Local Excision for organ preservation in early REctal cancer with No Adjuvant treatment (LORENA Trial): prospective observational study protocol

INTRODUCTION

Local resection (LR) is an alternative to total mesorectal excision (TME) that avoids its associated morbidity to the detriment of oncological radicality in early stages of rectal cancer. There are several conditioning factors for the success of this strategy, such as poor prognosis histological factors (PPHF), involvement of resection margins, clinical under staging, or complications that may lead to the indication for radical surgery with TME.

PATIENTS AND METHOD

An international multicenter prospective observational open-label study has been designed. Consecutive patients diagnosed with early rectal cancer (cT1N0 on MRI + / - endorectal ultrasound) whose lower limit is a maximum of 2 cm proximal to the ano-rectal junction will be included. The primary objective of the study is to determine the overall prevalence of PPHF after LR and requiring TME or postoperative radio-chemotherapy.

DISCUSSION

The prevalence of PPHF conditioning the success of LR in early distal rectal cancer has been scarcely studied in the literature, and there are very few prospective data. Considering the increasing interest in the watch and wait strategy in rectal cancer and its possible application in early-stage tumors, it seems necessary to know this information. The results of this study will help guide clinical practice in patients with early distal rectal cancer. It will also provide quality information for the design of future comparative studies to improve organ preservation success in these patients.

TRIAL REGISTRATION NUMBER

NCT05927584.

National observational study about the surgical treatment of anal fistula: Does the kind of hospital modify the results?

INTRODUCTION

Performing the surgical procedure in a high-volume center has been seen to be important for some surgical procedures. However, this issue has not been studied for patients with an anal fistula (AF).

MATERIAL AND METHODS

A retrospective multicentric study was performed including the patients who underwent AF surgery in 2019 in 56 Spanish hospitals. A univariate and multivariate analysis was performed to analyse the relationship between hospital volume and AF cure and fecal incontinence (FI).

RESULTS

1809 patients were include. Surgery was performed in a low, middle, and high-volume hospitals in 127 (7.0%), 571 (31.6%) y 1111 (61.4%) patients respectively. After a mean follow-up of 18.9 months 72.3% (1303) patients were cured and 132 (7.6%) developed FI. The percentage of patients cured was 74.8%, 75.8% and 70.3% (p = 0.045) for low, middle, and high-volume hospitals. Regarding FI, no statistically significant differences were observed depending on the hospital volume (4.8%, 8.0% and 7.7% respectively, p = 0.473). Multivariate analysis didńt observe a relationship between AF cure and FI.

CONCLUSION

Cure and FI in patients who underwent AF surgery were independent from hospital volume.

Epidemiology, oncologic results and risk stratification model for metachronous peritoneal metastases after surgery for pT4 colon cancers: results from an observational retrospective multicentre long-term follow-up study

PURPOSE

Metachronous peritoneal metastases (MPM) following a curative surgery procedure for pT4 colon cancer is a challenging condition. Current epidemiological studies on this topic are scarce.

METHODS

A retrospective multicentre trial was designed. All consecutive patients who underwent operations to treat pT4 cancers between 2015 and 2017 were reviewed. Demographic, clinical, operative, pathological and oncological follow-up variables were included. MPM were described as any oncological disease at the peritoneum, clearly different from a local recurrence. Univariate and multivariate Cox regression models were constructed. A risk stratification model was created on a cumulative factor basis. According to the calculated hazard ratio (HR), a scoring system was designed (HR < 3, 1 point; HR > 3, 2 points) and a scale from 0 to 6 was calculated for peritoneal disease-free rate (PDF-R). A risk stratification model was also created on the basis of these calculations.

RESULTS

Fifty different hospitals were involved, which included a total of 1356 patients. Incidence of MPM was 13.6% at 50 months median follow-up. The strongest independent risk factors for MPM were positive pN stage [HR 3.72 (95% CI 2.56-5.41; p < 0.01) for stage III disease], tumour perforation [HR 1.91 (95% CI 1.26-2.87; p < 0.01)], mucinous or signet ring cell histology [HR 1.68 (95% CI 1.1-2.58; p = 0.02)], poorly differentiated tumours [HR 1.54 (95% CI 1.1-2.2; p = 0.02)] and emergency surgery [HR 1.42 (95% CI 1.01-2.01; p = 0.049)]. In the absence of additional risk factors, pT4 tumours showed 98% and 96% PDF-R in 1-year and 5-year periods based on Kaplan-Meier curves.

CONCLUSIONS

Cumulative MPM incidence was 13.6% at 5-year follow-up. The sole presence of a pT4 tumour resulted in high rates of PDF-R at 1-year and 5-year follow-up (98% and 96% respectively). Five additional risk factors different from pT4 status itself were identified as possible MPM indicators during follow-up.

Diagnostic Accuracy of Abdominal CT for Locally Advanced Colon Tumors: Can We Really Entrust Certain Decisions to the Reliability of CT?

Many different options of neoadjuvant treatments for advanced colon cancer are emerging. An accurate preoperative staging is crucial to select the most appropriate treatment option. A retrospective study was carried out on a national series of operated patients with T4 tumors. Considering the anatomo-pathological analysis of the surgical specimen as the gold standard, a diagnostic accuracy study was carried out on the variables T and N staging and the presence of peritoneal metastases (M1c). The parameters calculated were sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios, as well as the overall accuracy. A total of 50 centers participated in the study in which 1950 patients were analyzed. The sensitivity of CT for correct staging of T4 colon tumors was 57%. Regarding N staging, the overall accuracy was 63%, with a sensitivity of 64% and a specificity of 62%; however, the positive and negative likelihood ratios were 1.7 and 0.58, respectively. For the diagnosis of peritoneal metastases, the accuracy was 94.8%, with a sensitivity of 40% and specificity of 98%; in the case of peritoneal metastases, the positive and negative likelihood ratios were 24.4 and 0.61, respectively. The diagnostic accuracy of CT in the setting of advanced colon cancer still has some shortcomings for accurate diagnosis of stage T4, correct classification of lymph nodes, and preoperative detection of peritoneal metastases.

"Long-term oncologic outcomes and risk factors for distant recurrence after pathologic complete response following neoadjuvant treatment for locally advanced rectal cancer. A nationwide, multicentre study"

BACKGROUND

Pathologic complete response (pCR) after multimodal treatment for locally advanced rectal cancer (LARC) is used as surrogate marker of success as it is assumed to correlate with improved oncologic outcome. However, long-term oncologic data are scarce.

METHODS

This retrospective, multicentre study updated the oncologic follow-up of prospectively collected data from the Spanish Rectal Cancer Project database. pCR was described as no evidence of tumour cells in the specimen. Endpoints were distant metastases-free survival (DMFS) and overall survival (OS). Multivariate regression analyses were run to identify factors associated with survival.

RESULTS

Overall, 32 different hospitals were involved, providing data on 815 patients with pCR. At a median follow-up of 73.4 (IQR 57.7-99.5) months, distant metastases occurred in 6.4% of patients. Abdominoperineal excision (APE) (HR 2.2, 95%CI 1.2-4.1, p = 0.008) and elevated CEA levels (HR = 1.9, 95% CI 1.0-3.7, p = 0.049) were independent risk factors for distant recurrence. Age (years) (HR 1.1; 95%-CI 1.05-41.09; p < 0.001) and ASA III-IV (HR = 2.0; 95%-CI 1.4-2.9; p < 0.001), were the only factors associated with OS. The estimated 12, 36 and 60-months DMFS rates were 96.9%, 91.3%, and 86.8%. The estimated 12, 36 and 60-months OS rates were 99.1%, 94.9% and 89.3%.

CONCLUSIONS

The incidence of metachronous distant metastases is low after pCR, with high rates of both DMFS and OS. The oncologic prognosis in LARC patients that achieve pCR after neoadjuvant chemo-radiotherapy is excellent in the long term.

Surgical treatment trends and outcomes for anal fistula: fistulotomy is still accurate and safe. Results from a nationwide observational study

PURPOSE

The aim of the present study was to analyse current surgical treatment preferences for anal fistula (AF) and its subtypes and nationwide results in terms of success and complications.

METHODS

A retrospective multicentre observational cohort study was conducted. The study period was 1 year (2019), with a follow-up period of at least 1 year. A descriptive analysis of patient characteristics and trends regarding technical options was performed. Univariate and multivariate Cox regression models were used to analyse factors associated with healing and faecal incontinence (FI).

RESULTS

Fifty-one hospitals were involved, providing data on 1628 patients with AF. At a median follow-up of 18.3 (9.9-28.3) months, 1231 (75.9%) patients achieved healing, while 390 (24.1%) did not; failure was catalogued as persistence in 279 (17.2.0%) patients and as recurrence in 111 (6.8%). On multivariate analysis, factors associated with healing were fistulotomy (OR 5.5; 95% CI 3.8-7.9; p < 0.001), simple fistula (OR 2.1; 95% CI 1.5-2.8; p < 0.001), single tract (HR 1.9; 95% CI 1.3-2.8; p < 0.001) and number of preparatory surgeries (none vs. 3; HR 1.8; 95% CI 1.2-2.8; p = 0.006). Regarding de novo FI, in the multivariate analysis previous anal surgery (OR 1.5, 95% CI 1.0-2.4, p = 0.037), age (OR 1.02, 95% CI 1.00-1.04, p = 0.002) and being female (OR 1.7, 95% CI 1.1-2.5, p = 0.008) were statistically related.

CONCLUSIONS

Anal fistulotomy is the most used procedure for AF, especially for simple AF, with a favourable overall balance between healing and continence impairment. Sphincter-sparing or minimally invasive sphincter-sparing techniques resulted in lower rates of healing. In spite of their intended sphincter-sparing design, a certain degree of FI was observed for several of these techniques.

Local tumor regrowth after clinical complete response following neoadjuvant therapy for rectal cancer: what happens when organ preservation falls short

Organ preservation strategies, especially watch and wait, after neoadjuvant treatment in locally advanced rectal cancer, have become topics that generate significant interest, for both patients and clinicians. The obvious advantage of these strategies is the avoidance of surgery with its associated risks and functional consequences. Over time, it has become evident that these strategies offer acceptable safety in oncological terms and, in most patients, allows preservation of the rectum without harming patients in terms of distant metastasis or survival. However, there is a small group of patients in whom the tumor returns after an initially diagnosed clinical complete response; patients with local tumor regrowth. The main threat in these patients is not simply local disease, which can be successfully managed in most cases, but the possible effects it may have on distant metastases. The pathophysiology of the phenomenon of local tumor regrowth is not well known and, therefore, strategies to minimize possible impact on survival are not well defined. Our aim is to review key issues in this subgroup that pose a substantial threat to the safety and viability of organ-preserving and watch-and-wait strategies. We also explore possible pathophysiologic explanations and future directions and perspectives that may improve both local and systemic disease control.

Traumatic deficient perineum: surgical management and outcome from a single center

INTRODUCTION AND HYPOTHESIS

Deficient perineum is a disruption of the perineal body and distal rectovaginal septum presenting with anal incontinence and a range of urogenital symptoms. There is scarce reported outcome of this condition with management often delayed and with a variety of surgical alternatives. This study aims to determine faecal continence outcomes after long-term surgical repair.

METHODS

Patients were included for analysis after surgical repair between 1989 and 2012. Cases were preoperatively assessed by endosonography and anorectal manometry with a record of their continence with the Cleveland Clinic Incontinence Score (CCIS). Surgical repair comprised an overlapping repair of the external anal sphincter (EAS) with levatorplasty. There was selective use of internal anal sphincter (IAS) suture and/or advancement perineoplasty for soft tissue reconstruction. Patients were clinically evaluated for functional outcomes with comparison of their postoperative CCIS.

RESULTS

There were 20 patients (median age 55.5 years; range 29-81 years) with a median duration of incontinence symptoms of 174 (range 1-540) months. All patients had an EAS and IAS defect with 14 (70%) undergoing an IAS suture and 10 (50%) a Corman-style anoplasty. Over a median follow-up of 137.2 (range 13-322) months, there was a significant decrease in the recorded median preoperative vs. postoperative CCIS 18, range 13-20 vs. 2, range 0-10, respectively; p < 0.001) with 18 (90%) satisfied with the functional outcome. Faecal diversion was not used in any of the patients.

CONCLUSIONS

Experienced delayed repair of a traumatic cloaca is associated with an acceptable functional outcome at medium- to long-term follow-up.

Peri-ileostomy pyoderma gangrenosum. Case report

Pyoderma gangrenosum is one of the most severe complications that can occur following stoma placement. Despite few cases reported in the literature, it is considered an underdiagnosed entity. We present a case of peri-ileostomy pyoderma gangrenosum (PPG) in a patient who underwent a pancoloproctectomy and permanent ileostomy due to ulcerative colitis (UC). Treatment was based on local cures, proper fitting of ostomy devices, topical tacrolimus and systemic corticosteroids, adalimumab and antibiotics. Satisfactory resolution was achieved in eight weeks.

Colorectal cancer and its delayed diagnosis: have we improved in the past 25 years?

OBJECTIVE

to determine the current delay in diagnosing colorectal cancer (CRC) and establish whether there has been any improvement in the past 25 years in the same healthcare setting using the same methods.

PATIENTS AND METHOD

152 patients undergoing surgery at our unit were personally interviewed during their hospital stay to determine the delay incurred for the diagnosis and treatment of their CRC. SPSS software was used for univariate and multivariate analysis of the data obtained.

RESULTS

the study population was comprised of 152 patients of mean age 71 years (SD 10; range 36 to 90 years), 82 men and 70 women (53.9 and 46.1% respectively; p > 0.05). The diagnostic delay for CRC at our unit currently runs at 7.28 months despite the fact that in 58% of patients the disease produced obvious symptoms such as rectal bleeding. Although this delay in diagnosis is reduced over that observed 25 years ago, the difference is statistically not significant in terms of both doctor-attributed or patient-attributed delay (doctor-attributed delay was 3.28 months in 1985 versus 1.89 at present and patient-attributed delay was 3.18 months versus today´s 2.75; p > 0.05). Unlike the situation 25 years ago, no link was detected between diagnostic delay and tumor stage. Paradoxically, stage D disease was diagnosed earlier (at 5.71 months) than stage A disease (at 11.16 months) (p < 0.05).

CONCLUSION

the diagnostic delay for CRC at our centre is 7.28 months. This delay is excessive for a disease that produces evident symptoms in 90% of patients. Over the last 25 years little improvement has been noted in the overall delay in diagnosing CRC, al though the delay attributed to the care provider has significantly improved. No relationship was detected between diagnostic delay and disease stage upon diagnosis. We feel the high prevalence of CRC, the failure of campaigns to increase awareness of early symptoms and no real improvement in its prognosis justify the introduction of large-scale colonoscopy screening for this disease.