Rachael Elizabeth Clifford

Background: Salvage surgery for local regrowth following watch-and-wait (W&W) after total neoadjuvant therapy (TNT) is perceived to be technically more difficult than immediate surgery after treatment. However, surgical difficulty lacks standardised definition and reporting. This methodological review proposes a structured minimum outcome set (MOS) to distinguish intra-operative technical complexity from surgery-related morbidity and evaluates current reporting against this framework. Methods: A predefined framework comprised two domains: (1) surgery-related morbidity (Clavien–Dindo major complications, 30- or 90-day mortality, anastomotic leak, reoperation/readmission within 30 days and stoma status) and (2) intra-operative technical complexity (surgical approach, conversion, operative time, blood loss and a predefined pelvic complexity metric). R0/R1 resection status was recorded separately as a contextual oncological measure. A systematic review identified studies reporting salvage surgery for local regrowth after TNT and W&W. Reporting of MOS variables was enumerated and risk of bias assessed using a topic-specific ROBINS-I tool. Results: Ten studies met the inclusion criteria, comprising 569 patients managed with TNT and W&W; 198 (35%) developed local regrowth and 172 (87%) underwent salvage surgery. Only one study reported major complications with salvage-specific denominators. Mortality, anastomotic leak, reoperation and stoma outcomes were absent or pooled. R0/R1 status was reported in seven studies but often without salvage-specific denominators. No study reported objective intra-operative metrics corresponding to predefined technical complexity variables. Risk of bias ranged from moderate to serious. Conclusions: Current reporting is insufficient to define the safety or technical complexity of salvage surgery after TNT and W&W. The proposed MOS offers an exploratory basis for standardised reporting and may inform future consensus-driven core outcome set development.

Background: Local recurrence of rectal cancer is a challenging problem for patients and clinicians. Surgical resection is associated with good outcomes if R0 margins are achieved; however, it is often complex, requires suitable patient fitness, and is associated with long term physical and psychological consequences. Meanwhile, continuing technical advances in radiotherapy have enabled the delivery of highly conformal treatment, thereby enabling dose escalation or pelvic reirradiation to be safely considered—either as definitive management or in the neoadjuvant setting—for patients with locally recurrent rectal cancer. Pelvic reirradiation may refer to patients who have received primary rectal radiotherapy with the aim of neoadjuvant downstaging or reducing the risk of locoregional recurrence, versus radiotherapy for a previous unrelated non-rectal pelvic malignancy. Methods: A literature search of pelvic reirradiation for non-metastatic, locally recurrent rectal cancer was conducted for full text articles published over the last 20 years. Additional papers were identified within the references of these papers. Studies focusing on non-rectal cancers, and patients having primary radiotherapy for locally recurrent rectal cancer were excluded. Due to the heterogenicity of the data, no meta-analysis was performed. Results: A total of 15 papers were included, containing a cohort of 840 patients. Several reirradiation modalities were reported, including external beam radiotherapy, brachytherapy, stereotactic ablative radiotherapy and heavy particle therapy (carbon ion). Carbon ion radiotherapy was the most common reirradiation treatment modality utilised with a median cumulative dose of 70.4 Gray (Gy). Treatment response, defined as either complete or partial improvement in tumour size, was only reported in seven studies, and varied from 14 to 88%. Overall 3-year survival was also variable with rates reported between 18 and 85%. These observations may be due to variation in patient selection, treatment intent, and technique. Pelvic reirradiation was associated with acceptable toxicity, low rates of G3+ toxicity, and improved symptom control. Conclusions: Our review describes the multitude of approaches to pelvic reirradiation for locally recurrent rectal cancer. Reviewing the radiobiological and patient outcomes is challenging in view of the degree of heterogeneity in patient selection, treatment approach, and reported outcomes. However, there is consensus that pelvic reirradiation—either for long term control or to downstage prior to definitive surgery—is feasible with potential utility in this setting.

There has been an increasing focus on the potential of cancer vaccines as a therapeutic oncological option, aiming to harness the immune system to recognize and eliminate malignant cells. Unlike traditional therapies, vaccines exploit tumour-associated antigens and neoantigens to generate durable, tumour-specific immune responses. This review provides a comprehensive overview of current vaccine strategies, their clinical applications, and implications for surgical oncology. Clinical trials highlight promising results in high-mutational burden cancers such as melanoma, lung, and bladder cancer, as well as in traditionally 'cold' tumours like pancreatic cancer. Combination strategies, particularly with checkpoint inhibitors, have shown enhanced efficacy, exemplified by messenger RNA-4157/V940 and autogene cevumeran in adjuvant settings. Off-the-shelf tumour-associated antigen vaccines offer scalability but face challenges of tolerance and limited specificity. Early data suggest vaccines may improve relapse-free survival and induce antigen spreading, broadening immune responses beyond the initial targets. Cancer vaccines are poised to complement surgery and systemic therapies, particularly in the perioperative window. Their integration into multimodal treatment strategies may redefine precision oncology, offering durable disease control and improved patient outcomes.

Background: Surgery for locally advanced pelvic malignancy is complex, requiring careful operative planning and effective patient consent. Traditional two-dimensional (2D) imaging can limit understanding of tumour-organ relationships for both clinicians and patients. Three-dimensional (3D) reconstructed imaging may have a role in enhancing surgical planning, patient understanding and trainee education. Methods: Adult patients with locally advanced rectal or anal cancer undergoing planned resection at a UK tertiary cancer centre were prospectively identified. CT scans were reconstructed into interactive 3D models using the Visible Patient™ platform. Models were reviewed by surgeons and trainees prior to outpatient consultations and then demonstrated to patients during the consent process. Surgeons, trainees, and patients completed structured questionnaires incorporating Likert-scale responses and free-text feedback. Qualitative data were analysed thematically. Results: Fifteen patient-specific pelvic models were created, with feedback obtained from all surgeons and trainees and from 13 patients. Patient responses were overwhelmingly positive, with median scores of 9–10/10 for realism, understanding of disease and surgery, and perceived benefit during consultation. Thematic analysis highlighted improved understanding, empowerment, and engagement in decision making. Surgeons rated the models moderately for operative planning but highly for trainee education and patient communication. No operative plans were altered following model review. Trainees reported strong educational value, while radiologists noted limitations in segmentation accuracy for intraluminal disease. Conclusion: CT-based 3D reconstructed pelvic models provide substantial benefit in patient education and shared decision making for complex pelvic cancer surgery, with additional value as a training tool. Further studies are warranted to define their role in operative planning and cost-effective implementation.

Aim: Chronic radiation proctopathy (CRP) is a significant side‐effect of radiotherapy, and poses a challenge in clinical management, necessitating effective and standardized therapeutic approaches. The aim of this review is to investigate the role of endoscopic interventions for CRP, focusing on argon plasma coagulation (APC) and formalin application. Method: A literature search was undertaken for studies that investigated the clinical responses to endoscopic management in patients with CRP. A systematic review was performed in accordance with PRISMA guidelines, and a meta‐analysis of proportions was conducted with a random‐effects model. ROBINS‐I and the Cochrane Collaboration's tool were used to assess risk of bias in cohort studies and randomized control trials, respectively. Results: A total of 82 studies met the inclusion criteria, including 11 randomized control trials, 20 systematic reviews, one cohort study and 50 case series. A robust 89% (95% CI 84%–92%, p < 0.01 and 95% CI 84%–93%, p = 0.03) pooled response rate was demonstrated for both APC and formalin therapies, respectively. Adverse effects were generally minimal. Conclusion: Endoscopic therapies, particularly APC and formalin, exhibit commendable clinical response rates in the management of CRP. However, the lack of standardized treatment protocols highlights the need for larger prospective studies. Clear guidelines, informed by defined outcomes and quality‐of‐life assessments, are imperative for enhancing patient outcomes and minimizing the morbidity associated with CRP.

Introduction: Pneumoperitoneum is widely used in gastrointestinal surgery, particularly for laparoscopic or robotic procedures, with suggested advantages associated with low pressure. While existing data predominantly focuses on laparoscopic cholecystectomy, the assessment of intra-abdominal pressures in other gastrointestinal surgeries remains unexplored. Methods: This study conducted an electronic literature search for randomized control trials comparing low-pressure pneumoperitoneum to standard or high-pressure counterparts. Results: Out of 26 articles meeting inclusion criteria, encompassing 2077 patients, 15 demonstrated positive associations with low-pressure pneumoperitoneum. No significant difference in postoperative pain was found in the remaining papers. Methodological variations, diverse outcome reporting, and a prevalent high risk of bias precluded meta-analysis. Conclusions: The study highlights substantial outcome variability, urging cautious interpretation of aggregated results. Despite positive associations in specific cases, insufficient evidence was found to support the superiority of low-pressure pneumoperitoneum. The study recommends future research employing validated patient-reported outcome measures and standardized reporting to help guide the development of evidence-based guidelines and optimize patient care in abdominal surgeries.

The first wave of the COVID-19 pandemic led to an unprecedented time for the management of colorectal cancer, with uncertainty as to cancer-specific risks and the circumventing of gold standard oncological strategies. Our study aimed to acquire a snapshot of the practice of multidisciplinary team (MDT) management and variability in response to rapidly emerging guidelines. The survey was disseminated to 150 colorectal cancer MDTs across England and Wales taken from the National Bowel Cancer Audit data set between 15 April and 30 June 2020 for completion by colorectal surgeons. Sixty-seven MDTs responded to the survey. Fifty-seven centres reported that they continued to perform colorectal cancer resections during the initial lockdown period. Fifty centres (74.6%) introduced routine preoperative COVID-19 testing and 50 (74.6%) employed full personal protective equipment for elective cases. Laparoscopic resections were continued by 25 centres (42.1%), whereas 28 (48.3%) changed to an open approach. Forty-nine (79.0%) centres reported experiencing patient-led surgical cancellations in 0–25% of their listings. If surgery was delayed significantly then 24 centres (38.7%) employed alternative neoadjuvant therapy, with short-course radiotherapy being their preferred adjunct of choice for rectal cancer. Just over 50% of the MDTs stated that they were uncomfortable or very uncomfortable with their management strategies. Our study demonstrates variability in the MDT management of colorectal cancer during the initial COVID-19 lockdown, incorporating adaptive patient behaviour and initially limited data on oncological safety profiles leading to challenging decision-making.

Aim: Post-operative pulmonary complications in perioperative SARS-CoV-2 infection are associated with significant morbidity and mortality. To maintain a safe cancer service, the Countess of Chester Hospital adopted “Cold-site” operating and maintained ERAS principles for patients undergoing elective colorectal cancer surgery during the pandemic. A comparative assessment of service was undertaken for benchmarking purposes. Method: A comparative retrospective audit was undertaken of consecutive patients undergoing elective colorectal cancer surgery from June to November 2019 and compared to June to November 2020. The Somerset Cancer Registry and electronic medical case records were used to obtain the dataset. Outcomes measured were approach to surgery; stoma rate; length of stay; level of care required; post-operative complications (>Clavien-Dindo 2) and survival at 30 days. Mann-Whitney U test and Chi-squared were used for analysis. Results: There were 33 and 24 elective colorectal cancer operations in 2019 and 2020 respectively. There was no difference in the median age (64:69; p = 0.3) or ASA grade (p = 0.9). The median length of stay was 5 and 4 days respectively (p = 0.3). There was a 32.2% reduction in laparoscopic approach to surgery in 2020 (69.7% vs 37.5%; p = 0.02). There was no difference in the stoma rate (p = 0.9), post-operative complication rate (p = 0.7), ITU admission rate (p = 0.3), length of ITU stay (p = 0.6) and 30-day mortality rates (p = 0.4). Conclusions: “Cold-site” operating allows robust ERAS care to be adopted to ensure comparative outcomes for patients undergoing colorectal cancer surgery and was associated with a non-significant trend to shorter hospital stay during the COVID-19 pandemic.

Aim: Benign anastomotic strictures following colorectal surgical resection are a commonly under‐reported complication in up to 30% of patients, with a significant impact upon quality of life. In this systematic review, we aim to assess the utility of endoscopic techniques in avoiding the need for surgical reintervention.Method: A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases. Additional papers were found by scanning the references of relevant papers.Results: A total of 34 papers were included, focusing upon balloon dilatation, endoscopic stenting, electroincision, stapler stricturoplasty and cortiocosteroids alone and in combination, with success rates varying from 20% to 100%. The most challenging strictures were reported as those with a narrow lumen, frequently observed following neoadjuvant chemoradiotherapy or an anastomotic leak. Endoscopic balloon dilatation was the most commonly used first‐line method; however, repeated dilatations were often required and this was associated with an increased risk of perforation. Although initial success rates for stents were good, patients often experienced stent migration and local symptoms. Only a small number of patients experienced endoscopic management failure and progressed to surgical intervention.Conclusion: Following identification of an anastomotic stricture and exclusion of underlying malignancy, endoscopic management is both safe and feasible as a first‐line option, even if multiple treatment exposures or multimodal management is required. Surgical resection or a defunctioning stoma should be reserved for emergency or failed cases. Further research is required into multimodal and novel therapies to improve quality of life for these patients.