Outcome of intraoperative brachytherapy as a salvage treatment for locally recurrent rectal cancer.

BACKGROUND: Locally advanced recurrent rectal cancer (RRC) requires a multimodal approach. Intraoperative high-dose-rate brachytherapy (HDR-BT) may reduce the risk of local recurrence. However, the optimal therapeutic regimen remains unclear. The aim of this retrospective monocentric study was to evaluate the toxicity of HDR-BT after resection of RRC. METHODS: Between 2018 and 2022, 17 patients with RRC received resection and HDR-BT. HDR-BT was delivered alone or as an anticipated boost with a median dose of 13 Gy (range 10-13 Gy) using an 192iridium microSelectron HDR remote afterloader (Elekta AB, Stockholm, Sweden). All participants were followed for assessment of acute and late adverse events using the Common Terminology Criteria for Adverse Events version 5.0 and the modified Late Effects in Normal Tissues criteria (subjective, objective, management, and analytic; LENT-SOMA) at 3­ to 6­month intervals. RESULTS: A total of 17 patients were treated by HDR-BT with median dose of 13 Gy (range 10-13 Gy). Most patients (47%) had an RRC tumor stage of cT3­4 N0. At the time of RRC diagnosis, 7 patients (41.2%) had visceral metastases (hepatic, pulmonary, or peritoneal) in the sense of oligometastatic disease. The median interval between primary tumor resection and diagnosis of RRC was 17 months (range 1-65 months). In addition to HDR-BT, 2 patients received long-course chemoradiotherapy (CRT; up to 50.4 Gy in 1.8-Gy fractions) and 2 patients received short-course CRT up to 36 Gy in 2­Gy fractions. For concomitant CRT, all patients received 5­fluorouracil (5-FU) or capecitabine. Median follow-up was 13 months (range 1-54). The most common acute grade 1-2 toxicities were pain in 7 patients (41.2%), wound healing disorder in 3 patients (17.6%), and lymphedema in 2 patients (11.8%). Chronic toxicities were similar: grade 1-2 pain in 7 patients (41.2%), wound healing disorder in 3 patients (17.6%), and incontinence in 2 patients (11.8%). No patient experienced a grade ≥3 event. CONCLUSION: Reirradiation using HDR-BT is well tolerated with low toxicity. An individualized multimodality approach using HDR-BT in the oligometastatic setting should be evaluated in prospective multi-institutional studies.

Assessing neoadjuvant therapy recommendations in 19 national and international guidelines for rectal cancer.

BACKGROUND:  Treatment guidelines belong to the most authoritative sources of evidence-based medicine and are widely implemented by health-care providers. Rectal cancer with an annual incidence of over 730,000 new cases and nearly 340,000 deaths worldwide, remains a significant therapeutic challenge. The total mesorectal excision (TME) leads to a dramatic improvement of local control. The addition of neoadjuvant treatment has been proposed to offer further advancement. However, this addition results in significant functional impairment and a decline in the quality of life. METHODS: This review critically assesses whether the recommendation for neoadjuvant treatment in current international guidelines is substantiated. A comprehensive search was conducted in July 2022 in PubMed resulting in 988 papers published in English between 2012 and 2022. After exclusions and proofs 19 documents remained for further analysis. RESULTS: Of the 19 guidelines considered in this review, 11 do not recommend upfront surgery, and 12 do not address the issue of functional impairment following multimodal treatment. The recommendation for neoadjuvant therapy relies on outdated references, lacking differentiated strategies based on current utilisation of MRI staging; numerous guidelines recommend neoadjuvant treatment also to subgroups of patients, who may not need this therapy. Also statements regarding conflicts of interest are often not presented. CONCLUSIONS: An immediate and imperative step is warranted to align the recommendations with the latest available evidence, thereby affording rectal cancer patients a commensurate standard of care. A meticulous assessment of the guideline formulation process has the potential to avert heterogeneity in the future.

Rectal adenocarcinoma: Ex vivo 9.4T MRI-correlation with histopathologic treatment response to neoadjuvant chemoradiotherapy.

OBJECTIVES: To determine the imaging details and diagnostic information of the treatment response to neoadjuvant chemoradiotherapy (nCRT) of rectal adenocarcinoma at 9.4T magnetic resonance imaging (MRI) by ex vivo. METHODS: Fifteen cases with locally advanced rectal cancer (LARC) followed by radical surgery after nCRT between September 2022 and February 2023 were recruited. Resected specimens were fixed in a perfluoropolyether-filled test tube and scanned with a 3.0T and 9.4T MRI system ex vivo. The residual tumor depth and MRI-based tumor regression grade (TRG) were subjectively assessed and then compared with the pathological findings. RESULTS: The ex vivo 9.4T T2WI without fat suppression clearly differentiated tumor tissue, fibrosis and normal rectal wall, which clearly corresponded to the pathologic tissues of the rectal specimens. The TRG could be accurately assessed on ex vivo 9.4T images in 13/15 specimens (86.7%), while in 11/15 specimens (73.3%) on ex vivo 3.0T images. CONCLUSION: Ex vivo 9.4T MR imaging clearly displayed the components of rectal wall and proved excellent diagnostic performance for evaluating the treatment response to nCRT, which allow radiologists to understand and then assess more accurately the TRG of LARC after nCRT.

Radiosensitization treatment using hydrogen peroxide for inoperable rectal cancer.

The treatment outcomes of patients with unresectable rectal cancer are complex, and concurrent chemoradiation therapy is the main treatment option. Radiosensitizers can enhance the effect of localized intratumoral hypoxia, contributing to local control and symptomatic relief. The present study evaluated the feasibility and safety of radiosensitization using hydrogen peroxide combined with radiation therapy (RT) in patients with unresectable rectal cancer. A total of 13 patients with rectal cancer were recruited in the present study. Radiosensitization was performed twice weekly in combination with RT. Gauze soaked in 3% hydrogen peroxide solution was inserted into the anus, ensuring firm contact with the lesion. In total, 45-65 Gy was delivered in 25-33 fractions to the whole pelvis from four directions using 10 MV X-rays 5 days per week. Acute and late adverse events were evaluated 1 and 6 months after the completion of RT. Treatment was well tolerated, with no acute grade 3 or worse events noted, and no patient developed rectal fistula, necrosis, obstruction, perforation, stenosis, ulcer or retroperitoneal hemorrhage. No notable late adverse events, beyond 6 months, were observed at the end of the analysis. All patients experienced pain relief, hemostatic effects and tumor shrinkage. Therefore, the use of a hydrogen peroxide solution-soaked gauze in the rectum may be a promising option for patients with inoperable rectal tumors. The limitations of the present study are that the patient population was small and the observation time was relatively short. This study was retrospectively registered with the University Hospital Medical Information Network Center (trial registration no. R000061902) on April 21, 2024.

A rare case report of mucinous adenocarcinoma exacerbated by long-standing solitary rectal ulcer syndrome.

Background: Solitary rectal ulcer syndrome (SRUS) is a rare chronic rectal lesion with potential for malignant transformation, although cases of rapid progression to mucinous adenocarcinoma are infrequent. This case report highlights such an instance in a 29-year-old male patient, emphasizing the importance of vigilance among clinicians for detecting canceration in SRUS patients. Case Description: The patient presented with recurrent constipation and anal discomfort, initially diagnosed with SRUS based on colonoscopy and pathological examination. Despite long-term mesalazine treatment, symptoms persisted, and subsequent evaluation revealed the development of mucinous adenocarcinoma within a short period. Surgical resection, combined with adjuvant FOLFOX chemotherapy, effectively controlled cancer progression. Immunohistochemical analysis showed positive expression of MLH1(+), MSH2(+), MSH6(+), PMS2(+), and HER2(+), providing molecular insights into SRUS-associated mucinous adenocarcinoma. Conclusions: This case underscores the need for increased awareness among clinicians regarding the potential for cancerous transformation in SRUS patients. Early detection and intervention are crucial for improving outcomes in SRUS-associated malignancies. Furthermore, this case adds to existing literature by presenting a rare instance of SRUS progressing rapidly to mucinous adenocarcinoma, highlighting the significance of regular monitoring and timely intervention in such cases. Further research is warranted to elucidate underlying mechanisms and risk factors, guiding future clinical practice and treatment strategies.

Recent racial/ethnic disparities in cancer-specific mortality among patients diagnosed with rectal cancer.

Background: African American patients frequently receive nonstandard treatment and demonstrate poorer overall survival (OS) outcomes compared to White patients. Our objective was to analysis whether racial/ethnic disparities in rectal cancer-specific mortality remain after accounting for clinical characteristics, treatment, and access-to-care-related factors. Methods: Individuals diagnosed with rectal cancer between 2011 and 2020 were identified using the Surveillance, Epidemiology, and End Results Database. The cumulative incidence of rectal cancer-specific mortality was computed. Sub-distribution hazard ratios (sdHRs) and 95% confidence intervals (CIs) for rectal cancer-specific mortality associated with race/ethnicity were estimated using Fine and Gray model with stepwise adjustments for clinical characteristics, treatment modalities, and factors related to access-to-care. Results: Among 54,370 patients, non-Hispanic (NH) Black individuals exhibited the highest cumulative incidence of rectal cancer-specific mortality (39%), followed by American Indian/Alaska Native (AI/AN) (35%), Hispanics (32%), NH-White (31%), and Asian/Pacific Islander (API) (30%). After adjusting for clinical characteristics, NH-Black patients had a 28% increased risk of rectal cancer mortality (sdHR, 1.28; 95% CI: 1.20-1.35) compared to NH-White patients. In contrast, mortality disparities between Hispanic-White, AI/AN-White, and API-White groups were not significant. The Black-White mortality differences persisted even after adjustments for treatment and access-to-care-related factors. In stratified analyses, among patients with a median household income below $59,999, AI/AN patients showed higher mortality than NH-Whites when adjusted for clinical characteristics (sdHR, 1.32; 95% CI: 1.03-1.70). Conclusions: Overall, the racial/ethnic disparities in rectal cancer-specific mortality were largely attributable to differences in clinical characteristics, treatment modalities, and factors related to access-to-care. These findings emphasize the critical need for equitable healthcare to effectively address and reduce the significant racial/ethnic disparities in rectal cancer outcomes.

Rectal prolapse in the pediatric population-a narrative review of medical and surgical management.

Background and Objective: Although more frequent in the adult population, rectal prolapse is a common anorectal condition that can occur in children and adolescents. While many cases spontaneously resolve without the need for intervention, the advent of newer minimally invasive procedures and operations have provided options for pediatric patients. Here, we review the pathophysiology, etiology, presentation, diagnosis and principles of management of rectal prolapse in the pediatric population as it has evolved over the past several decades. Methods: The literature was queried from free databases available to the public including the National Institute of Health National Library of Medicine MEDLINE and PubMed for manuscripts published from January 1, 1975 to December 1, 2023. Manuscripts without an accompanying English translation or those written entirely in foreign languages were excluded. Key Content and Findings: Numerous conditions contribute to rectal prolapse in children, including constipation, gastrointestinal infectious and non-infectious etiologies, cystic fibrosis, malnutrition, neurogenic, anatomic, lead points, and abuse. Initial management of rectal prolapse is medical management, addressing the underlying condition associated with rectal prolapse along with attempted manual reduction. For patients with recurrent rectal prolapse, a variety of noninvasive and procedural management options are available including injection sclerotherapy and anal encirclement in addition to surgical rectopexy by open and newer minimally invasive methods. Conclusions: Despite significant advances in the evaluation, procedural and surgical management of pediatric anorectal conditions in the last few decades, there continues to be substantial variation in clinicians' and surgeons' practice for the treatment of rectal prolapse in children and adolescents. Much remains to be studied in the future to improve clinical outcomes for this patient population.

GATIS score for predicting the prognosis of rectal neuroendocrine neoplasms: A Chinese multicenter study of 12-year experience.

BACKGROUND: There is currently a shortage of accurate, efficient, and precise predictive instruments for rectal neuroendocrine neoplasms (NENs). AIM: To develop a predictive model for individuals with rectal NENs (R-NENs) using data from a large cohort. METHODS: Data from patients with primary R-NENs were retrospectively collected from 17 large-scale referral medical centers in China. Random forest and Cox proportional hazard models were used to identify the risk factors for overall survival and progression-free survival, and two nomograms were constructed. RESULTS: A total of 1408 patients with R-NENs were included. Tumor grade, T stage, tumor size, age, and a prognostic nutritional index were important risk factors for prognosis. The GATIS score was calculated based on these five indicators. For overall survival prediction, the respective C-indexes in the training set were 0.915 (95% confidence interval: 0.866-0.964) for overall survival prediction and 0.908 (95% confidence interval: 0.872-0.944) for progression-free survival prediction. According to decision curve analysis, net benefit of the GATIS score was higher than that of a single factor. The time-dependent area under the receiver operating characteristic curve showed that the predictive power of the GATIS score was higher than that of the TNM stage and pathological grade at all time periods. CONCLUSION: The GATIS score had a good predictive effect on the prognosis of patients with R-NENs, with efficacy superior to that of the World Health Organization grade and TNM stage.

Effect of neoadjuvant chemoradiotherapy with or without PD-1 antibody sintilimab in pMMR locally advanced rectal cancer: A randomized clinical trial.

Neoadjuvant chemoradiotherapy (NACRT) was the standard treatment for patients with locally advanced rectal cancer (LARC) with proficient mismatch repair (pMMR) proteins. In this randomized phase 2 trial (ClinicalTrial.gov: NCT04304209), 134 pMMR LARC patients were randomly (1:1) assigned to receive NACRT or NACRT and the programmed cell death protein 1 (PD-1) antibody sintilimab. As the primary endpoint, the total complete response (CR) rate is 26.9% (18/67, 95% confidence interval [CI] 16.0%-37.8%) and 44.8% (30/67, 95% CI 32.6%-57.0%) in the control and experimental arm, respectively, with significant difference (p = 0.031 for chi-squared test). Response ratio is 1.667 (95% CI 1.035-2.683). Immunohistochemistry shows PD-1 ligand 1 (PD-L1) combined positive score is associated with the synergistic effect. The safety profile is similar between the arms. Adding the PD-1 antibody sintilimab to NACRT significantly increases the CR rate in pMMR LARC, with a manageable safety profile. PD-L1 positivity may help identify patients who might benefit most from the combination therapy.

Assessing the Role of Prognostic Nutritional Index in Predicting Outcomes for Rectal Cancer Surgery.

BACKGROUND & AIMS: The association of Prognostic Nutritional Index (PNI) with prognosis has been established for various cancer types, including rectal cancer. However, the precise relationship between PNI and body composition characteristics in patients with non-metastatic rectal cancer remain unclear. This study aimed to investigate the impact of PNI on overall survival and disease-free survival in non-metastatic rectal cancer patients undergoing total surgical resection. Additionally, it sought to assess the inflammatory status and body composition in patients across different PNI levels. METHODS: Patients with non-metastatic rectal cancer who underwent total surgical resection, were consecutively enrolled. PNI was calculated using the formula: PNI = (10 x serum albumin [g/dl]) + (0.005 x lymphocytes/µL). Body composition was assessed using CT-derived measurements and laboratory tests performed at diagnosis were used to calculate inflammatory indices. Univariate and multivariate logistic regression analyses as well as Kaplan-Meier curves were used to determine prognostic values. RESULTS: A total of 298 patients were included. Patients with low PNI demonstrated significantly reduced overall survival and disease-free survival compared to those with high PNI (Hazard ratio [HR] 1.85; Confidence interval [CI] 1.30-2 .62; p= 0.001). Moreover, patients with low PNI exhibited heightened systemic inflammatory status and reduced skeletal muscle index, increased muscle radiodensity, as well as a decrease in subcutaneous adipose tissue area, subcutaneous fat index, and low attenuation of both subcutaneous and visceral adipose tissue. CONCLUSION: The PNI, assessed prior to treatment initiation, serves as a prognostic biomarker for non-metastatic rectal cancer patients undergoing total surgical resection and is linked with both inflammation and alterations in body composition.

Protocol-based CT-guided brachytherapy for patients with prostate cancer and previous rectal extirpation-a curative approach.

OBJECTIVE: There are numerous curative treatment possibilities for prostate cancer. In patients who have undergone rectal extirpation for rectal cancer treatment, curative options are limited due to anatomic changes and previous irradiation of the pelvis. In this analysis, we validate the feasibility of CT-guided transperineal interstitial brachytherapy for this specific scenario. PATIENTS AND METHODS: We analyzed the treatment procedures and outcomes of 5 patients with metachronic nonmetastatic prostate cancer. Ultrasound-guided brachytherapy was not possible in any of the patients. Of these 5 patients, 3 were treated for prostate cancer using temporary brachytherapy with Ir-192 only, and 2 were treated with external-beam radiation therapy and temporary brachytherapy as a boost. CT-guided brachytherapy was performed in all patients. We analyzed the feasibility, efficacy, treatment-related toxicity, and quality of life (EORTC-30, IEFF, IPSS, and ICIQ questionnaires) of the treatments. RESULTS: Median follow-up was 35 months. Two out of five patients received boost irradiation (HDR 2â€¯× 9 Gy, PDR 30 Gy). Three out of five patients were treated with PDR brachytherapy in two sessions up to a total dose of 60 Gy. Dosimetric parameters were documented as median values as follows: V100 94.7% (94.5-98.4%), D2bladder 64.3% (50.9-78.3%), D10urethra 131.05% (123.2%-141.2%), and D30urethra 122.45% (116.2%-129.5%). At the time of analysis, no biochemical recurrence had been documented. Furthermore, neither early nor late side effects exceeding CTCAE grade 2 were documented. CONCLUSION: CT-guided transperineal brachytherapy of the prostate in patients with previous rectal surgery and radiation therapy is safe and represents a possible curative treatment option. Brachytherapy can be considered for patients with metachronic prostate cancer in this specific scenario, albeit preferably in experienced high-volume centers.

Correlation between dose-volume parameters and rectal bleeding after 12 fractions of carbon ion radiotherapy for prostate cancer.

BACKGROUND: Carbon ion radiotherapy (CIRT) is currently used to treat prostate cancer. Rectal bleeding is a major cause of toxicity even with CIRT. However, to date, a correlation between the dose and volume parameters of the 12 fractions of CIRT for prostate cancer and rectal bleeding has not been shown. Similarly, the clinical risk factors for rectal bleeding were absent after 12 fractions of CIRT. AIM: To identify the risk factors for rectal bleeding in 12 fractions of CIRT for prostate cancer. METHODS: Among 259 patients who received 51.6 Gy [relative biological effectiveness (RBE)], in 12 fractions of CIRT, 15 had grade 1 (5.8%) and nine had grade 2 rectal bleeding (3.5%). The dose-volume parameters included the volume (cc) of the rectum irradiated with at least x Gy (RBE) (Vx) and the minimum dose in the most irradiated x cc normal rectal volume (Dx). RESULTS: The mean values of D6cc, D2cc, V10 Gy (RBE), V20 Gy (RBE), V30 Gy (RBE), and V40 Gy (RBE) were significantly higher in the patients with rectal bleeding than in those without. The cutoff values were D6cc = 34.34 Gy (RBE), D2cc = 46.46 Gy (RBE), V10 Gy (RBE) = 9.85 cc, V20 Gy (RBE) = 7.00 cc, V30 Gy (RBE) = 6.91 cc, and V40 Gy (RBE) = 4.26 cc. The D2cc, V10 Gy (RBE), and V20 Gy (RBE) cutoff values were significant predictors of grade 2 rectal bleeding. CONCLUSION: The above dose-volume parameters may serve as guidelines for preventing rectal bleeding after 12 fractions of CIRT for prostate cancer.

Successfully Resected Isolated Lateral Lymph Node Recurrence in a Patient with T1 Lower Rectal Cancer: Case Report and Literature Review.

Lateral lymph node (LLN) metastasis in T1 rectal cancer has an incidence of less than 1%. However, its clinical features are largely uncharted. We report a case of LLN metastasis in T1 rectal cancer and review the relevant literature. A 56-year-old female underwent rectal resection for lower rectal cancer 2 years previously (pT1bN0M0). During follow-up, an elevated tumor marker CA19-9 was documented. Enhanced CT and MRI showed a round shape nodule 2 cm in size on the left side of pelvic wall. PET-CT showed high accumulation of FDG in the same lesion, leading to a diagnosis of isolated LLN recurrence. Because no other site of recurrence was detected, surgical resection of the LLN was performed. Microscopic findings were consistent with metastatic lymph node originating from the recent rectal cancer. Adjuvant chemotherapy for six months was given, and patient remains free of recurrent disease seven months after LLN resection. Although LLN recurrence after surgery for T1 rectal cancer is rare, post-surgical follow-up should not be omitted. When LLN metastasis is suspected on CT, MRI and/or PET-CT will be recommended. Surgical resection of LLN metastasis in patients with T1 rectal cancer may lead to favorable outcomes, when recurrence in other areas is not observed.

The Predictive Risk Factor of Postoperative Recurrence Following Altemeier's and Delorme's Procedures for Full-thickness Rectal Prolapse: An Analysis of 127 Japanese Patients in a Single Institution.

Objectives: We aimed to identify risk factors for postoperative recurrence (PR) after Altemeier's and Delorme's procedures for full-thickness rectal prolapse (FTRP). Methods: We enrolled 127 patients who underwent Altemeier's and Delorme's procedures for FTRP between April 2008 and September 2021. We divided the 127 patients into recurrence and non-recurrence groups and conducted univariate and multivariate analyses. We used six independent variables: age, body mass index (BMI), history of surgical repair for FTRP, coexistence of prolapse in other organs, poor fixation of the rectum on defecography before surgery, length of the prolapsed rectum, and type of surgical procedure (Altemeier's or Delorme's procedures). Results: PR developed in 51 (40.1%) patients during a mean follow-up period of 453 (range, 9-3616) days. Comparing the recurrence group (n=51) with the non-recurrence group (n=76), significant difference was observed regarding the coexistence of prolapse in other organs (p=0.017) in the univariate analysis. In the multivariate analysis, significant differences were observed in BMI (OR 1.18, 95% CI 1.030-1.350, p=0.020), coexistence of prolapse in other organs (OR 3.38, 95% CI 1.200-9.500, p=0.021), length of the prolapsed rectum (OR 1.030, 95% CI 1.010-1.060, p=0.015), poor fixity of the rectum on defecography (OR 0.332, 95% CI 0.129-0.852, p=0.022), and surgical procedures (OR 0.192, 95% CI 0.064-0.573, p=0.003). Conclusions: The study suggested that increasing BMI, coexistence of prolapse in other organs, length of the prolapsed rectum, poor fixation of the rectum on defecography before surgery, and types of surgical procedure might be risk factors of PR after perineal surgery for FTRP.

Hybrid Abdominal Robotic Approach Using the hinotori™ Surgical Robot System with Transanal Total Mesorectal Excision for Rectal Cancer: The First Ever Case Report for Rectal Cancer.

In Japan, the hinotori™ Surgical Robot System obtained pharmaceutical approval for use in colorectal cancer surgery in October 2022. This system has an operating arm with eight axes, adjustable arm base, and flexible three-dimensional viewer, which are expected to be advantageous in colorectal cancer surgery. A 55-year-old man presented to our hospital with melena and was diagnosed with cStage IIA (cT3N0M0) rectal cancer. The patient underwent intersphincteric resection using hinotori™ Surgical Robot System. Appropriate port placement was available for rectal manipulation, lymph node dissection, and arm base angle adjustment. Herein, we report the world's first rectal cancer surgery using the hinotori™ Surgical Robot System with TaTME by two teams.

Preservation of superior rectal artery in laparoscopic colectomy: The best choice for slow transit constipation?

Laparoscopic colectomy with ileorectal anastomosis may be beneficial for patients with slow transit constipation who do not respond to conservative treatment, particularly if the superior rectal artery (SRA) is preserved. Several important concerns have been addressed in this commentary. It is important to first go over the definition of surgical procedure as it is used in this text. Second, the current study lacked a control group that had SRA preservation. Thirdly, it would be best to use a prospective, randomized controlled study. Lastly, a description of the mesenteric defect's state following a laparoscopic colectomy is necessary.

Minimally invasive pelvic exenteration for primary or recurrent locally advanced rectal cancer: A glimpse into the future.

Surgeons have grappled with the treatment of recurrent and T4b locally advanced rectal cancer (LARC) for many years. Their main objectives are to increase the overall survival and quality of life of the patients and to mitigate postoperative complications. Currently, pelvic exenteration (PE) with or without neoadjuvant treatment is a curative treatment when negative resection margins are achieved. The traditional open approach has been favored by many surgeons. However, the technological advancements in minimally invasive surgery have radically changed the surgical options. Recent studies have demonstrated promising results in postoperative complications and oncological outcomes after robotic or laparoscopic PE. A recent retrospective study entitled "Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer: A 9-year review" was published in the World Journal of Gastrointestinal Surgery. As we read this article with great interest, we decided to delve into the latest data regarding the benefits and risks of minimally invasive PE for LARC. Currently, the small number of suitable patients, limited surgeon experience, and steep learning curve are hindering the establishment of minimally invasive PE.

Carbapenem Versus Non-carbapenem Therapy in Hematology Patients: Extended-Spectrum Beta-Lactamase Positive Enterobacteriaceae Colonization Impact.

BACKGROUND: Extended-spectrum beta-lactamase-producing Enterobacteriacea (ESBL-E) infections are a major source of mortality and morbidity in patients with hematologic cancers. One of the most significant risk factors for bacterial illness is prior colonization with resistant germs. Empiric usage of carbapenems is recommended for the treatment of infections in patients with a positive colonization history. OBJECTIVES: We aimed to determine the outcome of empirical carbapenem (de-escalation) versus non-carbapenem (escalation) therapy in adult hematology patients who have rectal extended-spectrum beta-lactamase positive ESBL-E colonization. METHODS: Two hundred three rectal swab cultures were collected from 130 patients, admission or during hospitalization between June 2014 and May 2015. Patients were followed till January 2016 for future infections due to ESBL-E. Empirical antibiotic treatment was started according to the patient's medical condition without consideration of previous colonization status. Stable patients received empirical escalation therapy. All-cause and early mortality of infections are analyzed. RESULTS: Seventy-three (36%) swabs were positive for ESBL-E. Patients with rectal ESBL-E colonization were defined as cases; patients without colonization were defined as controls. Prospective infection due to ESBL-E in the case and control group was 6.8% and 2.3%, respectively. No statistically significant relation was found between colonization and prospective infection due to ESBL-E (p=0.110). There was no all-cause or early mortality in prospective infections with ESBL-E. Among case patients, one patient each died from all-cause mortality in the escalation (n=55) and de-escalation (n=3) group. The all-cause mortality in the antibiotic switch group (n=30) was eight, including five patients in the early mortality group although the bacteriologic agents were susceptible to the given antibiotics. CONCLUSION: In our institution, rectal colonization with ESBL-E was high, but contracting an infection due to ESBL-E was surprisingly low. Colonization with ESBL-E may not necessarily end with an infection in some situations. In stable patients, disregarding colonization features before empirical therapy did not seem to be inappropriate.

Young-Onset Rectal Cancer: Is It for Real?

The incidence of early-onset colorectal cancer has been rising over the last two decades. Tumors in young patients have distinct features compared to older patients. They predominantly arise in the distal colon and rectum and have poor histological features. Patients tend to present at a more advanced stage and be exposed to more aggressive management approaches; however, this has not translated into a significant survival benefit compared to their older counterparts. This chapter will share current evidence on risk factors and management options for early onset colorectal cancer with a focus on rectal cancer.