Background
Pelvic exenteration for locally recurrent rectal cancer (LRRC) is associated with variable outcomes, with the majority of data from single‐centre series. This study analysed data from an ...international collaboration to determine robust parameters that could inform clinical decision‐making.
Methods
Anonymized data on patients who had pelvic exenteration for LRRC between 2004 and 2014 were accrued from 27 specialist centres. The primary endpoint was survival. The impact of resection margin, bone resection, node status and use of neoadjuvant therapy (before exenteration) was assessed.
Results
Of 1184 patients, 614 (51·9 per cent) had neoadjuvant therapy. A clear resection margin (R0 resection) was achieved in 55·4 per cent of operations. Twenty‐one patients (1·8 per cent) died within 30 days and 380 (32·1 per cent) experienced a major complication. Median overall survival was 36 months following R0 resection, 27 months after R1 resection and 16 months following R2 resection (P < 0·001). Patients who received neoadjuvant therapy had more postoperative complications (unadjusted odds ratio (OR) 1·53), readmissions (unadjusted OR 2·33) and radiological reinterventions (unadjusted OR 2·12). Three‐year survival rates were 48·1 per cent, 33·9 per cent and 15 per cent respectively. Bone resection (when required) was associated with a longer median survival (36 versus 29 months; P < 0·001). Node‐positive patients had a shorter median overall survival than those with node‐negative disease (22 versus 29 months respectively). Multivariable analysis identified margin status and bone resection as significant determinants of long‐term survival.
Conclusion
Negative margins and bone resection (where needed) were identified as the most important factors influencing overall survival. Neoadjuvant therapy before pelvic exenteration did not affect survival, but was associated with higher rates of readmission, complications and radiological reintervention.
Complete resection is key
Background
The management of lateral pelvic lymphadenopathy in low rectal cancer poses an oncological and technical challenge. Interpretation of the literature is confounded by different approaches ...to management in the East and West, and a lack of randomized data from which to draw accurate conclusions regarding the optimal approach. Recent collaboration between Eastern and Western centres has increased the standardization of care. Despite this, significant differences in international guidelines remain. The aim of this review was to appraise the available literature and propose a management algorithm.
Methods
A literature review of all relevant studies was performed to summarize the historical evidence, as well as establish the significance of clinically positive lateral pelvic sidewall nodes, and the role of neoadjuvant chemoradiotherapy and lateral pelvic node dissection. A management algorithm was developed based on this review of the literature.
Results
The management of pelvic sidewall lymphadenopathy in rectal cancer is non‐standardized, with geographical differences. The mechanism of lateral lymphatic spread is well defined; the risk increases with lower tumour height and advanced T category. Existing data indicate that acceptable disease‐free and overall survival can be achieved by neoadjuvant chemoradiotherapy with selective lateral pelvic node dissection.
Conclusion
Suspicious lateral pelvic sidewall nodes, particularly in the internal iliac chain, should be considered as resectable locoregional disease, and surgery offered for enlarged nodes that do not respond to neoadjuvant chemoradiotherapy.
Antecedentes
El tratamiento de las adenopatías en la pared pélvica lateral en el céncer de recto inferior plantea un desafío oncológico y técnico. La interpretación de la literatura es confusa por los diferentes abordajes en Oriente y Occidente y la falta de estudios aleatorizados a partir de los cuales extraer conclusiones precisas sobre cuél es el enfoque óptimo. La reciente colaboración entre los centros orientales y occidentales ha aumentado la estandarización del tratamiento. A pesar de ello, persisten diferencias significativas en las guías internacionales. El objetivo de esta revisión fue evaluar la literatura disponible y proponer un algoritmo terapéutico.
Métodos
Se realizó una revisión de la literatura de todos los estudios relevantes para resumir las evidencias existentes, así como para determinar la importancia de las adenopatías de la pared lateral pélvica clínicamente positivas, el papel de la quimiorradioterapia neoadyuvante (neoadjuvant chemoradiotherapy, NCRT) y de la linfadenectomía pélvica lateral (lateral pelvic node dissection, LPND). Se desarrolló un algoritmo de tratamiento basado en esta revisión de la literatura.
Resultados
El tratamiento de las adenopatías de la pared lateral de la pelvis en el céncer de recto no esté estandarizado y sigue habiendo diferencias geogréficas. El mecanismo de la diseminación linfética lateral esté bien definido con un mayor riesgo en los tumores de recto inferior y con un estadio T avanzado. Los datos existentes demuestran que se puede obtener una supervivencia libre de enfermedad y global aceptables mediante NCRT con LPND selectiva.
Conclusión
Las adenopatías sospechosas en la pared lateral de la pelvis, en particular en la cadena ilíaca interna, deben considerarse enfermedad locorregional resecable y se debe ofrecer cirugía para los ganglios aumentados de tamaño que no responden a la NCRT.
The management of pelvic sidewall lymphadenopathy in rectal cancer is controversial and non‐standardized, with significant geographical differences. Residual pelvic sidewall node involvement following neoadjuvant chemoradiotherapy (NCRT) and total mesorectal excision is associated with worse oncological outcomes. Highly selective lateral pelvic node dissection after NCRT can reduce rates of local recurrence, particularly in the pelvic sidewall.
Selective resection appropriate
To determine factors associated with outcomes following pelvic exenteration for advanced nonrectal pelvic malignancy.
The PelvEx Collaborative provides large volume data from specialist centers to ...ascertain factors associated with improved outcomes.
Consecutive patients who underwent pelvic exenteration for nonrectal pelvic malignancy between 2006 and 2017 were identified from 22 tertiary centers. Patient demographics, neoadjuvant therapy, histopathological assessment, length of stay, 30-day major complication/mortality rate were recorded.The primary endpoints were factors associated with survival. The secondary endpoints included the difference in margin rates across the cohorts, impact of neoadjuvant treatment on survival, associated morbidity, and mortality.
One thousand two hundred ninety-three patients were identified. 40.4% (n = 523) had gynecological malignancies (endometrial, ovarian, cervical, and vaginal), 35.7% (n = 462) urological (bladder), 18.1% (n = 234) anal, and 5.7% had sarcoma (n = 74).The median age across the cohort was 63 years (range, 23-85). The median 30-day mortality rate was 1.7%, with the highest rates occurring following exenteration for recurrent sarcoma or locally advanced cervical cancer (3.3% each). The median length of hospital stay was 17.5 days. 34.5% of patients experienced a major complication, with highest rate occurring in those having salvage surgery for anal cancer.Multivariable analysis showed R0 resection was the main factor associated with long-term survival. The 3-year overall-survival rate for R0 resection was 48% for endometrial malignancy, 40.6% for ovarian, 49.4% for cervical, 43.8% for vaginal, 59% for bladder, 48.3% for anal, and 48.1% for sarcoma.
Pelvic exenteration remains an important treatment in selected patients with advanced or recurrent nonrectal pelvic malignancy. The range in 3-year overall survival following R0 resection (40%-59%) reflects the diversity of tumor types.
Abstract Background Pelvic exenteration is a radical operative treatment reserved for the management of a number of advanced primary and recurrent pelvic malignancies, including, rectal, ...gynaecological and urological. The advances in radiological staging, surgical techniques and greater use of chemotherapeutic agents haves translated clinically into improvements in the overall survival of this cohort of patients, irrespective of underlying disease pathology. Consequently, a greater proportion of the surviving population will present to healthcare professionals with a range of physical and psychological issues, therefore the profiling and understanding of the health-related quality of life (HrQoL) is integral to the long term management of this cohort of patients. The aim of this systematic review is to identify HrQoL themes from the current literature relevant to patients undergoing a pelvic exenteration. Methods Literature searches were performed in three databases: MEDLINE (1975–November 2015), EMBASE and CINAHL. Each study was evaluated with regards to its design and statistical methodology. Data quality was reviewed in accordance with the Newcastle-Ottowa score and Critical Appraisal Skills Programme Checklist (CAPS) for quantitative and qualitative data accordingly. A narrative synthesis of all identified HrQoL issues was undertaken using the principles of content analysis. Results A total of 24 studies were identified; 20 quantitative and 4 qualitative with 976 patients assessed in total. HrQoL was assessed as the main primary endpoint in 15 studies. The majority of studies were retrospective. Baseline data prior to the initiation of treatments were available in 6 studies alone. Nine themes were identified across the literature, which included body image, social impact, sexual function, treatment expectations, symptoms, communication, psychological impact, relationships and work and finance. Conclusions Pelvic exenteration has a wide ranging impact on patients HrQoL affecting a range of physical and psychological domains.
Palliative pelvic exenteration (PPE) is a technically complex operation with high morbidity and mortality rates, considered in patients with limited life expectancy. There is little evidence to guide ...practice. We performed a systematic review to evaluate the impact of PPE on symptom relief and quality of life (QoL).
A systematic review was conducted according to the PRISMA guidelines using Ovid MEDLINE, EMBASe, and PubMed databases for studies reporting on outcomes of PPE for symptom relief or QoL. Descriptive statistics were used on pooled patient cohorts.
Twenty-three historical cohorts and case series were included, comprising 509 patients. No comparative studies were found. Most malignancies were of colorectal, gynaecological and urological origin. Common indications for PPE were pain, symptomatic fistula, bleeding, malodour, obstruction and pelvic sepsis. The pooled median postoperative morbidity rate was 53.6% (13–100%), the median in-hospital mortality was 6.3% (0–66.7%), and median OS was 14 months (4–40 months). Some symptom relief was reported in a median of 79% (50–100%) of the patients, although the magnitude of effect was poorly measured. Data for QoL measures were inconclusive. Five studies discouraged performing PPE in any patient, while 18 studies concluded that the procedure can be considered in highly selected patients.
Available evidence on PPE is of low-quality. Morbidity and mortality rates are high with a short median OS interval. While some symptom relief may be afforded by this procedure, evidence for improvement in QoL is limited. A highly selective individualised approach is required to optimise the risk:benefit equation.
A systemic review on tuberculosis Natarajan, Arvind; Beena, P M; Devnikar, Anushka V ...
Indian journal of tuberculosis
67, Številka:
3
Journal Article
Recenzirano
Tuberculosis (TB), which is caused by bacteria of the Mycobacterium tuberculosis complex, is one of the oldest diseases known to affect humans and a major cause of death worldwide. Tuberculosis ...continues to be a huge peril disease against the human population and according to WHO, tuberculosis is a major killer of the human population after HIV/AIDS. Tuberculosis is highly prevalent among the low socioeconomic section of the population and marginalized sections of the community. In India, National strategic plan (2017-2025) has a national goal of elimination of tuberculosis by 2025. It requires increased awareness and understanding of Tuberculosis. In this review article history, taxonomy, epidemiology, histology, immunology, pathogenesis and clinical features of both pulmonary tuberculosis (PTB) and extra-pulmonary tuberculosis (EPTB) has been discussed. A great length of detailed information regarding diagnostic modalities has been explained along with diagnostic algorithm for PTB and EPTB. Treatment regimen for sensitive, drug resistant and extensive drug resistant tuberculosis has been summarized along with newer drugs recommended for multi drug resistant tuberculosis. This review article has been written after extensive literature study in view of better understanding and to increase awareness regarding tuberculosis, as a sincere effort that will help eliminate tuberculosis off the face of the earth in near future.
Objective Vacuum‐assisted closure (VAC) has been used in our centre to aid the closure of abdominal wounds. The aim of this study was to examine the clinical outcome of patients in whom VAC therapy ...had been used in conjunction with laparostomy.
Method All patients in whom VAC was used in the management of open abdominal wounds from November 2003 to March 2005 were included in this study.
Results There were 29 patients in the study. Nineteen (65.5%) needed ICU care. Six (20%) patients developed leakage of small bowel contents into the abdominal wound cavity because of intestinal fistulation during the VAC therapy. Four of the six (66%) died, all from multi‐organ failure.
Conclusion Our study has demonstrated a high incidence of intestinal leakage following VAC therapy. The reasons for this are multifactorial. We would recommend caution in using it on patients with bowel anastomoses or enterotomy repairs.
