Impact of the laparoscopic approach, early closure and preoperative stimulation on outcomes of ileostomy closure after rectal resection.

AIM: To evaluate the clinical outcome of early closure of a protective ileostomy and preoperative stimulation of the efferent limb in a cohort of patients with rectal cancer treated surgically, primarily using the laparoscopic approach. METHODS: We performed an observational retrospective cohort study in a prospectively recorded series of patients with rectal cancer who underwent laparoscopic surgery with a protective loop ileostomy between 2017 and 2022. Ileostomy closure was programmed for within 3 months after surgery. All patients underwent stimulation of the efferent limb. Primary outcomes were morbidity and mortality, length of stay (LOS), and re-admission. RESULTS: Between 2017 and 2022, 108 patients underwent resection for rectal cancer and protective ileostomy. The laparoscopic approach was performed in 84.3% of patients (n = 91). Permanent ileostomy was performed in 5 patients (4.6%). Ileostomy closure was thus performed in 95.4% of patients (n = 103). Median time to closure was 74.5 days (range 57-113). In 63.1% (n = 65) of patients, reconstructive surgery was performed within 90 days. Prior to closure, efferent limb stimulation was performed in 77.8% (n = 84) of patients. Global morbidity was 26.2% (n = 27) (85.19%, n = 23 Clavien-Dindo I and 7.41%, n = 2 Clavien-Dindo II). The main causes of morbidity were postoperative ileus (10.7%, n = 11) and rectal bleeding (8.7%, n = 9). Anastomosis leakage occurred in 2 patients. Median hospital stay was 6 days (5-7). Readmission was needed in 6.8% (n = 7) of patients. CONCLUSION: A previous laparoscopic approach, early closure and stimulation of the efferent limb could be a useful strategy to reduce the morbidity and mortality of temporary ileostomy closure.

Local Excision for organ preservation in early REctal cancer with No Adjuvant treatment (LORENA Trial): prospective observational study protocol.

INTRODUCTION: Local resection (LR) is an alternative to total mesorectal excision (TME) that avoids its associated morbidity to the detriment of oncological radicality in early stages of rectal cancer. There are several conditioning factors for the success of this strategy, such as poor prognosis histological factors (PPHF), involvement of resection margins, clinical under staging, or complications that may lead to the indication for radical surgery with TME. PATIENTS AND METHOD: An international multicenter prospective observational open-label study has been designed. Consecutive patients diagnosed with early rectal cancer (cT1N0 on MRI +/- endorectal ultrasound) whose lower limit is a maximum of 2 cm proximal to the ano-rectal junction will be included. The primary objective of the study is to determine the overall prevalence of PPHF after LR and requiring TME or postoperative radio-chemotherapy. DISCUSSION: The prevalence of PPHF conditioning the success of LR in early distal rectal cancer has been scarcely studied in the literature, and there are very few prospective data. Considering the increasing interest in the watch and wait strategy in rectal cancer and its possible application in early-stage tumors, it seems necessary to know this information. The results of this study will help guide clinical practice in patients with early distal rectal cancer. It will also provide quality information for the design of future comparative studies to improve organ preservation success in these patients. TRIAL REGISTRATION NUMBER: NCT05927584.

Recrecimiento tumoral en pacientes bajo esquema de watch-and-wait en cáncer de recto. Ensayo pictórico / Regrowth during watch-and-wait scheme in rectal cancer. Pictorial essay

Resumen En las últimas décadas, la resonancia magnética (RM) ha cobrado un rol fundamental en el diagnóstico, la estadificación y el seguimiento de los pacientes con cáncer de recto. En la estadificación inicial, que sean o no tumores localmente avanzados es lo que determina el tratamiento neoadyuvante o quirúrgico, respectivamente. Posterior a la neoadyuvancia, los pacientes que logren una respuesta clínica completa pueden ser considerados para la inclusión dentro de un esquema de vigilancia activa, comúnmente conocido como watch and wait (WW). La estrategia WW se basa en tres pilares, que son el examen digital rectal, la endoscopía y la RM, buscando detectar la presencia temprana de recrecimiento tumoral. En relación a la RM, la secuencia potenciada en T2 de alta resolución, junto con la de difusión (DWI) y el mapa de ADC, son las piezas clave para la detección temprana de recrecimiento. La estrategia de WW lleva a evitar cirugías resectivas con una alta morbilidad y deterioro de la calidad de vida. El examen digital rectal y la endoscopía son métodos de vigilancia complementarios a la RM, con su principal limitación en lesiones sin compromiso mucoso. Esta razón posiciona a la RM como un pilar indispensable para su implementación, detectando no solo áreas de recrecimiento parietal, sino también aquellas extramurales no accesibles por los otros métodos de vigilancia. En nuestro conocimiento, este es el primer ensayo iconográfico que se centra en el análisis estricto del recrecimiento tumoral en pacientes bajo esquema de WW por RM. El objetivo es enfatizar el protocolo de estudio en estos pacientes y mostrar las distintas formas de recrecimiento tumoral con el fin de lograr su detección temprana.

Abstract During the last decades, the magnetic resonance imaging (MRI) has become an strategic tool for diagnosis, staging and surveillance in patients with rectal cancer. To differentiate patients with locally advanced rectal tumors from those who do not, determinate neoadjuvant therapy or total mesorectal excision, respectively. After neoadjuvant chemoradiotherapy, those who achieve complete clinical response may be considered for inclusion in an active surveillance scheme known as “watch and wait” (WW). WW strategy consists of three pillars, rectal digital exam, endoscopy and the MRI, and the main purpose is to reach the early detection of tumoral regrowth. Regarding MRI, the high-resolution T2-weighted images in conjunction with DWI, and the ADC map plays a key role in this instance. WW leads to avoid resective surgeries with high morbidity rates. The rectal digital exam and endoscopy are complementaries to MRI, whose main limitation is the detection of lesions with no mucosal involvement. This reason places the MRI as a cornerstone in tumoral regrowth, detecting not only luminal regrowth, but those in which the rectal wall is not involved, and thus, not accessible for the other surveillance methods. To our knowledge, this is the first pictorial essay in which imaging regrowth patterns are described. The purpose of this is to emphasize the MRI protocol study and to describe the different forms of tumoral regrowth in order to reach the early tumoral regrowth detection.

Clinicopathological features of colorectal cancer patients under 30 years of age.

BACKGROUND: Colorectal cancer (CRC) is the second cause of cancer death in the world and is estimated to have been responsible for almost 935,000 deaths during 2020. OBJECTIVE: Describe clinicopathological features, overall survival (OS) and progression-free survival (PFS) in CRC patients under 30 years. METHOD: This is a retrospective cohort study in patients under 30 years diagnosed with CRC. RESULTS: From 2017 to 2021, 1823 patients were diagnosed with CRC, of which 54 (2.96%) were under 30 years. The OS, during 4 years, was 41.5%. The clinical stage found IV (hazard ratio [HR]: 6.212; 95% confidence interval [95% CI]: 2.504-15.414; p < 0.001), giving neoadjuvant therapy (HR: 0.705; 95% CI: 0.499-0.996; p = 0.047) and no medical history of Lynch syndrome (HR: 3.925; 95% CI: 1.355-11.364; p = 0.012) are independent predictors of mortality. The PFS, during 4 years, was 21.3%. Clinical stage IV (HR: 2.418; 95% CI: 1.000-5.850; p < 0.050), and no diagnosis of Lynch syndrome (HR: 3.800; 95% CI: 1.398-10.326; p = 0.009) are independent predictors. CONCLUSIONS: Younger patients are usually diagnosed with CRC in advanced stages. Early symptoms and evaluation, irrespective of age, are crucial.

ANTECEDENTES: El cáncer colorrectal (CCR) es la segunda causa de muerte por cáncer en el mundo y se estima que fue responsable de casi 935,000 muertes durante el año 2020. OBJETIVO: Describir las características clinicopatológicas, la supervivencia global (SG) y la supervivencia libre de progresión (SLP) en pacientes con CCR menores de 30 años. MÉTODO: Estudio de cohorte retrospectivo en pacientes con diagnóstico de CCR menores de 30 años. RESULTADOS: Entre 2017 y 2021 se diagnosticaron 1823 pacientes con CCR, de los cuales 54 (2.96%) eran menores de 30 años. La SG a 4 años fue del 41.5%. Se encontró que la etapa clínica IV (hazard ratio [HR]: 6.212; intervalo de confianza del 95% [IC95%]: 2.504-15.414; p < 0.001), recibir tratamiento neoadyuvante (HR: 0.705; IC95%: 0.499-0.996; p = 0.047) y no tener antecedente de síndrome de Lynch (HR:3.925; IC95%: 1.355-11.364; p = 0.012) son predictores de mortalidad independientes. La SLP a 4 años fue del 21.3%. La etapa clínica IV (HR: 2.418; IC95%: 1.000-5.850; p < 0.050) y el no contar con diagnóstico de síndrome de Lynch (HR: 3.800; IC95%: 1.398-10.326; p = 0.009) son predictores independientes. CONCLUSIONES: Los pacientes jóvenes son diagnosticados con CCR en etapas avanzadas. Los síntomas iniciales, junto con la evaluación, independientemente de la edad, son cruciales.

Application of the REAL-score prognostic index in decision making in rectal cancer surgery.

BACKGROUND: Colorectal anastomosis leak (AL) is the most feared complication of rectal cancer surgery (1-19%) as it increases morbidity and mortality and worsens oncological outcomes in terms of local recurrence and survival. The publication of the REAL-score index makes it possible to predict the risk of AL and compare the expected results with those obtained. METHOD: Observational, descriptive, longitudinal and retrospective study of patients operated on for rectal cancer at the Miguel Servet University Hospital, in Zaragoza, Spain, in 2019. Statistical analysis of morbidity and mortality outcome variables and the REAL-score index using ROC curves. RESULTS: Of 80 patients operated on for rectal cancer, colorectal anastomosis was performed in 52 and temporary ileostomy in 11 (21.2%). Morbidity was high (38.4%), but severe only in 7.7% (Clavien-Dindo IIIb), with no deaths. There were four dehiscences: one type B and three type C. A direct relationship between high risk of AL and the practice of temporary stoma is observed when the cut-off point of the REAL-score exceeds 14.74%. CONCLUSIONS: REAL-score can help in decision-making in rectal cancer surgery. Above a cut-off point, the risk of AL would imply a selective ileostomy.

ANTECEDENTES: La dehiscencia de la anastomosis colorrectal (DA) es la complicación más temida de la cirugía del cáncer de recto (1-19%), pues incrementa la morbimortalidad y empeora los resultados oncológicos en términos de recidiva local y supervivencia. La publicación del índice REAL-score permite predecir el riesgo de DA y comparar los resultados esperados con los obtenidos. MÉTODO: Estudio observacional, descriptivo, longitudinal y retrospectivo, de pacientes intervenidos de cáncer de recto en el Hospital Universitario Miguel Servet, en Zaragoza, España, en 2019. Análisis estadístico de variables resultado de morbimortalidad y del índice REAL-score mediante curvas ROC. RESULTADOS: De 80 pacientes intervenidos de cáncer de recto, se realizó anastomosis colorrectal en 52 e ileostomía temporal en 11 (21.2%). La morbilidad fue alta (38.4%), pero grave solo en el 7.7% (Clavien-Dindo IIIb), sin ningún fallecimiento. Hubo cuatro dehiscencias: una de tipo B y tres de tipo C. Se observa una relación directa entre alto riesgo de DA y la práctica de estoma temporal cuando el punto de corte del REAL-score supera el 14.74%. CONCLUSIONES: El REAL-score puede ayudar en la toma de decisiones en la cirugía del cáncer de recto. Por encima de un punto de corte, el riesgo de DA implicaría ileostomía selectiva.

Heterogeneidad del tumor primario en la18F-FDG PET/TC pretratamiento para predecir el pronóstico en pacientes con cáncer de recto sometidos a cirugía tras terapia neoadyuvante / Primary tumor heterogeneity on pretreatment18F-FDG PET/CT to predict outcome in patients with rectal cancer who underwent surgery after neoadjuvant therapy

Objetivo Estudio retrospectivo cuyo objetivo fue investigar el valor de las características de textura de los tumores primarios en la PET/TC con 18F-FDG pretratamiento para la predicción de la respuesta al tratamiento, la progresión y la supervivencia global en pacientes con cáncer de recto que se sometieron a cirugía después de la terapia neoadyuvante (TNA). Métodos Se incluyeron en este estudio pacientes con cáncer de recto que se sometieron a estudio PET/TC con 18F-FDG antes del tratamiento y se sometieron a cirugía después de TNA. Se registraron las características clínico-patológicas, la fecha del último seguimiento, la evolución y fallecimiento. Los parámetros de las texturas y los convencionales de PET (Standard Uptake Value-SUVmax, volumen tumoral metabólico-MTV, glucólisis total de la lesión-TLG) se obtuvieron a partir de imágenes PET/TC utilizando el programa LifeX. Los parámetros se agruparon utilizando el índice de Youden en el análisis ROC. Los factores que predicen la respuesta patológica al tratamiento, la progresión y la supervivencia global se determinaron mediante regresión logística y análisis de regresión de Cox. Resultados Cuarenta y cuatro pacientes (26-59% hombres, 18-41% mujeres; 60,1 ± 11,4 años) con cáncer de recto fueron incluidos en este estudio. El número de pacientes respondedores y no respondedores a TNA fueron de 15 (34,9%) y 28 (65,1%), respectivamente. La mediana de la duración del seguimiento fue de 29,9 meses. 9 (20,5%) mostraron progresión de la enfermedad y 8 (18,2%) fallecieron durante el período de seguimiento. Los parámetros de entropía GLCM de diferencia y correlación GLCM se encontraron como predictores independientes para la respuesta a TNA. Los parámetros de positividad del margen quirúrgico, rango intercuartílico de intensidad CONV y textura AUC-CSHDISC fueron predictores independientes de progresión (AU)

Purpose This retrospective study aimed to investigate the value of texture features of primary tumors in pretreatment18F-FDG PET/CT in the prediction of response to treatment, progression, and overall survival in patients with rectal cancer who underwent surgery after neoadjuvant therapy (NAT). Method Patients with rectal cancer who had pretreatment18F-FDG PET/CT, and underwent surgery after NAT were included in this study. Clinicopathologic features, date of last follow-up, progression, and death were recorded. Textural and conventional PET parameters (maximum standardized uptake value-SUVmax, metabolic tumor volume-MTV, total lesion glycolysis-TLG) were obtained from PET/CT images using LifeX program. Parameters were grouped using Youden index in ROC analysis. Factors predicting the pathological response to treatment, progression, and overall survival were determined using logistic regression and Cox regression analyses. Results Forty-four patients (26(59%) male, 18 (41%) female; 60.1 ± 11.4 years) with rectal cancer were included in this study. The numbers of patients with responders and non-responders to NAT were15(34.9%) and 28(65.1%), respectively. One patient’ pathology report did not contain the response status to NAT. The median of follow-up duration was 29.9 months. 9(20.5%) showed disease progression, and 8(18.2%) died during the follow-up period. Difference entropy GLCM and correlation GLCM parameters were found as independent predictors for response to NAT. The positivity of surgical margin, intensity interquartile range CONV and AUC-CSHDISC texture parameters were independent predictors of progression, while normalized inverse difference GLCM and LZLGEGLZLM parameters were independent predictorsof mortality. Conclusion The texture parameters obtained from pretreatment18F-FDG PET/CT have presented a more robust predictive value than conventional parameters in patients with rectal cancer who underwent surgery after NAT (AU)

Abordaje robótico de la exenteración pélvica masculina. Sistematización de la técnica / Robotic pelvic exenteration in males: Systematization of the technique

La exenteración pélvica masculina es un procedimiento complejo con elevada morbilidad. En casos muy seleccionados, el abordaje robótico puede facilitar la disección y reducir la morbilidad gracias a la mejor visión y versatilidad de movimientos. Describimos la técnica de exenteración pélvica robótica sistematizada con DaVinci Xi y sus variantes en varones, tras haber intervenido tres casos en nuestro Centro. Describimos la colocación de trocares, material necesario, localización de minilaparotomía y secuencia de los procedimientos a realizar paso a paso. Distinguimos tres supuestos: exenteración pélvica total con amputación de recto, colostomía y urostomía; exenteración pélvica con preservación de esfínter, anastomosis colo-rectal/anal y urostomía; exenteración pélvica con amputación de recto, colostomía y reconstrucción de tracto urinario. (AU)

Male pelvic exenteration is a challenging procedure with high morbidity. In very selected cases robotic approach could make dissection easier and decrease morbidity due to a better view and higher range of movements. In this paper we describe port placement, instruments, minilaparotomy location and sequence of procedures step by step. We differentiate three situations: total pelvic exenteration with abdominoperineal resection, colostomy and urostomy; pelvic exenteration with colo-rectal/anal anastomosis and urostomy; pelvic exenteration with abdominoperineal resection, colostomy and urinary tract reconstruction. (AU)

Robotic pelvic exenteration in males: systematization of the technique.

Male pelvic exenteration is a challenging procedure with high morbidity. In very selected cases, the robotic approach could make dissection easier and decrease morbidity due to the better vision provided and higher range of movements. In this paper, we describe port placement, instruments, minilaparotomy location, and the stepwise sequence of these procedures. We address 3 different situations: total pelvic exenteration with abdominoperineal resection, colostomy and urostomy; pelvic exenteration with colorectal/anal anastomosis and urostomy; and pelvic exenteration with abdominoperineal resection, colostomy and urinary tract reconstruction.

Radioquimioterapia neoadyuvante en cáncer de recto: Relevancia clínica del downstaging y la respuesta patológica completa

Antecedentes: La radioquimioterapia neoadyuvante es uno de los pilares del tratamiento del cáncer de recto localmente avanzado. La neoadyuvancia ha demostrado disminuir la recidiva local, generando también un downstaging tumoral, llegando incluso a una respuesta patológica completa (RPC), esta última relacionada con una mejor sobrevida global (SG) y sobrevida libre de enfermedad (SLE). Objetivo: Reportar los resultados anátomo-patológicos del tratamiento con radioquimioterapia en cáncer de recto, analizando su relación con la SG y la SLE. Material y Método: Estudio de cohorte prospectivo. Se analiza base de datos de cirugías coloproctológicas del Hospital Clínico de la Universidad de Chile, entre los años 20042019, incluyendo pacientes con cáncer de recto medio y bajo localmente avanzados, los cuales recibieron neoadyuvancia y posteriormente cirugía. Se realizó el análisis de sobrevida con el método de Kaplan-Meier y el test Log-rank para su comparación. Se consideró estadísticamente significativo un valor de p < 0,05. Resultados: 411 pacientes fueron operados por cáncer de recto, 143 pacientes recibieron neoadyuvancia, el 19% registró RPC. La SG del grupo con RPC fue 94% (IC 95%; 59,79-79,41%) mientras que la del grupo sin RPC fue 71% (IC 95%; 66,64-99,20%) (p = 0,018), la SLE en aquellos pacientes con RPC alcanzó un 100%, mientras que en aquellos sin RPC fue 74% (IC 95%; 64,08-81,28) (p = 0,008). Conclusiones: Los pacientes con RPC mostraron mejores resultados a largo plazo que aquellos sin RPC. La RPC podría indicar un perfil tumoral biológico favorable, con menos tendencia a la recurrencia y mejor supervivencia.

Background: One of the mainstays in the treatment of locally advanced rectal cancer is neoadjuvant chemoradiotherapy. Neoadjuvant therapy have demonstrated to decrease local recurrence, also generating tumor downstaging, even leading to a pathological complete response (PCR), the latter related to better overall survival (OS) and disease-free survival (SLE). Aim: To report the anatomo-pathological results of treatment with chemoradiotherapy in rectal cancer, analyzing the relationship with OS and SLE. Material and Method: Prospective cohort study. A database of colorectal surgeries from the Clinical Hospital of the University of Chile between the years 2004-2019, including patients with locally advanced low and middle rectal cancer, who received neoadjuvant and later surgery. Survival analysis was made with the Kaplan-Meier method and the Log-rank test for comparison. A value of p < 0.05 was considered statistically significant. Results: 411 patients underwent surgery for rectal cancer, 143 patients received neoadjuvant therapy, 19% registered PCR. The OS of the group with PCR was 94% (95% CI; 59.79-79.41%) while that of the group without PCR was 71% (95% CI; 66.64-99.20%) (p = 0.018), the SLE in those patients with PCR reached 100%, while in those without PCR it was 74% (95% CI; 64.08-81.28) (p = 0.008). Conclusions: Patients with PCR have better long-term results than those without PCR. PCR could indicate a favorable biological tumor profile, with less tendency to recurrence and improved survival.

Laparoscopic radical resection for rectal cancer in a patient with uncorrected truncus arteriosus type IV: A case report.

Persistent truncus arteriosus is a rare congenital heart malformation which if not corrected, results in the death of about 50% of the patients, while fewer than 20% of the patients survive the first year of life. Here, we report the successful anesthetic management of an adult patient with uncorrected truncus arteriosus who presented for the laparoscopic radical resection of rectal cancer.

Primary tumor heterogeneity on pretreatment 18F-FDG PET/CT to predict outcome in patients with rectal cancer who underwent surgery after neoadjuvant therapy.

PURPOSE: This retrospective study aimed to investigate the value of texture features of primary tumors in pretreatment 18F-FDG PET/CT in the prediction of response to treatment, progression, and overall survival in patients with rectal cancer who underwent surgery after neoadjuvant therapy(NAT). METHODS: Patients with rectal cancer who had pretreatment 18F-FDG PET/CT, and underwent surgery after NAT were included in this study. Clinicopathologic features, date of last follow-up, progression, and death were recorded. Textural and conventional PET parameters(maximum standardized uptake value-SUVmax, metabolic tumor volume-MTV, total lesion glycolysis-TLG) were obtained from PET/CT images using LifeX program. Parameters were grouped using Youden index in ROC analysis. Factors predicting the pathological response to treatment, progression, and overall survival were determined using logistic regression and Cox regression analyses. RESULTS: Forty-four patients (26(59%) male, 18(41%) female; 60.1±11.4 years) with rectal cancer were included in this study. The numbers of patients with responders and non-responders to NAT were 15(34.9%) and 28(65.1%), respectively. One patient' pathology report did not contain the response status to NAT. The median of follow-up duration was 29.9 months. 9(20.5%) showed disease progression, and 8(18.2%) died during the follow-up period. Difference entropyGLCM and correlationGLCM parameters were found as independent predictors for response to NAT. The positivity of surgical margin, intensity interquartile rangeCONV and AUC-CSHDISC texture parameters were independent predictors of progression, while normalized inverse differenceGLCM and LZLGEGLZLM parameters were independent predictors of mortality. CONCLUSION: The texture parameters obtained from pretreatment 18F-FDG PET/CT have presented a more robust predictive value than conventional parameters in patients with rectal cancer who underwent surgery after NAT.

Resección radical laparoscópica para el cáncer de recto en un paciente con tronco arterioso no corregido tipoIV: informe de un caso / Laparoscopic radical resection for rectal cancer in a patient with uncorrected truncus arteriosus typeIV: A case report

El tronco arterioso persistente es una malformación cardíaca congénita poco frecuente. Si no se corrige, aproximadamente el 50% de los que lo padecen mueren; menos del 20% de estos pacientes sobreviven al primer año de vida. Presentamos el manejo anestésico exitoso de un paciente adulto con tronco arterioso no corregido que se sometió a resección radical laparoscópica de cáncer de recto.(AU)

Persistent truncus arteriosus is a rare congenital heart malformation which if not corrected, results in the death of about 50% of the patients, while fewer than 20% of the patients survive the first year of life. Here, we report the successful anesthetic management of an adult patient with uncorrected truncus arteriosus who presented for the laparoscopic radical resection of rectal cancer.(AU)

Experience in colorectal surgery at a quaternary care hospital in Bogotá, Colombia.

INTRODUCTION AND AIMS: Colorectal cancer is among the three most common cancers worldwide. Knowledge and identification of suboptimal outcome-associated factors enable comprehensive patient management. The aim of the present study was to present the results of the surgical management of colorectal cancer at a quaternary care university hospital. MATERIALS AND METHODS: An observational, analytic, cross-sectional study was conducted. Information was collected on a retrospective cohort of patients diagnosed with colorectal cancer from 2013 to 2017 at the Hospital Universitario Mayor Méderi, Bogotá, Colombia. RESULTS: Data on 452 patients, within the study period, were collected. A total of 48.5% of the patients were men, the overall complication rate was 24%, the surgical site infection (SSI) rate was 15.38%, anastomotic dehiscence occurred in 4.18% of the patients, bleeding required reoperation in 1.32%, and the intrahospital mortality rate was 7.47%. CONCLUSION: Colorectal cancer management at a university hospital was as beneficial as that provided by other types of hospitals, showing a direct association with complete R0 dissections; low complication rates, according to international reports; and reduced overall morbidity.

Primer caso de escisión mesorrectal total transanal (TaTME) para el tratamiento del cáncer de recto medio en un centro docente universitario: descripción de la técnica / First case of transanal total mesorectal excision (TaTME) for middle rectal cancer in a teaching tertiary center: technical aspects / Primeiro caso de excisão total do mesorreto transanal (TaTME) para tratamento de câncer de reto meio em um centro universitário de ensino: aspectos tecnicos

La escisión mesorrectal transanal (TaTME: transanal total mesorectal escision) es la última de una larga lista de desarrollos técnicos y tecnológicos para el tratamiento del cáncer de recto medio y bajo. Incluso para los cirujanos colorrectales experimentados, lograr una escisión mesorrectal total (emt) de calidad en cirugía oncológica no siempre es sencillo, por la dificultad de obtener un adecuado acceso a la pelvis. Los estudios realizados han mostrado resultados comparables al abordaje laparoscópico, con tasas elevadas de escisiones mesorrectales completas y bajo porcentaje de margen circunferencial radial (CRM: circumferential radial margin) y distal positivos, con un adecuado número de ganglios resecados. Como toda técnica nueva, su implementación puede traer consecuencias no intencionales. La complejidad del abordaje, la dificultad en la identificación de nuevos repères y planos anatómicos, ha llevado a complicaciones graves como la lesión uretral o la siembra tumoral pelviana. Por ello, la comunidad quirúrgica ha retrasado la implementación masiva de la técnica y desarrollado estrategias de enseñanza y monitorización de este procedimiento para su realización en centros de alto volumen. El objetivo de esta publicación es presentar el primer caso de TaTME en un centro docente universitario y difundir en nuestra comunidad científica el fundamento de la técnica, sus indicaciones, describir los principales pasos técnicos, complicaciones, resultados oncológicos y funcionales.

Transanal total mesorectal excision (TaTME) is the last of a long list of technical and technological developments for treatment of middle and low rectal cancer. Even for skilled colorectal surgeons, achieving a good quality total mesorectal excision (TME) in oncology surgery is not always simple, due to the difficulty of obtaining optimal access to the pelvis. So far, studies have shown similar results to laparoscopic surgery, with high rates of complete mesorectal excisions and low rate of circumferential radial margin (CRM) and distal margin with an appropriate number of resected lymph nodes. Like every new technique, its implementation can bring unwanted consequences. The complexity of the approach, the difficulty in the identification of new landmarks and anatomic planes, has led to serious complications such as urethral injury or tumoral seeding. This has made slowdown the massive implementation of the technique among the surgical community, addressing the need of developing training programs and mentoring of this procedure that belongs to high volume centers. The aim of this publication is to present the first case of TaTME in a teaching tertiary center and spread, in our scientific community, the principles of the technique, its indications, main technical steps, complications and functional and oncologic results.

A excisão mesorretal transanal (TaTME: transanal total mesorectal escision) é o mais recente de uma longa linha de desenvolvimentos técnicos e tecnológicos para o tratamento do câncer retal inferior e médio. Mesmo para cirurgiões colorretais experientes, nem sempre é fácil obter uma excisão total do mesorreto (EMT) de qualidade em cirurgia de câncer, devido à dificuldade de obter acesso adequado à pelve. Os estudos realizados mostraram resultados comparáveis ​​à abordagem laparoscópica, com altas taxas de excisões completas do mesorreto e baixo percentual de margem radial circunferencial positiva (CRM: circumferential radial margin) e distal, com número adequado de linfonodos ressecados. Como qualquer nova técnica, sua implementação pode ter consequências não intencionais. A complexidade da abordagem, a dificuldade em identificar novos repères e planos anatômicos, levou a complicações graves, como lesão uretral ou semeadura de tumor pélvico. Por esse motivo, a comunidade cirúrgica atrasou a implementação massiva da técnica e desenvolveu estratégias de ensino e acompanhamento desse procedimento para sua realização em centros de alto volume. O objetivo desta publicação é apresentar o primeiro caso de TaTME em um centro de ensino universitário e divulgar em nossa comunidade científica as bases da técnica, suas indicações, descrever as principais etapas técnicas, complicações, resultados oncológicos e funcionais.

Validación de la resonancia magnética pélvica como método de elección para determinar la distancia al margen anal en el cáncer de recto / Validation of pelvic magnetic resonance imaging as the method of choice to determine the distance to the anal margin in rectal cancer

Introducción: La altura exacta del tumor en el recto y sus relaciones anatómicas contribuyen a determinar la estrategia terapéutica multidisciplinar basada en la combinación de radio-quimioterapia y cirugía radical. Nuestro objetivo es valorar cuál es el método diagnóstico más preciso en la medición preoperatoria de la distancia al margen anal, y si la resonancia magnética pélvica (RM) puede sustituir a los métodos instrumentales clásicos. Métodos: Estudio prospectivo de precisión diagnóstica entre colonoscopia (CF), rectoscopia rígida (RRp) y RM en pacientes con indicación de cirugía radical. La RRp intraoperatoria fue considerada la prueba de referencia. Se analizaron las correlaciones entre las distintas técnicas y su coeficiente de determinación, así como el coeficiente de correlación intraclase y el grado de acuerdo entre los distintos test. Resultados: Se incluyeron 96 pacientes con edad media (DE) de 68 (14,1) años y predominio de varones (65%). Un 72% recibió tratamiento neoadyuvante. La distancia media al margen anal, medida mediante CF=103,5mm, fue significativamente mayor al resto, que obtuvieron valores similares: RRp=81,1, RM=77,4, RRp intraoperatoria=82,9mm (p<0,001). Se objetivó una significativa correlación intraclase y hubo un elevado acuerdo entre todas las mediciones pre e intraoperatorias a excepción de la realizada mediante CF, que sobreestimó el resultado. La RM aportó información más individualizada y precisa. Conclusiones: Existe variabilidad entre los métodos de medición, siendo la colonoscopia el menos fiable. La RM ofrece valores objetivos, comparables, precisos e individualizados que pueden sustituir a los obtenidos por RR en tumores de cualquier localización del recto. (AU)

Introduction: Distance from anal verge of rectal tumors and their anatomical relationships contribute to determine the multidisciplinary therapeutic strategy based on the combination of radio-chemotherapy and radical surgery. Our aims are to investigate which is the most accurate method for the preoperative measuring of the distance from the anal verge in rectal tumors and if the pelvic MRI can substitute the classical instrumental methods. Methods: Prospective study of diagnostic precision between flexible colonoscopy (FC), preoperative rigid rectosigmoidoscopy (pRR) and pelvic MRI in patients scheduled to radical surgery. Rigid intraoperative rectoscopy (iRR) was considered the reference test. The correlations between the different techniques and their determination coefficient as well as the intraclass correlation coefficient and the degree of agreement between the different tests were analyzed. Results: 96 patients (65% males), mean age (SD): 68 (14.1) years were included. 72% received neoadjuvant treatment. The mean distance to the anal margin measured by FC=103.5mm, was significantly greater than others, which had similar values: pRR=81.1; MRI=77.4; iRR=82.9mm (P<.001). A significant intraclass correlation was observed and there was high agreement between all pre- and intraoperative measurements except for the performed by FC, which overestimated the results. MRI provided more individualized and accurate information. Conclusions: There is variability between the measurement methods, being colonoscopy the least reliable. MRI offers objective, comparable, accurate and individualized values that can replace those obtained by pRR for tumors of any location in the rectum. (AU)

Resultados oncológicos del manejo neoadyuvante con quimiorradioterapia seguido de cirugía en cáncer de recto localmente avanzado: en el Instituto Oncológico Nacional de Panamá

Antecedentes y objetivos: Se reportan 720 000 nuevos casos cada año de cáncer de recto. En la etapa localmente avanzada (LARC), la terapia multimodal seguido de cirugía con escisión total del mesorrecto (TME) es el estándar de tratamiento con potenciales beneficios en toxicidad aguda, valoración de respuesta y resecabilidad. El objetivo es describir las características clínico-patológicas y resultados oncológicos en pacientes tratados con quimiorradioterapia neoadyuvante seguido de cirugía radical. Materiales y métodos: Estudio descriptivo, no experimental, transversal y retrospectivo en donde se analizaron 141 pacientes con diagnóstico de LARC definido como cT3T4N0 o cTXN+M0 programados para tratamiento con quimiorradioterapia neoadyuvante en el Instituto Oncológico Nacional durante el período de enero 2014 a diciembre 2019. Resultados: Un total de 119 pacientes completaron quimiorradioterapia neoadyuvante seguido de cirugía radical resultando en una resecabilidad de 90.1%. La tasa global de complicaciones posoperatorias fue de 17.4%. La tasa de pCR (La respuesta patológica completa) y desvalorización fue 19.6% y 70.6% respectivamente. La categoría N preoperatoria fue la única variable con un impacto estadísticamente significativo con respecto a la pCR vs no pCR (p = 0.04). La mediana de seguimiento fue de 39 meses, obteniendo una supervivencia global a 5 años de 69% y una supervivencia libre de enfermedad a 5 años de 74.4%.   Conclusiones: En el Instituto Oncológico Nacional de Panamá, el tratamiento del LARC con curso largo de quimiorradioterapia seguido de cirugía radical demostró una alta adherencia al tratamiento con una tasa de respuesta patológica completa y control local en concordancia con lo reportado a nivel internacional. (provisto por Infomedic International)

Background and objectives: 720,000 new cases of rectal cancer are reported each year. In the locally advanced stage (LARC), multimodal therapy followed by surgery with total mesorectal excision (TME) is the standard of care with potential benefits in acute toxicity, response assessment and resectability. The objective is to describe the clinicopathological characteristics and oncological results in patients treated with neoadjuvant chemoradiation therapy followed by radical surgery. Methods: A descriptive, non-experimental, cross-sectional and retrospective study in which the clinical records of 141 patients diagnosed with LARC defined as cT3T4N0 or cTXN+M0 scheduled for treatment with neoadjuvant chemoradiation therapy at the National Oncology Institute during the period from January 2014 to December 2019 were analyzed. Results: A total of 119 patients completed neoadjuvant chemoradiotherapy followed by radical surgery, resulting in a resectability of 90.1%. The overall rate of postoperative complications was 17.4%. The pCR and downstaging rate was 19.6% and 70.6%, respectively. Preoperative N category was the only variable with a statistically significant impact regarding pCR vs no pCR (p = 0.04). The median follow-up was 39 months, obtaining a 5-year overall survival of 69% and a 5-year disease-free survival of 74.4%. Conclusion: At the National Oncology Institute of Panama, the treatment of LARC with a long course of chemoradiation therapy followed by surgery with curative intent demonstrated high adherence to treatment with a rate of complete pathological response and local control in accordance with international reports. (provided by Infomedic International)

Resultados del tratamiento quirúrgico del cáncer de recto y ano en el Hospital Español / Results of the surgical treatment of rectal and anal cancer in the Hospital Español / Resultados do tratamento cirúrgico do câncer de reto e ânus no Hospital Español

La cirugía del cáncer de recto y ano se ha desarrollado considerablemente en las últimas décadas. En función de dichos avances, se ha observado una disminución en la morbimortalidad operatoria, así como también una mejoría en el pronóstico de estos pacientes. El objetivo del presente estudio es exponer y analizar los resultados del tratamiento quirúrgico del cáncer de recto y ano en un servicio universitario. Se realizó un estudio observacional, descriptivo y retrospectivo de todos los pacientes intervenidos por cáncer de recto y ano en el Hospital Español entre 2016 y 2020. Las variables registradas fueron: variables demográficas, clínico-oncológicas, relacionadas a la morbimortalidad operatoria y a la recidiva locorregional, y la sobrevida a 5 años. El procedimiento más realizado fue la resección anterior de recto (RAR) en 11 intervenciones (58%), mientras que las 8 restantes correspondieron a amputaciones abdominoperineales (AAP) (42%). Se diagnosticaron un total de 6 complicaciones intraoperatorias en 5 pacientes, siendo la perforación del tumor la más frecuente, y un total de 18 complicaciones postoperatorias en 11 pacientes, siendo la más frecuente la infección de la herida quirúrgica abdominal. La morbilidad operatoria mayor fue de 31,6% y la mortalidad operatoria a 90 días fue de 0%. La sobrevida global a 5 años fue de 63,2%. Los resultados quirúrgicos en la presente casuística fueron comparables con los de la bibliografía consultada. Destacamos la nula mortalidad a 90 días, con resultados oncológicos similares a los reportados en la literatura.

Rectal and anus surgery have been developed considerably in the last decades. Based on these advancements, it has been observed a decrease in the surgical morbidity and mortality, as well as an improved prognosis of these patients. The aim of the present study is to expose and analyze the results of the anus and rectal surgical treatment in a university service. An observational, descriptive and retrospective study was performed of all the intervened patients for rectum and anus cancer in the Hospital Español between 2016 and 2020. We recorded data about demographic, clinical-oncologic, related to the surgical morbidity and mortality, locoregional relapse and overall 5 year survival. The most performed procedure was the rectum anterior resection in 11 interventions (58%), while the 8 left corresponded to abdominoperineal resection (42%). There was a total of 6 intraoperative complications diagnosed in 5 patients, being the tumor perforation the most frequent one, and a total of 18 postoperative complications diagnosed in 11 patients, being the surgical wound infection the most frequent one. The serious surgical morbidity was 31,6%, while the surgical mortality rate at 90 days was 0%. Overall 5 year survival was 63,2%. The surgical results in the present study about the rectum and anal cancer were comparable with the results reported on the consulted bibliography. We highlight the null mortality within 90 days, with oncologic results similar to the ones reported in the literature.

A cirurgia do câncer retal e anal desenvolveu-se consideravelmente nas últimas décadas. Com base nesses avanços, observou-se diminuição da morbimortalidade operatória, bem como melhora no prognóstico desses pacientes. O objetivo deste estudo é apresentar e analisar os resultados do tratamento cirúrgico do câncer de reto e anal em um serviço universitário. Foi realizado um estudo observacional, descritivo e retrospectivo de todos os pacientes operados por câncer de reto e ânus no Hospital Espanhol entre 2016 e 2020. As variáveis ​​registradas foram: variáveis ​​demográficas, clínico-oncológicas, relacionadas à morbidade e mortalidade operatórias e recorrência locorregional. , e sobrevida em 5 anos. O procedimento mais realizado foi a ressecção anterior do reto (RAR) em 11 intervenções (58%) e as 8 restantes corresponderam a amputações abdominoperineais (AAP) (42%). Foram diagnosticadas 6 complicações intraoperatórias em 5 pacientes, sendo a perfuração tumoral a mais frequente, e um total de 18 complicações pós-operatórias em 11 pacientes, sendo a infecção da ferida operatória abdominal a mais frequente. A morbidade operatória maior foi de 31,6% e a mortalidade operatória em 90 dias foi de 0%. A sobrevida global em 5 anos foi de 63,2%. Os resultados cirúrgicos da presente casuística foram comparáveis ​​aos da bibliografia consultada. Destacamos a mortalidade nula em 90 dias, com resultados oncológicos semelhantes aos relatados na literatura.

Terapia neoadyuvante total (TNT) en el manejo del cáncer de recto localmente avanzado

El manejo multimodal del cáncer de recto, localmente avanzado (LARC), se ha convertido en las últimas décadas en el estándar terapéutico de este tipo de tumores, logrando cifras de recidiva local global alrededor del 10%. Sin embargo, las tasas de sobrevida global (OS) y de sobrevida libre de enfermedad (DFS) no superan el 75% en la mayoría de las series, debido a las fallas a distancia. La investigación de nuevas terapias que logren un control efectivo de la enfermedad sistémica se ha focalizado en agregar a la radioterapia pélvica distintos esquemas de quimioterapia en la etapa preoperatoria, es decir, neoadyuvante. En esta revisión se discuten los distintos esquemas denominados genéricamente TNT (total neoadjuvant therapy), las ventajas y las limitaciones de este nuevo enfrentamiento del LARC, basado principalmente en los estudios prospectivos y aleatorizados disponibles a la fecha, con foco en los resultados en OS y DFS.

Neoadjuvant chemoradiation followed by surgery with or without adjuvant chemotherapy has remained the mainstay of treatment of locally advanced rectal cancer (LARC) for the past two decades. Although this regimen has reduced rates of local recurrence to 10% or less, rates of systemic failure are 20 to 30%, leading to a 5-year survival of 70-75%, at best. This situation has led to investigations into the use of total neoadjuvant therapy in the form of induction or consolidation chemotherapy. This review put the focus on final outcomes like overall survival and disease-free survival based on the available prospective and randomized studies about different schemes of TNT.

Validation of pelvic magnetic resonance imaging as the method of choice to determine the distance to the anal margin in rectal cancer.

INTRODUCTION: Distance from anal verge of rectal tumours and their anatomical relationships contribute to determine the multidisciplinary therapeutic strategy based on the combination of radio-chemotherapy and radical surgery. Our aims are to investigate which is the most accurate method for the preoperative measuring of the distance from the anal verge in rectal tumours and if the pelvic MRI can substitute the classical instrumental methods. METHODS: Prospective study of diagnostic precision between flexible colonoscopy (FC), preoperative rigid rectosigmoidoscopy (pRR) and pelvic MRI in patients scheduled to radical surgery. Rigid intraoperative rectoscopy (iRR) was considered the reference test. The correlations between the different techniques and their determination coefficient as well as the intraclass correlation coefficient and the degree of agreement between the different tests were analyzed. RESULTS: 96 patients (65% males), mean age (SD): 68 (14.1) years were included. 72% received neoadjuvant treatment. The mean distance to the anal margin measured by FC = 103.5 mm, was significantly greater than others, which had similar values: pRR = 81.1; MRI = 77.4; iRR = 82.9 mm (P < .001). A significant intraclass correlation was observed and there was high agreement between all pre- and intraoperative measurements except for the performed by FC, which overestimated the results. MRI provided more individualized and accurate information. CONCLUSIONS: There is variability between the measurement methods, being colonoscopy the least reliable. MRI offers objective, comparable, accurate and individualized values that can replace those obtained by pRR for tumours of any location in the rectum.

Cáncer de recto a nivel de la reflexión peritoneal. Exactitud de la RM preoperatoria y correlación anatomopatológica. Estudio prospectivo / Rectal cancer at the peritoneal reflection. Preoperative MRI accuracy and histophatologic correlation. Prospective study

Introducción Establecer la exactitud de la resonancia magnética (RM) para determinar la localización de los tumores rectales en relación con la reflexión peritoneal (RP) y su potencial afectación. Métodos Estudio prospectivo de 161 pacientes intervenidos por cáncer de recto. Las piezas quirúrgicas han sido analizadas mediante un método de doble tinción, superficie serosa con colorante naranja y grasa mesorrectal con tinta china, para comparar los resultados con la RM preoperatoria. Resultados Veintidós tumores se localizaron por encima, 65 a nivel y 74 por debajo de la RP. La RM clasificó la localización del tumor respecto a la RP de manera correcta en el 90,6% y fue capaz de detectar el 80,5% de los casos con infiltración de la RP. La RM presentó una exactitud del 92,5% para clasificar el tumor como intra o extraperitoneal. El 28,7% de los tumores por encima y a nivel de la RP presentaba anatomopatológicamente infiltración de la serosa peritoneal. Conclusiones La RM es una prueba precisa para determinar la localización de los tumores de recto en relación con la RP y su posible afectación. En el tallado macroscópico, el método de doble colorante es eficaz para determinar la afectación serosa (pT4a) y diferenciarla de la fascia mesorrectal (AU)

Introduction To investigate magnetic resonance imaging (MRI) accuracy for determining the location of rectal tumors with respect to the peritoneal reflection (PR) and its potential involvement Methods Prospective study of 161 patients ongoing surgery for rectal cancer. A double-ink method has been aplied to examine surgical specimen, orange ink for the serosal surface and indian ink for the mesorrectal margin, and assess preoperative MRI accuracy. Results Twenty-two tumors were located above, 65 at and 74 below PR. MRI accuracy was 90.6% for determining tumor's location with respect to the PR and 80.5% for defining peritoneal involvement. For classifying tumors according to their intra or extraperitoneal location an accuracy of 92.5% was set for MRI. Histophatologic peritoneal involvement was found in 28.7% of tumors located above or at the PR. Conclusions Magnetic resonance imaging accurately predicts the location of rectal tumors with respect to the PR and its potential involvement. The double-ink method is useful to assess serosal involvement (pT4a) and to distinguish mesorrectal fascia from the peritonealized surface (AU)