Panagiotis Taflampas

Anastomotic leakage after low anterior resection for rectal cancer: Facts, obscurity, and fiction

The subject of anastomotic leakage after low anterior resection (LAR) for rectal cancer remains controversial. Risk factors have been discussed in several studies but the findings are often inconclusive. This review evaluates these studies and separates the known risk factors into those that are well documented, those that are obsolete, and those that require further research. We searched the Medline and PubMed databases using the keywords: “leakage,” “low anterior resection,” “rectal cancer,” “risk factors,” and their combinations. There were no language or publication year restrictions. References in published papers were also reviewed. Each risk factor was evaluated and discussed separately. The evidence suggests that low anastomoses are more prone to leakage. Other well-documented risk factors are male sex, smoking, and preoperative malnutrition. Routine mobilization of the splenic flexure and the use of a J-pouch seem to reduce the leakage rate. The effect of preoperative chemo-radiotherapy is under scrutiny. The indications for a protective stoma remain debatable. Omentoplasty, bowel preparation, the use of a drain, and tumor stage do not seem to affect the leakage rate. The type of operation (open or laparoscopic) and anastomosis (hand-sewn or stapled) is not crucial.

Plasma antioxidant capacity in morbidly obese patients before and after weight loss.

Background: Oxidative stress may play a critical role in the pathogenesis and development of obesity-associated co-morbidities. Reactive oxygen and nitrogen species are produced as a consequence of normal aerobic metabolism and removed and/or inactivated in vivo by both endogenous (uric acid, bilirubin, thiols) and diet-derived (exogenous) antioxidants. The purpose of this study is to measure the total plasma antioxidant capacity (TAC), as well as the corrected TAC (cTAC, an index of exogenous provided antioxidants) in morbidly obese patients before and after surgical weight reduction. Methods: 16 morbidly obese (5 male and 11 female) candidates for surgical intervention, median age 34 (range 22-56) years, median weight 128 (range 96-186) kg, median excess weight 62 (range 28-115) kg and median BMI 44.4 (range 33.7-60.1) kg/m2 were evaluated before and 6 months after implantation of an intragastric balloon. 15 healthy blood donors (4 male and 11 female) on a normal diet, median age 35 (range 21-52) years, median weight 64.3 (range 46-78) kg and median BMI 24.2 (range 23.7-25.2) kg/m2 were also evaluated. Blood samples for routine clinical chemistry, TAC and cTAC determination were drawn, and weight and BMI calculation were performed once in the control group, and in the morbidly obese patients (MO) before and 6 months after the balloon implantation. Results: 6 months after balloon placement, weight and BMI of the MO patients were statistically significantly reduced from the preoperative values (P<0.001). Plasma TAC and cTAC values in the MO group were significantly lower preoperatively, compared to the control group (P<0.05 and P<0.001 respectively). cTAC values in the MO patients increased significantly following weight loss (P<0.001) and were restored to normal. However, the postoperative TAC values in the MO group did not change significantly and remained lower than in the normal controls. A significant decrease (P<0.001) in uric acid values was also noticed in the MO group after weight loss. Conclusion: Plasma TAC and cTAC values are impaired in morbidly obese patients. Weight loss from an intragastric balloon is associated with significant increase in plasma cTAC values. Plasma TAC values, after the weight loss remain unchanged, possibly due to a decrease in uric acid, an important endogenous antioxidant.

Complete cytoreduction for pseudomyxoma peritonei is optimal but maximal tumor debulking may be beneficial in patients in whom complete tumor removal cannot be achieved.

BACKGROUND: Pseudomyxoma peritonei is a diffuse peritoneal malignancy that generally originates form a perforated appendiceal tumor. Optimal treatment requires extensive surgical resection to achieve complete cytoreduction combined with hyperthermic intraperitoneal chemotherapy. In a proportion of patients this is impossible, in particular, owing to extensive irresectable small-bowel involvement. There is ongoing debate as to the role of maximal tumor debulking in such cases. OBJECTIVE:  The aim of this study was to assess the outcomes of patients who underwent major tumor debulking for pseudomyxoma peritonei of appendiceal origin and to compare outcomes with patients who had complete cytoreduction during the same period. DESIGN: This is a retrospective study. SETTINGS: This investigation was conducted at a tertiary referral center for peritoneal surface malignancy. PATIENTS: A prospective database of 953 consecutive patients with peritoneal malignancy undergoing surgery at a UK national referral center between 1994 and 2012 was analyzed. Of these patients, 748 (78%) had surgery for pseudomyxoma peritonei of appendiceal origin. MAIN OUTCOME MEASURES: Survival, morbidity, and mortality in both groups were compared. Univariate and multivariate analyses were performed to identify negative prognostic factors in the group that underwent major tumor debulking. RESULTS: Complete cytoreductive surgery was achieved in 543/748 (73%) patients, and 205 (27%) had maximal tumor debulking. Median age was 56 years (172 (31.7%) men) in the complete cytoreductive surgery group and 59 years (108 (52.7%) men) in the maximal tumor debulking group. Overall survival at 3, 5, and 10 years was 90%, 82%, and 64% in the complete cytoreductive group and 47%, 30%, and 22% in the maximal tumor debulking group. The median survival in the maximal tumor debulking group was 32.8 months (95% CI, 24.1–41.5). LIMITATIONS: The retrospective analysis of prospective data was a limitation of this study. CONCLUSIONS: Maximal tumor debulking may help patients with pseudomyxoma peritonei in whom complete cytoreduction cannot be achieved with almost half alive at 3 years with long-term survival in some.

Sealants after axillary lymph node dissection for breast cancer: good intentions but bad results

BACKGROUND This study was conducted to evaluate the effect of 2 surgical sealants on postsurgical drainage and lymphocele formation after axillary surgery for breast cancer. METHODS This was a prospective, randomized study. Seventy-seven consecutive patients with breast cancer were included and randomized into a control group (18F vacuum drain) and 2 study groups (18F vacuum drain plus COSEAL or BioGlue). RESULTS The 3 groups were matched. Neither postsurgical drainage nor time to drain removal was affected by the use of either of the 2 sealants. Although no statistically significant difference in lymphocele formation and wound infection was noted, complications caused by intense foreign-body reaction that led to surgical intervention occurred in both study groups. COMMENTS The use of surgical sealants is not recommended after axillary lymph node dissection for breast cancer. Complications of their use may lead to reoperation.

The effect of preoperative chemoradiotherapy on lymph node harvest after total mesorectal excision for rectal cancer.

PURPOSE: This study was designed to evaluate whether preoperative chemoradiotherapy reduces the number of lymph nodes harvested after total mesorectal excision of rectal cancer. METHODS: From January 1995 to December 2007, 168 consecutive patients with rectal cancer underwent total mesorectal excision in the Department of Surgical Oncology at the University of Crete. The patients were divided into three groups (Group A, no chemoradiotherapy; Group B, short course of chemoradiotherapy; Group C, long course of chemoradiotherapy). The primary end points were the number of lymph nodes examined and the percentage of patients with fewer than 12 lymph nodes removed. RESULTS: The overall number of lymph nodes retrieved was not significantly reduced by the use of preoperative chemoradiotherapy. The percentage of patients with fewer than 12 lymph nodes examined, however, was significantly higher in Group C. The leakage rate and the duration of hospital stay were not affected. The rate of wound infections was higher in Group C. CONCLUSION: Preoperative chemoradiotherapy did not significantly decrease the overall number of lymph nodes retrieved but did increase the percentage of patients with fewer than 12 lymph nodes examined.

TOWARDS QUALITY CONTROL IN RECTAL CANCER SURGERY: A PRELIMINARY GREEK EXPERIENCE

Background:  The purpose of this study was to evaluate the effect of the introduction of a colorectal unit on provided services for patients with rectal cancer.

Evidence-Based Management of Acute Malignant Colorectal Obstruction: Diverting Colostomy as a Bridge to Elective Surgery is a Valid Alternative

Colorectal cancer presents relatively often as acute bowel obstruction, which requires immediate intervention. Operative morbidity and mortality are increased by deterioration of the patient and the commonly poor condition of the proximal bowel. The optimal curative approach for obstructing colorectal carcinoma continues to be a topic of discussion and is the subject of this literature review. The pros and cons of the various strategies based on data provided by clinical studies are discussed. Primary decompression of the bowel with a colostomy or stent and delayed colectomy has the advantage of providing time for improvement of the patient’s general condition, recovery of the initially dilated large bowel, accurate disease staging, planning of preoperative treatment and resection by an experienced surgeon. In the absence of significantly dilated bowel the definitive surgical procedure may be performed laparoscopically. Since placement of a self-expanding metallic stent as a bridge to elective surgery is associated with a high complication rate, and probably with impaired oncological outcome, it should be considered only as an alternative to emergency surgery in those patients who have an increased surgical risk, or as a palliative procedure. Local availability and expertise, and high costs are further issues that need to be considered. The creation of diverting colostomy as a bridge to elective surgery is a safe and valid alternative. Although a second operation is required, the overall morbidity and mortality are no higher than for primary resection, while the rate of permanent colostomy is significantly lower, and there is evidence that the two-stage approach is associated with a better oncological outcome.

Prognostic impact of inferior mesenteric artery lymph node metastasis in colorectal cancer.

We read with interest the article of Kang et al. concerning the prognostic significance of inferior mesenteric artery lymph node metastases in rectal and sigmoid cancer patients. We are pleased that the anatomic distribution of lymph node metastasis in colorectal cancer is gaining importance, and this article also suggests that it may also influence 5-year survival. The authors divided patients with rectal or sigmoid cancer in two groups (with or without inferior mesenteric lymph node involvement) and concluded that patients with inferior mesenteric lymph node metastases had a higher percentage of systemic metastases and far worse prognosis compared with the group with no metastases. We want to express some thoughts about the issues discussed. Data for local recurrence rate show that both isolated (0.0% vs. 4.4%) and overall local recurrence rate (3.0% vs. 8.6%) was worse in the group with no inferior mesenteric lymph node involvement. Because involved lymph nodes may act not only as predictors of systemic failure but also as foci for local recurrence, these results are difficult to explain. It would be easier to accept higher local recurrence rates in the group with involved lymph nodes. Taking into consideration that the overall lymph node collection yield was similar but that there was a marked difference in the number removed from the inferior mesenteric root between the two groups, one may hypothesize that the presence of enlarged lymph nodes in the area of inferior mesenteric artery in patients with nodal metastases had influenced the surgical technique and led to a more meticulous dissection of this area. Otherwise, the higher local recurrence rate in the group of patients with no metastases to the mesenteric root remains unaccounted for. The authors stated that inferior mesenteric root involvement was a prognostic factor for para-aortic and systemic metastases. Data that could reinforce this argument could come from the study of stage IV rectal and sigmoid patients of their database. If we accept the hypothesis that inferior mesenteric lymph nodes are a getaway for systemic metastases, then it is expected that patients with stage IV disease at the time of diagnosis who had been operated on with curative intent (operable liver or peritoneal metastases) will have a far higher percentage of involved inferior mesenteric lymph nodes. These data are missing from the presented data. In this context, rectal cancer patients who have been subjected to preoperative radiochemotherapy and who have advanced-stage disease also may have a higher percentage of involved inferior mesenteric lymph nodes. These data are also missing from this article. The authors concluded that, on the basis of the findings of their study, inferior mesenteric nodal metastasis was associated with high incidence of systemic recurrence and poor prognosis. In our opinion, this notion, in conjuction with articles that suggest no survival benefit from the high ligation of inferior mesenteric artery, could imply that inferior mesenteric artery nodal metastases must be classified under M and not under N stage in the tumor, node, metastasis system of classification as a result of their strong prognostic but poor therapeutic impact. This assumption remains open for debate if we accept the results of this article.