Current Surgical Strategies in the Management of Rectal Cancer

Azevedo, José; Vailati, Bruna Borba; Julião, Guilherme Pagin São; Fernández, Laura Melina; Perez, Rodrigo Oliva

doi:10.1007/s11888-019-00428-0

Cited by 4 publications

(1 citation statement)

References 61 publications

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“…With the high incidence of CRC and its high risk of onset in IBD patients, it is important to establish which of the various techniques and treatment regimens can be applied in this specific patient population. Neoadjuvant treatments have opened a path to organ preservation techniques, avoiding surgical related morbidities and the need for a definitive colostomy 12. With its use, the description and establishment of the WW programme have brought an improvement in the quality of life of patients with cancer of the rectum.…”

Section: Discussionmentioning

confidence: 99%

Watch and Wait for rectal cancer in inflammatory bowel disease

et al. 2023

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Colorectal cancer is currently the third most frequently diagnosed type of cancer and the second cause of cancer death in the western world. Inflammatory bowel disease patients are 2–6 times more likely to develop CRC than the general population. Patients with CRC arising through Inflammatory Bowel Disease have an indication for surgery. However, in patients without Inflammatory Bowel Disease, the use of organ (rectum) preservation strategies after neoadjuvant treatment is on the rise, which means that patients are able to keep the organ without the need for complete excision, either by treatment with radiotherapy and chemotherapy, or in combination with endoscopic or surgical techniques that allow local excision without the need for resection of the entire organ. The patient management approach known as the Watch and Wait programme was first introduced in 2004 by a team from São Paulo, Brazil. This approach suggested that patients who had an excellent or complete clinical response after neoadjuvant treatment could defer surgery and instead undergo Watch and Wait. This organ preservation technique became popular because it allowed patients to avoid the complications associated with major surgery while achieving similar oncological outcomes to those who underwent both neoadjuvant therapy and radical surgery. Following completion of neoadjuvant treatment, a decision to defer surgery is made based on whether a clinical Complete Response can be achieved, which means there is no evidence of tumour in clinical and radiological examination. The International Watch and Wait Database has published long-term oncological outcomes for patients treated with this strategy, and more patients are showing interest in this treatment option. However, it is important to note that up to 1/3 of patients selected for Watch and Wait may eventually require surgery for local regrowth (also known as ‘deferred definitive surgery’) at any time during follow-up after an initial ‘apparent’ clinical Complete Response. Compliance with a strict surveillance protocol ensures early detection of regrowth, which is usually amenable to R0 surgery and provides excellent long-term local disease control. Nonetheless, it is crucial to assess the perioperative consequences of having surgery for regrowth later and whether there are any negative effects from deferring surgery. Currently, the Watch and Wait strategy is recommended in the NCCN guidelines for clinical complete responders and only in specialised multidisciplinary centres.There is no case in the literature that portrays the use of the Watch and Wait programme for patients with inflammatory bowel disease and rectal cancer.The authors intend to present a case that demonstrates the difficulties in the assessment of patients with inflammatory bowel disease, the risks of using radiotherapy in this patients and the challenges of surveillance for patients with colorectal cancer and inflammatory bowel disease.

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Section: Discussionmentioning

confidence: 99%

Watch and Wait for rectal cancer in inflammatory bowel disease

et al. 2023

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Safe implementation of minimally invasive surgery in a specialized colorectal cancer unit

Azevedo,

Kashpor,

Fernandez

et al. 2024

Tech Coloproctol

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Introduction In the past 30 years, minimally invasive surgery (MIS) has made remarkable progress and has become the standard of care in colorectal cancer treatment. The implementation of new techniques or platforms is, therefore, a challenge for surgical teams. This study aims to analyze the experience in the implementation of minimally invasive surgery in the colorectal unit in a specialized colorectal cancer center. We will report and compare the clinical outcomes of the patients submitted to the different surgical approaches, reflecting the importance of surgical training in the laparoscopic and robotic field for the reduction of surgical complications and improve short-term outcomes. Methods This study involved a retrospective analysis of data collected from a prospectively maintained database at the colorectal unit of Champalimaud Foundation between 2012 and 2023. Data were collected as part of routine clinical documentation and included variables on patient’s demographics, staging, short-term outcomes, and follow-up. Results A total of 661 patients treated at the Champalimaud Foundation between 2012 and 2023 were included, of which 389 (59%) had colon and 272 (41%) rectal cancer. Most of the patients underwent elective surgery, with a minimally invasive approach performed in 91% of cases. A complete resection (R0) was achieved in 95.1% (619) of the procedures with a pathology report staging 64.5% (409) of tumors as pT3–4. Eleven percent (70) of patients had complications classified as Clavien-Dindo (CD) ≥ 3. Conclusion This study supports the safety of the implementation of minimally invasive surgery in colorectal cancer care, with improvement in postoperative outcomes and surgical quality, supporting the importance of surgical training and specialized teams.

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Key steps in exposure techniques for robotic total mesorectal excision (TME)

Tomada,

Azevedo,

Fernandez

et al. 2024

Tech Coloproctol

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Aim The use of robotic surgery is increasing significantly. Specific training is fundamental to achieve high quality and better oncological outcomes. This work defines key exposure techniques in robotic total mesorectal excision (TME). Based on a modular approach, macro- and microtractions for exposure in every step of a robotic TME are identified and described. The aim is to develop a step-by-step technical guide of the exposure techniques for a robotic TME. Methods Twenty-five videos of robotic rectal resections performed at Champalimaud Foundation (Lisbon, Portugal) with the Da Vinci™ Xi robotic platform were examined. Robotic TME was divided into modules and steps. Modules are essential phases of the procedure. Steps are exposure moments of each module. Tractions are classified as macro- and microtractions. Macrotraction is the grasping of a structure to expose an area of dissection. Microtraction consists in the dynamic grip of tissue to optimize macrotraction in a defined area of dissection. Results The procedure videos reviewed showed homogeneity concerning surgical methodology. Eight modules are outlined: abdominal cavity inspection and exposure, approach to and ligation of the inferior mesenteric vessels, medial to lateral dissection of the mesocolon, lateral colon mobilization, splenic flexure takedown, proctectomy with TME, rectal transection, and anastomosis. Each module was divided into steps, with a total of 45 steps for the entire procedure. This manuscript characterizes macrotraction and microtraction fine-tuning, detailing the large-scale macrotractions and the precision of microtractions at each step. Conclusion Tissue exposure techniques in robotic TME are key to precise dissection. This modular guide provides a functional system to reproduce this procedure safely; the addition of the exposure techniques could serve as a training method for robotic rectal cancer surgery.

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Current Surgical Strategies in the Management of Rectal Cancer

Cited by 4 publications

References 61 publications

Watch and Wait for rectal cancer in inflammatory bowel disease

Watch and Wait for rectal cancer in inflammatory bowel disease

Safe implementation of minimally invasive surgery in a specialized colorectal cancer unit

Key steps in exposure techniques for robotic total mesorectal excision (TME)

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