Latest Research on cancer surgery : Aug – 2020

Latest Research on cancer surgery : Aug – 2020

Results of radical surgery for rectal cancer

This paper examines the hypothesis that a reduction in the distal mural margin during anterior resection for sphincter conservation in rectal cancer excision is safe, provided total mesorectal excision is undertaken with wash-out of the clamped rectum. One hundred ninety-two patients underwent anterior resection and 21 (<10%) patients underwent abdomino-perineal excision (APE) by one surgeon (RJH). Anterior resections were classified as “curative” (79%) and “non-curative” (21%); in the “curative” sub-group <4% of patients developed local recurrence. The series was retrospectively analyzed for the effect of mural margins on local recurrence with 152 patients undergoing “curative” anterior resections and 40 patients undergoing “non-curative” resections. In the 152 specimens from curative resections, 110 had a resection margin >1 cm and 42 had a resection margin <1 cm. Four patients developed local recurrence in the >1 cm margin group (95% confidence interval: 0.8%–7.8%) and no patients developed local recurrence in the ≤1 cm margin group (95% confidence interval: 0%–5.9%). In each patient with local recurrence a cause for failure was apparent. There was no statistically significant difference in local recurrence rate between the ≤1 cm margin group and the >1 cm margin group. A reduction in resection margin therefore did not compromise survival after anterior resection.

The significance of lateral resection margins is discussed. The role of deep radiotherapy and cytotoxics are considered. However, in view of the low local recurrence rate that can be achieved by adequate surgery, it is the opinion of the author that radiotherapy and cytotoxics have little extra to offer in the management of cancer of the rectum treated by total mesorectal excision. Finally, the functional results following anterior resection and total mesorectal excision are analyzed and the refractory problem of anastomotic leakage is discussed.

Résumé

Cet article examine l’hypothèse de l’un des auteurs (RJH) selon laquelle la réduction de la marge de sécurité distale dans la résection antérieure du rectum avec conservation sphinctérienne pour cancer serait sans conséquence fâcheuse au plan cancinologique, à condition que l’excision du mésorectum soit complète et que le rectum soit clampé et irrigué en peropératoire. Cent quatre-vingt douze patients ayant eu une résection antérieure ont été comparés à 21 patients (soit 10% des cancers du rectum) ayant eu une amputation abdomino-périnéale, tous opérés par le même chirurgien (RJH). Les résections antérieures ont été classées en “curatives” (79%) et “non-curatives” (21%). Dans le groupe “curatives”, moins de 4% des patients ont vu se déveloper une récidive. Cette série a ensuite été analysée en détails en 1989 pour étudier le rapport entre la largeur des marges et le taux de récidive parmi 152 résections “curatives” et 40 résections “non-curatives”. Parmi les résections à visée curative, 110 avaient une marge de résection >1 cm et 42, une marge <1 cm. Il y avait quatre récidives locales dans le premier groupe (intervalle de confiance à 95%: 0.8%–7.8%) et aucune récidive dans le groupe avec une marge <1 cm (intervalle de confiance à 95%: 0%–5.9%). Dans chaque cas de récidive locale, la cause en était évidente. Il n’y avait pas de différence statistiquement significative entre le taux de récidive des patients ayant une marge <ou=1 cm comparé à ceux ayant une marge >1 cm. La réduction de la marge de sécurité n’a pas influencé de façon pejorative les résultats au plan carcinologique. L’étendue de la résection latérale reste un sujet de débat. Le rôle de la radiothérapie profonde et de la chimiothérapie sont discutés. Au vu des bons résultats obtenus par cette chirurgie, les auteurs pensent que ces traitements complémentaires offrent peu par rapport à une chirurgie radicale. Les résultats fonctionels dans ces deux types de chirurgie sont discutés, ainsi que le problème de fistule anastomotique. [1]

Beneficial Effects of Immediate Enteral Nutrition After Esophageal Cancer Surgery

This study was conducted to determine the effects of immediate enteral nutrition (EN) on nutritional status, immunological competence, and the suppression of excessive inflammatory responses in patients following esophageal cancer surgery. Twenty-four patients who underwent the same elective operation for thoracic esophageal carcinoma were randomized into an immediate enteral nutrition (IEN) group who received EN from postoperative day (POD) 1 and a parenteral nutrition (PAN) group. Both groups received comparable volumes and calories on the same POD. Laboratory studies were carried out preoperatively and on PODs 1–7. Other nutritional and immunological assessments were repeated on PODs 1 and 7. Plasma concentrations of nitrate and nitrite were also measured. All of the patients in the IEN group tolerated enteral feeding well. There were no significant differences in the results of nutritional assessments, lymphocyte function, or plasma nitrate and nitrite levels between the two groups. The IEN group showed a significantly earlier recovery of the total lymphocyte count. The serum levels of total bilirubin and C-reactive protein were significantly attenuated in the IEN group. These results indicate that immediate EN may have beneficial effects on immunological competence and the suppression of excessive inflammatory responses in patients following esophagectomy. Patients undergoing radical esophageal surgery who are subjected to severe surgical stress might benefit the most from early EN. [2]

Current Status of Pulmonary Embolism in General Surgery in Japan

The true incidence of pulmonary embolism (PE) after general surgery in Japan is unknown. We searched the PubMed and Japana Centra Revuo Medicina 1985–2002 databases, entering “surgery” and “pulmonary embolism” or “thromboembolism”, and reviewed the reported incidence of clinical PE associated with general surgery in Japan. The overall incidence of PE after general surgery was 0.33%. Fatal PE was reported in 0.08% of the surgical population and the mortality rate of patients with PE was 31%. The incidence of PE after cancer surgery ranged from 0.57% after colon malignancy to 3.85% after pancreatic cancer surgery, and was significantly higher than that after surgery for noncancerous conditions (0.20%). The incidence of PE after various cancer operations corresponded to a moderate or high risk, as defined by the 6th American College of Chest Physians consensus recommendations. There was no significant difference in the incidence of PE after laparoscopic and open abdominal surgery. The incidence of PE was four to six times lower in patients who had received mechanical prophylaxis, although the difference was not significant. In conclusion, the incidence of PE in Japanese surgical patients is not as low as previously thought. Perioperative prophylaxis against venous thromboembolism is important, but its benefits need to be confirmed by prospective clinical studies. [3]

The Impact of Body Mass Index on the Surgical Outcomes in Open Rectal Cancer Surgery

Technical difficulties which affect the outcomes of abdominal operations are common in obese patients, especially in rectal and gastric cancer cases. In several studies, it has been shown that increased body mass index (BMI) is associated with increased morbidity, reduced lymph node retrieval and prolonged hospital stay after colorectal surgery. The aim of this study was to assess the influence of obesity on the surgical outcomes (surgical margin, number of lymph nodes excised) of rectal cancer patients who were operated by open surgery. One hundred rectal cancer patients who underwent open surgery in a single center between January 2011 and August 2014 were included in this study. Patients were divided into two groups according to their BMI values. According to their preoperative BMI values, patients with a BMI of ≥30 kg/m2 (n=29) were defined as ‘obese’. Patients with a BMI of <30 kg/m2 (n=71) were placed in the normal (non-obese) group. Demographic data, surgical margins, the number of lymph nodes retrieved and surveillance of both groups were compared. Obese and normal groups were statistically indifferent in terms of age, sex and stage of the disease. Comparison of the obese and normal groups showed no statistically significant difference in terms of surgical margins and the number of lymph nodes retrieved. This study showed that obesity does not affect the surgical outcomes in rectal cancer. However, prospective studies with larger patient series are needed. [4]

Reference

[1] Heald, R.J. and Karanjia, N.D., 1992. Results of radical surgery for rectal cancer. World journal of surgery, 16(5), pp.848-857.

[2] Aiko, S., Yoshizumi, Y., Sugiura, Y., Matsuyama, T., Naito, Y., Matsuzaki, J. and Maehara, T., 2001. Beneficial effects of immediate enteral nutrition after esophageal cancer surgery. Surgery today, 31(11), pp.971-978.

[3] Sakon, M., Kakkar, A.K., Ikeda, M., Sekimoto, M., Nakamori, S., Yano, M. and Monden, M., 2004. Current status of pulmonary embolism in general surgery in Japan. Surgery today, 34(10), pp.805-810.

[4] Solmaz, A., Gülçiçek, O., Binboğa, E., Biricik, A., Erçetin, C., Yiğitbaş, H., Yavuz, E., Çelik, A. and Çelebi, F. (2016) “The Impact of Body Mass Index on the Surgical Outcomes in Open Rectal Cancer Surgery”, Journal of Advances in Medicine and Medical Research, 14(10), pp. 1-5. doi: 10.9734/BJMMR/2016/25148.

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