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Techniques in Coloproctology Jun 2024Four patients with rectal cancer required reconstruction of a defect of the posterior vaginal wall. All patients received neoadjuvant (chemo)radiotherapy, followed by an...
Four patients with rectal cancer required reconstruction of a defect of the posterior vaginal wall. All patients received neoadjuvant (chemo)radiotherapy, followed by an en bloc (abdomino)perineal resection of the rectum and posterior vaginal wall. The extent of the vaginal defect necessitated closure using a tissue flap with skin island. The gluteal turnover flap was used for this purpose as an alternative to conventional more invasive myocutaneous flaps (gracilis, gluteus, or rectus abdominis). The gluteal turnover flap was created through a curved incision at a maximum width of 2.5 cm from the edge of the perineal wound, thereby creating a half-moon shape skin island. The subcutaneous fat was dissected toward the gluteal muscle, and the gluteal fascia was incised. Thereafter, the flap was rotated into the defect and the skin island was sutured into the vaginal wall defect. The contralateral subcutaneous fat was mobilized for perineal closure in the midline, after which no donor site was visible.The duration of surgery varied from 77 to 392 min, and the hospital stay ranged between 3 and 16 days. A perineal wound dehiscence occurred in two patients, requiring an additional VY gluteal plasty in one patient. Complete vaginal and perineal wound healing was achieved in all patients. The gluteal turnover flap is a promising least invasive technique to reconstruct posterior vaginal wall defects after abdominoperineal resection for rectal cancer.
Topics: Humans; Female; Vagina; Buttocks; Rectal Neoplasms; Middle Aged; Plastic Surgery Procedures; Surgical Flaps; Aged; Perineum; Operative Time; Treatment Outcome
PubMed: 38907171
DOI: 10.1007/s10151-024-02941-3 -
Zhonghua Wei Chang Wai Ke Za Zhi =... Jun 2024To study the influence of neoadjuvant chemoradiotherapy on peritoneal wound recovery after abdominoperineal resection (APR). This was a retrospective cohort study of...
To study the influence of neoadjuvant chemoradiotherapy on peritoneal wound recovery after abdominoperineal resection (APR). This was a retrospective cohort study of data of 219 patients who had been pathologically diagnosed with low rectal cancer and undergone APR in the Union Hospital of Tongji Medical College of Huazhong University of Science and Technology between January 2018 and December 2021. Of these patients, 158 had undergone surgery without any pre-surgical treatment (surgery group), 35 had undergone surgery after neoadjuvant chemotherapy (neoadjuvant chemotherapy group), and 26 had undergone surgery after neoadjuvant chemoradiotherapy (neoadjuvant chemoradiotherapy group). The primary outcome was perineal wound complications occurring within 30 days. The status of wound healing was classified into the following three levels: Level A: abnormal wound seepage that improved after wound discharge; Level B: wound infection and dehiscence; and Level C: Level B plus fever. The patients' general condition, tumor status, perianal wound healing level, and intra- and post-operative recovery were recorded. None of the study patients had any complications during surgery. The duration of surgery was 240.0 (180.0-300.0) minutes, 240.0 (225.0-270.0) minutes and 270.0 (240.0-356.2) minutes in the surgery, neoadjuvant chemotherapy, and neoadjuvant chemoradiotherapy groups, respectively (=6.508, =0.039). The rates of perineal wound complications were 34.6% (9/26) and (22.9%, 8/35)in the neoadjuvant chemoradiotherapy group and the neoadjuvant chemotherapy group, being significantly higher than that in the surgery group (10.1%, 16/158). After adjusting for patient age and sex using a logistic regression model, the risk of complications was still higher in the neoadjuvant chemoradiotherapy than in the surgery group (OR=4.6, 95%CI: 1.7-12.7; OR=2.6, 95%CI: 1.0-6.8), these differences being statistically significant (both <0.05). The duration of hospital stay was 9.5 (7.0-12.0) days, 10.0 (8.0-17.0) days and 11.5 (9.0-19.5) days for patients in the surgery, neoadjuvant chemotherapy, and neoadjuvant chemoradiotherapy groups, respectively (=0.569, =0.752). However, after adjusting for patient age and sex by using a generalized linear model, hospital stay was longer in the neoadjuvant chemoradiotherapy than in the surgery group (β [95% CI]: 4.4 [0.5-8.4], =0.028). After surgery, 155 of 219 patients required further adjuvant chemotherapy. A higher proportion of patients with than without wound complications did not attend for follow-up (32.2% [10/31] vs. 16.1% [20/124]); this difference is statistically significant (χ=4.133, =0.023). In patients with low rectal cancer, neoadjuvant radiotherapy may be associated with an increased risk of perineal wound infection and non-healing.
Topics: Humans; Proctectomy; Retrospective Studies; Male; Female; Rectal Neoplasms; Neoadjuvant Therapy; Wound Healing; Middle Aged; Perineum; Peritoneum; Aged; Operative Time
PubMed: 38901995
DOI: 10.3760/cma.j.cn441530-20230724-00013 -
Zhonghua Wei Chang Wai Ke Za Zhi =... Jun 2024Colorectal cancer is the second most common malignant tumor in China, with rectal cancer accounting for approximately 50% of all cases. While neoadjuvant therapy is...
Colorectal cancer is the second most common malignant tumor in China, with rectal cancer accounting for approximately 50% of all cases. While neoadjuvant therapy is essential for diagnosis and treatment, proctectomy with radical resection remains indispensable. Especially for middle and low rectal cancer, the length of the distal resection margin is critical for prognosis, organ preservation, and postoperative quality of life. However, determining a "safe" margin to ensure the radical resection (R0) while maximizing the function of the anal sphincter poses a significant challenge for surgeons. Aiming at this, we conducted a comprehensive review of authoritative guidelines and literature domestically and internationally. We divided the issues related to resection margin in proctectomy into three chapters: (1) the concept and definition of the resection margin; (2) the evaluation of the resection margin in preoperative, intra-operative, and post-operative stages; and (3) radical resection of rectal cancer after neoadjuvant therapy. With the help of the Delphi method, the expert group voted twice for 14 recommendations and finally established the "Chinese Expert Consensus for Resection Margin in Rectal Cancer Surgery (2024 version)". This consensus serves as a valuable reference for clinicians to carry out proctectomy of rectal cancer, which can improve patient's quality of life without affecting their prognosis.
Topics: Humans; China; Consensus; Delphi Technique; Margins of Excision; Neoadjuvant Therapy; Proctectomy; Prognosis; Quality of Life; Rectal Neoplasms
PubMed: 38901985
DOI: 10.3760/cma.j.cn441530-20240403-00123 -
Journal of Visceral Surgery Jun 2024Treatment of ulcerative colitis (UC) has been revolutionized by the arrival of biotherapies and technical progress in interventional endoscopy and surgery. (Sub)total... (Review)
Review
Treatment of ulcerative colitis (UC) has been revolutionized by the arrival of biotherapies and technical progress in interventional endoscopy and surgery. (Sub)total emergency colectomy is required in the event of complicated severe acute colitis: colectasis, perforation, hemorrhage, organ failure. Corticosteroid therapy is the reference treatment for uncomplicated severe acute colitis, while infliximab and ciclosporin are 2nd-line treatments. At each step, before and after each line of treatment failure, surgery should be considered as an option. In cases refractory to medical treatment, the choice between surgery and change in medication must weigh the chronic symptoms associated with the disease against the risks of postoperative complications and functional sequelae inherent to surgery. Detection of dysplastic lesions necessitates chromoendoscopic imaging with multiple biopsies and anatomopathological verification. Endoscopic treatment of these lesions remains reserved for selected patients. These different indications call for multidisciplinary medical-surgical discussion. Total coloproctectomy with ileo-anal anastomosis (TCP-IAA) is the standard surgery, and it holds out hope for healing. Modalities depend on patient characteristics, previous emergency colectomy, and presence of dysplasia. It may be carried out in one, in two modified, or in three phases. The main complications are anastomotic fistula, short-term pouch-related fistula, ileo-anal pouch syndrome, pouchitis and long-term digestive and sexual disorders. For selected cases, an alternative can consist in total colectomy with ileo-rectal anastomosis or permanent terminal ileostomy. The objective of this update is to clarify the indications, modalities, and results of surgical treatment of ulcerative colitis in accordance with the most recent data in the literature.
Topics: Colitis, Ulcerative; Humans; Proctocolectomy, Restorative; Treatment Outcome; Colectomy; Postoperative Complications
PubMed: 38897710
DOI: 10.1016/j.jviscsurg.2024.05.004 -
Journal of Gastrointestinal Surgery :... Jun 2024Management of very-low rectal cancer is one of the most challenging issues faced by general and colorectal surgeons. Many feel compelled to pursue abdominoperineal over...
BACKGROUND
Management of very-low rectal cancer is one of the most challenging issues faced by general and colorectal surgeons. Many feel compelled to pursue abdominoperineal over low anterior resection to optimize oncologic outcomes. This study aims to determine differences in long-term oncologic outcomes between patients undergoing abdominoperineal or low anterior resection for very-low rectal cancer.
METHODS
The US Rectal Cancer Consortium (2010-2016) was queried for adults who underwent either abdominoperineal resection (APR) or low anterior resection (LAR) for Stage I-III rectal cancers <5cm from anorectal junction and met inclusion criteria. Primary outcome was disease-free survival. Secondary outcomes included overall survival, length of stay, complications, recurrence location, and perioperative factors.
RESULTS
431 patients with very-low rectal cancer who underwent APR or LAR were identified. 154 (35.7%) underwent abdominoperineal resection. The overall recurrence rate was 19.6%. Median follow-up was 42.5 months. An analysis adjusted for demographics and pathologic stage observed no difference in disease-free survival between operative types (APR-HR=0.90, 95% CI [0.53-1.52], p=0.70). Secondary outcomes demonstrated no significant difference between operation types, including overall survival (HR=1.29, 95% CI [0.71-2.32], p=0.39), complications (OR = 1.53, 95% CI [0.94 - 2.50], p=0.12) or length of stay (Estimate: 0.04, Std. error = 0.25, p=0.54).
CONCLUSIONS
We observed no significant difference in disease-free survival or overall survival between patients undergoing abdominoperineal or low anterior resection for very-low rectal cancer. This analysis supports the treatment of very-low rectal cancer, without sphincter involvement, by either abdominoperineal or low anterior resection.
PubMed: 38897287
DOI: 10.1016/j.gassur.2024.06.008 -
Langenbeck's Archives of Surgery Jun 2024Coloanal anastomosis with loop diverting ileostomy (CAA) is an option for low anterior resection of the rectum, and Turnbull-Cutait coloanal anastomosis (TCA) regained... (Meta-Analysis)
Meta-Analysis Comparative Study
Turnbull-Cutait pull-through coloanal anastomosis versus standard coloanal anastomosis plus diverting ileostomy for low anterior resection: a meta-analysis and systematic review.
PURPOSE
Coloanal anastomosis with loop diverting ileostomy (CAA) is an option for low anterior resection of the rectum, and Turnbull-Cutait coloanal anastomosis (TCA) regained popularity in the effort to offer patients a reconstructive option. In this context, we aimed to compare both techniques.
METHODS
PubMed, Cochrane, and Scopus were searched for studies published until January 2024. Odds ratios (RRs) with 95% confidence intervals (CIs) were pooled with a random-effects model. Statistical significance was defined as p < 0.05. Heterogeneity was assessed using the Cochran Q test and I statistics, with p-values inferior to 0.10 and I >25% considered significant. Statistical analysis was conducted in RStudio version 4.1.2 (R Foundation for Statistical Computing). Registered number CRD42024509963.
RESULTS
One randomized controlled trial and nine observational studies were included, comprising 1,743 patients, of whom 899 (51.5%) were submitted to TCA and 844 (48.5%) to CAA. Most patients had rectal cancer (52.2%), followed by megacolon secondary to Chagas disease (32.5%). TCA was associated with increased colon ischemia (OR 3.54; 95% CI 1.13 to 11.14; p < 0.031; I = 0%). There were no differences in postoperative complications classified as Clavien-Dindo ≥ IIIb, anastomotic leak, pelvic abscess, intestinal obstruction, bleeding, permanent stoma, or anastomotic stricture. In subgroup analysis of patients with cancer, TCA was associated with a reduction in anastomotic leak (OR 0.55; 95% CI 0.31 to 0.97 p = 0.04; I = 34%).
CONCLUSION
TCA was associated with a decrease in anastomotic leak rate in subgroups analysis of patients with cancer.
Topics: Humans; Anastomosis, Surgical; Ileostomy; Rectal Neoplasms; Colon; Anal Canal; Proctectomy; Anastomotic Leak; Postoperative Complications
PubMed: 38888662
DOI: 10.1007/s00423-024-03379-9 -
BMC Gastroenterology Jun 2024Transanal total mesorectal excision (taTME) has improved the laparoscopic dissection for rectal cancer in the narrow pelvis. Although taTME has more clinical benefits...
Transanal total mesorectal excision (taTME) has improved the laparoscopic dissection for rectal cancer in the narrow pelvis. Although taTME has more clinical benefits than laparoscopic surgery, such as a better view of the distal rectum and direct determination of distal resection margin, an intraoperative urethral injury could occur in excision ta-TME. This study aimed to determine the feasibility and efficacy of the ta-TME with IRIS U kit surgery. This retrospective study enrolled 10 rectal cancer patients who underwent a taTME with an IRIS U kit. The study endpoints were the safety of access (intra- or postoperative morbidity). The detectability of the IRIS U kit catheter was investigated by using a laparoscope-ICG fluorescence camera system. Their mean age was 71.4±6.4 (58-78) years; 80 were men, and 2 were women. The mean operative time was 534.6 ± 94.5 min. The coloanal anastomosis was performed in 80%, and 20% underwent abdominal peritoneal resection. Two patients encountered postoperative complications graded as Clavien-Dindo grade 2. The transanal approach with IRIS U kit assistance is feasible, safe for patients with lower rectal cancer, and may prevent intraoperative urethral injury.
Topics: Humans; Rectal Neoplasms; Male; Female; Aged; Middle Aged; Retrospective Studies; Urethra; Transanal Endoscopic Surgery; Feasibility Studies; Postoperative Complications; Operative Time; Proctectomy; Intraoperative Complications; Rectum; Anastomosis, Surgical; Laparoscopy
PubMed: 38886646
DOI: 10.1186/s12876-024-03279-8 -
Journal of Visualized Experiments : JoVE May 2024Ulcerative colitis (UC) is a chronic immune-mediated disease that affects the entire colon and rectum with a relapsing and remitting course, causing lifelong morbidity....
Ulcerative colitis (UC) is a chronic immune-mediated disease that affects the entire colon and rectum with a relapsing and remitting course, causing lifelong morbidity. When medical treatment is ineffective, especially in cases of massive gastrointestinal bleeding, perforation, toxic megacolon, or carcinogenesis, surgery becomes the last line of defense to cure UC. Total colorectal resection and ileal pouch-anal anastomosis (IPAA) offer the best chance for long-term treatment. Pouchitis is the most common and troublesome postoperative complication. In this investigation, microsurgery is employed to create an ileal pouch model in experimental rats via IPAA surgery. Subsequently, a sustained rat model of pouchitis is established by inducing inflammation of the ileal pouch with dextran sulfate sodium (DSS). The successful establishment of rat pouchitis is validated through analysis of postoperative general status, weight, food and water intake, fecal data, as well as pouch tissue pathology, immunohistochemistry, and inflammatory factor analysis. This experimental animal model of pouchitis provides a foundation for studying the pathogenesis and treatment of the condition.
Topics: Animals; Pouchitis; Rats; Disease Models, Animal; Proctocolectomy, Restorative; Dextran Sulfate; Colonic Pouches; Postoperative Complications; Male; Anastomosis, Surgical
PubMed: 38884498
DOI: 10.3791/66623 -
The British Journal of Surgery Jun 2024
Topics: Humans; Rectal Neoplasms; Proctectomy; Treatment Outcome; Female; Male
PubMed: 38884201
DOI: 10.1093/bjs/znae144 -
Annals of Surgery Open : Perspectives... Mar 2024To investigate the oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer and risk factors for local recurrence (LR).
OBJECTIVE
To investigate the oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer and risk factors for local recurrence (LR).
BACKGROUND
A high LR rate with a multifocal pattern early after TaTME has been reported in Norway and the Netherlands, causing controversy over the oncological safety of this technique.
METHODS
Twenty-six member institutions of the Japan Society of Laparoscopic Colorectal Surgery participated in this retrospective cohort study. A total of 706 patients with primary rectal cancer who underwent TaTME between January 2012 and December 2019 were included for analysis. The primary endpoint was the cumulative 3-year LR rate.
RESULTS
A total of 253 patients had clinical stage III disease (35.8%) and 91 (12.9%) had stage IV. Intersphincteric resection was performed in 318 patients (45.0%) and abdominoperineal resection in 193 (27.3%). There was 1 urethral injury (0.1%). A positive resection margin (R1) was seen in 42 patients (5.9%). Median follow-up was 3.42 years, and the 2- and 3-year cumulative LR rates were 4.95% (95% confidence interval: 3.50-6.75) and 6.82% (95% confidence interval: 5.08-8.89), respectively. A multifocal pattern was observed in 14 (25%) of 56 patients with LR. Tumor height from the anal verge, pathological T4 disease, pathological stage III/IV, positive perineural invasion, and R1 resection were significant risk factors for LR in multivariable analysis.
CONCLUSIONS
In this selected cohort in which intersphincteric resection or abdominoperineal resection was performed in more than half of cases, oncological outcomes were acceptable during a median follow-up of more than 3 years.
PubMed: 38883940
DOI: 10.1097/AS9.0000000000000369