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JAMA Network Open Dec 2020Standard therapy for locally advanced rectal cancer includes concurrent chemoradiotherapy followed by surgery and adjuvant chemotherapy (CRT plus A). An alternative... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Standard therapy for locally advanced rectal cancer includes concurrent chemoradiotherapy followed by surgery and adjuvant chemotherapy (CRT plus A). An alternative strategy known as total neoadjuvant therapy (TNT) involves administration of CRT plus neoadjuvant chemotherapy before surgery with the goal of delivering uninterrupted systemic therapy to eradicate micrometastases. A comparison of these 2 approaches has not been systematically reviewed previously.
OBJECTIVE
To determine the differences in rates of pathologic complete response (PCR), disease-free and overall survival, sphincter-preserving surgery, and ileostomy between patients receiving TNT vs standard CRT plus A.
DATA SOURCES
MEDLINE (via PubMed) and Embase (via OVID) were searched from inception through July 1, 2020, for the following terms: anal/anorectal neoplasms OR anal/anorectal cancer AND total neoadjuvant treatment OR total neoadjuvant therapy. Only studies in English were included.
STUDY SELECTION
Randomized clinical trials or prospective/retrospective cohort studies comparing outcomes in patients with locally advanced rectal cancer who received TNT vs CRT plus A.
DATA EXTRACTION AND SYNTHESIS
Data regarding the first author, publication year, location, sample size, and rates of PCR, sphincter-preserving surgery, ileostomy, and disease-free and overall survival were extracted using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and pooled using a random-effects model.
MAIN OUTCOMES AND MEASURES
Rates of PCR, sphincter-preserving surgery, ileostomy, and disease-free and overall survival.
RESULTS
After reviewing 2165 reports, 7 unique studies including a total of 2416 unique patients, of whom 1206 received TNT, were selected. The median age for the patients receiving TNT ranged from 57 to 69 years, with 58% to 73% being male. The pooled prevalence of PCR was 29.9% (range, 17.2%-38.5%) in the TNT group and 14.9% (range, 4.2%-21.3%) in the CRT plus A group. Total neoadjuvant therapy was associated with a higher chance of achieving a PCR (odds ratio [OR], 2.44; 95% CI, 1.99-2.98). No statistically significant difference in the proportion of sphincter-preserving surgery (OR, 1.06; 95% CI, 0.73-1.54) or ileostomy (OR, 1.05; 95% CI, 0.76-1.46) between recipients of TNT and CRT plus A was observed. Only 3 studies presented data on disease-free survival, and pooled analysis showed significantly higher odds of improved disease-free survival in patients who received TNT (OR, 2.07; 95% CI, 1.20-3.56; I2 = 49%). Data on overall survival were not consistently reported.
CONCLUSIONS AND RELEVANCE
The findings of this systematic review and meta-analysis suggest that TNT is a promising strategy in locally advanced rectal cancer, with superior rates of PCR compared with standard therapy. However, the long-term effect on disease recurrence and overall survival needs to be explored in future studies.
Topics: Chemoradiotherapy; Humans; Ileostomy; Neoadjuvant Therapy; Neoplasm Micrometastasis; Neoplasm Staging; Proctectomy; Rectal Neoplasms; Survival Analysis
PubMed: 33326026
DOI: 10.1001/jamanetworkopen.2020.30097 -
Cancers Feb 2021Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative... (Review)
Review
BACKGROUND
Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers).
METHODS
We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE.
RESULTS
Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43-0.71; < 0.01/Group B: OR 0.54, CI 0.17-1.68; = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35-0.68; < 0.001/Group B: OR 0.38, 95% CI 0.12-1.17; < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39-4.35; < 0.01) and major (OR 1.67, 95% CI 0.90-3.08; = 0.1) perineal complications in Group C.
CONCLUSION
Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.
PubMed: 33578769
DOI: 10.3390/cancers13040721 -
International Journal of Surgery... Apr 2024The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of... (Meta-Analysis)
Meta-Analysis Comparative Study
BACKGROUND
The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis.
MATERIALS AND METHODS
A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated.
RESULTS
A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P =0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P =0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P =0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P =0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P =0.02) compared to APR.
CONCLUSIONS
Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.
Topics: Humans; Rectal Neoplasms; Proctectomy; Anal Canal; Treatment Outcome; Disease-Free Survival; Neoplasm Recurrence, Local
PubMed: 36928167
DOI: 10.1097/JS9.0000000000000205 -
Polski Przeglad Chirurgiczny Apr 2022<b>Introduction:</b> Perineal hernia (PH), also termed pelvic floor hernia, is a protrusion of intraabdominal viscera into the perineum through a defect in...
<b>Introduction:</b> Perineal hernia (PH), also termed pelvic floor hernia, is a protrusion of intraabdominal viscera into the perineum through a defect in the pelvic floor. </br></br> <b>Aim:</b> The study was conducted to evaluate the cases of perineal hernia resulting as a complication of abdominoperineal resection (APR) of rectal cancer. </br></br> <b> Material and methods:</b> 30 cases from 24 articles published in reputable peer reviewed journals were evaluated for eight variables including [I] patient age, [II] gender, [III] time since APR, [IV] clinical presentation, [V] approach to repair, [VI] type of repair, [VII] presence/absence of pelvic adhesions [VIII] complications. </br></br> <b>Results:</b> There was a total of 30 cases (18 males and 12 females) with a mean age of 71.5 years. The time of onset of symptoms ranged from 6 days to 12 years. Perineal lump with pain was the chief presenting feature followed by intestinal obstruction. Different approaches were adopted to repair by various methods. </br></br> <b>Conclusions:</b> Perineal hernia as a complication of abdominoperineal resection is reported increasingly nowadays, as the approach to management of rectal cancer has gradually got shifted from open to minimally invasive in recent years. There is a need to spread awareness about this condition, so that it is actively looked for, during the postoperative follow-up. Management is surgical repair; the approach and type of repair should be individualized.
Topics: Female; Male; Humans; Aged; Proctectomy; Rectal Neoplasms; Intestinal Obstruction; Abdominal Cavity; Hernia
PubMed: 36468514
DOI: 10.5604/01.3001.0015.7677 -
Journal of Surgical Oncology Jun 2019This study is a systematic review with meta-analysis designed to compare the perioperative and oncological outcomes of the abdominoperineal resection (APR) carried out... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND OBJECTIVES
This study is a systematic review with meta-analysis designed to compare the perioperative and oncological outcomes of the abdominoperineal resection (APR) carried out in the prone jack-knife position (P-APR) vs the classic lithotomy position (C-APR).
METHODS
We conducted an electronic search through PubMed utilizing the PRISMA guidelines. We included all randomized and nonrandomized studies which allowed for comparative analysis between the two groups. Research that focused on and analyzed the extralevator abdominal excision were excluded. Pooled variables and number of events were analyzed using the random-effect model.
RESULTS
The final analysis included seven nonrandomized retrospective cohorts encompassing 1663 patients. P-APR was associated with decreased operative time (OT) (DM, -43.8 minutes; P < 0.01) and estimated blood loss (EBL) (DM, 86.9 mL; P < 0.01). There were no observed differences regarding perineal wound infections (PWI) (odds ratio [OR], 0.36; P = 0.18), intraoperative perforation of rectum (IOP) (OR, 0.98; P = 0.97), circumferential resection margin (CRM) positivity (OR, 1.02; P = 0.98) or 5-year LR (OR, 1.00; P = 0.99).
CONCLUSION
The prone approach for APR is associated with decreased EBL and OT, although not with any change in the incidence of PWI or IOP. Moreover, surgical positioning per se does not appear to affect the CRM positivity rates or LR rate.
Topics: Humans; Margins of Excision; Patient Positioning; Proctectomy; Prone Position; Randomized Controlled Trials as Topic; Rectal Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 30729542
DOI: 10.1002/jso.25402 -
International Journal of Surgery... Jul 2023
Meta-Analysis
How to reasonably deal with zero-events in meta-analysis of surgery-related outcomes? Oncologic outcomes of intersphincteric resection vs. abdominoperineal resection for lower rectal cancer: a systematic review and meta-analysis.
Topics: Humans; Rectal Neoplasms; Proctectomy; Treatment Outcome; Anal Canal
PubMed: 37300885
DOI: 10.1097/JS9.0000000000000379 -
Colorectal Disease : the Official... Nov 2022The aim of this systematic review was to analyse recurrence rates after different surgical techniques for perineal hernia repair. (Meta-Analysis)
Meta-Analysis
AIM
The aim of this systematic review was to analyse recurrence rates after different surgical techniques for perineal hernia repair.
METHOD
All original studies (n ≥ 2 patients) reporting recurrence rates after perineal hernia repair after abdominoperineal resection (APR) were included. The electronic database PubMed was last searched in December 2021. The primary outcome was recurrent perineal hernia. A weighted average of the logit proportions was determined by the use of the generic inverse variance method and random effects model.
RESULTS
A total of 19 studies involving 172 patients were included. The mean age of patients was 64 ± 5.6 years and the indication for APR was predominantly cancer (99%, 170/172). The pooled percentage of recurrent perineal hernia was 39% (95% CI: 27%-52%) after biological mesh closure, 29% (95% CI: 21%-39%) after synthetic mesh closure, 37% (95% CI: 14%-67%) after tissue flap reconstruction only and 9% (95% CI: 1%-45%) after tissue flap reconstruction combined with mesh.
CONCLUSION
Recurrence rates after mesh repair of perineal hernia are high, without a clear difference between biological and synthetic meshes. The addition of a tissue flap to mesh repair seemed to have a favourable outcome, which warrants further investigation.
Topics: Aged; Humans; Middle Aged; Hernia, Abdominal; Herniorrhaphy; Perineum; Proctectomy; Surgical Mesh; Free Tissue Flaps; Recurrence; Neoplasms
PubMed: 35712806
DOI: 10.1111/codi.16224 -
Medicine Feb 2023In malnourished patients with colorectal cancer, hypoalbuminemia is common and was proposed to determine the postoperative outcome of colorectal surgery. Mounting... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In malnourished patients with colorectal cancer, hypoalbuminemia is common and was proposed to determine the postoperative outcome of colorectal surgery. Mounting articles published but have not been evaluated. We aim to assess the predictive value of preoperative hypoalbuminemia in patients undergoing colorectal surgery.
METHODS
We performed a literature search from PubMed, Euro PMC, and Cochrane with the terms serum albumin, hypoalbuminemia, prognosis, outcome, colorectal cancer, and neoplasm. We also hand-searched and included any relevant papers. Hypoalbuminemia is defined as plasma albumin level < 3.5 mg/dL. We restricted the included studies to English language and adults undergoing colectomy, laparotomy, laparoscopy, or abdominoperineal resection. Any types of articles were included, except an abstract-only publication and those that did not report the key exposure or outcome of interest. The key exposures were mortality, hospitalization time, and morbid conditions (thrombosis, surgical site infection, sepsis, and wound events). We pooled the odds ratio from each included literature as effect size. The Newcastle Ottawa scale and GRADE were used to determine the quality of each included study.
RESULTS
Hereof 7 observational studies (236,480 individuals) were included. Our meta-analysis found that preoperative hypoalbuminemia can predict the postoperative outcome in colorectal cancer patients. Individuals with hypoalbuminemia were not associated with 30-day mortality (risk ratio [RR] 2.05 [0.72, 5.86], P = .18, I2 = 99%) but were associated with morbidity (RR 2.28 [1.78, 2.93], P < .00001, I2 = 87.5%), surgical complication (RR 1.69 [1.34, 2.13], P < .00001, I2 = 98%), and hospitalization (RR 2.21 [1.93, 2.52], P < .00001, I2 = 0%). According to newcastle ottawa scale, the included studies are of moderate to sound quality.
CONCLUSIONS
The current systematic review and meta-analysis showed that preoperative hypoalbuminemia was significantly associated with morbidity, length of stay, and surgical complication but not mortality.
Topics: Adult; Humans; Hypoalbuminemia; Prognosis; Malnutrition; Colectomy; Colorectal Neoplasms; Postoperative Complications; Risk Factors
PubMed: 36827017
DOI: 10.1097/MD.0000000000032938 -
Familial Cancer Oct 2022Desmoid tumours (DT) are one of the main causes of death in patients with familial adenomatous polyposis (FAP). Surgical trauma is a risk factor for DT, yet a colectomy... (Meta-Analysis)
Meta-Analysis Review
Desmoid tumours (DT) are one of the main causes of death in patients with familial adenomatous polyposis (FAP). Surgical trauma is a risk factor for DT, yet a colectomy is inevitable in FAP to prevent colorectal cancer. This systematic review and meta-analysis aimed to synthesize the available evidence on DT risk related to type, approach and timing of colectomy. A search was performed in MEDLINE, EMBASE and the Cochrane Library. Studies were considered eligible when DT incidence was reported after different types, approaches and timing of colectomy. Twenty studies including 6452 FAP patients were selected, all observational. No significant difference in DT incidence was observed after IRA versus IPAA (OR 0.99, 95% CI 0.69-1.42) and after open versus laparoscopic colectomy (OR 0.88, 95% CI 0.42-1.86). Conflicting DT incidences were seen after early versus late colectomy and when analysing open versus laparoscopic colectomy according to colectomy type. Three studies reported a (non-significantly) higher DT incidence after laparoscopic IPAA compared to laparoscopic IRA, with OR varying between 1.77 and 4.09. A significantly higher DT incidence was observed in patients with a history of abdominal surgery (OR 3.40, 95% CI 1.64-7.03, p = 0.001). Current literature does not allow to state firmly whether type, approach, or timing of colectomy affects DT risk in FAP patients. Fewer DT were observed after laparoscopic IRA compared to laparoscopic IPAA, suggesting laparoscopic IRA as the preferred choice if appropriate considering rectal polyp burden. PROSPERO REGISTRATION NUMBER: CRD42020161424.
Topics: Humans; Fibromatosis, Aggressive; Colectomy; Adenomatous Polyposis Coli; Laparoscopy; Incidence; Proctocolectomy, Restorative
PubMed: 35022961
DOI: 10.1007/s10689-022-00288-y -
Inflammatory Bowel Diseases Oct 2022Perianal Crohn's disease (pCD) is a potentially severe phenotype of CD. We conducted a systematic review with meta-analysis to estimate cumulative incidence, risk... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND AIMS
Perianal Crohn's disease (pCD) is a potentially severe phenotype of CD. We conducted a systematic review with meta-analysis to estimate cumulative incidence, risk factors, and outcomes of pCD in population-based cohort studies.
METHODS
Through a systematic literature review through March 1, 2021, we identified population-based inception cohort studies reporting cumulative incidence of perianal disease (primarily abscess and/or fistula) in patients with CD. We estimated the cumulative incidence of pCD at presentation and 1-, 5-, and 10-year follow-up, and risk factors for perianal disease and outcomes including risk of major (bowel resection, proctectomy, ostomy) and minor perianal (incision and drainage, seton placement, etc.) surgery.
RESULTS
In 12 population-based studies, prevalence of pCD was 18.7% (95% confidence interval [CI], 12.5%-27.0%) with 1-, 5-, and 10-year risk of perianal disease being 14.3% (95% CI, 7.9%-24.6%), 17.6% (95% CI, 11.3%-26.5%), and 18.9% (95% CI, 15.0%-23.4%), respectively. Approximately 11.5% of patients (95% CI, 6.7%-19.0%) had perianal disease at or before CD diagnosis. Colonic disease location and rectal involvement were associated with higher risk of pCD. Overall, 63.3% of patients (95% CI, 53.3-72.3) required minor perianal surgery and 6.4% of patients (95% CI, 1.8%-20.6%) required major abdominal surgery for pCD. Use of biologic therapy for pCD is common and has steadily increased throughout the years.
CONCLUSIONS
Approximately 1 in 5 patients with CD develops perianal disease within 10 years of CD diagnosis, including 11.5% who have perianal disease at presentation. Approximately two-thirds of patients require perianal surgery, with a smaller fraction requiring major abdominal surgery.
Topics: Cohort Studies; Crohn Disease; Humans; Incidence; Proctectomy; Rectal Fistula; Treatment Outcome
PubMed: 34792604
DOI: 10.1093/ibd/izab287