Reconstructive techniques following low anterior resection for carcinoma of the rectum: meta-analysis.

BACKGROUND: Multiple trials have compared reconstruction techniques used following the resection of distal rectal cancers, including straight colorectal anastomosis (SCA), colonic J pouch (CJP), side-to-end anastomosis (SEA), and transverse coloplasty (TCP). The latest meta-analysis on the subject concluded that all the reservoir techniques produce equally good surgical and functional outcomes compared with SCA. Numerous trials have been published in this regard subsequently. Hence, a network analysis (NMA) was performed to rank these techniques. METHODS: A literature search of MEDLINE, Embase, and the Cochrane Library from their inception until April 2021 was conducted to identify randomized trials. Functional and surgical outcome data were pooled. ORs and standardized mean differences (MDs) were used as pooled effect size measures. A frequentist NMA model was used. RESULTS: Thirty-two trials met the eligibility criteria comprising 3072 patients. CJP showed better functional outcomes, such as low stool frequency and better incontinence score, both in the short term (stool frequency, MD -2.06, P < 0.001; incontinence, MD -1.17, P = 0.007) and intermediate term (stool frequency, MD -0.81, P = 0.021; incontinence MD -0.56, P = 0.083). Patients with an SEA (long-term OR 4.37; P = 0.030) or TCP (long-term OR 5.79; P < 0.001) used more antidiarrheal medications constantly. The urgency and sensation of incomplete evacuation favoured CJP in the short term. TCP was associated with a higher risk of anastomotic leakage (OR 12.85; P < 0.001) and stricture (OR 3.21; P = 0.012). CONCLUSION: Because of its better functional outcomes, CJP should be the reconstruction technique of choice. TCP showed increased anastomotic leak and stricture rates, warranting judicious use.

Early versus delayed surgery following neoadjuvant chemoradiation for esophageal cancer: a systematic review and meta-analysis.

BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) followed by surgery, is the mainstay of managing locally advanced esophageal cancer. However, the optimal timing of surgery after neoadjuvant therapy is not defined clearly. METHODS: A systematic search of PubMed, Embase and Cochrane databases was conducted. 6-8 weeks were used as a cut-off to define early and delayed surgery groups. Overall Survival (OS) was the primary outcome, whereas pathological complete resolution (pCR), R0 resection, anastomotic leak, perioperative mortality, pulmonary complications, and major complication (> Clavien-Dindo grade 2) rates were secondary outcomes. Cohort studies and national registry bases studies were analysed separately. Survival data were pooled as Hazard Ratio (HR) and the rest as Odds Ratio (OR). According to heterogeneity, fixed-effect or random-effect models were used. RESULTS: Twelve retrospective studies, one RCT, and six registry-based studies (13,600 participants) were included. Pooled analysis of cohort studies showed no difference in OS (HR 1.03, CI 0.91-1.16), pCR (OR 0.98, CI 0.80-1.20), R0 resection (OR 0.90, CI 0.55-I.45), mortality (OR 1.03, CI 0.59-1.77), pulmonary complications (OR 1.26, CI 0.97-1.64) or major complication rates (OR 1.29, CI 0.96-1.73). Delayed surgery led to increased leak (OR 1.48, CI 1.11-1.97). Analysis of registry studies showed that the delayed group had a better pCR rate (OR 1.12, CI 1.01-1.24), with no improvement in survival (HR 1.01, CI 0.92-1.10). Delayed surgery was associated with increased mortality (OR 1.35, CI 1.07-1.69) and major complication rate (OR 1.55, CI 1.20-2.01). Available RCT reported surgical outcomes only. CONCLUSION: National registry-based studies' analysis shows that delay in surgery is riskier and leads to higher mortality and major complication rates. Further, well-designed RCTs are required.

Reconstructive techniques following low anterior resection for carcinoma of the rectum.

INTRODUCTION: Multiple reconstructive techniques have been described for reconstruction after a low anterior resection for carcinoma rectum. Colonic J pouch (CJP), Side to end anastomosis (SEA), transverse coloplasty pouch (TCP) and Straight Colo-rectal/anal anastomosis were the most widely studied. EVIDENCE ACQUISITION: PubMed, Embase and Cochrane data base were searched for randomized, non-randomized studies and systematic reviews from inception of the databases till July 31st, 2023. EVIDENCE SYNTHESIS: Considerable heterogeneity existed among different study findings. Reservoir techniques, including CJP, SEA, and TCP, exhibited reduced stool frequency, decreased urgency, and improved continence status compared to SCA, particularly in the short term. CJP maintained this advantage into the intermediate term. Other functional outcomes were similar among the techniques. However, these functional improvements did not translate into enhanced Quality of Life (QoL). TCP was associated with an elevated risk of anastomotic leaks. Other surgical outcomes remained comparable across all four techniques. Sexual outcomes also exhibited no significant variation. Some studies suggested that the size of the side limb in CJP or SEA may not significantly impact functional outcomes, implying that neorectum capacity may not be the primary determinant of improved function. The precise physiological mechanism underlying these findings remains unknown. CONCLUSIONS: In the short and intermediate terms, reservoir techniques demonstrated superior functional outcomes, but long-term performance was comparable among all techniques. Notably, enhanced functional outcomes did not translate to improved Quality of Life. TCP, while effective, is linked to an increased risk of anastomotic complications, necessitating cautious utilization.

The Practice of Pancreatoduodenectomy in India: A Nation-Wide Survey.

Introduction The way pancreatoduodenectomy (PD) is performed can vary a lot around the world, and there is no agreed-upon standard approach. To learn more about how PD is practised in India, a survey was conducted among Indian surgeons to gather information about their current practices. Methods A survey was created and shared with surgeons in India who practice pancreatic surgery. It had 33 questions that aimed to capture information about different aspects of PD practice. These questions covered topics such as the surgeons' education and experience, how they evaluated patients before surgery, what they considered during the operation, and how they managed patients after surgery. Results A total of 129 surgeons were sent the survey, and 110 of them completed it. The results showed that 40.9% of the surgeons had less than five years of experience, and 36.4% of them performed more than 15 PDs in a year. When deciding whether to perform preoperative biliary drainage, 60% of surgeons based their decision on the level of bilirubin in the patient's blood, while the rest considered other specific indications. The majority of surgeons (72.7%) looked at the trend of albumin levels to assess the patient's nutritional status before surgery. Venous infiltration was seen as a reason for neoadjuvant therapy by 76.4% of the participants, whereas 95.5% considered upfront surgery in cases of venous abutment. When it came to the type of PD, 40% preferred classical PD, 40.9% preferred pylorus-resecting PD (PRPD), and the rest chose pylorus-preserving PD (PPPD). Pancreatojejunostomy (PJ) was the preferred method for 77.3% of surgeons, while 6.3% preferred pancreatogastrostomy (PG). About 65.5% of surgeons used octreotide selectively during the operation when the duct diameter was small. Nearly all surgeons (94.5%) preferred to secure feeding access during PD, and all of them placed intraperitoneal drains. As for postoperative care, 37.3% of surgeons attempted early oral feeding within 48 hours, while 28.2% preferred to wait at least 48 hours before initiating oral feeds. Conclusions The survey revealed significant differences in how PD is practised among surgeons in India, highlighting the heterogeneity in their approaches and preferences.

IgG4-Related Pancreato-Biliary Disease in the Disguise of Malignancy.

The Immunoglobulin G4-related disease (IgG4-RD) is a multisystem inflammatory condition. Pancreaticobiliary manifestations often present as mass lesions that mimic malignancies. The diagnosis is confirmed by histopathological examination, that shows lymphoplasmacytic infiltration, storiform fibrosis, obliterative phlebitis, and positive immunohistochemistry for IgG4. We encountered 3 such patients in a tertiary care hospital in India. Two patients presented with obstructive jaundice and the third with pain abdomen. They had resectable lesions involving the pancreatic head, the right hepatic duct, and gallbladder fundus, respectively, on imaging. Tumor markers were not significantly elevated in any of them. All 3 patients underwent radical surgeries, suspecting malignancy. Surgical specimens showed typical features of IgG4-RD on histomorphology. Serum IgG4 level was elevated in first 2 patients but was normal in sclerosing cholecystitis patient. To conclude, IgG4-RD is a malignant mimicker; hence, on clinical suspicion, liberal attempts for tissue diagnosis may avoid radical surgeries.

Squamous Cell Carcinoma of the Sigmoid Colon: A Path Less Traveled.

Squamous cell carcinoma (SCC) involving the gastrointestinal tract is exceptionally rare, except in the esophagus and the anal canal. In the hindgut, a common site of involvement is the colo-rectum, commonly seen in the fifth decade of life. The presentation is usually in the advanced stages and carries a poor prognosis. Due to the rarity of the disease, before labeling it as a primary lesion, the possibility of metastasis from a distant primary should be entertained. Consensus guidelines regarding the management of such a rare condition are lacking. Here, we present the case of an elderly gentleman with a history of surgery for urinary bladder cancer 20 years back (the nature of which is not known). The patient presented with left lower abdominal pain and altered bowel habits. His pain had persisted for approximately two months along with a recent onset of overflow incontinence but no other associated constitutional symptoms. Examination revealed pallor and a vague abdominal mass in the left iliac fossa. On further evaluation with a colonoscopy, a growth was seen in the sigmoid colon. Computed tomography of the abdomen revealed a locally invasive growth arising from the sigmoid colon along with a space-occupying lesion in the left lobe of the liver enhancing on the portal phase. Biopsy from the sigmoid and the liver lesion was reported as SCC which was confirmed by immunohistochemistry. Given the metastatic nature of the lesion, treatment options were discussed in a multidisciplinary team setting, and the decision was made to proceed with diversion colostomy and palliative chemotherapy. SCC of the colon is a rare disease and is usually diagnosed at an advanced stage. Even in operable cases, the prognosis is dismal, and various treatment modalities have been attempted. Due to the rarity of the disease and paucity of data regarding definitive management, treatment varies from one patient to another.

Staple Line Dehiscence in Gastric Conduit Following Esophagectomy: A Complication Conspicuously Missing a Mention It Deserves.

Following esophagectomy, anatomical reconstruction with a gastric tube is the most common practice. The construction of the gastric tube is done with staplers nowadays, be it a minimally invasive esophagectomy or a conventional open surgery. Even though anastomotic leak and conduit necrosis are reported widely in the literature, the number of studies on staple line dehiscence is meager in comparison. Management of conduit failure usually sacrifices conduit combined with a diverting cervical esophagostomy. We report a case of successful surgical management of a big staple line dehiscence and 'salvaging of the conduit'.