COMPOSITE GRAFT: ANTROPYLORUS TRANSPOSITION AND GLUTEUS MAXIMUS WRAPDr Amit Dangi
THIS PRESENTATION DESCRIBES THE NOVEL SURGICAL TECHNIQUE OF TOTAL ANORECTAL RECONSTRUCTION WITH ANTROPYLORUS TRANSPOSITION AND GLUTEOPLASTY AND ITS RESULTS.
Lotti Marco MD - Cancer of the Oesophago-Gastric JunctionMarco Lotti
An analysis of the evidence about Transhiatal or Transthoracic approach for cancer of the oesophagogastric junction. Invited presentation at the 27th National Congress of the Italian Society of Young Surgeons SPIGC
COMPOSITE GRAFT: ANTROPYLORUS TRANSPOSITION AND GLUTEUS MAXIMUS WRAPDr Amit Dangi
THIS PRESENTATION DESCRIBES THE NOVEL SURGICAL TECHNIQUE OF TOTAL ANORECTAL RECONSTRUCTION WITH ANTROPYLORUS TRANSPOSITION AND GLUTEOPLASTY AND ITS RESULTS.
Lotti Marco MD - Cancer of the Oesophago-Gastric JunctionMarco Lotti
An analysis of the evidence about Transhiatal or Transthoracic approach for cancer of the oesophagogastric junction. Invited presentation at the 27th National Congress of the Italian Society of Young Surgeons SPIGC
Background: Transanal total Mesorectal Excision (TaTME) combined with traditional laparoscopy might be a promising alternative for locally advanced mid-low rectal cancer. However, some potential complications were recorded and should be evaluated further. The aim of this prospective study was assessment the results of TaTME combined with traditional laparoscopy in treatment of locally advanced mid-low rectal cancer of a single institution.Methods: Prospective study of patients with mid-low locally advanced rectal cancer who were undergone rectal resection with TaTME technique.
Mid Term Functional Results Following Surgical Treatment of Recto-Urinary Fistulas Post Prostate Cancer Treatment by Pierre Etienne Theveniaud in Experimental Techniques in Urology & Nephrology
Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinomaDr.Bhavin Vadodariya
Comprehensive review of evidence in Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinoma which includes classification of pancreatic cancer.
Peripheral neuropathy is a side effect of some cancer treatments and can result in pain, tingling or numbness in the area affected. Consultant Medical Oncologist Shirley Wong presented on why it happens, risk factors and what can be done to help. A BreaCan presentation held at Sunshine Hospital on 25 August 2016.
Background: Transanal total Mesorectal Excision (TaTME) combined with traditional laparoscopy might be a promising alternative for locally advanced mid-low rectal cancer. However, some potential complications were recorded and should be evaluated further. The aim of this prospective study was assessment the results of TaTME combined with traditional laparoscopy in treatment of locally advanced mid-low rectal cancer of a single institution.Methods: Prospective study of patients with mid-low locally advanced rectal cancer who were undergone rectal resection with TaTME technique.
Mid Term Functional Results Following Surgical Treatment of Recto-Urinary Fistulas Post Prostate Cancer Treatment by Pierre Etienne Theveniaud in Experimental Techniques in Urology & Nephrology
Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinomaDr.Bhavin Vadodariya
Comprehensive review of evidence in Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinoma which includes classification of pancreatic cancer.
Peripheral neuropathy is a side effect of some cancer treatments and can result in pain, tingling or numbness in the area affected. Consultant Medical Oncologist Shirley Wong presented on why it happens, risk factors and what can be done to help. A BreaCan presentation held at Sunshine Hospital on 25 August 2016.
Infovin – это первый федеральный российский on-line сервис проверки истории автомобиля по его VIN-коду, включающий информацию о страховой истории автомобиля, историю владения и регистраций.
Отчет показывает риски при покупке авто на вторичке.
Fundraising For Youth Radio Groups with Roman Mars and Carol Varneygenerationprx
Slides for a web event with Roman Mars, host and producer of 99% Invisible, and Carol Varney, Director of the Bay Area Video Coalition on helping youth radio groups fundraise with online tools.
Current evidence for laparoscopic surgery in colorectal cancersApollo Hospitals
The article lays an emphasis on the laparoscopic surgical method used to treat colorectal cancer. It reviews the current status of the laparoscopic colorectal surgeries and recommendation of evidences for short- and long-term outcome. The early results were against laparoscopic approach. There was a need of properly designed study to validate or invalidate these findings. Seven large-scale trials compared laparoscopic and open colectomy for colon carcinoma and examined short-term and long-term outcomes. These trials included the Clinical Outcomes of Surgical Therapies (COST) trial funded by the National Cancer Institute in the United States, the Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC) trial in the United Kingdom, the Colon Cancer Laparoscopic or Open Resection (COLOR), a multicenter European trial.
For the validation of the argument that laparoscopy is safe, meta-analysis was performed. Certain conclusions of meta-analysis are also presented in this article. The individual merits and weaknesses of laparoscopic surgery as compared with open surgery as the primary treatment of colorectal cancer are being highlighted in this article.
Colon cancer is one of the most common reasons for colonic obstruction. This presentation focusing on benign as well as malignant diseases with its management.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Information about Obstructed Recto Sigmoid Malignancy by Dr Dhaval Mangukiya.
Details of introduction of obstructed recto sigmoid malignancy, Epidemiology, Pathophysiology, Complications, Early Presentation, Stools, History, Late Presentation, Diagnosis, Imaging, Contrast enema, Screenig, Treatment, Management, Surgical management, Surgical options etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Information about Lap vs Open Colorectal Resection by Dr Dhaval Mangukiya.
Details of Factors compared, COST Trial, CLASSIC Trial, COLOR Trial, COREAN Trial, ALCCS Trial, Summary, SAGES Guidelines,
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Surgery of Rectal Cancer : Potentials and Limitations - Dimitris P. KorkolisDimitris P. Korkolis
EPIDEMOLOGY
2015 Estimates
New cases: 96,830 (colon); 40,000 (rectal)
Deaths: 50,310 (colon and rectal combined)
Death rate over last 20 years declining
Screening and improvements in treatment
Complications in Surgery- Mr G Williamsjimmystrein
Presentation given by Mr Graham Williams, Royal Wolverhampton Hospitals, at the Dukes' Club AGM 2012. Why do complications occur, identification and management of complications, management of the situation.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
4. Pseudo-obstruction
Always need contrast enema/CT scan
1st line neostigmine
2nd line colonoscopic decompression
3rd line surgery
5.
6. Obstructing colorectal cancer
Large Bowel Cancer Project (Br J
Surg) 1985
Survival rates unchanged for 30
years
Primary anastomosis established
right side
Primary resection 60% left side, 31%
primary anastomosis
8. Cochrane Database Syst Rev. 2004;(2):CD002101.
Curative surgery for obstruction from primary left
colorectal carcinoma: primary or staged resection?
De Salvo GL, Gava C, Pucciarelli S, Lise M
REVIEWERS' CONCLUSIONS:
The limited number of identified trials together
with their methodological weaknesses do not
allow a reliable assessment of the role of either
therapeutic strategy in the treatment of patients
with bowel obstruction from colorectal carcinoma.
It would appear advisable to conduct high quality
large scale RCT to establish which treatment is
more effective. However, it is doubtful whether
they could be carried out in a timely and
satisfactory way in this particular surgical context
9. Left colon-one stage resection
No. One stage Leak
(%) Rate (%)
Stewart 1993 73 86 6
Runkel 1998 35 63 5
Poon 1998 116 81 5
Deen 1998 143 85 1
10. Segmental resection vs Subtotal
colectomy
Scotia Study Group increased bowel
(Br J Surg) 1995 frequency in subtotal
group
Torralba et al post operative
(Dis Colon diarrhoea
Rectum) 1994 in 31%
11. Extended right vs Segmental
left
Nyam et al Dis Colon Rectum 1996
no difference in bowel frequency
no difference in complications
12. Mortality rates
Scotia Gp (Br J Surg) 1995
12%
Poon et al (Br J Surg) 1998
7%
Alvarez et al (Dig Dis) 2005
11%
Poon et al (Dis Col Rectum) 2005
11%
McGillicuddy et al (Arch Surg) 2009
15%
13.
14.
15.
16. Rationale – converting emergency
into elective surgery
Pre-operative correction and stabilisation
of fluid and electrolyte balance
Reduction of diaphragmatic splinting and
pain with improvement in respiratory
function
Treatment of medical co-morbid disease
Accurate pre-operative staging of the
patient
Referral to a specialist colorectal surgeon
In a few patients with rapidly progressive
(advanced) disease or unstable comorbid
disease, major surgery may be avoided
17. CReST is funded by CRUK and was developed by the NCRI Colorectal
Cancer CSG
CReST
18. Stenting needs to be properly evaluated in a
randomised controlled trial addressing two key
questions:
* Is there a worthwhile net benefit (in reduced operative
mortality and morbidity, reduced stoma formation and
better quality of life adjusted survival) from endoluminal
stenting for patients presenting with an obstructing
colonic cancer?
* If a benefit exists, is this identifiable in patients
undergoing attempted curative treatment, palliative
treatment, or both?
19. Eligibility criteria
Left sided colorectal cancer
Clinical or radiological evidence of
obstruction
Patient is fit for surgery
Responsible doctor feels that there
may be some benefit to the patient
from stenting as a bridge to surgery
20. Emergency surgery
Obstructing
Colorectal cancer R
Insertion of Failed stenting
endoluminal stent
Palliative
care
Successful
decompression
Elective
surgery
21. End Points
Primary:
1. 30 day mortality
2. Length of hospital stay
Secondary:
a) Presence and duration of a stoma
b) Stenting completion and complication rate
c) Anastomosis rate
d) Quality of life (EQ 5D and EORTC QLQ-CR 29)
e) Overall survival
f) Disease-free survival at three years (attempted
curative surgery group only)
g) Length of stay on ITU or HDU
h) In-hospital morbidity
i) Cost benefit analysis
j) Rate of adjuvant chemotherapy (stage II and
stage III cancer) and adherence to chosen
chemotherapy protocols
22. Evidence
>100 case series
4 systematic reviews
3 randomised trials
26. NICE draft guidance
Clinical question: For patients presenting with acute large
bowel obstruction as a first presentation of colorectal
cancer, what are the indications for stenting as a bridge to
elective surgery? What are the indications for stenting
patients and the optimal timing for stenting to occur?
Clinical evidence
There is very little evidence of any type with which to address this
topic. There are no directly applicable studies and so in assessing
the body of evidence, consideration was given to the possibility
that relevant evidence may not be directly available and so
studies which compared stenting as a bridge to surgery, stenting
for palliative purposes or immediate emergency surgery were also
reviewed to check whether these studies contained information
relevant to the topic. Despite this consideration, very little
evidence of relevance was found from these studies and what was
available was of very poor quality.
27. Dutch stent in 1 – Endoscopy 2008
21 pts with obstruction
Palliative cases
Premature closure of the trial
11 adverse events in stenting arm
6 perforations
• 4 early
• 2 late on chemotherapy
28. 2nd Dutch Stenting trial – multicentre
van Hooft Lancet Oncol 2011;12:344–52
Obstructing left sided
Primary outcome measure QoL
98 cases randomised
Increased 30 day morbidity in stent
gp (absolute risk increase 0.19)
Trial currently halted by DMEC
29. 2nd Dutch Stenting trial – multicentre
van Hooft Lancet Oncol 2011; 12: 344–52
No difference
• QoL
• Mortality
• Stoma rates
Stent group
• Perforation 13%
• Successfully placed in 70% (all relieved
obstruction)
• 31 pts bridge to surgery
Primary anastomosis in 20 (25% leak rate)
3 silent perforations found histologically
30. The authors concluded that colonic
stenting has no decisive clinical
advantages compared to emergency
surgery. They suggested that it could be
used as an alternative treatment in as yet
undefined subsets of patients, although
with caution because of concerns about
tumour spread caused by perforations.
31. French stenting trial – multi centre
– Pirlet et al Surg Endosc 2010
Obstructing left sided carcinoma
Endoscopic or radiological
60 patients randomised
53% technical failure stenting arm
No reduction in stoma rates
• 43% stenting arm, 56% emergency
surgery
2/30 perforations in stenting arm
Trial stopped early
32. Thus the evidence provided by published randomised trials to
date demonstrates no evidence of benefit from stenting and
importantly describes increased morbidity associated with
stenting.
The key questions relating to the use of stents in obstructing
colorectal cancer remain unanswered. These questions can only
be answered by a large randomised trial.
The current status of stenting in obstructing colorectal cancer is
analogous to the status of laparoscopic surgery for colorectal
cancer in 2000.
People should only have laparoscopic surgery as part of a
clinical trial.
In view of all the above we feel most strongly that the planned
NICE Colorectal Cancer guidelines should state that; in patients
fit enough to undergo emergency surgery, stenting in
obstructing colorectal cancer should be limited to clinical trials
so that we can be clear about its benefit and risks.
33. Clinical question: For patients presenting with acute large bowel
obstruction as a first presentation of colorectal cancer, what are
the indications for stenting as a bridge to elective surgery?
What are the indications for stenting patients and the optimal
timing for stenting to occur?
The guidance on Improving outcomes in
colorectal cancer‘ (2004) recommended stent
insertion instead of emergency surgery for
patients with acute bowel obstruction.
Consequently the question investigated by this
guideline focused on the indications and optimal
timing for stent insertion to occur. The evidence
you cite relates to the issue of stent insertion vs
emergency surgery and is therefore not relevant
to the topic which was considered by the
guideline.
34. “The failure to consider the directly randomised evidence on the
question addressed is indefensible and does a disservice to
patients and their medical carers. As this randomised evidence
points to the potential for serious harm as a result of insertion of
SEMS in patients with obstructing colorectal cancer, the NICE
Guidance’s recommendation that colorectal surgeons should
consider inserting a colonic stent in patients presenting with acute
large bowel obstruction, without mention that randomised trials
have failed to establish superiority of SEMS over decompression
surgery, is ”perverse”. The appropriate recommendation - and the
conclusion of the authors of all three randomised trials (see
below) - is that stenting as a bridge to surgery remains an
experimental procedure requiring further randomised evidence to
establish its clinical and cost-effectiveness. The newly published
guidance on SEMS should be corrected or withdrawn”.
35. 2. Recruitment (up to 14th November 2011)
Date recruitment started: 23-Apr-2009
Proposed date for recruitment to end: Extended to August 2013
Total number to be recruited: 400
Number recruited to date: 123
36.
37. First 100 patients
50 randomised to stenting
48 stent attempted
Success rate 85% (7 failures)
No perforations
38 surgery
10 no surgery
• 7 palliative cases
• 1 MI before surgery
• 1 benign disease
• 1 unknown
38. mean 23.2 (22.8)
(s.d.)
Time from stent median (IQR) 19.5 (4 , 35)
to surgery min 0
max 103
39. SAEs in stented patients having
surgery (38 patients)
Intra-abdominal abscess 2
Wound infection 2
PE 2
Myocardial 1
Urinary 2
Chest infection 3
Constipation 1
No anastomotic leaks but no. primary
anastomosis unknown
40. Summary
Colorectal community in UK has
accepted the need for a trial and is
supporting it
Recruitment is progressing at a
satisfactory rate
Safety data is reassuring
Given concerns raised by stenting
trials, CReST trial is important
Current NICE guidance is disservice
to patients
41. TREC Trial –
Transanal Endoscopic Microsurgery
(TEM) and Radiotherapy in Early
Rectal Cancer
Jim Hill
Manchester Royal Infirmary
42.
43. Phase II feasibility study comparing
radical TME surgery versus SCPRT
plus delayed local excision for
treatment of early rectal cancer (T1-
T2)
44. Early Rectal Cancer
10,000 new cases rectal cancer per year in England &
Wales
49 – 62% screen-detected rectal cancers are “early”
(pT1-2N0M0)
Standard of care: Total Mesorectal Excision (TME)
High rates of cure (3-6% relapse)
Significant high mortality (3-4%) & post-operative morbidity
45. Radical Resection vs Local
Excision
Balance of reduction in
morbidity and mortality
vs risk of oncological
disaster
46. Results of Local Excision Alone
T-Stage Local recurrence
%(range)
T1 9.7 (0-24)
T2 25 (0-50)
T3 38 (0-100)
48. Radical Resection - morbidity & mortality
Significant morbidity (up to 60%) and
mortality (0-12%)
Wound infections, wound and
parastomal herniae, urinary /sexual
dysfunction, anastomatic leakage,
stoma issues, anterior resection
syndrome, incontinence
APR: Perineal wound and stoma-
related physical, psychological and
financial cost
49. Short Course Pre-operative
Radiotherapy
Preoperative radiotherapy
more effective than post-op RT
Pre-op can reduce local
recurrence following TME
Can induce tumour shrinkage
or even complete pathological
response
Interval between SCPRT and
surgery key to downstaging
Surgery follows 1 week after
traditional schedules of
SCPRT
55. 50 patients randomised to stenting.
47 have a stent insertion date recorded.
3 don’t (1071, 1086, 1088)
Reasons for not having a stent insertion date are
as follows:
1 not eligible - small bowel tumour on review
(1071)
1 small bowel obstruction/fistula – going
straight to surgery (1086)
1 stent attempted but failed – missing date.
Assumed to be = date of surgery = 1 day after
rand. (1088)
56. Of the 48 with a stent date recorded:
38 have a surgery date
10 don’t.
Good reasons for not having a surgery date are
as follows:
7 palliative (1016, 1034, 1051, 1059, 1062,
1068, 1069)
1 died before surgery (1022)
Bad reasons for not having a surgery date are as
follows: (forms being chased)
1 possible non-cancer (1092)
1 unknown (1043)
57. CReST Recruitment
Proposed date for recruitment to end: Oct-2012
Total number to be recruited: 400
Number recruited to date, 19-Nov-10: 65
58. Benign disease
Small et al, Surg Endosc 2008
23 cases
Clinical success 22/23
Major complications 38%
87% occurred after 7 days
59. Planned analyses
Interval analysis after recruitment of 150
patients of post-operative complications,
in hospital stay, stoma formation, 30 day
mortality.
A primary analysis of outcome will be
made once all patients have 2 years of
follow up.
Statistical analyses will use standard
methods, e.g. comparisons of proportions
by Mantel-Haenszel or Fisher’s exact test,
logrank analyses of time to event data and
multi-level model with repeated measures
analysis for quality of life scores.
60. Conclusions of randomised trials
reported to date
No proven benefit for all comers
compared to emergency surgery
May be useful in selected patients (?
Which ones)
Further studies needed to look at
oncological outcomes
61. Exclusion criteria
Patients with signs of peritonitis and/or
perforation
Patients with obstruction in the rectum,
that may require neoadjuvant therapy (i.e.
tumours in the mid or lower rectum)
Patients who are unfit for surgical
treatments or refuse surgical treatment.
Patients who are unwilling to consent to
participate
Pregnant patients
62. Martinez-Santoz et al, Dis Colon
Rectum 2002
Emergency surgery (n=29)
Pre-operative stent and elective surgery
(n=26)
Stenting and elective surgery was
associated
• an increase in the primary anastomosis rate
(84.6% vs 41.4%, p=0.0025)
• a lower need for a colostomy (15.4% vs
58.6%)
• a significantly reduced hospital stay (14.23 vs
18.52 days and intensive care unit stay (0.3 vs
2.9 days)
63. Statistical Power
400 patients will be randomized over three years
from 40 centres in the UK and selected centres
overseas
The feasible study size would be adequate to
detect a 50% reduction in 30-day mortality with
stenting and elective surgery compared to
emergency surgery (e.g. 13% vs 27% as
reported in audit data)
90% power to detect a reduction in operative
complications from 40% to 25% - Martinez-
Santoz et al reported a reduction from 41% to
12% in their non-randomised study).
64. Statistical Power
90% power to detect a 0.35sd reduction in
days in hospital equivalent to 1-2 days. It
is not anticipated that there will be any
significant loss to follow-up.
90% power to detect differences in
survival of similar magnitude to those
seen in Birmingham audit data (where
survival at 6 months in the emergency
patients was 73% vs 87% in the elective
group) or those reported in a recent
national audit (mortality of 15.7%
following surgery for obstructing colorectal
65. Statistical Power
Adequate to detect a 50% reduction in 30-day
mortality with stenting and elective surgery
compared to primary anastomosis
90% power to detect a reduction in operative
complications from 40% to 25% - Martinez-
Santoz et al reported a reduction from 41% to
12% in their non-randomised study).
66. Sebastian et al, Am J Gastroenterol
2004
Pooled analysis of 1,198 patients in
54 studies.
Median technical and clinical success
rates of 94% (i.q.r 90-100) and 91%
(i.q.r 84-94).
Clinical success when used as a
bridge to surgery was 71.7%.
Major complications perforation
(3.7%), stent migration (11.8%).
Stent related mortality 0.58%.
67. Statistical Power
400 patients
90% power to detect differences in mortality if
similar to those reported in a recent national
audit (mortality of 15.7% following surgery for
obstructing colorectal cancer and 4% following
elective surgery).
90% power to detect a 0.35sd reduction in days
in hospital equivalent to 1-2 days.
90% power to detect a reduction in operative
complications from 40% to 25% - Martinez-
Santoz et al reported a reduction from 41% to
12% in their non-randomised study).
68. CReST to date
125 pts recruited
33 recruiting centres
50 sites open
69. Presentation and Outcome
COLORECTAL CANCER
Mode of % of all In-hospital
5 yr
presentation patients mortality
survival
Elective surgery 60 5
50
Emergency 25 20
25
Non-operative 15 40
71. Stenting workshops
Combined endoscopic/fluoroscopic
technique recommended
Double channel gastroscope
No pre or post stent insertion
dilatation allowed
Stent of radiologists/endoscopists
choice
Confidence levels of radiologists high
No specific colonic stent numbers
72. Systematic reviews
Little high level evidence
No data QoL and economic analysis
Little long term/survival data
73. 2007 UK National Bowel Cancer Audit
Project reported an 11 per cent
mortality after colonic stenting for
obstructing cancers
The authors commented that this
was higher than in
previously published
reports and needed
further study
75. Stenting vs open surgery
Tilney et at Surg Endosc 2007
451 pts
Lower mortality p<0.03
LOS shorter by 7.7 days
Stenting did not
affect survival
76. Watt et al Ann Surg 2007
88 articles,
Mortality comparable
Shorter LOS
Lower colostomy rates
Lower complications
77. Serious Adverse Events
SAEs – fatal, life-threatening, require or prolong hospitalisation or are
significantly or permanently disabling
For purposes of trial, adverse events include, but aren’t limited to:
- Failure to deploy the stent
- Bowel perforation
- Stent displacement
All SAEs reported to BCTU within 24 hrs
78.
79.
80. Question
In the absence of any randomised
clinical trial showing a benefit of
stenting in patients with obstructing
left sided colorectal cancer and
concerns about stenting (sufficient to
stop the trials) in the only three
randomised trials so far conducted,
should stenting be offered outside a
randomised trial?
81. Left colon-Staged resection
Cahill et al (Annals RCSE) 1991
44% prefer Hartmann
Wigmore et al (Br J Surg) 1995
32-60% never reanastomosed
Editor's Notes
CReST is funded by CRUK and was developed by the NCRI Colorectal Cancer CSG CReST is funded by CRUK and was developed by the NCRI Colorectal Cancer CSG