Total neoadjuvant therapy is an alternative to neoadjuvant chemoradiation alone for rectal cancer and has the benefits of more completion of planned therapy, increased downstaging, earlier treatment ...of micrometastases, and assessment of chemosensitivity; however, it may increase surgical complications, especially with increased radiation-to-surgery interval.
The study aimed to determine the impact of total neoadjuvant therapy on postoperative complications compared with neoadjuvant chemoradiation alone.
Retrospective cohort study.
Single tertiary referral center.
The patient included was a stage II/III rectal cancer patient who underwent total neoadjuvant therapy or long-course neoadjuvant chemoradiation followed by surgical resection from 2018-2020.
The main outcome measures included severe postoperative complications (Clavien-Dindo grade ≥3).
Of 181 patients, 86 (47.5%) underwent total neoadjuvant therapy and 95 (52.5%) underwent neoadjuvant chemoradiation. There was no difference in severe postoperative complications or any complications. There was also no difference in the rate of complete total mesorectal excision or negative circumferential margin. Total neoadjuvant therapy had a mean operative time of 355.5 minutes and estimated blood loss of 263.6 mL compared with 326.7 minutes and 297.5 mL in the neoadjuvant chemoradiation group. Total neoadjuvant therapy patients had a lower mean lymph node yield than neoadjuvant chemoradiation patients. On multivariable analysis, total neoadjuvant therapy was associated with increased operative time (OR, 1.19; p < 0.001) and estimated blood loss (OR, 1.22; p < 0.001) and decreased lymph node yield (OR, 0.67; p < 0.001). There was no difference in severe complications or any complications.
Selection bias uncontrolled by modeling.
We found no difference in risk of postoperative complications between patients who received total neoadjuvant therapy vs neoadjuvant chemoradiation. Total neoadjuvant therapy patients had longer operations and greater estimated blood loss. This may be a reflection of increased operative difficulty because of increased radiation-to-surgery interval and/or the effects of chemotherapy; however, the absolute differences were small and, therefore, should be interpreted cautiously. See Video Abstract at http://links.lww.com/DCR/C44 .
ANTECEDENTES:La terapia neoadyuvante total es una alternativa a la quimiorradiación neoadyuvante sola para el cáncer de recto y tiene los beneficios de una mayor finalización de la terapia planificada, mayor reducción del estadiage, tratamiento más temprano de las micrometástasis y evaluación de la quimiosensibilidad; sin embargo, puede aumentar las complicaciones quirúrgicas, especialmente con un mayor intervalo entre la radiación y la cirugía.OBJETIVO:Determinar el impacto de la terapia neoadyuvante total sobre las complicaciones posoperatorias en comparación con la quimiorradiación neoadyuvante sola.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro único de referencia terciario.PACIENTES:Paciente con cáncer de recto en estadio II/III que se sometieron a terapia neoadyuvante total o quimiorradiación neoadyuvante de larga duración seguida de resección quirúrgica entre 2018 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Complicaciones postoperatorias graves (grado de Clavien-Dindo ≥3).RESULTADOS:De 181 pacientes, 86 (47,5%) se sometieron a terapia neoadyuvante total y 95 (52,5%) se sometieron a quimiorradioterapia neoadyuvante. No hubo diferencia en las complicaciones postoperatorias graves o cualquier otra complicación. Tampoco hubo diferencia en la tasa de escisión mesorrectal total completa o margen circunferencial negativo. La terapia neoadyuvante total tuvo un tiempo operatorio promedio de 355,5 minutos y una pérdida de sangre estimada de 263,6 ml en comparación con 326,7 minutos y 297,5 ml en el grupo de quimiorradiación neoadyuvante. Los pacientes con terapia neoadyuvante total tuvieron una media de ganglios linfáticos más bajo en comparación con los pacientes con quimiorradioterapia neoadyuvante. En el análisis multivariable, la terapia neoadyuvante total se asoció con un mayor tiempo operatorio (OR = 1,19, p < 0,001) y pérdida de sangre estimada (OR = 1,22, p < 0,001) y menor cantidad los ganglios linfáticos (OR = 0,67, p < 0,001). No hubo diferencia en las complicaciones graves o cualquier complicación.LIMITACIONES:Sesgo de selección no controlado por modelado.CONCLUSIONES:No encontramos diferencias en el riesgo de complicaciones postoperatorias entre los pacientes que recibieron terapia neoadyuvante total versus quimiorradiación neoadyuvante. Los pacientes con terapia neoadyuvante total tuvieron operaciones más prolongadas y una mayor pérdida de sangre estimada. Esto puede ser un reflejo de una mayor dificultad quirúrgica como resultado de un mayor intervalo entre la radiación y la cirugía y/o los efectos de la quimioterapia; sin embargo, las diferencias absolutas fueron pequeñas y, por lo tanto, deben interpretarse con cautela. Consulte Video Resumen en http://links.lww.com/DCR/C44 . (Traducción- Dr. Francisco M. Abarca-Rendon ).
Unexpected focal colorectal 18 F-fluorodeoxyglucose uptake has become a common clinical dilemma. The aim of this study was to identify the clinical significance of incidentally detected colorectal ...lesions on PET/CT scans by comparing positive PET/CT findings with endoscopic and histopathological analysis.
A retrospective analysis of a colonoscopy database was reviewed. All patients that underwent colonoscopy secondary to focal incidental uptake on PET/CT were evaluated. PET/CT findings were correlated with endoscopic and histopathological results.
84 patients underwent colonoscopy secondary to incidental focal colorectal uptake on PET/CT. A total of 63 patients had an endoscopic and histological confirmation of the area of abnormality, for a positive predictive value of 75%. Newly diagnosed colorectal carcinoma was discovered in 13 patients (15.4%) and forty-four patients (52.3%) were discovered to have a premalignant lesion.
Incidental focal colorectal uptake of 18 F-fluorodeoxyglucose is associated with a substantial risk of underlying neoplastic colorectal lesions. Early identification of these lesions may alter patient management and treatment plans.
•Incidental focal colorectal uptake on PET/CT scan is associated with a substantial risk of neoplastic colorectal lesions.•Colonoscopy should be performed judiciously in patients suitable for further treatment.•Early identification of these lesions may alter patient management and treatment plans.
Introduction
Mucosal lesions located at the ileocecal valve may be challenging for endoscopic intervention because of angulated anatomy and a thinner wall with narrower lumen when compared to other ...locations of the bowel. This study aimed to evaluate the management and outcomes of ileocecal valve lesions treated endoscopically.
Material and methods
Patients with mucosal neoplasms involving the ileocecal valve managed with advanced endoscopy at a quaternary care hospital between 2011 and 2021 were included from a prospectively collected database. Patient demographics, lesion characteristics, complications, and outcomes are reported.
Results
From 1005 lesions, 80 patients (8%) underwent resection for neoplasms involving ileocecal valve by ESD (
n
= 38), hybrid ESD (
n
= 38), EMR (
n
= 2), and CELS (
n
= 2). The median age of the study group was 63(37–84) years, and 50% of patients were female. The median lesion size was 34 mm (5–75). The mean procedure time was 66 ± 44 min(range:18–200). The dissection was completed as piecemeal in 41(51%) patients and 35(44%) had
en-bloc
dissection. Seven(8%) endoscopic interventions required conversion to laparoscopic surgery due to inability to lift the mucosa(
n
= 4) and perforation(
n
= 3). No immediate bleeding occurred in the study group. Five patients had late rectal bleeding and two were admitted with post-polypectomy pain within 30 days of intervention. Pathology revealed 4(5%) adenocarcinomas, 33(41.2%) tubular adenomas, 30(37.8%) tubulovillous adenomas, and 5(6.2%) sessile serrated adenomas. Sixty-seven (84.5%) patients completed at least one follow-up colonoscopy and were followed for a median of 11(0–64) months. Six (8.9%) patients had recurrence and were managed with subsequent endoscopic removal.
Conclusion
Advanced endoscopy can be safely and effectively performed for the management of ileocecal valve polyps with low complication and acceptable recurrence rates. Advanced endoscopy promises an alternative approach to oncologic ileocecal resection while attaining organ preservation. Our study demonstrates the impact of advanced endoscopy for the treatment of mucosal neoplasms involving ileocecal valve.
The rate of stoma closure after cytoreductive surgery (CRS) ± hypethermic intraperitoneal chemotherapy (HIPEC) is reportedly low. This study aimed to assess predictors of stoma reversal.
We ...retrospectively analyzed all patients who underwent CRS with temporary ostomy at our center between 2009 and 2021, and compared reversed versus non-reversed patients.
Out of 625 CRS, 72 (11.5%) patients were included (median age 62 years, 65% female, 75% with HIPEC): 53 (74%) achieved stoma closure. Reversed patients had less high grade tumors, more appendiceal mucinous neoplasms, less ovarian primaries, and more loop ileostomies. The most common reason for non-reversal was disease progression or death (14 cases, 74%). At multivariate analysis, low/intermediate grade tumor differentiation was associated with higher stoma closure rate.
In our study, 74% of patients achieved stoma closure after CRS with temporary ostomy. The strongest predictor of stoma closure was a low/intermediate grade tumor.
•In this monocentric study on stoma reversal after cytoreductive surgery (CRS) with temporary ostomy including 72 patients, reversal was achieved in 74%.•The most common reason for non-reversal was disease progression or death.•Patients who achieved reversal had less high-grade tumors and higher disease-free survival than non-reversed patients, while, operative time, extent of surgery, concomitant hyperthermic intraperitoneal chemotherapy and postoperative morbidity was similar.•Low/intermediate grade tumor was the only predictor of stoma reversal at multivariate analysis.
Background
Appendiceal orifice lesions are often managed operatively with limited or oncologic resections. The aim is to report the management of appendiceal orifice mucosal neoplasms using advanced ...endoscopic interventions.
Methods
Patients with appendiceal orifice mucosal neoplasms who underwent advanced endoscopic resections between 2011 and 2021 with either endoscopic mucosal resection (EMR), endoscopic mucosal dissection (ESD), hybrid ESD, or combined endoscopic laparoscopic surgery (CELS) were included from a prospectively collected dataset. Patient and lesion details and procedure outcomes are reported.
Results
Out of 1005 lesions resected with advanced endoscopic techniques, 41 patients (4%) underwent appendiceal orifice mucosal neoplasm resection, including 39% by hybrid ESD, 34% by ESD, 15% by EMR, and 12% by CELS. The median age was 65, and 54% were male. The median lesion size was 20 mm. The dissection was completed piecemeal in 49% of patients. Post-procedure, one patient had a complication within 30 days and was admitted with post-polypectomy abdominal pain treated with observation for 2 days with no intervention. Pathology revealed 49% sessile-serrated lesions, 24% tubular adenomas, and 15% tubulovillous adenomas. Patients were followed up for a median of 8 (0–48) months. One patient with a sessile-serrated lesion experienced a recurrence after EMR which was re-resected with EMR.
Conclusion
Advanced endoscopic interventions for appendiceal orifice mucosal neoplasms can be performed with a low rate of complications and early recurrence. While conventionally lesions at the appendiceal orifice are often treated with surgical resection, advanced endoscopic interventions are an alternative approach with promising results which allow for cecal preservation.
The optimal surgical treatment approach for splenic flexure colon cancers remains controversial regarding the type of resection.
We hypothesized that both extended and segmental resections have ...similar surgical and oncologic outcomes. A retrospective review of prospectively collected database was performed on all patients who had colectomy for splenic flexure colon cancer between 1996 and 2018.
Of 142 patients, 119 underwent extended resection; therefore, this group was compared with the group which underwent segmental resection (n = 23). The groups were similar in age, sex, ASA scores, operative times, estimated blood loss, hospital length of stay, and postoperative complication rates (p > 0.05). Median follow-up was 9.58 years (IQR:5.46–16.48). Multivariable regression models demonstrated no significant association between resection approach and disease-free survival (HR 1.63 95%CI:0.91–2.92), as well as overall survival (HR 1.80 95%CI:0.97; 3.36).
In the treatment of splenic flexure colon cancer, segmental colon resections have similar oncologic outcomes when compared to extended colectomies.
•Surgical treatment of splenic flexure colon cancer remains controversial regarding extent of colon resection.•Dual lymphatic drainage in splenic flexure enquiries optimal extent of surgical resection and mesenteric vascular ligation.•The overall and disease free survival were similar for extended and segmental colonic resection groups.
Background
The laparoscopic approach for colon cancer has become widely accepted. However, its safety for T4 tumors, and particularly for T4b tumors when local invasion to adjacent structures occurs, ...remains controversial. This study aimed to compare short and long-term outcomes in patients undergoing laparoscopic vs. open resection for T4a and T4b colon cancers.
Methods
A prospectively maintained, single-institution database was queried to identify patients with pathological stage T4a and T4b colon adenocarcinomas electively operated on between 2000 and 2012. Patients were divided into two groups based on the use of laparoscopy. Patient characteristics, perioperative, and oncologic outcomes were compared.
Results
One hundred and nineteen patients 41 laparoscopic (L), 78 open surgeries (O) met the inclusion criteria. No difference was observed in age, gender, BMI, ASA, and procedure between groups. Tumors treated by L were smaller than O (
p
= 0.003). No difference was observed in morbidity, mortality, reoperation, or readmission between the groups. Length of hospital stay was shorter in L than O (6 vs. 9 days,
p
= 0.005). Conversion to open was necessary in 22% of all T4 tumors laparoscopic cases. However, when tumors were subdivided by pT4 classification, conversion was necessary for 4 of 34 (12%) pT4a patients vs. 5 of 7 (71%) pT4b patients (
p
= 0.003). In the pT4b cohort (
n
= 37), more tumors were treated by the open approach (30 vs. 7). For pT4b tumors, the R0 resection rate was 94% (86% in L vs. 97% in O,
p
= 0.249). The use of laparoscopy did not impact overall survival, disease-free survival, cancer-specific survival, or tumor recurrence overall in all T4 or T4a and T4b tumors.
Conclusions
Laparoscopic surgery can be safely performed in pT4 tumors with similar oncologic outcomes as compared to open surgery. However, for pT4b tumors, the conversion rate is very high. The open approach may be preferable.
Background
The surface morphology of colorectal polyps is well correlated with submucosal invasion in Eastern Countries but not in North America. We aimed to investigate associations between the ...Paris classification, surface morphology, and Kudo pit pattern to submucosal invasion in advanced endoscopic resection techniques.
Methods
We retrospectively analyzed prospectively collected data of consecutive advanced endoscopic procedures conducted by a single surgeon between August 2017 and October 2018. The data included patients’ demographics, the endoscopic finding of polyps (Paris, Kudo, and surface morphology), and pathology results.
Results
The study consisted of 138 lesions, and the mean age was 67 ± 10 years. The most common polyp locations were cecum (
n
= 41, 30%) followed by ascending colon (
n
= 28, 20%), and sigmoid colon (
n
= 18, 13%).The median polyp size was 30 mm (25–40). The
en-bloc
resection rate was 96%, and 11 (8%) polyps had adenocarcinoma with submucosal invasion. Nine patients (6.5%) had late bleeding, and 3 (2.2%) perforation occurred. Polyps with pit pattern of Kudo IV (
n
= 4, 36.4%) and Kudo V (
n
= 6, 54.5%) were associated with submucosal invasion.
Conclusions
Surface morphology and pit pattern can predict submucosal invasion in the North American patient population. Polyp morphology may aid polyp selection for advanced endoscopic interventions.
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