Neo adjuvant chemo-radiotherapy and rectal cancer: Can India follow the West?
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Abstract:
The management of locally advanced rectal cancer has changed over the years with an emphasis on neoadjuvant chemo radiation therapy (CT-RT) followed by surgery. This study is undertaken to evaluate the efficacy of this treatment in our set of patients with a special focus on the outcome in large circumferential tumors.The study included patients who underwent neo adjuvant CT-RT between Jan 2006 and Oct 2009 in our institution. They received radical radiotherapy with conventional fractionation to a dose of 45-50 Gy along with continuous two cycles of 5-FU infusion. All patients were assessed at four weeks clinically and by CT scan and underwent surgery if the tumor was resectable followed by adjuvant chemotherapy.A total of 52 patients received the neoadjuvant treatment in form of CT-RT out of which 13 patients had undergone defunctioning colostomy before commencing treatment for severe obstructive symptoms. Only 73% patients underwent surgery in form of AR (anterior resection) or APR (abdominoperineal resection) and adjuvant chemotherapy was delivered in 28 (53.8%) patients only. The patients who underwent diversion colostomy had worse disease-free survival (DFS) as compared to those who received definitive treatment (33% vs. 74.9%, P<0.009).This study represents Indian experience with standard neoadjuvant chemo radiotherapy followed by surgery in rectal cancer. Large circumferential tumors in our set of patients lead to poor outcome leading to more APR. Also this study supported the need for an abbreviated protocol which can be economically suited and organ preservation protocols have a long way to go.Keywords:
Abdominoperineal resection
Neoadjuvant Therapy
BACKGROUND: The most common injury to indicate definitive stoma is rectal cancer. Despite advances in surgical treatment, the abdominoperineal resection is still the most effective operation in radical treatment of malignancies of the distal rectum invading the sphincter and anal canal. Even with all the effort that surgeons have to preserve anal sphincters, abdominoperineal amputation is still indicated, and a definitive abdominal colostomy is necessary. This surgery requires patients to live with a definitive abdominal colostomy, which is a condition that modify body image, is not without morbidity and has great impact on the quality of life. AIM: To evaluate the technique of abdominoperineal amputation with perineal colostomy with irrigation as an alternative to permanent abdominal colostomy. METHOD: Retrospective analysis of medical records of 55 patients underwent abdominoperineal resection of the rectum with perineal colostomy in the period 1989-2010. RESULTS: The mean age was 58 years, 40 % men and 60 % women. In 94.5% of patients the indication for surgery was for cancer of the rectum. In some patients were made three valves, other two valves and in the remaining no valve at all. Complications were: mucosal prolapse, necrosis of the lowered segment and stenosis. CONCLUSION: The abdominoperineal amputation with perineal colostomy is a good therapeutic option in the armamentarium of the surgical treatment of rectal cancer.
Abdominoperineal resection
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Abdominoperineal resection
Perforation
Rectal carcinoma
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Reconstruction following abdominoperineal resection improves outcomes by reducing wound-related complications, particularly in irradiated patients. Little is known regarding system-level factors that impact patients' access to reconstructive surgery following abdominoperineal resection. This study aimed to identify barriers to undergoing reconstruction following abdominoperineal resection.Using the National Inpatient Sample database from 2012 to 2014, all encounters with colorectal or anorectal carcinoma patients who underwent abdominoperineal resection were extracted based on International Classification of Disease, Ninth Revision, diagnosis and procedure codes. Multivariable logistic regression analyzed the outcome of undergoing reconstruction.The weighted sample included encounters with 19,205 abdominoperineal resection patients, of whom 1243 (6.5 percent) received a flap. Notable patient-level predictors of receiving a flap included age younger than 55 years (OR, 1.82; 95 percent CI, 1.23 to 2.74; p = 0.003) and neoadjuvant chemoradiation therapy (OR, 1.37; 95 percent CI, 1.01 to 1.88; p = 0.041). Race, sex, income level, insurance type, and Elixhauser Comorbidity Index were not associated with increased odds of receiving a flap. For facility-level factors, urban teaching hospitals (OR, 23.6; 95 percent CI, 3.29 to 169.4; p = 0.002) and larger hospital bedsize (OR, 2.64; 95 percent CI, 1.53 to 4.56; p = 0.000) were associated with higher odds of reconstruction. Plastic surgery facility volume was not found to be a significant predictor of undergoing flap reconstruction (p > 0.05).Patients undergoing abdominoperineal resection at academic centers were over 23 times more likely to undergo reconstruction, after adjusting for available confounders. Patients undergoing abdominoperineal resection at smaller, nonacademic centers may not have equitable access to reconstruction despite being appropriate candidates. Given the morbidity of abdominoperineal resection, patients should be referred to large, academic centers to have access to flap reconstruction.Risk, III.
Abdominoperineal resection
Odds
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Abdominoperineal resection
Stoma (medicine)
Surgical oncology
Colorectal Surgery
Ileostomy
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PURPOSE: Following initial radiotherapy or chemoradiotherapy for the treatment of anal cancer, patients who present with either persistent or locally recurrent disease are treated by abdominoperineal resection. The aim of this retrospective study was to review the long-term survival and prognostic factors after such surgery in a single institution. METHODS: Over a 34-year period (1969–2003), 422 patients with nonmetastatic anal cancer were treated with a curative intent. Of these, 83 (median age 61 years; 74 women) underwent abdominoperineal resection. RESULTS: Forty-one patients underwent abdominoperineal resection for persistent disease and 42 for locally recurrent disease. Postoperative mortality was 4.8 percent and morbidity was 35 percent with 18 percent having perineal wound infections. Median follow-up was 104 months (range, 3–299). The 3-year and 5-year actuarial survival was 62.8 and 56.5 percent respectively. Using univariate analysis, patients below 55 years, females, T1–2 tumors, N0-N1 lymphadenopathy and the absence of locally advanced tumor were associated with significantly improved survival. Surgery, whether for persistent or locally recurrent disease, did not affect the 5year survival rate. CONCLUSIONS: Abdominoperineal resection for nonmetastatic anal cancer is associated with a high morbidity rate but may result in long-term survival regardless of the indication.
Abdominoperineal resection
Univariate analysis
Chemoradiotherapy
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Five patients with squamous or basaloid carcinoma of the anal canal have been treated with synchronous chemotherapy and external radiotherapy. Three were operable cases, of which one had abdominoperineal resection subsequently, while two had no surgery. The other two had a locally advanced inoperable tumour in one case and pelvic recurrence following abdominoperineal resection in the other. The chemotherapy regimen consisted of mitomycin C given as a single dose of 10 mg m ‐2 at commencement of radiotherapy and two i.v. infusions of 5‐fluorouracil 1000 mg m ‐2 /day for 4 consecutive days approximately 4 weeks apart. The radiation dose ranged from 50 Gy to 70 Gy in 25–35 fractions. All patients remain disease free with a median follow up of 14 months. Eradication of tumour at the primary site has been confirmed histologically in the three operable cases. A growing volume of data from the medical literature suggests that patients with operable carcinoma of the anal canal treated with this regimen have a probability of cure at least equal to that of abdominoperineal resection and have the advantage of retaining normal anal function and avoiding permanent colostomy.
Abdominoperineal resection
Regimen
Anal Carcinoma
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• Abdominoperineal resection was at one time 'the surgery' for rectal cancer • Abdominoperineal resection surgery has evolved over time • Abdominoperineal resection surgery tailored to tumor extent
Abdominoperineal resection
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Abdominoperineal resection
Debridement (dental)
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PURPOSE: Abdominoperineal resection has a high rate of postoperative morbidity of the perineal wound. This study aimed to determine the effects of perineal colostomy on perineal morbidity after abdominoperineal resection. METHODS: All patients who underwent an abdominoperineal resection for rectal adenocarcinoma between 1993 and 2007 were studied. Two groups were identified and compared who had undergone either an iliac colostomy or a perineal colostomy. RESULTS: The analysis included 110 patients (iliac colostomy group, n = 41; perineal colostomy group, n = 69). There were fewer instances of pelviperineal morbidity (P = .008) and fewer instances of wound dehiscence (P = .02) in the perineal colostomy group, which resulted in a shorter time to healing (35.3 vs 45.1 d, respectively; P = .04). There was no specific postoperative morbidity in any patient and no difference between the 2 groups regarding long-term perineal morbidity. The benefits from perineal colostomy were statistically significant in patients who received radiation therapy in terms of pelviperineal morbidity (P = .01) and healing time (50.8 vs 35.9 days, respectively; P = .02), whereas no difference was found in patients who had not received radiation therapy. CONCLUSION: Perineal colostomy is a safe and functionally acceptable procedure for perineal reconstruction after abdominoperineal resection for rectal adenocarcinoma. In the present study, there was no additional morbidity related to perineal colostomy, and this procedure was associated with a decrease in perineal morbidity and healing time compared with primary perineal closure, in particular, after radiotherapy treatment.
Abdominoperineal resection
Colorectal Surgery
Wound dehiscence
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