Evolution of transanal total mesorectal excision for rectal cancer: From top to bottom

The gold standard for curative treatment of locally advanced rectal cancer involves radical resection with a total mesorectal excision (TME). TME is the most effective treatment strategy to reduce local recurrence and improve survival outcomes regardless of the surgical platform used. However, there are associated morbidities, functional consequences, and quality of life (QoL) issues associated with TME; these risks must be considered during the modern-day multidisciplinary treatment for rectal cancer. This has led to the development of new surgical techniques to improve patient, oncologic, and QoL outcomes. In this work, we review the evolution of TME to the transanal total mesorectal excision (TaTME) through more traditional minimally invasive platforms. The review the development, safety and feasibility, proposed benefits and risks of the procedure, implementation and education models, and future direction for research and implementation of the TaTME in colorectal surgery. While satisfactory short-term results have been reported, the procedure is in its infancy, and long term outcomes and definitive results from controlled trials are pending. As evidence for safety and feasibility accumulates, structured training programs to standardize teaching, training, and safe expansion will aid the safe spread of the TaTME

Defining response to radiotherapy in rectal cancer using magnetic resonance imaging and histopathological scales

Aim: To define good and poor regression using pathology and MRI regression scales after neo-adjuvant chemotherapy for rectal cancer. Methods: A systematic review of all studies up to December 2015, without language restriction that were identified from MEDLINE, Cochrane Controlled Trials Register (1960–2015), and EMBASE (1991–2015). Searches were performed of article bibliographies and conference abstracts. MeSH and text words, included “tumour regression”, “mrTRG”, “poor response” and “colorectal cancers”. Clinical studies using either MRI or histopathological TRG scales to define good and poor responders were included in relation to outcomes (local (LR), distant recurrence (DR), disease free (DFS), overall survival (OS)). There was no age restriction to included patients nor stage of cancer.Data was extracted by two authors independently using pre-defined outcome measures. Results: Quantitative data (prevalence) were extracted and analysed according to meta-analytical techniques using comprehensive meta-analysis. Qualitative data (LR, DR, DFS &OS) were presented as ranges. The overall proportion of poor responders after neo-adjuvant CRT was 37.7% (CI: 30.1 to 45.8). There were 19 different reported histopathological scales and one MRI regression scale (mrTRG). Clinical studies used nine and six histopathological scales for poor and good responders respectively. All studies using MRI to define good and poor response used one scale. The most common histopathological definition for good response was the Mandard grades 1&2 or Dworak grades 3&4; Mandard 3,4&5 and Dworak 0,1&2 were used for poor response. For histopathological grades, the 5-year outcomes for poor responders were LR 3.4-4.3%, DR 14.3-20.3%, DFS 61.7-68.1% and OS 60.7-69.1. Good pathological response 5-year outcomes were LR, 0-1.8%; DR, 0-11.6%; DFS, 78.4-86.7%; and, OS, 77.4-88.2%. A poor response on MRI (mrTRG 4,5) resulted in 5-year LR 4-29%, DR 9%, DFS 31-59% and OS 27-68%. The 5-year outcomes with a good response on MRI (mrTRG 1,2 & 3) was LR 1-14%, DR 3%, DFS 64-83% and OS 72-90%. Conclusions: For histopathology regression assessment Mandard1,2/Dworak3,4 should be used for good and Mandard3,4,5/Dworak0,1,2 for poor response. MRI indicates good and poor response by mrTRG1-3 and mrTRG4-5 respectively

Interobserver agreement of radiologists assessing the response of rectal cancers to preoperative chemoradiation using the MRI tumour regression grading (mrTRG)

AIM: To investigate whether the magnetic resonance imaging (MRI) tumour regression grading (mrTRG) scale can be taught effectively resulting in a clinically reasonable interobserver agreement (>0.4; moderate to near perfect agreement). MATERIALS AND METHODS: This study examines the interobserver agreement of mrTRG, between 35 radiologists and a central reviewer. Two workshops were organised for radiologists to assess regression of rectal cancers on MRI staging scans. A range of mrTRGs on 12 patient scans were used for assessment. RESULTS: Kappa agreement ranged from 0.14–0.82 with a median value of 0.57 (95% CI: 0.37–0.77) indicating good overall agreement. Eight (26%) radiologists had very good/near perfect agreement (κ>0.8). Six (19%) radiologists had good agreement (0.8≥κ>0.6) and a further 12 (39%) had moderate agreement (0.6≥κ>0.4). Five (16%) radiologists had a fair agreement (0.4≥κ>0.2) and two had poor agreement (0.2>κ). There was a tendency towards good agreement (skewness: 0.92). In 65.9% and 90% of cases the radiologists were able to correctly highlight good and poor responders, respectively. CONCLUSIONS: The assessment of the response of rectal cancers to chemoradiation therapy may be performed effectively using mrTRG. Radiologists can be taught the mrTRG scale. Even with minimal training, good agreement with the central reviewer along with effective differentiation between good and intermediate/poor responders can be achieved. Focus should be on facilitating the identification of good responders. It is predicted that with more intensive interactive case-based learning a κ>0.8 is likely to be achieved. Testing and retesting is recommended

Brucellosis remains a neglected disease inthe developing world: a call forinterdisciplinary action

Brucellosis places significant burdens on the human healthcare system and limits the economic growth of individuals, communities, and nations where such development is especially important to diminish the prevalence of poverty. The implementation of public policy focused on mitigating the socioeconomic effects of brucellosis in human and animal populations is desperately needed. When developing a plan to mitigate the associated consequences, it is vital to consider both the abstract and quantifiable effects. This requires an interdisciplinary and collaborative, or One Health, approach that consists of public education, the development of an infrastructure for disease surveillance and reporting in both veterinary and medical fields, and campaigns for control in livestock and wildlife species

Social Media: Changing the Paradigm for Surgical Education

The role of social media (SoMe) in surgical education is emerging as a tool that augments and complements traditional learning. As SoMe usage has steadily increased in our personal and professional lives, it is no surprise that it has permeated into surgical education. Different SoMe sites offer distinct platforms from which knowledge can be transmitted, while catering to various learning styles. The purpose of this review is to outline the various SoMe platforms and their use in surgical education. Moreover, it will discuss their effectiveness in teaching and learning surgical knowledge and skills as well as other potential roles SoMe has to offer to improve surgical education

#colorectalsurgery

BACKGROUND: The use of social media platforms among healthcare professionals is increasing. A Twitter social media campaign promoting the hashtag #colorectalsurgery was launched with the aim of providing a specialty‐specific forum to collate discussions and science relevant to an engaged, global community of coloproctologists. This article reviews initial experiences of the early adoption, engagement and utilization of this pilot initiative. METHODS: The hashtag #colorectalsurgery was promoted via the online microblogging service Twitter across a 180‐day interval. Data on all tweets containing the #colorectalsurgery hashtag were analysed using online analytical tools. Data included total number of tweets, number of views, and user engagement since registration and launch of the campaign. Content of tweet and user demographic analysis was undertaken. RESULTS: The number of tweets using #colorectalsurgery grew rapidly following the launch on 24 April 2016; #colorectalsurgery was used in 15 708 tweets, which resulted in 65 398 696 impressions and involved 1863 individual Twitter accounts. Increased volumes of #colorectalsurgery tweets were noted in association with the timing of three major international colorectal surgical conferences, and geographical trends were noted. Some 88·4 per cent of all posts were by male users. The top 25 users by volume of #colorectalsurgery tweets had considerable influence and posted 8023 tweets (51·1 per cent). CONCLUSION: Online global communities formed via healthcare‐related hashtags, such as #colorectalsurgery, unify social media posts, scientists, surgeons and authors who have an interest in coloproctology. Furthermore, they facilitate greater connectivity among geographically separate users

The Future of Rectal Cancer Surgery: A Narrative Review of an International Symposium

Surgery remains the mainstay of curative treatment for primary rectal cancer. For mid and low rectal tumors, optimal oncologic surgery requires total mesorectal excision (TME) to ensure the tumor and locoregional lymph nodes are removed. Adequacy of surgery is directly linked to survival outcomes and, in particular, local recurrence. From a technical perspective, the more distal the tumor, the more challenging the surgery and consequently, the risk for oncologically incomplete surgery is higher. TME can be performed by an open, laparoscopic, robotic or transanal approach. There is a lack of consensus on the “gold standard” approach with each of these options offering specific advantages. The International Symposium on the Future of Rectal Cancer Surgery was convened to discuss the current challenges and future pathways of the 4 approaches for TME. This article reviews the findings and discussion from an expert, international panel

The Effect of Bacterial Infection on the Biomechanical Properties of Biological Mesh in a Rat Model

BACKGROUND: The use of biologic mesh to repair abdominal wall defects in contaminated surgical fields is becoming the standard of practice. However, failure rates and infections of these materials persist clinically. The purpose of this study was to determine the mechanical properties of biologic mesh in response to a bacterial encounter. METHODS: A rat model of Staphylococcus aureus colonization and infection of subcutaneously implanted biologic mesh was used. Samples of biologic meshes (acellular human dermis (ADM) and porcine small intestine submucosa (SIS)) were inoculated with various concentrations of methicillin-resistant Staphylococcus aureus [10(5), 10(9) colony-forming units] or saline (control) prior to wound closure (n = 6 per group). After 10 or 20 days, meshes were explanted, and cultured for bacteria. Histological changes and bacterial recovery together with biomechanical properties were assessed. Data were compared using a 1-way ANOVA or a Mann-Whitney test, with p<0.05. RESULTS: The overall rate of staphylococcal mesh colonization was 81% and was comparable in the ADM and SIS groups. Initially (day 0) both biologic meshes had similar biomechanical properties. However after implantation, the SIS control material was significantly weaker than ADM at 20 days (p = 0.03), but their corresponding modulus of elasticity were similar at this time point (p>0.05). After inoculation with MRSA, a time, dose and material dependent decrease in the ultimate tensile strength and modulus of elasticity of SIS and ADM were noted compared to control values. CONCLUSION: The biomechanical properties of biologic mesh significantly decline after colonization with MRSA. Surgeons selecting a repair material should be aware of its biomechanical fate relative to other biologic materials when placed in a contaminated environment

Yoga-Based Cardiac Rehabilitation After Acute Myocardial Infarction: A Randomized Trial

Background: Given the shortage of cardiac rehabilitation (CR) programs in India and poor uptake worldwide, there is an urgent need to find alternative models of CR that are inexpensive and may offer choice to subgroups with poor uptake (e.g., women and elderly). Objectives: This study sought to evaluate the effects of yoga-based CR (Yoga-CaRe) on major cardiovascular events and self-rated health in a multicenter randomized controlled trial. Methods: The trial was conducted in 24 medical centers across India. This study recruited 3,959 patients with acute myocardial infarction with a median and minimum follow-up of 22 and 6 months. Patients were individually randomized to receive either a Yoga-CaRe program (n = 1,970) or enhanced standard care involving educational advice (n = 1,989). The co-primary outcomes were: 1) first occurrence of major adverse cardiovascular events (MACE) (composite of all-cause mortality, myocardial infarction, stroke, or emergency cardiovascular hospitalization); and 2) self-rated health on the European Quality of Life–5 Dimensions–5 Level visual analogue scale at 12 weeks. Results: MACE occurred in 131 (6.7%) patients in the Yoga-CaRe group and 146 (7.4%) patients in the enhanced standard care group (hazard ratio with Yoga-CaRe: 0.90; 95% confidence interval [CI]: 0.71 to 1.15; p = 0.41). Self-rated health was 77 in Yoga-CaRe and 75.7 in the enhanced standard care group (baseline-adjusted mean difference in favor of Yoga-CaRe: 1.5; 95% CI: 0.5 to 2.5; p = 0.002). The Yoga-CaRe group had greater return to pre-infarct activities, but there was no difference in tobacco cessation or medication adherence between the treatment groups (secondary outcomes). Conclusions: Yoga-CaRe improved self-rated health and return to pre-infarct activities after acute myocardial infarction, but the trial lacked statistical power to show a difference in MACE. Yoga-CaRe may be an option when conventional CR is unavailable or unacceptable to individuals. (A study on effectiveness of YOGA based cardiac rehabilitation programme in India and United Kingdom; CTRI/2012/02/002408)