Transanal Endoscopic Microsurgery vs. Laparoscopic Total Mesorectal Excision for T2N0 Rectal Cancer

Objective

The aim was to compare transanal endoscopic microsurgery (TEM) and laparoscopic resection (LR) in terms of short-term and oncologic outcomes in patients with a preoperatively diagnosed T2N0 extraperitoneal rectal cancer.

Methods

We conducted a retrospective analysis of a prospective database. All patients with a preoperatively staged T2N0 extraperitoneal rectal adenocarcinoma were considered for LR. Patients refusing LR or medically unfit for LR were considered for TEM, which was associated with neoadjuvant RT in the last cases. Only patients with a minimum follow-up of 36?months were included.

Results

Seventy-eight patients were included. TEM was indicated or preferred in 43 patients; of these, 11 underwent neoadjuvant RT. Morbidity was significantly lower after TEM (p?<?0.001). The median follow-up was 70 (36?C140) months. A higher local recurrence rate was noted after TEM (26?%), compared to neoadjuvant RT + TEM (0?%) and LR (9?%) (p?=?0.070). Overall, 5-year survival rate was 76?% after TEM, 77.8?% after RT + TEM, and 96?% after LR, respectively (p?=?0.134).

Conclusions

While TEM alone may only be considered a palliative treatment, it might allow similar oncologic results to abdominal resection in responders to neoadjuvant RT. Large prospective randomized trials are awaited to confirm these findings.     

Transanal Endoscopic Microsurgery for Rectal Neoplasms. How I Do It

Introduction

Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcomes of transanal surgery, becoming the standard of treatment for large sessile rectal adenomas, and may represent a possible treatment modality for early rectal cancer.

Methods

A full-thickness excision is made on the rectal wall down to the perirectal fatty tissue. The specimen is retrieved transanally. After the parietal defect is disinfected, the wound is closed with one or more running sutures secured with silver clips.

Results

Peritoneal perforation during TEM is not associated with adverse short-term or oncologic outcomes. The postoperative morbidity rate ranges between 2 % and 15 %, and in most cases, complications can be conservatively managed. The local recurrence rate of large adenomas is about 6 %, and most recurrences can be safely re-resected by TEM. TEM represents an effective treatment for pT1 sm1 rectal malignancies, while pT1 sm2-3 and pT2 should be considered at high risk of recurrence if treated by TEM alone. Finally, TEM does not influence anorectal function or quality of life.

Conclusion

TEM is a safe procedure and provides excellent functional and oncologic outcomes in the treatment of large sessile benign rectal lesions and selected early rectal cancers.     

Hiatal hernia, Barrett’s esophagus, and long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux

Background

The aim of this study was to determine the long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux disease (GERD), and possible prognostic factors.

Methods

A cohort of 271 patients, operated on at a university hospital from 1996 through 2002, was eligible for evaluation after a median interval of 102?months (range?=?12–158). The time between surgery and recurrence of reflux symptoms (i.e., time to treatment failure) served as the end point for statistical analysis. Putative risk factors for symptom recurrence were analyzed by univariate analysis and by using Cox’s multiple-hazards regression.

Results

According to Kaplan–Meier estimates, the rate of reflux symptom recurrence was 15?% after 108?months, 11?% in cases without intestinal metaplasia, but 43?% in patients with long-segment (≥3?cm) Barrett’s esophagus (BE; p?<?0.0001). Reflux symptoms recurred in 22?% of cases with a hiatal hernia (HH)?≥3?cm before operation, but only in 7?% with smaller or absent HH (p?=?0.005). Multivariate analysis revealed a relative risk of 6.6 (CI?=?3.0–13.0) for long-segment BE and 3.0 (CI?=?1.7–10.1) for HH?≥?3?cm. A strong statistical interaction was found between HH?≥?3?cm and long-segment BE: the small group (n?=?18) of cases exhibiting both risk factors had an exaggerated recurrence rate of 72?% at 108?months.

Conclusions

Laparoscopic fundoplication for symptomatic GERD provided a long-lasting abolition of reflux symptoms in 231 of 271 (85?%) patients. HH?≥?3?cm and long-segment BE were shown as independent prognostic factors favoring recurrence.     

Selective Reoperation for Locally Recurrent or Metastatic Pancreatic Ductal Adenocarcinoma Following Primary Pancreatic Resection

Background

Resection of certain recurrent malignancies can prolong survival, but resection of recurrent pancreatic ductal adenocarcinoma is typically contraindicated because of poor outcomes.

Methods

All patients from 1992 to 2010 with recurrent pancreatic cancer after intended surgical cure were retrospectively evaluated. Clinicopathologic features were compared from patients who did and did not undergo subsequent reoperation with curative intent to identify factors associated with prolonged survival.

Results

Twenty-one of 426 patients (5?%) with recurrent pancreatic cancer underwent potentially curative reoperation for solitary local-regional (n?=?7) or distant (n?=?14) recurrence. The median disease-free interval after initial resection among reoperative patients was longer for those with lung or local-regional recurrence (52.4 and 41.1?months, respectively) than for those with liver recurrence (7.6?months, p?=?0.006). The median interval between reoperation and second recurrence was longer in patients with lung recurrence (median not reached) than with liver or local-regional recurrence (6 and 9?months, respectively, p?=?0.023). Reoperative patients with an initial disease-free interval >20?months had a longer median survival than those who did not (92.3 versus 31.3?months, respectively; p?=?0.033).

Conclusion

Patients with a solitary pulmonary recurrence of pancreatic cancer after a prolonged disease-free interval should be considered for reoperation, as they are more likely to benefit from resection versus other sites of solitary recurrence.     

Randomized clinical trial on preoperative radiotherapy 25 Gy in rectal cancer—treatment results at 5-year follow-up

Purpose

The purpose of this study was to establish the influence of time interval between preoperative hyperfractionated radiotherapy (5?×?5?Gy) and surgery on long-term overall survival (5?years) and recurrence rate in patients with locally advanced rectal cancer operated on according to total mesorectal excision technique.

Methods

The treatment group comprised 154 patients with locally advanced rectal cancer who were operated on between 1999 and 2006 in the 1st Department of General Surgery, Jagiellonian University, Cracow, Poland. The data on survival has been systematically collected until 31st of December 2010. In addition, the following aspects were analyzed: the significance of time interval between the end of radiotherapy and surgical treatment and its influence on downsizing, downstaging, rate of curative resections, and sphincter-sparing procedures. Patients were qualified to preoperative radiotherapy 5?×?5?Gy and then randomly assigned to subgroups with different time intervals between radiotherapy and surgery: one subgroup consisted of 77 patients operated on 7–10?days after the end of irradiation, and the second subgroup consisted of 77 patients operated on after 4–5?weeks. Both groups were homogenous in sex, age, cancer stage and localization, distal and circumferential resection margins, and number of resected lymph nodes.

Results

The 5-year survival rate in patients operated on 7–10?days after irradiation was 63%, whereas in those operated on after 4–5?weeks, it was 73%—the difference was not statistically significant (log rank, p?=?0.24). A statistically significant increase in 5-year survival rate was observed only in patients with downstaging after radiotherapy—90% in comparison with 60% in patients without response to neoadjuvant treatment (log rank, p?=?0.004). Recurrence was diagnosed in 13.2% of patients. A lower rate of systemic recurrence was observed in patients operated on 4–5?weeks after the end of irradiation (2.8% vs. 12.3% in the subgroup with a shorter interval, p?=?0.035). No differences in local recurrence rates were observed in both subgroups of irradiated patients (p?=?0.119). The longer time interval between radiotherapy and surgery resulted in higher downstaging rate (44.2% vs. 13% in patients with a shorter interval, p?=?0.0001) although it did not increase the rate of sphincter-saving procedures (p?=?0.627) and curative resections (p?=?0.132).

Conclusions

1. Improved 5-year survival rate is observed only in patients with downstaging after preoperative irradiation dose of 25?Gy.
2. Longer time interval after preoperative radiotherapy 25?Gy does not improve the rate of sphincter-saving procedures and curative resections (R0) despite higher downstaging rate observed in this regimen.

     

Outcome After Percutaneous Cholecystostomy for Acute Cholecystitis: a Single-Center Experience

Background

Percutaneous cholecystostomy is an alternative treatment for acute cholecystitis patients with high surgical risk.

Methods

One hundred and sixty-six patients consecutively treated by percutaneous cholecystostomy for acute cholecystitis in a single medical center were retrospectively reviewed.

Results

The cohort included 121 males and 45 females with mean age of 75.9?years. The overall inhospital mortality rate was 15.1?% (n?=?25). Elevated serum creatinine level at diagnosis [odds ratio (OR) 1.497; p?=?0.020], septic shock (OR 11.755; p?=?0.001), and development of cholecystitis during admission (OR 7.256; p?=?0.007) were predictive of inhospital mortality. Of 126 patients who recovered from calculous cholecystitis, 11 experienced recurrent cholecystitis within 2?months. Serum C-reactive protein (CRP) level >15?mg?dl^?1 at diagnosis [hazard ratio (HR) 10.141; p?=?0.027] and drainage duration of cholecystostomy longer than 2?weeks (HR 3.638; p?=?0.039) were independent risk factors of early recurrence. The 53 patients who underwent cholecystectomy had an 18.9?% perioperative complication rate and no operation-related mortality.

Conclusions

In-patients or those with septic shock or renal insufficiency have worse outcome. Prolonged drainage duration and high CRP level predict early recurrence. Removal of the drainage tube is recommended after resolution of the acute illness.     

Intramucosal carcinoma of the rectum can be safely treated with transanal endoscopic microsurgery; clinical support of the revised Vienna classification

Aim

The revised Vienna criteria were proposed for classifying rectal neoplasia and subsequent treatment strategies. Restaging intramucosal carcinoma to a non-invasive subgroup seems logical, but clinical support is lacking. In this study, we investigated whether distinction between intramucosal carcinomas (IMC) and rectal adenoma (RA) is of clinical relevance and whether these neoplasms can all be similarly and safely treated by transanal endoscopic microsurgery (TEM).

Methods

All consecutive patients with IMC and RA, treated with TEM between 1996 and 2010 in tertiary referral centre for TEM were included. Long-term outcome of 88 IMC was compared to 356 pure rectal adenomas (RA). Local recurrence (LR) rate was the primary endpoint. Risk factors for LR were analysed.

Results

LR was diagnosed in 7/88 patients (8.0 %) with IMC and in 33/356 patients with primary RA (9.3 %; p = 0.700) and LR-free survival did not differ (p = 0.438). Median time to recurrence was 10 months (IQR IMC 5–30; RA 6–16). Overall recurrence occurred mainly in the first 3 years (38/40; 95 %). None of the LR revealed malignancy on pathological evaluation. No differences could be found in complication rates (IMC 9 %; RA 13 %; p = 0.34). Metastases did not occur in either group. Independent risk factors for LR were irradical margins at final histopathology (HR 2.32; 95 % CI 1.17–4.59; p = 0.016) and more proximal tumours (HR 0.84; 95 % CI 0.77–0.92; P = <0.001).

Conclusion

In this study, IMC of the rectum and RA have similar recurrence rates. This supports the revised Vienna classification. Both entities can be safely treated with TEM.     

Diaphragmatic Hernia After Hepatic Resection: Case Series at a Single Western Institution

Background

Diaphragmatic hernia (DH) after hepatic resection (HR) is a rare and not well-described complication. We report our experience with DH following a high volume of HRs in a tertiary center.

Methods

Records of patients undergoing major HR for liver tumors between April 1992 and November 2011 were reviewed. The definitive diagnosis of DH was made based on radiologic studies. Primary repair was used for defects <10?cm in size. Transthoracic repair was used in patients with recurrent or complex hernias. Univariate analysis was performed to determine risk factors associated with posthepatectomy DH.

Results

DH developed in 10 out of 993 patients (1?%) at a median time interval of 15?months after HR. DH was not associated with old age (m?=?48.5?years), gender (male?=?50?%), or high body mass index (m?=?24.5). However, mean tumor size was large (m?=?9.2?cm). The majority of patients presented with symptoms (80?%), small (60?%) and right-sided (80?%) hernias, and underwent elective repair via an abdominal approach (70?%). Large defects (>10?cm; 30?%) were successfully repaired with prosthetic mesh. Increased incidence of DH was associated with diaphragmatic resection at the time of HR (5.4 vs. 0.7?%, p?=?0.001). At a median follow-up of 36?months (range, 10?C167?months) after hernia repair, recurrence occurred in one patient.

Conclusion

Diaphragmatic resection at the time of HR and large tumor size may put patients at risk of developing posthepatectomy DH. Early detection and prompt treatment is associated with low recurrence and offers the advantage of primary repair.     

Preoperative Treatment Does Not Improve the Therapeutic Results of Abdominosacral Amputation of the Rectum

Background

This study reviewed the impact of preoperative chemoradiotherapy/short-term radiotherapy on abdominosacral amputations of the rectum (ASAR) for the treatment of low-rectum cancers in terms of postoperative morbidity, local recurrence rates, and survival.

Methods

A total of 198 patients with stage II and III tumors located within 6?cm of the anorectal junction underwent ASAR between 1998 and 2008 and were selected for further analysis. Patients were compared according to the following groups: those who had surgery only (Group A) and those who had preoperative chemoradiotherapy/short-term radiotherapy (Group B).

Results

There were 44 and 154 patients in Groups A and B, respectively, including 135 males. The median age of the subjects was 63?years (range?=?35–88). The median follow-up period was 81?months (range?=?23–138). Neither the local recurrence rates (6.8% in Group A vs. 4.6% in Group B, p?=?0.544) nor the 5-year relative survival rates (72.4% in Group A vs. 69.3% in Group B, p?=?0.127) differed significantly between the groups.

Conclusion

Preoperative therapy in low-rectum cancer does not improve the therapeutic results of ASAR.     

Peri-Operative Bowel Perforation in Early Stage Colon Cancer is Associated with an Adverse Oncological Outcome

Background

The presence of an inflammatory response resulting from bowel perforation or anastomotic leakage has been suggested to enhance recurrence rates in colorectal cancer patients. Currently, it is unknown if bowel perforation or anastomotic leakage has prognostic significance in early stage colon cancer patients. In this study, the impact of peri-operative bowel perforation including anastomotic leakage on disease-free survival of stage I/II colon cancer patients was investigated.

Methods

Prospective follow up data of 448 patients with stages I/II colon cancer that underwent resection were included. Patients who died within 3?months after initial surgery were excluded.

Results

Median follow up was 56.0?months. Patients with peri-operative bowel perforation (n?=?25) had a higher recurrence rate compared to patients without perforation (n?=?423), 36.0?% vs. 16.1?% (p?=?0.01). Disease-free survival was significantly worse for the perforation group compared to patients without perforation (p?=?0.004). Multivariate analysis including T-stage, histological grade, and adjuvant chemotherapy showed peri-operative bowel perforation to be an independent factor significantly associated with disease recurrence (odds ratio, 2.7; 95?% CI, 1.1?C6.7).

Conclusion

Peri-operative bowel perforation is associated with increased recurrence rates and impaired disease-free survival in early-stage colon cancer patients.     

Endoscopic submucosal dissection versus transanal endoscopic microsurgery for the treatment of early rectal cancer

Background

Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are minimally invasive procedures that can be used to treat early rectal cancer.

Objective

The aim of this study was to compare clinical efficacy between ESD and TEM for the treatment of early rectal cancer.

Methods

Between July 2008 and August 2011, 24 patients with early rectal cancers were treated by ESD (11) or TEM (13) at the Cancer Institute of São Paulo University Medical School (São Paulo, Brazil). Data were analyzed retrospectively according to database and pathological reports, with respect to en bloc resection rate, local recurrence, complications, histological diagnosis, procedure time and length of hospital stay.

Results

En bloc resection rates with free margins were achieved in 81.8 % of patients in the ESD group and 84.6 % of patients in the TEM group (p = 0.40). Mean tumor size was 64.6 ± 57.9 mm in the ESD group and 43.9 ± 30.7 mm in the TEM group (p = 0.13). Two patients in the TEM group and one patient in the ESD group had a local recurrence. The mean procedure time was 133 ± 94.8 min in the ESD group and 150 ± 66.3 min in the TEM group (p = 0.69). Mean hospital stay was 3.8 ± 3.3 days in the ESD group and 4.08 ± 1.7 days in the TEM group (p = 0.81).

Limitations

This was a non-randomized clinical trial with a small sample size and selection bias in treatment options.

Conclusion

ESD and TEM are both safe and effective for the treatment of early rectal cancer.     

Evaluating the porcine dermis graft InteXen® in three-compartment transvaginal pelvic organ prolapse repair

Introduction and hypothesis

The aim was to assess the efficacy of three-compartment pelvic organ prolapse (POP) vaginal repair using the InteXen® biocompatible porcine dermal graft as compared to traditional colporrhaphy with sacrospinous ligament suspension.

Methods

Preoperative, operative, postoperative and follow-up data were collected retrospectively. Objective recurrence was defined as POP quantification ≥ stage II and subjective recurrence as a symptomatic bulge.

Results

Each group consisted of 63 patients. Surgery time was longer using InteXen® (72?±?24.5 vs 55?±?23.5 min, p?=?0.0002). Length of hospital stay (4.6?±?1.6 vs 4.9?±?2.1 days, p?=?0.34) as well as duration of follow-up (37.1 vs 35.7 months, p?=?0.45) were equivalent between the two groups. No case of mesh erosion or infection was noted. The objective (17% vs 8%, p?=?0.12) and subjective recurrence rates (13% vs 5%, p?=?0.12) between the two groups were not statistically different.

Conclusions

InteXen® was well tolerated but had similar efficacy to traditional colporrhaphy and sacrospinous ligament suspension.     

Surveillance of Small Rectal Carcinoid Tumors in the Absence of Metastatic Disease

Background

The incidence of rectal carcinoids is rapidly increasing, typically presenting as small (<1.0?cm), localized tumors. Although the evaluation of rectal carcinoids on presentation is well standardized, surveillance after resection has not been well established.

Methods

A prospective database documented patients with rectal carcinoids at our institution between January 1995 and September 2011. Information collected included patient and tumor characteristics, treatment method, surveillance schedule, recurrence, and survival.

Results

Twenty-eight patients with rectal carcinoid were identified. Ten patients were excluded for tumors >1?cm, known metastases at presentation, <6?months follow-up, or previous resections. The mean age of the remaining patients was 56?±?3?years, and 61?% of the patients were female. All patients were diagnosed at endoscopy, with 50?% diagnosed incidentally on screening endoscopy. Treatment methods included endoscopic therapy (n?=?13, 72?%), transanal excision (n?=?3, 17?%), and transanal endoscopic microsurgery (n?=?1, 5.5?%). One patient (5.5?%) received no additional invasive therapy after diagnostic endoscopy. The mean tumor diameter was 4.6?±?0.5?mm. The average length of follow-up was 5.4?±?0.9?years, with a median number of 2 follow-up endoscopies (range 0?C6). Two patients (11?%) died within the follow-up period from noncarcinoid causes. Importantly, no surviving patients developed local or distant recurrence with up to 12.3?years of follow-up.

Conclusions

On the basis of this experience, patients presenting with small (??1.0?cm), nonmetastatic rectal carcinoids are unlikely to develop local or distant recurrence after resection. Aggressive surveillance with repeat endoscopies or other imaging studies after resection may be unnecessary in this patient population.     

Recombinant human bone morphogenetic protein-2 versus autogenous iliac crest bone graft for lumbar fusion: a meta-analysis of ten randomized controlled trials

Background

Recombinant human bone morphogenetic protein-2 (rhBMP-2) as a substitute for iliac crest bone graft (ICBG) has been increasingly widely used in lumbar fusion. It has been proven non-inferior in fusion success and clinical outcomes when compared with ICBG. However, increasingly, some potentially uncommon and serious complications associated with the use of rhBMP-2 have been of great concern to surgeons. The purpose of this study was to determine whether rhBMP-2 could be considered an effective and, more importantly, a relatively safe substitute for ICBG in lumbar fusion.

Methods

Randomized controlled trials that compared rhBMP-2 with ICBG for lumbar fusion were identified by computer and manual searching. The risk of bias and clinical relevance of the included studies were assessed. Publication bias was explored using funnel plot and statistical tests (Egger??s test and Begg??s test). Meta-analyses were performed using the Cochrane systematic review methods.

Results

Ten randomized controlled trials (1,342 patients) met the inclusion criteria. Compared with ICBG, the use of rhBMP-2 significantly decreased the risk of fusion failure at all time intervals (6?months: p?<?0.0001, RR?=?0.55, 95?% CI?=?0.42?C0.72; 12?months: p?=?0.0003, RR?=?0.53, 95?% CI?=?0.37?C0.75; 24?months: p?<?0.00001, RR?=?0.31, 95?% CI?=?0.21?C0.46) and the rate of reoperation (p?=?0.0001, RR?=?0.52, 95?% CI?=?0.37?C0.72). There was no statistical difference in clinical improvement on the Oswestry Disability Index, although a favorable trend in the rhBMP-2 group was found (p?=?0.12, RR?=?0.73, 95?% CI?=?0.49?C1.08). Subgroup analyses stratified by the type of surgical procedure yielded similar results. Owing to the different data formats, meta-analysis on adverse events was not performed.

Conclusion

RhBMP-2 was superior to the ICBG for achieving fusion success and avoiding reoperation. However, evidence from the Food and Drug Administration document and subsequent independent studies has demonstrated that original, industry-sponsored trials underestimated rhBMP-2-related adverse events. There are still security risks in the use of rhBMP-2.     

A study of the incidence of implantation cyst at anastomotic sites after low anterior resection of the rectum with the double stapling technique

Background

The incidence of implantation cyst occurring at sites of anastomosis after low anterior resection of the rectum were studied in two different periods depending on the type of surgical devices used to close the rectal stump.

Subjects

The study included 361 patients undergoing the surgery during the first 8-year period between 1996 and 2003 and 87 patients undergoing the surgery during the second 3-year period between 2004 and 2006.

Results

Implantation cysts were found in nine (2.5%) of the patients undergoing the surgery during the first period and one of them also had local recurrence. Implantation cysts occurred 9 to 31 months postoperatively (mean, 17.1?±?6.9 months). Clinical symptoms were noted in one patient and treatment of the cysts, including local recurrence, was given to two patients. Anastomosis of the distal rectum was performed with the Roticulator or the Access 55 in all patients. Although implantation cysts were found in any patient undergoing surgery during the second period, no statistically significant difference was recognized (p?=?0.217). Anastomosis of the distal rectum was performed with the TX30 in all patients.

Conclusion

The pathogenesis of implantation cysts may be explained by the production of mucus when the mucosal epithelium of the colon is caught under the submucosa, forming a cyst after closure of the rectal stump, and the difference in the incidence rates of implantation cyst was presumably due to the characteristics of the device used and progress of the operative procedure.     

Laparoscopic versus open colorectal resections in patients with symptomatic stage IV colorectal cancer

Background

The purpose of this study was to evaluate short-term and oncologic outcomes of laparoscopic resection (LR) for patients with symptomatic stage IV colorectal cancer compared with open resection (OR).

Methods

This study is a retrospective analysis of a prospective database. Patients with a minimum follow-up of 12?months after LR or OR for metastatic colorectal cancer were included. All analyses were performed on an “intention-to-treat” basis.

Results

A total of 162 consecutive patients submitted to LR and 127 submitted to OR were included. In the LR group, conversion rate was 26.5?%, mostly due to locally advanced disease (88.4?%). A greater risk of conversion was observed among patients with a tumor size greater than 5?cm regardless the tumor site (P?=?0.07). Early postoperative outcome was significantly better for LR group, with a shorter hospital stay (P?=?0.008), earlier onset of adjuvant treatment, and similar postoperative complications (P?=?0.853) and mortality rates (P?=?0.958). LR for rectal cancer was associated with a higher morbidity compared with colon cancer (P?=?0.058). During a median follow-up time of 72?months, there was no significant difference in overall survival between the two groups (P?=?0.622).

Conclusions

LR for symptomatic metastatic CRC is safe and, compared with OR, is associated with a shorter hospital stay and with similar survival rates. Concerns remain about LR of bulky tumors and rectal cancers due to the increased risk of conversion and postoperative complications.     

Risk of Cancer-specific Mortality following Recurrence After Radical Nephroureterectomy

Purpose

To describe the natural history and identify predictors of cancer-specific survival in patients who experience disease recurrence after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

Methods

Of 2,494 UTUC patients treated with RNU without neoadjuvant chemotherapy, 597 patients experienced disease recurrence. A total of 148 patients (25?%) received adjuvant chemotherapy before disease recurrence. Multivariable Cox regression model addressed time to cancer-specific mortality after disease recurrence.

Results

The median time from RNU to disease recurrence was 12?months (interquartile range 5?C22). A total of 491 (82?%) of 597 patients died from UTUC, and 8 patients (1.3?%) died from other causes. The median time from disease recurrence to death of UTUC was 10?months. Actuarial cancer-specific survival estimate at 12?months after disease recurrence was 35?%. On multivariable analysis that adjusted for the effects of standard clinicopathologic characteristics, higher tumor stages [hazard ratio (HR) pT3 vs. pT0?CT1: 1.66, p?=?0.001; HR pT4 vs. pT0?CT1: 1.90, p?=?0.002], absence of lymph node dissection (HR 1.28, p?=?0.041), ureteral tumor location (HR 1.44, p?<?0.0005) and a shorter interval from surgery to disease recurrence (p?<?0.0005) were significantly associated with cancer-specific mortality. The adjusted 6-, 12- and 24-month postrecurrence cancer-specific mortality was 73, 60 and 57?%, respectively.

Conclusions

Approximately 80?% of patients who experience disease recurrence after RNU die within 2?years after recurrence. Patients with non-organ-confined stage, absence of lymph node dissection, ureteral tumor location and/or shorter time to disease recurrence died of their tumor more quickly than their counterparts. These factors should be considered in patient counseling and risk stratification for salvage treatment decision making.     

Pancreatic Volumetric Assessment as a Predictor of New-Onset Diabetes Following Distal Pancreatectomy

Introduction

Pancreatogenic diabetes after pancreatectomy is of growing importance due to the increasing life expectancy of pancreatectomized patients. Although reduction of pancreatic volume is thought to affect glucose metabolism, a consistent relationship has yet to be determined. This study aimed to investigate functional consequences of distal pancreatectomy (DP) in preoperatively non-diabetic patients.

Methods

This study included 61 non-diabetic patients who underwent DP. Clinical data were obtained, and the percent resected volume (PRV) of each pancreas was determined via multi-detector row computed tomography volumetry.

Results

During the follow-up period (median 26?months), 22 patients (36?%) developed new-onset diabetes within a median onset time of 8?months (range 0.5?C42?months) postoperatively. The remaining 39 patients also showed impaired glucose metabolism. Multivariate analysis identified preoperative hemoglobin A1c????5.7?% (odds ratio 15.6, p?=?0.001) and PRV?>?44?% (odds ratio 11.3, p?=?0.004) as independent risk factors for new-onset diabetes.

Conclusions

Key determinants of postoperative glycemic control include preoperative functional reserve of the endocrine pancreas and the volume reduction of pancreatic parenchyma. Our findings enable reliable preoperative evaluation of the risk of postoperative diabetes and appropriate postoperative surveillance, which is helpful for early intervention in high risk patients.     

Previous transanal endoscopic microsurgery for rectal cancer represents a risk factor for an increased abdominoperineal resection rate

Background

Transanal endoscopic microsurgery (TEM) represents a surgical option in the treatment of selected early rectal cancers. However, when definitive histopathology shows negative prognostic factors, rectal resection with total mesorectal excision (TME) is recommended to reduce the risk of recurrence. No studies have yet analyzed the impact of previous TEM on the perioperative outcomes of immediate laparoscopic TME (LTME) for rectal cancer. The aim of this study was to evaluate the perioperative outcomes of LTME after TEM for rectal cancer.

Methods

This study was a retrospective analysis of a prospective database. All patients undergoing LTME within 8 weeks after full-thickness TEM for rectal cancer between January 2001 and December 2011 were included. Each patient was matched on the basis of demographic and clinical characteristics with two patients undergoing primary LTME for rectal cancer during the same period. Age, gender, body mass index, tumor distance from the anal verge, tumor size, neoadjuvant chemoradiation, previous TEM, rectal wall defect size created during TEM, and intraoperative complications were included in a multivariate analysis to identify risk factors for abdominoperineal resection (APR).

Results

A total of 17 patients undergoing TEM followed by LTME were compared to 34 patients undergoing primary LTME. Mean operative time of LTME after TEM was significantly higher (206 vs. 188 min, P = 0.025). APR was more frequently performed after TEM [odds ratio (OR) 5.25, P = 0.028] and in male patients (OR 9.04, P = 0.034). On multivariate analysis, a previous TEM was the only independent predictor of APR (OR 4.13, P = 0.046). The incidence and severity of postoperative complications were similar in both groups. Mesorectum integrity was complete in all cases.

Conclusions

LTME after TEM is a challenging procedure, with a significantly higher risk of APR compared to primary LTME. Future improvements in preoperative patient selection for TEM are needed to reduce this risk.