Defining Benchmarks for Pelvic Exenteration Surgery: A Multicentre Analysis of Patients with Locally Advanced and Recurrent Rectal Cancer.

OBJECTIVE: To establish globally applicable benchmark outcomes for pelvic exenteration (PE) in patients with locally advanced primary (LARC) and recurrent rectal cancer (LRRC), using outcomes achieved at highly specialised centres. BACKGROUND DATA: PE is established as the standard of care for selected patients with LARC and LRRC. There are currently no available benchmarks against which surgical performance in PE can be compared for audit and quality improvement. METHODS: This international multicentre retrospective cohort study included patients undergoing PE for LARC or LRRC at 16 highly experienced centres between 2018 and 2023. Ten outcome benchmarks were established in a lower-risk subgroup. Benchmarks were defined by the 75th percentile of the results achieved at the individual centres. RESULTS: 763 patients underwent PE, of which 464 patients (61%) had LARC and 299 (39%) had LRRC. 544 patients (71%) who met predefined lower risk criteria formed the benchmark cohort. For LARC patients, the calculated benchmark threshold for major complication rate was ≤44%; comprehensive complication index (CCI): ≤30.2; 30-day mortality rate: 0%; 90-day mortality rate: ≤4.3%; R0 resection rate: ≥79%. For LRRC patients, the calculated benchmark threshold for major complication rate was ≤53%; CCI: ≤34.1; 30-day mortality rate: 0%; 90-day mortality rate: ≤6%; R0 resection rate: ≥77%. CONCLUSIONS: The reported benchmarks for PE in patients with LARC and LRRC represent the best available care for this patient group globally and can be used for rigorous assessment of surgical quality and to facilitate quality improvement initiatives at international exenteration centres.

Tata Memorial Centre Evidence Based Management of Colorectal cancer.

ABSTRACT: This review article examines the evidence-based management of colorectal cancers, focusing on topics characterized by ongoing debates and evolving evidence. To contribute to the scientific discourse, we intentionally exclude subjects with established guidelines, concentrating instead on areas where the current understanding is dynamic. Our analysis encompasses a thorough exploration of critical themes, including the evidence surrounding complete mesocolic excision and D3 lymphadenectomy in colon cancers. Additionally, we delve into the evolving landscape of perioperative chemotherapy in both colon and rectal cancers, considering its nuanced role in the context of contemporary treatment strategies. Advancements in surgical techniques are a pivotal aspect of our discussion, with an emphasis on the utilization of minimally invasive approaches such as laparoscopy and robotic surgery in both colon and rectal cancers, including advanced rectal cases. Moving beyond conventional radical procedures, we scrutinize the feasibility and implications of endoscopic resections for small tumors, explore the paradigm of organ preservation in locally advanced rectal cancers, and assess the utility of total neoadjuvant therapy in the current treatment landscape. Our final segment reviews pivotal trials that have significantly influenced the management of colorectal liver and peritoneal metastasis.

Spatial Epidemiology of Signet-ring Cell Colorectal Cancer in India.

Background: Signet-ring cell colorectal carcinoma (SRCC) is an extremely aggressive yet uncommon histologic subtype of colorectal cancer (CRC) with an unknown etiology. There is a stark difference in the prevalence of signet cancers between Western countries and the Indian subcontinent; however, India itself is a vast and diverse country with variable cancer incidence. Objective: To study the spatial epidemiology of SRCC in India for identifying regions with high prevalence. Methods: This retrospective study included all patients diagnosed with colorectal adenocarcinoma at Tata Memorial Hospital, the largest colorectal cancer referral unit in India, between January 2020 and December 2022. Geocoding based on the location of the residence was done to map the incidences. Comparisons were performed between the proportion of signet cell and non-signet colorectal cancers. Results: A total of 4100 patients with colon or rectal adenocarcinomas were included, of which signet cell histology was found in 624 (15%) patients. SRCC accounted for the highest proportions of CRCs in the Central (19%) and Northern (19%) regions, and the lowest in the North-Eastern (10%) and Western (12%) regions of India (P < 0.001), with non-overlapping confidence intervals. Compared with patients with non-signet CRCs, those with SRCC more commonly had colon cancers (22% vs. 17%; P = 0.003) and belonged to a lower socioeconomic background (67% vs. 59%; P < 0.001). Conclusions: This study found that SRCCs accounted for a significant proportion of CRC cases in India, but there was no substantial disparity in distribution across regions.

Comparing robotic with laparoscopic beyond total mesorectal excision for advanced rectal cancer-a propensity-matched analysis.

AIM: Robotic surgery is increasingly being used for rectal resection, with short-term benefits such as reduced hospital stay, faster bowel recovery and fewer complications. However, its utility for advanced rectal cancers requiring beyond total mesorectal excision has not been adequately evaluated. The aim of this study was to compare robotic and laparoscopic approaches for extended rectal resection, with postoperative and short-term oncological outcomes as endpoints. METHOD: A retrospective, single-centre study of patients with advanced rectal cancer requiring extended rectal resection between January 2017 and December 2022 was carried out. Beyond total mesorectal excisions included pelvic exenteration, en bloc soft tissue or partial organ resection with the rectum, and lateral pelvic node dissection. Propensity score matching in a 4:1 ratio of laparoscopic to robotic was performed with age, sex, comorbidities, body mass index, organs involved, clinical T stage and colonoscopic obstruction. RESULTS: A total of 425 beyond total mesorectal excisions were performed by minimally invasive approaches during the study period, and after propensity matching 228 laparoscopic operations were compared with 57 robotic resections. All baseline characteristics were balanced. No difference in blood loss, postoperative complications, length of hospital stay, positive resection margin or nodal yield was found, but there was a somewhat longer operating duration in robotics. The 2-year disease-free and overall survival were also similar. CONCLUSIONS: No differences in postoperative or short-term oncological outcomes were found between robotic and laparoscopic beyond total mesorectal excisions for advanced tumours when performed by teams experienced in both robotics and laparoscopy.

Patient reported outcomes after multivisceral resection for advanced rectal cancers in female patients.

INTRODUCTION: Multivisceral resections for rectal cancer can lead to long-term functional disturbances. This study aims to evaluate the quality-of-life outcomes in female patients who underwent multivisceral resection for rectal cancer, specifically focusing on urinary and sexual functions. METHODS: A cross-sectional study was conducted on female patients who underwent multivisceral rectal resections. Quality of life was assessed using the EORTC QLQ-CR29. RESULTS: Out of 198 female patients that underwent multivisceral resections, 69 were assessable for functional outcomes. The uterus was removed in 42 patients (61%), and the posterior vaginal wall in 34 (49%). A vaginal reconstructive procedure was carried out in 30% (21 patients). Patients reported the most troubles with urinary frequency (mean: 69.6; SD: 9.9), hair loss (mean: 64.7; SD: 13.9), pain during intercourse (mean: 44; SD: 40.7), and bowel frequency (mean: 36.9; SD: -10.7) in this order. Amongst the functional scales, anxiety about future health (mean: 42.5; SD: -018.9) and interest in sex (mean: 57.2; SD: 33.2) scored the lowest. CONCLUSION: Multivisceral rectal resections in female patients are associated with physical and psychosocial changes resulting in urinary and bowel complaints, anxiety about future health, poor sexual health, and pain.

Complete mesocolic excision for right colon cancer: Is D3 lymphadenectomy necessary?

AIM: Although complete mesocolic excision (CME) for colon cancer is oncologically sound, to date, there has been no consensus on the extent of lymphadenectomy in radical right colectomy. This study essentially compared the perioperative and survival outcomes of CME with two templates of lymphadenectomy for right colon cancer. METHOD: This was a propensity matched, retrospective analysis of a single centre, prospectively maintained database of all patients undergoing elective right colectomy for nonmetastatic, biopsy-proven adenocarcinoma from November 2013 to October 2018. CME + D3 was adopted selectively, documented prospectively, and compared with patients undergoing CME + central vascular ligation (CVL). The only technical difference between the groups was the excision of the surgical trunk of Gillot in the CME + D3 group. Postoperative, long-term outcomes and patterns of recurrence were compared between the groups. RESULTS: Of the 244 eligible patients, 88 (36.1%) and 156 (63.9%) underwent CME + D3 and CME + CVL, respectively. Matched groups (72 [CME + D3] vs. 108 [CME + CVL]) showed no difference in histology, tumour grade, postoperative complications, mortality, and hospital stay. CME + D3 was preferentially performed laparoscopically (35.2% vs. 9%), was associated with lower blood loss (215 mL vs. 297 mL, p = 0.001), higher nodal yield (31 vs. 25 nodes, p = 0.003) and a higher incidence of chyle leak (4 vs. 0, p = 0.013). At a median follow-up of more than 57 months, there was no significant difference in local recurrence, disease-free or overall survival. CONCLUSION: In this retrospective study, lymphadenectomy along the superior mesenteric vein, as a component of CME for right colon cancer, offered a higher nodal yield with no improvement in oncological outcome. Dissection of the SMV, over and above a D2 dissection, could therefore be restricted to specialized colorectal units until further studies establish the incremental oncological benefit of this extended lymphadenectomy or define a patient group in whom it is beneficial.

Pelvic exenterations combined with cytoreductions for T4 rectal cancers with peritoneal metastasis: a safety analysis.

BACKGROUND: Pelvic exenterations and cytoreduction are individually morbid procedures with oncological validity. The combination of these simultaneously in patients with rectal cancers has not been evaluated. The present study aimed to assess the surgical and survival outcomes of the combined procedure. METHODS: Retrospective, single-centre analysis of consecutive patients that underwent pelvic exenterations and cytoreductions for advanced or recurrent rectal cancers with peritoneal metastasis between 2013 and 2022. The primary outcome measure for safety was major complications (≥Grade IIIA). The threshold for considering the procedure unsafe was set at 50% for the upper confidence limit of major morbidity. Overall and recurrence-free survival were also assessed. RESULTS: Thirty-nine patients underwent the combined procedure that included 24 total pelvic and 15 posterior pelvic exenterations. The median age of the cohort was 35 years, 18 (46.2%) had signet ring cell cancers, and eight patients (21%) had extraperitoneal disease as well. The median PCI was 4 and CC-0 was achieved in 38 patients (97.4%). Hyperthermic intraperitoneal chemotherapy was delivered in 15 patients, and four had placement of an intraperitoneal chemo port. Major complications were experienced by 7 patients (18%; 95% confidence interval: 7.5%-33.5%). Median recurrence-free and overall survivals were 9 and 17 months, respectively. CONCLUSION: Combined pelvic exenterations and cytoreductions are safe operations in terms of morbidity. Survival, however, remains poor for this group of patients despite aggressive surgery.

Impact of consolidation chemotherapy in poor responders to neoadjuvant radiation therapy: magnetic resonance imaging-based clinical-radiological correlation in high-risk rectal cancers.

PURPOSE: The current study was conducted to examine the role of consolidation chemotherapy after neoadjuvant radiation therapy (NART) in decreasing the involvement of the mesorectal fascia (MRF) in high-risk locally advanced rectal cancers (LARCs). METHODS: In total, 46 patients who received consolidation chemotherapy after NART due to persistent MRF involvement were identified from a database. A team of 2 radiologists, blinded to the clinical data, studied sequential magnetic resonance imaging (MRI) scans to assess the tumor response and then predict a surgical plan. This prediction was then correlated with the actual procedure conducted as well as histopathological details to assess the impact of consolidation chemotherapy. RESULTS: The comparison of MRI-based parameters of sequential images showed significant downstaging of T2 signal intensity, tumor height, MRF involvement, diffusion restriction, and N category between sequential MRIs (P < 0.05). However, clinically relevant downstaging (standardized mean difference, > 0.3) was observed for only T2 signal intensity and diffusion restriction on diffusion-weighted imaging. No clinically relevant changes occurred in the remaining parameters; thus, no change was noted in the extent of surgery predicted by MRI. Weak agreement (Cohen κ coefficient, 0.375) and correlation (Spearman rank coefficient, 0.231) were found between MRI-predicted surgery and the actual procedure performed. The comparison of MRI-based and pathological tumor response grading also showed a poor correlation. CONCLUSION: Evidence is lacking regarding the use of consolidation chemotherapy in reducing MRF involvement in LARCs. The benefit of additional chemotherapy after NART in decreasing the extent of planned surgery by reducing margin involvement requires prospective research.

Splenic flexure cancer: is right extended hemicolectomy better than left hemicolectomy?

INTRODUCTION: There is no consensus on the optimal surgery for splenic flexure cancers. METHODS: Review of a prospectively maintained database of patients with splenic flexure cancer undergoing either a right extended hemicolectomy or left hemicolectomy at a tertiary care cancer hospital from 14.5.2010 to 16.9.2021. The primary outcome measures were postoperative morbidity and hospital stay with secondary outcomes being overall survival, disease-free survival, and long-term patient reported functional and quality of life outcomes. RESULTS: The demographic variables were evenly distributed between groups, and median follow-up was 44 months. The groups were comparable in terms of postoperative morbidity (Clavien-Dindo complication ≥ 3a 10.6% vs 10%, p = 0.322) and hospital stay (8 days vs 7 days, p = 0.316). Oncological outcomes were similar in both groups (3-year disease-free survival 71.8% vs 67.8%, p = 0.877, and 3-year overall survival 83.9% vs 75.8%, p = 0.787), and long-term patient-reported functional outcomes were excellent in both groups. CONCLUSION: Oncological outcomes, post operative morbidity, and long-term patient reported functional outcomes are comparable in patients undergoing either a right extended or left hemicolectomy for splenic flexure cancer.

Outcomes of Patients With Colorectal Liver Metastasis in the Developing World: Is Liver Transplantation for Unresectable Liver Metastasis, the Next Logical Step?

Background: While half of the patients with colorectal cancer develop metastasis, some 20% develop liver-only disease, and 10% of patients with unresectable liver disease live for 5 years. This study audits the outcomes of patients with colorectal liver metastasis to identify patients with unresectable liver metastasis eligible for a liver transplant. Method: All patients with colorectal liver metastasis, irrespective of the presence of metastasis at other sites, registered between January 1, 2018, and December 31, 2019, were included in this retrospective audit. Patients in whom R0 Resection with adequate future liver remnant was not possible even after downstaging with chemotherapy were deemed unresectable. Overall survival was calculated using the Kaplan-Meier analysis. Patients eligible for a liver transplant were identified using the International Hepato-Pancreatico-Biliary Association (IHBPA) consensus guidelines and Oslo and Fong clinical risk scores. Results: Out of 284 patients, 80 were treated with curative intent and 185 with palliative intent. At a median follow-up of 36 months, the median and 3-year OS were 37 months and 55% for the curative intent group and 9 months and 4% for the palliative intent group, respectively. Among 173 patients with liver-only metastasis, 13 patients (7%) satisfied the IHBPA consensus guidelines and had both Oslo and Fong scores of 2 or less. Transplant-eligible patients with unresectable liver metastasis had median and 3-year OS of 24 months and 25% against 9 months and 5% for ineligible patients, respectively. Conclusion: Liver transplant has the potential to benefit a small but significant portion of patients with unresectable liver metastasis.

Empty pelvis syndrome: a retrospective audit from a tertiary cancer center.

INTRODUCTION: Empty pelvis syndrome (EPS) has been defined as a complications arising as a sequel of empty space created after extensive pelvic surgery involving perineal resection. However this definition has been heterogenous throughout the limited literature available. Hence, EPS is a significant yet under recognized complication vexing both patients and surgeons. Even till date, prevention and management of EPS remain a challenge. Various preventive strategies have been employed each with its own complications. Few small studies mentioned incidence of this dreaded complication in between 20 and 40%. But most of these studies quote vague evidence and especially only after TPE surgeries. To the best of our knowledge, incidence after APR and PE has never been mentioned in literature. PURPOSE: To assess the clinical burden of empty pelvis syndrome in patients undergoing abdominoperineal resection (APR), posterior exenteration (PE), or total pelvic exenteration (TPE) for low rectal cancers. METHODS: This is a retrospective audit from a high-volume tertiary cancer center in India. Patients who underwent APR, PE, or TPE between the years 2013 to 2021 were screened and analyzed for incidence, presentation, and management of empty pelvic syndrome (EPS). RESULTS: A total of 1224 patients' electronic medical records were screened for complications related to empty pelvis. The overall incidence of EPS was 95/1224 (7%) with 55/1024 (5%) in APR, 8/39 (20.5%) in PE, and 32/143 (21.9%) in TPE. The most common clinical presentation was small bowel obstruction 43/95 (45.2%) and most presented late, 56/95 (60%), i.e., after 30 days of surgery. Most of the patients who had EPS were managed conservatively 55/95 (57%). CONCLUSION: EPS is a significant clinical problem that can lead to major morbidity, especially after exenterative surgeries warranting effective preventive strategies.

Should anorectal manometry be routine before stoma reversal in patients after an intersphincteric resection?

INTRODUCTION: Anorectal manometry (ARM) is sometimes performed before ostomy reversal in patients with an intersphincteric resection (ISR) to predict bowel function. However, no clinical predictive data exist regarding its utility. METHODS: The single-centre, retrospective data of ISR patients who had an ARM prior to ostomy reversal, and bowel functional assessment with the low anterior resection syndrome (LARS) and Wexner incontinence scores at least 6 months after reversal, were considered. Correlation statistics were performed with each of the manometric parameters and functional outcome categories. RESULTS: Eighty-nine patients were included. The median basal and squeeze pressures were 41 and 100 mmHg, respectively. Any LARS (score ≥20) and major incontinence (score ≥11) was observed in 51.7% and 16.9%, respectively. None of the manometric parameters (median basal or maximum squeeze pressure, anal canal length, volume at urge and the ability to expel) correlated with LARS or incontinence. CONCLUSIONS: Anorectal manometry (ARM) before ostomy reversal to predict bowel function at 6 months or beyond was not helpful in patients with an ISR and diverting stoma. No manometric parameter correlated with the LARS or Wexner incontinence scores.

Laparoscopic liver metastasectomy, retroperitoneal lymph node dissection and abdominoperineal resection for rectal cancer.

Video demonstrating the technical details of minimally invasive, simultaneous liver resection, retroperitoneal lymph node dissection, and abdominoperineal resection for synchronous metastasis.

Bidirectional Chemotherapy in Advanced Colorectal Cancer Peritoneal Metastases.

Colorectal cancer (CRC) patients with extensive peritoneal metastases who are not candidates for CRS-HIPEC have poor prognoses. We evaluated the role of systemic and intra-peritoneal (IP) chemotherapy in these patients. CRC patients with confirmed peritoneal metastasis were enrolled. After implantation of IP chemoport patients received weekly IP paclitaxel in incremental doses of 20 mg/m2 with systemic chemotherapy. The primary end-points were the feasibility, safety, and tolerance (perioperative complications), and the secondary end-point was the clinico-radiological response. Patients included in the study were registered between January 2018 and November 2021. IP chemoport was implanted in 18 patients of which 14 patients underwent successful instillation of IP chemotherapy. Four patients did not receive IP chemotherapy in view of port-site infection for which IP ports were removed. The median age was 39 years (range: 19-61 years). The site of the primary tumor was equal in the colon and rectum. Fifty percent of patients had signet ring-cell adenocarcinoma, and 21% had poorly differentiated adenocarcinoma. The median serum of CEA level was 12.27 ng/mL (1.63-116.16 ng/mL). The median PCI score was 25 (18-35). The median number of IP chemotherapy cycles (weekly) was 3.5 (1-12 cycles). In 14.3% of patients, IP chemoport had to be removed due to block and infection. Three, five, and four patients had clinico-radiologically disease progression, stable disease, and partial response, respectively. One patient underwent subsequent successful CRS-HIPEC. There were no grade 3-5 (CTCAE 3.0) complications. Incremental doses of IP paclitaxel with systemic chemotherapy is safe and feasible in selected colorectal adenocarcinoma patients with peritoneal metastases without any serious adverse events.

Outcomes of extended total mesorectal excision in patients with locally advanced rectal cancer.

AIM: Extended total mesorectal excision (eTME) is a complex procedure involving en bloc resection of the structures surrounding the various quadrants of the rectum. This study, presenting the largest series so far of patients undergoing eTME, aimed to assess the surgical and survival outcomes of patients following treatment with eTME and to compare these outcomes with historical data on pelvic exenteration. METHOD: The study is a retrospective review of all patients with locally advanced rectal cancer requiring an eTME (2014-2020). The database includes the demographic profile, operative details, histopathological features and follow-up. RESULTS: One hundred and sixty three patients who underwent eTME were analysed. The overall Clavien-Dindo complication rate of > IIIa was 21.1%. The anterior quadrant was the most common anatomical site resected (68.5%). The R1 resection rate was 10.4%. After a median follow-up of 28 months, there were 51 recurrences in the study and twenty two deaths were recorded. The local recurrence rate was 7.3% among the study population. The disease-free survival (DFS) and overall survival were 66.7% and 80.4%, respectively, at 3 years. The majority of the recurrences were distant metastasis (84.3%). In univariate analysis, the quadrant involved did not affect survival. In multivariate analysis, signet ring histology, metastatic presentation, inadequate tumour response and R1 resection affected DFS. CONCLUSION: The recurrence pattern, R1 resection rate and survival outcomes of patients in the present study were comparable with those for patients undergoing an exenteration. Therefore, eTME is probably a safe alternative to pelvic exenterations when R0 resection is achievable and when the procedure is performed in high-volume specialist tertiary care centres.