Small carcinomas involving less than one-quarter of the rectal circumference: local excision is still associated with a high risk of nodal positivity.

AIM: A study was carried out to determine the relationship between mesorectal lymph nodal involvement and T stage in a group of patients with a rectal cancer involving less than one-quarter of the rectal circumference, such as might be selected for local excision. METHOD: The data of patients having rectal resection between 2010 and 2014 were prospectively entered in a rectal carcinoma registry. A model for describing tumours involving less than one quadrant of the rectal circumference was created to facilitate the evaluation process. RESULTS: In all, 304 patients were included in the study. In 68 (22.4%) a small tumour (< 1 quadrant involved) was found. Of these, 26.5% had positive mesorectal lymph nodes (N+). In lesions of Stage ypT0 cancer 12.5% patients were node positive, in Stage Tis and T1 tumours there was no case of node positivity, but in Stage T2 and Stage T3 cancers the incidence of node positivity was 27.5% and 64%. CONCLUSION: The study demonstrated that, even for small tumours involving only one rectal quadrant, the risk of lymph nodal involvement was about 25%. Had the patients undergone local excision the treatment would have been incomplete.

[Predicting pN positivity in T3 rectal cancer]. / Moznosti predikce pN pozitivity u T3 nádoru rekta.

INTRODUCTION: Stage pN+ is a factor which determines the strategy for treatment of T3 rectal cancer. The sensitivity of preoperative imaging examinations revealing N+ is not entirely satisfactory. Risk factors that are associated with pT3pN+ stage and that are detectable by preoperative examination have not been reliably identified. The aim of the study is to analyze the predictive factors determining lymph node involvement in T3 rectal cancer. MATERIAL AND METHODS: Patients with rectal resection for (y)pT3 rectal cancer were analysed. All of the surgical interventions were performed at the Department of Surgery, University Hospital in Hradec Kralove, from 1 January 2011 to 28 February 2014. Data were prospectively collected and saved in the Rectal Cancer Oncologic Register. The parameters studied were age, gender, tumour localisation and its circumferential topography, preoperative chemoradiotherapy, absolute number of harvested lymph nodes and the number of positive lymph nodes in each specimen, tumour grading, presence of lymphovascular invasion and perineural invasion, and the depth of tumour penetration. RESULTS: After selection, 89 patients with T3 rectal cancer were included into the study. Resection for cancer of the upper rectum was performed in 22 (24.7%) patients, middle rectum in 37 (41.6 %) and lower rectum in 30 (33.7%) patients. 38 (42.7%) patients underwent primary operation, 41 (46.1%) patients received neoadjuvant chemoradiotherapy, and radiation therapy was administered to only 10 (11.2%) patients. Stage pN+ was found in 51 (57.3%) patients. Statistical analysis was used to identify the risk factors for pN+: lymphovascular invasion (p0.001), angioinvasion (p=0.030) and perineural invasion (p=0.010). On the border of statistical significance for pN+, low grading of the tumour (p=0.084) was found. The depth of penetration of the tumour into the mesorectum was not statistically significant (p=0.230). CONCLUSION: Our study has shown that pN positivity is associated with lymphovascular invasion, perineural invasion and low grading of the tumour. Accurate identification of these factors before treatment, however, remains very difficult.

[Evaluation of safe resection margins in rectal carcinoma]. / Problematika stanovení bezpecných resekcních okraju u karcinomu rekta.

The fact that surgically well performed total mesorectal excision with negative circumferential resection margin represents one of the most important prognostic factors in colorectal carcinoma is already well known. These parameters significantly affect the incidence of local tumour recurrence as well as distant metastasis, and are thus related to the duration of patient survival. The surgeons task is to perform mesorectal excision as completely as possible, i.e., to remove the rectum with an intact cylinder of mesorectal fat. The approach of the pathologist to evaluation of total mesorectal excision specimens differs greatly from that of resection specimens from other parts of the large bowel. Besides evaluation of the usual parameters for colon cancer staging, it is essential to assess certain additional factors specific to rectal carcinomas, namely tumour distance from circumferential (radial) resection margins and the quality of the mesorectal excision. In order to accurately evaluate these parameters, knowledge of a wide range of clinical data is indispensable (results of preoperative imaging, intraoperative findings). For objective evaluation of these parameters it is necessary to introduce standardized procedures for resection specimen processing and macro and microscopic examination. This approach is based mainly on standardized macroscopic photo-documentation of the integrity of the mesorectal surface. Parallel transverse sections of the resection specimens are made with targeted tissue sampling for histological examination. It is essential to have close cooperation between surgeons and pathologists within a multidisciplinary team enabling mutual feedback.

[The radicality of surgical resection in rectal cancer. Analysis of factors associated with incomplete mesorectal excision]. / Radikalita resekcní lécby pro karcinom rekta Analýza prediktivních faktoru spojených s nekompletní mezorektální excizí

INTRODUCTION: Circumferential resection margin (pCRM) and the completeness of mesorectal excision (ME) are two independent prognostic factors significantly associated with the radicality of surgical treatment. Positive pCRM and incomplete mesorectal excision are associated with a significantly higher incidence of local recurrence and worse patient prognosis. The aim of this article is to analyze the risk factors associated with incomplete mesorectal excision. MATERIAL AND METHODS: Patients operated on at the Department of Surgery, University Hospital Hradec Kralove between January 2011 and February 2013 were included in the study. The patients data were prospectively collected and entered in the Dg C20 registry. The following factors were analyzed: sex, age, BMI, cN, pT, clinical stage, the involved segment of the rectum, neoadjuvant therapy, circumferential tumour location, the type of surgical approach and the type of surgery. RESULTS: 168 patients were operated on during the above period. 9 (5.3%) palliative stomas and 159 (94.6%) resection procedures were performed in this group of 168 patients. 7 (4.4%) patients were excluded because the quality of excision was not assessed in them. 114 (75%) resections, including 5 intersphincteric resections, were performed in the group of the remaining 152 patients. 10 (7%) were Hartmanns procedures a 28 (18%) were amputation procedures. Out of 152 procedures, 69 (45%) were performed laparoscopically. Positive (y)pCRO was recorded in 26 (17%) patients, predominantly after abdominoperineal resection (APR) - 11 out of 27 (41%), and Hartmanns operation - 6 out of 10 (60%). Incomplete ME was observed in 45 patients (30%), complete ME in 81 patients (53%) and partially complete in 26 patients (17%). Univariate analysis confirmed statistically significant factors associated with incomplete mesorectal excision: (y)pT (P = 0.00027), type of surgery (P = 0.00001) and tumour location (P = 0.00001). Multivariate analysis then confirmed two independent prognostic factors associated with incomplete mesorectal excision. It was the location of the tumour in the distal third of the rectum and the (y)pT stage of the tumour. CONCLUSION: Distal rectum tumor location and higher (y)pT are associated with a higher risk of incomplete mesorectal excision with worse patient prognosis.

[Rectal cancer within 10 cm. Comparison of the radicality of laparoscopic and open surgical techniques with regard to the circumferential resection margin and the completeness of mesorectal excision]. / Karcinom rekta do 10 cm Srovnání radikality laparoskopické a otevrené operacní techniky s ohledem na cirkumferentní resekcní okraj a na kompletnost mezorektální excize.

INTRODUCTION: The issue of achieving radical circumferential margin in laparoscopic rectal surgery has not yet been satisfactorily clarified. In this paper we have focused on circumferential margin assessment and the quality of the mesorectal excision, comparing laparoscopic and open resection for cancer of the middle and lower rectum. MATERIAL AND METHODS: The results of surgical procedures for middle and low rectal cancer were analysed. All the interventions were performed at the Department of Surgery, Teaching Hospital in Hradec Kralove, during the period from January 2011 to December 2012. The data were prospectively collected and entered in the Rectal Cancer Registry. Age, gender, BMI, tumour localisation and topography, the clinical stage, preoperative chemoradiotherapy and response to it, the type of surgery, distal and circumferential margin characteristics, mesorectal excision quality, pT and pN were compared for laparoscopic and open surgery. RESULTS: A total of 161 patients were operated on for rectal cancer during the abovementioned period. 94 patients were included in the trial following selection. Laparoscopy was used in 40 patients and open surgery in 54 patients. Laparoscopic approach was performed in 33 (82.5%) low anterior resections (including four intersphincteric resections), 6 (15%) abdominoperineal amputations and 1 (2.5%) Hartmanns procedure. Open surgery was used for 26 (48.1%) low anterior resections, 21 (38.9%) APR and 7 (13%) Hartmanns procedures. Complete mesorectal excision was achieved in 45% of the laparoscopic resections vs. 46.3% of open resections. Nearly complete excision was performed in 22.5% and 11.1%, respectively. Finally, incomplete excision was described in 30% vs. 38.9%. No available data for TME was detected in three patients. The differences in TME were not statistically significant. Positive circumferential margin was found in 5 (12.5%) patients in the laparoscopy group; on the contrary, in the group undergoing open surgery, pCRO+ was found in 15 (27.8%) patients. Here, too, the results were not statistically significant. When patients without preoperative chemoradiotherapy were excluded, the relationship between ypCRM in the laparoscopy and open surgery group was on the border of statistical significance (Fischer=0.0556). CONCLUSION: As has been shown in our trial, the outcomes of laparoscopic and open approach in rectal cancer treatment are very similar. Particularly, mesorectal excision quality and negative CRM results have proven that the laparoscopic technique is safe and comparable to open surgery in rectal cancer treatment.

[Numbers of lymph nodes in large intestinal resections for colorectal carcinoma]. / Pocet uzlin u resekcí tlustého streva pro kolorektální karcinom.

INTRODUCTION: Precise evaluation of lymph nodes in the surgical specimen is crucial for the staging and subsequent decision about the adjuvant therapy in colorectal cancer. Prognosis of the patients can be assessed only in cases when at least 12 lymph nodes in the surgical specimen are examined. AIM OF THE WORK: To evaluate the radicalism of resections for colorectal carcinoma after introducing laparoscopic approach. METHODS: We compared all resections for primary colorectal cancer and rectal cancer (C 18-C20) performed in the Department of Surgery in University Hospital Hradec Králové in the years 2005 and 2008 and we evaluated numbers of examined lymph nodes in the surgical specimens. The patients with recurrent tumours and the patients with complete pathological response (negative histology) after neoadjuvant therapy were excluded from the study. RESULTS: 117 patients were included in the study in 2005, 2 of them were operated laparoscopically. 155 patients (more by 32.5%) were included in the study in 2008, 53 of them (34.2%) were operated laparoscopically. In tumours of the right part of the colon (C180-C184) treated by right hemicolectomy: on an average 7.9 (+/- 5.3) lymph nodes were examined in the specimens in 2005, and 15.3 (+/- 7.0) lymph nodes in 2008. In tumours of the left part of the colon (C185-C186) treated by left hemicolectomy: 6.5 (+/- 5.1) lymph nodes were examined in 2005, and 19.6 (+/- 15.6) in 2008. In tumours of the sigmoid colon (C187) 9.1 (+/- 6.9) lymph nodes were examined in 2005,and 15.4 (+/- 7.9) in 2008. In tumours of the rectosigmoid junction (C19) 8.0 (+/- 6.9) lymph nodes were examined in 2005, and 17.8 (+/- 11.2) in 2008. In rectal cancer (C20) 5.2 (+/- 4.5) lymph nodes were examined in 2005, and 13.6 (+/- 12.5) in 2008. There is a significant difference in a number of examined lymph nodes in patients without neodadjuvant treatment compared to those with neoadjuvant chemoradiotherapy and neoadjuvant radiotherapy. In 2005, in an average 3.7 (+/- 3.3) lymph nodes were removed in rectal resections after neoadjuvant chemoradiotherapy, in 2008 in an average 7.6 (+/- 6.1) lymph nodes were removed. In 2005, in an average 5.1 (+/- 3.7) lymph nodes in rectal resections after neoadjuvant radiotherapy were removed, in 2008 6.3 (+/- 4.3) lymph nodes were removed. In 2005, in an average 7.0 (+/- 5.5) lymph nodes in rectal resections without neoadjuvant therapy were removed, in 2008 20.9 (+/- 14.1) lymph nodes were removed. Laparoscopic resections were comparable with open resections regarding the number of examined lymph nodes in our group of patients. CONCLUSION: Introducing the laparoscopic approach to resections of colorectal carcinomas did not decrease radicalism of the operation as to the number of removed lymph nodes.

[Abdominal catastrophe--abdominal wall defect associated with gastrointestinal fistula--strategy of therapy]. / Abdominální katastrofa--defekt steny brisní komplikovaný strevní pístelí--strategie lécby.

BACKGROUND: Wound dehiscence complicated by gastrointestinal (GI) fistula to belong ,,abdominal catastrophe". Therapy is prolonged and connected with high morbidity and mortality rate. METHODS: In the period from October 2006 to July 2009 we performed 12 reconstructive surgical procedures on gastrointestinal tract in patients with abdominal catastrophe. Treatment of 12 consecutive patients (9 men, 3 women) was managed according to a standardize protocol. The protocol consists of treatment of septic complications, optimisation of nutritional state, special wound procedures, diagnosis of gastrointestinal fistulas and GI tract, timing of surgical procedures, reconstruction of GI tract and postoperative care. RESULTS: Reconstructive surgery of GI tract was successful on 11 patients. One patient developed recurrence of early GI fistula. In four patients we let open abdomen to heal per secundam. We observed no deaths after operation. CONCLUSION: With regard to complex character of therapy of abdominal catastrophe there is a need of multidisciplinary approach. Considering long-lasting and expensive therapy there is logical step to concentrate these patients into special centres which are experienced, equipped and their staff is trained in treatment of such a seriously impaired patients.

[Intestinal diverticulum localized in antimesenterial side of jejunum as a reason of perforation peritonitis--case report]. / Divertikl lokalizovaný na mezenteriální strane jejuna jako prícina perforacní peritonitidy--kazuistika.

Authors present the case of patient with perforation of atypicaly localised diverticula of small intestine. The most important in clinical picture of patient was the sudden progress of sepsis and symptoms of organ failure. This status was progreding after the first operative revision of abdominal cavity when no explanation for peritonitis was found. During the second operation revision we found the perforated diverticula of the mesenterial side of distal jejunum. In the period after operation several complications such as wound healing failure and organs failure were occurred.

[Peritonitides caused by gastrointestinal perforations--analysis of an elderly patient group]. / Peritonitidy zpusobené perforací trávicí trubice--analýza gerontologické skupiny pacientu.

AIM: The aim of this study was to assess causes of peritonitides resulting from acute abdominal perforations in a group of elderly patients and to evaluate the yield of common classification systems in predicting the risks of postoperative complications, in particular of postoperative death rates. PATIENTS AND METHODS: The retrospective analysis included 123 patients aged 70 y.o.a. and over (65 males, 58 females, the mean age was 78.7 y.o.a.), who underwent surgical revision for signs of peritonitis due to urgent GIT perforation, over a five-year period. The patients were assigned to groups based on their baseline diagnosis and on the procedure performed. The PSS (Peritonitis Severity Score) and MPI (Mannheim Peritonitis Index) classification systems factors were assessed. Statistical significance of the classification systems was evaluated, as well as their relation. RESULTS: Overall death rate of the studied group was 30% (37 patients). The highest death rate related to the baseline diagnosis was observed in the GIT ischemia group (67%). Based on the procedure, the highest death rate was observed in the enterostomy group (75%). Overall morbidity related to a known wound infection was 24% (29 patients). Significant correlation between the both classification systems was demonstrated (Spearman's correlation coefficient 0.86). Of the all studied factors creating classification schemes, the following proved statistically most significant: ASA IV, peritonitis Hinchey grade III-IV, existing immunosuppression and signs of organ failure (p < 0.0001). CONCLUSION: Perforation peritonitis remains a high risk condition, considering the postoperative morbidity rates, as well as the death rates. Perforation of the sigmoid diverticle was the commonest cause of GIT perforations in the elderly. The highest death rate was observed in those with ischemic ethiology. The PSS and MPI scoring systems are of high prediction value in the assessment of the risk of postoperative death.

[Intraperitoneal placement of composite implants--polyester mesh coated with polyurethane in experimental study]. / Intraperitoneální aplikace kompozitního implantátu - polyesterové sít'ky potazené polyuretanem v experimentu.

INTRODUCTION: Polyester and polypropylene are currently the most frequently materials for repair of abdominal wall hernias. Most of the mesh materials used intraperitoneally in repair of hernias lead to considerable adhesion formation, as well as the resultant bowel obstruction and intestinal fistula formation. Some newer composite products can reduce risk of adhesion formation. The aim of this experimental study is testing properties of patch, composite structure, characterised by the association of a non-woven textile structure made from polyester multifilaments, and a fine coat of polyurethane on one side, placed intraperitoneally in rat. MATERIALS AND METHODS: The experiment was carried out with 21 laboratory rats. Laboratory animals were divided into 3 groups - 7 animals in a group. In the first group the check-up laparotomy was realized the 7th day, in the second group the 14th day and in the third group the 28th day after the intraperitoneal implantation of a composite mesh. All animals were sacrificed and adhesion scoring and histological evaluation of tissue specimens with implanted mesh were done. RESULTS: A macroporous polyester mesh component supported an early and huge fibrous proliferation with a good adhesion onto the abdomen wall. On the other hand, a microporous polyurethane layer led to the creation of a fibrous pocket. During the check-up laparotomy, the larger adhesion of omentum to the fibrous layer, covering the polyurethane side of implanted mesh, were located in most laboratory rats - in all the groups. CONCLUSION: We can presume that the protective polyurethane layer does not eliminate risk of adhesion formation in rat.