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Colorectal Disease : the Official... Jun 2024There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate... (Comparative Study)
Comparative Study
AIM
There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate 30-day postoperative morbidity and mortality following HP, anterior resection (AR) and abdominoperineal resection (APR) for rectal cancer using a national registry.
METHODS
All patients operated for rectal cancer, tumour height 5-15 cm, between the years 2010 and 2017, were identified through the Swedish colorectal cancer registry.
RESULTS
A total of 8476 patients were included: 1210 (14%) undergoing HP, 5406 (64%) AR and 1860 (22%) APR. HP was associated with an increased risk of intra-abdominal infection (OR 1.7, CI 1.26-2.28, P = 0.0004) compared to AR and APR, while APR was related to an increased risk of overall complications (OR 1.18, CI 1.01-1.40, P = 0.040). No significant difference was observed in the rate of reoperations and readmissions between HP, AR and APR, and type of surgical procedure was not a risk factor for 30-day mortality. Findings from a subgroup analysis of patients with a tumour 5-7 cm from the anal verge revealed that HP was not associated with increased risk for complications or 30-day mortality.
CONCLUSIONS
For patients where AR is not appropriate HP is a valid alternative with a favourable outcome. APR was associated with the highest overall 30-day complication rate.
Topics: Humans; Rectal Neoplasms; Male; Female; Aged; Proctectomy; Postoperative Complications; Middle Aged; Sweden; Registries; Reoperation; Risk Factors; Colostomy; Aged, 80 and over; Patient Readmission; Intraabdominal Infections
PubMed: 38802985
DOI: 10.1111/codi.17033 -
Colorectal Disease : the Official... Jun 2024The standard treatment for low rectal cancer is preoperative chemoradiotherapy followed by surgery with low anterior resection with diverting ileostomy or...
AIM
The standard treatment for low rectal cancer is preoperative chemoradiotherapy followed by surgery with low anterior resection with diverting ileostomy or abdominoperineal resection, both of which have significant long-term effects on bowel and sexual function. Due to the high morbidity of surgery, there has been increasing interest in nonoperative management for low rectal cancer. The aim of this work is to conduct a pan-Canadian Phase II trial assessing the safety of nonoperative management for low rectal cancer.
METHOD
Patients with Stage II or III low rectal cancer completing chemoradiotherapy according to standard of care at participating centres will be assessed for complete clinical response 8-14 weeks following completion of chemoradiotherapy. Subjects achieving a clinical complete response will undergo active surveillance including endoscopy, imaging and bloodwork at regular intervals for 24 months. The primary outcome will be the rate of local regrowth 2 years after chemoradiotherapy. Nonoperative management will be considered safe (i.e. as effective as surgery to achieve local control) if the rate of local regrowth is ≤30% and surgical salvage is possible for all local regrowths. Secondary outcomes will include disease-free and overall survival.
CONCLUSION
The results will be highly clinically relevant, as it is expected that nonoperative management will be safe and lead to widespread adoption of nonoperative management in Canada. This change in practice has the potential to decrease the number of patients requiring surgery and the costs associated with surgery and long-term surgical morbidity.
Topics: Humans; Rectal Neoplasms; Chemoradiotherapy; Canada; Male; Female; Neoplasm Staging; Treatment Outcome; Middle Aged; Adult; Disease-Free Survival; Aged; Neoplasm Recurrence, Local; Neoadjuvant Therapy; Proctectomy
PubMed: 38797916
DOI: 10.1111/codi.17035 -
BJS Open May 2024The routine use of MRI in rectal cancer treatment allows the use of a strict definition for low rectal cancer. This study aimed to compare minimally invasive total... (Comparative Study)
Comparative Study
Total mesorectal excision in MRI-defined low rectal cancer: multicentre study comparing oncological outcomes of robotic, laparoscopic and transanal total mesorectal excision in high-volume centres.
BACKGROUND
The routine use of MRI in rectal cancer treatment allows the use of a strict definition for low rectal cancer. This study aimed to compare minimally invasive total mesorectal excision in MRI-defined low rectal cancer in expert laparoscopic, transanal and robotic high-volume centres.
METHODS
All MRI-defined low rectal cancer operated on between 2015 and 2017 in 11 Dutch centres were included. Primary outcomes were: R1 rate, total mesorectal excision quality and 3-year local recurrence and survivals (overall and disease free). Secondary outcomes included conversion rate, complications and whether there was a perioperative change in the preoperative treatment plan.
RESULTS
Of 1071 eligible rectal cancers, 633 patients with low rectal cancer were identified. Quality of the total mesorectal excision specimen (P = 0.337), R1 rate (P = 0.107), conversion (P = 0.344), anastomotic leakage rate (P = 0.942), local recurrence (P = 0.809), overall survival (P = 0.436) and disease-free survival (P = 0.347) were comparable among the centres. The laparoscopic centre group had the highest rate of perioperative change in the preoperative treatment plan (10.4%), compared with robotic expert centres (5.2%) and transanal centres (2.1%), P = 0.004. The main reason for this change was stapling difficulty (43%), followed by low tumour location (29%). Multivariable analysis showed that laparoscopic surgery was the only independent risk factor for a change in the preoperative planned procedure, P = 0.024.
CONCLUSION
Centres with expertise in all three minimally invasive total mesorectal excision techniques can achieve good oncological resection in the treatment of MRI-defined low rectal cancer. However, compared with robotic expert centres and transanal centres, patients treated in laparoscopic centres have an increased risk of a change in the preoperative intended procedure due to technical limitations.
Topics: Humans; Rectal Neoplasms; Robotic Surgical Procedures; Male; Female; Laparoscopy; Middle Aged; Magnetic Resonance Imaging; Aged; Neoplasm Recurrence, Local; Hospitals, High-Volume; Netherlands; Treatment Outcome; Disease-Free Survival; Proctectomy; Postoperative Complications; Retrospective Studies; Transanal Endoscopic Surgery; Anastomotic Leak
PubMed: 38788679
DOI: 10.1093/bjsopen/zrae029 -
The American Surgeon May 2024Total neoadjuvant therapy (TNT) for patients with locally advanced rectal cancer (LARC) is now the standard of care. Randomized trials suggest the use of short-course...
INTRODUCTION
Total neoadjuvant therapy (TNT) for patients with locally advanced rectal cancer (LARC) is now the standard of care. Randomized trials suggest the use of short-course radiotherapy (SCRT) and long-course radiotherapy (LCRT) are oncologically equivalent.
OBJECTIVE
To describe pathologic outcomes after surgical resections of patients receiving SCRT versus LCRT as part of TNT for LARC.
PARTICIPANTS
All patients with LARC treated at a single tertiary hospital who underwent proctectomy after completing TNT were included. Patients were excluded if adequate details of TNT were not available in the electronic medical record.
RESULTS
A total of 53 patients with LARC were included. Thirty-nine patients (73.5%) received LCRT and 14 (26.4%) received SCRT. Forty-nine patients (92.5%) were clinical stage III (cN1-2) prior to treatment. The average lymph node yield after proctectomy was 20.9 for SCRT and 17.0 for LCRT ( = .075). Of the 49 patients with clinically positive nodes before treatment, 76.9% of those who received SCRT and 72.2% of those who received LCRT achieved pN0 disease after TNT. Additionally, there were no significant differences in rates of pathologic complete response between patients who received SCRT and LCRT, 7.1% and 12.8%, respectively ( = .565).
CONCLUSION
Pathologic outcomes of patients with LARC treated with SCRT or LCRT, as part of TNT, may be similar. Further prospective trials are needed to assess long-term clinical outcomes and to determine best treatment protocols.
PubMed: 38770756
DOI: 10.1177/00031348241256055 -
BMC Surgery May 2024Abdominal perineal resection (APR) of rectal cancer, also known as Mile's procedure, is a classic procedure for the treatment of rectal cancer. Through the improvement...
BACKGROUND
Abdominal perineal resection (APR) of rectal cancer, also known as Mile's procedure, is a classic procedure for the treatment of rectal cancer. Through the improvement of surgical skills and neoadjuvant therapy, the sphincter-preserving rate in rectal cancer patients has improved, even in patients with ultralow rectal cancer who underwent APR in the past. However, APR cannot be completely replaced by low anterior resection (LAR) in reality. APR still has its indications, when the tumor affects the external sphincter, etc. Good perineal exposure in APR is difficult and can seriously affect surgical safety and the long-term prognosis.
METHODS
We reviewed the records of 16 consecutive patients with rectal cancer who underwent APR at Anqing Municipal Hospital from January 2022 to April 2023, including 11 males and 5 females, with an average age of 64.8 ± 10.3 years. The perineal operation was completed with the Lone-Star® retractor-assisted (LSRA) exposure method. After incising the skin and subcutaneous tissue, a Lone-Star® retractor was placed, and the incision was retracted in surrounding directions with 8 small retractors, which facilitated the freeing of deep tissues. We dynamically adjusted the retractor according to the plane to fully expose the surgical field.
RESULTS
All 16 patients underwent laparoscopic-assisted APR successfully. Thirteen procedures were performed independently by a single person, and the others were completed by two persons due to intraoperative arterial hemostasis. All specimens were free of perforation and had a negative circumferential resection margin (CRM). Postoperative complications occurred in 4 patients, including urinary retention in 1 patient, pulmonary infection in 1 patient, intestinal adhesion in 1 patient and peristomal dermatitis in 1 patient, and were graded as ClavienDindo grade 3 or lower and cured. No distant metastasis or local recurrence was found for any of the patients in the postoperative follow-up.
CONCLUSIONS
The application of the LSRA exposure method might be helpful for perineal exposure during APR for rectal cancer, which could improve intraoperative safety and surgical efficiency, achieve one-person operation, and increase the comfort of operators.
Topics: Humans; Rectal Neoplasms; Male; Female; Middle Aged; Perineum; Laparoscopy; Aged; Proctectomy; Retrospective Studies; Treatment Outcome
PubMed: 38769559
DOI: 10.1186/s12893-024-02453-9 -
Surgical Endoscopy Jun 2024This study aims to report our surgical techniques for robot-assisted laparoscopic anterior resection, specifically focusing on mesorectal division using rolling division...
BACKGROUND
This study aims to report our surgical techniques for robot-assisted laparoscopic anterior resection, specifically focusing on mesorectal division using rolling division of the mesorectum, and to elucidate short-term outcomes at a single institution. Tumor-specific mesorectal excision (TSME) is commonly performed for resection of a tumor located in the upper rectum. However, especially in a narrow pelvis, it is difficult to perform appropriate mesorectal division at an adequate distance from the tumor in robot-assisted laparoscopic anterior resection.
METHODS
Retrospective case series of patients with rectal cancer who underwent robot-assisted TSME using rolling division of mesorectum. Patient characteristics, perioperative clinical results, surgical and pathological details were recorded.
RESULTS
A total of 198 patients underwent robot-assisted TSME for rectal cancer using rolling division of mesorectum between May 2019 and December 2023.The tumor was located in the upper rectum in 45 patients, middle rectum in 115 patients and lower rectum in 38 patients. The types of resections were 40 high anterior resection and 158 low anterior resections. The median operation time was 175 (range 109-310) min, and median mesorectal division time was 24 (range 15-45) min. Median blood loss was 3 (range 0-20) ml; no patients required blood transfusion. The overall complication rate of Clavien-Dindo classification grades I-IV was 7.1%. Anastomotic leakage was observed in two patients (1.0%) with grade III. There was no surgical mortality in this series.
CONCLUSION
This robotic technique for anterior resection is a feasible and reliable procedure for achieving sufficient and safe TSME in this cohort.
Topics: Humans; Rectal Neoplasms; Robotic Surgical Procedures; Male; Female; Middle Aged; Retrospective Studies; Aged; Adult; Aged, 80 and over; Proctectomy; Treatment Outcome; Operative Time; Laparoscopy; Rectum; Postoperative Complications
PubMed: 38769186
DOI: 10.1007/s00464-024-10878-9 -
World Journal of Gastroenterology May 2024Colorectal surgeons are well aware that performing surgery for rectal cancer becomes more challenging in obese patients with narrow and deep pelvic cavities. Therefore,...
BACKGROUND
Colorectal surgeons are well aware that performing surgery for rectal cancer becomes more challenging in obese patients with narrow and deep pelvic cavities. Therefore, it is essential for colorectal surgeons to have a comprehensive understanding of pelvic structure prior to surgery and anticipate potential surgical difficulties.
AIM
To evaluate predictive parameters for technical challenges encountered during laparoscopic radical sphincter-preserving surgery for rectal cancer.
METHODS
We retrospectively gathered data from 162 consecutive patients who underwent laparoscopic radical sphincter-preserving surgery for rectal cancer. Three-dimensional reconstruction of pelvic bone and soft tissue parameters was conducted using computed tomography (CT) scans. Operative difficulty was categorized as either high or low, and multivariate logistic regression analysis was employed to identify predictors of operative difficulty, ultimately creating a nomogram.
RESULTS
Out of 162 patients, 21 (13.0%) were classified in the high surgical difficulty group, while 141 (87.0%) were in the low surgical difficulty group. Multivariate logistic regression analysis showed that the surgical approach using laparoscopic intersphincteric dissection, intraoperative preventive ostomy, and the sacrococcygeal distance were independent risk factors for highly difficult laparoscopic radical sphincter-sparing surgery for rectal cancer ( < 0.05). Conversely, the anterior-posterior diameter of pelvic inlet/sacrococcygeal distance was identified as a protective factor ( < 0.05). A nomogram was subsequently constructed, demonstrating good predictive accuracy (C-index = 0.834).
CONCLUSION
The surgical approach, intraoperative preventive ostomy, the sacrococcygeal distance, and the anterior-posterior diameter of pelvic inlet/sacrococcygeal distance could help to predict the difficulty of laparoscopic radical sphincter-preserving surgery.
Topics: Humans; Laparoscopy; Rectal Neoplasms; Female; Male; Nomograms; Middle Aged; Retrospective Studies; Aged; Anal Canal; Tomography, X-Ray Computed; Risk Factors; Organ Sparing Treatments; Adult; Pelvis; Imaging, Three-Dimensional; Treatment Outcome; Aged, 80 and over; Proctectomy; Logistic Models
PubMed: 38764764
DOI: 10.3748/wjg.v30.i18.2418 -
Techniques in Coloproctology May 2024
Topics: Humans; Rectal Neoplasms; Robotic Surgical Procedures; Surgical Stapling; Male; Proctectomy; Middle Aged; Female
PubMed: 38762703
DOI: 10.1007/s10151-024-02935-1 -
ANZ Journal of Surgery May 2024The impact of a permanent stoma, such as post-abdominoperineal resection (APR), on quality of life (QoL) is well-documented. While stoma-related QoL tools exist, their...
PURPOSE
The impact of a permanent stoma, such as post-abdominoperineal resection (APR), on quality of life (QoL) is well-documented. While stoma-related QoL tools exist, their relationship with stoma satisfaction is unclear. This study aimed to identify which aspects of QoL were most associated with stoma satisfaction.
METHODOLOGY
A cross-sectional study of consecutive patients who had an APR for rectal cancer at an Australian tertiary hospital (2012-2021), identified from a prospectively maintained database, was conducted. The Stoma-QoL questionnaire was used. Overall patient satisfaction with stoma function, and whether healthcare advice was sought for stoma dysfunction, were explored. Linear regression assessed the association between individual issues examined in the Stoma-QoL questionnaire and overall patient satisfaction with stoma function.
RESULTS
Overall, 64 patients (62.5% male, mean 68.1 years) participated. Stoma-QoL score was associated with stoma satisfaction (P < 0.05). QoL items impacting satisfaction were: needing to know nearest toilet location (P = 0.04), pouch smell concerns (P = 0.008), needing daytime rest (P = 0.02), clothing limitations (P = 0.02), sexual attractiveness concerns (P < 0.05), embarrassment (P < 0.05), difficulty hiding the pouch (P = 0.02), concerns about being burdensome (P = 0.04) and difficulty with interpersonal interaction (P = 0.03). Only 11 (17.2%) patients sought healthcare advice for stoma dysfunction.
CONCLUSION
While stoma-specific QoL is associated with stoma satisfaction, individual QoL aspects impact differently on satisfaction in permanent colostomy patients. These findings may help identify focus areas for peri-operative counselling for clinicians and stomal therapists, highlight the importance of tailored multidisciplinary care in ostomates and suggests that a stoma type-specific Stoma-QoL questionnaire is required.
PubMed: 38761003
DOI: 10.1111/ans.19034 -
Colorectal Disease : the Official... Jun 2024Some patients with inflammatory bowel disease (IBD) require subtotal colectomy (STC) with ileostomy. The recent literature reports a significant number of patients who...
AIM
Some patients with inflammatory bowel disease (IBD) require subtotal colectomy (STC) with ileostomy. The recent literature reports a significant number of patients who do not undergo subsequent surgery and are resigned to living with a definitive stoma. The aim of this work was to analyse the rate of definitive stoma and the cumulative incidence of secondary reconstructive surgery after STC for IBD in a large national cohort study.
METHOD
A national retrospective study (2013-2021) was conducted on prospectively collected data from the French Medical Information System Database (PMSI). All patients undergoing STC in France were included. The association between definitive stoma and potential risk factors was studied using univariate and multivariate analyses.
RESULTS
A total of 1860 patients were included (age 45 ± 9 years; median follow-up 30 months). Of these, 77% (n = 1442) presented with ulcerative colitis. Mortality and morbidity at 90 days after STC were 5% (n = 100) and 47% (n = 868), respectively. Reconstructive surgery was identified in 1255 patients (67%) at a mean interval of 7 months from STC. Seveny-four per cent (n = 932) underwent a completion proctectomy with ileal pouch anal anastomosis and 26% (n = 323) an ileorectal anastomosis. Six hundred and five (33%) patients with a definitive stoma had an abdominoperineal resection (n = 114; 19%) or did not have any further surgical procedure (n = 491; 81%). Independent risk factors for definitive stoma identified in multivariate analysis were older age, Crohn's disease, colorectal neoplasia, postoperative complication after STC, laparotomy and a low-volume hospital.
CONCLUSION
We found that 33% of patients undergoing STC with ileostomy for IBD had definitive stoma. Modifiable risk factors for definitive stoma were laparotomy and a low-volume hospital.
Topics: Humans; Middle Aged; Female; Male; France; Colectomy; Ileostomy; Retrospective Studies; Adult; Risk Factors; Inflammatory Bowel Diseases; Surgical Stomas; Reoperation; Postoperative Complications; Colitis, Ulcerative; Crohn Disease
PubMed: 38757256
DOI: 10.1111/codi.17020