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Jiang W, Brown KGM, Koh C, Karunaratne S, Solomon M, Beckenkamp PR, Cole R, Steffens D. Outcome Heterogeneity in Prehabilitation Trials-Are We Comparing Apples and Oranges? J Surg Res 2024; 296:366-375. [PMID: 38306943 DOI: 10.1016/j.jss.2023.12.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/11/2023] [Accepted: 12/29/2023] [Indexed: 02/04/2024]
Abstract
INTRODUCTION Over the last decade, the number of prehabilitation randomised controlled trials (RCTs) has increased significantly. Therefore, this review aimed to describe the outcomes reported in prehabilitation RCTs in patients undergoing cancer surgery. METHODS A search was conducted in Embase, Allied and Complementary Medicine Database, The Cochrane Library, PsycINFO, MEDLINE, and Cumulated Index to Nursing and Allied Health Literature from inception to July 2021. We included RCTs evaluating the effectiveness of preoperative exercise, nutrition, and psychological interventions on postoperative complications and length of hospital stay in adult oncology patients who underwent thoracic and gastrointestinal cancer surgery. The verbatim outcomes reported in each article were extracted, and each outcome was assessed to determine whether it was defined and measured using a validated tool. Verbatim outcomes were grouped into standardized outcomes and categorized into domains. The quality of outcome reporting in each identified article was assessed using the Harman tool (score range 0-6, where 0 indicated the poorest quality). RESULTS A total of 74 RCTs were included, from which 601 verbatim outcomes were extracted. Only 110 (18.3%) of the verbatim outcomes were defined and 270 (44.9%) were labeled as either "primary" or "secondary" outcomes. Verbatim outcomes were categorized into 119 standardized outcomes and assigned into one of five domains (patient-reported outcomes, surgical outcomes, physical/functional outcomes, disease activity, and intervention delivery). Surgical outcomes were the most common outcomes reported (n = 71 trials, 95.9%). The overall quality of the reported outcomes was poor across trials (median score: 2.0 [IQR = 0.00-3.75]). CONCLUSIONS Prehabilitation RCTs display considerable heterogeneity in outcome reporting, and low outcome reporting quality. The development of standardized core outcome sets may help improve article quality and enhance the clinical utility of prehabilitation following cancer surgery.
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Affiliation(s)
- Wilson Jiang
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia
| | - Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Department of Colorectal Surgery, Camperdown, NSW, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Department of Colorectal Surgery, Camperdown, NSW, Australia; Institute of Academic Surgery (IAS), Camperdown, NSW, Australia
| | - Sascha Karunaratne
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Institute of Academic Surgery (IAS), Camperdown, NSW, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Department of Colorectal Surgery, Camperdown, NSW, Australia; Institute of Academic Surgery (IAS), Camperdown, NSW, Australia
| | - Paula R Beckenkamp
- Faculty of Medicine and Health, Discipline of Physiotherapy, The University of Sydney, Camperdown, NSW, Australia
| | - Ruby Cole
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Camperdown, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Institute of Academic Surgery (IAS), Camperdown, NSW, Australia.
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Brown KGM, Ng KS, Solomon MJ, Chapuis PH, Koh CE, Ahmadi N, Austin KKS. Complete mesocolic excision for colon cancer: current status and controversies. ANZ J Surg 2024; 94:309-319. [PMID: 37850417 DOI: 10.1111/ans.18741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 10/19/2023]
Abstract
According to Hohenberger's original description, complete mesocolic excision for colon cancer involves precise dissection of the avascular embryonic plane between the parietal retroperitoneum and visceral peritoneum of the mesocolon. This ensures mesocolic integrity, access to high ligation of the supplying vessels at their origin and an associated extended lymphadenectomy. Results from centres which have adopted this approach routinely have demonstrated that oncological outcomes can be improved by the rigorous implementation of established principles of cancer surgery. Meticulous anatomical dissection along embryonic planes is a well-established principle of precision cancer surgery used routinely by the specialist colorectal surgeon. Therefore, the real question concerns the need for true central vascular ligation and associated extended (D3) lymphadenectomy or otherwise, particularly along the superior mesenteric vessels when performing a right colectomy. Whether this approach results in improved overall or disease-free survival remains unclear and its role remains controversial particularly given the potential for significant morbidity associated with a more extensive central vascular dissection. Current literature is limited by considerable bias, as well as inconsistent and variable terminology, and the results of established randomized trials are awaited. As a result of the current state of equipoise, various national guidelines have disparate recommendations as to when complete mesocolic excision should be performed if at all. This article aims to review the rationale for and technical aspects of complete mesocolic excision, summarize available short and long term outcome data and address current controversies.
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Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia
- The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia
- The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Pierre H Chapuis
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, 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), Sydney, New South Wales, Australia
- The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nima Ahmadi
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia
- The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, New South Wales, Australia
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Ebrahimi N, Brown KGM, Ng KS, Solomon MJ, Lee PJ. Impact of Intraoperative Decision-Making on Pathological Margin Status in Patients Undergoing Pelvic Exenteration for Locally Recurrent Rectal Cancer. Dis Colon Rectum 2024:00003453-990000000-00575. [PMID: 38380808 DOI: 10.1097/dcr.0000000000003131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
BACKGROUND A key component of preoperative preparation for pelvic exenteration surgery is development of an operative plan in a multidisciplinary setting, based on the extent of local tumor invasion on preoperative imaging. Changes to the extent of resection or operative plan may occur intraoperatively based on intraoperative findings. OBJECTIVE To report the frequency and extent of intraoperative deviation from the planned extent of resection during pelvic exenteration for locally recurrent rectal cancer, and whether this resulted in a more or less radical resection. DESIGN Retrospective observational study. SETTINGS A high-volume pelvic exenteration center. PATIENTS Patients who underwent pelvic exenteration for locally recurrent rectal cancer between January 2015 and December 2020. MAIN OUTCOME MEASURES Frequency and extent of intraoperative deviation from the planned extent of resection, R0 resection rate. RESULTS 136 patients underwent pelvic exenteration for locally recurrent rectal cancer, of which 110 (81%) had R0 resection margins. 12 patients were excluded due to missing information and 49 patients (40%) had a change to the operative plan. Operative changes were major in 30 patients (61%), more radical in 40 patients (82%), and margin relevant in 24 patients (49%). In patients where there was a change to the operative plan and R0 resection was achieved, the median distance to a relevant margin was 2.5 mm (range, 0.1-10mm). Of eight patients with a change in operative plan and R1 resection, three were margin relevant of which all were considered major, and two were more radical and one was less radical. LIMITATIONS Generalizability outside of specialist units may be limited. CONCLUSIONS Intraoperative changes to the planned extent of resection occur commonly and most often results in an unanticipated major, more radical resection. Such changes may contribute to high rates of R0 resection margins in specialist PE units that employ an ultra-radical approach in these patients. See Video Abstract.
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Affiliation(s)
- Nargus Ebrahimi
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
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Brown KGM, Pisaniello J, Ng KS, Solomon MJ, Sutton PA, Hatcher S, Steffens D. Variation in outcome measurement and reporting in studies of pelvic exenteration for locally advanced and recurrent rectal cancer: a systematic review. Colorectal Dis 2024; 26:272-280. [PMID: 38131647 DOI: 10.1111/codi.16844] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023]
Abstract
AIM There is increasing research interest in pelvic exenteration for locally advanced and recurrent rectal cancer. Heterogeneity in outcome reporting can prevent meaningful interpretation and valid synthesis of pooled data and meta-analyses. The aim of this study was to assess homogeneity in outcome measures in the current pelvic exenteration literature. METHOD MEDLINE, Embase, CENTRAL, CINAHL and Scopus databases were searched from 1990 to 25 April 2023 to identify studies reporting outcomes of pelvic exenteration for locally advanced or recurrent rectal cancer. All reported outcomes were extracted, merged with those of similar meaning and assigned a domain. RESULTS Of 4137 abstracts screened, 156 studies met the inclusion criteria. A total of 2765 outcomes were reported, of which 17% were accompanied by a definition. There were 1157 unique outcomes, merged into 84 standardized outcomes and assigned one of seven domains. The most reported domains were complications (147 studies, 94%), survival (127, 81%) and surgical outcomes (123, 79%). Resection margins were reported in 122 studies (78%): the definition of a clear resection margin was not provided in 45 studies (37%), it was unclear in 11 studies (9%) and not specified beyond microscopically 'clear' or 'negative' in 31 (28%). Measurements of 2, 1, 0.5 mm and any healthy tissue were all used to define R0 margins. CONCLUSION There is significant heterogeneity in outcome measurement and reporting in the current pelvic exenteration literature, raising concerns about the validity of comparative or collaborative studies between centres and meta-analyses. Coordinated international collaboration is required to define core outcome sets and benchmarks.
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Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Jade Pisaniello
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Paul A Sutton
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Sophie Hatcher
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Brown KGM, Solomon MJ. Topical haemostatic agents in surgery. Br J Surg 2024; 111:znad361. [PMID: 38156466 PMCID: PMC10771136 DOI: 10.1093/bjs/znad361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/15/2023] [Indexed: 12/30/2023]
Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
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Austin KKS, Brown KGM, Solomon MJ. En bloc lateral pelvic compartment excision during pelvic exenteration: video vignette. Br J Surg 2024; 111:znad407. [PMID: 38064685 DOI: 10.1093/bjs/znad407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 01/07/2024]
Affiliation(s)
- 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, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Brown KGM, Solomon MJ, Sutton PA, Shin JS, Steffens D. The definition of clear resection margins in locally recurrent rectal cancer-time for consensus. Br J Surg 2024; 111:znad450. [PMID: 38198158 DOI: 10.1093/bjs/znad450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 12/24/2023] [Indexed: 01/11/2024]
Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Paul A Sutton
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Joo-Shik Shin
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
- Department of Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
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Brown KGM, D'Souza N, Solomon MJ. How to access the presacral space using a posterior trans-sacral approach. ANZ J Surg 2023; 93:2993-2994. [PMID: 37872728 DOI: 10.1111/ans.18750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/03/2023] [Accepted: 10/13/2023] [Indexed: 10/25/2023]
Abstract
This article describes a posterior trans-sacral approach to the presacral space. This is an important technique in contemporary colorectal surgical practice for resection of presacral tumours, and less commonly to allow access for rectal sleeve advancement, segmental resection of the lower rectum (rarely indicated in the era of total mesorectal excision and trans-anal techniques), drainage of supralevator sepsis and resection of extensive ischiorectal fossa tumours.
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Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, Australia
| | - Nigel D'Souza
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, Australia
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Brown KGM, McBride KE, Anderson T, Solomon MJ. Delivering complex surgical services: lessons learned from the evolution of a specialised pelvic exenteration centre. AUST HEALTH REV 2023; 47:735-740. [PMID: 38029447 DOI: 10.1071/ah23186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023]
Abstract
Pelvic exenteration (PE) is a potentially curative, ultra-radical surgical procedure for the treatment of advanced pelvic tumours, which involves surgical resection of multiple pelvic organs. Delivering such a complex low-volume, high-cost surgical program presents a number of unique health management challenges, and requires an organisation-wide approach involving both clinical and administrative teams. In contrast to the United Kingdom and France, where PE services have been historically decentralised, a centralised approach was developed early on in Australia and New Zealand (ANZ) with referral of these complex patients to a small number of quaternary centres. The PE program at the authors' institution was established in 1994 and has since evolved into the highest volume PE centre in the ANZ region and the largest single institution experience globally. These achievements have required navigation of specific funding and management issues, supported from inception by a proactive and collaborative relationship with hospital administration and management. The comprehensive state-wide quaternary referral model that has been developed has subsequently been successfully applied to other complex surgical services at the authors' institution, as well as by more recently established PE centres in Australia. This article aims to summarise the authors' experience with establishing and expanding this service and the lessons learned from a health management perspective.
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Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Kate E McBride
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Teresa Anderson
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia; and Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
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Brown KGM, Risbey C, Solomon MJ, Austin KKS, Lee PJ, Byrne CM. Pelvic exenteration for chronic fistulating pelvic sepsis after multimodal treatment of pelvic malignancy. Eur J Surg Oncol 2023; 49:107124. [PMID: 37879161 DOI: 10.1016/j.ejso.2023.107124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/02/2023] [Accepted: 10/20/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Chronic fistulating pelvic sepsis is an uncommon complication of multimodal treatment of visceral pelvic tumours. Radical multi-visceral resection is reserved for patients with persistent, debilitating symptoms despite less invasive treatments and for which there is minimal published data. This study aimed to report the rates of morbidity and long-term sepsis control after pelvic exenteration for chronic fistulating pelvic sepsis. METHODS This retrospective cohort study was conducted at a high-volume pelvic exenteration referral centre. Patients who underwent pelvic exenteration for chronic fistulating pelvic sepsis between September 1994 and January 2023 after previous treatment for pelvic malignancy were included. Data relating to postoperative morbidity, mortality and the rate of recurrent pelvic sepsis or fistulae were retrospectively collected. RESULTS 19 patients who underwent radical resection for chronic fistulating pelvic sepsis after previous pelvic cancer treatment were included. 11 patients were male (58 %) and median age was 62 years (range 42-79). Previously treated rectal (8 patients, 42 %), prostate (5, 26 %) and cervical cancer (5, 26 %) were most common. 18 patients (95 %) had previously received high-dose pelvic radiotherapy, and 14 (74 %) had required surgical resection. Total pelvic exenteration was performed in 47 % of patients, total cystectomy in 68 % and major pubic bone resection in 37 %. There was no intraoperative or postoperative mortality. Major complication rate was 32 %. 12-month readmission rate was 42 %. At last follow up, 74 % had no signs or symptoms of persisting pelvic sepsis. CONCLUSIONS Pelvic exenteration for refractory pelvic sepsis following treatment of malignancy is safe and effective in selected patients.
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Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Charles Risbey
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia.
| | - Kirk K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
| | - Christopher M Byrne
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
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Risbey CWG, Brown KGM, Solomon MJ, Koh C, Karunaratne S, Steffens D. Impact of geographical health disparities on outcomes following pelvic exenteration at a centralised quaternary referral centre. Eur J Surg Oncol 2023; 49:107082. [PMID: 37738872 DOI: 10.1016/j.ejso.2023.107082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/22/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Pelvic exenteration (PE) is an ultra-radical procedure performed for primary or recurrent malignancies confined to the pelvis. Health outcomes for rural Australian populations are generally inferior compared to those from metropolitan centres, however, the effect of geographical location on outcomes following PE is poorly defined. The aim of this study was to investigate how geographical location affects oncological, quality of life (QoL) and survival outcomes following PE. METHODS Consecutive patients undergoing PE between 1994 and 2022 at a single centre were included. Patient post codes were linked with the Australian Statistical Geography Standard Remoteness Structure to stratify patients into five groups based on the geographical location of their residence. Primary outcome measures included patient survival, QoL and oncological outcomes. RESULTS A total of 953 patients were included, of which 626 (65.7%) were from major cities, 227 (23.8%) inner regional, 84 (8.8%) outer regional, 9 (0.9%) remote, and 7 (0.7%) very remote areas. Rural patients were more likely to undergo PE for primary rectal cancer (p = 002) and less likely for recurrent, non-rectal carcinoma (p = 0.027). Rural patients less frequently had health insurance (p < 0.001) but were more likely to have undergone neoadjuvant radiotherapy (p = 0.022). No difference in length-of-admission, in-hospital complication rates, QoL at 36 months or survival was observed between groups. CONCLUSIONS Despite geographical disparities, rural populations undergoing PE achieved equally favourable outcomes as populations from metropolitan areas. Enhancing access to specialised care may facilitate better outcomes of patients residing in regional and remote areas.
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Affiliation(s)
- Charles W G Risbey
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Cherry Koh
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Sascha Karunaratne
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Australia.
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Brown KGM, Solomon MJ, Steffens D, Ng KS, Byrne CM, Austin KKS, Lee PJ. Pelvic Exenteration for Squamous Cell Carcinoma of the Anus: Oncological, Morbidity, and Quality-of-Life Outcomes. Dis Colon Rectum 2023; 66:1427-1434. [PMID: 37493254 DOI: 10.1097/dcr.0000000000002919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Salvage surgery is the only potentially curative treatment option for recurrent squamous cell carcinoma of the anus. Where adjacent pelvic viscera, soft tissues, and bone are involved, pelvic exenteration with a wide perineal excision may be required to ensure clear surgical margins and increase the likelihood of long-term survival. OBJECTIVE To report oncological, morbidity, and quality-of-life outcomes of pelvic exenteration for anal squamous cell carcinoma. DESIGN Cohort study with retrospective analysis of prospectively collected data. SETTINGS This study was conducted at a high-volume pelvic exenteration center. PATIENTS Those who underwent pelvic exenteration for anal squamous cell carcinoma between 1994 and 2022. MAIN OUTCOME MEASURES Local recurrence-free and overall survival, intraoperative and postoperative complication rates, R0 resection rate, and long-term quality-of-life outcomes. RESULTS Of 958 patients who underwent pelvic exenteration, 66 (6.9%) had anal squamous cell carcinoma. Thirty-two patients (48.5%) were male and the median age was 57 years (range, 31-79). Ten patients (15%) had primary anal squamous cell carcinoma, 49 (74%) had a recurrent tumor, and 7 (11%) had a re-recurrent tumor. Twenty-two patients (33%) and 16 patients (24%) had a major complication and unplanned return to the operating theater, respectively. Of the 62 patients who underwent pelvic exenteration with curative intent, 50 (81%) had R0 resection, and the 5-year overall and local recurrence-free survival rates were 41% and 37%, respectively. R0 resection was associated with a higher 5-year overall survival (50% vs 8%, p < 0.001). The mental health component scores and several individual quality-of-life domains presented improved trajectories postoperatively (all p values <0.05). LIMITATIONS The generalizability of the findings outside specialist pelvic exenteration centers may be limited. CONCLUSIONS Morbidity, long-term survival, and quality-of-life outcomes after pelvic exenteration for anal squamous cell carcinoma are comparable to published outcomes of pelvic exenteration for other tumor types. EXENTERACIN PLVICA POR CARCINOMA EPIDERMOIDE DE ANO RESULTADOS ONCOLGICOS, DE MORBILIDAD Y DE CALIDAD DE VIDA ANTECEDENTES:La cirugía de rescate es la única opción de tratamiento potencialmente curativa para el carcinoma de células escamosas del ano recurrente. Cuando están involucradas vísceras pélvicas, tejidos blandos y huesos adyacentes, puede ser necesaria una exenteración pélvica con una escisión perineal amplia para asegurar márgenes quirúrgicos claros y aumentar la probabilidad de supervivencia a largo plazo.OBJETIVO:Informar sobre los resultados oncológicos, de morbilidad y de calidad de vida de la exenteración pélvica por carcinoma anal de células escamosas.DISEÑO:Estudio de cohortes con análisis retrospectivo de datos recogidos prospectivamente.ENTORNO CLINICO:Este estudio se realizó en un centro de exenteración pélvica de alto volumen.PACIENTES:Aquellos que se sometieron a exenteración pélvica por carcinoma anal de células escamosas entre 1994 y 2022.PRINCIPALES MEDIDAS DE VALORACIÓN:Supervivencia global y libre de recidiva local, tasas de complicaciones intraoperatorias y posoperatorias, tasa de resección R0 y resultados de calidad de vida a largo plazo.RESULTADOS:De 958 pacientes que se sometieron a exenteración pélvica, 66 (6,9%) tenían carcinoma anal de células escamosas. 32 pacientes (48,5%) eran varones y la mediana de edad fue de 57 años (rango 31-79). 10 pacientes (15%) tenían carcinoma anal primario de células escamosas, 49 (74%) tenían un tumor recurrente y 7 (11%) tenían una segunda recurrencia. 22 (33%) y 16 pacientes (24%) tuvieron una complicación mayor y regreso no planificado al quirófano, respectivamente. De los 62 pacientes que se sometieron a una exenteración pélvica con intención curativa, 50 (81%) tuvieron una resección R0, las tasas de supervivencia global y libre de recidiva local a los 5 años fueron del 41% y el 37%, respectivamente. La resección R0 se asoció con una mayor supervivencia general a los 5 años (50% frente a 8%, p < 0,001). Las puntuaciones del componente de salud mental y varios dominios de calidad de vida individuales presentaron trayectorias mejoradas después de la operación (todos los valores de p < 0,05).LIMITACIONES:La generalización de los hallazgos fuera de los centros especializados en exenteración pélvica puede ser limitada.CONCLUSIONES:Los resultados de morbilidad, supervivencia a largo plazo y calidad de vida después de la EP para el carcinoma anal de células escamosas son comparables a los resultados publicados de la exenteración pélvica para otros tipos de tumores. (Traducción-Dr. Ingrid Melo ).
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Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
- Department of Colorectal Surgery, Concord Repatriation General Hospital, Sydney, Australia
| | - Christopher M Byrne
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
| | - Kirk K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
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Brown KGM, Solomon MJ, Heriot A, Frizelle F. Treatment of locally advanced and recurrent rectal cancer in Australia and New Zealand: recent progress and future challenges. ANZ J Surg 2023; 93:2291-2292. [PMID: 37493074 DOI: 10.1111/ans.18635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/07/2023] [Accepted: 07/19/2023] [Indexed: 07/27/2023]
Affiliation(s)
- Kilian G M Brown
- Department of Colorectal Surgery, Surgical Outcomes Research Centre and Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Surgical Outcomes Research Centre and Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Alexander Heriot
- Department of Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Frank Frizelle
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Te Whatu Ora - Health, Christchurch, New Zealand
- Department of Surgery, University of Otago, Christchurch, New Zealand
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Naidu K, Chapuis PH, Brown KGM, Chan C, Rickard MJFX, Ng KS. Splenic flexure cancer survival: a 25-year experience and implications for complete mesocolic excision (CME) and central vascular ligation (CVL). ANZ J Surg 2023; 93:1861-1869. [PMID: 36978261 DOI: 10.1111/ans.18434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND The management of splenic flexure cancers (SFCs) in the era of complete mesocolic excision (CME) and central vascular ligation (CVL) is challenging because of its variable lymphatic drainage. This study aimed to compare survival outcomes for SFCs and non-SFCs, and better understand the clinicopathological characteristics which may define a distinct SFC phenotype. METHODS An observational cohort study at Concord Hospital, Sydney was conducted with patients who underwent resection for colon adenocarcinoma (1995-2019). Clinicopathological data were extracted from a prospective database. Overall survival (OS) and disease-free survival (DFS) estimates and their associations to clinicopathological variables were investigated with Kaplan-Meier and Cox regression analyses. RESULTS Of 2149 patients with colon cancer, 129 (6%) had an SFC. The overall 5-year OS and DFS rates were 63.6% (95% CI 62.5-64.7) and 59.4% (95% CI 58.3-60.5), respectively. SFCs were not associated with OS (P = 0.6) or DFS (P = 0.5). SFCs were more likely to present urgently (P < 0.001) with obstruction (P < 0.001) or perforation (P = 0.03), and more likely to require an open operation (P < 0.001). These characteristics were associated with poorer survival outcomes. No differences were noted between SFCs and non-SFCs with respect to tumour stage (P = 0.3). CONCLUSION SFCs have a distinct phenotype, the individual characteristics of which are associated with poorer survival. However, the survivals of SFCs and non-SFCs are similar, possibly because the most important determinant of outcome, tumour stage, is no different between the groups. This may have implications for the surgical approach to SFCs with respect to standardization of CME and CVL surgery for these cancers.
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Affiliation(s)
- Krishanth Naidu
- Colorectal Surgery Unit, Concord Hospital, Sydney, New South Wales, 2139, Australia
- Concord Institute of Academic Surgery, Concord Hospital, Sydney, New South Wales, 2139, Australia
- Concord Clinical School, Clinical Sciences Building, Concord Hospital, University of Sydney, Sydney, New South Wales, 2139, Australia
| | - Pierre H Chapuis
- Colorectal Surgery Unit, Concord Hospital, Sydney, New South Wales, 2139, Australia
- Concord Institute of Academic Surgery, Concord Hospital, Sydney, New South Wales, 2139, Australia
- Concord Clinical School, Clinical Sciences Building, Concord Hospital, University of Sydney, Sydney, New South Wales, 2139, Australia
| | - Kilian G M Brown
- Colorectal Surgery Unit, Concord Hospital, Sydney, New South Wales, 2139, Australia
| | - Charles Chan
- Concord Clinical School, Clinical Sciences Building, Concord Hospital, University of Sydney, Sydney, New South Wales, 2139, Australia
- Department of Anatomical Pathology, Concord Hospital, Sydney, New South Wales, 2139, Australia
| | - Matthew J F X Rickard
- Colorectal Surgery Unit, Concord Hospital, Sydney, New South Wales, 2139, Australia
- Concord Institute of Academic Surgery, Concord Hospital, Sydney, New South Wales, 2139, Australia
- Concord Clinical School, Clinical Sciences Building, Concord Hospital, University of Sydney, Sydney, New South Wales, 2139, Australia
| | - Kheng-Seong Ng
- Colorectal Surgery Unit, Concord Hospital, Sydney, New South Wales, 2139, Australia
- Concord Institute of Academic Surgery, Concord Hospital, Sydney, New South Wales, 2139, Australia
- Concord Clinical School, Clinical Sciences Building, Concord Hospital, University of Sydney, Sydney, New South Wales, 2139, Australia
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Rajendran S, Nguyen CL, Brown KGM, Solomon MJ. The evolution of oncovascular pelvic surgery: A historical perspective. Eur J Surg Oncol 2023; 49:1314-1316. [PMID: 36690534 DOI: 10.1016/j.ejso.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/08/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
Pelvic exenteration surgery has evolved dramatically in recent decades and now represents the standard of care for many patients with advanced pelvic malignancy. Most recently the use of complex vascular resection and reconstructive techniques have been applied in advanced pelvic oncology surgery at specialist units and these oncovascular techniques are considered one of the frontiers in this field. This article summaries the historical evolution of oncovascular surgery in the pelvis and sets the scene for where this treatment is going. The role of vascular resection and reconstruction in curative treatment of advanced pelvic malignancy is an evolving area that is redefining the boundaries of what was historically thought possible.
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Affiliation(s)
- Saissan Rajendran
- Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia; University of Sydney, New South Wales, Australia
| | - Chu Luan Nguyen
- Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, New South Wales, 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; University of Sydney, New South Wales, Australia
| | - Michael J Solomon
- 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; University of Sydney, New South Wales, Australia.
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Rajendran S, Nguyen CL, Brown KGM, Solomon MJ. Clinical algorithm for the management of advanced pelvic tumours involving the aortoiliac axis. Eur J Surg Oncol 2023; 49:1317-1319. [PMID: 36964055 DOI: 10.1016/j.ejso.2023.03.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/09/2023] [Indexed: 03/13/2023]
Abstract
Pelvic exenteration offers potentially curative treatment for locally advanced and recurrent pelvic tumours. Laterally infiltrating tumours involving the pelvic sidewall have historically been considered unresectable. Highly specialised exenteration units have accumulated experience with en bloc resection of part or all of the iliac vascular system for tumours with major vessel involvement. These approaches involve complex vascular dissection and reconstructive techniques requiring collaboration with the vascular surgery unit. Adding to the complexity is the paucity of evidence on oncovascular techniques in the pelvis given its developing nature. An algorithm for the workup to determine resectability and the vascular reconstruction approach for advanced pelvic tumours involving the aortoiliac axis is suggested based on current literature and personal experience from the authors' unit.
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Affiliation(s)
- Saissan Rajendran
- Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia; University of Sydney, New South Wales, Australia
| | - Chu Luan Nguyen
- Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, Australia; University of Sydney, New South Wales, 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; University of Sydney, New South Wales, Australia
| | - Michael J Solomon
- 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; University of Sydney, New South Wales, Australia.
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17
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Rajendran S, Brown KGM, Solomon MJ. Oncovascular surgery for advanced pelvic malignancy. Br J Surg 2023; 110:144-149. [PMID: 36427187 DOI: 10.1093/bjs/znac414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/22/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The number of units with experience in extended radical resections for advanced pelvic tumours has grown substantially in recent years. The use of complex vascular resections and reconstructive techniques in these units is expected to increase with experience. This review aimed to provide a cutting-edge overview of this evolving surgical approach to complex pelvic tumours with vascular involvement. METHODS This was a narrative review of published data on major vascular resection and reconstruction for advanced pelvic tumours, including preoperative evaluation, techniques used, and outcomes. Advice for treatment decisions is provided, and based on current literature and the personal experience of the authors. Current controversies and future directions are discussed. RESULTS Major vascular resection and reconstruction during surgery for advanced pelvic tumours is associated with prolonged operating time (510-678 min) and significant blood loss (median 2-5 l). R0 resection can be achieved in 58-82 per cent at contemporary specialist units. The risk of major complications is similar to that of extended pelvic resection without vascular involvement (30-40 per cent) and perioperative mortality is acceptable (0-4 per cent). Long-term survival is achievable in approximately 50 per cent of patients. CONCLUSION En bloc resection of the common or external iliac vessels during exenterative pelvic surgery is a feasible strategy for patients with advanced tumours which infiltrate major pelvic vascular structures. Oncological, morbidity, and survival outcomes appear comparable to more central pelvic tumours. These encouraging outcomes, combined with an increasing interest in extended pelvic resections globally, will likely lead to more exenteration units developing oncovascular experience.
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Affiliation(s)
- Saissan Rajendran
- Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
| | - Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Sutton PA, Brown KGM, Ebrahimi N, Solomon MJ, Austin KKS, Lee PJ. Long-term surgical complications following pelvic exenteration: Operative management of the empty pelvis syndrome. Colorectal Dis 2022; 24:1491-1497. [PMID: 35766998 DOI: 10.1111/codi.16238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 01/07/2023]
Abstract
AIM Pelvic exenteration (PE) has become the standard of care for locally advanced and recurrent rectal cancer. The high short-term morbidity reported from this procedure is well established; however, longer term complications of such radical surgery and their management have not been fully addressed. This study aimed to investigate the incidence, indications and outcomes of long-term (more than 90-day) reoperative surgery in this group of patients, with a focus on the empty pelvis syndrome (EPS). METHODS Clinical data were extracted from a prospectively maintained database, with additional data pertaining to indications, operative details and outcomes of reoperative surgery obtained from electronic medical records. Patients were excluded if reoperative surgery was endoscopic or radiologically guided, was for the investigation or treatment of recurrent disease, or was clearly unrelated to previous surgery. RESULTS Of 716 patients who underwent PE, 75 (11%) required 101 reoperative abdominal or perineal procedures, 52 (51%) of which were in 40 (6%) patients for complications of EPS. This group were more likely to have undergone a total PE (65% vs. 43%; P < 0.01) with either major bony (70% vs. 50%; P < 0.01) and/or nerve (40% vs. 25%; P = 0.03) resections at index exenteration. The patho-anatomy, surgical management and outcomes of these patients are described herein, considering separately complications of entero-cutaneous fistula, entero-perineal fistula, small bowel obstruction and local management of perineal wound complications. CONCLUSION Six per cent of PE patients will require re-intervention for the management of EPS. Reliable strategies for preventing EPS remain elusive; however, surgical management is feasible with acceptable short-term outcomes with the optimum strategy to be selected on an individual patient basis.
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Affiliation(s)
- Paul A Sutton
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Colorectal and Peritoneal Oncology Centre, The Christie Hospital, Manchester, UK.,Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Nargus Ebrahimi
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia
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Solomon MJ, Däster S, Loizides S, Sutton P, Brown KGM, Austin KKS, Lee PJ. Access to the anterior pelvic compartment in pelvic exenteration in women-the interlabial approach: video vignette. Br J Surg 2021; 108:e268-e269. [PMID: 34291281 DOI: 10.1093/bjs/znab127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/21/2021] [Indexed: 02/02/2023]
Affiliation(s)
- M J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney Local Health District, University of Sydney, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - S Däster
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - S Loizides
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - P Sutton
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - K G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - K K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney Local Health District, University of Sydney, Sydney, New South Wales, Australia
| | - P J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney Local Health District, University of Sydney, Sydney, New South Wales, Australia
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Hong JSY, Brown KGM, Waller J, Young CJ, Solomon MJ. Author's reply to commentary on "The role of MRI pelvimetry in predicting technical difficulty and outcomes of open and minimally invasive total mesorectal excision: a systematic review". Tech Coloproctol 2021; 25:983. [PMID: 34181153 DOI: 10.1007/s10151-021-02478-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Affiliation(s)
- J S-Y Hong
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia. .,The Institute of Academic Surgery at RPA, Sydney, Australia. .,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia. .,University of Sydney, Sydney, Australia.
| | - K G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - J Waller
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - C J Young
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - M J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
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21
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Chen MZ, Austin KKS, Solomon MJ, Brown KGM, Steffens D. Outcomes of metastasectomy and pelvic exenteration for patients with metastatic advanced primary or recurrent rectal cancer. ANZ J Surg 2021; 91:231-232. [PMID: 33740306 DOI: 10.1111/ans.16294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/28/2020] [Accepted: 08/16/2020] [Indexed: 01/20/2023]
Affiliation(s)
- Michelle Z Chen
- Surgical Outcomes Research Centre, University of Sydney & Sydney Local Health District, Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Surgical Outcomes Research Centre, University of Sydney & Sydney Local Health District, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre, University of Sydney & Sydney Local Health District, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kilian G M Brown
- Surgical Outcomes Research Centre, University of Sydney & Sydney Local Health District, Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre, University of Sydney & Sydney Local Health District, Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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22
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Rajendran S, Brown KGM, Solomon MJ, Austin KKS, Lee PJ, Robinson D, Steffens D. Complete resection of the iliac vascular system during pelvic exenteration: an evolving surgical approach to lateral compartment excision. Br J Surg 2021; 108:885-887. [PMID: 33824959 DOI: 10.1093/bjs/znab070] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/21/2021] [Indexed: 11/14/2022]
Abstract
Tumour infiltration of the lateral pelvic compartment has previously been associated with the highest rate of involved resection margins and carries significant risk of morbidity. In this study, consecutive patients undergoing pelvic exenteration at a single centre between 1994 and 2019 who required en bloc resection of the common or external iliac artery or vein were included.The results demonstrate that complete resection of the iliac vascular system, including resection and reconstruction of the common and external iliac vessels, can be performed safely during pelvic exenteration with oncological outcomes comparable to more central tumours.
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Affiliation(s)
- S Rajendran
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health Sciences, University of Sydney, Sydney, NSW, Australia.,The Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - K G M Brown
- The Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, NSW, Australia
| | - M J Solomon
- Faculty of Medicine and Health Sciences, University of Sydney, Sydney, NSW, Australia.,The Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, NSW, Australia
| | - K K S Austin
- The Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, NSW, Australia
| | - P J Lee
- The Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, NSW, Australia
| | - D Robinson
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health Sciences, University of Sydney, Sydney, NSW, Australia.,The Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - D Steffens
- Faculty of Medicine and Health Sciences, University of Sydney, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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23
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Chang KH, Brown KGM, Chen Lau Y, Solomon MJ. Excellent Outcomes After Extended Radical Pelvic Resection for Locally Advanced and Recurrent IBD-Associated Anorectal Cancer. Dis Colon Rectum 2021; 64:209-216. [PMID: 33315717 DOI: 10.1097/dcr.0000000000001744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Anorectal cancer arising in IBD can be challenging to manage. There is a paucity of reports describing locally advanced and recurrent anorectal cancer in this setting. OBJECTIVE This study aimed to describe patients who underwent extended radical pelvic resection for locally advanced and recurrent IBD-associated anorectal cancer. DESIGN This is a retrospective review of a prospectively maintained database of extended radical pelvic resection. SETTINGS This study was conducted at a quaternary pelvic malignancy referral center. PATIENTS All of the patients who underwent extended radical pelvic resection for IBD-associated anorectal cancer between September 1994 and September 2019 were included. MAIN OUTCOME MEASURES Demographic, operative, and oncologic outcomes were assessed. RESULTS Ten patients (1.3%) were identified of 765 (6 men; median age = 51 y). The average time from the diagnosis of IBD to cancer was 23 years. Five patients had surgery for primary cancer previously. All of the patients had previous complex abdominal and perineal surgical interventions. There were 7 adenocarcinomas and 3 squamous cell carcinomas. Nine underwent pelvic exenteration and 1 rectal resection with radical vaginectomy. The median operating time, intraoperative blood loss, and blood transfusion were 698 minutes, 1.8 L, and 4.5 units. The median hospital stay was 24 days. The operative mortality and morbidity rates were 0% and 60%. At a median follow-up of 51.3 months, 7 patients remained alive and free of cancer. LIMITATIONS This is a retrospective study of a small number of patients. CONCLUSIONS Extended radical pelvic resection offers a potential cure for locally advanced and recurrent IBD-associated anorectal cancer with acceptable operative mortality and morbidity rates. A high index of suspicion is required to achieve early diagnosis. Multiple factors need to be considered in the multimodal treatment of such complex patients. See Video Abstract at http://links.lww.com/DCR/B418. EXCELENTES RESULTADOS DESPUS DE LA RESECCIN PLVICA RADICAL EXTENDIDA POR CNCER ANORRECTAL RECURRENTE Y LOCALMENTE AVANZADA, ASOCIADA A ENFERMEDAD INFLAMATORIA INTESTINAL ANTECEDENTES:Cáncer anorrectal surgiendo de la enfermedad inflamatoria intestinal, puede ser difícil de manejar. Hay escasez de informes que describan el cáncer anorrectal localmente avanzado y recurrente en este contexto.OBJETIVO:El estudio tiene como objetivo, describir a los pacientes que se sometieron a resección pélvica radical extendida por cáncer anorrectal recurrente y localmente avanzada, asociada con enfermedad inflamatoria intestinal.DISEÑO:Esta es una revisión retrospectiva, de una base de datos mantenida prospectivamente de resección pélvica radical extendida.AJUSTES:El estudio se realizó en un centro de referencia cuaternaria en malignidad pélvica.PACIENTES:Se incluyeron a todos los pacientes sometidos a resección pélvica radical ampliada por cáncer anorrectal, asociada a enfermedad inflamatoria intestinal entre septiembre de 1994 y septiembre de 2019.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron los resultados demográficos, quirùrgicos y oncológicos.RESULTADOS:Diez pacientes (1.3%) fueron identificados de 765 (seis masculinos; mediana de edad 51 años). El tiempo promedio desde el diagnóstico de la enfermedad inflamatoria intestinal hasta el cáncer, fue de 23 años. Cinco pacientes fueron previamente sometidos a cirugía por cáncer primario. Todos los pacientes tuvieron previamente, intervenciones quirúrgicas abdominales y perineales complejas. Hubo siete adenocarcinomas y tres carcinomas de células escamosas. Nueve se sometieron a exenteración pélvica y una a resección rectal con vaginectomía radical. La mediana del tiempo de operación, pérdida de sangre intraoperatoria y transfusión sanguínea, fueron 698 minutos, 1.8 litros y 4.5 unidades respectivamente. La mediana de la estancia hospitalaria fue de 24 días. Las tasas de mortalidad y morbilidad operatoria fueron 0% y 60% respectivamente. En una mediana de seguimiento de 51,3 meses, siete pacientes permanecieron vivos y libres de cáncer.LIMITACIONES:Es un estudio retrospectivo con número pequeño de pacientes.CONCLUSIONES:La resección pélvica radical extendida, ofrece una cura potencial para el cáncer anorrectal recurrente y localmente avanzada, asociada a0 enfermedad inflamatoria intestinal y con tasas aceptables de mortalidad y morbilidad operatoria. Se requiere un alto índice de sospecha para obtener un diagnóstico temprano. Se deben considerar múltiples factores en el tratamiento multimodal de pacientes tan complejos. Consulte Video Resumen en http://links.lww.com/DCR/B418. (Traducción-Dr Fidel Ruiz Healy).
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Affiliation(s)
- Kah Hoong Chang
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Chris O'Brien Lifehouse Cancer Centre, Sydney, New South Wales, Australia
| | - Kilian G M Brown
- Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,The Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Yee Chen Lau
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Chris O'Brien Lifehouse Cancer Centre, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Chris O'Brien Lifehouse Cancer Centre, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,The Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
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24
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Agostinho N, Bains HK, Douglas CP, Walcott J, Brown KGM, Rawson R, Sandroussi C, Perera MRS. Pop goes the tumour! Spontaneous haemorrhage of a hepatocellular carcinoma tumour. J Surg Case Rep 2021; 2021:rjaa598. [PMID: 33569166 PMCID: PMC7852605 DOI: 10.1093/jscr/rjaa598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 11/17/2022] Open
Abstract
An 84-year-old man presented to a rural hospital in Australia with haemodynamic instability and abdominal pain. Investigation revealed haemorrhage from a lesion in his liver—an incidental finding of a hepatocellular carcinoma. Initial resuscitation and damage control surgery was performed at the peripheral hospital prior to transfer to a tertiary centre 386 km away for the second stage of management. The second stage of management included interventional radiological embolization of the bleeding liver vessel and subsequent resection of the liver tumour. This was all undertaken with new policies in place to limit the spread of infection at the peak of the COVID-19 epidemic.
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Affiliation(s)
- Nelson Agostinho
- Department of General Surgery, Dubbo Base Hospital, Dubbo, NSW, Australia
| | - Harinder K Bains
- Department of General Surgery, Dubbo Base Hospital, Dubbo, NSW, Australia
| | - Cameron P Douglas
- Department of General Surgery, Dubbo Base Hospital, Dubbo, NSW, Australia
| | - James Walcott
- Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Kilian G M Brown
- Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Robert Rawson
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Charbel Sandroussi
- Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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25
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Brown KGM, Ansari N, Solomon MJ, Austin KKS, Hamilton AER, Young CJ. Pelvic exenteration combined with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for advanced primary or recurrent colorectal cancer with peritoneal metastases. Colorectal Dis 2021; 23:186-191. [PMID: 32978813 DOI: 10.1111/codi.15378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 07/25/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023]
Abstract
AIM The aim was to report early outcomes of six patients who underwent combined pelvic exenteration (PE), cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for advanced or recurrent colorectal cancer with colorectal peritoneal metastases at a single centre. The literature contains limited data on the safety and oncological outcomes of patients who undergo this combined procedure. METHODS Six patients who underwent combined PE, CRS and HIPEC at Royal Prince Alfred Hospital, Sydney, between January 2017 and February 2020 were identified and included. Data were extracted from prospectively maintained databases. RESULTS Three patients underwent surgery for advanced primary rectal cancer, while two patients had recurrent sigmoid cancer and one had recurrent rectal cancer. All patients had synchronous peritoneal metastases. Two patients required total PE and two patients had a central (bladder-sparing) PE. The median peritoneal carcinomatosis index was 6 (range 3-12) and all patients underwent a complete cytoreduction. The median operating time was 702 min (range 485-900) and the median blood loss was 1650 ml (range 700-12,000). The median length of intensive care unit and hospital stay was 4.5 and 25 days, respectively. There was no inpatient, 30-day or 90-day mortality. Three patients (50%) experienced a major (Clavien-Dindo III/IV) complication. At a median follow-up of 11.5 months (range 2-18 months), two patients died with recurrent disease, one patient was alive with recurrence, while three patients remain alive and disease-free. Of the three patients who developed recurrent disease, one had isolated pelvic recurrence, one had pelvic and peritoneal recurrences and one had bone metastases. CONCLUSION Early results from this initial experience with simultaneous PE, CRS and HIPEC suggest that this combined procedure is safe and feasible; however, the long-term oncological and quality of life outcomes require further investigation.
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Affiliation(s)
- Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Nabila Ansari
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Kirk K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Auerilius E R Hamilton
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher J Young
- The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
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26
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Hong JSY, Brown KGM, Waller J, Young CJ, Solomon MJ. The role of MRI pelvimetry in predicting technical difficulty and outcomes of open and minimally invasive total mesorectal excision: a systematic review. Tech Coloproctol 2020; 24:991-1000. [PMID: 32623536 DOI: 10.1007/s10151-020-02274-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/20/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The difficulty of performing total mesorectal excision (TME) for rectal cancer partly relies on the surgeon's subjective assessment of the individual patient's pelvic anatomy and tumour characteristics, which generally influences the choice of platform used (open, laparoscopic, robotic or trans-anal surgery). Recent studies have found associations between several anatomical pelvic measurements and surgical difficulty. The aim of this study was to systematically review existing data reporting the use of magnetic resonance imaging (MRI)-based pelvic measurements to predict technical difficulty and outcomes of TME, and determine whether pelvimetry could optimise patient-specific selection of a particular surgical approach. METHODS MEDLINE, Embase and Cochrane Library databases were systematically searched for studies reporting MRI-based pelvic measurements in patients undergoing surgery for rectal cancer, and the effect of these measurements on surgical difficulty. RESULTS Eleven studies reporting the association between MRI-pelvimetry measurements and rectal cancer surgical outcomes were included. Indicators for surgical difficulty used in the included studies were involved circumferential resection margin, longer operative time, incomplete TME, higher blood loss, anastomotic leak, conversion to open surgery and overall complications. Bony pelvic measurements which were associated with increased surgical difficulty in more than one study were a smaller interspinous distance, a smaller intertubercle distance, a smaller pelvic inlet and larger pubic tubercle height. Two studies identified larger mesorectal fat area as a predictor of surgical difficulty. CONCLUSIONS Bony pelvic measurements may predict surgical difficulty during TME, however, use of different indicators of difficulty limit comparison between studies. Early data suggest MRI soft tissue measurements may predict surgical difficulty and warrants further investigation.
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Affiliation(s)
- J S-Y Hong
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia. .,Institute of Academic Surgery at RPA, Royal Prince Alfred Hospital, Missenden Road, PO Box M40, Camperdown, NSW, 2050, Australia. .,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia. .,Central Clinical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia.
| | - K G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,Institute of Academic Surgery at RPA, Royal Prince Alfred Hospital, Missenden Road, PO Box M40, Camperdown, NSW, 2050, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - J Waller
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - C J Young
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,Institute of Academic Surgery at RPA, Royal Prince Alfred Hospital, Missenden Road, PO Box M40, Camperdown, NSW, 2050, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Central Clinical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia
| | - M J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,Institute of Academic Surgery at RPA, Royal Prince Alfred Hospital, Missenden Road, PO Box M40, Camperdown, NSW, 2050, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Central Clinical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia
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27
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Fisher OM, Brown KGM, Coker DJ, McBride KE, Steffens D, Koh CE, Sandroussi C. Distributive justice during the coronavirus disease 2019 pandemic in Australia. ANZ J Surg 2020; 90:961-962. [PMID: 32452147 PMCID: PMC7283635 DOI: 10.1111/ans.16069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/19/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Oliver M Fisher
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kilian G M Brown
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David J Coker
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kate E McBride
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney, New South Wales, Australia
| | - Cherry E Koh
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Charbel Sandroussi
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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28
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Ahmadi N, Brown KGM, Lee P, Quinn M, Austin KKS, Solomon MJ. Is neoadjuvant chemoradiotherapy sufficient in patients with advanced rectal malignancy and positive extra-mesorectal lateral lymph nodes? Colorectal Dis 2020; 22:689-693. [PMID: 31909851 DOI: 10.1111/codi.14950] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 11/26/2019] [Indexed: 12/20/2022]
Abstract
AIM There is current debate about the optimal management of lateral pelvic lymph nodes (LPLNs) in rectal cancer between Western and Eastern centres. This paper aims to report the rate of histologically proven positive LPLNs in a group of patients undergoing the conventional Western approach to primary and recurrent rectal cancer. METHOD A retrospective cohort review of all patients who underwent LPLN dissection at Royal Prince Alfred Hospital in Sydney, Australia. This included patients who underwent pelvic exenteration who had LPLNs excised either en bloc for laterally invasive or recurrent tumours or as part of selective node dissection for suspicious lymph nodes on preoperative imaging. Histopathological results for these patients were compared with node status at preoperative imaging. RESULTS Seventy-one patients satisfied the inclusion criteria. Of those patients with positive nodes on histology, 27% (9/33) with radiologically positive LPLNs were treated with preoperative radiotherapy and 75% (9/12) with radiologically positive LPLNs were not treated with preoperative radiotherapy (P = 0.004). None of the 12 patients with radiologically negative nodes treated with radiotherapy had positive nodes; 25% (3/12) of the patients with radiologically negative nodes who were not treated with radiotherapy had positive nodes. Fifty-three per cent of patients developed postoperative complications. CONCLUSION Our study suggests that in patients with radiologically positive LPLNs chemoradiotherapy may not be enough to sterilize these extra-mesorectal lymph nodes as a large proportion (27%) will have residual viable adenocarcinoma cells. In patients with radiologically negative LPLNs, however, the addition of chemoradiotherapy may serve to adequately sterilize these lymph nodes without the need for prophylactic LPLN dissection.
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Affiliation(s)
- N Ahmadi
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - K G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney Local Health District, Newtown, New South Wales, Australia
| | - P Lee
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - M Quinn
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - K K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - M J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney Local Health District, Newtown, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
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29
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Abstract
There have been significant developments in the management of advanced and recurrent colorectal cancer in recent decades. 70% of primary colorectal tumours arise in the colon and for patients with stage I-III disease, the standard of care is surgical resection followed by adjuvant therapy where appropriate. Locoregional recurrence (LR) occurs in 4-11.5% of patients following treatment of primary colon cancer with curative intent, and can be categorised as peri-anastomotic, mesenteric/paracolic (nodal), retroperitoneal and peritoneal. Of these, peritoneal recurrence is usually recognised as the most challenging type of recurrence to manage. Patients with isolated peri-anastomotic or limited nodal recurrence in the mesentery or retroperitoneum may be curable by radical salvage surgery, which often requires en bloc multi-visceral resection, while patients with low volume peritoneal metastases may be candidates for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Ensuring complete resection along embryonic mesocolic planes or en bloc resection of contiguously involved structures are best strategies to reduce the likelihood of local recurrence through a R1 resection margin. The role of complete mesocolic excision (CME) with high vascular ligation has been demonstrated to increase nodal yield and improve overall survival although this is more contentious. In patients with T4a disease and serosal surface involvement, peritoneal recurrence represents the greatest threat. Efforts for early diagnosis of peritoneal recurrence in these patients or prophylactic treatment, while intuitive have not demonstrated the survival benefit that would be expected. Other than locoregional recurrence (LR), systemic recurrence may occur in up to 50% of patients who have undergone curative resection for colorectal cancer. In keeping with portal venous outflow, the most common site of systemic recurrence is the liver. Although previously thought to be a fatal condition, liver resection is now the standard of care where liver metastases can be completely resected with clear margins plus leaving an adequate liver remnant with intact vascular inflow, outflow and biliary drainage. This can usually be achieved in 26-45% of patients presenting with liver metastases. Liver surgeons at the forefront of liver resection have also developed techniques to induce liver hypertrophy so as to improve likelihood of resectability. Even where patients have non-resectable disease, ablative techniques have become increasingly common. Naturally, none of these would be possible without the advent of improved chemotherapeutic and biological options in the field of medical oncology. Pulmonary metastasectomy with curative intent may be possible in a small number (10%) of patients with lung metastases, which is associated with an overall survival of up to 40%. Unlike liver metastases, proportionally less patients with pulmonary metastases will be resectable. For these patients, several ablative options are available. For all patients with recurrent colon cancer, patient selection for radical salvage surgery and decisions surrounding treatment strategy (including use of systemic therapy or ablative procedures) should take place in a multidisciplinary team setting.
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Affiliation(s)
- Kilian G M Brown
- SOuRCe (Surgical Outcomes Research Centre), Royal Prince Alfred Hospital, Sydney, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Cherry E Koh
- SOuRCe (Surgical Outcomes Research Centre), Royal Prince Alfred Hospital, Sydney, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Medical School, Discipline of Surgery, University of Sydney, Australia
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McBride KE, Brown KGM, Fisher OM, Steffens D, Yeo DA, Koh CE. Impact of the COVID-19 pandemic on surgical services: early experiences at a nominated COVID-19 centre. ANZ J Surg 2020; 90:663-665. [PMID: 32259337 PMCID: PMC7262155 DOI: 10.1111/ans.15900] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 01/28/2023]
Affiliation(s)
- Kate E McBride
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital and the University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney, New South Wales, Australia
| | - Kilian G M Brown
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital and the University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Oliver M Fisher
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital and the University of Sydney, Sydney, New South Wales, Australia.,Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - David A Yeo
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital and the University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Upper Gastrointestinal and Hepatobiliary Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Cherry E Koh
- RPA Institute of Academic Surgery, Royal Prince Alfred Hospital and the University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Lau YC, Brown KGM, Cheong J, Byrne C, Lee PJ. LIFT and BioLIFT: a 10-Year Single-Centre Experience of Treating Complex Fistula-In-Ano With Ligation of Intersphincteric Fistula Tract Procedure With or Without Bio-prosthetic Reinforcement (BioLIFT). J Gastrointest Surg 2020; 24:671-676. [PMID: 31240556 DOI: 10.1007/s11605-019-04305-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 06/10/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE To assess the outcome of ligation of intersphincteric fistula tract (LIFT) and bioprosthetic graft (BioLIFT) in the management of transsphincteric perianal fistula. METHODS A single-institution retrospective analysis of all patients undergoing LIFT and BioLIFT from January 2009 to June 2018 was performed. Only patients who had LIFTs and BioLIFT performed as their primary sphincter-preserving procedure was included. Primary outcome measured was primary healing. Secondary outcomes measured were secondary healing, morbidity, time to recurrence, and pre- and post-operative anorectal manometry. Chi-square analysis was used to determine predictive factors. RESULTS A total of 116 patients were identified. One hundred five had LIFT and 11 had BioLIFT. The total primary healing rate was 60.3% (62.9% and 34.9% for LIFT and BioLIFT respectively). The overall secondary healing rate was 80.2% (80.0% and 81.9% for LIFT and BioLIFT respectively). There was no inpatient morbidity or post-procedural faecal incontinence reported. There was no significant change in the pre- and post-operative manometries in either group (P = 0.417 and P = 0.834 for LIFT and BioLIFT respectively). The only predictor for primary failure identified was anteriorly located fistula. CONCLUSION LIFT and BioLIFT compare favourably with other sphincter-preserving procedures. LIFT and BioLIFT can be performed safely, with minimal morbidity and with no reported loss of sphincteric function.
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Affiliation(s)
- Yee Chen Lau
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia. .,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
| | - Juyong Cheong
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia
| | - Christopher Byrne
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
| | - Peter J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
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O'Shannassy SJ, Brown KGM, Steffens D, Solomon MJ. Referral patterns and outcomes of a highly specialised pelvic exenteration multidisciplinary team meeting: A retrospective cohort study. Eur J Surg Oncol 2020; 46:1138-1143. [PMID: 32122755 DOI: 10.1016/j.ejso.2020.02.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 01/31/2020] [Accepted: 02/20/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The purpose of this study was to review recommendations made from a specialist pelvic exenteration (PE) multidisciplinary team (MDT) and to provide insights as to the impact of the MDT on patient selection and clinical decision making. MATERIALS & METHODS A retrospective review was conducted at Royal Prince Alfred Hospital's PE MDT between June 2014 and December 2015. Data was collected from the recorded minutes of MDT meetings. Referral information and clinical data was extracted from individual patient files. Additional data including operative dates and surgical resection margins were collected from electronic medical records. RESULTS Of the 183 patients considered for PE during the MDT meeting, 104 (57%) were recommended for surgery. Factors that influenced the recommendation in favour of surgery were referral by a surgeon (P = 0.004), referral from a rural location (P = 0.05) and having locally advanced primary cancer (P < 0.001). Patients who were seen by the unit's surgeon prior to the MDT did not impact on the MDT recommendation nor the decision for or against surgery (P = 0.771). The most common reason for recommendation against PE was unresectable distant metastatic disease (43%). CONCLUSIONS The PE MDT meeting is a critical step in the patient care pathway and facilitates critical decision making. Anatomically-based contraindications to surgery (i.e. involvement of adjacent organs, bone and neurovascular structures) do not appear to influence MDT decision making regarding resectability.
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Affiliation(s)
- Sarah J O'Shannassy
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery (IAS), Sydney, Australia.
| | - Kilian G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery (IAS), Sydney, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; The University of Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia; RPA Institute of Academic Surgery (IAS), Sydney, Australia; The University of Sydney, New South Wales, Australia
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Solomon MJ, Brown KGM. Extended Radical Resection: The Standard of Care for Patients with Advanced Pelvic Malignancy. Ann Surg Oncol 2020; 27:323-324. [DOI: 10.1245/s10434-019-07817-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Indexed: 08/30/2023]
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Brown KGM, Solomon MJ. Exenterative Surgery for Squamous Cell Carcinoma Arising from Pelvic Organs of Cloacal Origin. Ann Surg Oncol 2020; 27:2135-2136. [PMID: 31980983 DOI: 10.1245/s10434-020-08230-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney Local Health District, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia. .,The Institute of Academic Surgery at RPA, Sydney Local Health District, Australia. .,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia. .,University of Sydney, Sydney, NSW, Australia.
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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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Brown KGM, Di Re A, Fisher D. Suture retraction of the uterus using a percutaneous port closure needle during laparoscopic mesorectal dissection. ANZ J Surg 2019; 90:1499-1500. [PMID: 31782230 DOI: 10.1111/ans.15564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/18/2019] [Accepted: 10/13/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Kilian G M Brown
- Department of Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,The Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia
| | - Angelina Di Re
- Department of Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia
| | - Dean Fisher
- Department of Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia
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Affiliation(s)
- Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia
- The Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia
- The Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- University of Sydney, New South Wales, Australia
| | - Kate Mahon
- University of Sydney, New South Wales, Australia
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, Australia
| | - Sarah O'Shannassy
- The Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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Ansari N, Brown KGM, McBride KE, Steffens D, Koh CE, Young CJ, Solomon MJ, Moran BJ. Accelerating the learning curve in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy using an external mentor model. ANZ J Surg 2019; 89:1097-1101. [PMID: 31280498 DOI: 10.1111/ans.15331] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/24/2019] [Accepted: 05/25/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an accepted therapeutic approach in selected patients with peritoneal malignancy. The aim of this study was to describe early outcomes in the first 50 patients managed with CRS and HIPEC in a newly established peritoneal malignancy centre in Sydney, Australia, under the guidance of an experienced peritoneal malignancy mentor. METHODS This is a retrospective review of a prospective maintained database of early outcomes in the first 50 patients who underwent CRS and HIPEC between April 2017 and April 2018 at a newly established peritoneal malignancy centre. Type of primary, surgery time, length of hospital stay, blood loss, peritoneal carcinomatosis index, completeness of surgery, complications, recurrence rate and 30-day mortality were reviewed. RESULTS A total of 135 patients were referred and reviewed at the multidisciplinary team meeting with 50 (26 male) patients undergoing CRS and HIPEC. Of these 50 patients, 47 (94%) underwent complete cytoreduction while three (6%) had maximal tumour debulking surgery. Tumour pathology was of appendix origin (44%) and colorectal peritoneal metastases (44%). Median surgical time was 7.4 h (interquartile range 5.7-10.0). Median length of hospital stay was 13 days (interquartile range 9.7-19.0). Six (12%) patients experienced a grade III or IV Clavien-Dindo complication. There was no 30-day mortality. CONCLUSION This study reports the successful establishment of a peritoneal malignancy centre under the guidance of an experienced peritoneal malignancy mentor. The short-term surgical outcomes observed in the first 50 cases are promising and comparable to other more experienced centres.
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Affiliation(s)
- Nabila Ansari
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kate E McBride
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Christopher J Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brendan J Moran
- Peritoneal Malignancy Institute, North Hampshire Hospital, Basingstoke, UK
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Lee PJ, Tan W, Brown KGM, Solomon MJ. Response to Carboni et al. Colorectal Dis 2019; 21:490-491. [PMID: 30724456 DOI: 10.1111/codi.14578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/02/2019] [Indexed: 02/08/2023]
Affiliation(s)
- P J Lee
- Lifehouse Cancer Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - W Tan
- Lifehouse Cancer Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - K G M Brown
- Lifehouse Cancer Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - M J Solomon
- Surgical Outcomes Research Centre (SOuRCe), School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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Lee P, Tan WJ, Brown KGM, Solomon MJ. Addressing the empty pelvic syndrome following total pelvic exenteration: does mesh reconstruction help? Colorectal Dis 2019; 21:365-369. [PMID: 30548166 DOI: 10.1111/codi.14523] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/26/2018] [Indexed: 12/29/2022]
Abstract
AIM Perineal wound complications and pelvic abscesses remain a major source of morbidity after total pelvic exenteration. The void created in the pelvis after these multi-visceral resections leads to fluid accumulation and translocation of bowel within the pelvic cavity, which may increase the risk of pelvic abscess, perineal fluid discharge with perineal wound dehiscence and prolonged ileus. This study describes a novel technique using degradable synthetic mesh with overlying omentum to preclude small bowel and fill the empty space after total pelvic exenteration, and aimed to investigate the rate of pelvic abscess and perineal wound-related complications in this group. METHOD Ten patients who underwent total pelvic exenteration followed by implantation of degradable synthetic mesh at a quaternary referral centre were identified and included. The mesh was moulded to the contours of the bony pelvis at the level of the pubic symphysis anteriorly and inferior to the sacral promontory posteriorly. The data on the number of postoperative perineal wound-related complications including pelvic abscesses were collected. RESULTS There was no perioperative mortality. Five patients (50%) developed postoperative complications. One patient developed an abscess inferior to the mesh that required surgical drainage and another had a pre-sacral collection that was successfully managed conservatively. Two patients developed intra-abdominal collections requiring percutaneous drainage. Median length of stay was 20 days (range 16-35). No perineal hernia or entero-perineal fistula was detected in any patient either clinically or radiologically at a median follow-up of 7 months. CONCLUSION Degradable synthetic mesh reconstruction following exenterative surgery may reduce postoperative complications related to the perineal wound.
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Affiliation(s)
- P Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia
| | - W J Tan
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia
| | - K G M Brown
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia
| | - M J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, New South Wales, Australia.,Institute of Academic Surgery at RPA, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
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Brown KGM, Solomon MJ. Progress and future direction in the management of advanced colorectal cancer. Br J Surg 2019; 105:615-617. [PMID: 29652083 DOI: 10.1002/bjs.10759] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/17/2017] [Indexed: 11/11/2022]
Abstract
Improving advanced colorectal cancer care
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Affiliation(s)
- K G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Institute of Academic Surgery at Royal Prince Alfred Hospital, and Department of Colorectal Surgery, Royal Prince Alfred Hospital, PO, Box M157, Missenden Road, Sydney, New South Wales, 2050, Australia
| | - M J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Institute of Academic Surgery at Royal Prince Alfred Hospital, and Department of Colorectal Surgery, Royal Prince Alfred Hospital, PO, Box M157, Missenden Road, Sydney, New South Wales, 2050, Australia.,University of Sydney, Sydney, New South Wales, Australia
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Dunne B, Brown KGM, Sholler G, Trivedi A, Smith G, Winlaw DS. Fatal Acute Appendicitis in a Neonate With Congenital Heart Disease. World J Pediatr Congenit Heart Surg 2016; 8:2150135116640787. [PMID: 27143717 DOI: 10.1177/2150135116640787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 02/23/2016] [Indexed: 02/28/2024]
Abstract
We describe a case of fatal acute appendicitis in a neonate associated with congenital cardiac disease requiring staged surgery. Neonatal appendicitis is extremely rare and usually associated with prematurity and congenital abdominal conditions. This report serves to highlight the risk of this disease due to vascular insufficiency and ischemia in neonates with congenital cardiac disease and highlight the importance of considering this diagnosis in such a neonate with unexplained sepsis even in the absence of clear abdominal signs.
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Affiliation(s)
- Ben Dunne
- Kids Heart Research, The Children's Hospital at Westmead, Sydney, Australia The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia The Sydney Children's Hospital Network Cardiac Service, Sydney, Australia
| | | | - Gary Sholler
- Kids Heart Research, The Children's Hospital at Westmead, Sydney, Australia The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia The Sydney Children's Hospital Network Cardiac Service, Sydney, Australia Sydney Medical School, University of Sydney, Sydney, Australia
| | - Amit Trivedi
- Sydney Medical School, University of Sydney, Sydney, Australia Grace Centre for Newborn Care, The Children's Hospital at Westmead, Sydney, Australia
| | - Grahame Smith
- Sydney Medical School, University of Sydney, Sydney, Australia The Department of Urology, The Children's Hospital at Westmead, Sydney, Australia
| | - David S Winlaw
- Kids Heart Research, The Children's Hospital at Westmead, Sydney, Australia The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia The Sydney Children's Hospital Network Cardiac Service, Sydney, Australia Sydney Medical School, University of Sydney, Sydney, Australia
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Brown KGM, Storey CE. Acquiring surgical skills: the history of surgical teaching at the University of Sydney 1883-2014. ANZ J Surg 2016; 86:448-53. [DOI: 10.1111/ans.13469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Kilian G. M. Brown
- Sydney Medical School; University of Sydney; Sydney New South Wales Australia
| | - Catherine E. Storey
- Sydney Medical School; University of Sydney; Sydney New South Wales Australia
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Brown KGM, Rao PJ, Oo TH, Fowler A. Granular cell tumors of the spinal canal: intramedullary case report and a review of the literature. J Spine Surg 2015; 1:94-98. [PMID: 27683684 PMCID: PMC5039862 DOI: 10.3978/j.issn.2414-469x.2015.08.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 08/17/2015] [Indexed: 06/06/2023]
Affiliation(s)
| | - Prashanth J. Rao
- Department of Neurosurgery, Children’s Hospital at Westmead, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - Than-Htike Oo
- Department of Anatomical Pathology, Children’s Hospital at Westmead, Sydney, Australia
| | - Adam Fowler
- Department of Neurosurgery, Children’s Hospital at Westmead, Sydney, Australia
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Solomon MJ, Brown KGM, Koh CE, Lee P, Austin KKS, Masya L. Lateral pelvic compartment excision during pelvic exenteration. Br J Surg 2015; 102:1710-7. [PMID: 26694992 DOI: 10.1002/bjs.9915] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/05/2015] [Accepted: 07/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Involvement of the lateral compartment remains a relative or absolute contraindication to pelvic exenteration in most units. Initial experience with exenteration in the authors' unit produced a 21 per cent clear margin rate (R0), which improved to 53 per cent by adopting a novel technique for en bloc resection of the iliac vessels and other side-wall structures. The objective of this study was to report morbidity and oncological outcomes in consecutive exenterations involving the lateral compartment. METHODS Patients undergoing pelvic exenteration between 1994 and 2014 were eligible for review. RESULTS Two hundred consecutive patients who had en bloc resection of the lateral compartment were included. R0 resection was achieved in 66·5 per cent of 197 patients undergoing surgery for cancer and 68·9 per cent of planned curative resections. For patients with colorectal cancer, a clear resection margin was associated with a significant overall survival benefit (P = 0·030). Median overall and disease-free survival in this group was 41 and 27 months respectively. Overall 1-, 3- and 5-year survival rates were 86, 46 and 35 per cent respectively. No predictors of survival were identified on univariable analysis other than margin status and operative intent. Excision of the common or external iliac vessels or sciatic nerve did not confer a survival disadvantage. CONCLUSION The continuing evolution of radical pelvic exenteration techniques has seen an improvement in R0 margin status from 21 to 66·5 per cent over a 20-year interval by routine adoption of a more lateral anatomical plane. Five-year overall survival rates are comparable with those for more centrally based tumours.
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Affiliation(s)
- M J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.,Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney Local Health District, New South Wales, Australia.,Discipline of Surgery, University of Sydney, Sydney, New South Wales, Australia
| | - K G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | - C E Koh
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.,Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney Local Health District, New South Wales, Australia
| | - P Lee
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia
| | - K K S Austin
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia
| | - L Masya
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, New South Wales, Australia
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Brown KGM, Koh CE, Solomon MJ, Choy IC, Dubenec S. Spiral saphenous vein graft for major pelvic vessel reconstruction during exenteration surgery. Ann Vasc Surg 2015; 29:1323-6. [PMID: 25770390 DOI: 10.1016/j.avsg.2015.01.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 01/17/2015] [Accepted: 01/27/2015] [Indexed: 12/13/2022]
Abstract
This article describes a great saphenous vein spiral graft technique for reconstruction of iliac vessels after en bloc resection during pelvic exenteration. Use of different size syringes as a scaffold allows the surgeon to construct autologous vascular interposition conduits of variable diameter to match the luminal size of the vessel requiring reconstruction. Autologous vascular grafts are preferred in exenteration surgery in which the operative field is commonly contaminated by concomitant bowel resection, which carries an increased risk of graft infection.
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Affiliation(s)
- Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; The Institute of Academic Surgery at RPA, Sydney Local Health District, Sydney, Australia; University of Sydney, Sydney, Australia.
| | - Ian C Choy
- Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and Sydney School of Public Health, University of Sydney, Sydney, Australia; Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Steven Dubenec
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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