A modified sentinel lymph node technique combined with endoluminal loco-regional resection for the treatment of rectal tumours: a 14-year experience

Engineering-Aided Inventive Surgery

This Editorial presents a new Special Issue dedicated to some old and new interdisciplinary areas of cooperation between engineering and surgery. The first two sections offer some food for thought, in terms of a brief introductory and general review of the past, present, future and visionary perspectives of the synergy between engineering and surgery. The last section presents a very short and reasoned review of the contributions that have been included in the present Special Issue. Given the vastness of the topic that this Special Issue deals with, we hope that our effort may have offered a stimulus, albeit small, to the development of cooperation between engineering and surgery.

Local excision following chemoradiotherapy in T2-T3 rectal cancer: current status and critical appraisal

Local excision following chemoradiotherapy in rectal cancer is an organ-preserving procedure which aims at reducing morbidity and functional disorders associated with total mesorectal excision (TME) in selected patients. Although TME after chemoradiotherapy remains the gold standard for locally advanced mid and low rectal cancer, in the last years multicenter research trials have offered encouraging oncologic results which have allowed to preserve the rectum in patients with a pathologic complete response after chemoradiotherapy. A review of the available literature on this topic was conducted to define the state of the art of this conservative approach and to focus on the most controversial aspects concerning local excision performed after chemoradiotherapy, in particular tumor scatter and lymph node status, completion and salvage surgery, morbidity and quality of life. The analysis of these topics should be considered, in trial setting or in current practice, for their clinical implications. Oncologic outcomes of recent trials are encouraging for part of the patients presenting T2 rectal cancer; however, TME still remains the standard treatment in clinical practice. In such cases, local excision should include a surgical safety margin of at least 1 cm from the resection margin to achieve a true negative margin from residual tumor cells. The selection of the patients should be carefully performed and their consensus extremely detailed because TME is necessary in about 30% of cases. Failing that, morbidity and quality of life are negatively affected. However, about half of these patients refuse radical surgery (45%), thus undergoing only palliative care.

Organ-saving surgery for rectal cancer after neoadjuvant chemoradiation: Analysis of failures and long-term results

BACKGROUND

To analyze long-term results and risk of relapse in the clinical TNM stages II and III, mid-low rectal cancer patients (RC pts), treated with transanal local excision (LE) after major response to neoadjuvant chemoradiation (n-CRT).

METHODS

Thirty-two out of 345 extraperitoneal cT3-4 or N+ RC pts (9.3%) underwent LE.

INCLUSION CRITERIA

extraperitoneal RC, adenocarcinoma, ECOG Performance Status ≤2. Pts with distant metastases were excluded.

RESULTS

All pts showed histologically clear margins of resection and 81.2% were restaged ypT0/mic/1. Nine out of 32 (28.1%) pts relapsed: 7 (21.8%) showed a local recurrence, of which 5 (15.6%) at the endorectal suture, 1 (3.1%) pelvic and 1 (3.1%) mesorectal. Two pts (6.2%) relapsed distantly. Among the pT0/1, 11.5% relapsed vs 100% of the pT2 and pT4 ones. The six pts relapsing locally or in the mesorectal fat underwent a salvage total mesorectal excision surgery. The old patient with pelvic recurrence relapsed after 108 months and underwent a re-irradiation; the two pts with distant metastases were treated with chemotherapy followed by radical surgery.

CONCLUSIONS

Presently combined approach seems a valid option in major responders, confirming its potential curative impact in the ypT0/mic/1 pts. A strict selection of pts is basic to obtain favourable results.

Is a drain necessary after anterior resection of the rectum? A systematic review and meta-analysis

OBJECTIVE

The anastomotic leak rate in colorectal surgery is highest in patients receiving anterior rectal resections. The placement of prophylactic pelvic drains remains a routine option for preventing postoperative leaks, despite increasing evidence suggesting no clinical benefit. The present study seeks to identify a consensus on the use of prophylactic drains in anterior rectal resections.

METHODS

A systematic search was conducted of MEDLINE, Scopus, EMBASE, and Cochrane Library databases to identify clinical trials comparing the use of drainage to non-drainage in cases of colorectal anastomosis.

RESULTS

Three randomized clinical trials (RCTs) and two controlled clinical trials (CCTs) were identified that met the inclusion criteria, with a total of 1702 patients with rectal cancer who underwent anterior resection: 1206 with a pelvic drain and 496 without a pelvic drain. Meta-analysis showed that the use of a drain did not significantly improve the outcomes of anastomotic leaks; the overall reoperation rate during the 30-day postoperative period and the postoperative mortality were statistically lower in the drained group (OR 2.82, 95% CI 1.33 to 5.97; I2 = 0%).

CONCLUSIONS

The use of prophylactic pelvic drainage after anterior rectal resections does not provide significant benefits with respect to anastomotic leaks and overall complication rates. However, an approximately threefold reduction of the postoperative mortality of the drained patients was observed. Given the limitations of the present study, these findings warrant the use of a drain after anterior rectal resection. Nevertheless, due to the low quality of the available data, further multicenter trials with uniform inclusion criteria are needed to evaluate drain usage in the anterior rectal resection.