Level of vascular ligation and association with oncological expediency in sigmoid and rectal cancer

Introduction: The techniques and oncology feasibility of high vascular ligation of the inferior mesenteric artery along with their varieties – low tie (LT) and high tie (HT) techniques in left-sided colon and rectal cancer, were described more than 100 years ago by Miles and Moynihan. However, the relationship between the level of vascular ligation and the microperfusion of the proximal anastomosis segment, on the one hand, and the volume and quality of lymphatic dissection, on the other, are the subject of numerous clinical trials and discussions. The vegetative nerve spare in the different approaches is also included in a consideration. Despite the well-established modern standardization in conventional and laparoscopic left colon and rectal cancer surgery, some surgeons still do ligation at the a. rectalis superior level in rectal cancer, which contradicts modern oncology principles.Materials and Methods: Prospective non-randomized comparative cohort study of patients from the Department of Surgery in Alexandrovska University Hospital with cancer of the sigmoid colon or rectum in clinical stage I-III, operated by an open or laparoscopic approach over a 4-year period, stratified into two groups according to the level of ligation of the inferior mesenteric artery (IMA) and vein - high tie - at the site of the origin  (1 cm) from aorta and low tie - distal to the origin of the left colic artery. The comparative indicators included the anastomotic leakage rate, the number of lymph nodes harvested with a metastatic lymph node index, a 3-year disease-free survival (DFS), disease-related survival OS. The follow-up period was 12-48 months.Results: For the period 2014-2018 a total of 217 patients with cancer of the sigmoid colon or rectum underwent 169 laparoscopic and 48 open surgeries. The distribution was as follows: 69% high ligation compared to 31% low ligation; 52 in an emergency or delayed emergency manner; 58% male and 42% female, mean age 64 ± 0.8 years; 56% in clinical stage III, 40% in II and only 4% in clinical stage I, relatively evenly distributed in the two target groups. There were wide variations in the number of lymph nodes harvested from the specimen (n = 4 to 22) for both groups without significant differences in the metastatic index. There was no statistically significant difference in the incidence of anastomotic leaks for both groups (3.8% for HT versus 3.0% for LT). With respect to the 3-year disease-free interval, there were also significant differences - 81.2% (HT) and 79.4% (LT) and the overall survival rate of 79.1% (HT) compared to 77.2% (LT) with a 72% follow-up coefficient.Discussion: The findings of this study are broadly consistent with those published so far and analyzed in three systematic reviews - the last one in 2018. This indicates that no statistically significant difference between high and low vascular ligation has been identified for the most important comparative indicators. It is extremely important to discuss several technical issues at present - contemporary problems requiring future high-quality clinical trials: the necessity and means of implementing left colic flexure mobilization in both types of vascular ligation with the lack of standardization; adequate and accurate identification of a correct cleavage plane of the dissection with differentiation of target vascular areas, avoiding erroneous entry into the sigmoid mesentery along with separate ligation of sigmoid vessels - oncologically inappropriate; sequence and level of ligation of the lower mesenteric vein with wide variations; pathoanatomic processing of the specimen with adequate isolation and examination of the removed lymph nodes, respectively adequacy of the pathohistological N-staging as well as the quality of the mesorectal excision; the need for stage control of the microvascular perfusion of the anastomosis segments by ICG fluorescence on the already validated global methods (hence the prevention of anastomotic leaks); progress in the importance and technical feasibility of low tie vascular ligation + perivascular lymph dissection to the IMA origin, and complete mesocolic excision (CME) in colon carcinoma (similar to TME in the rectal), the subject of more and more current studies; the specifics and advantages of robotic surgery of left-sided colon and rectal cancer with respect to accuracy of vascular and lymphatic dissection

Prognostic factors for anastomotic insufficiency in elective colorectal surgery

Introduction: Anastomotic insufficiency is a severe, potentially fatal complication of colorectal surgery. Its frequency, according to different authors, reaches up to 20%. It is related to two main types of risk factors: associated with the patient and associated with the therapeutic approach.Aim: The aim of the study is to determine prognostic factors for anastomotic insufficiency. The collected data from patients operated on for a period of 5 years (2013-2017) in the Second Surgery Clinic, Alexandrovska University Hospital, Sofia, were analyzed.Materials and Methods: A total of 158 patients undergoing elective colorectal surgery have been retrospectively included. These on emergency, non-proven malignancies and with preoperative haemotransfusion were excluded from the study. All patients were evaluated by age, gender, BMI, ASA score, Charlson Comorbidity Score, localization, TNM stage and histological type. The surgical approach and the method of resection were determined. The postoperative period and complications were classified according to the Clavien-Dindo scale. The number of leukocytes, platelets, RDW, CRP and albumin were examined preoperatively, and on the day 1 and day 4, in the early postoperative period.Results: The average age of the patients was 67 (29-87). Of these, 100 (63.3%) were men, and 58 (36.7%) are women. The mean BMI was 27.1 (23-33). A total of  78.9% of the operated patients weree in TNM stage II and III. Histologically, 77.8% were moderately differentiated adenocarcinomas. The mean Charlson Comorbidity Score for the sample was 7.1 (range: 2-13), and the ASA score was 3 (2-4). The rectum was the most common localization - 40.1%, followed by right colon 22.8%, and the sigmoid colon 20.9%. Over the review period, most resections were conventional, with only 15.2% laparoscopic approach. The operations performed were right hemicolectomy - 36 (22.8%), left hemicolectomy -15 (9.5%), segmental resection - 38 (24.1%), total colectomy - 4 (2.5%) resection of the rectum - 44 (27.9%), and other - 21 (13.3%). In 12 (7.6 %) of the patients insufficiency was reported between day 2 and day 3, postoperatively. Five of them were treated conservatively and the other six were reoperated. Seven of the insufficiencies were after anterior resection of the rectum, 2 were after left hemicolectomy, 1 after resection of the sigmoid colon, one was after right hemicolectomy, which had been treated conservatively. The mean postoperative period of patients with insufficiency was 22 days (range: 9-45). For patients without complications, the postoperative period was 9.4 days (range: 4-21) and there was a strict statistical difference (P <0.05). All patients experienced an increase in leukocyte counts postoperatively, albumin drop, increased CRP and ESR. The mean platelet counts depended on the presence of insuffiency.Conclusion: The anterior resection, which is associated with technically more difficult anastomosis and neoadjuvant radiotherapy is a potential risk factor for anastomotic insufficiency. The use of blood parameters in the postoperative period allows early diagnosis of the complication and possible change of the therapeutic strategy

Metachronous Development of Meningothelial Meningioma, Basal Cell Carcinoma, and Glioblastoma Multiforme in a Patient with Pancreatic Incidentaloma

We report the unique case of a 61-year-old male patient with known pancreatic incidentaloma who additionally developed 3 other histologically different tumors: left sphenoid wing meningothelial meningioma, basal cell carcinoma of the occiput, and right occipital lobe glioblastoma multiforme. The latter were totally removed with a favorable clinical outcome. The patient’s family history was unremarkable, and no data on any previous head and neck irradiation were found

Intraoperative Radiotherapy with Balloon-Based Electronic Brachytherapy System—A Systematic Review and First Bulgarian Experience in Breast Cancer Patients

(1) Background: We aimed to analyze currently available studies with intraoperative radiotherapy (IORT) as a choice of treatment where the Xoft Axxent® electronic brachytherapy (eBx) system was used as a single-dose irradiation and an exclusive radiotherapy approach at the time of surgery in patients with early breast cancer (EBC). We also compared the results of the systematic review to the Bulgarian experience. (2) Methods and Materials: We performed a systematic review of the studies published before February 2021, which investigate the application of a single-fraction 20 Gy radiation treatment, delivered at the time of lumpectomy in EBC patients with the Xoft Axxent® eBx System. A systematic search in PubMed, Scopus, and ScienceDirect was performed. The results are reported following the PRISMA guidelines. The criteria on patients’ selection for IORT (the additional need for EBRT), cosmetic outcomes, and recurrence rate from the eligible studies are compared to the treatment results in Bulgarian patients. (3) Results: We searched through 1032 results to find 17 eligible studies. There are no published outcomes from randomized trials. When reported, the cosmetic outcomes in most of the studies are defined as excellent. The observed recurrence rate is low (1–5.8%). Still, the number of patients additionally referred to postoperative external breast radiotherapy (EBRT) is up to 31%. Amongst the 20 patients treated in Bulgaria, the cosmetic outcomes are also evaluated as excellent, five of which (25%) are referred for EBRT. Within median follow-up of 39 months, there was one local and one distal recurrence. (4) Conclusions: Current evidence demonstrates the Xoft Axxent® eBx system as a safe and feasible technique for IORT delivery in EBC patients. There are no randomized controlled trials conducted at this time point to prove its long-term effectiveness. Better patient selection and a reimbursement strategy have to be proposed to extend the application of this technique in Bulgaria