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Journal of Clinical Imaging Science 2024Presacral/Retrorectal tumors (RRT) are rare lesions that comprise a multitude of histological types. Data on surgical management are limited to case reports and small... (Review)
Review
Presacral/Retrorectal tumors (RRT) are rare lesions that comprise a multitude of histological types. Data on surgical management are limited to case reports and small case series. The aim of the study was to provide a comprehensive review of the epidemiology, pathological subtypes, surgical approaches, and clinical outcomes. A PubMed search using terms "retrorectal tumor" and "presacral tumor" was used to identify articles reporting RRT of non-urological, non-gynecologic, and non-metastatic origin. Articles included were between 2015 and 2023. A total of 68 studies were included, comprising 570 patients. About 68.2% of patients were female, and the mean overall age of both sexes was 48.6 years. Based on histopathology, 466 patients (81.8%) had benign lesions, and 104 (18.2%) were malignant. In terms of surgical approach, 191 (33.5%) were treated anteriorly, 240 (42.1%) through a posterior approach, and 66 (11.6%) combined. The mean length of stay was 7.6 days. Patients treated using the posterior approach had a shorter length of stay (5.7 days) compared to the anterior and combined approaches. RRT are rare tumors of congenital nature with prevalence among the female sex. R0 resection is crucial in its management, and minimal access surgery appears to be a safer option in appropriate case selection.
PubMed: 38841312
DOI: 10.25259/JCIS_27_2024 -
The Cochrane Database of Systematic... Oct 2015Colorectal cancer represents 10% of all cancers and is the third most common cause of death in women and men. Almost two-thirds of all bowel cancers are cancers of the... (Review)
Review
BACKGROUND
Colorectal cancer represents 10% of all cancers and is the third most common cause of death in women and men. Almost two-thirds of all bowel cancers are cancers of the colon and over one-third (34%) are cancers of the rectum, including the anus. Surgery is the cornerstone for curative treatment of rectal cancer. Mesorectal excision decreases the rate of local recurrences; however, it does not improve the overall survival of people with locally advanced rectal cancer. There have been significant research efforts since the mid-1990s to optimise the treatment of rectal cancer. Based on the findings of clinical trials, people with T3/T4 or N+ rectal tumours are now being treated preoperatively with radiation and chemotherapy, mainly fluoropyrimidine. However, the incidence of distant metastases remains as high as 30%. Combination chemotherapy regimens, similar to those used in metastatic disease with the addition of oxaliplatin and irinotecan, have been tested to improve the prognosis of people with rectal cancer.
OBJECTIVES
To compare outcomes (including overall survival, disease-free survival and toxicity) between two 5-fluorouracil-containing chemotherapy regimens in people with stage II and III rectal cancer who are receiving preoperative chemoradiation.
SEARCH METHODS
We searched the Cochrane Colorectal Cancer Group Specialised Register (January 2015), the Cochrane Central Register of Controlled Trials (2015, Issue 1), Ovid MEDLINE (1950 to January 2015), Ovid EMBASE (1974 to January 2015) and LILACS (1982 to January 2015). We reviewed the reference lists of included studies, checked clinical trials registers and handsearched relevant journal proceedings. We applied no language or publication restrictions.
SELECTION CRITERIA
Randomised controlled trials (RCTs) comparing single-agent chemotherapy (fluoropyrimidine) versus combination chemotherapy (fluoropyrimidine plus another agent including, but not limited to, oxaliplatin) during preoperative radiochemotherapy in people with resectable rectal cancer.
DATA COLLECTION AND ANALYSIS
Two review authors (HMR, EMKS) independently extracted data and assessed trial quality. When necessary, we requested additional information and clarification of published data from the authors of individual trials.
MAIN RESULTS
We included four RCTs involving 3875 people with resectable rectal cancer. In the preoperative period, the participants of these studies were randomised to receive chemoradiation either with a single fluoropyrimidine agent (capecitabine or 5-fluorouracil) or with a combination of drugs (fluoropyrimidine plus oxaliplatin). The only study that reported overall survival and disease-free survival found no significant differences between the intervention and control groups; we considered this evidence very low quality. For pathological complete response after preoperative treatment (ypCR) there was high quality evidence favouring the intervention group (odds ratio (OR) 1.23, 95% confidence interval (CI) 1.04 to 1.46), but there was also moderate quality evidence suggesting a higher risk for early toxicity in the intervention group (OR 2.07, 95% CI 1.31 to 3.27). Moderate to high quality evidence suggested that the control group had better compliance to radiotherapy (OR 0.32, 95% CI 0.14 to 0.75). There were no significant differences between groups in postoperative mortality within 60 days, postoperative morbidity, resection margins, abdominoperineal resection and Hartmann procedures.
AUTHORS' CONCLUSIONS
There was very low quality evidence that people with resectable rectal cancer who receive combination preoperative chemotherapy have no improvements in overall survival or disease-free survival. There was high quality evidence that suggested that combination chemotherapy with oxaliplatin may improve local tumour control in people with resectable rectal cancer, but this regimen also caused more toxicity. The review included four RCTs but only one reported survival; therefore, we cannot make robust conclusions or useful clinical recommendations. The publication of more survival data from these studies will contribute to future analyses.
PubMed: 35658163
DOI: 10.1002/14651858.CD008531.pub2 -
Surgical Endoscopy Apr 2022Evidence and practice recommendations on the use of transanal total mesorectal excision (TaTME) for rectal cancer are conflicting. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Evidence and practice recommendations on the use of transanal total mesorectal excision (TaTME) for rectal cancer are conflicting.
OBJECTIVE
We aimed to summarize best evidence and develop a rapid guideline using transparent, trustworthy, and standardized methodology.
METHODS
We developed a rapid guideline in accordance with GRADE, G-I-N, and AGREE II standards. The steering group consisted of general surgeons, members of the EAES Research Committee/Guidelines Subcommittee with expertise and experience in guideline development, advanced medical statistics and evidence synthesis, biostatisticians, and a guideline methodologist. The guideline panel consisted of four general surgeons practicing colorectal surgery, a radiologist with expertise in rectal cancer, a radiation oncologist, a pathologist, and a patient representative. We conducted a systematic review and the results of evidence synthesis by means of meta-analyses were summarized in evidence tables. Recommendations were authored and published through an online authoring and publication platform (MAGICapp), with the guideline panel making use of an evidence-to-decision framework and a Delphi process to arrive at consensus.
RESULTS
This rapid guideline provides a weak recommendation for the use of TaTME over laparoscopic or robotic TME for low rectal cancer when expertise is available. Furthermore, it details evidence gaps to be addressed by future research and discusses policy considerations. The guideline, with recommendations, evidence summaries, and decision aids in user-friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/4494 .
CONCLUSIONS
This rapid guideline provides evidence-informed trustworthy recommendations on the use of TaTME for rectal cancer.
Topics: GRADE Approach; Humans; Laparoscopy; Postoperative Complications; Proctectomy; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery
PubMed: 35212821
DOI: 10.1007/s00464-022-09090-4 -
Indian Journal of Surgical Oncology Dec 2022Rectal cancer is a common tumor within a difficult anatomic constraint. Total mesorectal excision with longitudinal and circumferential free margins is considered... (Review)
Review
Rectal cancer is a common tumor within a difficult anatomic constraint. Total mesorectal excision with longitudinal and circumferential free margins is considered imperative for good prognosis. In this article, the authors systematically reviewed all published literature with specific Mesh terms until the end of year 2019. Thereafter, retrieved articles were assessed using the Newcastle-Ottawa Scale and meta-analysis was conducted comparing local recurrence among 1-cm, 5-mm, and narrow (< 1-mm)/infiltrated margins. Thirty-nine articles were included in the study. Macroscopic distal margin < 1 cm carried a higher incidence of recurrence for those who did not receive neoadjuvant radiation, without affecting neither estimated overall nor disease-free survival. Less than 5-mm margin after radiation therapy is accepted oncologically. Infiltrated margins and narrow margins (< 1 mm) microscopically are associated with higher incidence of local recurrence and shorter overall and disease-free survival. Surgeons should aim at 1-cm safety margin in radiotherapy-naïve patients and microscopic free margin > 1 mm for those who received neoadjuvant therapy. The cost/benefit of reoperation for patients with infiltrated margins is still inadequately studied.
PubMed: 36687255
DOI: 10.1007/s13193-022-01565-z -
Yeungnam University Journal of Medicine Jul 2021Omental transposition has been used to facilitate perineal wound healing in patients undergoing abdominoperineal resection (APR). However, there is no high-level...
BACKGRUOUND
Omental transposition has been used to facilitate perineal wound healing in patients undergoing abdominoperineal resection (APR). However, there is no high-level evidence supporting the effectiveness of omental transposition in this regard. This study aimed to investigate the clinical efficacy of omental transposition in facilitating perineal wound healing after APR.
METHODS
In this systematic review, we systematically searched the PubMed/MEDLINE, Embase, Scopus, Cochrane Library, and Web of Science databases for literature regarding the topic of our study. Studies published since the inception of each database were considered for review. The outcomes of interest were the perineal wound healing rate at 1 and 3 months postoperatively, perineal wound infection rate, and perineal wound healing period.
RESULTS
Of the 1,923 studies identified, four articles representing 819 patients (omental transposition patients, n=295) were included in the final analysis. The wound healing rates at 1 and 3 months postoperatively in the omental transposition group (68.5% and 79.7%, respectively) did not significantly differ from those in the control group (57.4% and 78.7%, respectively) (p=0.759 and p=0.731, respectively). Perineal wound infection and chronic wound complication rates, including sinus, dehiscence, and fistula rates, also did not significantly differ between the omental transposition (8% and 7%, respectively) and control (11% and 7%, respectively) groups (p=0.221 and p=0.790, respectively).
CONCLUSION
Our results suggest that omental transposition does not affect perineal wound healing in patients who undergo APR.
PubMed: 33557001
DOI: 10.12701/yujm.2020.00871 -
International Journal of Surgery... Jul 2023
Meta-Analysis
How to reasonably deal with zero-events in meta-analysis of surgery-related outcomes? Oncologic outcomes of intersphincteric resection vs. abdominoperineal resection for lower rectal cancer: a systematic review and meta-analysis.
Topics: Humans; Rectal Neoplasms; Proctectomy; Treatment Outcome; Anal Canal
PubMed: 37300885
DOI: 10.1097/JS9.0000000000000379 -
Surgery Aug 2021Circumferential resection margin is considered an important prognostic parameter after rectal cancer surgery, but its impact might have changed because of improved... (Meta-Analysis)
Meta-Analysis
Prognostic importance of circumferential resection margin in the era of evolving surgical and multidisciplinary treatment of rectal cancer: A systematic review and meta-analysis.
BACKGROUND
Circumferential resection margin is considered an important prognostic parameter after rectal cancer surgery, but its impact might have changed because of improved surgical quality and tailored multimodality treatment. The aim of this systematic review was to determine the prognostic importance of circumferential resection margin involvement based on the most recent literature.
METHODS
A systematic literature search of MEDLINE, Embase, and the Cochrane Library was performed for studies published between January 2006 and May 2019. Studies were included if 3- or 5-year oncological outcomes were reported depending on circumferential resection margin status. Outcome parameters were local recurrence, overall survival, disease-free survival, and distant metastasis rate. The Newcastle Ottawa Scale and Jadad score were used for quality assessment of the studies. Meta-analysis was performed using a random effects model and reported as a pooled odds ratio or hazard ratio with 95% confidence interval.
RESULTS
Seventy-five studies were included, comprising a total of 85,048 rectal cancer patients. Significant associations between circumferential resection margin involvement and all long-term outcome parameters were uniformly found, with varying odds ratios and hazard ratios depending on circumferential resection margin definition (<1 mm, ≤1 mm, otherwise), neoadjuvant treatment, study period, and geographical origin of the studies.
CONCLUSION
Circumferential resection margin involvement has remained an independent, poor prognostic factor for local recurrence and survival in most recent literature, indicating that circumferential resection margin status can still be used as a short-term surrogate endpoint.
Topics: Combined Modality Therapy; Humans; Margins of Excision; Proctectomy; Prognosis; Rectal Neoplasms
PubMed: 33838883
DOI: 10.1016/j.surg.2021.02.029 -
Frontiers in Surgery 2016The aim of this review is to provide an overview of the evidence for the use of biologic mesh in the reconstruction of the pelvic floor after extralevator... (Review)
Review
INTRODUCTION
The aim of this review is to provide an overview of the evidence for the use of biologic mesh in the reconstruction of the pelvic floor after extralevator abdominoperineal excision of the rectum (ELAPE).
METHODS
A systematic search of PubMed was conducted using the search terms: "ELAPE," "extralevator abdominoperineal excision of rectum," or "extralevator abdominoperineal resection." The search yielded 17 studies.
RESULTS
Biologic mesh was used in perineal reconstruction in 463 cases. There were 41 perineal hernias reported but rates were not consistently reported in all studies. The most common complications were perineal wound infection (n = 93), perineal sinus and fistulae (n = 26), and perineal haematoma or seroma (n = 11). There were very few comparative studies, with only one randomized control trial (RCT) identified that compared patients undergoing ELAPE with perineal reconstruction using a biological mesh, with patients undergoing a conventional abdominoperineal excision of the rectum with no mesh. There was no significant difference in perineal hernia rates or perineal wound infections between the groups. Other comparative studies comparing the use of biologic mesh with techniques, such as the use of myocutaneous flaps, were of low quality.
CONCLUSION
Biologic mesh-assisted perineal reconstruction is a promising technique to improve wound healing and has comparable complications rates to other techniques. However, there is not enough evidence to support its use in all patients who have undergone ELAPE. Results from high-quality prospective RCTs and national/international collaborative audits are required.
PubMed: 26909352
DOI: 10.3389/fsurg.2016.00009 -
Annals of Coloproctology Dec 2021Intersphincteric resection (ISR) is the ultimate anus-sparing technique for low rectal cancer and is considered an oncologically safe alternative to abdominoperineal... (Review)
Review
Intersphincteric resection (ISR) is the ultimate anus-sparing technique for low rectal cancer and is considered an oncologically safe alternative to abdominoperineal resection. The application of the robotic approach to ISR (RISR) has been described by few specialized surgical teams with several differences regarding approach and technique. This review aims to discuss the technical aspects of RISR by evaluating point by point each surgical controversy. Moreover, a systematic review was performed to report the perioperative, oncological, and functional outcomes of RISR. Postoperative morbidities after RISR are acceptable. RISR allows adequate surgical margins and adequate oncological outcomes. RISR may result in severe bowel and genitourinary dysfunction affecting the quality of life in a portion of patients.
PubMed: 34784706
DOI: 10.3393/ac.2021.00836.0119 -
Gastroenterology Research and Practice 2016Aim. To evaluate the influence of interval between neoadjuvant chemoradiotherapy (NCRT) and surgery on oncological outcome. Methods. A systematic search was conducted in... (Review)
Review
Aim. To evaluate the influence of interval between neoadjuvant chemoradiotherapy (NCRT) and surgery on oncological outcome. Methods. A systematic search was conducted in PubMed, the Cochrane Library, and Embase databases for publications reporting oncological outcomes of patients following rectal cancer surgery performed at different NCRT-surgery intervals. Relative risk (RR) of pathological complete response (pCR) among different intervals was pooled. Results. Fifteen retrospective cohort studies representing 4431 patients met the inclusion criteria. There was a significantly increased rate of pCR in patients treated with surgery followed 7 or 8 weeks later (RR, 1.45; 95% CI, 1.18-1.78; and P < 0.01 and RR, 1.49; 95% CI, 1.15-1.92; and P = 0.002, resp.). There is no consistent evidence of improved local control or overall survival with longer or shorter intervals. Conclusion. Performing surgery 7-8 weeks after the end of NCRT results in the highest chance of achieving pCR. For candidates of abdominoperineal resection before NCRT, these data support implementation of prolonging the interval after NCRT to optimize the chances of pCR and perhaps add to the possibility of ultimate organ preservation.
PubMed: 27190505
DOI: 10.1155/2016/6756859