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Pseudomyxoma peritonei (PMP) is a rare condition mostly originating from low malignant potential mucinous tumours of the appendix. Although this disease process is minimally invasive and rarely causes haematogenous or lymphatic metastases, expectation of long-term survival are limited with no prospect of cure. Recently, the combined approach of cytoreductive surgery (CRS) and perioperative loco-regional chemotherapy (PLC) has been proposed as the standard of treatment for the disease. The present paper summarizes the available literature data and the main features of the comprehensive loco-regional treatment of PMP. The controversial issues concerning the indications and technical methodology in PMP management were discussed through a web-based voting system by internationally known experts. Results were presented for further evaluation during a dedicated session of "The Fifth International Workshop on Peritoneal Surface Malignancy (Milan, Italy, December 4-6, 2006)". The experts agreed that multiple prospective trials support a benefit of the procedure in terms of improved survival, as compared with historical controls. Concerning the main controversial methodological questions, there was an high grade of consistency among the experts and agreement with the findings of the literature.

Summary Cancer in pregnancy is uncommon, with an incidence of about one to two cases in every 1000 pregnancies. There are no randomised trials on any aspect of the management of cancer in pregnancy. Stage for stage cancer outcomes are similar in women who are pregnant compared with those who are not. Misdiagnosis and delayed diagnosis are common where the index of suspicion by the mother and health carers is low. Surgical interventions pose some risk to the fetus, especially laparotomy for abdominal tumours and procedures undertaken during the first trimester. Chemotherapy is teratogenic in the early stages, but seems to be safe in later pregnancy, and radiotherapy can be used for localised tumours remote from the uterus, such as head and neck or limb neoplasms. Suspicious symptoms should be appropriately investigated during pregnancy, and recent advances in non-ionising-radiation staging techniques, such as MRI and ultrasound, are especially helpful. Surgical interventions can be safely undertaken with minimum risk, although there is almost always some element of maternal–fetal conflict.

Contains fulltext : 52485.pdf (Publisher’s version ) (Closed access) Mounting evidence highlights that adhesions are now the most frequent complication of abdominopelvic surgery, yet many surgeons are still not aware of the extent of the problem and its serious consequences. While many patients go through life without apparent problems, adhesions are the major cause of small bowel obstruction and a leading cause of infertility and chronic pelvic pain in women. Moreover, adhesions complicate future abdominal surgery with important associated morbidity and expense and a considerable risk of mortality. Studies have shown that despite advances in surgical techniques in recent years, the burden of adhesion-related complications has not changed. Adhesiolysis remains the main treatment even though adhesions reform in most patients. Recent developments in adhesion-reduction strategies and new anti-adhesion agents do, however, offer a realistic possibility of reducing the risk of adhesions forming and potentially improving the clinical outcomes for patients and reducing the associated onward burden to healthcare systems. This paper provides a synopsis of the impact and extent of the problem of adhesions with reference to the wider literature and also consideration of the key note papers presented in this special supplement to Colorectal Disease. It considers the evidence of the risk of adhesions in colorectal surgery and the opportunities and strategies for improvement. The paper acts as a 'call for action' to colorectal surgeons to make prevention of adhesions more of a priority and importantly to inform patients of the risks associated with adhesion-related complications during the consent process.

Epithelial appendiceal tumors are uncommon but can present as an emergency simulating appendicitis, or unexpectedly at laparotomy, laparoscopy, or on cross-sectional imaging. Occult rupture with features of pseudomyxoma peritonei may be encountered. We report the operative findings, pathologic assessment, and early outcomes in 123 consecutive patients with a perforated appendiceal neoplasm presenting as pseudomyxoma peritonei. From March 1994 to March 2004, 292 patients were referred to a peritoneal malignancy surgical treatment center. Complete tumor removal (cytoreduction) was attempted in selected patients and, if achieved, surgery was combined with intraoperative, intraperitoneal mitomycin C (10 mg/m2). In total, 123 patients (52 males; 41 percent) underwent laparotomy for a perforated appendiceal malignancy presenting as pseudomyxoma peritonei. The median age was 52 (range 30–77) years. Complete cytoreduction was achieved in 83 of 123 patients (67 percent), major palliative resection in 34 patients (28 percent), and 6 patients (5 percent) were inoperable. Postoperative mortality was 6 of 123 patients (5 percent). Kaplan-Meier analysis of the 83 patients who had complete tumor removal predicted 75 percent disease-free survival at five years. A perforated appendiceal epithelial tumor most frequently presents as pseudomyxoma peritonei. This treatment strategy, involving surgery and intraperitoneal chemotherapy, can result in good outcomes in this rare and otherwise fatal disease.

BackgroundAppendiceal neoplasms are rare and most present unexpectedly as acute appendicitis. The classification and management are confusing, and there are few substantial reports in the literature.MethodsA systematic literature review was performed to access relevant publications on the presentation, pathology and management of appendiceal tumours.ResultsAppendiceal tumours account for 0·4 to 1 per cent of all gastrointestinal tract malignancies and are found in 0·7 to 1·7 per cent of appendicectomy specimens. Carcinoid tumours are most common. Most are cured by simple appendicectomy if the tumour is less than 2 cm in size and does not involve the resection margin or mesoappendix. Epithelial tumours may present with, or in time develop, pseudomyxoma peritonei, the optimal management of which involves complete tumour resection and intraperitoneal chemotherapy, usually available only in specialized centres.ConclusionSuggested algorithms for the management of unexpected appendiceal tumours are provided. Recommendations are made for follow-up of patients with a perforated appendiceal epithelial tumour.

The development, funding and early treatment outcomes of a centre for the assessment and management of a rare tumour is outlined. Central government funding, as obtained from the National Health Service in this instance, is optimal to allow service development and outcome assessment. The initiation and development of a new specialized service is probably best approached by focusing on a condition that is rare, with a reasonable number of cases and good outcomes. This report reviews an experience focusing on "pseudomyxoma peritonei of appendiceal origin" with an estimated annual incidence of one per million per year. The experience of a colorectal unit in structuring a national centre is reviewed in an attempt to document the development, funding and resources required to initiate and maintain a unit. The surgical skill, with its associated learning curve, and some early results of treatment are presented with the hope that such an experience may be of help to others.

Most series report lymph node involvement as the main predictor for local recurrence. The principal lymphatic drainage of the rectum is to nodes in the mesorectum and then nodes along the superior rectal and inferior mesenteric arteries. If total mesorectal excision provides adequate block dissection of the lymphatics of the rectum, good local control with low rates of local recurrence should be achieved even in node-positive disease. Prospective data on all rectal cancers have been collected since 1978; 170 patients with Dukes C rectal cancer have undergone anterior resection and total mesorectal excision. We did not perform any internal iliac node dissections. Follow-up data were analyzed for local recurrence and distant recurrence. The local recurrence rate was 2 percent for Dukes A cases, 4 percent for Dukes B, and 7.5 percent for Dukes C (P = 0.0127). The systemic recurrence rate was 8 percent for Dukes A, 18 percent for Dukes B, and 37 percent for Dukes C (P = 0.0001). If surgical priority is given to the difficult task of excision of the whole mesorectum, anterior resection with total mesorectal excision in node-positive rectal cancer, local recurrence rates of < 10 percent can be achieved.

The adaptive response of skeletal muscle fibres depends on a variety of biological factors including loading conditions and neuromuscular activity. An extreme type of atrophy-inducing change in contractile activity is represented by the physical disconnection between the motor nerve and its respective fibre unit. Since fibre type alterations have a striking effect on the Ca(2+)-regulatory apparatus, we have investigated the fate of a key Ca(2+)-pump and essential Ca(2+)-binding proteins in extensor digitorum longus specimens two weeks after nerve crush or complete denervation. In contrast to increased levels of sarcalumenin, immunoblotting revealed that the expression of the fast SERCA1 Ca(2+)-ATPase isoform is drastically decreased and fast calsequestrin is slightly reduced. Analysis of myosin heavy chain isoforms agreed with this result and showed a fast-to-slow fibre type shifting process following denervation. Hence, changes in muscle activity appear to have a profound effect on the abundance and isoform expression pattern of Ca(2+)-handling elements.

Preoperative selection of suitable patients for liver resection is dependent on the quality of radiological imaging. Computed tomography (CT) identifies approximately 70 per cent of lesions. Computed tomographic arterial portography (CTAP) during contrast enhancement of the liver via the portal vein may be superior to conventional CT. Preoperative CTAP was evaluated in 60 patients with hepatic neoplasm (48 having colorectal metastases) who subsequently underwent laparotomy. The preoperative images were compared with intraoperative palpation, intraoperative ultrasonography and histology of the resected liver. Fifty-six patients (93 per cent) underwent partial hepatectomy. The detection rate sensitivity for CTAP was 110 of 116 lesions in the 56 patients (95 per cent) and for intraoperative ultrasonography was 114 of 116 (98 per cent). CTAP correctly identified all lesions found at histology in 50 of 56 (89 per cent) resected specimens. At laparotomy four of 60 patients (7 per cent) were inoperable; two of these had been predicted to be so by this technique. CTAP correctly identifies and locates the majority of hepatic tumours, particularly metastases, and is the procedure of choice for selection of suitable candidates for partial hepatectomy.

The initiation of a Program in Peritoneal Malignancy is a long and complex process. The novelty, technically demanding nature and steep learning curve that characterize this treatment strategy calls for a carefully planned, systematic, controlled, and informed introduction is an institution, for which an Institutional Review Board approved protocol is suggested. Commitment of a surgical team and institution, education of other physician, nurses, and ancillary personnel involved in the procedure, safety precaution for patients and health care workers, and proper patient selection are important requirements for initiating the program. This manuscript provides a guide for implementation of this treatment strategy with a minimum of untoward events, reduced apprehension of medical and nursing colleagues, and a maximum benefit for patients.

Anastomotic dehiscence is a serious, life-threatening complication of any rectal anastomosis and may be associated with an increased risk of local cancer recurrence. The leak rate following low anterior resection is in the region of 10% as supported by the recent randomised Dutch rectal cancer trial. Although accurate prediction of risk is impossible, certain factors are known to influence leak rates. There is an inverse relationship between the height of anastomoses from the anal verge and leak rate, with the lower anastomoses carrying the highest risk. Proximal defunctioning mitigates the consequences of leakage but does not abolish risk. There is little difference in rates of dehiscence between stapled and sutured colorectal anastomoses. A short colon pouch may reduce the chance of leakage. The highest risks are in unprotected anastomoses less than 5 cm from the anal verge in men who smoke and/or drink excessively, particularly if they have received pre-operative chemotherapy or chemo-radiotherapy. A high index of suspicion is required in detecting the early nonspecific signs of a leak and urgent surgical intervention is usually required to avert a life-threatening situation. Judicious use of faecal diversion should never be regarded as surgical timidity.

Stent is a potential alternative to a stoma

Objectif Analyser le risque fistule pancreatique (FP) apres pancreatectomie gauche (PG), au cours d’une chirurgie de cytoreduction (CCR) avec CHIP pour carcinose peritoneale (CP). Methodes Etude multicentrique retrospective, incluant 112 malades operes entre 2007 et 2013 dans 7 centres specialises. La definition de l’ISGPF (International Study Group Of Pancreatic Fistula) a eteutilisee. Resultats Le PCI median etait de 19 [1–39]. Le nombre median d’exerese viscerale etait de 5 [1–13]. En postoperatoire, 49 patients (41,5 %) ont presente une complication severe (DINDO > II) et 39 (33 %) une FPPO. Le taux de mortalite a 90 j etait de 7,6 % (n = 9). Vingt deux FPPO ont ete traitees par drainage interventionnel et 11 par drainage chirurgical. Le delai mediane de tarissement de la FFPO etait de 21 j [5–80]. Le taux de complications severes (89 vs 43 %, p vs 13 j, p vs 9 %, ns). En multivariee, les facteurs de risque de FPPO identifies etaient un PCI > 20, des durees operatoire globale et d’hyperthermie > 550 et 90 minutes, l’utilisation d’un sel de platine et d’une CHIP par voie ouverte. Conclusion La realisation d’une PG au cours d’une CCR avec CHIP est associee a des taux de complications severes et de FPPO acceptables, sans surmortalite et ne doit pas etre consideree comme une limite a une exerese extensive pour CP.

TPS3653 Background: In locally advanced rectal cancer (LARC), local recurrence is uncommon with good quality total mesorectal excision (TME) allowing preoperative chemo-radiotherapy (PCRT) to be om...

4033 Background: We built nomograms for predicting overall (OS) and progression-free survivals (PFS) in patients with pseudomyxoma peritonei (PMP) treated with cytoreductive surgery (CRS)+/-intraperitoneal chemotherapy (IPCT). Methods: Data from 1,715 PMP patients in 31 centers from 1993 to 2012 constituted the developing set. The covariates were previous systemic chemotherapy (sCT), histologic subtype (Ronnett’s criteria), peritoneal cancer index (PCI), completeness of cytoreduction (CC), IPCT (Hyperthermic intraperitoneal chemotherapy [HIPEC], early postoperative chemotherapy [EPIC], or both), lymph node status (LN), G3-5 morbidity (NCI CTCAE v3), and surgical proficiency. Centers with >100 procedures for PMP were considered proficient. Continuous variables were transformed using restricted cubic splines. We handled missing data using multiple imputation with chained equations (MICE) approach. We fitted a Cox model in each of the different completed developing datasets generated by MICE. Pooled estimate...

Background The consequences of leakage from low colorectal or coloanal anastomoses are reduced by the use of a loop stoma to divert the faecal stream. Controversy continues as to whether loop ileostomy (LI) or loop transverse colostomy (LTC) is the optimal method of defunctioning such anastomoses. Methods Patients requiring defunctioning following anterior resection and total mesorectal excision were randomized to receive either LI or LTC. Comparison was made between the groups regarding the difficulty of stoma formation and closure, the recovery after stoma closure and stoma-related complications. The minimum follow-up after stoma closure was 6 months (median 36 months). Results Between October 1995 and August 1999, 70 patients were randomized (LTC 36, LI 34) of whom 63 underwent stoma closure (LTC 31, LI 32). There were no significant differences in the difficulty of formation or closure, or in the postoperative recovery between the groups. However, there were ten complications related directly to the stoma in the LTC group: faecal fistula (one patient), prolapse (two), parastomal hernia (two) and incisional hernia during follow-up (five). None of these complications occurred in the LI group. Conclusion In this randomized study, the frequency of herniation before or after colostomy closure supports the choice of LI as a method of defunctioning a low anastomosis. Both methods appear to provide satisfactory protection for the low anastomosis.

Summary Background Adhesions after abdominal and pelvic surgery are important complications, although their basic epidemiology is unclear. We investigated the frequency of such complications in the general population to provide a basis for the targeting and assessment of new adhesion-prevention measures. Methods We used validated data from the Scottish National Health Service medical record linkage database to identify patients undergoing open abdominal or pelvic surgery in 1986, who had no record of such surgery in the preceding 5 years. Patients were followed up for 10 years and subsequent readmissions were reviewed and outcomes classified by the degree of adhesion. We also assessed the rate of adhesion-related admissions in 1994 for the population of 5 million people. Findings 1209 (5·7%) of all readmissions (21 347) were classified as being directly related to adhesions, with 1169 (3·8%) managed operatively. Overall, 34·6% of the 29 790 patients who underwent open abdominal or pelvic surgery in 1986 were readmitted a mean of 2·1 times over 10 years for a disorder directly or possibly related to adhesions, or for abdominal or pelvic surgery that could be potentially complicated by adhesions. 22·1% of all outcome readmissions occurred in the first year after initial surgery, but readmissions continued steadily thoughout the 10-year period. In 1994, 4199 admissions were directly related to adhesions. Interpretation Postoperative adhesions have important consequences to patients, surgeons, and the health system. Surgical procedures with a high risk of adhesion-related complications need to be identified and adhesion prevention carefully assessed.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin : a consensus statement

Objective To examine the role of total mesorectal excision in the management of rectal cancer. Design A prospective consecutive case series. Setting A district hospital and referral center in Basingstoke, England. Patients Five hundred nineteen surgical patients with adenocarcinoma of the rectum treated for cure or palliation. Interventions Anterior resections (n=465) with low stapled anastomoses (407 total mesorectal excisions), abdominoperineal resections (n=37), Hartmann resections (n=10), local excisions (n=4), and laparotomy only (n=3). Preoperative radiotherapy was used in 49 patients (7 with abdominoperineal resections, 38 with anterior resections, 3 with Hartmann resections, and 1 with laparotomy). Main Outcome Measures Local recurrence and cancer-specific survival. Results Cancer-specific survival of all surgically treated patients was 68% at 5 years and 66% at 10 years. The local recurrence rate was 6% (95% confidence interval, 2%-10%) at 5 years and 8% (95% confidence interval, 2%-14%) at 10 years. In 405 "curative" resections, the local recurrence rate was 3% (95% confidence interval, 0%-5%) at 5 years and 4% (95% confidence interval, 0%-8%) at 10 years. Disease-free survival in this group was 80% at 5 years and 78% at 10 years. An analysis of histopathological risk factors for recurrence indicates only the Dukes stage, extramural vascular invasion, and tumor differentiation as variables in these results. Conclusions Rectal cancer can be cured by surgical therapy alone in 2 of 3 patients undergoing surgical excision in all stages and in 4 of 5 patients having curative resections. In future clinical trials of adjuvant chemotherapy and radiotherapy, strategies should incorporate total mesorectal excision as the surgical procedure of choice.

Geoffrey Donald Oates (“Geoff”) died suddenly in Switzerland, aged 84, en route from his adopted home in Verbier to attend the conference of the British Association of Surgical Oncology. He was carrying his handwritten Christmas cards (for postage in England), which were subsequently posted by Liz, who had to add a note on each envelope that Geoff had died on the way. He would have been very disappointed at the added cost at having to post them in Switzerland owing to the sudden change in events. In the cards that we both received, he related that he and Liz were in great health and that he might not make it to a meeting we were attending in St Gallen a few weeks later, as …

The management of patients with locally advanced rectal cancer (LARC) has evolved with the aim of reducing local recurrence and improving survival. Current practice has developed from refinements in surgical technique, the availability of different types of preoperative imaging, the selective or blanket use of neoadjuvant treatment (usually radiation) and sophisticated efforts exploring multimodality treatments to achieve organ preservation. Both short-course preoperative radiotherapy (SCPRT) and long-course chemoradiation (CRT) are considered standard neoadjuvant strategies, which are advocated in different parts of the world. New techniques in the delivery of radiotherapy, such as intensity-modulated radiotherapy (IMRT), may allow more precise dosing to the target volume (tumour and/or locoregional lymph nodes) and limit radiation doses to critical normal structures; however, current schedules of SCPRT and CRT impact on late function, and if they do not improve survival in resectable cancers, can they be omitted in selected cases?

A new technique that facilitates laparoscopic anterior resection is described. The technique is a modification of a triple stapling technique that the authors currently use for conventional anterior resection of the mid- and low-rectal cancers. The new laparoscopic technique may reduce the risk of staple line or port site recurrence.

114 www.thelancet.com/oncology Vol 11 February 2010 We read with great interest the article “Extended lymphadenectomy versus conventional surgery for rectal cancer: a meta-analysis” by Georgiou and colleagues in The Lancet Oncology. However, we have to disagree with the methodology and conclusions. The title of the paper suggests that the authors did a meta-analysis and concluded that extended lymphadenectomy does not confer a signifi cant oncological advantage, and is associated with increased genito-urinary dysfunction, compared with conventional surgery. However, there are some fundamental problems with the methods used which result in some misleading conclusions. The main issue revolves around the validity of doing a meta-analysis on disparate groups. With the exception of the single small randomised study, the extended lymphadenectomy group undoubtedly had more advanced tumours—ie, larger (higher T stage), nodepositive, and more aggressive pathology—compared with the non-extended lymphadenectomy group. Therefore, one cannot “meta-analyse” these entirely diff erent groups. In fact we would interpret the results as the exact opposite to the authors’ conclusion: the extended lymphadenectomy group benefi ted substantially, as the survival and local recurrence were the same despite the more advanced nature of the disease. Furthermore, the time period of this review is very long (1984–2007). Over the past two decades, as Moriya argued in his article in the same issue of The Lancet Oncology, there have been substantial changes in the Japanese approach to treating rectal cancer in terms of indication criteria and the techniques used. Extended lymphadenectomy for upper rectal cancer has practically been abandoned, and Japanese surgeons are far more selective in the indications for extended lymphadenectomy using meticulous analysis of their experiences, and outcomes, and using modern imaging techniques. Additionally, nerve-sparing techniques have recently been developed and refi ned with markedly improved function. Based on a large recent multicentre study and other reports, we strongly believe that recent refi nements and optimal extended lymphadenectomy might be benefi cial to selected patients, particularly with low rectal cancer, and perhaps equivalent or better than pre-operative chemoradiotherapy and standard total mesorectal excision. The misinterpretation of the data in Lateral pelvic lymph-node dissection: still an option for cure

Spontaneous stercoral perforation resulting in rectovaginal fistula is uncommon. A patient is reported who developed a colon pouch vaginal fistula during an episode of severe constipation more than 3 years after successful surgery for rectal cancer. Patients with colon pouch to anus anastomosis may have an incresed lifelong risk of this complication and faecal impaction should be treated urgently. Colon pouch to anus anastomosis has become the standard reconstruction technique following low anterior resection and total mesorectal exision. Early vaginal fistula remains a well recognised complication whether a straight coloanal or a colon pouch to anal anastomosis is performed. No previous report has been found of a late colon pouch vaginal fistula in the absence of radiotherapy or recurrent disease.

Background The Surgical and Clinical Adhesions Research (SCAR) study set out to determine the long-term morbidity associated with postoperative adhesions following open abdominal and pelvic surgery, including the burden associated with adhesions after surgery in the upper abdomen. Methods Scotland's National Health Service hospital admissions are recorded by the Scottish Medical Record Linkage system. This system allows detailed analysis of hospital activity throughout Scotland including follow-through of individual patients, with sophisticated accuracy checks to ensure the quality and totality of the data set. Within the SCAR study, the total number of individuals who underwent an open abdominal or pelvic procedure in 1986 was defined, a subset of whom underwent surgery in the anatomical area of the upper abdomen (fore gut and related organs). Disease (International Classification of Diseases version 9) and procedure (Office of Population Censuses and Surveys 3/4) codes for adhesion-related problems or reoperations that might be complicated by the presence of adhesions were identified. For the purposes of the study only readmissions for directly related adhesion complications during the following 10 years were considered (e.g. small bowel obstruction and adhesiolysis). The study was steered by a multidisciplinary panel of surgeons, gynaecologists and health economists. Results In 1986 in Scotland, a total cohort of 8714 patients had open surgery in the upper abdomen which was considered likely to cause adhesions. This compared to 12 585 undergoing open surgery in the lower abdomen (mid hindgut) and 8489 in the female reproductive tract. The majority of patients in this cohort underwent open surgery on the gallbladder (44·4 per cent) or stomach (20·6 per cent). During the 10-year study 3293 individuals (37·8 per cent) required one or more readmissions for surgical or medical treatment for conditions either related to adhesions or involving a reoperation which could be complicated by adhesions. In total, 7048 surgical or medical readmissions were identified, with a mean of 2·1 readmissions per patient. At least 321 (4·6 per cent) of these readmissions were a direct result of abdominal or pelvic adhesions, constituting a large clinical burden. Analysis of readmissions over time showed that this burden continued steadily over the 10-year study period. As well as this workload burden, there was a risk for the patient associated with open surgery on the foregut with a mean of 3·7 readmissions for direct adhesion complications for every 100 initial procedures. This rate varied according to the site of initial surgery: 3·0 per 100 procedures for open surgery of the gallbladder, 3·5 per 100 for the stomach and 7·3 per 100 for open surgery on the pancreas. Conclusion The SCAR study provides the first epidemiological assessment of postoperative adhesions. Using an extremely conservative view, the medical and surgical impact following open surgery in the upper abdomen is considerable with 4·6 per cent of readmissions over a 10-year period directly attributable to adhesions. The full impact of adhesions, including their effect on subsequent surgery, is likely to be considerably greater and extensive research is being progressed with the SCAR data set to investigate further the burden and associated costs, and optimum strategies to reduce the problem.

EDITOR—Tumour shrinkage by preoperative chemoradiotherapy is now an everyday reality, and pathological complete responses are not uncommon.1 A “new dilemma” is posed by the apparent complete disappearance of cancer on magnetic resonance imaging, and often clinically, after chemoradiotherapy. A delay of six to 10 weeks is usual before operating—a time perceived as a “window of opportunity,” as regrowth in the irradiated area …