Abstract
Background
Adequate MRI-based staging of early rectal cancers is essential for decision-making in an era of organ-conserving treatment approaches. The aim of this population-based study was ...to determine the accuracy of routine daily MRI staging of early rectal cancer, whether or not combined with endorectal ultrasonography (ERUS).
Methods
Patients with cT1–2 rectal cancer who underwent local excision or total mesorectal excision (TME) without downsizing (chemo)radiotherapy between 1 January 2011 and 31 December 2018 were selected from the Dutch ColoRectal Audit. The accuracy of imaging was expressed as sensitivity, specificity, and positive predictive value (PPV) and negative predictive value.
Results
Of 7382 registered patients with cT1–2 rectal cancer, 5539 were included (5288 MRI alone, 251 MRI and ERUS; 1059 cT1 and 4480 cT2). Among patients with pT1 tumours, 54·7 per cent (792 of 1448) were overstaged by MRI alone, and 31·0 per cent (36 of 116) by MRI and ERUS. Understaging of pT2 disease occurred in 8·2 per cent (197 of 2388) and 27·9 per cent (31 of 111) respectively. MRI alone overstaged pN0 in 17·3 per cent (570 of 3303) and the PPV for assignment of cN0 category was 76·3 per cent (2733 of 3583). Of 834 patients with pT1 N0 disease, potentially suitable for local excision, tumours in 253 patients (30·3 per cent) were staged correctly as cT1 N0, whereas 484 (58·0 per cent) and 97 (11·6 per cent) were overstaged as cT2 N0 and cT1–2 N1 respectively.
Conclusion
This Dutch population-based analysis of patients who underwent local excision or TME surgery for cT1–2 rectal cancer based on preoperative MRI staging revealed substantial overstaging, indicating the weaknesses of MRI and missed opportunities for organ preservation strategies.
Graphical Abstract
This population-based study determined the accuracy of routine daily MRI staging of early rectal cancer, whether or not combined with endorectal ultrasonography. The results showed that preoperative MRI led to substantial overstaging in patients who underwent local excision or total mesorectal incision surgery for cT1–2 rectal cancer, indicating the weaknesses of MRI and missed opportunities for organ preservation strategies.
Graphical Abstract
Imaging weakness
Abstract
Background
Transanal total mesorectal excision (TaTME) has been proposed as an approach in patients with mid and low rectal cancer. The TaTME procedure has been introduced in the Netherlands ...in a structured training pathway, including proctoring. This study evaluated the local recurrence rate during the implementation phase of TaTME.
Methods
Oncological outcomes of the first ten TaTME procedures in each of 12 participating centres were collected as part of an external audit of procedure implementation. Data collected from a cohort of patients treated over a prolonged period in four centres were also collected to analyse learning curve effects. The primary outcome was the presence of locoregional recurrence.
Results
The implementation cohort of 120 patients had a median follow up of 21·9 months. Short-term outcomes included a positive circumferential resection margin rate of 5·0 per cent and anastomotic leakage rate of 17 per cent. The overall local recurrence rate in the implementation cohort was 10·0 per cent (12 of 120), with a mean(s.d.) interval to recurrence of 15·2(7·0) months. Multifocal local recurrence was present in eight of 12 patients. In the prolonged cohort (266 patients), the overall recurrence rate was 5·6 per cent (4·0 per cent after excluding the first 10 procedures at each centre).
Conclusion
TaTME was associated with a multifocal local recurrence rate that may be related to suboptimal execution rather than the technique itself. Prolonged proctoring, optimization of the technique to avoid spillage, and quality control is recommended.
Graphical Abstract
During the learning curve, the transanal total mesorectal excision procedure is associated with a high multifocal local recurrence rate, which appears to be related to suboptimal execution rather than the technique, and necessitates prolonged proctoring, optimization of the technique avoiding spillage, participation in controlled clinical trials with surgical quality control, and centralization until oncological safety is demonstrated.
Graphical Abstract
Defines a learning curve
Background
Neoadjuvant chemoradiotherapy (nCRT) for locally advanced rectal cancer may induce a pathological complete response (pCR) but increase surgical morbidity due to radiation‐induced fibrosis. ...In this study the association between pCR and postoperative surgical morbidity was investigated.
Methods
Patients in the Netherlands with rectal cancer who underwent nCRT followed by total mesorectal excision between 2009 and 2017 were included. Data were stratified into patients who underwent resection with creation of a primary anastomosis and those who had a permanent stoma procedure. The association between pCR and postoperative morbidity was investigated in univariable and multivariable logistic regression analyses.
Results
pCR was observed in 976 (12·2 per cent) of 8003 patients. In 3472 patients who had a primary anastomosis, the presence of pCR was significantly associated with surgical complications (122 of 443 (27·5 per cent) versus 598 of 3029 (19·7 per cent) in those without pCR) and anastomotic leak (35 of 443 (7·9 per cent) versus 173 of 3029 (5·7 per cent) respectively). Multivariable analysis also showed associations between pCR and surgical complications (adjusted odds ratio (OR) 1·53, 95 per cent c.i. 1·22 to 1·92) and pCR and anastomotic leak (adjusted OR 1·41, 1·03 to 2·05). Of 4531 patients with a permanent stoma, surgical complications were observed in 120 (22·5 per cent) of 533 patients with a pCR, compared with 798 (20·0 per cent) of 3998 patients with no pCR (adjusted OR 1·17, 0·94 to 1·46).
Conclusion
Patients with a pCR in whom an anastomosis was created were at increased risk of developing an anastomotic leak.
Antecedentes
La quimiorradioterapia neoadyuvante (neoadjuvant chemoradiotherapy, nCRT) para el cáncer de recto localmente avanzado puede inducir una respuesta patológica completa (pathological complete response, pCR), pero también puede aumentar la morbilidad quirúrgica debido a la fibrosis inducida por la radiación. En este estudio se investigó la asociación entre pCR y morbilidad quirúrgica postoperatoria.
Métodos
Se incluyeron los pacientes con cáncer de recto que recibieron nCRT seguida de resección total del mesorrecto entre 2009 y 2017 en los Países Bajos. Los datos se estratificaron en pacientes en los que se realizó una resección con anastomosis primaria y en los que se realizó una resección con estoma permanente. La asociación entre pCR y morbilidad postoperatoria se investigó mediante análisis de regresión logística univariable y multivariable.
Resultados
Se observó una pCR en 976 (12,2%) de 8.003 pacientes. En el grupo de pacientes con anastomosis primaria (n = 3472), la presencia de pCR se asoció significativamente con complicaciones quirúrgicas (n = 122; 27,5% versus n = 598; 19,7% sin pCR) y fuga anastomótica (n = 35; 7,9 % versus n = 173; 5,7% sin pCR). Las asociaciones entre la pCR y las complicaciones quirúrgicas y la pCR y la fuga anastomótica también se confirmaron en los análisis multivariables (razón de oportunidades ajustada, odds ratio, OR ajustado: 1,53; i.c. del 95%: 1,22‐1,92; OR ajustado: 1,41; i.c. del 95%: 1,03‐2,05, respectivamente). En el grupo con estoma permanente (n = 4.531), se observaron complicaciones quirúrgicas en 120 pacientes (22,5%) en los casos con presencia de pCR en comparación con 798 pacientes (20%) en ausencia de pCR (OR ajustado: 1,17; i.c. del 95%: 0,94‐1,46).
Conclusión
Los pacientes con pCR en los que se realizó una anastomosis tenían mayor riesgo de presentar una fuga anastomótica.
This study aimed to clarify the relationship between pathological response to neoadjuvant chemoradiotherapy and surgical complications. To do this, surgical complication rates were investigated in a nationwide population‐based study.
More leaks
Introduction
Information on the long-term performance of biosynthetic meshes is scarce. This study analyses the performance of biosynthetic mesh (Phasix™) over 24 months.
Methods
A prospective, ...international European multi-center trial is described. Adult patients with a Ventral Hernia Working Group (VHWG) grade 3 incisional hernia larger than 10 cm
2
, scheduled for elective repair, were included. Biosynthetic mesh was placed in sublay position. Short-term outcomes included 3-month surgical site occurrences (SSO), and long-term outcomes comprised hernia recurrence, reoperation, and quality of life assessments until 24 months.
Results
Eighty-four patients were treated with biosynthetic mesh. Twenty-two patients (26.2%) developed 34 SSOs, of which 32 occurred within 3 months (primary endpoint). Eight patients (11.0%) developed a hernia recurrence. In 13 patients (15.5%), 14 reoperations took place, of which 6 were performed for hernia recurrence (42.9%), 3 for mesh infection (21.4%), and in 7 of which the mesh was explanted (50%). Compared to baseline, quality of life outcomes showed no significant difference after 24 months. Despite theoretical resorption, 10.7% of patients reported presence of mesh sensation in daily life 24 months after surgery.
Conclusion
After 2 years of follow-up, hernia repair with biosynthetic mesh shows manageable SSO rates and favorable recurrence rates in VHWG grade 3 patients. No statistically significant improvement in quality of life or reduction of pain was observed. Few patients report lasting presence of mesh sensation. Results of biosynthetic mesh after longer periods of follow-up on recurrences and remodeling will provide further valuable information to make clear recommendations.
Trial registration
Registered on clinicaltrials.gov (NCT02720042), March 25, 2016.
Background
Pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) is found in 15–20% of patients with locally advanced rectal cancer. A watch-and-wait (W&W) strategy has been ...introduced as an alternative strategy to avoid surgery for selected patients with a clinical complete response at multidisciplinary response evaluation. The primary aim of this study was to evaluate the efficacy of the multidisciplinary response evaluation by comparing the proportion of patients with pCR since the introduction of the structural response evaluation with the period before response evaluation.
Methods
This retrospective cohort study enrolled patients with locally advanced rectal cancer who underwent nCRT between January 2009 and May 2018, categorizing them into cohort A (period 2009–2015) and cohort B (period 2015–2018). The patients in cohort B underwent structural multidisciplinary response evaluation with the option of the W&W strategy. Proportion of pCR (ypT0N0), time-to-event (pCR) analysis, and stoma-free survival were evaluated in both cohorts.
Results
Of the 259 patients in the study, 21 (18.4%) in cohort A and in 8 (8.7%) in cohort B had pCR (
p
= 0.043). Time-to-event analysis demonstrated a significant pCR decline in cohort B (
p
< 0.001). The stoma-free patient rate was 24% higher in cohort B (
p
< 0.001).
Conclusion
Multidisciplinary clinical response evaluation after nCRT for locally advanced rectal cancer led to a significant decrease in unnecessary surgery for the patients with a complete response.
Perforated colon cancer (PCC) is a distinct clinical entity with implications for treatment and prognosis, however data on PCC seems scarce. The aim of this systematic review is to provide a ...comprehensive overview of the recent literature on clinical outcomes of PCC.
A systematic literature search of MEDLINE (PubMed), Embase, Cochrane library and Google scholar was performed. Studies describing intentionally curative treatment for patients with PCC since 2010 were included. The main outcome measures consisted of short-term surgical complications and long-term oncological outcomes.
Eleven retrospective cohort studies were included, comprising a total of 2696 PCC patients. In these studies, various entities of PCC were defined. Comparative studies showed that PCC patients as compared to non-PCC patients have an increased risk of 30-day mortality (8–33% vs 3–5%), increased post-operative complications (33–56% vs 22–28%), worse overall survival (36–40% vs 48–65%) and worse disease-free survival (34–43% vs 50–73%). Two studies distinguished free-perforations from contained perforations, revealing that free-perforation is associated with significantly higher 30-day mortality (19–26% vs 0–10%), lower overall survival (24–28% vs 42–64%) and lower disease-free survival (15% vs 53%) as compared to contained perforations.
Data on PCC is scarce, with various PCC entities defined in the studies included. Heterogeneity of the study population, definition of PCC and outcome measures made pooling of the data impossible. In general, perforation, particularly free perforation, seems to be associated with a substantial negative effect on outcomes in colon cancer patients undergoing surgery. Better definition and description of the types of perforation in future studies is essential, as outcomes seem to differ between types of PCC and might require different treatment strategies.
Introduction
Non-healing of anastomotic leakage can be observed in up to 50% after total mesorectal excision for rectal cancer. This study investigates the efficacy of early transanal closure of ...anastomotic leakage after pre-treatment with the Endosponge
®
therapy.
Methods
In this prospective, multicentre, feasibility study, transanal suturing of the anastomotic defect was performed after vacuum-assisted cleaning of the presacral cavity. Primary outcome was the proportion of patients with a healed anastomosis at 6 months after transanal closure. Secondary, healing at last follow-up, continuity, direct medical costs, functionality and quality of life were analysed.
Results
Between July 2013 and July 2015, 30 rectal cancer patients with a leaking low colorectal anastomosis were included, of whom 22 underwent neoadjuvant radiotherapy. Median follow-up was 14 (7–29) months. At 6 months, the anastomosis had healed in 16 (53%) patients. At last follow-up, anastomotic integrity was found in 21 (70%) and continuity was restored in 20 (67%) patients. Non-healing at 12 months was observed in 10/29 (34%) patients overall, and in 3/14 (21%) when therapy started within three weeks following the index operation. Major LARS was reported in 12/15 (80%) patients. The direct medical costs were €8933 (95% CI 7268–10,707) per patient.
Conclusion
Vacuum-assisted early transanal closure of a leaking anastomosis after total mesorectal excision with 73% preoperative radiotherapy showed that acceptable anastomotic healing rates and stoma reversal rates can be achieved. Early diagnosis and start of treatment seems crucial.
Objective: This study aims to evaluate the effects of pelvic floor rehabilitation (PFR) after low anterior resection (LAR) at one-year follow-up. Summary Background Data: After LAR, with restoration ...of bowel continuity, up to 90% of patients develop anorectal dysfunction, significantly impacting their quality of life. However, standardized treatment is currently unavailable. The FORCE trial demonstrated the beneficial effects of PFR after three months regarding specific domains of the Fecal Incontinence QoL (FIQL) questionnaire and urgency compared to usual care. Methods: The FORCE trial is a multicenter, two-arm, randomized clinical trial. All patients undergoing LAR were randomly assigned to receive either usual care or a standardized PFR program. The primary outcome measure is the Wexner incontinence score, and the secondary endpoints included the LARS score, the EORTC colorectal-specific QoL questionnaire, and health- and fecal incontinence-related QoL. Assessments were conducted at baseline before randomization, at three months and one-year follow-ups. Results: A total of 86 patients were included (PFR: n=40, control: n=46). After one year, PFR did not significantly improve Wexner incontinence scores (PFR: -3.33, 95% CI -4.41 to -2.26, control: -2.54, 95% CI -3.54 to -1.54, P =0.30). Similar to the three-month follow-up, patients without near-complete incontinence at baseline showed sustained improvement in fecal incontinence (PFR: -2.82, 95% CI -3.86 to -1.76, control: -1.43, 95% CI -2.36 to -0.50, P =0.06). Significant improvement was reported in the FIQL domains Lifestyle (PFR: 0.51, control: -0.13, P =0.03) and Coping and Behavior (PFR: 0.40, control: -0.24, P =0.01). Conclusion: At one-year follow-up, no significant differences were found in fecal incontinence scores; however, PFR was associated with improved fecal incontinence related QoL compared to usual care.
Anorectal melanoma is a rare malignancy with a dismal prognosis. The purpose of this study was to investigate whether the survival per stage is influenced by the surgical approaches (local excision ...or extensive resection), to assess prognostic factors of survival, and to answer the question whether the practiced surgical approaches changed over time.
Dutch cancer registry organizations (IKNL and PALGA) were queried for all patients with a diagnosis of anorectal melanoma (1989–2019). Patients with disseminated disease at diagnosis were excluded. Survival outcomes were compared for the two surgical approaches stratified by stage (clinical node negative (cN0) and clinical node positive (cN+)) and date of diagnosis.
A total of 103 patients were included in this study. In both cN0 and cN+ patients the surgical strategy did not significantly influence survival (cN0: 21.7% 5-year survival, median 25 months for local excision versus 13.7% 5-year survival, median 17 months for extensive resection (p = 0.228), cN+: 11.1% 5-year survival for local excision, median 17 months versus 8.7% 5-year survival, median 14 months for extensive resection (p = 0.741)). Stage and date of diagnosis showed to be prognostic factors of survival. The ratio between the two surgical approaches was unchanged over three decades.
Extensive resection does not seem to improve survival in both cN0 and cN+ anorectal melanoma patients compared to local excision. However in the past three decades no shift towards local excision has been found. cN+ stage and an older date of diagnosis are predictors for worse survival.
•Extensive resection does not seem to improve survival in both cN0 and cN + anorectal melanoma.•In the past three decades no shift towards local excision.•cN + stage and an older date of diagnosis are negative predictors of survival.
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