Prognostic Nutritional Index Prior to Rectal Cancer Resection Predicts Overall Survival.

Prognostic nutritional index (PNI) correlates with postoperative complications and survival in colorectal cancers. Separate studies for rectal cancers are not available where the majority have preoperative radiation, operated by minimally invasive approaches and have diverting ostomies.Consecutive rectal resections between October 2014 and December 2017 from a single center were included. PNI was calculated as 10 x (serum Albumin) + 0.005 x TLC (per mm3) before operation. Multivariate cox regression was used with overall survival (OS) as the dependent variable. Interaction terms of PNI with neoadjuvant therapy, surgical approach and postoperative complications were used to assess specific subgroups.Three-hundred forty elective rectal resections were included with a mean PNI of 46.711 (SD - 6.692), and a median follow up of 44 mo. In multivariable regression, PNI predicted OS (HR - 0.943; p-0.001). Interaction of PNI with preoperative radiation or surgical approach (open, laparoscopic, or robotic) did not change its influence on survival. PNI predicted survival with similar hazard even in patients without major postoperative complicationsDespite routine diversion after rectal resections, PNI predicted OS with an absolute survival benefit of 1.2% at 3-year for every unit increase in PNI irrespective of preoperative therapy or surgical approach.

Bladder preserving robotic pelvic exenteration for locally advanced rectal cancer-technique and short-term outcomes.

AIM: In selected patients with advanced rectal cancers involving the prostate or seminal vesicles, the bladder can be preserved to avoid the complications associated with an ileal conduit. The study was aimed at reviewing the technique and short-term outcomes of patients that underwent bladder sparing robotic pelvic exenteration with suprapubic cystostomy (SPC). METHODS: Case series of bladder preserving exenteration from a single tertiary care center. Technique for en-bloc prostatectomy with abdominoperineal resection is described. RESULTS: Five patients underwent bladder sparing robotic pelvic exenteration with SPC, all had R0 resections. Four patients had prostatic invasion and one patient had prostatic adenocarcinoma. Postoperative complications were seen in three patients of which two were re-explored. At a median follow-up of 10 months, two patients developed systemic relapses. There were no local recurrences. CONCLUSION: Robotic bladder sparing exenteration is technically feasible, provides acceptable short-term outcomes, and avoids complications of ileal conduit.

Early-onset non-metastatic colon cancers do not portend worse prognosis - implications for adjuvant chemotherapy.

BACKGROUND: Early-onset colon cancers are increasing and the independent influence of age on prognosis and therapeutic efficacy of adjuvant therapy is unclear. The primary aim of the present study was to determine if young age was an independent prognostic factor for survival. Secondarily, age would be used in the context of known factors that predict benefit with adjuvant chemotherapy in stages II and III. METHODS: Retrospective, single centre study of operated, non-metastatic colon cancer (> 15 cm from anal verge) without pre-operative therapy. Early onset cancers were defined as age ≤ 45 years. Primary endpoint was disease-free survival (DFS). RESULTS: Six-hundred thirty-three patients were included with 206 (32.5%) early-onset cancers. With a median follow-up of 48 months, 5-year DFS was 79.5% and 76.2% for early and late-onset cancers, respectively (p - 0.585). In multivariate analysis, only tumour sidedness, family history, T4 stage, node positivity and microsatellite instability status influenced DFS and not the age of onset (HR - 0.969; 95% - 0.63-1.49). These results were consistent with different models and with stage-wise distribution. CONCLUSIONS: Early-onset colon cancers treated with curative intent had survivals similar to older cohorts. Age was not an independent prognostic factor for recurrences. Age did not influence disease-free survival when stage-wise predictive variables for therapeutic benefit with adjuvant chemotherapy were considered.

Outcomes of rectal cancer patients with a positive pathological circumferential resection margin.

PURPOSE: Evidence-based management of positive pathological circumferential resection margin (pCRM) following preoperative radiation and an adequate rectal resection for rectal cancers is lacking. METHODS: Retrospective analysis of prospectively maintained single-centre institutional database was done to study the patterns of failure and management strategies after a rectal cancer surgery with a positive pCRM. RESULTS: A total of 86 patients with rectal adenocarcinoma with a positive pCRM were identified over 8 years (2011-2018). Majority had low-lying rectal cancers (90.7%) and were operated after preoperative radiotherapy (95.3%). Operative procedures included abdomino-perineal resections, inter-sphincteric resections, low anterior resections and pelvic exenteration in 61 (70.9%), 9 (10.5%), 11(12.8%) and 5 (5.8%) patients respectively. A total of 83 (96.5%) received chemotherapy as the sole adjuvant treatment modality while 2 patients (2.3%) were given post-operative radiotherapy and 1 patient underwent revision surgery. A total of 53 patients (61.6%) had recurrence, with 16 (18.6%), 20 (23.2%), 8(9.3%) and 9 (10.5%) patients having locoregional, systemic, peritoneal and simultaneous local-systemic relapse. Systemic recurrences were more often detected either by surveillance in an asymptomatic patient (20.1%) while local (13.1%) and peritoneal (13.2%) recurrences were more often symptomatic (p = 0.000). The 2-year overall survival (OS) and disease-free survival (DFS) of the cohort was 82.4% and 74.0%. Median local recurrence-free survival (LRFS) was 10.3 months. CONCLUSIONS: Patients with a positive pCRM have high local and distal relapse rates. Systemic relapses are more often asymptomatic as compared to peritoneal or locoregional relapse and detected on follow-up surveillance. Hence, identification of such recurrences while still salvageable via an intensive surveillance protocol is desirable.

Optimal neoadjuvant strategy for signet ring cell carcinoma of the rectum-Is TNT the solution?

INTRODUCTION: The results of total neoadjuvant therapy (TNT) for locally advanced rectal cancers (LARC) cannot be extrapolated to signet-ring cell cancers (SRCC) that have an extremely aggressive biology. METHODS: A retrospective study comparing long course chemoradiation (CTRT) against short course radiation (SCRT) and 12 weeks of chemotherapy for high-risk LARC. Primary endpoints were treatment failure and disease-free survival (DFS) RESULTS: CTRT was given to 74 (59.7%) and SCRT/Chemotherapy to 50 patients (40.3%). Additional chemotherapy was required in 54.1% and 28%, respectively. Except for nodal staging, no other MRI parameter down-staged. Treatment failures were seen in 33.9% and 25.8% had progression. The peritoneum was the commonest site of progression (59.4%). Of the patients that were surgically explored, 63.7% had R0 resections and pathological complete response was seen in 9.7%. At a median follow-up of 35 months, 56.5% had DFS events with a 3-year DFS of 39.5%. Recurrences were noted in 45.1% after curative resections and the 3-year OS/DFS of these patients were 67.2%/56.4%. On multivariate regression, the type of preoperative therapy did not influence treatment failures or DFS. CONCLUSIONS: SRCC is a very aggressive disease and none of the treatment strategies could show superiority over the other with very high peritoneal progression rates and relapses.

Comparative study of functional outcomes between ultra-low anterior resection and inter-sphincteric resection: a propensity matched analysis.

BACKGROUND: Comparative bowel functional outcomes between ultralow anterior resections (ULAR) and inter-sphincteric resection (ISR) for similar tumour and patient characteristics is not known. METHODS: Single centre study of low rectal caners (<5cm from anal verge) with 1:1 propensity matching of age, sex, body mass index, prior radiation, and surgical approach (open vs. minimally invasive) was performed for the ULAR and ISR groups. Primary outcome measure was Wexner Incontinence scores and Low Anterior Resection Syndrome (LARS) score at a single time point after stoma reversal. RESULTS: Seventy-two matched patients were included. Median Wexner scores were five and eight for the ULAR and ISR cohorts (p = 0.006). Major incontinence (Wexner >11) was found in 5.6% versus 33% after ULAR and ISR, respectively. Major LARS (score > 29) was demonstrated in 11% versus 25% in ULAR versus ISR (p = 0.293). Majority in both groups has no LARS (score < 20), that is, 72.2% versus 63.9% in ULAR against ISR. Besides these, stool fragmentation (p < 0.001), nocturnal defecation (p < 0.001) and use of anti-diarrhoeal medications (p = 0.023) were significantly more after ISR. CONCLUSIONS: Bowel continence was relatively inferior after ISR as compared to an ULAR for low rectal cancers in matched cohorts. Major LARS in ISR was twice as prevalent without statistical differences.

Learning curve analysis for lateral pelvic lymph node dissection in rectal cancers - Outcomes improve with experience.

INTRODUCTION: Lateral pelvic lymph node dissection (LPLND) is a technically challenging procedure and its learning curve has not been analysed against an oncologically relevant outcome. The purpose of the study was to determine the learning curve for LPLND in rectal cancers using nodal retrieval as performance measure. METHODS: Consecutive LPLND for rectal adenocarcinomas from a single institution were retrospectively analysed. Cumulative sum (CUSUM) control charts were used to detect difference in performance with respect to lymph node yield. Negative binomial regression was used to determine factors influencing nodal harvest using Incidence Risk Ratios (IRR). Separate CUSUM curves were generated for open and minimally invasive surgeries (MIS). RESULTS: One-hundred and twenty patients were included and all received preoperative radiation. MIS was used in 53.3%. Median lymph node yield was 6 with 20% nodal positivity. Increasing experience (IRR - 1.196) and MIS (IRR - 1.586) were the only factors that influenced nodal harvest. CUSUM charts revealed that learning curve was achieved after the 83rd case overall and after the 19 operations in MIS. There was a 20% increase in nodal yield after every 30 MIS LPLND performed. CONCLUSIONS: Learning curve for LPLND is relatively long and only increasing experience and minimally invasive operations increased nodal yield.

Prospective study to assess the role of FDG PET/CT in detecting systemic metastatic spread in rectal cancers with lateral pelvic lymph nodes.

INTRODUCTION: The utility of positron emission tomography (PET) in detecting additional M1 patients over conventional staging modalities is not known in rectal cancer patients with enlarged lateral pelvic nodes. METHODS: Prospective, single center, single-arm interventional study of consecutive rectal cancer patients that had baseline lateral pelvic nodes on MRI (>10 mm) between February 2017 to December 2018. Such patients underwent PET after confirming non-metastatic status on CT of thorax and abdomen. Primary outcome measure was additional M1 sites detected on PET. A 10% distant metastasis rate was expected with 80% confidence interval (CI) set at 5% as the lower limit. RESULTS: 44 patients were included and the concordance between MRI and PET in detection of lateral nodes was 97.7% (43 patients). Additional sites of metastasis were detected in 5 patients (11.36%; 80% CI - 5.63%-20.6%), and there was a change in treatment plan in 7 (15.9%). The number needed to treat (NNT) for PET scans to detect additional metastatic sites and change treatment were 9 and 6 respectively. There was a change in treatment intent (curative to palliative) in 2 patients (4.5%, NNT - 22). CONCLUSION: In rectal cancer patients with LPLN, the use of FDG-PET-CT over conventional staging studies led to the detection of additional extra-pelvic metastasis in 11.4% and changed the treatment plan in 15.9%. This met the pre-defined threshold to endorse the use of PET-CT in patients that match the study characteristics.

Incidence and Treatment Outcomes of Rectovaginal Fistula After Rectal Cancer Resection.

OBJECTIVES: Rectovaginal fistulas (RVFs) are an uncommon and disturbing complication with limited success in treatment. This study was aimed at determining the incidence of RVFs after rectal resections in the era of neoadjuvant radiation therapy and the outcomes of their treatment. METHODS: This was a retrospective study of female patients who underwent sphincter-preserving total mesorectal excision for rectal cancer and developed RVF. RESULTS: Four hundred eighty-eight patients underwent rectal resections between January 2013 and December 2019, and 9 developed RVF (1.8%). Average time to presentation was 280 days (range, 6-540 days). The median time to onset for those presenting prior to stoma reversal was 90 days, whereas the duration between stoma reversal and RVF detection in those presenting after stoma closures was 115 days. Success rates of fecal diversion and local procedures for treatment of RVF were 20% (2/10 procedures) and 40% (2/5 procedures), respectively. Redo coloanal anastomosis was performed for 2 patients with successful outcome. An average of 2.1 procedures were performed per patient (19/9) with a per-procedure success rate of 31.6% (6/19 procedures) and a per-patient success rate of 66.7% (6/9). At median follow-up of 64 months, 50% (3/6) of patients with a healed fistula were free of stoma, and all of them were continent. Four patients were sexually active. CONCLUSIONS: The incidence of RVF after rectal resection is low, but treatment outcomes are disappointing. Diversions and local repairs had high failure rates in our patients where the majority received preoperative radiation therapy. After successful healing, sexual function and continence are acceptable.

The Technique and Justification for Minimally Invasive Surgery in COVID-19 Pandemic: Laparoscopic Anterior Resection for Near Obstructed Rectal Carcinoma.

Introduction: The recent COVID-19 pandemic outbreak has made surgeons change and take on newer strategies and safe exercises. All elective cases have been put off, but oncology cases need to be done to prevent progression of the disease. There is concern about minimally invasive surgery due to aerosol formation. Here we discuss how we have dealt with this in our colorectal surgery department taking into account current evidence about the danger of viral transmission during laparoscopic surgery. Discussion: We report a case of 28 years old female patient with carcinoma rectum. The patient had near total intestinal obstruction. She was operated on utilizing laparoscopic anterior resection. The air seal (CONMED, Utica, NY) and high-efficiency particulate air (HEPA) filter was utilized for safe gas evacuation. There is no evidence against laparoscopic surgery, which suggest viral transmission. One should take utmost precautions using N95 masks and personal protective equipment (PPE). Air filtration products like aerosol, HEPA filters will be of great aid in safe evacuation of gases. Conclusion: At present, there is no solid evidence to suggest viral transmission through surgical smoke. We believe due to effective smoke containment, less blood loss, and less postoperative stay, laparoscopy will be a non-inferior option than open surgical procedure. We advise taking all precautions for operating room staff to lessen the danger of transmission.

Diode Laser in Management of Tracheobronchial Typical Carcinoid: A Case Report with Review of Literature.

Tracheobronchial carcinoids are relatively uncommon neoplasms with malignant (though indolent) potential and variable behavior. Clinical presentation is usually similar to any obstructive tracheobronchial lesions or rarely with presentation of carcinoid syndrome. Management varies from Pneumonectomy to use of lung sparing bronchoscoplastic techniques. We report the case of a 32-year-old male patient diagnosed with carcinoid of left main bronchus. Patient was successfully treated with trans-bronchoscopic diode laser. At 24 months of follow up patient remains asymptomatic and recurrence-free.