MS; however, the variety of HRQOL outcomes used makes it difficult to determine definitive conclusions. Future larger-scale randomized studies with long-term follow-up are recommended to better understand the effect of FES on HRQOL. This will inform prescribing decisions and support compliance with FES over the longer-term.

The clinical- and cost-effectiveness of functional electrical stimulation and ankle-foot orthoses for foot drop in Multiple Sclerosis: a multicentre randomized trial

OBJECTIVE

To compare the clinical- and cost-effectiveness of ankle-foot orthoses (AFOs) and functional electrical stimulation (FES) over 12 months in people with Multiple Sclerosis with foot drop.

DESIGN

Multicentre, powered, non-blinded, randomized trial.

SETTING

Seven Multiple Sclerosis outpatient centres across Scotland.

SUBJECTS

Eighty-five treatment-naïve people with Multiple Sclerosis with persistent (>three months) foot drop.

INTERVENTIONS

Participants randomized to receive a custom-made, AFO (n = 43) or FES device (n = 42).

OUTCOME MEASURES

Assessed at 0, 3, 6 and 12 months; 5-minute self-selected walk test (primary), Timed 25 Foot Walk, oxygen cost of walking, Multiple Sclerosis Impact Scale-29, Multiple Sclerosis Walking Scale-12, Modified Fatigue Impact Scale, Euroqol five-dimension five-level questionnaire, Activities-specific Balance and Confidence Scale, Psychological Impact of Assistive Devices Score, and equipment and National Health Service staff time costs of interventions.

RESULTS

Groups were similar for age (AFO, 51.4 (11.2); FES, 50.4(10.4) years) and baseline walking speed (AFO, 0.62 (0.21); FES 0.73 (0.27) m/s). In all, 38% dropped out by 12 months (AFO, n = 21; FES, n = 11). Both groups walked faster at 12 months with device (P < 0.001; AFO, 0.73 (0.24); FES, 0.79 (0.24) m/s) but no difference between groups. Significantly higher Psychological Impact of Assistive Devices Scores were found for FES for Competence (P = 0.016; AFO, 0.85(1.05); FES, 1.53(1.05)), Adaptability (P = 0.001; AFO, 0.38(0.97); FES 1.53 (0.98)) and Self-Esteem (P = 0.006; AFO, 0.45 (0.67); FES 1 (0.68)). Effects were comparable for other measures. FES may offer value for money alternative to usual care.

CONCLUSION

AFOs and FES have comparable effects on walking performance and patient-reported outcomes; however, high drop-outs introduces uncertainty.

An exploration of the experiences and utility of functional electrical stimulation for foot drop in people with multiple sclerosis

Purpose: Functional electrical stimulation (FES) is effective in improving walking in people with multiple sclerosis (MS) with foot drop. There is limited research exploring people's experiences of using this device. This study aims to explore the utility, efficacy, acceptability, and impact on daily life of the device in people with MS.Methods: An interpretative phenomenological approach was employed. Ten participants who had used FES for 12 months were interviewed. Transcripts were analysed, and emergent themes identified.Results: Nine participants continued to use the device. Three relevant super-ordinate themes were identified; impact of functional electrical stimulation, sticking with functional electrical stimulation, and autonomy and control. Participants reported challenges using the device; however, all reported positive physical and psychological benefits. Intrinsic and external influences such as; access to professional help, the influence of others, an individual's ability to adapt, and experiences using the device, influenced their decisions to continue with the device. A thematic model of these factors was developed.Conclusions: This study has contributed to our understanding of people with MS experiences of using the device and will help inform prescribing decisions and support the continued, appropriate use of FES over the longer term.Implications for RehabilitationPeople with multiple sclerosis using functional electrical stimulation report benefits in many aspects of walking, improved psychological well-being and increased engagement in valued activities.A number of challenges impact on functional electrical stimulation use. Factors such as; a positive experience using the device, access to professional help, the influence of others, a strong sense of personal autonomy and an individual's ability to adapt, influence an individual's decision to continue using functional electrical stimulation.Clinicians prescribing functional electrical stimulation should be aware of these factors so that the right support and guidance can be provided to people with multiple sclerosis, thus improving outcomes and compliance over the long term.

A comparison of the initial orthotic effects of functional electrical stimulation and ankle-foot orthoses on the speed and oxygen cost of gait in multiple sclerosis

Background

Foot drop affects walking in people with multiple sclerosis (pwMS). This study compares the initial orthotic effects of two treatments for foot drop: ankle-foot orthoses (AFO) and functional electrical stimulation (FES), on the speed and oxygen cost of walking in MS.

Method and materials

Seventy-eight pwMS were randomised to receive AFO or FES (ODFS PACE (OML, Salisbury, UK)). Participants completed the 25-ft walk test (25ftWT) and 5-min self-selected walk test (5minSSWT), from which oxygen cost was determined, with and without their device. Between-, within- and sub-group analyses (based on baseline walking speed of <0.8 m/s (slow) or ≥0.8 m/s (fast)) were undertaken.

Results

No significant differences between baseline measures were observed. The AFO group walked significantly slower than the FES group (5minSSWT, p = 0.037, 0.11 m/s). The AFO group walked significantly slower with than without AFO (25ftWT, p = 0.037), particularly in the fast-walking group ( p = 0.011). The slow-walking FES group walked significantly faster with FES than without (25ftWT; p = 0.029, 5minSSWT; p = 0.037). There were no differences in the fast-walking FES group or in the oxygen cost for either device.

Conclusion

AFO reduced walking speed, particularly in fast walkers. FES increased walking speed in slow, but not fast walkers.

Functional Electrical Stimulation for Foot Drop in Multiple Sclerosis: A Systematic Review and Meta-Analysis of the Effect on Gait Speed

OBJECTIVE

To review the efficacy of functional electrical stimulation (FES) used for foot drop in people with multiple sclerosis (pwMS) on gait speed in short and long walking performance tests.

DATA SOURCES

Five databases (Cochrane Library, CINAHL, Embase, MEDLINE, and PubMed) and reference lists were searched.

STUDY SELECTION

Studies of both observational and experimental design where gait speed data in pwMS could be extracted were included.

DATA EXTRACTION

Data were independently extracted and recorded. Methodologic quality was assessed using the Effective Public Health Practice Project tool.

DATA SYNTHESIS

Nineteen studies (described in 20 articles) recruiting 490 pwMS were identified and rated as moderate or weak, with none gaining a strong rating. All studies rated weak for blinding. Initial and ongoing orthotic and therapeutic effects were assessed regarding the effect of FES on gait speed in short and long walking tests. Meta-analyses of the short walk tests revealed a significant initial orthotic effect (t=2.14, P=.016), with a mean increase in gait speed of .05m/s, and ongoing orthotic effect (t=2.81, P=.003), with a mean increase of .08m/s. There were no initial or ongoing effects on gait speed in long walk tests and no therapeutic effect on gait speed in either short or long walk tests.

CONCLUSIONS

FES used for foot drop has a positive initial and ongoing effect on gait speed in short walking tests. Further fully powered randomized controlled trials comparing FES with alternative treatments are required.

Successful management of abdominal wound dehiscence using a vacuum assisted closure system combined with mesh-mediated medial traction

Management of the open abdomen has advanced significantly in recent years with the increasing use of vacuum assisted closure (VAC) techniques leading to increased rates of fascial closure. We present the case of a patient who suffered two complete abdominal wall dehiscences after an elective laparotomy, meaning primary closure was no longer possible. She was treated successfully with a VAC system combined with continuous medial traction using a Prolene(®) mesh. This technique has not been described before in the management of patients following wound dehiscence.

Recurrence and outcome after complete tumour removal and hyperthermic intraperitoneal chemotherapy in 512 patients with pseudomyxoma peritonei from perforated appendiceal mucinous tumours

BACKGROUND

Pseudomyxoma peritonei (PMP) usually originates from perforated mucinous appendiceal tumours and may present unexpectedly at surgery, or be suspected at cross sectional imaging. The optimal treatment involves macroscopic tumour removal by cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). The 10-year Kaplan-Meier predicted disease-free survival is 61%. Some patients with recurrence are amenable to further CRS and HIPEC.

AIM

To evaluate the outcomes of re-do surgery in a large single centre series of reoperation for recurrence of peritoneal surface malignancy.

METHOD

Retrospective analysis of prospective database of 752 patients undergoing CRS for perforated appendiceal tumours analysed. Routine follow up involved annual CT scans and serum tumour marker measurement. The survival and recurrence in the 512/752 (68.1%) who had complete cytoreduction between March 1994 and January 2012 was calculated by Kaplan-Meier univariate analysis.

RESULTS

Overall 137/512 (26.4%) developed recurrence and of those 35/137 (25.5%) underwent repeat surgery. Complete tumour removal was again achieved in 20/35 (57.1%). There were no postoperative deaths and no significant difference in early postoperative complications and length of stay compared to primary CRS surgery. The 5-year survival in the 375 without recurrence, the 35 who had re-do surgery and the 102 who had recurrence with no surgery was 90.9%, 79.0% and 64.5% respectively.

CONCLUSION

Approximately one in four patients develops recurrence after complete CRS and HIPEC for PMP of appendiceal origin. Selected patients can undergo salvage surgery with good outcomes.

Clinical outcome following Doppler-guided haemorrhoidal artery ligation: a systematic review

AIM

Doppler-guided haemorrhoidal artery ligation (DGHL) has experienced wider uptake and has recently received National Institute for Health and Clinical Excellence (NICE) approval in the UK. A systematic review of the literature was conducted to assess its safety and efficacy.

METHOD

This review was conducted in keeping with PRISMA guidelines. MEDLINE, EMBASE, Google Scholar and Cochrane Library databases were searched. Studies describing DGHL as a primary procedure and reporting clinical outcome were considered. Primary end-points were recurrence and postoperative pain. Secondary end-points included operation time, complications and reintervention rates. Studies were scored for quality with either Jadad score or NICE scoring guidelines.

RESULTS

Twenty-eight studies including 2904 patients were included in the final analysis. They were of poor overall quality. Recurrence ranged between 3% and 60% (pooled recurrence rate 17.5%), with the highest rates for grade IV haemorrhoids. Postoperative analgesia was required in 0-38% of patients. Overall postoperative complication rates were low, with an overall bleeding rate of 5% and an overall reintervention rate of 6.4%. The operation time ranged from 19 to 35 min.

CONCLUSION

DGHL is safe and efficacious with a low level of postoperative pain. It can be safely considered for primary treatment of grade II and III haemorrhoids.

Laparo-endoscopic resection for extensive and inaccessible colorectal polyps: a feasible and safe procedure

INTRODUCTION

Polypectomy at colonoscopy may be difficult or dangerous. In such instances colonic resection may be indicated. Novel combined laparoscopic-endoscopic procedures have the potential to allow safe extensive extramucosal resection, thus avoiding resection. Laparoscopic colon mobilisation provides a more favourable orientation for endoscopic mucosal resection and facilitates identification of possible perforation sites with immediate laparoscopic repair or resection if necessary. This study aimed to assess the efficacy and safety of laparo-endoscopic resection (LER) of colonic polyps.

PATIENTS AND METHODS

Data were collected prospectively on consecutive patients undergoing LER. The mode of presentation, referral pattern, lesion site and size, hospital stay, procedural details, complications, histology and further treatment were recorded.

RESULTS

A total of 13 patients underwent attempted LER (16 polyps in total) and this was completed for 10, with a median hospital stay of 2 days. Five polyps were removed whole and eight piecemeal. Excision was clinically complete in all cases. Three procedures were converted to colonic resection. One lesion appeared malignant, indicating a conversion to laparoscopic right hemicolectomy. Two polyps were not amenable to LER and resection was performed. One patient underwent subsequent colonic resection based on the histological findings. There were no perforations or serious complications.

CONCLUSIONS

LER is a safe and effective treatment for large and inaccessible colonic polyps that would otherwise be treated by colonic resection.