A Comparison of the Short-term Outcomes of Three Flap Reconstruction Techniques Used After Beyond Total Mesorectal Excision Surgery for Anorectal Cancer.

BACKGROUND: Surgery for advanced or recurrent pelvic malignancy can result in perineal defects that cannot be closed by wound edge approximation. Myocutaneous flaps can fill the defect and accelerate healing. No reconstruction has been proven to be superior to the others. OBJECTIVE: This study aimed to compare 3 flap procedures after beyond total mesorectal excision surgery. DESIGN: This is a retrospective analysis of a prospective database, according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. SETTINGS: This study was performed at a tertiary hospital. PATIENTS: Consecutive series of patients who required flap reconstruction after beyond total mesorectal excision surgery between 2007 and 2016 were included. MAIN OUTCOME MEASURES: Short-term outcomes after oblique rectus abdominis flap vs vertical rectus abdominis flap vs inferior gluteal artery perforator flap reconstruction were evaluated. RESULTS: Included are 65 (59%) oblique rectus abdominis flap, 30 (27.3%) vertical rectus abdominis flap, and 15 (13.7%) inferior gluteal artery perforator flap outcomes. Sacrectomy was performed in 12 (18.5%), 10 (33.3%), and 8 (53.3%) patients (p = 0.016). Preoperative radiotherapy was used in 60 (92.3%), 26 (86.7%), and 11 (73.3%) patients (p = 0.11). Flap infection and dehiscence occurred in 7 (10.8%), 1 (3.3%), and 4 (26.7%) patients. There was an increased risk of flap complication with inferior gluteal artery perforator flap vs vertical rectus abdominis flap (p = 0.036). Inferior gluteal artery perforator flap (OR, 6.26; p = 0.02) and obesity (OR, 4.96; p = 0.02) were associated with flap complications. Only complications of the oblique rectus abdominis flap decreased significantly over time (p = 0.03). The length of stay and complete (R0) resection rate were not different between the groups. LIMITATIONS: This study was limited because of its retrospective nature and because it was conducted at a single center. CONCLUSIONS: The techniques appear comparable. The approaches should be considered complementary, and the choice should be individualized. See Video Abstract at http://links.lww.com/DCR/B141. COMPARACIÓN DE RESULTADOS A CORTO PLAZO DE TRES TÉCNICAS DE RECONSTRUCCIÓN CON COLGAJO UTILIZADAS DESPUÉS DE LA CIRUGÍA DE ESCISIÓN MESORRECTAL TOTAL EXTENDIDA PARA EL CÁNCER ANORRECTAL: La cirugía para malignidad pélvica avanzada o recurrente puede provocar defectos perineales, que no pueden cerrarse por aproximación de los bordes de la herida. Los colgajos miocutáneos pueden llenar el defecto y acelerar la curación. Ninguna reconstrucción ha demostrado ser superior a las demás.Comparar tres procedimientos de colgajo después de una cirugía de escisión mesorrectal total extendida.Análisis retrospectivo de una base de datos prospectiva, de acuerdo con la Declaración de Fortalecimiento de los informes de estudios observacionales en epidemiología.Hospital de tercer nivel.Series consecutivas de pacientes que requirieron reconstrucción con colgajo después de una cirugía de escisión mesorrectal total extendida entre 2007 y 2016.Resultados a corto plazo después del colgajo oblicuo recto abdominal versus colgajo vertical recto abdominal versus reconstrucción del colgajo perforador de la arteria glútea inferior.Se incluyen 65 (59%) colgajo oblicuo recto abdominal oblicuo, 30 (27.3%) colgajo vertical recto abdominal y 15 (13.7%) colgajo perforador de la arteria glútea inferior. Sacrectomía se realizó en 12 (18.5%), 10 (33.3%) y 8 (53.3%) pacientes respectivamente (p = 0.016). La radioterapia preoperatoria se utilizó en 60 (92.3%), 26 (86.7%) y 11 (73.3%) (p = 0,11). La infección del colgajo y la dehiscencia ocurrieron en 7 (10.8%), 1 (3.3%) y 4 (26.7%). Hubo un mayor riesgo de complicación con el colgajo perforador de la arteria glútea inferior en comparación al colgajo vertical del recto abdominal (p = 0.036). El colgajo perforador de la arteria glútea inferior (OR 6.26, p = 0.02) y la obesidad (OR 4.96, p = 0.02) se asociaron con complicaciones del colgajo. Solo las complicaciones del colgajo oblicuo recto abdominal disminuyeron significativamente con el tiempo (p = 0.03). La duración de la estancia hospitalaria y la tasa de resección completa (R0) no fue diferente entre los grupos.Estudio retrospectivo en centro único.Las técnicas parecen comparables. Los enfoques deben considerarse complementarios y la elección individualizada. Consulte Video Resumen en http://links.lww.com/DCR/B141.

Predictors of short-term readmission after beyond total mesorectal excision for primary locally advanced and recurrent rectal cancer.

Unplanned readmissions heavily affect the cost of health care and are used as an indicator of performance. No clear data are available regarding beyond-total mesorectal excision (bTME) procedure. Aim of the study is to identify patient-related and surgery-related factors influencing the 30-day readmissions after bTME. Retrospective data were collected from 220 patients who underwent bTME procedures at single centre between 2006 and 2016. Patient-related and operative factors were assessed, including body mass index (BMI), age, gender, American Society of Anaesthesiologists' (ASA) score, preoperative stage, neo-adjuvant therapy, primary tumour vs recurrence, the extent of surgery. The readmission rate was 8.18%. No statistically significant association was found with BMI, ASA score, length of stay and stay in the intensive care unit, primary vs recurrent tumour or blood transfusions. Not quite statistically significant was the association with pelvic side wall dissection (OR 3.32, p = 0.054). Statistically significant factors included preoperative stage > IIIb (OR: 4.77, p = 0.002), neo-adjuvant therapy (OR: 0.13, p = 0.0006), age over 65 years (OR: 5.96, p = 0.0005), any re-intervention during the first admission (OR: 7.4, p = 0.0001), and any post-operative complication (OR: 9.01, p = 0.004). The readmission rate after beyond-TME procedure is influenced by patient-related factors as well as post-operative morbidity.

The obesity paradox in beyond total mesorectal excision surgery for locally advanced and recurrent rectal cancer.

The objective is to investigate preoperative body mass index (BMI) in patients receiving beyond total mesorectal excision (bTME) surgery. The primary end point is length of postoperative stay. Secondary end points are length of intensive care stay, postoperative morbidity and overall survival. BMI is the most commonly used anthropometric measurement of nutrition and studies have shown that overweight and obese patients can have improved surgical outcomes. Patients who underwent a bTME operation for locally advanced or recurrent rectal cancer were put into three BMI (kg/m2) groups of normal weight (18.5-24.9), overweight (25-29.9) and obese (≥ 30) for analysis. Included are 220 consecutive patients from a single centre. The overall length of stay, in days ± standard deviation (range), for normal weight, overweight and obese patients was 21.14 ± 16.4 (6-99), 15.24 ± 4.3 (7-32) and 19.10 ± 9.8 (8-62) respectively (p = 0.002). The mean ICU length of stay was 5.40 ± 9.1 (1-69), 3.37 ± 2.4 (0-19) and 3.60 ± 2.4 (1-14), respectively (p = 0.030). There was no significant difference between the three groups in terms of postoperative morbidity or overall survival. Patients with a normal weight BMI in this cohort have a significantly longer length of stay in ICU and in hospital than overweight or obese patients. This is seen with no significant difference in morbidity or overall survival.

Discrepancies between NCCN and ESMO guidelines in the management of anal cancer: a qualitative review.

There is an ever-growing need, with the ongoing developments in research and the progress towards patient centered care, to delineate standardized protocols of management of anal cancer. However, guidelines from different societies show some degree of disagreement. This is a systematic review of the literature to identify similarities and discrepancies between the guidelines for the management of anal cancer drafted by the European Society for Medical Oncology (ESMO) and by the National Comprehensive Cancer Network (NCCN). We found essentially similar management for investigation, diagnosis, chemotherapy regimens, and radiotherapy doses in both ESMO and NCCN recommendations in the management of anal cancer. There were few differences, which included the levels of evidence and grades of recommendations, the delineation of radiotherapy fields, and the treatment of the elderly and personalized medicine based on genetics. The follow-up regime is also marginally different in the first 2 years. Even if the observed differences may be justified by a different implementation of evidence-based medicine among different countries for particular management modalities of anal cancer, we identified the grey areas which need further study. In addition, these facets should be assessed more carefully when planning future guidelines.

Colorectal cancer diagnosed during pregnancy: systematic review and treatment pathways.

The aim of this study was to identify the mode of presentation and incidence of colorectal cancer in pregnancy (CRC-p), assess the outcomes of the mother and foetus according to gestational age, treatment delivered and cancer features and location. A systematic review of the literature was carried out to identify studies reporting on CRC-p and pooled analysis of the reported data. Seventy-nine papers reporting on 119 patients with unequivocal CRC-p were included. The calculated pooled risk is 0.002% and age at diagnosis has decreased over time. The median age at diagnosis was 32 (range, 17-46) years. Twelve per cent, 41 and 47% of CRC-p were diagnosed during the first, second and third trimester. The CRC-p site was the colon in 53.4% of cases, the rectum in 44% and multiple sites in 2.6%. Bleeding occurred in 47% of patients, abdominal pain in 37.6%, constipation in 14.1%, obstruction in 9.4% and perforation in 2.4%. Out of 82 patients whose treatment was described, 9.8% received chemotherapy during pregnancy. None of their newborns developed permanent disability, one developed hypothyroidism and 72% of newborns were alive. Vaginal delivery was possible in 60% of cases. Anterior resection was performed in 30% of patients and abdominoperineal excision of the rectum in 14.9%. Five patients had either synchronous (60%) or metachronous liver resection (40%). The median survival in these patients was 42 (0-120) months. Fifty-five per cent of patients were alive at the last available follow-up. The median survival of the mother was 36 (0-360) months. Patients with rectal cancer had longer survival compared with patients with colon cancer (P=0.0072). CRC-p is rare, leading to symptoms being overlooked, and diagnosis made at advanced stages. Cases described in the literature include patients who had cancer before pregnancy or developed it after delivery. Survival has not increased over time and the management of these patients requires collaboration between specialties and active interaction with the patients.

A Systematic Review to Assess Resection Margin Status After Abdominoperineal Excision and Pelvic Exenteration for Rectal Cancer.

OBJECTIVE: The aim of this study was to assess resection margin status and its impact on survival after abdominoperineal excision and pelvic exenteration for primary or recurrent rectal cancer. SUMMARY OF BACKGROUND DATA: Resection margin is important to guide therapy and to evaluate patient prognosis. METHODS: A meta-analysis was performed to assess the impact of resection margin status on survival, and a regression analysis to analyze positive resection margin rates reported in the literature. RESULTS: The analysis included 111 studies reporting on 19,607 participants after abdominoperineal excision, and 30 studies reporting on 1326 participants after pelvic exenteration. The positive resection margin rates for abdominoperineal excision were 14.7% and 24.0% for pelvic exenteration. The overall survival and disease-free survival rates were significantly worse for patients with positive compared with negative resection margins after abdominoperineal excision [hazard ratio (HR) 2.64, P < 0.01; HR 3.70, P < 0.01, respectively] and after pelvic exenteration (HR 2.23, P < 0.01; HR 2.93, P < 0.01, respectively). For patients undergoing abdominoperineal excision with positive resection margins, the reported tumor sites were 57% anterior, 15% posterior, 10% left or right lateral, 8% circumferential, 10% unspecified. A significant decrease in positive resection margin rates was identified over time for abdominoperineal excision. Although positive resection margin rates did not significantly change with the size of the study, some small size studies reported higher than expected positive resection margin rates. CONCLUSIONS: Resection margin status influences survival and a multidisciplinary approach in experienced centers may result in reduced positive resection margins. For advanced anterior rectal cancer, posterior pelvic exenteration instead of abdominoperineal excision may improve resection margins.

Integrated Patient Coordination System (IntPaCS): a bespoke tool for surgical patient management.

BACKGROUND: Efficient handover of patient information is fundamental for patient care and service efficiency. An audit exploring surgeons' views on written handover within a Trust's surgical specialties concluded that clear deficiencies existed. Such concerns have been echoed in the General Medical Council's guidance on safe surgical handover. AIMS: To design and implement bespoke software for surgical handover using the audit results of surgeons' perceptions of existing processes. To gain feedback from the surgical department on this new software and implement a long-term sustainability strategy. METHODS: Following an initial review, a proposal was presented for a new patient management tool. The software was designed and developed in-house to reflect the needs of our surgeons. The bespoke programme used open-source coding and was maintained on a secure server. A review of surgical handover occurred 12 and 134 weeks post-implementation of the new software. RESULTS: Integrated Patient Coordination System (IntPaCS) was successfully developed and delivered. The system is a centralised platform that enables the visualisation, handover and audit/research of surgical inpatient information in any part of the hospital. Feedback found that clinicians found it less stressful to create a post-take handover (60% vs 36%) than using a Word document. IntPaCS was found to be quicker to use too (15 min (SD 4) vs 24 min (SD 7.5)). Finally, the new system was considered safer with less reported missing/incorrect patient data (48% vs 9%). CONCLUSIONS: This study has shown that careful use of emerging technology and innovation over time has the potential to improve all aspects of clinical governance.