RODRIGO OLIVA PEREZ

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  • article 3 Citação(ões) na Scopus
    Role of Simulation-Based Training in Minimally Invasive and Robotic Colorectal Surgery
    (2021) ARAUJO, Sergio Eduardo Alonso; PEREZ, Rodrigo Oliva; KLAJNER, Sidney
    Properly performing minimally invasive colorectal procedures requires specific skills. With a focus on patient safety, the training of surgeons on patients is only accepted under exceptionally controlled, expensive, and challenging conditions. Moreover, many new techniques in colorectal surgery have been developed. Therefore, undertaking minimally invasive colorectal surgery in modern times requires specific psychomotor skills that trainee surgeons must gather in less time. In addition, there are not enough proctors with sufficient expertise for such an expressive number of new different techniques likes transanal and robotic procedures. Studies that have demonstrated an improvement in minimally invasive surgery skills to the actual operating room in general surgery and a stepwise approach to surgical simulation with a combination of various training methods appears to be useful in colorectal surgery training programs. However, the scientific evidence on the transfer of skills specifically for colorectal surgery is extremely scarce and very variable. Thus, the evaluation of the results remains quite difficult. In this review, we present the best available evidence on the types of training based on simulation, their characteristics, advantages and disadvantages, and finally the results available on their adoption. Nevertheless, scientific evidence about the benefit of simulation training in minimally invasive colorectal surgery is limited and there is a need to build more robust evidence.
  • article 26 Citação(ões) na Scopus
    Extralevator Abdominal Perineal Excision Versus Standard Abdominal Perineal Excision: Impact on Quality of the Resected Specimen and Postoperative Morbidity
    (2017) HABR-GAMA, Angelita; JULIO, Guilherme P. Sao; MATTACHEO, Adrian; CAMPOS-LOBATO, Luiz Felipe de; ALEMAN, Edgar; VAILATI, Bruna B.; GAMA-RODRIGUES, Joaquim; PEREZ, Rodrigo Oliva
    Background Abdominal perineal excision (APE) has been associated with a high risk of positive circumferential resection margin (CRM+) and local recurrence rates in the treatment of rectal cancer. An alternative extralevator approach (ELAPE) has been suggested to improve the quality of resection by avoiding coning of the specimen decreasing the risk of tumor perforation and CRM+. The aim of this study is to compare the quality of the resected specimen and postoperative complication rates between ELAPE and ""standard"" APE. Methods All patients between 1998 and 2014 undergoing abdominal perineal excision for primary or recurrent rectal cancer at a single Institution were reviewed. Between 1998 and 2008, all patients underwent standard APE. In 2009 ELAPE was introduced at our Institution and all patients requiring APE underwent this alternative procedure (ELAPE). The groups were compared according to pathological characteristics, specimen quality (CRM status, perforation and failure to provide the rectum and anus in a single specimen-fragmentation) and postoperative morbidity. Results Fifty patients underwent standard APEs, while 22 underwent ELAPE. There were no differences in CRM+ (10.6 vs. 13.6%; p = 0.70) or tumor perforation rates (8 vs. 0%; p = 0.30) between APE and ELAPE. However, ELAPE were less likely to result in a fragmented specimen (42 vs. 4%; p = 0.002). Advanced pT-stage was also a risk factor for specimen fragmentation (p = 0.03). There were no differences in severe (Grade 3/4) postoperative morbidity (13 vs. 10%; p = 0.5). Perineal wound dehiscences were less frequent among ELAPE (52 vs 13%; p < 0.01). Despite short follow-up (median 21 mo.), 2-year local recurrence-free survival was better for patients undergoing ELAPE when compared to APE (87 vs. 49%; p = 0.04). Conclusions ELAPE may be safely implemented into routine clinical practice with no increase in postoperative morbidity and considerable improvements in the quality of the resected specimen of patients with low rectal cancers.
  • article 63 Citação(ões) na Scopus
    Baseline T Classification Predicts Early Tumor Regrowth After Nonoperative Management in Distal Rectal Cancer After Extended Neoadjuvant Chemoradiation and Initial Complete Clinical Response
    (2017) HABR-GAMA, Angelita; JULIAO, Guilherme Pagin Sao; GAMA-RODRIGUES, Joaquim; VAILATI, Bruna Borba; ORTEGA, Cinthia; FERNANDEZ, Laura Melina; ARAUJO, Sergio Eduardo Alonso; PEREZ, Rodrigo Oliva
    BACKGROUND: Selected patients with rectal cancer and complete clinical response after neoadjuvant chemoradiation have been managed nonoperatively with acceptable outcomes. However, approximate to 20% of these patients will develop early tumor regrowth. Identification of these patients could select candidates for more intensive follow-up. OBJECTIVE: The purpose of this study was to investigate the influence of baseline radiological T classification on recurrences after a complete clinical response managed nonoperatively after chemoradiation. DESIGN: This was a retrospective review of a prospective collected database. SETTINGS: The study was conducted at a single center. PATIENTS: Patients with distal rectal cancer (cT2-4N0-2M0) undergoing extended chemoradiation (54 Gy + 5-fluorouracil-based chemotherapy) were eligible. Patients were reassessed for tumor response at 10 weeks after radiation completion. Patients with complete clinical response (clinical, radiological, and endoscopic) were managed nonoperatively and strictly followed. MAIN OUTCOMES MEASURES: Complete clinical response rates, early tumor regrowth rates (<12 mo), local recurrence-free survival, and distant metastases-free survival were measured. RESULTS: A total of 91 consecutive patients with rectal cancer underwent extended chemoradiation. Sixty-one patients developed initial complete clinical response (67%). cT2 patients developed similar initial complete clinical response rates compared with cT3/T4 (72% vs 63%; p = 0.403). Early tumor regrowths were more frequent among baseline cT3/4 when compared with cT2 patients (30% vs 3%; p = 0.007). There were no differences in late local recurrences (p = 0.593) or systemic recurrences (p = 0.387). Local recurrence-free survival was significantly better for cT2 patients at 1 year (96% vs 69%; p = 0.009). After Cox regression analysis, baseline T stage was an independent predictor of improved local recurrence-free survival at 1 year (p = 0.03; OR = 0.09 (95% CI, 0.01-0.81)). LIMITATIONS: This study was limited by its small sample size, retrospective nature, and short follow-up. CONCLUSIONS: cT2 patients who develop complete clinical response after extended chemoradiation managed nonoperatively are less likely to develop early tumor regrowths when compared with cT3/4 patients. cT3/4 patients should undergo more intensive follow-up after a complete clinical response to allow for early detection of early regrowths.
  • article 54 Citação(ões) na Scopus
    Transanal Endoscopic Microsurgery (TEM) Following Neoadjuvant Chemoradiation for Rectal Cancer: Outcomes of Salvage Resection for Local Recurrence
    (2016) PEREZ, Rodrigo Oliva; HABR-GAMA, Angelita; JULIAO, Guilherme Pagin Sao; PROSCURSHIM, Igor; FERNANDEZ, Laura Melina; AZEVEDO, Rafael Ulysses de; VAILATI, Bruna B.; FERNANDES, Felipe Alexandre; GAMA-RODRIGUES, Joaquim
    Transanal endoscopic microsurgery (TEM) has been considered an alternative for selected patients with rectal cancer following neoadjuvant chemoradiation (CRT). Immediate total mesorectal completion for all patients with unfavorable pathological features would result in unnecessary protectomies in a significant proportion of patients. Instead, salvage total mesorectal excision (TME) could be restricted for patients developing local recurrence. The aim of the present study is to determine oncological outcomes of salvage resection for local recurrences following CRT and TEM. Consecutive patients undergoing TEM following neoadjuvant CRT for rectal cancer were reviewed. Patients with ""near"" complete response to CRT (a parts per thousand currency sign3 cm; ycT1-2N0) were offered TEM. Salvage surgery was attempted in the event of a local recurrence. A total of 53 patients were managed by CRT followed by TEM. Unfavorable pathological features were present in 36 patients (68 %). None of the patients underwent immediate completion TME. There were 12 patients who developed local recurrence resulting in a 2-year local recurrence-free survival of 77 % (95 % CI, 53-100 %). Of these patients, 9 developed exclusively local recurrences, and all had at least 1 unfavorable pathological feature in the specimen after TEM (100 %). Eight patients (8 of 9) underwent salvage resection (abdominoperineal resection [APR] in 87 %) with CRM+ in 7 of 8 patients (87 %). Four patients developed local re-recurrence after a median 36 months of follow-up. The 2-year local re-recurrence free survival was 60 %. Salvage resection for local recurrence following CRT and TEM is associated with high rates of R1 resection (CRM+) and local re-recurrence. Immediate completion of TME should be considered for patients with unfavorable pathological features after TEM.
  • article 105 Citação(ões) na Scopus
    Transanal Endoscopic Microsurgery for Residual Rectal Cancer (ypT0-2) Following Neoadjuvant Chemoradiation Therapy: Another Word of Caution
    (2013) PEREZ, Rodrigo Oliva; HABR-GAMA, Angelita; LYNN, Patricio Bernardo; JULIAO, Guilherme Pagin Sao; BIANCHI, Romina; PROSCURSHIM, Igor; GAMA-RODRIGUES, Joaquim
    BACKGROUND: Significant tumor downstaging among patients with rectal cancer following neoadjuvant chemoradiation has raised the issue of offering patients with small residual cancers restricted to the bowel wall an alternative treatment strategy to total mesorectal excision. Transanal endoscopic microsurgery may allow proper primary tumor resection with promising oncological outcomes, less postoperative morbidity, and minimal long-term sexual, urinary, and fecal continence disorders in comparison with radical resection. OBJECTIVE: The aim of this study was to determine the oncological outcomes of patients with residual rectal cancers restricted to the rectal wall (ypT0-2) following neoadjuvant chemoradiation and transanal endoscopic microsurgery. DESIGN: This study considered a prospective cohort of patients with residual rectal cancers following neoadjuvant chemoradiation treated by transanal endoscopic microsurgery and no additional systemic therapy. SETTINGS: This study was a single-institution experience. PATIENTS: Patients with adenocarcinoma of the rectum located no more than 7 cm from the anal verge and endorectal ultrasound-or magnetic resonance-staged cT2-4N0-2M0 treated by neoadjuvant chemoradiation (50.4-54 Gy and 5-fluorouracil-based chemotherapy) were eligible for the study. Patients with small residual tumors (<= 3 cm) radiologically staged ycT0-2N0 were treated by transanal endoscopic microsurgery. INTERVENTIONS: Transanal endoscopic microsurgery was performed. MAIN OUTCOME MEASURES: The primary outcome measured was local recurrence. RESULTS: Of the 27 patients treated by transanal endoscopic microsurgery, 3 had ypT0, 6 had ypT1, and 18 had ypT2 cancers. All patients underwent R0 transanal endoscopic microsurgery excision. Local recurrence was observed in 4 (15%) patients after a median follow-up of 15 months. Only lymphovascular invasion was an independent predictive factor for local failure (p = 0.04). Tumor size, ypT status, T-status downstaging, lateral/radial margins, and tumor regression grade were not predictors of local failure. LIMITATIONS: This study was limited by the small sample size and limited follow-up. CONCLUSIONS: A local failure rate of 15% after transanal endoscopic microsurgery for patients with residual rectal cancers restricted to the bowel wall (ypT0-2) may limit the indication of this procedure to highly selected patients as an alternative to standard radical total mesorectal excision.
  • article 0 Citação(ões) na Scopus
    Time to rethink transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation for highly selected patients
    (2017) PEREZ, Rodrigo Oliva; JULIAO, Guilherme Pagin Sao; VAILATI, Bruna Borba
  • article 18 Citação(ões) na Scopus
    Complete clinical response in rectal cancer: a turning tide
    (2016) PEREZ, Rodrigo Oliva
  • article 28 Citação(ões) na Scopus
    Is neoadjuvant chemoradiation with dose-escalation and consolidation chemotherapy sufficient to increase surgery-free and distant metastases-free survival in baseline cT3 rectal cancer?
    (2018) JULIAO, Guilheime Pagin Sao; HABR-GAMA, Angelita; VAILATI, Bruna Borba; AGUILAR, Patricia Bailao; SABBAGA, Jorge; ARAUJO, Sergio Eduardo Alonso; MATTACHEO, Adrian; ALEXANDRE, Flavia Andrea; FERNANDEZ, Laura Melina; GOMES, Diogo Bugano; GAMA-RODRIGUES, Joaquim; PEREZ, Rodrigo Oliva
    Patients with cT3 rectal cancer are less likely to develop complete response to neoadjuvant chemoradiation (nCRT) and still face significant risk for systemic relapse. In this setting, radiation (RT) dose-escalation and consolidation chemotherapy in ""extended"" nCRT regimens have been suggested to improve primary tumor response and decrease the risks of systemic recurrences. For these reasons we compared surgery-free and distant-metastases free survival among cT3 patients undergoing standard or extended nCRT. Methods: Patients with distal and non-metastatic T3 rectal cancer managed by nCRT were retrospectively reviewed.. Patients undergoing standard CRT (50.4 Gy and 2 cycles of 5FU-based chemotherapy) were compared to those undergoing extended CRT (54 Gy and 6 cycles of 5FU-based chemotherapy). Patients were assessed for tumor response at 8-10 weeks. Patients with complete clinical response (cCR) underwent organ-preservation strategy (Watch & Wait). Patients were referred to salvage surgery in the event of local recurrence during follow-up. Cox's logistic regression was performed to identify independent features associated with improved surgery-free survival after cCR and distant-metastases-free survival. Results: 155 patients underwent standard and 66 patients extended CRT. Patients undergoing extended CRT were more likely to harbor larger initial tumor size (p = 0.04), baseline nodal metastases (cN+; p < 0.001) and higher tumor location (p = 0.02). Cox-regression analysis revealed that the type of nCRT regimen was not independently associated with distinct surgery-free survival after cCR or distant-metastases-free survival (p > 0.05). Conclusions: Dose-escalation and consolidation chemotherapy are insufficient to increase long-term surgery-free survival among cT3 rectal cancer patients and provides no advantage in distant metastases-free survival.
  • article 0 Citação(ões) na Scopus
    Real-World Situation of Lateral Lymph Node Dissection for Rectal Cancer in Japan Reply
    (2019) PEREZ, Rodrigo Oliva; KONISHI, Tsuyoshi; JULIAO, Guilherme P. Sao; VAILATI, Bruna Borba; FERNANDEZ, Laura Melina; MATTACHEO, Adrian
  • article 98 Citação(ões) na Scopus
    Organ Preservation in cT2N0 Rectal Cancer After Neoadjuvant Chemoradiation Therapy The Impact of Radiation Therapy Dose-escalation and Consolidation Chemotherapy
    (2019) HABR-GAMA, Angelita; JULIAO, Guilherme Pagin Sao; VAILATI, Bruna Borba; SABBAGA, Jorge; AGUILAR, Patricia Bailao; FERNANDEZ, Laura Melina; ARAUJO, Sergio Eduardo Alonso; PEREZ, Rodrigo Oliva
    Objective: To demonstrate the difference in organ-preservation rates and avoidance of definitive surgery among cT2N0 rectal cancer patients undergoing 2 different chemoradiation (CRT) regimens. Background: Patients with cT2N0 rectal cancer are more likely to develop complete response to neoadjuvant CRT. Organ preservation has been considered an alternative treatment strategy for selected patients. Radiation dose-escalation and consolidation chemotherapy have been associated with increased rates of response and may improve chances of organ preservation among these patients. Methods: Patients with distal and nonmetastatic cT2N0 rectal cancer managed by neoadjuvant CRT were retrospectively reviewed. Patients undergoing standard CRT (50.4 Gy and 2 cycles of 5-FU-based chemotherapy) were compared with those undergoing extended CRT (54 Gy and 6 cycles of 5-FUbased chemotherapy). Patients were assessed for tumor response at 8 to 10 weeks. Patients with complete clinical response (cCR) underwent organ-preservation strategy (""Watch and Wait""). Patients were referred to salvage surgery in the event of local recurrence during follow-up. Results: Thirty-five patients underwent standard and 46 patients extended CRT. Patients undergoing extended CRT were more likely to undergo organ preservation and avoid definitive surgical resection at 5years (67% vs 30%; P = 0.001). After development of a cCR, surgery-free survival is similar between extended and standard CRT groups at 5 years (78% vs 56%; P = 0.12). Conclusions: Dose-escalation and consolidation chemotherapy leads to increased long-term organ-preservation rates among cT2N0 rectal cancer. After achievement of a cCR, the risk for local recurrence and need for salvage surgery is similar, irrespective of the CRT regimen.