Intraoperative Electron Beam Radiation Therapy (IOERT) Versus High-Dose-Rate Intraoperative Brachytherapy (HDR-IORT) in Patients With an R1 Resection for Locally Advanced or Locally Recurrent Rectal Cancer.

PURPOSE: Intraoperative radiation therapy (IORT), delivered by intraoperative electron beam radiation therapy (IOERT) or high-dose-rate intraoperative brachytherapy (HDR-IORT), may reduce the local recurrence rate in patients with locally advanced and locally recurrent rectal cancer (LARC and LRRC, respectively). The aim of this study was to compare the oncological outcomes between both IORT modalities in patients with LARC or LRRC who underwent a microscopic irradical (R1) resection. METHODS: All consecutive patients who received IORT because of an R1 resection of LARC or LRRC between 2000 and 2016 in two tertiary referral centers were included. In LARC, a resection margin of ≤2 mm was considered R1. A resection margin of 0 mm was considered R1 in LRRC. RESULTS: In total, 215 patients with LARC were included, of whom 151 (70%) received IOERT and 64 (30%) received HDR-IORT; in addition, 158 patients with LRRC were included, of whom 112 (71%) received IOERT and 46 (29%) received HDR-IORT. After multivariable analyses, the overall survival was not significantly different between the two IORT modalities. The local recurrence-free survival was significantly longer in patients treated with HDR-IORT, both in LARC (hazard ratio [HR], 0.496; 95% CI, 0.253-0.973; P = .041) and LRRC (HR, 0.567; 95% CI, 0.349-0.920; P = .021). In patients with LARC, major postoperative complications were similar for both IORT modalities (IOERT, 30%; HDR-IORT, 27%), whereas in patients with LRRC, the incidence of major postoperative complications was higher after HDR-IORT (IOERT, 26%; HDR-IORT, 46%). CONCLUSIONS: This study showed a significantly better local recurrence-free survival in favor of HDR-IORT in patients with an R1 resection for LARC or LRRC. Optimization of the IOERT technique seems warranted.

A Systematic Review and Meta-analysis on Omentoplasty for the Management of Abdominoperineal Defects in Patients Treated for Cancer.

OBJECTIVE: The objective of this systematic review and meta-analysis was to examine the effects of omentoplasty on pelviperineal morbidity following abdominoperineal resection (APR) in patients with cancer. BACKGROUND: Recent studies have questioned the use of omentoplasty for the prevention of perineal wound complications. METHODS: A systematic review of published literature since 2000 on the use of omentoplasty during APR for cancer was undertaken. The authors were requested to share their source patient data. Meta-analyses were conducted using a random-effects model. RESULTS: Fourteen studies comprising 1894 patients (n = 839 omentoplasty) were included. The majority had APR for rectal cancer (87%). Omentoplasty was not significantly associated with the risk of presacral abscess formation in the overall population (RR 1.11; 95% CI 0.79-1.56), nor in planned subgroup analysis (n = 758) of APR with primary perineal closure for nonlocally advanced rectal cancer (RR 1.06; 95% CI 0.68-1.64). No overall differences were found for complicated perineal wound healing within 30 days (RR 1.30; 95% CI 0.92-1.82), chronic perineal sinus (RR 1.08; 95% CI 0.53-2.20), and pelviperineal complication necessitating reoperation (RR 1.06; 95% CI 0.80-1.42) as well. An increased risk of developing a perineal hernia was found for patients submitted to omentoplasty (RR 1.85; 95% CI 1.26-2.72). Complications related to the omentoplasty were reported in 4.6% (95% CI 2.5%-8.6%). CONCLUSIONS: This meta-analysis revealed no beneficial effect of omentoplasty on presacral abscess formation and perineal wound healing after APR, while it increases the likelihood of developing a perineal hernia. These findings do not support the routine use of omentoplasty in APR for cancer.

Acute malignant obstruction in patients with peritoneal carcinomatosis: The role of palliative surgery.

INTRODUCTION: Patients with peritoneal carcinomatosis who do not have curative treatment options often develop acute obstructive symptoms and when conservative management fails, surgical treatment is the remaining option. However, palliative surgery is associated with high morbidity and mortality and the chance of success is unclear. The aim of this study was to evaluate outcomes of palliative surgery and to provide guidance for surgeons, medical oncologists and patients in their decision-making. METHODS: All consecutive patients who underwent palliative surgery for acute obstruction caused by peritoneal carcinomatosis between January 2005 and October 2017 where identified. RESULTS: In total 148 patients underwent surgery. Primary malignancy was colorectal cancer (28.4%), neuroendocrine tumor (20.3%), ovarian cancer (14.2%) or 'other' (37.2%). Median length of postoperative hospital stay was 16 days (IQR 9-24). More than half (58.1%) of the patients developed postoperative complications, 29.1% developed ≥2 complications. In-hospital mortality was 8.8%. Readmission (56.1%) and re-obstruction (35.0%) were common. Median overall survival was 119 days (IQR 48-420). Patients with a neuroendocrine tumor had a significantly better overall survival compared to other primary malignancies (p < 0.001). Patients who developed an obstruction during or within 6 months after treatment with chemotherapy had a worse overall survival (p < 0.001), compared to patients treated with chemotherapy longer than 6 months ago, or patients not treated with chemotherapy. CONCLUSION: Palliative surgery is associated with high rates of complications and readmission and re-obstruction are common. Comfort care is often a better option than surgery, especially in patients with disease progression under recent treatment with chemotherapy.

The influence of hospital volume on long-term oncological outcome after rectal cancer surgery.

PURPOSE: The association between hospital volume and outcome in rectal cancer surgery is still subject of debate. The purpose of this study was to assess the impact of hospital volume on outcomes of rectal cancer surgery in the Netherlands in 2011. METHODS: In this collaborative research with a cross-sectional study design, patients who underwent rectal cancer resection in 71 Dutch hospitals in 2011 were included. Annual hospital volume was stratified as low (< 20), medium (20-50), and high (≥ 50). RESULTS: Of 2095 patients, 258 patients (12.3%) were treated in 23 low-volume hospitals, 1329 (63.4%) in 40 medium-volume hospitals, and 508 (24.2%) in 8 high-volume hospitals. Median length of follow-up was 41 months. Clinical tumor stage, neoadjuvant therapy, extended resections, circumferential resection margin (CRM) positivity, and 30-day or in-hospital mortality did not differ significantly between volume groups. Significantly, more laparoscopic procedures were performed in low-volume hospitals, and more diverting stomas in high-volume hospitals. Three-year disease-free survival for low-, medium-, and high-volume hospitals was 75.0, 74.8, and 76.8% (p = 0.682). Corresponding 3-year overall survival rates were 75.9, 79.1, and 80.3% (p = 0.344). In multivariate analysis, hospital volume was not associated with long-term risk of mortality. CONCLUSIONS: No significant impact of hospital volume on rectal cancer surgery outcome could be observed among 71 Dutch hospitals after implementation of a national audit, with the majority of patients being treated at medium-volume hospitals.