Achieving a Complete Clinical Response After Neoadjuvant Chemoradiation That Does Not Require Surgical Resection: It May Take Longer Than You Think!

BACKGROUND: Patients with rectal cancer who achieve complete clinical response after neoadjuvant chemoradiation have been managed by organ-preserving strategies and acceptable long-term outcomes. Controversy still exists regarding optimal timing for the assessment of tumor response after neoadjuvant chemoradiation. OBJECTIVE: The purpose of this study was to estimate the time interval for achieving complete clinical response using strict endoscopic and clinical criteria after a single neoadjuvant chemoradiation regimen. DESIGN: This was a retrospective review of consecutive patients managed by 54-Gy and consolidation 5-fluorouracil-based chemotherapy. Assessment of response was performed at 10 weeks after radiation. Patients with suspected complete clinical response were offered watch-and-wait strategy and reassessment every 6 to 8 weeks until achievement of strict criteria of complete clinical response or overt residual cancer. SETTINGS: This study was conducted at a single tertiary care center. PATIENTS: Patients with complete clinical response who underwent a successful watch-and-wait strategy until last follow-up were eligible. Dates of radiation completion and achievement of strict endoscopic and clinical criteria (mucosal whitening, teleangiectasia, and no ulceration or irregularity) were recorded. Patients with incomplete response or with initial complete clinical response followed by local recurrence or regrowth were excluded. MAIN OUTCOMES MEASURES: The distribution of time intervals between completion of radiation and achievement of strict complete clinical response was measured. Patients who achieved early complete clinical response (≤16 wk) were compared with late complete clinical response (>16 wk). RESULTS: A total of 49 patients achieved complete clinical response and were successfully managed nonoperatively. A median interval of 18.7 weeks was observed for achieving strict complete clinical response. Only 38% of patients achieved complete clinical response between 10 and 16 weeks from radiation completion. Patients with earlier cT status (cT2/T3a) achieved a complete clinical response significantly earlier when compared with those patients with more advanced disease (T3b-d/4; 19 vs 26 wk; p = 0.03). LIMITATIONS: This was a retrospective study with a small sample size. CONCLUSIONS: Assessment at 10 to 16 weeks may detect a minority of patients who achieve complete clinical response without additional recurrence after neoadjuvant chemoradiation. Patients suspected for a complete clinical response should be considered for reassessment beyond 16 weeks before definitive management when considered for a watch and wait strategy. See Video Abstract at http://links.lww.com/DCR/A901.

Minimally invasive approach to chagasic megacolon: laparoscopic rectosigmoidectomy with posterior end-to-side low colorectal anastomosis.

The effectiveness of anterior resection for the surgical treatment of Chagasic megacolon and the advantages of laparoscopy for performing colorectal surgery are well known. However, current experience with laparoscopic surgery for Chagasic megacolon is restricted. Moreover, associated long-term results remain poorly analyzed. The aims of the present study were to ascertain the immediate results of laparoscopic anterior resection for the surgical treatment of Chagasic megacolon, to identify risk factors associated with adverse outcomes, and to settle late results. A retrospective review of a prospective database was conducted. Between November 2000 and September 2012, 44 patients with Chagasic megacolon underwent laparoscopic anterior resection with posterior end-to-side low colorectal anastomosis. Fifteen (34.1%) patients were male. Mean age was 51.6 years (31 to 77 y). The mean body mass index (BMI) was 22.9 kg/m (16.9 to 36.7 kg/m). Thirty-four previous abdominal operations had been performed. Mean operative time was 265 minutes (105 to 500 min). Four surgeons operated on all cases. Surgeon's experience with the operation was not associated with surgical time (P=0.36: linear regression). Mean operative time between patients with and without previous abdominal surgery was similar (237.7 vs. 247.5 min: P=0.78). There was no association between BMI and the duration of the operation (P=0.22). Intraoperative complications occurred in 2 (4.5%) cases. Conversion was necessary in 3 (6.8%) cases. There was no association between conversion and previous abdominal surgery (P=0.56) or between conversion and surgeon's experience (P=0.43). However, a significant association (P=0.01) between BMI and conversion was observed. Postoperative complications occurred in 10 (22.7%) cases. Anastomotic-related complications occurred in 4 cases. Two of them required diversion ileostomy. Restoration of transanal evacuation was achieved in all cases. Mean duration of postoperative hospital stay was 9.8 days (4 to 45 d). Of 19 patients with known clinical late follow-up, only 1 (5.3%) reported use of enemas and 5 (26.3%) reported use of laxatives. Thirteen (68.4%) patients reported daily bowel movements. There was no association between postoperative complications and use of laxatives (P=0.57). It was concluded that laparoscopic anterior resection for Chagasic megacolon is safe. Obesity was a risk factor for conversion. Restoration of transanal evacuation after surgical treatment of infectious complications was achieved. Minimally invasive surgery for Chagasic megacolon is associated with satisfactory late intestinal function with no significant constipation relapse.

Short-duration virtual reality simulation training positively impacts performance during laparoscopic colectomy in animal model: results of a single-blinded randomized trial : VR warm-up for laparoscopic colectomy.

BACKGROUND: Several studies have demonstrated skills transfer after virtual reality (VR) simulation training in laparoscopic surgery. However, the impact of VR simulation training on transfer of skills related to laparoscopic colectomy remains not investigated. The present study aimed at determining the impact of VR simulation warm-up on performance during laparoscopic colectomy in the porcine model. METHODS: Fourteen residents naive to laparoscopic colectomy as surgeons were randomly assigned in block to two groups. Seven trainees completed a 2-h VR simulator training in the laparoscopic sigmoid colectomy module (study group). The remaining seven surgeons (control group) underwent no intervention. On the same day, all participants performed a sigmoid colectomy with anastomosis on a pig. All operations were video recorded. Two board-certified expert colorectal surgeons independently assessed performance during the colectomy on the swine. Examiners were blinded to group assignment. The two examiners used a previously validated clinical instrument specific to laparoscopic colectomy. The primary outcome was the generic and specific skills score values. RESULTS: Surgeons undergoing short-duration training on the VR simulator performed significantly better during laparoscopic colectomy on the pig regarding general and specific technical skills evaluation. The average score of generic skills was 17.2 (16.5-18) for the control group and 20.1 (16.5-22) for the study group (p = 0.002). The specific skills average score for the control group was 20.2 (19-21.5) and 24.2 (21-27.5) for the study group (p = 0.001). There was acceptable concordance (Kendall's W) regarding the video assessment of generic (W = 0.78) and specific skills (W = 0.84) between the two examiners. CONCLUSIONS: A single short-duration VR simulator practice positively impacted surgeons' generic and specific skills performance required to accomplish laparoscopic colectomy in the swine model.

DNA ploidy status and prognosis in colorectal cancer: a meta-analysis of published data.

PURPOSE: In colorectal cancer, the negative effect of aneuploidy has been a controversy for more than 20 years. Studies to determine a survival-deoxyribonucleic acid content relationship have conflicting results. A systematic literature search followed by a meta-analysis of published studies addressing prognostic effect of aneuploidy for patients who underwent surgical treatment of colon and rectal cancer was conducted. METHODS: The main outcome measure was the five-year overall mortality rate after surgical resection. For the selected studies, we estimated this outcome for three subsets of patients through separate meta-analyses: 1) for all patients with colorectal cancer; 2) only between patients with Stage II colon cancer; and 3) only for studies in which follow-up losses were declared. The presence of publication bias was assessed with a funnel plot for asymmetry. RESULTS: A total of 5,478 patients with colorectal cancer were represented in 32 studies (Group 1), we estimated a reduction in the five-year overall mortality from 43.2 percent for aneuploid tumors to 29.2 percent for diploid tumors (combined relative risk = 1.44; 95 percent confidence interval = 1.34-1.55; P < 0.001). In addition, 357 patients with Stage II colon cancer (Group 2) extracted from three studies had an absolute reduction of 14.3 percent in five-year overall mortality favoring diploid tumors (combined relative risk = 1.93; 95 percent confidence interval = 1.29-2.89; P = 0.001). Lastly, of 14 studies in which follow-up losses were declared (Group 3), 2,221 patients were represented and a 15.7 percent mortality reduction was measured favoring patients with diploid tumors (combined relative risk = 1.44; 95 percent confidence interval = 1.3-1.61; P < 0.001). CONCLUSIONS: Patients who undergo an aneuploid colorectal cancer surgical resection have a higher risk of death after five years. This finding may ultimately impact survival of patients with node-negative colon cancer through adjuvant therapy.

Surgical treatment of rectal prolapse: experience and late results with 51 patients.

UNLABELLED: The "best" surgical technique for the management of complete rectal prolapse remains unknown. Due to its low incidence, it is very difficult to achieve a representative number of cases, and there are no large prospective randomized trials to attest to the superiority of one operation over another. PURPOSE: Analyze the results of surgical treatment of complete rectal prolapse during 1980 and 2002. METHOD: Retrospective study. RESULTS: Fifty-one patients underwent surgical treatment during this period. The mean age was 56.7 years, with 39 females. Besides the prolapse itself, 33 patients complained of mucous discharge, 31 of fecal incontinence, 14 of constipation, 17 of rectal bleeding, and 3 of urinary incontinence. Abdominal operations were performed in 36 (71%) cases. Presacral rectopexy was the most common abdominal procedure (29 cases) followed by presacral rectopexy associated with sigmoidectomy (5 cases). The most common perineal procedure was perineal rectosigmoidectomy associated with levatorplasty (12 cases). Intraoperative bleeding from the presacral space developed in 2 cases, and a rectovaginal fistula occurred in another patient after a perineal rectosigmoidectomy. There were 2 recurrences after a mean follow-up of 49 months, which were treated by reoperation. CONCLUSION: Abdominal and perineal procedures can be used to manage complete rectal prolapse with safety and good long-term results. Age, associated medical conditions, and symptoms of fecal incontinence or constipation are the main features that one should bear in mind in order to choose the best surgical approach.

Surgical treatment of rectal prolapse: experience and late results with 51 patients

A técnica cirúrgica mais apropriada para a correção da procidência retal permanece motivo de controvérsia. Por se tratar de afecção pouco freqüente, há dificuldade de avaliação de número adequado de pacientes em estudos randomizados e existe pouca evidência para comprovar a superioridade de alguma das técnicas. OBJETIVO: Analisar os resultados de eficácia e segurança do tratamento cirúrgico da procidência retal em pacientes operados entre 1980 e 2002. MÉTODO: Estudo retrospectivo. RESULTADOS: Cinqüenta e um pacientes foram operados. A idade média foi de 56,7 anos e 39 eram mulheres. Além do prolapso, 33 pacientes queixavam-se de eliminação de muco, 31 tinham incontinência anal, 14 apresentavam constipação, 17 com sangramento retal e 3 incontinência urinária. Operações abdominais foram realizadas em 36 (71%) casos, sendo a retopexia sem prótese a operação mais realizada (29 casos) seguida pela retossigmoidectomia com retopexia (5 casos). A operação perineal mais realizada foi a retossigmoidectomia com plastia dos elevadores (12 casos). O sangramento sacral foi a única complicação intra-operatória e ocorreu em dois casos. Como complicação pós-operatória, houve um caso de fístula retovaginal após operação de retossigmoidectomia perineal. Após seguimento médio de 49 meses, observamos recidiva da procidência em 2 casos. CONCLUSÕES: Operações abdominais e perineais podem ser utilizadas com segurança e eficácia no tratamento cirúrgico da procidência do reto. A idade, a presença de afecções associadas, comorbidades e os sintomas de constipação e incontinência são as principais variáveis envolvidas na escolha da operação. As operações de retopexia abdominal e retossigmoidectomia perineal estão associadas a bons resultados.

Gluteal and perianal hidradenitis suppurativa: surgical treatment by wide excision.

PURPOSE: Hidradenitis suppurativa is a chronic inflammatory disease of the skin and subcutaneous tissue. Extensive gluteal and perianal disease represents a challenge presentation. The aim of this study was to present results of management of extensive hidradenitis suppurativa in gluteal, perineal, and inguinal areas. METHODS: From January 1980 to May 2000, 56 patients underwent treatment of hidradenitis suppurativa in gluteal, perineal, and inguinal areas through wide excision; 52 (93 percent) were male and 36 (64 percent) were white. Mean age was 40 years. We evaluated distribution of disease, associated conditions, use of diverting colostomy, management of operative wounds, time to complete healing, complications, and recurrence. RESULTS: Twenty-one (37.6 percent) and 17 (30.6 percent) patients had gluteal and perineal disease, respectively. Squamous-cell carcinoma and Crohn's disease were observed in one patient each. Wide surgical excision was performed in all. Healing by second intention was the choice in 32 (57.1 percent) patients, and 24 (42.9 percent) patients underwent delayed skin-grafting. Diverting colostomy was used in 23 (41 percent) patients. Mean time for complete healing in the nongrafted group was 10 (range, 7-17) weeks and in the skin graft group was 6 (range, 3-9) weeks. New resection was performed in five (8.9 percent) patients. Partial graft loss rate was 37.5 percent and recurrence was observed in only one (1.8 percent) patient. CONCLUSION: Significant morbidity derives from extensive gluteal and perineal hidradenitis suppurativa caused by the disease extension and large wounds that result from surgical treatment. Wide surgical excision is the treatment of choice and leads to cure. Skin-grafting and healing by second intention lead to effective wound healing.

Squamous cell carcinoma of the pancreas with gastric metastasis: case report

Carcinoma de células escamosas do pâncreas e um tumor bastante raro, na maioria das séries demonstra uma frequência de 0,5 - 3,5 por cento. A apresentaçäo clinica e comportamento biológico desta variedade de cancer pancreatico e similar a do adenocarcinoma ductal. Relatamos um caso, em homem de 70 anos, cuja apresentaçäo clinica que o levou a procurar o servico médico foi hemorragia digestiva alta por invasäo do tumor na parede posterior do estomago que a biopsia mostrou carcinoma de celulas escamosas, e que foi levado a cirurgia apara coibir o sangramento, utilizando tatica cirurgica que foi crucial para interrupçäo da hemorragia