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Kazi M, Sukumar V, Desouza A, Saklani A. State-of-the-art surgery for recurrent and locally advanced rectal cancers. Langenbecks Arch Surg 2021; 406:1763-1774. [PMID: 34341869 DOI: 10.1007/s00423-021-02285-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023]
Abstract
Extended and beyond total mesorectal excisions (TME) for advanced and recurrent rectal cancers are increasingly performed with acceptable oncological and functional outcomes. These are undoubtedly due to better understanding of tumor biology and improved patient selection rather than surgical valor and technical refinements alone. In the present review, we attempt to present the current surgical standards for advanced and recurrent cancers requiring surgery outside the TME planes based on involved pelvic compartments. The available procedures, their indications, and extent of resection and reconstruction are highlighted. Emphasis is on formation of dedicated exenteration teams, structured training, and referral systems that increase hospital and surgeon volume to improve patient outcomes and reduce morbidity. Areas of deficiencies in literature were recognized with regards to factors influencing recurrences, patient selection, and quality of life. Finally, the most appropriate preoperative therapy for these tumors is unclear in both the primary and recurrent settings.
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Affiliation(s)
- Mufaddal Kazi
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Vivek Sukumar
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Ashwin Desouza
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India
| | - Avanish Saklani
- Division of Colorectal Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, 400012, India.
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Liccardo F, Baird DLH, Pellino G, Rasheed S, Kontovounisios C, Tekkis PP. Predictors of short-term readmission after beyond total mesorectal excision for primary locally advanced and recurrent rectal cancer. Updates Surg 2019; 71:477-484. [PMID: 31250396 PMCID: PMC6686032 DOI: 10.1007/s13304-019-00669-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/22/2019] [Indexed: 11/24/2022]
Abstract
Unplanned readmissions heavily affect the cost of health care and are used as an indicator of performance. No clear data are available regarding beyond-total mesorectal excision (bTME) procedure. Aim of the study is to identify patient-related and surgery-related factors influencing the 30-day readmissions after bTME. Retrospective data were collected from 220 patients who underwent bTME procedures at single centre between 2006 and 2016. Patient-related and operative factors were assessed, including body mass index (BMI), age, gender, American Society of Anaesthesiologists’ (ASA) score, preoperative stage, neo-adjuvant therapy, primary tumour vs recurrence, the extent of surgery. The readmission rate was 8.18%. No statistically significant association was found with BMI, ASA score, length of stay and stay in the intensive care unit, primary vs recurrent tumour or blood transfusions. Not quite statistically significant was the association with pelvic side wall dissection (OR 3.32, p = 0.054). Statistically significant factors included preoperative stage > IIIb (OR: 4.77, p = 0.002), neo-adjuvant therapy (OR: 0.13, p = 0.0006), age over 65 years (OR: 5.96, p = 0.0005), any re-intervention during the first admission (OR: 7.4, p = 0.0001), and any post-operative complication (OR: 9.01, p = 0.004). The readmission rate after beyond-TME procedure is influenced by patient-related factors as well as post-operative morbidity.
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Affiliation(s)
- Filomena Liccardo
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - Daniel L H Baird
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK
| | - Gianluca Pellino
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Advanced Medical and Surgical Sciences, Universitá della Campania "Luigi Vanvitelli, Naples, Italy
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK. .,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK. .,Department of Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK.
| | - Paris P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, 369 Fulham Rd, London, SW10 9NH, UK.,Department of Colorectal Surgery, Chelsea and Westminster NHS Foundation Trust, London, UK
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Baird DLH, Simillis C, Pellino G, Kontovounisios C, Rasheed S, Tekkis PP. The obesity paradox in beyond total mesorectal excision surgery for locally advanced and recurrent rectal cancer. Updates Surg 2019; 71:313-321. [PMID: 30790208 PMCID: PMC6647851 DOI: 10.1007/s13304-019-00631-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/11/2019] [Indexed: 12/18/2022]
Abstract
The objective is to investigate preoperative body mass index (BMI) in patients receiving beyond total mesorectal excision (bTME) surgery. The primary end point is length of postoperative stay. Secondary end points are length of intensive care stay, postoperative morbidity and overall survival. BMI is the most commonly used anthropometric measurement of nutrition and studies have shown that overweight and obese patients can have improved surgical outcomes. Patients who underwent a bTME operation for locally advanced or recurrent rectal cancer were put into three BMI (kg/m2) groups of normal weight (18.5-24.9), overweight (25-29.9) and obese (≥ 30) for analysis. Included are 220 consecutive patients from a single centre. The overall length of stay, in days ± standard deviation (range), for normal weight, overweight and obese patients was 21.14 ± 16.4 (6-99), 15.24 ± 4.3 (7-32) and 19.10 ± 9.8 (8-62) respectively (p = 0.002). The mean ICU length of stay was 5.40 ± 9.1 (1-69), 3.37 ± 2.4 (0-19) and 3.60 ± 2.4 (1-14), respectively (p = 0.030). There was no significant difference between the three groups in terms of postoperative morbidity or overall survival. Patients with a normal weight BMI in this cohort have a significantly longer length of stay in ICU and in hospital than overweight or obese patients. This is seen with no significant difference in morbidity or overall survival.
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Affiliation(s)
- Daniel L H Baird
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster and the Royal Marsden Campus, London, UK
| | | | - Gianluca Pellino
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster and the Royal Marsden Campus, London, UK.
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK.
| | - Shahnawaz Rasheed
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster and the Royal Marsden Campus, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
| | - Paris P Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster and the Royal Marsden Campus, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
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Kontovounisios C, Tan E, Pawa N, Brown G, Tait D, Cunningham D, Rasheed S, Tekkis P. The selection process can improve the outcome in locally advanced and recurrent colorectal cancer: activity and results of a dedicated multidisciplinary colorectal cancer centre. Colorectal Dis 2017; 19:331-338. [PMID: 27629565 DOI: 10.1111/codi.13517] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 06/23/2016] [Indexed: 12/31/2022]
Abstract
AIM There is wide disparity in the care of patients with multivisceral involvement of rectal cancer. The results are presented of treatment of advanced and recurrent colorectal cancer from a centre where a dedicated multidisciplinary team (MDT) is central to the management. METHOD All consecutive MDT referrals between 2010 and 2014 were examined. Analysis was undertaken of the referral pathway, site, selection process, management decision, R0 resection rate, mortality/morbidity/Clavien-Dindo (CD) classification of morbidity, length of stay (LOS) and improvement of quality of life. RESULTS There were 954 referrals. These included locally advanced primary rectal cancer (LAPRC b-TME) (39.0%), rectal recurrence (RR) (22.0%), locally advanced primary colon cancer (LAPCC T3c/d-T4) (21.1%), colon cancer recurrence (CR) (12.4%), locally advanced primary anal cancer (LAPAC-failure of CRT/T3c/d-T4) (3.0%) and anal cancer recurrence (AR) (2.2%). Among these patients 271 operations were performed, 212 primary and 59 for recurrence. These included 16 sacrectomies, 134 total pelvic exenterations and 121 other multi-visceral exenterative procedures. An R0 resection (no microscopic margin involvement) was achieved in 94.4% and R1 (microscopic margin involvement) in 5.1%. In LAPRC b-TME the R0 rate was 96.1% and for RR it was 79%. The LOS varied from 13.3 to 19.9 days. RR operations had the highest morbidity (CD 1-2, 33.3%) and LAPRC operations had the highest rate of CD 3-4 complications (18.4%). Most (39.6%) of the referred patients were from other UK hospitals. CONCLUSION Advanced colorectal cancer can be successfully treated in a dedicated referral centre, achieving R0 resection in over 90% with low morbidity and mortality. Implementation of a standardized referral pathway is encouraged.
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Affiliation(s)
- C Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - E Tan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - N Pawa
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK
| | - G Brown
- Department of Radiology, The Royal Marsden Hospital, London, UK
| | - D Tait
- Department of Clinical Oncology, The Royal Marsden Hospital, London, UK
| | - D Cunningham
- Gastrointestinal and Lymphoma Unit, The Royal Marsden Hospital, London, UK
| | - S Rasheed
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - P Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
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Abstract
The optimal management of rectal cancer is achieved through a shared multidisciplinary decision making process with accurate staging by imaging being critical for treatment planning. Good quality, high-resolution MRI has become the imaging gold standard as it allows consistent staging and stratification of patients into distinct prognostic groups according to MR-findings. Imaging features other than T and N have been proven to influence patient outcomes, and increasingly these features are taken into consideration when determining treatment options: distance of tumour to the potential circumferential margin (CRM), presence of tumour within the extramural rectal vessels (EMVI), discontinuous tumour deposits (N1c), relationship to the intersphincteric plane in low rectal tumours and to pelvic compartments in advanced disease. The presence or absence of proven adverse MR features should be included in the MRI report and shared with the patient when treatment choices are offered. MRI enables the identification of high risk tumours where the use of neoadjuvant therapy is justified and is a robust method of identifying patients with a strong likelihood of complete response after preoperative treatment.
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