Feasibility and Colonoscopy Yield Using the Fecal Immunochemical Test (FIT)-Based Colorectal Cancer Screening in a Latin America Country

BACKGROUND & AIMS

Organized colorectal cancer (CRC) screening is not widely practiced in Latin America and the results of regional studies may help overcome barriers for implementation of national screening programs. We aimed to describe the implementation and findings of a fecal immunochemical test (FIT)-based program in Brazil.

METHODS

In a prospective population-based study, asymptomatic individuals (50-75 years old) from Sao Paulo city were invited to undergo FIT for CRC screening. Participants with positive FIT (≥10 μg Hb/g feces) were referred for colonoscopy. Subjects were classified into groups according to the presence of CRC, precursor lesions, and other benign findings, possibly related to bleeding.

RESULTS

Of a total of 9881 subjects, 7.8% had positive FIT and colonoscopy compliance was 68.9% (n = 535). Boston scale was considered adequate in 99% and cecal intubation rate was 99.4%. CRC was diagnosed in 5.9% of the cases, adenoma in 63.2%, advanced adenoma in 31.4%, and advanced neoplasia in 33.0%. Age was positively associated with CRC (P = .03). Higher FIT concentrations were associated with increased detection of CRC (P < .008), advanced adenoma (P < .001), and advanced neoplasia (P < .001).

CONCLUSIONS

Implementation of a FIT-based CRC screening program was feasible in a low-resource setting, and there was a high yield for neoplasia in individuals with a positive FIT. This approach could be used as a model to plan and disseminate organized CRC screening more broadly in Brazil and Latin America.

Predictive factors of response to infliximab therapy in Brazilian inflammatory bowel disease patients

Background

Biological therapies have revolutionized the treatment of patients with inflammatory bowel disease (IBD). Infliximab (IFX) has been shown to be effective in inducing and maintaining remission in patients with Crohn's disease and ulcerative colitis. However, about one-third of the patients are primary non-responders, and up to half can lose response over time. Hence, it is important to assess which factors are related to treatment failure.

Objectives

We aimed to identify factors predicting clinical and endoscopic remission with IFX treatment during maintenance therapy in a Brazilian IBD referral center.

Design

We conducted a cross-sectional study to describe demographic, clinical, and IBD therapy-related characteristics of IBD patients treated with IFX for at least 6 months in a Brazilian referral center. Subsequently, we evaluated factors associated with clinical and endoscopic remission (primary and secondary outcomes, respectively).

Methods

We used descriptive statistics to summarize the essential demographic and clinical characteristics of the population. The association of sociodemographic and clinical variables with outcomes was analyzed using multivariable logistic regression.

Results

A total of 131 IBD patients (the mean age 41.7 years) were enrolled in this study. Clinical and endoscopic remission were observed in 79.4% and 58.2% of the patients, respectively. In the multivariable analysis, IFX therapy duration and higher albumin levels increased the likelihood of clinical remission, while previous surgery decreased its chance. Prior use of adalimumab and higher C-reactive protein levels reduced the likelihood of endoscopic remission.

Conclusion

In summary, this study has enhanced our understanding of the predictive factors of treatment response to IFX in a well-characterized Brazilian IBD population.

Trial registration

4.254.501 and 2.903.748.

Magnifying chromoendoscopy is a reliable method in the selection of rectal neoplasms for local excision

PURPOSE

Adequate staging of early rectal neoplasms is essential for organ-preserving treatments, but magnetic resonance imaging (MRI) frequently overestimates the stage of those lesions. We aimed to compare the ability of magnifying chromoendoscopy and MRI to select patients with early rectal neoplasms for local excision.

METHODS

This retrospective study in a tertiary Western cancer center included consecutive patients evaluated by magnifying chromoendoscopy and MRI who underwent en bloc resection of nonpedunculated sessile polyps larger than 20 mm, laterally spreading tumors (LSTs) [Formula: see text] 20 mm, or depressed-type lesions of any size (Paris 0-IIc). Sensitivity, specificity, accuracy, and positive and negative predictive values of magnifying chromoendoscopy and MRI to determine which lesions were amenable to local excision (i.e., [Formula: see text] T1sm1) were calculated.

RESULTS

Specificity of magnifying chromoendoscopy was 97.3% (95% CI 92.2-99.4), and accuracy was 92.7% (95% CI 86.7-96.6) for predicting invasion deeper than T1sm1 (not amenable to local excision). MRI had lower specificity (60.5%, 95% CI 43.4-76.0) and lower accuracy (58.3%, 95% CI 43.2-72.4). Magnifying chromoendoscopy incorrectly predicted invasion depth in 10.7% of the cases in which the MRI was correct, while magnifying chromoendoscopy provided a correct diagnosis in 90% of the cases in which the MRI was incorrect (p = 0.001). Overstaging occurred in 33.3% of the cases in which magnifying chromoendoscopy was incorrect and 75% of the cases in which MRI was incorrect.

CONCLUSION

Magnifying chromoendoscopy is reliable for predicting invasion depth in early rectal neoplasms and selecting patients for local excision.

Gastric and Duodenal Fistulas in Crohn's Disease, a Surgical Challenge: Report of 5 Cases and a Review of the Literature

BACKGROUND Fistulas involving the stomach and duodenum in Crohn's disease are rare (occurring in less than 1% of patients). Here, we reviewed registers from 855 patients with Crohn's disease treated in our service from January 2007 to December 2020 and found 4 cases of duodenal fistula and 1 case of gastric fistula. CASE REPORT The fistula origin was in the ileocolic segment in all cases, and all of the patients underwent preoperative optimization with improvement of nutritional status and infection control. They then underwent surgical treatment with resection of the affected segment and duodenal or gastric closure with covering by an omental patch. One case of a duodenal fistula was complicated by duodenal dehiscence. This was treated surgically with duodenojejunostomy. Each of the other patients had an uneventful postoperative course. All patients were successfully cured of their gastroduodenal fistulas, and at the time of this publication, none of them died or had fistula recurrence. CONCLUSIONS Fistulas with the involvement of the stomach and duodenum in patients with Crohn's disease are almost always due to inflammation in the ileum, colon, or previous ileocolic anastomosis. Management of this situation is complex and often requires clinical and surgical assistance; preoperative optimization of the patient's general condition can improve the surgical results. The surgical approach is based on resection of the affected segment and gastric or duodenal closure with covering by an omental patch. Gastrojejunostomy or duodenojejunostomy can be performed in selected patients with larger defects and minor jejunal disease. To prevent recurrence, prophylactic therapy with anti-TNF agents and early endoscopic surveillance are also essential for successful treatment.

Impact of a Routine Colorectal Endoscopic Submucosal Dissection in the Surgical Management of Nonmalignant Colorectal Lesions Treated in a Referral Cancer Center

BACKGROUND

Recent data show an increasing number of abdominal surgeries being performed for the treatment of nonmalignant colorectal polyps in the West but in settings in which colorectal endoscopic submucosal dissection is not routinely performed. This study evaluated the number of nonmalignant colorectal lesions referred to surgical treatment in a tertiary cancer center that incorporated magnification chromoendoscopy and endoscopic submucosal dissection as part of the standard management of complex colorectal polyps.

OBJECTIVE

The study aimed to estimate the number of patients with nonmalignant colorectal lesions referred to surgical resection at our institution after the standardization of routine endoscopic submucosal dissection and to describe outcomes for patients undergoing colorectal endoscopic submucosal dissection.

DESIGN

Single-center retrospective study from a prospectively collected database of endoscopic submucosal dissections and colorectal surgeries performed between January 2016 and December 2019.

SETTING

Reference cancer center.

PATIENTS

Consecutive adult patients with complex nonmalignant colorectal polyps were included.

INTERVENTIONS

Patients with nonmalignant colorectal polyps were treated by endoscopic submucosal dissection or surgery (elective colectomy, rectosigmoidectomy, low anterior resection, or proctocolectomy).

MAIN OUTCOMES MEASURES

The primary outcome measure was the percentage of patients referred to colorectal surgery for nonmalignant lesions.

RESULTS

In the study period, 1.1% of 825 colorectal surgeries were performed for nonmalignant lesions, and 97 complex polyps were endoscopically removed by endoscopic submucosal dissection. The en bloc, R0, and curative resection rates of endoscopic submucosal dissection were 91.7%, 83.5%, and 81.4%, respectively. The mean tumor size was 59 (SD 37.8) mm. Perforations during endoscopic submucosal dissection occurred in 3 cases, all treated with clipping. One patient presented with a delayed perforation 2 days after the endoscopic resection and underwent surgery. The mean follow-up period was 3 years, with no tumor recurrence in this cohort.

LIMITATIONS

Single-center retrospective study.

CONCLUSIONS

A workflow that includes assessment of the lesions with magnification chromoendoscopy and resection through endoscopic submucosal dissection can lead to a very low rate of abdominal surgery for nonmalignant colorectal lesions. See Video Abstract at http://links.lww.com/DCR/C123 .

IMPACTO DE LA DISECCIN SUBMUCOSA ENDOSCPICA COLORRECTAL DE RUTINA EN EL MANEJO QUIRRGICO DE LESIONES COLORRECTALES NO MALIGNAS TRATADAS EN UN CENTRO ONCOLGICO DE REFERENCIA

ANTECEDENTES:Datos recientes muestran un número cada vez mayor de cirugías abdominales realizadas para el tratamiento de pólipos colorrectales no malignos en Occidente, pero no en los entornos donde la disección submucosa endoscópica colorrectal se realiza de forma rutinaria. El estudio evaluó el número de lesiones colorrectales no malignas referidas a tratamiento quirúrgico en un centro oncológico terciario, que incorporó cromoendoscopia de aumento y disección submucosa endoscópica como parte del manejo estándar de pólipos colorrectales complejos.OBJETIVO:Estimar el número de pacientes con lesiones colorrectales no malignas referidos para resección quirúrgica en nuestra institución, después de la estandarización de la disección submucosa endoscópica de rutina y describir los resultados para los pacientes sometidos a disección submucosa endoscópica colorrectal.DISEÑO:Estudio retrospectivo de un solo centro, a partir de una base de datos recolectada prospectivamente de disecciones submucosas endoscópicas y cirugías colorrectales realizadas entre enero de 2016 y diciembre de 2019.AJUSTE:Centro oncológico de referencia.PACIENTES:Pacientes adultos consecutivos con pólipos colorrectales no malignos complejos.INTERVENCIONES:Pacientes con pólipos colorrectales no malignos tratados mediante disección submucosa endoscópica o cirugía (colectomía electiva, rectosigmoidectomía, resección anterior baja o proctocolectomía).PRINCIPALES MEDIDAS DE RESULTADO:La medida de resultado primario fue el porcentaje de pacientes remitidos a cirugía colorrectal por lesiones no malignas.RESULTADOS:En el período, 1,1% de 825 cirugías colorrectales fueron realizadas por lesiones no malignas y 97 pólipos complejos fueron extirpados por. disección submucosa endoscópica. Las tasas de resección en bloque, R0 y curativa de disección submucosa endoscópica fueron 91,7%, 83,5% y 81,4%, respectivamente. El tamaño tumoral medio fue de 59 (DE 37,8) mm. Se produjeron perforaciones durante la disección submucosa endoscópica en 3 casos, todos tratados con clipaje. Un paciente presentó una perforación diferida 2 días después de la resección endoscópica y fue intervenido quirúrgicamente. El seguimiento medio fue de 3 años, sin recurrencia tumoral en esta cohorte.LIMITACIONES:Estudio retrospectivo de un solo centro.CONCLUSIONES:Un flujo de trabajo que incluye la evaluación de las lesiones con cromoendoscopia de aumento y resección a través de disección submucosa endoscópica, puede conducir a una tasa muy baja de cirugía abdominal para lesiones colorrectales no malignas. Consulte Video Resumen en http://links.lww.com/DCR/C123 . (Traducción-Dr. Fidel Ruiz Healy ).

MRI-based radiomic score increased mrTRG accuracy in predicting rectal cancer response to neoadjuvant therapy

PURPOSE

To develop a magnetic resonance imaging (MRI)-based radiomics score, i.e., "rad-score," and to investigate the performance of rad-score alone and combined with mrTRG in predicting pathologic complete response (pCR) in patients with locally advanced rectal cancer following neoadjuvant chemoradiation therapy.

METHODS

This retrospective study included consecutive patients with LARC who underwent neoadjuvant chemoradiotherapy followed by surgery from between July 2011 to November 2015. Volumes of interest of the entire tumor on baseline rectal MRI and of the tumor bed on restaging rectal MRI were manually segmented on T2-weighted images. The radiologist also provided the ymrTRG score on the restaging MRI. Radiomic score (rad-score) was calculated and optimal cut-off points for both mrTRG and rad-score to predict pCR were selected using Youden's J statistic.

RESULTS

Of 180 patients (mean age = 63 years; 60% men), 33/180 (18%) achieved pCR. High rad-score (> - 1.49) yielded an area under the curve (AUC) of 0.758, comparable to ymrTRG 1-2 which yielded an AUC of 0.759. The combination of high rad-score and ymrTRG 1-2 yielded a significantly higher AUC of 0.836 compared with ymrTRG 1-2 and high rad-score alone (p < 0.001). A logistic regression model incorporating both high rad-score and mrTRG 1-2 was built to calculate adjusted odds ratios for pCR, which was 4.85 (p < 0.001).

CONCLUSION

Our study demonstrates that a rectal restaging MRI-based rad-score had comparable diagnostic performance to ymrTRG. Moreover, the combined rad-score and ymrTRG model yielded a significant better diagnostic performance for predicting pCR.

Multiple colorectal liver metastases resection can offer long-term survival: The concept of a chronic neoplastic disease

BACKGROUND

Resection for colorectal liver metastases has evolved significantly and, currently, there are no limits to the number of resected nodules. This study aimed to evaluate the outcomes and prognostic factors after liver resection for patients with ≥4 colorectal liver metastases, emphasizing long-term survival.

METHODS

The study population consisted of 137 patients with ≥4 colorectal liver metastases out of a total of 597 patients with colorectal liver metastases who underwent curative intent liver resection from January 2010 to July 2019 in a single hepatobiliary center.

RESULTS

The probability of overall and disease-free survival at 1, 3, and 5 years was 90.8%, 64.5%, 40.6%, and 37.7%, 19.3%, 18.1%, respectively. In a multivariate analysis for overall survival, the size of the largest metastatic nodule was the only unfavorable factor (P = .001). For disease-free survival, complete pathological response was a favorable factor (P = .04), and the following were negative factors: number of nodules ≥7 (P = .034), radiofrequency ablation during surgery (P = .04), positive primary tumor lymph nodes (P = .034), R1 resection (P = .011), and preoperative carcinoembryonic antigen >20 ng/mL (P = .015). After the first and second years of follow-up, 59 patients (45.3%) and 45 patients (34.6%), respectively, were not receiving chemotherapy. After 5 years of follow-up, 21 (16.1%) multimetastatic patients were chemotherapy-free.

CONCLUSION

A significant number of patients with multiple colorectal liver metastases will present long-term survival and should not be denied surgery. The long-term survival rates, even in the presence of recurrence, characterize a chronic neoplastic disease.

Hexafluoroisopropanol decreases liver ischemia-reperfusion injury by downregulation of high mobility group box-1 protein

Liver ischemia-reperfusion (IR) injury is associated with poor outcome after liver transplantation and liver resections. Hexafluoroisopropanol (HFIP) is a tri-fluorinated metabolites of volatile anesthetics and has modulatory effects on inflammation that have been observed mainly in cell culture experiments. In this survey, we investigated the effects of HFIP in a rat model of normothermic hepatic ischemia-reperfusion injury. Twenty-four male Wistar rats were randomized into three groups: (1) control in which animals were submitted to 30 min of partial liver ischemia with resection of non-ischemic liver lobes immediate after reperfusion, (2) pre-ischemia (PI) group in which animals received intravenous HFIP (67 mg/kg) 5 min before liver ischemia, and (3) pre-reperfusion (PR) group in which animals received intravenous HFIP (67 mg/kg) 5 min before reperfusion. Four hours after reperfusion, all animals were euthanized for sample collection. Aspartate and alanine transaminases, glucose, and high mobility group box-1 (HMGB-1) protein concentrations showed a significant decreased, and malondialdehyde was increased in the PR group compared with control and PI groups. Interleukin 6 (IL-6) was increased in the PI group compared with control and PR groups. IL-10 and -12 were increased in the PR and PI groups, respectively, when compared with the control group. Glucose decreased in the PR when compared with the control group. Post-conditioning with HFIP led to a decrease in hepatocellular injury and was associated with a downregulation of HMGB-1. The HFIP resulted in a better control of inflammatory response to ischemia-reperfusion even without causing a reduction in oxidative stress.

Use of an electromagnetic-guided device to assist with post-pyloric placement of a nasoenteral feeding tube: A systematic review and meta-analysis

Background and study aims  While endoscopic-guided placement (EGP) of a post-pyloric nasoenteral feeding tube may improve caloric intake and reduce the risk of bronchoaspiration, an electromagnetic-guided placement (EMGP) method may obviate the need for endoscopic procedures. Therefore, the primary aim of this study was to perform a systematic review and meta-analysis of randomized trials comparing the efficacy and safety of EMGP versus EGP of a post-pyloric feeding tube. Methods  Protocolized searches were performed from the inception through January 2021 following PRISMA guidelines. Only randomized controlled trials were included comparing EMGP versus EGP. Study outcomes included: technical success (defined as appropriate post-pyloric positioning), tube and patient associated adverse events (AEs), time to enteral nutrition, procedure-associated cost, and procedure time. Pooled risk difference (RD) and mean difference (MD) were calculated using a fixed-effects model and heterogeneity evaluated using Higgins test (I ² ). Results  Four randomized trials (n = 536) were included. A total of 287 patients were included in the EMGP group and 249 patients in the EGP group. There was no difference between EMGP versus EGP regarding technical success, tube-related AEs, patient-related AEs, procedure time, and time in the right position. Time to enteral nutrition favored EMGP (MD: -134.37 [-162.13, -106.61]; I ²  = 35 %); with significantly decreased associated cost (MD: -127.77 ($) [-135.8-119.73]; I ²  = 0 %). Conclusions  Based on this study, EMGP and EGP were associated with similar levels of technical success and safety as well as time to complete the procedure. Despite this, EMGP was associated with reduced cost and time to initiation of nutrition.

Tumor size predicts worse prognosis in esophagogastric junction adenocarcinoma

Adenocarcinoma of the esophagogastric junction (AEGJ) has an increasing incidence and is associated with limited overall survival. Several studies have tried to identify prognostic factors for AEGJ, although few have described relationships between prognosis and the tumor's size or anatomical location. Thus, this retrospective study evaluated 188 patients with resected locally advanced AEGJ. Tumor location was determined using upper endoscopy, and the following groups were created: E&E + EGJ (distal esophagus, esophagogastric junction, and distal esophagus), EGJ (esophagogastric junction), EGJ + G (esophagogastric junction and proximal stomach), G (proximal stomach), and E + EGJ + G (esophagus to the proximal stomach, including the esophagogastric junction). Other variables of interest were tumor size and differentiation, TNM stage, comorbidities, surgery type, and survival outcomes. Among 188 patients included, 163 were men (86.7%), and the mean age was 64.9 years. Forty-eight (25.6%) patients underwent total gastrectomy and distal esophagectomy, while 140 (74.4%) subtotal esophagectomy with proximal gastrectomy. Presence of comorbidities, tumor size, angiolymphatic and perineural invasion, and pTNM status were different between groups according to tumor location. The mean follow-up period was 47.4 months. The disease-free survival (DFS) rates were as follows: 72.7% (G), 68.0% (E&E + EGJ), 63.4% (EGJ), 57.1% (EGJ + G), and 44.4% (E + EGJ + G), while the overall survival (OS) rates were 81.0% (EGJ + G), 78.8% (G), 64.0% (E&E + EGJ), 54.9% (EGJ), and 48.1% (E + EGJ + G). Multivariate analysis revealed that tumor size of < 5 cm, and tumor location G subgroups were associated with better DFS. High histological grade and advanced pT status were independent factors related to worse OS. In conclusion, the prognosis of AEGJ may be preoperatively predicted by a tumor size of ≥ 5 cm and its anatomical location.

18F-FDG-PET/CT-measured parameters as potential predictors of residual disease after neoadjuvant chemoradiotherapy in patients with esophageal carcinoma

Objective

To evaluate the maximum and mean standardized uptake values, together with the metabolic tumor value and the total lesion glycolysis, at the primary tumor site, as determined by ¹⁸F-fluorodeoxyglucose positron-emission tomography/computed tomography (¹⁸F-FDG-PET/CT), performed before and after neoadjuvant chemoradiotherapy (nCRT), as predictors of residual disease (RD) in patients with esophageal cancer.

Materials and Methods

The standardized uptake values and the volumetric parameters (metabolic tumor value and total lesion glycolysis) were determined by ¹⁸F-FDG-PET/CT to identify RD in 39 patients before and after nCRT for esophageal carcinoma. We used receiver operating characteristic curves to analyze the diagnostic performance of ¹⁸F-FDG-PET/CT parameters in the definition of RD. The standard of reference was histopathological analysis of the surgical specimen.

Results

Eighteen patients (46%) presented RD after nCRT. Statistically significant areas under the curve (approximately 0.72) for predicting RD were obtained for all four of the variables evaluated after nCRT. Considering the presence of visually detectable uptake (higher than the background level) at the primary tumor site after nCRT as a positive result, we achieved a sensitivity of 94% and a specificity of 48% for the detection of RD.

Conclusion

The use of ¹⁸F-FDG-PET/CT can facilitate the detection of RD after nCRT in patients with esophageal cancer.

Status of bariatric endoscopy–what does the surgeon need to know? A review

BACKGROUND

Obesity is a chronic and multifactorial disease with a variety of potential treatment options available. Currently, there are several multidisciplinary therapeutic options for its management, including conservative, endoscopic, and surgical treatment.

AIM

To clarify indications, technical aspects, and outcomes of bariatric endoscopy.

METHODS

Narrative review of current literature based on electronic databases including MEDLINE (PubMed), Cochrane Library, and SciELO.

RESULTS

Bariatric endoscopy is in constant development and comprises primary and revisional treatment options as well as management of surgical complications. Various devices act upon different mechanisms of action, which may be individualized to each patient. Despite favorable results for the endoscopic treatment of obesity, prospective randomized studies with long-term follow-up are required to fully validate primary and revisional endoscopic therapies. Regarding the management of bariatric surgery complications, endoscopic therapy may be considered the procedure of choice in a variety of situations. Still, as there is no standardized algorithm, local experience should be considered in decision-making.

CONCLUSION

The treatment of patients with obesity is complex, and a multidisciplinary approach is essential. Bariatric endoscopy has shown impressive results both in the treatment of obesity and its surgical complications, and therefore, must be part of the armamentarium in the fight against this disease.

Fournier’s Gangrene During Pregnancy in a Patient with Crohn’s Disease

Patient: Female, 29-year-old

Final Diagnosis: Crohn’s associated Perianal and perirectal abscess • Fournier’s gangrene

Symptoms: Anal pain

Medication: —

Clinical Procedure: —

Specialty: Surgery

SALVAGE SURGERY IN GASTRIC CANCER

AIM

Salvage surgery (SS) is defined as surgical resection after the failure of the first treatment with curative intent. The aim of this study was to report the experience of a reference center with SS for stomach adenocarcinoma.

METHODS

This is a retrospective study of patients with gastric cancer (GC) operated on between 2009 and 2020.

RESULTS

Notably, 40 patients were recommended for salvage gastrectomy with curative-intent treatment. For analysis purpose, patients were divided into two groups: 23 patients after endoscopic resection and 17 patients after gastrectomy. In the first group, all patients underwent R0 resection, their average hospital length of stay (LOS) was 15.7 days, and 2 (8.6%) patients had major complications. During the average follow-up of 37.2 months, there was only one recurrence. The median overall survival (OS) was 46 months. In the postgastrectomy group, 9 (52.9%) patients were rescued with curative intent, the average hospital LOS was 12.2 days, and 3 (17.6%) had major complications. In a mean follow-up of 22 months, five patients relapsed. Median OS and disease-free survival were 24 and 16.5 months, respectively.

CONCLUSION

SS in GC offers the possibility of long-term disease control and increased survival rate with an acceptable complication rate.

Two decades of liver resection with a multidisciplinary approach in a single institution: What has changed? Analysis of 1409 cases

OBJECTIVES

To evaluate results of patients undergoing liver resection in a single center over the past two decades with a particular look at Colorectal Liver Metastasis (CRLM) and Hepatocellular Carcinoma (HCC).

METHOD

Patients were divided into two eras, from 2000 to 2010 (Era 1) and 2011 to 2020 (Era 2). The most frequent diagnosis was CRLM and HCC, with 738 (52.4%) and 227 (16.1%) cases respectively. An evaluation of all liver resection cases and a subgroup analysis of both CRLM and HCC were performed. Preoperative and per operative variables and long-term outcomes were evaluated.

RESULTS

1409 liver resections were performed. In Era 2 the authors observed higher BMI, more: minimally invasive surgeries, Pringle maneuvers, and minor liver resections; and less transfusion, less ICU necessity, and shorter length of hospital stay. Severe complications were observed in 14.7% of patients, and 90-day mortality was 4.2%. Morbidity and mortality between eras were not different. From 738 CRLM resections, in Era 2 there were significantly more patients submitted to neoadjuvant chemotherapy, bilateral metastases, and smaller sizes with significantly less transfusion, the necessity of ICU, and shorter length of hospital stay. More pedicle clamping, minimally invasive surgeries, and minor resections were also observed. From 227 HCC resections, in Era 2 significantly more minimally invasive surgeries, fewer transfusions, less necessity of ICU, and shorter length of hospital stay were observed. OS was not different between eras for CRLM and HCC.

CONCLUSIONS

Surgical resection in a multidisciplinary environment remains the cornerstone for the curative treatment of primary and metastatic liver tumors.

Common variable immunodeficiency: an important but little-known risk factor for gastric cancer

INTRODUCTION

although it is a rare disease, common variable immunodeficiency (CVID) stands out as the most frequent primary symptomatic immunodeficiency. Carriers are prone to a variety of recurrent bacterial infections, in addition to the risk of developing autoimmune diseases and neoplasms including gastric cancer (GC). Despite the recognized risk, there are no specific standardized protocols for the management of GC in these patients, so the reported oncological results are varied. Thus, this study aims to describe the clinicopathological characteristics and prognosis of patients with CVID undergoing surgical treatment of GC.

METHODS

all patients with GC undergoing surgical treatment between 2009 and 2020 were retrospectively evaluated. Later, patients diagnosed with CVID were identified and this group was compared with the remaining patients without any immunodeficiency.

RESULTS

among the 1101 patients with GC evaluated in the period, 10 had some type of immunodeficiency, and 5 were diagnosed with CVID. Patients with CVID had younger age, lower BMI, and smaller lesions compared to those without CVID. Four patients underwent curative gastrectomy and one patient underwent jejunostomy. Two patients died (1 palliative and 1 curative) and one patient had disease recurrence. There was no statistically significant difference regarding the incidence of postoperative complications and survival between the evaluated groups.

CONCLUSION

the CVID incidence in patients with GC undergoing surgical treatment was 0.5%, occurring at a less advanced age, but with no difference regarding surgical and oncological results.

Cytotoxic T-lymphocyte-associated protein 4 in gastric cancer: Prognosis and association with PD-L1 expression

BACKGROUND

Cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) is one of the most studied immune checkpoint in gastric cancer (GC). However, the prognostic role of CTLA-4 expression in GC is poorly described. This study aimed to evaluate CTLA-4 expression in GC and its impact on survival, including patients treated with standard platinum-based chemotherapy (CMT), and association with PD-L1 expression.

METHODS

All GC patients who underwent D2-gastrectomy were investigated retrospectively. Tumor samples were examined for CTLA-4 and PD-L1 by immunohistochemistry. Tumor-infiltrating inflammatory cells, including CD4 + and CD8 + , were also examined.

RESULTS

Among the 284 GC patients included, 159 (56%) were CTLA-4 positive and the remaining 125 (44%) were classified as negative. CTLA-4 positive GC was associated with increased inflammatory cell infiltration (p < 0.001), high CD8 + T cells (p = 0.016) and PD-L1 expression (p = 0.026). Considering GC referred for treatment, CTLA-4 negative patients who received CMT had a significant improvement in disease-free survival compared to untreated CLTA-4 negative (p = 0.028). In multivariate analysis, GC positive for both CTLA-4 and PD-L1 had a prognostic impact on survival.

CONCLUSION

CTLA-4 positive was associated with PD-L1 expression and a high tumor-infiltrating CD8 + T cells. Accordingly, positivity for both CTLA-4 and PD-L1 was an independent factor associated to better survival in GC patients.

Impact of COVID-19 pandemic on the surgical treatment of gastric cancer

OBJECTIVE

The Coronavirus Disease 2019 (COVID-19) pandemic has been recognized as one of the most serious public health crises. This study aimed to evaluate the short-term impact of the pandemic on the surgical treatment of patients with gastric cancer (GC) in addition to their clinicopathological characteristics. We also verified adherence to the COVID-19 screening protocol adopted in the institution.

METHODS

All patients with GC who underwent surgical treatment between 2015 and 2021 were retrospectively evaluated and divided into two groups according to the time period: control group (2015-2019) and COVID group (2020-2021). The institutional protocol recommends that patients referred for surgery undergo RT-PCR for severe acute respiratory syndrome coronavirus 2 infection.

RESULTS

A total of 83 patients were classified into the COVID group and 535 into the control group. The number of surgical procedures performed in the control group was 107 (SD±23.8) per year. Diagnostic procedures (p=0.005), preoperative chemotherapy (p<0.001), and adenocarcinomas without Lauren's subtype (p=0.009) were more frequent in the COVID group than in the control group. No significant difference was observed in the pathological characteristics and surgical outcomes of curative GC between the two groups. Evaluation of protocol compliance showed that of 83 patients with GC in the COVID group, 19 (22.9%) were not tested for COVID-19 before surgery. Two patients tested positive for COVID-19 (one preoperative and one postoperative).

CONCLUSION

A decrease in the average number of surgeries and a higher frequency of diagnostic procedures occurred during the pandemic than in the previous time period. Tumor/node/metastasis classification, morbidity rates, and mortality rates in patients with GC during the pandemic did not differ from those in the previous time period. Accordingly, GC surgical treatment with acceptable screening protocol compliance could be safely performed during the COVID-19 pandemic.

Anorectal Mucosal Melanoma: A Case Report and Literature Review

BACKGROUND Anorectal mucosal melanoma (AMM) is a rare and aggressive neoplasm, with a 5-year survival rate of 10%. Due to its rarity and nonspecific symptoms, the diagnosis is often made late. Surgical resection remains the criterion standard for treatment of anorectal melanoma. CASE REPORT We present the case of an 81-year-old woman presenting with hematochezia, anal secretion, tenesmus, difficulty in defecation, and perianal pain. On physical examination, there was a prolapse of a 5-cm melanocytic nodule in the anal canal, hard on palpation. Biopsy confirmed anorectal melanoma. Staging revealed anal and metastatic disease, with adrenal, lymphatic, and hepatic involvement. As the patient continued to have bleeding, severe pain, and difficulty in defecation, she was submitted to a wide local excision. At 5-month follow-up, the anal lesion had relapsed, and the patient died 10 months after the procedure. CONCLUSIONS AMM is a rare and extremely aggressive tumor. Symptoms are nonspecific but early diagnosis should be pursued to allow curative treatment. Surgical resection with free margins is the goal of surgical treatment. New therapies are being studied, including immunotherapy, which can improve the dismal prognosis of this rare disease.

Jejunostomy in the palliative treatment of gastric cancer: A clinical prognostic score

BACKGROUND

Clinical stage IV gastric cancer (GC) may need palliative procedures in the presence of symptoms such as obstruction. When palliative resection is not possible, jejunostomy is one of the options. However, the limited survival of these patients raises doubts about who benefits from this procedure.

AIM

To create a prognostic score based on clinical variables for 90-d mortality for GC patients after palliative jejunostomy.

METHODS

We performed a retrospective analysis of Stage IV GC who underwent jejunostomy. Eleven preoperative clinical variables were selected to define the score categories, with 90-d mortality as the main outcome. After randomization, patients were divided equally into two groups: Development (J1) and validation (J2). The following variables were used: Age, sex, body mass index (BMI), American Society of Anesthesiologists classification (ASA), Charlson Comorbidity index (CCI), hemoglobin levels, albumin levels, neutrophil-lymphocyte ratio (NLR), tumor size, presence of ascites by computed tomography (CT), and the number of disease sites. The score performance metric was determined by the area under the receiver operating characteristic (ROC) curve (AUC) to define low and high-risk groups.

RESULTS

Of the 363 patients with clinical stage IVCG, 80 (22%) patients underwent jejunostomy. Patients were predominantly male (62.5%) with a mean age of 62.4 years old. After randomization, the binary logistic regression analysis was performed and points were assigned to the clinical variables to build the score. The high NLR had the highest value. The ROC curve derived from these pooled parameters had an AUC of 0.712 (95%CI: 0.537-0.887, P = 0.022) to define risk groups. In the validation cohort, the diagnostic accuracy for 90-d mortality based on the score had an AUC of 0.756, (95%CI: 0.598-0.915, P = 0.006). According to the cutoff, in the validation cohort BMI less than 18.5 kg/m2 (P < 0.001), CCI ≥ 1 (P = 0.001), ASA III/IV (P = 0.002), high NLR (P = 0.012), and the presence of ascites on CT exam (P = 0.004) were significantly associated with the high-risk group. The risk groups showed a significant association with first-line (P = 0.012), second-line chemotherapy (P = 0.009), 30-d (P = 0.013), and 90-d mortality (P < 0.001).

CONCLUSION

The scoring system developed with 11 variables related to patient's performance status and medical condition was able to distinguish patients undergoing jejunostomy with high risk of 90 d mortality.

Laparoscopic gastrectomy for early and advanced gastric cancer in a western center: a propensity score-matched analysis

The employment of laparoscopic gastrectomy (LG) in the management of gastric cancer (GC) is increasing. Despite recent results from randomized trials, its effectiveness and oncological results in different scenarios remain controversial, especially in western centers. The aim of this study was to compare the short-term outcomes and survival of LG with open gastrectomy (OG) for GC. We reviewed all GC patients who underwent curative gastrectomy from a prospective database. Propensity score-matched (PSM) analysis including 10 variables was conducted to reduce patient selection bias using a 1:1 case-control match. A total of 530 GC were eligible for inclusion (438 OG and 92 LG). Older age, lower hemoglobin levels, total gastrectomy, larger tumor size, greater depth of tumor invasion and advanced pTNM stage was more frequent in the OG group. After PMS analysis, 92 patients were matched in each group. All variables assigned in the score were well matched. LG group had a slightly higher number of retrieved lymph nodes (42.3 vs 37.6), however, without reaching statistical significance (p = 0.072). No differences were recorded about the frequency of major postoperative complications (POC) and mortality rates between OG and LG groups (12% vs 15.2%, p = 0.519, respectively). In survival analysis, after matching, there was no difference in survival between the two groups. Multivariate analysis showed that only ASA and pN stage were independent factor associated with survival after PSM. In conclusion, laparoscopic gastrectomy was a safe and effective surgical technique for gastric cancer, with short-term and oncological outcomes comparable to open surgery.

Indocyanine green imaging to guide lymphadenectomy in laparoscopic distal gastrectomy - With vídeo

Gastric cancer (GC) is one of the most lethal malignancies and Gastrectomy with D2 lymphadenectomy is considered the standard surgical treatment. Adequate lymph node dissection is necessary for patients' prognosis, but D2 lymphadenectomy is technically demanding due to the complexity of anatomy, even more so if performed laparoscopically. The learning curve requires a high degree of training with a considerable number of cases and standardization of the technique. Recently, Indocyanine Green (ICG) and Near-Infrared (NIR) Fluorescence Imaging have been presented as promising image-guided surgery techniques, providing real-time anatomy assessment and intra-operative visualization of blood flow, lymph nodes and lymphatic vessels. ICG fluorescence imaging has been studied in GC surgery, especially for real-time lymphatic mapping. At present, we are conducting a prospective, open-label, single-arm clinical trial (Clinical trial - NCT03021200) to evaluate the feasibility and outcomes of ICG and NIR Fluorescence Imaging in GC surgery. In this technical note, we present one approach to the use of this technique to guide lymphadenectomy in laparoscopic distal gastrectomy.

Gastric Mixed Neuroendocrine Non-Neuroendocrine Neoplasms: A Western Center Case Series

BACKGROUND

Mixed neuroendocrine non-neuroendocrine neoplasms (MiNENs) represent a rare tumor composed of adenocarcinoma and neuroendocrine carcinoma components. This study reports a case series of gastric MiNEN and discusses issues related to its diagnosis, management, and outcomes.

METHODS

We retrospectively analyzed data from patients with gastric MiNEN who underwent surgical resection at our service from 2009 to 2020. Patients with gastric adenocarcinoma served as a comparison group. Clinical, pathologic, and surgical characteristics were compared.

RESULTS

During the selected period, 5 gastric MiNEN patients and 597 patients with gastric adenocarcinoma were included. Among the clinical variables, age, sex, BMI, and laboratory exams were similar between the two groups. Only ASA classification was different (p = 0.015). Pathological variables such as tumor size, lymphovascular invasion, number of retrieved lymph nodes, and pTNM staging were also similar between both groups. Lastly, early surgical outcomes and long-term survival did not differ between gastric MiNEN and adenocarcinoma patients.

CONCLUSION

A MiNEN is a rare tumor that represents less than 1% of GC patients undergoing curative treatment, and demonstrated clinicopathological characteristics and outcomes similar to gastric adenocarcinoma.

ANORECTAL MANOMETRY STANDARD OF A BRAZILIAN POPULATION AT PRODUCTIVE AGE WITHOUT PELVIC FLOOR DISORDERS: A PROSPECTIVE VOLUNTEERED STUDY

Background:

Due to the lack of normal standards of anorectal manometry in Brazil, data used are subject to normality patterns described at different nationalities.

Aim:

To determine the values and range of the parameters evaluated at anorectal manometry in people, at productive age, without pelvic floor disorders comparing the parameters obtained between male and female.

Methods:

Prospective analysis of clinical data, such as gender, age, race, body mass index (BMI) and anorectal manometry, of volunteers from a Brazilian university reference in pelvic floor disorders.

Results:

Forty patients were included, with a mean age of 45.5 years in males and 37.2 females (p=0.43). According to male and female, respectively in mmHg, resting pressures were similar (78.28 vs. 63.51, p=0.40); squeeze pressures (153.89 vs. 79.78, p=0.007) and total squeeze pressures (231.27 vs. 145.63, p=0.002). Men presented significantly higher values of anorectal squeeze pressures, as well as the average length of the functional anal canal (2.85 cm in male vs. 2.45 cm in female, p=0.003).

Conclusions:

Normal sphincter pressure levels in Brazilians differ from those used until now as normal literature standards. Male gender has higher external anal sphincter tonus as compared to female, in addition a greater extension of the functional anal canal

Long-term outcomes of endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors

BACKGROUND AND AIM

Endoscopic submucosal dissection and transanal endoscopic microsurgery are good options for the treatment of rectal adenomas and early rectal carcinomas, but whether long-term outcomes of these procedures are comparable is not known. The aim of this study was to address this question.

METHODS

A retrospective single-center study evaluating 98 consecutive procedures between June 2008 and December 2017 was performed in a tertiary cancer center. Consecutive patients who had undergone either endoscopic submucosal resection or transanal endoscopic microsurgery for rectal adenomas and early rectal carcinomas were evaluated, and long-term recurrence and complication rates were compared.

RESULTS

Both groups were similar regarding sex, age, preoperative surgical risk, and en bloc resection rate (95.7% in the endoscopic and 100% in the surgical group, P = 0.81). Mean follow-up period was 37.6 months. Lesions resected endoscopically were significantly larger (68.5 mm) than those resected by transanal resection (44.5 mm), P = 0.003. Curative resections occurred in 97.2% of endoscopic resections and 85.2% of the surgical ones (P = 0.04). Comparing resections that fulfilled histologic curative criteria, there were no recurrences in the endoscopic group (out of 69 cases) and two recurrences in the transanal group (8.3% of 24 cases), P = 0.06. Late complications occurred in 12.7% of endoscopic procedures and 25.9% of surgical procedures (P = 0.13).

CONCLUSIONS

In our experience, endoscopic submucosal resection seems to have advantages over transanal endoscopic microsurgery, with similar en bloc resection rate and lower rate of late complications and recurrences. Multicenter randomized controlled trials are needed to support our findings.

A NEW APPROACH FOR HEMORRHOID DISEASE: SELECTIVE DEARTERIALIZATION AND MUCOPEXY WITHOUT DOPPLER GUIDANCE

Background:

Transanal hemorrhoidal dearterialization (THD) is safe and effective minimally invasive treatment for hemorrhoidal disease, but reports regarding recurrence and postoperative complications (pain and tenesmus) vary significantly.

Aim:

To evaluate if selective dearterialization and mucopexy at the symptomatic hemorrhoid only, without Doppler guidance, achieves adequate control of the prolapse and bleeding and if postoperative morbidity is reduced with this technique.

Methods:

Twenty consecutive patients with grade II and III hemorrhoids were treated with this new approach and were evaluated for postoperative complications and recurrence.

Results:

Control of prolapse and bleeding was achieved in all patients (n=20). Postoperative complications were tenesmus (n=2), external hemorrhoidal thrombosis (n=2) and urinary retention (n=2). After a mean follow-up of 13 months no recurrences were diagnosed.

Conclusion:

Selective dearterialization and mucopexy is safe and achieves adequate control of prolapse and bleeding and, by minimizing sutures in the anal canal, postoperative morbidity is diminished. Doppler probe is unnecessary for this procedure, which makes it also more interesting from an economic perspective.

Is it Safe to Perform Elective Colorectal Surgical Procedures during the COVID-19 Pandemic? A Single Institution Experience with 103 Patients

OBJECTIVES

Since the outbreak of the novel coronavirus disease 2019 (COVID-19), all health services worldwide underwent profound changes, leading to the suspension of many elective surgeries. This study aimed to evaluate the safety of elective colorectal surgery during the pandemic.

METHODS

This was a retrospective, cross-sectional, single-center study. Patients who underwent elective colorectal surgery during the COVID-19 pandemic between March 10 and September 9, 2020, were included. Patient data on sex, age, diagnosis, types of procedures, hospital stay, mortality, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) preoperative screening tests were recorded.

RESULTS

A total of 103 colorectal surgical procedures were planned, and 99 were performed. Four surgeries were postponed due to positive preoperative screening for SARS-CoV-2. Surgical procedures were performed for colorectal cancer (n=90) and inflammatory bowel disease (n=9). Laparoscopy was the approach of choice for 43 patients (43.4%), 53 (53.5%) procedures were open, and 3 (3%) procedures were robotic. Five patients developed COVID-19 in the postoperative period, and three of them died in the intensive care unit (n=3/5, 60% mortality). Two other patients died due to surgical complications unrelated to COVID-19 (n=2/94, 2.1% mortality) (p<0.01). Hospital stay was longer in patients with SARS-CoV-2 infection than in those without (38.4 versushttps://doi.org/10.3 days, respectively, p<0.01). Of the 99 patients who received surgical care during the pandemic, 94 were safely discharged (95%).

CONCLUSION

Our study demonstrated that elective colorectal surgical procedures may be safely performed during the pandemic; however, preoperative testing should be performed to reduce in-hospital infection rates, since the mortality rate due to SARS-CoV-2 in this setting is particularly high.

The novel BPRST classification for hemorrhoidal disease: A cohort study and an algorithm for treatment

BACKGROUND

The classification for HD was developed by Goligher in 1980 and does not contemplate important aspects of this disease, which limits its use in guiding treatment. The aim of this study if to apply in clinical practice the new classification for hemorrhoids named BPRST (bleeding, prolapse, reduction, skin tags, thrombosis), to compare it with the original classification proposed by Goligher and to propose an algorithm for treatment.

MATERIALS AND METHODS

This is a prospective study conducted at the University of São Paulo's teaching hospital and Hospital 9 de Julho. Patients with HD treated from March 2011 to July 2013 were included. Patients were classified according to BPRST and Goligher classifications and treated according to personal experience and most updated guidelines. The association between both classifications and the treatment adopted was compared and an algorithm for treatment was developed.

RESULTS

229 patients were included in this study and 28 patients were lost due to follow-up. According to Goligher, 29, 61, 85 and 26 were classified as grades I, II, III and IV, respectively. According to the BPRST, 23 were classified as stage I, 95 as stage II and 83 as stage III. Six patients classified as Goligher I were reclassified as BPRST stage III and required conventional hemorrhoidectomy, either due to thrombosis (n = 4) or intolerable skin tags (n = 2). The BPRST classification was more closely associated with the type of treatment employed and had few outliers than Goligher (p < 0.001).

CONCLUSION

There are limitations to the use of Goligher's classification in clinical practice. The novel BPRST classification includes important aspects of HD that should be considered when deciding the best treatment option. Our algorithm for treatment contemplates the most commonly used techniques and can help to guide the treatment of this complex disease.

Abdominal Surgery in Crohn's Disease: Risk Factors for Complications

Introduction

Abdominal surgery in patients with Crohn's disease (CD) is challenging, especially in the biologic era. The aim of this study was to evaluate factors associated with increased risk for postoperative complications in CD.

Methods

A retrospective study was conducted with consecutive patients who underwent abdominal surgery for CD from January 2012 to January 2018.

Results

Of 103 patients, 32% had postoperative complications. Gender, age, disease location and phenotype, hemoglobin and albumin levels, previous abdominal surgery, and preoperative optimization did not differ between the groups with or without complications. Thirty-five percent of the patients were under anti-TNF therapy, and this medication was not associated with increased risk for postoperative complications. Time since the onset of the disease was significantly higher in patients with complications (12.9 vs. 9.4, p = 0.04). In multivariate analysis, creation of ostomy and urgent surgery were the only variables independently associated with increased risk for complications (OR 3.2, 95% CI 1.12-9.46 and OR 2.94, 95% CI 0.98-9.09, respectively).

Conclusion

Urgent surgery for CD should preferably be performed in specialized centers, and creation of stoma is not necessarily associated with lower rate of postoperative complications but rather less severe complications.

IS LAPAROSCOPIC REOPERATION FEASIBLE TO TREAT EARLY COMPLICATIONS AFTER LAPAROSCOPIC COLORECTAL RESECTIONS?

Background:

Recently, with the performance of minimally invasive procedures for the management of colorectal disorders, it was allowed to extend the indication of laparoscopy in handling various early and late postoperative complications.

Aim:

To present the experience with laparoscopic reoperations for early complications after laparoscopic colorectal resections.

Methods:

Patients undergoing laparoscopic colorectal resections with postoperative surgical complications were included and re-treated laparoscopically. Selection for laparoscopic approach were those cases with early diagnosis of complications, hemodynamic stability without significant abdominal distention and without clinical comorbidities that would preclude the procedure.

Results:

In four years, nine of 290 (3.1%) patients who underwent laparoscopic colorectal resections were re-approached laparoscopically. There were five men. The mean age was 40.67 years. Diagnoses of primary disease included adenocarcinoma (n=3), familial adenomatous polyposis (n=3), ulcerative colitis (n=1), colonic inertia (n=1) and chagasic megacolon (n=1). Initial procedures included four total proctocolectomy with ileal pouch anal anastomosis; three anterior resections; one completion of total colectomy; and one right hemicolectomy. Anastomotic dehiscence was the most common complication that resulted in reoperations (n=6). There was only one case of an unfavorable outcome, with death on the 40^th day of the first approach, after consecutive complications. The remaining cases had favorable outcome.

Conclusion:

In selected cases, laparoscopic access may be a safe and minimally invasive approach for complications of colorectal resection. However, laparoscopic reoperation must be cautiously selected, considering the type of complication, patient’s clinical condition and experience of the surgical team.

Outcomes of surgical treatment for patients with distal rectal cancer: A retrospective review from a single university hospital

INTRODUCTION AND AIM

Surgery for distal rectal cancer (DRC) can be performed with or without sphincter preservation. The aim of the present study was to analyze the outcomes of two surgical techniques in the treatment of DRC patients: low anterior resection (LAR) and abdominoperineal resection (APR).

METHODS

Patients with advanced DRC that underwent surgical treatment between 2002 and 2012 were evaluated. We compared the outcomes of the type of surgery (APR vs LAR) and analyzed the associations of survival and recurrence with the following factors: age, sex, tumor location, lymph nodes obtained, lymph node involvement, and rectal wall involvement. Patients with distant metastases were excluded.

RESULTS

A total of 148 patients were included, 78 of whom were females (52.7%). The mean patient age was 61.2years. Neoadjuvant chemoradiation therapy was performed in 86.5% of the patients. APR was performed on 86 (58.1%) patients, and LAR on 62 (41.9%) patients. No differences were observed between the two groups regarding clinical and oncologic characteristics. Eighty-seven (62%) patients had pT3-4 disease, and 41 patients (27.7%) had lymph node involvement. In the multivariate analysis, only poorly differentiated tumors (P=.026) and APR (P=.009) correlated with higher recurrence rates. Mean follow-up time was 32 (16-59.9) months. Overall 5-year survival was 58.1%. The 5-year survival rate was worse in patients that underwent APR (46.5%) than in the patients that underwent LAR (74.2%) (P=.009).

CONCLUSIONS

Patients with locally advanced DRC that underwent APR presented with a lower survival rate and a higher local recurrence rate than patients that underwent LAR. In addition, advanced T/stage, lymph node involvement, and poor tumor differentiation were associated with recurrence and a lower survival rate, regardless of the procedure.

Long-term survival analysis after endoscopic stenting as a bridge to surgery for malignant colorectal obstruction: comparison with emergency diverting colostomy

OBJECTIVE

The use of colorectal self-expanding metal stents (SEMS) as bridge therapy for malignant colorectal obstruction was first reported more than 20 years ago. However, its use remains controversial. In this study, we aimed to compare the long-term survival of patients with potentially resectable malignant colorectal obstruction who had undergone colorectal SEMS placement and emergency surgery.

METHODS

This study was a retrospective analyses. Patients who received treatment between 2009 and 2017 were included. According to the eligibility criteria, 21 patients were included in the SEMS group and 67 patients were included in the surgical group..

RESULTS

The majority of the patients in the SEMS group were female (57.1%), whereas the majority of those in the surgical group were male (53.7%). The median follow-up time was 60 months for both groups with the same interquartile range of 60 months. There was no difference in the overall survival rate (log rank p=0.873) and disease-free survival rate (log rank p=0.2821) in the five-year analysis. There was no difference in local recurrence rates (38.1% vs. 22.4%, p=0.14) or distant recurrence rates (33.3% vs. 50.7%, p=0.16) in the SEMS and the surgical groups. Technical and clinical success rates of endoscopic stenting were 95.3% and 85.7%, respectively. There were no immediate adverse events (AEs). Severe AEs included perforation (14.3%), silent perforation (4.7%), reobstruction (14.3%), and bleeding (14.3%). Mild AEs included pain (42.8%), tenesmus (9.5%), and incontinence (4.76%). The limitations of this study was retrospective and was conducted at a single center.

CONCLUSIONS

No differences in disease-free and overall survival rates were observed in the five-year analysis of patients with resectable colorectal cancer who had undergone SEMS placement or colostomy for the treatment of malignant colorectal obstruction. Patients in the SEMS group had a higher rate of primary anastomosis and a lower rate of temporary colostomy than did those in the surgery group.

IS THERE A DIFFERENCE BETWEEN RIGHT- VERSUS LEFT-SIDED COLON CANCERS? DOES SIDE MAKE ANY DIFFERENCE IN LONG-TERM FOLLOW-UP?

BACKGROUND

Since 1990 it was proposed that distal and proximal location of colon cancer might follow different biological, epidemiology, pathology and prognosis, probably due to embryologic different development of the two segments of the colon, which may represent two separate disease entities. These differences might have consequences for the treatment of patients with colorectal cancer.

AIM

To compare the characteristics between patients with right and left colon cancer, with severity and tumor characteristic that influence in the survival of these patients.

METHOD

Were evaluated the outcomes of surgical treatment of patients with colon cancer with data collected retrospectively from prospectively collected database.

RESULTS

The tumor's side did not influence survival time of patients with colon cancer (p=0.112) in the regression model. Only the diseases stage leads to influence on survival time; patients with right colon cancer have more advanced staging (III or IV) and present a risk of death greater in 3.23 times.

CONCLUSION

This analysis provides evidence that the prognosis of localized left-sided colon cancer is better compared to right-sided colon cancer. Also, the patients with right colon cancer have more advanced stage, mucinous tumor and are older.

T≤2N0 TRG1-2 in Post-Chemoradiation Therapy MRI: What can it Predict?

BACKGROUND

Total mesorectal excision is the standard radical operation after neoadjuvant chemoradiotherapy for patients with middle/low locally advanced rectal cancer. However, it carries significant rates of morbidity, sexual/urinary dysfunction, fecal impairment and permanent stoma. The ability to identify patients with a complete or nearly-complete response could help steer patients to less-invasive surgery or a watch-and-wait strategy.

OBJECTIVE

To assess the ability to predict good responders and a favorable prognosis among rectal cancer patients by post-chemoradiation therapy MRI.

PATIENTS

Consecutive patients stage T3-4N0M0 or T(any)N+M0 located within 10cm from the anal verge were enrolled. Patients were staged and re-staged 8.8 weeks after the completion of chemoradiation by digital exam, colonoscopy, pelvic-MRI, and thorax and abdominal CT scans. All patients underwent total mesorectal excision with curative intent.

RESULTS

Of the total 309 patients, 275 were eligible, and 199 (72.4%) of these were stage III. Restaging-MRI identified 59 (21.4%) T=2N0/TRG1-2. Specimen pathologic evaluation revealed 43 (15.6%) patients with a complete pathologic response. Estimates of the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of MRIyT=2N0/TRG1-2 for the identification of ypT0N0 were 79.7%, 84.5%, 53.5%, 39%, and 90.7%, respectively. Estimates for the identification of ypN0 were 48.4%, 27.8%, 92%, 88.1%, and 48.4%, respectively. In a multivariate analysis, the only pre-CRT/MRI variables that were associated with an increased risk of lymph node involvement at the specimen were N+ (OR=2.22) and extramural vascular invasion (OR=2.28). MRI yT=2N0/TRG1-2 patients showed improved estimated 5-year disease-free survival, but no difference in estimated 5-year survival.

CONCLUSION

Although MRIyT=2N0/TRG1-2 cannot predict all cases of a complete pathologic response, it can effectively predict a low rate of lymph node involvement and a better prognosis in patients who undergo total mesorectal excision.

Diagnostic performance of magnetic resonance to assess treatment response after neoadjuvant therapy in patients with locally advanced rectal cancer

PURPOSE

Our study aimed to evaluate the diagnostic performance of rectal magnetic resonance imaging (MRI) for local restaging in patients with non-metastatic locally advanced rectal cancer (LARC) after neoadjuvant chemoradiotherapy (CRT) using surgical histopathology of total mesorectal excision as the reference standard.

METHODS

Ninety-five patients with LARC who underwent rectal MRI after CRT between January 2014 and December 2016 were included. Accuracy, sensitivity, specificity, positive, and negative predictive value for local staging regarding T-stage, N-stage, circumferential resection margin, and MRI tumor regression grade (ymriTRG) were calculated, and inter-test agreements were assessed.

RESULTS

22/95 (23.2%) patients had radiological complete response (rCR), whereas 20/95 (21.1%) had pathological complete response (pCR). Among the patients with pCR, 11/20 (55%) had rCR. Fair agreement was demonstrated between ymriTRG and pathological TRG (ypTRG) (κ = 0.255). The sensitivity and specificity for detection of pCR were 61.1% (95% CI 35.7-82.7) and 89.6% (95% CI 80.6-95.4). For the detection of ypTRG grades 1 and 2, the corresponding values were 67.2% (95% CI 54.3-78.4) and 51.6 (95% CI 33.1-69.8). The accuracy of ymriTRG was 24.2% (95% CI 15.6-32.8). Inter-test agreement in TRG between MRI and pathology was overall fair (κ = 0.255) and slight (κ = 0.179), if TRG 1 + 2.

CONCLUSION

Qualitative assessment on MRI for diagnosing pCR showed moderate sensitivity and high specificity, whereas the diagnosis of TRG had moderate sensitivity and low specificity with slight to fair inter-test agreement when compared with pathological specimens.

PROGNOSTIC FACTORS FOR LEFT COLECTOMY FOR COLON CANCER: A TEN YEARS EXPERIENCE OF A SINGLE UNIVERSITY INSTITUTION

Background:

Colorectal cancer is the third most common cancer in the world. In Brazil, it is the leading cause of cancer in the gastrointestinal tract.

Aim:

To evaluate the preoperative, perioperative, and postoperative risk factors for recurrence and overall survival of patients with left colon cancer operated during a ten-year period.

Methods:

Patients with left colon cancer surgically treated underwent clinical preoperative workout and cancer staging. The following factors were studied: gender, age, tumor location, T stage, lymph node yield, N stage, M stage, histological type, and tumor differentiation. It was analyzed the influence in five-year overall survival.

Results:

A total of 173 patients underwent left colectomy for colon cancer. There was a slight predominance of male gender with 50.9%. The mean age was 60.8 years old. Fifteen (8.7%) tumors were located at splenic flexure, 126 (72.8%) at sigmoid colon, and 32 (18.5%) at descending colon. The median length of hospital stay was seven days. Mean survival was 47.5 months. At 60 months seven patients (4%) lost follow-up, 38 patients (21.9%) deceased and 135 patients (78%) were alive. Overall survival time was 48 months.

Conclusion:

Advanced stages (T3-T4, N+ and M+) were the only factors associated with poor long term survival in left colon cancer.

HEALTH-RELATED QUALITY OF LIFE ASSESSMENT IN PATIENTS WITH RECTAL CANCER TREATED WITH CURATIVE INTENT

BACKGROUND

The treatment of median and distal rectal cancer has evolved a lot in the last decades due to the dissemination of the technique of total mesortal excision and the use of neoadjuvant chemotherapy and radiotherapy. However, this multidisciplinary approach can affect patients' quality of life in a number of ways that deserve to be adequately assessed.

OBJECTIVE

To evaluate immediate and late health related quality of life in patients with rectal cancer treated with curative intent.

METHODS

Prospective study including patients with non-metastatic mid or low rectal cancer. EORTC QLQ-C30 and EORTC-CR38 questionnaires were applied before, 3 months and 12 months after treatment. The mean scores of the questionnaires were stratified into 4 categories for the purpose of comparing the results at different moments.

RESULTS

Twenty nine patients completed the 1st and 2nd questionnaires and 12 completed the three questionaries. Patient´s mean age was 50.8 years and 62% were female. Sphincter preservation was possible in 89.6%. Overall health scores and quality of life improved after three months after 12 months. After three months, sexual satisfaction, female sexual problems and future perspective were worsen, but gastrointestinal symptoms, sphincter problems, and weight loss were improved. After 12 months the Future Perspective deteriorated, but there was improvement of the problems related to stoma, sphincter problems and body image.

CONCLUSION

Despite the complexity of the treatment of rectal cancer within a specialized service, quality of life was preserved and was satisfactory in most of the studied aspects.

Pathologic complete response implies a fewer number of lymph nodes in specimen of rectal cancer patients treated by neoadjuvant therapy and total mesorectal excision

Studies have suggested that the use of neoadjuvant chemoradiation results in a lower lymph nodes yield in rectal cancer patients.

OBJECTIVE

To evaluate factors associated with less than 12 lymph nodes harvested on patients with rectal cancer treated with preoperative chemoradiotherapy followed by total mesorectal excision.

PATIENTS

This was a cohort/retrospective single cancer center study. Low and mid locally advanced rectal cancer or T2N0 under risk of sphincter resection underwent chemoradiotherapy followed by total mesorectal excision with curative intent. Chemotherapy consisted of 5-FU and leucovorin IV. Total dose of pelvic radiation was 5040 Gys. All patients were staged and restaged by digital rectal examination, proctoscopy, colonoscopy, CT of abdomen and chest, and MRI of the pelvis. Patients were stratified in two groups: ≥12 and < 12 L N retrieved. The possible factors affecting number of LN were analyzed.

RESULTS

95 patients met the inclusion criteria. Mean LN harvest was 23.2 (3-67). 81 patients (85%) had ≥12 L N. Gender, age, tumor size, tumor stage, tumor location, length of specimen, presence of LN involvement, type of surgery, and surgical access showed no association with number of LN retrieved. Only pathological complete response showed a statistically significant association with <12 L N on univariate (p = 0.004) and multivariate analyses (p = 0.002).

LIMITATIONS

Data were collected retrospectively. The number of patients disparity between the two groups.

CONCLUSIONS

Complete pathologic response is associated with <12 L N harvested. Thus, the number of lymph nodes should not be used as a surrogate for oncologic adequacy of resection in patients with pathologic complete response.

Cyclooxygenase-2 gene polymorphisms and susceptibility to colorectal cancer in a Brazilian population

BACKGROUND

Multi-ethnicity of Brazilian population displays high levels of genomic diversity. Polymorphism may detect people at higher risk of developing cancer, distinctive response to treatment, and prognosis. Cyclooxygenase-2 (COX-2) is induced in response to growth factors and cytokines, and is expressed in inflammatory diseases, precancerous lesions and colorectal cancer (CRC). The aim of this study was to evaluate the influence of COX-2 -1195A > G and 8473T > C polymorphisms as a risk factor of developing CRC.

METHODS

We evaluated COX-2 Single Nucleotide Polymorphism (SNP) of 230 CRC patients and 196 healthy controls by Real-Time Polymerase Chain Reaction.

RESULTS

Populations were in Hardy-Weinberg equilibrium (HWE), except for control group of 8473T > C SNP. The frequencies were similar in both groups for genotypes and haplotypes. There was no association between studied polymorphisms and risk of CRC.

CONCLUSIONS

The gene polymorphisms studied do not participate in the genetic susceptibility to CRC in a Brazilian population.

Understanding the factors associated with reduction in the number of lymph nodes in rectal cancer patients treated by neoadjuvant treatment

INTRODUCTION

Rectal cancer patients frequently present with locally advanced disease for which the standard of care includes neoadjuvant chemoradiotherapy followed by total mesorectal excision. Positive lymph nodes are one of the most powerful risk factors for recurrence and survival in colorectal cancer. In the absence of specific rectal guidelines, the literature recommends to the pathologist to optimize the number of rectal lymph nodes (LN) retrieved. We made a literature review in order to identify factors that could potentially affect the number of LN retrieved in specimens of patients with rectal cancer treated by chemoradiotherapy (CRT) followed by total mesorectal excision (TME).

RESULTS

Age did not have a significant effect on LN yield. The effect of sex on LN number is not consistent in the literature. Most of the papers did not find a relationship between lower LN obtained and gender. Laparoscopy for primary rectal cancer is associated with a greater number of LN as well as short-term benefits. Tumors in the upper rectum are associated with a higher number of LN than those in the mid and lower rectum. The type of surgery had no effect on lymph node yield either. Tumors with complete or almost complete pathologic regression were exactly the ones with lower number of lymph nodes detected. Approximately one-third of patients with neoadjuvant treatment had less than 12 LN yield.

CONCLUSION

The tumor regression grade is the most important factor for the decrease in the number of lymph nodes.

Prognostic factors affecting outcomes in multivisceral en bloc resection for colorectal cancer

OBJECTIVES:

This study sought to determine the clinical and pathological factors associated with perioperative morbidity, mortality and oncological outcomes after multivisceral en bloc resection in patients with colorectal cancer.

METHODS:

Between January 2009 and February 2014, 105 patients with primary colorectal cancer selected for multivisceral resection were identified from a prospective database. Clinical and pathological factors, perioperative morbidity and mortality and outcomes were obtained from medical records. Estimated local recurrence and overall survival were compared using the log-rank method, and Cox regression analysis was used to determine the independence of the studied parameters. ClinicalTrials.gov: NCT02859155.

RESULTS:

The median age of the patients was 60 (range 23-86) years, 66.7% were female, 80% of tumors were located in the rectum, 11.4% had stage-IV disease, and 54.3% received neoadjuvant chemoradiotherapy. The organs most frequently resected were ovaries and annexes (37%). Additionally, 30.5% of patients received abdominoperineal resection. Invasion of other organs was confirmed histologically in 53.5% of patients, and R0 resection was obtained in 72% of patients. The overall morbidity rate of patients in this study was 37.1%. Ureter resection and intraoperative blood transfusion were independently associated with an increased number of complications. The 30-day postoperative mortality rate was 1.9%. After 27 (range 5-57) months of follow-up, the mortality and local recurrence rates were 23% and 15%, respectively. Positive margins were associated with a higher recurrence rate. Positive margins, lymph node involvement, stage III/IV disease, and stage IV disease alone were associated with lower overall survival rates. On multivariate analysis, the only factor associated with reduced survival was lymph node involvement.

CONCLUSIONS:

Multivisceral en bloc resection for primary colorectal cancer can be performed with acceptable rates of morbidity and mortality and may lead to favorable oncological outcomes.

Endoscopic colostomy with percutaneous colopexy: an animal feasibility study

BACKGROUND

Indications for colostomy in colorectal diseases are obstruction of the large bowel, such as in cancer, diverticular disease in the acute phase, post-radiotherapy enteritis, complex perirectal fistulas, anorectal trauma and severe anal incontinence. Some critically ill patients cannot tolerate an exploratory laparotomy, and laparoscopic assisted colostomy also requires general anesthesia.

OBJECTIVE

To evaluate the feasibility, safety and efficacy of performing colostomy assisted by colonoscopy and percutaneous colopexy.

MATERIALS AND METHODS

Five pigs underwent endoscopic assisted colostomy with percutaneous colopexy. Animals were evaluated in post-operative days 1, 2, 5 and 7 for feeding acceptance and colostomy characteristics. On day 7 full colonoscopy was performed on animals followed by exploratory laparotomy.

RESULTS

Average procedure time was 27 minutes (21-54 min). Postoperative mobility and feeding of animals were immediate after anesthesia recovery. Position of the colostomy, edges color, appearance of periostomal area, as well as its function was satisfactory in four animals. Retraction of colostomy was present in one pig. The colonoscopy and laparotomy control on the seventh day were considered as normal. A bladder perforation that was successfully repaired through the colostomy incision occurred in one pig. The main limitation of this study is its experimental nature.

CONCLUSION

Endoscopic assisted colostomy with percutaneous colopexy proves to be a safe and effective method with low morbidity for performing colostomy in experimental animals, with possible clinical application in humans.

Short-term outcomes after laparoscopic colorectal surgery in patients with previous abdominal surgery: A systematic review

AIM: To perform a systematic review focusing on short-term outcomes after colorectal surgery in patients with previous abdominal open surgery (PAOS).

METHODS: A broad literature search was performed with the terms “colorectal”, “colectomy”, “PAOS”, “previous surgery” and “PAOS”. Studies were included if their topic was laparoscopic colorectal surgery in patients with PAOS, whether descriptive or comparative. Endpoints of interest were conversion rates, inadvertent enterotomy and morbidity. Analysis of articles was made according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS: From a total of 394 citations, 13 full-texts achieved selection criteria to be included in the study. Twelve of them compared patients with and without PAOS. All studies were retrospective and comparative and two were case-matched. The selected studies comprised a total of 5005 patients, 1865 with PAOS. Among the later, only 294 (16%) had history of a midline incision for previous gastrointestinal surgery. Conversion rates were significantly higher in 3 of 12 studies and inadvertent enterotomy during laparoscopy was more prevalent in 3 of 5 studies that disclosed this event. Morbidity was similar in the majority of studies. A quantitative analysis (meta-analysis) could not be performed due to heterogeneity of the studies.

CONCLUSION: Conversion rates were slightly higher in PAOS groups, although not statistical significant in most studies. History of PAOS did not implicate in higher morbidity rates.

Postoperative complications in the treatment of rectal neoplasia by transanal endoscopic microsurgery: a prospective study of risk factors and time course

PURPOSE

Transanal endoscopic microsurgery (TEM) is a safe and efficient minimally invasive treatment for rectal benign and early malignant neoplasia, but postoperative complications may be severe. We aimed to evaluate the risk factors related to the incidence, severity, and time course of postoperative complications of TEM.

METHODS

This is a prospective study of postoperative complications in 53 patients (>18 years old) with benign or early rectal neoplasia who underwent TEM with curative intention or, for higher stages, palliation. Outcome measures included age, sex, American Society of Anesthesiologists score, neoadjuvant chemoradiotherapy, lesion height and size, pathologic margins, tumor histology, and suture type.

RESULTS

Overall morbidity was 50 %. Temporary fecal incontinence was the most frequent complication (17.3 %). Complication rates of Clavien-Dindo grades I and II were 21.1 % and those of grades III and IV 3.8 %. Of patients with complications, more had lesions under the first rectal valve than over the first valve (61.54 % vs 38.46 %, p = 0.04). Patients submitted to chemoradiotherapy had a 24-fold greater chance of presenting grade II complications (p = 0.002). When the surgical defect was treated using the TEM device to perform the suture, the chance of having grade III complications was reduced 16-fold (p = 0.04). Fifty-three percent of complications occurred in the first 10 days and 95 % within 20 days.

CONCLUSIONS

Postoperative complications after transanal endoscopic microsurgery for the treatment of rectal neoplasia are frequent, acceptable, and usually controllable with pharmacologic treatment. Over time the nature of complications is continuous, centered on the first 20 days after surgery.

Prognostic factors of surgically-treated patients with cancer of the right colon: a ten years' experience of a single universitary institution

BACKGROUND

Colorectal cancer is one of the most common malignancies in the world. There are many controversies in the literature about the prognostic value of primary tumor location. Many studies have shown higher survival rates for tumors in the right colon, and worse prognosis for lesions located more distally in the colon.

AIM

To analyze the results of surgical treatment of right-sided colon cancers patients operated in one decade period and identify the prognostic factors that were associated with lower overall survival in stages I-IV patients.

METHODS

A retrospective review from the prospectively collected database identified 178 patients with right-sided colon cancer surgically treated with curative intent. Demographic factors (gender and age), tumor factors (site, T stage, N stage, M stage, histological type and tumor differentiation), and lymph node yield were extracted to identify those associated with lower overall survival.

RESULTS

Mean age was 65 (± 12) years old, and 105 (56.1%) patients were female. Most common affected site was ascending colon (48.1%), followed by cecum (41.7%) and hepatic flexure (10.2%). Mean length of hospital stay was 14 (± 2.8) days. T stage distribution was T1 (4.8%), T2 (7.5%), T3 (74.9%), and T4 (12.8%). Nodal involvement was present in 46.0%, and metastatic disease in 3.7%. Twelve or more lymph nodes were obtained in 87.2% of surgical specimens and 84.5% were non-mucinous tumors. Mean survival time was 38.3 (± 30.8) months. Overall survival was affected by T stage, N stage, M stage, and final stage. Lymph node involvement (OR=2.06) and stage III/IV (OR=2.81) were independent negative prognostic factors.

CONCLUSION

Right-sided colon cancer presented commonly at advanced stage. Advanced stage and lymph node involvement were factors associated with poor long term survival.