Faculty Bibliography

OBJECTIVE:To assess the outcomes and patterns of treatment failure of patients who underwent pelvic exenteration surgery for recurrent rectal cancer. BACKGROUND:Despite advances in the management of rectal cancer, local recurrence still occurs. For appropriately selected patients, pelvic exenteration surgery can achieve long-term disease control. METHODS:Prospectively maintained databases of 5 high volume institutions for pelvic exenteration surgery were reviewed and data combined. We assessed the combined endpoints of overall 5-year survival, cancer-specific 5-year mortality, local recurrence, and the development of metastatic disease. RESULTS:Five hundred thirty-three patients who had undergone surgery for locally recurrent rectal cancer were identified. Five-year cancer-specific survival for patients with a complete (R0) resection is 44%, which was achieved in 59% of patients. For those with R1 and R2 resections, the 5-year survival was 26% and 10%, respectively. Radical resection required sacrectomy in 170 patients (32%), and total cystectomy in 105 patients (20%). Treatment failure included local recurrence alone in 75 patients (14%) and systemic metastases with or without local recurrence in 226 patients (42%). Chemoradiotherapy before exenteration was associated with a significant (P < 0.05) improvement in overall 5-year cancer-specific survival for those patients with an R0 resection. Postoperative chemotherapy did not alter outcomes. CONCLUSIONS:R0 resection of the pelvic recurrence is the most significant factor affecting overall and disease-free survival. The surgery is complex and often highly morbid, and where possible patients should be given perioperative chemoradiotherapy. Further investigations are required to determine the role of adjuvant chemotherapy.

AIM/OBJECTIVE:Several sphincter-preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula. METHOD/METHODS:A PubMed search from 1992 to 2015. An assessment of adoption, duration of study and success rate was undertaken. RESULTS:We found 133 studies (5604 patients): AFP (40 studies, 2333 patients), FGS (31 studies, 871 patients), LIFT (19 studies, 759 patients), ACP (43 studies, 1641 patients). Success rates ranged from 0% to 100%. Study duration was significantly associated with success rates in AFP (P = 0.01) and FGS (P = 0.02) but not in LIFT or ACP. The duration of use of individual procedures since first publication was associated with success rate only in AFP (P = 0.027). There were no statistically significant differences in success rates relative to the number of the patients included in each study. CONCLUSION/CONCLUSIONS:Success and adoption rates tend to decrease with time. Differences in patient selection, duration of follow-up, length of availability of the individual procedure and heterogeneity of treatment protocols contribute to the diverse results in the literature. Differences in success rates over time were evident, suggesting that both international trials and global best practice consensus are desirable. Further prospective randomized controlled trials with homogeneity and clear objective parameters would be needed to substantiate these findings.

BACKGROUND:Rectovaginal and enterovesical fistulae are difficult to treat in patients with Crohn's disease. Currently, there is no consensus regarding their appropriate management. AIM OF THE STUDY:The aim of the study was to review the literature on the medical management of rectovaginal and enterovesical fistulae in Crohn's disease and to assess their response to treatment. METHOD:A literature search of MEDLINE, EMBASE, Science Citation Index Expanded, and Cochrane was performed. RESULTS:Twenty-three studies were identified, reporting on 137 rectovaginal and 44 enterovesical fistulae. The overall response rates of rectovaginal fistulae to medical therapy were: 38.3% complete response (fistula closure), 22.3% partial response, and 39.4% no response. For enterovesical fistulae the response rates to medical therapy were: 65.9% complete response, 20.5% partial response, and 13.6% no response. Specifically, response to anti-tumor necrosis factor therapy of 78 rectovaginal fistulae was: 41.0% complete response, 21.8% partial response, and 37.2% no response. Response of 14 enterovesical fistulae to anti-tumor necrosis factor therapy was: 57.1% complete response, 35.7% partial response, and 7.1% no response. The response to a combination of medical and surgical therapy in 43 rectovaginal fistulae was: 44.2% complete response, 20.9% partial response, and 34.9% no response. CONCLUSIONS:Medical therapy, alone or in combination with surgery, appears to benefit some patients with rectovaginal or enterovesical fistula. However, given the small size and low quality of the published studies, it is still difficult to draw conclusions regarding treatment. Larger, better quality studies are required to assess response to medical treatment and evaluate indications for surgery.

Anastomotic leaks are a feared complication of colorectal resections and novel techniques that have the potential to decrease them are still sought. This study aimed to compare the anastomotic leak rates in patients undergoing compression anastomoses versus hand-sewn or stapled anastomoses. Randomized controlled trials (RCTs) comparing outcomes of compression versus conventional (hand-sewn and stapled) colorectal anastomosis were collected from MEDLINE, Embase and the Cochrane Library. The quality of the RCTs and the potential risk of bias were assessed. Pooled odds ratios (OR) were calculated for categorical outcomes and weighted mean differences for continuous data. Ten RCTs were included, comprising 1969 patients (752 sutured, 225 stapled, and 992 compression anastomoses). Most used the biofragmentable anastomotic ring. There was no significant difference between the two groups in terms of anastomotic leak rates (OR 0.80, 95 % confidence interval (CI) 0.47, 1.37; p = 0.42), stricture (OR 0.54: 95 % CI 0.18, 1.64; p = 0.28) or mortality (OR 0.70; 95 % CI 0.39, 1.26; p = 0.24). Compression anastomosis was associated with an earlier return of bowel function: 1.02 (95 % CI 1.37, 0.66) days earlier (p < 0.001) and a shorter postoperative stay; 1.13 (95 % CI 1.52, 0.74) days shorter (p < 0.001), but significant heterogeneity among studies was observed. There was an increased risk of postoperative bowel obstruction in the compression group (OR 1.87; 95 % CI 1.07, 3.26; p = 0.03). There was no significant difference in wound-related and general complications, or length of surgery. Compression devices do not appear to provide an advantage over conventional techniques in fashioning colorectal anastomoses and are associated with an increased risk of bowel obstruction.

AIM/OBJECTIVE:Several studies have suggested an increased lymph node yield, reduced locoregional recurrence and increased disease-free survival after complete mesocolic excision (CME) for colorectal cancer. This review was undertaken to assess the use of CME for colon cancer by evaluating the technique and its clinical outcome. METHOD/METHODS:A literature search of publications was performed using PubMed and Medline. Only studies published in English were included. Studies assessed for quality and data were extracted by two independent reviewers. End-points included number of lymph nodes per patient, quality of the plane of mesocolic excision, postoperative mortality and morbidity, 5-year locoregional recurrence and 5-year cancer-specific survival. RESULTS:There were 34 articles comprising 12 retrospective studies, nine prospective studies and 13 original articles including case series, observational studies and editorials. Of the prospective studies, four reported an increased lymph node harvest and a survival benefit. The others reported an improvement in the quality of the specimen as assessed by histopathological examination. Laparoscopic CME has the same oncological outcome as open surgery but completeness of excision during laparoscopy may be compromised for tumours in the transverse colon. CONCLUSION/CONCLUSIONS:Studies demonstrate that CME removes significantly more tissue around the tumour including maximal lymph node clearance. There is little information on serious adverse events after CME and a long-term survival benefit has not been proved.

AIM/OBJECTIVE:The efficacy of sacral nerve stimulation (SNS) in low anterior resection syndrome (LARS) is largely undocumented. A review of the literature was carried out to study this question. METHOD/METHODS:Pubmed, Medline and Cochrane databases were searched for relevant articles up to August 2014. Studies were included if they evaluated the use of SNS following rectal resection and assessed at least one of the following end-points: bowel function, quality of life and ano-neorectal physiology. No restrictions on language or study size were made. RESULTS:Seven papers were identified including one case report and six prospective case series. These included 43 patients with a median follow-up of 15 months. After peripheral nerve evaluation definitive implantation was carried out in 34 (79.1%) patients. Overall, 32 (94.1%) of the 34 patients experienced improvement of symptoms which, based on intention to treat, was 32/43 (74.4%). CONCLUSION/CONCLUSIONS:The review suggests that SNS for faecal incontinence in LARS has success rates comparable to its use for other forms of faecal incontinence.

AIM/OBJECTIVE:This study compared the operative outcome and long-term survival of three types of hand-sewn coloanal anastomosis (CAA) for low rectal cancer. METHOD/METHODS:Patients presenting with low rectal cancer at a single centre between 2006 and 2014 were classified into three types of hand-sewn CAA: type 1 (supra-anal tumours undergoing transabdominal division of the rectum with transanal mucosectomy); type 2 (juxta-anal tumours, undergoing partial intersphincteric resection); and type 3 (intra-anal tumours, undergoing near-total intersphincteric resection with transanal mesorectal excision). RESULTS:Seventy-one patients with low rectal cancer underwent CAA: 17 type 1; 39 type 2; and 15 type 3. The median age of patients was 61.6 years, with a male/female ratio of 2:1. Neoadjuvant therapy was given to 56 (79%) patients. R0 resection was achieved in 69 (97.2%) patients. Adverse events occurred in 25 (35.2%) of the 71 patients with a higher complication rate in type 1 vs type 2 vs type 3 (47.1% vs 38.5% vs 13.3%, respectively; P = 0.035). Anastomotic separation was identified in six (8.5%) patients and pelvic haematoma/seroma in five (7%); two (8.3%) female patients developed a recto-vaginal fistula. Ten (14.1%) patients were indefinitely diverted, with a trend towards higher long-term anastomotic failure in type 1 vs type 2 vs type 3 (17.6% vs 15.5% vs 6.7%). The type of anastomosis did not influence the overall or disease-free survival. CONCLUSION/CONCLUSIONS:CAA is a safe technique in which anorectal continuity can be preserved either as a primary restorative option in elective cases of low rectal cancer or as a salvage procedure following a failed stapled anastomosis with a less successful outcome in the latter. CAA has acceptable morbidity with good long-term survival in carefully selected patients.

This pilot study aimed to determine the feasibility of serum neurotensin/IL-8 values being used as a screening tool for colorectal cancer. Fifty-six patients and 15 healthy controls were assigned to seven groups according to their disease entity based on theater records and histology report. Blood samples for neurotensin and IL-8 were measured using an enzyme-linked immunosorbent assay. There were no differences in the clinical and biochemical parameters of patients and controls. Group (p=0.003) and age (p=0.059, marginally significant) were independent predictors of neurotensin plasma values. Neurotensin (p=0.004) and IL-8 (p=0.029) differed between healthy and colorectal cancer patients. Neurotensin values differentiate the control group from all remaining groups. The value of plasma neurotensin ≤ 54.47 pg/ml at enrollment selected by receiver operating characteristic (ROC) curves demonstrated a sensitivity of 77 %, specificity of 90 %, and an estimate of area under ROC curve (accuracy) of 85 % in predicting colorectal cancer. At enrollment, the value of plasma IL-8 ≥ 8.83 pg/ml had a sensitivity of 85 %, specificity 80 %, and an estimate of area under ROC curve (accuracy) of 81 % in predicting colorectal cancer. IL-8 should be used complementary to neurotensin due to its lower specificity. None of the colorectal cancer patients displayed a combination of high neurotensin and low IL-8 values (beyond cutoffs). It seems that a blood neurotensin/IL-8 system may be used as a screening tool for colorectal cancer, but much has to be done before it is validated in larger-scale prospective studies.

AIM/OBJECTIVE:A tension-free well vascularized colorectal or coloanal anastomosis is not always possible following rectal or sigmoid resection. The study reports on the short-term and long-term outcome of a modified right colon inversion technique as a means of facilitating a low colorectal or coloanal anastomosis. METHOD/METHODS:All patients who underwent right colonic inversion, a modified Deloyers' procedure, were identified retrospectively from the prospective database of the Colorectal Department of the Royal Marsden Hospital from October 2008 to December 2013. RESULTS:There were 14 (nine male) patients of median age 58.7 (45-75) years. The main indication was extensive diverticular disease (50%) and previous colonic surgery (21.4%). A defunctioning stoma was performed in 64.3% which was reversed in all within 3-6 months. Three (21.4%) patients developed postoperative complications (Clavien-Dindo 1-2) and none required reoperation. The median duration of follow-up was 11 months. One (7.2%) patient had one bowel movement per day, 10 (71.4%) patients had two bowel movements per day and three (21.4%) patients had three per day. CONCLUSION/CONCLUSIONS:The modified right colonic inversion technique is safe and achieves intestinal continuity with a tension-free well vascularized anastomosis. Good function and low morbidity show that the procedure is a credible alternative to ileorectal or ileoanal anastomosis.