Luis R. Taveras

Current Trends in the Rate of Rectal Cancer Restorative Operations in the Era of Neoadjuvant Chemoradiation

Purpose of ReviewThe following review addresses the relationship between neoadjuvant chemoradiotherapy and the rate of restorative operations in patients with rectal cancer.Recent FindingsThe rate of restorative operations performed for rectal cancer has improved over the past several decades. The relationship between this increase and the addition of neoadjuvant chemoradiotherapy to the treatment regimen for locally advanced rectal cancer is still being defined. Improved rates of sphincter-sparing procedures between patients who receive preoperative chemoradiation compared to those who receive treatment postoperatively have not been supported in the literature. The patients who seem to benefit from neoadjuvant therapy in terms of sphincter preservation are those with distal tumors. Better tumor response to neoadjuvant chemotherapy and longer interval to surgical intervention appear to have little if any benefit to preserving the sphincter.SummaryIncreased rates of restorative operations for rectal cancer seem to be most significant among distal tumors. The reasons for the increase are likely multifactorial and include improvements in patient selection, surgical technique, imaging modalities, and patient care. The role of neoadjuvant chemoradiotherapy in this setting remains equivocal.

Can We Reliably Predict a Clinical Complete Response in Rectal Cancer? Current Trends and Future Strategies

Purpose of ReviewPrediction of clinical complete response is pivotal in the management of patients with rectal cancer. The ability to determine tumor response to neoadjuvant therapy in rectal cancer might guide subsequent treatment modalities. We review the current literature on predictors of complete response after neoadjuvant for rectal cancer with an emphasis of clinical complete response rather than pathological complete response.Recent FindingsClinical and radiological findings have been used to predict response, as well as a myriad of biomarkers. There is limited evidence validating most of these strategies. The role of imaging in defining tumor response has been assessed retrospectively. The TRIGGER trial is a randomized trial that will evaluate stratified management of rectal cancer based on their tumor regression grade.SummaryThe management of locally advanced rectal cancer is evolving. The ability to predict clinical complete response in patients that have undergone neoadjuvant chemoradiation will allow us to select potential patients that can benefit from a “watch and wait” strategy. Identifying patients that will have a complete response will result in decreased surgical overtreatment, favoring organ-sparing strategies. Treatment individualization will require further research. Emphasis should be made in validating prediction markers; these should be cost-effective and of minimally invasive retrieval. Surveillance protocols to assess for tumor regrowth are yet to be determined.

A case report of a de Garengeot hernia in a nonagenarian veteran

Highlights • A hernia containing the vermiform appendix [de Garengeot hernia (DGH)] is an exceedingly rare event.• Most cases of DGH are made during inguinal exploration.• In the present report, we discuss a patient who underwent an operation which revealed a DGH with appendicitis.• This case is unusual because it occurred in a nonagenarian male veteran patient.• The unique aspect of this case is that it was performed in its entirety under local anesthetic.

Burn Surgeon and Palliative Care Physician Attitudes Regarding Goals of Care Delineation for Burned Geriatric Patients

Palliative care specialists (PCS) and burn surgeons (BS) were surveyed regarding: 1) importance of goals of care (GoC) conversations for burned seniors; 2) confidence in their own specialtys ability to conduct these conversations; and 3) confidence in the ability of the other specialty to do so. A 13-item survey was developed by the steering committee of a multicenter consortium dedicated to palliative care in the injured geriatric patient and beta-tested by BS and PCS unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Burn Association and American Academy for Hospice and Palliative Medicine. Forty-five BS (7.3%) and 244 PCS (5.7%) responded. Palliative physicians rated being more familiar with GoC, were more comfortable having a discussion with laypeople, were more likely to have reported high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to BS. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so. BS favored leading team discussions, whereas palliative specialists preferred jointly led discussions. Both groups agreed that discussions should occur within 72 hours of admission. Both groups believe themselves to conduct GoC discussions for burned seniors better than the other specialty perceived them to do so, which led to disparate views on perceptions for the optimal leadership of these discussions.

Clinical and molecular diagnosis of pathologic complete response in rectal cancer: an update

ABSTRACT Introduction: The standard of care for locally advanced rectal cancer includes neoadjuvant chemoradiation with subsequent total mesorectal excision. This approach has shown various degrees of response to neoadjuvant chemoradiation (ranging from complete response to further tumor growth), which have substantial prognostic and therapeutic implications. A total regression of the tumor is a predictor of superior oncologic outcomes compared with partial responders and non-responders. Further, this concept has opened the possibility of nonoperative strategies for complete responders and explains the widespread research interest in finding clinical, radiographic, pathologic, and biochemical parameters that allow for identification of these patients. Areas covered: The present review evaluates the most recent efforts in the literature to identify predictors of patients likely to achieve a complete response following neoadjuvant treatment for the management of rectal cancer. This includes clinical predictors of pathologic complete response such as tumor location, size, and stage, molecular predictors such as tumor biology and microRNA, serum biomarkers such as carcinoembryogenic antigen and nomograms. Expert commentary: There has been significant progress in our ability to predict pathological complete response. However, more high-quality research is still needed to use this concept to confidently dictate clinical management.

Prospective validation of the Parkland Grading Scale for Cholecystitis

BACKGROUNDnThe Parkland Grading Scale for Cholecystitis (PGS) was developed as an intraoperative grading scale to stratify gallbladder (GB) disease severity during laparoscopic cholecystectomy (LC). We aimed to prospectively validate this scale as a measure of LC outcomes.nnnMETHODSnEleven surgeons took pictures of and prospectively graded the initial view of 317u202fGBs using PGS while performing LC (LIVE) between 9/2016 and 3/2017. Three independent surgeon raters retrospectively graded these saved GB images (STORED). The Intraclass Correlation Coefficient (ICC) statistic assessed rater reliability. Fishers Exact, Jonckheere-Terpstra, or ANOVA tested association between peri-operative data and gallbladder grade.nnnRESULTSnICC between LIVE and STORED PGS grades demonstrated excellent reliability (ICCu202f=u202f0.8210). Diagnosis of acute cholecystitis, difficulty of surgery, incidence of partial and open cholecystectomy rates, pre-op WBC, length of operation, and bile leak rates all significantly increased with increasing grade.nnnCONCLUSIONSnPGS is a highly reliable, simple, operative based scale that can accurately predict outcomes after LC. TABLExa0OF CONTENTS SUMMARY: The Parkland Grading Scale for Cholecystitis was found to be a reliable and accurate predictor of laparoscopic cholecystectomy outcomes. Diagnosis of acute cholecystitis, surgical difficulty, incidence of partial and open cholecystectomy rates, pre-op WBC, operation length, and bile leak rates all significantly increased with increasing grade.