RESUMEN
Locally recurrent cancer of the rectum has been under-recognized as a complication, although it affects up to 40% of patients treated with surgery alone. Even in the best centers, rates average 25%. While radiotherapy may reduce recurrence, it is now apparent that total mesorectal excision is the most effective modality, with rates as low as 5%. The dramatic decrease in local recurrence can also be linked to increased survival in prospective studies, an effect more significant than any adjuvant therapy. The options, however, for patients with locally recurrent cancer are limited. Fifteen percent of patients with this complication die without systemic spread. Salvage by surgery offers potential cure. Other than anastomotic recurrences that can be locally resected, the best approach for long-term survival is an extensive surgical procedure requiring en bloc removal of adjacent organs and pelvic structures-so-called composite resection. With careful selection, 30% 5-year survival can be achieved and palliation is considerable, with 50% long-term local control. Intraoperative radiotherapy and brachytherapy, and/or preoperative chemoradiation may provide better results in future. Newer techniques of coloanal anastomosis, improved urinary diversion, and myocutaneous flaps for perineal reconstruction radically reduce the morbidity of these procedures. The approach to recurrent rectal cancer requires a sophisticated multidisciplinary team to obtain optimum results.
Asunto(s)
Recurrencia Local de Neoplasia/cirugía , Exenteración Pélvica/métodos , Neoplasias del Recto/cirugía , Braquiterapia , Quimioterapia Adyuvante , Humanos , Cuidados Intraoperatorios , Recurrencia Local de Neoplasia/prevención & control , Cuidados Paliativos , Selección de Paciente , Estudios Prospectivos , Radioterapia Adyuvante , Procedimientos de Cirugía Plástica , Neoplasias del Recto/prevención & control , Recto/cirugía , Factores de Riesgo , Terapia Recuperativa , Tasa de SupervivenciaRESUMEN
Improved results for pancreatic resection have been attributed to the concentration of pancreatic surgery in high-volume centers. The evidence supporting a relationship between hospital case volume and operative mortality for pancreatectomy is reviewed. The surgeon's case volume does not appear to influence mortality independently, but other surgeon-related characteristics, like specialized training, have not been examined. More research is needed to elucidate the factors that have contributed to reduced mortality for this complex surgery.
