ABSTRACT
Approximately 10% to 25% of patients have a pathologic complete response after neoadjuvant chemoradiation. There is a compelling argument for attempting to avoid surgery in carefully selected groups of patients. Although nerve-preserving surgical techniques are now standard, the rates of urinary and sexual dysfunction are significant. Also, although sphincter function and quality of life among patients undergoing an ultra-low anterior resection is acceptable, results are poorer than expected and may be disabling. Trials of omission of surgery for selected patients with complete response after preoperative chemoradiation, otherwise known as "Watch and Wait," have shown favorable long-term results. We review the current literature on accepted standards of care and identify areas of controversy and important ongoing clinical studies aiming to resolve these issues.
Subject(s)
Rectal Neoplasms/drug therapy , Rectal Neoplasms/surgery , Biopsy , Chemoradiotherapy , Colonography, Computed Tomographic , Lymph Nodes/pathology , Magnetic Resonance Imaging , Neoadjuvant Therapy , Organ Preservation , Positron-Emission Tomography/methods , Preoperative Care , Proctoscopy/methods , Rectal Neoplasms/diagnostic imaging , Rectal Neoplasms/radiotherapy , Rectum/diagnostic imaging , Remission Induction , UltrasonographyABSTRACT
BACKGROUND: Conventional laparoscopy has been applied to colorectal resections for more than 2 decades. However, laparoscopic rectal resection is technically demanding, especially when performing a tumor-specific mesorectal excision in a difficult pelvis. Robotic surgery is uniquely designed to overcome most of these technical limitations. The aim of this study was to confirm the feasibility of robotic rectal cancer surgery in a large multicenter study. METHODS: Retrospective data of 425 patients who underwent robotic tumor-specific mesorectal excision for rectal lesions at seven institutions were collected. Outcome data were analyzed for the overall cohort and were stratified according to obese versus non-obese and low versus ultra-low resection patients. RESULTS: Mean age was 60.9 years, and 57.9 % of patients were male. Overall, 51.3 % of patients underwent neoadjuvant therapy, while operative time was 240 min, mean blood loss 119 ml, and intraoperative complication rate 4.5 %. Mean number of lymph nodes was 17.4, with a positive circumferential margin rate of 0.9 %. Conversion rate to open was 5.9 %, anastomotic leak rate was 8.7 %, with a mean length of stay of 5.7 days. Operative times were significantly longer and re-admission rate higher for the obese population, with all other parameters comparable. Ultra-low resections also had longer operative times. CONCLUSION: Robotic-assisted minimally invasive surgery for the treatment of rectal cancer is safe and can be performed according to current oncologic principles. BMI seems to play a minor role in influencing outcomes. Thus, robotics might be an excellent treatment option for the challenging patient undergoing resection for rectal cancer.
Subject(s)
Adenocarcinoma/surgery , Digestive System Surgical Procedures , Minimally Invasive Surgical Procedures , Postoperative Complications , Rectal Neoplasms/surgery , Robotic Surgical Procedures , Adenocarcinoma/pathology , Feasibility Studies , Female , Follow-Up Studies , Humans , Laparoscopy , Length of Stay , Male , Middle Aged , Neoplasm Staging , Prognosis , Rectal Neoplasms/pathology , Retrospective Studies , Risk Factors , Time FactorsABSTRACT
BACKGROUND: Annual screening for anal cancer is recommended only for HIV patients at increased risk: men who have sex with men, individuals with a history of anogenital warts, and women with cervical dysplasia. OBJECTIVE: The aim of this study was to examine the screening outcomes between HIV populations with and without these risk factors. METHODS: We reviewed the records of all HIV patients referred for anal cytology and high-resolution anoscopy from June 2009 to June 2010. Patients were stratified into an increased-risk group or a standard-risk group. MAIN OUTCOME: Of the 329 evaluable patients, 285 (89.8% men, 10.2% women, mean age 46 ± 10 years) were classified to the increased-risk group, whereas 44 (72.7% men, 27.3% women, mean age 52 ± 8 years) were included in the standard-risk group. Male sex, white race, sexual orientation, past and current receptive anal intercourse, noncompliance with condom use, and absence of a new sexual partner were significantly different in the increased-risk group in comparison with the standard-risk group. In the increased-risk group, 187 (66.5%) patients had biopsy-proven dysplasia of which 118 (42.0%) had high-grade disease. In the standard-risk group, 15 (34.9%) patients had biopsy-proven dysplasia of which 7 (16.3%) had high-grade disease. Cytology detected biopsy-confirmed high-grade dysplasia only in 23 of 118 (19.5%) patients in the increased-risk group and in 2 of 7 (28.6%) patients in the standard-risk group. Kappa agreement in detecting high-grade disease was low for both increased-risk and standard-risk groups: 0.16 (95% CI 0.07-0.23) and 0.40 (95% CI 0.02-0.40). LIMITATIONS: Our study is a chart-based retrospective review of data with a small female population. Histology reports came from 2 different laboratories. CONCLUSION: High-grade anal dysplasia was prevalent even among HIV patients who only have standard risk factors. Anal cytology and high-resolution anoscopy have poor agreement. We suggest considering annual screening by using high-resolution anoscopy in addition to cytology for all HIV patients regardless of risk factors.