John T. Jenkins

Abstract Background Muscle depletion is characterized by reduced muscle mass (myopenia), and increased infiltration by intermuscular and intramuscular fat (myosteatosis). This study examined the role of particular body composition profiles as prognostic markers for patients with colorectal cancer undergoing curative resection. Methods Patients with colorectal cancer undergoing elective surgical resection between 2006 and 2011 were included. Lumbar skeletal muscle index (LSMI), visceral adipose tissue (VAT) surface area and mean muscle attenuation (MA) were calculated by analysis of CT images. Reduced LSMI (myopenia), increased VAT (visceral obesity) and low MA (myosteatosis) were identified using predefined sex-specific skeletal muscle index values. Univariable and multivariable Cox regression models were used to determine the role of different body composition profiles on outcomes. Results Some 805 patients were identified, with a median follow-up of 47 (i.q.r. 24·9–65·6) months. Multivariable analysis identified myopenia as an independent prognostic factor for disease-free survival (hazard ratio (HR) 1·53, 95 per cent c.i. 1·06 to 2·39; P = 0·041) and overall survival (HR 1·70, 1·25 to 2·31; P < 0·001). The presence of myosteatosis was associated with prolonged primary hospital stay (P = 0·034), and myopenic obesity was related to higher 30-day morbidity (P = 0·019) and mortality (P < 0·001) rates. Conclusion Myopenia may have an independent prognostic effect on cancer survival for patients with colorectal cancer. Muscle depletion may represent a modifiable risk factor in patients with colorectal cancer and needs to be targeted as a relevant endpoint of health recommendations.

We examined the relationships between computed tomography (CT)-defined skeletal muscle parameters and the systemic inflammatory response (SIR) in patients with operable primary colorectal cancer (CRC).Muscle depletion is characterized by a reduced muscle mass (myopenia) and increased infiltration by inter- and intramuscular fat (myosteatosis). It is recognized as a poor prognostic indicator in patients with cancer, but the underlying factors remain unclear.A total of 763 patients diagnosed with CRC undergoing elective surgical resection between 2006 and 2013 were included. Image analysis of CT scans was used to calculate Lumbar skeletal muscle index (LSMI), and mean muscle attenuation (MA). The SIR was quantified by the preoperative neutrophil to lymphocyte ratio (NLR) and albumin levels. Correlation and multivariate regression analysis was performed to identify independent relationships between patient SIR and muscle characteristics.Patients with NLR > 3 had significantly lower LSMI and lower MA than those with NLR < 3 [LSMI = 42.07 cmm vs 44.27 cmm (P = 0.002) and MA = 30.04 Hounsfield unit (HU) vs 28.36 HU (P = 0.016)]. Multivariate logistic regression analysis showed that high NLR [odds ratio (OR) = 1.78 (95% confidence interval [CI]: 1.29-2.45), P < 0.001] and low albumin [OR = 1.80 (95% CI: 1.17-2.74), P = 0.007] were independent predictors of reduced muscle mass. High NLR was significantly related with a low mean MA and hence myosteatosis [OR = 1.60 (95% CI: 1.03-2.49), P = 0.038].These results highlight a direct association between myopenia, myosteatosis, and the host SIR in patients with operable CRC. A better understanding of factors that regulate muscle changes such as myopenia and myosteatosis may lead to the development of novel therapies that influence a more metabolically "healthy" skeletal muscle and potentially alter cancer outcomes.

Abstract Background Pelvic exenteration for locally recurrent rectal cancer (LRRC) is associated with variable outcomes, with the majority of data from single-centre series. This study analysed data from an international collaboration to determine robust parameters that could inform clinical decision-making. Methods Anonymized data on patients who had pelvic exenteration for LRRC between 2004 and 2014 were accrued from 27 specialist centres. The primary endpoint was survival. The impact of resection margin, bone resection, node status and use of neoadjuvant therapy (before exenteration) was assessed. Results Of 1184 patients, 614 (51·9 per cent) had neoadjuvant therapy. A clear resection margin (R0 resection) was achieved in 55·4 per cent of operations. Twenty-one patients (1·8 per cent) died within 30 days and 380 (32·1 per cent) experienced a major complication. Median overall survival was 36 months following R0 resection, 27 months after R1 resection and 16 months following R2 resection (P &amp;lt; 0·001). Patients who received neoadjuvant therapy had more postoperative complications (unadjusted odds ratio (OR) 1·53), readmissions (unadjusted OR 2·33) and radiological reinterventions (unadjusted OR 2·12). Three-year survival rates were 48·1 per cent, 33·9 per cent and 15 per cent respectively. Bone resection (when required) was associated with a longer median survival (36 versus 29 months; P &amp;lt; 0·001). Node-positive patients had a shorter median overall survival than those with node-negative disease (22 versus 29 months respectively). Multivariable analysis identified margin status and bone resection as significant determinants of long-term survival. Conclusion Negative margins and bone resection (where needed) were identified as the most important factors influencing overall survival. Neoadjuvant therapy before pelvic exenteration did not affect survival, but was associated with higher rates of readmission, complications and radiological reintervention.

Background The appropriate timing for laparoscopic cholecystectomy in the treatment of acute cholecystitis remains controversial. More recent evaluation indicates early laparoscopic surgery may be a safe option in acute cholecystitis, although conversion rates may be higher. No conclusive evidence establishing best practice in terms of clinical benefit exists. Methods All randomized clinical studies published between 1987 and 2006 comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis were analyzed, irrespective of language, blinding, or publication status. Exclusions were quasi-randomized trials, inadequate follow-up description, or allocation concealment. Endpoints included conversion rates, postoperative complications, total hospital stay, and operation time. Random and fixed-effect models were used to aggregate the study endpoints and assess heterogeneity. Results Four studies containing 375 patients were included. No significant study heterogeneity or publication bias was found. There was no significant difference in conversion rates (odds ratio = .915 [95% confidence interval (CI), .567–1.477], P = .718) and postoperative complications (odds ratio = 1.073 [95% CI, .599–1.477], P = .813) between both groups. Operation time was significantly reduced (weighted mean difference [WMD] = .412 [95% CI, .149–.675], P = .002) with delayed cholecystectomy. The total hospital stay was significantly reduced (WMD = .905 [95% CI, .630–1.179], P = .0005) with early cholecystectomy. The postoperative stay was significantly reduced in the delayed group (WMD = .393 [95% CI, .128–.659], P = .004). Conclusions These meta-analysis data suggest that early laparoscopic cholecystectomy allows significantly shorter total hospital stay at the cost of a significantly longer operation time with no significant differences in conversion rates or complications.

The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority.Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus.The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management.The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.

The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority.Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus.The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management.The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.

Strong evidence indicates that excessive adipose tissue distribution or reduced muscle influence short-, mid-, and long-term colorectal cancer outcomes. Computerized tomography-based body composition (CTBC) analysis quantifies this in a reproducible parameter. We reviewed the evidence linking computerized tomography (CT) based quantification of BC with short and long-term outcomes in colorectal cancer (CRC).A systematic review was performed according to PRISMA guidelines. A literature search was performed by two independent reviewers on all studies that included CTBC analysis in patients undergoing treatment for CRC using Medline, EMBASE, Google Scholar, and Cochrane databases. Outcomes of interest included short-term recovery, oncological outcomes, and survival.Seventy-five studies were identified; sixteen met the inclusion criteria. None were randomized controlled trials and all were cohort studies of small sample size. Several types of CTBC image analysis software were identified, reporting subcutaneous, visceral and skeletal muscle tissues. Visceral obesity and reduced muscle mass were categorical parameters quantified by CTBC analysis. Due to marked study heterogeneity, quantitative data synthesis was not possible. High visceral adipose tissue and reduced skeletal muscle resulted in poorer short-term recovery (eleven studies), poorer oncological outcomes (six studies), and poorer survival (six studies).CTBC techniques may be linked to outcomes in colorectal cancer patients, however larger studies are required. CTBC based assessment may allow early identification of high-risk patients, allowing early optimisation of patients undergoing cancer treatments.

In Brief Objective: This study aims to determine the role of the neutrophil to lymphocyte ratio (NLR) as a prognostic marker for patients with nonmetastatic colorectal cancer undergoing curative resection. Background: An NLR reflects a systematic inflammatory response, with some evidence suggesting that an elevated preoperative NLR of more than 5.0 is associated with poorer survival in patients with colorectal cancer. Methods: Data from 506 consecutive patients with a diagnosis of nonmetastatic colorectal adenocarcinoma undergoing surgical resection between 2006 and 2011 were included. Receiver operating characteristic curve analysis was used to identify the optimal value for NLR in relation to disease-free and overall survival. Univariate and multivariate Cox regression models were used to determine the role of NLR after stratification by several clinicopathological factors. Patients were followed by a standardized protocol until February 2013. Results: Median follow-up was 45 months [interquartile range, 21–65]. Multivariate Cox regression analysis identified an NLR of more than 3 as an independent prognostic factor for disease-free survival (odds ratio = 2.41; 95% confidence interval = 1.12–5.15; P = 0.024) but not for overall survival (odds ratio = 1.23; 95% confidence interval = 0.80–1.90; P = 0.347). A high NLR was significantly associated with older age, higher T and N stages, the presence of microvascular invasion, low preoperative albumin levels, and higher ASA (American Society of Anesthesiologists) status of the patient. Conclusions: For patients with colorectal cancer, a preoperative NLR of more than 3.0 may be an independent prognostic factor for disease-free survival. Considering this in addition to well-established prognostic variables may improve the processes of identifying patients at higher risk of recurrence who would benefit from adjuvant therapies or more frequent surveillance, thereby providing more personalized cancer care. This study aims to determine the role of the neutrophil to lymphocyte ratio as a prognostic marker for patients with nonmetastatic colorectal cancer undergoing curative resections. Its key finding is that a preoperative value of more than 3.0 is an independent prognostic indicator for disease-free survival.

Selection of patients for preoperative treatment in rectal cancer is controversial. The new 2020 National Institute for Health and Care Excellence (NICE) guidelines, consistent with the National Comprehensive Cancer Network guidelines, recommend preoperative radiotherapy for all patients except for those with radiologically staged T1-T2, N0 tumours. We aimed to assess outcomes in non-irradiated patients with rectal cancer and to stratify results on the basis of NICE criteria, compared with known MRI prognostic factors now omitted by NICE.For this retrospective cohort study, we identified patients undergoing primary resectional surgery for rectal cancer, without preoperative radiotherapy, at Basingstoke Hospital (Basingstoke, UK) between Jan 1, 2011, and Dec 31, 2016, and at St Marks Hospital (London, UK) between Jan 1, 2007, and Dec 31, 2017. Patients with MRI-detected extramural venous invasion, MRI-detected tumour deposits, and MRI-detected circumferential resection margin involvement were categorised as MRI high-risk for recurrence (local or distant), and their outcomes (disease-free survival, overall survival, and recurrence) were compared with patients defined as high-risk according to NICE criteria (MRI-detected T3+ or MRI-detected N+ status). Kaplan-Meier and Cox proportional hazards analyses were used to compare the groups.378 patients were evaluated, with a median of 66 months (IQR 44-95) of follow up. 22 (6%) of 378 patients had local recurrence and 68 (18%) of 378 patients had distant recurrence. 248 (66%) of 378 were classified as high-risk according to NICE criteria, compared with 121 (32%) of 378 according to MRI criteria. On Kaplan-Meier analysis, NICE high-risk patients had poorer 5-year disease-free survival compared with NICE low-risk patients (76% [95% CI 70-81] vs 87% [80-92]; hazard ratio [HR] 1·91 [95% CI 1·20-3·03]; p=0·0051) but not 5-year overall survival (80% [74-84] vs 88% [81-92]; 1·55 [0·94-2·53]; p=0·077). MRI criteria separated patients into high-risk versus low-risk groups that predicted 5-year disease-free survival (66% [95% CI 57-74] vs 88% [83-91]; HR 3·01 [95% CI 2·02-4·47]; p<0·0001) and 5-year overall survival (71% [62-78] vs 89% [84-92]; 2·59 [1·62-3·88]; p<0·0001). On multivariable analysis, NICE risk assessment was not associated with either disease-free survival or overall survival, whereas MRI criteria predicted disease-free survival (HR 2·74 [95% CI 1·80-4·17]; p<0·0001) and overall survival (HR 2·44 [95% CI 1·51-3·95]; p=0·00027). 139 NICE high-risk patients who were defined as low-risk based on MRI criteria had similar disease-free survival as 118 NICE low-risk patients; therefore, 37% (139 of 378) of patients in this study cohort would have been overtreated with NICE 2020 guidelines. Of the 130 patients defined as low-risk by NICE guidelines, 12 were defined as high-risk on MRI risk stratification and would have potentially been missed for treatment.Compared to previous guidelines, implementation of the 2020 NICE guidelines will result in significantly more patients receiving preoperative radiotherapy. High-quality MRI selects patients with good outcomes (particularly low local recurrence) without radiotherapy, with little margin for improvement. Overuse of radiotherapy could occur with this unselective approach. The high-risk group, with the most chance of benefiting from preoperative radiotherapy, is not well selected on the basis of NICE 2020 criteria and is better identified with proven MRI prognostic factors (extramural venous invasion, tumour deposits, and circumferential resection margin).None.

Abstract Objective Colonoscopy is regarded as the most sensitive method of evaluating the colon. Inadequate preparation reduces sensitivity and has adverse implications for individual patients and the Heath Service. Method Data concerning the adequacy of bowel preparation and colonoscopy completion rates were prospectively collected on all colonoscopies performed in a single centre between January 1996 and January 2005. In addition, the strategy of further investigation in the event of incomplete examination was assessed. Results A total of 10 571 colonoscopies were assessed and poor bowel preparation was identified in 1788 of these cases (16.9%). The completion rate was 67.5% in those with satisfactory preparation. In patients with poor preparation, 36% of colonoscopies were complete. Incomplete examination was more likely with poor preparation [OR = 3.76 (95% CI, 3.38–4.18), P = 0.0005]. Poor preparation was more likely for inpatients [OR = 3.54 (95% CI 3.14–3.96), P = 0.0005]. Even with satisfactory preparation, inpatient completion rates were significantly less [OR = 1.78 (95% CI, 3.14–3.96), P = 0.0005). A further 542 diagnostic procedures were undertaken in the poor preparation group, an additional £101 950 (€149 459) in expenditure. Conclusion This study supports the view that inpatients fare badly. This is partly explained by higher rates of poor preparation; however, completion rates were reduced even with adequate preparation. Failed investigation and prolonged hospital stay increase cost. Colonoscopy completion rates need to be improved with particular attention to inpatients.

Abstract Background Although surgical resection remains the central element in curative treatment of gastrointestinal cancer, increasing emphasis and resource has been focused on neoadjuvant or adjuvant therapy. Developments in these modalities have improved outcomes, but far less attention has been paid to improving oncological outcomes through optimization of perioperative care. Methods A narrative review is presented based on available and updated literature in English and the authors' experience with enhanced recovery research. Results A range of perioperative factors (such as lifestyle, co-morbidity, anaemia, sarcopenia, medications, regional analgesia and minimal access surgery) are modifiable, and can be optimized to reduce short- and long-term morbidity and mortality, improve functional capacity and quality of life, and possibly improve oncological outcome. The effect on cancer-free and overall survival may be of equal magnitude to that achieved by many adjuvant oncological regimens. Modulation of core factors, such as nutritional status, systemic inflammation, and surgical and disease-mediated stress, probably influences the host's immune surveillance and defence status both directly and through reduced postoperative morbidity. Conclusion A wider view on long-term effects of expanded or targeted enhanced recovery protocols is warranted.

Previous attempts at sentinel lymph node (SLN) mapping in colon cancer have been compromised by ineffective tracers and the inclusion of advanced disease. This study evaluated the feasibility of fluorescence detection of SLNs with indocyanine green (ICG) for lymphatic mapping in T1/T2 clinically staged colonic malignancy.Consecutive patients with clinical T1/T2 stage colon cancer underwent endoscopic peritumoral submucosal injection of indocyanine green (ICG) for fluorescence detection of SLN using a near-infrared (NIR) camera. All patients underwent laparoscopic complete mesocolic excision surgery. Detection rate and sensitivity of the NIR-ICG technique were the study endpoints.Thirty patients mean age = 68 years [range = 38-80], mean BMI = 26.2 (IQR = 24.7-28.6) were studied. Mesocolic sentinel nodes (median = 3/patient) were detected by fluorescence within the standard resection field in 27/30 patients. Overall, ten patients had lymph node metastases, with one of these patients having a failed SLN procedure. Of the 27 patients with completed SLN mapping, nine patients had histologically positive lymph nodes containing malignancy. 3/9 had positive SLNs with 6 false negatives. In five of these false negative patients, tumours were larger than 35 mm with four also being T3/T4.ICG mapping with NIR fluorescence allowed mesenteric detection of SLNs in clinical T1/T2 stage colonic cancer. CLINICALTRIALS.GOV: ID: NCT01662752.

Anti-tumour necrosis factor (TNF)s form a major part of therapy in Crohn's disease and have a primary nonresponse rate of 10%-30% and a secondary loss of response rate of 5% per year. Myopenia is prevalent in Crohn's disease and is measured using body composition analysis tools.To test the hypothesis that body composition can predict outcomes of anti-TNF primary nonresponse and secondary loss of response.Between January 2007 and June 2012, 106 anti-TNF naïve patients underwent anti-TNF therapy for Crohn's disease with body composition parameters analysed using CT scans to estimate body fat-free mass. The outcome measures were primary nonresponse and secondary loss of response. COX-regression analysis was used with 3 year follow-up data.A total of 106 patients were included for analysis with 26 (24.5%) primary nonresponders and 29 (27.4%) with secondary loss of response to anti-TNF therapy. Sex-specific cut-offs for muscle and fat were ascertained by stratification analysis. On univariate analysis, primary nonresponse was associated with low albumin (OR 0.94; 0.88-0.99, P = .04) and presence of myopenia (OR 4.69; 1.83-12.01, P = .001) when taking into account patient's medical therapy, severity of disease and body composition. On multivariate analysis, presence of myopenia was associated with primary nonresponse (OR 2.93; 1.28-6.71, P = .01). Immunomodulator therapy was associated with decreased secondary loss of response (OR 0.48; 0.23-0.98, P = .04). BMI was poorly correlated with lean body mass (r2 = 0.15, P = .54).In this cohort study, body composition profiles did not correlate well with BMI. Myopenia was associated with primary nonresponse with potential implications for dosing and serves as an explanation for pharmacokinetic failure.

The management of recurrent rectal cancer is challenging. At the present time, pelvic exenteration with en bloc sacrectomy offers the only hope of a lasting cure.The purpose of this study was to evaluate clinical outcome measures and complication rates following sacrectomy for recurrent rectal cancer.A search was conducted on Pub Med for English language articles relevant to sacrectomy for recurrent rectal cancer with no time limitations.Studies reported sacrectomy with survival data for recurrent rectal adenocarcinoma.Disease-free survival following sacrectomy for recurrent rectal cancer was the main outcome measured.A total of 220 patients with recurrent rectal cancer were included from 7 studies, of which 160 were men and 60 were women. Overall median operative time was 717 (570-992) minutes and blood loss was 3.7 (1.7-6.2) L. An R0 (>1-mm resection margin) resection was achieved in 78% of patients. Disease-free survival associated with R0 resection was 55% at a median follow-up period of 33 (17-60) months; however, none of the patients with R1 (<1-mm resection margin) survived this period. Postoperative complication rates and median length of stay were found to decrease with more distal sacral transection levels. In contrast, R1 resection rates increased with more distal transection.The studies assessed by this review were retrospective case series and thus are subject to significant bias.Sacrectomy performed for patients with recurrent rectal cancer is associated with significant postoperative morbidity. Morbidity and postoperative length of stay increase with the level of sacral transection. Nevertheless, approximately half of patients eligible for rectal excision with en bloc sacrectomy may benefit from disease-free survival for up to 33 months, with R0 resection predicting disease-free survival in the medium term.

Abstract Background and Aims Alterations in body composition are common in inflammatory bowel disease [IBD] and have been associated with differences in patient outcomes. We sought to consolidate knowledge on the impact and importance of body composition in IBD. Methods We performed a systematic search of MEDLINE, EMBASE and conference proceedings by combining two key research themes: inflammatory bowel disease and body composition. Results Fifty-five studies were included in this review. Thirty-one focused on the impact of IBD on body composition with a total of 2279 patients with a mean age 38.4 years. Of these, 1071 [47%] were male. In total, 1470 [64.5%] patients had Crohn’s disease and 809 [35.5%] had ulcerative colitis. Notably, fat mass and fat-free mass were reduced, and higher rates of sarcopaenia were observed in those with active IBD compared with those in clinical remission and healthy controls. Twenty-four additional studies focused on the impact of derangements in body composition on IBD outcomes. Alterations in body composition in IBD are associated with poorer prognoses including higher rates of surgical intervention, post-operative complications and reduced muscle strength. In addition, higher rates of early treatment failure and primary non-response are seen in patients with myopaenia. Conclusions Patients with IBD have alterations in body composition parameters in active disease and clinical remission. The impacts of body composition on disease outcome and therapy are broad and require further investigation. The augmentation of body composition parameters in the clinical setting has the potential to improve IBD outcomes in the future.

Recently, the number of prehabilitation trials has increased significantly. The identification of key research priorities is vital in guiding future research directions. Thus, the aim of this collaborative study was to define key research priorities in prehabilitation for patients undergoing cancer surgery.The Delphi methodology was implemented over three rounds of surveys distributed to prehabilitation experts from across multiple specialties, tumour streams and countries via a secure online platform. In the first round, participants were asked to provide baseline demographics and to identify five top prehabilitation research priorities. In successive rounds, participants were asked to rank research priorities on a 5-point Likert scale. Consensus was considered if > 70% of participants indicated agreement on each research priority.A total of 165 prehabilitation experts participated, including medical doctors, physiotherapists, dieticians, nurses, and academics across four continents. The first round identified 446 research priorities, collated within 75 unique research questions. Over two successive rounds, a list of 10 research priorities reached international consensus of importance. These included the efficacy of prehabilitation on varied postoperative outcomes, benefit to specific patient groups, ideal programme composition, cost efficacy, enhancing compliance and adherence, effect during neoadjuvant therapies, and modes of delivery.This collaborative international study identified the top 10 research priorities in prehabilitation for patients undergoing cancer surgery. The identified priorities inform research strategies, provide future directions for prehabilitation research, support resource allocation and enhance the prehabilitation evidence base in cancer patients undergoing surgery.

Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is no consensus on the best approach. We evaluated and compared the complications associated with each reconstruction technique with the aim of determining which is associated with the lowest incidence of complications related to the empty pelvis.The systematic review protocol was prospectively registered with PROSPERO (CRD42021239307). PRISMA-P guidelines were used to present the literature. PubMed and MEDLINE were systematically searched up to 1 February 2021. A dataset containing predetermined primary and secondary outcomes was extracted.Eighteen studies fulfilled our criteria; these included 375 patients with mainly rectal and gynaecological cancer. Only three studies had a follow-up greater than 2 years. Six surgical interventions were identified. Mesh reconstruction and breast prosthesis were associated with low rates of small bowel obstruction (SBO), entero-cutaneous fistulas and perineal hernia. Findings for myocutaneous flaps were similar; however, they were associated with high rates of perineal wound complications. Omentoplasty was found to have a high perineal wound infection rate (40%). Obstetric balloons were found to have the highest rates of perineal wound dehiscence and SBO. Silicone expanders effectively kept small bowel out of the pelvis, although rates of pelvic collections remained high (20%).The morbidity associated with an empty pelvis remains considerable. Given the low quality of the evidence with small patient numbers, strong conclusions in favour of a certain technique and comparison of these interventions remains challenging.

Automated computed tomography (CT) scan segmentation (labelling of pixels according to tissue type) is now possible. This technique is being adapted to achieve three-dimensional (3D) segmentation of CT scans, opposed to single L3-slice alone. This systematic review evaluates feasibility and accuracy of automated segmentation of 3D CT scans for volumetric body composition (BC) analysis, as well as current limitations and pitfalls clinicians and researchers should be aware of. OVID Medline, Embase and grey literature databases up to October 2021 were searched. Original studies investigating automated skeletal muscle, visceral and subcutaneous AT segmentation from CT were included. Seven of the 92 studies met inclusion criteria. Variation existed in expertise and numbers of humans performing ground-truth segmentations used to train algorithms. There was heterogeneity in patient characteristics, pathology and CT phases that segmentation algorithms were developed upon. Reporting of anatomical CT coverage varied, with confusing terminology. Six studies covered volumetric regional slabs rather than the whole body. One study stated the use of whole-body CT, but it was not clear whether this truly meant head-to-fingertip-to-toe. Two studies used conventional computer algorithms. The latter five used deep learning (DL), an artificial intelligence technique where algorithms are similarly organized to brain neuronal pathways. Six of seven reported excellent segmentation performance (Dice similarity coefficients > 0.9 per tissue). Internal testing on unseen scans was performed for only four of seven algorithms, whilst only three were tested externally. Trained DL algorithms achieved full CT segmentation in 12 to 75 s versus 25 min for non-DL techniques. DL enables opportunistic, rapid and automated volumetric BC analysis of CT performed for clinical indications. However, most CT scans do not cover head-to-fingertip-to-toe; further research must validate using common CT regions to estimate true whole-body BC, with direct comparison to single lumbar slice. Due to successes of DL, we expect progressive numbers of algorithms to materialize in addition to the seven discussed in this paper. Researchers and clinicians in the field of BC must therefore be aware of pitfalls. High Dice similarity coefficients do not inform the degree to which BC tissues may be under- or overestimated and nor does it inform on algorithm precision. Consensus is needed to define accuracy and precision standards for ground-truth labelling. Creation of a large international, multicentre common CT dataset with BC ground-truth labels from multiple experts could be a robust solution.

Background Colorectal cancer is the second most common cause of death in the United Kingdom. Most cancers are believed to arise within preexisting adenomas. Although colorectal adenomas have a clear neoplastic potential, hyperplastic polyps do not. It, therefore, would be helpful to be able to differentiate between different polyps at a colonoscopy. Autofluorescence (AF) endoscopy has been developed to enhance conventional white light (WL) endoscopy in the diagnosis of GI lesions. Objective The aim of the present study was to evaluate whether AF colonoscopy can facilitate endoscopic detection and differentiation of colorectal polyps. Design Patients were invited to attend for colonic assessment with both AF and WL endoscopy. AF readings, pictures, and biopsy specimens were taken of any visible pathology and of any high AF areas. Setting Gartnavel General Hospital, Glasgow, U.K. Patients A total of 107 patients were assessed. Intervention Each patient was assessed with AF and WL colonoscopy. Main Outcome Measurements An AF intensity ratio (AIR) was calculated for each polyp (ratio of direct polyp AF reading/background rectal AF activity). Results A total of 75 polyps were detected: 54 adenomatous and 21 hyperplastic polyps. Colorectal adenomas had a significantly higher AIR compared with hyperplastic polyps (median, interquartile range): adenoma (3.54, 2.54-5.00] versus hyperplastic (1.60, 1.30-2.24); P = .0001). When using an AIR with the empirically cutoff value of 2.3, AF endoscopy had a sensitivity of 85% and a specificity of 81% at distinguishing adenomatous polyps from hyperplastic polyps. Conclusions AF colonoscopy may be a valuable tool for the visual distinction between adenomatous and hyperplastic polyps. Colorectal cancer is the second most common cause of death in the United Kingdom. Most cancers are believed to arise within preexisting adenomas. Although colorectal adenomas have a clear neoplastic potential, hyperplastic polyps do not. It, therefore, would be helpful to be able to differentiate between different polyps at a colonoscopy. Autofluorescence (AF) endoscopy has been developed to enhance conventional white light (WL) endoscopy in the diagnosis of GI lesions. The aim of the present study was to evaluate whether AF colonoscopy can facilitate endoscopic detection and differentiation of colorectal polyps. Patients were invited to attend for colonic assessment with both AF and WL endoscopy. AF readings, pictures, and biopsy specimens were taken of any visible pathology and of any high AF areas. Gartnavel General Hospital, Glasgow, U.K. A total of 107 patients were assessed. Each patient was assessed with AF and WL colonoscopy. An AF intensity ratio (AIR) was calculated for each polyp (ratio of direct polyp AF reading/background rectal AF activity). A total of 75 polyps were detected: 54 adenomatous and 21 hyperplastic polyps. Colorectal adenomas had a significantly higher AIR compared with hyperplastic polyps (median, interquartile range): adenoma (3.54, 2.54-5.00] versus hyperplastic (1.60, 1.30-2.24); P = .0001). When using an AIR with the empirically cutoff value of 2.3, AF endoscopy had a sensitivity of 85% and a specificity of 81% at distinguishing adenomatous polyps from hyperplastic polyps. AF colonoscopy may be a valuable tool for the visual distinction between adenomatous and hyperplastic polyps.

Complete mesocolic excision with central vascular ligation (CME) produces an optimal colonic cancer specimen. The ability of expert laparoscopic surgeons to produce equivalent specimens is unknown.Fresh specimen photographs and clinicopathological data from patients undergoing laparoscopically assisted CME at St Mark's Hospital, Harrow, were submitted for independent pathological review. Surgery was performed by a mixture of consultant specialists and trainees under consultant specialist supervision, between February 2010 and July 2011. The planes of surgery were graded and tissue morphometry was performed using standard methods. The results were compared with published data from open CME and non-CME surgery.In total, 69 patients were identified, and in 96 per cent resection was performed completely or partially by surgical trainees. Laparoscopic CME produced a similar specimen to open CME. The laparoscopic mesocolic plane resection rate was similar to that for open surgery (90 versus 88 per cent). The distance between the bowel wall and site of vascular division was similar for laparoscopic and open right-sided CME (92 versus 95 mm respectively). The corresponding values for left-sided CME were also similar (103 versus 107 mm). Compared with values from two non-CME series, laparoscopic CME had a higher mesocolic plane rate (90 versus 40 and 48 per cent), and resected more tissue between the bowel wall and the vascular division (right-sided: 92 versus 72 and 76 mm; left-sided: 103 versus 85 and 70 mm). The lymph node yield remained low following laparoscopic CME compared with open CME (median 18 versus 32; P < 0·001) and identical to that of non-CME surgery (median 18).Laparoscopic CME can be performed to the same standard as open surgery by supervised trainees. However, this did not increase the lymph node yield.

Fistulizing Crohn’s disease represents an evolving, yet unresolved, issue for multidisciplinary management. Perianal fistulas are the most frequent findings in fistulizing Crohn’s disease. While enterocutaneous fistulas are rare, they are associated with considerable morbidity and mortality. Detailed evaluation of the fistula tract by advanced imaging techniques is required to determine the most suitable management options. The fundamentals of perianal fistula management are to evaluate the complexity of the fistula tract, and exclude proctitis and associated abscess. The main goals of the treatment are abscess drainage, which is mandatory, before initiating immunosuppressive medical therapy, resolution of fistula discharge, preservation of continence and, in the long term, avoidance of proctectomy with permanent stoma. The management of enterocutaneous fistulas comprises of sepsis control, skin care, nutritional optimization and, if needed, delayed surgery.

Muscle depletion is a poor prognostic indicator in colorectal cancer (CRC) patients, but there were no data assessing comparative temporal body composition changes following elective CRC surgery. We examined patient skeletal muscle index trajectories over time after surgery and determined factors that may contribute to those alterations.Patients diagnosed with CRC undergoing elective surgical resection between 2006 and 2013 were included in this study. Image analysis of serial computed tomography (CT) scans was used to calculate lumbar skeletal muscle index (LSMI). A multilevel mixed-effect linear regression model was applied using STATA (version 12.0) using the xtmixed command to fit growth curve models (GCM) for LSMI and time.In 856 patients, a total of 2136 CT images were analyzed; 856 (38.2 %) were preoperative. A quadratic GCM with random intercept and random slope for patients' LSMI was identified that demonstrated laparoscopy produces a positive change on the LSMI curve [estimate = 0.17 cm(2)/m(2), standard error (SE) 0.06 cm(2)/m(2); p = 0.03], whereas Union for International Cancer Control (UICC) stage III + IV disease contributed to a negative curve change (estimate = -0.19 cm(2)/m(2), SE 0.09 cm(2)/m(2); p = 0.03). Older age (p < 0.01), female gender (p < 0.01), higher American Society of Anesthesiologists (ASA) score (p < 0.01), and altered systemic inflammatory response [SIR] (p = 0.03) were factors significantly associated with lower values of LSMI over time.In patients undergoing CRC surgery, laparoscopy and the absence of a significantly elevated SIR favored preservation and restoration of skeletal muscle, postoperatively. These emerging data may permit the development of new treatment protocols whereby monitoring and modification of body composition has therapeutic potential.

Objective: To examine the impact of The National Training Program for Lapco on the rate of laparoscopic surgery and clinical outcomes of cases performed by Lapco surgeons after completion of training. Summary of Background Data: Lapco provided competency-based supervised clinical training for specialist colorectal surgeons in England. Methods: We compared the rate of laparoscopic surgery, mortality, and morbidity for colorectal cancer resections by Lapco delegates and non-Lapco surgeons in 3-year periods preceding and following Lapco using difference in differences analysis. The changes in the rate of post-Lapco laparoscopic surgery with the Lapco sign-off competency assessment and in-training global assessment scores were examined using risk-adjusted cumulative sum to determine their predictive clinical validity with predefined competent scores of 3 and 5 respectively. Results: One hundred eight Lapco delegates performed 4586 elective colo-rectal resections pre-Lapco and 5115 post-Lapco while non-Lapco surgeons performed 72,930 matched cases. Lapco delegates had a 37.8% increase in laparoscopic surgery which was greater than non-Lapco surgeons by 20.9% [95% confidence interval (CI), 18.5–23.3, P &lt; 0.001) with a relative decrease in 30-day mortality by -1.6% (95% CI, -3.4 to -0.2, P = 0.039) and 90-day mortality by -2.3% (95% CI, -4.3 to -0.4, P = 0.018). The change point of risk-adjusted cumulative sum was 3.12 for competency assessment tool and 4.74 for global assessment score whereas laparoscopic rate increased from 44% to 66% and 40% to 56%, respectively. Conclusions: Lapco increased the rate of laparoscopic colorectal cancer surgery and reduced mortality and morbidity in England. In-training competency assessment tools predicted clinical performance after training.

This article adopts a multidisciplinary approach, including surgery, oncology, radiology and patient perspectives, to discuss the key points of debate surrounding a watch and wait approach. In an era of shared decision-making, discussion of watch and wait as an option in the context of complete clinical response is appropriate, although it is not the gold standard treatment. Key challenges are the difficulty in assessing for a complete clinical response, prediction of recurrence and access to timely diagnostics for surveillance. Salvage surgery has good results if regrowth is detected early but does have imperfect outcomes, with only a 90% salvage rate. Good communication with patients about the risks and alternatives is essential. Patients undergoing watch and wait should ideally be enrolled in prospective registries or clinical trials.

Abstract Background With the adoption of enhanced recovery and emerging new modalities of analgesia after laparoscopic colorectal resection (LCR), the role of epidural analgesia has been questioned. This pilot trial assessed the feasibility of a randomized controlled trial (RCT) comparing epidural analgesia and use of a local anaesthetic wound infusion catheter (WIC) following LCR. Methods Between April 2010 and May 2011, patients undergoing elective LCR in two centres were randomized to analgesia via epidural or WIC. Sham procedures were used to blind surgeons, patients and outcome assessors. The primary outcome was the feasibility of a large RCT, and all outcomes for a definitive trial were tested. The success of blinding was assessed using a mixed-methods approach. Results Forty-five patients were eligible, of whom 34 were randomized (mean(s.d.) age 70(11·8) years). Patients were followed up per-protocol; there were no deaths, and five patients had a total of six complications. Challenges with capturing pain data were identified and resolved. Mean(s.d.) pain scores on the day of discharge were 1·9(3·1) in the epidural group and 0·7(0·7) in the WIC group. Median length of stay was 4 (range 2–35, interquartile range 3–5) days. Mean use of additional analgesia (intravenous morphine equivalents) was 12 mg in the WIC arm and 9 mg in the epidural arm. Patient blinding was successful in both arms. Qualitative interviews suggested that patients found participation in the trial acceptable and that they would consider participating in a future trial. Conclusion A blinded RCT investigating the role of epidural and WIC administration for postoperative analgesia following LCR is feasible. Rigorous standard operating procedures for data collection are required.

Abstract Background The literature on laparoscopic restorative proctectomy (RP) and proctocolectomy (RPC) is limited. This study compared clinical outcomes of laparoscopic RP and RPC with those of conventional open surgery at one centre. Methods Data were analysed from consecutive patients undergoing RPC and RP between November 2006 and November 2011. A standard laparoscopic technique was developed during the first 2 years, performed by two laparoscopic surgeons, with selection of patients who had not previously undergone open colectomy. Study endpoints included postoperative length of stay, 30-day morbidity, readmission, reoperation, pouch function and failure. Results A total of 207 patients were included; open surgery was performed in 131 (63·3 per cent) and a laparoscopic procedure in 76 (36·7 per cent). There were no significant differences in patient demographics. The conversion rate was 9 per cent (7 of 76). The median (i.q.r.) duration of operation was shorter for open than for laparoscopic procedures: 208 (178–255) versus 285 (255–325) min respectively (P &amp;lt; 0·001). Laparoscopic RPC had a shorter length of stay: median (i.q.r.) 6 (4–8) versus 8 (7–12) days (P &amp;lt; 0·001). The rate of minor complications was lower in the laparoscopic group (33 versus 50·4 per cent; odds ratio (OR) 0·48, 95 per cent confidence interval 0·27 to 0·87). There were no significant differences in total complications (51 per cent after laparoscopy versus 61·5 per cent after open surgery; OR 0·66, 0·37 to 1·17), anastomotic leakage, major morbidity, 30-day readmission, reoperation and stoma closure rates. Pouch failure (including permanent stoma) occurred in 14 (7·7 per cent) of 181 patients. Three patients died, all in the open surgery group. Conclusion Laparoscopic RPC is feasible with some short-term advantages.

Laparoscopic approaches and standardized recovery protocols have reduced morbidity following colorectal cancer surgery. As the optimal regimen remains inconclusive, a network meta-analysis was undertaken of treatments for the development of postoperative complications and mortality.MEDLINE, Embase, trial registries and related reviews were searched for randomized trials comparing laparoscopic and open surgery within protocol-driven or conventional perioperative care for colorectal cancer resection, with complications as a defined endpoint. Relative odds ratios (ORs) for postoperative complications and mortality were estimated for aggregated data.Forty trials reporting on 11 516 randomized patients were included with the network. Open surgery within conventional perioperative care was the index for comparison. The OR relating to complications was 0·77 (95 per cent c.i. 0·65 to 0·91) for laparoscopic surgery within conventional care, 0·69 (0·48 to 0·99) for open surgery within protocol-driven care, and 0·43 (0·28 to 0·67) for laparoscopic surgery within protocol-driven care. Sensitivity analyses excluding trials of low rectal cancer and those with a high risk of bias did not affect the treatment estimates. Meta-analyses demonstrated that mortality risk was unaffected by perioperative strategy.Laparoscopic surgery combined with protocol-driven care reduces colorectal cancer surgery complications, but not mortality. The reduction in complications with protocol-driven care is greater for open surgery than for laparoscopic approaches. Registration number: CRD42015017850 (https://www.crd.york.ac.uk/PROSPERO).

The role of microbiota:immune system dysregulation in the etiology of colorectal cancer (CRC) is poorly understood. CRC develops in gut epithelium, accompanied by low level inflammatory signaling, intestinal microbial dysbiosis and immune dysfunction. We examined populations of intraepithelial lymphocytes in non-affected colonic mucosa of CRC and healthy donors and circulating immune memory to commensal bacterial species and yeasts. γδ T cells and resident memory T cells, populations with a regulatory CD39-expressing phenotype, were found at lower frequencies in the colonic tissue of CRC donors compared to healthy controls. Patterns of T cell proliferative responses to a panel of commensal bacteria were distinct in CRC, while B cell memory responses to several bacteria/yeast were significantly increased, accompanied by increased proportions of effector memory B cells, transitional B cells and plasmablasts in blood. IgA responses to mucosal microbes were unchanged. Our data describe a novel immune signature with similarities to and differences from that of inflammatory bowel disease. They implicate B cell dysregulation as a potential contributor to parainflammation and identify pathways of weakened barrier function and tumor surveillance in CRC-susceptible individuals.

The pathogenesis of chronic anal fissure (CAF) remains incompletely understood but most are associated with a high resting anal pressure and reduced perfusion at the fissure site. To date, no major distinction has been made between anterior and posterior anal fissures and their aetiology and treatment. We compared anterior and posterior fissures in patients who have failed to respond to medical treatment with respect to their underlying aetiology, anal canal pressures and sphincter muscle integrity.Seventy consecutive patients (54 female:16 male) with a symptomatic CAF and 39 normal controls (19 female:20 male) without evidence of significant ano-rectal pathology were prospectively assessed by manometry and anal endosonography.Anterior anal fissures were identified in a younger age group [33 years (IQR 26-37) vs 41 years (IQR 36-52)] and predominantly in women. Anterior fissure patients were significantly more likely to have underlying external anal sphincter defects compared with posterior fissures [OR 10.9 (95% CI 3.4-35.4)]. Maximum resting pressure was not significantly elevated for anterior fissures compared with controls (P = 0.316) but was significantly elevated in posterior fissures (P = 0.005). The maximum squeeze pressure was significantly lower in the anterior fissure group [167 cmH2O (IQR 126-196) vs 205 cmH2O (IQR 174-262), P = 0.004]. A history of obstetric trauma was significantly associated with anterior fissure location [OR 13.9 (95% CI 3.4-55.7)].Anterior anal fissures are associated with occult external anal sphincter injury and impaired external anal sphincter function compared with posterior fissures. These findings have implications for treatment, especially if a definitive procedure, such as lateral internal sphincterotomy, is considered.

This study aims to determine whether traditional risk models can accurately predict morbidity and mortality in patients undergoing major surgery by colorectal surgeons within an enhanced recovery program.One thousand three hundred eighty patients undergoing surgery performed by colorectal surgeons in a single UK hospital (2008-2013) were included. Six risk models were evaluated: (1) Physiology and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM), (2) Portsmouth POSSUM (P-POSSUM), (3) ColoRectal (CR-POSSUM), (4) Elderly POSSUM (E-POSSUM), (5) the Association of Great Britain and Ireland (ACPGBI) score, and (6) modified Estimation of Physiologic Ability and Surgical Stress Score (E-PASS). Model accuracy was assessed by observed to expected (O:E) ratios and area under Receiver Operating Characteristic curve (AUC).Eleven patients (0.8%) died and 143 patients (10.4%) had a major complication within 30 days of surgery. All models overpredicted mortality and had poor discrimination: POSSUM 8.5% (O:E 0.09, AUC 0.56), P-POSSUM 2.2% (O:E 0.37, AUC 0.56), CR-POSSUM 7.1% (O:E 0.11, AUC 0.61), and E-PASS 3.0% (O:E 0.27, AUC 0.46). ACPGBI overestimated mortality in patients undergoing surgery for cancer 4.4% (O:E = 0.28, AUC = 0.41). Predicted morbidity was also overestimated by POSSUM 32.7% (O:E = 0.32, AUC = 0.51). E-POSSUM overestimated mortality (3.25%, O:E 0.57 AUC = 0.54) and morbidity (37.4%, O:E 0.30 AUC = 0.53) in patients aged ≥ 70 years and over.All models overestimated mortality and morbidity. New models are required to accurately predict the risk of adverse outcome in patients undergoing major abdominal surgery taking into account the reduced physiological and operative insult of laparoscopic surgery and enhanced recovery care.

Body composition degenerates with cancer. Optimizing body composition is rarely, if ever, undertaken. This narrative review highlights and evaluates emerging treatments that have the potential to improve outcomes for our cancer patients.Body composition in cancer patients has been shown to be modifiable; enhanced body composition is associated with improved short term, long-term outcomes and survival in addition to improvements in function and quality of life.A multimodal approach to body composition optimization formulated by a multidisciplinary team in a patient-centric manner can improve outcome. As part of a multifaceted approach to patient treatment, body composition modification should be considered to expand our armoury in fighting the systemic burden of cancer.

The effects of COVID-19 on cancer are substantial, highlighting both novel and existing challenges for health-care systems. We were therefore encouraged to see The Lancet Oncology's call for cancer care to be safeguarded in a post-COVID-19 world.1The Lancet OncologySafeguarding cancer care in a post-COVID-19 world.Lancet Oncol. 2020; 21: 603Summary Full Text Full Text PDF PubMed Scopus (49) Google Scholar We endorse this position for cancer surgery specifically, and propose several recommendations aiming to reduce the so-called collateral damage of COVID-19. The International Cancer Benchmarking Partnership (ICBP) is a global collaboration seeking to compare and improve cancer survival across high-income countries.2Arnold M Rutherford MJ Bardot A et al.Progress in cancer survival, mortality, and incidence in seven high-income countries 1995–2014 (ICBP SURVMARK-2): a population-based study.Lancet Oncol. 2019; 20: 1493-1505Summary Full Text Full Text PDF PubMed Scopus (609) Google Scholar Within the ICBP, we came together to provide a voice for the international cancer surgery community. Cancer is a major cause of morbidity and mortality, made acutely worse by the COVID-19 pandemic, and requires sustained investment and coordinated planning in a COVID-19 world. Health leaders now need to safeguard capacity and regain lost progress in cancer control. Available resources should be directed to those most likely to benefit. National media campaigns should be used to boost screening uptake and help-seeking behaviour for potential cancer symptoms, addressing the current delays and barriers in access to health care. Investment in cancer diagnostic workforces will be key, particularly in building up provisions for tests and biopsy procedures and shortening diagnosis-to-treatment intervals. The pandemic has also created opportunities to improve efficiencies in care, such as virtual consultations and visits. Facilitating multidisciplinary team meetings digitally is one of many potential changes requiring long-term investment in technology and infrastructure. Cancer surgery services need to be well prepared as we navigate through the COVID-19 era. Substantial reconfigurations will be required to deal with heightened caseloads. Together with other time-sensitive and life-threatening procedures, cancer surgery should be prioritised over less urgent operations. Increased theatre space availability, surgeon capacity, and postoperative surveillance resources will be required. More frequent and widespread testing is needed to ensure relatively COVID-19-free hospitals or designated Cancer Hubs that are safe for patients and staff. More acute-care nurses should be recruited to manage more patients preoperatively and postoperatively. The widespread implementation of enhanced recovery after surgery services is recommended to match increased surgical volumes. Expansions in the capacity of intensive care units must remain in place while services manage an unprecedented number of patients with cancer coming back into the system. Capturing real-time data will be crucial to benchmark hospital performance and inform rapid quality improvement as centres grapple with the new reality of a post-COVID-19 world. We must also prepare for consecutive waves of outbreaks, with the need to restrict services for uncertain periods of time. Finally, efforts to benchmark cancer outcomes internationally and regionally are now essential to better understand the global impacts of COVID-19 on cancer care and enable countries to share knowledge on best practice during pandemics in future. To support cancer surgery services, we propose several recommendations (panel). These recommendations should inform policies to deal with a new cancer burden in a post-COVID-19 environment and to mitigate a potential crisis in excess deaths due to cancer. Countries and regions will be affected in different ways and should prioritise these recommendations on the basis of their own resources and planning.PanelRecommendations•Run media campaigns to boost screening uptake and encourage patients to seek help for potential cancer symptoms•Resume evidence-based screening programmes and other early diagnosis initiatives as soon as possible•Implement risk stratification tools and effective triage assessments to account for restricted diagnostic capacity and to prioritise patients with concerning symptoms or requiring staging over those in follow-up•Mitigate the risks of nosocomial SARS-CoV-2 infection, including testing all patients admitted for major cancer surgery and by using relatively COVID-19-free institutions (designated stand-alone diagnostic and treatment facilities) or isolating within sites•Investing in technology and infrastructure to facilitate virtual consultations, multidisciplinary team meetings, and other innovations•Prioritise cancer surgery over elective and less urgent operations, and among these cancer cases, prioritise patients according to urgency of surgical care and patient benefit•Anticipate increased volumes of cancer surgery with appropriate workforce and resource planning in a slower throughput environment, including theatre space, surgeon capacity, and postoperative surveillance resources, potentially to levels higher than before COVID-19•Maintain increased levels of intensive care unit capacity and standards to ensure prioritisation of patients with cancer and other time critical and life-threatening conditions•Adopt evidence-based perioperative pathways such as enhanced recovery after surgery to improve recovery of patients with cancer after surgery, allowing for increased throughput of patients and capacity of the health-care system•Capture data and track of the number of cases, patient stage, and treatment in real-time to benchmark performance and respond to system stresses•Support cancer health-care teams and administrative staff to minimise and respond to burnout•Prepare and plan for subsequent waves of COVID-19 and other pandemics to reduce future effects on cancer care•Benchmark international and regional cancer outcomes in the new context of COVID-19SARS-CoV-2=severe acute respiratory syndrome coronavirus 2. •Run media campaigns to boost screening uptake and encourage patients to seek help for potential cancer symptoms•Resume evidence-based screening programmes and other early diagnosis initiatives as soon as possible•Implement risk stratification tools and effective triage assessments to account for restricted diagnostic capacity and to prioritise patients with concerning symptoms or requiring staging over those in follow-up•Mitigate the risks of nosocomial SARS-CoV-2 infection, including testing all patients admitted for major cancer surgery and by using relatively COVID-19-free institutions (designated stand-alone diagnostic and treatment facilities) or isolating within sites•Investing in technology and infrastructure to facilitate virtual consultations, multidisciplinary team meetings, and other innovations•Prioritise cancer surgery over elective and less urgent operations, and among these cancer cases, prioritise patients according to urgency of surgical care and patient benefit•Anticipate increased volumes of cancer surgery with appropriate workforce and resource planning in a slower throughput environment, including theatre space, surgeon capacity, and postoperative surveillance resources, potentially to levels higher than before COVID-19•Maintain increased levels of intensive care unit capacity and standards to ensure prioritisation of patients with cancer and other time critical and life-threatening conditions•Adopt evidence-based perioperative pathways such as enhanced recovery after surgery to improve recovery of patients with cancer after surgery, allowing for increased throughput of patients and capacity of the health-care system•Capture data and track of the number of cases, patient stage, and treatment in real-time to benchmark performance and respond to system stresses•Support cancer health-care teams and administrative staff to minimise and respond to burnout•Prepare and plan for subsequent waves of COVID-19 and other pandemics to reduce future effects on cancer care•Benchmark international and regional cancer outcomes in the new context of COVID-19 SARS-CoV-2=severe acute respiratory syndrome coronavirus 2. ADA reports grants (as a clinical trial site principal investigator), speaker fees, and travel reimbursement from AstraZeneca; is a member of the drug advisory board of AstraZeneca; and reports grants from Clovis, Merck, CancerCare Manitoba foundation, and the Canadian Clinical Trials Group outside of the submitted work. PAC reports personal fees from Seqirus outside of the submitted work. All other authors declare no competing interests.

In recent years there has been an increasing uptake in the use of barbed sutures, particularly in minimally invasive and laparoscopic procedures where they may reduce operating time and improve surgical efficiency. However, little is known about the adverse events associated with these new materials and concerns have arisen regarding their safety in certain procedures.We performed a search of electronic databases (PubMed, EMBASE, and Cochrane Database). We reveal up to 15 cases of small bowel obstruction (SBO) complicating laparoscopic pelvic surgery that have been reported to date adding two cases of SBO in our own practice following the use of barbed sutures in laparoscopic operations, both requiring surgical re-intervention in the early post-operative period.Fifteen similar cases of small bowel obstruction were identified, all of which occurred in patients undergoing surgery below the transverse colon . Surgical re-intervention was required in all cases although 60% of these were performed laparoscopically.These cases highlight that although barbed sutures provide an attractive means to allow easier and faster laparoscopic suturing, they should be used carefully in inframesocolic surgery and the suture end cut and buried to avoid inadvertent attachment to the small bowel or its mesentery. Barbed suture entanglement should be considered as an uncommon yet potentially serious differential cause for SBO presenting in the early period after laparoscopic surgery where a barbed suture has been used.

Abstract Background There is strong evidence suggesting that excessive fat distribution, for example, in the bowel mesentery or a reduction in lean body mass (sarcopenia) can influence short-, mid-, and long-term outcomes from patients undergoing various types of surgery. Body composition (BC) analysis aims to measure and quantify this into a parameter that can be used to assess patients being treated for abdominal wall hernia (AWH). This study aims to review the evidence linking quantification of BC with short- and long-term abdominal wall hernia repair outcomes. Methods A systematic review was performed according to the PRISMA guidelines. The literature search was performed on all studies that included BC analysis in patients undergoing treatment for AWH using Medline, Google Scholar and Cochrane databases by two independent reviewers. Outcomes of interest included short-term recovery, recurrence outcomes, and long-term data. Results 201 studies were identified, of which 4 met the inclusion criteria. None of the studies were randomized controlled trials and all were cohort studies. There was considerable variability in the landmark axial levels and skeletal muscle(s) chosen for analysis, alongside the methods of measuring the cross-sectional area and the parameters used to define sarcopenia. Only two studies identified an increased risk of postoperative complications associated with the presence of sarcopenia. This included an increased risk of hernia recurrence, postoperative ileus and prolonged hospitalisation. Conclusion There is some evidence to suggest that BC techniques could be used to help predict surgical outcomes and allow early optimisation in AWH patients. However, the lack of consistency in chosen methodology, combined with the outdated definitions of sarcopenia, makes drawing any conclusions difficult. Whether body composition modification can be used to improve outcomes remains to be determined.

This report summarizes the early experience of implementing elective colorectal cancer surgery during the COVID-19 pandemic.A pathway to minimize the risk of including COVID-19-positive patients for elective surgery was established. Prioritization and additional safety measures were introduced into clinical practice. Minimal invasive surgery was used where appropriate.Thirty-eight patients were prioritized, and 23 patients underwent surgery (eight colon, 14 rectal and one anal cancer). The minimal invasive surgery rate was 78%. There were no major postoperative complications or patients diagnosed with COVID-19. Histopathological outcomes were similar to normal practice.A safe pathway to offer standard high-quality surgery to colorectal cancer patients during the COVID-19 pandemic is feasible.

<h2>Abstract</h2> Chemotherapy dosing is traditionally based on body surface area calculations; however, these calculations ignore separate tissue compartments, such as the lean body mass (LBM), which is considered a big pool of drug distribution. In our era, colorectal cancer patients undergo a plethora of computed tomography scans as part of their diagnosis, staging and monitoring, which could easily be used for body composition analysis and LBM calculation, allowing for personalised chemotherapy dosing. This systematic review aims to evaluate the effect of muscle mass on dose-limiting toxicity (DLT), among different chemotherapy regimens used in colorectal cancer patients. This review was carried out according to the PRISMA guidelines. MEDLINE and EMBASE databases were searched from 1946 to August 2019. The primary search terms were 'sarcopenia', 'myopenia', 'chemotherapy toxicity', 'chemotherapy dosing', 'dose limiting toxicity', 'colorectal cancer', 'primary colorectal cancer' and 'metastatic colorectal cancer'. Outcomes of interest were – DLT and chemotoxicity related to body composition, and chemotherapy dosing on LBM. In total, 363 studies were identified, with 10 studies fulfilling the selection criteria. Seven studies were retrospective and three were prospective. Most studies used the same body composition analysis software but the chemotherapy regimens used varied. Due to marked study heterogeneity, quantitative data synthesis was not possible. Two studies described a toxicity cut-off value for 5-fluorouracil and one for oxaliplatin based on LBM. The rest of the studies showed an association between different body composition metrics and DLTs. Prospective studies are required with a larger colorectal cancer cohort, longitudinal monitoring of body composition changes during treatment, similar body composition analysis techniques, agreed cut-off values and standardised chemotherapy regimens. Incorporation of body composition analysis in the clinical setting will allow early identification of sarcopenic patients, personalised dosing based on their LBM and early optimisation of these patients undergoing chemotherapy.

The host local immune response (LIR) to cancer is a determinant of cancer outcome. Regulation of this local response is largely achieved through chemokine synthesis from the tumor microenvironment such as C-Chemokine-Receptor-7 (CCR7). We examined the LIR measured as CCR7 expression, in colorectal cancers (CRC) and explored relationships with body composition (BC) and survival.A study of paraffin-embedded tissue specimens was carried out in 116 patients with non-metastatic CRC. CCR7 expression was determined by immunohistochemistry. Analysis of computer tomography scans was used to calculate BC parameters. Survival analyses and multivariate regression models were used.High CCR7(+) cell density within the tumor stroma and at the margin was significantly associated with increased age, the presence of lymphovascular invasion, higher tumor stage, lymph node metastasis, high Klintrup-Makinen immune score, and myosteatosis. High CCR7(+) cell density in the tumor margin was significantly associated with shorter disease-free (DFS) and overall survival (OS) (P < 0.001). This was also significantly associated with shorter survival in multivariate analysis (HR = 8.87; 95%CI [2.51-31.3]; P < 0.01 for OS and HR = 4.72; 95%CI (1.24-12.9); P = 0.02 for DFS).Our results suggest that a specific immune microenvironment may be associated with altered host's BC and tumor behavior, and that CCR7 may serve as a novel prognostic biomarker.

Dendritic cells (DCs) either boost the immune system (enhancing immunity) or dampen it (leading to tolerance). This dual effect explains their vital role in cancer development and progression. DCs have been tested as a predictor of outcomes for cancer progression. Eight studies evaluated tumour-infiltrating DCs (TIDCs) as a predictor for colorectal cancer (CRC) outcomes. The detection of TIDCs has not kept pace with the increased knowledge about the identification of DC subsets and their maturation status. For that reason, it is difficult to draw a conclusion about the performance of DCs as a predictor of outcome for CRC. In this review, we comprehensively examine the evidence for the in situ immune response due to DC infiltration, in predicting outcome in primary CRC and how such information may be incorporated into routine clinical assessment.

Benchmark comparisons in surgery allow identification of gaps in the quality of care provided. The aim of this study was to determine quality thresholds for high (HAR) and low (LAR) anterior resections in colorectal cancer surgery by applying the concept of benchmarking.This 5-year multinational retrospective study included patients who underwent anterior resection for cancer in 19 high-volume centres on five continents. Benchmarks were defined for 11 relevant postoperative variables at discharge, 3 months, and 6 months (for LAR). Benchmarks were calculated for two separate cohorts: patients without (ideal) and those with (non-ideal) outcome-relevant co-morbidities. Benchmark cut-offs were defined as the 75th percentile of each centre's median value.A total of 3903 patients who underwent HAR and 3726 who had LAR for cancer were analysed. After 3 months' follow-up, the mortality benchmark in HAR for ideal and non-ideal patients was 0.0 versus 3.0 per cent, and in LAR it was 0.0 versus 2.2 per cent. Benchmark results for anastomotic leakage were 5.0 versus 6.9 per cent for HAR, and 13.6 versus 11.8 per cent for LAR. The overall morbidity benchmark in HAR was a Comprehensive Complication Index (CCI®) score of 8.6 versus 14.7, and that for LAR was CCI® score 11.9 versus 18.3.Regular comparison of individual-surgeon or -unit outcome data against benchmark thresholds may identify gaps in care quality that can improve patient outcome.

The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR.Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed.Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%).The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

<h2>Abstract</h2><h3>Introduction</h3> Pathological factors that influence and predict survival following pelvic exenteration (PE) for locally advanced (LARC) or locally recurrent rectal cancer (LRRC), especially LRRC, remain poorly understood. A clear resection margin has previously been demonstrated to be of most significance. <h3>Materials and methods</h3> A retrospective cohort study was performed for all patients undergoing a curative PE for LARC or LRRC between 2008 and 2021 at a tertiary referral UK specialist colorectal hospital. Cox regression analysis was planned to identify pathological factors associated with overall (OS), disease free (DFS) and local recurrence free survival (LRFS). <h3>Results</h3> 388 patients were included in the analysis with 256 resections for LARC and 132 for LRRC. 62.4% of patients were male with a median age of 59 years (IQR 49–67). 247 (64%) partial pelvic exenterations and 141 (36%) total pelvic exenterations performed. Overall R0 rate 86.6%. Poorly differentiated tumours and a positive resection margin independently influenced OS, DFS and LRFS on multivariate analysis in LARC. On multivariate analysis venous invasion negatively influenced DFS and poorly differentiated lesions negatively influenced LRFS in LRRC. <h3>Conclusions</h3> A positive resection margin and poorly differentiated tumours are significant negative prognostic markers for survival and recurrence in LARC. The results of this study support the need to look for alternative prognostic markers beyond that in the existing standard reporting dataset for rectal cancers. With increasing R0 rates, novel prognostic pathological markers are required to help guide treatment and surveillance for patients with LRRC.

Abstract Objective Female faecal incontinence (FI) is largely because of sphincter injury at childbirth. Sphincter assessment aims to identify surgically correctable defects. We aimed to identify endoanal ultrasonography (EAUS) parameters that correlate with sphincter function. Method One hundred females with FI and 28 healthy asymptomatic females were prospectively assessed. Wexner FI score was recorded and all subjects underwent anorectal manometry and EAUS. Multiple EAUS parameters were assessed and correlated with external (EAS) and internal (IAS) anal sphincter function, determined by maximum squeeze pressure (MSP) and maximum resting pressure (MRP) respectively. Parameters included sphincter quality (echogenicity), thickness, perineal body thickness (PBT) and defect characteristics (angle, length). Results are expressed as medians and interquartile range (IQR). Results Median Wexner score was 14 (12–17). Maximum EAS thickness significantly correlated with MSP ( P = 0.019). EAS defects were detected in 84 patients and seven controls ( P &lt; 0.0001). Full‐length EAS defects were only detected in FI group and had significantly lower MSP [MSP mmHg: full length 85 (65–103) vs partial length 119 (75–155), P = 0.006]. FI patients were more likely to have a mixed echogenicity of EAS compared with controls. EAS ring quality, PBT and defect angle were not significant. IAS quality was significantly associated with MRP [MRP mmHg: uniform 62 (43–82) vs mixed 47 (30.5–57.5), P = 0.002]. Conclusion Certain EAUS parameters can be predictive of anal sphincter function. These include the presence of an EAS defect and its length, EAS maximum thickness, IAS ring quality. Integration of these parameters can give better EAUS correlation with manometry for FI evaluation.

RRx-001, an experimental systemically non-toxic epi-immunotherapeutic agent, which potentiates the resensitization of resistant cancer cells to formerly effective therapies, is under active investigation in several clinical trials that are based on sequential or concomitant rechallenge to resistant first- or second-line regimens. One of these trials is designated TRIPLE THREAT (NCT02489903), because it explores the conditioning or priming effect of RRx-001 on three tumor types - non-small cell lung cancer (NSCLC), small cell lung cancer and high-grade neuroendocrine tumors - prior to re-administration of platinum doublets. In follow-up to a recent case study, which describes early monotherapeutic benefit with RRx-001 in a refractory EGFR-mutated NSCLC tumor, we present subsequent evidence of a radiological partial response to reintroduced platinum doublets after RRx-001. For the 50% of patients with EGFR-mutated NSCLC who progress on EGFR-tyrosine kinase inhibitors (without evidence of a T790M mutations) as well as platinum doublets and pemetrexed/taxane, no other clinically established treatment options exist. A retrial of these therapies in EGFR-positive NSCLC patients via priming with epigenetic agents such as RRx-001 constitutes a strategy to ‘episensitize' tumors (i.e. reverse resistance by epigenetic means) and to extend overall survival.

Neuroendocrine tumors (NETs) are grouped together as a single class on the basis of histologic appearance, immunoreactivity for the neuroendocrine markers chromogranin A and synaptophysin, and potential secretion of hormones, neurotransmitters, neuromodulators and neuropeptides. Nevertheless, despite these common characteristics, NETs differ widely in terms of their natural histories: high-grade NETs are clinically aggressive and, like small cell lung cancer, which they most closely resemble, tend to respond to cisplatin and etoposide. In contrast, low-grade NETs, which as a rule progress and behave indolently, do not. In either case, the treatment strategy, apart from potentially curative surgical resection, is very poorly defined. This report describes the case of a 28-year-old white male with a diagnosis of high-grade NET of undetermined primary site metastatic to the lymph nodes, skin and paraspinal soft tissues, treated with the experimental anticancer agent RRx-001, in the context of a phase II clinical trial called TRIPLE THREAT (NCT02489903); serial sampling of tumor material through repeat biopsies demonstrated an intratumoral inflammatory response, including the amplification of infiltrating T cells, which correlated with clinical and symptomatic benefit. This case suggests that pseudoprogression or RRx-001-induced enlargement of tumor lesions, which has been previously described for several RRx-001-treated patients, is the result of tumoral lymphocyte infiltration.

Despite multimodal therapy 5-15% of patients who undergo resection for advanced rectal cancer (LARC) will develop local recurrence. Management of locally recurrent rectal cancer (LRRC) presents a significant therapeutic challenge and even with modern exenterative surgery, 5-year survival rates are poor at 25-50%. High rates of local and systemic recurrence in this cohort are reflective of the likely biological aggressiveness of these tumour types. This review aims to appraise the current literature identifying pathological factors associated with survival and tumour recurrence in patients undergoing exenterative surgery.A systematic review was carried out searching MEDLINE, EMBASE and COCHRANE Trials database for all studies assessing pathological factors influencing survival following pelvic exenteration for LARC or LRRC from 2010 to July 2021 following PRISMA guidelines. Risk of bias was assessed using QUIPS tool.Nine cohort studies met inclusion criteria, reporting outcomes for 2864 patients. Meta-analysis was not possible due to significant heterogeneity of reported outcomes. Resection margin status and nodal disease were the most commonly reported factors. A positive resection margin was demonstrated to be a negative prognostic marker in six studies. Involved lymph nodes and lymphovascular invasion also appear to be negative prognostic markers with tumour stage to be of lesser importance. No studies assessed other adverse tumour features that would not otherwise be included in a standard histopathology report.Pathological resection margin status is widely demonstrated to influence disease free and overall survival following pelvic exenteration for rectal cancer. With increasing R0 rates, other adverse tumour features must be explored to help elucidate differences in survival and potentially guide tailored oncological treatment.

Abstract Perineal hernias are rare and result from the herniation of a viscus through the pelvic floor. Symptomatic perineal hernias are repaired surgically, historically via an open perineal, abdominal or abdominoperineal approach. We describe laparoscopic repair of a primary perineal hernia with mesh using the transabdominal approach. We believe that for uncomplicated primary perineal hernias laparoscopic repair is technically feasible, and associated with rapid recovery and minimal complications.

Abstract Objective Male faecal incontinence (FI) has received little attention. No consistent pathophysiological abnormality has been identified in those studies that have specifically assessed male patients with FI or faecal leakage (FL). This study was designed to re‐examine the different theories relating to the pathophysiology of male incontinence and to assess if manometric and ultrasound assessment yields clinically relevant information that directs patient care. Method This was a prospective study of all men referred to a Coloproctology clinic with incontinence. The Wexner Incontinence score was used to assess severity of symptoms. Specific investigations included anal manometry, rectal sensation and endo‐anal ultrasound (EAUS). Results were compared with a group of 20 normal male controls. Results A total of 59 symptomatic male patients were investigated (36 FI, 23 FL). FL and control groups had similar maximum resting (MRP) and maximum squeeze pressure (MSP). The incontinence group had a significantly lower MRP &amp; MSP compared with controls [MRP: FI 58 (42–75.5) vs control 85 (72–104)] ( P &lt; 0.0001), [MSP: FI 167 (125–215) vs control 248 (192–302)] ( P &lt; 0.0001). There was no significant difference in rectal sensation between the groups and the defecation index was also similar. EAUS detected only one external anal sphincter defect amongst the 23 male patients with FL. One external sphincter defect and three internal sphincter defects were identified amongst the 36 patients with incontinence. Of these five patients with sphincter defects, four had previously undergone anorectal surgery. [Results expressed as median (interquartile range): manometry expressed as mmHg]. Conclusion Male patients presenting with faecal incontinence frequently show impaired sphincter function which may be associated with sphincter defects. In contrast, those presenting predominantly with FL have no morphological or physiological changes that might account for their symptoms. Investigating such patients with anorectal physiology and EAUS is usually unhelpful and can be omitted.

Abstract Objective Endorectal ultrasound (ERUS) is well established as an accurate modality for local staging of rectal tumours. The aim of this study was to identify reasons for inaccurate staging of tumours, and to assess whether difficulties encountered during scanning are likely to influence accuracy. Patients and methods ERUS was performed by a single operator using a 10 MHz rigid instrument. One hundred and seventeen patients that had both ERUS and surgery are included in this study (patients that had pre‐operative radiotherapy were excluded). During ERUS, procedural conditions and limiting factors were recorded. Data was collected prospectively. Results In 78 (66.7%) patients no technical difficulty was encountered during ERUS. In this group accuracy was 80% for T‐stage and 77% for N‐stage. Specific reasons for inaccuracy identified in this group were: inflammatory lymph nodes (from a tumour associated abscess and a colovesical fistula) and deep biopsy causing a submucosal defect with intramural haemorrhage in benign lesions (2 cases). In the remaining 39 (33.3%), the following problems were encountered: stenotic lesions (23), patient discomfort (8), poor bowel preparation (6), and scarring from previous surgery (2). In 11 patients from this group, the scan was considered inconclusive and no stage could be determined. For the other 28, the accuracy for T‐stage was 68% and for N‐stage 67%. Conclusion A technically difficult ERUS is likely to give an inconclusive or inaccurate result for both T‐stage ( P = 0.001) and N‐stage ( P = 0.003). In this situation a repeat scan may be considered (where appropriate). Alternatively, further assessment by MRI or flexible endoscopic ultrasound may be considered.

Treatment strategies for advanced or recurrent rectal cancer have evolved such that the ultimate surgical goal to achieve a cure is complete pathological clearance. To achieve this where the sacrum is involved, en bloc sacrectomy is the current standard of care. Sacral resection is technically challenging and has been described; however, the technique has yet to be streamlined across units. This comprehensive review aims to outline the surgical approach to en bloc sacrectomy for locally advanced or recurrent rectal cancer, with standardisation of the operative steps of the procedure and to discuss options that enhance the technique.

The pre-operative phase in planning a pelvic exenteration or extended resections is critical to optimising patient outcomes. This review summarises the key components of preoperative assessment and planning in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LLRC) being considered for potential curative resection. The preoperative period can be considered in 5 key phases: 1) Multidisciplinary meeting (MDT) review and recommendation for neoadjuvant therapy and surgery, 2) Anaesthetic preoperative assessment of fitness for surgery and quantification of risk, 3) Shared decision making with the patient and the process of informed consent, 4) Prehabilitation and physiological optimisation 5) Technical aspects of surgical planning. This review will focus on patients who have been recommended for surgery by the MDT and have completed neoadjuvant therapy. Other important considerations beyond the scope of this review are the various neoadjuvant strategies employed which in this patient group include Total Neo-adjuvant Therapy and reirradiation. Critical to improving perioperative outcomes is the dual aim of achieving a negative resection margin in a patient fit enough for extended surgery. Advanced, realistic communication is required pre-operatively and should be maintained throughout recovery. Optimising patient's physiological and psychological reserve with a preoperative prehabilitation programme is important, with physiotherapy, psychological and nutritional input. From a surgical perspective, image based technical preoperative planning is important to identify risk points and ensure correct surgical strategy. Careful attention to the entire patient journey through these 5 preoperative phases can optimise outcomes with the accumulation of marginal gains at multiple timepoints.

Locally advanced intestinal neoplasms including colon cancer may require radical en bloc pancreaticoduodenectomy and right hemicolectomy (PD-RC) to achieve curative, margin-negative resection, but the safety and benefit of this uncommon procedure has not been established. The Association of Coloproctology of Great Britain and Ireland IMPACT initiative has also highlighted a lack of awareness about current services available within the UK for patients with advanced colorectal cancer and concerns about low-volume centres managing complex cases. Thus, we aimed to review the feasibility, safety and long-term outcomes of this procedure at a single high-volume hepatopancreaticobiliary surgery unit in the UK.A retrospective cohort study was performed using a database of all consecutive patients with intestinal cancer who had been referred to our regional advanced multidisciplinary team and undergone PD-RC in a 7-year period (2013-2020). Clinico-pathological and outcome data were reviewed.Ten patients (mean age 54 ± 13, 8/10 men) were identified. Final histology revealed the primary tumour sites were colon (n = 7) and duodenum (n = 3). R0 resection was achieved in all cases. The major complication rate (Clavien-Dindo ≥ 3) was 10% (1/10) with no deaths within 90 days of surgery. The Kaplan-Meier estimated 5-year overall survival was 83.3% (95% CI 58.3%-100%). Univariate survival analysis identified perineural invasion and extra-colonic origin as predictors of poor survival (log-rank P < 0.05).En bloc PD-RC for locally advanced intestinal cancer can be performed safely with a high proportion of margin-negative resections and resultant long-term survival in carefully selected patients.

Shared decision-making in pelvic exenteration is a complex and detailed process, which must balance clinical, oncological and patient-reported outcomes (PROs), whilst addressing and valuing the patient priorities. Communicating patient-centred information on quality of life (QoL) and functional outcomes is an essential component of this. The aim of this systematic review was to understand the impact of pelvic exenteration on QoL PROs over a longitudinal period and to develop QoL trajectories to support decision-making in this context.MEDLINE, Embase and Web of Science databases were searched between 1st January 2000 and 20th December 2021 Studies reporting on PROs, including QoL, in adults undergoing pelvic exenteration were included. Risk of bias was assessed using the ROBINS-I assessment tool. Data from studies reporting QoL using the same outcome measure at the same candidate timepoint were extracted and synthesised to develop a longitudinal QoL trajectory.Fourteen studies consisting of 1370 patients were included in this review. QoL trajectories were constructed in the domains of physical function, psychological function, role function, sexual function, body image and general and specific symptoms. Decision-making was only assessed by one study, with satisfaction with decision-making reported to be high. There is an initial decline in QoL scores in the domains of physical function, role function, sexual function, body image and general health and symptoms deteriorating during the first 3-6 months post-operatively. Psychological function is the only QoL domain that remains stable throughout the post-operative period.Mapping QoL trajectories provides a visual representation of post-operative progress, highlighting the enduring impact of pelvic exenteration on patients and can be used to inform pre-operative shared decision-making.

Dendritic cells (DCs) are antigen-presenting cells that can acquire tumour antigens and initiate cytotoxic T cell reactions. Obesity has been proposed as a cause for tumours escaping immune surveillance, but few studies investigate the impact of other body composition parameters. We examined the relationship of DC phenotype with computer tomography (CT)-defined parameters in patients with colorectal cancer (CRC). DCs were identified within peripheral blood mononuclear cells by flow cytometry as HLA-DR positive and negative for markers of other cell lineages in 21 patients. Analysis of CT scans was used to calculate lumbar skeletal muscle index (LSMI) and mean muscle attenuation (MA). Positive correlation between the LSMI and expression of CD40 in all DCs (r = 0.45; p = 0.04) was demonstrated. The MA was positively correlated with scavenger receptor CD36 [all DCs (r = 0.60; p = 0.01) and myeloid DCs (r = 0.63; p < 0.01)]. However, the MA was negatively correlated with CCR7 expression in all DCs (r = −0.46, p = 0.03.) and with CD83 [all DCs (r = −0.63; p = 0.01) and myeloid DCs (r = −0.75; p < 0.01)]. There were no relationships between the fat indexes and the DC phenotype. These results highlight a direct relationship between muscle depletion and changes in stimulatory, migratory and fatty acid-processing potential of DC in patients with CRC.

Abstract Aim Anastomotic leakage ( AL ) is often identified 7–10 days after colorectal surgery. However, in retrospect, abnormalities may be evident much earlier. This study aims to identify the clinical time point when AL occurs. Method This is a retrospective case‐matched cohort comparison study, assessing patients undergoing left‐sided colorectal resection between 2006 and 2015 at a specialist colorectal unit. Patients who developed AL ( LEAK ) were case‐matched to two CONTROL patients by procedure, gender, laparoscopic modality and diverting stoma. Case note review allowed the collection of basic observation data and blood tests (leukocyte count, C‐reactive protein, bilirubin, alanine transaminase, creatinine) up to postoperative day ( POD ) 4. The cohorts were compared, with the main outcome measure being changes in basic observation data. Results Of 554 patients, 49 developed AL . These were matched to 98 CONTROL patients. Notes were available for 105 patients (32 LEAK /73 CONTROL ). Groups were similar in demographics, tumour or nodal status, preoperative radiotherapy, intra‐operative air‐leak integrity and drain usage. AL was detected clinically at a median of 7.5 days postoperatively. There was a significantly increased heart rate by the evening on POD 1 in LEAK patients (82.8 ± 14.2/min vs 75.1 ± 12.7/min, P = 0.0081) which persisted for the rest of the study. By POD 3, there was a significant increase in respiratory rate (18.0 ± 4.2/min vs 16.5 ± 1.3/min, P = 0.0069) and temperature (37.0 ± 0.4C vs 36.7 ± 0.3C, P = 0.0006) in LEAK patients. C‐reactive protein was significantly higher in LEAK patients from POD 2 (165 ± 95 mg/l vs 121 ± 75 mg/l, P = 0.023). Conclusions Physiological and biochemical changes associated with AL happen very early postoperatively, suggesting that AL may occur within 36 h after surgery, despite much later clinical detection.

To determine the earliest time point at which anastomotic leaks can be detected in patients undergoing total colectomy with primary ileorectal anastomosis for familial adenomatous polyposis.This was a case-controlled study of 10 anastomotic leak patients vs 20 controls following laparoscopic total colectomy with ileorectal anastomosis for familial adenomatous polyposis (from 96 consecutive patients between 2006 and 2013). Panel time-series data regression was performed using a double subscript structure to include both variables. A generalized least squares multivariate approach was applied in a random effects setting to calculate correlations for observations, with anastomotic leak being the dependent variable. Univariate and multivariate regression calculations were then performed according to individual observations at each recorded time point. Time-series analysis was used to determine when a variable became significant in the leak group.Multivariate analysis identified a significant difference between leak and control groups in mean heart rate (P < 0.001), mean respiratory rate (P = 0.017) and mean urine output (P = 0.001). Time-point analysis showed that heart rate was significantly different between leak and control groups at postoperative day 4.25. Multivariate analysis identified a significant difference between groups in alanine transaminase (P = 0.006), bilirubin (P = 0.008), creatinine (P = 0.001), haemoglobin (P < 0.001) and urea (P = 0.007). There were no differences between groups with regard to markers of inflammation such as albumin, white blood cell count, neutrophil count and C-reactive protein.Anastomotic leaks can be detected early (within 4.5 days of surgery) through changes in physiological, blood test and observational parameters, providing an opportunity for early intervention in these patients to salvage the anastomosis.

Obesity is an increasing problem in the UK and bariatric surgery is likely to increase in volume in the future. While substantial weight loss is the primary outcome following bariatric surgery, the effect on obesity-related morbidity, mortality and quality of life (QOL) is equally important. This study reports on weight loss, QOL, and health outcomes following laparoscopic adjustable gastric banding (LAGB) in a low volume bariatric centre (<20 cases/year) and presents the first assessment of factors relating to the QOL which has been produced from a UK based surgical practice.Questionnaire based study of patients who had LAGB. Each patients' initial body mass index (BMI), QOL, and comorbidities were recorded. Change in these parameters was measured including excess weight loss, and output from both the Moorehead-Ardelt QOL questionnaire, and the Bariatric Analysis and Reporting Outcome System (BAROS).Eighty-one patients (14 males, 67 females) answered the questionnaire. More than 50% excess weight loss was recorded in 52/81 patients (64%). Sixty-four patients (79%) reported improvement in their QOL including self-esteem, physical activity, social involvement, and ability to work. Seventy-one patients had initial obesity related comorbidity. In 61 of these patients (86%) their comorbidities resolved or improved. Minor port site related complications were recorded in nine patients while two patients had removal of the band because of infection.LAGB is a safe method of bariatric surgery. It can achieve satisfactory weight loss with significant improvement in QOL and comorbidity.

Sarcopenia, myosteatosis and visceral obesity (VO) are known to negatively impact on outcomes from colorectal cancer (CRC). Little is known about tumour factors associated with these body composition (BC) phenotypes. We aimed to identify whether histopathological tumour characteristics were associated with various BC phenotypes.A prospectively collected database of patients undergoing surgery for primary CRC at a tertiary referral unit in the United Kingdom was analysed. Sarcopenia, myosteatosis and VO were identified on preoperative CT. Binary logistic regression modelling was performed to determine significant associations between tumour stage, grade and BC phenotype.Final analysis included 795 patients; median age 69, 56% male, 65% were sarcopenic, 72% myosteatotic, 52% VO and 20% had sarcopenic obesity (SO). VO patients were significantly less likely to have advanced T Stage (T3-4) OR0.62(95%CI 0.44-0.86, p = 0.005); nodal metastases OR0.60(95%CI 0.44-0.82, p = 0.001); vascular invasion OR0.63(95%CI 0.46-0.88, p = 0.006) and poor tumour differentiation OR0.49(95%CI 0.28-0.86, p = 0.012). Myosteatotic patients were more likely to have metastatic disease OR2.31(95%CI 1.15-4.63, p = 0.018) but less likely to have poorly differentiated tumours OR0.48(95%CI 0.27-0.86, p = 0.013). SO patients were significantly more likely to have poorly differentiated tumours OR2.01(95%CI 1.04-3.87, p = 0.037).VO predisposes to earlier stage tumours with a less aggressive tumour phenotype. The SO group have adverse tumour characteristics which may be explained by differences in fat distribution. Myosteatosis relates to increased likelihood of distant metastasis that may be related to a systemic inflammatory response, despite the association with better differentiated tumours.

OBJECTIVE: Cardiac transplant recipients often develop hypertension as a side effect of immunosuppressive treatment. The aim of this study was to use the serial endomyocardial biopsies taken to monitor rejection to study the early and sequential arterial changes in human myocardial resistance arteries as hypertension develops. METHODS: At least 14 biopsies were studied from each of 23 patients, divided into a normotensive group (12 patients with a diastolic pressure never greater than 90 mm Hg) and a hypertensive group (11 patients with more than 10% of diastolic pressure measurements above 100 mm Hg). Morphometric analysis of between 30 and 50 arteries and arterioles in two widely separated histological levels from each biopsy was undertaken using an Optomax image analyser. RESULTS: There was a correlation between blood pressure, particularly diastolic pressure, and rate of medial thickening of intramyocardial coronary resistance arteries and arterioles (P = 0.0025). There was also a correlation between serum cyclosporin A concentrations and mean artery wall thickness (P = 0.003). CONCLUSIONS: Hypertension and cyclosporin A treatment are associated with significant wall thickening of intramyocardial resistance vessels in cardiac allograft recipients. These changes may be functionally and clinically important.

Training is an increasingly relevant issue in the UK.1 The structure of postgraduate medical training is undergoing significant change at present, with attempts to streamline and shorten duration. Modernising medical careers (MMC) marks a major reform in postgraduate medical education.2 Endoscopic retrograde cholangiopancreatography (ERCP) requires considerable training to perform effectively and safely.3 Competency has been based on total procedure numbers performed by trainees. Consensus suggests 180–200 diagnostic/therapeutic ERCPs are required to obtain competence within a training facility with sufficient case volume for viable training opportunities.2 Selective cannulation of the bile duct has been used as a benchmark for technical success.4 Moreover, multivariate analyses find case volume to independently predict ERCP related complications.5–8 “Diagnostic” ERCP should rarely be required with …

<h3>Introduction</h3> Long standing ulcerative colitis (UC) is associated with an increased risk of colorectal cancer (CRC), with a cumulative incidence of about 15% at 30 years. The finding of a colonic stricture in a patient with colitis raises the possibility of neoplasia. Unlike in Crohn9s disease, benign strictures in UC are rare and historically have been managed surgically with colectomy, partly due to difficulty of excluding cancer within the stricture. Radical surgery carries a risk of major morbidity including permanent stoma formation and segmental colectomy is currently not considered appropriate due to oncologic risk. The authors aimed to assess the outcome of the patients with benign strictures in UC who were managed non-operatively. <h3>Methods</h3> Patients who had a colonoscopy between January 2003 and December 2008 at our institution and were found to have a stricture without proven malignancy within a segment of colitis were retrospectively identified from the endoscopic database. Those patients who had a follow-up of more than 24 months were included. Colonoscopy and histopathology reports and clinical notes were reviewed. <h3>Results</h3> In the study period, 15 patients (6 female, median age 49 years) underwent colonoscopy for UC and were found to have a benign stricture. The median follow-up was 36 months. 14 of 18 strictures were left sided; mean duration of the stricture was 2.9 years (SD 2.1 years) and mean length of the stricture was 3.3 cm (SD 2.8 cm). Only two patients were symptomatic and both underwent endoscopic balloon dilatation. Two others underwent dilatation to allow passage of the colonoscope into the proximal colon. One patient ultimately developed CRC, but not within the strictured area of the colon. Two patients underwent surgery, one for CRC outside the stricture and one for what was revealed to be extrinsic compression secondary to endometriosis. One patient developed minor bleeding following endoscopic dilatation, which was managed conservatively. <h3>Conclusion</h3> Although uncommon, benign strictures are a recognised complication of long standing UC. Careful and detailed consideration including histological and radiological assessment is needed to rule out dysplasia and malignancy. In this series, the majority of patients did not require intervention as the strictures were asymptomatic and ongoing endoscopic surveillance of the remainder of the colon was possible. Endoscopic balloon dilatation was safe and prevented the need for major surgery in four patients while allowing continued endoscopic surveillance. Reconsideration of the place of conservative management and segmental colectomy in benign UC strictures through larger studies may be appropriate.

A phase II study of ip 5-FU was performed in 14 patients with ovarian cancer who were refractory to systemic chemotherapy including prior iv 5-FU in 12 of the patients. 5-FU was administered via a semipermanent Tenckhoff peritoneal dialysis catheter. The starting concentration of 5-FU in the dialysate was 4 mM. The patients received eight consecutive 2-L exchanges, each of 4-hour duration, for a total of 36 hours including time for instillation and drainage. Treatment courses were repeated every 2 weeks for six cycles or until disease progression occurred. A total of 69 cycles of ip 5-FU were administered to 14 patients. There was one complete response to therapy documented by second-look laparotomy. While the response rate was only 7%, in seven of eight (88%) patients with small volume disease (tumor masses less than 2.0 cm in diameter), there was no evidence for disease progression while receiving ip 5-FU therapy. In this phase II trial, the major toxic effect of ip 5-FU was abdominal pain. While there were no cases of documented bacterial peritonitis, all of the patients experienced some degree of abdominal discomfort while receiving therapy. Fifty percent of the patients had severe abdominal pain with at least one cycle of therapy. Other toxic effects included myelosuppression, mucositis, nausea and vomiting, and skin rash. The results of this study indicate that ip 5-FU should be further evaluated in patients with ovarian cancer who have a small volume of disease and who have not had prior therapy with 5-FU.

Abstract Background The aim was to evaluate the applicability of laparoscopic surgery in the treatment of primary rectal cancer in a training unit. Methods A cohort analysis was undertaken of consecutive patients undergoing elective surgery for primary rectal cancer over a 7-year interval. Data on patient and operative details, and short-term clinicopathological outcomes were collected prospectively and analysed on an intention-to-treat basis. Results A total of 306 patients (213 men, 69·6 per cent) of median (i.q.r.) age 67 (58–73) years with a median body mass index of 26·6 (23·9–29·9) kg/m2 underwent surgery. Median tumour height was 8 (6–11) cm from the anal verge, and 46 patients (15·0 per cent) received neoadjuvant radiotherapy. Seven patients (2·3 per cent) were considered unsuitable for laparoscopic surgery and underwent open resection; 299 patients (97·7 per cent) were suitable for laparoscopic surgery, but eight were randomized to open surgery as part of an ongoing trial. Some 291 patients (95·1 per cent) underwent a laparoscopic procedure, with conversion required in 29 (10·0 per cent). Surgery was partially or completely performed by trainees in 72·4 per cent of National Health Service patients (184 of 254), whereas private patients underwent surgery primarily by consultants. Median postoperative length of stay for all patients was 6 days and the positive circumferential resection margin rate was 4·9 per cent (15 of 306). Conclusion Supervised trainees can perform routine laparoscopic rectal cancer resection.

Multiple industries and organisations are afflicted by and respond to institutional crises daily. As surgeons, we respond to crisis frequently and individually such as with critically unwell patients or in mass casualty scenarios; but rarely, do we encounter institutional or multi-institutional crisis with multiple actors as we have seen with the COVID-19 pan-demic. Businesses, private industry and the financial sector have been in a more precar-ious position regarding crisis and consequently have developed rapid response strate-gies employing foresight to reduce risk to assets and financial liquidity. Moreover, large nationalised governmental organisations such as the military have strategies in place ow-ing to a rapidly evolving geopolitical climate with the expectation of immediate new chal-lenges either in the negotiating room or indeed the field of conflict. Despite both nation-alised and privatised healthcare systems existing, both appeared ill-prepared for the COVID-19 global crisis.A narrative review of the literature was undertaken exploring the approach to crisis man-agement and models used in organisations exposed to institutional crises outside the field of medicine.There are many parallels between the organisational management of private business institutions, large military organisations and surgical organisational management in healthcare. Models from management consultancies and the armed forces were ex-plored discussed and adapted for the surgical leader providing a framework through which the surgical leader can bring about an successful response to an institutional crisis and ensure future resilience.We believe that healthcare, and surgeons (as leaders) in particular, can learn from these other organisations and industries to engage appropriate generic operational plans and contingencies in preparation for whatever further crises may arise in the future, both near and distant. As such, following a review of the literature, we have explored a number of models we believe are adaptable for the surgical community to ensure we remain a dy-namically responsive and ever prepared profession.

Retrorectal masses are abnormalities located anatomically in the retrorectal space. A significant proportion are asymptomatic with no malignant potential while others cause symptoms due to mechanical pressure or malignant infiltration. We reviewed and categorised the retrorectal masses encountered over a 30-year time period in a specialist colorectal hospital and describe our management algorithm for consideration by other multidisciplinary teams (MDT).This was a retrospective analysis of consecutive patients referred between 1984-2019. A detailed review of clinical presentation, imaging features, postoperative histology and impact on morbidity and anorectal function is reported.A total of 143 patients with median age of 46 years and female preponderance (74%) were reviewed. The commonest presenting symptom was pain (46%) and all malignant cases had symptoms (n = 17). Over the last decade, more asymptomatic patients have presented with a retrorectal mass (33%, p = 0.04) and more patients are opting for surveillance rather than resection (33%, p = 0.013). Increasing age and lesion size were associated with malignancy (p < 0.05). Radiological features associated with malignancy included: solid/heterogeneous component, lobulated borders or locally invasive. Following surgery, complications included chronic pain (40%), poor wound healing (23%) and bowel dysfunction (10%).The management of retrorectal masses remains complex. There are features, both clinical and radiological, that can help determine the best management strategy. Management should be in a high-volume tertiary centre and preferably through a complex rectal cancer MDT. Long-term sequelae such as chronic pain must be highlighted to patients. We advocate the establishment of an international registry to further record and characterise these rare, potentially troublesome lesions.

Obesity is an increasing problem in Scotland and Laparoscopic Adjustable Gastric Bands (LAGB) are an effective method of weight reduction. Most outcome data are reported from high volume units with extensive experience or dedicated bariatric practice. We aimed to assess an experienced laparoscopic surgeon's outcome working outwith a dedicated bariatric practice in the west of Scotland.All LAGB procedures performed by a single surgeon were prospectively assessed from 1997 to 2004. LAGB were inserted using pars flaccida approach. Patient selection was based on BMI >35 or significant obesity related co-morbidities. Outcomes included percentage excess weight loss (%EWL) and excess BMI loss (EBL). We assessed total operating time to assess the learning curve for LAGB placement.125 patients were assessed (107 F:18 M). 123 patients were in regular follow-up (98%). Median age was 44 years (range 25-63). Mean follow-up was 34 months (range 11-91). Median initial BMI was 49 (range 37-73). 31% were BMI 35-45, 36% were BMI 45-50 and 33% were BMI>50. %EWL at 1,3 and 5 years was 45, 58 and 74, respectively. EBL at 1, 3 and 5 years was 11.7, 16.1, and 21.7, respectively. Complications included 4 converted procedures, 1 failed band insertion after conversion and re-operation for removal in five. Eight patients had tubing access port problems requiring intervention. The median overall total operation time was 80 minutes (range 50 - 160).In this cohort LAGB insertion by an experienced laparoscopic surgeon is safe with few re-operations. Satisfactory weight loss is obtained and patient compliance with follow-up is high.

Abstract Objective Endo‐anal ultrasound (EAUS) can detect anal sphincter injuries. However, anterior external anal sphincter (EAS) defects can be difficult to define. We assessed different EAUS techniques to determine if any particular method improved defect identification. Method Ninety females with faecal incontinence were prospectively studied. Wexner faecal incontinence scores were obtained. All patients underwent anorectal manometry and EAUS using three different techniques: standard, digit‐assisted (gloved finger pressing on posterior vaginal wall) and balloon‐assisted (standard balloon inflated into the vagina). The three techniques were assessed by comparing defect characteristics (detection, angle, edges and scar tissue), and perineal body thickness. All measurements were performed at the mid anal canal level. Results are expressed as medians (IQR). Results Standard EAUS (S‐EAUS) identified a sphincter defect in 54 patients. Digit assisted EAUS (D‐EAUS) and balloon‐assisted EAUS (B‐EAUS) ultrasound revealed a sphincter defect in additional 11 and 9 patients respectively compared to S‐EAUS. Correlation of maximum squeeze pressure with EAUS findings improved on D‐EAUS and B‐EAUS. The defect angle was significantly wider with D‐EAUS and B‐EAUS [S‐EAUS 90°(63–97), D‐EAUS 100°(81–101.5), B‐EAUS 100°(80–105), P = 0.0005]. The perineal body was significantly thicker when measured with B‐EAUS [D‐EAUS 9 mm (7–10) vs B‐EAUS 10 mm (8–11), P = 0.0005]. Inter‐observer agreement was comparable [S‐EAUS (K) = 0.677, D‐EAUS (K) = 0.658, B‐EAUS (K) = 0.601]. Conclusion EAS anterior defect detection and definition on EAUS may be improved by the demarcation and gentle pressure on the posterior vaginal wall.

A literature search did not produce any evidence-based objective criteria to determine which patients with locally advanced rectal cancer would benefit from a defunctioning stoma prior to neoadjuvant chemoradiotherapy. Our criteria for formation of a defunctioning stoma are: faecal incontinence and inability to cannulate the tumour at colonoscopy. The aim of this study was to examine whether these current criteria are appropriate.Forty-nine consecutive locally advanced rectal cancer patients treated from February 2003 to November 2006 were identified from our colorectal database. All received long-course chemoradiotherapy (Bossett regimen) and definitive surgery was performed 6-8 weeks later.Of the 49 patients, 31 presented with diarrhoea and two with faecal incontinence; nine patients were defunctioned by trephine stoma prior to treatment [cannulation impossible at colonoscopy (n = 8); faecal incontinence (n = 1)]. One patient with faecal incontinence refused early defunctioning stoma. Median hospital stay was 12 days (interquartile range: 7-30), and complications included pneumonia (n = 1) and peristomal cellulitis (n = 2). Of the 40 patients who went directly to neoadjuvant chemoradiotherapy, two subsequently required a defunctioning stoma for severe diarrhoeal symptoms during therapy. Eight patients had worsening diarrhoeal symptoms but tolerated treatment. Three patients, who had stoma formation, did not proceed to definitive surgery following neoadjuvant therapy: poor operative fitness (n = 2) and disease progression (n = 1).Stenosis causing inability to cannulate the tumour at colonoscopy and faecal incontinence were the only objective indications for an early defunctioning stoma. Worsening diarrhoea during therapy (unless severe) did not appear to be a good indication for a defunctioning stoma.

Aims: Neo-adjuvant therapy followed by surgery is the mainstay of curative treatment for locally advanced oesophageal cancer.Histological response in the neoadjuvant phase is often associated with better survival.The aim of this study was to compare responses in patients undergoing chemotherapy and surgery (CS) or chemoradiotherapy and surgery (CRS) and examine the impact of response on survival.Methods: Forty-seven patients underwent CS and 50 underwent CRS.Response to neo-adjuvant therapy was measured by tumour regression grade (TRG) where Grades 1-3 indicate complete or high degrees of response and Grades 4-5 indicate little or no response.Survival data was analysed using Kaplan-Meier and Cox regression analysis.Results: Although a significantly smaller proportion of patients had TRG 1-3 following CS compared to CRS (8/47 vs. 35/50, P = 0•001) those who responded did equally well in terms of medium-term survival (CS 81% and 52%, CRS 80% and 62•8% at 1 and 3 years).TRG 1-3 was associated with better survival than TRG 4-5 in both groups (overall TRG 1-3: 81% and 60%, TRG 4-5: 61% and 30% at 1 and 3 years, P = 0•02).Conclusions: Significant tumour regression occurs more frequently after chemoradiotherapy and surgery than chemotherapy and surgery.Tumour regression grade is a strong predictor of outcome after both forms of treatment.

Extended pelvic side wall excision is a useful technique for treatment of recurrent or advanced rectal cancer involving sciatic notch and does not compromise the dissection of major pelvic vessels and vascular control.

Abstract Aim Anastomotic leak causes significant morbidity for patients undergoing pelvic intestinal surgery. Fluoroscopic assessment of anastomotic integrity using water‐soluble contrast enema (WSCE) is of questionable benefit over examination alone. We hypothesized that MRI‐enema may be more accurate. The aim of this study was to compare MRI‐enema with fluoroscopic WSCE. Method Patients referred for WSCE with pelvic intestinal anastomosis and defunctioning ileostomy (including patients with suspected or known leaks) were invited to participate. WSCE and MRI‐enema were undertaken within 48 h of each other. MRI sequences were performed before, during and immediately after the introduction of 400 ml of 1% gadolinium contrast solution per anus. MRI examinations were reported to protocol by two blinded gastrointestinal radiologists. A Likert‐scale patient questionnaire was administered to compare patient experience. Follow‐up was &gt;12 months after ileostomy reversal. Anastomotic leak was determined by unblinded consensus of examination and radiological findings. Results Sixteen patients were recruited, with a median age of 39 years (range 22–69). Ten were men, 11 had ileoanal pouch formation and five had low anterior resection. Five patients had anastomotic leak identified by MRI and four by WSCE. The radial location of the anastomotic defect was identified in all five patients by MRI versus two on WSCE. MRI revealed additional information including contents of a widened presacral space. Patient experience was equivalent. Eleven patients eventually had ileostomy reversal without complications. Conclusion MRI‐enema is a feasible and tolerable alternative to WSCE and offers greater anatomical detail in the context of pelvic intestinal anastomotic leak. Larger prospective studies are required to define its potential role in the UK National Health Service.

Chapter 3 Preoperative Assessment of Tumor Anatomy and Surgical Resectability Akash M. Mehta, Akash M. Mehta Department of Surgery, Complex Cancer Clinic, St. Mark's Hospital, London, UKSearch for more papers by this authorDavid Burling, David Burling Department of Gastro-Intestinal Radiology, Complex Cancer Clinic, St. Mark's Hospital, London, UKSearch for more papers by this authorJohn T. Jenkins, John T. Jenkins Department of Surgery, Complex Cancer Clinic, St. Mark's Hospital, London, UKSearch for more papers by this author Akash M. Mehta, Akash M. Mehta Department of Surgery, Complex Cancer Clinic, St. Mark's Hospital, London, UKSearch for more papers by this authorDavid Burling, David Burling Department of Gastro-Intestinal Radiology, Complex Cancer Clinic, St. Mark's Hospital, London, UKSearch for more papers by this authorJohn T. Jenkins, John T. Jenkins Department of Surgery, Complex Cancer Clinic, St. Mark's Hospital, London, UKSearch for more papers by this author Book Editor(s):Michael E. Kelly, Michael E. Kelly St. Vincent's University Hospital, Dublin, IrelandSearch for more papers by this authorDesmond C. Winter, Desmond C. Winter St. Vincent's University Hospital, Dublin, IrelandSearch for more papers by this author First published: 10 September 2021 https://doi.org/10.1002/9781119518495.ch3 AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Summary This chapter provides a more detailed review of current practice for preoperative assessment of tumor anatomy and resectability. There are several methods for assessing cancer anatomy and resectability. Various exenterative techniques have evolved to address the specific anatomical and surgical challenges posed by advanced pelvic cancers. Examination under anesthetic (EUA) is a common method for determining whether the cancer is adherent to adjacent structures. Radiological assessment of cancer anatomy provides more accurate assessment of margins and the relationship to adjacent structures than EUA. The chapter also presents a case study of a 32-year-old female patient who presented to her local hospital with a perforated primary rectal beyond total mesorectal excision and underwent an emergency laparotomy and fashioning of a defunctioning colostomy prior to downsizing with a combination of radiotherapy and systemic chemotherapy. Approximately 50% of patients with recurrent rectal cancer will have metachronous metastatic disease at the time of diagnosis of pelvic recurrence. Surgical Management of Advanced Pelvic Cancer RelatedInformation

Laparoscopic restorative proctocolectomy is a complex procedure with a steep learning curve. It has been proven to be safe and feasible with outcomes comparable to those of open surgery if performed in experienced centers. Published evidence in favor of laparoscopic approach is mainly from small case series and data from randomized controlled trials are currently awaited. This article reviews and analyzes the existing literature on laparoscopic ileoanal pouch surgery in light of the available evidence, demonstrating safety and efficacy of the laparoscopic approach and potential short-term benefits. Technical aspects and future directions in the minimally invasive approach to restorative proctocolectomy are also discussed.

Colorectal DiseaseEarly View CORRESPONDENCE Response to: Boyle J M, et al. ‘What is the impact of hospital and surgeon volumes on outcomes in rectal cancer surgery?’ Colorectal Disease 2023; 25: 1981–1993 Justin Davies, Corresponding Author Justin Davies [email protected] Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK University of Cambridge, Cambridge, UK Correspondence Justin Davies, Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK. Email: [email protected]Search for more papers by this authorMark Cheetham, Mark Cheetham Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UKSearch for more papers by this authorGraham Branagan, Graham Branagan Salisbury NHS Foundation Trust, Salisbury, UKSearch for more papers by this authorNicola Eardley, Nicola Eardley orcid.org/0000-0001-6528-4292 Countess of Chester NHS Foundation Trust, Chester, UKSearch for more papers by this authorJim Tiernan, Jim Tiernan Leeds Teaching Hospitals NHS Trust, Leeds, UKSearch for more papers by this authorAthur Harikrishnan, Athur Harikrishnan Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UKSearch for more papers by this authorAntonino Spinelli, Antonino Spinelli Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy IRCCS Humanitas research Hospital, Rozzano, Milan, ItalySearch for more papers by this authorJames Wheeler, James Wheeler Cambridge University Hospitals NHS Foundation Trust, Cambridge, UKSearch for more papers by this authorBrendan Moran, Brendan Moran orcid.org/0000-0002-8184-2511 Basingstoke and North Hampshire Hospital, Basingstoke, UKSearch for more papers by this authorJohn T. Jenkins, John T. Jenkins orcid.org/0000-0001-8723-9409 St Mark's Hospital, London, UKSearch for more papers by this authorCharles Maxwell-Armstrong, Charles Maxwell-Armstrong Nottingham University Hospitals NHS Trust, Nottingham, UKSearch for more papers by this author Justin Davies, Corresponding Author Justin Davies [email protected] Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK University of Cambridge, Cambridge, UK Correspondence Justin Davies, Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK. Email: [email protected]Search for more papers by this authorMark Cheetham, Mark Cheetham Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UKSearch for more papers by this authorGraham Branagan, Graham Branagan Salisbury NHS Foundation Trust, Salisbury, UKSearch for more papers by this authorNicola Eardley, Nicola Eardley orcid.org/0000-0001-6528-4292 Countess of Chester NHS Foundation Trust, Chester, UKSearch for more papers by this authorJim Tiernan, Jim Tiernan Leeds Teaching Hospitals NHS Trust, Leeds, UKSearch for more papers by this authorAthur Harikrishnan, Athur Harikrishnan Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UKSearch for more papers by this authorAntonino Spinelli, Antonino Spinelli Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy IRCCS Humanitas research Hospital, Rozzano, Milan, ItalySearch for more papers by this authorJames Wheeler, James Wheeler Cambridge University Hospitals NHS Foundation Trust, Cambridge, UKSearch for more papers by this authorBrendan Moran, Brendan Moran orcid.org/0000-0002-8184-2511 Basingstoke and North Hampshire Hospital, Basingstoke, UKSearch for more papers by this authorJohn T. Jenkins, John T. Jenkins orcid.org/0000-0001-8723-9409 St Mark's Hospital, London, UKSearch for more papers by this authorCharles Maxwell-Armstrong, Charles Maxwell-Armstrong Nottingham University Hospitals NHS Trust, Nottingham, UKSearch for more papers by this author First published: 22 December 2023 https://doi.org/10.1111/codi.16843Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Open Research DATA AVAILABILITY STATEMENT No data as this is a comment on a published manuscript. REFERENCES 1Boyle JM, van der Meulen J, Kuryba A, Cowling TE, Braun MS, Aggarwal A, et al. What is the impact of hospital and surgeon volumes on outcomes in rectal cancer surgery? Colorectal Dis. 2023; 25: 1981–1993. 10.1111/codi.16745 PubMedGoogle Scholar 2 Optimal_Resources_for_Rectal_Cancer_Care_2020.pdf. (facs.org) Google Scholar 3Brady JT, Bingmer K, Bliggenstorfer J, Xu Z, Fleming FJ, Remzi FH, et al. Could meeting the standards of the National Accreditation Program for rectal cancer in the National Cancer database improve patient outcomes? Colorectal Dis. 2023; 25: 916–922. 10.1111/codi.16503 PubMedWeb of Science®Google Scholar 4Moran BJ, Holm T, Brannagan G, Chave H, Quirke P, West N, et al. The English national low rectal cancer development programme: key messages and future perspectives. Colorectal Dis. 2014; 16: 173–178. 10.1111/codi.12501 CASPubMedWeb of Science®Google Scholar 5Jones H, Moran B, Crane S, Hompes R, Cunningham C, LOREC Group. The LOREC APE registry: operative technique, oncological outcome and perineal wound healing after abdominoperineal excision. Colorectal Dis. 2017; 19: 172–180. 10.1111/codi.13423 CASPubMedWeb of Science®Google Scholar 6Maxwell-Armstrong C, Cheetham M, Branagan G, Davies J, Davies M, Eardley N, et al. Rectal cancer services- is it time for specialization within units? Colorectal Dis. 2023; 25: 1332–1335. 10.1111/codi.16572 PubMedWeb of Science®Google Scholar 7 NICE. Colorectal Cancer NICE Guideline 1512020. Available from: https://www.nice.org.uk/guidance/ng151/resources/colorectal-cancer-pdf-66141835244485. Accessed 13 November 2023 Google Scholar 8Archampong D, Borowski DW, Dickinson HO. Impact of surgeon volume on outcome of rectal cancer: a ststematic review and meta-analysis. Surgeon. 2010; 8: 341–352. 10.1016/j.surge.2010.07.003 CASPubMedWeb of Science®Google Scholar 9Rottoli M, Spinelli A, Pellino G, Gori A, Calini G, Flacco ME, et al. Effect of centre volume on pathological outcomes and postoperative complications after surgery for colorectal cancer: results of a multicentre national study. Br J Surg. 2023; 1–9. https://doi.org/10.1093/bjs/znad373 10.1093/bjs/znad373 Web of Science®Google Scholar 10Curtis NJ, Foster JD, Miskovic D, Brown CSB, Hewett PJ, Abbott S, et al. Association of surgical skill assessment with clinical outcomes in cancer surgery. JAMA Surg. 2020; 155: 590–598. 10.1001/jamasurg.2020.1004 PubMedWeb of Science®Google Scholar 11 NICE. Colorectal cancer (update) surgical volumes and outcomes for rectal cancer. NICE guideline NG151. Evidence Reviews. 2020 Accessed 13 November 2023. 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Arteries are usually studied morphometrically after pressurized fixation and resin embedding. These procedures are impracticable when dealing with diagnostic biopsies. The accuracy of arterial morphometry is determined partly by the degree of tissue distortion during section preparation. The axial ratios of 7340 arteries were measured in 353 endomyocardial biopsies from 23 patients and then compared with those expected from mathematical modelling. An excess of elliptical arteries was found. The distribution of orientation of the long axes of these best fitted a simulated 10 per cent linear distortion in the direction of microtomy. In conclusion, these results suggest that although there is some tissue distortion during sectioning, useful data may be obtained from morphometry of arteries in routinely processed endomyocardial biopsies. © 1997 John Wiley & Sons, Ltd.

Abstract Aim Colectomy in patients with adenomatous polyposis (AP) syndromes demands good oncological and surgical outcome. Total colectomy with ileorectal anastomosis (TC‐IRA) is one surgical option for these patients. Anastomotic leakage rates of 11% have been reported following TC‐IRA. Ileo‐distal sigmoid anastomosis (IDSA) is a recent modification of our practice. Our aim was to compare postoperative outcome in patients with AP following near‐total colectomy with IDSA (NT‐IDSA) and TC‐IRA at a single institution. Method A prospectively maintained database was reviewed to identify patients with AP who underwent laparoscopic NT‐IDSA and TC‐IRA. Patient demographics, early morbidity and mortality and outcome of endoscopic surveillance were evaluated. Results A total of 191 patients with AP underwent laparoscopic colectomy between 2006 and 2017, of whom 139 (72.8%) underwent TC‐IRA and 52 (27.2%) NT‐IDSA. The median age at surgery in the TC‐IRA and NT‐IDSA groups was 20 years (IQR 17–45) and 27 years (IQR 19–50), respectively. Grade II complications were comparable between the two groups. There were no anastomotic leakages in the NT‐IDSA group compared with 15 (10.8%) in the TC‐IRA group ( P = 0.0125) and no reoperation in the NT‐IDSA group compared with 17 (12.2%) in the TC‐IRA group ( P = 0.008). The frequency of polypectomies per flexible sigmoidoscopy was comparable between the two groups. Conclusion This study demonstrates that laparoscopic NT‐IDSA for polyposis is associated with a significant improvement in anastomotic leakage rates and surgical outcome. It is too soon to tell whether NT‐IDSA alters the need for further intervention, either endoscopic polypectomy or further surgery.

Abstract Background Colorectal cancer is associated with secondary sarcopenia (muscle loss) and myosteatosis (fatty infiltration of muscle) and patients who exhibit these host characteristics have poorer outcomes following surgery. Furthermore, patients, who undergo curative advanced rectal cancer surgery such as pelvic exenteration, are at risk of skeletal muscle loss due to immobility, malnutrition and a post-surgical catabolic state. Neuromuscular electrical stimulation (NMES) may be a feasible adjunctive treatment to help ameliorate these adverse side-effects. Hence, the purpose of this study is to investigate NMES as an adjunctive pre- and post-operative treatment for rectal cancer patients in the radical pelvic surgery setting and to provide early indicative evidence of efficacy in relation to key health outcomes. Method In a phase II, double-blind, randomised controlled study, 58 patients will be recruited and randomised (1:1) to either a treatment (NMES plus standard care) or placebo (sham-NMES plus standard care) group. The intervention will begin 2 weeks pre-operatively and continue for 8 weeks after exenterative surgery. The primary outcome will be change in mean skeletal muscle attenuation, a surrogate marker of myosteatosis. Sarcopenia, quality of life, inflammatory status and cancer specific outcomes will also be assessed. Discussion This phase II randomised controlled trial will provide important preliminary evidence of the potential for this adjunctive treatment. It will provide guidance on subsequent development of phase 3 studies on the clinical benefit of NMES for rectal cancer patients in the radical pelvic surgery setting. Trial registration Protocol version 6.0; 05/06/20. ClinicalTrials.gov NCT04065984 . Registered on 22 August 2019; recruiting.

Introduction Anti-tumour necrosis factor (TNF)s form a major part of therapy in Crohn’s disease and has a primary non-response rate of 10–30% and a secondary loss of response rate of 5% per patient-year. Myopenia is prevalent in patients with Crohn’s disease who are in clinical remission and can be measured using body composition analysis tools. We hypothesise that body composition can predict for outcomes of anti-TNF primary non-response and secondary loss of response. Methods Between January 2007 to June 2012, 650 anti-TNF naive patients underwent anti-TNF therapy for Crohn’s disease in a single centre. CT images were analysed for body composition parameters and used to estimate body fat-free mass. The outcome measures were primary non-response and secondary loss of response. COX-regression analysis was used to predict for outcomes with three-year follow-up data. A hypothetical dose of 5 mg/kg was delivered with estimated tissue levels. Results Of the 650 patients with anti-TNF therapy, 106 were included. 26 (24.5%) were primary non-responders and 29 (27.4%) had secondary loss of response. 13 patients were obese (BMI > 30). Sex-specific cut-offs that defined a significant association between low muscle, high visceral fat and myosteatosis with outcomes were ascertained by stratification analysis. On multivariate analysis, myopenia predicted for primary non-response (HR 4.74;1.81-12.39,p =0.002) (Figure 1). Large anti-TNF dose variations resulted due to different body compositions. (Figure 2) Conclusion In this cohort study with three-year follow-up data, body composition profiles varied widely and did not correlate well with BMI. Myopenia was a predictor of primary non-response with potential implications for dosing and serves as an explanation for pharmacokinetic failure. Disclosure of Interest None Declared

Abstract Aim Enhanced recovery after surgery (ERAS) produces benefits to patients by reducing the length of hospital stay and morbidity. Its effect on nursing and physiotherapy workload has been studied, but the demand upon radiology is unclear. We aimed to determine radiology use to understand possible hidden expenditure not included in existing ERAS cost‐effectiveness analyses. Method Two‐hundred and sixty‐five patients from a prospective multidimensional ERAS database were retrospectively assessed for postoperative radiology use. All had undergone colorectal surgery within an established ERAS programme from 2008 to 2009, with all data prospectively recorded. Laparoscopy was offered for all primary colon and rectal resections. All adverse events, including gut dysfunction, surgical site infection and reoperation, were assessed. All radiology within 30 days of surgery was recorded. Results Radiology data were absent in 12 patients, leaving 253 for analysis. Postoperative radiology was used in 71 (28%) patients, and 41 (16%) had CT of the abdomen and pelvis (A/P) within 30 days of surgery. In 33 (13%) patients this was required during the primary admission, including 30% of patients with any postoperative adverse event. Nine (27%; 3.6% of the whole cohort) of the 33 patients required reoperation. No patient required interventional radiology. The median time to CT (A/P) during primary admission was 5 (interquartile range, 3–8) days. Eight (3%) patients had CT (A/P) after readmission with one reoperation. Forty (16%) patients underwent plain radiology (chest or abdominal) and six (2%) had abdominal ultrasound. Using general estimates of CT and plain radiology total costs, these data suggest an overall radiology cost of over £22 000, amounting to a radiology cost of £90 per ERAS patient. Conclusion Postoperative radiology is required in a significant proportion of ERAS patients, potentially reflecting a low threshold to investigate in the presence of an adverse event. Very few require subsequent intervention. Radiology costs incurred with ERAS should be considered in future economic analyses.