INTRODUCTION:Watch-and-Wait (WW) strategy is increasingly offered to rectal cancer patients achieving a clinical complete response to avoid major surgery. However, the safety of this approach relies on variables beyond response. The present study explores variables that determine the safety of a WW program using mathematical modelling. METHODS:This study utilized a Markov state-transition model to simulate 10,000 patients, aiming to quantify the specific tipping points where WW becomes oncologically inferior to immediate Total Mesorectal Excision (TME). Probabilistic and deterministic sensitivity analyses were performed. RESULTS:The simulation compared outcomes over a 5-year horizon for Disease-Free Survival (DFS) and 10 years for Overall Survival (OS). The base-case analysis showed that while 10-year overall survival was equivalent between the two strategies (83.0% for WW versus 81.5% for TME), the salvage rate, the success of surgery following tumor regrowth, emerged as the dominant driver of patient safety. The model identified that WW becomes inferior to immediate surgery if the salvage rate drops below 75% for DFS or below 61% for OS. Survival is also compromised if the proportion of near-complete responders exceeds 68%, or if the early regrowth rate surpasses 10% per six-month cycle. CONCLUSIONS:Watch-and-Wait yields outcomes comparable to radical surgery only when specific quality benchmarks are met. Programs must maintain salvage rates above 75% and strictly monitor early regrowth velocity. Clinical teams should use these thresholds to guide patient counseling, suggesting that immediate TME is the safer option for patients falling outside these safety parameters.

Background: Achieving competency is crucial to ensure optimal outcomes in minimally invasive Intersphincteric resection. This study documents the learning curves for minimally invasive Intersphincteric resection using risk-adjusted cumulative sum curves with the surgical failure as a composite endpoint, providing a dynamic assessment of performance and competency attainment. Methods: All consecutive minimally invasive Intersphincteric resections performed by a single team of surgeons at a tertiary referral colorectal cancer unit were audited. Surgical failure was defined as any of the following: positive resection margin, local recurrence, or unreversed ostomy at one year. Risk-adjusted cumulative sum and Bernoulli cumulative sum curves were used for sequential assessment of performance. Results: Amongst 310 Intersphincteric resections, surgical failure was observed in 66 patients (21%). A positive margin was seen in 11 patients (3.5%), unreversed stoma at one year in 53 (17%), and local recurrence in 18 patients (5.8%). The risk-adjusted cumulative sum identified the first inflexion point corresponding to the achievement of competency after the 40th case. Further, other instances of higher-than-predicted surgical failures were observed and explained. While laparoscopic Intersphincteric resection risk-adjusted cumulative sum curves mirrored the curves for entire cohort, the robotic curves could not identify any discernable inflexion. Conclusions: The learning curve for Intersphincteric resection by minimally invasive technique was achieved after the 40th case for a team that was trained in minimally invasive colorectal surgery. The broader applicability of cumulative sum curves for early detection of deterioration in outcomes highlights the need for their wider use in procedural monitoring.

Parastomal herniation is a prevalent complication of colostomies, with rates as high as 60

Rectal neuroendocrine tumours are rare but increasing worldwide. However, there is limited data from regions like the Indian subcontinent, where clinical presentations and outcomes may differ due to unique demographic and biological factors. This study aimed to characterize rectal neuroendocrine tumours in our region, focusing on clinic-pathological presentation, and treatment outcomes. This was an observational single-centre retrospective cohort study from a high-volume tertiary care centre in Western India. Sixty-five consecutive patients with rectal neuroendocrine tumours treated between 2013 and 2023 were included. The main outcome measures were overall survival and disease-free survival. Secondarily, we tried to evaluate the impact of pathological grade and surgery-type on survival outcomes. The median age at diagnosis was 50 years, younger than the global median (56–57 years), with a male predominance (80

This study looks at sexual and urinary dysfunction and quality of life in male patients undergoing extended total mesorectal excision. This cross-sectional study used International Prostatic Symptom Score (IPSS) and the International Index of Erectile Function Score (IIEF) questionnaire-based retrospective analysis of male patients who underwent extended total mesorectal excision from 2015 to 2022. Quality of life was assessed using EORTC QLQ C-30 and EORTC QLQ CR-29. Sixty-eight male patients were included, with a median age of 44 years. Urinary retention and incontinence occurred in 10.3

The introduction of total mesorectal excision improved locoregional control for rectal adenocarcinoma significantly. Standardisation of the technique of LPLND is lacking in literature. We describe the current practices of case selection and technical details of lateral lymph node dissection in rectal cancer. We also describe the approach when post neo-adjuvant fibrosis renders standard resection unsafe. Careful case selection and standardisation of the lateral lymph node dissection technique is important to ensure an oncologically sound and surgically procedure . Step-by-step procedures of LPLND are described in this article, and a video is demonstrated. Standardisation of the techniques of lateral lymph node dissection is essential. The procedure has a definite learning curve, requiring considerable expertise to avoid complications and achieve optimal outcomes.

AIM:To compare oncological outcomes of short-course radiation therapy (SCRT) versus long-course chemoradiation (LCRT) in patients with low rectal cancer, particularly in a high-volume center with expertise in extended total mesorectal excision (TME). METHODS:This was a single-institution, retrospective propensity-matched study using a prospectively maintained database. Patients with low rectal cancer (≤ 5 cm from the anal verge) who underwent neoadjuvant radiation (SCRT or LCRT) followed by TME between January 2014 and January 2021 were included. A 3:1 propensity score match was performed based on key clinical variables. Patients with metastatic disease or prior pelvic radiation were excluded. SCRT (25 Gy in 5 fractions) ± chemotherapy was followed by immediate or delayed surgery, while LCRT (50-50.4 Gy in 25-28 fractions) was given with capecitabine ± chemotherapy, followed by surgery. Extended resections were performed as indicated. RESULTS:After matching, 466 LCRT and 157 SCRT patients were analyzed. Three-year disease-free survival (DFS) was similar (62% LCRT vs. 64% SCRT, p = 0.8), with no significant differences in overall survival (OS), local recurrence-free survival (LRFS), pathological complete response (pCR: 18% vs. 20%, p = 0.5), or circumferential resection margin (CRM) positivity (6.4% vs. 10%, p = 0.12). Complication rates and local recurrence were also comparable. However, among clinical T4 tumors, SCRT was associated with significantly lower 2-year DFS (41.2% vs. 58.7%, p = 0.03) and a trend toward worse OS. CONCLUSION:SCRT provides comparable oncological outcomes to LCRT in low rectal cancer when appropriately selected. However, in clinical T4 tumors, LCRT appears.

This study investigates the functional outcomes of patients with low rectal cancer undergoing inter-sphincteric resection (ISR) following brachytherapy boost radiotherapy (BoRT), compared to those who underwent ISR after standard chemoradiotherapy. BoRT is an alternative to total neoadjuvant therapy for increasing organ preservation rates in low rectal cancers. However, its impact on sphincter function following stoma reversal remains unclear. The study involved a retrospective analysis of 145 patients treated at a single institution between 2013 and 2021. Eighteen patients received pre-operative BoRT and were compared with 127 patients who did not, using propensity score matching based on age, sex, body mass index, and tumor distance from the anal verge with match ratio 1:4. Functional outcomes were assessed six months post-stoma reversal using the Low Anterior Resection Syndrome (LARS) Score, Wexner Score, and Kirwan Grade. The results revealed that patients in the boost RT group had significantly worse functional outcomes, with a median LARS score of 36 (very high) compared to 10 in the no boost group (p < 0.001). Similarly, the median Wexner score was higher in the boost RT group (17 vs. 8, p < 0.001). The Kirwan Grade was consistent across both groups. This study highlights the detrimental impact of BoRT on functional status, underscoring the importance of comprehensive patient counselling before initiating BoRT in candidates eligible for sphincter preservation. If optimal outcomes are not achieved following brachytherapy boost, surgical options like ISR or APR should be thoroughly discussed with patients to ensure informed decision-making.

BACKGROUND:Textbook outcome is an integrated measure including both clinical and oncological outcomes. Within minimally invasive rectal cancer surgery, whether the achievement of textbook outcome translates into improved oncological outcomes is not studied. OBJECTIVE:To evaluate textbook outcome and its associated factors for patients undergoing minimally invasive total mesorectal excision. DESIGN:Single-center retrospective study. SETTINGS:The study was conducted at a high-volume tertiary referral cancer center in India. PATIENTS:All patients receiving elective laparoscopic or robotic total mesorectal excision from 2013 to 2023 were included. MAIN OUTCOME MEASURES:The number of patients achieving textbook outcome, institute's time trend, factors affecting textbook outcome, and intermediate oncological outcomes were evaluated. RESULTS:Of the 1394 patients who underwent minimally invasive total mesorectal excision, 831 patients (60%) achieved textbook outcome. The conversion rate to open surgery is 0.2% with Clavien-Dindo grade 3 or higher complications in 1.6% of patients. Twenty-seven percent of patients had a prolonged hospital stay, with a 30-day readmission rate being 3%. Four percent of patients had a poor lymph node yield, the R0 resection rate was 98%, and adjuvant therapy delay was observed in 6% of patients. The achievement of textbook outcome resulted in improved 3-year overall survival (92.1% vs 83.7%, p < 0.001) and disease-free survival (81.5% vs 75.7%, p = 0.007). LIMITATION:The results of our study cannot be generalized to open total mesorectal excision, beyond total mesorectal excision and extended total mesorectal excision, where benchmark criteria definitions vary. CONCLUSIONS:Textbook outcome for minimally invasive total mesorectal excision was achieved in 60% of patients with rectal cancer at a high-volume tertiary cancer institute. It could be used for benchmarking, thus improving the results of minimally invasive total mesorectal excision, and as a quality indicator in nationwide surgical audits. See Video Abstract . RESULTADOS TPICOS DE LA ESCISIN MESORRECTAL TOTAL MNIMAMENTE INVASIVA UNA HERRAMIENTA COMPUESTA PARA EVALUAR Y COMPARAR RESULTADOS O ESTABLECER PUNTOS DE REFERENCIA:ANTECEDENTES:El resultado teórico es una medida integrada que incluye tanto los resultados clínicos como los oncológicos. En el ámbito de la cirugía mínimamente invasiva del cáncer rectal, no se ha estudiado si la consecución del resultado teórico se traduce en una mejora de los resultados oncológicos.OBJETIVO:Evaluar el resultado teórico y sus factores asociados en pacientes sometidos a disección mesorrectal total mínimamente invasiva.DISEÑO:Estudio retrospectivo en un único centro.ENTORNO:El estudio se llevó a cabo en un centro oncológico terciario de referencia con un gran volumen de pacientes en la India.PACIENTES:Se incluyeron todos los pacientes sometidos a una extirpación mesorrectal total laparoscópica o robótica electiva entre 2013 y 2023.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron el número de pacientes que alcanzaron el resultado teórico, la tendencia temporal del instituto, los factores que influyeron en el resultado teórico y los resultados oncológicos intermedios.RESULTADOS:De los 1394 pacientes que se sometieron a una extirpación mesorrectal total mínimamente invasiva, 831 (60 %) lograron el resultado teórico. La tasa de conversión a cirugía abierta es del 0,2 %, con complicaciones ≥ Clavien-Dindo 3 en el 1,6 % de los pacientes. El 27 % de los pacientes tuvieron una estancia hospitalaria prolongada, con una tasa de reingreso a los 30 días del 3 %. El 4 % de los pacientes presentó un rendimiento linfonodal deficiente, la tasa de resección R0 fue del 98 % y se observó un retraso en la terapia adyuvante en el 6 % de los pacientes. El logro de los resultados teóricos dio lugar a una mejora de la supervivencia global a 3 años (92,1 % frente a 83,7 %, p <0,001) y de la supervivencia libre de enfermedad (81,5 % frente a 75,7 %, p = 0,007).LIMITACIONES:Los resultados de nuestro estudio no pueden generalizarse a la disección mesorrectal total abierta, más allá de la disección mesorrectal total y la disección mesorrectal total ampliada, donde varían las definiciones de los criterios de referencia.CONCLUSIÓN:Se obtuvieron resultados de libro de texto para la extirpación mesorrectal total mínimamente invasiva en el 60 % de los pacientes con cáncer rectal en un instituto oncológico terciario de alto volumen. Podría utilizarse como referencia, mejorando así los resultados de la extirpación mesorrectal total mínimamente invasiva y también como indicador de calidad en auditorías quirúrgicas a nivel nacional. (Traducción-Dr. Felipe Bellolio ).

Cancers of the esophagus tend to be aggressive with a poor prognosis. Neuroendocrine carcinoma (NEC) of the esophagus is very rare and currently does not have any established treatment regimens. This is in part due to its rare prevalence. This case report presents an unusual case of distal esophageal NEC, which was complicated by liver metastasis and paraneoplastic syndrome. A 56-year-old postmenopausal woman came with complaints of weight loss, pain in the epigastric region, and intermittent dysphagia to solids for three months. An endoscopy revealed a 2 cm x 1 cm ulceronodular lesion located at the gastroesophageal junction. The biopsy showed NEC on histological examination, and the immunohistochemistry was positive for multiple neuroendocrine markers. A positron emission tomography (PET) scan revealed a stage IV metastatic disease that had spread to the liver as well as gastrohepatic and peri-gastric lymph nodes. Subsequently, the patient received palliative intent chemotherapy with Etoposide and Cisplatin for four cycles, which resulted in a partial response. Due to this, she was advised four more cycles of chemotherapy, but after two cycles, she developed signs of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Following management with hypertonic saline, her health deteriorated, resulting in death within one year of diagnosis. NECs of the esophagus tend to be detected at later stages and show a worse prognosis and disease course than squamous cell carcinoma or adenocarcinoma of the esophagus. With improvements in investigation methods, an increase in the detection of NEC in the esophagus can be expected in the future. Early diagnosis can help overall survival and boost quality of life. Further research and clinical trials are needed to assess ideal treatment plans.

Purpose: Inter-sphincteric resection (ISR) is being increasingly performed in metastatic rectal adenocarcinoma (with oligo-metastasis) patients. There has been a trend towards worse prognosis in this group. This study compares the oncological and surgical outcomes of patients with and without pre-operative oligo-metastasis who underwent ISR. The outcomes compared include prognostic factors like margin positivity, recurrence rates, stoma reversal rate, surgical failure rate (defined as a combination of one or more of the aforestated factors). The demographic pattern, American Society of anaesthesia grade (ASA), treatment received, clinical and histopathological T and N stage, grade, type of MIS approach, neoadjuvant therapy and pathological high-risk features are also studied. Methods: Patients who underwent minimally invasive ISR over ten years at a high-volume tertiary cancer centre were selected for the study. Factors used for the assessment of oncological outcomes were margin positivity (circumferential resection and distal margin), recurrence (both local and systemic) and stoma reversal rate. A descriptive and comparative analysis were performed. Results: Four hundred and eight patients underwent minimally invasive ISR of which 25 (6.12%) patients were oligo-metastatic. Higher recurrence (24% versus 18.5%) and low stoma reversal rate (36.8% versus 67.3%) were observed in the oligo-metastatic group with statistically significant differences. Though no local recurrence was seen in the oligometastatic group the difference was not statistically different. Margin positivity was the same in both groups. Conclusion: This study shows that oligometastatic patients who underwent ISR experienced higher recurrence and low stoma reversal rates without affecting margin positivity.

BACKGROUND:Extramural vascular invasion (EMVI) is a bad prognostic feature in rectal cancer and cancers that remain EMVI positive after neoadjuvant therapy are at high risk for having involved circumferential resection margins. Conventional total mesorectal excision (TME) resections are inadequate in such cases and often lead to positive margins. METHODS:We propose a technique for the surgical management of locally advanced tumours with persistent EMVI after neoadjuvant therapy. Ten such tumours were resected using a "beyond TME" (b-TME) approach with or without lateral pelvic lymph node dissection or seminal vesical excision. RESULTS:A b-TME approach, customized to the anatomy of the tumour allowed for an R0 resection with a negative circumferential resection margin (CRM) in all 10 cases. CONCLUSION:A tailored b-TME approach can achieve good results in cases at high risk for CRM involvement.

Sharma, Ankit M.S., M.Ch.; Raghavan, Sriniket M.S., M.Ch.; Saklani, Avanish M.S., F.R.C.S. Author Information

Abstract Introduction APR is standard of care surgery for low rectal cancers involving sphincter. Surgery is commonly done in minimally invasive way. Robotic surgery has recently gained popularity due to ease of procedure. Margin positivity and local recurrence still remain a challenge. Methods It is a retrospective study from prospectively maintained database from Aug 2013 to Aug 2023. Surgical and oncological outcome were analyzed using SPSS version 25 software. Results Total 657 minimally invasive APRs were done. All were done in supine lithotomy position. 570 were laparoscopic and 87 robotic. Mean age was 48.4 years. 6 cases were converted to open (5 lap and 1 robotic). Mean BMI was 22.3. Mean distance from anal verge was 3 cm. Majority patients were cT3 (74%). Median blood loss was 150 ml. Clavien Dindo grade III and beyond complications were seen in 11.2%. Mean hospital stay was 7 days. Mean nodes harvested were 13. Mean no of positive nodes were 1.22. Extended resections (extended TME) were 25% in lap and 42% in robotic. Poorly differentiated and signet histology was seen in 27%. CRM positivity was 6.9%. It increases to 15.5% in signet ring histology. Median follow up achieved was 46 months. Local recurrence was 5.5%. Distant recurrence was 20%. 3-year OS and DFS were 73% and 63% respectively. Conclusion In high volume minimally invasive surgery centre, MIS abdominoperineal resection - both laparoscopic and robotic has acceptable surgical and oncological outcomes.

Sharma, Ankit M.S., M.Ch.; Vispute, Tejas P. M.S., M.Ch.; Saklani, Avanish M.S., F.R.C.S. Author Information