Outcome following local excision of T1 anal cancers-a systematic review

PURPOSE

In most cases, squamous cell carcinoma of the anus (SCCA) is treated with chemo-radiotherapy preserving sphincter function and offering good long-term survival and low recurrence rates. However, chemo-radiotherapy has several side effects: dyspareunia, impotence, fecal incontinence, pain, and skin symptoms. Small/T1 tumors, without metastatic disease, can be treated with local excision alone. We aimed to systematically review the literature regarding outcome following local excision of T1 SCCA.

METHODS

PubMed and Embase databases were searched for studies that investigated outcome following local excision of SCCA.

RESULTS

Twenty-three studies were included. Twenty of the studies were retrospective, and three studies included more than 100 patients. Most of the studies were published before the 1980s. Overall there was great heterogeneity and missing data across the included studies when comparing patient demographics, resection margins, definitions on tumor location, and outcome. Overall 5-year survival was 69% (95% CI 66-72) following local excision. Overall 5-year recurrence was 37% (95% CI 30-45) following local excision. No complications were reported following local excision.

CONCLUSION

The current literature on outcome following local excision of T1 anal cancers consists predominantly of smaller, retrospective, and heterogenous studies. Overall 5-year survival is acceptable, but worse than following chemo-radiation therapy. However, local excision seems to have no or only few minor complications. Recurrence rates are high. Therefore, a thorough follow-up program is needed when performing local excision as primary treatment for T1 SCCA. There is an evident need for further studies.

Long-term outcomes in patients after ligation of the intersphincteric fistula tract

INTRODUCTION

Ligation of the intersphincteric fistula tract (LIFT) to treat transsphincteric fistulae has yielded varied but promising results. However, it has been shown that long-term follow-up (> 250 days) is vital to obtain the correct surgical outcome. Here, we present the long-term results of patients undergoing the LIFT procedure at Herlev Hospital, Denmark.

METHODS

The study was based on a retrospective chart review of 65 consecutive patients who underwent the LIFT procedure for transsphincteric fistula-in-ano in 2011-2015.

RESULTS

At the first follow-up, at a median 50 (interquartile range (IQR): 29-92) days, there were 28 recurrences of which 17 were transsphincteric. At the long-term follow-up, a median of 274 (IQR: 162-573) days, 16 patients (ten of whom were asymptomatic at the first follow-up) presented with a recurrence, of which seven were transsphincteric; 27 patients (42%) showed complete fistula healing following their initial LIFT surgery. Another 29 patients presented complete healing after repeated surgical treatment (additional LIFT, advancement flap and/or simple incision/fistulotomy), yielding a positive outcome in 86% of our patients.

CONCLUSION

The present study shows that the LIFT procedure is a viable treatment option for transsphincteric fistulae. Furthermore, a second LIFT procedure is a plausible option for recurrent transsphincteric fistulae. In the case of recurrence, the fistula was frequently downgraded to a more benign intersphincteric variant. The study supports previous findings showing that long-term follow-up is required to successfully measure the outcome of LIFT surgery.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Quality of life following salvage surgery for squamous cell carcinoma of the anus

INTRODUCTION

Squamous cell carcinoma of the anus is a rare condition. First line treatment is combined chemo-radio therapy. As many as a third of patients undergoing chemo-radiotherapy will experience recurrence. These patients often undergo salvage surgery with an extended abdominoperineal excision. The aim of this study was to examine the quality of life in disease free survivors following salvage surgery for squamous cell carcinoma of the anus.

MATERIAL AND METHODS

Patients undergoing salvage surgery for SCCA at Copenhagen University Hospital Herlev between 1st of January 2011 and 31st December 2016 were identified and quality of life was assessed with EORTC QLQ-C30 and EORTC QLQ-CR29 questionnaires.

RESULTS

47 patients underwent salvage surgery for relapse or residual tumor in the period. From this cohort 25 disease-free survivors were identified. Fourteen (56%) patients returned a completed questionnaire. Overall median global health status was 75(range 20-100). Functional scores were generally high. In General, symptom scores were low, however all men reported impotence with a median symptom score of 100(range 67-100) and half the women reported dyspareunia. Urinary impairment was present in half the patients. Abdominal and buttock pain scores were low.

CONCLUSION

Quality of life following salvage surgery for squamous cell carcinoma of the anus is affected but at an acceptable level. However, there are considerable side-affects in the form of impotence, dyspareunia and urinary impairment.

[Calcified bowel mesentery - heterotopic mesenteric ossification]

A 64-year-old man suffered blunt abdominal trauma. He developed ischaemic colon and had a colectomy with primary anastomosis, complicated with anastomotic leakage. A temporary stoma was created. Six months later when the stoma was to be reversed, the bowel mesentery was found to be extensively calcified. Heterotopic mesenteric ossification is an extremely rare condition. The pathogenesis is unknown but associated with mesenteric ischaemia, generalised peritonitis or abdominal trauma. Treatment should be as conservative as possible, avoiding surgery to prevent further ossification.

Unenhanced MR Imaging in adults with clinically suspected acute appendicitis

PURPOSE

The purpose of the study was to evaluate unenhanced Magnetic Resonance Imaging (MRI) for the diagnosis of appendicitis or another surgery-requiring condition in an adult population scheduled for emergency appendectomy based on a clinical diagnosis of suspected acute appendicitis.

MATERIALS AND METHODS

The prospective study included 48 consecutive patients (29 female, 19 male, 18-70 years old, mean age=37.1 years). MRI examination was designed to be comfortable and fast; no contrast was administered. The sequences were performed during quiet respiration. The MRI findings were reviewed by two radiologists and one surgeon independent of each other and compared with surgical and pathological records.

RESULTS

According to the surgical and histopathological findings 30 of 48 patients (63%) had acute appendicitis. Of the remaining 18 patients, 4 patients had no reasons for the clinical symptoms and 14 patients had other pathology. For the three reviewers the performance of MRI in the diagnosis of acute appendicitis showed the following sensitivity, specificity and accuracy ranges: 83-93%, 50-83% and 77-83%. Moderate (κ=0.51) and fair (κ=0.31) interobserver agreements in the MR diagnosis of acute appendicitis were found between the reviewers. Sensitivity, specificity and accuracy values for overall performance of MRI in detecting pelvic abnormalities were 100%, 75% (3 of 4 healthy patients were identified by MRI) and 98%, respectively.

CONCLUSION

Unenhanced fast MRI is feasible as an additional fast screening before the appendectomy. It may prevent unnecessary surgeries. The fast MRI examination can be adequately performed on an MRI unit of broad range of field strengths.

Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial

CONTEXT

Use of 80% oxygen during surgery has been suggested to reduce the risk of surgical wound infections, but this effect has not been consistently identified. The effect of 80% oxygen on pulmonary complications has not been well defined.

OBJECTIVE

To assess whether use of 80% oxygen reduces the frequency of surgical site infection without increasing the frequency of pulmonary complications in patients undergoing abdominal surgery.

DESIGN, SETTING, AND PATIENTS

The PROXI trial, a patient- and observer-blinded randomized clinical trial conducted in 14 Danish hospitals between October 2006 and October 2008 among 1400 patients undergoing acute or elective laparotomy.

INTERVENTIONS

Patients were randomly assigned to receive either 80% or 30% oxygen during and for 2 hours after surgery.

MAIN OUTCOME MEASURES

Surgical site infection within 14 days, defined according to the Centers for Disease Control and Prevention. Secondary outcomes included atelectasis, pneumonia, respiratory failure, and mortality.

RESULTS

Surgical site infection occurred in 131 of 685 patients (19.1%) assigned to receive 80% oxygen vs 141 of 701 (20.1%) assigned to receive 30% oxygen (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.72-1.22; P = .64). Atelectasis occurred in 54 of 685 patients (7.9%) assigned to receive 80% oxygen vs 50 of 701 (7.1%) assigned to receive 30% oxygen (OR, 1.11; 95% CI, 0.75-1.66; P = .60), pneumonia in 41 (6.0%) vs 44 (6.3%) (OR, 0.95; 95% CI, 0.61-1.48; P = .82), respiratory failure in 38 (5.5%) vs 31 (4.4%) (OR, 1.27; 95% CI, 0.78-2.07; P = .34), and mortality within 30 days in 30 (4.4%) vs 20 (2.9%) (OR, 1.56; 95% CI, 0.88-2.77; P = .13).

CONCLUSION

Administration of 80% oxygen compared with 30% oxygen did not result in a difference in risk of surgical site infection after abdominal surgery.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00364741.

Perioperative oxygen fraction - effect on surgical site infection and pulmonary complications after abdominal surgery: a randomized clinical trial. Rationale and design of the PROXI-Trial

BACKGROUND

A high perioperative inspiratory oxygen fraction may reduce the risk of surgical site infections, as bacterial eradication by neutrophils depends on wound oxygen tension. Two trials have shown that a high perioperative inspiratory oxygen fraction (FiO(2) = 0.80) significantly reduced risk of surgical site infections after elective colorectal surgery, but a third trial was stopped early because the frequency of surgical site infections was more than doubled in the group receiving FiO(2) = 0.80. It has not been settled if a high inspiratory oxygen fraction increases the risk of pulmonary complications, such as atelectasis, pneumonia and respiratory failure. The aim of our trial is to assess the potential benefits and harms of a high perioperative oxygen fraction in patients undergoing abdominal surgery.

METHODS AND DESIGN

The PROXI-Trial is a randomized, patient- and assessor blinded trial of perioperative supplemental oxygen in 1400 patients undergoing acute or elective laparotomy in 14 Danish hospitals. Patients are randomized to receive either 80% oxygen (FiO(2) = 0.80) or 30% oxygen (FiO(2) = 0.30) during surgery and for the first 2 postoperative hours. The primary outcome is surgical site infection within 14 days. The secondary outcomes are: atelectasis, pneumonia, respiratory failure, re-operation, mortality, duration of postoperative hospitalization, and admission to intensive care unit. The sample size allows detection of a 33% relative risk reduction in the primary outcome with 80% power.

DISCUSSION

This trial assesses benefits and harms of a high inspiratory oxygen fraction, and the trial may be generalizable to a general surgical population undergoing laparotomy.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00364741.

Splenic injury after colonoscopy

Splenic injury is a rare and serious complication of colonoscopy. The most likely mechanism is tension on the splenocolic ligament and adhesions. Eight cases were identified among claims for compensation submitted to the Danish Patient Insurance Association during the period 1992-2006, seven of which were reported after 2000. The total number of colonoscopies in Denmark in 2004 was 39 067. Seven of the eight patients were aged 65 years or over. Loops causing difficulties during the colonoscopy had been reported in four patients. All the patients had a symptom-free interval after the colonoscopy, ranging from 4 hours to 7 days, before presenting with signs of splenic injury. In all cases the spleen was torn, and the amount of blood in the peritoneal cavity ranged from 1500 mL to 5000 mL. Two patients died postoperatively. The number of cases reported after 2000 indicates that this potentially lethal complication might be more common than was previously assumed, and it is possibly under-reported. Preventive measures include good colonoscopic technique to avoid loop formation and the use of excessive force; and it is possible that emerging endoscopic technologies will lead to a reduced risk of splenic injury. The information given to patients both before and after the procedure should include information on the signs of this complication, and patients should be also informed that these signs can develop after a symptom-free interval.