BJS Open. 2019 Feb 28;3(3):403-414. doi: 10.1002/bjs5.50138. eCollection 2019 Jun.
Background: End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection.
Methods: This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model.
Results: In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001).
Conclusion: Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone.
Background: Many data suggest that patients with low rectal adenocarcinoma who achieved ypT0N0 status have improved survival and disease-free survival (DFS) compared to all other stages however only few data are available regarding the specific prognosis factors of this subgroup. This study aimed to evaluate predictive factors for disease free survival after complete pathological response (CPR) in cases of low rectal adenocarcinoma.
Materials and methods: From January 2005 to December 2013, all patients with low rectal adenocarcinoma who underwent neoadjuvant chemoradiotherapy followed by total mesorectal excision and achieved CPR were included at 7 Moroccan and 1 Algerian centres. Predictive factors for disease-free survival were analysed by uni and multivariate analysis.
Results: Eigthy-four (12.1%) patients achieved a CPR (ypT0N0). Multivariate analysis revealed that both poorly differentiated tumors (OR, 9.23; 95 CI 1.35-62.82; P = 0.023) and the occurrence of perineal sepsis (OR, 13.51; 95 CI 1.96-93.12; P = 0.008) were independently associated with impaired DFS.
Conclusions: Patients with low rectal cancer who exhibited a CPR after neoadjuvant therapy have good prognoses; however, the occurrence of perineal sepsis and/or poor initial differentiation may be associated with impaired DFS in these patients.
Trial registration: The study was retrospectively registered the 28th July 2018 in ClinicalTrials.gov register with the reference NCT03601689.
Keywords: Complete pathological response; Disease-free survival; Neoadjuvant treatment; Predictive factors; Rectal neoplasm.
The mainstay of management for locally advanced rectal cancer is chemoradiotherapy followed by surgical resection. Following chemoradiotherapy, a complete response may be detected clinically and radiologically (cCR) prior to surgery or pathologically after surgery (pCR). We aim to report the overall complete pathological response (pCR) rate and the reliability of detecting a cCR by conventional pre-operative imaging.
A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients treated by elective rectal resection were included. A pCR was defined as a ypT0 N0 EMVI negative primary tumour; a partial response represented any regression from baseline staging following chemoradiotherapy. The primary endpoint was the pCR rate. The secondary endpoint was agreement between post-treatment MRI restaging (yMRI) and final pathological staging.
Of 2572 patients undergoing rectal cancer surgery in 277 participating centres across 44 countries, 673 (26.2%) underwent chemoradiotherapy and surgery. The pCR rate was 10.3% (67/649), with a partial response in 35.9% (233/649) patients. Comparison of AJCC stage determined by post-treatment yMRI with final pathology showed understaging in 13% (55/429) and overstaging in 34% (148/429). Agreement between yMRI and final pathology for T-stage, N-stage, or AJCC status were each graded as ‘fair’ only (n = 429, Kappa 0.25, 0.26 and 0.35 respectively).
The reported pCR rate of 10% highlights the potential for non-operative management in selected cases. The limited strength of agreement between basic conventional post-chemoradiotherapy imaging assessment techniques and pathology suggest alternative markers of response should be considered, in the context of controlled clinical trials.
PMID: 30255641 / DOI: 10.1111/codi.14361
Colorectal Dis. 2018 Sep;20 Suppl 6:33-46. doi: 10.1111/codi.14376.
Transanal total mesorectal excision (TaTME) has rapidly emerged as a novel approach for rectal cancer surgery. Safety profiles are still emerging and more comparative data is urgently needed. This study aimed to compare indications and short-term outcomes of TaTME, open, laparoscopic, and robotic TME internationally.
A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients undergoing elective total mesorectal excision (TME) for malignancy between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak.
Of 2579 included patients, 76.2% (1966/2579) underwent TME with restorative anastomosis of which 19.9% (312/1966) had a minimally invasive approach (laparoscopic or robotic) which included a transanal component (TaTME). Overall, 9.0% (175/1951, 15 missing outcome data) of patients suffered an anastomotic leak. On univariate analysis both laparoscopic TaTME (OR 1.61, 1.02-2.48, P = 0.04) and robotic TaTME (OR 3.05, 1.10-7.34, P = 0.02) were associated with a higher risk of anastomotic leak than non-transanal laparoscopic TME. However this association was lost in the mixed-effects model controlling for patient and disease factors (OR 1.23, 0.77-1.97, P = 0.39 and OR 2.11, 0.79-5.62, P = 0.14 respectively), whilst low rectal anastomosis (OR 2.72, 1.55-4.77, P < 0.001) and male gender (OR 2.29, 1.52-3.44, P < 0.001) remained strongly associated. The overall positive circumferential margin resection rate was 4.0%, which varied between operative approaches: laparoscopic 3.2%, transanal 3.8%, open 4.7%, robotic 1%.
This contemporaneous international snapshot shows that uptake of the TaTME approach is widespread and is associated with surgically and pathologically acceptable results.
PMID: 30255642 / DOI: 10.1111/codi.14376
Colorectal Dis. 2018 Sep;20 Suppl 6:15-32. doi: 10.1111/codi.14362.
The optimal bowel preparation strategy to minimise the risk of anastomotic leak is yet to be determined. This study aimed to determine whether oral antibiotics combined with mechanical bowel preparation (MBP+Abx) was associated with a reduced risk of anastomotic leak when compared to mechanical bowel preparation alone (MBP) or no bowel preparation (NBP).
A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 Left Sided Colorectal Resection audit was performed. Patients undergoing elective left sided colonic or rectal resection with primary anastomosis between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak.
Of 3676 patients across 343 centres in 47 countries, 618 (16.8%) received MBP+ABx, 1945 MBP (52.9%) and 1099 patients NBP (29.9%). Patients undergoing MBP+ABx had the lowest overall rate of anastomotic leak (6.1%, 9.2%, 8.7% respectively) in unadjusted analysis. After case-mix adjustment using a mixed-effects multivariable regression model, MBP+Abx was associated with a lower risk of anastomotic leak (OR 0.52, 0.30-0.92, P = 0.02) but MBP was not (OR 0.92, 0.63-1.36, P = 0.69) compared to NBP.
This non-randomised study adds ‘real-world’, contemporaneous, and prospective evidence of the beneficial effects of combined mechanical bowel preparation and oral antibiotics in the prevention of anastomotic leak following left sided colorectal resection across diverse settings. We have also demonstrated limited uptake of this strategy in current international colorectal practice.
PMID: 30255646 / DOI: 10.1111/codi.14362
Dahiri M, Salmi N, Ahallat A, El Bahaoui N, Belkouchi O, Souadka A, Majbar A, Benkabbou A, Bougtab A, Mohsine R.
AME Case Rep. 2018 Jun 14;2:31. doi: 10.21037/acr.2018.06.01. eCollection 2018.
Cervical cancer is the second most common cancer and the third cause of cancer death in women. Radiotherapy occupies a prominent place in the therapeutic arsenal of cervical cancer in localized stages. Radiation induced secondary cancer is an entity that has been well described in the literature. We report a case of a rectal adenocarcinoma occurring in a woman previously treated by radiotherapy and brachytherapy for a squamous cell carcinoma of the cervix.
Rectal cancer; cervical cancer; radiation induced cancer; secondary cancer
Awab A(1), El Mansoury D, Benkabbou A, Elmoussaoui R, Elhijri A, Alilou M, Azzouzi A.
(1)Surgery Intensive Care Unit, Ibn Sina Teaching Hospital, Rabat, Morocco.
PMID: 21689335 [Indexed for MEDLINE]
Colorectal Dis. 2012 Feb;14(2):e76. doi: 10.1111/j.1463-1318.2011.02654.x.
Dumont F(1), Souadka A, Goéré D, Lasser P, Elias D.
(1)Department of Surgery, Institut Gustave Roussy Cancer Center, Villejuif, France. firstname.lastname@example.org
BACKGROUND: Abdominoperineal resections (APR) for anorectal tumors are associated with a high rate of perineal wound complications. The aim of this study was to evaluate the impact of pseudocontinent perineal colostomy (PPC) following APR on perineal wound healing.
METHODS: All patients undergoing APR between 2000 and 2009 were retrospectively reviewed. Perineal wound healing was compared between patients with PPC and those with perineal closure alone.
RESULTS: APR was performed in 132 patients, including 31 with PPC and 101 with no PPC. Risk factors such as radiotherapy, smoking, diabetes mellitus, and obesity were not different between the two groups. The PPC group had significantly fewer cases of omentoplasty and adenocarcinoma histology. The overall perineal complication rate, perineal infection, or wound dehiscence was similar in the two groups, but the perineal healing rate at 6 and 12 weeks was significantly increased in the PPC group than in the non-PPC group (70.9% vs. 50%, P = 0.04, at 6 weeks; 90.3% vs. 73%, P = 0.04, at 12 weeks).
CONCLUSIONS: PPC accelerates perineal wound healing after APR without decreasing the overall perineal complication rate.
Copyright © 2011 Wiley Periodicals, Inc.
PMID: 21953024 [Indexed for MEDLINE]
J Surg Oncol. 2012 Jun 1;105(7):628-31. doi: 10.1002/jso.22105. Epub 2011 Sep 22.
Honoré C(1), Goéré D, Souadka A, Dumont F, Elias D.
(1)Department of Surgical Oncology, Institut Gustave Roussy, Cancer Center, Villejuif, France. email@example.com
Comment in Eur J Surg Oncol. 2016 Jun;42(6):836-40.
BACKGROUND: In colorectal cancer, complete cytoreductive surgery associated with hyperthermic intraperitoneal chemotherapy achieves encouraging results in early peritoneal carcinomatosis (PC), but this early detection can only be accurately accomplished during a systematic second-look surgery. This costly and invasive approach can only be proposed to selected patients. The objective of this study was to identify risk factors predictive of developing PC after curative surgery for colorectal cancer.
METHODS: After a systematic review of the literature published between 1940 and 2011, all clinical studies reporting the incidence of PC after curative surgery for colorectal cancer were searched for factors associated with the primary tumor that were likely to influence the incidence of recurrent PC.
RESULTS: Sixteen clinical studies were considered informative, all nonrandomized, three prospective and 13 retrospective, including 4-395 patients. Overall, the methodological quality of the reported studies was low. Data were available for the following factors: synchronous PC, synchronous ovarian metastases, perforated primary tumor, serosal and/or adjacent organ invasion, histological subtype, and positive peritoneal cytology with reported incidences of recurrent PC between 8 and 75%. No study was found that mentioned an impact of lymph node invasion, tumor location, laparoscopy, occlusive tumors, or bleeding tumor on recurrent PC.
CONCLUSIONS: Evidence regarding the incidence of recurrent PC after curative surgery for colorectal cancer is poor. Emerging data indicate three situations that could result in a real higher risk of recurrent PC: synchronous PC, synchronous isolated ovarian metastases, and a perforated primary tumor.
PMID: 23090572 [Indexed for MEDLINE]
Ann Surg Oncol. 2013 Jan;20(1):183-92. doi: 10.1245/s10434-012-2473-5. Epub 2012 Oct 23.