Mid-Term Audit of a National Peritoneal Surface Malignancy Program Implementation in a Low Middle Income Country: The Moroccan Experience.

Implementing a multimodal management of peritoneal surface malignancies is a steep and complex process, especially as complete cytoreductive surgery (CRS) is the backbone and the major prognostic factor for hyperthermic intraperitoneal chemotherapy (HIPEC) procedures. The implementation of such a program is a challenging process, particularly in low-middle income (LMIC) countries where ressource restrictions may represent a major hurdle to HIPEC appliances acquisition. Herein is the first audit of the implementation of a national peritoneal malignancy program in a north African country. The audit process was performed according to the three implementation steps, namely initiation ("1":2005-2008), transition ("2":2009-2013) and consolidation ("3":2014-2017). We included all consecutive CRS without HIPEC performed with curative intent for ovarian, gastric, colorectal and pseudomyxoma peritonei type of malignancies with an Eastern Cooperative Oncology Group (ECOG) performance Status ≤ 2. Target outcomes for incomplete cytoreduction (ICRS), serious complications ≥ 3b according to the Clavien-Dindo scoring, and early oncologic failure (EOF; disease progression within 2 years of treatment) were compared between the three phases. Independent risk factors correlated to these three outcomes were calculated using a logistic regression model.198 CRS procedures were completed with 49, 60 and 89 cases performed in the three phases, respectively. Overall, patients were comparable except for ECOG and ASA scores which were more severe in the third phase. The comparison of ICRS, serious complications and EOF rates showed a significant reduction between the three phases with (34%, 18% and 4% p = <0.001), (30.6%, 20% and 11.2%, p = 0.019) and (38.8%, 23.3% and 12.4% p = 0.002) respectively. Undergoing CRS in phase 3 on the other hand was a predictive factor of better short term surgical and oncological outcomes and completeness of cytoreduction, while ECOG performance status and spleno-pancreatectomy were also predictive factors of serious complications.

Functional outcomes over time following perineal pseudocontinent colostomy reconstruction after abdominoperineal resection for ultralow rectal adenocarcinoma.

BACKGROUND AND OBJECTIVES: Pseudocontinent-perineal colostomy (PCPC) following abdominoperineal resection (APR) is a promising technique associated with good quality of life. This study evaluates over time the functional results after PCPC using the Kirwan score. METHODS: All PCPC patients operated on from January 2001 to January 2016 were followed with their functional results assessed at four checkpoints. A/B Kirwan scores and a 48 to 72 hours colonic irrigation rhythm were considered "good" and "convenient" and their overall variations over time were assessed by means of Cochran's Q test corrected by Bonferroni post hoc test. RESULTS: Fifty-seven eligible patients were included in the study with 33 (58%) women. We noted a significant difference in both Kirwan score and colic irrigation rhythm during the four checkpoints in follow-up with Q(1) = 85.01 and Q(2) = 69. 86. By the fourth checkpoint, 86% of patients had a Kirwan score of A/B. Concerning the rhythm of colonic irrigation, there was a significant improvement between 6 months and other checkpoints. In the second year, 63% of patients reduced their colonic irrigation rhythm. CONCLUSIONS: The functional results of PCPC after APR improve and stabilize from 6 months to 1 year after surgery thus making PCPC a good alternative that surgeons can present to their patients.

Predictive factors of disease-free survival after complete pathological response to neoadjuvant radiotherapy for rectal adenocarcinoma: retrospective case series.

BACKGROUND: Many data suggest that patients with low rectal adenocarcinoma who achieved ypT0N0 status have improved survival and disease-free survival (DFS) compared to all other stages however only few data are available regarding the specific prognosis factors of this subgroup. This study aimed to evaluate predictive factors for disease free survival after complete pathological response (CPR) in cases of low rectal adenocarcinoma. MATERIALS AND METHODS: From January 2005 to December 2013, all patients with low rectal adenocarcinoma who underwent neoadjuvant chemoradiotherapy followed by total mesorectal excision and achieved CPR were included at 7 Moroccan and 1 Algerian centres. Predictive factors for disease-free survival were analysed by uni and multivariate analysis. RESULTS: Eigthy-four (12.1%) patients achieved a CPR (ypT0N0). Multivariate analysis revealed that both poorly differentiated tumors (OR, 9.23; 95 CI 1.35-62.82; P = 0.023) and the occurrence of perineal sepsis (OR, 13.51; 95 CI 1.96-93.12; P = 0.008) were independently associated with impaired DFS. CONCLUSIONS: Patients with low rectal cancer who exhibited a CPR after neoadjuvant therapy have good prognoses; however, the occurrence of perineal sepsis and/or poor initial differentiation may be associated with impaired DFS in these patients. TRIAL REGISTRATION: The study was retrospectively registered the 28th July 2018 in ClinicalTrials.gov register with the reference NCT03601689.

Perineal pseudocontinent colostomy for ultra-low rectal adenocarcinoma: the muscular graft as a pseudosphincter.

BACKGROUND AND STUDY AIM: The aim of this study was to analyze objectively the role of the muscular graft in the continence using manometric study in the patients who underwent pseudocontinent perineal colostomy after abdominoperineal resection for rectal adenocarcinoma. PATIENTS AND METHODS: This was a retrospective study including all the patients from January 2002 to December 2009 who underwent an abdominoperineal resection followed by perineal pseudocontinent colostomy for ultra-low rectal adenocarcinoma and agreed to perform the manometric evaluation of the muscular graft. RESULTS: Fifteen patients were included, six males and nine females, with a mean age of 50 years. According to Kirwan's classification, 2 (13.3%) patients had normal continence (Stage A) had 10 (66.6%) no soiling (stage B) and 3 (20%) patients had minimal soiling (Stage C). The manometric evaluation was performed after a median period of 12 months post-surgery. The mean maximal resting and squeeze pressures were respectively 41 cmH2O and 59 cmH2O and the mean colonic sensory volume was 12 ml. CONCLUSION: This study showed that the musculae graft of Pseudocontinent Perineal colostomy acted as a hypotonic sphincter that pressure can increase during the voluntary squeeze. These data may help to clarify the functional outcomes of this technique after APR for ultra-low rectal adenocarcinoma.

Perineal pseudocontinent colostomy is safe and efficient technique for perineal reconstruction after abdominoperineal resection for rectal adenocarcinoma.

BACKGROUND: The aim of this study was to evaluate oncologic results and satisfaction rate results of pseudocontinent perineal colostomy (PCPC) using Schmidt's technique in patients undergoing abdominoperineal resection (APR) for managing low rectal adenocarcinoma. METHODS: From January 1993 and December 2007, One hundred and forty six patients underwent successfully PCPC after abdominoperineal resection for lower rectal adenocarcinoma. There were 75 women, with an average age of 47 years old. All patients received neoadjuvant radiotherapy with or without chemotherapy. Long-term oncological results and satisfaction rate were evaluated. RESULTS: After a median follow up of 36 months (range 12-156) months, the five-year overall survival and disease free survival rate were 74.6% and 60.3% respectively. Local and distant recurrences occurred respectively in 10 (6,8%) and 29 (20%) patients. Seventy-seven percent (77%) of the patients were highly satisfied with this technique and only one patient was unsatisfied. However, none of them accepted the conversion to an abdominal colostomy neither would have changed PCPC for an iliac colostomy at first intent. CONCLUSION: This study showed that pseudocontinent perineal colostomy is a safe and reliable pelvic reconstruction technique after abdominoperineal resection for low rectal adenocarcinoma. It provides high degree of patient satisfaction without compromising oncological results. It is a good option in selected patients, especially in Muslim countries.

Risk factors of poor functional results at 1-year after pseudocontinent perineal colostomy for ultralow rectal adenocarcinoma.

BACKGROUND: Pseudocontinent perineal colostomy is one of the techniques that helps recover the body image of patients undergoing abdominoperineal resection. This technique is rarely used internationally given its unknown functional results. OBJECTIVE: The study aimed to evaluate 1-year functional outcomes of perineal pseudocontinent colostomy and to determine the risk factors for "poor" functional results. DESIGN: This study is a retrospective interventional case series. SETTINGS: This study was conducted at a tertiary care university hospital and oncological center in Morocco. PATIENTS: From January 1993 to December 2007, 149 patients underwent pseudocontinent perineal colostomy after abdominoperineal resection for low rectal adenocarcinoma. INTERVENTION: Pseudocontinent perineal colostomy was performed with the use of the Schmidt technique after abdominoperineal resection. MAIN OUTCOME MEASURES: One-year functional results were assessed according to the Kirwan classification system. Functional results were considered "poor" when the Kirwan score was C, D, or E. Univariable and multivariable analyses were used to evaluate the impact of age, sex, type of surgery, irrigation frequency, palpable muscular ring, concomitant chemoradiotherapy, stage, and perineal complications on functional results. RESULTS: One hundred forty-six patients were analyzed. According to the Kirwan system, the scores showed that 100 (68.5%) patients had "good" continence results (stage A-B) and 46 (31.5%) patients had altered functional results (stage C-D-E). With the exception of pelvic recurrences, no conversions from a perineal colostomy to an abdominal colostomy were performed for dissatisfactory functional results. In multivariate analysis, the only independent predictive factors of poor functional results were the occurrence of perineal complications (OR, 3.923; 95% CI, 1.461-10.35; p = 0.007) and extended resection (OR, 3.03; 95% CI, 1.183-7.750; p = 0.021) LIMITATION OF THE STUDY:: This study is an observational retrospective study on selected patients (mainly a young population). CONCLUSIONS: This study showed that perineal complications and extended resection are associated with poor functional results after pseudocontinent perineal colostomy. These data can help clinicians to better inform patients about the outcomes of this technique and to assist them in choosing the right reconstruction technique after abdominoperineal resection.