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Frontiers in Genetics 2023The standard treatment for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy (nCRT). To select patients who would benefit the most from nCRT, there...
The standard treatment for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy (nCRT). To select patients who would benefit the most from nCRT, there is a need for predictive biomarkers. The aim of this study was to evaluate the role of clinical, pathological, radiological, inflammation-related genetic, and hematological parameters in the prediction of post-nCRT response. analysis of published transcriptomics datasets was conducted to identify candidate genes, whose expression will be measured using quantitative Real Time PCR (qRT-PCR) in pretreatment formaline-fixed paraffin-embedded (FFPE) samples. In this study, 75 patients with LARC were prospectively included between June 2020-January 2022. Patients were assessed for tumor response in week 8 post-nCRT with pelvic MRI scan and rigid proctoscopy. For patients with a clinical complete response (cCR) and initially distant located tumor no immediate surgery was suggested ("watch and wait" approach). The response after surgery was assessed using histopathological tumor regression grading (TRG) categories from postoperative specimens by Mandard. Responders (R) were defined as patients with cCR without operative treatment, and those with TRG 1 and TRG 2 postoperative categories. Non-responders (NR) were patients classified as TRG 3-5. Responders group comprised 35 patients (46.6%) and NR group 53.4% of patients. Analysis of published transcriptomics data identified genes that could predict response to treatment and their significance was assessed in our cohort by qRT-PCR. When comparison was made in the subgroup of patients who were operated (TRG1 vs. TRG4), the expression of IDO1 was significantly deregulated ( < 0.05). Among hematological parameters between R and NR a significant difference in the response was detected for neutrophil-to-monocyte ratio (NMR), initial basophil, eosinophil and monocyte counts ( < 0.01). According to MRI findings, non-responders more often presented with extramural vascular invasion ( < 0.05). Based on logistic regression model, factors associated with favorable response to nCRT were tumor morphology and hematological parameters which can be easily and routinely derived from initial laboratory results (NMR, eosinophil, basophil and monocyte counts) in a minimally invasive manner. Using various metrics, an aggregated score of the initial eosinophil, basophil, and monocyte counts demonstrated the best predictive performance.
PubMed: 37719698
DOI: 10.3389/fgene.2023.1245594 -
Irish Journal of Medical Science Apr 2022Transanal minimally invasive surgery (TAMIS) has gained worldwide acceptance as a means of local excision of early rectal cancers and benign rectal lesions. However, it... (Review)
Review
Transanal minimally invasive surgery (TAMIS) has gained worldwide acceptance as a means of local excision of early rectal cancers and benign rectal lesions. However, it is technically challenging due to the limitations of rigid laparoscopic instruments in the narrow rectal lumen. Robotic platforms offer improved ergonomics that are valuable in operative fields with limited space. Robotic TAMIS represents an exciting new development that may be more versatile than traditional TAMIS. In this review, we describe the first case of robotic TAMIS performed in our country and a review of current literature on the technique.
Topics: Humans; Ireland; Rectal Neoplasms; Rectum; Robotic Surgical Procedures; Transanal Endoscopic Surgery
PubMed: 33977392
DOI: 10.1007/s11845-021-02645-9 -
BMC Medical Education May 2023The objective of our study is to develop an effective training platform for transanal endoscopic surgery and to validate a step-by-step training program for learning the...
BACKGROUND
The objective of our study is to develop an effective training platform for transanal endoscopic surgery and to validate a step-by-step training program for learning the basic skills necessary for this approach.
METHODS
We have designed a two-part study: an experimental study (with the aim to design the training platform and the training exercises - on synthetic and biological material) and a prospective analytical study, in order to validate the training program by enrolling as participants general surgery residents and specialists, without previous experience in transanal endoscopic interventions. The performance of the participants was assessed based on the time of completion, as well as the quality of the execution.
RESULTS
We have developed three different diameter platforms (5 cm, 7.5 and 10 cm), that can be used with both the TEO and TAMIS platforms; specific exercises were developed to train different surgical skills like manipulation of tissue, cutting, dissection and suturing. Forty participants were enrolled for the validation of the proposed training program (12 young residents, 16 senior residents and 12 specialist surgeons). A statistically significant improvement of the performance time, from round to round, was observed for all participants in all exercises. The time of completion for the exercises, considering the correct technical execution, was the shortest for more experienced surgeons: specialist surgeons, followed by senior residents and young residents. The biological material exercises, that closely recreate intraoperative conditions and had more strict technical requirements, were difficult to be performed by young residents; better completion rates were seen in senior residents, while all the participants in the specialist surgeons group have completed these exercises.
CONCLUSIONS
Our training program is an effective simulation based educational model for recreating intraoperative conditions particular to transanal endoscopic surgery. The proposed step-by-step training program has demonstrated to be useful in developing the important basic skills needed for transanal endoscopic surgery and assured the progress of all the participants, regardless of their surgical experience.
Topics: Humans; Prospective Studies; Transanal Endoscopic Surgery; Surgeons; Computer Simulation; Dissection; Clinical Competence; Simulation Training
PubMed: 37170198
DOI: 10.1186/s12909-023-04296-z -
BMC Surgery Feb 2022Transanal endoscopic microsurgery (TEM) has been accepted worldwide for the treatment of local rectal lesions. We aimed to assess the efficacy and safety of TEM in the...
BACKGROUND
Transanal endoscopic microsurgery (TEM) has been accepted worldwide for the treatment of local rectal lesions. We aimed to assess the efficacy and safety of TEM in the treatment of rectal neuroendocrine tumors (RNET).
METHODS
A retrospective study of patients who had undergone TEM for RNET at our institution between December 2006 and June 2019 was performed. Demographic and tumor characteristics, operative and pathological details, complications, anal function questionnaires, and follow-up data were included.
RESULTS
A total of 144 patients was included. TEM was performed as primary excision in 54 patients, after endoscopic forceps biopsy in 57 patients, and after incomplete resection by endoscopic excision in 33 patients. The median size of all primary tumors was 0.6 cm (range, 0.3-2.0 cm), and the negative resection margin was achieved in 142 (98.6%) patients. Postoperative complications (referring to only bleeding) occurred in 3 (2.1%) patients and was successfully managed with conservative method. After a median follow-up of 75.5 months after surgery, 3 patients died of other causes, and 2 patients suffered metastasis. An anal function questionnaire was posted 24 months after TEM. Among the results, 3 (2.1%) patients complained of major low anterior resection syndrome (LARS), including 1 (0.7%) who suffered from complete incontinence, while 6 (4.2%) patients had minor LARS.
CONCLUSIONS
TEM has satisfying long-term outcomes and relatively low anal function disturbance as for the treatment of small RNET. TEM also acts as a preferred salvage treatment for incomplete endoscopic excision.
Topics: Humans; Microsurgery; Neuroendocrine Tumors; Postoperative Complications; Rectal Neoplasms; Retrospective Studies; Syndrome; Transanal Endoscopic Microsurgery; Treatment Outcome
PubMed: 35120483
DOI: 10.1186/s12893-022-01494-2 -
Danish Medical Journal Jul 2019The advantages of transanal total mesorectal excision (taTME) would be a reduction of the hernia rate and surgical trauma. The present study reports data for patients... (Comparative Study)
Comparative Study
INTRODUCTION
The advantages of transanal total mesorectal excision (taTME) would be a reduction of the hernia rate and surgical trauma. The present study reports data for patients undergoing taTME and compares the post-operative immune response in taTME with those of conven-tional laparoscopic surgery (CLS) and single-port laparo-scopic surgery (SPLS).
METHODS
A comparative cohort study in patients with rectal cancer undergoing taTME. C-reactive protein (CRP) and white blood cell count (WBC) were measured pre-operatively and on post-operative days one, two, three and four.
RESULTS
A total of 40 patients were included in taTME, 20 patients in CLS and 20 in SPLS. Patients' demographics (except for clinical staging), R0 resection and post-operative complication rates were comparable. The length of abdom-inal incisio-n was significantly lower by taTME than by both SPLS and CLS (p < 0.001). Distant resection margin was shorter in the taTME group (p < 0.01), and the quality of specimen differed between groups (p < 0.01). CRP and WBC increased significantly in each group (p < 0.05), but there was no difference between the groups.
CONCLUSIONS
There is no difference in the inflammatory response in patients with rectal cancer undergoing taTME surgery compared with CLS and SPLS. We therefore conclude that the length/presence of abdominal incision does not further reduce the post-operative inflammatory stress response in minimally invasive procedures. The surgical trauma extends beyond the abdominal incision and depends on the intra-abdominal handling of the tissue.
FUNDING
none.
TRIAL REGISTRATION
ID NCT00157972, ethical approval ID H-1-2011-007, H-15000540.
Topics: Aged; Aged, 80 and over; C-Reactive Protein; Cohort Studies; Female; Humans; Inflammation; Laparoscopy; Leukocyte Count; Male; Middle Aged; Neoplasm Recurrence, Local; Operative Time; Postoperative Complications; Rectal Neoplasms; Transanal Endoscopic Surgery
PubMed: 31256779
DOI: No ID Found -
BJGP Open Sep 2022Quality service delivery in primary care requires motivated and competent health professionals. In the Kenyan private sector, GPs with no postgraduate training in family...
BACKGROUND
Quality service delivery in primary care requires motivated and competent health professionals. In the Kenyan private sector, GPs with no postgraduate training in family medicine offer primary care. There is a paucity of evidence on the ability of primary care providers to deliver comprehensive care and no such evidence is available for GPs practising in the private sector in Kenya.
AIM
To evaluate GPs' training and experience in the skills required for comprehensive primary care.
DESIGN AND SETTING
A cross-sectional descriptive survey in 13 primary care clinics in the private sector of Nairobi, Kenya.
METHOD
A questionnaire, originally designed for a national survey of primary care doctors in South Africa, was adapted. The study collected self-reported data on performance of clinical skills by 25 GPs. Data were analysed using the Statistical Package for Social Sciences (SPSS, version 25).
RESULTS
GPs were mostly aged <40 years, with ≤10 years of experience, and there was an equal sex distribution. GPs reported moderate performance with adult health, communication and consultation, and clinical administration; and weak performance with emergencies, child health, surgery, ear, nose, and throat (ENT) and eyes, women's health, and orthopaedics. The GPs lacked training in specific skills such as proctoscopies, contraceptive devices, skin procedures, intra-articular injections, red reflex tests, and use of genograms.
CONCLUSION
GPs lacked training and performed poorly in some of the essential skills required in primary care. Continuing professional development, training in family medicine, broadening the model of care, and deployment of family physicians to the clinics could improve care comprehensiveness.
PubMed: 35256356
DOI: 10.3399/BJGPO.2021.0233 -
Journal of Investigative Surgery : the... Dec 2023To compare the effectiveness, safety and cost-effectiveness of endoscopic submucosal dissection (ESD) with transanal endoscopic microsurgery (TEM) in early rectal... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To compare the effectiveness, safety and cost-effectiveness of endoscopic submucosal dissection (ESD) with transanal endoscopic microsurgery (TEM) in early rectal neuroendocrine tumor (RNET) patients. This article will provide reliable evidence for surgeons in regards to clinical decision-making.
METHODS
Systematic literature retrieval was performed in Pubmed, Embase and Cochrane database from 2013/4/30 to 2023/4/30. Methodology validation was performed by using the Newcastle-Ottawa Scale (NOS). Data-analysis was conducted by using the Review manager version 5.3 software.
RESULTS
A total of three retrospective studies were included in our meta-analysis. All eligible studies were considered to be high quality. By comparing baseline characteristics between TEM and ESD, patients in the TEM group seemed to be characterized by a larger tumor size and lower tumor level, even though no statistical significance was found. Clear statistical significance favoring TEM was identified in terms of R0 resection rate, procedure time and hospital stay. No statistical significance was found in terms of recurrence rate, adverse events rate and additional treatment rate.
CONCLUSIONS
Compared with ESD, TEM was a more effective treatment modality for early RNET patients; it was associated with a relatively higher R0 resection rate and a similar degree of safety. However, the relatively higher cost and complicated manipulation restricted the promotion of TEM. Surgeons should opt for TEM as a primary treatment in patients with a larger tumor size and deeper degree of tumorous infiltration if the financial condition and hospital facility permit.
Topics: Humans; Transanal Endoscopic Microsurgery; Endoscopic Mucosal Resection; Neuroendocrine Tumors; Retrospective Studies; Rectal Neoplasms
PubMed: 37970828
DOI: 10.1080/08941939.2023.2278191 -
Surgical Endoscopy Dec 2023Retrorectal tumors (RRTs) are rare and often surgically excised due to the risk of malignant degeneration and compressive or obstructive symptoms. The approach for...
INTRODUCTION
Retrorectal tumors (RRTs) are rare and often surgically excised due to the risk of malignant degeneration and compressive or obstructive symptoms. The approach for excision has traditionally been based on tumor location and performed using either a transabdominal or perineal approach depending on the position of the tumor. The advent of minimally invasive surgery, however, has challenged this paradigm. Here, we determined the applicability and potential advantages of a laparoscopic transabdominal approach in a series of 23 patients with RRTs.
MATERIAL AND METHODS
We included 23 patients presenting with RRTs treated at the Surgical Gastrointestinal Unit at Hospital de Sant Pau that were registered prospectively since 1998. The preoperative evaluation consisted of colonoscopy, CT scan and/or MRI, mechanical bowel lavage, and antibiotic therapy. Signed consent was obtained from all patients for a laparoscopic transabdominal approach unless the tumor was easily accessible via a perineal approach. In case of recurrence, a transanal endoscopic microsurgery (TEM) approach was considered. Surgical details, immediate morbidity, and short- and long-term outcomes were recorded.
RESULTS
Of the 23 RRT cases evaluated, 16 patients underwent a laparoscopic transabdominal approach and 6 underwent a perineal approach. No patients required conversion to open surgery. In the laparoscopic transabdominal group, the mean operating time was 158 min, the average postoperative hospital stay was 5 days, and postoperative morbidity was 18%. Three patients had recurrent RRTs, two of the three underwent surgical reintervention. The third patient was radiologically stable and close follow-up was decided.
CONCLUSION
Our results show that laparoscopic transabdominal excision of RRT is a safe and effective technique, offering the potential advantages of less invasive access and reduced morbidity. This approach challenges the traditional paradigm of excision of these infrequent tumors based solely on tumor location and offers a viable alternative for the treatment of these infrequent tumors.
Topics: Humans; Neoplasm Recurrence, Local; Laparoscopy; Rectal Neoplasms; Colonoscopy; Transanal Endoscopic Microsurgery; Treatment Outcome
PubMed: 37798533
DOI: 10.1007/s00464-023-10448-5 -
The Journal of International Medical... Jun 2020To determine the diagnostic accuracy of preoperative T/N stage using MRI in lower and middle rectal cancer patients and the impacts on clinical decision-making. (Observational Study)
Observational Study
BACKGROUND
To determine the diagnostic accuracy of preoperative T/N stage using MRI in lower and middle rectal cancer patients and the impacts on clinical decision-making.
PATIENTS AND METHODS
There were 354 patients recruited from May 2017 to February 2019. MRI was performed within 2 weeks before surgery. Histopathologic results were evaluated for the postoperative T/N stage and MRI diagnostic accuracy was assessed based on the postoperative histopathologic results. Accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and Kappa values were used to evaluate MRI diagnostic accuracy and analysis consistency compared with postoperative histopathologic staging.
RESULTS
Overall MRI diagnostic accuracy was 78.2% and 56.8% for T1-4 and N0-2 staging. The Kappa values were 0.625 and 0.323 for T1-4 and N0-2 staging, respectively. After combination, MRI diagnostic accuracy was 85% and 69.5% for T and N staging. The Kappa values were 0.693 and 0.4 for T and N staging. The diagnostic accuracy of MRI for treatment decision-making was 79.1%.
CONCLUSION
MRI enables a highly accurate preoperative assessment of T stage but only a fairly accurate preoperative assessment of the N stage for rectal cancer with surgery. The diagnostic accuracy of MRI for treatment decision-making is promising.
Topics: Aged; Chemoradiotherapy, Adjuvant; Clinical Decision-Making; Female; Humans; Image-Guided Biopsy; Magnetic Resonance Imaging; Male; Middle Aged; Neoadjuvant Therapy; Neoplasm Staging; Practice Guidelines as Topic; Predictive Value of Tests; Preoperative Care; Proctectomy; Proctoscopy; Rectal Neoplasms; Rectum; Retrospective Studies
PubMed: 32495710
DOI: 10.1177/0300060520928685 -
International Journal of Surgery Case... Apr 2023Clostridial myonecrosis (CM), or gas gangrene, is a rare necrotizing muscle infection caused most often by Clostridium perfringens or C. septicum. Inoculation can occur...
INTRODUCTION AND IMPORTANCE
Clostridial myonecrosis (CM), or gas gangrene, is a rare necrotizing muscle infection caused most often by Clostridium perfringens or C. septicum. Inoculation can occur either traumatically or spontaneously. CM has a high mortality rate if not treated promptly.
CASE PRESENTATION
A 64-year-old male presented to the emergency department (ED) with sudden onset left flank pain and fever. Repeated CT scans demonstrated progressive edema around the left iliopsoas muscle with gas formation and bleeding. The patient received intravenous fluids, meropenem, and clindamycin. Emergency laparotomy was performed on suspicion of necrotizing fasciitis and revealed a necrotic left iliopsoas muscle which was partially excised. Blood cultures were positive at 12 h with growth of C. septicum. Prolonged stay in the intensive care unit, and six additional surgical interventions to the abdomen, left thigh, and flank were needed. The patient was discharged after four months to a nursing home.
CLINICAL DISCUSSION
C. septicum CM more often occurs spontaneously and is associated with colorectal malignancy. However, for our patient, CT colonography and proctoscopy did not reveal any pathology. Therefore, we believe the CM resulted from an injury the patient sustained while working in his backyard, either a cut from barbed wire on his arm or from soil contaminating his psoriatic lesions. Successful outcomes for patients with CM require a high index of suspicion, timely treatment with antibiotics, and repeated surgical debridements.
CONCLUSION
This case report describes the presentation and management of a presumably injury-related CM caused by C. septicum.
PubMed: 36940540
DOI: 10.1016/j.ijscr.2023.108000