Fissurectomy with mucosal advancement flap anoplasty: The end of a dogma?

INTRODUCTION: The goal was to compare fissurectomy with mucosal advancement flap anoplasty to fissurectomy alone in the surgical treatment of anal fissure. PATIENTS AND METHODS: This study included patients who underwent surgery in 2019 for solitary, idiopathic, non-infected, posterior anal fissure, after failure of medical treatment. The choice to perform advancement flap anoplasty was based on surgeon preference and did not depend on the fissure itself. The main endpoint was the time to relief of pain. RESULTS: Of 599 fissurectomies performed during the study period, 226 patients (37.6% women, mean age 41.7±12.0 years old) underwent fissurectomy alone (n=182) or associated with advancement flap anoplasty (n=44). The two groups differed as to their sex ratio (33.5 vs. 54.5% women, P=0.01), body mass index (25.3±4.0 vs. 23.6±3.9, P=0.013) and Bristol score (3.2 vs. 3.4, P=0.038). Time to relief of pain, time to disappearance of bleeding and time to healing were 1.1 (0.5-2.3), 1.0 (0.5-2.1) and 2.0 (1.1-3.6) months, respectively. The rate of healing was 93.8% and the complication rate was 6.2%. The differences between the two groups for these outcomes were not statistically significant. The risk factors associated with absence of healing were age ≥ 40 years (Odds ratio (OR): 3.84; 95% CI, 1.12-17.68) and pre-surgical duration of fissure<35.6 weeks (OR: 6.54; 95% CI: 1.69-43.21). CONCLUSION: Mucosal advancement flap anoplasty does not provide any added value to fissurectomy alone.

Prognosis of poorly cohesive gastric cancer after complete cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (CYTO-CHIP study).

BACKGROUND: The incidence of gastric poorly cohesive carcinoma (PCC) is increasing. The prognosis for patients with peritoneal metastases remains poor and the role of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is controversial. The aim was to clarify the impact of gastric PCC with peritoneal metastases treated by CRS with or without HIPEC. METHODS: All patients with peritoneal metastases from gastric cancer treated with CRS with or without HIPEC, in 19 French centres, between 1989 and 2014, were identified from institutional databases. Clinicopathological characteristics and outcomes were compared between PCC and non-PCC subtypes, and the possible benefit of HIPEC was assessed. RESULTS: In total, 277 patients were included (188 PCC, 89 non-PCC). HIPEC was performed in 180 of 277 patients (65 per cent), including 124 of 188 with PCC (66 per cent). Median overall survival (OS) was 14.7 (95 per cent c.i. 12.7 to 17.3) months in the PCC group versus 21.2 (14.7 to 36.4) months in the non-PCC group (P < 0.001). In multivariable analyses, PCC (hazard ratio (HR) 1.51, 95 per cent c.i. 1.01 to 2.25; P = 0.044) was associated with poorer OS, as were pN3, Peritoneal Cancer Index (PCI), and resection with a completeness of cytoreduction score of 1, whereas HIPEC was associated with improved OS (HR 0.52; P < 0.001). The benefit of CRS-HIPEC over CRS alone was consistent, irrespective of histology, with a median OS of 16.7 versus 11.3 months (HR 0.60, 0.39 to 0.92; P = 0.018) in the PCC group, and 34.5 versus 14.3 months (HR 0.43, 0.25 to 0.75; P = 0.003) in the non-PCC group. Non-PCC and HIPEC were independently associated with improved recurrence-free survival and fewer peritoneal recurrences. In patients who underwent HIPEC, PCI values of below 7 and less than 13 were predictive of OS in PCC and non-PCC populations respectively. CONCLUSION: In selected patients, CRS-HIPEC offers acceptable outcomes among those with gastric PCC and long survival for patients without PCC.

New treatment strategies for non-metastatic rectal cancer.

The most widely practiced (standard) treatment of non-metastatic rectal cancer is based on proctectomy with mesorectal excision (partial or total according to the location of the tumor and commonly called TME). Surgery is preceded by CAP50-type chemoradiotherapy (capecitabineand 50 Grays radiation) and performed 6-8 weeks after the end of chemoradiotherapy. The development of new endoscopic, surgical, radiation-based and chemotherapeutic modalities leads surgeons to envisage customized treatment to find the best compromise between functional and oncologic results according to the locoregional extension of the tumor. Superficial lesions are amenable to transanal excision. T2-3 tumors<4cm are amenable to rectal preservation when neoadjuvant treatment obtains a complete response, allowing local excision or close surveillance. Intensification endocavitary radiotherapy and induction and consolidation chemotherapy regimens to avoid recourse to salvage abdomino-perineal resection (APR) are under investigation. For locally advanced rectal cancers (T3-4 and all N+ irrespective of T), the following scenarios can be envisaged: for initially resectable tumors (T3N0, T1-T3N+, circumferential resection margin>2mm), neoadjuvant chemotherapy alone aims to minimize the risk of local recurrence while avoiding the sequelae of radiotherapy. In case of initially non-resectable tumors (T4, circumferential resection margin<1mm), induction chemotherapy before chemoradiotherapy and consolidation chemotherapy after short course radiotherapy provide better results than standard treatment in terms of complete response and recurrence-free survival, and should be routinely proposed in this indication.

Adult appendicitis: Clinical practice guidelines from the French Society of Digestive Surgery and the Society of Abdominal and Digestive Imaging.

INTRODUCTION: The French Society of Digestive Surgery (SFCD) and the Society of Abdominal and Digestive Imaging (SIAD) have collaborated to propose recommendations for clinical practice in the management of adult appendicitis. METHODS: An analysis of the literature was carried out according to the methodology of the French National Authority for Health (HAS). A selection was performed from collected references and then a manual review of the references listed in the selected articles was made in search of additional relevant articles. The research was limited to articles whose language of publication was English or French. Articles focusing on the pediatric population were excluded. Based on the literature review, the working group proposed recommendations whenever possible. These recommendations were reviewed and approved by a committee of experts. RESULTS: Recommendations about appendicitis in adult patients were proposed with regard to clinical, laboratory and radiological diagnostic modalities, treatment strategy for uncomplicated and complicated appendicitis, surgical technique, and specificities in the case of macroscopically healthy appendix, terminal ileitis and appendicitis in the elderly and in pregnant women. CONCLUSION: These recommendations for clinical practice may be useful to the surgeon in optimizing the management of acute appendicitis in adults.

A Reappraisal of Outcome of Elective Surgery After Successful Non-Operative Management of an Intra-Abdominal Abscess Complicating Ileocolonic Crohn's Disease: A Subgroup Analysis of a Nationwide Prospective Cohort.

BACKGROUND AND AIMS: Few prospective data exist on outcomes of surgery in Crohn's disease [CD] complicated by an intra-abdominal abscess after resolution of this abscess by antibiotics optionally combined with drainage. METHODS: From 2013 to 2015, all patients undergoing elective surgery for CD after successful non-operative management of an intra-abdominal abscess [Abscess-CD group] were selected from a nationwide multicentre prospective cohort. Resolution of the abscess had to be computed tomography/magnetic resonance-proven prior to surgery. Abscess-CD group patients were 1:1 matched to uncomplicated CD [Non-Penetrating-CD group] using a propensity score. Postoperative results and long-term outcomes were compared between the two groups. RESULTS: Among 592 patients included in the registry, 63 [11%] fulfilled the inclusion criteria. The abscess measured 37 ±â€…20 mm and was primarily managed with antibiotics combined with drainage in 14 patients and nutritional support in 45 patients. At surgery, a residual fluid collection was found in 16 patients [25%]. Systemic steroids within 3 months before surgery [p = 0.013] and the absence of preoperative enteral support [p = 0.001] were identified as the two significant risk factors for the persistence of a fluid collection. After propensity score matching, there was no significant difference between the Abscess-CD and Non-Penetrating-CD groups in the rates of primary anastomosis [84% vs 90% respectively, p = 0.283], overall [28% vs 15% respectively, p = 0.077] and severe postoperative morbidity [7% vs 7% respectively, p = 1.000]. One-year recurrence rates for endoscopic recurrence were 41% in the Abscess-CD and 51% in the Non-Penetrating-CD group [p = 0.159]. CONCLUSIONS: Surgery after successful non-operative management of intra-abdominal abscess complicating CD provides good early and long-term outcomes.

Impact of the local care environment and social characteristics on aggregated hospital fatality rate from COVID-19 in France: a nationwide observational study.

OBJECTIVES: We aimed to investigate possible differences in the aggregated hospital fatality rate from coronavirus disease 2019 (COVID-19) in France at the early phase of the outbreak and to determine whether factors related to population or healthcare supply before the pandemic could be associated with outcome differences. STUDY DESIGN: This is a nationwide observational study including all French hospitals from January 24, 2020, to April 11, 2020. METHODS: We analyzed the aggregated hospital fatality rate. A Poisson regression was performed to investigate associations between characteristics pertaining to populational health, socio-economic context and local healthcare supply at baseline, and the chosen outcome. RESULTS: On April 11, 2020, a total number of 30,960 patients were hospitalized among the 3046 French healthcare facilities, including 6832 patients in the intensive care unit (ICU). A total of 8581 deaths due to COVID-19 had been recorded, with a median mortality rate per 10,000 people per department of 0.53 (interquartile range: 0.29-1.90). There were significant variations between the 95 French departments even after adjusting for outbreak inception (P < 0.001). After multivariable analysis, four factors were independently associated with a significantly higher aggregated hospital fatality rate: a higher ICU capacity at baseline (estimate = 1.47; P = 0.00791), a lower density of general practitioners (estimate = 0.95; P = 0.0205), a lower fraction of activity from the for-profit private sector (estimate = 0.99; P < 0.001), and the ratio of people older than 75 years (estimate = 0.91; P = 0.0023). CONCLUSIONS: The aggregated hospital fatality rate from COVID-19 in France seems to vary among geographic areas, with some factors pertaining to local healthcare supply being associated with the outcome.

International variation in managing locally advanced or recurrent rectal cancer: prospective benchmark analysis.

BACKGROUND: Tumour extension beyond the mesorectal plane (ymrT4) occurs in 5-10 per cent of patients with rectal cancer and 10 per cent of patients develop locally recurrent rectal cancer (LRRC) after primary surgery. There is global variation in healthcare delivery for these conditions. METHODS: An international benchmark trial of the management of ymrT4 tumours and LRRC was undertaken in France and Australia between 2015 and 2017. Heterogeneity in management and operative decision-making were analysed by comparison of surgical resection rates, blinded intercountry reading of pelvic MRI, quality-of-life assessment and qualitative evaluations. RESULTS: Among 154 patients (97 in France and 57 in Australia), 31·8 per cent had ymrT4 disease and 68·2 per cent LRRC. The surgical resection rates were 88 and 79 per cent in France and Australia respectively (P = 0·112). The concordance in operative planning was low (κ = 0·314); the rate of pelvic exenteration was lower in France than Australia both in clinical practice (36 of 78 versus 34 of 40; P < 0·001) and in theoretical conditions (10 of 25 versus 50 of 57; P = 0·002). The R0 resection rate was lower in France than Australia for LRRC (25 of 49 versus 18 of 21; P = 0·007) but not for ymrT4 tumours (21 of 26 versus 15 of 15; P = 0·139). Morbidity rates were similar. Patients who underwent non-exenterative procedures had higher scores on the mental functioning subscale at 12 months (P = 0·047), and a lower level of distress at 6 months (P = 0·049). Qualitative analysis highlighted five categories of psychosocial factors influencing treatment decisions: patient, strategy, specialist, organization and culture. CONCLUSION: This international benchmark trial has highlighted the differences in worldwide treatment of locally advanced and LRRC. Standardized care should improve outcomes for these patients.

ANTECEDENTES: La extensión del tumor más allá del plano del meso-rrecto (ymrT4) ocurre en el 5-10% de los pacientes con cáncer de recto y el 10% de los pacientes desarrollan recidiva local del cáncer de recto (locally recurrent rectal cáncer, LRRC) después de una cirugía primaria. Existe una variación global en la prestación de la asistencia sanitaria para esta pato-logía. MÉTODOS: Se realizó un ensayo de referencia internacional sobre el manejo de ymrT4 y LRRC en Francia y Australia entre 2015 y 2017. La heterogeneidad en el manejo y la toma de decisiones quirúrgicas se analizaron mediante la comparación de las tasas de resección quirúrgica, la lectura a ciegas de la resonancia magnética (RM) pélvica entre países, la evaluación de la calidad de vida y las evaluaciones cualitativas. RESULTADOS: De 154 pacientes (97 en Francia versus 57 en Australia), el 32% tenía ymrT4 y el 68% tenía cáncer de recto con recidiva local. Las tasas de resección quirúrgica fueron del 87,6% versus 77,8% (P = 0,112). La tasa de concordancia en la decisión quirúrgica fue baja (coeficiente kappa = 0,314) con una tasa más baja de exenteración pélvica en Francia, tanto en la práctica clínica (46% versus 85%; P < 0,0001) como en condiciones teóricas (40% versus 88%; P = 0,002). La tasa de resección R0 fue menor en Francia para la LRRC (51% versus 86%, P = 0,007) pero no para el ymrT4 (81% versus 100%, P = 0,139). Las tasas de morbilidad fueron similares. Los pacientes que se sometieron a procedimientos no exenterativos tuvieron una subescala de funcionamiento mental más alta a los 12 meses (P = 0,04) y un nivel de angustia más bajo a los 6 meses (P = 0,04). El análisis cualitativo destacó 5 categorías de factores psicosociales que afectaron a la decisión del tratamiento: paciente, estrategia, especialista, organización y cultura. CONCLUSIÓN: Este ensayo de referencia internacional destaca las diferencias en el tratamiento mundial del cáncer de recto localmente avanzado y de la LRR. La aten-ción estandarizada debería mejorar los resultados para estos pacientes.

Colon sparing resection versus extended colectomy for left-sided obstructing colon cancer with caecal ischaemia or perforation: a nationwide study from the French Surgical Association.

AIM: It is not known whether patients with obstructive left colon cancer (OLCC) with caecal ischaemia or diastatic perforation (defined as a blowout of the caecal wall related to colonic overdistension) should undergo a (sub)total colectomy (STC) or an ileo-caecal resection with double-barrelled ileo-colostomy. We aimed to compare the results of these two strategies. METHOD: From 2000 to 2015, 1220 patients with OLCC underwent surgery by clinicians who were members of the French Surgical Association. Of these cases, 201 (16%) were found to have caecal ischaemia or diastatic perforation intra-operatively: 174 patients (87%) underwent a STC (extended colectomy group) and 27 (13%) an ileo-caecal resection with double-end stoma (colon-sparing group). Outcomes were compared retrospectively. RESULTS: In the extended colectomy group, 95 patients (55%) had primary anastomosis and 79 (45%) had a STC with an end ileostomy. In the colon-sparing group, 10 patients (37%) had simultaneous resection of their primary tumour with segmental colectomy and an anastomosis which was protected by a double-barrelled ileo-colostomy. The demographic data for the two groups were comparable. Median operative time was longer in the STC group (P = 0.0044). There was a decrease in postoperative mortality (7% vs 12%, P = 0.75) and overall morbidity (56% vs 67%, P = 0.37) including surgical (30% vs 40%, P = 0.29) and severe complications (17% vs 27%, P = 0.29) in the colon-sparing group, although these differences did not reach statistical significance. Cumulative morbidity included all surgical stages and the rate of permanent stoma was 66% and 37%, respectively, with no significant difference between the two groups. Overall survival and disease-free survival were similar between the two groups. CONCLUSION: The colon-sparing strategy may represent a valid and safe alternative to STC in OLCC patients with caecal ischaemia or diastatic perforation.

[Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis]. / Crise sanitaire liée au COVID-19 : modalités du traitement de l'appendicite aiguë non compliquée de l'adulte par antibiothérapie seule comme alternative à l'appendicectomie.

The massive inflow of patients with COVID-19 requiring urgent care has overloaded hospitals in France and impacts the management of other patients. Deferring hospitalization and non-urgent surgeries has become a priority for surgeons today in order to relieve the health care system. It is obviously not simple to reduce emergency surgery without altering the quality of care or leading to a loss of chance for the patient. Acute appendicitis is a very specific situation and the prevalence of this disease leads us to reconsider this particular disease in the context of the COVID-19 crisis. Indeed, while the currently recommended treatment for uncomplicated acute appendicitis is surgical appendectomy, the non-surgical alternative of medical management by antibiotic therapy alone has been widely evaluated by high-quality studies in the literature. Insofar as the main limitation of exclusively medical treatment of uncomplicated acute appendicitis is the risk of recurrent appendicitis, this treatment option represents an alternative of choice to reduce the intra-hospital overload in this context of health crisis. The aim of this work is therefore to provide physicians and surgeons with a practical guide based on a review of the literature on the medical treatment of uncomplicated acute appendicitis in adults, to offer this alternative treatment to the right patients and under good conditions, especially when access to the operating room is limited or impossible.

Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis.

The massive inflow of patients with COVID-19 requiring urgent care has overloaded hospitals in France and impacts the management of other patients. Deferring hospitalization and non-urgent surgeries has become a priority for surgeons today in order to relieve the health care system. It is obviously not simple to reduce emergency surgery without altering the quality of care or leading to a loss of chance for the patient. Acute appendicitis is a very specific situation and the prevalence of this disease leads us to reconsider this particular disease in the context of the COVID-19 crisis. Indeed, while the currently recommended treatment for uncomplicated acute appendicitis is surgical appendectomy, the non-surgical alternative of medical management by antibiotic therapy alone has been widely evaluated by high-quality studies in the literature. Insofar as the main limitation of exclusively medical treatment of uncomplicated acute appendicitis is the risk of recurrent appendicitis, this treatment option represents an alternative of choice to reduce the intra-hospital overload in this context of health crisis. The aim of this work is therefore to provide physicians and surgeons with a practical guide based on a review of the literature on the medical treatment of uncomplicated acute appendicitis in adults, to offer this alternative treatment to the right patients and under good conditions, especially when access to the operating room is limited or impossible.

Laser ablation of fistula tract (LAFT) and complex fistula-in-ano: "the ideal indication" is becoming clearer .

BACKGROUND: An initial study enabled us to achieve 60% healing of high transsphincteric fistula-in-ano with laser ablation of fistula tract (LAFT) The purpose of this new study was to investigate other predictors of the success of this technique in the treatment of complex anoperineal fistulas. METHODS: All patients treated with LAFT in our department between May 2017 and October 2018 were included prospectively. LAFT was used for patients with complex anoperineal fistulas who were at high risk of anal incontinence after fistulotomy. The fistula was considered healed when the internal and external openings were closed and the patient experienced no pain or leakage. RESULTS: A total of 100 consecutive patients (65 males) with a median age of 43 years (range 22-88 years) were included in the study. Eight patients were lost to follow-up. The fistulas were low (8%) or high (79%) transsphincteric, and suprasphincteric (13%). After a median follow-up of 13.6 months (range 6-23 months), fistula healing was observed in 41 patients (44.6%). On univariate analysis, an anterior location, a narrow internal orifice and administration of less than 400 J of energy were significantly associated with healing. On multivariate analysis, a narrow internal orifice and low energy administration remained significant predictive factors of success [OR 5.08 (1.03-25.03), p = 0.046; OR 2.59 (1.08-6.17), p = 0.032]. No new cases of anal incontinence or any worsening of pre-existing anal incontinence was observed during follow up. CONCLUSIONS: This study indicates that complex anoperineal fistulas with a narrow internal orifice can be successfully treated with less than 400 J and are ideal for LAFT.

Intraluminal bypass devices as an alternative to protective ostomy for prevention of colorectal anastomotic leakage: a systematic review of the literature.

AIM: Anastomotic leakage (AL) is the most important complication of colorectal surgery, leading to high morbidity and mortality. Protective ostomy, the current standard of care for protecting a colorectal anastomosis, has important drawbacks that require the creation of an alternative strategy. Over the past 30 years, several intraluminal bypass devices, designed to shield the anastomosis from the faecal stream, have been developed. The aim of this literature review was to create an updated overview of the devices available and their effectiveness in preventing AL, and to investigate whether they could serve as an alternative to protective ostomy in the future. METHOD: A systematic review of the literature on intraluminal bypass devices used for preventing colorectal AL was performed. The MEDLINE and Cochrane Library databases were searched, and articles were marked as relevant if an intraluminal bypass device was studied in an animal or human population. RESULTS: The database search yielded 24 relevant articles related to 10 intraluminal bypass devices protecting a colorectal anastomosis. These articles included experimental animal studies, preclinical (pilot) studies, as well as retrospective and prospective clinical studies. Each device was assessed with regard to surgical technique, effectiveness and device-related complications. CONCLUSION: Intraluminal bypass devices show promise in preventing AL and its clinical consequences. However, there is insufficient high-level evidence to draw firm conclusions. There is a need for randomized controlled trials that directly compare these devices with the protective ostomy.

Long-term functional results and quality of life after redo rectal surgery: delayed versus immediate colo-anal anastomosis.

AIM: To compare the functional results and quality of life after delayed colo-anal anastomosis (DCAA) or immediate colo-anal anastomosis (ICAA) following redo rectal surgery. METHOD: Twenty-six patients with DCAA between 2014 and 2018 were studied retrospectively (group A). Two control groups were used: 26 ICAA after redo surgery (group B) and 52 colo-anal anastomosis (CAA) after anterior resection (group C). Control groups were matched for age, sex, pelvic radiotherapy and time to surgery. Low Anterior Resection Syndrome (LARS) and Gastrointestinal Quality of Life Index (GIQLI) scores were used to assess function and quality of life. RESULTS: The indications for surgery were comparable for groups A and B: anastomotic failure with chronic sepsis (38% vs 50%, P = 0.40), vaginal fistula (42% vs 42%, P = 1) and urinary fistula (20% vs 8%, P = 0.22) as well as the number of previous abdominal operations (1.3 ± 0.9 vs 1.1 ± 0.6, P = 0.19). The median LARS score in the first 2 years was 30 [interquartile range (IQR) 14-41] for group A, 23 (IQR 0-41) for group B and 22 (IQR 11-37) for group C. After 2 years, the median LARS score improved in each group [A, 21 (IQR 11-35); B, 18 (IQR 5-26); C, 13 (IQR 9-20)], but was still high in group A. There was a tendency toward more major LARS in group A than in group B (46% vs 27%; P = 0.149). There was no difference in the mean GIQLI score between groups A and B (120 ± 16 vs 117 ± 19; P = 0.53) at the end of the follow-up period. Time after stoma closure (< 2 years) and previous radiotherapy were risk factors for major LARS in all populations. CONCLUSION: ICAA should be the procedure of choice where possible in redo surgery as it has better functional outcomes.

The management of perineal hernia following abdomino-perineal excision for cancer.

PURPOSE: Perineal hernia (PH) is a tardive complication following abdomino-perineal resection (APR). Many repair methods are described and evidences are lacking. The aim of this study was to report PH management, analyze surgery outcomes and review the available literature. METHODS: We retrospectively included all consecutive PH repair after APR performed between 2001 and 2017. We recorded data on APR surgery, PH symptoms and repair, and follow-up (recurrence and morbidity). Literature review included published articles on PubMed between 1960 and 2017. RESULTS: 24 PH repairs were included. The approach was perineal N = 16, abdominal N = 5 and combined N = 3. A biological mesh was used for 17, a synthetic for 5 and a flap for 2 patients. The median follow-up was 25 months. Overall morbidity was 37.5% (N = 9): 37.5% for the perineal, 20% for the abdominal, and 66.7% for the combined approach. Complications occurred in 35.3% of biological and 20% of synthetic mesh repairs. Recurrence rate was 41.7%, similar for biological (n = 8, 47.1%) and synthetic meshs (n = 2; 40%). No recurrence occurred in the flap group. Depending of the approach, we found 50% for perineal (n = 8) and 40% of the abdominal cohort (N = 2). Among twelve studies, recurrence rates ranged from 0 to 66.7%. Abdominal or laparoscopic approach with synthetic mesh was associated with less recurrences (0 and 12.5% respectively) and complications (37.5% and 9.5%). CONCLUSIONS: Recurrences following PH repair are high irrespective of the repair technique. More studies are necessary to identify PH risk factors and decide the appropriate perineal reconstruction.

Management of colorectal peritoneal metastases: Expert opinion.

When peritoneal metastases are diagnosed (strong agreement of experts): (i) seek advice from a multidisciplinary coordination meeting (MCM) with large experience in peritoneal disease (e.g. BIG RENAPE network); (ii) transfer (or not) the patient to a referral center with experience in hyperthermic intraperitoneal chemotherapy (HIPEC), according to the advice of the MCM. With regard to systemic chemotherapy (strong agreement of experts): (i) it should be performed both before and after surgery, (ii) for no longer than 6 months; (iii) without postoperative anti-angiogenetic drugs. With regard to cytoreductive surgery (strong agreement of experts): (i) Radical surgery requires a xiphopubic midline incision; (ii) no cytoreductive surgery via laparoscopy. With regard to HIPEC: HIPEC can be proposed for trials outside an HIPEC referral center (weak agreement between experts): (i) if surgery is radical; (ii) if the expected morbidity is "reasonable"; (iii) if the indication for HIPEC was suggested by a MCM, and; (iv) mitomycin is preferred to oxaliplatin (which cannot be recommended) for this indication.

Morbidity and oncological outcomes of rectal cancer impaired by previous prostate malignancy.

BACKGROUND: Specific surgical and oncological outcomes in patients with rectal cancer surgery after a previous diagnosis of prostate cancer have not been well described. The aim of this study was to compare surgical outcomes in patients with rectal cancer with or without a history of prostate cancer. METHODS: Patients who had surgery for rectal cancer with (PC group) or without (no-PC group) previous curative treatment for prostate cancer were enrolled between January 2001 and December 2015. Comparisons between the two groups were performed by multivariable Cox analysis, and after propensity score matching in a 3 : 1 ratio for demographic and tumour characteristics, and surgical and oncological outcomes. RESULTS: A total of 944 patients with rectal cancer were enrolled, of whom 10·8 per cent had a history of prostate cancer. After matching, 83 patients who had received treatment for prostate cancer were compared with 249 who had not. The PC and no-PC groups were similar regarding patient characteristics. Extended total mesorectal excision, conversion to open surgery, transfusion and tumour perforation were more frequent in the PC group than in the no-PC group. Major surgical morbidity (28 versus 17·2 per cent; P = 0·036), anastomotic leakage (25 versus 13·7 per cent; P = 0·019) and permanent stoma (41 versus 12·4 per cent; P < 0·001) occurred more frequently in the PC group. Local recurrence was increased significantly in the PC group (17 versus 8·0 per cent; P = 0·019), and resulted in a significant decrease in disease-free and overall survival. CONCLUSION: Prostate cancer treatment increases short- and long-term surgical morbidity in patients with rectal cancer, and impairs oncological outcomes.

Does transanal local resection increase morbidity for subsequent total mesorectal excision for early rectal cancer?

AIM: Local excision is recommended for early rectal cancer (pT1). Complementary total mesorectal excision (cTME) is warranted when bad pathological features are present. The impact of a prior local resection on the outcome remains unclear. The aim of this study was to assess if prior local excision increases the morbidity of a subsequent cTME compared with primary TME. METHODS: From 2001 to 2016 all patients who underwent TME after local excision for rectal adenocarcinoma were studied. All were matched (1:1) with patients who underwent primary TME, without neoadjuvant radiochemotherapy. The matching factors included age, sex, body mass index, American Society of Anesthesiologists score and type of surgery. Short-term morbidity and pathological examination of the resected specimen were compared. RESULTS: Forty-one patients were included (14 women, 34%, mean age 65 ± 11 years), comprising classic transanal excision (66%) and transanal endoscopic microsurgery (34%), and were matched to 41 patients who had primary TME. cTME was significantly longer (315 min ± 87 vs 275 min ± 58, P = 0.03). The overall morbidity was 48.8% in the local excision group vs 31.7% in the control group (P = 0.18). Surgical morbidity was 31.7% vs 26.8% (P = 0.8). Anastomotic related morbidity was similar (local excision 17% vs TME 14.6%, P = 0.84) and the mean length of stay was similar (14 days) in both groups. There was a tendency to a worse quality of mesorectal excision in the cTME group (17% vs 5%, P = 0.15). CONCLUSION: Local excision prior to TME for early rectal cancer tends to increase overall morbidity and may worsen the quality of the mesorectal plane but should be considered as a surgical approach in select cases.