451 research outputs found
Factors associated with metachronous metastases and survival in locally advanced and recurrent rectal cancer
No full textBackground
Better understanding of the impact of metachronous metastases in locally advanced and recurrent rectal cancer may improve decision‐making. The aim of this study was to investigate factors influencing metachronous metastasis and its impact on survival in patients who have a beyond total mesorectal excision (bTME) operation.
Methods
This was a retrospective study of consecutive patients who had bTME surgery for locally advanced and recurrent rectal cancer at a tertiary referral centre between January 2006 and December 2016. The primary outcome was overall survival. Cox proportional hazards regression analyses were performed. The influence of metachronous metastases on survival was investigated.
Results
Of 220 included patients, 171 were treated for locally advanced primary tumours and 49 for recurrent rectal cancer. Some 90·0 per cent had a complete resection with negative margins. Median follow‐up was 26·0 (range 1·5–119·6) months. The 5‐year overall survival rate was 71·1 per cent. Local recurrence and metachronous metastasis rates were 11·8 and 22·2 per cent respectively. Patients with metachronous metastases had a worse overall survival than patients without metastases (median 52·9 months versus estimated mean 109·4 months respectively; hazard ratio (HR) 6·73, 95 per cent c.i. 3·23 to 14·00). Advancing pT category (HR 2·01, 1·35 to 2·98), pN category (HR 2·43, 1·65 to 3·59), vascular invasion (HR 2·20, 1·22 to 3·97) and increasing numbers of positive lymph nodes (HR 1·19, 1·07 to 1·16) increased the risk of metachronous metastasis. Nine of 17 patients (53 per cent) with curatively treated synchronous metastases at presentation developed metachronous metastases, compared with 40 of 203 (19·7 per cent) without synchronous metastases (P = 0·002). Corresponding median length of disease‐free survival was 17·5 versus 90·8 months (P < 0·001).
Conclusion
As metachronous metastases impact negatively on survival after bTME surgery, factors associated with metachronous metastases may serve as selection tools when determining suitability for treatment with curative intent
Predictors of short-term readmission after beyond total mesorectal excision for primary locally advanced and recurrent rectal cancer
No full textUnplanned 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
No full textThe 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
A national perspective on the decline of abdominoperineal resection for rectal cancer
No full textObjective: To assess rates of abdominoperineal excision of the rectum (APER) for rectal cancer between centers and over time, and to evaluate the influence of patient characteristics, including social deprivation, on,APER rate. Methods: Data on patients undergoing APER or anterior resection (AR) in England were extracted from a national administrative database for the years 1996 to 2004. The primary outcome was the proportion of patients presenting with rectal cancer undergoing APER. Hierarchical logistic regression was used to identify independent factors associated with a nonrestorative resection. Results: Data on 52,643 patients were analyzed, 13,109(24.9%) of whom underwent APER. The APER rate significantly reduced over the study period from 29.4% to 21.2% (P < 0.001). Operative mortality following AR decreased significantly during the period of study (5. 1 % to 4.2%, P = 0.002), while that following APER did not (P = 0.075). Male patients were more likely to undergo APER (P < 0.001), whereas those with an emergency presentation more commonly underwent AR (P < 0.00 1). Independent predictors of increased APER rate were male gender (odds ratio [OR] = 1.239, P < 0.001) and social deprivation (most vs. least deprived; OR 1.589, P < 0.001), whereas increasing patient age (OR = 0.977, P = 0.027 per 10-year increase), year of study (2003/4 vs. 1996/7; OR = 0.646, P < 0.001) and initial presentation as an emergency (OR = 0.713, P < 0.001) were associated with lower APER rates. After accounting for case-mix, there was significant between-center variability in APER rates. Conclusion: Socially deprived patients were more likely to undergo abdominoperineal resection. Significant improvements in rates of nonrestorative resection were seen over time but although short-term outcomes following AR have improved, those following APER have not. Permanent stoma rates following rectal cancer surgery may be considered a surrogate marker of surgical qualit
Improving outcomes for the treatment of Anal Squamous Cell Carcinoma and Anal Intraepithelial Neoplasia
No full textA systematic review of sacral nerve stimulation for faecal incontinence following ileal pouch anal anastomosis
No full textFaecal incontinence is a common complication of ileal pouch anal anastomosis (IPAA) and seems to worsen with time. The aim of this paper is to review the evidence of the use of sacral nerve stimulation (SNS) for patients with faecal incontinence after IPAA. A literature search was performed on PubMed and Cochrane databases for all relevant articles. All studies, which reported the outcome of SNS in patients with faecal incontinence after IPAA, were reviewed. Three papers were identified, including a case report, cohort study and retrospective study. The total number of patients was 12. The follow-up duration included 3 months, 6 months and 24 months. After peripheral nerve evaluation, definitive implantation was performed in 10 (83.3%) patients. All three studies reported positive outcomes, with CCF scores and incontinence episodes improving significantly. Preliminary results suggest good outcome after permanent SNS implant. Studies with larger sample sizes, well-defined patient characteristics and standardized outcome measures are required to fully investigate the effect of SNS in IPAA patients
The role of adjuvant chemotherapy on survival and recurrence after curative rectal cancer surgery on patients who are histologically node negative after neoadjuvant chemoradiotherapy.
No full textAIM: The aim of this study is to evaluate whether adjuvant chemotherapy will affect recurrence rates, disease free and overall survival in patients with rectal adenocarcinoma who were staged with MRI node positive disease (mrN+) preoperatively and underwent neoadjuvant chemoradiotherapy with curative rectal cancer surgery and their pathological staging was negative for nodal disease (ypN0). There is no consensus on the role of adjuvant chemotherapy in these patients. METHOD: Patients who received neoadjuvant chemoradiotherapy and underwent curative rectal cancer surgery for rectal adenocarcinoma staged as [mrTxN+M0] on MRI staging and on pathological staging were found to be [ypTxN0M0] were retrospectively identified from 01/2008-12/2012 from two tertiary referral centers (Royal Marsden Hospital and Saint-Andre Hospital). RESULTS: 163 patients were recruited and after propensity matching at a ratio of 2:1 n=80 patients were divided into adjuvant (n=28) and no adjuvant treatment (n=52) respectively. A comparison of adjuvant chemotherapy vs no adjuvant therapy showed that the mean overall survival was 2.67 vs 3.60 years (p=0.42), disease free survival was 2.27 vs 3.32 years (p=0.14). CONCLUSION: This study found no significant difference in survival or disease recurrence between patients who received adjuvant chemotherapy and patients who did not. There is no clear evidence to support or dismiss the use of adjuvant chemotherapy for patients who have been node positive on pre-operative MRI and node negative on histopathological staging. Further multicenter prospective randomised trials are needed to identify the appropriate treatment regime for this group of patients
Comparison of western and asian guidelines concerning the management of colon cancer
No full textBACKGROUND: Guidelines are important to standardize treatments and optimize outcomes. Several societies have published authoritative guidelines for patients with colon cancer, and a certain degree of variation can be predicted. OBJECTIVE: This study aims to compare Western and Asian guidelines for the management of colon cancer. DATA SOURCES: A literature review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for studies published between 2010 and 2017 by the online resources from the official Web sites of the societies/panels. Sources included guidelines by European Society of Medical Oncology, the Japanese Society for Cancer of the Colon and Rectum, and the National Comprehensive Cancer Network. STUDY SELECTION: Only full-text studies and the latest guidelines dealing with colon cancer were included. Studies and guidelines were separately assessed by 2 authors, who independently identified discrepancies and areas for further research. These were discussed and agreed with by all the authors. MAIN OUTCOME MEASURES: The recommendations of the guidelines of each society were compared, seeking discrepancies and potential areas for improvement. RESULTS: Endoscopic techniques for the management of early colon cancer are discussed in detail in the Asian guidelines. Asian guidelines advocate extended (D3) lymphadenectomy on a routine basis in T3/T4 and in selected T2 patients, whereas such an approach is still under investigation in Western countries. Only US guidelines describe neoadjuvant chemotherapy and radiotherapy. All the guidelines recommend adjuvant treatment in selected stage II patients, but agreement exists that this is performed without solid evidence, because better outcomes are hypothesized based on studies including stage III or stage II/III patients. The role of cytoreductive surgery with intra-abdominal chemotherapy is dubious, and European guidelines only recommend it in the setting of trials. Asian guidelines endorse an aggressive surgical approach to peritoneal disease. Only US guidelines include a patient advocate in the drafting panel. LIMITATIONS: Bias may have arisen from country-specific socioeconomic and cultural issues, and from the latest available updates. CONCLUSIONS: Surgical approaches to colon cancer differ significantly among Western and Asian guidelines, reflecting different concepts of treatment. The role of adjuvant treatment in node-negative disease and quality-of-life assessment need further research
Squamous Cell Carcinoma of the Anal Transitional Zone after Ileal Pouch Surgery for Ulcerative Colitis: Systematic Review and Treatment Perspectives
No full textBackground: Few cases of pouch-related cancers have been reported in ulcerative colitis (UC), and squamous cell carcinoma (SCC) is very rare. Method: A systematic review of the literature was performed to identify all unequivocal cases of pouch-related SCC in UC patients. Results: Eight cases of SCC developing after ileal pouch-anal anastomosis (IPAA) have been observed since 1978. Two arose from the pouch mucosa and 6 from below. The pooled cumulative incidence of SCC is below 0.06% after IPAA. Many patients had neoplasia on the preoperative specimen, but squamous metaplasia of the pouch or anorectal mucosa may have an important role in SCC. These patients are rarely offered chemoradiation therapy and the outcome is poor. Selected patients with SCC located close to the pouch outlet can be treated with chemoradiation prior to consideration of surgery and salvage their pouch. A chemoradiation regimen is suggested to avoid pouch excision in these patients. Conclusions: SCC is rare after pouch surgery but associated with extremely poor survival. Very low SCC can be managed with chemoradiation treatment, preserving the pouch and avoiding surgery, even in older patients. The role of pouch metaplasia, surveillance frequency, and treatment modalities after IPAA need further studying
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