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BJU International May 2024
PubMed: 38740562
DOI: 10.1111/bju.16396 -
The British Journal of Surgery May 2024Ileal pouch-anal anastomosis ('pouch surgery') provides a chance to avoid permanent ileostomy after proctocolectomy, but can be associated with poor outcomes. The...
BACKGROUND
Ileal pouch-anal anastomosis ('pouch surgery') provides a chance to avoid permanent ileostomy after proctocolectomy, but can be associated with poor outcomes. The relationship between hospital-level/surgeon factors (including volume) and outcomes after pouch surgery is of increasing interest given arguments for increasing centralization of these complex procedures. The aim of this systematic review was to appraise the literature describing the influence of hospital-level and surgeon factors on outcomes after pouch surgery for inflammatory bowel disease.
METHODS
A systematic review was performed of studies reporting outcomes after pouch surgery for inflammatory bowel disease. The MEDLINE (Ovid), Embase (Ovid), and Cochrane CENTRAL databases were searched (1978-2022). Data on outcomes, including mortality, morbidity, readmission, operative approach, reconstruction, postoperative parameters, and pouch-specific outcomes (failure), were extracted. Associations between hospital-level/surgeon factors and these outcomes were summarized. This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD42022352851).
RESULTS
A total of 29 studies, describing 41 344 patients who underwent a pouch procedure, were included; 3 studies demonstrated higher rates of pouch failure in lower-volume centres, 4 studies demonstrated higher reconstruction rates in higher-volume centres, 2 studies reported an inverse association between annual hospital pouch volume and readmission rates, and 4 studies reported a significant association between complication rates and surgeon experience.
CONCLUSION
This review summarizes the growing body of evidence that supports centralization of pouch surgery to specialist high-volume inflammatory bowel disease units. Centralization of this technically demanding surgery that requires dedicated perioperative medical and nursing support should facilitate improved patient outcomes and help train the next generation of pouch surgeons.
Topics: Humans; Proctocolectomy, Restorative; Inflammatory Bowel Diseases; Postoperative Complications; Colonic Pouches; Surgeons; Treatment Outcome; Patient Readmission; Hospitals
PubMed: 38740552
DOI: 10.1093/bjs/znae088 -
Clinical Colorectal Cancer Jun 2024Standard of care for most patients with locally advanced rectal cancer in The Netherlands consists of neoadjuvant chemoradiotherapy (nCRT) followed by resection....
BACKGROUND
Standard of care for most patients with locally advanced rectal cancer in The Netherlands consists of neoadjuvant chemoradiotherapy (nCRT) followed by resection. Enlarged lateral lymph nodes (LLNs), especially in the iliac compartment, appears to be associated with an increased risk of local recurrence. Little is known about the risk of local recurrence after nCRT.
MATERIALS AND METHODS
This study included patients with locally advanced rectal cancer and enlarged LLNs on pretreatment MRI-scan located in the internal iliac, obturator, external iliac, or common iliac compartment. Patients were treated with nCRT and response to therapy was evaluated with MRI-scan. The primary endpoint was local lateral recurrence after nCRT. Secondary endpoints included overall survival and postoperative complications.
RESULTS
Out of 260 patients treated for rectal cancer, a total of 46 patients with enlarged LLNs (18% of all patients) were included between 2012 and 2019 in 2 Dutch hospitals. No patients had lateral lymph node recurrence (LLNR) after nCRT. Only 1 patient had local recurrence of rectal cancer after radical resection during a median follow up of 3 years. Disseminated disease was seen in 12 patients and 9 patients died during follow-up, which result in an overall survival rate of 80.4%. Postoperative complications were seen in 41% of patients. There was no 90-days postoperative mortality.
CONCLUSION
Enlarged LLNs are rare after nCRT and no LLNR was found after nCRT in our study population. This could suggest that nCRT only with or without an extra radiotherapeutic boost on enlarged LLNs already reduces the risk of LLNR.
Topics: Humans; Rectal Neoplasms; Male; Female; Middle Aged; Aged; Lymph Nodes; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Adult; Lymphatic Metastasis; Netherlands; Survival Rate; Magnetic Resonance Imaging; Retrospective Studies; Chemoradiotherapy; Follow-Up Studies; Proctectomy; Postoperative Complications; Aged, 80 and over; Chemoradiotherapy, Adjuvant
PubMed: 38735828
DOI: 10.1016/j.clcc.2024.02.003 -
Asian Journal of Surgery May 2024
PubMed: 38724370
DOI: 10.1016/j.asjsur.2024.04.178 -
World Journal of Surgical Oncology May 2024The primary treatment for non-metastatic rectal cancer is curative resection. However, sphincter-preserving surgery may lead to complications. This study aims to develop...
BACKGROUND
The primary treatment for non-metastatic rectal cancer is curative resection. However, sphincter-preserving surgery may lead to complications. This study aims to develop a predictive model for stoma non-closure in rectal cancer patients who underwent curative-intent low anterior resection.
METHODS
Consecutive patients diagnosed with non-metastatic rectal cancer between January 2005 and December 2017, who underwent low anterior resection, were retrospectively included in the Chang Gung Memorial Foundation Institutional Review Board. A comprehensive evaluation and analysis of potential risk factors linked to stoma non-closure were performed.
RESULTS
Out of 956 patients with temporary stomas, 10.3% (n = 103) experienced non-closure primarily due to cancer recurrence and anastomosis-related issues. Through multivariate analysis, several preoperative risk factors significantly associated with stoma non-closure were identified, including advanced age, anastomotic leakage, positive nodal status, high preoperative CEA levels, lower rectal cancer presence, margin involvement, and an eGFR below 30 mL/min/1.73m2. A risk assessment model achieved an AUC of 0.724, with a cutoff of 2.5, 84.5% sensitivity, and 51.4% specificity. Importantly, the non-closure rate could rise to 16.6% when more than two risk factors were present, starkly contrasting the 3.7% non-closure rate observed in cases with a risk score of 2 or below (p < 0.001).
CONCLUSION
Prognostic risk factors associated with the non-closure of a temporary stoma include advanced age, symptomatic anastomotic leakage, nodal status, high CEA levels, margin involvement, and an eGFR below 30 mL/min/1.73m2. Hence, it is crucial for surgeons to evaluate these factors and provide patients with a comprehensive prognosis before undergoing surgical intervention.
Topics: Humans; Rectal Neoplasms; Retrospective Studies; Female; Male; Middle Aged; Surgical Stomas; Aged; Prognosis; Risk Factors; Follow-Up Studies; Anastomotic Leak; Neoplasm Recurrence, Local; Postoperative Complications; Adult; Proctectomy; Aged, 80 and over
PubMed: 38715036
DOI: 10.1186/s12957-024-03403-8 -
Surgical Case Reports May 2024Colorectal cancer (CRC) often metastasizes to the liver, lungs, lymph nodes, and peritoneum but rarely to the bladder, small intestine, and skin. We here report the rare...
BACKGROUND
Colorectal cancer (CRC) often metastasizes to the liver, lungs, lymph nodes, and peritoneum but rarely to the bladder, small intestine, and skin. We here report the rare metastasis of anal cancer in the left bladder wall, followed by metastases to the small intestine and skin, after abdominoperineal resection and left lateral lymph node dissection with chemotherapy in a patient with clinician Stage IVa disease.
CASE PRESENTATION
A 66-year-old man presented with 1-month history of bloody stool and anal pain and diagnosed with clinical Stage IVa anal cancer with lymph node and liver metastases (cT3, N3 [#263L], M1a [H1]). Systemic chemotherapy led to clinical complete response (CR) for the liver metastasis and clinical near-CR for the primary tumor. Robot-assisted laparoscopic perineal rectal resection and left-sided lymph node dissection were performed. Computed tomography during 18-month postoperative follow-up identified a mass in the left bladder wall, which was biopsied with transurethral resection, was confirmed as recurrent anal cancer by histopathologic evaluation. After two cycles of systemic chemotherapy, partial resection of the small intestine was performed due to bowel obstruction not responding to conservative therapy. The histopathologic evaluation revealed lymphogenous invasion of the muscularis mucosa and subserosa of all sections. Ten months after the first surgery for bowel obstruction and two months before another surgery for obstruction of the small intestine, skin nodules extending from the lower abdomen to the thighs were observed. The histopathologic evaluation of the skin biopsy specimen collected at the time of surgery for small bowel obstructions led to the diagnosis of skin metastasis of anal cancer. Although panitumumab was administered after surgery, the patient died seven months after the diagnosis of skin metastasis.
CONCLUSIONS
This case illustrates the rare presentation of clinical Stage IVa anal cancer metastasizing to the bladder wall, small intestine, and skin several years after CR to chemotherapy.
PubMed: 38714637
DOI: 10.1186/s40792-024-01913-x -
Surgical Endoscopy Jun 2024This study aims to analyze the influencing factors of postoperative Low Anterior Resection Syndrome (LARS) in patients with middle and low rectal cancer who underwent...
BACKGROUND
This study aims to analyze the influencing factors of postoperative Low Anterior Resection Syndrome (LARS) in patients with middle and low rectal cancer who underwent robotic surgery. It also seeks to predict the probability of LARS through a visual, quantitative, and graphical nomogram. This approach is expected to lower the risk of postoperative LARS in these patients and improve their quality of life through effective prevention and early intervention.
PATIENTS AND METHODS
This research involved patients with middle and low rectal cancer who underwent robotic surgery in the Department of Gastrointestinal Surgery at the First Affiliated Hospital of Nanchang University from January 2015 to October 2022. A series of intestinal dysfunction symptoms arising from postoperative rectal cancer were diagnosed and graded using LARS scoring criteria. After the initial screening of all variables related to LARS with Lasso regression, they were included in logistic regression for further univariate and multivariate analysis to identify independent risk factors for LARS. A prediction model was then constructed.
RESULTS
The study included 358 patients. The parameters identified by Lasso regression included obstruction, BMI, tumor localization, maximum tumor diameter, AJCC stage, stoma, neoadjuvant therapy (NAT), and postoperative adjuvant therapy (AT). Univariate and multivariate analyses indicated that a higher BMI, lower tumor localization, higher AJCC stage, neoadjuvant therapy, and postoperative adjuvant therapy were independent risk factors for total LARS. The AUC of the prediction nomogram was 0.834, with a sensitivity of 0.825 and specificity of 0.741. The calibration curve demonstrated excellent concordance with the nomogram, indicating the prediction curve fit the diagonal well.
CONCLUSION
Higher BMI, lower tumor localization, higher AJCC stage, neoadjuvant therapy, and adjuvant therapy were identified as independent risk factors for total LARS. A new predictive nomogram for postoperative LARS in patients with middle and low rectal cancer undergoing robotic surgery was developed, proving to be stable and reliable. This tool will assist clinicians in managing the postoperative treatment of these patients, facilitating better clinical decision-making and maximizing patient benefits.
Topics: Humans; Robotic Surgical Procedures; Nomograms; Male; Rectal Neoplasms; Female; Middle Aged; Risk Factors; Postoperative Complications; Syndrome; Aged; Proctectomy; Adult; Retrospective Studies; Low Anterior Resection Syndrome
PubMed: 38714570
DOI: 10.1007/s00464-024-10863-2 -
MedRxiv : the Preprint Server For... Apr 2024Recent data have demonstrated that in locally advanced rectal cancer (LARC), a total neoadjuvant therapy (TNT) approach improves compliance with chemotherapy and...
ALLIANCE A022104/NRG-GI010: The Janus Rectal Cancer Trial: a randomized phase II/III trial testing the efficacy of triplet versus doublet chemotherapy regarding clinical complete response and disease-free survival in patients with locally advanced rectal cancer.
BACKGROUND
Recent data have demonstrated that in locally advanced rectal cancer (LARC), a total neoadjuvant therapy (TNT) approach improves compliance with chemotherapy and increases rates of tumor response compared to neoadjuvant chemoradiation (CRT) alone. They further indicate that the optimal sequencing of TNT involves consolidation (rather than induction) chemotherapy to optimize complete response rates. Data, largely from retrospective studies, have also shown that patients with clinical complete response (cCR) after neoadjuvant therapy may be managed safely with the watch and wait approach (WW) instead of preemptive total mesorectal resection (TME). However, the optimal consolidation chemotherapy regimen to achieve cCR has not been established, and a randomized clinical trial has not robustly evaluated cCR as a primary endpoint. Collaborating with a multidisciplinary oncology team and patient groups, we designed this NCI-sponsored study of chemotherapy intensification to address these issues and to drive up cCR rates, to provide opportunity for organ preservation, improve quality of life for patients and improve survival outcomes.
METHODS
In this NCI-sponsored multi-group randomized, seamless phase II/III trial (1:1), up to 760 patients with LARC, T4N0, any T with node positive disease (any T, N+) or T3N0 requiring abdominoperineal resection or coloanal anastomosis and distal margin within 12 cm of anal verge will be enrolled. Stratification factors include tumor stage (T4 vs T1-3), nodal stage (N+ vs N0) and distance from anal verge (0-4; 4-8; 8-12 cm). Patients will be randomized to receive neoadjuvant long course chemoradiation (LCRT) followed by consolidation doublet (mFOLFOX6 or CAPOX) or triplet chemotherapy (mFOLFIRINOX) for 3-4 months. LCRT in both arms involves 4500 cGy in 25 fractions over 5 weeks + 900 cGy boost in 5 fractions with a fluoropyrimidine (capecitabine preferred). Patients will undergo assessment 8-12 (+/- 4) weeks post-TNT completion. The primary endpoint for the phase II portion will compare cCR between treatment arms. A total number of 296 evaluable patients (148 per arm) will provide statistical power of 90.5% to detect an 17% increase in cCR rate, at a one-sided alpha=0.048. The primary endpoint for the phase III portion will compare disease-free survival (DFS) between treatment arms. A total of 285 DFS events will provide 85% power to detect an effect size of hazard ratio 0.70 at a one-sided alpha of 0.025, requiring enrollment of 760 patients (380 per arm). Secondary objectives include time-to event outcomes (overall survival, organ preservation time and time to distant metastasis) and adverse effects. Biospecimens including archival tumor tissue, plasma and buffy coat in EDTA tubes, and serial rectal MRIs will be collected for exploratory correlative research. This study, activated in late 2022, is open across the NCTN and has a current accrual of 312. Support: U10CA180821, U10CA180882, U24 CA196171; https://acknowledgments.alliancefound.org .
DISCUSSION
Building off of data from modern day rectal cancer trials and patient input from national advocacy groups, we have designed the current trial studying chemotherapy intensification via a consolidation chemotherapy approach with the intent to enhance cCR and DFS rates, increase organ preservation rates, and improve quality of life for patients with rectal cancer.
TRIAL REGISTRATION
Clinicaltrials.gov ID: NCT05610163 ; Support includes U10CA180868 (NRG) and U10CA180888 (SWOG).
PubMed: 38712176
DOI: 10.1101/2024.04.25.24306396 -
Diseases of the Colon and Rectum Jun 2024Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different... (Review)
Review
BACKGROUND
Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these techniques.
OBJECTIVE
To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy.
DATA SOURCE
Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.
STUDY SELECTION
Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis.
INTERVENTION
IPAA technique.
MAIN OUTCOME MEASURES
Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function).
RESULTS
Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques.
LIMITATIONS
A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy.
CONCLUSIONS
Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.
Topics: Humans; Colitis, Ulcerative; Proctocolectomy, Restorative; Anastomosis, Surgical; Surgical Stapling; Anastomotic Leak; Colonic Pouches; Postoperative Complications; Treatment Outcome
PubMed: 38710588
DOI: 10.1097/DCR.0000000000003292 -
Cureus Apr 2024Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic inflammatory disorder affecting the terminal follicular epithelium within the apocrine skin...
Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic inflammatory disorder affecting the terminal follicular epithelium within the apocrine skin glands. When these lesions develop in the genital and perianal regions, there is a potential risk of progression to squamous cell carcinoma or mucinous adenocarcinoma. The tumor may appear in the perianal area, perineum, or buttocks. Here, we present a rare case of long-standing perianal HS with associated fistula-related mucinous adenocarcinoma and the challenges we faced in managing this condition.
PubMed: 38707052
DOI: 10.7759/cureus.57585