Sunil V. Patel

Distance to the anal verge is associated with pathologic complete response to neoadjuvant therapy in locally advanced rectal cancer.

Achieving a pathologic complete response (pCR) after neoadjuvant therapy has been associated with better prognosis in rectal cancer patients. The objective of this study was to investigate the relationship between distance to the anal verge (DTAV) and pCR.

Abdominal metastases from colorectal cancer: intraperitoneal therapy.

Patients with peritoneal metastasis from colorectal cancer represent a distinct subset with regional disease rather than systemic disease. They often have poorer survival outcomes with systemic chemotherapy. Optimal cytoreductive surgery and intraperitoneal chemotherapy (IPC) offers such patients a more directed therapy with improved survival. In this review, we discuss the diagnosis, evaluation and classification, as well as rational for treatment of peritoneal carcinomatosis (PC) secondary to colorectal cancer.

The Final 30 Days of Life: A Study of Patients With Gastrointestinal Cancer in Ontario, Canada

Background: Studies have reported overly aggressive end-of-life care (EOLC) in many cancers. We investigate trends in, and factors associated with, aggressive EOLC among patients who died of gastrointestinal (GI) cancers in Ontario, Canada. Methods: All patients with primary cause of death from esophageal, gastric, colon, and anorectal cancer from January 2003 to December 2013 were identified through the Ontario Cancer Registry, and information was collected from linked databases. Outcomes representing aggressive EOLC were assessed: administration of chemotherapy, any emergency department (ED) visits, hospital admissions, intensive care unit (ICU) admissions (all within 30 days of death), death in hospital and in ICU, and a composite outcome representing any aggressive EOLC. Temporal trends were analyzed using the Cochran-Armitage test. Results: There were 34 630 patients in the cohort: 43% colon, 26% anorectal, 19% gastric, and 12% esophageal cancers. Aggressive EOLC was delivered to 65%, with a significantly decreasing trend from 64.8% in 2003 to 62.5% in 2013 (P = .001). Utilization of specific elements of aggressive EOLC included 8% chemotherapy, 46% ED visits, 49% hospital admissions, 6% ICU admissions, 45% death in hospital, and 5% death in ICU. Trends over the study period showed that ED visits (from 43% to 46.9%; P = .0001) and death in ICU (from 3.7% to 4.9%; P = .04) significantly increased; hospital admissions (from 48.9% to 47.8%; P = .02) and death in hospital (from 46.6% to 38.9%; P < .0001) significantly decreased. Conclusions: Two-thirds of patients with GI cancer had aggressive EOLC in the last 30 days of life.

Management of stage III colon cancer in the elderly: Practice patterns and outcomes in the general population

Clinical trials have established surgical resection and adjuvant chemotherapy (ACT) as the standard management for stage III colon cancer; however, the extent to which these results apply to elderly patients in routine practice is unclear. This article describes the management and outcomes of elderly patients with stage III colon cancer.

Peri-operative blood transfusion for resected colon cancer: Practice patterns and outcomes in a population-based study

BACKGROUND & OBJECTIVES Literature suggests that peri-operative blood transfusion among patients with resected colon cancer may be associated with inferior long-term survival. The study objective was to characterize this association in our population. METHODS This is a retrospective cohort study using the population-based Ontario Cancer Registry (2002-2008). Pathology reports were obtained for a 25% random sample of all cases and constituted the study population. Log binomial regression was used to identify factors associated with transfusion. Cox proportional hazards model explored the association between transfusion and cancer specific survival (CSS) and overall survival (OS). RESULTS The study population included 7198 patients: 18% stage I, 36% stage II, 40% stage III, and 6% stage IV. Twenty-eight percent of patients were transfused. Factors independently associated with transfusion included advanced age (p<0.001), female sex (p<0.001), greater comorbidity (p<0.001), more advanced disease (p<0.001) and open surgical resection (p<0.001). Transfusion was associated with inferior CSS (HR 1.51, 95% CI 1.38-1.65) and OS (HR 1.52, 95% CI 1.41-1.63), after adjusting for important confounders. CONCLUSIONS Peri-operative transfusion rates among patients with colon cancer have decreased over time. Transfusion is associated with inferior long-term CSS and OS.

Robotic Rectal Resection

The short-term benefits of minimally invasive laparoscopic colectomy for colon cancer are advantageous compared to open resection and include speedier recovery time, briefer hospital stay, decreased need for analgesic medication, and better cosmesis. For these reasons, the adoption of laparoscopic techniques in the surgical treatment of colon cancer has accelerated over the past decade. However, laparoscopic approaches to rectal cancer surgery have not had the same popularity. This may be due to the increased technical demands of pelvic surgery and the limitations imposed by the straight, rigid laparoscopic instrumentation, with corresponding ergonomic disadvantages for the operating surgeon. High rates of conversion have moved surgeons to develop hybrid procedures, in which the difficult pelvic portion of the operation is performed via a low Pfannenstiel incision (Moloo et al., Cochrane Database Syst Rev (10):CD006585, 2010) or even a transanal approach (Lacy et al., Surg Endosc 27(1):339046, 2013). As a result, the adoption of laparoscopy in rectal resection has been low. The robotic platform helps overcome many of the limitations of standard laparoscopy. In this chapter, we discuss the current evidence supporting the use of robotic technology in rectal cancer surgery. We also provide a description of the technique, including ways to avoid common pitfalls.

Is a transanal total mesorectal excision programme feasible in a single-team setting?

Rectal cancer surgery is a challenging endeavour, for multiple reasons. The theory behind what a perfect rectal cancer removal represents, as conceptualized by total mesorectal excision (TME), was described by Professor Bill Heald in the early 1980s. Most colorectal surgeons today have a clear understanding of the anticipated outcome of such an operation. However, translating that knowledge into the reality of surgical practice has proved to be quite difficult, mostly because of the anatomical challenges posed by the location of the rectum inside the rigid pelvis, all of which are exacerbated by male gender and body fat. Transanal total mesorectal excision (TaTME) can overcome these challenges. Today, TaTME has achieved a great deal of sophistication and complexity and, as such, the majority of institutions where it is performed advocate for two surgical teams. This makes sense, along with centralization and subspecialization of the management of rectal cancer. Nonetheless, there are institutions where the stringent requirements for management of rectal cancer are present but not the luxury of having two surgeons available to perform TaTME. In this article we aim to rationalize the argument for a single-team TaTME at institutions that have the capability to implement such a programme but where a second surgeon is lacking. At the same time, we endeavour to re-create a fair depiction of the significant challenges that these institutions would encounter in implementing a single-surgeon TaTME programme. Caution should be exercised when entertaining this idea. The current literature on transanal total mesorectal excision (TaTME) has mainly focused on describing the relevant aspects of the procedure as performed by two teams. There are very few data available on a singleteam approach. We present our reflections on its significant challenges, as well as the possible avenues for responsibly introducing and performing this procedure in a single-team setting. Total mesorectal excision (TME) was first described more than 30 years ago [1]. Despite the benefits of TME, the confines of the pelvis can pose significant difficulties with regard to the ability of surgeons to obtain adequate visualization and carry out proper dissection [2]. These difficulties are even more evident in male patients and obese individuals, especially when lesions are located in the distal two-thirds of the rectum. TaTME is a novel technique introduced into the surgical armamentarium for the management of rectal cancer. Since its description in 2010 [3] several authors have published results regarding its advantages [4–6]. Transanal techniques facilitate sphincter preservation and enhance exposure of the distal rectum [4– 6]. The development of the TAMIS platform (Applied Medical, Rancho Santa Margarita, California, USA) certainly enabled a rapid expansion of the TaTME approach [7]. As TaTME has gained in popularity, much emphasis has been placed on using a two-team approach (Cecil). This approach may result in shorter operative times and potentially a safer procedure [8,9]. The two-team approach is advantageous, but may not be feasible at every centre. Several institutions/surgeons, who otherwise have the capacity and ability to perform TaTME, may not have the luxury of a second minimally invasive/rectal surgeon; in these settings a single-team approach may be considered as an alternative [10,11]. Careful planning is necessary for safe introduction and implementation and to ensure the long-term sustainability of a TaTME programme. Patients are at increased risk of injury during the early phases of new procedures, including TaTME [12– 14], and technological aids can be relevant in minimizing these risks [15–17]. Authors have warned about the uncoordinated and undisciplined implementation of novel procedures, which can lead to a significant number of complications [18]. In order to avoid injuries and complications in the single-team setting it is imperative for the main operator to master both the laparoscopic and the TaTME techniques. This requires detailed knowledge of the anatomical landmarks of the pelvis as seen from above as well as from the perineal aspect. Prior to implementation, a rectal surgeon needs to consider two things: am I the right person to initiate this programme and perform this procedure and is my institution the right place to develop this initiative [19,20]? The proper and necessary training for TaTME has not yet been completely defined, and different pathways have been proposed [17–20]. It is clear that a weekend course is not sufficient to achieve proficiency, thus proctoring is very important [21,22]. Volume is relevant: arbitrary values have been set to ensure proficiency, and some have proposed that a minimum of 20–30 TaTME procedures should be completed annually [21–25]. The surgeon needs to

Spin in Minimally Invasive Transanal Total Mesorectal Excision Articles (TaTME): An assessment of the current literature

Minimally invasive transanal total mesorectal excision (TaTME) is a new approach for treating rectal cancer. ‘Spin’ can be defined as ‘reporting strategies to highlight that the experimental treatment is beneficial’ despite limitations in study design. The aim of this study was to assess spin within publications about TaTME.

Disease Characteristics, Clinical Management, and Outcomes of Young Patients With Colon Cancer: A Population-based Study

Micro‐Abstract The present population‐based study explored the disease characteristics, treatment, and outcomes of young patients (age < 40 years) with resected colon cancer. Younger patients were more likely than were older patients to have advanced‐stage disease. They were also more likely to receive adjuvant chemotherapy. Despite the more aggressive biology, the survival of young patients was superior to that of older patients with colon cancer. Introduction The incidence of colorectal cancer in young patients has been increasing. We evaluated whether the disease characteristics, management, and outcomes of patients with colon cancer differ among patients aged ≤ 40 years compared with those of older patients. Materials and Methods Using the Ontario Cancer Registry, all cases of colon cancer (stage I, II, III) treated with surgery in Ontario from 2002 to 2008 were identified. The electronic medical records of treatment were used to identify the use of surgery and adjuvant chemotherapy (ACT). The pathology reports were obtained for a random 25% sample of all cases. A Cox model was used to identify the factors associated with overall (OS) and cancer‐specific survival (CSS). Results The study population included 6775 patients. The age distribution was 2%, 5%, 14%, and 79% for patients aged ≤ 40, 41 to 50, 51 to 60, and > 60 years, respectively. Compared with patients aged > 60 years, younger patients (age ≤ 40 years) were more likely to have lymphovascular invasion (35% vs. 27%; P = .005), T3/T4 tumors (88% vs. 79%; P = .005) and lymph node–positive disease (58% vs. 41%; P < .001). The stage distribution varied by age: stage I, 8% versus 19%; stage II, 34% versus 40%; and stage III, 58% versus 41% for those aged ≤ 40 years versus those aged > 60 years, respectively (P < .001). ACT was delivered more often to patients aged ≤ 40 years than to those aged > 60 years for stage II (50% vs. 13%; P < .001) and stage III (≥ 92% vs. 57%; P < .001) disease. The adjusted OS (hazard ratio [HR], 0.32; 95% confidence interval [CI], 0.21‐0.49) and CSS (HR, 0.41; 95% CI, 0.26‐0.64) were superior for patients aged ≤ 40 years compared with the OS and CSS for those aged > 60 years. Conclusion Young patients with colon cancer have more aggressive and advanced disease but improved outcomes compared with older patients.