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European Journal of Trauma and... Apr 2022Direct peritoneal resuscitation (DPR) has been used to help preserve microcirculation by reversing vasoconstriction and hypoperfusion associated with the... (Review)
Review
PURPOSE
Direct peritoneal resuscitation (DPR) has been used to help preserve microcirculation by reversing vasoconstriction and hypoperfusion associated with the pathophysiological process of shock, which can occur despite appropriate intravenous resuscitation. This approach depends on infusing a hyperosmolar solution intraperitoneally via a percutaneous catheter with the tip ending near the pelvis or the root of the mesentery. The abdomen is usually left open with a negative pressure abdominal dressing to continuously evacuate the infused dialysate. Hypertonicity of the solution triggers visceral vasodilation to help maintain blood flow, even during shock, and is also associated with reduced local inflammatory cytokines and other mediators, preservation of endothelial cell function, and mitigation of organ edema and necrosis. It also has a direct effect on liver perfusion and edema, more rapidly corrects electrolyte abnormalities compared to intravenous resuscitation alone, and may requireless intravenous fluid to stabilize blood pressure, all of which shortens the time required to close patients' abdomen.
METHODS
An online query using the search term "direct peritoneal resuscitation" was carried out in PubMed, MEDLINE and SciELO, limited to publications indexed from January 2014 to June 2020. Of the 20 articles returned, full text was able to be obtained for 19. A manual review of included articles' references was resulted in the addition of 1 article, for a total of 20 included articles.
RESULTS
The 20 articles were comprised of 15 animal studies, 4 clinical studies,and 1 expert opinion. The benefits include both local and possibly systemic effects on perfusion, hypoxia, acidosis, and inflammation, and are associated with improved outcomes and reduced complications.
CONCLUSION
DPR shows promise in patients with hemorrhagic shock, septic shock, and other conditions resulting in an open abdomen after damage control laparotomy.
Topics: Animals; Edema; Fluid Therapy; Humans; Rats; Rats, Sprague-Dawley; Resuscitation; Shock, Hemorrhagic
PubMed: 34773466
DOI: 10.1007/s00068-021-01821-x -
European Journal of Surgical Oncology :... Jan 2022The management of locally advanced rectal cancer (LARC) requires a multidisciplinary approach, with an increasing interest for non-operative strategies. Liquid biopsy...
BACKGROUND
The management of locally advanced rectal cancer (LARC) requires a multidisciplinary approach, with an increasing interest for non-operative strategies. Liquid biopsy for obtaining circulating tumor DNA (ctDNA) can provide information on neoadjuvant chemoradiotherapy (nCRT) pathological response and cancer-specific prognosis, and therefore might be a promising guide for these treatments.
METHODS
A systematic review of the studies available in literature has been performed to assess the role of ctDNA as a predictive and prognostic biomarker in LARC patients.
RESULTS
We retrieved 21 publications, of which 17 full-text articles and 4 abstracts. Results have been labelled into two groups: predictive and prognostic. Data about the usefulness of liquid biopsy in this setting is still inconclusive. However, baseline higher levels of longer fragments of cell-free DNA and integrity index, tumor-specific mutations and certain methylated genes could predict non-responders. Also, undetectable baseline ctDNA and decrease of common rectal cancer mutations throughout treatment (dynamic monitoring) were predictive factors of pathological complete response. The continuous detection of ctDNA in different timepoints of treatment (minimal residual disease) was consistently associated with worse prognosis.
CONCLUSIONS
ctDNA is a promising biomarker that could assist predicting treatment response to nCRT and prognosis in patients with LARC. The ideal methods and timings for the liquid biopsy still have to be defined.
Topics: Carcinoma; Chemoradiotherapy; Circulating Tumor DNA; Humans; Liquid Biopsy; Mesentery; Neoadjuvant Therapy; Proctectomy; Prognosis; Rectal Neoplasms
PubMed: 34511270
DOI: 10.1016/j.ejso.2021.08.034 -
Colorectal Disease : the Official... Nov 2021Dissection with subsequent ligation and resection of arteries at their origin (central vascular ligation) is essential for adequate oncological resection during right... (Meta-Analysis)
Meta-Analysis Review
A systematic review and meta-analysis of variants of the branches of the superior mesenteric artery: the Achilles heel of right hemicolectomy with complete mesocolic excision?
AIM
Dissection with subsequent ligation and resection of arteries at their origin (central vascular ligation) is essential for adequate oncological resection during right hemicolectomy with complete mesocolic excision. This technique is technically demanding due to the highly variable arterial pattern of the right colon. Therefore, this study aims to provide a comprehensive evidence-based assessment of the arterial vascular anatomy of the right colon.
METHODS
A thorough systematic literature search through September 2020 was conducted on the electronic databases PubMed, Scopus and Web of Science to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using MetaXl software.
RESULTS
A total of 41 studies (n = 4691 patients) were included. The ileocolic artery (ICA), right colic artery (RCA) and middle colic artery (MCA) were present in 99.7% (95% CI 99.4%-99.8%), 72.6% (95% CI 61.3%-82.5%) and 96.9% (95% CI 94.2%-98.8%) respectively of patients. Supernumerary RCA and MCA were observed in 3.2% and 11.4% respectively of all cases. The RCA shared a common trunk with the ICA and MCA in 13.2% and 17.7% respectively of patients. A retro-superior mesenteric vein course of the ICA and RCA was observed in 55.1% and 11.4% respectively of all cases.
CONCLUSION
The vascular anatomy of the right colon displays several notable variations, namely the absence of some branches (RCA absent in 27.4% of cases), supernumerary branches, common trunks, and retro-superior mesenteric vein courses. These variations should be taken into consideration during right hemicolectomy with complete mesocolic excision to ensure adequate oncological resection while minimizing intra-operative complications.
Topics: Colectomy; Colonic Neoplasms; Humans; Laparoscopy; Mesenteric Artery, Superior; Mesocolon
PubMed: 34358401
DOI: 10.1111/codi.15861 -
Techniques in Coloproctology Sep 2021The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin involvement... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin involvement is unclear. The aim of this study was to provide a comprehensive review of the literature on the impact of TAE on CRR in patients without neoadjuvant chemoradiotherapy (CRT).
METHODS
We performed a systematic review of the literature up to March 2020. Medline and Cochrane libraries were searched for studies reporting outcomes of CRR after TAE for ERC. We excluded patients who had neoadjuvant CRT and endoscopic local excision. Surgical, functional, pathological and oncological outcomes were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed.
RESULTS
Sixteen studies involving 353 patients were included. Pathology following TAE was as follows T0 = 2 (0.5%); T1 = 154 (44.7%); T2 = 142 (41.2%); T3 = 43 (12.5%); Tx = 3 (0.8%); T not reported = 9. Fifty-three percent were > T1. Abdominoperineal resection (APR) was performed in 80 (23.2%) patients. Postoperative major morbidity and mortality occurred in 22 (11.4%) and 3 (1.1%), patients, respectively. An incomplete mesorectal fascia resulting in defects of the mesorectum was reported in 30 (24.6%) cases. Thirteen (12%) patients developed recurrence: 8 (3.1%) local, 19 (7.3%) distant, 4 (1.5%) local and distant. The 5-year cancer-specific survival was 92%. Only 1 study assessed anal function reporting no continence disorders in 11 patients. In the meta-analysis, CRR after TAE showed an increased APR rate (OR 5.25; 95% CI 1.27-21.8; p 0.020) and incomplete mesorectum rate (OR 3.48; 95% CI 1.32-9.19; p 0.010) compared to primary total mesorectal excision (TME). Two case matched studies reported no difference in recurrence rate and disease free survival respectively.
CONCLUSIONS
The data are incomplete and of low quality. There was a tendency towards an increased risk of APR and poor specimen quality. It is necessary to improve the accuracy of preoperative staging of malignant rectal tumors in patients scheduled for TAE.
Topics: Humans; Mesocolon; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Neoplasm Staging; Proctectomy; Rectal Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 34173121
DOI: 10.1007/s10151-020-02401-8 -
Techniques in Coloproctology Oct 2021The introduction of complete mesocolic excision (CME) for right colon cancer has raised an important discussion in relation to the extent of colic and mesenteric... (Meta-Analysis)
Meta-Analysis Review
Right hemicolectomy with complete mesocolic excision is safe, leads to an increased lymph node yield and to increased survival: results of a systematic review and meta-analysis.
BACKGROUND
The introduction of complete mesocolic excision (CME) for right colon cancer has raised an important discussion in relation to the extent of colic and mesenteric resection, and the impact this may have on lymph node yield. As uncertainty remains regarding the usefulness of and indications for right hemicolectomy with CME and the benefits of CME compared with a traditional approach, the purpose of this meta-analysis is to compare the two procedures in terms of safety, lymph node yield and oncological outcome.
METHODS
We performed a systematic review of the literature from 2009 up to March 15th, 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two hundred eighty-one publications were evaluated, and 17 met the inclusion criteria and were included. Primary endpoints analysed were anastomotic leak rate, blood loss, number of harvested lymph nodes, 3- and 5-year oncologic outcomes. Secondary outcomes were operating time, conversion, intraoperative complications, reoperation rate, overall and Clavien-Dindo grade 3-4 postoperative complications.
RESULTS
In terms of safety, right hemicolectomy with CME is not inferior to the standard procedure when comparing rates of anastomotic leak (RR 0.82, 95% CI 0.38-1.79), blood loss (MD -32.48, 95% CI -98.54 to -33.58), overall postoperative complications (RR 0.82, 95% CI 0.67-1.00), Clavien-Dindo grade III-IV postoperative complications (RR 1.36, 95% CI 0.82-2.28) and reoperation rate (RR 0.65, 95% CI 0.26-1.75). Traditional surgery is associated with a shorter operating time (MD 16.43, 95% CI 4.27-28.60) and lower conversion from laparoscopic to open approach (RR 1.72, 95% CI 1.00-2.96). In terms of oncologic outcomes, right hemicolectomy with CME leads to a higher lymph node yield than traditional surgery (MD 7.05, 95% CI 4.06-10.04). Results of statistical analysis comparing 3-year overall survival and 5-year disease-free survival were better in the CME group, RR 0.42, 95% CI 0.27-0.66 and RR 0.36, 95% CI 0.17-0.56, respectively.
CONCLUSIONS
Right hemicolectomy with CME is not inferior to traditional surgery in terms of safety and has a greater lymph node yield when compared with traditional surgery. Moreover, right-sided CME is associated with better overall and disease-free survival.
Topics: Colectomy; Colonic Neoplasms; Humans; Laparoscopy; Lymph Node Excision; Lymph Nodes; Mesocolon; Treatment Outcome
PubMed: 34120270
DOI: 10.1007/s10151-021-02471-2 -
Annals of Surgical Oncology Dec 2021Previous systematic reviews suggest that the implementation of 'complete mesocolon excision' (CME) for colon tumors entails better specimen quality but with limited... (Meta-Analysis)
Meta-Analysis Review
BACKGROUNDS
Previous systematic reviews suggest that the implementation of 'complete mesocolon excision' (CME) for colon tumors entails better specimen quality but with limited long-term outcomes. We performed a meta-analysis to compare the pathological, perioperative, and oncological results of CME with conventional surgery (CS) in primary colon cancer.
METHODS
Embase, MEDLINE and CENTRAL databases were searched using Medical Subject Headings for CME and D3 lymphadenectomy. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
RESULTS
A total of 18,989 patients from 27 studies were included. Postoperative complications were higher in the CME group (relative risk [RR] 1.13, 95% confidence interval [CI] 1.04-1.22, I = 0%), while no differences were observed in terms of anastomotic leak (I = 0%) or perioperative mortality (I = 49%). CME was associated with a higher number of lymph nodes harvested (I = 95%), distance to high tie (I = 65%), bowel length (I = 0%), and mesentery area (I = 95%). CME also had positive effects on 3- and 5-year overall survival (RR 1.09, 95% CI 1.04-1.15, I = 88%; and RR 1.05, 95% CI 1.02-1.08, I = 62%, respectively) and 3-year disease-free survival (RR 1.10, 95% CI 1.04-1.17, I = 22%), as well as decreased local (RR 0.35, 95% CI 0.24-0.51, I = 51%) and distant recurrences (RR 0.71, 95% CI 0.60-0.85, I = 34%).
CONCLUSIONS
Limited evidence suggests that CME improves oncological outcomes with a higher postoperative adverse events rate but no increase in anastomotic leak rate or perioperative mortality, compared with CS.
Topics: Colectomy; Colonic Neoplasms; Humans; Laparoscopy; Lymph Node Excision; Mesocolon; Neoplasm Recurrence, Local; Treatment Outcome
PubMed: 34089109
DOI: 10.1245/s10434-021-10186-9 -
International Journal of Colorectal... Sep 2021This meta-analysis aims to investigate the role of complete mesocolic excision (CME) in the treatment of right-side colon cancer when compared with standard right-side... (Meta-Analysis)
Meta-Analysis
BACKGROUND
This meta-analysis aims to investigate the role of complete mesocolic excision (CME) in the treatment of right-side colon cancer when compared with standard right-side hemicolectomy, focusing on oncological outcomes, mortality and morbidity rates.
MATERIALS AND METHODS
A systematic literature search was performed on MEDLINE and EMBASE archives, including studies on CME in right-side colon cancer. Primary outcomes were five-year disease-free survival and five-year overall survival. Secondary outcomes investigated were mortality and morbidity rates, intraoperative blood loss, anastomotic leakage, postoperative ileus, day of postoperative flatus, pulmonary infection, duration of hospital stay and number of lymph nodes harvested.
RESULTS
Seventeen studies have been included in this meta-analysis for a total of 3918 patients. The five-year disease-free survival (DFS) and overall survival (OS) results improved in the CME group with respect to conventional right-side colectomy with an OR 1.88 (95% CI 1.02-3.45) and OR 2.77 (95% CI 1.33-5.74), respectively. The incidence of mortality and morbidity was comparable between the two groups. Moreover, conventional surgery time was faster than CME (MD 33.69 min, 95% CI 12.79-54.59), while no significant differences were reported in mean blood loss and hospital stay. Furthermore, the CME group showed a higher mean number of harvested lymph nodes (MD 7.08 lymph nodes 95% CI 4.90-9.27).
CONCLUSION
Complete mesocolic excision of the right-side colectomy improves oncological outcomes without increasing mortality and morbidity rates compared to standard right-side hemicolectomy. CME should therefore be routinely performed in the treatment of right-side colon cancer.
Topics: Colectomy; Colonic Neoplasms; Humans; Laparoscopy; Lymph Node Excision; Mesocolon; Treatment Outcome
PubMed: 33983451
DOI: 10.1007/s00384-021-03951-5 -
Surgical Endoscopy Sep 2021In right-sided colon cancer surgery, currently there is a great deal of discussion and debate regarding complete mesocolic excision (CME) versus conventional right... (Review)
Review
Complete mesocolic excision and D3 lymphadenectomy with central vascular ligation in right-sided colon cancer: a systematic review of postoperative outcomes, tumor recurrence and overall survival.
BACKGROUND
In right-sided colon cancer surgery, currently there is a great deal of discussion and debate regarding complete mesocolic excision (CME) versus conventional right hemicolectomy (CRH) on postoperative outcomes and oncological results. Our aim was to perform a systematic review of the short- and long-term outcomes of CME to standardize surgical approach in patients with right-sided colon cancer.
METHODS
A systematic review was performed examining available data on randomized and non-randomized studies evaluating the role of CME and D3 lymphadenectomy in the treatment of right-sided colon cancer, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards.
RESULTS
After literature search, 919 studies have been recorded, 110 studies underwent full-text reviews and 30 studies met inclusion criteria. The total number of CME procedures was 5931. Postoperative complications was reported in 28 studies with pooled overall complications of 1.88% for CME surgery. Six studies reported 0% of overall postoperative complications and they demonstrated a low incidence of complications following CME procedure. Anastomotic leak was reported in 27 studies with pooled proportion of 0.92% after CME resections. There were 16 papers reporting overall survival following CME procedure, with a mean of 85% of patients survived at 5 years. Mean 5-year overall survival was 93.05% in stage I patients, 89.76% in stage II patients and 79.65% in stage III patients. Local and distant recurrence were included in 21 studies, reporting tumor recurrence rate of 12.25% following CME. 5-year tumor recurrence was 5.8% in stage I patients, 7.68% in stage II patients and 15.69% in stage III patients.
CONCLUSIONS
CME does not increase the risk of postoperative complications and significantly improves the long-term oncological impact. Prospective multicentre studies results are needed to verify if CME could be considered standard surgery for right colon cancer.
Topics: Colectomy; Colonic Neoplasms; Humans; Laparoscopy; Ligation; Lymph Node Excision; Mesocolon; Neoplasm Recurrence, Local; Prospective Studies; Treatment Outcome
PubMed: 33977376
DOI: 10.1007/s00464-021-08529-4 -
Colorectal Disease : the Official... Jul 2021Complete mesocolic excision (CME) lacks consistent data advocating operative superiority compared to conventional surgery for colon cancer. We performed a systematic... (Meta-Analysis)
Meta-Analysis Review
AIM
Complete mesocolic excision (CME) lacks consistent data advocating operative superiority compared to conventional surgery for colon cancer. We performed a systematic review and meta-analysis, analysing population characteristics and perioperative, pathological and oncological outcomes.
METHODS
D3 extended lymphadenectomy dissection was considered comparable to CME, and D2 and D1 dissection to be comparable to conventional surgery. Outcomes reviewed included lymph node yield, R1 resection, overall complications, overall survival and disease-free survival.
RESULTS
In all, 3039 citations were identified; 148 studies underwent full-text reviews and 31 matched inclusion criteria: total cohort 26 640 patients (13 830 CME/D3 vs. 12 810 conventional). Overall 3- and 5-year survival was higher in the CME/D3 group compared with conventional surgery: relative risk (RR) 0.69 (95% CI 0.51-0.93, P = 0.016) and RR 0.78 (95% CI 0.64-0.95, P = 0.011) respectively. Five-year disease-free survival also demonstrated CME/D3 superiority (RR 0.67, 95% CI 0.52-0.86, P < 0.001), with similar findings at 1 and 3 years. There were no statistically significant differences between the CME/D3 and conventional group in overall complications (RR 1.06, 95% CI 0.97-1.14, P = 0.483) or anastomotic leak (RR 1.02, 95% CI 0.81-1.29, P = 0.647).
CONCLUSIONS
Meta-analysis suggests CME/D3 may have a better overall and disease-free survival compared to conventional surgery, with no difference in perioperative complications. Quality of evidence regarding survival is low, and randomized control trials are required to strengthen the evidence base.
Topics: Colectomy; Colonic Neoplasms; Humans; Laparoscopy; Lymph Node Excision; Mesocolon
PubMed: 33934455
DOI: 10.1111/codi.15644 -
European Journal of Surgical Oncology :... Aug 2021Locally advanced rectal cancer is routinely treated with neo-adjuvant long course chemoradiotherapy or short course radiotherapy, followed by total mesorectal excision....
BACKGROUND
Locally advanced rectal cancer is routinely treated with neo-adjuvant long course chemoradiotherapy or short course radiotherapy, followed by total mesorectal excision. Not all patients respond to this treatment and there has been an emergence of novel treatment strategies designed to improve outcomes for these patients. This systematic review aims to assess the current novel neo-adjuvant treatment strategies being utilised in the treatment of patients with rectal cancer and how these impact pathological complete response (pCR) rates.
METHODS
A systematic review of the literature was performed to evaluate pathological response in patients with rectal cancer receiving novel neo-adjuvant therapy. EMBASE and Medline electronic databases were searched for relevant articles. Articles published between January 2008 and February 2019 were retrieved. Included studies underwent critical appraisal and complete pathological response rates were recorded.
RESULTS
Of the initial 1074 articles identified, 217 articles fulfilled the inclusion criteria, of these 60 articles (4359 patients) were included. Neo-adjuvant therapy delivered included novel long course chemoradiation therapy, neoadjuvant chemotherapy alone, addition of a biological agent, total neo-adjuvant therapy, novel short course radiation therapy and studies utilising biomarkers to select patients for therapy. Complete pathological response rates ranged from 0 to 60%.
CONCLUSION
A validated novel neo-adjuvant therapy that significantly increases pCR rates in patients with rectal cancer has not been identified.
Topics: Antineoplastic Agents; Chemoradiotherapy; Humans; Mesentery; Neoadjuvant Therapy; Proctectomy; Radiotherapy; Rectal Neoplasms
PubMed: 33814240
DOI: 10.1016/j.ejso.2021.03.245