Search

Introduction Peritoneal metastases confer the worst survival amongst all sites of metastatic colorectal cancer. The adoption of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has become an option for patients with isolated colorectal peritoneal metastases (CRPM). The aim of this study was to evaluate the outcomes following CRS and HIPEC for CRPM from published high volume cohort studies and to highlight the latest controversies and future directions of CRPM treatment. Materials and methods A systematic review was performed on published studies on the treatment outcomes of CRS and HIPEC for colorectal peritoneal metastases. Results Twenty studies met the inclusion criteria for the systematic review. The median survival for all patients ranged from 14.6 to 60.1 months. The 5-year overall survival ranged from 23.4% to 52%. For patients with complete cytoreduction, the median survival was 25 to 49 months. Major morbidity and mortality ranged from 15.1% to 47.2% and 0% to 4.5%, respectively. Conclusion CRS and HIPEC for the treatment of CRPM is safe and current evidence suggests it improves both median and disease-free survival. However, the efficacy of intraperitoneal chemotherapy, in particular oxaliplatin, has recently come under scrutiny. Accordingly, higher quality evidence is urgently required to contribute to multidisciplinary and international consensus on CRPM treatment strategies.

Background Locally advanced rectal cancer is routinely treated with neo-adjuvant long course chemoradiotherapy or short course radiotherapy, followed by total mesorectal excision. Not all patients respond to this treatment and there has been an emergence of novel treatment strategies designed to improve outcomes for these patients. This systematic review aims to assess the current novel neo-adjuvant treatment strategies being utilised in the treatment of patients with rectal cancer and how these impact pathological complete response (pCR) rates. Methods A systematic review of the literature was performed to evaluate pathological response in patients with rectal cancer receiving novel neo-adjuvant therapy. EMBASE and Medline electronic databases were searched for relevant articles. Articles published between January 2008 and February 2019 were retrieved. Included studies underwent critical appraisal and complete pathological response rates were recorded. Results Of the initial 1074 articles identified, 217 articles fulfilled the inclusion criteria, of these 60 articles (4359 patients) were included. Neo-adjuvant therapy delivered included novel long course chemoradiation therapy, neoadjuvant chemotherapy alone, addition of a biological agent, total neo-adjuvant therapy, novel short course radiation therapy and studies utilising biomarkers to select patients for therapy. Complete pathological response rates ranged from 0 to 60%. Conclusion A validated novel neo-adjuvant therapy that significantly increases pCR rates in patients with rectal cancer has not been identified.

Highlights • Neuroendocrine tumours are the most common type of small bowel neoplasm. • Robotic technique may be superior to open technique for lymph node dissection. • Robotic-assisted complete mesocolic excision is a safe and effective technique., Introduction Neuroendocrine tumours are the most common type of primary small bowel neoplasm. Consensus guidelines recommend a multimodal approach to treatment of such tumours, with aggressive surgical resection remaining the mainstay of management. There is evidence that complete mesocolic excision (CME) of lymph nodes is associated with superior oncological outcomes including longer disease-free survival in patients with colorectal cancer than standard lymph node dissection and there is increasing evidence to suggest that the robotic approach may be superior to laparoscopic or open CME. This report discusses a robotic-assisted approach to CME with central vessel ligation (CVL) and para-aortic lymph node dissection in a case of multifocal neuroendocrine tumour of the small bowel. Presentation of case and technical approach This report details the case of a 73-year-old male with multifocal small bowel neuroendocrine tumour. He underwent a robotic-assisted right hemicolectomy, small bowel resection, CME, CVL and para-aortic lymph node dissection. The approach described involved undertaking CME, CVL and bowel resection with a standard right hemicolectomy robotic set-up before re-docking the robot to perform the retroperitoneal para-aortic lymph node dissection. Discussion This case highlights the management of multifocal small bowel neuroendocrine tumour using a robotic approach for surgical resection and lymph node clearance. Conclusion The robotic approach provides a safe and effective technique for undertaking surgical resection of small bowel neuroendocrine tumour as well as complete mesocolic excision of lymph nodes. With a change in port positions, a robotic approach can be utilised for CME/CVL as well as retroperitoneal node dissection.

Highlights • The safe adoption of transanal total mesorectal excision (taTME) has occurred in many countries worldwide. • Planes beyond TME can be utilised in more advanced cases to achieve negative margins during transanal dissection. • In this case, the transanal technique allowed the surgeons to ensure organ preservation and control the R1 risk point during dissection. • An R0 resection was achieved. • This technical note highlights that in experienced hands, taTME can be safely implemented to maintain restorative options in locally advanced rectal cancer requiring resection beyond the mesorectal plane., Background The safe adoption of transanal total mesorectal excision (taTME) has occurred in Australasia as previously reported by the current authors. Planes beyond TME can be utilised in more advanced cases to achieve negative margins during transanal dissection. Methods In this article we describe how taTME is used to perform an en-bloc partial vaginectomy and aid restore intestinal and vaginal continuity in a young female with a locally advanced rectal cancer and posterior vaginal wall involvement in the pre-treatment magnetic resonance imaging. Results The transanal technique allowed the surgeons to remove a disc of vagina, ensure organ preservation and control the main R1 risk point. An R0 resection was achieved. Conclusion This technical note highlights that in experienced hands, taTME may be safely implemented to maintain restorative options in locally advanced rectal cancer requiring resection beyond the total mesorectal excision plane.

To examine the changes in exenterative surgery over three decades analysing oncological outcomes and whether changes in surgical approach have led to improved patient outcomes.Advances in surgical technology, perioperative care and pattern of disease recurrence have coincided with an evolutionary change in exenterative surgery.A review of a prospectively maintained databases of pelvic exenteration surgery from 1988 to 2018 at two high volume specialised institutions. The total cohort was divided into three major time points (1988-2004, 2005-2010 and 2011 to 2018) to allow comparative analysis. Primary endpoints were overall survival in primary and recurrent disease at each time point. Secondary endpoints included anastomotic leak, blood transfusion, ileus, wound infection rates and evolution of case complexity. Data were analysed using R with a p 0.05 considered significant.Six hundred and seventy patients underwent exenterative surgery. In 2011-2018 there was an increase in resection of recurrent malignancy with a continuous increase in GI malignancies resected over each time period(p 0.001,0.01) and a reduction in gynaecological malignancy(p 0.001). A significant increase in sacrectomy, pelvic sidewall resection and ileal conduit reconstruction was observed (p 0.01,0.001).In 2005-2010 patients had increased rates of ileus and anastomotic leak(p 0.05). Patients undergoing resection for primary disease had improved overall survival at time points 1988-2004 and 2011-2018 compared to those with recurrent disease(p = 0.007,0.001). Overall survival was significantly improved in patients with primary versus recurrent disease(p = 0.022).There has been a significant improvement in survival in patients undergoing pelvic exenteration surgery from primary disease. Case complexity has increased without significant morbidity.

Introduction Clostridium difficile ( C. difficile ) is the most common cause of antibiotic-related diarrhoea. In the immunocompromised host it is a source of considerable morbidity. Transmission between patients is preventable. The aim of this study was to survey healthcare professionals' knowledge of Clostridium difficile infection (CDI) at our institution. Methods A written survey was distributed to doctors and nurses of a major tertiary institution. The survey polled knowledge and management decisions regarding clinical scenarios relating to C. Difficile -associated disease and transmission. Survey responses were collated and analysed. Results One hundred and forty-six healthcare professionals (91.3%) completed the survey (81 nurses, 65 doctors). Thirty-two (21.9%) had attended an educational seminar on C. difficile . No healthcare worker was able to correctly answer all survey questions. Only four (2.7%) respondents correctly identified all major risk factors for CDI. Respondents who had previously attended a CDI information session were more likely to identify broad-spectrum antibiotic use as a risk factor (97% v. 82%, P =0.046), and more likely to be aware of the existence of CDI in the community setting (97% v. 78%, P =0.02). Thirty-four (23.3%) respondents identified the most important management aspects in non-severe CDI, while 85 (58.2%) identified the best method to remove C. difficile spores. Doctors were less likely to identify the correct method of preventing the transmission of the spore-form of C. difficile than nurses (49% v. 69%, P =0.04). Overall survey performance was better among employees who had attended an information session regarding CDI, (63.1% v. 56.7%, P Conclusions Knowledge of CDI is poor among healthcare professionals. A potential for further education exists.