ABSTRACT
PURPOSE: To assess local control after preoperative radiation and local excision and to determine an optimal radiotherapy regimen. METHODS: Eighty-nine patients with G1-2 rectal adenocarcinoma <3-4 cm; unfavourable cT1N0 (23.6%), cT2N0 (62.9%) or borderline cT2/cT3N0 (13.5%) received 5 × 5 Gy plus 4 Gy boost (71.9%) or 55.8 Gy in 31 fractions with 5-FU and leucovorin (28.1%). Local excision (traditional technique 56.2%, transanal endoscopic microsurgery 41.6%, Kraske procedure 2.2%) was performed 6-8 weeks later. If patients were downstaged to ypT0-1 without unfavourable factors (good responders), this was deemed definitive treatment. Immediate conversion to radical surgery was recommended for remaining patients. RESULTS: Good response to radiation was seen in 67.2% of patients in the short-course group and in 80.0% in the chemoradiation group, p = 0.30. Local recurrence at 2 years (median follow-up) in good responders was 11.8% in the short-course group and 6.2% in the chemoradiation group, p = 0.53. In the total group, a lower rate of local recurrence at 2 years was observed in elderly patients (>69 years, median value) when compared to the younger patients; 8.3% vs. 27.7%, Cox analysis hazard ratio 0.232, p = 0.016. A total of 18 patients initially managed with local excision required conversion to abdominal surgery but either refused it or were unfit. In this group, local recurrence at 2 years was 37.1%. CONCLUSIONS: This study suggests an acceptable local recurrence rate after preoperative radiotherapy and local excision of small, radiosensitive tumours in elderly patients.
Subject(s)
Rectal Neoplasms/radiotherapy , Rectal Neoplasms/surgery , Aged , Aged, 80 and over , Combined Modality Therapy , Female , Follow-Up Studies , Humans , Male , Middle Aged , Neoplasm Recurrence, Local , Prospective Studies , Rectal Neoplasms/pathology , ReoperationABSTRACT
BACKGROUND: Distal intramural spread is present within 1 cm from visible tumor in a substantial proportion of patients. Therefore, ≥ 1 cm of distal bowel clearance is recommended as minimally acceptable. However, clinical results are contradictory in answering the question of whether this rule is valid. The aim of this review was to evaluate whether in patients undergoing anterior resection, a distal bowel gross margin of <1 cm jeopardizes oncologic safety. METHODS: A systematic review of the literature identified 17 studies showing results in relation to margins of approximately <1 cm (948 patients) versus >1 cm (4626 patients); five studies in relation to a margin of ≤ 5 mm (173 patients) versus >5 mm (1277 patients), and five studies showing results in a margin of ≤ 2 mm (73 patients). In most studies, pre- or postoperative radiation was provided. RESULTS: A multifactorial process was identified resulting in selection of favorable tumors for anterior resection with the short bowel margin and unfavorable tumors for abdominoperineal resection or for anterior resection with the long margin. In total, the local recurrence rate was 1.0% higher in the <1-cm margin group compared to the >1-cm margin group (95% confidence interval [CI] -0.6 to 2.7; P = 0.175). The corresponding figures for ≤ 5 mm cutoff point were 1.7% (95% CI -1.9 to 5.3; P = 0.375). The pooled local recurrence rate in patients having ≤ 2 mm margin was 2.7% (95% CI 0 to 6.4). CONCLUSIONS: In the selected group of patients, <1 cm margin did not jeopardize oncologic safety.
Subject(s)
Neoplasm Recurrence, Local , Rectal Neoplasms/surgery , Rectum/surgery , Anastomosis, Surgical , Digestive System Surgical Procedures/methods , Digestive System Surgical Procedures/standards , Humans , Rectal Neoplasms/radiotherapyABSTRACT
Advances of minimally invasive surgery caused return to operative treatment of gastroesophageal reflux disease (GERD). Authors present advantages and faults of laparoscopic treatment of gastroesophageal reflux disease (in literature and own experience).
Subject(s)
Gastroesophageal Reflux/surgery , Laparoscopy , Humans , Laparoscopy/adverse effectsABSTRACT
The advent of laparoscopic colorectal surgery evoked discussion on its advantages and limitations. Although application of laparoscopy in the management of benign colorectal diseases has been widely accepted, its use for treatment of malignancies is still controversial. Many reports suggest that laparoscopic operations provide similar oncological radicality as open procedures, with less operative trauma, shorter hospital stay and low complication rate. In the hands of well-trained surgeon laparoscopic colorectal surgery seems to be attractive operative modality. Authors present own experience with laparoscopic colorectal surgery.