Review of Neoadjuvant Chemotherapy Alone in Locally Advanced Rectal Cancer.

BACKGROUND: Currently, the standard management of locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy followed by resection. Despite the significant improvement in local recurrence, survival benefits are not gained due to distant failure and radiotherapy-associated toxicity. Compliance to adjuvant chemotherapy after preoperative chemoradiotherapy is also poor. Neoadjuvant chemotherapy alone followed by surgery may be an alternative. The objective of this review is to determine the efficacy of neoadjuvant chemotherapy alone in operable LARC. MATERIALS AND METHODS: Electronic databases searched (from database inception-December 2013) were Medline, PubMed, Embase, Scopus, Cochrane library, and the Clinical Trials Register. Specific journals were also hand searched. The selection criteria were studies published in English investigating stage II-III non-metastatic rectal cancer patients treated with neoadjuvant chemotherapy (oral, intravenous or rectal route) followed by curative resection. The primary outcome measure was tumour response. Secondary outcome measures included acute toxicity, operative morbidity, R0 resection, local recurrence, overall survival (OS) and disease-free survival (DFS). RESULTS: One randomised phase III trial, six single-arm phase II trials and one retrospective case series study were eligible for inclusion. Six studies administered fluoropyrimidine-based multiple agent regimens and two studies administered fluorouracil-based monotherapy. The studies with multiple agents and stronger chemotherapy regimens (intravenous and/or oral) followed by delayed surgery showed better tumour response rates. The overall objective response rate was good and ranged from 62.5 to 93.7 %. Pathological complete response ranged from 3.8 to 33.3 %. The R0 resection and compliance rates were also high ranging from 90 to 100 % and 72 to 100 %, respectively. Grade 3-4 toxicities ranged from 2.3 to 39 %. Four- to 5-year OS and DFS ranged from 67.2 to 91 % and 60.5 to 84 %, respectively. CONCLUSION: This review demonstrates that neoadjuvant chemotherapy could be affectively administered in LARC and could provide a good alternative to chemoradiotherapy in moderate-risk rectal cancers without compromising short- and long-term outcomes.

Medium-Term Recurrence and Quality of Life Assessment Using the Hernia-Specific Carolinas Comfort Scale Following Laparoscopic Inguinal Hernia Repair.

OBJECTIVES: To determine the long-term outcomes and quality of life (QoL) following laparoscopic mesh repair of inguinal hernias using the hernia-specific Carolinas Comfort Scale(®) (CCS) questionnaire (Carolinas Laparoscopic and Advanced Surgery Program, Carolinas HealthCare System, Charlotte, NC). MATERIALS AND METHODS: All patients who underwent elective primary or recurrent laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair from January 2005 to May 2010 were identified from a prospectively maintained clinical database. Baseline patient characteristics were recorded, including occupation, in addition to mean operating time, hernia recurrence rates, and postoperative CSS. RESULTS: Four hundred fifty-nine patients underwent surgery during the study period. The median follow-up interval from the date of operation to the date the questionnaire sent was 23 months (interquartile range, 32 months), and the total number of valid responses was 250. The median age of patients was 58 years (interquartile range, 21 years). The median operating time was 42 minutes (interquartile range, 21 minutes). Thirty-five patients (15%) and 15 patients (12%) had bilateral and recurrent hernia repairs, respectively. Three patients (1.1%) were confirmed to have hernia recurrence. Analysis of the CSS scores revealed that 41 patients (16%) reported pain, 44 (18%) reported mesh sensation, and 25 (10%) reported movement limitation. However, severe or disabling mesh-related symptoms were present in 5 patients (2%) for the pain category, in 8 patients (3%) for the mesh sensation category, and in 9 patients (3%) for the movement limitation symptom. The number of patients who were completely asymptomatic in all three symptom categories was 190 (24%). The only significant risk factor for developing mesh-related symptoms was young age at the time of surgery. CONCLUSIONS: Patient-reported medium-term symptoms following laparoscopic inguinal hernia repair appear common; however, the prevalence of severe or disabling symptoms is low.

Congenital band of the vitelline artery remnant as a cause of chronic lower abdominal pain in an adult: Case report.

INTRODUCTION: Intraabdominal bands of the vitelline vessel remnant are the rarest form of congenital mesodiverticluar bands which may or may not be associated with Meckel's diverticulum. In the majority of cases they cause an acute abdominal disease such as intestinal obstruction, especially in children. PRESENTATION OF CASE: We report a case of a 64 year old gentleman who experienced recurrent episodes of abdominal distension and bloating over two years. Computed tomography of his abdomen, colonoscopy, and barium follow through were all normal. Diagnostic laparoscopy revealed a single band adhesion stretching between the distal ileal mesentery and the anterior abdominal wall near the umbilicus. DISCUSSION: Congenital vascular bands are established causes of acute intestinal obstruction especially in children but are relatively uncommon. Their role in chronic abdominal pain is rare and diagnosis is difficult preoperatively. Pain in the patient was most likely due to recurrent partial twisting and untwisting of the bowel around the band. CONCLUSION: This case not only highlights an unusual cause of chronic abdominal pain, but also the effectiveness of laparoscopy as a diagnostic tool in such patients.

Laparoscopic Nissen fundoplication for the management of failed Angelchik prosthesis.

BACKGROUND: Angelchik is a silicone gel-filled prosthesis that was historically placed around the gastro-esophageal junction like a horse's halter for the treatment of gastro-esophageal reflux disease. It was first described by Angelchik and Cohen in 1979, after which its usage expanded due to its simplicity and ease of insertion by open surgery. However, the use of this device has largely been abandoned due to numerous complications and a consequent high removal rate. The most common complications cited have been dysphagia, disruption, migration, and erosion into the stomach. Although many reports of Angelchik prosthesis removal have appeared in the literature, we present a case of laparoscopic removal of this device that has been inserted 25 years ago, followed immediately by Nissen fundoplication. The main indication for operation was recurrent severe reflux symptoms refractory to medical treatment. METHODS: Case note review and literature search. RESULTS: There was no intraoperative or postoperative complication although the procedure was extremely challenging laparoscopically primarily due to attenuated anatomy and dense adhesions. The patient made an uneventful recovery with subsequent complete resolution of symptoms. CONCLUSION: Patients who have severe recurrent gastro-esophageal reflux disease symptoms refractory to medical treatment after placement of an Angelchik prosthesis can be treated by laparoscopic removal of the device followed by Nissen fundoplication.