Background and Objectives
Extended vertical rectus abdominis myocutaneous (eVRAM) flap has been proposed for reconstruction of large pelviperineal defects where traditional VRAM flap is insufficient. ...We present our experience with eVRAM flap for pelviperineal reconstruction following oncologic resection.
Methods
A retrospective study was conducted, including all the patients who underwent reconstruction with eVRAM flap after complex pelvic resection, between 2012 and 2020. EVRAM flap was indicated when traditional VRAM was considered deficient to cover or reach the skin defect or to fill the dead space.
Results
Forty‐four patients were included in the study. Successful reconstruction with eVRAM flap was achieved in 40 patients. There were three flap failures, and one patient died in the second postoperative day because of multiple organ failure. Perineal wound complications occurred in 17 patients (38.6%), eight of them requiring surgical reoperation. Donor site problems were present in five patients (11.4%), and only one patient required surgical closure because of a major dehiscence.
Conclusions
The authors found the eVRAM flap to be a useful and reliable flap for reconstruction of complex pelviperineal wounds, with a low rate of donor site morbidity.
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The objective of the study is to compare 2 techniques for histological handling of rectal cancer specimens, namely whole-mount in a large block vs conventional sampling using small ...blocks, for mesorectal pathological assessment of circumferential resection margin status and depth of tumor invasion into the mesorectal fat.
This is a prospective study including 27 total mesorectal excision specimens of rectal cancer from patients treated for primary rectal carcinoma between 2020 and 2022 in a specialized multidisciplinary Colorectal Unit. For each total mesorectal excision specimen, 2 contiguous representative tumoral slices were selected and comparatively analyzed with whole-mount and small blocks macroscopic dissection techniques, enabling comparison between them in the same surgical specimen. The agreement between the 2 techniques to assess the distance of the tumor from the circumferential resection margin as well as the depth of tumor invasion was evaluated with the Student’s t-test for paired samples, Pearson’s correlation coefficient, and the Bland-Altman method comparison analysis.
Complete mesorectal excision was observed in 8% of cases. Circumferential resection margin involvement was observed in only one case (4 %). The whole-mount and small block techniques obtained similar results when we assessed the distance to the circumferential resection margin (t-test P = 0.8, r = 0.92) and the depth of mesorectal infiltration (t-test P = 0.6, r = 0.95).
Both gross dissection techniques (whole-mount vs multiple small cassettes) are equivalent and reliable to assess the distance to circumferential resection margin and the depth of mesorectal infiltration in the mesorectal fat in rectal cancer staging.
El objetivo del estudio es comparar dos técnicas para el manejo histológico de especímenes de cáncer de recto (el montaje completo en un bloque grande frente al muestreo convencional utilizando bloques pequeños) para la evaluación patológica del estado del margen de resección circunferencial y la profundidad de infiltración tumoral en la grasa mesorrectal.
Este es un estudio prospectivo que incluyó veintisiete especímenes de escisión total de mesorrecto de pacientes tratados por carcinoma de recto primario entre 2020 y 2022 en una Unidad Colorrectal multidisciplinaria especializada. Para cada especimen se seleccionaron dos cortes tumorales representativos contiguos que fueron analizados de manera comparativa utilizando las técnicas de disección macroscópica de montaje completo y la de bloques pequeños, permitiendo una comparación entre ellas en el mismo espécimen quirúrgico. La concordancia entre las dos técnicas para la evaluación de la distancia del tumor al margen de resección circunferencial y la profundidad de infiltración tumoral se evaluó con la prueba t de Student para muestras pareadas, el coeficiente de correlación de Pearson y el análisis de comparación de métodos, descrito por Bland y Altman.
Se observó una escición completa del mesorrecto en el 85%de los casos. El margen de resección circunferencial se consideró afecto en solo un caso (4%). Las técnicas de montaje completo y bloques pequeños obtuvieron resultados similares al evaluar la distancia al margen de resección circunferencial (p = 0,8 en la prueba t, r = 0,92) y la profundidad de infiltración mesorrectal (p = 0,6 en la prueba t, r = 0,95).
Ambas técnicas de disección macroscópica (montaje completo vs. múltiples bloques pequeños) son equivalentes y fiables para evaluar la distancia al margen de resección circunferencial y la profundidad de infiltración tumoral en la grasa mesorrectal en la estadificación del cáncer de recto.
Endoscopic resection offers advantages over surgical resection for early colorectal cancer (ECC). However, there might be a presumed risk of recurrence. We aimed to determine the risk of recurrence ...after endoscopic removal of ECC.
A single-centre series of endoscopic resections for ECC. Patients were stratified according to four risk factors: positive resection margins, Haggitt 4, lymphatic/vascular invasion and tumour budding.
We included 127 patients. Haggitt classification was grade 4 in 54.0%. Positive margins were found in 43 (33.9%), 16 (12.6%) had lymphatic or vascular invasion, and 5 (4.0%) had high grade budding. In 82 (64.5%) endoscopic excision was the definitive treatment, 45 (35.4%) underwent surgery. Six patients (13.3%) had residual tumour on specimen and/or node metastases. Postoperative complications occurred in ten (22.2%). At a median follow-up of 63 months, none of the 82 patients treated with endoscopic resection alone had recurrence. After stratifying patients according to risk factors, those who had residual tumour also had ≥2 risk factors.
Endoscopic follow up might be a valid option for patients with ECC. A risk-adjusted management seems prudent.
Perforated jejunal diverticulitis (PJD) is rare, but it has high mortality rates. The role of nonsurgical management is debated. The aim of this study is to assess the outcomes of medical and ...surgical management of PJD.
A single-centre study on a series of emergency patients diagnosed with PJD between 2010 and 2016 was conducted.
Eleven patients with PJD were treated (seven women). Nine out of 11 were diagnosed by a computed tomography scan, and two were diagnosed at laparotomy. The initial approach was medical treatment in five patients, based on clinical and imaging findings. Four (80%) of these five patients were discharged without the need for surgical intervention. The median hospital stay was 7.5 days. Seven patients required surgery overall with a median length of hospital stay of 10.8 days. Surgical procedures consisted of segmental bowel resection and primary anastomosis in six patients and simple closure in one. There was no perioperative deaths. One patient required percutaneous drainage because of anastomotic leak, and one required reoperation owing to evisceration.
Selected patients with PJD can be successfully managed with conservative approach, based on clinical and computed tomography findings.
INTRODUCTIONEndoscopic resection offers advantages over surgical resection for early colorectal cancer (ECC). However, there might be a presumed risk of recurrence. We aimed to determine the risk of ...recurrence after endoscopic removal of ECC. METHODSA single-centre series of endoscopic resections for ECC. Patients were stratified according to four risk factors: positive resection margins, Haggitt 4, lymphatic/vascular invasion and tumour budding. RESULTSWe included 127 patients. Haggitt classification was grade 4 in 54.0%. Positive margins were found in 43 (33.9%), 16 (12.6%) had lymphatic or vascular invasion, and 5 (4.0%) had high grade budding. In 82 (64.5%) endoscopic excision was the definitive treatment, 45 (35.4%) underwent surgery. Six patients (13.3%) had residual tumour on specimen and/or node metastases. Postoperative complications occurred in ten (22.2%). At a median follow-up of 63 months, none of the 82 patients treated with endoscopic resection alone had recurrence. After stratifying patients according to risk factors, those who had residual tumour also had ≥2 risk factors. CONCLUSIONSEndoscopic follow up might be a valid option for patients with ECC. A risk-adjusted management seems prudent.
Abstract
Background and Aims
Crohn’s disease increases colorectal cancer risk, with high prevalence of synchronous and metachronous cancers. Current guidelines for colorectal cancer in Crohn’s ...disease recommend pan-proctocolectomy. The aim of this study was to evaluate oncological outcomes of a less invasive surgical approach.
Methods
This was a retrospective database analysis of Crohn’s disease patients with colorectal cancer undergoing surgery at selected European and US tertiary centres. Outcomes of segmental colectomy were compared with those of extended colectomy, total colectomy, and pan-proctocolectomy. Primary outcome was progression-free survival. Secondary outcomes included overall survival, synchronous and metachronous colorectal cancer, and major postoperative complications.
Results
Ninety-nine patients were included: 66 patients underwent segmental colectomy and 33 extended colectomy. Segmental colectomy patients were older p = 0.0429, had less extensive colitis p = 0.0002 and no preoperatively identified synchronous lesions p = 0.0109.
Median follow-up was 43 31–62 months. There was no difference in unadjusted progression-free survival p = 0.2570 or in overall survival p = 0.4191 between segmental and extended colectomy. Multivariate analysis adjusting for age, sex, ASA score, and AJCC staging, confirmed no difference for progression-free survival (hazard ratio HR 1.00, p = 0.9993) or overall survival HR 0.77, p = 0.6654. Synchronous and metachronous cancers incidence was 9% and 1.5%, respectively. Perioperative mortality was nil and major complications were comparable 7.58% vs 6.06%, p = 0.9998.
Conclusions
Segmental colectomy seems to offer similar long-term outcomes to more extensive surgery. Incidence of synchronous and metachronous cancers appears much lower than previously described. Further prospective studies are warranted to confirm these results.
Oncological outcomes of self-expanding metallic stent used as a bridge to surgery in potential curative patients with left-sided colonic cancer obstruction remain unclear. The aim of this study was ...to investigate perioperative and mid-term oncological outcomes of 2 of the currently most commonly performed treatments in left-sided colonic cancer obstruction.
This is a retrospective multicenter study including patients with left-sided colonic cancer obstruction treated with curative intent between 2013 and 2017. The presence of metastasis at diagnosis was an exclusion criterion. The primary outcome was to evaluate the noninferiority, in terms of overall survival, of bridge to surgery strategy compared with emergency colonic resection. The secondary outcomes were perioperative morbimortality, disease free survival, local recurrence, and distant recurrence.
A total of 564 patients were included, 320 in the emergency colonic resection group and 244 in the bridge to surgery group. Twenty-seven patients of the bridge-to-surgery group needed urgent operation. Postoperative morbidity rates were statistically higher in the emergency colonic resection group (odds ratio 95% confidence interval 0.37 0.24–0.55, P < .001). There was no difference in 90-day mortality between groups (odds ratio 95% confidence interval 0.85 0.36–1.99, P = .702). The median follow-up was 3.80 years (2.29–4.92). The results show the noninferiority of bridge to surgery versus emergency colonic resection in terms of overall survival (hazard ratio 95% confidence interval) 0.78 0.56–1.07, P = .127). There were no differences in disease free survival, distant recurrence, and local recurrence rates between bridge to surgery and emergency colonic resection groups.
Self-expanding metallic stent as bridge to surgery might not lead to a negative impact on the long-term prognosis of the tumor compared with emergency colonic resection in expert hands and selected patients.
