Is Rectal Washout Effective for Preventing Localized Recurrence After Anterior Resection for Rectal Cancer?

PURPOSE  The present study evaluated the effect of rectal washout in reducing local recurrence after resection for rectal cancer. METHODS  A literature search was performed on studies published since 1989 that compared rectal washout to no washout for rectal cancer resection. Primary end point was local cancer recurrence. Random-effect meta-analysis was used and subgroup analysis was performed. RESULTS  Five studies matched the selection criteria, and reported on 176 patients who underwent rectal washout and 256 who did not undergo washout. Different washout solutions were used in every study, and total mesorectal excision was not universally applied. Overall local recurrence rate was 8 percent (33/432). Local recurrence rate for rectal washout patients was 4.8 percent compared with 10.2 percent for patients who did not undergo rectal washout, a difference that was not statistically significant (odds ratio = 0.64; 95 percent confidence interval = 0.2–2.04). When only studies using total mesorectal excision were considered, there was no significant difference between the two groups (odds ratio = 1.21; 95 percent confidence interval = 0.37–3.92). CONCLUSIONS  Although no definitive conclusions may be drawn because of the nonrandomized nature of the included studies, rectal washout is relatively risk-free and adds little to the operative time. This may be performed until a randomized, controlled trial is undertaken to resolve this contentious issue.     

Postoperative Radiotherapy for Stage IIIA Rectal Cancer: Is It Justified?

Purpose  Adjuvant radiotherapy is currently recommended for all node-positive rectal cancers to reduce local recurrence. This study evaluated if an adequate mesorectal excision can obviate the need for radiotherapy in early node-positive cancer. Methods  Stage IIIA rectal cancer patients were identified in a prospectively maintained database. Patients who received postoperative radiotherapy (radiotherapy) and those who did not (no radiotherapy) were compared for recurrence, survival, bowel function, and quality of life. Quality of life was assessed using the Short Form-36 Medical Outcomes Survey. Results  Eighty-six patients underwent proctectomy for T1-T2,N1 rectal cancers from 1978 to 2004. Patients receiving radiotherapy (n = 34) were younger and had a higher percentage of T1 tumors than patients who did not receive radiotherapy (n = 52). Other tumor characteristics, type of surgery, and number of involved lymph nodes were comparable. Estimated 5-year local recurrence was radiotherapy 3.4 percent and no radiotherapy 4.7 percent; distant recurrence was radiotherapy 13.5 percent and no radiotherapy 16.5 percent; and disease-specific mortality rates were similar 13.5 vs. 11.3 percent, for radiotherapy and no radiotherapy (all P > .05). Patients receiving radiotherapy had higher frequency of daytime bowel movements, urgency, and usage of pads and antidiarrheal medications. Age adjusted quality of life parameters were comparable between treatments. Conclusion  Postoperative radiotherapy did not reduce recurrence or mortality. Function but not quality of life was adversely affected. Routine postoperative radiotherapy for Stage IIIA rectal cancer should be reconsidered. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Local Therapy for Rectal Cancer: Still Controversial?

Purpose Many considerations, such as morbidity, sexual and urinary dysfunction, or risk of definitive stoma have led to the increased popularity of local therapy in the therapeutic strategy for rectal cancer. However, its role in curative intent is still controversial with oncologic long-term results lower than those obtained by radical surgery. Methods MEDLINE, EMBASE, LILACS, Abstract books, and reference lists from reviews were searched with English language publications to review the current status of evidence for local therapy in rectal cancer, looking especially at the oncologic results and patient selection. We have focused on the new strategies combining neoadjuvant and adjuvant treatment to explain their place in the management of rectal cancer. Results and Conclusions The key to potentially curative local treatment for rectal cancer is patient selection by identifying the best candidates with preoperative tumor staging and clinical and pathologic assessment of favorable features. Low-risk T1 is suitable for local excision alone. Limited data suggest that adjuvant chemoradiotherapy may be helpful in patients with unfavorable T1 and T2 lesions, achieving a local recurrence rate<20 percent. However, the efficacy of salvage surgery after local excision is uncertain.     

Beta-blockers in heart failure: Is more better?

Therapies that modulate the sympathetic nervous system and renin-angiotensin-aldosterone system reduce morbidity and mortality in patients with heart failure. However, they are grossly underused in clinical practice; when used, the doses prescribed are substantially smaller than the target doses used in the large-scale studies that established their utility. Whether these suboptimal doses are as effective in reducing morbidity and mortality is largely unknown. This review focuses on the relationship between the dose of β-blockers and their effect on clinical outcomes. Because direct dose comparisons of β-blockers are limited, we draw upon a broader spectrum of clinical trials across the cardiovascular continuum that involved neurohormonal modulators to address the question, ‘Is more better?’     

Levalbuterol for asthma: A better treatment?

The purpose of this review is to determine whether the proinflammatory actions identified in vitro for (S)-albuterol provide a clinically significant therapeutic advantage for levalbuterol over racemic albuterol. Clinical trials evaluating the bronchodilation in chronic and acute asthma provide conflicting evidence. Older trials suggested an advantage for levalbuterol; however, the newer trials have failed to confirm those advantages. Although (S)-albuterol produces increased bronchial hyperresponsiveness in vitro and in animal models, this has not been consistently confirmed in clinical trials; however, the heterogeneity of the trials precludes definitive conclusions. Current clinical trials do not provide evidence of a substantial advantage of levalbuterol over racemic albuterol although the data are insufficient to determine whether subsets of the patient population might benefit from single isomer therapy.