A systematic review and meta-analysis comparing surgical and oncological outcomes of upper rectal, rectosigmoid and sigmoid tumours

The Landmark Series: Neoadjuvant Therapy for Locally Advanced Rectal Cancer

The management of locally advanced rectal cancer (LARC) has seen much development over recent decades. Neoadjuvant radiotherapy combined with high-quality total mesorectal excision saw improvements in locoregional control. With the advent of several key trials, neoadjuvant therapy for LARC has seen a shift toward total neoadjuvant therapy, with corresponding improvements in tumor response and survival outcomes. The collective pool of evidence has allowed for increasingly personalized treatment of LARC, with organ-preservation now an option for many. The aims of the review are to summarize the evolution of neoadjuvant therapy for LARC, highlight key studies informing contemporary best practices, navigate the complexity of options available, and present areas of ongoing development.

Long-Term Outcomes of Sigmoid, Rectosigmoid, and Rectal Cancers: A Matched Analysis

BACKGROUND

To determine a population-based comparative matched overall survival analysis for patients undergoing curative resection for sigmoid, rectosigmoid, and rectal cancers stage by stage.

METHODS

Patients who underwent curative surgery for nonmetastatic adenocarcinoma of the sigmoid, rectosigmoid, and rectum between 2000 and 2020 were identified using the US SEER cancer registry data. Each anatomical subsegment was matched in a 1:1 ratio based on age, sex, time of surgery, grade of differentiation, and histopathological stage. Multivariate (MV) Cox regression analysis was conducted.

RESULTS

A total of 19,607 patients fulfilled the criteria per group. Whereas chemotherapy rates were comparable among groups, radiotherapy rates were significantly higher in the rectum. Compared to the initial time period (2000-2005), there was a significant improvement in 3- and 5-year overall survival rates for each stage in the time period of 2016-2020. During the study period, a 10% improvement was observed for Stage-2 and Stage-3 patients for each site (p < 0.05). MV analysis showed that sex (p < 0.001), primary cancer site (p < 0.001), year category (p < 0.001), age (p < 0.001), stage (p < 0.001), degree of differentiation (p < 0.001), and CTx status (p < 0.001) were independently associated with overall survival.

CONCLUSION

This large population-based, comprehensive registry study demonstrates significant survival differences among sigmoid, rectosigmoid, and rectal cancers. Further studies defining distinct landmarks between rectal and colon cancers may improve treatment approaches, cancer care, and survival.

Small-bites versus large-bites closure of midline laparotomies: A systematic review and meta-analysis

AIM

Surgical site infection (SSI) and incisional hernia (IH) are common complications following midline laparotomy. The small-bites technique for closing a midline laparotomy has been suggested to improve SSI and IH rates compared with the classic mass closure. The aim of this work was to perform a systematic review, meta-analysis and fragility assessment of existing evidence comparing small-bites and conventional closure.

METHOD

The study was registered with PROSPERO. A systematic search of PubMed and EMBASE databases was performed for all comparative studies examining small-bites versus conventional closure for midline laparotomy. The fragility index for randomized controlled trials (RCTs) was assessed and the number of outcomes required to render results insignificant using the Fisher exact test was calculated.

RESULTS

Seven studies were included, with a total of 3807 patients. Small bites was performed in 1768 and large bites in 2039. Follow-up ranged from 12 to 52 months. On meta-analysis of all studies, small bites is associated with a lower risk of IH (p < 0.00001), SSI (p = 0.0002) and wound dehiscence (p = 0.02). On meta-analysis of RCTs there is a lower risk of IH (p = 0.01) but no difference in SSI (p = 0.06) or wound dehiscence (p = 0.73). Fragility is evident among RCTs reporting differences in IH rates.

CONCLUSION

There is evidence to suggest that small-bites closure provides a decreased likelihood of IH over varying follow-up in RCTs but significant fragility exists among studies.

Review of definition and treatment of upper rectal cancer

While the treatment of locally advanced lower and middle rectal cancer with total mesorectal excision (TME) after neoadjuvant therapy is now well defined, the treatment of locally advanced upper rectal cancer (LAURC) remains controversial. Although most teams and academic societies recommend upfront surgery (US) with partial mesorectal excision (PME), as this appears to be sufficient for these tumors, the literature remains conflicting regarding the additional use of neoadjuvant therapy and TME. Current recommendations for the treatment of LAURC do not reflect actual clinical practice. Notably, there is a paucity of published data specific to the treatment of LAURC since most of the data are from sub-analyses of different cohorts. Another important point responsible for the inconsistent data situation is the fact that the current definition of upper rectal cancer is based on anatomical criteria that are difficult to reproduce and therefore also differ between international professional societies. The aim of this review is to provide a deeper insight into the issues surrounding the treatment of LAURC based on an analysis of the current literature, including anatomic and embryologic data.

Frailty Increases Morbidity and Mortality in Patients Undergoing Oncological Liver Resections: A Systematic Review and Meta-analysis

BACKGROUND

Considered to reflect a patients' biological age, frailty is a new syndrome shown to predict surgical outcomes in elderly patients. In view of the increasing age at which patients are proposed oncological liver surgery and the morbidity associated with it, we attempted to perform a systematic review and meta-analysis to compare morbidity and mortality between frail and nonfrail patients after liver resections.

METHODS

The study was registered with PROSPERO. A systematic search of PubMed and EMBASE databases was performed for all comparative studies examining surgical outcomes after liver resections between frail and nonfrail patients.

RESULTS

Ten studies were included based on the selection criteria with a total of 71,102 patients, split into two groups: frail (n = 17,167) and the control group (n = 53,928). There were more elderly patients with a lower preoperative albumin level in the frail group (p = 0.02, p = 0.001). Frail patients showed higher rates of morbidity with more major complications and a higher incidence of postoperative liver failure (p < 0.001). Mortality (p < 0.001) and readmission rate (p = 0.021) also was higher in frail patients.

CONCLUSIONS

Frailty seems to be a solid predictive risk factor of morbidity and mortality after liver surgery and should be considered a selection criterion for liver surgery in at-risk patients.

Dental Appliances for the Treatment of Obstructive Sleep Apnea in Children: A Systematic Review and Meta-Analysis

Background and objectives: Obstructive sleep apnea (OSA) in children is a debilitating disease, difficult to treat. Dental appliances have been proposed as a valid therapy for improving functional outcomes with good compliance rates. Herein, we aimed to perform a meta-analysis comparing clinical outcomes between OSA children treated with dental appliances versus controls. Materials Methods: The study was registered with PROSPERO. A systematic search was performed for all comparative studies examining outcomes in pediatric patients who underwent treatment of OSA with oral appliances versus controls. Data was extracted and analyzed using a random effects model via Rev Man 5.3. Results: Six studies including 180 patients were analyzed split into two groups: patients treated with dental appliances (n = 123) and the controls (n = 119). Therapy with dental appliances was shown to significantly improve the apnea-hypopnea index (p = 0.009) and enlarge the superior posterior airway space (p = 0.02). Maxilla-to-mandible measurements were not significantly different between the two groups, nor was the mean SO2 (p = 0.80). Conclusions: This is the most updated meta-analysis assessing the role of dental appliances for OSA in children; it shows that such devices can improve functional outcomes by decreasing the apnea-hypopnea index.

Laparoscopic versus open resection of primary colorectal cancers and synchronous liver metastasis: a systematic review and meta-analysis

PURPOSE

Combined resection of primary colorectal cancer and associated liver metastases is increasingly common. This study compares peri-operative and oncological outcomes according to surgical approach.

METHODS

The study was registered with PROSPERO. A systematic search was performed for all comparative studies describing outcomes in patients that underwent laparoscopic versus open simultaneous resection of colorectal primary tumours and liver metastases. Data was extracted and analysed using a random effects model via Rev Man 5.3 RESULTS: Twenty studies were included with a total of 2168 patients. A laparoscopic approach was performed in 620 patients and an open approach in 872. There was no difference in the groups for BMI (mean difference: 0.04, 95% CI: 0.63-0.70, p = 0.91), number of difficult liver segments (mean difference: 0.64, 95% CI:0.33-1.23, p = 0.18) or major liver resections (mean difference: 0.96, 95% CI: 0.69-1.35, p = 0.83). There were fewer liver lesions per operation in the laparoscopic group (mean difference 0.46, 95% CI: 0.13-0.79, p = 0.007). Laparoscopic surgery was associated with shorter length of stay (p < 0.00001) and less overall postoperative complications (p = 0.0002). There were similar R0 resection rates (p = 0.15) but less disease recurrence in the laparoscopic group (mean difference: 0.57, 95% CI:0.44-0.75, p < 0.0001).

CONCLUSION

Synchronous laparoscopic resection of primary colorectal cancers and liver metastases is a feasible approach in selected patients and does not demonstrate inferior peri-operative or oncological outcomes.

Conservative surgery versus colorectal resection for endometriosis with rectal involvement: a systematic review and meta-analysis of surgical and long-term outcomes

PURPOSE

The optimal surgical approach for removal of colorectal endometrial deposits is unclear. Shaving and discoid excision of colorectal deposits allow organ preservation but risk recurrence with associated functional issues and re-operation. Formal resection risks potential higher complications but may be associated with lower recurrence rates. This meta-analysis compares peri-operative and long-term outcomes between conservative surgery (shaving and disc excision) versus formal colorectal resection.

METHODS

The study was registered with PROSPERO. A systematic search was performed on PubMed and EMBASE databases. All comparative studies examining surgical outcomes in patients that underwent conservative surgery versus colorectal resection for rectal endometrial deposits were included. The two main groups (conservative versus resection) were compared in three main blocks of variables including group comparability, operative outcomes and long-term outcomes.

RESULTS

Seventeen studies including 2861 patients were analysed with patients subdivided by procedure: colorectal resection (n = 1389), shaving (n = 703) and discoid excision (n = 742). When formal colorectal resection was compared to conservative surgery there was lower risk of recurrence (p = 0.002), comparable functional outcomes (minor LARS, p = 0.30, major LARS, p = 0.54), similar rates of postoperative leaks (p = 0.22), pelvic abscesses (p = 0.18) and rectovaginal fistula (p = 0.92). On subgroup analysis, shaving had the highest recurrence rate (p = 0.0007), however a lower rate of stoma formation (p < 0.00001) and rectal stenosis (p = 0.01). Discoid excision and formal resection were comparable.

CONCLUSION

Colorectal resection has a significantly lower recurrence rate compared to shaving. There is no difference in complications or functional outcomes between discoid excision and formal resection and both have similar recurrence rates.