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Du Q, Yang W, Zhang J, Qiu S, Liu X, Wang Y, Yang L, Zhou Z. Oncologic outcomes of intersphincteric resection versus abdominoperineal resection for lower rectal cancer: a systematic review and meta-analysis. Int J Surg 2024; 110:2338-2348. [PMID: 36928167 PMCID: PMC11020000 DOI: 10.1097/js9.0000000000000205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 11/20/2022] [Indexed: 03/18/2023]
Abstract
BACKGROUND The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis. MATERIALS AND METHODS A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated. RESULTS A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P =0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P =0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P =0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P =0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P =0.02) compared to APR. CONCLUSIONS Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.
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Affiliation(s)
- Qiang Du
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Wenming Yang
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Jianhao Zhang
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Siyuan Qiu
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Xueting Liu
- Department of Evidence-Based Medicine and Clinical Epidemiology
| | - Yong Wang
- Department of General Surgery, Division of Gastrointestinal Surgery
| | - Lie Yang
- Department of General Surgery, Division of Gastrointestinal Surgery
- Institute of Digestive Surgery, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zongguang Zhou
- Department of General Surgery, Division of Gastrointestinal Surgery
- Institute of Digestive Surgery, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Anaraki F, Alemrajabi M, Shekouhi R, Sohooli M, Sabz SA. Evaluation of long-term oncological outcomes of inter-sphincter resection compared with abdominoperineal resection for treatment of ultra-low rectal cancers: a single center 5-year experience. SURGERY IN PRACTICE AND SCIENCE 2023; 14:100191. [PMID: 39845857 PMCID: PMC11749175 DOI: 10.1016/j.sipas.2023.100191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/06/2023] [Accepted: 06/11/2023] [Indexed: 01/24/2025] Open
Abstract
Objectives Abdominoperineal resection (APR) is considered the gold standard surgical treatment for ultra-low rectal cancer. Anus-preserving alternative procedures have been tested to avoid the need for a permanent colostomy. The present study compares the functional and oncological outcomes of the traditional APR methods with inter-sphincteric resection (ISR). Methods Sixty patients with ultra-low rectal cancers that underwent tumor resection using the ISR and APR methods were compared retrospectively. Patients' demographic information as well as tumor characteristics were evaluated. All patients were followed after the operation every three months for two years, and then every six months for at least three years. Results Thirty-four (56.6%) patients were male, and 26 (43.3%) were females, which showed no statistical significance between the two groups. The mean tumor distance from the anal verge in the APR group was 5.11±0.06 cm and in the ISR group was 5.22±1.1 cm. In the APR group, 9 (30%) patients developed primary tumor recurrence, while in the ISR group, 10 (33.3%) patients had relapses. The observed difference was not statistically significant. However, the study showed that patients with a T stage of T2 or higher had a higher probability of tumor recurrence. Conclusion There is no significant difference in the efficacy of the ISR method compared with the conventional APR for the treatment of ultra-low rectal cancer.
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Affiliation(s)
- FakhroSadat Anaraki
- Department of General Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahdi Alemrajabi
- Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Ramin Shekouhi
- Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Sohooli
- Colorectal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed-Ali Sabz
- Ayatollah Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Zheng K, Hu Q, Yu G, Zhou L, Yao Y, Zhou Y, Wang H, Hao L, Yu E, Lou Z, Zhang Y, Qiu H, Meng R, Zhang W. Trends of sphincter-preserving surgeries for low lying rectal cancer: A 20-year experience in China. Front Oncol 2022; 12:996866. [PMID: 36568186 PMCID: PMC9773833 DOI: 10.3389/fonc.2022.996866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Over the last 2 decades, patients with low rectal cancer have had better outcomes from improvements in surgical techniques in sphincter preservation. We aimed to quantify the trends in sphincter-preserving surgeries for low rectal cancer over 20 years in a top tertiary hospital in China. METHODS Between 1999 and 2021, a cohort of patients with primary malignant rectal tumor ≤5cm from the anal verge and who received elective surgeries at Changhai Hospital, Shanghai, China, was identified. Data were extracted from electronic medical records. A Joinpoint Regression Model was used to analyze trends in surgical procedures by average annual percentage change (AAPC). Adjusted Cox proportional hazards regression model was used to assess overall survival. RESULTS Among a total of 4,172 patients during the study period, 3,111 (74.6%) underwent a sphincter-preserving surgery and 1,061 (25.4%) received APR. Sphincter-preserving surgery increased 3.6% per year (95%CI, 2.3-4.9). Low anterior resection was the most performed procedure (86.3%) and maintained a steady trend, while intersphincteric resection increased 49.4% annually (95%CI, 19.5-86.7) after initiation. Laparoscopic techniques increased 15.1% per year (95%CI, 8.4-43.4) after initiation. Sphincter-preserving surgery increased annually for tumors ≤2cm, 2-≤3cm and 3-≤4cm from the anal verge (AAPC 7.1, 4.5-9.8; 4.7, 3.1-6.3; 2.7, 1.7-3.6, respectively). Furthermore, patients with sphincter-preserving surgery had a better overall survival than abdominoperineal resection (APR) patients (adjusted HR 0.78, 95% CI, 0.65-0.93, p=.01). CONCLUSIONS Utilization of sphincter-preserving surgeries increased significantly over the last 20 years. Patients with low rectal cancer who underwent sphincter preservation had better survival than similar patients who underwent APR.
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Affiliation(s)
- Kuo Zheng
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Qingqing Hu
- Global Epidemiology, Office of Chief Medical Officer, Johnson & Johnson, Shanghai, China
| | - Guanyu Yu
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Leqi Zhou
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Yuting Yao
- Department of Professional Education, Johnson & Johnson Medical (Shanghai) LTD, Shanghai, China
| | - Yuan Zhou
- Department of Professional Education, Johnson & Johnson Medical (Shanghai) LTD, Shanghai, China
| | - Hao Wang
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Liqiang Hao
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Enda Yu
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Zheng Lou
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Yongjing Zhang
- Global Epidemiology, Office of Chief Medical Officer, Johnson & Johnson, Shanghai, China
| | - Hong Qiu
- Global Epidemiology, Office of Chief Medical Officer, Johnson & Johnson, Shanghai, China
| | - Ronggui Meng
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Wei Zhang
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
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Hu X, Li J, Sun Y, Sun Y, Tong T. Percentage of Tumor Invasion at Pretreatment High-Resolution Magnetic Resonance Imaging: Associating With Aggressive and Tumor Response in Chinese T3 Rectal Cancer-Preliminary Results. Front Oncol 2022; 12:616310. [PMID: 35463367 PMCID: PMC9021692 DOI: 10.3389/fonc.2022.616310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/22/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose The purpose of the study was to assess the ability of percentage of tumor invasion (PTI) of T3 rectal cancer on pretreatment MRI as an imaging biomarker to reflect aggressiveness and to predict tumor response after neoadjuvant chemoradiation (NCRT) in Chinese population. Methods A total of 107 Chinese rectal cancer patients who underwent pretreatment MRI staging as T3 were included. The extramural depth of tumor invasion (EMD), the distance between outer border of muscularis propria (MP) and mesorectal fascia (MRF) we called "thickness of the mesorectum (TM)") at the same slice and direction were measured at pretreatment MRI, and PTI was equal to EMD/TM, was calculated. The EMD and PTI of subgroups based on pretreatment CEA, CA19-9 levels; N category and pathological complete response (pCR) were compared. The parameters, which described tumor invasion, were compared between pCR and non-pCR group. Student t-tests and logistic analysis were applied. Results The pretreatment PTI was higher in CEA ≥5.2 ng/ml patients (58.52% ± 27.68%) than in CEA <5.2 ng/ml patients (47.27% ± 24.15%) (p = 0.034). The pretreatment EMD in non-pCR group (7.21 ± 2.85 mm) was higher than in pCR group (6.14 ± 3.56 mm) (p = 0.049). The pretreatment PTI in non-pCR group (57.4% ± 26.4%) was higher than in pCR group (47.3% ± 29.1%) (p = 0.041). Compared with patients with PTI ≥50%, MRF (+), more patients with PTI <50%, MRF (-) showed pCR (OR = 8.44, p = 0.005; OR = 6.32, p = 0.024). Conclusion The PTI obtained at pretreatment MRI may serve as an imaging biomarker to reflect tumor aggressiveness and predict which T3 rectal cancer patients may benefit from NCRT in Chinese population.
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Affiliation(s)
- Xiaoxin Hu
- Department of Radiology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jianwen Li
- Department of Urology, Dushu Lake Hospital Affiliated To Soochow University, Medical Center of Soochow University, Suzhou Dushu Lake Hospital, Suzhou, China
| | - Yinan Sun
- Department of Propaganda，Shanghai Yangpu District Central Hospital, Shanghai, China
| | - Yiqun Sun
- Department of Radiology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Tong Tong
- Department of Radiology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Zhang XY, Li XT, Shi YJ, Lu QY, Cao W, Zhang HM, Wang L, Zhu HT, Yu T, Guan Z, Sun RJ, Zhu HB, Wu AW, Sun YS. Correlation Between the Distance to Mesorectal Fascia and Prognosis of cT3 Rectal Cancer: Results of a Multicenter Study From China. Dis Colon Rectum 2022; 65:322-332. [PMID: 34459446 DOI: 10.1097/dcr.0000000000002167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The cT3 substage criteria based on extramural depth of tumor invasion in rectal cancer have several limitations. OBJECTIVE This study proposed that the distance between the deepest tumor invasion and mesorectal fascia on pretherapy MRI can distinguish the prognosis of patients with cT3 rectal cancer. DESIGN This is a cohort study. SETTING This study included a prospective, single-center, observational cohort and a retrospective, multicenter, independent validation cohort. PATIENT Patients who had cT3 rectal cancer with negative mesorectal fascia undergoing neoadjuvant chemoradiotherapy followed by radical surgery were included in 4 centers in China from January 2013 to September 2014. INTERVENTION Baseline MRI with the distance between the deepest tumor invasion and mesorectal fascia, extramural depth of tumor invasion, and mesorectum thickness were measured. MAIN OUTCOME MEASURES The cutoff of the distance between the deepest tumor invasion and mesorectal fascia was determined by time-dependent receiver operating characteristic curves, supported by a 5-year progression rate from the prospective cohort, and was then validated in a retrospective cohort. RESULTS There were 124 and 274 patients included in the prospective and independent validation cohorts. The distance between the deepest tumor invasion and mesorectal fascia was the only predictor for cancer-specific death (HR, 0.1; 95% CI, 0.0-0.7) and was also a significant predictor for distant recurrence (HR, 0.4; 95% CI, 0.2-0.9). No statistically significant difference was observed in prognosis between patients classified as T3a/b and T3c/d. LIMITATIONS The sample size is relatively small, and the study focused on cT3 rectal cancers with a negative mesorectal fascia. CONCLUSIONS A cutoff of 7 mm of the distance between the deepest tumor invasion and mesorectal fascia on baseline MRI can distinguish cT3 rectal cancer from a different prognosis. We recommend using the distance between the deepest tumor invasion and mesorectal fascia on baseline MRI for local and systemic risk assessment and providing a tailored schedule of neoadjuvant treatment. See Video Abstract at http://links.lww.com/DCR/B682.CORRELACIÓN ENTRE LA DISTANCIA DE LA FASCIA MESORRECTAL Y EL PRONÓSTICO DEL CÁNCER DE RECTO cT3: RESULTADOS DE UN ESTUDIO MULTICÉNTRICO DE CHINAANTECEDENTES:Los criterios de subestadificación cT3 basados en la profundidad extramural de invasión tumoral en el cáncer de recto tienen varias limitaciones.OBJETIVO:Este estudio propuso que la distancia entre la invasión tumoral más profunda y la fascia mesorrectal en la resonancia magnética preterapia puede distinguir el pronóstico de los pacientes con cT3.DISEÑO:Estudio de cohorte.ENTORNO CLINICO:El estudio incluyó una cohorte observacional, prospectiva, unicéntrica, y una cohorte de validación retrospectiva, multicéntrica e independiente.PACIENTE:Se incluyeron pacientes con cáncer de recto cT3 con fascia mesorrectal negativa sometidos a quimio-radioterapia neoadyuvante seguida de cirugía radical en cuatro centros de China desde enero de 2013 hasta septiembre de 2014.INTERVENCIÓN:Imágenes de resonancia magnética de referencia fueron medidas con la distancia entre la invasión tumoral más profunda y la fascia mesorrectal; la profundidad extramural de la invasión tumoral y el grosor del mesorrecto.PRINCIPALES MEDIDAS DE VALORACION:El límite de la distancia entre la invasión tumoral más profunda y la fascia mesorrectal se determinó mediante curvas características operativas del receptor dependientes del tiempo y se apoyó en la tasa de progresión a 5 años de la cohorte prospectiva, y luego se validó en una cohorte retrospectiva.RESULTADOS:Se incluyeron 124 y 274 pacientes en la cohorte de validación prospectiva e independiente, respectivamente. La distancia entre la invasión tumoral más profunda de la fascia mesorrectal fue el único predictor de muerte específica por cáncer (Hazard ratio: 0.1, 95% CI, 0,0-0,7); y también fue un predictor significativo de recurrencia distante Hazard ratio: 0,4, 95% CI, 0,2-0,9). No se observaron diferencias estadísticamente significativas en el pronóstico entre los pacientes clasificados como T3a/b y T3c/d.LIMITACIONES:El tamaño de la muestra es relativamente pequeño y el estudio se centró en los cánceres de recto cT3 con fascia mesorrectal negativa.CONCLUSIONES:Un límite de 7 mm de distancia entre la invasión tumoral más profunda y la fascia mesorrectal en la resonancia magnética de referencia puede distinguir el cáncer de recto cT3 de diferentes pronósticos. Recomendamos la distancia entre la invasión tumoral más profunda y la fascia mesorrectal en la resonancia magnética de referencia para la evaluación del riesgo local y sistémico, proporcionando un programa personalizado de tratamiento neoadyuvante. Consulte Video Resumen en http://links.lww.com/DCR/B682. (Traducción- Dr. Francisco M. Abarca-Rendon).
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Affiliation(s)
- Xiao-Yan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
| | - Xiao-Ting Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
| | - Yan-Jie Shi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
| | - Qiao-Yuan Lu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
| | - Wuteng Cao
- Department of Radiology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Hong-Mei Zhang
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Chaoyang District, Beijing, China
| | - Lin Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
| | - Hai-Tao Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
| | - Tao Yu
- Department of Medical Imaging, Cancer Hospital of China Medical University, Dadong District, Shenyang, Liaoning Province, China
- Department of Medical Imaging, Liaoning Cancer Hospital & Institute, Dadong District, Shenyang, Liaoning Province, China
| | - Zhen Guan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
| | - Rui-Jia Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
| | - Hai-Bin Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
| | - Ai-Wen Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
| | - Ying-Shi Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Hai Dian District, Beijing, China
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Zuin M, Capelli G, Gennaro N, Ruffolo C, Spolverato G, Pucciarelli S, Albertoni L, Fassan M. Prognostic significance of pathological sub-classification of pT3 rectal cancer. Int J Colorectal Dis 2022; 37:131-139. [PMID: 34586474 DOI: 10.1007/s00384-021-03991-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Patients with pT3 rectal cancer represent a heterogeneous prognostic group. A more accurate histological sub-classification of pT status has been suggested as an improvement of the TNM staging system. The aim of the study was to evaluate the prognostic implication of a histopathologic sub-classification of pT3 rectal cancer. METHODS In this retrospective single-center study, pT3 rectal cancer patients who underwent surgery from January 2000 to December 2018 were evaluated. The maximum depth of tumor invasion beyond the muscularis propria was recorded. A ROC curve identified the best prognostic cutoff value to classify patients in two prognostic groups. Survival curves were estimated by the Kaplan-Meier method, and univariate and multivariate analyses with the Cox regression model were used to find independent factors influencing survival. RESULTS Overall, 203 patients were included. Four millimeters was identified as the best cutoff value: 82 patients showed a depth of invasion < 4 mm (group A) and 121 ≥ 4 mm (group B). Both the estimated 5-year OS and DFS were statistically better in group A than in group B (OS: 83.9% vs 62.2%, p < 0.01; DFS: 78.3% vs 40.6%, p < 0.01). The depth of tumor invasion was an independent risk factor for OS (HR 2.25, 95% CI 1.26-3.99, p = 0.006) and DFS (HR 2.30, 95% CI 1.40-3.78, p = 0.001). CONCLUSION Our findings suggest that a sub-classification of pT3 rectal cancer, based on the depth of tumor invasion, should be considered to be introduced in the TNM staging system.
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Affiliation(s)
- Matteo Zuin
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University-Hospital of Padua University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Giulia Capelli
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University-Hospital of Padua University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Nicola Gennaro
- Regional Health Service, Epidemiology Unit Veneto Region, Padua, Italy
| | - Cesare Ruffolo
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University-Hospital of Padua University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
| | - Gaya Spolverato
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University-Hospital of Padua University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Salvatore Pucciarelli
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University-Hospital of Padua University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Laura Albertoni
- Pathology and Cytopathology Unit, Department of Medicine, University of Padova , Padua, Italy
| | - Matteo Fassan
- Pathology and Cytopathology Unit, Department of Medicine, University of Padova , Padua, Italy
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Zhang X, Lu Q, Guo X, Cao W, Zhang H, Yu T, Li X, Guan Z, Li X, Sun R, Sun Y. Better prognostic determination of cT3 rectal cancer through measurement of distance to mesorectal fascia: A multicenter study. Chin J Cancer Res 2021; 33:606-615. [PMID: 34815634 PMCID: PMC8580799 DOI: 10.21147/j.issn.1000-9604.2021.05.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/26/2021] [Indexed: 12/01/2022] Open
Abstract
Objective To forward the magnetic resonance imaging (MRI) based distance between the deepest tumor invasion and mesorectal fascia (DMRF), and to explore its prognosis differentiation value in cT3 stage rectal cancer with comparison of cT3 substage. Methods This was a retrospective, multicenter cohort study including cT3 rectal cancer patients undergoing neoadjuvant chemoradiotherapy followed by radical surgery from January 2013 to September 2014. DMRF and cT3 substage were evaluated from baseline MRI. The cutoff of DMRF was determined by disease progression. Multivariate cox regression was used to test the prognostic values of baseline variables. Results A total of 804 patients were included, of which 226 (28.1%) developed progression. A DMRF cutoff of 7 mm was chosen. DMRF category, the clock position of the deepest position of tumor invasion (CDTI) and extramural venous invasion (EMVI) were independent predictors for disease progression, and hazard ratios (HRs) were 0.26 [95% confidence interval (95% CI), 0.13−0.56], 1.88 (95% CI, 1.33−2.65) and 1.57 (95% CI, 1.13−2.18), respectively. cT3 substage was not a predictor for disease progression. Conclusions The measurement of DMRF value on baseline MRI can better distinguish cT3 rectal cancer prognosis rather than cT3 substage, and was recommended in clinical evaluation.
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Affiliation(s)
- Xiaoyan Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Qiaoyuan Lu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xiangjie Guo
- Department of Forensic Medicine, Shanxi Medical University, Taiyuan 030001, China
| | - Wuteng Cao
- Department of Radiology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, China
| | - Hongmei Zhang
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Tao Yu
- Department of Medical Imaging, Cancer Hospital of China Medical University, Shenyang 110042, China
| | - Xiaoting Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Zhen Guan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xueping Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Ruijia Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yingshi Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
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Chen Y, Pei W, Wang Q, Wang W, Xu T, Jing C, Li L, Zhang J. One-stitch versus traditional method of protective loop ileostomy in laparoscopic low anterior rectal resection: A retrospective comparative study. Int J Surg 2020; 80:117-123. [PMID: 32650118 DOI: 10.1016/j.ijsu.2020.06.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/08/2020] [Accepted: 06/16/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Protective loop ileostomy is widely performed during rectal resection surgery. The study aimed to introduce the one-stitch method (OM) of protective loop ileostomy in laparoscopic low anterior resection and compare this new method with the traditional method (TM). MATERIALS AND METHODS A retrospective analysis was conducted on 109 patients with pathologically diagnosed adenocarcinoma of the rectum from January 2017 to December 2018 in the study centre, and the intraoperative details and postoperative outcomes of the two groups were measured. RESULTS A total of 95 patients were included: 54 underwent protective loop ileostomy with the TM, while 41 underwent surgery utilizing the OM. Univariate analysis demonstrated that the operative times of resection and closure were significantly shorter (resection, 200.0 vs. 227.5 min, P = 0.028; closure, 70.0 vs. 92.5 min, P = 0.018) and the peristomal adhesions during closure were milder (P = 0.007) in the OM group than in the TM group. The postoperative complications were similar in both groups. In multivariate analysis, the OM (OR 0.352, 95% CI = 0.155-0.799, P = 0.013) was a significant factor influencing the operative time of resection. The peristomal adhesion extent was the only independent risk factor for the stoma closure time (mild, OR 0.036, 95% CI = 0.010-0.129, P < 0.001; moderate, OR 0.128, 95% CI = 0.033-0.494, P = 0.003). No significant predictive factor of peristomal adhesion extent was identified in multivariable analysis. CONCLUSION The OM of protective loop ileostomy in laparoscopic low anterior resection was time-saving, simple and easy to popularize and did not lead to more postoperative complications than the TM.
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Affiliation(s)
- Yuezhi Chen
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China
| | - Wenting Pei
- Qilu Children's Hospital of Shandong University, Jinan, Shandong, 250000, China
| | - Qiang Wang
- Department of Personnel Office, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Personnel Office, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China
| | - Wenchen Wang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China
| | - Tao Xu
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China
| | - Changqing Jing
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China
| | - Leping Li
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China
| | - Jizhun Zhang
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China; Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, 250021, China.
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9
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Hajibandeh S, Hajibandeh S, Sarma DR, East J, Zaman S, Mankotia R, Thompson CV, Torrance AW, Peravali R. Meta-analysis of temporary loop ileostomy closure during or after adjuvant chemotherapy following rectal cancer resection: the dilemma remains. Int J Colorectal Dis 2019; 34:1151-1159. [PMID: 31129697 DOI: 10.1007/s00384-019-03321-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To evaluate comparative outcomes of temporary loop ileostomy closure during or after adjuvant chemotherapy following rectal cancer resection. METHODS We systematic searched MEDLINE, EMBASE, CINAHL, CENTRAL, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov , ISRCTN Register and bibliographic reference lists. Overall perioperative complications, anastomotic leak, surgical site infection, ileus and length of hospital stay were the evaluated outcome parameters. Combined overall effect sizes were calculated using fixed effects or random effects models. RESULTS We identified 4 studies reporting a total of 436 patients comparing outcomes of temporary loop ileostomy closure during (n = 185) or after (n = 251) adjuvant chemotherapy following colorectal cancer resection. There was no significant difference in overall perioperative complications (OR 1.39; 95% CI 0.82-2.36, p = 0.22), anastomotic leak (OR 2.80; 95% CI 0.47-16.56, p = 0.26), surgical site infection (OR 1.97; 95% CI 0.80-4.90, p = 0.14), ileus (OR 1.22; 95% CI 0.50-2.96, p = 0.66) or length of hospital stay (MD 0.02; 95% CI - 0.85-0.89, p = 0.97) between two groups. Between-study heterogeneity was low in all analyses. CONCLUSIONS The meta-analysis of the best, albeit limited, available evidence suggests that temporary loop ileostomy closure during adjuvant chemotherapy following rectal cancer resection may be associated with comparable outcomes to the closure of ileostomy after adjuvant chemotherapy. We encourage future research to concentrate on the completeness of chemotherapy and quality of life which can determine the appropriateness of either approach.
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Affiliation(s)
- Shahin Hajibandeh
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.
| | - Shahab Hajibandeh
- Department of General Surgery, The Pennine Acute Hospitals NHS Trust, North Manchester General Hospital, Manchester, UK
| | - Diwakar Ryali Sarma
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Jamie East
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Rajnish Mankotia
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Andrew W Torrance
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Rajeev Peravali
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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10
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Abstract
Since the first reports in the late 1950's, a large amount of data have been collected. The analysis of the main evidence from the major randomized trials will be analyzed in this paper according to preoperative, postoperative and chemoradiation approaches. Fifteen randomized preoperative trials were reported; they have been grouped according to the fractionation schedule. In the hypofractionation group (5 Gy for fraction), all five studies that delivered 3-5 doses in one week had a significant improvement in local control and one of them also showed improvement in survival. Operative mortality was higher in the radiotherapy arm if inadequate techniques had been applied. In 3 out of 8 studies with conventional fractionation there was a significant improvement in local control, but no impact in survival was detected. No studies with total dose lower than 34 Gy had an improvement in local control. None of the six randomized postoperative studies showed an improvement in local control or survival. In all trials the local control rate was uniform; ranging from 76% to 84%. Toxicity was higher in the radiotherapy arm. One preoperative and five postoperative randomized studies that used chemoradiation were analyzed. One postoperative chemoradiation study showed a significant improvement in survival in comparison to the surgery arm, and another showed the same advantage compared to the postoperative arm. Protracted infusional administration of 5FU concomitant to radiotherapy showed better survival than bolus administration. No advantages were shown in using MeCCNU or Levamisole in two studies. Toxicity was high and related to the dose and the modality of administration of the drugs in order to adequately treat the different stages of rectal cancer, patients must be carefully selected in order to prescribe the most effective and the least toxic treatment for the individual stage; organ preservation should be an essential goal for its impact on quality of life, and the cost estimates should be taken into account.
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Affiliation(s)
- V Valentini
- Cattedra di Radioterapia, Università Cattolica S. Cuore, Rome, Italy.
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11
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Tsukamoto S, Kanemitsu Y, Shida D, Ochiai H, Mazaki J. Comparison of the clinical results of abdominoperanal intersphincteric resection and abdominoperineal resection for lower rectal cancer. Int J Colorectal Dis 2017; 32:683-689. [PMID: 28091845 DOI: 10.1007/s00384-017-2755-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to compare the oncologic results of abdominoperanal intersphincteric resection (ISR) and abdominoperineal resection (APR). METHODS Between 2003 and 2014, 277 consecutive patients with stage I-III low rectal cancer located within 5 cm from the anal verge underwent curative ISR and APR. A retrospective comparison of these two procedures was performed. RESULTS Overall, 128 patients underwent ISR and 149 underwent APR. The ISR group had earlier clinical stages and shorter distal margins (p < 0.01). The 5-year relapse-free survival rates in patients who underwent ISR/APR were 84.7/74.7% with T1-2 tumors and 51.3/67.6% with T3-4 tumors. In T3-4 tumors, the rate of local recurrence was higher in the ISR group (13.2%) than in the APR group (3.8%). The 5-year relapse-free survival rates in patients who underwent ISR/APR were 89.7/92.3% for stage I cases, 84.4/87.5% for stage II cases, and 39.8/51.8% for stage III cases. Patients with stage III tumors had high rates of distant recurrence in both groups (24.3 vs. 26.3%). CONCLUSION ISR is a feasible surgical procedure for T1-2 tumors. Patients with stage III tumors should be considered for adjuvant therapy to control distant recurrence regardless of the surgical procedure.
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Affiliation(s)
- Shunsuke Tsukamoto
- Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Chuo-ku, Tokyo, 104-0045, Japan.
| | - Yukihide Kanemitsu
- Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Chuo-ku, Tokyo, 104-0045, Japan
| | - Dai Shida
- Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Chuo-ku, Tokyo, 104-0045, Japan
| | - Hiroki Ochiai
- Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Chuo-ku, Tokyo, 104-0045, Japan
| | - Junichi Mazaki
- Department of Colorectal Surgery, National Cancer Center Hospital, 5-1-1 Chuo-ku, Tokyo, 104-0045, Japan
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12
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Efficacy of an additional flap operation in bladder-preserving surgery with radical prostatectomy and cystourethral anastomosis for rectal cancer involving the prostate. Surg Today 2017; 47:1119-1128. [PMID: 28260135 PMCID: PMC5532415 DOI: 10.1007/s00595-017-1484-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 01/12/2017] [Indexed: 02/07/2023]
Abstract
Purpose Sphincter-preserving operations performed with bladder-preserving surgery and a cystourethral anastomosis (CUA) do not require a urinary stoma, but leakage from the CUA may develop. The aim of this study was to evaluate the efficacy of performing an additional flap operation. Methods The subjects were 39 patients who underwent bladder-preserving surgery for advanced rectal cancer involving the prostate, between 2001 and 2015.32 of whom had a CUA and one of whom had a neobladder. Five of these 32 patients underwent an ileal flap operation, 2 underwent an omental flap operation, and 3 underwent an operation using both flaps. Results Leakage developed in 3 (30%) of the 10 patients who underwent additional flap operations, but in 14 (60.9%) of the 23 patients who did not undergo a flap operation. The mean periods of catheterization for the patients who suffered leakage were 31 weeks (8–108 weeks) in those without a flap and 16 weeks (8–20 weeks) in those with a flap. Four (33.3%) of the 12 patients with leakage after surgery without a flap had a period of urinary catheterization >30 weeks, and 2 (16.7%) had leakage of CTCAE grade 3. There were no cases of leakage after flap surgery. Conclusion An additional flap operation may decrease the risk of leakage from a CUA.
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13
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Bianco F, Romano G, Tsarkov P, Stanojevic G, Shroyer K, Giuratrabocchetta S, Bergamaschi R. Extralevator with vs nonextralevator abdominoperineal excision for rectal cancer: the RELAPe randomized controlled trial. Colorectal Dis 2017; 19:148-157. [PMID: 27369739 DOI: 10.1111/codi.13436] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 05/12/2016] [Indexed: 02/08/2023]
Abstract
AIM A randomized controlled trial was conducted to test the null hypothesis that there is no difference in circumferential resection margin (CRM) between extralevator abdominoperineal excision (ELAPE) and non-ELAPE for rectal cancer. METHOD This was a multicentre, randomized controlled trial registered as NCT01702116. Patients with rectal cancer involving the external anal sphincter were randomized to ELAPE or non-ELAPE following neoadjuvant chemoradiation. Randomization was performed according to Consolidated Standards of Reporting Trials (CONSORT) guidelines. The primary end-point was CRM (in mm), defined as the shortest distance between the tumour and the cut edge of the specimen. Pathologists and centralized pathology were blinded to the patients' study arm. Interrater reliability (IRR) was assessed using Kendall's coefficient. Intra-operative perforation (IOP) was any rectal defect determined at pathology. Complications were classified using the Clavien-Dindo classification. Participating surgeons were retrained and credentialed. A sample size calculation showed that 34 subjects would provide sufficient power to reject the null hypothesis. RESULTS Thirty-four patients underwent the allocated intervention. Seventeen patients treated with ELAPE were comparable with 17 patients treated with non-ELAPE regarding age, gender, body mass index (BMI), American Society of Anesthesiology (ASA) class and pre-existing comorbidities. CRM depth (7.14 ± 5.76 mm vs 2.98 ± 3.28 mm, P = 0.016) and involvement rates (5.8% vs 41.0%, P = 0.04) were significantly increased in patients treated with ELAPE. The IRR for CRM was 0.78. There were no significant differences in IOP (5.8% vs 11.7%, P = 0.77) and complication rates (29% vs 29%, P = 0.97). CONCLUSIONS ELAPE was associated with statistically improved CRM with no difference in IOP and complication rates compared with non-ELAPE for rectal cancer involving the external anal sphincter.
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Affiliation(s)
- F Bianco
- Division of Colorectal Surgery, State University of New York, Stony Brook, New York, USA.,Department of Colorectal Surgery, National Cancer Institute, Naples, Italy
| | - G Romano
- Department of Colorectal Surgery, National Cancer Institute, Naples, Italy
| | - P Tsarkov
- Department of Colorectal Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | - G Stanojevic
- Department of Colorectal Surgery, School University of Niš, Niš, Serbia
| | - K Shroyer
- Department of Pathology, State University of New York, Stony Brook, New York, USA
| | - S Giuratrabocchetta
- Division of Colorectal Surgery, State University of New York, Stony Brook, New York, USA
| | - R Bergamaschi
- Division of Colorectal Surgery, State University of New York, Stony Brook, New York, USA
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14
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Zinicola R, Pedrazzi G, Haboubi N, Nicholls RJ. The degree of extramural spread of T3 rectal cancer: an appeal to the American Joint Committee on Cancer. Colorectal Dis 2017; 19:8-15. [PMID: 27883254 DOI: 10.1111/codi.13565] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/20/2016] [Indexed: 12/13/2022]
Abstract
The T3 category of the TNM classification includes over 60% of all rectal tumours and encompasses the greatest variance in cancer-specific end-points than any other T category. The most recent edition of the cancer staging handbook of the American Joint Committee on Cancer (AJCC) dated 2010 does not divide T3 tumours into subgroups which reflect cancer-specific outcome more sensitively. The original aim of the present study was to review the literature to assess the influence of the degree of extramural extent of T3 rectal cancer on local recurrence and survival. An article written by the authors was accepted for publication but was withdrawn immediately after they became aware of the publication of the 4th edition of the TNM Supplement by the Union for International Cancer Control dated 2012, which was not accessible by the search system used. This article dealt with the subdivision of the T3 category although this was not included in the most up-to-date AJCC guidelines and was stated to be 'entirely optional'. Medline, PubMed and Cochrane Library searches were performed to identify all studies that investigated the degree of extramural spread and its relationship to survival and local recurrence. Twenty-two studies were identified of which 12 assessed the degree of histopathological extramural spread measured in millimetres. In 18 of the 22 studies the degree of extramural spread was a statistically significant prognostic factor for survival and local recurrence. Analysis of the studies indicated that the subdivision of category T3 rectal cancer into two subgroups of extramural spread ≤ 5 mm or more than 5 mm resulted in markedly different survival and local recurrence rates. The data were insufficient to allow validation of any greater subdivision. Measurement of the extent of extramural spread by MRI before any treatment agreed with the histopathological measurement in the surgical specimen to within 1 mm. The extent of extramural spread in T3 rectal cancer measured in millimetres is a powerful prognostic factor. A subdivision of T3 into T3a and T3b of less than or equal to or more than 5 mm appears to give the greatest discrimination of local recurrence and survival. Preoperative T3 subdivision by MRI has the same sensitivity as histopathological examination of the resected specimen. Given the clinical need for the pretreatment classification of the T3 category for oncological management planning, the evidence strongly indicates that the subdivision of the T3 category by MRI should be formally considered as part of the TNM staging system for rectal cancer.
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Affiliation(s)
- R Zinicola
- Department of Emergency Surgery, University Hospital Parma, Parma, Italy
| | - G Pedrazzi
- Department of Neuroscience, University of Parma, Parma, Italy
| | - N Haboubi
- Department of Pathology, Spire Hospital, Manchester, UK
| | - R J Nicholls
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital Campus, London, UK
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15
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Liu L, Huang Q, Wang J, Chen Q, Lin R, Ge B. Protection of low rectal anastomosis with a new tube ileostomy using a biofragmentable anastomosis ring: A retrospective study. Medicine (Baltimore) 2016; 95:e5345. [PMID: 27828857 PMCID: PMC5106063 DOI: 10.1097/md.0000000000005345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A temporarily defunctioning stoma, while effective at reducing symptomatic anastomotic leakage after low anterior resection (LAR) of rectal cancer, and its subsequent closure, is associated with significant morbidity. Here, we devised a new tube ileostomy using a biofragmentable anastomosis ring (TIB) with no need for reversal.This is a retrospective cohort study. From June 2011 to March 2015, TIBs were performed on 31 consecutive patients with mid- or low-rectal cancer who underwent elective laparoscopic LARs. From January 2008 to May 2011, 25 similarly diseased patients underwent elective laparoscopic LARs and conventional loop ileostomy (LI) and were included as controls. All of the anastomotic sites were within 6 cm of the anal verge. Demographic, clinical feature, and operative data were recorded.The demographic features of both groups were similar. The TIB mean surgical duration was significantly lower than in the LI group (215 ± 28 vs 245 ± 54 min, P = 0.010). Because of readmission for stoma closure, the total hospital stay of the LI group was longer than that of the TIB group (38.1 ± 26.5 vs 19.1 ± 7.9 days, respectively, P = 0.002). Ileal content was completely diverted by TIB for 13.7 ± 2.1 (range, 10-19) days postoperatively. The drainage tube was removed on postoperative day 27.8 ± 6.9 (range, 20-44), and the mean continued duration of the discharge tract, before fistula healing, was 4.5 ± 1.9 (range, 2-10) days. Postoperative complications of the 2 modalities were not significant. In the TIB group, 1 rectovaginal fistula occurred 30 days postsurgery. In the LI group, 1 rectovaginal fistula occurred 3 months after stoma closure. Both complications were treated with transverse colostomy. No major TIB associated complications were observed in the present study.TIB is a safe, feasible, effective, but time-limited diversion technique, which may reduce symptomatic anastomosis leakage after LAR for rectal cancer.
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Affiliation(s)
| | | | | | | | | | - Bujun Ge
- Department of General Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
- Correspondence: Bujun Ge, Department of General Surgery, Tongji Hospital, Tongji University School of Medicine, 389 XinCun Road, Shanghai 200065, China (e-mail: )
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16
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Quality of Life and Timing of Stoma Closure in Patients With Rectal Cancer Undergoing Low Anterior Resection With Diverting Stoma: A Multicenter Longitudinal Observational Study. Dis Colon Rectum 2016; 59:281-90. [PMID: 26953986 DOI: 10.1097/dcr.0000000000000545] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND After low anterior resection for rectal cancer, creation of a diverting stoma is recommended. Data on the impact of a diverting stoma on quality of life are conflicting. Optimal timing of stoma closure in the setting of adjuvant chemotherapy is unclear. OBJECTIVE The purpose of this study was to investigate the impact of a diverting stoma on quality of life in patients undergoing rectal cancer resection before and after stoma closure. Furthermore, the study was conducted to look at the timing of stoma reversal and the potential influence of factors such as adjuvant chemotherapy. DESIGN This was a longitudinal, observational, multicenter study. SETTINGS The study was conducted at 17 German colorectal centers. PATIENTS Patients with rectal cancer who planned for elective curative surgery with creation of temporary diverting stoma were included. MAIN OUTCOME MEASURES This longitudinal observational study assessed quality of life at 3 occasions using European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core Questionnaire/Colorectal Cancer Module before cancer resection, before stoma closure, and 6 months after stoma closure. Furthermore, the timing of stoma closure and continence were evaluated. RESULTS A total of 120 patients (64% men; mean age, 63.2 ± 11.5 years) were analyzed. Longitudinal global quality of life was not influenced by the presence of a stoma. Several functional and GI symptom scales were markedly impaired after stoma creation. Physical, role functioning, and sexual interest recovered after stoma closure. Social functioning stayed impaired (p < 0.0001). Median time to stoma closure was 5 months (range, 17 days to 18 months). A total of 3.4% of patients had very early stoma closure (within 30 days). Adjuvant chemotherapy delayed stoma closure (median, 5.6 vs 3.4 months without chemotherapy; p = 0.0001). LIMITATIONS The study was limited by its missing quality-of-life data for sexual function. CONCLUSIONS The presence of a stoma had a negative impact on social functioning and GI symptoms. However, this had no clinically relevant influence on global quality of life. Time to stoma closure was nearly doubled when patients underwent adjuvant chemotherapy.
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Sandra-Petrescu F, Herrle F, Hinke A, Rossion I, Suelberg H, Post S, Hofheinz RD, Kienle P. CoCStom trial: study protocol for a randomised trial comparing completeness of adjuvant chemotherapy after early versus late diverting stoma closure in low anterior resection for rectal cancer. BMC Cancer 2015; 15:923. [PMID: 26589718 PMCID: PMC4654836 DOI: 10.1186/s12885-015-1838-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 10/20/2015] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Current evidence supports a diverting stoma in patients undergoing low anterior resection with total mesorectal excision for rectal cancer as it reduces clinical severity of anastomotic leakage. However, relevant stoma morbidity after rectal cancer surgery exists and has a significant impact on quality of life. Moreover, a diverting stoma has an influence on completeness of chemotherapy but it remains unclear in which way. There is no evidence regarding optimal timing for stoma closure in relation to adjuvant chemotherapy. Two randomised controlled trials have studied early stoma closure after low anterior resection in patients with rectal cancer, one of them showing that early closure around day 8 after resection is possible without increasing morbidity. METHODS/DESIGN CoCStom is a randomised multicentre trial comparing completeness of adjuvant chemotherapy as primary endpoint after early (8-10 days after resection, before starting adjuvant therapy) versus late (~26 weeks after resection and completion of adjuvant therapy) stoma closure in patients with locally advanced rectal cancer undergoing low anterior resection after neoadjuvant therapy. After exclusion of post-operative anastomotic leakage 257 patients from 30 German hospitals are planned to be included in order to assure a power of 80% for the confirmatory analysis of at least 214 evaluable cases. An absolute increase of 20% for the rate of completely administered adjuvant chemotherapy is regarded as a clinically meaningful step forward and serves as basis for sample size calculation. Quality of life, stoma-related complications, individual completeness of chemotherapy rate, percentage of patients stopping adjuvant therapy or undergoing dose modifications or delay, oncological outcomes, cumulative days of hospitalisation and number of readmissions, rate of symptomatic anastomotic leaks after stoma closure, mortality, post-operative complications and toxicity of adjuvant chemotherapy are secondary endpoints. DISCUSSION The CoCStom trial aims to clarify optimal timing of stoma closure in the context of adjuvant chemotherapy. Depending on the results of the trial, patients could benefit either from early or late stoma closure in regard to long term oncological survival due to a higher rate of completeness of adjuvant chemotherapy treatment and thus better effectiveness. TRIAL REGISTRATION German Clinical Trials Register, DRKS00005113. Registered 28 August 2013.
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Affiliation(s)
- Flavius Sandra-Petrescu
- Surgical Department, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Florian Herrle
- Surgical Department, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Axel Hinke
- Wissenschaftlicher Service Pharma GmbH, Karl-Benz-Str. 1, 40764, Langenfeld, Germany.
| | - Inga Rossion
- Study Center of the German Surgical Society, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| | - Heiko Suelberg
- Wissenschaftlicher Service Pharma GmbH, Karl-Benz-Str. 1, 40764, Langenfeld, Germany.
| | - Stefan Post
- Surgical Department, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Ralf-Dieter Hofheinz
- Oncological Department, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Peter Kienle
- Surgical Department, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Koyama M, Murata A, Sakamoto Y, Morohashi H, Hasebe T, Saito T, Hakamada K. Risk Factors for Anastomotic Leakage After Intersphincteric Resection Without a Protective Defunctioning Stoma for Lower Rectal Cancer. Ann Surg Oncol 2015; 23 Suppl 2:S249-56. [PMID: 25743332 DOI: 10.1245/s10434-015-4461-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Intersphincteric resection (ISR) is performed as an alternative to abdominoperineal resection for super-low rectal cancer. The purpose of this study was to evaluate risk factors for anastomotic leakage (AL) after ISR without a defunctioning stoma for lower rectal cancer. METHODS Between 1995 and 2012, 135 consecutive patients with lower rectal cancer underwent curative ISR without a protective defunctioning stoma. Univariate and multivariate analyses were performed to determine the risk factors for AL. RESULTS The radiological and symptomatic AL rate was 17.0 % (23/135). Univariate analysis demonstrated that male sex (P = 0.030), preoperative chemotherapy (P = 0.016), partial ISR (P < 0.001), lateral lymph-node dissection (P = 0.042), distal tumor distance from the dentate line (P = 0.007), and straight reconstruction (P < 0.001) were significantly associated with AL. Severe AL requiring re-laparotomy developed in 13 (9.6 %) patients. Univariate analysis demonstrated that male sex (P = 0.006), partial ISR (P < 0.001), distal tumor distance from the dentate line (P = 0.002), and straight reconstruction (P < 0.001) were significantly associated with AL requiring relaparotomy. Multivariate analysis demonstrated that partial ISR [odds ratio (OR) 6.701; P = 0.001] and straight reconstruction (OR 5.552; P = 0.002) were independently predictive of AL. CONCLUSIONS Partial ISR and straight reconstruction increased the risk of AL after ISR without a protective defunctioning stoma. A defunctioning stoma might be mandatory in patients with the risk factors identified in this analysis.
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Affiliation(s)
- Motoi Koyama
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan.
| | - Akihiko Murata
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yoshiyuki Sakamoto
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Hajime Morohashi
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Tatsuya Hasebe
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Takeshi Saito
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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Clinical outcomes of robot-assisted intersphincteric resection for low rectal cancer: comparison with conventional laparoscopy and multifactorial analysis of the learning curve for robotic surgery. Int J Colorectal Dis 2014; 29:555-62. [PMID: 24562546 DOI: 10.1007/s00384-014-1841-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND This study evaluated the feasibility of robot-assisted intersphincteric resection (ISR) for low rectal cancer. Further, we attempted to analyze the learning curve for robotic surgery. METHODS A total of 64 patients were retrospectively chart-reviewed. Patients were classified into a laparoscopic procedure (n = 28) group and a robot-assisted (n = 36) group. Comparisons of age, gender, clinical staging, operating time, complications, and pathologic status were analyzed. Besides, we used a seventh-order moving average method for the construction of a learning curve in robotic surgery. RESULTS Operating time was 374.3 min (range, 210-570 min) in the laparoscopic group and 485.8 min (range, 315-720 min) in the robotic group, with statistical difference between these two groups (P < 0.001). Thirteen patients (46.4 %) received diverting stoma in the laparoscopic group and seven patients (19.4 %) in the robotic group, with statistical difference between these two groups (P = 0.021). Operative experience of robotic ISR showed that the mean operating time was 519.5 min (range, 360-720 min) in the first stage and 448.2 min (range, 315-585 min) in the second stage, with statistical difference between these two stages (P = 0.02). Multifactorial analysis showed that protective diverting stoma creation or neorectum necrosis was not associated with age, sex, pretreatment T stage, or surgeons' experience. CONCLUSIONS Our data shows that robot-assisted ISR for low rectal cancer is feasible and safe with no compromising oncological outcomes. The surgeons' experience improves operating time in robotic surgery.
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Abdel-Gawad W, Zaghloul A, Fakhr I, Sakr M, Shabana A, Lotayef M, Mansour O. Evaluation of the frequency and pattern of local recurrence following intersphincteric resection for ultra-low rectal cancer. J Egypt Natl Canc Inst 2014; 26:87-92. [PMID: 24841159 DOI: 10.1016/j.jnci.2014.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 12/26/2013] [Accepted: 02/03/2014] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Abdomino-perineal resection has been the standard treatment for rectal tumors located ≤5cm from the anal verge. Recently, intersphincteric resection became a valid option which preserves the bowel continuity with better functional outcome. AIM Is to evaluate the oncological and functional outcome alongside the associated surgical morbidity in patients with T1-3 rectal cancer, who underwent intersphincteric resection (ISR). PATIENTS & METHODS Between the years 2006 and 2011, 55 patients with invasive rectal adenocarcinoma, T1-3 lesions, located 2-5cm from the anal verge underwent ISR with total mesorectal excision. When inevitable, complete. ISR was performed, otherwise partial ISR was done. All T3 patients underwent total meso-rectal excision (TME) while some had lateral lymph node dissection (LND) with concomitant pelvic autonomic nerve preservation (PANP). RESULTS Among the 55 patients, 21 (38.1%) patients were T1-2 and 34 (61.9%) patients were T3. The tumor location range was 0-5cm from the anal verge (median 2.3cm). Partial or complete ISR was done for 35 (63.6%) and 20 (36.4%), respectively. Patients were followed for a median of 1.5 years (range 1-4.6 years). The 3 year local recurrence and distant metastasis free rates were 85.2% and 85.6%, respectively. All the 3 local recurrences occurred in T3 patients group, and had positive circumferential resection margins. Overall 3-year disease-free survival was 82.6%; while the overall 3-year survival was 88.7%. CONCLUSION Intersphincteric resection with TME does not affect the local recurrence or overall survival rate in early rectal cancer T1-2 & 3, with preservation of bowel continuity and better life quality.
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Affiliation(s)
- W Abdel-Gawad
- Surgical Oncology Department, National Cancer Institute (NCI), Fom-El-Khalig, Cairo, Egypt
| | - A Zaghloul
- Surgical Oncology Department, National Cancer Institute (NCI), Fom-El-Khalig, Cairo, Egypt
| | - I Fakhr
- Surgical Oncology Department, National Cancer Institute (NCI), Fom-El-Khalig, Cairo, Egypt.
| | - M Sakr
- Surgical Pathology Department, National Cancer Institute (NCI), Fom-El-Khalig, Cairo, Egypt
| | - A Shabana
- Radio-Diagnosis Department, National Cancer Institute (NCI), Fom-El-Khalig, Cairo, Egypt
| | - M Lotayef
- Radiation Oncology Department, National Cancer Institute (NCI), Fom-El-Khalig, Cairo, Egypt
| | - O Mansour
- Medical Oncology Department, National Cancer Institute (NCI), Fom-El-Khalig, Cairo, Egypt
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Hong KS, Oh BY, Kim EJ, Chung SS, Kim KH, Lee RA. Psychological attitude to self-appraisal of stoma patients: prospective observation of stoma duration effect to self-appraisal. Ann Surg Treat Res 2014; 86:152-60. [PMID: 24761424 PMCID: PMC3994620 DOI: 10.4174/astr.2014.86.3.152] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 11/07/2013] [Accepted: 11/11/2013] [Indexed: 11/30/2022] Open
Abstract
PURPOSE In recent years, many psychological problems in patients with stomas have been addressed in a number of studies. But there are only a few studies that use objective measures to take into account self-appraisal by patients with permanent or temporary stomas. The aim of this study is to compare the psychological attitude of patients with permanent and temporary stomas and to determine the most appropriate psychological supportive care. METHODS Sixty-five patients, who received a stoma between January 2009 and March 2012, were classified into two groups with either permanent or temporary stomas and were observed prospectively. We developed a questionnaire with the aid of a psychiatrist to analyze the grade of psychological attitude of self-appraisal of patients. The questionnaire was categorized into three parts; body image scale, self-esteem scale, and depression scale. Patients responded to the questionnaire 4 weeks after the operation and the answers of each group were compared. RESULTS Out of 65 patients, 42 received temporary stomas and 23 received permanent stomas. There was no significant mean difference between permanent and temporary stoma patients in the body image scale, the self-esteem scale, and the depression scale. However, patients with a permanent stoma tended to have a worse body image and lower self-esteem on some specific items within the questionnaires. CONCLUSION Patients with stomas have negative attitudes toward themselves and some meaningful differences were found between different types of stoma applied. Surgeons should be concerned about postoperative psychological support for patients with stomas.
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Affiliation(s)
- Kyung Sook Hong
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Bo-Young Oh
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Eui-Jung Kim
- Department of Psychiatry, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Soon Sup Chung
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kwang Ho Kim
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
| | - Ryung-Ah Lee
- Department of Surgery, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea
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Koyama M, Murata A, Sakamoto Y, Morohashi H, Takahashi S, Yoshida E, Hakamada K. Long-term clinical and functional results of intersphincteric resection for lower rectal cancer. Ann Surg Oncol 2014; 21 Suppl 3:S422-8. [PMID: 24562938 DOI: 10.1245/s10434-014-3573-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intersphincteric resection (ISR) is an alternative to abdominoperineal resection (APR) for super-low rectal cancer. The aim of this study was to evaluate the long-term curability after ISR over an average 6-year observational period, to compare the postoperative functional outcomes for ISR with those for low anterior resection (LAR), and to determine whether ISR is a function-preserving surgery. METHODS Between 2000 and 2007, a total of 77 consecutive patients with low rectal cancer underwent curative ISR. The curability outcomes for ISR, LAR, and APR were compared. We evaluated the postoperative defecation functions, Wexner incontinence score (WIS), and defecation quality of life (QOL) for a between-groups comparison (ISR/LAR). RESULTS The 5-year survival rate after ISR was 76.4 %, and the outcome was better than for APR (APR 51.2 %, LAR 80.7 %). Local recurrence after ISR occurred in 7.8 % of patients (APR 12.1 %, LAR 11.7 %). The average daily frequency of defecation was 3.7 times for the ISR patients and 3.2 times for the LAR patients, indicating no significant difference between the groups. Moreover, there were no significant differences between the groups for defecation functions. The WIS was 8.1 for ISR and 4.9 for LAR, and the defecation QOL for ISR and LAR was not significantly different (modified fecal incontinence QOL score: ISR 34.3, LAR 26.5). CONCLUSIONS The long-term clinical and functional results suggest that ISR may be the optimal sphincter-preserving surgery for patients with lower rectal cancers who cannot be treated with a double-stapling technique.
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Affiliation(s)
- Motoi Koyama
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan,
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Han JW, Lee MJ, Park HK, Shin JH, An MS, Ha TK, Kim KH, Bae KB, Kim TH, Choi CS, Oh SH, Oh MK, Kang MS, Hong KH. Association between a close distal resection margin and recurrence after a sphincter-saving resection for t3 mid- or low-rectal cancer without radiotherapy. Ann Coloproctol 2013; 29:231-7. [PMID: 24466537 PMCID: PMC3895546 DOI: 10.3393/ac.2013.29.6.231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 07/12/2013] [Indexed: 01/08/2023] Open
Abstract
PURPOSE To maintain the patient's quality of life, surgeons strive to preserve the sphincter during rectal cancer surgery. This study evaluated the oncologic safety of a sphincter-saving resection with a distal resection margin (DRM) <1 cm without radiotherapy in T3, mid- or low-rectal cancer. METHODS This retrospective study enrolled 327 patients who underwent a sphincter-saving resection for proven T3 rectal cancer located <10 cm from the anal verge and without radiotherapy between January 1995 and December 2011. The oncologic outcomes included the 5-year cancer-specific survival, the local recurrence, and the systemic recurrence rates. RESULTS In groups A (DRM ≤1 cm) and B (DRM >1 cm), the 5-year cancer-specific survival rates were 81.57% and 80.03% (P = 0.8543), the 5-year local recurrence rates were 6.69% and 9.52% (P = 0.3981), and the 5-year systemic recurrence rates were 19.46% and 23.11% (P = 0.5750), respectively. CONCLUSION This study showed that the close DRM itself should not be a contraindication for a sphincter-saving resection for T3 mid- or low-rectal cancer without radiotherapy. However, a prospective randomized controlled trial including the effect of adjuvant therapy will be needed.
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Affiliation(s)
- Jae Woong Han
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Min Jae Lee
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ha Kyung Park
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jae Ho Shin
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Min Sung An
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Tae Kwun Ha
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kwang Hee Kim
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Ki Beom Bae
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Tae Hyun Kim
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Chang Soo Choi
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sang Hoon Oh
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Min Kyung Oh
- Clinical Trial Center in Pharmacology, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Mi Seon Kang
- Department of Pathology, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Kwan Hee Hong
- Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
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Li SY, Chen G, Bai X, Zuo FY, Chen G, Du JF, Wei XJ, Cui W. Anus-preserving rectectomy via telescopic colorectal mucosal anastomosis for low rectal cancer: Experience from a Chinese cohort. World J Gastroenterol 2013; 19:3841-3846. [PMID: 23840123 PMCID: PMC3699045 DOI: 10.3748/wjg.v19.i24.3841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 06/04/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the safety and efficacy of anus-preserving rectectomy via telescopic colorectal mucosal anastomosis (TCMA) for low rectal cancer.
METHODS: From August 1993 to October 2012, 420 patients including 253 males and 167 females with low rectal cancer underwent transabdominal and transanal anterior resection, followed by TCMA. The distance between the anus and inferior margin of the tumor ranged from 5 to 7 cm, and was 5 cm in 6 patients, 6 cm in 127, and 7 cm in 287 patients. Tumor-node-metastasis staging showed that 136 patients had stage I, 252 had stage II and 32 had stage III. Fifty-six patients with T3 or over received preoperative neoadjuvant chemoradiotherapy.
RESULTS: The postoperative follow-up rate was 91.9% (386/420) with a median time of 6.4 years. All 420 patients underwent radical resection. No postoperative death occurred. Postoperative complications included anastomotic leakage in 13 (3.1%) patients and anastomotic stenosis in 7 (1.6%). The local recurrence rate after surgery was 6.2%, the hepatic metastasis rate was 13.2% and the pulmonary metastasis rate was 2.3%. The 5-year survival rate was 74.0% and the disease-free survival rate was 71.0%. Kirwan classification showed that continence was good in 94.4% of patients with stage I when scored 12 mo after resection.
CONCLUSION: TCMA for patients with low rectal cancer leads to better quality of life and satisfactory defecation function, and lowers anastomotic leakage occurrence, and might be one of the safe operative procedures in anus-preserving rectectomy.
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Inada R, Yamamoto S, Oshiro T, Takawa M, Fujita S, Akasu T. A case-matched comparison of the short-term outcomes between laparoscopic and open abdominoperineal resection for rectal cancer. Surg Today 2013; 44:640-5. [DOI: 10.1007/s00595-013-0611-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 01/23/2013] [Indexed: 12/21/2022]
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Yeh YS, Chen MJ, Tsai HL, Huang MY, Chen CW, Huang YH, Sheen MC, Wang JY. Transanal inside-out rectal resection for ultra-low rectal cancer. J INVEST SURG 2012; 25:375-380. [PMID: 23215794 DOI: 10.3109/08941939.2012.655369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Two major issues encountered in the surgical resection of low rectal cancers (tumor located <6 cm from anal verge) are tumor-free surgical resection margin and adequate fields of colo-anal pull-through anastomosis. The clinical consequences of ensuring gross tumor-free surgical resection margin by transanal inside-out rectal resection technique were assessed for ultra-low rectal cancer patients. From February 2009 to September 2011, ultra-low anterior resection with a new method of eversion of the rectum through the anal canal after resecting the distal rectum and colo-anal anastomosis extracorporally performed in 30 patients (age range, 41-80 years) was reviewed. All patients received preoperative neoadjuvant concurrent chemoradiotherapy (CCRT) before the surgical resection. The median operating time was 265 min (range, 220-400 min), and the median intraoperative blood loss was 325 ml (range, 80-855 ml). No in-hospital mortality was noted among these patients. R0 resection (tumor-free margin range, 0.9-2.5 cm) was confirmed in all patients by pathologic reports, except one patient with 0.5 cm tumor-free margin. The new surgical technique of transanal inside-out rectal resection and colo-anal pull-through anastomosis for selected patients with ultra-low rectal cancers seems to be a safe and alternative procedure.
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Affiliation(s)
- Yung-Sung Yeh
- Division of Trauma, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Affiliation(s)
- J Nicholls
- Imperial College of Science, Technology and Medicine, London and St Mark's Hospital, London, UK.
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Saito N, Suzuki T, Tanaka T, Sugito M, Ito M, Kobayashi A, Nishizawa Y, Minagawa N, Nishizawa Y, Watanabe K. Preliminary experience with bladder preservation for lower rectal cancers involving the lower urinary tract. J Surg Oncol 2010; 102:778-83. [DOI: 10.1002/jso.21717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Akasu T, Takawa M, Yamamoto S, Yamaguchi T, Fujita S, Moriya Y. Risk factors for anastomotic leakage following intersphincteric resection for very low rectal adenocarcinoma. J Gastrointest Surg 2010; 14:104-11. [PMID: 19841989 DOI: 10.1007/s11605-009-1067-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Accepted: 10/06/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to perform a retrospective analysis of the risk factors for anastomotic leakage following intersphincteric resection (ISR) for very low rectal cancer. METHODS Between 1993 and 2007, 120 patients with T1-T3 rectal adenocarcinomas located 1 to 5 cm (median 3 cm) from the anal verge underwent ISR without radiotherapy. Univariate and multivariate analyses of 47 prospectively recorded parameters were conducted. RESULTS All patients had total mesorectal excision after complete bowel preparation. Of them, 103 underwent partial resection, and 17 underwent complete resection of the internal sphincter. Some 108 patients had a defunctioning stoma. Morbidity and mortality rates were 33% and 0.8%, respectively. Fifteen patients (13%) developed clinical leakage, and six (5%) had severe leakage causing relaparotomy, permanent stoma, or death. Univariate analysis of risk factors for clinical leakage revealed tumor annularity, intraoperative blood transfusion, and pulmonary disease to be significant. Multivariate analysis showed transfusion (hazard ratio, 6.5 [95% confidence interval, 1.4 to 30]; p = 0.018) and pulmonary disease (6.3 [1.6 to 26]; p = 0.009) to be independently significant. Moreover, transfusion (71 [3.0 to 1000]; p = 0.008), colonic J-pouch (32 [1.8 to 500]; p = 0.018), and pulmonary disease (32 [1.1 to 1000]; p = 0.044) were independently associated with severe leakage. CONCLUSIONS This study suggests intraoperative blood transfusion and pulmonary disease as independent risk factors for clinical and severe leakage following ISR and colonic J-pouch as that for severe leakage. By considering these factors, we may be able to stratify high-risk patients and prepare countermeasures.
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Affiliation(s)
- Takayuki Akasu
- Colorectal Surgery Division, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan.
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Saito N, Sugito M, Ito M, Kobayashi A, Nishizawa Y, Yoneyama Y, Nishizawa Y, Minagawa N. Oncologic outcome of intersphincteric resection for very low rectal cancer. World J Surg 2009; 33:1750-6. [PMID: 19488814 DOI: 10.1007/s00268-009-0079-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND In 2000 we launched a prospective program of intersphincteric resection (ISR) for very low rectal cancer. In this study we compared the oncologic outcome of patients who underwent ISR with the outcome of patients who underwent abdominoperineal resection (APR). METHODS The data of 202 patients with very low rectal cancer who underwent curative ISR (n = 132) or curative APR (n = 70) between 1995 and 2006 were analyzed. Patients were divided into ISR and APR groups. Survival and local recurrence were investigated in both groups. RESULTS The median follow-up was 40 months in the ISR group and 57 months in the APR group. The 5-year local relapse-free survival rate was 83% in the ISR group and 80% in the APR group (p = 0.364), and the 5-year disease-free survival rate was 69% in the ISR group and 63% in the APR group (p = 0.714). CONCLUSIONS For very low rectal cancers, ISR appears to be oncologically acceptable and can reduce the number of APRs.
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Affiliation(s)
- Norio Saito
- Colorectal and Pelvic Surgery Division, Department of Surgical Oncology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
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Han JG, Wei GH, Gao ZG, Zheng Y, Wang ZJ. Intersphincteric resection with direct coloanal anastomosis for ultralow rectal cancer: the experience of People's Republic of China. Dis Colon Rectum 2009; 52:950-7. [PMID: 19502861 DOI: 10.1007/dcr.0b013e31819f13a3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the oncologic and functional outcomes of intersphincteric resection in ultralow rectal cancer. METHODS From 2000 to 2007, intersphincteric resection with total mesorectal excision was performed in 40 patients with very low rectal cancer (total intersphincteric resection in 5 patients, partial intersphincteric resection in 23 patients, and partial intersphincteric resection with partial dentate line preservation [modified partial intersphincteric resection] in 12 patients). The preoperative tumor stage was T12N01M0. RESULTS Morbidity occurred in three patients (anastomotic leakage in one patient, wound infection in two patients), but there was no postoperative mortality. The five-year overall survival rate was 97 percent, and the five-year disease-free survival rate was 86 percent. Patients who underwent a modified partial intersphincteric resection (P = 0.004) or a partial intersphincteric resection (P = 0.008) had significantly better continence than those who underwent total intersphincteric resection, and patients with a diverting stoma had significantly better continence (P = 0.043) than those without a stoma, at 12 months after surgery. CONCLUSIONS Intersphincteric resection is a safe procedure for sphincter-saving rectal surgery in selected patients with very low rectal tumors. A temporary diverting stoma may be beneficial to improve anal function. Modified partial intersphincteric resection under the precondition of radical resection yielded better anal function and a lower rate of incontinence.
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Affiliation(s)
- Jia Gang Han
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Chaoyang District, Beijing, People's Republic of China
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Abstract
At present, the preferred treatment for rectal cancer is low anterior resection with total mesorectal excision and sphincter preservation. Complete removal of the tumor's lymphatic and vascular pad with free resection margins has led to a reduction in rates of local recurrence and improved disease-specific survival. In addition to the distal and proximal margins from the tumor edge, for an optimal outcome, it is essential to consider distal mesorectal spread and the circumferential mesorectal margin.
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Affiliation(s)
- Nir Wasserberg
- Department of Surgery B, Rabin Medical Center, Petah Tiqwa, Israel
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Akasu T, Takawa M, Yamamoto S, Ishiguro S, Yamaguchi T, Fujita S, Moriya Y, Nakanishi Y. Intersphincteric resection for very low rectal adenocarcinoma: univariate and multivariate analyses of risk factors for recurrence. Ann Surg Oncol 2008; 15:2668-76. [PMID: 18618181 DOI: 10.1245/s10434-008-0047-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Revised: 06/03/2008] [Accepted: 06/04/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND The aim of this study was to analyze the risk factors for local and distant recurrence after intersphincteric resection (ISR) for very low rectal adenocarcinoma. METHODS One hundred twenty consecutive patients with T1-T3 rectal cancers located 1-5 (median 3) cm from the anal verge underwent ISR. Univariate and multivariate analyses of prospectively recorded clinicopathologic parameters were performed. RESULTS Fifty patients had disease categorized as stage I, 21 as stage II, 46 as stage III, and 3 as stage IV on the basis of International Union Against Cancer tumor, node, metastasis staging system. Median follow-up time was 3.5 years. The 3-year rates of local and distant recurrence were 6% and 13%, respectively. Univariate analysis of the risk factors for local recurrence revealed pathologic T, pathologic stage, focal dedifferentiation, microscopic resection margins, and preoperative serum CA 19-9 level to be statistically significant. Multivariate analysis showed resection margin, focal dedifferentiation, and serum CA 19-9 level to be independently significant. Univariate analysis of the risk factors for distant recurrence indicated tumor location, combined resection, tumor annularity, pathologic N, lateral pelvic lymph node metastasis, pathologic stage, histologic grade, lymphovascular invasion, perineural invasion, and adjuvant chemotherapy to be significant. Multivariate analysis identified pathologic N, histologic grade, and tumor location to be independently significant. CONCLUSION Profiles of risk factors for local and distant recurrences after ISR are different. With local recurrence, the resection margin, focal dedifferentiation, and serum CA 19-9 level are important. For distant recurrence, the lymph node status, histologic grade, and tumor location need to be taken into account.
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Affiliation(s)
- Takayuki Akasu
- Colorectal Surgery Division, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
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Nicholls R, Tekkis PP. Multidisciplinary Treatment of Cancer of the Rectum: A European Approach. Surg Oncol Clin N Am 2008; 17:533-51, viii. [DOI: 10.1016/j.soc.2008.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Tsunoda A, Tsunoda Y, Narita K, Watanabe M, Nakao K, Kusano M. Quality of life after low anterior resection and temporary loop ileostomy. Dis Colon Rectum 2008; 51:218-22. [PMID: 18172730 DOI: 10.1007/s10350-007-9101-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Revised: 06/11/2007] [Accepted: 07/21/2007] [Indexed: 02/06/2023]
Abstract
PURPOSE Low anterior resection has become the operation of choice for mid rectal or low rectal cancer. A defunctioning stoma is routinely created at some centers to decrease the risk of leakage requiring surgical intervention. This study was designed to evaluate the quality of life in patients undergoing low anterior resection with a temporary ileostomy. METHODS A prospective longitudinal study was conducted in 22 patients with rectal cancer who underwent low anterior resection with a loop ileostomy. Quality of life was assessed by using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR38 questionnaires. Twenty-five patients who underwent high anterior resection for rectosigmoid cancer were studied concurrently to evaluate the impact of major colorectal resection without a stoma. RESULTS Patients' scores on the quality of life questionnaires generally improved after high anterior resection; however, for patients who underwent low anterior resection, the scores for physical and role functioning before ileostomy closure were worse than the preoperative values. The scores on the quality of life questionnaires generally improved after ileostomy closure. Ileostomy closure required a short hospital stay and was rarely associated with complications. CONCLUSION Patients who underwent low anterior resection with ileostomy had significant reductions in physical and role functioning, which apparently improved after ileostomy closure. Similar declines in these quality of life variables were not found in patients who underwent high anterior resection. A temporary ileostomy should be created in selected patients with the highest risk of anastomotic leakage. Increased resources for not only surgical care but also for stoma therapy are necessary for patients who undergo low anterior resection with a temporary ileostomy.
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Affiliation(s)
- Akira Tsunoda
- Department of General and Gastroenterological Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan.
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Akasu T, Takawa M, Yamamoto S, Fujita S, Moriya Y. Incidence and Patterns of Recurrence after Intersphincteric Resection for Very Low Rectal Adenocarcinoma. J Am Coll Surg 2007; 205:642-7. [DOI: 10.1016/j.jamcollsurg.2007.05.036] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Revised: 05/23/2007] [Accepted: 05/30/2007] [Indexed: 01/03/2023]
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Daniels IR, Fisher SE, Heald RJ, Moran BJ. Accurate staging, selective preoperative therapy and optimal surgery improves outcome in rectal cancer: a review of the recent evidence. Colorectal Dis 2007; 9:290-301. [PMID: 17432979 DOI: 10.1111/j.1463-1318.2006.01116.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The current optimal management of locally advanced rectal cancer has evolved from surgical excision followed by postoperative therapy in patients with involved margins, to an increasing use of a preoperative strategy to 'down-stage and/or down-size' the tumour. This treatment strategy is based on the relationship of the tumour to the mesorectal fascia, the optimal surgical circumferential resection margin that can be achieved by total mesorectal excision. We have reviewed the recent evidence for this strategy. METHOD An electronic literature search using PubMed identified articles on the subject of rectal cancer between January 2000 and December 2005. The search was limited to English language publications with secondary references obtained from key articles. Articles published in high impact factor journals formed the basis of the review, together with articles related to national programmes on the management of rectal cancer. This does lead to a selection bias, particularly as the articles identified had a European bias. CONCLUSION The UK NHS Cancer Plan has outlined the basis for the multidisciplinary team (MDT) management of rectal cancer. Advances in preoperative assessment through accurate staging and the recognition of the importance of the relationship of the tumour to the mesorectal fascia has allowed the selection of patients for a preoperative strategy to down-size/down-stage the tumour if this fascial layer is involved or threatened. Improvements in the quality of surgical resection through the acceptance of the principle of total mesorectal excision have ensured that optimal surgery remains the cornerstone to successful treatment. Further refinements of the MDT process strive to improve outcome. Accurate radiological staging, optimal surgery and detailed histopathological assessment together with consideration of a preoperative neoadjuvant strategy should now form the basis for current treatment and future research in rectal cancer.
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Affiliation(s)
- I R Daniels
- Pelican Cancer Foundation, North Hampshire Hospital, Basingstoke RG24 9NA, UK
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Polglase AL, Grodski SF, Tremayne AB, Chee JBL, Bhathal PS. Local recurrence following surgical treatment for carcinoma of the lower rectum. ANZ J Surg 2005; 74:745-50. [PMID: 15379800 DOI: 10.1111/j.1445-1433.2004.03136.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The present paper examines the local recurrence rate following surgical treatment for carcinoma of the lower rectum with principally blunt dissection directed at tumour-specific mesorectal excision (including total mesorectal excision when appropriate). METHODS During the period April 1987-December 1999, 123 consecutive resections for carcinoma of the middle and distal thirds of the rectum were performed. The patients had low anterior resection, ultra low anterior resection or abdomino-perineal resection. Ninety-six eligible patients underwent curative resection. The mean follow-up period was 66.8 months +/-44.3 (range 3-176 months). Data were available on all patients having been prospectively registered and retrospectively collated and computer coded. RESULTS The overall rate of local recurrence was 5.2% (four recurrences following ultra low anterior resection and one following abdomino-perineal resection. No local recurrence occurred after low anterior resections.). Local recurrences occurred between 16 and 52 months from the time of resection, and the cumulative risk of developing local recurrence at 5 years for all patients was 7.6%. The overall 5-year cancer specific survival of the 96 patients was 80.8%, and the overall probability of being disease free at 5 years, including both local and distal recurrence, was 71.8%. CONCLUSION The results of the present series confirm the safety of careful blunt techniques combined with sharp dissection for rectal mobilization along fascial planes resulting in extraction of an oncologic package with tumour-specific mesorectal excision (or total mesorectal excision when appropriate).
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Affiliation(s)
- Adrian L Polglase
- Cabrini Monash University Academic Surgical Department, Cabrini Hospital, Melbourne, Victoria, Australia.
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Rullier E, Laurent C, Bretagnol F, Rullier A, Vendrely V, Zerbib F. Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule. Ann Surg 2005; 241:465-9. [PMID: 15729069 PMCID: PMC1356985 DOI: 10.1097/01.sla.0000154551.06768.e1] [Citation(s) in RCA: 250] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To assess oncologic outcome of patients treated by conservative radical surgery for tumors below 5 cm from the anal verge. SUMMARY BACKGROUND DATA Standard surgical treatment of low rectal cancer below 5 cm from the anal verge is abdominoperineal resection. METHODS From 1990 to 2003, patients with a nonfixed rectal carcinoma at 4.5 cm or less from the anal verge and without external sphincter infiltration underwent conservative surgery. Surgery included total mesorectal excision with intersphincteric resection, that is, removal of the internal sphincter, to achieve adequate distal margin. Patients with T3 disease or internal sphincter infiltration received preoperative radiotherapy. RESULTS Ninety-two patients with a tumor at 3 (range 1.5-4.5) cm from the anal verge underwent conservative surgery. There was no mortality and morbidity was 27%. The rate of complete microscopic resection (R0) was 89%, with 98% negative distal margin and 89% negative circumferential margin. In 58 patients with a follow-up of more than 24 months, the rate of local recurrence was 2% and the 5-year overall and disease-free survival were 81% and 70%, respectively. CONCLUSIONS The technique of intersphincteric resection permits us to achieve conservative surgery in patients with a tumor close to or in the anal canal without compromising local control and survival. Tumor distance from the anal verge is no longer a limit for sphincter-saving resection.
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Affiliation(s)
- Eric Rullier
- Department of Surgery, Saint-André Hospital, Bordeaux, France.
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Abstract
Total mesorectal excision (TME) has gained a revolutionary impact on the surgical therapy of rectal cancer within the last 2 decades, providing superior local tumor control in comparison to conventional resection. Consequently, 85% of rectal carcinomas can be resected by sphincter-preserving surgery without compromising either oncologic radicality or continence. With the introduction of TME, local recurrence rates have been reliably decreased below 10% after curative resection. Surgical dissection along the connective tissue space between rectal and parietal pelvic fascia with complete mesorectal excision results in reliable excision of all relevant lymphatic pathways with preservation of continence and sexual function. Complete removal of a TME specimen is mandatory in carcinomas of the middle and lower third of the rectum. Both removal of the complete TME specimen and careful pathologic examination of the circumferential resection margin have decisive significance. An additional pelvic lymphadenectomy with the potential risk of increased morbidity does not improve prognosis. As a spread of tumor distally along the bowel wall rarely exceeds a few centimeters, a distal resection margin of 1-2 cm is oncologically sufficient in sphincter-saving procedures without compromising prognosis. Taken together, the convincing results of TME provide a rationale for using TME as the dissection policy of choice to resect rectal cancers in the distal two-thirds of the rectum, despite the absence of direct evidence from prospective randomized trials. The question whether laparoscopic curative resection for rectal cancer is oncologically adequate cannot be definitely answered to date, as results of randomized studies are currently missing. However, the preliminary results of laparoscopic resection for rectal cancer provided by centers are promising.
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Affiliation(s)
- H-P Bruch
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck.
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O'Leary DP, Fide CJ, Foy C, Lucarotti ME. Quality of life after low anterior resection with total mesorectal excision and temporary loop ileostomy for rectal carcinoma. Br J Surg 2001; 88:1216-20. [PMID: 11531870 DOI: 10.1046/j.0007-1323.2001.01862.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Low anterior resection (LAR) with total mesorectal excision (TME) may be the optimal operation for carcinoma of the mid or lower rectum. Routine formation of a temporary defunctioning stoma has been recommended with TME. The impact of this strategy on health-related quality of life (HRQOL) has not been addressed. METHODS A prospective longitudinal study was conducted among 24 patients undergoing LAR with TME and loop ileostomy for rectal cancer. Clinical outcomes were documented. HRQOL was assessed using Short Form 36 (SF-36). Twenty-three patients undergoing high anterior resection (HAR) for rectosigmoid cancer were studied concurrently to determine the effects of major colorectal resection without a stoma. RESULTS Time to resume normal diet, length of stay in hospital and time to return to non-work activities were similar after HAR or LAR with TME and loop ileostomy. Twelve weeks after HAR SF-36 scores were stable or improved compared with preoperative levels. In contrast, 12 weeks after LAR + TME patients had a reduction in physical functioning scores on SF-36. SF-36 scores improved after ileostomy closure. Ileostomy closure increased total hospital stay and time off non-work activities. CONCLUSION LAR with TME and temporary loop ileostomy for rectal cancer results in a long total hospital stay and impairs aspects of HRQOL. Prompt stoma closure should be a priority in these patients.
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Affiliation(s)
- D P O'Leary
- Department of Surgery, Gloucestershire Royal Hospital, Gloucester, UK.
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Gandy, O'Leary, Falk, Roe. Results of a selective policy for preoperative radiotherapy in rectal cancer surgery. Colorectal Dis 2000; 2:36-40. [PMID: 23577933 DOI: 10.1046/j.1463-1318.2000.00129.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Preoperative radiotherapy (pRT) for rectal cancer may reduce local recurrence and improve survival. This study was undertaken to assess a selective policy of pRT in rectal cancer. The aim was to determine whether patients likely to have involved circumferential margins (CRM) could be reliably selected for pRT using clinical criteria. We have used CRM and delay in surgery as outcome measures. PATIENTS AND METHODS Seventy-nine patients with rectal cancer were assessed for preoperative radiotherapy using clinical criteria. RESULTS Twelve of 26 (46%) pRT patients had positive CRM compared with three of 53 (5.6%) who did not receive pRT (P < 0.0001). Using pRT resulted in patients waiting a further 21 days before surgery (pRT 34 days vs no pRT 13 days; P < 0.0001). CONCLUSION This policy has been effective in selecting patients most likely to benefit from radiotherapy and has avoided excessive delays prior to surgery. However, almost half of the pRT patients did not have involved CRM. With improved imaging techniques we may be able to refine our selection criteria further.
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Affiliation(s)
- Gandy
- North Bristol NHS Trust, Department of General Surgery, Southmead Hospital, Bristol, UK, Bristol Oncology Centre, Bristol, UK
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44
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Paty PB, Cohen AM. The role of surgery and chemoradiation therapy for cancer of the rectum. Curr Probl Cancer 1999; 23:229-49. [PMID: 10536747 DOI: 10.1016/s0147-0272(99)90011-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- P B Paty
- Department of Surgery, Cornell University Medical College, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Abstract
Rectal cancer surgery is difficult due to the rectum's relatively inaccessible pelvic position and its direct relation to many vital structures. The surgeon is challenged to restore intestinal continuity while working in a confined space. Despite the importance of these issues, the embryology and surgical anatomy of the rectum have been poorly understood. In recent years, cadaver dissections and operative resection under direct vision have provided a clearer picture of the structure of the rectum and mesorectum, their innervation, blood supply, and surrounding structures. New imaging techniques will shed further light on the anatomy of these structures and their anatomic variations.
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Affiliation(s)
- R J Heald
- North Hampshire Hospitals Trust, The North Hampshire Hospital, Basingstoke, United Kingdom
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Risk factors associated with local recurrence after curative resection for rectal cancer. Surg Today 1997. [DOI: 10.1007/bf02385678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sailer M, Leppert R, Bussen D, Fuchs KH, Thiede A. Influence of tumor position on accuracy of endorectal ultrasound staging. Dis Colon Rectum 1997; 40:1180-6. [PMID: 9336113 DOI: 10.1007/bf02055164] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
UNLABELLED Endorectal ultrasound is a well-established method of preoperative staging of rectal neoplastic lesions. PURPOSE This study was undertaken to evaluate whether tumor site (in terms of height) and position (with respect to the rectal circumference) have an influence on the reliability of endoluminal ultrasound staging. METHODS From January 1991 to May 1996, 154 consecutive patients with a total of 162 rectal tumors were examined preoperatively using endorectal ultrasound. Apart from staging all tumors using the uT/uN classification, tumor level and tumor position were recorded prospectively. Neoplasms were subdivided into low rectal (0-6 cm from the anal verge), mid rectal (7-12 cm), and higher lesions (> 12 cm). Furthermore, the lumen was divided into an anterior, left lateral, posterior, and right lateral position, and all tumors, apart from circular lesions (n = 9), were subclassified accordingly. RESULTS Overall, we found 40 (25 percent) adenomas, 15 (9 percent) T1, 29 (18 percent) T2, 67 (41 percent) T3, and 11 (7 percent) T4 lesions. Overall accuracy was 78 percent. Staging accuracy for low rectal tumors (n = 41) was 68 percent, whereas 76 and 88 percent of mid (n = 96) and high (n = 25) neoplasms were staged correctly, respectively. The difference was not statistically significant. With regard to position, 47 tumors were situated anteriorly (77 percent accuracy), 42 in the left lateral position (69 percent accuracy), 33 posteriorly (73 percent accuracy), and 31 in the right lateral position (81 percent accuracy). Differences did not reach statistical significance. CONCLUSION Endorectal ultrasound is currently the best method for preoperative assessment of the depth of infiltration of rectal tumors. However, rectal anatomy seems to affect staging accuracy in the lower rectum because the structure of the ampulla recti renders endosonographic examination more difficult. In addition, endosonographic layers are less well defined at this level. Both factors contribute to a lower reliability and predictive value of endorectal ultrasound staging in the lower rectum, although statistical significance was not reached in this study. On the other hand, tumor position with respect to rectal circumference does not influence the predictive value of endorectal ultrasound.
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Affiliation(s)
- M Sailer
- Surgical Department, University School of Medicine, Würzburg, Germany
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