Cherry E. Koh

Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes.

The management of primary rectal cancer beyond total mesorectal excision planes (PRC‐bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority.

Systematic review of randomized controlled trials of the effectiveness of biofeedback for pelvic floor dysfunction

Pelvic floor dysfunction (PFD) is a type of functional constipation. The effectiveness of biofeedback as a treatment remains unclear.

Quality of life and other patient-reported outcomes following exenteration for pelvic malignancy

Pelvic exenteration is highly radical surgery offering the only potential cure for locally advanced pelvic cancer. This study compared quality of life and other relevant patient‐reported outcomes over 12 months for patients who did and those who did not undergo pelvic exenteration.

Management of deeply infiltrating endometriosis involving the rectum.

BACKGROUND: Rectal endometriosis can cause debilitating symptoms. Rectal resection in this setting has been shown to improve symptoms; however, there remain some reservations about this intervention because of the risk of complications such as anastomotic leak and rectovaginal fistula. OBJECTIVE: The aim of this study is to review our experience with rectal resection in patients with rectal endometriosis. DATA SOURCES: Hospital records and prospectively maintained electronic databases of an endogynecologist and colorectal surgeon were reviewed. STUDY SELECTION: This is a retrospective study of consecutive patients who underwent rectal resection for endometriosis from 2001 to 2010. INTERVENTIONS: All patients underwent either disc or segmental resection of the rectum. MAIN OUTCOME MEASURES: Outcomes of interest were operative complications and recurrence requiring surgical reintervention. RESULTS: Ninety-one patients underwent 92 resections for endometriosis. Sixty-five (71%) were disc resections, 25 (27%) were segmental resections, and 1 patient underwent both disc and segmental resections. Eighty-one (88%) procedures were completed laparoscopically. Patients requiring segmental resection had more extensive disease, and this was associated with open conversion (p ⩽ 0.0001). Average duration of procedure was 209 minutes. Three patients (3%) required defunctioning ileostomies. Intramural endometriosis was confirmed in 96.7% of specimens. Complications occurred in 13 patients (15%); 4 were minor. Three patients had small pelvic collections treated with antibiotics, 5 patients required transfusion for bleeding (3 intraoperative, 2 anastomotic bleeds that settled conservatively), and 1 patient sustained ureteric injury that was reimplanted with no sequelae. None had anastomotic leak or rectovaginal fistula. Ten patients (11%) required reintervention for recurrent symptoms. Of these, 8 (8.8%) patients were found to have recurrent endometriosis. No correlation could be found between involved margins on pathology and need for redo surgery. LIMITATIONS: This study is limited by its retrospective nature. CONCLUSIONS: Laparoscopic rectal resection for deeply infiltrative endometriosis is feasible and safe, and it provides durable symptom control with acceptable recurrence rates.

The Outcomes and Patterns of Treatment Failure After Surgery for Locally Recurrent Rectal Cancer

Objective: To assess the outcomes and patterns of treatment failure of patients who underwent pelvic exenteration surgery for recurrent rectal cancer. Background: Despite advances in the management of rectal cancer, local recurrence still occurs. For appropriately selected patients, pelvic exenteration surgery can achieve long-term disease control. Methods: Prospectively maintained databases of 5 high volume institutions for pelvic exenteration surgery were reviewed and data combined. We assessed the combined endpoints of overall 5-year survival, cancer-specific 5-year mortality, local recurrence, and the development of metastatic disease. Results: Five hundred thirty-three patients who had undergone surgery for locally recurrent rectal cancer were identified. Five-year cancer-specific survival for patients with a complete (R0) resection is 44%, which was achieved in 59% of patients. For those with R1 and R2 resections, the 5-year survival was 26% and 10%, respectively. Radical resection required sacrectomy in 170 patients (32%), and total cystectomy in 105 patients (20%). Treatment failure included local recurrence alone in 75 patients (14%) and systemic metastases with or without local recurrence in 226 patients (42%). Chemoradiotherapy before exenteration was associated with a significant (P < 0.05) improvement in overall 5-year cancer-specific survival for those patients with an R0 resection. Postoperative chemotherapy did not alter outcomes. Conclusions: R0 resection of the pelvic recurrence is the most significant factor affecting overall and disease-free survival. The surgery is complex and often highly morbid, and where possible patients should be given perioperative chemoradiotherapy. Further investigations are required to determine the role of adjuvant chemotherapy.

Neoadjuvant chemotherapy with FOLFOX: improved outcomes in Chinese patients with locally advanced gastric cancer.

Although the role of peri‐operative chemotherapy is established in the treatment of locally advanced gastric cancer, the optimal regime remains to be determined. FOLFOX has been used in palliative setting with good response rates but its role in a neoadjuvant setting is not well established.

Myenteric plexitis at the proximal resection margin is a predictive marker for surgical recurrence of ileocaecal Crohn's disease

Identifying predictors for the recurrence of Crohns disease (CD) after surgery to improve disease surveillance or targeted therapy is rational. The purpose of this study was to examine the relationship between myenteric plexitis (MP) and clinical or surgical recurrence.

Outcomes After En Bloc Iliac Vessel Excision and Reconstruction During Pelvic Exenteration.

BACKGROUND: Advanced pelvic cancers involving the lateral pelvic compartment, and particularly the iliac vasculature, are difficult to manage. Common or external iliac vessel involvement has traditionally been considered a contraindication for curative surgery. OBJECTIVE: The purpose of this study was to investigate pathological and surgical outcomes, particularly postoperative morbidity of pelvic exenteration with en bloc major iliac vascular excision and reconstruction. DESIGN: This study was a case series. SETTINGS: The study was conducted at a quaternary referral center for pelvic exenteration in Sydney. PATIENTS: Patients included those undergoing en bloc iliac vessel excision as part of their pelvic exenteration for a locally advanced pelvic malignancy. MAIN OUTCOME MEASURES: Over the study period, 336 patients underwent pelvic exenteration. Twenty-one patients (6.3%) underwent en bloc vascular excision of 29 vessels for tumor involvement. Twenty-four vessels required reconstruction. The primary outcomes were postoperative complications and pathologic outcomes. Survival rates were estimated using the Kaplan-Meier technique. RESULTS: Operating time for patients who underwent vascular excision and reconstruction was longer, but this did not reach significance (631 vs 531 minutes; p = 0.052). Mean blood loss was significantly higher in the vascular excision and reconstruction group (6.8 vs 3.4 L; p < 0.001). Patients who required en bloc vascular excision were less likely to have R0 margins compared with patients who did not (38% vs 78%; p < 0.001). There was no intraoperative or 30-day mortality. Overall graft patency and limb loss at 1 year were 96% and 0%. A total of 52% of patients had at least 1 vascular related complication. Median overall and disease-free survival times were 34 and 26 months. LIMITATIONS: This study is limited by a relatively small number of heterogeneous patients. CONCLUSIONS: En bloc vascular resection and reconstruction for contiguous tumor involvement is feasible and safe in selected patients. Advanced pelvic tumors involving iliac vessels should not be precluded from curative surgery in specialized institutions.

Preservation or division of the intercostobrachial nerve in axillary dissection for breast cancer: Meta-analysis of Randomised Controlled Trials

PURPOSE Management of the ICBN during axillary dissection is controversial and the division of ICBN is often trivialised. The effect of dividing the ICBN, and its association with sensory disturbance, is unclear. A systematic review and meta-analysis was performed to evaluate the effect of preserving the ICBN during axillary dissection. METHODS A systematic literature review and meta-analysis is performed according to the PRISMA and Cochrane Collaboration guidelines. RESULTS Three RCTs and four non-RCTs were reviewed. A meta-analysis demonstrated that the incidence of sensory disturbance was significantly lower with preservation of ICBN compared to division of the ICBN with Mantel-Haenzel combined odds ratio 0.31 (0.17-0.57, 95% CI). There was relatively low level of heterogeneity (I(2) = 19%, χ(2) = 2.48, df = 2). The sensory disturbance was more likely to be hyposensitivity when compared to hypersensitivity (p < 0.0001). No difference on number of lymph nodes dissected or operating time was noted. CONCLUSION This meta-analysis demonstrates that division of the ICBN is associated with higher risk of sensory disturbance, and that the nature of this sensory disturbance is more likely to be hyposensitivity, attributable to reduced nerve function.

Clinical algorithms for the diagnosis and management of urological leaks following pelvic exenteration.

BACKGROUND Urine leak following pelvic exenteration for locally advanced pelvic malignancy is a major complication leading to increased mortality, morbidity and length of stay. We reviewed our experience and developed a diagnostic and management algorithm for urine leaks in this patient population. METHODS Consecutive patients who underwent en bloc cystectomy and conduit formation as part of pelvic exenteration at a single quaternary referral centre from 1995 to 2012 were reviewed. Patients with urine leak were identified. Medical records were reviewed to extract data on diagnosis and management and a suggested clinical algorithm was developed. RESULTS Of 325 exenterations, there were 102 conduits, of which 15 patients (15%) developed a conduit related urine leak. Most (14/15) patients were symptomatic. Diagnosis was made by drain creatinine studies (12/15) and/or imaging (15/15). Management comprised of conservative management, radiologic urinary diversion, early surgical revision and late surgical revision in 3, 11, 2 and 1 patients respectively. Important lessons from our 17 year experience include a high index of suspicion in a patient who is persistently septic despite appropriate treatment, the importance of regular drain creatinine studies, CT (computer tomography) with delayed images (CT intravenous pyelogram) when performing a CT for investigation of sepsis and early aggressive management with radiologic urinary diversion to facilitate early healing. CONCLUSION Urine leak after pelvic exenteration is a complex problem. Conservative management usually fails and early diagnosis and intervention is the key. It is hoped that our algorithms will facilitate diagnosis and subsequent management of this group of patients.