Christos Kontovounisios

Complete mesocolic excision in colorectal cancer: a systematic review.

AIM Several studies have suggested an increased lymph node yield, reduced locoregional recurrence and increased disease-free survival after complete mesocolic excision (CME) for colorectal cancer. This review was undertaken to assess the use of CME for colon cancer by evaluating the technique and its clinical outcome. METHOD A literature search of publications was performed using PubMed and Medline. Only studies published in English were included. Studies assessed for quality and data were extracted by two independent reviewers. End-points included number of lymph nodes per patient, quality of the plane of mesocolic excision, postoperative mortality and morbidity, 5-year locoregional recurrence and 5-year cancer-specific survival. RESULTS There were 34 articles comprising 12 retrospective studies, nine prospective studies and 13 original articles including case series, observational studies and editorials. Of the prospective studies, four reported an increased lymph node harvest and a survival benefit. The others reported an improvement in the quality of the specimen as assessed by histopathological examination. Laparoscopic CME has the same oncological outcome as open surgery but completeness of excision during laparoscopy may be compromised for tumours in the transverse colon. CONCLUSION Studies demonstrate that CME removes significantly more tissue around the tumour including maximal lymph node clearance. There is little information on serious adverse events after CME and a long-term survival benefit has not been proved.

A systematic review of sacral nerve stimulation for low anterior resection syndrome

The efficacy of sacral nerve stimulation (SNS) in low anterior resection syndrome (LARS) is largely undocumented. A review of the literature was carried out to study this question.

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.

A Systematic Review to Assess Resection Margin Status After Abdominoperineal Excision and Pelvic Exenteration for Rectal Cancer.

Objective: The aim of this study was to assess resection margin status and its impact on survival after abdominoperineal excision and pelvic exenteration for primary or recurrent rectal cancer. Summary of Background Data: Resection margin is important to guide therapy and to evaluate patient prognosis. Methods: A meta-analysis was performed to assess the impact of resection margin status on survival, and a regression analysis to analyze positive resection margin rates reported in the literature. Results: The analysis included 111 studies reporting on 19,607 participants after abdominoperineal excision, and 30 studies reporting on 1326 participants after pelvic exenteration. The positive resection margin rates for abdominoperineal excision were 14.7% and 24.0% for pelvic exenteration. The overall survival and disease-free survival rates were significantly worse for patients with positive compared with negative resection margins after abdominoperineal excision [hazard ratio (HR) 2.64, P < 0.01; HR 3.70, P < 0.01, respectively] and after pelvic exenteration (HR 2.23, P < 0.01; HR 2.93, P < 0.01, respectively). For patients undergoing abdominoperineal excision with positive resection margins, the reported tumor sites were 57% anterior, 15% posterior, 10% left or right lateral, 8% circumferential, 10% unspecified. A significant decrease in positive resection margin rates was identified over time for abdominoperineal excision. Although positive resection margin rates did not significantly change with the size of the study, some small size studies reported higher than expected positive resection margin rates. Conclusions: Resection margin status influences survival and a multidisciplinary approach in experienced centers may result in reduced positive resection margins. For advanced anterior rectal cancer, posterior pelvic exenteration instead of abdominoperineal excision may improve resection margins.

Adoption and success rates of perineal procedures for fistula-in-ano: a systematic review

Several sphincter‐preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula.

Modified right colon inversion technique as a salvage procedure for colorectal or coloanal anastomosis

A tension‐free well vascularized colorectal or coloanal anastomosis is not always possible following rectal or sigmoid resection. The study reports on the short‐term and long‐term outcome of a modified right colon inversion technique as a means of facilitating a low colorectal or coloanal anastomosis.

An Extremely Rare Small Bowel Lesion Associated With Refractory Ascites

Question: An 81-year-old man presented with a 6-month history of a 20-kg weight loss associated with increased abdominal istention. He complained about crampy abdominal pain, anorexia, constipation, and bilateral lower limb edema. He had an therwise unremarkable medical history. Clinically, he had abdominal distention, normal temperature, and no lymphadenopthy. An extensive workup was performed. Laboratory blood results revealed normocytic anemia and hypoalbuminemia, ith normal liver and renal function tests. Hepatitis virus panel and tumor markers were within normal ranges. Upper and ower gastrointestinal endoscopy revealed only uncomplicated sigmoid diverticular disease. Computed tomography of the bdomen revealed the presence of severe ascites, thickening of the terminal ileum, and distension of the rest of the small bowel. here was no obvious lymphadenopathy or other pathology from the visceral organs (Figure A). A diagnostic paracentesis of the ascites showed low serum ascites albumin gradient. The fluid was sent for cytology, full biochemistry, and microbiology. The Gram stain and cytopathology did not reveal any abnormality. The patient had also a negative test for tuberculosis. Intraoperatively, we found a large amount of serous ascites with some mucinous and gelatinous material in the pelvis. The last 30 cm of terminal ileum had markedly thickened wall without gross serosal lesions or signs of perforation. There was no mesenteric lymphadenopathy. The cecum was distorted and there was a perforation in the base of a grossly normal appendix which was surrounded by deposits of mucus. We proceeded with right hemicolectomy along with en-block resection of the involved part of the terminal ileum (Figure B). On pathology, the mucosa of the ileum was grossly edematous and congested, causing almost complete obstruction of the lumen. Thick wall dilated vessels were present in the lamina propria (Figure C). By elastin staining, veins seemed more rominent than their accompanying arteries and had markedly narrowed lumen. Signs of lymphocytic phlebitis were not resent (Figure D). The appendix exhibited mostly villous adenomatous changes with some degree of epithelial atypia and arked distension of the lumen. Perforation resulted in dissemination of mucoid material in the peritoneal cavity (Figure E). The patient had an uncomplicated postoperative period and was referred for an oncologic consultation. What is the diagnosis of the terminal ileal narrowing?

Incidental findings in focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients: speaking about cost to benefit.

BACKGROUND The purpose of this study was to identify which age-related groups of hemodynamically stable blunt trauma patients will present a positive cost-to-benefit ratio, in regard to the screening of incidental findings on Focused Assessment with Sonography for Trauma (FAST). METHODS We conducted a prospective study using retrospective data taken from the trauma registry of 6,041 consecutive hemodynamically stable blunt trauma patients who underwent FAST at our Level I urban trauma hospital during the year 2009. A receiver operating characteristic curve was used to determine whether age level is useful in detecting organ-/system-specific incidental findings in trauma patients undergoing FAST and to establish the required diagnostic cutoff value of this selected test. A cost-benefit analysis was then performed for the age-specific cutoff values of each organ/system evaluated by FAST. RESULTS We found 522 incidental findings in 468 patients (7.8%). Further diagnostic workup was instructed in 35% (168 of 468) of patients with incidental findings. The cost-benefit analysis for the age-specific cutoff values found in the receiver operating characteristic curve analysis showed that the project of screening for incidental findings on FAST was viable only when the ultrasound operator additionally searches the liver/biliary tree (≥43 years) and the kidneys (≥56 years). CONCLUSIONS A systematic examination of the liver and biliary tree and both kidneys of specific age groups during FAST screening of hemodynamically stable blunt trauma patients may disclose a potentially unknown pathology with a positive cost-to-benefit ratio.

Surgical and Survival Outcomes Following Pelvic Exenteration for Locally Advanced Primary Rectal Cancer: Results from an International Collaboration

Objective: The aim of the study was to analyze data from an international collaboration, and ascertain prognostic indicators that inform clinical decision-making and practices regarding the role of pelvic exenteration for locally advanced primary rectal cancer (LARC). Background: With improved national screening programs fewer patients present with LARC. Despite this, select cohorts of patients require pelvic exenteration. To date, the majority of outcome data are from single-center series. Methods: Anonymized data from 14 countries on patients who had pelvic exenteration for LARC between 2004 and 2014 were accumulated. The primary endpoint was overall survival. The impact of resection margin, nodal status, bone resection, and use of neoadjuvant therapy (before exenteration) on survival was evaluated using multivariable analysis. Results: Of 1291 patients, 778 (60.3%) were male with a median (range) age of 63 (18–90) years; 78.1% received neoadjuvant therapy. Bone resection en bloc was performed in 8.2% of patients (n = 106), and 22.6% (n = 292) had resection combined with flap reconstruction. Negative resection margin (R0 resection) was achieved in 79.9%. The 30-day postoperative mortality was 1.5%. The median overall survival following R0, R1, and R2 resection was 43, 21, and 10 months (P < 0.001) with a 3-year survival of 56.4%, 29.6%, and 8.1%, respectively (P < 0.001); 37.8% of patients experienced one or more major complication. Neoadjuvant therapy increased the risk of 30-day morbidity (P < 0.012). Multivariable analysis identified resection margin and nodal status as significant determinants of overall survival (other than advanced age). Conclusions: Attainment of negative resection margins (R0) is the key to survival. Neoadjuvant therapy may improve survival; however, it does so at the increased risk of postoperative morbidity.

Selection process can improve the outcome in locally advanced and recurrent colorectal cancer: activity and results of a dedicated multidisciplinary colorectal cancer centre.

There is wide disparity in the care of patients with multivisceral involvement of rectal cancer. The results are presented of treatment of advanced and recurrent colorectal cancer from a centre where a dedicated multidisciplinary team (MDT) is central to the management.