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1.
Ann Surg Oncol ; 27(2): 417-427, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31414295

RESUMO

BACKGROUND: Preoperative magnetic resonance imaging (MRI) allows highly reliable imaging of the mesorectal fascia (mrMRF) and its relationship to the tumor. The prospective multicenter observational study OCUM uses these findings to indicate neoadjuvant chemoradiotherapy (nCRT) in rectal carcinoma. METHODS: nCRT was indicated in patients with positive mrMRF (≤ 1 mm) in cT4 and cT3 carcinomas of the lower rectal third. RESULTS: A total of 527 patients (60.2%) underwent primary total mesorectal excision, and 348 patients (39.8%) underwent long-term nCRT followed by surgery. The mrMRF was involved in 4.6% of the primary surgery group and 80.7% of the nCRT group. Rates of resections within the mesorectal plane (90.8%), sparing of pelvic nerves on both sides (97.8%), and number of regional lymph nodes (95.3% with ≥ 12 lymph nodes examined) are indicative of high-quality surgery. Resection was classified as R0 in 98.3%, the pathological circumferential resection margin (pCRM) was negative in 95.1%. Patients in the nCRT group had more advanced carcinomas with a significantly higher rate of abdominoperineal excision. Independent risk factors for pCRM positivity were advanced stage (T4), metastatic lymph nodes, resection in the muscularis propria plane, and location in the lower third. CONCLUSIONS: The risk classification of rectal cancer patients by MRI seems to be highly reliable and allows the restriction of nCRT to approximately half of the patients with clinical stage II and III rectal carcinoma, provided there is a high-quality MRI diagnostic protocol, high-quality surgery, and standardized examination of the resected specimen.

2.
Int J Colorectal Dis ; 34(11): 1895-1905, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31641849

RESUMO

PURPOSE: Therapy of anal cancer follows national and international guidelines that are mainly derived from randomized trials. This study aimed to analyze long-term results of stage-dependent treatment of anal cancer in a non-selected patient cohort. PATIENTS AND METHOD: All consecutive patients treated for anal cancer between 2000 and 2015 were retrieved from a prospective database. Risk-dependent screening for human immunodeficiency virus showed no infection. Main outcome measure was overall survival with respect to tumor site and treatment. Secondary endpoints were cause-specific survival, stoma free survival, and the rate of salvage operations. RESULTS: In total, 106 patients were treated for anal cancer. Of those, 69 (65.1%) suffered from anal canal cancer and 37 (34.9%) from anal margin cancer. Three patients with synchronous distant metastases were excluded from analysis. The majority of patients (n = 79, 76.7%) were treated by chemoradiotherapy in curative intention. Twenty-two patients underwent local surgery. Five-year overall survival was 73.1% and cause-specific survival at 5 years was 87.4%. Overall, 14 patients (13.6%) needed salvage surgery. Their 5-year cause-specific survival was 57.7%. A permanent ostomy was avoided in 77.7%. CONCLUSIONS: Treatment of anal cancer results in low rates of salvage surgery and permanent ostomies, when therapy was determined by a multidisciplinary team following national and international guidelines.

3.
J Surg Oncol ; 120(3): 438-445, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31168858

RESUMO

BACKGROUND: Synchronous metastases are considered a negative prognostic factor in patients with metastatic colorectal cancer (CRC). We investigated the outcomes of stage IV CRC patients undergoing complete gross resection (R0/1) of both the primary tumor and the metastases under the guidance of a multidisciplinary team (MDT). METHODS: All CRC patients with synchronous metastases were retrieved from a prospective database. Patients treated from 2006 to 2017 who underwent complete resection were analyzed. Various factors, including multiple metastatic sites and complex procedures, were investigated. Univariate and multivariate overall survival (OS) calculations were performed. RESULTS: Of 330 consecutive patients with synchronous metastases, 101 (30.6%) achieved an R0/1 status including 12 (11.9%) patients with multiple metastatic sites. Complex procedures were necessary in 45 (44.6%) patients. Five-year OS was 53.0% for the R0/1 patient group. Multivariate analysis could not detect factors associated with prognosis. CONCLUSIONS: With modern treatment, the prognosis of patients with synchronous CRC metastases can be improved. Decisions made by a MDT offered one-third of patients a potentially curative approach to their stage IV disease. Despite the treatment of a high rate of patients with complex metastases necessitating complex procedures, we achieved a favorable 5-year OS rate.


Assuntos
Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Neoplasias Primárias Múltiplas/secundário , Neoplasias Primárias Múltiplas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Estimativa de Kaplan-Meier , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Neoplasias Pulmonares/secundário , Neoplasias Pulmonares/cirurgia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Peritoneais/secundário , Neoplasias Peritoneais/cirurgia , Estudos Retrospectivos
4.
Int J Colorectal Dis ; 34(4): 747-762, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30721417

RESUMO

PURPOSE: Treatment of rectal cancer often results in disturbed anorectal function, which can be quantified by the Low Anterior Resection Syndrome (LARS) score. This study investigates the association of impaired anorectal function as measured with the LARS score with quality of life (QoL) as measured with the EORTC-QLQ-C30 and CR38 questionnaires. METHODS: All stoma-free patients who had undergone sphincter-preserving surgery for rectal cancer from 2000 to 2014 in our institution were retrieved from a prospective database. They were contacted by mail and asked to return the questionnaires. QoL was evaluated in relation to LARS and further patient- and treatment factors using univariate and multivariate analysis. RESULTS: Of the eligible patients (n = 331), 261 (78.8%) responded with a complete LARS score. Mean score for global QoL according to the EORTC-QLQ-C30 questionnaire was 63 ± 21 for all patients. If major LARS was present, mean score decreased to 56 ± 19 in contrast to 67 ± 20 in patients with no/minor LARS (p < 0.001). In regression analysis, major LARS was furthermore associated with reduced physical, role, emotional, cognitive and social functioning as well as impaired body image, more micturition problems and poorer future perspective. It was not related to sexual function. The variance explained by major LARS in the differences of QoL was approximately 10%. CONCLUSION: The presence of major LARS after rectal resection for cancer is negatively associated with global health as well as many other aspects of QoL. Preserving anorectal function and treatment of LARS are potential measures to improve QoL in this patient group.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Qualidade de Vida , Inquéritos e Questionários , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Síndrome
5.
Int J Colorectal Dis ; 33(6): 787-798, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29541896

RESUMO

PURPOSE: Severity of anorectal dysfunction after low anterior resection is associated with various patient- and treatment-related factors. We aimed to quantify anorectal dysfunction after treatment for rectal cancer using the low anterior resection syndrome (LARS) score. METHODS: We retrieved from a prospective database 331 eligible patients on whom anterior resection for rectal cancer had been performed from 2000 to 2014. All patients were sent a LARS score accompanied by a supplementary questionnaire. Response rate was 78.8% (261 patients). The main outcome measure was the relation of the LARS score to potentially associated patient and treatment factors. Secondary endpoints were further measures that reflect anorectal dysfunction, e.g., Vaizey score. RESULTS: Overall, 144 (55.2%) patients exhibited scores > 20 reflecting minor (n = 51 (19.5%)) or major (n = 93 (35.6%)) LARS. A significant difference for scores > 20 was found for intersphincteric resection (IR, 73.2% affected patients) compared to total mesorectal excision (TME, 58.4%) and partial mesorectal excision (PME, 38.0%, p = 0.001). Radio(chemo)therapy resulted in LARS scores > 20 in 64.6% of patients compared to 43.1% in patients without irradiation (p = 0.001). Type of procedure (TME and IR as compared to PME), radio(chemo)therapy, and younger age were independently associated with LARS in logistic regression analysis. However, younger age remained the only independent factor for higher scores after exclusion of PME. CONCLUSIONS: The LARS score identified a substantial proportion of patients after surgery for rectal cancer with anorectal dysfunction. The extent of surgical procedure is independently associated with the severity of symptoms whereas the role of radiotherapy needs further assessment.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Intestinos/fisiopatologia , Neoplasias Retais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Reto/patologia , Reto/cirurgia , Resultado do Tratamento
7.
Int J Colorectal Dis ; 31(10): 1729-37, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27631643

RESUMO

PURPOSE: Extralevator abdominoperineal excision (ELAPE) was introduced to improve outcomes for low-lying locally advanced rectal cancers (LARC) not amenable to sphincter preserving procedures. This study investigates prospectively outcomes of patients operated on with ELAPE compared with a similar cohort of patients operated on with conventional APE. METHODS: After the exclusion of patients without neoadjuvant therapy, in-hospital mortality, and incomplete metastatectomy, we identified 72 consecutive patients who had undergone either conventional APE (n = 36) or ELAPE (n = 36) for LARC ≤6 cm from the anal verge. The primary outcome measure was local recurrence at 5 years, and secondary outcome measures were cause-specific and overall survival. RESULTS: Median distance from the anal verge was significantly lower in the ELAPE group (2 vs. 4 cm, p = 0.029). Inadvertent bowel perforation could be completely avoided in the ELAPE group, but amounted to 16.7 % in the conventional APE group (p = 0.025). Cumulative local recurrence rate at 5 years was 18.2 % in the APE group compared to 5.9 % in the ELAPE group (p = 0.153). Local recurrence without distant metastases occurred in 15.5 % in the APE group but was not observed in the ELAPE group (p = 0.039). We did not detect significant differences in cause-specific nor in overall survival. CONCLUSION: ELAPE results in lower local recurrence rates as compared with conventional APE. We conclude that the extralevator approach should be the procedure of choice for advanced low rectal cancer not amenable to sphincter preserving procedures.


Assuntos
Abdome/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Períneo/cirurgia , Neoplasias Retais/cirurgia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do Tratamento
9.
Ann Surg ; 263(4): 751-60, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25822672

RESUMO

OBJECTIVE: This study aimed to validate a magnetic resonance imaging (MRI) staging classification that preoperatively assessed the relationship between tumor and the low rectal cancer surgical resection plane (mrLRP). BACKGROUND: Low rectal cancer oncological outcomes remain a global challenge, evidenced by high pathological circumferential resection margin (pCRM) rates and unacceptable variations in permanent colostomies. METHODS: Between 2008 and 2012, a prospective, observational, multicenter study (MERCURY II) recruited 279 patients with adenocarcinoma 6 cm or less from the anal verge. MRI assessed the following: mrLRP "safe or unsafe," venous invasion (mrEMVI), depth of spread, node status, tumor height, and tumor quadrant. MRI-based treatment recommendations were compared against final management and pCRM outcomes. RESULTS: Overall pCRM involvement was 9.0% [95% confidence interval (CI), 5.9-12.3], significantly lower than previously reported rates of 30%. Patients with no adverse MRI features and a "safe" mrLRP underwent sphincter-preserving surgery without preoperative radiotherapy, resulting in a 1.6% pCRM rate. The pCRM rate increased 5-fold for an "unsafe" compared with "safe" preoperative mrLRP [odds ratio (OR) = 5.5; 95% CI, 2.3-13.3)]. Posttreatment MRI reassessment indicated a "safe" ymrLRP in 33 of 113 (29.2%), none of whom had ypCRM involvement. In contrast, persistent "unsafe" ymrLRP posttherapy resulted in 17.5% ypCRM involvement. Further independent MRI assessed risk factors were EMVI (OR = 3.8; 95% CI, 1.5-9.6), tumors less than 4.0 cm from the anal verge (OR = 3.4; 95% CI, 1.3-8.8), and anterior tumors (OR = 2.8; 95% CI, 1.1-6.8). CONCLUSIONS: The study validated MRI low rectal plane assessment, reducing pCRM involvement and avoiding overtreatment through selective preoperative therapy and rationalized use of permanent colostomy. It also highlights the importance of posttreatment restaging.


Assuntos
Adenocarcinoma/patologia , Imagem por Ressonância Magnética , Recidiva Local de Neoplasia/patologia , Cuidados Pré-Operatórios/métodos , Neoplasias Retais/patologia , Adenocarcinoma/cirurgia , Adenocarcinoma/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Quimiorradioterapia Adjuvante , Colostomia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Análise Multivariada , Estadiamento de Neoplasias , Estudos Prospectivos , Neoplasias Retais/cirurgia , Neoplasias Retais/terapia , Medição de Risco , Fatores de Risco
10.
Int J Colorectal Dis ; 31(2): 377-84, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26546443

RESUMO

PURPOSE: Although lymph node metastases to pancreatic and gastroepiploic lymph node stations in transverse colon cancer have been described, the mode of lymphatic spread in this area remains unclear. This study was undertaken to describe possible pathways of aberrant lymphatic spread in the complex anatomic area of the proximal superior mesenteric artery and vein, the greater omentum, and the lower pancreatic border. METHODS: Abdominal specimens obtained from four cadaveric donors were dissected according to the principles of complete mesocolic excision. The vascular architecture of the transverse colon was scrutinized in search of possible pathways of lymphatic spread to the pancreatic and gastroepiploic lymph nodes. RESULTS: Vascular connections between the transverse colon and the greater omentum at the level of both the hepatic and the splenic flexures could be identified. In addition, small vessels running from the transverse mesocolon to the lower pancreatic border in the area between the middle colic artery and the inferior mesenteric vein were demonstrated. Moreover, venous tributaries to the gastrocolic trunk could be exposed to highlight its surgical importance as a guiding structure for complete mesocolic excision. CONCLUSION: The technical feasibility to clearly separate embryologic compartments by predefined tissue planes in complete mesocolic excision was confirmed. However, the vicinity of all three endodermal intestinal segments (foregut, midgut, and hindgut) obviously gives way to vascular connections that might serve as potential pathways for lymphatic metastatic spread of transverse colon cancer.


Assuntos
Colo Transverso/irrigação sanguínea , Colo Transverso/patologia , Neoplasias do Colo/patologia , Neoplasias do Colo/cirurgia , Mesocolo/cirurgia , Cadáver , Humanos , Linfonodos/patologia , Metástase Linfática , Artérias Mesentéricas/anatomia & histologia , Veias Mesentéricas/anatomia & histologia , Omento/irrigação sanguínea , Pâncreas/irrigação sanguínea
11.
Int J Colorectal Dis ; 30(6): 797-806, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25922143

RESUMO

PURPOSE: This study aimed to investigate the outcome for stage II and III rectal cancer patients compared to stage II and III colonic cancer patients with regard to 5-year cause-specific survival (CSS), overall survival, and local and combined recurrence rates over time. METHODS: This prospective cohort study identified 3,355 consecutive patients with adenocarcinoma of the colon or rectum and treated in our colorectal unit between 1981 and 2011, for investigation. The study was restricted to International Union Against Cancer (UICC) stages II and III. Postoperative mortality and histological incomplete resection were excluded, which left 995 patients with colonic cancer and 726 patients with rectal cancer for further analysis. RESULTS: Five-year CSS rates improved for colonic cancer from 65.0% for patients treated between 1981 and 1986 to 88.1% for patients treated between 2007 and 2011. For rectal cancer patients, the respective 5-year CSS rates improved from 53.4% in the first observation period to 89.8% in the second one. The local recurrence rate for rectal cancer dropped from 34.2% in the years 1981-1986 to 2.1% in the years 2007-2011. In the last decade of observation, prognosis for rectal cancer was equal to that for colon cancer (CSS 88.6 vs. 86.7%, p = 0.409). CONCLUSION: Survival of patients with colon and rectal cancer has continued to improve over the last three decades. After major changes in treatment strategy including introduction of total mesorectal excision and neoadjuvant (radio)chemotherapy, prognosis for stage II and III rectal cancer is at least as good as for stage II and III colonic cancer.


Assuntos
Adenocarcinoma/mortalidade , Adenocarcinoma/cirurgia , Neoplasias do Colo/mortalidade , Neoplasias do Colo/cirurgia , Neoplasias Retais/mortalidade , Neoplasias Retais/cirurgia , Adenocarcinoma/patologia , Idoso , Neoplasias do Colo/patologia , Humanos , Terapia Neoadjuvante , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Estudos Prospectivos , Neoplasias Retais/patologia , Taxa de Sobrevida , Resultado do Tratamento
12.
Dis Colon Rectum ; 55(7): 750-5, 2012 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-22706126

RESUMO

BACKGROUND: Total fistulectomy with simple closure of the internal opening has been used for the management of complex anal fistulas. This approach involves complete removal of the fistula tract and closure of the internal opening with sutures. OBJECTIVE: This study aimed to report long-term outcomes in patients with complex cryptoglandular fistulas who undergo this procedure. DESIGN: This is a retrospective review of a prospectively collected consecutive series. SETTINGS: This study was conducted at a community-based hospital with a specialized colorectal unit. PATIENTS: : Patients included in this study had cryptoglandular fistulas and underwent total fistulectomy with simple closure of the internal opening between 1997 and 2007. MAIN OUTCOME MEASURES: The main outcome measures were success rate and postoperative continence (Cleveland Clinic Florida Fecal Incontinence Scale). Treatment was considered successful if the external opening was closed and no drainage was present at the last follow-up. RESULTS: Success was achieved in 187 (74%) patients with a median follow-up time of 70 (range, 14-141) months. Patients with posterior transsphincteric or suprasphincteric fistulas had a higher success rate than those with other types of fistulas (82% vs 67%;p = 0.014), and patients for whom the procedure failed were significantly younger than those for whom the procedure was a success (mean, 45 vs 50 years; p = 0.010). Of 160 patients with success who had no previous surgery, 89 (56%) had normal continence postoperatively (CCF-FI score = 0). LIMITATIONS: The limitations of this study include its retrospective nature, the potential for selection bias, and the lack of preoperative continence scores. CONCLUSIONS: Total fistulectomy with simple closure of the internal opening is effective for the long-term closure of complex cryptoglandular fistulas.However, this procedure may affect continence despite its sphincter-sparing quality. Nonetheless, the high success rate in patients with posterior transsphincteric or suprasphincteric fistulas renders this procedure a reasonable option in this subgroup of patients with complex fistulas.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Fístula Retal/cirurgia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Incontinência Fecal/epidemiologia , Incontinência Fecal/etiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Técnicas de Sutura , Resultado do Tratamento , Adulto Jovem
13.
Langenbecks Arch Surg ; 397(5): 771-8, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22350643

RESUMO

PURPOSE: Stapled transanal rectal resection (STARR) has recently been recommended for patients with obstructed defecation caused by rectocele and rectal wall intussusception. Our study investigates the long-term results and predictive factors for outcome. METHODS: Between November 2002 and February 2007, 80 patients (69 females) were operated on using the STARR procedure and included in the following study. Symptoms were defined according to the ROME II criteria. Preoperative assessment included clinical examination, colonoscopy, video defecography, and dynamic MRI. Preoperatively and during follow-up visits, we evaluated the Cleveland Constipation Score (CCS) to rate the severity of outlet obstruction and the Wexner Incontinence Score to rate anal incontinence. Patients were asked to judge the outcome of the operation as improved or poor/dissatisfied. We performed a univariate analysis for 11 patient- and disease-related factors to detect an association with outcome. RESULTS: The median follow-up was 39 months (range 20-78). Major postoperative complications (one staple line insufficiency, one urosepsis, one prolonged urinary dysfunction with indwelling catheter) were found in 3.8%. The result after STARR procedure was a success in the long-term follow-up in 62 patients (77.5%), although the improvement did not persist in 15 patients (18.7%). The mean value of the CCS decreased significantly from 9.3 before surgery to 4.6 after 2 years and increased again slightly to 6.5 after 4-6 years. The Median Wexner Incontinence Score was 3.3 at baseline, but rose significantly to 6.0. However, a third of patients who reported deteriorated continence developed the symptoms 1-4 years after surgery. Of the factors investigated for the prediction of outcome, we could only identify the number of pelvic floor changes in defecography or dynamic MRI as being associated with the success of the operation. CONCLUSION: Our study indicates that STARR is a safe procedure. A significant improvement of symptoms is to be expected, but this improvement may deteriorate with time. Patients' satisfaction is also associated with the occurrence of urge to defecate or incontinence. It remains difficult to predict outcome.


Assuntos
Constipação Intestinal/complicações , Obstrução Intestinal/cirurgia , Proctoscopia/métodos , Reto/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Estudos de Coortes , Constipação Intestinal/diagnóstico , Defecação/fisiologia , Defecografia , Incontinência Fecal/etiologia , Incontinência Fecal/fisiopatologia , Feminino , Seguimentos , Humanos , Obstrução Intestinal/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Recuperação de Função Fisiológica , Reto/diagnóstico por imagem , Estudos Retrospectivos , Índice de Gravidade de Doença , Técnicas de Sutura , Suturas , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
14.
Dis Colon Rectum ; 54(8): 947-57, 2011 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-21730782

RESUMO

BACKGROUND: Extralevator abdominoperineal excision results in superior oncologic outcome for advanced low rectal cancer. The exact definition of surgical resection planes is pivotal to achieving negative circumferential resection margins. OBJECTIVE: This study aims to describe the surrounding anatomical structures that are at risk for inadvertent damage during extralevator abdominoperineal excision. DESIGN AND SETTING: Joint surgical and macroanatomical dissection was performed in a university laboratory of clinical anatomy. METHODS: A stepwise dissection study was conducted according to the technique of extralevator abdominoperineal excision by abdominal and perineal approaches in 4 human cadaveric pelvises. Muscular, fascial, tendinous, and neural structures were carefully exposed and related to the corresponding surgical resection planes. RESULTS: In addition to the autonomic nerves to be identified and preserved during total mesorectal excision, further structures endangered during extralevator abdominoperineal excision can be clearly identified. Terminal pudendal nerve branches come close to the surgical resection plane at the outer surface of the puborectal sling. Likewise, the pelvic plexus and its neurovascular bundles embedded within the parietal pelvic fascia extend close to the apex of the prostate where the parietal pelvic fascia has to be divided. These neural structures converge in the region of the perineal body, an area that provides no "self-opening" planes for surgical dissection. Thus, the necessity to sharply detach the anorectal specimen anteriorly from the perineal body and the superficial transverse perineal muscle bears the risk of both inadvertent damage of the aforementioned anatomical structures and perforation of the specimen. LIMITATIONS: The study focused primarily on the macroscopic topography relevant to the surgical procedure, so that previously published histologic examinations were not performed. CONCLUSION: The present anatomical dissection study highlights those anatomical landmarks that require clear identification for the successful achievement of both negative circumferential resection margins and preservation of urogenital functions during extralevator abdominoperineal excision.


Assuntos
Dissecação/métodos , Pelve/anatomia & histologia , Pelve/inervação , Neoplasias Retais/cirurgia , Canal Anal/anatomia & histologia , Canal Anal/cirurgia , Cadáver , Humanos , Períneo/anatomia & histologia , Períneo/cirurgia , Reto/anatomia & histologia , Reto/cirurgia
15.
Int J Colorectal Dis ; 26(10): 1227-40, 2011 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-21603901

RESUMO

BACKGROUND: After introduction of total mesorectal excision (TME) as the gold standard for rectal cancer surgery, oncologic results appeared to be inferior for abdominoperineal excision (APE) as compared to anterior resection. This has been attributed to the technique of standard APE creating a waist at the level of the tumor-bearing segment. This systematic review investigates outcome of both standard and extended techniques of APE regarding inadvertent bowel perforation, circumferential margin (CRM) involvement, and local recurrence. METHODS: A literature search was performed to identify all articles reporting on APE after the introduction of TME using Medline, Ovid, and Embase. Extended APE was defined as operations that resected the levator ani muscle close to its origin. All other techniques were taken to be standard. Studies so identified were evaluated using a validated instrument for assessing nonrandomized studies. Rates for perforation, CRM involvement, and local recurrence were compared using chi-square statistics. RESULTS: In the extended group, 1,097 patients, and in the standard group, 4,147 patients could be pooled for statistical analysis. The rate of inadvertent bowel perforation and the rate of CRM involvement for extended vs. standard APE was 4.1% vs. 10.4% (relative risk reduction 60.6%, p = 0.004) and 9.6% vs. 15.4% (relative risk reduction 37.7%, p = 0.022), respectively. The local recurrence rate was 6.6% vs. 11.9% (relative risk reduction 44.5%, p < 0.001) for the two groups. CONCLUSION: This systematic review suggests that extended techniques of APE result in superior oncologic outcome as compared to standard techniques.


Assuntos
Abdome/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Procedimentos Cirúrgicos do Sistema Digestório/normas , Períneo/cirurgia , Neoplasias Retais/cirurgia , Humanos , Recidiva , Padrões de Referência
16.
Dis Colon Rectum ; 54(4): 401-11, 2011 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21383559

RESUMO

BACKGROUND: Neoadjuvant treatment in the multimodal therapy concept of rectal carcinoma has considerable effects on prognosis appraisal. OBJECTIVE: This study aimed to evaluate the tumor response specified as an improvement by at least one stage defined in terms of the International Union Against Cancer stages as a prognostic factor. DESIGN: This investigation was designed as a prospective cohort study. SETTING: This study was performed at a community-based hospital with a specialized colorectal unit. PATIENTS: One hundred seventy-four patients with locally advanced rectal carcinoma, treated in the Dresden-Friedrichstadt hospital from 1997 to 2009, who received long-term preoperative chemoradiotherapy and underwent curative resection, were included in this study. MAIN OUTCOME MEASURES: The main outcome measures were cause-specific and disease-free survival with respect to T and N category, International Union Against Cancer stage, venous and lymphatic invasions, grading, CEA level, complete pathologic response, tumor regression grading, International Union Against Cancer stage shift, T, N, and CEA shift, types of neoadjuvant therapy, adjuvant therapy, interval between completion of neoadjuvant chemoradiotherapy and surgery, and number of extracted lymph nodes in resected specimens. Univariate and multivariate analyses were performed. RESULTS: Median follow-up was 45 months. One hundred twenty-one patients (69.5%) showed a response to the treatment, whereas 53 (30.5%) did not. Five-year cause-specific and disease-free survival for responders (n = 121) vs nonresponders (n = 53) were 92.6% and 73.7% vs 84.9% and 47.9%. In the univariate analysis, ypN category, venous and lymphatic invasion, tumor regression grading, International Union Against Cancer stage shift, and T and N shift were significantly predictive for cause-specific and disease-free survival. Furthermore, ypUICC stage, ypT category, grading, and complete pathologic response had an impact on disease-free survival. In the multivariate analysis, only the International Union Against Cancer stage shift kept its independent explanatory power for cause-specific P = .012, HR 3.10 (95% CI 1.28-7.51) and disease-free survival P < .001, HR 3.85 (95% CI 1.98-7.51). LIMITATIONS: The determination of International Union Against Cancer stage shift depends on the pretreatment staging modalities. CONCLUSION: Our investigation demonstrates that the response of tumor to neoadjuvant therapy is an independent prognostic factor in patients with rectal carcinoma.


Assuntos
Adenocarcinoma/terapia , Terapia Neoadjuvante , Neoplasias Retais/terapia , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Prognóstico , Estudos Prospectivos , Neoplasias Retais/patologia , Taxa de Sobrevida
17.
Int J Colorectal Dis ; 26(7): 919-25, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21350936

RESUMO

BACKGROUND: Extra-levator abdominoperineal excision (ELAPE) has been introduced to avoid oncologic problems encountered with conventional abdominoperineal excision (APE) such as high rates of inadvertent bowel perforation and of positive circumferential resection margin. We compare our short-term results of this new approach with a historic patient cohort. PATIENTS AND METHODS: From 1997 until 2010, we performed 46 consecutive conventional APE and 28 ELAPE after neoadjuvant therapy with a macroscopically complete resection in the true pelvis. Patient data was prospectively collected in our colorectal tumor database. Patient and tumor characteristics were compared as were the rates of inadvertent bowel perforation, of circumferential margin involvement, and of wound abscesses. RESULTS: The rates of inadvertent bowel perforation, of circumferential margin involvement, and of wound abscesses were 15.2% vs. 0 (p = 0.04), 4.9% vs. 0 (p = 0.511), and 17.4% vs. 10.7% (p = 0.518), respectively, in the conventional APE vs. ELAPE group. CONCLUSION: With a significant reduction of the bowel perforation rate and a reduction of circumferential margin involvement and wound abscess formation, ELAPE improves important surrogate parameters for local recurrence rate and survival.


Assuntos
Abdome/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Períneo/cirurgia , Neoplasias Retais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Perfuração Intestinal/complicações , Perfuração Intestinal/patologia , Perfuração Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Neoplasias Retais/patologia , Fatores de Tempo , Resultado do Tratamento
18.
Int J Colorectal Dis ; 25(9): 1093-102, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20549219

RESUMO

PURPOSE: In 2007, the German Working Group "Workflow Rectal Cancer II" published 19 quality indicators with 36 quality goals for the treatment of rectal cancer. We investigate whether these parameters are practicable in a specialized coloproctologic unit. PATIENTS AND METHODS: We included 578 consecutive patients with rectal cancer who were treated in our institution from January 2000 to December 2008. Patient data were collected in a prospective database. Follow-up was conducted in a colorectal tumor clinic. Data were analyzed for the defined reference groups, and the results were compared with the quality goals. RESULTS: Median follow-up was 54.4 (range 1-116) months. We achieved 19 of the 36 defined quality goals. Among these were important parameters such as the rate of postoperative mortality (0.9%), the rate of intraoperative local tumor perforation (2.2% for anterior resection and 8.5% for abdominoperineal excision), the 5-year local recurrence rate (5.9% stages I-III), and the 5-year overall survival rates for stages yII and II (79.9%), and stages yIII and III (60.7%) for patients with microscopically negative resection margins. CONCLUSION: Most of the defined quality goals can be achieved in a specialized coloproctologic unit. The debate on quality goals has the potential to enable further improvement in the care of rectal cancer patients.


Assuntos
Metas , Indicadores de Qualidade em Assistência à Saúde , Neoplasias Retais/terapia , Humanos , Terapia Neoadjuvante , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Prognóstico , Neoplasias Retais/patologia , Análise de Sobrevida
19.
Dis Colon Rectum ; 52(7): 1264-71, 2009 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-19571703

RESUMO

PURPOSE: Relative survival estimates are widely used by cancer registries. They provide survival rates adjusted for causes of death other than cancer. They have rarely been used in clinical settings. When compared with cause-specific survival rates or competing risks analysis, their applicability is hardly known. This study compares these three outcome measures on the basis of a well-documented clinical database of patients with colorectal cancer. METHODS: We selected a consecutive series of 1,791 histopathologically completely resected colorectal cancer patients without neoadjuvant therapy from a prospective database from 1981 through 2006. Median follow-up was 4.7 (range, 0-23) years with only 3.1% patients lost. Cause-specific and relative survival are reported as failure rates as is the cumulative incidence in the presence of competing risks. RESULTS: The analysis comprised 1,081 patients with colon cancer and 710 patients with rectal cancer. Stage distribution was as follows: Stage I, 480 patients; Stage II, 785 patients; Stage III, 472 patients; and Stage IV, 54 patients. The "cause-specific" failure rate, the "relative" failure rate, and the cumulative incidence in the presence of competing risks at five years (95% CI) for all patients were 21.1 (range, 19.0-23.4) %, 22.5 (range, 19.6-25.2) %, and 19.0 (range, 17.0-20.9) %, respectively. CONCLUSION: Because we could demonstrate almost identical failure rates, we consider relative survival to be a powerful tool in clinical settings in which a comprehensive follow-up is not possible. It is especially useful as a reference parameter for clinical audit.


Assuntos
Carcinoma/mortalidade , Neoplasias Colorretais/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma/patologia , Carcinoma/terapia , Causas de Morte , Estudos de Coortes , Neoplasias Colorretais/patologia , Neoplasias Colorretais/terapia , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Taxa de Sobrevida , Falha de Tratamento
20.
J Gastrointest Surg ; 12(7): 1246-50, 2008 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-18340498

RESUMO

BACKGROUND: The time schedule for chemotherapy and primary tumor resection in patients with rectal carcinoma (RC) and unresectable synchronous metastases (USM) is not well defined. We evaluated whether response to chemotherapy is an appropriate criterion for deciding to perform surgery. METHODS: We treated 22 patients with RC and USM who received chemotherapy and were regularly evaluated. After documentation of a partial remission (PR) or stable disease (SD), patients were offered resection of the primary tumor. Results were compared with those of a historical control group of 42 patients who underwent immediate surgery. RESULTS: Seven patients had a PR, four showed SD, and 11 progressed under chemotherapy. Seven patients underwent resection of the primary tumor (no perioperative mortality). The median survival for all 22 patients was 20.2 months. Patients with primary tumor resection survived 27.2 months, whereas patients without resection survived only 12.4 months (p = 0.017). The median survival in the control group was 13.5 months (perioperative mortality, 9.5%). CONCLUSION: Chemotherapy and response-dependent resection of the primary tumor results in the same survival time as that attained with immediate surgery. Patients who face a poor prognosis due to progressive disease are thereby spared the risks of major rectal surgery.


Assuntos
Antineoplásicos/uso terapêutico , Carcinoma de Células Renais/cirurgia , Procedimentos Cirúrgicos Eletivos/métodos , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Cuidados Pré-Operatórios/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Renais/tratamento farmacológico , Carcinoma de Células Renais/secundário , Feminino , Seguimentos , Humanos , Neoplasias Renais/tratamento farmacológico , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica , Cuidados Paliativos/métodos , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do Tratamento
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