Surgical treatment of rectal prolapse: experience and late results with 51 patients

The "best" surgical technique for the management of complete rectal prolapse remains unknown. Due to its low incidence, it is very difficult to achieve a representative number of cases, and there are no large prospective randomized trials to attest to the superiority of one operation over another. PURPOSE: Analyze the results of surgical treatment of complete rectal prolapse during 1980 and 2002. METHOD: Retrospective study. RESULTS: Fifty-one patients underwent surgical treatment during this period. The mean age was 56.7 years, with 39 females. Besides the prolapse itself, 33 patients complained of mucous discharge, 31 of fecal incontinence, 14 of constipation, 17 of rectal bleeding, and 3 of urinary incontinence. Abdominal operations were performed in 36 (71%) cases. Presacral rectopexy was the most common abdominal procedure (29 cases) followed by presacral rectopexy associated with sigmoidectomy (5 cases). The most common perineal procedure was perineal rectosigmoidectomy associated with levatorplasty (12 cases). Intraoperative bleeding from the presacral space developed in 2 cases, and a rectovaginal fistula occurred in another patient after a perineal rectosigmoidectomy. There were 2 recurrences after a mean follow-up of 49 months, which were treated by reoperation. CONCLUSION: Abdominal and perineal procedures can be used to manage complete rectal prolapse with safety and good long-term results. Age, associated medical conditions, and symptoms of fecal incontinence or constipation are the main features that one should bear in mind in order to choose the best surgical approach.A técnica cirúrgica mais apropriada para a correção da procidência retal permanece motivo de controvérsia. Por se tratar de afecção pouco freqüente, há dificuldade de avaliação de número adequado de pacientes em estudos randomizados e existe pouca evidência para comprovar a superioridade de alguma das técnicas. OBJETIVO: Analisar os resultados de eficácia e segurança do tratamento cirúrgico da procidência retal em pacientes operados entre 1980 e 2002. MÉTODO: Estudo retrospectivo. RESULTADOS: Cinqüenta e um pacientes foram operados. A idade média foi de 56,7 anos e 39 eram mulheres. Além do prolapso, 33 pacientes queixavam-se de eliminação de muco, 31 tinham incontinência anal, 14 apresentavam constipação, 17 com sangramento retal e 3 incontinência urinária. Operações abdominais foram realizadas em 36 (71%) casos, sendo a retopexia sem prótese a operação mais realizada (29 casos) seguida pela retossigmoidectomia com retopexia (5 casos). A operação perineal mais realizada foi a retossigmoidectomia com plastia dos elevadores (12 casos). O sangramento sacral foi a única complicação intra-operatória e ocorreu em dois casos. Como complicação pós-operatória, houve um caso de fístula retovaginal após operação de retossigmoidectomia perineal. Após seguimento médio de 49 meses, observamos recidiva da procidência em 2 casos. CONCLUSÕES: Operações abdominais e perineais podem ser utilizadas com segurança e eficácia no tratamento cirúrgico da procidência do reto. A idade, a presença de afecções associadas, comorbidades e os sintomas de constipação e incontinência são as principais variáveis envolvidas na escolha da operação. As operações de retopexia abdominal e retossigmoidectomia perineal estão associadas a bons resultados

Second St. Gallen European Organisation for Research and Treatment of Cancer Gastrointestinal Cancer Conference: consensus recommendations on controversial issues in the primary treatment of rectal cancer

Primary treatment of rectal cancer was the focus of the second St. Gallen European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Cancer Conference. In the context of the conference, a multidisciplinary international expert panel discussed and voted on controversial issues which could not be easily answered using published evidence. Main topics included optimal pretherapeutic imaging, indication and type of neoadjuvant treatment, and the treatment strategies in advanced tumours. Here we report the key recommendations and summarise the related evidence. The treatment strategy for localised rectal cancer varies from local excision in early tumours to neoadjuvant radiochemotherapy (RCT) in combination with extended surgery in locally advanced disease. Optimal pretherapeutic staging is a key to any treatment decision. The panel recommended magnetic resonance imaging (MRI) or MRI + endoscopic ultrasonography (EUS) as mandatory staging modalities, except for early T1 cancers with an option for local excision, where EUS in addition to MRI was considered to be most important because of its superior near-field resolution. Primary surgery with total mesorectal excision was recommended by most panellists for some early tumours with limited risk of recurrence (i.e. cT1-2 or cT3a N0 with clear mesorectal fascia on MRI and clearly above the levator muscles), whereas all other stages were considered for multimodal treatment. The consensus panel recommended long-course RCT over short-course radiotherapy for most clinical situations where neoadjuvant treatment is indicated, with the exception of T3a/b N0 tumours where short-course radiotherapy or even no neoadjuvant therapy were regarded to be an option. In patients with potentially resectable tumours and synchronous liver metastases, most panel members did not see an indication to start with classical fluoropyrimidine-based RCT but rather favoured preoperative short-course radiotherapy with systemic combination chemotherapy or alternatively a liver-first resection approach in resectable metastases, which both allow optimal systemic therapy for the metastatic disease. In general, proper patient selection and discussion in an experienced multidisciplinary team was considered as crucial component of care

The predictive and prognostic potential of plasma telomerase reverse transcriptase (TERT) RNA in rectal cancer patients

Background: Preoperative chemoradiotherapy (CRT) followed by surgery is the standard care for locally advanced rectal cancer, but tumour response to CRT and disease outcome are variable. The current study aimed to investigate the effectiveness of plasma telomerase reverse transcriptase (TERT) levels in predicting tumour response and clinical outcome. Methods: 176 rectal cancer patients were included. Plasma samples were collected at baseline (before CRT\ubcT0), 2 weeks after CRT was initiated (T1), post-CRT and before surgery (T2), and 4\u20138 months after surgery (T3) time points. Plasma TERT mRNA levels and total cell-free RNA were determined using real-time PCR. Results: Plasma levels of TERT were significantly lower at T2 (Po0.0001) in responders than in non-responders. Post-CRT TERT levels and the differences between pre- and post-CRT TERT levels independently predicted tumour response, and the prediction model had an area under curve of 0.80 (95% confidence interval (CI) 0.73\u20130.87). Multiple analysis demonstrated that patients with detectable TERT levels at T2 and T3 time points had a risk of disease progression 2.13 (95% CI 1.10\u20134.11)-fold and 4.55 (95% CI 1.48\u201313.95)-fold higher, respectively, than those with undetectable plasma TERT levels. Conclusions: Plasma TERT levels are independent markers of tumour response and are prognostic of disease progression in rectal cancer patients who undergo neoadjuvant therapy

The risk of distant metastases in patients with clinical complete response managed by watch and wait after neoadjuvant therapy for rectal cancer: the influence of local regrowth in the International Watch and Wait Database

BACKGROUND: Nearly 30% of patients with rectal cancer develop local regrowth after initial clinical complete response managed by watch and wait. These patients might be at higher risk for distant metastases.OBJECTIVE: This study aimed to investigate risk factors for distant metastases using time-dependent analyses.DESIGN: Data from an international watch and wait database were retrospectively reviewed. Cox regression analysis was used to determine risk factors for worse distant metastases-free survival. Conditional survival modeling was used to investigate the impact of risk factors on the development of distant metastases.SETTING: Retrospective, multicenter database.PATIENTS: A total of 793 patients (47 institutions) with rectal cancer and clinical complete response to neoadjuvant treatment from the International Watch & Wait Database were included.MAIN OUTCOME MEASURES: Distant metastases-free survival.RESULTS: Of the 793 patients managed with watch and wait (median follow-up 55.2 mo)‚ 85 patients (10.7%) had distant metastases. Fifty-one of 85 patients (60%) had local regrowth at any time. Local regrowth was an independent factor associated with worse distant metastases-free survival in the multivariable model. Using conditional estimates, patients with local regrowth without distant metastases for 5 years (from decision to watch and wait) remained at higher risk for development of distant metastases for 1 subsequent year compared to patients without local regrowth (5-year conditional distant metastases-free survival 94.9% vs 98.4%).LIMITATIONS: Lack of information on adjuvant chemotherapy, salvage surgery for local regrowth, and heterogeneity of individual surveillance/follow-up strategies used may have affected results.CONCLUSIONS: In patients with clinical complete response managed by watch and wait, development of local regrowth at any time is a risk factor for distant metastases. The risk of distant metastases remains higher for 5 years after development of local regrowth.Surgical oncolog

The value of metabolic imaging to predict tumour response after chemoradiation in locally advanced rectal cancer

Preliminary data of this work were presented by RCM and awarded at the 2009 Annual Meeting of the Spanish Society of Coloproctology (AECP) held in Barcelona.Background: We aim to investigate the possibility of using 18F-positron emission tomography/computer tomography (PET-CT) to predict the histopathologic response in locally advanced rectal cancer (LARC) treated with preoperative chemoradiation (CRT). Methods: The study included 50 patients with LARC treated with preoperative CRT. All patients were evaluated by PET-CT before and after CRT, and results were compared to histopathologic response quantified by tumour regression grade (patients with TRG 1-2 being defined as responders and patients with grade 3-5 as non-responders). Furthermore, the predictive value of metabolic imaging for pathologic complete response (ypCR) was investigated. Results: Responders and non-responders showed statistically significant differences according to Mandard's criteria for maximum standardized uptake value (SUVmax) before and after CRT with a specificity of 76,6% and a positive predictive value of 66,7%. Furthermore, SUVmax values after CRT were able to differentiate patients with ypCR with a sensitivity of 63% and a specificity of 74,4% (positive predictive value 41,2% and negative predictive value 87,9%); This rather low sensitivity and specificity determined that PET-CT was only able to distinguish 7 cases of ypCR from a total of 11 patients. Conclusions: We conclude that 18-F PET-CT performed five to seven weeks after the end of CRT can visualise functional tumour response in LARC. In contrast, metabolic imaging with 18-F PET-CT is not able to predict patients with ypCR accuratelyFounded by the Fundación Investigación Mutua Madrileña. We are indebted to M. Expósito Ruiz for statistical support. and to J-L Marín Aznar for pathologic analysisYe

ESTUDO SOBRE OS RESULTADOS DA IRRIGAÇÃO EM COLOSTOMIZADOS SUBMETIDOS A UM PROCESSO DE TREINAMENTO SISTEMATIZADO

O presente estudo versa sobre os resultados do emprego da auto-irrigaçâo por 40 colostomizados, por nós treinados através de um processo de treinamento sistematizado. A efetividade do processo de treinamento pode ser constatada à medida que a maioria dos clientes o adotou em seus itens básicos, apontando pequeno número de dificuldades técnicas. Quanto aos resultados da autoirrigaçâo, como método de controle do hábito intestinal, verificou-se que 37,50% da população apresentou ausência de perdas fecais e 42,50%, perdas esporádicas entre as irrigações; 27,50% e 35,00% com ausência e redução dos gases nesses intervalos, respectivamente e 32,50% e 37,50% com abolição total e parcial do uso da bolsa coletora, respectivamente