Robotic abdominoperineal resection, posterior vaginectomy and abdomino-lithotomy sacrectomy: technical considerations and case vignette.

When working with patients who have locally advanced rectal cancer (LARC) the ability to undertake minimally invasive procedures becomes more challenging but no less important for patient outcomes. We performed a minimally invasive approach to surgery for LARC invading the posterior vagina and sacrum. The patient was a 75-year-old lady who presented with a locally advanced rectal tumour staged T4N2 with invasion into the posterior wall of the vagina and coccyx/distal sacrum. We introduce a robotic abdominoperineal resection, posterior vaginectomy and abdomino-lithotomy sacrectomy using a purely perineal approach with no robotic adjuncts or intracorporal techniques. Final histology showed moderately differentiated adenocarcinoma invading the vagina and sacrum, ypT4b N0 TRG2 R0 and the patient entered surgical follow-up with no immediate intra- or postoperative complications. A literature review shows the need for more minimally invasive techniques when relating to major pelvic surgery and the benefits of a purely perineal approach include less expensive resource use, fewer training requirements and the ability to utilise this technique in centres that are not robotically equipped.

Indications and outcomes for repeat cytoreductive surgery and heated intra-peritoneal chemotherapy in peritoneal surface malignancy.

INTRODUCTION: Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is offered in specialist centres as a treatment for peritoneal surface tumours. Despite its demonstrated efficacy, intra-abdominal recurrence occurs in 31-57% of patients. The aim of this study is to review the early and long-term outcomes in patients who undergo repeat CRS/HIPEC. MATERIALS AND METHODS: A retrospective review of a prospectively maintained database of patients who had undergone repeat CRS/HIPEC for appendiceal neoplasms and colorectal peritoneal metastases (CRPM) from 2003 to 2019 was performed at a single specialist centre. Data pertaining to both short term outcomes and survival were evaluated. RESULTS: Of 1259 patients who had undergone CRS/HIPEC, 84(6.7%) underwent repeat surgery: 45(53.6%) had pseudomyxoma peritonei (PMP) secondary to low grade appendiceal mucinous neoplasms (LAMN), 21(25.0%) had appendix carcinoma and 18(21.4%) had CRPM. Demographics, intra-operative findings and short-term outcomes were comparable across tumour types and between procedures. Median (95% CI) interval between procedures was 22.7(18.9-26.6) months and was comparable between tumour types. Median (95%CI) overall survival was not reached for the cohort overall or for those with PMP, but was 61.0(32.6-89.4) months for those with appendix cancer and 76.9(47.4-106.4) months for CRPM (p=<0.001). Survival was favourable in the PMP group (HR [95%CI] 0.044 [0.008-0.262]; p = 0.000) and unfavourable in the CC2-3 at index CRS procedure group (HR [95%CI] 25.612 [2.703-242.703]; p = 0.005). CONCLUSION: Our findings demonstrate that repeat cytoredutive surgery with HIPEC can result in favourable survival, especially for patients with PMP when complete cytoreduction is achieved at index operation. We recommend that detailed patient assessment is performed through an expert multidisciplinary team meeting (MDT).

Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for limited peritoneal metastasis. The PSOGI international collaborative registry.

INTRODUCTION: A laparoscopic approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (L-CRS+HIPEC) in highly selected patients has been reported in small cohorts with a demonstrable reduction in length of stay and post-operative morbidity. This study aims to analyse individual patient data from these international centres collected through the Peritoneal Surface Oncology Group International (PSOGI) L-CRS+HIPEC registry. METHODS: An international registry was designed through a networking database (REDCAP®). All centres performing L-CRS+HIPEC were invited through PSOGI to submit data on their cases. Patient's characteristics, postoperative outcomes and survival were analysed. RESULTS: Ten international centres contributed a total of 143 L-CRS+HIPEC patients during the study period. The most frequent indication was low grade pseudomyxoma peritonei in 79/143 (55%). Other indications were benign multicyst mesothelioma in 21/143(14%) and peritoneal metastasis from colon carcinoma in 18/143 (12,5%) and ovarian carcinoma in 13/143 (9%). The median PCI was 3 (2-5). The median length of stay was 6 (5-10) days, with 30-day major morbidity rate of 8.3% and 30-day mortality rate of 0.7%. At a median follow-up of 37 (16-64) months 126/143 patients (88.2%) were free of disease. CONCLUSIONS: Analysis of these data demonstrates that L-CRS+HIPEC is a safe and feasible procedure in highly selected patients with limited peritoneal disease when performed at experienced centres. While short to midterm outcomes are encouraging in patients with less invasive histology, longer follow up is required before recommending it for patients with more aggressive cancers with peritoneal dissemination.

Validation of nomogram for disease free survival for colon cancer in UK population: A prospective cohort study.

AIMS: To externally validate the MSKCC nomogram in a UK population, and determine if it could be used in our practice here in the UK. METHODS: The colon cancer database from a district general hospital in England was used to extract all patients who had a curative colon cancer resection. Inclusion criteria were all patients who had curative elective colon cancer resection between 01/01/1998 and 31/12/2003. Patients were followed up for up to ten years. Five and ten year predictions were calculated for each patient, and plotted against the actual recurrence using a ROC curve, and AUC was calculated for both the five and ten year nomogram. RESULTS: 138 patients were included in the study. Overall five year recurrence rate was 26.8% with a mean follow up of 60.24 months (SD = 38.6). 118 patients were included in the five year nomogram validation, and 102 patients were included in the ten year nomogram validation. A ROC curve was plotted for both the five and ten year nomogram and AUC was calculated. For the five year nomogram AUC was 0.673, and for the ten year nomogram AUC was 0.687. Two cut off points were identified for each nomogram and this divided the cohort into low, medium and high risk groups for recurrence. Cox regression showed there was significant difference between all groups for both nomograms. CONCLUSION: The MSKCC colon cancer nomogram was validated in our cohort, but it is recommended to be used in conjunction with AJCC TNM staging system.

Colon cancer presenting with polymyositis-A case report.

INTRODUCTION: Colorectal cancer most often presents with a change in bowel habit, weight loss or with bleeding per rectum. Much less commonly, colorectal cancer may present as part of a paraneoplastic syndrome. Polymyositis is a rare disease most often considered a complement-mediated idiopathic inflammatory myopathy manifested by proximal muscle weakness. However, polymyositis may also be part of a paraneoplastic syndrome associated with an underlying malignancy. The relationship between polymyositis and malignancy is well known, but it has been suggested that tumours of the large bowel are rarely complicated by myositis. PRESENTATION OF CASE: The authors describe a case report of an 82-year-old gentleman with a presumed musculoskeletal or neurological deficit who was subsequently diagnosed with metastatic colon cancer in the setting of progressive fatigue and muscle weakness. Concurrently, we review the current literature looking at the relationship between cancer and polymyositis. DISCUSSION: Colorectal cancer rarely presents with symptoms such as muscle weakness, however it is important to be aware of the possibility of an underlying malignancy when seeing patients with symptoms which are suggestive of polymyositis. CONCLUSION: The diagnosis of polymyositis in the elderly population should raise suspicion of an underlying malignancy.

Conservative surgery in the management of a benign ovarian cystic teratoma presenting as a rectal mass: a case report.

Ovarian cystic teratomas constitute 10-15% of all ovarian tumours and are the most common ovarian neoplasms found in adolescence and during pregnancy. Nevertheless, ovarian cystic teratomas have also been described in patients aged 1-91 years. We report an unusual case of a benign ovarian cystic teratoma presenting as a rectal mass that was managed surgically using radical resection by a multidisciplinary team. This case report highlights the importance of preoperative investigations including colonoscopy and radiological investigations. A dedicated pelvic radiologist/pathologist and the involvement of a multidisciplinary team at the time of initial diagnosis and a gynaecologist and colorectal surgeon at the time of surgery will lead to an accurate diagnosis and the most appropriate treatment. Although rare, erosion of an ovarian dermoid into the rectum should be considered in young women who have an atypical presentation and are found to have a lesion in the rectum with biopsies indicating benign pathology.

Loop ileostomy following anterior resection: is it really temporary?

INTRODUCTION: A temporary loop ileostomy is often created to minimize the impact of peritoneal sepsis if anastomotic dehiscence occurs following low colorectal anastomosis. Although it has been suggested that a loop ileostomy should be reversed within 12 weeks of formation, this is often not the case. We set out to analyse the use of loop ileostomy following elective anterior resection in England and to identify factors associated with non and delayed reversal. METHOD: Hospital episode statistics for the years 2001-2006 were obtained from the Department of Health. Patients undergoing elective anterior resection with a loop ileostomy for a primary diagnosis of rectal or recto-sigmoid cancer between April 2001 and March 2003 were identified as the study cohort. This cohort was followed until March 2006 to identify patients undergoing reversal of an ileostomy in an English NHS Hospital. RESULTS: A total of 6582 patients had an elective anterior resection between April 2001 and March 2003, of which 964 (14.6%) also had an ileostomy. Seven hundred and two (75.1%) patients were reversed before March 2006. Advancing age and comorbidity were statistically related to nonreversal. Median time to reversal was 207 days (Interquartile range 119-321.5 days). Postoperative chemotherapy and comorbidity significantly delayed reversal. CONCLUSIONS: One in four loop ileostomies performed to defunction an elective anterior resection is not reversed, and in the presence of significant comorbidity one in three is not reversed. Only 12% is reversed within 12 weeks.

Optimal conditions for successful ablation of high-grade dysplasia in Barrett's oesophagus using aminolaevulinic acid photodynamic therapy.

Photodynamic therapy (PDT) using 5-aminolaevulinic acid (ALA-PDT) is an attractive alternative to PDT with porfimer sodium for the treatment of high-grade dysplasia (HGD) in Barrett's oesophagus (BO) because of the shorter duration of light photosensitivity and low risk of oesophageal stricture formation. Published results, however, show marked variation in its efficacy, and optimum treatment parameters have not been defined. This study investigated how the dose of ALA and the colour of the illuminating light influenced the biological effect. Twenty-seven patients were enrolled into a randomised controlled trial of red versus green (635 nm or 512 nm) laser light activation for the eradication of HGD with ALA-PDT in Barrett's oesophagus. A further 21 patients were subsequently treated with the most effective regimen. Regular endoscopic follow-up with quadrantic biopsies every 2 cm was performed. The primary outcome measure was eradication of HGD. Patient's receiving ALA at 30 mg/kg relapsed to HGD more than those receiving 60 mg/kg (P = 0.03). Additionally, for those treated with ALA 60 mg/kg, red laser light was more effective than green laser light (P = 0.008). Kaplan-Meier analysis of the 21 patients who were subsequently treated with this optimal regimen demonstrated an eradication rate of 89% for HGD and a cancer-free proportion of 96% at 36 months' follow-up. Using an ALA dose of 60 mg/kg activated by 1,000 J/cm red laser light, we found that ALA-PDT was a highly effective treatment for high-grade dysplasia in Barrett's oesophagus.

The Noble plication: new indication for a historical procedure.

Complications following ileal pouch-anal anastomosis (IPAA) have been well-described in the literature. While rare, small bowel volvulus following IPAA has been described. We describe the successful use of the modified Noble plication in such a patient with small bowel volvulus about an elongated mesentery. This largely 'historical' technique is well-suited to manage small bowel volvulus, especially when non-resectional management is preferred.

Mucosal ablation in Barrett's esophagus.

Barrett's esophagus is a prevalent, premalignant condition affecting the gastroesophageal junction and distal esophagus. Ablation plus antireflux therapy has recently been advocated to prevent the development of adenocarcinoma or to treat those unfit or unwilling to undergo esophagectomy. The present article, based on a search of Medline/ISI databases and cross-referencing of relevant articles, reviews the literature on this subject. A number of techniques have been used to remove the affected mucosa, including laser, electrocoagulation, argon plasma coagulation and photodynamic therapy but, as yet, none has been shown to be superior. Depending on the method used, ablation results in complete removal of Barrett's esophagus in approximately one third of patients and a partial response in nearly two-thirds. The resultant squamous mucosa is apparently 'normal' but may regress. To promote and maintain regeneration, antireflux therapy must be sufficient to reduce repetitive injury to the esophageal mucosa. Whether ablation reduces the cancer risk or delays its occurrence is unknown, though recent data suggests benefit. Complications are infrequent and usually mild. Regular follow-up endoscopy and deep biopsies continue to be necessary. Careful data from much larger populations with long-term follow-up is required before ablation reaches the stage of broad clinical application.

Photodynamic therapy and the alimentary tract.

Photodynamic therapy offers the possibility of relatively selective tumour necrosis and normal tissue healing. It has many potential applications but as yet no clear role. Articles, editorials and case reports published primarily in English and listed in Medline/ISI up to April 2000 or identified by a manual search have been reviewed in an attempt to provide a comprehensive overview of the use of photodynamic therapy in the alimentary tract. It is concluded that photodynamic therapy can be an effective treatment for superficial pre-malignant mucosal lesions and early cancers, especially in diffuse disease. Suitable patients include those wishing to avoid surgery, high risk subjects or those in whom other forms of treatment have failed. Superiority over other methods of ablation has not so far been demonstrated. Cheaper and more effective photosensitizers and improved techniques of light delivery are likely to increase the application of photodynamic therapy.