Tom Cecil

Evolution of Surgical Treatment for Rectal Cancer: a Review

Surgery that produces an optimal total mesorectal excision (TME) resection specimen remains the cornerstone of curative rectal cancer management. In the modern era, despite the results of recent randomised trials, laparoscopic TME is a crucial technique in the TME surgery armamentarium. Laparoscopic surgery offers the benefit of magnified views that aid sharp and precise dissection. However operating in the confines of a narrow pelvis, particularly when the mesorectum is bulky, requires significant technical skill. This is compounded by limited angulation of laparoscopic instruments and staplers. The final challenge is to preserve the integrity of the mesorectum during delivery of the specimen. The principles of TME surgery, on which Bill Heald founded the Basingstoke Colorectal unit, can equally be applied to laparoscopic, transanal and robotic TME, but great care must be taken to preserve the key principle—that no steps are taken that have the potential to shed tumour cells or compromise the quality of the mesorectal specimen.

SAGE(S) advice: application of a standardized train the trainer model for faculty involved in a Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) hands-on course

IntroductionCurrently, no prerequisite teaching qualification is required to serve as faculty for SAGES hands-on courses (SAGES-HOC). The Lapco-Train-the-Trainers (Lapco-TT) is a course for surgical trainers, in which delegates learn a standardized teaching technique for skills acquisition. The aims of this study were to 1) determine if this curriculum could be delivered in a day course to SAGES-HOC faculty and 2) assess the impact of such training on learners’ educational experience taught by this faculty at a subsequent SAGES-HOC.Methods and proceduresSix experts attended a one-day Lapco-TT course. SAGES-HOC participants were split into two groups: Group A taught by Lapco-TT trained, and Group B by “untrained” course faculty. Opinion surveys were completed by both the SAGES-HOC learners and the Lapco-TT trained course faculty. Furthermore, the latter underwent self-, learner-, and observer-based evaluation using a previously validated teaching assessment tool (cSTTAR). Mean scores were reported and analyzed [Mann–Whitney U, t test (p < 0.05)].ResultsAll 6 Lapco-TT delegates found the course useful (5), and felt that it would influence the way they taught in the OR (4.83), that their course objectives were met (4.83), and that they would recommend the course to their colleagues (4.83). Of the SAGES-HOC participants, compared to Group B (n = 22), Group A learners(n = 10) better understood what they were supposed to learn (5 vs. 4.15 [p = 0.046]) and do (5 vs. 4 [p = 0.046]), felt that the session was well organized (5 vs. 4 [p = 0.046]), that time was used effectively (5 vs. 3.9 [p = 0.046]), and that performance feedback was sufficient (5 vs. 3.9 [p = 0.028]) and effective (5 vs. 3.95 [p = 0.028]). Group A faculty were rated significantly higher by their learners on the cSTTARs than Group B (p < 0.0005). Group A faculty rated themselves significantly lower than both expert observers (p < 0.0005) and compared to the Group B faculty’s self-assessment (p < 0.002).ConclusionsThe Lapco-TT course can be delivered effectively over one day and impacts the educational experience of learners at a SAGES-HOC. This could help establish a standardized method of teaching at SAGES-HOCs and thereby increase their value for learners.

Clinical presentation, diagnosis, classification and management of peritoneal mesothelioma: a review

Peritoneal mesothelioma (PM) is an uncommon but a serious, and often, fatal primary peritoneal tumour, with increasing incidence worldwide. Conventional systemic chemotherapy, generally based on experience with pleural mesothelioma, usually has disappointing results considering PM as a terminal condition. Patients usually present with non-specific symptoms of abdominal distension and pain making the diagnosis challenging. As PM is confined to the abdomen for all, or much, of its clinical course, a multimodality treatment combining cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as a new standard of care, and has been reported to achieve promising survival outcomes and local disease control in selected patients with PM. This review updates the presentation, diagnosis, classification and treatment strategies for PM.

LAP-VEGaS Practice Guidelines for Reporting of Educational Videos in Laparoscopic Surgery: A Joint Trainers and Trainees Consensus Statement.

Objective: Consensus statement by an international multispecialty trainers and trainees expert committee on guidelines for reporting of educational videos in laparoscopic surgery. Summary of Background Data: Instructive laparoscopy videos with appropriate exposition could be ideal for initial training in laparoscopic surgery, but there are no guidelines for video annotation or procedural educational and safety evaluation. Methods: Delphi questionnaire of 45 statements prepared by a steering group and voted on over 2 rounds by committee members using an electronic survey tool. Committee selection design included representative surgical training experts worldwide across different laparoscopic specialties, including general surgery, lower and upper gastrointestinal surgery, gynecology and urology, and a proportion of aligned surgical trainees. Results: All 33 committee members completed both the first and the second round of the Delphi questionnaire related to 7 major domains: Video Introduction/Authors’ information; Patient Details; Procedure Description; Procedure Outcome; Associated Educational Content; Peer Review; and Use in Educational Curriculae. The 17 statements that did not reach at least 80% agreement after the first round were revised and returned into the second round. The committee consensus approved 37 statements to at least an 82% agreement. Conclusion: Consensus guidelines on how to report laparoscopic surgery videos for educational purposes have been developed. We anticipate that following our guidelines could help to improve video quality. These reporting guidelines may be useful as a standard for reviewing videos submitted for publication or conference presentation.

Preserving fertility in pseudomyxoma peritonei, a novel approach

Abstract Background Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is the gold standard treatment for patients with pseudomyxoma peritonei (PMP) but involves routine bilateral salpingo-oophorectomy. Young women wishing to maintain fertility may be reluctant to pursue this. An alternative strategy in women with low-grade PMP has been explored in the form of laparoscopic evacuation of pelvic and ovarian mucin with resection of the appendiceal tumour. Methods Between January 2012 and January 2015, four young women (aged 28–35 years) with PMP seeking to maintain fertility underwent laparoscopy, appendicectomy and pelvic mucinous evacuation and washout. Data regarding intra-operative and histopathological findings were collected. Endpoints were fertility-related outcomes and oncological follow-up. Results Infertility was a presenting symptom in three of the four women. All four had significant pelvic mucinous disease on radiological imaging and were offered CRS and HIPEC as definitive treatment, but chose laparoscopy with appendicectomy and copious irrigation and washout of the pelvis with stripping of mucinous disease off the ovarian surfaces. Postoperative histology demonstrated a low-grade appendiceal mucinous neoplasm (LAMN) in all patients with acellular mucin or low-grade mucinous carcinoma peritonei in the peritoneal cavity. All patients successfully conceived subsequently and gave birth to healthy babies. After 12–29 months follow-up, all women are well with no radiological or laparoscopic evidence of disease recurrence. Conclusions In patients with low-grade PMP, initial therapeutic laparoscopy can restore fertility, whilst providing short- to medium-term disease control. This modality in young women wishing to have children appears to be a feasible alternative to immediate CRS and HIPEC.

Risk of Ovarian Involvement in Advanced Colorectal or Appendiceal Tumors Involving the Peritoneum

BACKGROUND: Ovarian metastases of GI tumors grow rapidly and are relatively resistant to systemic chemotherapy. They may be unilateral or bilateral and macroscopic or occult. The risk of macroscopic ovarian involvement or occult involvement of macroscopically normal ovaries is unquantified. OBJECTIVE: This study aims to quantify the risks of ovarian involvement in patients with peritoneal malignancy undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. DESIGN: This was a retrospective analysis of a dedicated prospective malignancy database. SETTINGS: This study was conducted at a high-volume tertiary referral center for peritoneal malignancy. PATIENTS: Female patients with at least 1 remaining ovary, undergoing complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for appendiceal tumors or colorectal peritoneal metastases between January 2010 and March 2015 were included. OUTCOME MEASURES: Data regarding ovarian involvement was extracted from surgical and histological records. RESULTS: Two hundred fifty-eight female patients with at least 1 ovary underwent complete cytoreduction and hyperthermic intraperitoneal chemotherapy during the study period. In total, 141 of 258 (54.7%) patients had ovarian tumor involvement, and 80% with at least 1 macroscopically abnormal ovary had bilateral involvement. Of 40 patients with 1 macroscopic ovarian metastasis, microscopic involvement of the contralateral ovary was found in 18 of 40 (45.0%). Of 141 patients in whom both ovaries were macroscopically normal, 24 of 141 (17.0%) patients had microscopic ovarian involvement. LIMITATIONS: The retrospective nature limits the interpretation of these results. CONCLUSIONS: Occult malignancy was present in 17% when both ovaries looked macroscopically normal and in 45% of contralateral normal-looking ovaries if the other ovary was macroscopically involved. These results help to inform preoperative consent and intraoperative decision making in patients with advanced appendiceal and colorectal malignancy, and are of benefit in managing advanced lower GI tract malignancy.

Do patients undergoing cytoreductive surgery and HIPEC for peritoneal malignancy need parenteral nutrition

Abstract Background To analyse the duration of parenteral nutrition (PN) in patients treated for peritoneal malignancy with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) over a 2 year period at a single UK National referral centre. Methods A retrospective analysis of prospective data for all patients (n=321) who underwent CRS and HIPEC for peritoneal malignancy at the Peritoneal Malignancy Institute Basingstoke between April 1, 2013 and March 31, 2015. Duration of PN was compared between primary tumour site (appendix, colorectal, mesothelioma and other); completeness of CRS (complete CRS vs. major tumour debulking) and pre-operative nutritional assessment measures (including Mid Upper Arm Circumference). Results The median duration of PN was 9 days (range 2–87 days). A total of 13 % of patients had PN for less than 7 days and 6 % for 5 days or less. There was no significant difference in duration of PN between the different tumour sites. Two factors that may increase the duration of PN include having major tumour debulking (MTD) and a baseline MUAC<23.5 cm. Conclusions Most patients who underwent CRS and HIPEC for peritoneal malignancy required PN for more than 7 days with poor pre-operative nutritional status and inability to achieve complete cytoreduction predictors of prolonged PN requirements.

Outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal mesothelioma and predictors of survival

Abstract Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) benefits selected patients with peritoneal mesothelioma. We present the outcomes of this treatment strategy in a UK peritoneal malignancy national referral centre. Methods: Observational retrospective analysis of data prospectively collected in a dedicated peritoneal malignancy database between March 1998 and January 2016. Results: Of 1586 patients treated for peritoneal malignancy, 76 (4.8%) underwent surgery for peritoneal mesothelioma. Median age was 49 years (range 21–73 years). 34 patients (45%) were female. Of the 76 patients, 39 (51%) had low grade histological subtypes (mostly multicystic mesothelioma), and 37 (49%) had diffuse malignant peritoneal mesothelioma (DMPM; mostly epithelioid mesothelioma). Complete cytoreduction was achieved in 52 patients (68%) and maximal tumour debulking (MTD) was performed in 20 patients (26%); the remaining 4 patients (5%) underwent a laparotomy with biopsy only. HIPEC was administered in 67 patients (88%). Median overall (OS) and disease-free survival (DFS) after CRS was 97.8 (80.2–115.4) and 58.8 (47.4–70.3) months, respectively. After complete cytoreduction, 100% overall survival was observed amongst patients with low-grade disease. Ki-67 proliferation index was significantly associated with survival outcomes after complete cytoreduction for DMPM and was an independent predictor of decreased survival. Conclusion: With adequate patient selection (guided by histological classification and Ki-67 proliferation index) and complete cytoreduction with HIPEC, satisfactory outcomes can be achieved in selected patients with peritoneal mesothelioma.

Peritoneal Involvement Is More Common Than Nodal Involvement in Patients With High-grade Appendix Tumors Who Are Undergoing Prophylactic Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND: Right hemicolectomy is routinely recommended in patients with histologic findings of high-grade appendix tumors after appendicectomy. Undetected peritoneal disease may be encountered at surgery. In high-grade appendix tumors with disease detected radiologically, complete cytoreduction may not be possible and outcomes poor. For these reasons, we adopted a policy of prophylactic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. OBJECTIVE: The purpose of this study was to quantify the rates of peritoneal and nodal metastatic disease in patients with high-grade appendix tumors without obvious metastatic disease and to report the long-term outcomes of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in these patients. DESIGN: Data regarding peritoneal and nodal metastatic disease were extracted from surgical and histologic records. SETTINGS: The study was conducted at a high-volume tertiary referral center for peritoneal malignancy. PATIENTS: Patients referred with histologically high-grade appendix tumors at appendicectomy, without detectable metastatic spread, between January 1994 and September 2016 were included MAIN OUTCOME MEASURES: A total of 62 patients with high-grade pathology at appendicectomy, without clinical or radiological peritoneal disease, underwent complete cytoreduction with hyperthermic intraperitoneal chemotherapy. RESULTS: Thirty-five (57%) of 62 patients had peritoneal disease (median peritoneal cancer index 5 (range, 1–28)). Eleven (31%) of 35 had microscopic peritoneal disease. Overall, 23 (37%) of 62 had peritoneal disease beyond the confines of a standard right hemicolectomy. Nine (15%) of 62 had nodal involvement. Mean overall and disease-free survival were 110.9 (95% CI, 94.8–127.0 mo) and 102.1 months (95% CI, 84.3–119.9 mo), with 5-year overall and disease-free survival of 83.2% and 76.0%. LIMITATIONS: The retrospective nature limits the interpretation of these results. CONCLUSIONS: Complete cytoreduction was achieved in all of the patients, with excellent long-term survival. The incidence of peritoneal spread (57%) compared with nodal involvement (15%) supports cytoreductive surgery and hyperthermic intraperitoneal chemotherapy as definitive treatment rather than prophylaxis in patients with high-grade appendix tumors, even without radiologically detectable disease. High-grade appendix tumors benefit from early aggressive operative management to deal with potential peritoneal and nodal spread and should be considered for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. See Video Abstract at http://links.lww.com/DCR/A360.