The subject of anastomotic leakage after low anterior resection (LAR) for rectal cancer remains controversial. Risk factors have been discussed in several studies but the findings are often inconclusive. This review evaluates these studies and separates the known risk factors into those that are well documented, those that are obsolete, and those that require further research. We searched the Medline and PubMed databases using the keywords: "leakage," "low anterior resection," "rectal cancer," "risk factors," and their combinations. There were no language or publication year restrictions. References in published papers were also reviewed. Each risk factor was evaluated and discussed separately. The evidence suggests that low anastomoses are more prone to leakage. Other well-documented risk factors are male sex, smoking, and preoperative malnutrition. Routine mobilization of the splenic flexure and the use of a J-pouch seem to reduce the leakage rate. The effect of preoperative chemo-radiotherapy is under scrutiny. The indications for a protective stoma remain debatable. Omentoplasty, bowel preparation, the use of a drain, and tumor stage do not seem to affect the leakage rate. The type of operation (open or laparoscopic) and anastomosis (hand-sewn or stapled) is not crucial.
Maximal tumor debulking may help patients with pseudomyxoma peritonei in whom complete cytoreduction cannot be achieved with almost half alive at 3 years with long-term survival in some.
HIPEC with paclitaxel following cytoreductive surgery is feasible, relatively safe, and associated with a highly favorable pharmacokinetic profile, despite its short treatment duration. Larger studies with a more homogenous patient cohort and adequate follow-up should be performed to demonstrate its efficacy.
Plasma TAC and cTAC values are impaired in morbidly obese patients. Weight loss from an intragastric balloon is associated with significant increase in plasma cTAC values. Plasma TAC values, after the weight loss remain unchanged, possibly due to a decrease in uric acid, an important endogenous antioxidant.
Preoperative chemoradiotherapy did not significantly decrease the overall number of lymph nodes retrieved but did increase the percentage of patients with fewer than 12 lymph nodes examined.
We read with interest the article of Kang et al. concerning the prognostic significance of inferior mesenteric artery lymph node metastases in rectal and sigmoid cancer patients. 1 We are pleased that the anatomic distribution of lymph node metastasis in colorectal cancer is gaining importance, and this article also suggests that it may also influence 5-year survival. The authors divided patients with rectal or sigmoid cancer in two groups (with or without inferior mesenteric lymph node involvement) and concluded that patients with inferior mesenteric lymph node metastases had a higher percentage of systemic metastases and far worse prognosis compared with the group with no metastases.We want to express some thoughts about the issues discussed. Data for local recurrence rate show that both isolated (0.0% vs. 4.4%) and overall local recurrence rate (3.0% vs. 8.6%) was worse in the group with no inferior mesenteric lymph node involvement. Because involved lymph nodes may act not only as predictors of systemic failure but also as foci for local recurrence, these results are difficult to explain. It would be easier to accept higher local recurrence rates in the group with involved lymph nodes. Taking into consideration that the overall lymph node collection yield was similar but that there was a marked difference in the number removed from the inferior mesenteric root between the two groups, one may hypothesize that the presence of enlarged lymph nodes in the area of inferior mesenteric artery in patients with nodal metastases had influenced the surgical technique and led to a more meticulous dissection of this area. Otherwise, the higher local recurrence rate in the group of patients with no metastases to the mesenteric root remains unaccounted for.The authors stated that inferior mesenteric root involvement was a prognostic factor for para-aortic and systemic metastases. Data that could reinforce this argument could come from the study of stage IV rectal and sigmoid patients of their database. If we accept the hypothesis that inferior mesenteric lymph nodes are a getaway for systemic metastases, then it is expected that patients with stage IV disease at the time of diagnosis who had been operated on with curative intent (operable liver or peritoneal metastases) will have a far higher percentage of involved inferior mesenteric lymph nodes. These data are missing from the presented data. In this context, rectal cancer patients who have been subjected to preoperative radiochemotherapy and who have advanced-stage disease also may have a higher percentage of involved inferior mesenteric lymph nodes. These data are also missing from this article.The authors concluded that, on the basis of the findings of their study, inferior mesenteric nodal metastasis was associated with high incidence of systemic recurrence and poor prognosis. In our opinion, this notion, in conjuction with articles that suggest no survival benefit from the high ligation of inferior mesenteric artery, could imply that inferior mesenteric artery noda...
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