Table of Contents

Original ArticlesPhase II/III Randomized Controlled Trial of Concomitant Hyperfractionated Radiotherapy plus Cetuximab (Anti-EGFR Antibody) or Chemotherapy in Locally Advanced Head and Neck Cancer ................................................06Khaled Al-Saleh, Mustafa El-Sherify, Reham Safwat, Amany Elbasmy, Jitendra Shete, Amany Hussein, Marwa Nazeeh, Ahmad Bedair

Betel Chewing: A New Analysis, In Vitro and In Vivo, of the Risk Factors in Oral Cancer .......................................................................13Roberto Menicagli, Ortensio Marotta, Maione Nunzia, Casotti Maria Teresa

Retrospective Analysis of Outcomes of Patients with Relapsed, Refractory and Metastatic Sarcomas who have received Metronomic Chemotherapy ........................................................................................................................................22Santhosh Kumar Devadas, Sripad Banavali

Does Adjuvant Chemotherapy for Locally Advanced Resectable Rectal Cancer treated with Neoadjuvant Chemoradiotherapy have an impact on survival? A Single Moroccan Institute Retrospective Study ..............................29Youssef Seddik, Sami Aziz Brahmi, Said Afqir

A Multicenter Study of the Impact of Body Mass Index (BMI) on the incidence of Pathologic Complete Response (pCR) Among Saudi Patients with locally advanced Breast cancer (LABC) post Neoadjuvant Chemotherapy (NAC) ......................................33Khalid Al-Saleh, Nashwa Abd El-Aziz, Arwa Ali, Waleed Abo Zeed, Tareq Salah, Sherif Elsamany, Ayman Rasmy, Ola ElFarargy, Sufia Husain, Ammar Al-Rikabi, Eyad Alsaeed, Abdurrahman Aldiab, Ahmed Abd El-Warith

Effects of Tualang Honey on Cancer Related Fatigue: A Multicenter Open-label Trial of H&N Cancer Patients ....................................43Viji Ramasamy, Norhafiza binti Mat Lazim, Baharudin Abdullah, Avatar Singh

The Incidence and Clinical Significance of Atypical Glandular Cells of Undetermined Significance on Cervical Pap Smears .............52Ehab Al-Rayyan, Mitri Rashed, Maher Maaita, Sultan Qudah, Omar Taso, William Haddadin

Total or Subtotal Colectomy with Primary Anastomosis for Occlusive Left Colon Cancer: A Safe, Acceptable and Applicable Procedure ..........................................................................................................................................57William A. Nehmeh, Michel Gabriel, Ahmad Tarhini, Ghassan Chakhtoura, Riad Sarkis, Bassam Abboud, Roger Noun, Cyril Tohmé

Descriptive Study of Nasopharyngeal Carcinoma and Treatment Outcomes: An Eight Years Experience in Hadhramout National Cancer Centre, Yemen ............................................................................................61Abdulrahman Ali Bahannan, Ahmed Mohammed Badheeb, Samir Yeslam Baothman

Review ArticlesPreoperative Denosumab plus Surgery in the Management of Giant Cell Tumor of Bone: A Comprehensive Narrative Literature Review .........................................................................................................................................67Ahmed Abu-Zaid, Sadiq Issa Alaqaili, Syed Osama Ahmad, Ibrahim Bin Hazzaa, Hani Alharbi

Case ReportsMalignant Pleural Mesothelioma: A Multi-Disciplinary Approach ..........................................................................................................76Muhammad Atif Mansha, Nasir Ali, Shaukat Ali, Nausheen Azam, Agha Muhammad Hammad Khan

Stage 4S Neuroblastoma: A Report of Two Cases Presenting with Extremes of Biological Behavior ....................................................81Mohamed Mubarak, Arbinder Kumar Singal, Ashok Gawdi

Conference Highlights/Scientific Contributions• NewsNotes ............................................................................................................................................................................................85

• Advertisements .....................................................................................................................................................................................88

• ScientificeventsintheGCCandtheArabWorldfor2019 ..................................................................................................................89

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Corresponding author: William A. Nehmeh M.D, Digestive Surgery Department, Hotel Dieu De France University Hospital, Saint Joseph University Faculty

of Medicine, Beirut, Lebanon. Tel: 00961 70 196 074, Email: billanehme@gmail.com.

Abstract

Introduction: Occlusive left colon cancer is a major emergency setting in colon cancer with high morbidity and mortality rates. Different surgical treatment exist since there is no clear guidelines for the best treatment. We have conducted this retrospective study in order to evaluate the safety, morbidity, and bowel movement status of the operated patients.

Methods: One-hundred and one left occlusive colon cancer patients were operated of total or subtotal colon resection with primary anastomosis from March 2000 till March 2017 in Hotel Dieu de France hospital. We analyzed the sex ratio, age, caecum condition, tumor localization, number of synchronous adenoma and adenocarcinoma, Dukes stage, major complications and the number of stools per day at 3 and 12 months after surgery.

Results: Mean hospital stay was 7.8 days. Thirteen complications were observed in 11 (10.9%) patients, in which one (1%) patient had splenectomy for severe hemorrhage. Six synchronous adenocarcinoma and 40 adenoma with dysplasia were diagnosed on pathology specimens proximal to occlusion site. Caecum laceration was found in 33 (32.6%) of cases. No patient had anastomotic leak. After 12 months of surgery, the average bowel movement was 2 stools per day.

Conclusion: Our study showed that treating occlusive left colon cancer with total or subtotal colectomy with primary anastomosis is a safe procedure, with a good bowel movement status and presents the advantage to resect an important number of synchronous tumors and adenomas proximal to the occlusion site.

Keywords: Occlusive left colon cancer, total colectomy, primary anastomosis.

Original Article

Total or Subtotal Colectomy with Primary Anastomosis for Occlusive Left Colon Cancer: A Safe, Acceptable and

Applicable ProcedureWilliam A. Nehmeh, Michel Gabriel, Ahmad Tarhini, Ghassan Chakhtoura,

Riad Sarkis, Bassam Abboud, Roger Noun, Cyril Tohmé

Digestive Surgery Department, Hotel Dieu De France University Hospital, Saint Joseph University Faculty of Medicine, Beirut, Lebanon.

BackgroundColo-rectal cancer (CRC) is the fourth leading cause

of cancer death in the world accounting in for almost 550,000 death in 2018 with an incidence of about one million (1). Mortality of CRC is estimated to increase in 2030 to reach 1.1 million deaths (2). An emergency presentation of CRC may be attributed to 30% of cases with higher morbidity and mortality (3,4). Obstruction is the most emergency setting and it accounts for 75% distal to the splenic flexure. Perforation occurs mainly in tumor site in 70% of cases. Caecum is the most vulnerable to perforation when it occurs distant to the tumor (5,6). The consensus of managing occlusive right colon cancer (ORCC) is clear and includes primary resection with direct anastomosis. Treating occlusive left side colon cancer (OLCC) remains controversial. Treatment options vary between loop colostomy, stenting for decompression,

Hartmann procedure (HP) and primary resection with anastomosis (PRA) (7). We present in a retrospective observational study the safety, feasibility, and acceptable bowel movement status of total or subtotal colectomy with PRA in managing OLCC.

Materials and Methods

Study design

This is a retrospective descriptive study conducted in Hotel Dieu De France Hospital. The ethical committee of

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Total Colectomy With Primary Anastomosis for Occlusive Left Colon Cancer, William A. Nehmeh, et. al.

the Saint-Joseph University of Beirut approved the study protocol. Helsinki declarations of 1963 were taken into consideration: respect, confidentiality and anonymity of the patients. Patient information was taken from the hospital records. Operated patients of total or subtotal colectomy with PRA for OLCC was included in the study from March 2000 until March 2017. One hundred and one cases were eligible for the study.

Data source and variables

Information on sex, age, clinical presentation, Dukes score, type of operation, surgery time, caecal condition, caecal diameter, surgical complications, and hospital stay were obtained from the clinic registration records and from pathology reports. Bowel movement was followed at 3 and 12 months and it was measured by the number of stools per day.

Statistical methods

SPSS software was used for statistical analysis. Clinical data were expressed as mean ± standard deviation (SD) or percentage.

ResultsThe major characteristics of patients were summarized

in Table 1. The mean age at operation was 68.2 (±15.38) years old with 26 and 87 as extreme ages. Male to female ratio is 1:4. All patients presented with large bowel occlusion. Only 5 (5%) patients have associated clinical peritonitis. The majority of the tumors were localized in the sigmoid or rectosigmoid junction in 59 (58.4%) cases, the rest was localized proximal to the sigmoid. Caecum diameter was 10.6 cm in average. Caecal laceration was found in 33 (32.6%) of cases. We observed caecum perforation in 5 patients (5%).

The majority of tumors were Duke C with 42.5%, followed by Duke B with 39.6% and Duke D 17.9%. Duke A was not present in any resected tumor. We observed 40 synchronous adenomas with different dysplasia grades in all resected pieces. Six patients had synchronous adenocarcinoma proximal to the occlusion site. Mean surgery time was 190 minutes (±55.6). Three patients had spleen injuries during surgery. One splenectomy was performed due to severe hemorrhage. One patient had left angle perforation during surgery. The mean hospital stay was 7.8 days. Thirteen post-operative complications were observed in 11 patients. We had one mortality at day 5 post surgery due to cardiac failure. Intestinal occlusion was observed in 6 patients (6%). Two patients with intestinal occlusion were operated at 10 and 18 months from surgery. Bowel movement status was followed in 92 patients. The average stool number per day at 3 and Table 1. Tumors and Complication Characteristics.

Number (%)

Number of synchronous lesions on pathology

Adenocarcinoma 6

Adenoma 40

Dukes Stage

A 0 (0%)

B 40 (39.6%)

C 41 (40.5%)

D 17 (16.8%)

Symptoms

Constipation 66 (67.3%)

Alternation 20 (20.4%)

Diarrhea/Constipation 19 (19.4%)

Rectorrhagia

Tumor localization

Sigmoide 57 (58.2%)

Descending Colon 41 (41.8%)

Metastasis

Liver 12 (12.2%)

Pulmonary 1 (1%)

Carcinosis 6 (6.1%)

Caecum condition

Perforated 5 (5.1%)

Lacerated 32 (32.6%)

Type of anastomosis

Ileo-Rectal 59 (60%)

Ileo-Sigmoid 39 (40%)

Total morbidity 26 (25.7%)

Controlled Spleen Hemorrhage 5 (4.9%)

Splenectomy 1 (1%)

Intestinal Occlusion 6 (5.9%)

Peritonitis 1 (1%)

Acalculous Cholecystitis 1 (1%)

Incisional Hernia 1 (1%)

Intra-Abdominal Abscess 2 (1.9%)

Respiratory Decompensation 2(1.9%)

Acute Kidney Injury 1(1%)

Deep Venous Thrombosis 1(1%)

Urinary Complication 5 (4.9%)

Functional result – number of stools per day

At 3 months 4.2

At 12 months 2

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G. J. O. Issue 30, 2019

study. We have not conducted a diverting stoma since no advantage in reducing anastomotic leak was seen in colorectal anastomosis (19).

ConclusionOLCC is a serious disease with high morbidity and

mortality rates. Our study showed that total or subtotal colectomy with primary anastomosis is a valid, safe and acceptable option to treat this condition. Bowel movement average of 2 stools per day after 12 months of ileorectal or ileosigmoid anastomosis is a promising result which support the good functional status of patients operated in our work. Further large prospective studies are warranted in order to confirm our results, since no clear guidelines exist in treating patients with OLCC.

References1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal

A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov;68(6):394–424.

2. Arnold M, Sierra MS, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global patterns and trends in colorectal cancer incidence and mortality. Gut. 2017;66(4):683–91.

3. Zielinski MD, Merchea A, Heller SF, You YN. Emergency management of perforated colon cancers: how aggressive should we be? J Gastrointest Surg Off J Soc Surg Aliment Tract. 2011 Dec;15(12):2232–8.

4. Kundes F, Kement M, Cetin K, Kaptanoglu L, Kocaoglu A, Karahan M, et al. Evaluation of the patients with colorectal cancer undergoing emergent curative surgery. SpringerPlus. 2016;5(1):2024.

5. Chen T-M, Huang Y-T, Wang G-C. Outcome of colon cancer initially presenting as colon perforation and obstruction. World J Surg Oncol. 2017 Aug 25;15(1):164.

6. Pisano M, Zorcolo L, Merli C, Cimbanassi S, Poiasina E, Ceresoli M, et al. 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg WJES. 2018;13:36.

7. Trompetas V. Emergency Management of Malignant Acute Left-Sided Colonic Obstruction. Ann R Coll Surg Engl. 2008 Apr;90(3):181–6.

8. Tekkis PP, Kinsman R, Thompson MR, Stamatakis JD, Association of Coloproctology of Great Britain, Ireland. The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer. Ann Surg. 2004 Jul;240(1):76–81.

9. Mella J, Biffin A, Radcliffe AG, Stamatakis JD, Steele RJ. Population-based audit of colorectal cancer management in two UK health regions. Colorectal Cancer Working Group, Royal College of Surgeons of England Clinical Epidemiology and Audit Unit. Br J Surg. 1997 Dec;84(12):1731–6.

12 months from surgery was 4.2 and 2 respectively. No patient had fecal incontinence. Twenty-four patient (26%) were on anti-diarrheal drugs.

DiscussionMalignant large bowel obstruction is an independent

bad prognosis factor for operated patients with CRC (8). Post-operative mortality after CRC surgery is related to bowel obstruction in 25% of cases (9). This worsened prognosis may be related to the advanced age and advanced pathology tumor stage observed in patients operated with an emergency setting (4). Different approaches exist in the management of OLCC without any clear recommendation or consensus despite the severity of the disease (6). HP was the first choice for decades before and it remains one of the most procedures performed for OLCC even in stable patients (7). HP necessity is not to be discussed in serious unstable patients, but it is contested in stable patients. Failure to reverse HP is a common and serious problem, with successful closure rates tend to be under 50% and 25% (10). Loop colostomy (LC) is not superior to HP in treating OLCC. No difference in term of morbidity, mortality, recurrence rate and survival was observed between both methods (11). In recent years there is a growing information to support PRA for OLCC (6). Primary resection with anastomosis was first reported by Fielding et al in 1979 with better survival rates over staged resection (12). Anastomotic leak is the major complication facing PRA in OLCC treatment with largely separated rates from 0.7% (13) to 12% (14) in different studies.

In our study, no anastomotic leak was observed. Age, ASA score, Dukes stage and operative urgency where identified as important anastomotic leak predictive factors (8). The absolute indication for total or subtotal colectomy in OLCC are caecal tear or perforation, ischemia of the right colon and synchronous proximal malignant tumor (15). We have conducted a total or subtotal colectomy with direct anastomosis in our patients. The first advantage of this approach over segmental colectomy is time saving by avoiding mechanical bowel decompression or intracolonic irrigation (16). The second is the discovery of synchronous tumors and adenomas: 40 adenomas and 6 synchronous adenocarcinomas were diagnosed on pathology in our study. The third is in lowering the risk of anastomotic leak when performing total or subtotal colectomy in comparison of segmental colectomy (17). The randomized controlled trial SCOTIA has confirmed the safety of total colectomy in terms of morbidity and mortality but with significant worse bowel movement status (18). After 12 months of surgery our patients had an average of 2 stools per day and only 26% were on intestinal motility inhibitors which represent an acceptable functional result in contrast with the SCOTIA

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Total Colectomy With Primary Anastomosis for Occlusive Left Colon Cancer, William A. Nehmeh, et. al.

10. Horesh N, Rudnicki Y, Dreznik Y, Zbar AP, Gutman M, Zmora O, et al. Reversal of Hartmann’s procedure: still a complicated operation. Tech Coloproctology. 2018;22(2):81–7.

11. Krstic S, Resanovic V, Alempijevic T, Resanovic A, Sijacki A, Djukic V, et al. Hartmann’s procedure vs loop colostomy in the treatment of obstructive rectosigmoid cancer. World J Emerg Surg WJES. 2014;9(1):52.

12. Fielding LP, Stewart-Brown S, Blesovsky L. Large-bowel obstruction caused by cancer: a prospective study. Br Med J. 1979 Sep 1;2(6189):515–7.

13. Deen KI, Madoff RD, Goldberg SM, Rothenberger DA. Surgical management of left colon obstruction: the University of Minnesota experience. J Am Coll Surg. 1998 Dec;187(6):573–6.

14. Villar JM, Martinez AP, Villegas MT, Muffak K, Mansilla A, Garrote D, et al. Surgical options for malignant left-sided colonic obstruction. Surg Today. 2005;35(4):275–81.

15. Finan PJ, Campbell S, Verma R, MacFie J, Gatt M, Parker MC, et al. The management of malignant large bowel obstruction: ACPGBI position statement. Colorectal Dis Off J Assoc Coloproctology G B Irel. 2007 Oct;9 Suppl 4:1–17.

16. Hennekinne-Mucci S, Tuech J-J, Bréhant O, Lermite E, Bergamaschi R, Pessaux P, et al. Emergency subtotal/total colectomy in the management of obstructed left colon carcinoma. Int J Colorectal Dis. 2006 Sep;21(6):538–41.

17. al KS et. Subtotal colectomy for malignant left-sided colon obstruction is associated with a lower anastomotic leak rate than segmental colectomy.

18. Single-stage treatment for malignant left-sided colonic obstruction: a prospective randomized clinical trial comparing subtotal colectomy with segmental resection following intraoperative irrigation. The SCOTIA Study Group. Subtotal Colectomy versus On-table Irrigation and Anastomosis. Br J Surg. 1995 Dec;82(12):1622–7.

19. Kube R, Granowski D, Stübs P, Mroczkowski P, Ptok H, Schmidt U, et al. Surgical practices for malignant left colonic obstruction in Germany. Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2010 Jan;36(1):65–71.