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1.
Zhonghua Wei Chang Wai Ke Za Zhi ; 23(1): 92-95, 2020 Jan 25.
Artigo em Chinês | MEDLINE | ID: mdl-31958939

RESUMO

Extralevator abdominoperineal excision (ELAPE) has been suggested to potentially improve oncological outcomes in advanced low rectal cancer patients. However, the urogenital function impairment as one of the main complications deteriorates the quality of life in these patients. The key point to prevent urogenital function impairment is to avoid autonomic nerve injury, including the superior and inferior hypogastric nerve plexus and neurovascular bundle. Three areas should be especially focused during surgery, including the posterolateral aspect of the prostate during the separation of the rectum from prostate, the lateral wall of ischioanal fossa and the area in front of anal canal. Previous presumption supposed that extended resection, though promoting oncologic outcomes, might lead to enlarged injury to surrounding vessels and nerves that deteriorated patients' urogenital function. But recent studies show that postoperative urogenital function outcomes of rectal cancer patients who underwent ELAPE are not inferior to conventional APE after the induction of minimal invasive approaches including laparoscopic and robotic surgery. Their quality of life can be comparable with patients who underwent conventional APE, and are even better in some particular area. Moreover, as further improvement of ELAPE procedure has been made, the concept of individualized ELAPE addressed the importance of personalized surgical procedure based on tumor stage and location, dedicating to avoid injury to vessels and nerves through preserving more surrounding tissues. Urogenital function outcomes, as part of postoperative outcomes, get more and more attention in recent years. We review current studies on urogenital function after ELAPE from anatomy to clinical research, in order to raise surgeons' attention of nerve preservation technique and to improve their understanding of ELAPE procedure.


Assuntos
Sistema Nervoso Autônomo/lesões , Traumatismos dos Nervos Periféricos/prevenção & controle , Protectomia/efeitos adversos , Protectomia/métodos , Neoplasias Retais/cirurgia , Sistema Urogenital/inervação , Sistema Nervoso Autônomo/cirurgia , Humanos , Diafragma da Pelve/lesões , Diafragma da Pelve/cirurgia , Períneo , Traumatismos dos Nervos Periféricos/etiologia , Protectomia/normas , Qualidade de Vida , Resultado do Tratamento , Sistema Urogenital/lesões , Sistema Urogenital/cirurgia
2.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(12): 1118-1123, 2019 Dec 25.
Artigo em Chinês | MEDLINE | ID: mdl-31874526

RESUMO

As the rapid development of minimally invasive techniques, anesthesia, and enhanced recovery after surgery (ERAS), anorectal day surgery receiving more and more attention by improving efficiency of medical care while reducing cost and hospitalized infection. However, day surgery also faces the challenge of completing the whole process from patient admission to discharge within 24 hours. Therefore, establishing a reasonable and detailed day surgery process is the cornerstone to guarantee safe medical practice and patients satisfaction. National Clinical Research Center for Geriatric Disorders (Xiangya), together with China Ambulatory Surgery Alliance formulates the clinical practice guideline for anorectal day surgery 2019 edition. Here we make some interpretations of the guidelines on the detailed process of anorectal day surgery, including indication, preoperative examination, preoperative risk evaluation, health education, assessment of day surgery anesthesia and before leaving postanesthesia care unit (PACU), postoperative management, assessment of discharge and follow-up, for the convenience of various medical centers.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/normas , Assistência ao Paciente/normas , Guias de Prática Clínica como Assunto/normas , Protectomia/normas , Idoso , Canal Anal/cirurgia , Humanos , Reto/cirurgia
3.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 920-925, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630487

RESUMO

The theory of membrane surgery actually holds the same concepts as that of traditional cancer surgery, which believes that tumor spread is regarded as an isotropic process but the tumor is confined by the block of the membrane. Therefore, the radical resection can be achieved by complete mesentery excision along the membrane plane. The surgical practice derived from these conceptions is extended excision and lays emphasis on tumor-free margins. But the theory is controversial in the view of the existence of mesorectal fascial envelope and the feasibility of complete excision of mesorectum along the "holy plane". Based on ontogenetic anatomy, the compartment theory suggeststhat tumor spread is not isotropic, and it is locally confined within the ontogenetic compartment derived from a common primordium for a relatively long phase during their natural course. Local tumor is suppressed by the boundary instead of fascia. The anatomical territory developing from each anlage primordium may be separated morphologically. Consequently, ontogenetic compartment theory states that optimal local control of cancer is achieved by whole compartment resection, irrespective of margin width. The compartment model of tumor spread provides explanations for total mesorectal excision (TME) which excises the complete rectum compartment including the rectum and its surrounding vascular and ligamentous mesenteries. The compartment theory may set up the new principles for surgical tumor treatment, namely the resection of the tumor bearing compartment rather than target organ.


Assuntos
Mesentério/patologia , Mesentério/cirurgia , Protectomia/métodos , Neoplasias Retais/patologia , Neoplasias Retais/cirurgia , Colectomia/métodos , Colectomia/normas , Fáscia/patologia , Humanos , Margens de Excisão , Mesocolo/patologia , Mesocolo/cirurgia , Invasividade Neoplásica , Metástase Neoplásica , Protectomia/normas , Reto/anatomia & histologia , Reto/patologia
4.
World J Gastroenterol ; 25(23): 2887-2897, 2019 Jun 21.
Artigo em Inglês | MEDLINE | ID: mdl-31249447

RESUMO

Through the implementation of national bowel cancer screening programmes we have seen a three-fold increase in early pT1 colorectal cancers, but how these lesions should be managed is currently unclear. Local excision can be an attractive option, especially for fragile patients with multiple comorbidities, but it is only safe from an oncological point of view in the absence of lymph node metastasis. Patient risk stratification through careful analysis of histopathological features in local excision or polypectomy specimens should be performed according to national guidelines to avoid under- or over-treatment. Currently national guidelines vary in their recommendations as to which factors should be routinely reported and there is no established multivariate risk stratification model to determine which patients should be offered major resectional surgery. Conventional histopathological parameters such as tumour grading or lymphovascular invasion have been shown to be predictive of lymph node metastasis in a number of studies but the inter- and intra-observer variation in reporting is high. Newer parameters including tumour budding and poorly differentiated clusters have been shown to have great potential, but again some improvement in the inter-observer variation is required. With the implementation of digital pathology into clinical practice, quantitative parameters like depth/area of submucosal invasion and proportion of stroma can be routinely assessed. In this review we present the various histopathological risk factors for predicting systemic spread in pT1 colorectal cancer and introduce potential novel quantitative variables and multivariable risk models that could be used to better define the optimal treatment of this increasingly common disease.


Assuntos
Adenocarcinoma/patologia , Neoplasias Colorretais/patologia , Mucosa Intestinal/patologia , Metástase Linfática/diagnóstico , Guias de Prática Clínica como Assunto , Adenocarcinoma/diagnóstico , Adenocarcinoma/cirurgia , Colectomia/normas , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/cirurgia , Detecção Precoce de Câncer/métodos , Detecção Precoce de Câncer/normas , Humanos , Mucosa Intestinal/cirurgia , Linfonodos/patologia , Programas de Rastreamento/métodos , Programas de Rastreamento/normas , Gradação de Tumores , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Variações Dependentes do Observador , Protectomia/normas , Prognóstico , Medição de Risco/métodos , Fatores de Risco
5.
J Surg Res ; 230: 28-33, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30100036

RESUMO

BACKGROUND: Controversy exists regarding current National Comprehensive Cancer Network guidelines, which recommend local excision for rectal carcinoids ≤2 cm and radical resection for tumors >2 cm. Given the limited data examining optimal surgical approach for these lesions, we queried a national database to determine the impact of extent of resection on survival. METHODS: Patients undergoing treatment for clinical stage I and II rectal carcinoid (RC) were identified from the National Cancer Data Base (1998-2012). The association between extent of surgery, tumor size, and the likelihood of pathologic lymph node positivity was examined. Kaplan-Meier analysis was used to compare overall survival. RESULTS: In total, 1900 patients were identified, of whom 1644 (86.5%) were treated with local excision, and 256 (13.5%) were treated with radical resection. A significant majority of patients with tumors ≤2.0 cm (89.0%) and nearly half with tumors 2.1-4.0 cm (44.8%) or >4.0 cm (45.8%) underwent local excision. Nodal positivity was correlated with tumor size (7.1% positivity with ≤2.0 cm tumors, 31.3% with 2.1-4.0 cm tumors, and 50.0% with >4 cm tumors). However, 5-y survival was equivalent between surgical approaches for tumors ≤2 cm (93.0% versus 93.0%) and tumors 2.1-4.0 cm (76.0% versus 76.0%). CONCLUSIONS: We demonstrate in early-stage RC that nearly half of intermediate and large tumors are being treated with local excision outside National Comprehensive Cancer Network guidelines. In addition, radical resection does not appear to be associated with improved overall survival for tumors of any size. These findings suggest that the preferred approach to early-stage RCs without aggressive biological characteristics is local excision due to the decreased morbidity and mortality versus radical resection.


Assuntos
Tumor Carcinoide/cirurgia , Neoplasias Intestinais/cirurgia , Protectomia/métodos , Neoplasias Retais/cirurgia , Tumor Carcinoide/mortalidade , Tumor Carcinoide/patologia , Feminino , Humanos , Neoplasias Intestinais/mortalidade , Neoplasias Intestinais/patologia , Estimativa de Kaplan-Meier , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Guias de Prática Clínica como Assunto , Protectomia/normas , Neoplasias Retais/mortalidade , Neoplasias Retais/patologia , Estudos Retrospectivos , Taxa de Sobrevida , Carga Tumoral
7.
J Natl Compr Canc Netw ; 16(7): 874-901, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-30006429

RESUMO

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Rectal Cancer address diagnosis, staging, surgical management, perioperative treatment, management of recurrent and metastatic disease, disease surveillance, and survivorship in patients with rectal cancer. This portion of the guidelines focuses on the management of localized disease, which involves careful patient selection for curative-intent treatment options that sequence multimodality therapy usually comprised of chemotherapy, radiation, and surgical resection.


Assuntos
Oncologia/normas , Recidiva Local de Neoplasia/terapia , Neoplasias Retais/terapia , Sociedades Médicas/normas , Protocolos de Quimioterapia Combinada Antineoplásica/normas , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Biópsia , Quimiorradioterapia/métodos , Quimiorradioterapia/normas , Intervalo Livre de Doença , Humanos , Incidência , Quimioterapia de Indução/métodos , Terapia Neoadjuvante/métodos , Terapia Neoadjuvante/normas , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Seleção de Pacientes , Protectomia/métodos , Protectomia/normas , Ensaios Clínicos Controlados Aleatórios como Assunto , Neoplasias Retais/diagnóstico , Neoplasias Retais/epidemiologia , Neoplasias Retais/patologia , Reto/patologia , Reto/cirurgia , Estados Unidos/epidemiologia , Conduta Expectante/métodos , Conduta Expectante/normas
8.
J Natl Compr Canc Netw ; 16(7): 909-915, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-30006431

RESUMO

Locally advanced rectal cancer (LARC) carries higher risks of local and distant recurrence when treated with surgical resection alone. Multiple treatment strategies have been investigated to reduce recurrence risk and improve survival. Currently, there are 3 primary strategies for managing LARC: (1) preoperative long-course radiotherapy (RT) combined with radiosensitizing chemotherapy, which is better tolerated than postoperative chemoradiotherapy and provides tumor downstaging and improved pathologic complete response (pCR), followed by postoperative chemotherapy; (2) preoperative short-course RT alone as an alternative strategy for reducing the risk of local recurrence, followed by adjuvant postoperative chemotherapy; and (3) total neoadjuvant therapy with induction chemotherapy followed by chemoradiotherapy to improve pCR and reduce the difficulty of delivering chemotherapy in the postoperative setting. In addition to these currently recommended treatment paradigms, promising new strategies are available for treatment reduction. Neoadjuvant chemotherapy alone may allow for omission of RT in select patients with favorable LARC. For patients who have complete clinical responses to neoadjuvant chemotherapy and RT, nonoperative management is being considered for sphincter preservation, with surgery used as salvage. These are active areas of investigation in both institutional and cooperative group trials. The results are anticipated to provide better tailoring of neoadjuvant therapy based on patient tumor and disease response characteristics.


Assuntos
Recidiva Local de Neoplasia/prevenção & controle , Guias de Prática Clínica como Assunto , Neoplasias Retais/terapia , Reto/patologia , Canal Anal/cirurgia , Protocolos de Quimioterapia Combinada Antineoplásica/normas , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimiorradioterapia Adjuvante/métodos , Quimiorradioterapia Adjuvante/normas , Quimioterapia Adjuvante/métodos , Quimioterapia Adjuvante/normas , Intervalo Livre de Doença , Humanos , Incidência , Quimioterapia de Indução/métodos , Quimioterapia de Indução/normas , Oncologia/normas , Terapia Neoadjuvante/métodos , Terapia Neoadjuvante/normas , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Tratamentos com Preservação do Órgão/métodos , Tratamentos com Preservação do Órgão/normas , Protectomia/efeitos adversos , Protectomia/métodos , Protectomia/normas , Radiossensibilizantes/administração & dosagem , Neoplasias Retais/epidemiologia , Neoplasias Retais/patologia , Reto/cirurgia , Terapia de Salvação , Sociedades Médicas/normas , Estados Unidos/epidemiologia
9.
J Natl Compr Canc Netw ; 16(5S): 611-615, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29784738

RESUMO

Results from the pivotal IDEA trial, which evaluated 3 versus 6 months of adjuvant oxaliplatin-based chemotherapy, are incorporated into the NCCN Guidelines for Colon Cancer. The guidelines recommend that for patients with low-risk stage III disease, the preferred regimen is CAPEOX for 3 months or FOLFOX for 3 to 6 months. For patients with high-risk stage III disease, the preferred regimen is CAPEOX for 3 to 6 months or FOLFOX for 6 months. In metastatic disease, tumor sidedness should be a consideration when choosing a biologic. For BRAF-mutated disease, several triplets are now recommended options. Importantly, for a subset of patients with metastatic disease, new to the NCCN Guidelines is the incorporation of nivolumab and pembrolizumab as subsequent therapy for those with microsatellite instability-high or mismatch repair-deficient tumors.


Assuntos
Antineoplásicos Imunológicos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Biomarcadores Tumorais/genética , Neoplasias Colorretais/terapia , Guias de Prática Clínica como Assunto , Antineoplásicos Imunológicos/normas , Protocolos de Quimioterapia Combinada Antineoplásica/normas , Quimioterapia Adjuvante/métodos , Quimioterapia Adjuvante/normas , Colectomia/normas , Neoplasias Colorretais/genética , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/patologia , Reparo de Erro de Pareamento de DNA/genética , Intervalo Livre de Doença , Fluoruracila/normas , Fluoruracila/uso terapêutico , Humanos , Leucovorina/normas , Leucovorina/uso terapêutico , Oncologia/normas , Instabilidade de Microssatélites , Mutação , Estadiamento de Neoplasias , Compostos Organoplatínicos/normas , Compostos Organoplatínicos/uso terapêutico , Oxaliplatina/uso terapêutico , Protectomia/normas , Proteínas Proto-Oncogênicas B-raf/genética , Ensaios Clínicos Controlados Aleatórios como Assunto , Sociedades Médicas/normas , Estados Unidos/epidemiologia
10.
J Natl Compr Canc Netw ; 16(5S): 617-619, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29784739

RESUMO

The NCCN Guidelines for Rectal Cancer are now more closely aligned with those for colon cancer. A new MRI-based definition of the rectum has been included and the use of MRI in staging has been elevated in importance. There is a new emphasis on neoadjuvant therapy, especially the concurrent use of chemotherapy and radiotherapy. One of the biggest changes is more acceptance of an observational approach-"watch and wait, nonoperative management"-for select patients experiencing a complete clinical response with no evidence of residual disease after neoadjuvant therapy.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Guias de Prática Clínica como Assunto , Protectomia/normas , Neoplasias Retais/terapia , Conduta Expectante/normas , Protocolos de Quimioterapia Combinada Antineoplásica/normas , Quimiorradioterapia/métodos , Quimiorradioterapia/normas , Intervalo Livre de Doença , Fluoruracila/normas , Fluoruracila/uso terapêutico , Humanos , Leucovorina/normas , Leucovorina/uso terapêutico , Oncologia/normas , Terapia Neoadjuvante/métodos , Terapia Neoadjuvante/normas , Estadiamento de Neoplasias , Compostos Organoplatínicos/normas , Compostos Organoplatínicos/uso terapêutico , Protectomia/métodos , Neoplasias Retais/diagnóstico por imagem , Neoplasias Retais/mortalidade , Neoplasias Retais/patologia , Reto/diagnóstico por imagem , Reto/patologia , Reto/cirurgia , Sociedades Médicas/normas , Estados Unidos/epidemiologia
11.
Am J Surg ; 215(3): 430-433, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28954711

RESUMO

BACKGROUND: Regional differences in utilization of services in healthcare are commonly understood, but risk-adjusted evaluation of outcomes has not been done. METHODS: Risk-adjusted adverse outcomes (AOs) for elective Medicare colorectal resections were studied for 2012-2014. Risk-adjusted metrics were inpatient deaths, prolonged postoperative length-of-stay, 90-day post-discharge deaths, and 90-day relevant post-discharge readmissions. The nine Census Bureau regions of the U.S. were evaluated by using standard deviations of predicted adverse outcomes to evaluate observed versus expected events. RESULTS: Overall AO rate was 24.3% from 86,624 patients in 1497 hospitals. Region 9 (Pacific) had the best outcomes (z-score = -3.06; risk-adjusted AO rate = 22.9%) and Region 1 (New England) the poorest (z-score = +1.86; risk-adjusted AO rate = 25.4%). CONCLUSIONS: A 4.9 SD difference exists among the best and poorest performing regions in risk-adjusted colorectal surgery outcomes. Alternative Payment Models should consider regional benchmarks as a variable for the evaluation of quality and pricing of episodes of care.


Assuntos
Colectomia , Procedimentos Cirúrgicos Eletivos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Medicare , Protectomia , Risco Ajustado , Idoso , Idoso de 80 Anos ou mais , Colectomia/normas , Feminino , Humanos , Modelos Logísticos , Masculino , Protectomia/normas , Estados Unidos
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