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Pathology Oncology Research : POR Jan 2015In lower rectal cancer, postoperative outcome is still subject of controversy between the advocates of abdominoperineal resection (APR) and low anterior resection (LAR).... (Meta-Analysis)
Meta-Analysis Review
In lower rectal cancer, postoperative outcome is still subject of controversy between the advocates of abdominoperineal resection (APR) and low anterior resection (LAR). Reports suggest that low anterior resection may be oncologically superior to abdominoperineal excision, although no good evidence exists to support this. Publications were identified which assessed the differences comparing 5-year survival, local recurrence, circumferential resection margin rate, complications and so on. A meta-analysis was performed to clarify the safety and feasibility of the two procedures with several types of outcome measures. A total of 13 studies met the inclusion criteria, and comprised 6,850 cases. Analysis of these data showed that LAR group was highly correlated with 5-year survival (pooled OR = 1.73, 95%CI: 1.30-2.29, P = 0.0002 random-effect). And local recurrence rate of APR group was significantly higher than that in LAR group (pooled OR = 0.63, 95%CI: 0.53-0.75, P < 0.00001 fixed-effect). Also, the circumferential resection margin (CRM) were high involved in APR group than in LAR group. (5 trials reported the data, pooled OR = 0.43, 95%CI: 0.36-0.52, P < 0.00001 fixed-effect). Besides, the incidents of overall complications of APR group was higher compared with LAR group (pooled OR = 0.52, 95%CI: 0.29-0.92, P = 0.03 random-effect). Patients treated by APR have a higher rate of CRM involvement, a higher local recurrence, and poorer prognosis than LAR. And there is evidence that in selected low rectal cancer patients, LAR can be used safely with a better oncological outcome than APR. due to the inherent limitations of the present study, for example, the trails available for this systematic review are limited and the finite retrospective data, future prospective randomized controlled trials will be useful to fully investigate these outcome measures and to confirm this conclusion.
Topics: Animals; Digestive System Surgical Procedures; Humans; Neoplasm Recurrence, Local; Rectal Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 25430561
DOI: 10.1007/s12253-014-9863-x -
Danish Medical Journal Jul 2014Single-port laparoscopic surgery (SPLS) for colonic disease has been widely described, whereas data for SPLS rectal resection are sparse. This review aimed to evaluate... (Review)
Review
INTRODUCTION
Single-port laparoscopic surgery (SPLS) for colonic disease has been widely described, whereas data for SPLS rectal resection are sparse. This review aimed to evaluate the feasibility, safety and complication profile of SPLS for rectal diseases.
METHODS
A systematic literature search of PubMed and Embase was performed in September 2013 according to the PRISMA guidelines. Original reports on the use of SPLS in high and low anterior resection, Hartmann's operation and abdominoperineal resection were included. Outcome measures were intra-operative details and complications, short-term oncological outcome and early complication profile.
RESULTS
No randomised studies or controlled clinical studies were identified. All studies were case series or case reports. Only five studies included more than ten patients operated with SPLS, comprising a total of 120 patients. These studies formed the basis for the final analyses of outcome. Operative times ranged from 79 to 280 min. Conversion rates to conventional laparoscopic surgery and to open surgery were 12% and 2.5%, respectively. The number of harvested lymph nodes in malignant cases was 13-18. The post-operative complication rate was 25.5%. Length of hospital stay was 1-16 days. No 30-day mortality was reported.
CONCLUSION
Short-term results suggest that SPLS for rectal disease is feasible and safe with an acceptable complication rate when performed by experienced surgeons in selected patients. Oncological safety and the possible benefits remain to be proven. Future rectal SPLS procedures should be performed in a protocolled set-up.
Topics: Conversion to Open Surgery; Feasibility Studies; Humans; Laparoscopy; Length of Stay; Lymph Node Excision; Operative Time; Rectal Diseases; Rectal Neoplasms
PubMed: 25123124
DOI: No ID Found -
World Journal of Gastroenterology Aug 2014Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the surgical treatment of choice for many patients with medically refractory ulcerative... (Review)
Review
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the surgical treatment of choice for many patients with medically refractory ulcerative colitis (UC) and familial adenomatous polyposis (FAP). UC patients with IPAA (UC-IPAA) are, nevertheless, susceptible to inflammatory and noninflammatory sequelae such as pouchitis, which is only rarely noted in FAP patients with IPAA. Pouchitis is the most frequent long-term complication of UC-IPAA patients, with a cumulative prevalence of up to 50%. Although the aetiology of pouchitis remains unclear, accumulating evidence suggests that a dysbiosis of the pouch microbiota and an abnormal mucosal immune response are implicated in its pathogenesis. Studies using culture and molecular techniques have detected a dysbiosis of the pouch microbiota in patients with pouchitis. Risk factors, genetic associations, and serological markers suggest that interactions between the host immune response and the pouch microbiota underlie the aetiology of this idiopathic inflammatory condition. This systematic review focuses on the dysbiosis of the microbiota that inhabit the pouch in UC and FAP patients and its interaction with the mucosal immune system. A meta-analysis was not attempted due to the highly heterogeneous microbiota composition and the different detection methods used by the various studies. Although no specific bacterial species, genus, or family has as yet been identified as pathogenic, there is evidence that a dysbiosis characterized by decreased gut microbiota diversity in UC-IPAA patients may, in genetically predisposed subjects, lead to aberrant mucosal immune regulation triggering an inflammatory process.
Topics: Bacteria; Colitis, Ulcerative; Dysbiosis; Host-Pathogen Interactions; Humans; Immunity, Mucosal; Inflammation Mediators; Pouchitis; Proctocolectomy, Restorative; Risk Factors
PubMed: 25110406
DOI: 10.3748/wjg.v20.i29.9665 -
World Journal of Gastrointestinal... Jun 2014To give a comprehensive review of current literature on robotic rectal cancer surgery.
AIM
To give a comprehensive review of current literature on robotic rectal cancer surgery.
METHODS
A systematic review of current literature via PubMed and Embase search engines was performed to identify relevant articles from january 2007 to november 2013. The keywords used were: "robotic surgery", "surgical robotics", "laparoscopic computer-assisted surgery", "colectomy" and "rectal resection".
RESULTS
After the initial screen of 380 articles, 20 papers were selected for review. A total of 1062 patients (male 64.0%) with a mean age of 61.1 years and body mass index of 24.9 kg/m(2) were included in the review. Out of 1062 robotic-assisted operations, 831 (78.2%) anterior and low anterior resections, 132 (12.4%) intersphincteric resection with coloanal anastomosis, 98 (9.3%) abdominoperineal resections and 1 (0.1%) Hartmann's operation were included in the review. Robotic rectal surgery was associated with longer operative time but with comparable oncological results and anastomotic leak rate when compared with laparoscopic rectal surgery.
CONCLUSION
Robotic colorectal surgery has continued to evolve to its current state with promising results; feasible surgical option with low conversion rate and comparable short-term oncological results. The challenges faced with robotic surgery are for more high quality studies to justify its cost.
PubMed: 24936229
DOI: 10.4251/wjgo.v6.i6.184 -
World Journal of Gastrointestinal... May 2014To systematically analyze the randomized trials comparing the oncological and clinical effectiveness of laparoscopic total mesorectal excision (LTME) vs open total...
AIM
To systematically analyze the randomized trials comparing the oncological and clinical effectiveness of laparoscopic total mesorectal excision (LTME) vs open total mesorectal excision (OTME) in the management of rectal cancer.
METHODS
Published randomized, controlled trials comparing the oncological and clinical effectiveness of LTME vs OTME in the management of rectal cancer were retrieved from the standard electronic medical databases. The data of included randomized, controlled trials was extracted and then analyzed according to the principles of meta-analysis using RevMan(®) statistical software. The combined outcome of the binary variables was expressed as odds ratio (OR) and the combined outcome of the continuous variables was presented in the form of standardized mean difference (SMD).
RESULTS
Data from eleven randomized, controlled trials on 2143 patients were retrieved from the electronic databases. There was a trend towards the higher risk of surgical site infection (OR = 0.66; 95%CI: 0.44-1.00; z = 1.94; P < 0.05), higher risk of incomplete total mesorectal resection (OR = 0.62; 95%CI: 0.43-0.91; z = 2.49; P < 0.01) and prolonged length of hospital stay (SMD, -1.59; 95%CI: -0.86--0.25; z = 4.22; P < 0.00001) following OTME. However, the oncological outcomes like number of harvested lymph nodes, tumour recurrence and risk of positive resection margins were statistically similar in both groups. In addition, the clinical outcomes such as operative complications, anastomotic leak and all-cause mortality were comparable between both approaches of mesorectal excision.
CONCLUSION
LTME appears to have clinically and oncologically measurable advantages over OTME in patients with primary rectal cancer in both short term and long term follow ups.
PubMed: 24891934
DOI: 10.4253/wjge.v6.i5.209 -
International Journal of Surgery... 2013This best evidence topic was investigated according to a described protocol. The question posed was: should the irradiated perineal wound following abdominoperineal... (Review)
Review
This best evidence topic was investigated according to a described protocol. The question posed was: should the irradiated perineal wound following abdominoperineal resection (APR) be closed with primary repair or a myocutaneous flap. Using the reported search 364 papers were found of which eight represented the best evidence to answer the clinical question. The conclusion drawn is that there is some limited evidence for recommending flap closure in abdominoperineal resection post radiotherapy. The best evidence available was from a systematic review of cohort studies and case series. Although no meta-analysis was performed, overall wound healing was improved using flap closure with a low frequency of flap necrosis. Other studies providing evidence were case-control series or cohort studies. Three papers prospectively compared vertical rectus abdominus muscle (VRAM) flap with primary closure; two of which demonstrated statistically significant improvement in complication rates with flap closure. Two retrospective case control series showed significant improvement in major wound complication rates in the flap group. Two studies retrospectively compared gracilis flap repair with primary closure and showed significantly lower incidence of major perineal complications. Most studies suffered from significant limitations, small sample sizes and no direct comparisons between matched groups with respect to type of anatomic flap, wound size, tumour recurrence or radiation dose. Whilst there is evidence that myocutaneous flap closure following APR in radiotherapy patients can reduce wound related complications, prospective randomized controlled trials are warranted.
Topics: Abdomen; Cohort Studies; Humans; Perineum; Rectal Neoplasms; Surgical Flaps; Wound Closure Techniques; Wound Healing
PubMed: 23707627
DOI: 10.1016/j.ijsu.2013.05.004 -
Alimentary Pharmacology & Therapeutics May 2013Serological markers such as anti-neutrophil cytoplasmic antibody (ANCA) and anti-Saccharomyces cerevisiae antibody (ASCA) may be associated with pouchitis after ileal... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Serological markers such as anti-neutrophil cytoplasmic antibody (ANCA) and anti-Saccharomyces cerevisiae antibody (ASCA) may be associated with pouchitis after ileal pouch-anal anastomosis (IPAA).
AIM
To perform a systematic review with meta-analysis of studies evaluating the association of ANCA and ASCA status with risk of acute and chronic pouchitis after IPAA.
METHODS
We searched multiple databases (upto September 2012) for studies reporting ANCA and/or ASCA status along with risk of acute or chronic pouchitis after IPAA in adults with ulcerative colitis (UC). We abstracted odds ratio (OR) or raw data from the individual studies to calculate summary OR estimates with 95% CIs using random-effects model.
RESULTS
Eight studies reporting 184 cases of acute pouchitis and six studies reporting 151 cases of chronic pouchitis were included. The odds of chronic pouchitis were 76% higher in ANCA-positive patients than ANCA-negative (six studies; OR: 1.76; 95% CI: 1.19-2.61; P < 0.01). ASCA-positivity was not associated with the risk of chronic pouchitis (three studies; OR: 0.89; 95% CI: 0.49-1.59; P = 0.68). Neither ANCA (eight studies; OR: 1.54; 95% CI: 0.79-3.02; P = 0.21) nor ASCA-positivity (two studies; OR: 1.28; 95% CI: 0.25-6.54; P = 0.77) were associated with the risk of acute pouchitis.
CONCLUSIONS
The risk of chronic pouchitis after IPAA is higher in ANCA-positive patients, but the risk of acute pouchitis is unaffected by ANCA status. ASCA status was not associated with the risk of acute or chronic pouchitis. This information may be used to counsel UC patients regarding their risk of pouchitis after IPAA.
Topics: Acute Disease; Anal Canal; Anastomosis, Surgical; Antibodies, Antineutrophil Cytoplasmic; Antibodies, Bacterial; Biomarkers; Chronic Disease; Colitis, Ulcerative; Colonic Pouches; Humans; Pouchitis; Proctocolectomy, Restorative; Risk Factors; Saccharomyces cerevisiae
PubMed: 23480145
DOI: 10.1111/apt.12274 -
The Cochrane Database of Systematic... Dec 2012For almost one hundred years abdominoperineal excision has been the standard treatment of choice for rectal cancer. With advances in the techniques for rectal resection... (Review)
Review
BACKGROUND
For almost one hundred years abdominoperineal excision has been the standard treatment of choice for rectal cancer. With advances in the techniques for rectal resection and anastomosis, anterior resection with preservation of the sphincter function has become the preferred treatment for rectal cancers, except for those cancers very close to the anal sphincter. The main reason for this has been the conviction that the quality of life for patients with a colostomy after abdominoperineal excision was poorer than for patients undergoing an operation with a sphincter-preserving technique. However, patients having sphincter-preserving operations may experience symptoms affecting their quality of life that are different from stoma-patients.
OBJECTIVES
To compare the quality of life in rectal cancer patients with or without permanent colostomy.
SEARCH METHODS
We searched PUBMED, EMBASE, LILACS, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Colorectal Cancer Group's specialised register. Abstract books from major gastroenterological and colorectal congresses were searched. Reference lists of the selected articles were scrutinized.
SELECTION CRITERIA
All controlled clinical trials and observational studies in which quality of life was measured in patients with rectal cancer having either abdominoperineal excision/Hartmann's operation or low anterior resection, using a validated quality of life instrument, were considered.
DATA COLLECTION AND ANALYSIS
One reviewer (JP) checked the titles and abstracts identified from the databases and hand search. Full text copies of all studies of possible relevance were obtained. The reviewer decided which studies met the inclusion criteria. Both reviewers independently extracted data. If information was insufficient the original author was contacted to obtain missing data. Extracted data were cross-checked and discrepancies resolved by consensus.
MAIN RESULTS
Sixty-nine potential studies were identified. Thirty-five of these, all non-randomised and representing 5127 participants met the inclusion criteria. Fourteen trials found that people undergoing abdominoperineal excision/Hartmann's operation did not have poorer quality of life measures than patients undergoing anterior resection. The rest of the studies found some difference, but not always in favour of non-stoma patients. Due to clinical heterogeneity and the fact that all studies were observational trials, meta-analysis of the included studies was not possible.
AUTHORS' CONCLUSIONS
The studies included in this review do not allow firm conclusions as to the question of whether the quality of life of people after anterior resection is superior to that of people after abdominoperineal excision/Hartmann's operation. The included studies challenges the assumption that anterior resection patients fare better. Larger, better designed and executed prospective studies are needed to answer this question.
Topics: Anal Canal; Colostomy; Controlled Clinical Trials as Topic; Humans; Organ Sparing Treatments; Quality of Life; Rectal Neoplasms; Rectum
PubMed: 23235607
DOI: 10.1002/14651858.CD004323.pub4 -
Annals of Surgical Oncology Mar 2012Distal intramural spread is present within 1 cm from visible tumor in a substantial proportion of patients. Therefore, ≥ 1 cm of distal bowel clearance is recommended... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Distal intramural spread is present within 1 cm from visible tumor in a substantial proportion of patients. Therefore, ≥ 1 cm of distal bowel clearance is recommended as minimally acceptable. However, clinical results are contradictory in answering the question of whether this rule is valid. The aim of this review was to evaluate whether in patients undergoing anterior resection, a distal bowel gross margin of <1 cm jeopardizes oncologic safety.
METHODS
A systematic review of the literature identified 17 studies showing results in relation to margins of approximately <1 cm (948 patients) versus >1 cm (4626 patients); five studies in relation to a margin of ≤ 5 mm (173 patients) versus >5 mm (1277 patients), and five studies showing results in a margin of ≤ 2 mm (73 patients). In most studies, pre- or postoperative radiation was provided.
RESULTS
A multifactorial process was identified resulting in selection of favorable tumors for anterior resection with the short bowel margin and unfavorable tumors for abdominoperineal resection or for anterior resection with the long margin. In total, the local recurrence rate was 1.0% higher in the <1-cm margin group compared to the >1-cm margin group (95% confidence interval [CI] -0.6 to 2.7; P = 0.175). The corresponding figures for ≤ 5 mm cutoff point were 1.7% (95% CI -1.9 to 5.3; P = 0.375). The pooled local recurrence rate in patients having ≤ 2 mm margin was 2.7% (95% CI 0 to 6.4).
CONCLUSIONS
In the selected group of patients, <1 cm margin did not jeopardize oncologic safety.
Topics: Anastomosis, Surgical; Digestive System Surgical Procedures; Humans; Neoplasm Recurrence, Local; Rectal Neoplasms; Rectum
PubMed: 21879269
DOI: 10.1245/s10434-011-2035-2 -
Diseases of the Colon and Rectum Apr 2009Iron and/or vitamin B12 deficiency anemias, which have adverse effects on patients' quality of life, are commonly observed and often overlooked complications after... (Review)
Review
PURPOSE
Iron and/or vitamin B12 deficiency anemias, which have adverse effects on patients' quality of life, are commonly observed and often overlooked complications after restorative proctocolectomy. We performed a systematic review of publications on the prevalence of anemia as well as on the impact of anemia on a range of clinical, functional, quality of life, and economic outcomes in restorative proctocolectomy patients. This information is important to help healthcare providers through a comprehensive overview to increase awareness about a condition that could require therapy to improve patient healthcare and quality of life.
METHODS
We reviewed the English language publications on the incidence of anemia and its adverse effect after restorative proctocolectomy The United States National Library of Medicine database (MEDLINE), the Excerpta Medica database (EMBASE), the Cochran Library, and the Google search engine were searched for published articles on the prevalence and impact of anemia in post-restorative proctocolectomy surgical patients.
RESULTS
The long-term complication most frequently described after RPC is pouchitis. Pouchitis is significantly associated with iron deficiency anemia caused by pouch mucosal bleeding. Other causes are insufficient and/or impaired iron absorption. It has also been observed, however, that restorative proctocolectomy patients with underlying familial adenomatous polyposis rarely develop pouchitis yet show higher rates of iron deficiency anemia compared to those patients with underlying ulcerative colitis. Other causes shown as independent risk factors for iron deficiency anemia in restorative proctocolectomy patients are malignancy, desmoid tumors, and J-pouch configuration. Vitamin B12 deficiency anemia is also common after restorative proctocolectomy. About one-third of restorative proctocolectomy patients show abnormal Schilling test and 5 percent have low referenced serum cobalamin. It has been observed that the degree resection of the terminal-ileum, malabsorption, bacterial overgrowth, and dietary factors are among the known causes of cobalamin deficiency. Folate deficiency has not been reported in restorative proctocolectomy patients. Describing restorative proctocolectomy surgery and its outcomes, in patients without anemia, the quality of life is reported excellent regardless of operative technique.
CONCLUSIONS
Anemia is not uncommon following restorative proctocolectomy and has been shown to have negative effects on the patient's quality of life and the economy and may substantially increase healthcare costs. The treatment of anemia and its underlying causes is important to improving clinical and economic outcomes.
Topics: Anemia, Iron-Deficiency; Colitis, Ulcerative; Folic Acid Deficiency; Hemoglobins; Humans; Postoperative Complications; Pouchitis; Prevalence; Proctocolectomy, Restorative; Quality of Life; Risk Factors; Transferrin; Vitamin B 12 Deficiency
PubMed: 19404082
DOI: 10.1007/DCR.0b013e31819ed571