Optimal wait between long-course neoadjuvant chemoradiotherapy

and surgery in locally advanced rectal cancer: a dilemma

Long-course neoadjuvant chemoradiotherapy (NACRT) prior to sur-gical management of locally advanced, non-metastatic rectal canceris a well-established management protocol worldwide. Its effect ontumour downsizing is well known (Fig. 1). However, the optimaltime period between completion of radiotherapy and surgery formaximal downstaging remains debatable.

The Lyon R90-01 randomized trial1 concluded that a long waitingperiod of 6–8 weeks between NACRT and TME (total mesorectalexcision) surgery increased tumour downstaging, with no adverseeffects on toxicity or outcome. Hereafter, this waiting period wasarbitrarily designated as 6 weeks and followed as such by the sur-gical fraternity.

Subsequent studies by Glehen et al.,2 de Campos-Lobato et al.3

and Evans et al.4 in stage II and stage III rectal cancers go on to statethat a longer time interval between NACRT and surgery correlatedwith better pathological response.

In a comprehensive study, Wolthius et al.5 tried to assess the roleof different time intervals between NACRT and radical surgery forlocally advanced, non-metastatic rectal cancer as well as their effecton pathological response, post-operative morbidity and oncologicaloutcome. They dichotomized patients into two groups based on thewaiting period as short interval (<7 weeks) and long interval (>7weeks). Their study proved that a waiting period of more than 7weeks correlated with better overall survival (84% versus 77%) aswell as statistically significant improvement in recurrence-free sur-vival (P = 0.0261) and cancer-specific survival (P = 0.0457).

O’Neill et al.,6 Dhadda et al.7 and Habr-Gama et al.8 have advo-cated a waiting period of 10–14 weeks prior to TME surgery, with nocompromise on the oncological outcomes.

The possibility of further enhancing the downsizing of the tumourhas been considered, although another area of interest is the allevia-tion of patient anxiety during this waiting period. In their studypublished in 2009, Habr-Gama et al.8 proposed additional chemo-therapy (three cycles of 5-fluorouracil/leucovorin) in this restingperiod. The longer waiting time did not have an impact on post-operative morbidity, more radical surgeries or anastomotic leaksafter low anterior resection.

The questions that still remain unanswered are the optimization ofthis waiting interval, regularity of assessment in order to determinethe best period for surgical intervention and the need for re-staging.Additionally, which tumours are more likely to respond to thisadditional chemotherapy, if advocated in the waiting period, stillremains food for thought.

Caution also needs to be exercised as regards the widening of thiswait, as some patients may even experience tumour re-growth andspread. Multi-centre randomized trials are thus mandatory to bridgethe gap in this hiatus of knowledge.

However, it can be safely said that a minimum duration of 8weeks should be maintained between NACRT and surgery. Anyinadvertent delay due to scheduling/demographic issues is unlikelyto lead to any significant adverse impact until 10–14 weeks ofwaiting interval.

Fig. 1. Top: Pre-neoadjuvant chemoradiotherapy (NACRT) tumour.Bottom: Post-NACRT downsized tumour.

PERSPECTIVESANZJSurg.com

© 2014 Royal Australasian College of SurgeonsANZ J Surg 84 (2014) 4–8

References

1. Francois Y, Nemoz CJ, Baulieux J et al. Influence of the interval betweenpreoperative radiation therapy and surgery on downstaging and on the rateof sphincter-sparing surgery for rectal cancer: the Lyon R90-01randomized trial. J. Clin. Oncol. 1999; 17: 2396–402.

2. Glehen O, Chapet O, Adham M et al. Long-term results of the LyonsR90-01 randomized trial of preoperative radiotherapy with delayedsurgery and its effect on sphincter saving surgery in rectal cancer. Br. J.Surg. 2003; 90: 996–8.

3. de Campos-Lobato LF, Geisler DP, da Luz Moreira A et al. Neoadjuvanttherapy for rectal cancer: the impact of longer interval betweenchemoradiation and surgery. J. Gastrointest. Surg. 2010; 15: 444–50.

4. Evans J, Tait D, Swift I et al. Timing of surgery following preoperativetherapy in rectal cancer: the need for a prospective randomized trial? Dis.Colon Rectum 2011; 54: 1251–9.

5. Wolthuis AM, Pennickx F, Haustermans K et al. Impact of intervalbetween neoadjuvantchemoradiotherapy and TME for locally advancedrectal cancer on pathological response and oncologic outcome. Ann. Surg.Oncol. 2012; 19: 2833–41.

6. O’Neill BD, Brown G, Heald RJ et al. Non-operative treatment afterneoadjuvant chemoradiotherapy for rectal cancer. Lancet Oncol. 2007; 8:625–33.

7. Dhadda AS, Zaitoun AM, Bessell EM. Regression of rectal cancer withradiotherapy with or without concurrent capecitabine – optimising thetiming of surgical resection. Clin. Oncol. (R. Coll. Radiol.) 2009; 21:23–31.

8. Habr-Gama A, Perez RO, Wynn G et al. Complete clinical response afterneoadjuvant chemoradiotherapy for distal rectal cancer: characterizationof clinical and endoscopic findings for standardization. Dis. ColonRectum 2010; 53: 1692–8.

Gaurav Aggarwal, MS, FAGEManas K. Roy, MS, MCh

Sudeep Banerjee, MS, DNBDepartment of Surgical Oncology (GI Surgery),

Tata Medical Center, Kolkata, West Bengal, India

doi: 10.1111/ans.12449

Troubleshooting in laparoscopy: how to treat ‘poor image quality’

Introduction

Laparoscopic surgery is one of the greatest improvements in surgerywithin the last decades. However, the introduction of sophisticatedtechnical equipment in laparoscopic surgery has made the surgicalenvironment more complex. New problems are created due to man–machine interactions during high-tech operations, thereby increas-ing the risk of errors or incidents leading to potential adverse events.Technical problems also cause an increase in operating theatre timeand therefore increase the cost of operative procedures.

Operating rooms are complex environments, which can be over-whelming; however, well-established protocols, such as the surgicalsafety checklist have measurably reduced (peri)operative risks.1,2

Studies have shown that surgeons are aware of the existence of userproblems with equipment and instruments in laparoscopic surgery.3

There is therefore an argument for the establishment of protocols to befollowed should a surgeon face technical failure during laparoscopy.The occurrence of incidents with technical laparoscopic equipmenthas been quantified in an observational study by Verdaasdonk et al.4

who investigated the incidence of technical equipment problemsduring laparoscopic cholecystectomies in order to develop adequatespecific defence strategies. The study revealed that technical failure orinstrument problems can occur in up to 87% of laparoscopies.The authors concluded that improvement and standardization ofequipment in combination with the preoperative usage of a checklistwill help to prevent laparoscopy associated problems. They wenton to suggest a 28-item checklist, based on frequently occurringlaparoscopic problems.5 Their data revealed that the usage of thischecklist was feasible and helped to reduce problems with thelaparoscopic equipment in the operating room. However, implement-ing and internalizing a checklist is often time consuming and tedious.

Based on a review of the literature, using the terms ‘laparoscopy,laparoscopic surgery, minimal invasive surgery, troubleshooting,

image quality, visibility, technical problems’ in PubMed,1–5 discus-sions with technical specialists (ConMed Linvatec Australia) and oursurgical experiences, we have compiled a hierarchy of the mostcommon error sources responsible for image quality and technicalproblems in laparoscopic surgery that should be kept in mind whilefacing an intra-operative technical problem.

Common error sources:(1) Scope(2) Operator(3) Image capture device(4) Camera head(5) Light(6) Cables(7) Camera console(8) Monitor

The use of checklists provides a reliable way of dealing with tech-nical problems, but checklists have to be user-friendly and appli-cable in in the daily routine. Considering the different typesof image quality deterioration, we have proposed a systematicsequence (Fig. 1a,b) the surgeon could follow in order to minimizedelay and rectify the problem efficiently. We believe this would beof use to junior surgeons in particular who are often unfamiliarwith laparoscopic equipment and is generic enough to be trans-ferred to commonly available and used laparoscopic systems andinstruments.

Troubleshooting – proposed approach to treatpoor image quality

In general, all elements of the image chain – consisting of scope,camera head including camera cable, light guide and light source,camera processor, cables and monitor – need to be checked to findthe error source as each component is equally responsible for

Perspectives 5

© 2014 Royal Australasian College of Surgeons