Prediction of Isolated Local Recurrence After Resection of Pancreatic Ductal Adenocarcinoma: A Nationwide Study.

BACKGROUND: Distinguishing postoperative fibrosis from isolated local recurrence (ILR) after resection of pancreatic ductal adenocarcinoma (PDAC) is challenging. A prognostic model that helps to identify patients at risk of ILR can assist clinicians when evaluating patients' postoperative imaging. This nationwide study aimed to develop a clinically applicable prognostic model for ILR after PDAC resection. PATIENTS AND METHODS: An observational cohort study was performed, including all patients who underwent PDAC resection in the Netherlands (2014-2019; NCT04605237). On the basis of recurrence location (ILR, systemic, or both), multivariable cause-specific Cox-proportional hazard analysis was conducted to identify predictors for ILR and presented as hazard ratios (HRs) with 95% confidence intervals (CIs). A predictive model was developed using Akaike's Information Criterion, and bootstrapped discrimination and calibration indices were assessed. RESULTS: Among 1194/1693 patients (71%) with recurrence, 252 patients (21%) developed ILR. Independent predictors for ILR were resectability status (borderline versus resectable, HR 1.42; 95% CI 1.03-1.96; P = 0.03, and locally advanced versus resectable, HR 1.11; 95% CI 0.68-1.82; P = 0.66), tumor location (head versus body/tail, HR 1.50; 95% CI 1.00-2.25; P = 0.05), vascular resection (HR 1.86; 95% CI 1.41-2.45; P < 0.001), perineural invasion (HR 1.47; 95% CI 1.01-2.13; P = 0.02), number of positive lymph nodes (HR 1.04; 95% CI 1.01-1.08; P = 0.02), and resection margin status (R1 < 1 mm versus R0 ≥ 1 mm, HR 1.64; 95% CI 1.25-2.14; P < 0.001). Moderate performance (concordance index 0.66) with adequate calibration (slope 0.99) was achieved. CONCLUSIONS: This nationwide study identified factors predictive of ILR after PDAC resection. Our prognostic model, available through www.pancreascalculator.com , can be utilized to identify patients with a higher a priori risk of developing ILR, providing important information in patient evaluation and prognostication.

Total mesorectal excision for rectal cancer - laparoscopic versus robotic approach.

INTRODUCTION: The primary goal of this study was to evaluate peroperative and early postoperative results of laparoscopic and robotic surgery for rectal cancer with total mesorectal excision (TME) and with primary anastomosis. METHODS: 404 patients were enrolled in the study, divided in two cohorts and compared retrospectively: a laparoscopic group (n=236) versus a robotic (TME + primary coloanal anastomosis) group (n=168). The evaluated cohorts were comparable in sex, age, BMI, ASA score, distal tumor margin from anal verge and neoadjuvant chemoradiotherapy. More advanced tumor stages were observed in the robotic group (p=0.009). RESULTS: The duration of robotic resection was significantly longer compared to laparoscopic resection (p.

Risk factors of low anterior resection syndrome after miniinvasive restorative rectal resection.

INTRODUCTION: Over the last decades outcomes for rectal cancer surgery have improved with increasing survival and lower recurrence rates. Nevertheless, functional disorders are still frequent. Low anterior resection with total mesorectal excision (TME) in patients with rectal cancer has improved oncological outcomes. However, most of them will have significant changes in quality of life, including varying degree of bowel dysfunction. Aim of this study was to analyse prevalence of LARS (low anterior resection syndrome) in patients with rectal cancer after miniinvasive restorative resection and to define its risk factors. METHODS: Between March 2016 and June 2018, patients who underwent elective miniinvasive (laparoscopic or robotic) rectal resection were enrolled. Bowel dysfunction was evaluated by LARS questionnaire and filled out 6, 12, and 24 months after primary operation or after ileostomy closure. 98 patients completed the questionnaires - 58 laparoscopic operations, 34 robotic and 6 open procedures. 69 patients underwent TME, tumor-specific mesorectal excision 21 patients. 8 patients underwent transanal TME. The clinical characteristics, surgical perioperative and postoperative outcomes did not differ between these groups. Only, significantly more patients underwent neoadjuvant radiotherapy in the robotic group (p=0.004). RESULTS: 59.8% patients reported major LARS 6 months after surgery and 29.7% after 24 months. Protentional risk factors are age (p.

Fluorescent angiography in colorectal surgery, the influence of augmented reality in the operating room on the anastomotic leakage after low rectal resection.

INTRODUCTION: Near-infrared (NIR) fluorescence angiography (FA) is an augmented reality (AR) technique. When used in the operating room, it allows colorectal surgeons to visualize and evaluate intestinal blood flow in real time, identify lymph nodes, ureters, or peritoneal metastases. Evaluation of perfusion with FA in augmented reality mode has an impact on reducing the ALR (anastomotic leakage rate) in rectal resections. METHODS: Data analysis of patients after minimally invasive surgery (MIS) for middle and lower rectal adenocarcinoma with total mesorectal excision (TME) using fluorescent angiography (FA) with indocyanine green (ICG) (100 patients, 20152019) were subsequently compared with a historical control group (100 patients) operated on for the same diagnosis before the introduction of the FA-ICG method (20122015) using minimally invasive approach (MIS). The patients were operated on consequently at one workplace. RESULTS: In fifteen patients (15%), the resection line was shifted due to insufficient perfusion detected by FA-ICG. The incidence of AL was lower in the group with FA compared to the group without FA (9% vs. 19%, p=0.042, χ test). A retrospective analysis of the group revealed a significant risk factor (RF) for the anastomotic leak, namely diabetes (p=0.036) and, among others, a protective factor, application of the transanal drain (NoCoil) (p=0.032). CONCLUSION: The introduction of new procedures and the use of new technologies, such as the use of the FA method in the AR mode in resections of the rectum with TME for cancer can lead to a reduction in the incidence of anastomotic leakage.

[Fluorescence angiography in the detection of anastomotic perfusion during rectal and sigmoid resection - preliminary report]. / Fluorescencní angiografie v detekci kvality perfuze anastomózy u resekce sigmoidea a rekta - zhodnocení prubezných výsledku.

INTRODUCTION: The aim of the study was to evaluate the results of fluorescence angiography for assessing anastomotic perfusion after resection of the sigmoid colon and rectum since its introduction into clinical practice at the authors´ workplace and to evaluate the incidence of necessary resection line repositioning based on the quality of perfusion, and also to record any complications in anastomotic healing. METHOD: Retrospective unicentric analysis of prospectively collected data from patients with resection of the sigmoid colon and rectum with primary anastomosis. The patient set included 50 patients, 27 males and 23 females; the median age was 64.5 years (33-80). Forty-four patients were indicated for resection for cancer of the sigmoid colon or rectum, while 6 patients had a benign disease. Twenty-nine patients underwent total mesorectal excision with coloanal mechanical or hand-sewn anastomosis and 21 underwent resection of the sigmoid colon or upper rectum with mechanical anastomosis. Prior to the construction of the anastomosis, assessment of perfusion of the anastomotic segments by near infrared (NIR) indocyanine green (ICG) fluorescence angiography was performed in all patients. The quality of perfusion of the mesocolon and bowel wall and its impact on moving the resection line and complications of anastomotic healing 30 days postoperatively were all evaluated. RESULTS: Assessment of perfusion using fluorescence angiography was technically successfully performed in all 50 patients. In 5 cases (10%) the resection line had to be moved for signs of poor perfusion of the bowel wall. Postoperatively, healing of the anastomosis was complicated in four patients (8%). Dehiscence was recorded in 3 patients (10.3%) with total mesorectal excision and in 1 patient (4.8%) after resection of the sigmoid colon and upper rectum. CONCLUSION: The presented results indicate that fluorescence angiography may lead to a decrease in the incidence of anastomotic dehiscence after colorectal resections by mapping in detail the perfusion of the anastomosed segments.Key words: fluorescence angiography - indocyanine green - anastomotic leak - colorectal resection.

[Laparoscopic parastomal hernia repair with modified Sugarbaker technique in patients after abdominoperineal resection of the rectum - initial experience]. / Laparoskopická modifikovaná Sugarbakerova plastika parastomální hernie u pacientu po abdominoperineální amputaci rekta - pilotní zkusenosti.

INTRODUCTION: Parastomal hernia is a common stoma complication. Surgical treatment is necessary in approximately 10 to 20% of cases. Mesh hernia repair gives significantly better results. The authors present their initial experience with laparoscopic repair of parastomal hernia using the modified Sugarbaker technique. MATERIAL AND METHODS: In the period from January 2011 to December 2013, 15 patients with a symptomatic parastomal hernia underwent laparoscopic repair with modified Sugarbaker technique. All patients had a parastomal hernia at the site of terminal colostomy after abdominoperineal resection. 14 patients underwent primary hernia repair, 1 patient was operated on for recurrence of parastomal hernia after open hernia repair. Parietex Parastomal mesh was used for hernia repair in all cases. RESULTS: Laparoscopic repair was performed successfully in all patients. The mean operating time was 45 minutes (range: 2080 minutes). The mean postoperative hospital stay was 3 days (range: 26 days). No serious postoperative complication was recorded. In the postoperative period, a recurrent symptomatic hernia was found in 1 of 15 patients (6.7%) with reintervention 17 months after primary surgery. CONCLUSION: Laparoscopic hernia repair of parastomal hernia with modified Sugarbaker technique seems to be a safe method with a very low risk of postoperative complications, including hernia recurrence. .

[Colon cancer - evaluation of complications and risks of planned resections]. / Karcinom tlustého streva - zhodnocení komplikací a rizik plánovaných resekcních výkonu

INTRODUCTION: Resection procedures for colorectal cancer are burdened with a relatively high number of complications. The aim of this study is to define risk factors associated with the development of postoperative complications based on retrospective data analysis. MATERIAL AND METHODS: From January 1 st 2007 to December 31st 2012, 1093 patients underwent surgery for colorectal cancer. Retrospectively, we selected a group of 406 patients who underwent planned, elective colon resection for colon cancer. Open surgery was performed in 158 patients (38.9%), laparoscopic resection in 248 patients (61.1%). Based on initial staging of the disease, there were 85 patients (20.9%) in stage I, 137 patients (33.8%) in stage II, 110 patients (27.1%) in stage III and 74 patients (18.2%) in stage IV. Postoperative complications were evaluated according to Clavien - Dindo classification. RESULTS: Grade I complications were observed in 34 patients (8.4%), grade II in 25 patients (6.2%), grade III in 43 patients (10.6%), grade IV in 7 patients (1.7%) and grade V in 8 patients (2.0%). The highest incidence of complications was observed in left colon resection procedures (41.1%), open resections (39.8%), procedures lasting longer than 301 minutes (50%), patients older than 81 years (41.6%) and in procedures performed by the youngest, less experienced surgeon (40.6%). CONCLUSION: Our results confirmed that the type and approach of surgical procedure, patients age and surgeons experience are risk factors associated with a higher incidence of postoperative complications. High-risk surgical patients should be operated on by experienced surgeon who regularly performs a high number of resection procedures.

Recurrent disease detection after resection of pancreatic ductal adenocarcinoma using a recurrence-focused surveillance strategy (RADAR-PANC): protocol of an international randomized controlled trial according to the Trials within Cohorts design.

BACKGROUND: Disease recurrence remains one of the biggest concerns in patients after resection of pancreatic ductal adenocarcinoma (PDAC). Despite (neo)adjuvant systemic therapy, most patients experience local and/or distant PDAC recurrence within 2 years. High-level evidence regarding the benefits of recurrence-focused surveillance after PDAC resection is missing, and the impact of early detection and treatment of recurrence on survival and quality of life is unknown. In most European countries, recurrence-focused follow-up after surgery for PDAC is currently lacking. Consequently, guidelines regarding postoperative surveillance are based on expert opinion and other low-level evidence. The recent emergence of more potent local and systemic treatment options for PDAC recurrence has increased interest in early diagnosis. To determine whether early detection and treatment of recurrence can lead to improved survival and quality of life, we designed an international randomized trial. METHODS: This randomized controlled trial is nested within an existing prospective cohort in pancreatic cancer centers in the Netherlands (Dutch Pancreatic Cancer Project; PACAP) and the United Kingdom (UK) (Pancreas Cancer: Observations of Practice and survival; PACOPS) according to the "Trials within Cohorts" (TwiCs) design. All PACAP/PACOPS participants with a macroscopically radical resection (R0-R1) of histologically confirmed PDAC, who provided informed consent for TwiCs and participation in quality of life questionnaires, are included. Participants randomized to the intervention arm are offered recurrence-focused surveillance, existing of clinical evaluation, serum cancer antigen (CA) 19-9 testing, and contrast-enhanced computed tomography (CT) of chest and abdomen every three months during the first 2 years after surgery. Participants in the control arm of the study will undergo non-standardized clinical follow-up, generally consisting of clinical follow-up with imaging and serum tumor marker testing only in case of onset of symptoms, according to local practice in the participating hospital. The primary endpoint is overall survival. Secondary endpoints include quality of life, patterns of recurrence, compliance to and costs of recurrence-focused follow-up, and the impact on recurrence-focused treatment. DISCUSSION: The RADAR-PANC trial will be the first randomized controlled trial to generate high level evidence for the current clinical equipoise regarding the value of recurrence-focused postoperative surveillance with serial tumor marker testing and routine imaging in patients after PDAC resection. The Trials within Cohort design allows us to study the acceptability of recurrence-focused surveillance among cohort participants and increases the generalizability of findings to the general population. While it is strongly encouraged to offer all trial participants treatment at time of recurrence diagnosis, type and timing of treatment will be determined through shared decision-making. This might reduce the potential survival benefits of recurrence-focused surveillance, although insights into the impact on patients' quality of life will be obtained. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04875325 . Registered on May 6, 2021.

Dioxin-like and endocrine disruptive activity of traffic-contaminated soil samples.

Pollution of surface soils by traffic, especially along major highways, can be a significant issue. Numerous studies have demonstrated traffic to be an important source of particulate matter and gas-phase organic air pollutants that produce many types of deleterious effects. This article brings original information about the presence of contaminants with specific mechanisms of action in traffic-influenced soils as determined by bioanalytical approaches and instrumental analyses. The initial phase of the study aimed to compare contamination of soils near highways with those from reference localities, whereas the second phase of the study investigated the influence of traffic pollution in soils at various distances from highways. For the reference areas, forest soils contained greater concentrations of 2,3,7,8-tetrachlorodibenzo-p-dioxin equivalents (TCDD-EQs; 483 to 2094 pg/g) than did arable soils (96 to 478 pg/g), which represent the relevant reference for the studied soils along highways. The total concentration of TCDD-EQs determined in the in vitro transactivation assay ranged from 225 to 27,700 pg/g in traffic-affected soils. The greatest concentration of TCDD-EQs among the studied sites was observed in soils collected near highway D1, which is the primary thoroughfare in the Czech Republic. The concentrations of TCDD-EQs in roadside soils were the greatest and decreased with increased distance from highways, and this spatial distribution corresponded with the levels of polycyclic aromatic hydrocarbons (PAHs). Soils collected 100 m away from highways in most cases contained concentrations of TCDD-EQs similar to background values. Most TCDD-EQ presence was caused by nonpersistent compounds in soils, with a significant contribution from PAHs as well as other unknown nonpersistent chemicals. Extracts from most soils collected near highways exhibited antiestrogenic and in some cases antiandrogenic activities; for several sites the activity was also detected in soils farther from highways. The presence of TCDD-EQs and antihormonal activity in highway-affected soils points to traffic as a source of polluting compounds having specific effects.

[Ten-year experience with Barron ligature in the Ostrava surgical clinic]. / 10 let zkuseností s Barronovou ligaturou na chirurgické klinice Ostrava.

The authors aim to present the problematics of hemorrhoid treatment using the Barron ligature semiinvasive method, to healthcare professionals.

[Laparoscopic colorectal surgery for carcinomas--assessment of the authors' patient group]. / Laparoskopická kolorektální chirurgie pro karcinom--zhodnocení vlastního souboru.

AIM OF THE WORK: The aim was to assess short-term and long-term results of miniinvasive procedures for colorectal carcinomas. METHODS: This prospective study assessed patients indicated for laparoscopic procedures for their large intestinal or rectal carcinomas from 1993 to 2004. Primarily, their peroperative complications, postoperative course and long-term results were assessed. The Kaplan-Meier analysis was used to assess long-term survival rates. RESULTS: Over the 11-year period, a total number of 399 patients (236 males and 163 females) were laparoscopically operated for colorectal carcinomas. In 284 patients, the tumor was located in the colon region and in 115 patients in the rectal region. The stage B and C (Dukes classification), medium to highly differenciated, tumors prevailed. Resection of the sigmoid, right-sided hemicolectomy, low anterior resection of the rectum and amputation of the rectum were the most frequently conducted procedures. 311 procedures (78%) were curative, 88 were paliative (22%). Peroperative complications occured in 16 patients (4%), reoperations were required in 34 patients (8.5%). The recovery time for peristalsis was on the second postoperative day, on average. Food load was, on average, tolerated since the third postoperative day and the first stool appeared, on average, on the fourth postoperative day. Early mortality rate reached 6.5%. Postoperative hospitalization lasted, on average, 12 days. In our patient group, a five-year survival rate without relapses was 80% in the carcinoma patients and 68% in the rectal carcinoma patients. CONCLUSION: Laparoscopic colorectal surgery is a safe method with a number of pros for a patient as well as a surgeon in a comparable oncological radicality as that of the open method.

[Safe distance of the inferior resection line in the rectal carcinoma surgery]. / Bezpecná vzdálenost dolní resekcní linie pri operaci karcinomu rekta.

The authors present results of a study of a distal intramural spread of the rectal carcinoma beneath its aboral margin, which was conducted over several years. The authors closely cooperated with the Pathological Anatomy Institute of the Faculty Hospital in Ostrava, where each preparation was examined not only macro- and microscopically, but also the tumor's microscopic spread beneath its macroscopic margin was assessed in standard distances of 2 mm, 5 mm, 1 cm, 2 cm and 5 cm. The study did not record tumorous spread at the distance of 5 cm from the aboral margin of the tumor. The authors also confirmed that the distal intramural spread of the tumor is fairly rare and, at the same time, it signifies a highly advanced and aggressive disorder with a poor prognosis. Therefore, the authors favor management with a maximum quantity of the sphincter- saving procedures, with a sufficiently radical mesorectal excision, which they consider the essential method of the radical surgical treatment. Furthermore, the authors have not recorded cases of the differenciated adenocarcinoma spread, even at the distance of 2 mm from the aboral margin of the tumor. All positive findings of the distal intramural spread have been recorded in medium- low differenciated adenocarcinomas.

[Laparoscopic resection of the rectum: a fashionable extreme or a golden standard?]. / Laparoskopická resekce rekta: módní výstrelek ci zlatý standard?

The authors point out advantages of the laparoscopic approach in colorectal surgery. The laparoscopic approach is not commonly used in a number of our clinics, therefore, the authors would like to present a rectal resection procedure used in the Surgical Clinic of the Faculty Hospital in Ostrava.

[The rectal carcinoma treatment history]. / Historie lécby karcinomu rekta.

The authors demonstrate a history of the rectal carcinoma surgical therapy, based on the available literature data or on oral information. Furthermore, they add their own experience with treatment of the rectal carcinoma, the disorder, which in the Czech Republic and, namely, in the Northern Moravian region, has one of the highest worldwide incidence rates.

[The first case of management of the rectovaginal fistule using transanal endocsopic microsurgery]. / První prípad resení rektovaginální pístele pomocí transanální endoskopické mikrochirurgie.

The authors present an unusual and, according to the available literature data, so far unused method--management of the rectovaginal fistule, using a T.E.M. technique (transanal endoscopic microsurgery). In their case-review of a female patient, they present advantages of this technique in a case of a rare disorder - a benign rectovaginal fistule. All of the following employment of a harmonic scalpel in the T.E.M. method, as well as of a tissue adhesive Tissucol and of a surgical rectoscope in the vaginal phase of the procedure, deserve attention of surgeons and gynaecologists.

The highest incidence in the world of rectal cancer is in Czech Republic.

Czech Republic is among the countries with the highest incidence of rectal cancer. The aim of the prospective study was to monitor the surgical treatment of patients with the diagnosis of rectal cancer. Certain aspects were examined: mainly the safety distance of the lower resection line during the operation of rectal cancer, the types of operations carried out, the amount of lymphatic nodes spotted in mesorectum and the possibility of laparoscopic utilization. In our study we focused on patients with rectal cancer who were operated within the three-year period (2000-2002) at the Department of Surgery at University Hospital of Ostrava. During this time there were 188 patients with rectal cancer treated. In the trial we shaved proved that in the direction from aboral margin of tumour the possibility of submucosal spread decreases in accordance with the literature. The submucosal spread of tumour occurs in 11.8% of cases. The spread of the tumour was not found at a distance of 5 cm below the bottom margin of tumour. In cases of microscopical positivity below the bottom margin of tumour there was a middle or low differentiated adenocarcinoma. The spread of well differentiated adenocarcinoma was not found. (Tab. 4, Fig. 5, Ref. 18.)

[Virtual colonoscopy as a part of the algorithm of the facultative examinations prior to the colorectal carcinoma procedure]. / Virtuální kolonoskopie jako souciást algoritmu fakultativních vysetriení pred operací kolorektálního karcinomu.

The authors present their own initial experience with virtual colonoscopy. Both benign and malignant stenosing processes of the colon and rectum, which make examining oral parts of the colon using colonoscopy or irrigography impossible, are the main indication for the procedure described. The authors' first experience with this method is totally positive. The more experienced the examiners, the better interpretation of the findings not only by radiologists but also by operating surgeons. In certain indications, the examination has its firm place in the algorithm of the facultative examinations prior to the colorectal carcinoma surgical procedures.

[Surgical management of advanced stages of rectal carcinomas]. / Chirurgická lécba pokrocilých stadií rektálního karcinomu.

The authors present a summary of literature data and their own experience with management of locally advanced rectal carcinomas. They prefer advanced surgical procedures, such as pelvic exenterations, and urge for preserving "quality of life".

[Surgical treatment of distally located rectal carcinomas using the rendez-vous method--a laparoscopic resection in combination with T.E.M]. / Chirurgická lécba nízce ulozeného karcinomu rekta metodou rendez-vous--laparoskopickou resekcí v kombinaci s T.E.M.

The aim of this work is to introduce a surgical procedure, which would make operations of distally located rectal carcinomas indicated for abdominoperineal extirpation of the rectum possible while maintaining intestinal continence and full functioning of the sphincter system. At the same time, we have aimed at the maximum use of all pros of contemporary miniinvasive surgical techniques. We have labelled our proposed surgical technique the "rendez-vous technique". The trial group includes the original group of 10 patients, who have been operated in our clinic since April 2004, using the rendez-vous technique. We are aware of the fact, that the trial group is small, however we believe that this trial group is the starting group, which will continue to enlarge and that it will bring results to the patients themselves, as well as for a valid prospective study in order to confirm or challenge the proposed method's effectiveness.